ISSUE 2 IPE: At Last!
Introduction by Mary Lee Pollard, Dean, Excelsior College School of Nursing
Responding to the 2011 Mega-Disaster in Japan: New Frontiers in Interprofessional Collaboration by Steven M. Becker, PhD
Shedding Our Protective Professional Skin: A New Common Language for IPE by Rebecca Deal Poston, PhD, RN, CPNP
Build It and They Will Come: A Closer Look at Expanding Interprofessional Education at East Tennessee State University by Michael A. Crouch, PharmD, FASHP, BCPS and Wilsie Bishop, DPA
Virtual Technology in IPE at East Carolina University by Dr. Ann King, DNP, FNP-BC, APRN (interview)
Acknowledgements, Commenting Policies, and other Fine Print
Welcome to the second issue of Nursing in the 21st Century, a mobile journal designed to stimulate conversation around the rapidly changing roles of nurses in America. In this issue we continue to look at the progress of the nursing profession in implementing the recommendations from the landmark publication, The Future of Nursing: Leading Change Advancing Health (Institute of Medicine and Robert Wood Johnson Foundation, 2010) specifically, the recommendation to promote interprofessional education and practice to better enable nurses and other health professionals to practice as members of well-functioning teams.
The concept of interprofessional education and practice have been discussed in the health care literature for well over two decades, with case studies from nursing, medicine, pharmacy, social work and other professions touting the benefits of collaboration and teamwork in improving patient outcomes. Unfortunately, barriers to implementation of interprofessional collaboration still exist in education and practice settings. As recently as December 2013, a panel of health care leaders convened to discuss the implementation of recommendations included in the IOM report, confirmed “the current incentive-based payment systems increase tensions between disciplines rather than foster integration,” and the current professional education system does not encourage collaboration but instead is invested in the status quo of discipline-based education (IOM 2013 Richard and Hinda Rosenthal Lecture). At this same conference, Risa Lavizzo-Mourey, RWJF President and CEO has acknowledged, “While we’ve come far, we are far from the end. Nurses belong at the center of transformative change in health and health care. The way forward will be challenging, but I know we will succeed.” (IOM 2013 Richard and Hinda Rosenthal Lecture)
Before nurses assume a central role in transformative change related to collaboration, the profession must delineate the knowledge and skills unique to the discipline and clearly articulate what nursing brings to the patient care arena. As the profession with the most direct patient contact, nurses need to take the lead in developing and supporting universal interprofessional practice standards appropriate for all health professions and supportive of those unique attributes each discipline brings to the patient care setting. Until this occurs, the IOM recommendation to promote interprofessional education and practice as a means of improving patient care will not be accomplished.
The articles selected for inclusion in this issue describe implementation of interprofessional education programs in university settings, recommendations for the successful integration of interprofessional collaboration in the practice setting, a case study on the effectiveness of an interdisciplinary team approach in responding to a natural disaster, and a discussion on the current barriers to interprofessional collaboration in a practice setting. The article by Michael Crouch and Wilsie Bishop, "Build It and They Will Come," provides a first-hand account of their experience at East Tennessee University in developing a model for interprofessional education in the 1990s. The authors describe their process for implementing an interprofessional education program with two cohorts of students and their plans for continued growth of the program.
Dr. Rebecca Deal Poston challenges health care providers to move from the comfort of doing things as we have always done them to recognizing the need for a new style of communicating among health care providers, patients, and families. She suggests members of the health care team need to develop a common language that will be “responsive, flexible, engaging, inclusive, cognizant of the range of skills within a network, and geared toward team-based problem solving and outcomes.” According to Poston, one way to achieve this goal is by integrating the core competencies established by the Interprofessional Education Collaborative (IPEC) into the curricula of all health professions and to provide additional education on collaboration for currently practicing professionals who have not had the benefit of interprofessional education.
In "Responding to the 2011 Triple Disaster in Japan: New Frontiers in Interprofessional Collaboration," Dr. Steve Becker, a nationally recognized expert in environmental health and disaster management, describes the interdisciplinary approach to responding to the 2011 earthquake, tsunami, and Fukushima nuclear reactor failure in Japan in March 2011. This article stresses the need for flexibility and adaptability on the part of all disciplines, and that when working in an environment defined by change, it is necessary that all involved be open to new ideas.
Maureen Boshier's interview with Ann King suggests simulation is an effective means for developing a virtual clinical setting appropriate for introducing the concepts of interprofessional collaboration in education of health care professionals.
We hope you enjoy these articles and they motivate you to comment on the content and your impression on the role the nursing profession can assume in fully implementing interprofessional education and practice to better enable nurses and other health professionals to practice as members of well-functioning teams.
Mary Lee Pollard, PhD, RN, CNE
Excelsior College School of Nursing
The era in which we are living can be described in many ways. Certainly, two of its most striking features are rapid change and growing interconnectedness. From the internet to financial markets and trade between nations, to television and cinema, to international airline travel, people and processes, societies--and the individuals within them--are increasingly becoming more linked. What happens in one place can often have implications across town, across the nation, and across the globe.
If this is true under “normal” circumstances, it is even more the case in the context of catastrophe. In large-scale disasters and emergencies, conditions often change rapidly and unpredictably, regular resources and information may not be available, the initial calamity can produce a cascade of secondary events, and people in affected areas may experience a wide range of needs. In such an environment, genuine interprofessional collaboration, across disciplines and professions, is crucial for response, recovery, and assistance efforts.
2011 Earthquake and Tsunami in Japan
Japan’s 2011 mega-disaster is a good illustration of the usefulness of interprofessional collaboration in health care. This unprecedented calamity included an earthquake, a tsunami, and a nuclear accident, and required a rapid and complex collaborative response.
Friday March 11, 2011
As is well known, on the afternoon of March 11, an immensely powerful magnitude 9.0 earthquake struck off the coast of Japan. One of the five largest quakes ever to occur in modern times, the seismic event caused widespread damage of its own, then unleashed a towering tsunami. Water and debris swept far into northeastern Japan’s coastal areas, devastating entire communities. The earthquake-tsunami disaster would eventually claim the lives of 15,883 people and injure 6,146 others. In addition, 2,654 people would still be missing some 2 ½ years later.
In addition, the earthquake-tsunami disaster severely damaged the Fukushima Dai-ichi nuclear generating station in Fukushima Prefecture. Radioactive contaminants were released, large numbers of people were evacuated, and an exclusion area had to be created around the facility. As of the time of this writing, some 80,000 people from affected communities are still unable to return home.
The Team Is Assembled
The Tokushukai Medical Group, one of Japan’s largest healthcare networks, issued an urgent request for outside assistance shortly after the earthquake-tsunami-nuclear accident struck. The request went directly to NYC Medics, a New York-based global disaster relief organization specializing in speedily assembling and deploying assistance teams to affected areas. While Tokushukai did not lack experience with disaster response, the current situation, involving two major simultaneous natural disasters and a rapidly developing radiation emergency represented a new, highly complex--and in many ways unprecedented--kind of challenge.
NYC Medics flew an advance team to Japan, consisting of Dr. Rob Bristow, a physician, and Ms. Katherine Bequary, a nurse, to meet with Tokushukai officials and assess how the U.S. non-profit organization could best help.
Arrival of the Team
After the advance team arrived, it was jointly decided that NYC Medics would assemble and deploy a special Radiological Emergency Assistance Mission. Tokushukai, its staff, and many in the broader Japanese public had some familiarity with earthquakes and even tsunamis, but the radiation emergency was less familiar. There were many questions: What was the meaning and significance of environmental radiation measurements? What about the use of personal protective equipment? How to ensure the safety and well-being of hospital staff families? How best to communicate with health care staff, patients and the general public about radiation? An independent team with broad expertise on radiation issues and actual field experience at previous radiation emergencies would be necessary.
Creating such a team would be a new experience. In the past, at other global disaster sites, radiation incident assistance efforts had been carried out by various governments and international organizations, such as the United Nations. While similar official efforts were being launched, with U.S. civilian and military specialists deployed to Japan to carry out vital activities, including aerial radiation monitoring and mapping, this would be the first time a non-governmental Radiological Emergency Assistance Mission would be assembled and deployed to help a major health care network in another nation during a disaster.
Due to the complex array of concerns, questions, issues, and information needs associated with the unfolding situation, NYC Medics knew immediately that the Radiological Emergency Assistance Mission would need to be interdisciplinary in every regard: composition, approach, and practice. The team would also need to be small so that it could be created quickly. Furthermore, it would have to be able to carry its own radiation detection equipment and be comfortable operating in a situation with continuing aftershocks (some quite strong).
NYC Medics Team Response
After reaching out to U.S. agencies and organizations with expertise on radiation emergencies, NYC Medics was able to assemble a three-person expert team: an MD, a health physicist, and a disaster management specialist. The first team member, Dr. Katherine Uraneck, was selected because she was a board certified, residency-trained, emergency physician with extensive knowledge of the medical and public health emergency preparedness aspects of radiation emergencies. Her primary focus areas were radiation incident planning and response, hospital surge capacity, population screening, and pediatric preparedness. The second member, Dr. P. Andrew Karam, was asked to participate because he was a board-certified health physicist with considerable international experience. Health physics is the branch of physics that deals with the health and safety aspects of ionizing radiation. Karam’s areas of expertise include radiation emergencies, radiation education, and the management of radioactive materials. I was the third member, invited to join the Mission because of expertise on the public health, community response, and risk communication issues associated with major radiation incidents and other emergencies. My experience included extensive on-site disaster field work, including the 1999 nuclear accident at Tokaimura, also in Japan.
Each member of the Assistance Mission brought particular skills, experience and expertise, but what defined the effort was full-fledged integration. Whether assessing community impacts, responding to questions, or exchanging ideas with Japanese counterparts, it was by combining insights and perspectives from our respective disciplines that the team members were able to gain a fuller understanding of a highly complex, rapidly developing situation. Stated another way, the Assistance Mission was more than just the sum of separate, individual parts; it operated as a cohesive, interdisciplinary unit.
In practice, this meant having a series of conference calls prior to the mission, having team reviews and coordination meetings each evening while on the ground in Japan, and having frequent, rapid discussions to develop team positions on issues or to make quick decisions while in the field. All three team members had worked closely together before on disaster and emergency management issues, which facilitated team coordination and integration on the ground in Japan. Furthermore, all three had great respect for each other’s expertise and experience.
The Radiological Emergency Assistance Mission brought this integrated approach to bear in a variety of ways. One was in carrying out its situation assessment. Team members operated in various affected areas, including the Emergency Evacuation Preparation Zone (20-30 km zone), and traveled to hospitals, operations centers, areas that received evacuees, and a community slated for evacuation. Members of the team also observed a radiological screening site, went to evacuation centers, and met with disaster response organizations and elected officials. Throughout the process, the Assistance Mission approached each issue or problem in an integrated way. For example, in discussing the radiological screening process, team members considered the technical (equipment) requirements, the personnel training requirements, privacy issues, documentation and follow-up, psychological aspects, implications for social stigma, the needs of children and other vulnerable populations, the challenges of communicating and interpreting health risk information, and more.
Perhaps the most obvious way the integrated approach was brought to bear was in meeting the many requests for training while on the ground in Japan. Officials at Tokushukai asked the Assistance Team to combine its past experience of radiation disasters with specific knowledge of the current situation, and to develop and deliver practical, tailored training to Japanese health care professionals and emergency responders. The training was intended to meet several needs. For professionals with previous radiological training, the new training would serve as a refresher and an opportunity to ask questions and clarify issues. For many with little or no previous radiological training, the new training would provide needed background and practical knowledge. Meanwhile, for health care practitioners with questions and concerns about the safety and well-being of their own family members, the training would provide useful, independent information. Finally, because so many groups--hospital support staff, hospital patients, and the public more generally--tend to look to health care professionals and emergency responders for information, the training was designed to provide participants with key insights about risk perception, people’s information needs in radiation emergencies, and risk communication.
A total of six interdisciplinary training sessions were conducted in different parts of Japan over a one-week period, with most taking place in hospitals. With the assistance of highly-expert simultaneous translators provided by their Japanese hosts, all three team members spoke at each training session. To make translation easier, each team member took the lead on some of the content. But no matter which team member was speaking at a particular point in the training, the entire team had the opportunity to elaborate, comment, and provide examples and illustrations. This was a jointly-developed, jointly-delivered curriculum. Team members covered such interrelated topics as types of radiation and their properties, personal protective equipment, working safely with radiological patients, contamination control and decontamination practices, health effects of radiation, age-dependent radiation sensitivity, isotopes of concern and their behavior in the body, communicating about radiation issues, the use of radiation dose comparisons, the use of cancer risk estimates, radiation effects on the developing fetus, concerns of health care professionals and first responders, community responses to nuclear accidents, groups at high risk for psychological impacts, the problem of social stigma during radiation emergencies, and special needs of children in disasters involving invisible agents. In addition to the curriculum itself, many other issues were covered in the question-and-answer sessions that followed.
By the time the Radiological Emergency Assistance Mission finished the six sessions, more than 1,100 Japanese health care professionals and emergency responders had participated in the integrated training. The training, crafted and delivered on-scene, and incorporating a wide range of issues not often taught together, helped to create a more realistic understanding of the situation and its implications. Each issue and each piece of information was seen as part of a complex mosaic that team members worked to put together into an integrated whole. This could not have occurred without a high degree of interprofessional collaboration.
Much was learned from this unique Assistance Mission, and two “lessons learned” articles have now been published (Becker, 2011 and 2013). Additional articles articles are in development. Meanwhile, there has been considerable interest in the team’s work and integrated approach on the part of health, medical and first responder organizations in the U.S. and elsewhere. In response, team members gave a variety of presentations in 2012 and 2013, including a recorded panel discussion of lessons learned, with more expected in 2014.
Application to Practice
No two situations are alike, but the model of an integrated Radiological Emergency Assistance Mission likely has broader applicability to other radiation emergencies and to other disaster situations involving invisible contaminants, such as toxic chemical emergencies. This integrated team approach may also have value in “normal” situations where highly complex challenges need to be identified, understood, and addressed. By bringing to bear the complementary skills and insights from various fields, health care professionals can be better prepared to meet the challenges posed by the multi-faceted, complex problems found in today’s fast-paced, interconnected world.
Working in an environment defined by change and interconnectedness requires openness to new ideas, continuous learning, a more global perspective, and considerable flexibility and adaptability. Unraveling and addressing the highly complex problems that characterize 21st century life requires an increasingly interdisciplinary approach. Only by bringing to bear the combined knowledge and expertise from multiple disciplines can complicated, multifaceted challenges be effectively disentangled and managed.
Special thanks to the Tokushukai Medical Assistance Team, Tokushukai Medical Group, and NYC Medics for organizing the disaster assistance mission; ANA Airlines for providing special disaster relief flights; the expert translators who assisted with the site assessment and the training sessions; and the following individuals who helped make the mission a success: Katherine Uraneck, P. Andrew Karam, Torao Tokuda, Takao Suzuki, Ichiji Ishii, Tetsu Tokuda, Narumi Koshizawa, Giichiro Oketani, Fumika Ezawa, Kenta Ebisawa, Kato Takurou, Phil Suarez, Rob Bristow and Katherine Bequary.
Becker SM. The Fukushima Dai-ichi Accident: Additional Lessons from a Radiological Emergency Assistance Mission. Health Physics 105 ( 5 ): 455-461, November 2013.
Becker SM. Learning from the 2011 Great East Japan Disaster: Insights from a Special Radiological Emergency Assistance Mission. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 9(4): 394-404, December 2011.
Learning a Common Language for IPE
In an age of an increasingly complex health care system, the idea of doing things as we have always done them seems outmoded and dangerous. A changing landscape of resources and approaches to health care is the norm. The way health care professionals are trained and educated must keep up with the environment. Care delivery models are swiftly morphing to accommodate a population that demands a highly integrated and networked system of care that produces high-quality outcomes, with an eye on cost.
An integrated approach to care requires a new framework, one rooted in the concepts of teams and collaboration. Such a framework challenges the traditional medical-legal model that for decades has defined systems of care delivery, with physicians at the top of the hierarchy (Lingard, Vanston, Durrant, et al, 2012). Now, health care providers are asked to approach patient care in concert with one another, interprofessionally, from the ground up. Meaning, they come to the problem already in conversation about the patient's care. The idea of knowing when to "call for a consult" from the experts is no longer enough. We start now, embedding a mindset that enables professionals to think and converse differently.
A new vocabulary is developing and taking hold all along the patient continuum, a new style of communicating that ripples out and affects all involved: from providers, to members of health care teams, to families. In fact, change is so radical that extensive glossaries of new terms introduced by the Affordable Care Act are part of consumer-facing discussions.
As it evolves, this new common language will need to be responsive, flexible, engaging, inclusive, cognizant of the range of skills within a network, and geared toward team-based problem solving and outcomes. If the new framework is going to succeed, all must be willing to adapt, to engage in the problem-solving process from the outset, to transcend insular, professional language ingrained during pre-professional academic training in discipline-specific silos, and adopt a more inclusive style that maximizes the role of team communication on patient care outcomes.
What we have always done
Traditionally, education for health care professionals has occurred within discipline-specific professional boundaries. Only in the clinical practicum experiences were students exposed to other members of the health care team. Clinical practicum experiences do provide a glimpse into the real world and offer insight into the necessity of valuing the skill sets and roles of colleagues. However, evidence shows the experience barely scratches the surface of teaching effective interprofessional communication. In addition, implications for poor teamwork and deficient collaboration rooted in missed communication between team members have been pervasive and far reaching. Interprofessional communication failures have been established as a root cause of over 70% of the adverse medical events (Prescher, 2013) that contribute to as many as 98,000 deaths in U.S. hospitals annually (Institute of Medicine, 1999). Additionally, the associated cost of medical error is estimated between $17 billion and $29 billion U.S. dollars per year (IOM, 1999).
Defining the Terms
Interprofessional education (IPE) is not a new concept, and in fact was introduced into an evolving common language in health care education as far back as the 1970s. Dr. Hugh Barr and the Centre for the Advancement of Interprofessional Education (CAIPE) in the United Kingdom states that "Interprofessional Education occurs when two or more professionals learn with, from and about each other to improve collaboration and the quality of care."(CAIPE, 2002) CAIPE uses the term IPE to include any learning in an academic or work environment before or after professional certification. It also expands the traditional concept of "professional" to include a timeline that spans pre- and post-licensure. Definitions of IPE have become more familiar and easy to find. This brief clip from Karen Rose, Associate Professor of Nursing and Director, Baccalaureate Program (BSN) for the University of Virginia School of Nursing illustrates a clear, concise, definition. Madeline Hubbard Smith, PhD, RN, FAAN, FNAP (School of Nursing, University of Rochester), offers a historical retrospective of the idea of IPE, the rationale for its need, and its role in United States health care. Her talk was recorded in 2009, as part of the University of Virginia's "Medical Center Hour." Additionally, in 2010, the World Health Organization (WHO), based on mounting evidence from three decades of research, issued recommendations in a lengthy report that called for interprofessional collaboration in education as a strategy to transform health care delivery on a global level in an effort to strengthen health systems and improve patient outcomes. (WHO, 2010).
Many colleges and universities tout the benefits of encouraging students to cross boundaries between traditional departments. On its website, the University of Pennsylvania asserts that "interdisciplinary opportunities allow students to express academic creativity and discover new ways of synthesizing information."(University of Pennsylvania, 2013). This approach to education implies blurred lines between disciplines and merges expertise in new ways for educational experiences.
Similarly the concept of a multidisciplinary approach is the language more often heard in the halls of research in academia. Multidisciplinary implies combining several, usually separate, branches of learning or fields of expertise, suggesting a slightly different focus than the "blurring" of lines in interdisciplinary education. For example, the concept of a "multidisciplinary approach" is often part of the call for research proposals and has become a mainstay research in health care. In fact, an entire journal, Journal of Multidisciplinary Healthcare, is dedicated to discussing health care research from a perspective that reinforces the idea that "healthcare is not bounded by person, place or time."(Journal of Multidisciplinary Healthcare, 2013). While these concepts do describe an academic view, they are insufficient on their own. A foundational common language for health professional education is necessary to achieve collaborative practice.
Formed in 2009, the Interprofessional Education Collaborative (IPEC) is a partnership of six national education associations of schools of the health professions that includes: the American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association, Association of American Medical Colleges, and Association of Schools of Public Health. That same year, an expert panel was convened by IPEC to establish individual level core competencies for interprofessional collaborative practice for all health care professionals, clarifying and unifying the curricular goals for all health care education programs (IPEC, 2011). According to a press release from the Robert Wood Johnson Foundation (RWJF, 2011), the recommendations from the IPEC expert panel call for future health care professionals to be able to:
- Assert values and ethics of interprofessional practice by placing the interests, dignity, and respect of patients at the center of health care delivery, and embracing the cultural diversity and differences of health care teams.
- Leverage the unique roles and responsibilities of interprofessional partners to appropriately assess and address the health care needs of patients and populations served.
- Communicate with patients, families, communities, and other health professionals in support of a team approach to preventing disease and disability, maintaining health, and treating disease.
- Perform effectively in various team roles to deliver patient/population-centered care that is safe, timely, efficient, effective, and equitable.
The core competencies for interprofessional practice and collaboration are simple yet stimulate a new body of research and evidence to outline their application and impact in health professions education. The IPEC has defined the core competencies for interprofessional practice and collaboration as follows:
- Values/Ethics for Interprofessional Practice - Work with individuals of other professions to maintain a climate of mutual respect and shared values.
- Roles/Responsibilities - Use the knowledge of one's own role and those of other professions to appropriately assess and address the healthcare needs of the patients and populations served.
- Interprofessional Communication - Communicate with patients, families, and other health professionals in a responsive and responsible manner that supports a team approach to the maintenance of health and the treatment of disease.
- Teams and Teamwork - Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan and deliver patient/population centered care that is safe, timely, efficient, and equitable.
In addition, the report laid out baseline operational definitions for such terms as "interprofessional education," "interprofessional collaborative practice," "interprofessional teamwork," "interprofessional team-based care," "professional competencies in health care," and "interprofessional competency domain." The full IPEC report can be read here.
Highlighting this content within our health professions educational curricula to develop students with competencies in these four areas listed above is a task many health care professions educators are hard at work to achieve. This content is also weaving its way into the accreditation standards that govern our health professions. Eighteen of twenty-one accreditation documents analyzed for practice-level degrees in dentistry, medicine, nursing, occupational therapy, pharmacy, physical therapy, physician assistant, psychology, public health and social work included language centered on interprofessional education (Zorek & Raehl, 2013).
What this means for multiple generations of providers
Conceptually, the central ideas of interprofessional education and collaborative practice have surfaced in small but significant increments in health care education curricula over the last three decades. Meaningful experiences centered on team-based approaches to health care and collaborative practice appear in the clinical practicum experience and are structured to expose pre-licensure health professions students to the skills and language of the professional roles of the health care team. Successful health care education programs integrate the core concepts of interprofessional practice and collaboration in a longitudinal manner building the students' level of expertise and exposure as they move through the program in a progressive manner. Health care providers, nurses and physicians especially, who have completed their professional education in higher education centers in the recent past will most likely have been introduced to these concepts and have a working knowledge and respect for the roles and expertise of their professional colleagues.
What does this mean for those who were not exposed to these concepts in their health care professions training? How do differing educational experiences impact the dynamic of relationships between health care professionals attempting to work together for optimal patient outcomes? What should happen in the arena of continuing education to guarantee that each generation of providers has the appropriate "lingua franca" at their disposal? What will it take to implement the core competencies of interprofessional practice centered on collaborative communication at the start of the first clinical encounter?
These questions challenge the next stage of implementation of interprofessional education and collaborative practice not only in the pre-licensure educational landscape for health professions, but also in traditional approaches to discipline-specific required continuing education. How can we bridge the gap between providers that taps into both the experience and expertise of those educated in traditional discipline-specific "silo" curricula and those from budding curricula and systems of collaborative team work? It is not just learning the new language of a new curricula threaded with interprofessional concepts that flatten the traditional hierarchical medical model. It is also finding ways to teach the language and mindset of interprofessional collaborative practice to those who learned to practice in the traditional medical model. These questions stimulate the next stage of discovery in interprofessional education and collaborative practice.
Interprofessional education is a potential solution to improving team work and collaboration among providers by offering experiences that eliminate professional barriers to consistently poor communication and ineffective collaboration among the health care team. Integrating core competencies into existing discipline specific health professions curricula is admittedly a challenge that asks educators to shed their protective professional skin and create a new structure for an integrated longitudinal and progressive curriculum. To succeed, this new structure for curriculum must include developmentally appropriate interprofessional educational experiences that build upon each other as the student progresses through the journey of establishing their unique but integrated professional identity on the health care team.
A dire need for interprofessional education experiences focused on team skill development and collaboration from the beginning of the health care education experience are called for. Health care educators are tasked with preparing health care professionals well versed in the concepts of interprofessional practice and collaboration.
While this task seems herculean to some in healthcare education, there are those for whom interprofessional practice and collaboration was woven into pre-licensure health professions educational experience. These practitioners are poised to be advocates and leaders for the transformation that must come to health care education now. In 2013, communications researcher Dr. Lorelei Lingard, who studies health care teams and their communication patterns, gave an informative and inspirational view into the concept of collective competence, differentiating it from the need for individual competence.
Now is the time for expert teams. We all must learn to embrace a new common language to support improved patient outcomes.
Interprofessional Education Collaborative (2011). Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Accesssed on October 9, 2013 from https://ipecollaborative.org/uploads/IPEC-Core-Competencies.pdf
Institute of Medicine (1999). To Err is Human: Building a safer health system. Accessed on October 9, 2013 from http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is
Lingard L, Vanstone M, Durrant M, et al. (2012). Conflicting messages: examining the dynamics of leadership on interprofessional teams. Academic Medicine, 87(12):1762ñ1767.doi: 10.1097/ACM.0b013e318271fc82.
Prescher, Hannes (August, 2013). Interprofessional communication: 'To Err is Human,' To Educate is Imperative." Accessed on October 9, 2013 from http://ipep.arizona.edu/blog/interprofessional_communication_%E2%80%98_err_human%E2%80%99_
Robert Wood Johnson Foundation (2011). Advancing Interprofessional Education. May 16, 2011 Accessed on October 9, 2013 from http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2011/05/advancing-interprofessional-education.html
World Health Organization (2010). Framework for Action on Interprofessoinal Education & Collaborative Practice. Health Professional Networks, Nursing & Midwifery, Human Resources for Health. Accessed on October 9, 2013 from
Zorek, J. & Raehl, C. (2013). Interprofessional education accreditation standards in the USA: a comparative analysis. Journal of Interprofessional Care, 27(2), 123-30. doi:10.3109/13561820.2012.718295
The term interprofessional education (IPE) first appeared in the literature in 1965. Although the concept of interdisciplinary collaboration is well founded, it has not been adequately adapted by universities to educate health science students. Lately, the drumbeat for educational reform has become more pronounced, and recent publications have renewed interest in expanding interprofessional education. Importantly, these publications provide key components to realistically implement IPE, including: 1) a framework to interrelate the health and educational systems, 2) a model for competency-based education with specific levels of learning, and 3) core competencies for interprofessional collaborative practice.
East Tennessee State University (ETSU) has a rich history of interprofessional education. As far back as 1991, ETSU was one of seven universities that received a grant from the W.K. Kellogg Foundation to initiate the Community Partnerships for Health Professions Education Program (CPP). The $6 million grant supported the development of a model of health professions education that included partnerships with two rural Appalachian counties, and it provided the necessary structure and resources for interprofessional courses and experiential education.
Over twenty years later, the university continues to offer three health sciences courses developed as part of the initial grant: 1) Communications Skills for Health Professionals (CSHP), 2) Rural Health Research and Practice, and 3) Rural Community-Based Health Projects. CSHP remains a required course for medical, pharmacy, nursing, and psychology students. The two rural health courses are required components of the Rural Health Track offered to medical students and other health-related disciplines within the Academic Health Sciences Center. In 2011, ETSU embarked on a process to markedly expand IPE with the Academic Health Sciences Center.
Process to Expand Interprofessional Education
The Academic Health Sciences Center (AHSC) at ETSU consists of five colleges: clinical and rehabilitative health sciences, medicine, nursing, pharmacy, and public health. ETSU also has departments outside of the AHSC that serve as training grounds for health care professionals, including psychology and social work. AHSC colleges work collectively to provide certain IPE experiences, many of which are remnants of the W.K. Kellogg Foundation grant. All AHSC students, however, do not take these IPE experiences, and it was clear a systematic approach was necessary to expand IPE to all health sciences students in order to capture the advantages of exposure to team-based learning.
In January 2011, Dr. Wilsie Bishop the Vice President for Health Affairs, convened AHSC leaders at an interprofessional planning retreat. This retreat served as an opportunity to consider long-term visioning, and Bishop challenged leaders to consider ways to expand interprofessional education (IPE) to all AHSC students. Attendees at the retreat included the university president, the vice president for Health Affairs, deans, associate deans, department chairs, faculty members, and selected students from each college. The outcome of the retreat was a consensus and commitment of attendees to elevate IPE within the AHSC. A key decision of the retreat was to develop a systematic approach to provide a series of interprofessional opportunities to every professional and graduate AHSC student.
At the retreat, attendees identified barriers that may prevent IPE from being implemented effectively across all the health sciences. They included: 1) a need to maintain professional identity, 2) scheduling and programmatic conflicts related to curricula, and 3) accreditation issues.
Attendees expressed a sincere desire to maintain unique professional identity as part of any IPE expansion. To address this concern, the concept for the new interprofessional education program included a proposed “graduation requirement” that would apply to all professional colleges. Students would complete individual requirements of respective degree programs, but also participate in IPE experiences that are considered “value-added.”
The second major concern of IPE expansion was scheduling and programmatic conflicts. Presently, the five AHSC colleges are not physically located on the same campus and travel to and from venues as well as parking were concerns. Moreover, retreat attendees realized that semester schedules for each college do not align well. For instance, colleges start and finish each semester on different dates and fall and spring breaks do not match. To address this issue, the group identified ways to leverage existing IPE courses and recommend implementation of activities outside the classroom that would not conflict with course schedules.
The final major concern regarding IPE expansion related to accreditation issues. In addition to the university having accreditation by Southern Association of Colleges and Schools (SACS), individual colleges had accrediting bodies. The fear was a systematic IPE program might adversely affect or directly conflict with specific accreditation standards. This concern was alleviated in two ways. In May 2012, the Interprofessional Education Collaborative published Core Competencies of Interprofessional Collaborative Practice. This document provided national consensus among associations that represent colleges of nursing, osteopathic medicine, public health, pharmacy, dentistry, and medicine (allopathic). Table 1 provides an overview of the four competency domains advocated by this collaborative. In addition to this consensus document, accreditation guidelines for pharmacy, nursing, and medicine all have been recently updated and each emphasizes requirements for IPE as part of college curricula.
In June 2011, the vice president for Health Affairs and AHSC deans met again for a second retreat. The goal of the session was to ensure commitment of all AHSC colleges to expand IPE and to develop a clear process to implement a new interprofessional education program. During this retreat, the AHSC leadership established its own Interprofessional Education Committee (IPEC), and identified a chair and diverse membership from each college.
Interprofessional Education Program (iPEP)
The university's Interprofessional Education Committee (IPEC) met for the first time in October 2011 to begin work on the new Interprofessional Education Program (iPEP). The committee was charged “to expand interprofessional education (IPE) for professional and graduate students enrolled within the Academic Health Sciences Center at ETSU by building upon existing IPE experiences and developing new efforts.” To meet this goal, the committee decided to adopt the World Health Organization’s (WHO) definition of IPE: “when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.”
Based on the founding concepts for the program, the committee developed a two-year pilot program that addresses learning on the informative, formative, and transformative levels (see Table 2). The program includes students from all five AHSC colleges and the Department of Psychology in the College of Arts and Sciences. Beginning in fall 2014, the program will also include graduate students from the Department of Social Work. After completion of the pilot program, the ultimate goal will be to develop a graduation requirement that applies to all professional and graduates students within the AHSC. Figure 1 provides an overview of the program. Overall, there are three phases to the two-year program. Phase 1 is the prologue that helps students become experts on interprofessional education. Phase 2 promotes professionalization around key competency domains. Phase 3 promotes students becoming change agents that expect interprofessional collaboration.
The prologue of the program occurs annually in the fall semester, and it offers students an overview of interprofessional education program. For the first cohort of students, 15% of eligible students were included. Pharmacy and medical students complete a four-year professional degree program, and eligible students from these colleges are in their second professional year. For all other students (public health, nursing, and clinical and rehabilitative health sciences), eligible students are those in their first year of a two-year graduate program. In fall 2013, the second cohort began the program, and it included 25% of eligible graduate and professional degree students.
To avoid scheduling issues, the prologue occurs on a Saturday in late September or early October. This three-quarters day program includes registration, composite photos, a welcome and overview of IPE at ETSU, icebreakers, numerous group activities, and student presentations to the entire group. Overall, the intent of this phase of the program is to allow students of other professions to become acquainted and to provide information regarding interprofessional education and collaboration so that students become IPE experts.
The second phase of the program is the experiences, which include interprofessional courses and activities. Students in the program must complete at least four separate experiences, each one addressing one of the four program competency domains from the Core Competencies for Interprofessional Collaborative Practice (see Table 1). A key aspect of the program is that students may complete up to two of the four competency domains through existing IPE courses. The aforementioned courses that were developed as part of the W.K. Kellogg Foundation grant (Communications Skills for Health Professionals, Rural Health Research and Practice, and Rural Community-Based Health Projects) meet specific program competencies. Additionally, IPEC members have worked to put forward additional IPE courses to meet students’ needs. The ultimate goal is to have all students completetwo competency domains through course work.
For competencies not achieved through coursework, students’ self-select interprofessional activities that are completed outside the classroom and college curricula. Each semester AHSC colleges provide competency-based IPE activities, and these activities are coordinated among the colleges to ensure diverse offerings to meet students’ needs. Example activities include: high fidelity simulation (hypertensive crisis; clinical team training), clinical site visits and activities (patients with cerebrovascular accidents, neonatal intensive care follow-up clinic; tinnitus support group), off-campus sessions (the adobe experience related to essential of public health), movies with application (e.g., Contagion), application of team care models (prescription drug abuse prevention; patient-centered medical home; patient-centered outcomes research), and selected online experiences (weight of the nation, safety of vaccines, LGBT health care). Students begin to sign up for activities after completion of the prologue, and then semesterly, and all four competency-based experiences occur over the subsequent 18 months (four semesters). The overall goal of this phase of the program is formative learning where students become professionalized around IPE competency domains.
The final component of iPEP is the capstone event, with the first offering occurring in spring 2014. Similar to the prologue, this event will occur on a Saturday and encompass an entire day. The event will occur at the Valleybrook campus of ETSU, which is a large remote campus that includes open acreage and buildings previously donated to the University. Leaders of the activity will assemble students into the same interprofessional groups that were used as part of the prologue, and the event will start with students arriving early in the morning and being provided a scenario that requires a team-based approach to solve multiple problems. Students must work as collaborative teams and use the knowledge and skill gained in the second phase of the program (experiences). The overall goal of the capstone is to provide an experience that allows students the opportunity for transformation where they become change agents who advocate for interprofessional collaboration.
Future Programmatic Growth
The university continues to evaluate the pilot Interprofessional Education Program (iPEP) that includes evaluation research and general student assessment of instruction. The first cohort of 48 students joined the program in fall 2012 and completed the prologue on September 22, 2012. These students are currently finishing the second phase of the program (experiences) and will complete the capstone in March of 2014. In fall 2012, 71 students joined the second cohort of students completing the prologue on October 5, 2013. These students are beginning the second phase of the program (experiences).
The ultimate goal of the program is to include all professional and graduate students within the AHSC (approximately 400 students per cohort) as a graduation requirement. The next step toward this goal is to expand the total number of students in the third cohort (fall 2014) and expand opportunities for online students. A significant number of students in the College of Nursing and College of Clinical and Rehabilitative Health Sciences are part of blended or completely online courses, respectively. The prologue occurring in fall 2014 will be provided online and asynchronously for these students. Additionally, the number of online activities as part of phase two of the program will be expanded.
The next major initiative to elevate IPE at the university is to identify and expand resources. An Office of Interprofessional and Community-Based Education has been established and funding is in place to support program leadership. The office staff supports both the Interprofessional Education Committee (IPEC), the steering committee for the program, and the Interprofessional Curriculum Committee (ICC) that guides the development and maintenance of IPE courses. Financial resources are also available to expand interprofessional education. Presently, an interim space exists for the program. Long-term space has been identified, and renovation of a 40,000 square-foot building will commence in 2014. This building will include a large multiuse classroom, small group rooms, a simulation center, a café, and office space for IPE leadership.
East Tennessee State University has successfully expanded interprofessional education within the Academic Health Sciences Center (AHSC). Unique aspects of the program include a competency-based approach that uses activities outside the classroom to supplement existing IPE courses. The program has effectively overcome common barriers of IPE implementation. The commitment of the vice president and each academic dean to interprofessional education has been instrumental in sustaining the project and positioning the AHSC to achieve its ultimate goal of establishing a graduation requirement in interprofessional education that applies to all professional and graduates students in the health professions at ETSU.
East Tennessee State University held a Health Sciences Interprofessional Education Program on February 21, 2013 and can be viewed here.
Powers LS. Interprofessional education and medicolegal conflict as seen from the other side. J Med Educ 1965;40:233-44.
Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-58.
Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. May 2011.
Accreditation standards and guidelines for the professional programs in pharmacy leading to the Doctor of Pharmacy degree. Accreditation Council for Pharmacy Education (ACPE). Available at: https://www.acpe-accredit.org/pdf/FinalS2007Guidelines2.0.pdf. Accessed October 2013.
The essentials of baccalaureate education for professional nursing practice (2008). American Association of Colleges of Nursing. Available at: http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf. Accessed October 2013.
Standards for accreditation of medical education programs leading to the M.S. degree. Liaison Committee on Medical Education (LCME). Available at: http://www.lcme.org/publications/functions2013june.pdf. Accessed October 2013.
Cross LB, Blackwelder RB, Crouch MA. A prologue to interprofessional collaborative practice. Presented at the American Association of Colleges of Pharmacy 2013 Annual Meeting. Chicago, Illinois. July 13-17, 2013.
Maureen Boshier, editor of N21, and associate visiting professor at Old Dominion University in the joint master's in public health program with Eastern Virginia Medical School, recently interviewed Dr. Ann King, one of the engineers of the IPE program at ECU.
Their discussion centered on simulation, virtual environments, how they are created, and the student response. Listen here.
Dr. King completed her BSN and MSN at East Carolina University in the Family Nurse Practitioner concentration, and then graduated from Duke University’s Doctor of Nursing Practice program in 2010. She has worked in a variety of health care settings include medical-surgical inpatient units, labor and delivery, newborn nursery, acute psychiatric, school health, public health, and community clinics. Her current clinical practice is at the WATCH program in Goldsboro, North Carolina, which is a free clinic for uninsured residents of Wayne County. She joined the faculty at ECU in 2010 and currently teaches in the Adult Gerontology and Family Nurse Practitioner programs and the DNP program.
Retired former CEO of CGFNS International, an organization recognized globally for its expertise in credentials assessment of foreign-educated health professionals and currently President and CEO of Barbara Nichols Consulting.
PhD, RN, FAAN, a Professor and Senior Faculty Associate, Hartford Institute for Geriatric Nursing both at the College of
Nursing, New York University. She is a Nurse Attending at New York University Langone Medical Center. Her work focuses on the organization and delivery of nursing care.
DIANE L. HUBER
PhD, RN, NE-BC, FAAN, and a nationally recognized nursing administration expert, researcher, academic, speaker, and consultant. She specializes in leadership and nursing care management, emphasizing case and population health management.
Compass Clinical Consulting Managing Director, RN, and PhD, with more than 30 years of experience in senior health care leadership roles in university, regional, state and national organizations. She is a regular keynote speaker throughout the country and has authored a leading college text on law and ethics in healthcare.
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