Teaching interprofessional collaboration in the health disciplines:
Practical Suggestions for Educators
LIVWELL Research Group Research Mission
To foster innovative and interdisciplinary research and advance knowledge on living well with chronic disease across the life course. Members: Scott Lear, Faculty of Health Sciences Dawn Mackey, Department of Biomedical Physiology and Kinesiology Miriam Rosin, Department of Biomedical Physiology and Kinesiology Nadine Schuurman, Department of Geography Andrew Wister, Department of Gerontology
Acknowledgements Information reported in this publication was supported by the LiVWELL Research Group and funded through the Community Trust Endowment Fund at Simon Fraser University. Project evaluation and report preparation by Helen Kang. Final editing and layout by Darlene Seto. Š LiVWELL Research Group, 2014. This document is distributed for purposes of comment, discussion, and research only. It may not be reproduced without permission of the author and publisher. The opinions expressed in this document are those of the authors and do not necessarily reflect those of the LiVWELL Research Group. More information on LiVWELL Research Group can be found at: www.livwellresearch.ca.
“Interprofessional education involves educators and learners from 2 or more health professions and their foundational disciplines who jointly create and foster a collaborative learning environment. The goal of these efforts is to develop knowledge, skills and attitudes that result in interprofessional team behaviors and competence. Ideally, interprofessional education is incorporated throughout the entire curriculum in a vertically and horizontally integrated fashion.” CENTRE FOR THE ADVANCEMENT OF INTERPROFESSIONAL EDUCATION, 2009
Introduction In 2002, in its review of the Canadian health care system, the Romanow Commission stressed the importance of integrated care in order to meet the health needs of Canadians and stated:
“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.
“
(p.109)
Current literature points to two major challenges in interprofessional care: effectively communicating across differences and negotiating relations of power between the professions (Sheehan et al., 2007). It has been argued that interprofessional education (IPE) at the pre-licensure level can help future healthcare providers to address these challenges in the workplace by shaping their professional identity around the idea that they are members of a care team (Solomon et al., 2003; Curran et al., 2005). In their two-part overview of existing literature on IPE, Ivy Oandasan and Scott Reeves (2005a; 2005b) identify several factors that can impact the success and sustainability of IPE that range from micro-level, meso-level and macro-level factors as well as the specific teaching and learning context. At the micro-level issues of professional turf-guarding and stereotyping can affect interactions between professions in a team setting. Meso-level factors include administrative and organizational factors at the level of the teaching institution, such as accreditation process and academic timetables. Macro-level factors extend
beyond the teaching and learning context to include the broader healthcare system in relation to which IPE takes place, including policies, licensing and care delivery systems. In this brief report, we consider strategies and challenges in teaching interprofessional collaboration in the training of future health care providers by drawing on the findings from a quality assessment of an interprofessional undergraduate course on HIV Prevention and Care. We reflect on the priorities and pertinent issues that emerge within the classroom and behind the scenes in interprofessional education (IPE). Our goal is to provide practical suggestions for educators who plan to design and implement an interprofessional curriculum, and points for further reflection and discussion for educators who are already engaged in IPE.
The Course: HIV Prevention and Care (HIV-P&C) The HIV Prevention and Care (HIV-P&C) course at the University of British Columbia’s (UBC) College of Health Disciplines is targeted at undergraduate health sciences students in nursing, medicine, social work, pharmacy, dietetics, dentistry and interdisciplinary studies. The course is offered annually during the intensive summer semester by an interprofessional faculty consisting of a physician, a nurse, a pharmacist, a social worker, two community educators, a dietician and a dental hygienist. The course enrollment is restricted to thirty students with as equal number of students from each of the seven disciplines as possible. Mon
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Figure 1. Course schedule
The course objectives are to increase skills-based competency in HIV prevention, management and care, and to foster interprofessional values, such as collaboration, team communication and reflection of professional roles. These goals are reflected in the curriculum structure (see Figure 1 above). During the first two weeks, the students engage in online learning for basic clinical and care knowledge about HIV. The subsequent four weeks (Weeks 2-6) consist of face-to-face time, where students alternate between classroom learning and experiential learning in clinical and community placements. Classroom learning includes lectures by the faculty and guest speakers who are members of the HIV care community in Vancouver, as well as problem-based learning (PBL) sessions in small groups. Another goal of the HIVP&C course is to increase students’ understanding of the social determinant of HIV and patient advocacy. HIV/AIDS is an illness that affects disproportionally socially marginalized groups, such as gay men, intravenous drug users, people of colour, immigrants and refugees, and people living with addictions, poverty and mental illness. Social determinants of health and the history of HIV/AIDS epidemic are repeated throughout the course content.
BACKGROUND In 2012, through the support of LiVWELL Research Group, an evaluator was hired to assess the effectiveness of the pedagogy of the HIV-P&C course at UBC (IHHS 402) in fostering interprofessional collaboration among its students. In this report, the evaluator’s recommendations are distilled into the following eight practical suggestions for educators. The suggestions are followed by a brief discussion of relevant observations from the HIV-P&C course.
One of the current faculty members is a staff at a local community-based AIDS service organization (Positive Living Society of BC) and six individuals living with HIV are directly involved in the course as teachers (Positive Role Models) during the PBL sessions.
Priorities, Lessons, Challenges Drawing on Oandasan and Reeves’ overview of the factors that can affect the success and sustainability of IPE, we focus on the impacts of differing professional socialization (micro-level factor), of teaching and learning strategies, and of administrative processes (meso-level factor) on IPE in the context of the HIV-P&C course.
Navigating difference Practical Suggestion #1: Consider forming smaller PBL groups that simulate case management teams. When planning PBL in an IPE curriculum, consider forming smaller PBL groups that simulate case management teams, rather than have learners solve isolated problems as a group. This way, the learners can directly engage with one another as a team over a period of time. When composing a team and facilitating the dynamic, consider the hierarchical relations between professions and how various power dynamics can affect the PBL group dynamic. Also consider other demographic factors that could affect student interactions, such as age, clinical experience and language proficiency. The most interactions between the students occur in the PBL group sessions. On the first day of class, each student is assigned to one of six PBL groups with as equal representation of each discipline in each group as possible. These PBL sessions run differently from those found in some medical school curriculum, which tend to be driven by solving specific medical problems (Bate et al., 2014). Each PBL group in the HIV-P&C course is facilitated by a faculty member and a Positive Role Model, and the group is assigned a fictional case: a person living with HIV with a unique personal history and challenges. The group functions as a care team for this client. Over five PBL sessions during the course, the groups are given new updates on the client’s progress and are tasked to come up with a care plan at the end of each session. On the last day of class, each group presents its case in its entirety in the context of the client’s illness journey. Hence, the course’s PBL is modeled after case management (Wagner, 2000).
In the 2012 cohort, the students not only varied in disciplinary backgrounds but also in age and level of training. Many of the pre-medical and pre-pharmacy students tended to be younger with minimal clinical experience, if any. Many of the social work and nursing students tended to be older and some of them were already working in health care and had enrolled in the course for postgraduate training. In the health care workplace, physicians tend to have greater authority and decision-making power than other professions, such as nurses and social workers, a hierarchical relationship that can negatively affect interprofessional collaboration. Having a greater number of nursing and social work students in the class who were generally older and had more clinical experience meant that these students often took leadership in the PBL discussions and set the tone for the interprofessional dynamic. Whereas medical students are generally trained to be self-sufficient leaders (Kennedy et al., 2009), nursing and social work education has a greater emphasis on collaboration (Canadian Association of Nurses in HIV/AIDS Care, 2013) and the latter dominated the PBL group.
Practical Suggestion #2: During PBL sessions, the primary focus of the educator should not be to transfer content but to facilitate discussion and learning across differences. Allow learners to make mistakes, work through difficult problems and try things out before jumping in too quickly with the solution. Consider using role-playing in order to work through difficult scenarios. Encourage peer teaching and peer learning, particularly across disciplines in ways that are attentive to the traditional hierarchy between the professions, i.e. make sure that the medical students are not doing all the peer teaching. Encourage learners to question assigned professional roles and consider integrating rolereversal in role-playing. For student who lacked clinical experience, the PBL sessions were a way to discover and play-out their professional role in relation to other professions. These students asked questions such as: “Is this what I would do as a pharmacist?” and “Should I take the person at this point to a nurse or a doctor?” Having a mixed group of undergraduate and postgraduate students meant that the more experience students could also teach their classmates: “This is what you would do as a nurse.” In addition, students negotiated care
roles, particularly the role of patient counselling, which the social work students as well as the social work faculty insisted should be done by everyone including the doctor, contrary to many health care workplaces where the care roles can be more compartmentalized. For the postgraduate students and those with clinical experience, the course was also a way to pause and reflect on the theory and concepts behind practice. Several of the faculty members had the students do role-playing during the PBL sessions, especially for difficult situations such as breaking a bad news to a client. These role-plays helped students to see how particular care practices may unfold in a controlled situation where they could try something and then “rewind” and modify their approach, pause and ask questions or receive feedback from others during the role-play. In cases where a professional role was lacking in a PBL group—which was typically the dieticians in the 2012 cohort—a student of another profession could volunteer to take on the role. One student who was in interdisciplinary studies took on the role of a dietician in her PBL group after shadowing a dietician during a clinical placement and found learning about a new profession very rewarding.
Practical Suggestion #3: When evaluating your IPE program, consider the possibility of adding a focus group session in addition to or in lieu of satisfaction surveys. It would be ideal to have an external non-faculty person with experience in qualitative research or group facilitation to conduct this focus group session. Disciplinary differences were also reflected in the students’ preferred learning styles. The medical, pharmacy and pre-med/pre-pharmacy students were generally more responsible to didactic form of learning (e.g., lectures that are based on transferring content). Meanwhile, the nursing and social work students generally responded more positively to interactive and hands-on learning (e.g., group activities and reflections on practice). On the last day of class, the evaluator received open feedback from the students (the faculty members were absent in this session). Some of the social work students, who were greatest in number, commented that they found the presentations by clinicians to be the least engaging, to which some of the (pre-)med/ (pre-)pharmacy students responded that they found these presentations the most interesting. What followed was a discussion between the students from these two groups about different disciplinary priorities.
This difference can be attributed to the manner in which the two types of disciplines train their students: medical and pharmacy schools and premedical programs tend to focus on content retention, while nursing and social work programs emphasize human interactions. Hence, when evaluating an IPE curriculum based on student feedback, it is important to take disciplinary differences into account. Satisfaction surveys can be a useful tool for quickly collecting student feedback and the anonymity can help students to express sentiments that they might not otherwise articulate, but the surveys tend to be administered and completed individually. A group evaluation ran as a focus group in addition or in place of a satisfaction survey can help to get a sense of how students make sense of and respond to disciplinary differences. This type of evaluation can also serve as a pedagogical tool to help students reflect on their own learning as well as the learning of others who might not share their disciplinary priorities.
Enriching how learners understand the concept of “team” Practical Suggestion #4: Include formal discussion about the concepts of interprofessionality as part of the curriculum. During the first PBL group session, the groups came up with the name of their care team and visually represent the team’s values. This arts-based activity had a duo function: to serve as an icebreaker for the teams and to orient the students to the values and concepts of interprofessional collaboration. In their groups, the students generated repeating themes, such as “equal voice”, “listening”, “trust” and “being non-judgmental”, as well as common imageries, such as people holding hands and the patient in the centre. This activity is followed by a class discussion, led by the faculty, about the concepts of inter-professionality, such as differences in professional priorities and approach to care, as well as the hierarchical relationship between the professions in the workplace that could make interprofessional collaboration difficult. Carlisle, Cooper and Watkins (2004) note that “[s]taff often pay lip-service to the principles of interdisciplinary teamwork, and understanding of basic
concepts can be poor� (545). Hence, it is important to supplement such an activity with practical learning in which students must enact interprofessionality, not just describe it. In the HIV-P&C course, this is accomplished through the PBL group sessions and through the clinical and community placements.
Practical Suggestion #5: If possible, include an experiential learning component where the learners can see at first hand what a successful team looks like. This can take the form of a placement but if such resources are lacking, invite a care team as guest speakers. In the case of the latter, do some groundwork with the guest speakers on the kinds of themes and concepts they should highlight for your learners, e.g. emphasize case examples, share communication tools (e.g. clinic forms) where appropriate, and role-play a situation. While these forms of interactive presentations are more difficult to do, preparing this session can be a moment of reflection and learning for the guest speakers as well. Among the clinical and community placements in the HIV-P&C course are an HIV primary care clinic and an HIV specialist clinic for women where several of the faculty members work as part of interprofessional care teams. These clinics have a long history of successful interprofessional collaboration between physicians, specialists, nurses, nurse practitioners, social workers, dieticians, pharmacists and counsellors, and as such serve as models for well-functioning care teams. The students often referred to their placement experiences in these clinics, particularly the communication structure at the primary care clinic that is both effective and time-saving and the patient-friendly and kidfriendly atmosphere of the specialist clinic. In addition to the placements, interprofessional mental health care teams were invited as guest speakers to comment on their clinical experiences. The interaction between these guest speakers during the presentation and the case examples that they shared with the students served as yet another opportunity for the students to be exposed to interprofessional collaboration.
Practical Suggestion #6: Consider integrating patient-centered care into the IPE curriculum. This is particularly salient for socially stigmatized illnesses such as HIV and mental illness and for illnesses where patients are involved in their own care. When integrating the values of patient-centered into an IPE curriculum, it is important to understand the client and/or the affected community (e.g. are there support groups or local community-based organizations that represents the client population?) If so, be sure to collaborate with these groups as partners. In particular, involve educators and leaders in such groups as active teachers in the IPE curriculum. A member of the HIV-P&C course faculty is a staff at Positive Living Society of BC, a local community-based AIDS service organization, and is directly involved in curriculum design and teaching. The course also invites Positive Role Models, individuals who live with HIV and are actively involved in community frontline work to support others living with HIV. These individuals, who are often staff at AIDS service organizations and/or hospital clinics, are experts and teachers in their own right. They are not only experts of their own experience of living with HIV but also an invaluable care team member who can bridge the person living with HIV with health care services, support networks and resources as a peer. The Positive Role Models and community speakers are remunerated with an honorarium. The involvement of clients as teachers is also a feature of AIDS activism in Vancouver. Historically, since the early days of the HIV/AIDS epidemic, there has been a strong alliance between HIV-affected communities and the health care professionals at Vancouver’s St. Paul’s Hospital, which is located in the downtown gay village, the West End neighbourhood (Brown, 1997). Some were from both groups, such as gay nurses and doctors. The HIV-P&C course emerged out of this alliance in 1997 and has maintained the legacy of patient advocacy and community engagement. Course faculty are dedicated to these ideals, as reflected in the involvement of Positive Role Models as teachers, community staff as members of course planning faculty, and community frontline workers as guest speakers. The integration of individuals living with HIV and the HIV/AIDS community(ies) in the course challenges the distinction between “patient” and “teacher”, and also extends the concept of a health care team to include community frontline workers.
Designing a sustainable IPE curriculum Practical Suggestion #7: Find a disciplinary or departmental home for the IPE course that best reflects the learning objectives and the target student groups, i.e. can provide the appropriate credits and fits into the academic calendar of each discipline. The HIV-P&C course is housed in the College of Health Disciplines, whose mandate is to advance interprofessional education, practice and research. The course is equivalent to 6 credits, a relatively high number that is attractive to undergraduate students across the health disciplines. The classroom and placement portion of the course is offered during late-May to June, a time that fits in with the academic calendar for each discipline represented in the course. Scheduling the course around four major disciplines can be difficult and can require creative maneuvering on the part of the course faculty.
Practical Suggestion #8: When inviting community members or patients as teachers or guest speakers, it is important to provide renumeration for their contribution to the course. Search for funding opportunities at the earliest stage of course planning as possible. Where possible and appropriate, establish partnerships with local hospitals, health authorities or health service organizations for greater sustainability. Also, integrate an evaluation process into the curriculum as early as possible, as evaluation reports can be useful in applying for grants. There is considerable behind the scenes work involved in running the HIVP&C course outside of the classroom and the 6-week session. During the rest of the year, course faculty plan the next semester, which includes securing sources of funding to provide honorarium for Positive Role Models. Efforts are underway to provide honorarium for community speakers as well. Each faculty member is responsible for one or two classroom days, which means contacting and securing speakers and organizing panel sessions. The depth and breadth of the content of the HIV-P&C course hinge on the professional
and personal contacts of each faculty member and their ability to invite expert speakers to attend the course. The HIV-P&C course has deep ties to the BC Centre for Excellence in HIV/AIDS (BC-CfE)—one of the founding members of the course, Irene Goldstone, was a staff of BC-CfE. The BC-CfE continues to be involved in the course by way of administrative support and involvement in curriculum design. Starting in 2013, the BC-CfE will also generate quality assessment reports and will conduct research studies that examine the impact of IPE on health sciences students and ultimately on the lives of those living with HIV/AIDS.
Conclusion In this report, we have outlined several Practical Suggestions that serve as lessons learned from the interprofessional course, HIV Prevention and Care and the University of British Columbia. We think that these Practical Suggestions, though by no means exhaustive, address some of the micro- and meso-level factors as well as the learning context that Oandasan and Reeves (2005a; 2005b) have identified, and can help educators in planning and implementing their own unique IPE curriculum. To conclude, it is worth noting that in many ways the HIV-P&C course is a labour of love. Each faculty member is dedicated to the course as a way to train the next generation of health care providers who not only excel in their own disciplinary practices, but also are able to work in effective teams for the ultimate purpose of improving the lives of those living with HIV/AIDS. Planning and executing the course that crosses disciplinary boundaries present multiple challenges every year, one of the greatest being the budget and institutional support. It is no small feat that this course has been offered every year since 1997. There are lessons to be learned from its longevity and sustainability.
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