Aston, Sheree J. OD, PhD; Rheault, Wendy PT, PhD; Arenson, Christine MD; Tappert, Susan K. PT, DPT; Stoecker, Judith PT, PhD; Orzoff, Jordan PhD; Galitski, Hayes; Mackintosh, Susan DO
Interprofessional education (IPE) has been championed as a critical strategy for improving health care outcomes. The World Health Organization (WHO) first recognized its importance in 1978,1 and landmark reports from the Institute of Medicine (IOM)—To Err Is Human: Building a Safer Health System,2 Crossing the Quality Chasm: A New Health System for the 21st Century,3 and Health Professions Education: A Bridge to Quality4 raised the issue to prominence in America. The literature, such as reported by Provonost and Freishlag5 as well as Zwarenstein and colleagues,6 documents the benefits of coordinated interprofessional team care to improve outcomes in acute care settings and for delivery of preventive services. This evidence has increased awareness that IPE will be an important part of creating a safer and more effective health care system. Despite emerging evidence, however, IPE has been adopted only sporadically across health professions training programs.
Recognizing the potential of IPE, some academic health care centers are implementing IPE as part of their curricula. Although IPE is perceived as an essential component of training, participating institutions are experiencing similar barriers with its development and implementation.
To guide other institutions considering implementing IPE, our intent is to describe the developmental process and content of IPE programs at Western University of Health Sciences (WesternU), Thomas Jefferson University (TJU), and Rosalind Franklin University of Medicine and Science (RFUMS) by comparing and contrasting issues such as planning, competencies, curricular models, and assessment strategies.
Participating Institutions and Their IPE Programs
WesternU is a graduate-level health sciences university located in Pomona, California. The graduating professions are osteopathic medicine, physician assistant, physical therapy, pharmacy, graduate nursing, veterinary medicine, podiatric medicine, optometry, and dental medicine.
TJU is a private health sciences university and academic health center located in Philadelphia, Pennsylvania. TJU includes Jefferson Medical College (JMC), the College of Graduate Studies, and the Jefferson Schools of Nursing, Health Professions, Pharmacy, and Population Health.
RFUMS is a small, private health sciences university located outside Chicago and is composed of five schools: the Chicago Medical School, the William M. Scholl College of Podiatric Medicine, the College of Health Professions, the College of Pharmacy, and the School of Graduate and Post-Doctoral Studies. The College of Health Sciences houses graduate-level programs in physical therapy, physician assistant studies, nurse anesthesia, and clinical psychology, among others.
As pioneering programs in IPE, all three institutions were somewhat disadvantaged by the lack of established competencies or accrediting bodies to ensure successful program implementation. Whereas the schools independently implemented programs tailored to their specific institutions, all three gravitated toward similar goals and outcomes based on the early literature and definitions of IPE.
The current definition of IPE is “occasions when [students] from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.”7 This definition implies a form of discovery where different professions must actively learn about each other to effectively work together to improve the quality of patient care.
Molding an academic plan from this philosophy was a complicated process with which each of the three institutions struggled. Each program is guided by specific outcomes and competencies that their graduates must demonstrate before being awarded degrees. In contrast, some existing IPE programs do not have specific standards providing a solid foundation for a truly interprofessional educational experience. To compound the problem, only a few professions, such as pharmacy, have IPE listed as a required competency.8 Consequently, pioneering programs were left in the dark as they independently but dynamically developed IPE curricula.
Fortunately, some guiding principles did exist. A robust body of literature, summarized by the WHO and IOM reports, highlighted communication, teamwork, and patient-centered care. More recently, a report from the Canadian Interprofessional Health Collaborative, A National Competency Framework, described six competency domains for IPE: role clarification, team functioning, patient/client/family/community-centered care, collaborative leadership, interprofessional communication, and interprofessional conflict resolution.9 Within the United States, the Interprofessional Education Collaborative (made up of representatives from the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, Association of Schools of Public Health, American Association of Colleges of Pharmacy, American Dental Education Association, and Association of American Medical Colleges) released Core Competencies for Interprofessional Collaborative Practice. This report identified four domains very similar to the Canadian Interprofessional Health Collaborative: values/ethics for interprofessional practice; roles/responsibilities for collaborative practice; interprofessional communication; and interprofessional teamwork and team-based care.10 Independently, each of the three institutions naturally gravitated toward this same set of nontechnical competencies during development and implementation of their respective IPE programs.
Planning the Programs
Another successful commonality among the programs was their in-depth, comprehensive planning process. Initially and critically, all three had support from their respective senior administrations. Similarly, all three programs tackled important issues such as curricular mapping; faculty participation; logistics, including locations and resources; and expectations of student workload.
For WesternU, the planning process started in July 2007. Faculty representatives from all participating colleges participated on eight working committees and collaboratively developed a pilot study that determined the initial course design. With help from the IPE Implementation Committee and support from the college deans, the provost’s office effectually organized a common spring break period across participating professions and a dedicated IPE day and time, thereby making synchronized IPE courses a reality. Construction of a new Health Education Center, completed in December 2009, provided the additional small-group meeting spaces necessary to accommodate all first-year students in this university-wide IPE initiative. As planning has continued on an annual basis, the original curriculum has evolved to the status described below.11
A tradition of IPE has existed for many years at TJU, with examples in geriatric education, primary care, intensive care, cancer care, and others. In 2006, TJU adopted a new strategic plan that called for educating future health professionals and scientists to be the leaders of integrated, interprofessional clinical and research teams. Inclusion of IPE in the university strategic plan resulted in two major new resources that are having dramatic impacts on education at TJU. A dedicated IPE space houses the state-of-the-art University Clinical Skills and Simulation Center (UCSSC), in addition to large, medium, and small instructional spaces bringing students together from all of their clinical training programs. Additionally, the Jefferson Interprofessional Education Center was created to facilitate and nurture IPE across campus.
For RFUMS, the concept of the interprofessional curriculum began with the university’s strategic plan, which emphasized the importance of interprofessional collaboration. Essential to the success of the interprofessional strategy was the full support of the president and deans. The president clearly articulated IPE as an important strategic initiative, appointing a dean as the administrator of the strategy. A task force of approximately 20 individuals representing the participating schools was established. The development process took approximately one year. During that time, the curriculum was presented for approval at all of the curriculum committees representing the eight professions.
The Three IPE Curricula
Although all three programs have gravitated toward a common set of competencies, each differs in its approach to curriculum content and delivery. Yet the three programs have each adopted a phased curricular approach that begins with student awareness and progresses to clinical training mastery.
WesternU developed and continues to refine a three-phase program. Phase I is a set of two, case-based courses where students are exposed to realistic medical cases. Instead of focusing on clinical perspectives, the students discuss nontechnical competencies critical for all professions such as communication, team formation, professional roles and responsibilities, a culture of safety, quality of life, One Health, and the ethical and legal environment of health care. During the 2011–2012 academic year, the TeamSTEPPS curriculum12 (an evidence-based teamwork system to improve communication and teamwork skills among health care professionals developed collaboratively by the Department of Defense and the Agency for Healthcare Research and Quality) was integrated into the course, and students are expected to participate in case discussions and submit a group assignment such as an interprofessional care plan. The two courses are one semester each, counted as one seminar credit per semester, and required for students in all entry-level health professional programs. For case discussions, the 846 first-year students were divided into 94 groups of 9 interprofessional students with a faculty facilitator. Using a faculty trainer from its College of Veterinary Medicine experienced in small-group, problem-based learning, WesternU has developed approximately 300 faculty and qualified external participants to facilitate its interprofessionally mixed Phase I small groups.
Phase II, designed to provide experiential teamwork, first launched in August 2010 for 650 second-year osteopathic medical, dental, pharmacy, optometry, podiatry, and veterinary medical students. Currently, the Phase II courses are required one-credit courses per semester. The majority of the course was designed to occur online with a face-to-face capstone each semester and was based on the TeamSTEPPS program.
The online portion of these courses includes PowerPoint presentations with vignettes, readings, and self-reflective assignments. The update course focuses on the TeamSTEPPS curriculum; however, the teams are unified and consistent throughout the year to promote cohesiveness. The teams work asynchronously on blogs that focus on situations such as patient safety scenarios and ethical dilemmas to communicate and apply TeamSTEPPS skills. The students participate in two face-to-face tabletops. The first-semester course tabletop focuses on patient safety, and the second semester emphasizes morals and ethics. Future capstone activities will focus on naturally forming teams that would solve community and patient safety scenarios such as food safety, reduction in medication errors, and reduction in falls.
Phase III, the clinical care portion of the program, began in the 2011–2012 academic year as a pilot program for students in at least four health professions programs. Activities include working with other health professions students and clinical faculty to provide patient-centric and collaborative care of patents in the new Western Diabetes Institute, an integrated practice unit dedicated to improving the value of diabetes care delivery over the full cycle. The team often uses the specially designed interprofessional diagnostic suites for diagnostic services as well as development of collaborative treatment. Additionally, off-campus IPE rotations are in the planning stages. Figure 1 presents a model of the WesternU IPE program.
During the 2010–2011 academic year, a subcontracted project with the Health Resources and Services Administration–funded California Geriatric Education Center resulted in a pilot IPE team objective structured clinical examination (TOSCE). The focus of this activity was forming a health care team in an asynchronous setting. The primary goal was to provide patient-centered care while successfully navigating the patient through the ambulatory care system. Forty-eight students from four professions participated in the study. The scenario involved a geriatric patient recently discharged from the hospital status post cerebral vascular accident. Instead of simply focusing on clinical management, the students were expected to demonstrate behaviors such as team formation, closing the loop with other team members, recognizing missing information and other safety issues, and situation awareness. The case and concomitantly developed assessment battery were based on the TeamSTEPPS curriculum12 but also included elements of interprofessional competencies9 and geriatric competencies.13 The activity was more widely implemented as a Phase III activity in 2011–2012. In fall 2011, WesternU opened an osteopathic medical program in Lebanon, Oregon. Because IPE course work is required at WesternU, an innovative interinstitutional IPE program was created with Oregon State University and Linn-Benton Community College.
In 2006, JMC was the recipient of an Association of American Medical Colleges/Josiah Macy, Jr. Foundation–Advancing Chronic Illness Care Education grant. Recognizing that medical students could not learn effective chronic illness care outside of an interprofessional team, faculty from nursing, occupational therapy, physical therapy, and pharmacy were included in planning. This team determined that entering students must achieve an appreciation for and understanding of the roles of other health professionals and a deep understanding of patient-centered care from the onset of training. The team borrowed from the geriatric education literature and senior mentor programs as the basis for the Health Mentors Program (HMP).14 This is now a required two-year longitudinal IPE experience for all medical, traditional bachelor of science in nursing, occupational therapy, physical therapy, pharmacy, and couple and family therapy students, of which there were 1,312 in 2011–2012.15
The HMP brings teams of four to five students from at least three professions together with a person living with one or more chronic conditions or disabilities (the health mentor) to complete a series of four required modules over two years. Modules are comprehensive health history, lifelong wellness planning, patient safety (including home safety and a home visit), and working with patients to support behavior change and self-management strategies. Each module consists of online, didactic self-study materials, a visit with specific activities and objectives with the health mentor, a team project, individual reflection, self-assessment of team function, and facilitated small-group reflection.
Although the HMP has provided an excellent platform to deliver fundamental didactic and experiential IPE content and competencies, teamwork and interprofessional skills must extend into clinical simulation and care environments in order to reinforce and build on early lessons. The physical facilities and interprofessional teamwork modeled by the TJU UCSSC faculty provide a robust platform for delivering clinical skills IPE training. Unfortunately, logistical barriers, crowded disciplinary accreditation requirements, and a lack of evidence-based tools for assessing team competency in the clinical skills environment have all slowed widespread adoption of team clinical skills training at Jefferson.
Nevertheless, a growing number of TJU students participate in clinical skills IPE. A simulated family discharge planning meeting, including medical, nursing, physical and occupational therapy, and pharmacy students meeting with a standardized patient and standardized adult child, is offered on an elective basis. Medical and nursing students are working together with UCSSC faculty to create a team “code blue” simulation as an extracurricular activity. Graduate medical educators are working closely with nursing and other professionals at TJU Hospital to deliver high-fidelity simulation training “in situ” to practice critical team response to patient emergencies and to proactively engage in quality improvement processes.
The final phase of institutional IPE at TJU is to provide required clinical IPE team experiences to every student before graduation. Currently, only about 10% participate in formal, clinical IPE, including an interprofessional falls risk assessment or geriatric assessment program, interprofessional team rounds on inpatient services, outpatient group visits, rehabilitation or palliative care service rotations, or similar activities. Each of these is highly valued by learners and improves understanding of the value of interprofessional collaboration.
Over the next two years, TJU will develop competency-driven, mandatory clinical IPE placements for all clinical students that will include all postgraduate trainees. These experiences will provide a “capstone” for team-based, patient-centered care competencies and will be evaluated using new IPE competency-based tools that measure specific behaviors. This will require significant training of clinical preceptors, including graduate medical trainees.
All first-year students entering RFUMS take two courses, Interprofessional Healthcare Teams and Cultural Issues in Healthcare.16 Four hundred eighty students from eight professions (medicine, podiatric medicine, nurse anesthesia, physician assistant studies, physical therapy, pathologists’ assistant studies, clinical psychology, and medical radiation physics) are divided into interprofessional teams of 16 students with one faculty mentor. The mentor of the group is a designated faculty member from any of the eight programs.
The university embraces an educational model based on eight central tenets of education: interprofessional learning, student-centered learning, student ownership in the learning process, faculty as facilitator or mentor, integration of adaptive curriculum, competency-based instruction, assessment-validated change, and evidence-based best educational practice. These tenets are heavily embedded in the mandatory IPE courses.
A student-centered learning approach focuses on what and how a student learns rather than what an instructor teaches. Active learning is a key part of both courses, and the role of the teacher is also redefined so that instructors use facilitator and mentoring roles to assist students in acquiring knowledge, attitudes, and skills.
An adaptive curriculum modifies and personalizes learning. Educational methodology includes small-group instruction, larger-group instruction, debate, learning in the community, and online independent learning. The courses are organized around competencies and assessment validated. Finally, the curriculum and delivery are guided by best practice whenever available.
The first course is based on the IOM’s five core competencies.4 In addition, students are encouraged to work together in interprofessional teams while employing the concepts of social responsibility, current health issues, and advocacy. Case studies are used throughout, and students are encouraged to communicate using an online discussion. An additional phase of the course was launched requiring students to implement an interprofessional, community-based prevention education service learning project. The purpose of the projects was to promote prevention education in physical fitness, prevention screening, nutrition, and healthy choices. Educational materials for the projects were funded by a grant from the Association for Prevention Teaching and Research.
Students remain in their assigned groups for the second course in the series, where similar methods are employed: small- and large-group discussion, case studies, and group projects. The topics include the scope and definition of culture, personal and professional stereotypes and prejudices, and the impact of culture on health care. One assignment involves the group developing educational materials for a certain population using their knowledge of cultural issues and health literacy.
Central to the success of the program was the training of the roughly 40 mentors from the eight professions. The curricular resources developed by the methods committee include objectives, learning experiences, discussion questions, handouts, and other materials. With a small grant from the Physician Assistant Foundation, outside experts were recruited to help faculty with small-group facilitation because many mentors had not taught in a small-group environment.
The next stage involved development of interprofessional clinical experiences, and three pilot studies have been completed and evaluated. In the future, all students will be required to complete an IPE rotation or experience. In addition, a five-year review of the course sequence is currently taking place with the anticipation of the evolution of the two courses into a “first-year experience” involving didactic, service, and clinical experiences.
Each of the three programs approached assessment differently, yet all are approaching assessment from the continuum of attitudes escalating through knowledge and observable behaviors. Our intent is not to focus on the data collected and analyzed from the three institutions but, instead, to describe the assessment strategies employed by each of the three academic institutions. Although a detailed discussion of results is important, it is beyond the scope of this article but may become the basis for future articles with more rigorous analyses. Although all three universities are using published attitudinal surveys as part of their assessment plans, WesternU and TJU independently developed strategies to assess the validity and utility of the published scales.
WesternU’s assessment plan (see Table 1) generates an overall picture of the program’s effectiveness and impact by collecting data at multiple times from multiple sources. In the first year of the program, seven assessment tools were employed, including student and faculty baseline and exit surveys, evaluations of facilitator training, faculty assessment of student competencies, and focus groups. The data showed that students felt better prepared to contribute to collaborative care of patients. Some differences emerged across professions, such as collaboration with other professions that respondents anticipated encountering during their careers. For example, pharmacy students expected the most collaboration with other health professions, whereas veterinary students expected the least.
As the course moved out of the pilot phase, the assessment strategy shifted emphasis away from formative measures (used for program improvement) to summative measures (for assessing outcomes and impact). Focus groups and surveys were reduced in number. Competency-based knowledge quizzes assessed students’ mastery of content. The baseline and exit surveys were revised to evaluate the validity of published interprofessional instruments. The surveys were randomly distributed so that half the students received a version including the Interprofessional Attitudes Questionnaire (IAQ),17 whereas the other half received the Readiness for Interprofessional Learning Scale (RIPLS).18 Although students and faculty scored toward the upper end of the interprofessionalism scales on both instruments, IAQ was found to have a strong negative skew and limited variability, implying a social desirability bias. The RIPLS appeared to have a multifactorial structure, suggesting that more nuanced interpretation might be possible with this instrument.
For the Phase II courses, students were given quizzes after each teamwork training module. A group teamwork activity took place at the end of each course, generating a demonstration “work product” such as an action plan or communications map. These capstone products were then assessed by a team of faculty raters using an evaluation rubric. Course evaluations addressing both attitudes toward the course and teamwork outcomes were also administered.
For the TOSCE project, a set of new instruments was created, including a behavioral intentions survey and a multirater evaluation system using behavioral observation scales. Digital video recordings of standardized patient encounters were also used to measure the frequencies of anticipated interprofessional behaviors by students. Data collection and analysis for these activities are currently under way.
Phase III assessment began with the launch of a baseline interprofessional clinical skills survey for students in clinical rotations and their supervisors. A more robust Phase III assessment strategy will be developed concomitant with the Phase III content.
TJU has adopted a longitudinal, mixed-methods evaluation strategy for assessing new IPE activities. Baseline data on attitudes toward IPE and chronic illness care were collected at the beginning of IPE education transformation efforts and are tracked annually. All students are surveyed at matriculation, periodically during their course work, and at graduation. The RIPLS18 has been found to have very high baseline performance and little sensitivity to change. The Interdisciplinary Education Perception Scale (IEPS),19 also widely used in the IPE literature, seems to have slightly more utility. The Jefferson Attitudes toward Chronic Illness Care tool has been used as one measure of impact on patient-centered care. Focus groups and student course evaluations have provided important feedback on curriculum design. Qualitative assessment of reflection papers and formal rubrics for assessing student proficiency at designing an interprofessional team for a paper case scenario have proved most effective at measuring impact on key IPE goals and objectives for the HMP. Beginning in 2011, TJU partnered with faculty from the University of Delaware to institute a longitudinal, mixed-method assessment of interprofessional acculturation, using the Student Stereotypes Rating Questionnaire20 and qualitative interviews with a cohort of students from each discipline to assess impact of IPE and the HMP on role development and team acculturation over time.21
A team-based checklist, completed by peers, faculty, and standardized patients, has been extremely effective in the clinical skills setting, and video review and formal debriefings are routinely used for simulation exercises. Baseline assessment of graduates 5 to 10 years after graduation is currently being collected through the Jefferson Longitudinal Survey and will be used to assess change as students exposed to formal IPE curriculum enter the workforce over the next several years.
RFUMS conducts assessment using four elements: a course evaluation (including evaluation of the mentor), an assessment of students’ knowledge and attitudes (using the RIPLS and IEPS before and after the educational experience), a qualitative analysis of the student reflections, and numerous student and faculty focus groups. In general, the educational experience and participating mentors have been highly rated. The majority of students agreed or strongly agreed that mentors respectfully facilitated group work, kept them on task, managed conflict well, and encouraged participation, thereby reinforcing to program planners the importance of mentor training.
Asking participants to reflect on a course provides particular insight. Two trends were evident in the qualitative evaluation. First, students valued team interactions with peers from other institutional professions. This was also validated by feedback from the mentors. Second, students expressed an understanding of the roles and responsibilities and education of other health care professionals.
Suggestions for Academic Institutions Considering IPE Program Implementation
A number of universities are taking a leadership role in crafting innovative IPE programs. Although there has been some progress in this area, there is much yet to be accomplished. On the basis of our experiences, we suggest the following projects: developing, testing, and validating instruments to assess interprofessional communication and behaviors of students evaluating standardized patients; implementing and studying the impact on patient care of student-run, interprofessional, ambulatory health clinics; developing interprofessional protocols designed to improve diabetes care based on teamwork methodology; developing and testing models of communication protocols for the medical home that are grounded in the principles of teamwork; and designing and conducting rigorous, multisite research projects on enhancing outcomes in patients receiving care by clinicians trained in interprofessional practice.
Although the direction of IPE is still an evolving process, it is increasingly recognized as a crucial component of the future of health care professions training. The academic institutions we have discussed offer advice and recommendations for programs considering the implementation of an IPE curriculum.
Lessons from the participating institutions suggest that the following are essential for a successful IPE program: dedicated support and budgetary resources from the senior administration and college deans, maintenance of balanced faculty workload, development of a formal IPE department with faculty and support staff, creation of an academic calendar that allows for IPE, and planning space for small-group and interprofessional care. Institutions considering IPE implementation must rigorously plan because the logistics are complex. Teams of faculty from each program or college are critical to the development and implementation of all courses and activities. Significantly, institutions should require the participation of their health care programs. Most important, all institutions must craft rigorous assessment plans to provide the necessary evidence that IPE works.
Although variable from institution to institution, IPE is undoubtedly an educational paradigm with a bright future. Ultimately, we believe that students trained in strong, carefully planned, team-based comprehensive IPE programs can shatter the current siloed system of health care in this country.
Funding/Support: The content of this article was not directly supported by grant funding; however, some projects that were grant funded are briefly described within the body of the article.
Other disclosures: This article was made possible by Cooperative Agreement No. 6UB4HP19202 from the Health Resources and Services Administration (HRSA).
A portion of this article was made possible by funding received from the Josiah Macy, Jr. Foundation. Funding for the Association for Prevention Teaching and Research (APTR) Institute for Interprofessional Prevention Education and related projects was made possible in part through cooperative agreements between APTR and the Centers for Disease Control and Prevention (no. 5U50CD300860) and the Office of Disease Prevention and Health Promotion (no. APTHP020003), U.S. Department of Health and Human Services. Additional funding was received from the American Academy of Physician Assistants (AAPA).
Ethical approval: Not applicable.
Disclaimer: The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of HRSA, the Josiah Macy, Jr. Foundation, CDC, ODPHP, DHHS, APTR, or AAPA.