The role of Interprofessional education (IPE) in improving interprofessional

Historically within the UK, HCPs have been educated in silos and subsequently work in silos regulated by distinct professional bodies. Both undergraduate and postgraduate education continues to be predominately a uniprofessional enterprise resulting in limited interaction across professional sectors. In a peer-reviewed practice review conducted by Rosenthal et al. (2010a) that looked at the barriers to pharmacy practice change in Canada, the authors suggested that if the field of pharmacy was to advance and have greater involvement in and engagement with the interprofessional team, the profession would need to transition from the rigid and historical educational models and embrace innovative and collaborative methods of education. One method that is currently being adopted in a variety of healthcare programmes is interprofessional education (IPE). Defined as occasions when “two or more

professionals learn with, from and about each other to improve collaboration and the quality of care” (pg. 6)(Barr, 2002b), IPE “is the process by which students from different professional programmes learn together during certain periods of their education with a view to enhancing collaboration and team work, and ultimately improving patient-centred care” (pg. 23) (World Health Organisation, 2013). IPE ultimately aims to improve interprofessional collaboration and patient care. Although the concept of IPE has been around since the 1960s (Barr, 2002a) it has only recently gained traction in undergraduate programmes.

With a range of benefits attributed to IPE that may directly address issues associated with uniprofessional practice, IPE is being championed both nationally and internationally. So much so that the Lancet Commission stated in 2010 that IPE can be central to the reform in healthcare professionals’ education (Frenk et al., 2010). The World Health Organisation (2010) responded by issuing specific guidance on IPE, highlighting that it can be integral to improving interprofessional relationships and removing barriers between HCPs, leading to the delivery of safe, high quality patient care. Here, the WHO summarised that IPE could: (i) develop students’ communication skills; (ii) further students abilities to critically reflect; (iii) teach students to appreciate the challenges and benefits of working
in teams; (iv) foster respect among HCPs; (v) eliminate harmful stereotypes; and (vi) evoke a patient- centred ethic in practice. These benefits align with the findings of a range of studies conducted (often based on HCP and service user perceptions – see section 2.7.1.1 for further details on IPE studies) which have cited benefits around: (i) the development of students’ interprofessional communication and relationships skills (Greiner and Knebel, 2003; Carpenter and Dickinson, 2014); (ii) reduction in their levels of professional bias, prejudice, stereotypes and rivalry (Freeth et al., 2008; Barr et al., 2017); (iii) recognition of their own and other HCPs’ roles and responsibilities (Freeth et al., 2008; Jacobsen et al., 2009); (iv) improved trust and respect across professions (Barr et al., 2017) and (v) a greater appreciation of safe and good practice (Barr et al., 2017).

With a number of benefits recognised by WHO they therefore concluded that IPE should be implemented in both undergraduate and postgraduate healthcare programmes worldwide (World Health Organisation, 2013). These international drivers prompted the Department of Health (2013a) to provide a statement on the need for greater incorporation of relevant and meaningful IPE across UK healthcare education.

As a consequence of these reports (particularly that by Frenk, 2010 and WHO 2010, a number of regulatory bodies including the General Pharmaceutical Council (GPhC) and the

General Medical Council (GMC) have made IPE a required element of the respective undergraduate degree programmes (General Medical Council, 2009; General Pharmaceutical Council, 2011). Essentially, policy makers believe that IPE can help equip the healthcare workforce with the ability to work effectively across health sectors and deal with issues that require the input of the interprofessional teams which will be necessary in order to effectively treat the growing numbers of patients with complex conditions and help patients cope with chronic illness (Barr et al., 2017).

2.7.1.1. Evidence surrounding the benefits and development of IPE

Whilst IPE is an activity that has become relatively commonplace within the pharmacy undergraduate curriculum it is clear that in order for students to achieve the beneficial outcomes attributed to IPE it must be implemented in a meaningful and relevant way and delivered effectively (see chapter 3 for further discussion). One challenge in achieving this has been directly measuring the benefits of IPE with much of the evidence surrounding its use of low quality.

In an update of a Cochrane systematic review of the literature relating to IPE, Reeves et al. (2010c) concluded that although some progress has been made in assessing the effectiveness of IPE (having increased from zero relevant studies in their first Cochrane review (Zwarenstein et al., 1999) to six studies ten years later) further work is needed to understand and evaluate the outcomes of IPE and ultimately demonstrate its benefit. Furthermore, of the six studies included (five from the USA one from the UK) just two reported positive outcomes of IPE (Morey et al., 2002; Young et al., 2005), two reported a mixed set of outcomes (positive and neutral effects) (Brown et al., 1999; Campbell et al., 2001), and two reported that IPE had no impact on either health care processes or patient health care or outcomes (Thompson et al., 2000a; Thompson et al., 2000b) (all studies have been summarised in Table 2.3). The absence of high quality evidence is likely due to a number of ethical considerations surrounding the use of RCTs in education (Reeves and Barr, 2016) and challenges in attributing improved outcomes related to communication and teamworking directly to the provision of IPE (Freeth et al., 2005). In its place, many evaluations of IPE focus on student and faculty perceptions of IPE which although valuable in determining beliefs about IPE they are poor at measuring student’s progress as interprofessional practitioners (Thistlethwaite and Moran, 2010).

This led Reeves et al. (2016) to conduct a Best Evidence Medical Education (BEME) systematic review of studies which rigorously assessed (using high methodological quality) the beliefs and perceptions towards IPE. The review included 46 studies which represented

a significant increase since the previous review (n=21) (Hammick et al., 2007). Findings from the studies indicated that students responded well to IPE and had positive attitudes towards IPE. For example McFadyen et al. (2010) employed a longitudinal controlled trial design and gathered IPE attitudinal data with the use of two pre-validated surveys with over 500 students in either an intervention group (n=313) or control group (n=260) and found that students from a range of health and social care courses began their pre-registration education with strong positive views of the principles behind IPE. The review also showed that attitudes and perceptions of one another improved. For example Curran et al. (2007) used a mixed method pre- and poststudy quantitative and qualitative evaluation to find IPE was effective in enhancing understanding of the roles of other professions, fostering respect and positive attitudes toward interprofessional collaboration, developing collaborative competencies, and promoting organisational change. Similarly, the review evidenced that students improved their interprofessional knowledge and skills for practice. For example Carpenter et al. (2006) used a mixed methods approach of quantitative questionnaires and interviews to evaluate a postgraduate IPE programme designed to enable health and social care professionals to work together to deliver new community mental health programmes and found that students reported statistically significant increases in their knowledge and skills in interprofessional team working and use of psychosocial interventions.

Table 2.3. Summary of the studies (n=6) included in the Cochrane review conducted by Reeves et al. (2010c) which assessed the effectiveness of interprofessional education Author Study design and reported outcomes of IPE activities

Morey et al. (2002)

USA

Aim: to improve collaborative behaviour of emergency department staff through the use of a controlled before and after study (CBA) Activities: lectures, discussion of videotaped segments of teamwork and clinical vignettes, teamwork exercises (8 hours)

Participants: Doctors, nurses, technicians, clerks

Positive reported outcomes: This showed a statistically significant improvement in quality of observed team behaviours between the experimental and control

groups following training. The clinical error rate significantly decreased from 30.9% to 4.4% in the intervention group (p 1⁄4 0.039) 


Young et al. (2005)

USA

Aim: to improve competence of mental health practitioners through the use of a CBA

Activities: presentations, small group discussions, role play and 3–4 day detailing visits, 16 hours of follow-up discussions Participants: Psychiatrists, mental health nurses, therapists, case managers

Positive reported outcomes: This found that mental health practitioners in the intervention group, in comparison to those in the control group, reported

significantly higher scores in relation to: teamwork; holistic approaches; education about care; rehabilitation methods and overall competency. 


Brown et al. (1999)

USA

Aim: to enhance practitioners’ communication skills through the use of a RCT

Activities: 4-hour interactive workshop, two hours of subsequent homework, and a four-hour follow-up workshop (didactic components, role playing, dialogue) Participants: Doctors, nurse practitioners, doctors’ assistants, optometrists

Mixed reported outcomes: This reported that while the communication skills training program did not improve patient satisfaction scores, clinicians’ mean score

in a survey they completed improved more in the control group than in the intervention group. This improvement, however, was not statistically significant. 


Campbell et al. (2001)

USA

Aim: to improve effectiveness of collective response of emergency department teams to intimate partner violence through the use of a RCT Activities: Two-day information and team planning intervention (didactic instruction, role playing, team planning, team work)

Participants: Doctors, nurses, social workers, administrators, domestic violence advocates

Mixed reported outcomes: This study found that the emergency departments which received the intervention recorded significantly higher levels on all

components of the ‘culture of the emergency department’ system-change indicator (e.g., appropriate protocols, materials such as posters, brochures, medical record intervention checklists, referral information and training for staff) and higher levels of patient satisfaction than the emergency departments in the control group. There were no significant differences in the identification rates of domestic violence victims in the medical records of the experimental and control groups.

Thompson et al. (2000a)

UK

Aim: to enhance recognition and management of depression in primary care practices through the use of a RCT

Activities: Four-hour seminar delivered to the primary healthcare teams (videotapes, small group discussion of cases, role play) Participants: Doctors and nursing teams from the participating primary care practices

Reported no significant impact on outcomes: This study reported no differences between the intervention and control groups in relation to the recognition of

depressive symptoms. The outcome of depressed patients at six weeks or six months after the assessment did not significantly improve. 


Thompson et al. (2000b)

USA

Aim: to improve identification and management of domestic violence in primary care clinics through the use of a RCT

Activities: Two half-day training sessions, three training sessions for opinion leaders, newsletter, four additional educational sessions, system support (e.g.,

posters in waiting areas, provider cue cards)

Participants: Doctors, nurse practitioners, doctors’ assistants, registered nurses, licensed practical nurses, medical assistants

Reported no significant impact on outcomes: Although documented inquiries about domestic violence increased 3.9-fold at nine months in intervention clinics

However, Reeves et al. (2016) did recognise that the self-report data used in these studies represented “a weak measure of knowledge and skills given an individual’s inability to assess such gains accurately” (pg. 16) and also felt these studies should be used with caution when assessing behavior change. The review also made a number of high level recommendations for the effective delivery and research of IPE, including the need for educators to ensure that IPE reflects current or future practice in order for sessions to be effective.

A small number of studies (most often involving the evaluation of students’ perceptions of single sessions through either questionnaires to interviews) have evaluated IPE sessions involving pharmacists (for example Jones et al. (2012), Henderson et al. (2013), Coulman et al. (2014), Rotz et al. (2015), Myers Virtue et al. (2017), Vogler et al. (2017)). However, the study numbers are limited and methodological quality varied (highlighted by the absence of these studies from the review by Reeves et al. (2016)). This makes it challenging to compare and contrast educational approaches and extrapolate findings further afield, leading Carpenter and Dickinson (2014) to conclude that greater levels of research are required within the field of pharmacy IPE to further develop and enhance its provision within the profession.

In 2017 the UK Centre for the Advancement of Interprofessional Education (CAIPE) released IPE guidelines to help educators develop meaningful and relevant IPE using a framework (Barr et al., 2017). Whilst this document helped summarise areas of the literature and provided discussion on implementing IPE, engaging service users, utilising resources, aligning learning and regulation and evaluating IPE, there was limited specificity in terms of the specific sessions that would be of value to developing practitioners. The recommendations for example did not elaborate on appropriate topics and learning outcomes that would be value to students, which HCPs to include in IPE (which ones and how many) and the time to introduce sessions. This represents a challenge for educators in knowing whether the sessions developed are relevant and reflective of day-to-day practice, something Barr et al. (2017) stressed was vital in ensuring sessions are in order for students to be actively engaged and see value in sessions (aligning with adult learning theory (Knowles, 1973), see chapter 3 for more detail). Given the current limited guidance relating to the development and delivery of effective, meaningful and relevant IPE, the paucity of literature detailing the IPE undertaken within pharmacy education and a lack of understanding about pharmacists’ interprofessional role(s) in practice, developing and embedding meaningful IPE is likely to remain a significant challenge for pharmacy educators.