A reality-oriented approach to interdisciplinary work

A reality-oriented approach to interdisciplinary work

ORIGINAL ARTICLES A Reality-Oriented Approach to Interdisciplinary Work KATHLEEN ANN LONG, RNCS, PHD, FAAN Although there is a long history of suppor...

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ORIGINAL ARTICLES A Reality-Oriented Approach to Interdisciplinary Work KATHLEEN ANN LONG, RNCS, PHD, FAAN

Although there is a long history of support in the literature for interdisciplinary education, practice, and research, the actual implementation of such activities has varied greatly. Numerous variables inhibit interdisciplinary work, including a tendency to focus on the many barriers to, rather than opportunities for, such work, a lack of solid data documenting its benefits, the difficulty inherent in finding solutions to the conflicts that arise among the disciplines involved, and organizational reward and regulation systems geared toward single-discipline work. Nonetheless, the goal of interdisciplinary work persists, and there are several notable examples of success. Strategies are outlined for incremental achievement of interdisciplinary aspirations in less-than-ideal environments. These strategies include scanning the environment for promising opportunities, setting realistic goals, building commitment to those goals, avoiding useless battles, and celebrating successes. Specific examples of such strategies as used in the Health Science Center at the University of Florida are provided. (Index words: Health professions education/practice, Interdisciplinary education, Interdisciplinary practice, Interdisciplinary research) J Prof Nurs 17:278-282, 2001. Copyright © 2001 by W.B. Saunders Company

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HE IDEA OF INTERDISCIPLINARY education, practice, and research for the health professions has a long and interesting history. For over half a century, educators and health policy leaders have written about and promoted interdisciplinary approaches as an ideal way to educate health-professions students

Professor and Dean, University of Florida College of Nursing, Gainesville, FL. Address correspondence and reprint requests to Dr. Kathleen Ann Long: Professor and Dean, University of Florida College of Nursing, HSC PO Box 100197, Gainesville, FL 32610-0197. Copyright © 2001 by W.B. Saunders Company 8755-7223/01/1706-0006$35.00/0 doi:10.1053/jpnu.2001.28183

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and provide care for patients (Huff & Garrola, 1995). Interdisciplinary research has also been encouraged as a venue for addressing the complex and interrelated problems of disease prevention and health maintenance. Baldwin (1993) suggested that interdisciplinary work in the health professions has experienced numerous cycles of wax and wane. In reviewing this history, one aspect becomes apparent: If writing about, recommending, or even funding were enough to make interdisciplinary education, practice, and research a widespread reality, there would be very different situations today in hospitals, clinics, laboratories, and health-professions schools. The Reality of Interdisciplinary Efforts

Interdisciplinary activities, though often supported in discussion, are hard to implement and harder to maintain. Data documenting the benefits that supposedly accrue to students and patients from interdisciplinary work are rare. Funding for interdisciplinary projects comes and goes, but it is uncommon for these externally funded initiatives to become institutionalized. Reward and regulation systems throughout the health professions rarely support interdisciplinary work. The universities in which health-professions education programs are imbedded focus primarily on productivity and accomplishment by, rather than across, disciplines. National accrediting agencies and state licensing boards actively, if not deliberately, discourage interdisciplinary activity. One need only try, for example, to have a physician or a physical therapist, teach a nursing course, and the reality of each discipline’s regulatory structures becomes apparent. Several investigators (Stumpf & Clark, 1999; Zungolo, 1994) have eloquently detailed the barriers to interdiscipli-

Journal of Professional Nursing, Vol 17, No 6 (November–December), 2001: pp 278-282

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nary education and practice— barriers that exist even when such endeavors occur within the structure of supportive organizations and are seeded with external dollars. Reasons why it cannot be performed vary from the simple, such as classroom size, to the sublime, such as the long-standing tradition and hierarchy of each discipline. Remarkably, after decades of writing and discussion, sometimes even the meaning of the term interdisciplinary is markedly different across the various health professions. Against such a backdrop, it could be concluded that the interdisciplinary ideal, one that nursing-education leaders have long espoused (American Association of Colleges of Nursing, 1995), is rather illusory. However, there are several sound reasons to persevere in efforts to achieve it. Although it is true that interdisciplinary approaches to health-professions education, practice, and research have not been widely adopted, it is also the case that the idea and the ideal refuse to disappear. In fact, it seems that each generation of health care providers discovers anew the potential that exists in combining the complementary skills, knowledge, and approaches of the various disciplines. Common sense alone supports the notion of coordinating a team approach to provide holistic care for patients. When this common sense is bolstered by experience, it is obvious to health care educators, analysts, and leaders that each facet of their profession— education, practice, and research— can be enriched by organized cooperation among the disciplines. Further, there are outstanding, albeit infrequent, examples of enduring success in interdisciplinary work. The education and practice collaboration project at East Tennessee State University has shown not only that genuine interdisciplinary work can be accomplished over a sustained period of time, but that it can effect positive change in the health and welfare of an entire community (Behringer, Bishop, Edwards, & Frank, 1999; Edwards & Smith, 1998). A diverse array of successful interdisciplinary projects have also been ongoing at the Medical University of South Carolina. These have shown in particular, the importance of administrative support in institutionalizing interdisciplinary approaches (Greenberg & Bellack, 1999). Other striking examples of success in interdisciplinary work are highlighted in the publication Catalysts in Interdisciplinary Education: Innovation by Academic Health Centers (Holmes & Osterweis, 1999). Each of these success stories represents a unique set of circumstances capitalized on by special leaders with particular motivation to realize interdisciplinary goals.

Incremental Approaches to Achieving Interdisciplinary Goals

Judging from the literature, the unique situations that foster interdisciplinary work do not occur frequently and, even when present, require sustained and committed effort to yield successful and lasting activities. When leaders in nursing and other health professions are committed to interdisciplinary work but find themselves in less-than-ideal circumstances, incremental approaches to achieving their goals may work best. At the Health Science Center of the University of Florida (UF), incremental approaches have been useful within the context of a research-intensive institution that historically has had no special focus on interdisciplinary work in the health professions. As the result of a new strategic plan, faculty members and administrators from the UF College of Nursing began to actively search out opportunities for interdisciplinary collaboration beginning in 1996, and these efforts have yielded several worthwhile outcomes. Some endeavors have failed over time, but others have resulted in continuing projects that make small, but real, differences. There are some lessons to be learned from this modest success. Interdisciplinary work can be realized in a variety of settings, expressed in a number of ways, and need not be the major thrust of an institution to have meaningful results. Strategies used in developing the UF interdisciplinary initiatives may be useful to others who believe that small steps and moderate successes can make a real difference in strengthening collaboration among the health professions. The primary lesson to be learned from this modest success is that small steps and moderate successes can make a real difference in strengthening collaboration among the health professions. In addition, it is important to recognize that interdisciplinary work can be realized in a variety of settings and expressed in a number of ways, and that it need not be the major thrust of an institution to have meaningful results. The following description of specific strategies used in developing the UF interdisciplinary initiatives may be useful to others who are struggling to achieve interdisciplinary goals under less-than-ideal circumstances.

SCAN THE ENVIRONMENT

An initial step in identifying interdisciplinary opportunities is to scan the environment for situations or circumstances that can foster, support, or even just permit such projects. At UF, one unique circumstance

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was the turnover of all six Health Science Center deans within a relatively short space of time. Six individuals were subsequently hired who genuinely respected and liked each other and had a desire to expand interactions across their colleges, thus, creating potential for interdisciplinary work. Now there was top-down support for faculty projects that had begun on an ad hoc basis, and there was a reasonable level of deans’ support when interdisciplinary work disrupted the status quo, such as faculty workload, space allocations, or student credithour production. The importance of committed leadership for the success of interdisciplinary efforts has been cited frequently in the literature (Edwards & Smith, 1998; Greenberg & Bellack, 1999). Greenberg and Bellack noted in particular the role that deans can play in developing and sustaining interdisciplinary initiatives. This experience highlights the general need to periodically scan one’s own environment to identify any and all variables that might support interdisciplinary work. Too often, the focus is on “why it won’t work here,” rather than on “what we have that will support it.” Every institutional environment has some individuals, resources, or circumstances that can—and if mobilized, will—support interdisciplinary projects. SET REALISTIC GOALS

Setting realistic goals for one’s particular environment is the next critical step. If, for example, one’s environment simply will not allow for interdisciplinary educational experiences, are there opportunities for interdisciplinary practice or research? Not only are these valuable endeavors in their own right, but they often lead to relationships and develop awareness across disciplines that later can facilitate additional or expanded interdisciplinary work. No institutional setting is likely to be well suited for interdisciplinary work in all mission areas, so selecting research, practice, or education as a starting point is a useful strategy. Several wise colleagues have also pointed out that an activity or project is not valuable simply because it is interdisciplinary, rather, the interdisciplinary aspect must strengthen or improve core activities to which each discipline is already committed. Realistic goal setting may also mean defining interdisciplinary as activities that involve just two disciplines. Although the ideal may be a linking of many disciplines, starting with a small two-college project may be a necessity. If the project is performed right, it will often attract other disciplines to participate. At UF, an initiative was developed to teach pharmacy and

nursing students to do family interviewing and assessment in community-based settings. Later, it attracted positive attention and colleagues from medicine asked to participate as well. BUILD COMMITMENT TO THE GOAL, THEN NEGOTIATE THE MEANS

Interdisciplinary projects by their nature are often difficult to implement. Naysayers find a million reasons why the specifics of any given interdisciplinary activity cannot be performed. However, building cross-college consensus among administrators and faculty members on selected interdisciplinary goals can form the basis for working through the difficulties inherent in the specifics, including conflicts over time, space, and money. Once there is shared commitment to a goal, it becomes possible to negotiate the means for achieving it. Two examples show this lesson. At UF, the Health Science Center deans had all espoused a commitment to interdisciplinary research projects, by which they meant cross-college, not just cross-department, endeavors. However, the distribution of indirect cost returns and the actual university credit for research projects had historically been tied to the principal investigator on any given grant. As a result, the work of faculty members on research proposals initiated outside their own colleges yielded no tangible benefit for the home college. The deans’ commitment to a common goal of facilitating interdisciplinary research resulted in the development of a new procedure for allowing shared credit and shared indirect cost returns across colleges proportional to the effort of each faculty member. In another instance, the development of what was termed a real interdisciplinary clinic—including interdisciplinary education, practice, and administration— resulted in a long series of controversies over participation, control, and resource distribution. Despite these roadblocks, such a clinic is currently operational. It has the active participation of students and faculty members from five health science colleges, and an interdisciplinary committee provides oversight. This result reflects individual perseverance and collective belief in a goal. The fact that all deans and the vice president had initially agreed on the goal allowed the group to stay the course through several difficult negotiations about how to achieve it. AVOID USELESS BATTLES

An old proverb advises, “Don’t try to teach a pig to sing, you will frustrate yourself and annoy the pig.” In

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every setting and in any given time period, battles between disciplines break out that will yield no useful outcomes. In fact, they are likely to expend much of the goodwill that existed between disciplines and might otherwise have been available for interdisciplinary collaborations. The expansion of nursing roles in areas of advanced practice, for example, has been a source of particular conflict recently with those in various areas of primary care medicine. Interdisciplinary work, by its nature, requires give and take and therefore must be built on a reasonable level of trust and goodwill across the involved disciplines. Taking a stand on specific issues such as access to patients or practice reimbursement may at times be necessary and appropriate. However, the leaders in each discipline need to carefully weigh the implications of each turf battle, considering not only the benefits of winning, but the inherent costs of a win. A wise strategy is to identify as many win-win practice, education, or research initiatives as possible and use these to strengthen cross-discipline relationships. Even in physician-dominated environments, there are often opportunities for genuine interdisciplinary work with selected departments or even selected individuals. At UF, for example, the College of Nursing has built a sizeable and successful faculty practice both by identifying practice sites and patient populations that were largely noncompetitive, compared with those of other disciplines, and by working to facilitate shared practice opportunities involving providers from other disciplines whenver possible. In establishing a nurse-managed clinic recently, the college faculty has been particularly sensitive to the need to invite active participation from other disciplines. Further, the support of colleague deans and the health science center leadership in resolving cross-discipline conflicts in a reasonably equitable fashion has been an important aspect in the development of cross-discipline trust and the realization of win-win outcomes. MEASURE AND CELEBRATE SUCCESS

It is particularly important to track and report on the results of interdisciplinary projects, even small ones. These can be easily lost when the emphasis is on major research grants, practice income, accreditation review, and other big issues. Those involved in interdisciplinary work need to be recognized and rewarded. Even more importantly, the results of such projects need to be documented and publicized. Such data will

act as critical support for sustaining the project, especially during times of faculty turnover or shrinking financial resources. Measuring the outcomes of interdisciplinary education or practice projects can be particularly challenging. Selected outcomes, such as the career type and setting choice of graduates or patients’ adherence to treatment, should be identified at the onset of the project and tracked. Although outcome measures are imperfect indicators of the direct or exclusive effects of an interdisciplinary component, they are still useful, and particularly so if data are available from comparable single-discipline teaching or practice activities. At the UF Health Science Center, special emphasis has been placed on securing adequate publicity, internal and external, for the accomplishments of all of the colleges, and there has been a particular effort to highlight interdisciplinary work in annual reports and similar documents. The College of Nursing administration has actively sought out opportunities to provide video and oral presentations on interdisciplinary practice and education projects to influential bodies such as the boards of directors of the university foundation and the university’s affiliated health system. Such presentations have included data showing outcomes for graduates, patients, and communities, including grant dollars and state or national awards.

It Is Never Easy

Interdisciplinary education, practice, and research rarely occur by chance. They require commitment and hard work. There are two major underlying factors that tend to work against the success of interdisciplinary activities: professional orientation and workplace structure. Deep-seated professional traditions result in a desire to protect the identity and stature of one’s own profession. Underlying feelings of distrust or even dislike for the other profession are often manifested in heated disagreements about mundane issues, such as faculty or student qualifications, classroom space, or scheduling (Stumpf & Clark, 1999). Rarely do the professionals involved feel comfortable enough to discuss and resolve the underlying issues, and frequently they are not even fully aware of them, having been so well socialized into their own disciplines. Additionally, the workplace structures of the health professions, in both education and health care delivery, discourage interdisciplinary collaboration. Hospital and educational institution accreditations, profes-

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sional licensure, national rankings, and practice reimbursement are all predicated on the achievements, activities, or accomplishments of single disciplines. Changing these structures is akin to turning a very large ship: it may happen, but it will take a very long time. In environments in which large interdisciplinary initiatives are not a part of the institutional culture, and in which there has not been an infusion of significant external dollars to seed projects, initiating and sustaining interdisciplinary work is especially challenging. However, an incremental approach, based on realistic goals that are suited to the institution’s current envi-

ronment, can yield significant small successes and pave the way for larger initiatives. Interdisciplinary projects, even small ones, also provide inspiration for the next generation of health care providers and investigators, while enhancing comprehensive care for patients.

Acknowledgements The author acknowledges with respect and appreciation Dr. Kenneth Burns, Dr. David Challoner, and her colleague deans at the University of Florida Health Science Center. Each, in his own way, has been an inspiration to challenge the status quo and reach beyond the confines of a single discipline.

References American Association of Colleges of Nursing. (1995). Interdisciplinary education and practice. Position Statement. Washington, DC: Author. Baldwin, D. C. (1993). Some historical perspectives on interdisciplinary education and team work. In, National Rural Health Association, Interdisciplinary development of health professions to maximize health provide resources in rural areas (pp. 5-12). Rockville, MD: Author. Behringer, B. A., Bishop, W. S., Edwards, J. B., & Frank, R. D. (1999). A model for partnerships among communities, disciplines and institutions. In D. E. Holmes & M. Osterweis (Eds.), Catalysts in interdisciplinary education. Innovation by academic health centers (pp. 43-58). Washington, DC: Association of Academic Health Centers. Edwards, J., & Smith, P. (1998). Impact of interdisciplinary education in underserved areas: Health professions collaboration in Tennessee. Journal of Professional Nursing, 14, 144-149.

Greenberg, R. S., & Bellack, J. P. (1999). Building an interdisciplinary culture. In D. E. Holmes & M. Osterweis (Eds.), Catalysts in interdisciplinary education. Innovation by academic health centers (pp. 59-77). Washington, DC: Association of Academic Health Centers. Holmes, D. E. & Osterweis, M. (1999). Catalysts in interdisciplinary education. Innovation by academic health centers. Washington, DC: Association of Academic Health Centers. Huff, F., & Garrola, G. (1995). Potential patterns. Conceptual and practical issues in interdisciplinary education. Journal of Allied Health, 24, 359-365 Stumpf, S. H., & Clark, J. Z. (1999). The promise and pragmatism of interdisciplinary education. Journal of Allied Health, 28, 30-32. Zungolo, E. (1994). Interdisciplinary education in primary care: The challenge. Nursing & Health Care, 15, 288292.