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Building Community:
EDUCATION UPDATE BUILDING COMMUNITY Developing Skills for Interprofessional Health Professions Education and Relationship-Centered Care ABSTRACT In 1995, the National League for Nursing commissioned a Panel on Interdisciplinary/Transdisciplinary Education. The focus of the Panel’s work was to examine educational issues that transcend the health professions and to make recommendations for future implementation of an interdisciplinary approach to addressing them. This article is being simultaneously published by several professional journals. The goal is to seek as much feedback as possible. q 1998 by the American College of Nurse-Midwives. OVERVIEW AND HISTORICAL PERSPECTIVE
Health professionals from many disciplines need to work in concert to address the complex health needs of the diverse and changing populations within the United States. Although each discipline has its own focus, ‘‘all health care disciplines share a common and primary commitment to serving the patient and working toward the ideal of health for all’’ (1). Therefore, society and health care would be better served if students in the health professions ‘‘have opportunities to experience working together. . .in valid models of cooperative health care delivery’’ (2). Consistent with the National League for Nursing’s vision, which involves ‘‘strengthening ties with the community and expanding interdisciplinary activities’’ (3), a presidential panel on interdisciplinary/transdisciplinary education and practice for the health professions was established in 1995. This timely vision called for convening interdisciplinary health professionals to examine such issues as professional boundaries, clinical practice competencies, processes for education primary care, collaborating partnerships for communitybased health care delivery, and program accreditation. The expected outcome is to target reform agendas and identify quality benchmark indicators for interdisciplinary health professions education.
Address correspondence to Joyce J. Fitzpatrick, PhD, FAAN, Dean and Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4904.
The history of interprofessional team care has been briefly summarized as follows (3). The use of interprofessional teams to provide health services to communities was used by missionaries in India in the early 1900s, followed, before World War I, by the call of Cabot and others in Boston for ‘‘teamwork’’ of health professionals in the interest of ‘‘clinical efficiency.’’ After World War II, both Cherkasky and Silver initiated early efforts to employ interprofessional teams to meet the multiple needs of chronically ill patients and families in the community. In the 1960s, the use of interdisciplinary teams was encouraged by the federal government at their funded neighborhood health centers. A major effort at interdisciplinary team training for health profession students was initiated at a number of schools in the 1970s, and in the 1980s, the Veterans Administration funded a nationwide effort to train teams of health professionals in the care of aging veterans. During the past decade, there has been a revival of interest regarding the use of interprofessional teams in health care, under pressure for greater efficiency and fiscal accountability from the government and managed care organizations. This has led in the development of model interdisciplinary training programs with a strong community emphasis for advanced practice nurses, master’s level social workers, residents in internal medicine and family practice, and students in the health professions. Despite the demonstrated value of interprofessional practice, however, a number of structural, organizational, and reimbursement barriers continue to prevent the development of interprofessional practice and educational efforts. The benefits of team and collaborative care have long been known. In addition to the well-known successes of multidisciplinary specialty teams in hospital settings and in the community, interprofessional teams in primary care have enhanced delivery of comprehensive and continuous care to many, especially underserved, populations. Specific benefits have included ‘‘enhanced patient compliance and greater patient satisfaction. . ., increased efficiency and reduced costs. . ., reduction in
Journal of Nurse-Midwifery • Vol. 43, No. 1, January/February 1998 q 1998 by the National League for Nursing Issued by Elsevier Science Inc.
61 0091-2182/98/$19.00 • PII S0091-2182(97)00120-1
broken appointments. . ., decreases in hospitalization, cost of care, and use of physicians.’’ Studies also have found ‘‘lower infant mortality rates, fewer hospitalizations. . ., and fewer emergency room visits’’ as well as ‘‘fewer visits for illness and more visits for health supervision’’ (4). ‘‘In the field of geriatrics, team delivery of comprehensive care has resulted in lower mortality, fewer hospitalizations and reductions in length of stay, more home discharges, fewer drug prescriptions, greater satisfaction on the part of patients and caretakers, less commitment to and time in nursing homes, improved morale and functional status, and lower direct costs’’ (4). As better answers are being sought to the continuing problems of access, quality, and cost-effectiveness of care, it is clear that there needs to be an even more efficient and effective use of all kinds and levels of health professionals through increased cooperation and collaboration. As health professionals responsive to the needs of our patients and society, we must be open to interprofessional collaborative models of practice. To achieve this goal, the health professions must be prepared to put aside traditional disciplinary concerns and engage in creative dialogue with each other. Nowhere is this more
Panelists on Interdisciplinary/Transdisciplinary Education: Joyce J. Fitzpatrick, PhD, RN, FAAN (Panel Co-Chair), President, Academy for Nursing, Dean and Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH Sheila Ryan, PhD, RN, FAAN (Panel Co-Chair), President, National League for Nursing, Dean, University of Rochester School of Nursing, Rochester, NY DeWitt Baldwin, MD, Chicago, IL Roger Bulger, MD, Academic Health Centers, Washington, DC Nancy DeBasio, PhD, RN, American Association of Colleges of Nursing, Dean, Research College of Nursing, Kansas City, MO Jean Johnson-Pawlson, PhD, NP-C, Associate Dean, Health Sciences Program, George Washington University, Washington, DC Christopher McLaughlin, BA, Academic Health Centers, Washington, DC Maureen Kelley, CNM, PhD, FACNM, Chair, Division of Education, American College of Nurse-Midwives, Stone Mountain, GA Leopold Selketr, PhD, Senior Vice-President for Research, Evanston Hospital Corporation, Evanston, IL Bernardine Lacey, EdD, RN, FAAN, Western Michigan University School of Nursing, Kalamazoo, MI Charlene Hanson, EdD, FNP, CS, FAAN, National Organization of Nurse Practitioner Faculties, Georgia Southern University, Statesboro, GA Robin Harvan, EdD, Director, Office of Academic Programs, University of Colorado Health Sciences Center, Denver, CO Patricia Hinton Walker, PhD, RN, FAAN, Dean and Professor, University of Colorado Health, Sciences Center, Denver, CO David Sluyter, EdD, Program Director, Fetzer Institute, Kalamazoo, MI MaryJoan Ladden, PhD, RN, CS, Department of Ambulatory Care and Prevention, Harvard Medical School, Harvard Pilgrim Care, Boston, MA Neal Vanselow, MD, Tulane University Medical School, Department of Health Systems, Management, New Orleans, LA
62
necessary than in health professions education. If we expect students to be able to practice together it appears logical to educate them together. ‘‘Unfortunately, students enrolled in medicine, nursing, and the other health professions and occupations, usually have little contact with each other in the process of their education and still less collaborative learning experiences designed to promote interdisciplinary or interprofessional health care team relationships’’ (4). For health professionals to rise above or transcend the traditional adversarial perceptions and preconditions that often separate the parties or groups involved, the goal should be one of achieving consensus rather than compromise. In this view, organizational and institutional agendas should be consciously set aside, while professionals, as individuals and teams, commit themselves to seeking new and higher levels of understanding and acceptance of the problems, as well as the concerns and contributions of each other. The result of this kind of consensus building will be a new vision of interprofessional education and practice and a new spirit of cooperation and collaboration. Some of these issues have been addressed in the Pew Commission report on relationship-centered care. While renewing the call for interprofessional collaboration and teams in patient care, the report focuses on the network of relationships involved in optimal health care: patient–practitioner, community– practitioner, and practitioner–practitioner. These are the relationships that ‘‘form the context within which people are helped to maintain their functioning and grow in the faith of changes within themselves and their environments’’ (4). GOAL
The goal of the Interdisciplinary Health Education Panel, formed by the National League for Nursing in April of 1996 and including representatives of the major health professions, is to develop a consensus statement regarding interprofessional education that includes: 1. Recommendations for interdisciplinary/transdisciplinary (Baldwin recommends interprofessional here) education and practice 2. Core content and competencies for educating community-focused primary care health practitioners 3. Reform agendas and target areas for consideration related to health professional education and program accreditation 4. Quality indicators that will serve as benchmarks for interprofessional education 5. Recommendations for funding priorities and initiatives for pilot demonstration projects that can leverage change
Journal of Nurse-Midwifery • Vol. 43, No. 1, January/February 1998
GLOSSARY OF TERMS
To facilitate understanding of terms frequently used interchangeably in this consensus statement, the following definitions have been referenced from the literature. Multidisciplinary: ‘‘different aspects of a patient’s case are handled independently by appropriate experts from different professions. Rather than integrated care, the patient’s problems are subdivided and treated in parallel, with each provider responsible only for his or her own area’’ (5). Interprofessional: first introduced in 1975 and has been used with increasing frequency in reference to clinical practice (4). Interdisciplinary versus Interprofessional: interdisciplinary—‘‘denotes the provision of health care by providers from different professions in a coordinated manner, which addresses the various aspects of the patient’s health care needs. Providers share mutual goals, resources, and responsibility for patient care. Interdisciplinary is frequently used to describe the education process while the term interprofessional care is used to describe clinical practice.’’ Page vi, from health professions education (5). Transdisciplinary: yields different results than interdisciplinary approaches because it ‘‘requires each team member to become sufficiently familiar with the concepts and approaches of his or her colleagues as to blur the disciplinary bounds and enable the team to focus on the problem as part of broader phenomena: as this happens, discipline authorization fades in importance, and the problem and its context guide an appropriately broader and deeper analysis’’ (10). CONSENSUS, CORE COMPONENTS, AND COMPETENCIES OF INTERPROFESSIONAL EDUCATION
Professional education is built on preprofessional education; therefore, it is important to foster collaborative learning experiences between and among learners with different backgrounds. The use of collaborative servicelearning models also enhances interdisciplinary education by developing critical thinking skills as well as a sense of valuing and sensitivity to the needs of others different from themselves (5). These models not only foster collaboration among professions but enable students and faculty to provide valuable services to communities, as they learn about relationship-centered care that is personal, professional, and community sensitive (6). Underlying assumptions for educating students to value interprofessional education and practice include: 1. Interdisciplinary education is better served by a health, rather than medical, model.
2. Learning together will lead to working together. 3. Learning together will enhance understanding of the problems and solutions. 4. Learning necessarily involves self-awareness and self-disclosure; one must develop integrity that is both personal and professional. 5. Professionals have a responsibility for lifelong learning. 6. Professionals must accept responsibility and accountability for their own actions. 7. Professionals can learn to respect and trust persons from other disciplines. 8. Models of authority do not foster relationship-centered practice. 9. Professional identity (collegiality) is strengthened by sharing and diversity. 10. Solutions should be need based (demand side rather than supply side oriented). 11. Community building is a basic human need. 12. Professional service and stewardship is rooted in the principle of social justice. Interprofessional education can be defined as ‘‘an educational approach in which two or more disciplines collaborate in the learning process with the goals of fostering interprofessional interactions that enhance the practice of each discipline’’ (5). Such interdisciplinary education is based on mutual understanding and respect for the actual and potential contributions of the disciplines. Collaborative learning among disciplines should take place, both in the classroom and in clinical settings. Cooperation and collaboration should be woven throughout every aspect of the curriculum and built into every learning experience. Throughout education there should be a focus on the quality improvement process. CORE CONTENT
Core content should be taught across disciplinary boundaries and integrate values and process components of professional behavior. The following skills and common knowledge areas should be included: ● ● ● ● ● ● ● ● ● ● ● ● ● ●
behavioral sciences common terminology community health death and dying growth and development (including aging) health care systems health promotion and prevention health informatics nutrition change and the change process ethics and values health assessment interpersonal and communication skills relationship-centered care
Journal of Nurse-Midwifery • Vol. 43, No. 1, January/February 1998
63
FIGURE 1. Interpersonal health education curricula matrix.
● ● ● ●
role theory skills for community building skills for team work and teaming socialization and professionalism
Educational philosophies and beliefs underlying interprofessional education: ● ● ● ● ● ● ●
knowledge and skills go hand in hand. affective learning enhances didactic learning. experiential learning enhances skills development. problem-based learning enhances cognitive learning. self-learning flows from group learning. diversity of views enhances group learning. personal awareness and self-esteem flow from interpersonal interaction. ● dignity and respect are basic requirements for student well-being and learning. ● faculty and students should be companions in learning ‘‘guide by the side rather than sage on the stage.’’ Competence has been defined as skilled knowledge; capability and the state of being duly qualified or fit (7). For the health professions, competency is related to the ability to perform comprehensive health assessment, develop sensitive and perceptive diagnoses (including psycho/social diagnoses), and determine appropriate pharmacologic and nonpharmacologic intervention and management for patients and families. Clinical competence is necessary for trust and respect, and it is probably the most important basis for successful collaborative relationships among providers. However, for interdisciplinary education and interprofessional practice, competence in interpersonal and communication skills is required for success. Interpersonal competence is an appreciation of the skill and uniqueness of all individuals involved. It encompasses and includes a flexible, nonhierarchical stance with open communication both verbally and nonverbally. Heightened interpersonal competence comes from working at relationships over time to increase interrelatedness and mutuality. Mutuality is defined as full appreciation of the ‘‘other,’’ acknowledging different ways of doing and valuing differences among the professions. A fine-tuned intuitive and
64
responsive communication style is vital to success in interprofessional education and practice (8). The Pew-Fetzer report on relationship-centered care highlights the importance of developing competencies that revolve ‘‘around the complexities and uncertainties involved in caring for people’s health in relationships with patient, communities, and other practitioners’’ (9). To work effectively in all dimensions of these relationships, interprofessional education programs must assist the practitioner in developing knowledge and skills in, and attribute value to, the following areas: self, relationship with others, and community. One approach for organization and identification of the skills and content required for the development of competencies is to use a matrix. The matrix shown in Figure 1 is designed to assist in organizing the process and content required in shaping interprofessional health education curricula to ensure that competencies mentioned previously are addressed. This matrix is also designed to facilitate discussion among health professionals for the development of knowledge, skills, and values needed in the context of interprofessional relationship-centered care.
STRATEGIES
Strategies for stimulating interprofessional education among the health professions and obtaining consensus include the following: ● Initiate a ‘‘clarion call’’ in an open letter to interdisci-
plinary colleagues in education and practice (placed on web pages of the Association of Academic Health Centers, National League for Nursing, and other interdisciplinary groups such as the National Academies of Practice), which invites: ● Dialogue Input and feedback Consensus building Sharing of databases Curricular ideas
Journal of Nurse-Midwifery • Vol. 43, No. 1, January/February 1998
Sharing of best practices and educational models Presentations of this topic or the Panel’s work at professional conferences Support from and collaboration with concurrent change agents and movements (primary care, generalist training, continuous quality improvement, and managed care, and so forth). ● Call for action Publish the results of this consensus document in practice and education journals Letter to editors of journals ● Invitational conferences Encourage existing and develop new conferences to include topics on interprofessional education and practice Develop invitational conferences to stimulate change ● Identify groups who might be interested Community groups Foundations and other funders Consumer groups Education groups among each profession ● Interface with practice organizations in all professions Encourage response and input via the Internet through web pages Encourage publication within professional journals Encourage inclusion of interprofessional topics at conferences Encourage coalitions among health provider organizations ● Identify champions among the professions who will: Speak and write effectively to promote interprofessional collaboration Accept responsibility for stimulating change within professions and institution Attend invitational conferences to stimulate change Facilitate response among colleagues to a web page ‘‘clarion call’’ ● Encourage both top-down and bottom-up approaches to the development of interprofessional education and practice opportunities Sharing exemplars Obtaining curricular ideas from young faculty and students Invite best papers and practices A strong link between the education and practice components is critical to preparing health professionals for interprofessional collaboration. Although theory and classroom education are important, the clinical practice setting infuses a critical sense of reality into the learning process. Real partnerships across disciplines are necessary to develop the education–practice linkages, and the
use of formal arrangements, such as joint appointments, enhances and encourages consistent collaboration and shared accountability. The formation and use of teams in academic health centers is a key strategy that should be increasingly used for teaching interdisciplinary team delivery. Also, continuous quality improvement remains both a tool and a goal. The Interdisciplinary Health Education Panel encourages input and response from all health care professionals and is interested in recognizing the work that is already ongoing related to this important topic. To foster enthusiasm and implementation for interprofessional education, a brief synopsis of this consensus document has been placed on web sites of interprofessional organizations. The purpose is to encourage top-down and bottom-up feedback and suggestions and to build consensus among professionals from all health-related disciplines. Initially, two web sites have been chosen to facilitate discussion and response to this consensus document; the Association of Academic Health Centers and the National Academies of Practice. These web sites can be accessed through the addresses listed below. The Academic Health Center’s web site address: HTTP://WWW.AHCNET.ORG The National Academies of Practice web site Address: http://home.att.net/n.a.p./ REFERENCES 1. American Association of Colleges of Nursing Position Statement. Interdisciplinary education and practice. J Professional Nurs 1996;12:119 –23. 2. Pellegrino ED. Interdisciplinary education in the health professions: assumptions, definitions, and some notes on teams, Educating for The Health Team. Conference report of the Institute of Medicine, 1972. 3. National League for Nursing. NLN Vision and Mission Statement (1995–1997). 4. Baldwin DC Jr. Some historical notes on interdisciplinary and interprofessional education and practice in health care in the U.S.A. J Interprofessional Care 1996;10:173– 87. 5. Tresolini CP, the Pew-Fetzer Task Force. Health Professions Education and Relationship Centered Care, San Francisco. Pew Health Professions Commission, 1994. 6. Sigmon R. Service-learning: three Principles, Synergist. National Center for Service-Learning, Action 1979;8:9 –11. 7. American Association of College of Nursing Position Statement, 1996. 8. Hanson CM. Desired competencies for nurse practitioners: a Delphi study of masters level curriculum priorities. Dissertation Abstracts Interactions 1986;4712. 87-06888, Book A. 9. Hamric AB, Spross JA, Hanson DM. Advanced practice nursing: an integrative approach. Philadelphia: WB Saunders, 1996. 10. Interdisciplinary Collaborative Teams in Primary Care. A model curriculum and resource guide. Pew Health Professions Commission 1995.
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Health professionals from many disciplines need to work in concert to address the complex health needs of the diverse and changing populations within the United States. Although each discipline has its own focus, ‘‘all health care disciplines share a common and primary commitment to serving the patient and working toward the ideal of health for all’’ (1). Therefore, society and health care would be better served if students in the health professions ‘‘have opportunities to experience working together. . .in valid models of cooperative health care delivery’’ (2). Consistent with the National League for Nursing’s vision, which involves ‘‘strengthening ties with the community and expanding interdisciplinary activities’’ (3), a presidential panel on interdisciplinary/transdisciplinary education and practice for the health professions was established in 1995. This timely vision called for convening interdisciplinary health professionals to examine such issues as professional boundaries, clinical practice competencies, processes for education primary care, collaborating partnerships for communitybased health care delivery, and program accreditation. The expected outcome is to target reform agendas and identify quality benchmark indicators for interdisciplinary health professions education.
Address correspondence to Joyce J. Fitzpatrick, PhD, FAAN, Dean and Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4904.
The history of interprofessional team care has been briefly summarized as follows (3). The use of interprofessional teams to provide health services to communities was used by missionaries in India in the early 1900s, followed, before World War I, by the call of Cabot and others in Boston for ‘‘teamwork’’ of health professionals in the interest of ‘‘clinical efficiency.’’ After World War II, both Cherkasky and Silver initiated early efforts to employ interprofessional teams to meet the multiple needs of chronically ill patients and families in the community. In the 1960s, the use of interdisciplinary teams was encouraged by the federal government at their funded neighborhood health centers. A major effort at interdisciplinary team training for health profession students was initiated at a number of schools in the 1970s, and in the 1980s, the Veterans Administration funded a nationwide effort to train teams of health professionals in the care of aging veterans. During the past decade, there has been a revival of interest regarding the use of interprofessional teams in health care, under pressure for greater efficiency and fiscal accountability from the government and managed care organizations. This has led in the development of model interdisciplinary training programs with a strong community emphasis for advanced practice nurses, master’s level social workers, residents in internal medicine and family practice, and students in the health professions. Despite the demonstrated value of interprofessional practice, however, a number of structural, organizational, and reimbursement barriers continue to prevent the development of interprofessional practice and educational efforts. The benefits of team and collaborative care have long been known. In addition to the well-known successes of multidisciplinary specialty teams in hospital settings and in the community, interprofessional teams in primary care have enhanced delivery of comprehensive and continuous care to many, especially underserved, populations. Specific benefits have included ‘‘enhanced patient compliance and greater patient satisfaction. . ., increased efficiency and reduced costs. . ., reduction in
Journal of Nurse-Midwifery • Vol. 43, No. 1, January/February 1998 q 1998 by the National League for Nursing Issued by Elsevier Science Inc.
61 0091-2182/98/$19.00 • PII S0091-2182(97)00120-1
broken appointments. . ., decreases in hospitalization, cost of care, and use of physicians.’’ Studies also have found ‘‘lower infant mortality rates, fewer hospitalizations. . ., and fewer emergency room visits’’ as well as ‘‘fewer visits for illness and more visits for health supervision’’ (4). ‘‘In the field of geriatrics, team delivery of comprehensive care has resulted in lower mortality, fewer hospitalizations and reductions in length of stay, more home discharges, fewer drug prescriptions, greater satisfaction on the part of patients and caretakers, less commitment to and time in nursing homes, improved morale and functional status, and lower direct costs’’ (4). As better answers are being sought to the continuing problems of access, quality, and cost-effectiveness of care, it is clear that there needs to be an even more efficient and effective use of all kinds and levels of health professionals through increased cooperation and collaboration. As health professionals responsive to the needs of our patients and society, we must be open to interprofessional collaborative models of practice. To achieve this goal, the health professions must be prepared to put aside traditional disciplinary concerns and engage in creative dialogue with each other. Nowhere is this more
Panelists on Interdisciplinary/Transdisciplinary Education: Joyce J. Fitzpatrick, PhD, RN, FAAN (Panel Co-Chair), President, Academy for Nursing, Dean and Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH Sheila Ryan, PhD, RN, FAAN (Panel Co-Chair), President, National League for Nursing, Dean, University of Rochester School of Nursing, Rochester, NY DeWitt Baldwin, MD, Chicago, IL Roger Bulger, MD, Academic Health Centers, Washington, DC Nancy DeBasio, PhD, RN, American Association of Colleges of Nursing, Dean, Research College of Nursing, Kansas City, MO Jean Johnson-Pawlson, PhD, NP-C, Associate Dean, Health Sciences Program, George Washington University, Washington, DC Christopher McLaughlin, BA, Academic Health Centers, Washington, DC Maureen Kelley, CNM, PhD, FACNM, Chair, Division of Education, American College of Nurse-Midwives, Stone Mountain, GA Leopold Selketr, PhD, Senior Vice-President for Research, Evanston Hospital Corporation, Evanston, IL Bernardine Lacey, EdD, RN, FAAN, Western Michigan University School of Nursing, Kalamazoo, MI Charlene Hanson, EdD, FNP, CS, FAAN, National Organization of Nurse Practitioner Faculties, Georgia Southern University, Statesboro, GA Robin Harvan, EdD, Director, Office of Academic Programs, University of Colorado Health Sciences Center, Denver, CO Patricia Hinton Walker, PhD, RN, FAAN, Dean and Professor, University of Colorado Health, Sciences Center, Denver, CO David Sluyter, EdD, Program Director, Fetzer Institute, Kalamazoo, MI MaryJoan Ladden, PhD, RN, CS, Department of Ambulatory Care and Prevention, Harvard Medical School, Harvard Pilgrim Care, Boston, MA Neal Vanselow, MD, Tulane University Medical School, Department of Health Systems, Management, New Orleans, LA
62
necessary than in health professions education. If we expect students to be able to practice together it appears logical to educate them together. ‘‘Unfortunately, students enrolled in medicine, nursing, and the other health professions and occupations, usually have little contact with each other in the process of their education and still less collaborative learning experiences designed to promote interdisciplinary or interprofessional health care team relationships’’ (4). For health professionals to rise above or transcend the traditional adversarial perceptions and preconditions that often separate the parties or groups involved, the goal should be one of achieving consensus rather than compromise. In this view, organizational and institutional agendas should be consciously set aside, while professionals, as individuals and teams, commit themselves to seeking new and higher levels of understanding and acceptance of the problems, as well as the concerns and contributions of each other. The result of this kind of consensus building will be a new vision of interprofessional education and practice and a new spirit of cooperation and collaboration. Some of these issues have been addressed in the Pew Commission report on relationship-centered care. While renewing the call for interprofessional collaboration and teams in patient care, the report focuses on the network of relationships involved in optimal health care: patient–practitioner, community– practitioner, and practitioner–practitioner. These are the relationships that ‘‘form the context within which people are helped to maintain their functioning and grow in the faith of changes within themselves and their environments’’ (4). GOAL
The goal of the Interdisciplinary Health Education Panel, formed by the National League for Nursing in April of 1996 and including representatives of the major health professions, is to develop a consensus statement regarding interprofessional education that includes: 1. Recommendations for interdisciplinary/transdisciplinary (Baldwin recommends interprofessional here) education and practice 2. Core content and competencies for educating community-focused primary care health practitioners 3. Reform agendas and target areas for consideration related to health professional education and program accreditation 4. Quality indicators that will serve as benchmarks for interprofessional education 5. Recommendations for funding priorities and initiatives for pilot demonstration projects that can leverage change
Journal of Nurse-Midwifery • Vol. 43, No. 1, January/February 1998
GLOSSARY OF TERMS
To facilitate understanding of terms frequently used interchangeably in this consensus statement, the following definitions have been referenced from the literature. Multidisciplinary: ‘‘different aspects of a patient’s case are handled independently by appropriate experts from different professions. Rather than integrated care, the patient’s problems are subdivided and treated in parallel, with each provider responsible only for his or her own area’’ (5). Interprofessional: first introduced in 1975 and has been used with increasing frequency in reference to clinical practice (4). Interdisciplinary versus Interprofessional: interdisciplinary—‘‘denotes the provision of health care by providers from different professions in a coordinated manner, which addresses the various aspects of the patient’s health care needs. Providers share mutual goals, resources, and responsibility for patient care. Interdisciplinary is frequently used to describe the education process while the term interprofessional care is used to describe clinical practice.’’ Page vi, from health professions education (5). Transdisciplinary: yields different results than interdisciplinary approaches because it ‘‘requires each team member to become sufficiently familiar with the concepts and approaches of his or her colleagues as to blur the disciplinary bounds and enable the team to focus on the problem as part of broader phenomena: as this happens, discipline authorization fades in importance, and the problem and its context guide an appropriately broader and deeper analysis’’ (10). CONSENSUS, CORE COMPONENTS, AND COMPETENCIES OF INTERPROFESSIONAL EDUCATION
Professional education is built on preprofessional education; therefore, it is important to foster collaborative learning experiences between and among learners with different backgrounds. The use of collaborative servicelearning models also enhances interdisciplinary education by developing critical thinking skills as well as a sense of valuing and sensitivity to the needs of others different from themselves (5). These models not only foster collaboration among professions but enable students and faculty to provide valuable services to communities, as they learn about relationship-centered care that is personal, professional, and community sensitive (6). Underlying assumptions for educating students to value interprofessional education and practice include: 1. Interdisciplinary education is better served by a health, rather than medical, model.
2. Learning together will lead to working together. 3. Learning together will enhance understanding of the problems and solutions. 4. Learning necessarily involves self-awareness and self-disclosure; one must develop integrity that is both personal and professional. 5. Professionals have a responsibility for lifelong learning. 6. Professionals must accept responsibility and accountability for their own actions. 7. Professionals can learn to respect and trust persons from other disciplines. 8. Models of authority do not foster relationship-centered practice. 9. Professional identity (collegiality) is strengthened by sharing and diversity. 10. Solutions should be need based (demand side rather than supply side oriented). 11. Community building is a basic human need. 12. Professional service and stewardship is rooted in the principle of social justice. Interprofessional education can be defined as ‘‘an educational approach in which two or more disciplines collaborate in the learning process with the goals of fostering interprofessional interactions that enhance the practice of each discipline’’ (5). Such interdisciplinary education is based on mutual understanding and respect for the actual and potential contributions of the disciplines. Collaborative learning among disciplines should take place, both in the classroom and in clinical settings. Cooperation and collaboration should be woven throughout every aspect of the curriculum and built into every learning experience. Throughout education there should be a focus on the quality improvement process. CORE CONTENT
Core content should be taught across disciplinary boundaries and integrate values and process components of professional behavior. The following skills and common knowledge areas should be included: ● ● ● ● ● ● ● ● ● ● ● ● ● ●
behavioral sciences common terminology community health death and dying growth and development (including aging) health care systems health promotion and prevention health informatics nutrition change and the change process ethics and values health assessment interpersonal and communication skills relationship-centered care
Journal of Nurse-Midwifery • Vol. 43, No. 1, January/February 1998
63
FIGURE 1. Interpersonal health education curricula matrix.
● ● ● ●
role theory skills for community building skills for team work and teaming socialization and professionalism
Educational philosophies and beliefs underlying interprofessional education: ● ● ● ● ● ● ●
knowledge and skills go hand in hand. affective learning enhances didactic learning. experiential learning enhances skills development. problem-based learning enhances cognitive learning. self-learning flows from group learning. diversity of views enhances group learning. personal awareness and self-esteem flow from interpersonal interaction. ● dignity and respect are basic requirements for student well-being and learning. ● faculty and students should be companions in learning ‘‘guide by the side rather than sage on the stage.’’ Competence has been defined as skilled knowledge; capability and the state of being duly qualified or fit (7). For the health professions, competency is related to the ability to perform comprehensive health assessment, develop sensitive and perceptive diagnoses (including psycho/social diagnoses), and determine appropriate pharmacologic and nonpharmacologic intervention and management for patients and families. Clinical competence is necessary for trust and respect, and it is probably the most important basis for successful collaborative relationships among providers. However, for interdisciplinary education and interprofessional practice, competence in interpersonal and communication skills is required for success. Interpersonal competence is an appreciation of the skill and uniqueness of all individuals involved. It encompasses and includes a flexible, nonhierarchical stance with open communication both verbally and nonverbally. Heightened interpersonal competence comes from working at relationships over time to increase interrelatedness and mutuality. Mutuality is defined as full appreciation of the ‘‘other,’’ acknowledging different ways of doing and valuing differences among the professions. A fine-tuned intuitive and
64
responsive communication style is vital to success in interprofessional education and practice (8). The Pew-Fetzer report on relationship-centered care highlights the importance of developing competencies that revolve ‘‘around the complexities and uncertainties involved in caring for people’s health in relationships with patient, communities, and other practitioners’’ (9). To work effectively in all dimensions of these relationships, interprofessional education programs must assist the practitioner in developing knowledge and skills in, and attribute value to, the following areas: self, relationship with others, and community. One approach for organization and identification of the skills and content required for the development of competencies is to use a matrix. The matrix shown in Figure 1 is designed to assist in organizing the process and content required in shaping interprofessional health education curricula to ensure that competencies mentioned previously are addressed. This matrix is also designed to facilitate discussion among health professionals for the development of knowledge, skills, and values needed in the context of interprofessional relationship-centered care.
STRATEGIES
Strategies for stimulating interprofessional education among the health professions and obtaining consensus include the following: ● Initiate a ‘‘clarion call’’ in an open letter to interdisci-
plinary colleagues in education and practice (placed on web pages of the Association of Academic Health Centers, National League for Nursing, and other interdisciplinary groups such as the National Academies of Practice), which invites: ● Dialogue Input and feedback Consensus building Sharing of databases Curricular ideas
Journal of Nurse-Midwifery • Vol. 43, No. 1, January/February 1998
Sharing of best practices and educational models Presentations of this topic or the Panel’s work at professional conferences Support from and collaboration with concurrent change agents and movements (primary care, generalist training, continuous quality improvement, and managed care, and so forth). ● Call for action Publish the results of this consensus document in practice and education journals Letter to editors of journals ● Invitational conferences Encourage existing and develop new conferences to include topics on interprofessional education and practice Develop invitational conferences to stimulate change ● Identify groups who might be interested Community groups Foundations and other funders Consumer groups Education groups among each profession ● Interface with practice organizations in all professions Encourage response and input via the Internet through web pages Encourage publication within professional journals Encourage inclusion of interprofessional topics at conferences Encourage coalitions among health provider organizations ● Identify champions among the professions who will: Speak and write effectively to promote interprofessional collaboration Accept responsibility for stimulating change within professions and institution Attend invitational conferences to stimulate change Facilitate response among colleagues to a web page ‘‘clarion call’’ ● Encourage both top-down and bottom-up approaches to the development of interprofessional education and practice opportunities Sharing exemplars Obtaining curricular ideas from young faculty and students Invite best papers and practices A strong link between the education and practice components is critical to preparing health professionals for interprofessional collaboration. Although theory and classroom education are important, the clinical practice setting infuses a critical sense of reality into the learning process. Real partnerships across disciplines are necessary to develop the education–practice linkages, and the
use of formal arrangements, such as joint appointments, enhances and encourages consistent collaboration and shared accountability. The formation and use of teams in academic health centers is a key strategy that should be increasingly used for teaching interdisciplinary team delivery. Also, continuous quality improvement remains both a tool and a goal. The Interdisciplinary Health Education Panel encourages input and response from all health care professionals and is interested in recognizing the work that is already ongoing related to this important topic. To foster enthusiasm and implementation for interprofessional education, a brief synopsis of this consensus document has been placed on web sites of interprofessional organizations. The purpose is to encourage top-down and bottom-up feedback and suggestions and to build consensus among professionals from all health-related disciplines. Initially, two web sites have been chosen to facilitate discussion and response to this consensus document; the Association of Academic Health Centers and the National Academies of Practice. These web sites can be accessed through the addresses listed below. The Academic Health Center’s web site address: HTTP://WWW.AHCNET.ORG The National Academies of Practice web site Address: http://home.att.net/n.a.p./ REFERENCES 1. American Association of Colleges of Nursing Position Statement. Interdisciplinary education and practice. J Professional Nurs 1996;12:119 –23. 2. Pellegrino ED. Interdisciplinary education in the health professions: assumptions, definitions, and some notes on teams, Educating for The Health Team. Conference report of the Institute of Medicine, 1972. 3. National League for Nursing. NLN Vision and Mission Statement (1995–1997). 4. Baldwin DC Jr. Some historical notes on interdisciplinary and interprofessional education and practice in health care in the U.S.A. J Interprofessional Care 1996;10:173– 87. 5. Tresolini CP, the Pew-Fetzer Task Force. Health Professions Education and Relationship Centered Care, San Francisco. Pew Health Professions Commission, 1994. 6. Sigmon R. Service-learning: three Principles, Synergist. National Center for Service-Learning, Action 1979;8:9 –11. 7. American Association of College of Nursing Position Statement, 1996. 8. Hanson CM. Desired competencies for nurse practitioners: a Delphi study of masters level curriculum priorities. Dissertation Abstracts Interactions 1986;4712. 87-06888, Book A. 9. Hamric AB, Spross JA, Hanson DM. Advanced practice nursing: an integrative approach. Philadelphia: WB Saunders, 1996. 10. Interdisciplinary Collaborative Teams in Primary Care. A model curriculum and resource guide. Pew Health Professions Commission 1995.
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