Health Services Executive

Interprofessional Learning Master Class

20th June 2012

Helena Low

Health Services Executive

CAIPE Interprofessional Learning Master Class

Learning Together to Work Together,

Working Together to Learn together’

The foundations for collaborative Care

Helena LowVice Chair

Centre for the Advancement of Interprofessional Education

Themes and Questions

What is interprofessional collaborative practice / interprofessional collaborative care - what do we actually mean when we use these terms?

What difference does it make? Why the global emphasis on it? What are the competencies required? Why do we need interprofessional learning to develop collaborative practice ?

What do we mean by interprofessional education? Why is it essential for professional education?

Aims of the Master classFoster a greater and shared understanding of what collaborative care means and what is involved within the Irish context

Generate interest and engagement in interprofessional learning for collaborative practice

Encourage you to consider practical application in the workplace

Encourage you to identify further areas of interest in relation to taking forward collaborative initiatives

Interprofessional learning and collaborative practice in the context of global health

International / global trends Economic factors – limited Resources Modernisation Ageing population Integration, Collaboration, Decentralisation Service User focus Community participation Emphasis on patient safety

H. Low

Drivers of change resource constraints

Rising cost of care, Increasing demand, diminishing resources

demography Ageing population, Movement of people

technological advances More people surviving defects, Illness, disease, accidents

consumer expectations more informed recipients of care.

loss of confidence in professionals Medical errors, lack of communication between professionals

Health systems worldwide

are struggling with:

increasingly complex and costly challenges,

ever more demands on health workers

patients needs have become more complex and more - challenging.

Modernisation essential todeal with:

inequalities in access to health and care,

growing pressures of chronic non communicable illnesses

services for the vulnerable, older people and children suffering

Issues around patient safety

Global picture

‘In a world of radically increased interdependenceinterdependence, health nearly everywhere is being shaped by the same powerful forces, like demographic ageing, rapid urbanization, and the globalization of unhealthy lifestyles.’

Dr Margaret Chan Director-General WHO 2012

The impact of globalisation globalisation - the international movement of professionals and professional knowledge and the resulting cross cultural transition of ideas are all manifestations of the global interdependence in health and education.

Lancet Commission (2010)

World Health Reports A series of reports produced regularly by the

World Health Organization (WHO). Published annually or biennially in multiple languages, Each report includes an expert assessment of a specific

global health topic, relating to all countries that are Member States of the organization.

Learning Together to Work Together for Health. World Health Organisation (1988)

Report of a WHO Study Group on Multiprofessional Education for Health Personnel. The Team Approach Technical Report Series 769. Geneva: WHO

World Health Report ‘Working Together for Health’ WHO (2006)

WHO significant Reports

World Health Report (2006) ‘Working Together for Health’ Highlighted a "global health workforce crisis". an estimated shortage of almost 4.3 million doctors, nurses, midwives, and other health human resources worldwide.

World Health Report (2008) Primary Health Care (Now more than ever)’ ‘Now, more than ever, the health of people worldwide depends on health professionals working together across the boundaries of disciplines, professions and conventions’

Framework for Action on Interprofessional Education & Collaborative Practice (2010) – Report to the WHO The WHO and its partners acknowledge that there is sufficient evidence to indicate that effective interprofessional education enables effective collaborative practice.’

In response to these challenges:

In countries across the world government policies on workforce development have focused on the need for

- collaborative frameworks for education and practice; - integrated approaches to care; - co-operation, - working across professional and organisational

boundaries

Internationally, IPE and collaborative practice are seen as potential strategies to mitigate global health workforce crisis

An effective, interagency, interprofessional workforce is seen as critical for the health and welfare of future generations.

Impact of this approach

Modernisation is about looking at the workforce in a different way, as teams of people rather than as different professional ‘tribes’

Global modernising politics reshaping healthcare relationships

Health and social care professions are faced with substantial changes in the pattern of their relationships.

Response to the Challenges by Governments around the world

Some examples

United Kingdom Canada Japan Australasia

In Ireland ?

‘

Programme of reform Universal health insurance Community based services

through a primary care setting New models of care National Clinical Care

Programmes designed and implemented by clinically led multidisciplinary teams

Emphasis on standards and patient safety

greater flexibilities in work practices and rosters to achieve more efficient delivery of services

HSE Report 2011

‘Implementation of theNational Clinical programmesis driving a re engineering oftraditional models of care andof service delivery’’

‘Our Health services arefacing challenges on a scale never experienced before’

‘All of these are being designedand implemented by clinicallyled multidisciplinary teams.’

Health systems

Interprofessional Learning and Collaborative Practice

No one profession can respond adequately to the multiplicity of problems that many patients present, be they children at risk, alienated young people, members of dysfunctional families, chronically sick and disabled people living longer, or amongst the growing number of old people surviving to an advanced age.

H. Low

Patient SafetyInquiries into medical errors, e.g. the United States (Institute of Medicine, 2001) and the United Kingdom (Kennedy, 2001), have attributed failure to problematic communications and relationships between professions (Meads & Ashcroft, 2005).

WHO (2011) Patient Safety Curriculum Guide: Multi-professional EditionFor the past three years, the World Health Organization has been exploring the links between education and health practice – between the education of the healthcare workforce and the safety of the health system. As an outcome, it has developed this multi-professional Patient Safety Curriculum Guide, which addresses a variety of ideas and methods for teaching and assessing patient safety more effectively.

Modernisation is about cultural change

Professions have to work in a different way – and make collaboration a normal part of professional practice.

Collaboration is easy to say, but working together with other professions, new partners and in different ways is not easy.

H. Low

Collaboration

complex process with multiple components

- can be a process, product or both

connecting,

cooperating,

consulting,

- encompasses: coordinating,

co-locating,

community building and

contracting.

- Is more than the sum of its parts

H.Lawson (2004)

Health & CareServicesbased on people’s

needs

Policy makersInternational, national, regional

and local government

Academic institutions Higher & Further education

new partnerships

CommunitiesVoluntary organisations

Service users and carers

Health & CareEmployers / managers

new organisations and agencies

Independent sector

Health & CareProfessionsnew roles, new

occupations, new professions

Connections for

Collaboration

Patient Voices

Why Collaborate? A Video

The Lancet Commission Report – Health professional for a new century: transforming education to strengthen health systems in an interdependent world (2010)

Increasingly interdependent in terms of key health resources, especially skilled workers’

‘imperative to align professional competencies to changing contexts’

What are the competences of interprofessional learning and working

‘soft skills’ and complex achievements

social practices that are highly context dependent,

team working, developing supportive relationships, reflection and self awareness, working across boundaries, communication, interpersonal skills

Mix of dispositions, understandings, attributes andpractices

Competencies for Interprofessional Collaborative practice

CUILU (2006) Interprofessional capability framework. Sheffield: The Combined Universities Interprofessional Learning Unit.

Interprofessional Education Collaborative Expert Panel (2011) Core competencies for interprofessional collaborative practice: report of an expert panel. Washington D.C.: Interprofessional collaborative

Canadian Interprofessional Health Collaborative. A national competency framework for interprofessional collaboration. www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf

‘Core Competencies for Interprofessional Care’ in Healthforce Ontario (2010) Implementing Interprofessional Care in Ontario: Final Report of the Interprofessional Care Strategic Implementation Committee. Ontario

 

Why do we need inter-professional education

Learning for working across professional, organisational and agency boundaries, together, is essential

‘Inter-professional working must be grounded in inter-professional learning’ John Horder 2005

A flexible collaborative ready workforce is dependent on the way in which professionals are educated

Lancet Commission 2010

H. Low

Interprofessional education

‘Occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care’ (CAIPE 2002)

Principles

CAIPE commends a number of principles, drawn from the experience of its members and the interprofessional literature. These highlight the: values

process and

outcomes

deemed essential for effective interprofessional learning and working (CAIPE 2011)

The Evidence Base?

Patients report higher levels of satisfaction, better acceptance of care and improved health outcomes following treatment by a collaborative team.

There is now sufficient evidence to indicate that interprofessional education enables effective collaborative practice which in turn optimizes health services, strengthens health systems and improves health outcomes. World Health Organisation 2010

Hammick et al (2007)

21 studies discussed of the 399 reviewed (UK 11, USA 7, Canada 1, Finland 1, Sweden 1)

15 of the studies (72%) considered undergraduate IPE.

All peer reviewed papers and reports, quantitative and qualitative approaches included

Considered the following outcomes of learning: learners reactions; changes in skills, knowledge, perceptions of and attitude to others; changes in behaviour as well as impact on service users

Findings

Competent facilitation of IPE essential

Learner reaction to IPE is related to multiple factors

IPE needs to reflect appropriate and relevant service delivery settings

Principles of adult learning are key

IPE generally well received and enables learning of the knowledge & skills for collaborative working

In the context of quality improvement initiatives IPE frequently used to enhance development of practice & improvement of services

Cochrane Systematic Review (Reeves et al 2009)

Six studies met the inclusion criteria (small but first IPE review in 2000 found none)

4 RCTs and 2 Controlled Before and After (CBA) Studies

Five studies conducted in the US, one in the UK

All studies undertaken with groups of qualified staff in established teams eg A&E, PHC

Findings

Four of the studies indicated that IPE produced positive outcomes in the following areas:

- emergency dept culture and pt satisfaction; - collaborative team behaviour & reduction of clinical error rates in

emergency dept teams; - management of care to domestic violence victims; - mental health practitioner competencies related to the delivery of

patient care

Two studies reported mixed outcomes (positive and neutral)

Two studies reported that IPE had no impact on either professional practice or patient care

Outcomes, Effectiveness & Evaluation

Outcomes: what you intend to achieve by theend of the Project

Effectiveness: the extent to which youroutcomes have been achieved

Evaluation: process of looking at the evidence /data, to determine whether something has made adifference, ie; to measure any changes that haveoccurred from the initial situation.

Outcomes of Interprofessional Education

Reaction Learners’ view on the learning experience and its interprofessional nature

Modifications of attitudes / perceptionsChanges in reciprocal attitudes or perceptions between participant groups. Changes in perception or attitude

towards the value and/or use of team approaches to caring for specific client group

Acquisition of knowledge / skillsIncluding knowledge and skills linked tointerprofessional collaboration

Outcomes of Interprofessional Education

Behavioural ChangeIdentifies individuals’ transfer ofinterprofessional learning to their practice setting and changed professional practice

Change in organisational practiceWider changes in the organisation and delivery of care

Benefits to patients / clientsImprovements in health or well being of patients and carers

Freeth et al 2003 (modified from Kirkpatrick 1967

Move towards competency based professional education – outcomes expressed as competences

contemporary professional education has adjusted and changed to meet workforce requirements;

so interprofessional education has been seen as necessary to equip professionals for multi dimensional collaboration

Standards and outcomes set by regulatory body and others eg, national occupational standards

Different types, different level.

Common, complementary and collaborative competences

Professionalism

Initial growth of professionalism mid 19th Century Uni professional education, By mid 20th Century professions being challenged Attempts to bring health and social care professions in

general and medicine in particular under greater control Growing concerns about public safety and professional

powers in light of, e.g. tragedies of Bristol Royal Infirmary events and Victoria Climbie

Reform of Professional Regulatory bodies Establishment of Council for Healthcare Regulatory

Excellence

Lancet commission Report (2010)

Idea of professions and professionalism beginning to change

New professions emerging Attempts to break down the barriers between professions Move towards interprofessional practice and

interprofessionalism Need for reforms guided by transformative learning and

interdependence Competency-based education transprofessional teamwork that includes non-professional

health workers

Challenges for IPE in professional

education

Professional socialization Professional culture Professional language / jargon Organizational difficulties Lack of service support Lack of equality and reciprocity

Challenges for IPE in Professional Education

Different educational and social backgrounds Fear of dilution of professional role / loss of

professional identity Separate professional education – stereotyping Perceived different status and power Poor communication Poor facilitation of IPL

Professionalism - key element in agendas related to interprofessional education in the UK

Professions as regulatory bodies assume different degrees of significance in different societies

These set the parameters at national international level for the operation of specific professions, including in education.

Opportunities for creating interprofessional education for practice are not just shaped by the educational institutions concerned and employer partners, but also by professional bodies.

45

Challenges re the practicalities

Fitting IPE into a full curriculum – issues of ‘add on’ / integration

Timetabling and logistics

Resistance from colleagues and students

Hierarchies between professions

Silos and territorialism in universities and in practice

Lack of support from professional organisations

Poor communication systems

Interprofessional learning and working

Works to improve the quality of care Focuses on the needs of service users and

carers Encourages professions to learn with, from

and about each other Respects the integrity and contribution of each

profession Enhances practice within professions

H. Low

Benefits of Inter-professional Learning

and Working Shifts focus from professional roles to patient

needs

Implicitly builds inter-professional team learning/working

Demonstrates the power of sharing knowledge and experience

It fosters innovation and capacity for change

H. Low

Interprofessional Education

Applies principles of Adult Learning

Is practice led

Includes common and comparative learning

Is interactive

Involves service users

Is competency based

Is assessed

Improves practice

Is evaluated

Facilitating Interprofessional Learning

Evidence indicates that the success of interprofessional learning is dependent to a significant extent on the effectiveness of those who facilitate it, at every level.

Facilitation of interprofessional learning

Individuals may be experienced clinicians, practitioners and / or educationalists, but may lack the particular knowledge, skills and confidence to facilitate learning with groups of people from diverse professional backgrounds

Even very experienced teachers find the challenges of multi professional teaching difficult to manage. Preparation is crucial

Facilitation of interprofessional learning requires a level of expertise which builds on but extends beyond the range of knowledge, skills and attitudes required for uni professional teaching.

Facilitators of interprofessional learning of multi professional groups must:

Have the ability to discern and address a range of complex issues, such as different professional cultures. perceived power and status of different professions and professional language.

They must also have the sensitivity required to work across professional and organisational barriers to achieve change.

Members of different professions have different

Styles of learning Patterns of thinking Attitudes to authority

and therefore different constructions of reality.

Different professionals have different skills,

knowledge, concepts

and therefore different value systems

Values and relationships

The values that are part of professional culture will be reflected in the way professionals perceive other professions and affect the way relationships are (or not) developed.

These relationships are crucial to effective interprofessional working and collaboration and influence the way in which interprofessional education is taken forward.

H. Low

IPE is not achieved by structural and systems change alone

It relies on the development of collaborative relationships, changed attitudes and behavioursfor the long term, to develop a culture of IPE

is an applied discipline dependent on the context where it takes place

learning is transferable to new contexts and dependent on reinforcement

Some Key Factors for effective Interprofessional Learning and Interprofessional working

agreed aims, objectives and values address anxieties regarding any perceived reduction of

standards and dilution of professional service. recognise issues of status and authority equity – all contributions are valued, individual and

professional confidence enhanced respect differences Mutual respect and mutual support are important Recognise own and others’ knowledge and expertise Recognise where these are different and where they

overlapShared Learning: A Good Practice Guide ENB/CCETSW (Low.H,

Weinstein.J)

Key factors for successful planning & delivery of an IPE initiative

identify and get support of key stakeholders strong leadership identify enthusiasts/ champions for IPE work in a partnership of educators and service providers,

plan together involve staff at all levels involve service users resources Start with what you have!

Shared Learning: A Good Practice Guide ENB/CCETSW (Low.H, &Weinstein.J)

Health & CareServicesbased on people’s

needs

Policy makersInternational, national, regional

and local government

Academic institutions Higher & Further education

new partnerships

CommunitiesVoluntary organisations

Service users and carers

Health & CareEmployers / managers

new organisations and agencies

Independent sector

Health & CareProfessionsnew roles, new

occupations, new professions

Identifying stakeholders

potential partners

Connections for

Collaboration

Global Interprofessional networks - connections and relationships

INTERED THE

INTERNATIONAL ASSOCIATION FOR

INTER-PROFESSIONAL EDUCATION &

COLLABORATION

EIPEN EUROPEAN INTER-

PROFESSIONAL EDUCATION NETWORK IN

HEALTH & SOCIAL CARE

JAIPE THE JAPANESE

ASSOCIATION FOR INTER-PROFESSIONAL

EDUCATION

CAIPE UK CENTRE FOR THE

ADVANCEMENT OF INTER-

PROFESSIONAL EDUCATION

Interprofessional learning & working is not just about individuals, groups and organisations coming together and redesigning the way they do things.

It is also about reflecting on the quality of

relationships with each other