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Interprofessional education

An information resource from the Board of Medical Education
May 2006

• Introduction
• The call for IPE
• IPE in practice
• Weighing up IPE
• Summary

Introduction
In the current healthcare system, patients are cared for by multidisciplinary teams involving a wide range of healthcare and other professionals. It is therefore vital that effective team-working, collaboration and communication exists across professional boundaries, ensuring high-quality care that benefits patients. Interprofessional education (IPE) between different professions is a means of achieving such team-working.

IPE is defined by the UK Centre for the Advancement of Interprofessional Education (CAIPE) as ‘occasions when two or more professions learn from and about each other to improve collaboration and the quality of care’[Go to note 1]. IPE should not be confused with multiprofessional education, which involves two or more professions learning the same content side by side. IPE focuses on not only the subject matter, but also on the way in which practitioners work together. It may include aspects on developing respect for other professions, trust and communication skills in working with other professions, appreciation of different ways of working, and the strengths of a diverse workforce. It can also be useful in achieving a better understanding of the principles and organisation of the NHS. This report summarises and signposts the current literature and initiatives being carried out in IPE.

The call for IPE
IPE originated in the UK in the late 1960s, with many examples in succeeding years where medicine was included[Go to note 2]. In the NHS Plan (2000)[Go to note 3] the government made a commitment to increasing IPE in medical education. This is part of a wider policy to change current practices and develop new ways of working in order to break down professional and organisational barriers to working and learning together.

One factor found to be potentially divisive for teams of healthcare professionals is slightly differing perceptions of their own professional ethics and lack of understanding about other professional codes. In the past, for example, nurses and doctors saw their ethical obligations to patients in rather different terms, with nurses often seeing themselves as the patient’s advocate. Awareness in their training of the common values underpinning most professional codes may help the different professionals appreciate that they are all working towards the same goals and with the same basic values, even if these are expressed differently [Go to note 4].

The inquiry into children’s heart surgery at the Bristol Royal Infirmary (2001)[Go to note 5] and the Victoria Climbié inquiry (2003)[Go to note 6] both highlight what can go wrong when there is ineffective collaboration between healthcare professionals. These inquiries raise the need to increase and expand IPE as a means of ensuring that health professionals work well together in multidisciplinary teams. The need for effective team working in healthcare is discussed in Meads & Ashcroft et al (2005) The case for collaboration in health and social care[Go to note 7]. The NHS Plan and Bristol Inquiry both stress that IPE must begin at the earliest stages of undergraduate training for all health professionals. Furthermore, in its report Healthcare in a rural setting (2005)[Go to note 8], the BMA recommends that ‘doctors should carry out part of their training in association with other healthcare professionals to create respect and trust between team members, and to allow professionals to work across boundaries of traditionally defined roles. IPE should be part of the complete undergraduate curriculum.’

There is backing by the medical profession for shared learning. In Tomorrow’s doctors (2003)[Go to note 9], which provides guidance on undergraduate medical education, the General Medical Council (GMC) highlights the importance of communication skills in the medical curriculum, and of medical schools exploring opportunities for students to learn and work with other health and social care professionals. The Royal College of Physicians of London in its recent report on professionalism, Doctors in society (2005)[Go to note 10], recommends that the complementary skills of leadership and team working need to be incorporated into doctors’ training to ensure high standards of professionalism.

Box 1: King’s College London – The South East London IPE Programme www.kcl.ac.uk/ipe (Accessed May 2006) A programme involving King’s College London (KCL), University of Greenwich, London South Bank University and the 14 NHS trusts within the South East London Workforce Development Confederation (SELWDC). The IPE curriculum for pre-qualification students in the health and social care professions takes place in two phases. First year students participate in the ‘Common Learning Foundation Programme’, which is a classroom-based course on communication skills and healthcare ethics. Students in their second year or in later years participate in ‘Interprofessional Learning in Practice (ILP)’, which is placement experience in the various NHS trusts and social care organisations within south east London. Within this placement, students are brought together to process-map a real patient journey over three facilitated sessions, and learning takes place entirely in the practice setting with facilitators drawn from the universities and trusts. There are 13 professions involved in the IPE programme: dental hygiene, dentistry, diagnostic radiography, dietetics, medicine, midwifery, nursing, occupational therapy, pharmacy, physiotherapy, social work, speech and language therapy and therapeutic radiography. To prepare staff to facilitate health/social care students undertaking the ILP course while allocated to a practice placement, a workshop entitled ‘Facilitator Training for Interprofessional Learning in Practice’ is offered. Reports are available concerning the development, implementation and evaluation of the ILP course at www.kcl.ac.uk/ipe/outputs/reports/index.html .

IPE in practice
In its publication Working together, learning together: a framework for lifelong learning for the NHS (2001)[Go to note 11], the Department of Health (DH) outlined plans to develop more pre-registration IPE programmes, and identified IPE as a key priority for strategic health authorities (SHAs) and higher education institutions. The DH aimed to ensure that:

• all healthcare professionals should expect their education and training to include common learning with other professions (the DH has used ‘common learning’ as a synonym for IPE)
• common learning runs from undergraduate and pre-registration programmes, through to continuing professional education
• common learning takes place in practice placements as well as the classroom
• common learning centres on the needs of patients.

The current emphasis for the implementation of IPE is at the undergraduate level[Go to note 12], and various pilot schemes have been undertaken between medical, health sciences and other schools. In 2001, the DH together with Workforce Development Confederations invested nearly £3 million in four undergraduate sites leading the way in IPE. Lessons learned from these projects are being shared and used to inform future practice. Details of these pilot schemes are given in boxes 1-4, and information on further case studies can be found in appendix A.

Box 2: University of Southampton, Hampshire and Isle of Wight NHS Workforce Development Confederation and University of Portsmouth – The New Generation Project www.commonlearning.net (Accessed May 2006) The curriculum for medicine, nursing, health sciences and social work contains two courses for IPE. ‘Learning in Common’ is taught and assessed within the profession specific programmes, and aims to prepare students for IPE by teaching the underlying knowledge and skills common to all the programmes. ‘Interprofessional Learning (IPL)’ takes place in multi-professional groups of students, and aims to encourage them to learn from and about each other, with subsequent assessment on their achievement of interprofessional learning outcomes. There are 10 professions involved in the IPE programme: audiology, medicine, midwifery, nursing, occupational therapy, pharmacy, physiotherapy, podiatry, radiography and social work. Newsletters containing updated information on this project are available from www.commonlearning.net/cl_newsletters.asp Interprofessional Facilitator Workshops and E-facilitation courses are run to develop the skills of both university and practice staff to support the facilitation of the IPL units of the curriculum. The New Generation Project Longitudinal Study (NGPLS) is being carried out in parallel to IPL to investigate the impact on pre-registration health and social care students. The NGPLS has a cohort of over 2,300 participants and data are collected on the beliefs and attitudes of two groups of students being followed through the progress of their training. Data have already been collected on students at registration, and are now being collected as the students are about to leave university. Further data will subsequently be collected when these students are a year into practice. Yearly newsletters on the progress of the NGPLS are available at www.hciu.soton.ac.uk/research/IPL_research/ipl_research_annual%20ngpls%20newsletters.htm .

Undergraduate IPE sites have been developed nationwide, and the ‘Creating an Interprofessional Workforce’ programme innovations database, currently under construction, will provide a resource for information on innovative work in IPE (Go to appendix A).

Medical education does not stop at graduation, but continues throughout the course of a professional’s training and career through continuing professional development (CPD). IPE can contribute much to CPD, and is already being incorporated into training practices. The postgraduate educational framework, implemented in January 2001, is approached on an interprofessional basis and in September 2002 the postgraduate certificate in interprofessional mentorship and teaching was introduced[Go to note 11]. In primary care, a project developing IPE has been set up in the Beechtree Health Centre. A report on this project has been published in the Journal of Interprofessional Care[Go to note 13].

The establishment of foundation programmes for the first two years of postgraduate training has been carried out under the auspices of Modernising Medical Careers. One of the key aims of this initiative is to develop doctors who are skilled at communicating and working in a team[Go to note 14]. Throughout the curriculum for these two years, skills in communication and working in teams are emphasised.

Box 3: Sheffield University – The Combined Universities Interprofessional Learning Unit (CUILU) www.shef.ac.uk (Accessed May 2006) This was a joint initiative between The University of Sheffield and Sheffield Hallam University with additional funding from the South Yorkshire Workforce Development Confederation. The project was funded for a two-year period, and completed in May 2005. Professions involved in the IPE programme included: clinical psychology, dentistry, radiography, dietetics, occupational therapy, paramedic, pharmacy, physiotherapy, podiatry, medicine, midwifery, nursing, social work and speech and language therapy. In light of this project, good practice guidelines for patient and service user participation in teaching and assessing were published.

Weighing up IPE
Emerging evidence suggests that IPE can, in favourable circumstances and in different ways, contribute to improving collaboration in practice[Go to note 15]. The evidence base at present, however, is only comprised from a small number of evaluations and further research therefore needs to be carried out. This could take the form of randomised controlled trials (RCT), of which several have already been published, but there is a repertoire of methodologies employed in educational evaluation. Indeed, it could be questioned as to how a research method such as RCT could be designed to screen out the numerous variables. A critical review of IPE in the UK is given in the 2002 review Interprofessional education: today, yesterday and tomorrow[Go to note 2]. Theoretical perspectives of IPE are discussed in the 2005 publications Effective interprofessional education: argument, assumption and evidence[Go to note 15] and The theory-practice relationship in interprofessional education[Go to note 16].

A recent consultation document from the GMC in 2005, Strategic options for undergraduate medical education, which looks at the future direction of medical education, discusses the use of IPE and asks questions such as ‘What types of interprofessional or collaborative learning are most effective?’ and ‘Should Tomorrow’s doctors place more emphasis on the need for interprofessional learning and practice?’ The outcomes of this consultation will be published in spring 2006. These questions are also addressed in the systematic review by H Barr in the 2005 publication, Effective interprofessional education: argument, assumption and evidence[Go to note 15]. The companion volume is the 2005 publication by D Freeth, Effective interprofessional education: development, delivery and evaluation[Go to note 17].

There are several important considerations for the implementation of IPE. There may be logistical barriers, as a high level of commitment from the organisers and facilitators will be required in terms of their time and training, which requires appropriate resource allocation. Challenges will include coordination of the timetables of different professions and availability of the necessary resources. In addition, the length of training differs between professions, and entry level requirements vary greatly. Furthermore, accrediting bodies may have different requirements, which can be difficult to integrate. Geographical problems may also be encountered, and cooperation could be necessary between different universities, not merely departments, as not all universities teach all health professions.

Research into the inclusion of an appropriate evaluation method will be needed. The 2005 publication Evaluating interprofessional education: a self-help guide[Go to note 18] aims to help people wishing to evaluate interprofessional education to plan and conduct studies that are achievable within a given context and provide robust results. It also provides an outline of key aspects of the evaluation process and directs readers to supplementary resources.

The stage of the curriculum at which IPE is introduced must be considered. There is debate about whether IPE should be introduced early in training, when potentially detrimental stereotypes are less likely to have been formed, or further into training when students have a clearer understanding of their own professional role. Currently, arguments are being made for a continuum of interwoven interprofessional, multiprofessional and uniprofessional learning from the outset. Attention also needs to be given to the format of the IPE programme. For example, it may take the form of interactive learning methods that facilitate exchange and mutual learning between the participant professions[Go to note 15]. Curricula will vary within professions, resulting in differing knowledge and experience bases, so care must be taken to make the IPE programme accessible and relevant to all.

There are possible cultural barriers to the success of IPE. In the past, there has been resistance to IPE from both clinical middle managers and staff[Go to note 19]. There may be a strong professional identity, creating barriers that have long been impermeable. It is important to acknowledge the risk of entrenching negative attitudes rather than fostering good ones. For IPE to be successful, prejudices must be broken down, and there must be willingness among all involved to engage in the process. Of course, one of the aims of IPE is to remove such prejudices, thus allowing effective collaboration. Consideration, however, must be given to the benefit of IPE as an educational aim/activity to healthcare professionals, as well as to patients.

Box 4: Newcastle University – The Common Learning Programme http://commonlearning.ncl.ac.uk/clp/index_html (Accessed May 2006) The universities of Northumbria, Teesside and Newcastle in partnership with the Northumberland, Tyne and Wear SHA and the County Durham and Tees Valley SHA are involved in this programme. The curriculum involves self-directed and enquiry-based learning, and is focused on the management of chronic disease. Students from different disciplines work together in small groups to care for one or more patients for four to six weeks. Professions involved in the IPE programme include: medicine, nursing, occupational therapy, physiotherapy, social work and speech and language therapy. Each placement is co-ordinated by a common learning facilitator, for whom two training resources are offered. The ‘mentor training package’ is a free standing workshop to help train facilitators in the skills essential for interprofessional education, and a framework document on multi-dimensional placements sets out three models of interprofessional education in the workplace and was designed as a resource to help potential facilitators think about how interprofessional education may be implemented in their area. The usual modes of summative assessment for the student’s own course, the placement that they are on and for interprofessional skills are used. In addition, a reflective log is also provided through which students are expected to record and demonstrate their progress and achievements, and forms part of the evaluation of the scheme.

Summary
IPE has the potential to improve the effectiveness of team working between healthcare professionals and thus the quality of patient care. It does, however, require a high degree of commitment from the facilitators and thus adequate resources, necessitating careful planning and organisation. Barriers that could be encountered, both in terms of practicalities and student attitudes, need careful consideration prior to the implementation of an IPE programme, as an ineffective programme could potentially further ingrain negative stereotypes. The pilot schemes commissioned by the DH, along with further case studies outlined in appendix A , are a valuable resource and a base upon which to build.

This report is summarised in a leaflet which is available from the Science and Education Department: info.science@bma.org.uk or can be downloaded above.