Mehran Hossaini DMD Linda Centore PhD RN

University of California San Francisco ADEA Symposium, Saturday March 12th 2011

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Interprofessional Education1

Definition:

“Interprofessional education involves educators and learners from two or more health professions and their foundational disciplines who jointly create and foster a collaborative learning environment. The goal of these efforts is to develop knowledge, skills, and attitudes that result in interprofessional team behaviors and competence. Ideally, interprofessional education is incorporated throughout the entire curriculum in a vertically and horizontally integrated fashion”

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Objectives • Review and discuss interprofessional education (IPE):

– The need for IPE

– The value to the healthcare education

– The impact on the educational system and learners

• Discuss the Interprofessional Standardized Patient Exercise with emphasis on the UCSF experience:

– Goals, logistics, and outcomes

– Implementation, challenges, and lessons learned

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Mehran Hossaini, DMD

Department of Oral and Maxillofacial Surgery

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Acknowledgments • Maria Wamsley: Professor of Clinical Medicine, Department of

Medicine

• Jennifer Staves: Third-year medical student

• Lisa Kroon: Professor of Clinical Pharmacy, School of Pharmacy,

• Kimberly Topp: Professor, Department of Physical Therapy and Rehabilitation Science and Department of Anatomy

• Barbara Newlin: Assistant Clinical Professor, School of Nursing

• Caroline Lindsay: Third-year pharmacy student

• Bridget O’Brien: Assistant Adjunct Professor, Department of Medicine and Office of Medical Education

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Definitions IPE occurs when two or more professions learn with,

from and about each other to improve collaboration and improve quality of care.

“Center for the Advancement of Interprofessional Education, 2002”

“Professional” is an all-encompassing term that includes individuals with the knowledge and/or skills to contribute to the physical, mental and social well-being of a community.

“Framework for action on interprofessional education and collaborative practice.” Published 2010.

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Justification World Health Organization:

Interprofessional education is a necessary step in preparing a collaborative practice-ready health force that is better prepared to respond to local health needs.

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Justification Institute of Medicine:

The ability to work effectively in interdisciplinary teams is a core educational competency for all health care professionals.

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Goals of IPE To improve:

Knowledge of one’s own professional role and the roles of others

Skills to work effectively with other healthcare professionals, resolve conflicts, and provide high quality patient care

Attitudes enabling cooperation, respect, and openness to work in interprofessional teams

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Limitations Our collective understanding is evolving:

Composition of the curriculum

Implementation

Outcome assessment

Indicators for curricular success

Limited involvement of professional students

Small sample sizes

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Essential Elements Direct engagement of students

Collaborative learning vs. “learning in parallel”

Clinically realistic scenarios that reflect professional roles of participants

Integration of simulation

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Key Role of Faculty2

The Interprofessional Facilitator - rather than expert

Work with faculty stereotypes about other professions

Facilitators must prepare for interprofessional friction over sensitive issues e.g.. misunderstanding of roles

Controversy about when best to introduce IPE- one thought- introduce early to avoid negative stereotypes vs. introduce later- need to be secure in roles to function effectively as team members

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Linda Centore, RN PhD

Department of Preventive & Restorative Dental Science

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Oral Health in America 20003 Surgeon General David Satcher

Major Finding/Recommendation

o Change health providers' perceptions. Too little time devoted to oral health /disease in the education of nondental health professionals…. all care providers should contribute to enhancing oral health

o Ideas- include oral exam in medical exam, advise on diet and tobacco cessation, & refer to oral health practitioners for care prior to medical /surgical treatments e.g.. chemotherapy / radiation to the head and neck….

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Oral Health in America 2000 o HCPs should be ready, willing, and able to work in

collaboration to provide optimal health care for their patients…. Having informed health care professionals will ensure that the public using the health care system will benefit from interdisciplinary services and comprehensive care…

o To prepare providers for this role will involve… curriculum changes and multidisciplinary training.

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The Dental Home: Primary Care Oral Health Concept4

Nowak & Casamassimo 2002 JADA

Accessible

Family-Centered

Continuous

Comprehensive

Coordinated

Compassionate

Culturally Competent

Dentistry Medicine

Nursing Pharmacy

INTERPROFESSIONAL PARADIGM 16

Dental School Pre-doctoral Clinics

& Collaborative Practice Many dental schools have

psychologists, nurses, or social workers working collaboratively

Sharing knowledge, collegial attitudes, and collaborative decision-making

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IOM 2003 Health Professions Education: A Bridge to Quality5

5 Core Competencies

Patient-centered care

Interdisciplinary teams

Evidence-based medicine

Quality improvement

Information technology

Of note –

o Panel consisted of physicians, pharmacists, nurses, PAs, & allied health professionals.

o Dentistry had no representation on planning committee/ or among attendees

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IOM 2009 Report on Continuing Professional Development6

o Provide interprofessional continuing education aimed at bringing health care professionals from various disciplines together in carefully tailored learning environments

o Establish a national interprofessional CE institute to foster improvements in how HCPs carry out responsibilities

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2010 Framework for Action- Nursing and Midwifery7

World Health Organization & Interprofessional Education

http://www.who.int/hrh/resources/framework_action/en/index.html

Main Points on IPE

Mitigate Global Health Workforce Crisis

Necessary to Collaborative Practice Model

Involves HCPs from different professional backgrounds

Provides a HCP who is collaborative-practice ready

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IPE: Educator Mechanisms Framework for Action 2010

Champions

Institutional Support

Managerial Support

Shared Objectives

Staff/Faculty Training

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IPE: Curricular Mechanisms Framework for Action 2010

Adult Learning Principles

Assessment

Compulsory Attendance

Contextual Learning

Learning Outcomes

Logistics/Scheduling

Program Content

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IPE Key Elements: Learner, Educator, Learning Context2

Create non-threatening environment –Contact Hypothesis (Tajfel 1981)

Reflection- on hierarchy, role blurring, leadership, decision-making, communication, respect – engage in reflection in action

Create learning experiences- directly relevant to current or future practice

Clinical problem-vector through which learners understand how to work with each other

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IPE Key Elements: Learner, Educator, Learning Context2

Group balance – equal mix of professionals

Group size - 5-10 learners

Group stability – interaction enhanced with stable membership

Pre-licensure vs. post-licensure- the former our focus

Enhanced learning through informal experiences among the learners- eat lunch together, car-pool to the IPE- think about setting aside time deliberately for informal learning

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Collaborative Competencies2

Describe one’s role/responsibilities to others

Recognize/observe constraints of one’s role…yet perceive needs in a wider framework

Recognize/respect the roles & responsibilities of others

Work with other professions to effect change /resolve conflict in providing care and treatment

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Collaborative Competencies2 (continued)

Work with others to assess, plan, provide, & renew care for individual patients

Tolerate differences, misunderstandings, shortcomings in other professions

Facilitate interprofessional case conferences, team meetings etc.

Enter in interdependent relationships with other professions

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IPE Key Elements: Factors, Processes, Outcomes2

Effects of professional socialization in silos

Stereotypes of own profession and others

Turf issues and protectionism

Lack of commitment from institutional /political leadership

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IPE Key Elements: Factors, Processes, Outcomes

2007 Cochrane Review8 on IPE: concludes “despite large body of literature on evaluation of IPE, studies lack methodological rigor…to understand impact of IPE on professional practice and/or health care outcomes; 89 papers none qualified for inclusion.

“The absence of evidence of effect is not evidence of absence of effect” (Cochrane Reviewers’ Handbook 4.1.5, section 9.7)

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Cochrane Meta-Analysis 20099

positive study outcomes limited by lack of rigorous research design

6 studies reviewed: 4 RCT and 1 CBA

4/6 studies reported positive outcomes on:

culture of the emergency department (ED) & patient satisfaction (Campbell 2001)

collaborative team behavior/ reduced clinical errors for ED teams (Morey 2002)

management of care to domestic violence victims (Thompson 2000a)

MH practitioner competencies related to delivery of patient care (Young 2005)

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Mehran Hossaini, DMD

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UCSF Experience: ISPE Participating Professional Schools:

Dentistry, Medicine, Nursing, Pharmacy, Physical Therapy

Goals:

Enhance knowledge of other healthcare professionals’ roles

Foster collaboration in patient care management

Improve communication skills with other healthcare professionals

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Logistics Teams of 4-5 students

Required participation for students of Schools of Dentistry and Medicine.

Volunteer participation of students of Schools of Nursing, Pharmacy, Physical therapy.

One faculty observer from each school

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Logistics 4 hour exercise

Case discussion and strategizing: 15 min

Each student interview the SP: 15 min/student

Discussion after each interview: 5 min

Develop comprehensive plan: 15 min

Debriefing and discussion: 30-45 min

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Standardized Patient Each SP required 6 hours of training:

Case review

Role play with a faculty or SP trainer

Responsibilities:

Simulate a realistic patient contact

Evaluate each student on patient-provider interaction skills

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Paul Harris • Problem List:

– Atrial fibrillation with anticoagulation therapy

– Hypertension

– Hyperlipidemia

– Advance periodontal disease

– Low back pain with limiting activity

– Medication non-compliance

– Recent transient ischemic attack

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Feedback to the Students

Discussion and Debriefing session

SP’s comments and score of the student

DVD of each encounter is provided to the students.

Opportunity to review the DVD of the encounter with a faculty.

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Evaluation • Attitudes Toward Health Care Teams (ATHCT) survey

was used10-12

• Pre-Post Attitudes survey toward:

– Team value

– Team efficiency

– Physician’s shared role on the team

• Perceived achievement of the objectives

• Student and faculty overall satisfaction with the experience

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Minor Details! Development /implementation:

1055 person-hours

The execution of the exercise:

Total: 431person/hours

Faculty teaching time: 135 hours

Simulation support staff: 84 hours

Administrative support: 104 hours

Standardized patient time: 108 hours

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Characteristics of Participants Professional

School

ISPE Group

N=101

Control Group

N=209

Total

N=310

Class

Dentistry 23 (23%) 19 (9%) 42 (14%) 88

Medicine 26 (26%) 47 (22%) 73 (24%) 150

Nursing 21 (21%) 27 (13%) 48 (15%) 62

Pharmacy 24 (24%) 107 (51%) 131 (42%) 127

Physical

Therapy

7 (7%) 9 (4%) 16 (5%) 22

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Pre-Post ISPE Attitudes Towards Healthcare

Teams

0

1

2

3

4

5

6

Team Value Team Efficiency Physician's Shared

Role

Pre

Post

1 = strongly disagree, 6 = strongly agree

Attitude Toward Team Value

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Pre-ISPE Mean (SD)

n

Post-ISPE Mean (SD)

n Comparison Mean (SD)

n Class Size

DENTISTRY 4.46 (0.51) 21 4.89 (0.53) 18 4.46 (0.38) 19 88

MEDICINE 4.71 (0.41) 23 4.83 (0.55) 24 4.89 (0.56) 47 150

NURSING 5.05 (0.47) 19 5.36 (0.41) 19 5.10 (0.44) 27 62

PHARMACY 5.06 (0.43) 24 5.40 (0.38) 23 4.96 (0.52) 107 127

PHYSICAL THERAPY

5.22 (0.42) 7

5.38 (0.35) 9

5.19 (0.54) 9 22

ALL 4.85 (0.51) 94 5.14 (0.52) 91 4.93 (0.53) 209

1 = strongly disagree, 6 = strongly agree

Attitude Toward Team Efficiency

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Pre-ISPE Mean (SD)

n

Post-ISPE Mean (SD)

n Comparison Mean (SD)

n Class Size

DENTISTRY 3.78 (0.67) 21 4.31 (0.67) 18 3.60 (0.88) 19 88

MEDICINE 4.44 (0.57) 23 4.48 (0.60) 24 4.54 (0.65) 47 150

NURSING 4.57 (0.50) 19 5.06 (0.52) 19 4.91 (0.41) 27 62

PHARMACY 4.62 (0.35) 24 5.01 (0.47) 23 4.34 (0.73) 107 127

PHYSICAL THERAPY

4.42 (0.63) 7 4.91 (0.45) 9 4.40 (0.76) 9 22

ALL 3.78 (0.67) 94 4.73 (0.63) 91 4.64 (0.68) 209

1 = strongly disagree, 6 = strongly agree

Attitude Toward Physician’s Shared Role on Team

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Pre-ISPE Mean (SD)

n

Post-ISPE Mean (SD)

n Comparison Mean (SD)

n Class Size

DENTISTRY 3.65 (0.70) 21 3.81 (0.56) 18 3.59 (0.62) 19 88

MEDICINE 3.26 (0.54) 23 3.19 (0.57) 24 3.06 (0.67) 47 150

NURSING 3.98 (0.70) 19 4.12 (0.78) 19 4.18 (0.64) 27 62

PHARMACY 3.45 (0.68) 24 3.77 (0.76) 23 3.53 (0.71) 107 127

PHYSICAL THERAPY

3.55 (0.72) 7 3.46 (1.21) 9 4.44 (0.65) 9 22

ALL 3.40 (1.04) 94 3.68 (0.78) 91 3.56 (0.77) 209

1 = strongly disagree, 6 = strongly agree

Students Impression of ISPE Item Mean (SD)

N = 58 I learned about the patient care roles of other healthcare professionals during the ISPE

5.34 (0.66)

I found the debriefing session to be helpful to process my group's experience

4.90 (1.00)

The ISPE increased my comfort in working collaboratively in an interprofessional team to develop a patient care plan

5.19 (0.69)

I would recommend the ISPE to a fellow student in my profession

5.40 (0.82)

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1 = strongly disagree, 6 = strongly agree

Faculty Impressions of ISPE

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Item Mean (SD) n=17

The ISPE fosters communication between participating health professional students.

5.65 (0.61)

The ISPE increases collaboration between participating health professional students.

5.59 (0.80)

The ISPE encourages students to communicate effectively with a patient who has chronic illness.

5.47 (0.72)

The ISPE enhances student understanding of the patient care roles of different health professionals.

5.65 (0.61)

I would recommend participation in the ISPE for learners in my profession.

5.82 (0.39)

1 = strongly disagree, 6 = strongly agree

Focus Group One focus group for each profession

Voluntary participation:

Dentistry: 2 students

Medicine: 5

Nursing: 4

Pharmacy: 5

Physical Therapy: 6

Themes of Process and Outcome

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Assigning Tasks/Roles… “At the beginning we discussed the order, and why we

thought that order was appropriate, and how everybody’s role would sort of fit in with that order.” (Physical Therapy)

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Negotiating Roles…

“So I just hope that in working in a team…that we would have a little bit more time in the beginning to kind of brainstorm each other’s role…because I think I hadn’t worked with a dental student before, or with a pharmacy student directly, or even a nurse-practitioner…I think we took more time and then there were more redundant questions that were asked, that could have been more streamlined.” (Medicine)

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Authenticity… “We usually get all the information, medical

information, dental history, filled out by patient in advance, so we review it and then we review X-rays beforehand, so that we kind of get some idea of the patient.” (Dentistry)

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Integration of Dentistry… “When we organized the order, who’s going to go first and

stuff, actually, it was pretty hard, where a dentist can fit in among these four professionals, because they’re all connected to each other, and I felt like we’re kind of isolated.” (Dentistry)

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Learning About Professions… “It was one of those things that just really opens your

eyes and just gives you a little more insight into what other people do, but – more empathy for understanding their programs, and that they’re just as valuable.” (Nursing)

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Increase in Confidence… “I’m a little more comfortable talking to the physician, in

the sense of – he might not know a lot about physical therapy…they might actually want that information from me, so it’s not so much intimidating to go up to the physician and say, hey, this is what I feel should happen to this patient...” (Physical Therapy)

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Summary of Results ISPE improved attitudes towards working in

interprofessional teams: Team Value and efficiency

ISPE did not improve attitudes towards the Physicians’ Shared Role in interprofessional teams.

Dental students’ attitudes were significantly lower prior to ISPE participation compare to other professions.

Their attitudes improved significantly after ISPE participation.

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Discussion of Results Dental students’ lower initial ratings may reflect the lack

of exposure that dental students have in interprofessional care at our institution.

For nursing, pharmacy, and physical therapy participation in the ISPE was voluntary. Volunteers may would have more positive attitudes towards interprofessional teams and could bias results.

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Discussion of Results (Continued) o Ineffective integration of learners from dentistry

o Possibly due to the nature of the case or the challenges of creating an authentic simulation for dental students.

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Mehran Hossaini, DMD

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Linda Centore, RN PhD

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Contact Info

Mehran Hossaini DMD, Clinical Associate Professor

Department of Oral & Maxillofacial Surgery

Mehran.Hossaini@ucsf.edu

Linda Centore PhD RN, Clinical Professor

Department of Preventive & Restorative Dentistry

Chair, Division of Behavioral Sciences & Community-Based Dental Education

Linda.Centore@ucsf.edu

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References 1. Center for the Advancement of Interprofessional Education.

(2002) London, England: Higher Education Academy Downloaded from website: http://www.caipe.org.uk/

2. Oandasan I, and Reeves S. (2005). Key elements for interprofessional education. Part 1: The learner, the educator, and the learning context. Journal of Interprofessional Care, 1, 21-38.

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References 3. US Department of Health and Human Services. (2000) Oral

Health in America: A Report of the Surgeon General-- Executive Summary . Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health.

4. Nowak AJ, and Casamassimo PS. (2002) The dental home: A primary care concept. American Dental Association, 133, 93-98.

5. Institute of Medicine. (2003) Health Professions Education: A Bridge to Quality. Health Educations Education Summit June 17-18, 2002 Workshop Report.

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References 6. Institute of Medicine (2009). Redesigning Continuing Education

in the Health Professions downloaded form http://www.nap.edu/catalog/12704.html

7. World Health Organization (WHO). (2010) Framework for action on interprofessional education and collaborative practice. Downloaded from http://www.who.int/hrh/resources/framework_action/en/index.html

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References 8. Reeves S, Zwarenstein M, Goldman J, Barr H, Freeth D,

Hammick M, Koppel I. (2008) Interprofessional education: Effects on professional practice and health care outcomes. Cochrane Database Systematic Review, 1: CD002213.

9. Reeves S, Zwarenstein M, Goldman J, Barr H, Freeth D, Hammick M, and Kippel I. (2009). Interprofessional Education: Effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, 1: CD002213.

10. Heinemann GD, Schmitt MH, Farrell MP, Brallier SA. A. (1999) Development of an attitudes toward health care teams scale. Eval Health Prof. 1999;22:123-142.

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References 11. Hyer K, Fairchild S, Abraham I, Mezey M, Fulmer T. (2000)

Measuring attitudes related to interdisciplinary training: Revisiting the Heinemann, Schmitt and Farrell “Attitudes Toward Health Care Teams” scale. J Interprof Care,14, 249–258.

12. Leipzig RM, Hyer K, Kirsten E, Wallenstein S, Vezina ML, Fairchild S, Cassel CK, Howe J. (2002) Attitudes toward working on interdisciplinary healthcare teams: a comparison by discipline. J Am Geriatr Soc., 50:1141-1148.

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