Foundational Documents in Interprofessional Practice

Romanow, Roy J. (2002). Building on Values: The Future of Health Care in Canada – Final Report (Report No. C2002-980275-X). Retrieved from http://publications.gc.ca/collections /Collection/CP32-85-2002E.pdf

The Commission for the Future of Health Care in Canada, or the Romanow Commission, led

by Commissioner Roy Romanow, released a final report on their investigation of the status of health care in Canada and recommendations for change. It is one of the first reports in Canada that indicates the importance of interprofessional education and learning for health care professionals. It recognizes that the health care system has changed and that focus has shifted to become more patient-centred, which changes the scope of practice of all health care professions.

With this come new roles and responsibilities that current health care education programs do not properly prepare students for and which current health care providers do not practice. The changing system requires more collaboration between professions in order to meet the needs of patients, as well as education programs that clearly delineate the new or changed roles of the different professions in order for patient care to be as efficient as possible. The reports states: “if health care providers are expected to work together and share expertise in a team environment, it makes sense that their education and training should prepare them for this type of working arrangement” (109). Therefore, Recommendation 17 of the report is: “the Health Council of Canada should review existing education and training programs and provide recommendations to the provinces and territories on more integrated education programs for preparing health care providers, particularly for primary health settings” (108). The report regards interprofessional education as one way to a more efficient health care system that meets the needs of Canadians.

This is a foundational work commissioned by the government and is a starting place for many of the interprofessional education initiatives in Canada since.

World Health Organization, Health Professions Networks Nursing and Midwifery Human Resources for Health. (2010). Framework for Action on Interprofessional Education and Collaborative Practice (WHO/HRH/HPN/10.3). Retrieved from http://whqlibdoc.who.int/ hq/2010/WHO_HRH_HPN_10.3_eng.pdf

The World Health Organization’s Framework for Action on Interprofessional Education and Collaborative Practice is a call to action in response to recent global health issues, such as shortages in health care workers and inefficiency. It is a framework for local authorities/ policy makers to use when trying to combat health care issues, because the WHO identifies interprofessional education and collaboration as a valid solution supported by the literature and proven in practice. It is important to note that this framework simply presents ideas that can be locally contextualized and adapted to suit a particular system—these are not requirements for interprofessional education. The report identifies various mechanisms that shape IPE and collaborative practice. These mechanisms, organized into three groups (interprofessional education, collaborative practice and health and education systems), are combined with possible actions for implementation at a local level. The expectations of the WHO are that users of this global framework will adapt it to fit their needs in a local level by: “examining their local context to determine their needs and capabilities; committing to building interprofessional collaboration into new and existing programmes; [and] championing successful initiatives and teams” (13).

Frank, J.R., Brien, S. (Eds.). (2008). The Safety Competencies: Enhancing Patient Safety Across the Health Professions. Ottawa: Canadian Patient Safety Institute.

The Canadian Patient Safety Institute developed The Safety Competencies as part of their mission to create a patient safety framework that could be implemented and integrated in health care across Canada, stating: “The ultimate goal of The Safety Competencies initiative is to foster a culture of patient safety that will help to ensure safe practice and improve quality of care across a diverse range of health care settings” (29). It is acknowledged that interprofessional education and practice is inherent in the basic nature of patient safety because of the complexity of the Canadian health care system – patients are rarely engaging with only one professional. While the framework’s focus is on patient safety, these competencies are valid for interprofessional learning as well, because patient safety depends upon an interprofessional team.

This framework outlines 24 key competencies deemed important to the education and practice of health care professionals, and organizes them into six domains. The domains are: contribute

to a culture of patient safety; work in teams for patient safety; communicate effectively for patient safety; manage safety risks; optimize human and environmental factors; and recognize, respond to and disclose adverse events. Each domain is defined and explained, followed by a listing of the key competencies. The competencies are then further broken down into enabling competencies, of which there are 140. This breakdown (domain – key competency – enabling competencies) makes the teaching of The Safety Competencies much easier, which follows the CPSI’s goal of nationwide implementation of the framework. Obstacles to its implementation are briefly outlined as well, to take note of and consider when attempting to use the framework.

These obstacles are things such as workload, resources and disruption. This framework is meant to be used in both a practical setting and a classroom setting, with focus on the classroom so that future health care providers are well versed in interprofessional collaboration and patient safety.

It is also hoped that the competencies will be incorporated into national standards to ensure the adoption of the framework and the commitment to continued and better patient safety.

D’eon, M. (2005). A blueprint for interprofessional learning. Journal of Interprofessional Care, 1, 49-59. doi:10.1080/13561820512331350227

This paper is an outline of two approaches to interprofessional education that can be used as, like the title states, a blueprint for teaching IPE to students. Its focus is on the teaching and learning of the competences of IPE, not performing them. There are two conceptual frameworks to be considered: “progressive complexity of learning tasks within a program or course to enhance transfer and a cooperative-experiential approach to engaging in those tasks” (50). The article says that by structuring these tasks in a progressive manner, making each one a little more difficult, students will absorb the knowledge from the first task and then transfer it to problem solve on the next task. This will translate into the professional world when a new health professional encounters a situation he/she does not have experience with. The knowledge gained from the progressively complex tasks in school should theoretically be transferred to the situation at hand and aid them in coming up with a solution. Furthermore, students should be learning in interprofessional groups as early as possible, because this cooperative learning promotes teamwork, which is vital to professional practice today. There are five essential

features to cooperative learning: “positive interdependence, face-to-face promotive interaction, individual accountability, interpersonal and small-group skills, and group processing” (53).

These features are also important to interprofessional teams in the workplace, so using this model in interprofessional teaching is a good simulation of real-life work. Cooperative learning can be problem based and/or case based. The learning done within these frameworks is experiential, “the result of an encounter with an experience that is planned by instructors within a course, program or curriculum” (55). One of the best ways to maximize the experiential learning is to progress from paper cases to simulated cases to real cases, while working in an interdisciplinary team. This paper is intended to be a guideline to building an interprofessional education curriculum by identifying desired outcomes and explaining models that can be used to achieve those outcomes.

Frenk, J., Chen, C., Bhutta, Z.A. et al. (2010). Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet, 376, 1923-1958. doi: 10.1016/S0140-6736(10)61854-5

This report was done by an international independent commission whose goal was to create a framework that would allow health professions to share a common global vision for the future.

The focus is on health education and how to reform the system in order to create a global health care system that equally meets the needs of all people. Perspectives are global, and promote adaptation of the framework at a local level while using global resources and knowledge. The Commission identifies three aspects of education: institutional design (structure and function), instructional design (processes), and educational outcomes. Reforms would be institutional and instructional, with the desired outcomes being interdependence in education and transformative learning (fostering and developing leadership attitudes to become agents of social change). In total, ten reforms are discussed (six instructional, four institutional) – see page 1951, Panel 9, for a summary. Most pertinent to interprofessional education is the reform based on competencies and competency-based education (Reform 1, Panel 9), as well as the promotion of interprofessional and transprofessional education (Reform 2, Panel 9). The Commission supports a competency-based education approach, which is driven by the desired learning

objectives rather than the curriculum. They say that “attainment of specific competencies, not time or academic turf protection, must be the defining feature of the education and evaluation of future health professionals” (1943). Competencies would be both discipline-specific and more general to promote both individual and team learning. This allows professional roles to become more aligned, which in turn fosters an interprofessional approach to health care: “The more the educational experience includes competencies for that type of work, the better health professionals will be equipped to adapt to the teamwork that is imperative of good practice” (1944). This report is a foundational work, suggesting policy changes and institutional and instructional reforms that can lead to a better, more equal global health care system through increased global interdependence and helping future health care professionals become agents of social change and members of professional teams. Focus is on the global outcome, but the reforms are meant to be taken locally and adapted to particular contexts, but with a global perspective in mind.

Thistlethwaite, J., Marin, M. (2010). Learning outcomes for interprofessional education (IPE): Literature review and synthesis. Journal of Interprofessional Care, 24, 503-513. doi: 10.3109/13561820.2010.483366

This is a literature review on the learning outcomes defined when interprofessional education programs are being developed. The authors, writing on behalf of WHO, attempt to synthesize information about IPE learning outcomes to answer the question: “What are the learning outcomes for health professionals that may only be achieved completely through interprofessional education?” (504). Focus is on generic outcomes that cover all professions and can therefore be called interprofessional outcomes. The authors warn against getting caught up in the terminology, as learning outcomes are also called “objectives”, “competencies”, and “capabilities”, though all describing the same thing. After the review, which consisted of 88 citations, the various learning outcomes were synthesized into six major themes, the most popular being teamwork. The remaining themes were roles/responsibilities, communication, learning/reflection, the patient and ethics/attitudes. These are what the majority of the outcomes listed in literature were aimed at. This review breaks those themes down further into more

specific objectives (see Table 1, page 511). It also separates the outcomes that can be learned in school and those that are learned in a professional, working environment. These outcomes, as opposed to profession specific ones, can only be learned through IPE and are therefore extremely important to health care education in general. This review was written as part of a WHO initiative to explore the ways learning outcomes are defined and presented. It is intended to help form a consensus on what learning outcomes can be achieved in IPE.

Canadian Patient Safety Institute. (2011). Canadian Framework for Teamwork and Communications. Retrieved from http://www.patientsafetyinstitute.ca/English/tools Resources/teamworkCommunication/Documents/ Canadian%20Framework%20for%20Teamwork%20and%20Communications.pdf

The Canadian Patient Safety Institute issued this report in 2011 to offer healthcare providers a framework to implement improved teamwork and communication in their organizations.

It is identified that the breakdown of these leads to reduced patient safety as a such they are key to safe healthcare culture. The Teamwork and Communications working group conducted a literature search on the two concepts, and their relation to patient safety and healthcare in general. The literature identifies various knowledge, skills, and attitudes (KSAs) that are characteristic of effective teamwork (table on page 4). The issue is how to ensure that these KSAs are effectively transferred into clinical practice, and both the framework and the literature suggest that multi-component training offers the best approach, but most importantly training should be done as a team. There is also a summary of the characteristics of effective communication (table on page 5-6). This is an important section as many interprofessional education programs stress communication as one of the core competencies for students to learn and this framework could provide contextualized information for educators. There is however an acknowledged dearth of literature on the best delivery approach to team training. The framework goes further, summarizing a needs assessment to identify perceptions that could be barriers to teamwork and communication in healthcare, as well as a summary of research on team training programs. The programs are meant for professional development. This framework is intended more for the training of current healthcare workers, not future ones, but the concepts

of teamwork and communication are important in IPE, and as such this framework can be used as background evidence and a summary of the literature pertaining to the two concepts for IPE educators.

Health Professions Act, Chapter H-7 (2011). Retrieved from http://www.qp.alberta.ca/documents /Acts/h07.pdf

The Alberta Health Professions Act (HPA) was passed in 1999 to regulate all the self-governing health professions. This act was meant to bring all the professions under a common set of rules for education, registration, practice and management. The HPA also divides all the professions specifically and outlines each one's roles and scopes of practice (see Part 10: Profession Specific Provisions, page 120). The purpose of this is to reflect the changing nature of healthcare in Alberta, where it is acknowledged that more and more often different professions have the required competence to perform a specific task. In order to streamline the healthcare system and make it as efficient and safe as possible, professions' roles and responsibilities need to be clearly defined. The HPA does this, but also makes the rules under which the governing bodies of the profession consistent, so that all colleges operate under the same rules guidelines. A work such as this (as well as a 1999 summary, listed below) is helpful in IPE education in Alberta to teach students their roles as a future professional, and how they fit in with other professions.

D’Amour, D., Oandasan, I. (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: an emerging concept. Journal of Interprofessional Care, 1, 8-20. DOI: 10.1080/1356182050008 1064

This paper aims to identify the elements of collaborative care, and introduces a concepts called "interprofessionality". They define it as "the development of a cohesive practice between professionals from different disciplines" (9). It links the spheres of interprofessional learning and interprofessional practice, which separately cannot hope to improve health care delivery.

What it means to the authors is a new approach to health care in which both educators and

practitioners work collaboratively. They also identify a framework that can be used to link the two areas, "Interprofessional Education for Collaborative Patient-centred Practice", or IECPCP. This frameworks helps to identify the processes that both influence educational programs to teach IPE and influence the adoption of IP practice in the system (see page 11 for a figure).

These two spheres, while being separate, are interdependent: "if we train competent collaborative practitioners, more collaborative practice settings will be developed over time" (12). In the education sphere, there is a lot of emphasis on socialization issues, i.e. the influence of professional and cultural beliefs and attitudes towards interprofessional collaboration. Educators are an important factor in this, because their attitudes and beliefs will influence the students they train, meaning that educators can be either enablers or barriers to students gaining professional competencies. Furthermore, in order for educators to successfully teach these competencies they have to be clearly defined. The authors acknowledge that there are fewer formal learning opportunities to learn to be collaborative practitioners at the pre-licensure level (14). In the sphere of practice, the authors stress the importance of realizing that collaboration is a set processes made up of complex interactions between individuals and between individuals and organizations. Therefore, interprofessional teams of healthcare workers should share common goals and visions, as well as have personal and professional connections (in order to trust each other and to easily share professional territories. This paper introduces a framework that looks at IPE in a different way, and underscores the interdependence between education and practice, as well as the factors and influences that can affect its adoption. As such this paper is a good contextual information for developing IPE programs.

Lapkin, S., Levett-Jones, T., Gilligan, C. (2011). A systematic review of the effectiveness of interprofessional health education in health professional programs. Nurse Education Today, doi: 10.1016/j.nedt.2011.11.006

The purpose of this systematic review is to determine how effective IPE is for health students.

The authors agree that IPE is being globally accepted as an approach to address many healthcare issues. However, while it is being adopted into many health professional programs at the university level, research on the effectiveness of teaching it to health students has not been

thoroughly done. A literature search for randomised controlled trials and quasi-experimental studies was done, where learning outcomes were assessed by validated instruments (such as RIPLS or IEPS). Ten databases were searched and four journals hand-searched for relevant studies. 4217 articles were found, from which 75 were deemed relevant based on titles and abstracts. This number was then reduced to 12 based on full text reviews, and 9 were selected after analysis of methodological quality (see list below). The chosen studies are presented in this review as a narrative because of the different outcomes, control groups, and interventions.

Participants of all studies were most commonly nursing and medical students, but covered many different health professions (dental hygiene, dentistry, occupational therapy, pharmacy, physical therapy/physiotherapy, podiatry, prosthetics and orthotics, radiography, and respiratory care).

The 9 studies were from 6 different countries, and all used convenience sampling. All the studies compared outcomes between the control and experimental groups. The results of the studies vary between attitudinal changes after IPE to mixed results. None showed a negative change in attitudes. Only one of the studies assessed participants 3-4 months after the intervention, the results of which showed that attitudes returned to where they were prior to the intervention. The authors note this as an important finding, because IPE is supposed to be transferable to professional practice, and therefore they say that further study into its transferability needs to be conducted to fully understand its effectiveness. They also note that only one study used practicebased learning opportunities, and say that ‘ideally, on-campus IPE initiatives should be supported by deliberate opportunities for IPE during the experiential learning that occurs during clinical placements’ (12), as this is the place where students are able to integrate theoretical and practical skills. It is suggested that changes are required at multiple levels within the university/ institution in order to address the constraints healthcare programs may have when trying to implement IPE. They also suggest that e-learning may be a future of IPE, as one study successfully implemented it as part of the intervention. The authors conclude that more research is needed to fully understand the impact of IPE on health students and its sustainability over time. They also suggest that future studies should consider cluster-randomised designs to reflect the number of different professions usually represented in an IPE intervention.

Accreditation of Interprofessional Health Education (AIPHE). (2009). Principles and practices

for integrating interprofessional education into the accreditation standards for six health professions in Canada. Retrieved from http://www.cihc.ca/files/complementary/AIPHE _PrinciplesandPracticesGuide_2009.pdf

AND Accreditation of Interprofessional Health Education (AIPHE). AIPHE Interprofessional Health Education Accreditation Standards Guide. Retrieved from http://www.cihc.ca/files/ resources/public/English/ AIPHE%20Interprofessional%20Health%20Education%20Accreditation%20Standards%20Guid e_EN.pdf

In order to implement recommendations from the Romanow Report and CIHC, in November 2007 representatives from eight participating health science colleges and accreditation bodies formed the AIPHE group to review current standards for the accreditation of health science educational programs and to recommend guidelines through which accreditation bodies can require integration of interprofessional education in health science programs. They were funded

by Health Canada. The initial report, Principles and practices for integrating interprofessional education into the accreditation standards for six health professions in Canada, is a document that “describes the rationale for this attention to IPE, articulates guiding principles, provides sample standards and examples of evidence, as well as a resource list for education programs to access material needed to embed IPE in curricula� (5). The purpose is to ensure that IPE is a high priority for Canadian health education programs. This report lists guiding principles for the development and implementation of IPE standards (see page 8 for the list). It also has examples of IPE standards and evidence of IPE in five domains: institutional commitment, academic program, students, faculty, and resources. These examples are to help professions either adopt new standards or change existing ones to reflect IPE in their national accreditation programs.

There is also a list of resources (references and links) to curriculum, professional development, and evaluation materials for further development of IPE programs (see page 11), and a table of existing standards among the eight participating accreditation bodies that relate to the IECPCP framework (see page 16).

The second report from AIPHE, Interprofessional Health Education Accreditation Standards Guide, is called Phase Two. It builds off of the first report, and provides suggestions that can be considered by accreditation agencies when developing standards. The content is meant to be adapted to each body’s specific context, and it is not in any way exhaustive. The purpose of Phase Two was to design a guide “to ensure consistent evaluation of interprofessional education evidence in any health professional organization” (6). This guide was developed by a subcommittee of AIPHE, the Standards Development Working Group (SDWG), with representation from each accreditation body. Five domains common to all health professional programs were included (the same as were listed in Principles and practices: organizational commitment, faculty, students, educational programs, and resources). Each domain was then broken down into four areas: context, language, criteria, and examples. Explanations of these areas can be found on page 7. The purpose of this is to frame the different elements of the standard. The context suggestions describe the focus of the standard. The language suggestions give examples of how the suggestion can be written. The criteria suggestions are examples of the types of evidence that accreditation surveyors look for, and the example suggestions are the ways of finding or assessing the evidence. The purpose of this is to provide options for development and adaptation of standards that integrate IPE as an important aspect of health education programs.