The potential advantages and disadvantages of introducing interprofessional education into the healthcare curricula in Spain

Nurse Education Today (2008) 28, 327–336

Nurse Education Today intl.elsevierhealth.com/journals/nedt

The potential advantages and disadvantages of introducing interprofessional education into the healthcare curricula in Spain ´ndez a,*, Navidad Canga Armayor Marı´a J. Pumar Me Marı´a Teresa Dı´az Navarlaz a,2, Ann Wakefield b,3

a,1

,

a

University of Navarra, School of Nursing, C/Irunlarrea s/n, Pamplona, Navarra 31080, Spain School of Nursing Midwifery and Social Work, University of Manchester, Coupland Building 3, Coupland Street, Manchester M13 9PL, United Kingdom b

Accepted 15 June 2007

KEYWORDS

Summary The complexity of contemporary clinical practice demands that increasingly skilled high quality health and social care is provided to individuals. However, the failure of health and social care professionals to work collaboratively has been widely reported in the international literature. Hence, interprofessional education has been suggested as a means of improving both interprofessional understanding and respect across a diverse range of practice disciplines. In this way, functional barriers can be challenged or broken down; teamwork enhanced and healthcare outcomes improved. Lack of conclusive evidence to substantiate the above healthcare benefits has been attributed to weak methodological approaches when evaluating such educational initiatives. In Spain barriers to implementing interprofessional education are potentially less challenging. Recent legislative demands following the Bologna Agreement on European Higher Education is compelling Spanish higher education institutes to engage in radical educational reforms. Consequently, this paper examines some of the advantages and disadvantages of introducing interprofessional education into health and social care curricula in Spain to see when and how interprofessional initiatives might be assimilated into the health care curricula. In

Interprofessional education; Collaborative team working; Healthcare curricula; Integrative care

* Corresponding author. Tel.: +34 625 97 88 50; fax: +34 948 425 740. E-mail addresses: [email protected] (M.J. Pumar Me ´ndez), [email protected] (N.C. Armayor), [email protected] (M.T. Dı´az Navarlaz), [email protected] (A. Wakefield). 1 Tel.: +34 948 425 600x6446; fax: +34 948 425 740. 2 Tel.: +34 948 255 400x2435; fax: +34 948 425 740. 3 Tel.: +44 0161 275 7007; fax: +44 0161 275 7566.



0260-6917/$ - see front matter c 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2007.06.007

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M.J. Pumar Me ´ndez et al. this way lessons learned from a thorough review of the relevant literature might help to inform such educational reforms across mainland Europe and beyond. c 2007 Elsevier Ltd. All rights reserved.

 Introduction

An ageing population, the escalation of chronic illness and modern endemic diseases such as HIV now characterise contemporary healthcare (Goble, 2003; Hall and Weaver, 2001). For this reason, it is no longer possible for one health discipline to provide a complete package of care for such conditions (Heinemann, 2002; McCallin, 2003). However, merely assembling multiple professionals together does not guarantee the attainment of high quality care. Instead, the co-ordination and integration of comprehensive care packages are now thought to be essential if healthcare is to be successful (Heinemann, 2002). Nevertheless, there is considerable evidence to suggest that contemporary healthcare professionals find it difficult to work together (Davoli and Fine, 2004; Elston and Holloway, 2001; Johnson et al., 2003). Examples of the later are evidenced by teamwork failures highlighted during inquiries following tragic incidents in the UK (The Bristol Inquiry, 2001; The Shipman Inquiry, 2002). For this reason, the literature has repeatedly attempted to explore why practitioners are unwilling to engage in interprofessional working. Newbury et al. (1997, p. 84) summarise these reasons suggesting reluctance to participate in collaborative working emanates from role confusion; tribalism and professional rivalry. The origins of such dynamics have been laid at the door of educational establishments where students are first initiated into a profession. Hence, in those faculties where unidisciplinary education abounds, there is little opportunity for teaching interprofessional skills; increasing communication difficulties and perpetuating isolationist practices (Drinka and Clark, 2000; Tunstall-Pedoe et al., 2003). To compound this situation, Brooks and Brown’s (2002) phenomenological qualitative study looking at the significance of organizational routines involving nurses, doctors and allied health professionals, revealed that rigid organisational structures and professional hierarchies reinforced solitary attitudes from the outset of an individual’s career. Interprofessional education is one way of facing up to such dilemmas and occupational hindrances by encouraging two or more professions to learn with, from and about each other to facilitate collaboration and improve the quality of care

(Barr, 2000a; Barr, 2001; CAIPE, 2004; Goble, 2003). Healthcare benefits following the implementation of interprofessional education are seen as the long-term payback derived from achieving greater collaboration amongst professionals (Barr, 1994; Barr, 2000b; WHO, 1988). Contemporary patient care needs to be seen as part of an integrated whole. Thus, by encouraging professionals to share knowledge and work collaboratively, interprofessional education lays down solid foundations on which to integrate professional expertise in order to provide holistic care, which can then result in improved health outcomes (Barr, 2001; Gill and Ling, 1995). Apart from enhanced healthcare outcomes, other valuable effects expected from improving communication and collaboration between professionals are reductions in task duplication, the speeding up of care delivery and more congruent provision of information for patients (Barr, 1994; Bultema et al., 1996). More importantly, given that interprofessional education provides practitioners with a broader knowledge base, professionals are better able to cope with a wider number of tasks (Barr, 2001). This, in turn, leads to a more flexible workforce, maximisation of human resources and alleviation of workforce shortages (Barr, 2001; Miller et al., 1999; Spratley and Pietroni, 1996). Diverse professions covering the same or similar aspects of care leads to a sharing of professional workload pressures and a diminution of functional barriers (Barr, 1994; Barr, 2000b; Barr et al., 1998; McMichael and Gilloran, 1984). Thus, by enhancing interprofessional relationships and sharing workload pressures, practitioners are able to achieve increased job satisfaction, thereby reducing the incidence of burnout (Barr et al., 1998; Barr, 2000b; McGrath, 1991). Recognizing the potential of interprofessional education, international organisations such as the World Health Organisation (WHO), the World Federation of Medical Education (WFME) and the Organisation for Economic Co-operation and Development (OECD) have rigorously campaigned for its worldwide expansion since the early 1970s (Oandasan and Reeves, 2005a; Tope, 1996). These movements have had a strong impact in countries such as Finland, Sweden, Norway, The Sudan, South Africa and Thailand all of which have en-

The potential advantages and disadvantages of introducing interprofessional education gaged in national endeavours to introduce interprofessional education into their healthcare curricula (Areskog, 1988; Barr, 2000b; Goble, 1994). Additionally the United Kingdom, United States, Australia and more recently Canada have also undertaken a number of research projects to introduce interprofessional education into healthcare curricula (Baldwin, 1996; Barr, 2000b; Goble, 2003; McNair et al., 2005; Oandasan and Reeves, 2005a). Although many projects were initiated in the early 1970s, innovations leading to the integration of interprofessional education within healthcare curricula are still in their infancy and evidence to support the indiscriminate implementation of interprofessional education across the full spectrum of healthcare curricula remains scant (Barr, 2001; Freeth et al., 2002; Goosey and Barr, 2002; Hall and Weaver, 2001; Mattick and Bligh, 2003; Zwarenstein et al., 2001, 2005). Evidence supporting the putative association between implementing interprofessional education and subsequent improvements in interprofessional collaboration and patient outcomes tends not to have been generated from university based programmes but workplace base initiatives (Cooper et al., 2001; Freeth et al., 2002; Zwarenstein et al., 2005). Despite evaluations of interprofessional education programmes revealing positive outcomes in terms of participants’ satisfaction with the learning experience, modified perceptions towards other disciplines and self reported attitudinal and/or behavioural change towards greater interprofessional working, little is known about its effectiveness and/or impact on patient care (Cooper et al., 2001; Freeth et al., 2002). Zwarenstein et al. (2001) and Freeth et al. (2002) argue that lack of evidence is not the same as evidence of ineffectiveness. The lack of conclusive evidence regarding the efficacy of interprofessional education is partly explained by the lack of methodological rigour and lack of appropriate evaluation methods employed in existing research projects. Therefore, far from suggesting the abandonment of such educational strategies, further research using more rigorous evaluation methods undertaken on a global basis is recommended to strengthen the evidence available to underpin the implementation of such strategies (Barr, 2000b; Freeth et al., 2002; Zwarenstein et al., 2001). In Spain, where little interprofessional healthcare education currently occurs, both the University Education System and healthcare curricula are undergoing profound change in response to the European Higher Education requirements for reform (Ley 44, 2003; Ministerio de Educacio ´n, Cultura y Deporte, 2003). The ensuing modernization pro-

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gramme includes the expansion of undergraduate nursing, physiotherapy and social work curricula impacting on the length and content of such courses while also opening the gates for postgraduate study opportunities. Following such reforms all health care disciplines will have an equal opportunity for postgraduate study (Ley 44, 2003; Ministerio de Educacio ´n, Cultura y Deporte, 2003; Ministerio de Sanidad y Consumo, 2006a). Moreover, the above programmes now have to include interprofessional communication skills teaching (Consejo General de Enfermerı´a, 2003; Ley 44, 2003; Macia ´ Soler et al., 2006). Such radical reform provides a singular opportunity within Spain to introduce interprofessional education within healthcare curricula to further attest to its effectiveness as an educational strategy. Hence, it is an opportunity for Spanish higher educational establishments to contribute to the body of knowledge regarding interprofessional education if implemented and evaluated using rigorous methodological approaches. Hence, this paper attempts to examine the relevant literature on interprofessional education in order to analyse the feasibility of introducing this educational approach within healthcare curricula in Spain. To fulfil this objective the ensuing debate will explore the advantages and disadvantages of introducing interprofessional education within healthcare curricula, as well as exploring a number of unresolved debates regarding when and how best to introduce this educational approach.

Advantages of interprofessional education The main goal of interprofessional education is to improve teamwork, overcome functional barriers and improve healthcare outcomes (CAIPE, 1997; Miller et al., 1999; WHO, 1988). Interprofessional education has the potential to achieve greater collaboration between healthcare professionals, by encouraging greater understanding through the creation of a common knowledge base and culture (Areskog et al., 1995; Barr, 1994; Barr et al., 1998; WHO, 1988). Moreover, international authors have highlighted that interprofessional education has the potential to promote better understanding between the professions by encouraging students to engage in a detailed exploration of health and social roles (Areskog et al., 1995; Barr, 2001; McNair et al., 2005; WHO, 1988). Analysis of each participating profession’s occupational role inspired by interprofessional learning generates better understanding of both the exclusive and overlapping competencies evident within

330 the caring arena (Baxter, 2004; Cullen et al., 2003; Fraser et al., 2000; Guest et al., 2002; Morison et al., 2003; Parsell et al., 1998). This improved understanding culminates in increased self-confidence, enhances an individual’s recognition of the contribution of others and helps abolish ingrained stereotypes (Cooke et al., 2003; Fraser et al., 2000; Guest et al., 2002; Jones, 1986). Interprofessional education therefore leads to the development of a common knowledge base, language and culture by introducing common concepts, values and perspectives into the curriculum. This latter aspect is achieved by bringing together learners from different disciplines and encouraging them to focus on educational activities that are seen as relevant to all those involved. Thus, by reinforcing the commonalities between the disciplines it is possible to enhance understanding between the professions, enabling practitioners to work towards common clinical goals (Areskog et al., 1995; Barr et al., 2000; WHO, 1988).

M.J. Pumar Me ´ndez et al. For this reason, it has been suggested that specific clinical skills such collaborative problem solving (Baxter, 2004; Fraser et al., 2000), health education (Iliffe and Manthorpe, 2004) and/or technical skills (Guest et al., 2002) could be improved if they were to be delivered as part of an interprofessional education programme. Similarly, interprofessional education has been described as an appropriate means of introducing students to new forms of knowledge common to all practitioners, such as management skills, education and information technology (Areskog et al., 1995; Barr, 1994; WHO, 1988). More importantly, the introduction of interprofessional education can be focused not only on the accomplishment of specific or devolved tasks, but also the enhancement of collaborative competencies (Barr, 1994; Barr, 1998; Barr, 2001; WHO, 1988). Interprofessional education is therefore seen as the way forward to teaching such competences, because of its potential to enhance understanding, trust and respect among professionals while fostering successful communication (Barr, 2001; Miller et al., 1999; Reeves and Freeth, 2002; Smith and Christie, 2004).

Educational benefits associated with interprofessional education It has been argued that a number of educational advantages can be brought about following the introduction of interprofessional education. For example, it is thought that interprofessional education has the capacity to increase knowledge and assimilate new areas of learning whilst encouraging interagency communication (Areskog et al., 1995; Barr, 1994; Funnell, 1995; Gill and Ling, 1995; McNair et al., 2005; Oandasan and Reeves, 2005a; WHO, 1988). Integrating common educational activities across a diverse range of curricula requires a broadening of curriculum content, particularly if it is to satisfy each participant’s learning needs. This expansion of the educational content has the capacity to enhance knowledge (Areskog et al., 1995; Barr, 1994; Miller et al., 1999). Moreover, drawing on a range of interactive learning methods is not only a strength of this approach, but also one of the main underlying principles of interprofessional education (Areskog et al., 1995; Barr, 1997). Hence, it is now recognised that to use an assortment of educational strategies when engaging in interprofessional education leads to better learning outcomes (Funnell, 1995). For example, didactic teaching can be reinforced with interactive learning, fostering reflection on others’ perspectives, furnishing students with a more accurate picture of contemporary practice (Reeves and Freeth, 2002; Reeves et al., 2002).

Potential benefits of interprofessional education within Spain In Spain, the national quality plan stressed the need for improving interprofessional collaboration to advance the quality of care and enhance patient outcomes (Ministerio de Sanidad y Consumo, 2006b). Consistently, curriculum planners have reinforced the importance of equipping healthcare professionals with the necessary collaborative skills to be able to perform their roles effectively within an interprofessional context (Ley 44, 2003). This latter acknowledgement has been reflected in draft proposals for a new nursing curriculum customized to meet the European higher education convergence process standards agreed in Bologna in 1999 (Consejo General de Enfermerı´a, 2003; Macia ´ Soler et al., 2006). These proposals underline that interprofessional collaboration should not be taken for granted. For this reason, specifically structured interprofessional education need to be included within future Spanish healthcare curricula. Moreover, following the implementation of interprofessional education improved collaboration between professionals is perceived to have a positive impact on patient outcomes. Additionally, it is thought that interprofessional education will increase job satisfaction and workforce flexibility while simultaneously reducing organisational pressures across the Spanish

The potential advantages and disadvantages of introducing interprofessional education Health System. Despite Spain being an exporter of health professionals it is currently experiencing severe workforce shortages of its own (Consejo General de Enfermerı´a, 2005; Gonza ´lez Lo ´pez-Valca ´rcel and Barber Pe ´rez, 2006). Experts in Spain together with its recognised professional bodies agree the solution to this problem is to retain staff (Gonza ´lez Lo ´pez-Valca ´rcel and Barber Pe ´rez, 2006; Gonzalez Jurado, 2006). Accordingly in order to retain staff, opportunities for career development and reward among healthcare professionals need to be improved and organisational pressures reduced. In such a climate it could be argued that the potential for interprofessional education to achieve better job satisfaction and greater collaborative working can be rigorously tested and/or perhaps contribute to the solution of this age old problem both nationally and internationally.

Disadvantages of interprofessional education The main concern for those opposed to interprofessional education is the potential for such a strategy to blur a profession’s discrete disciplinary focus (Barr, 2000b; Barr et al., 2000; Funnell, 1995; Miller et al., 1999). For example, interprofessional learning addresses the curriculum content on a much broader basis, to accommodate the interprofessional audience (Barr, 1994; Miller et al., 1999). Critics of interprofessional education assert the benefits of this educational approach can never be achieved without sacrificing the specificity of curriculum content, with the latter seen as having superior value for future practice (Barr et al., 2000; Funnell, 1995; Miller et al., 1999). Moreover, some express scepticism about the real goals behind expanding healthcare curricula and making the healthcare workforce more flexible. The underlying question that such individual’s are now asking is: are advocates of interprofessional education concerned with facilitating integrated care and better patient outcomes or simply reducing human resource costs? (Allen, 2003; Masterson, 2002). In Spain, this apprehension may be expressed by those disciplines for which educational reform does not involve changing the length of the basic degree, namely medicine and pharmacy. While nursing and allied health disciplines might find curriculum broadening attractive since it expands the knowledge base, medicine and pharmacy may declare it impossible without sacrificing specialised content. Nevertheless, commitment from the deans, senior administrators and lecturers across

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all faculties and schools in each individual institution is critical as they are the ones who can influence change and the reallocation of resources necessary to make such reforms work (Barr, 2000b; Gilbert, 2005; Oandasan and Reeves, 2005b; Real Decreto 55, 2005; Real Decreto 56, 2005). Cross-faculty ignorance of the importance of interprofessional perspectives and the need for teamwork may result in an imbalance in the variety of disciplines involved in interprofessional education. This would challenge the underlying philosophy of such an initiative with a subsequent loss of interprofessional focus (Miller et al., 1999). Moreover, if the value of interprofessional education is not fully understood or acknowledged, faculty and school administrators will not be willing to divert precious resources used to underpin unidisciplinary initiatives to support the development of interprofessional curricula (Gilbert, 2005; Mitchell et al., 2006). Such action would preclude the development of effective interprofessional activities as they are expensive to plan, conduct and evaluate. For instance, the scheduling of simultaneous activities across curricula is complex requiring administrators and lecturers to expend considerable time in their planning and co-ordination. Equally, the delivery of interactive learning methods, typical of interprofessional education, such as role playing or problem-based learning, requires a large number of facilitators, (Gilbert, 2005; Mitchell et al., 2006). Moreover, evaluation of both process and outcomes of interprofessional education requires additional investment (Gilbert, 2005; Mitchell et al., 2006; Zwarenstein et al., 2005). On top of these expenses, in Spain and elsewhere, institutions also need to add in the costs of training lecturers to facilitate interactive learning as many staff may not be familiar with this mode of educational delivery.

Timing of the interdisciplinary educational initiative To date, interprofessional educational initiatives across the globe have been piloted within healthcare curricula at all levels although the debate expounding precisely when to introduce interprofessional education within healthcare curricula remains unresolved. The following paragraphs are intended to explore the implications of this debate for the introduction of interprofessional education within Spain.

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Interprofessional education at undergraduate level The introduction of undergraduate interprofessional initiatives is particularly controversial, with the literature reporting very few schemes that fully integrate interprofessional education at this level (Freeth et al., 2002). Those that have been introduced have taken place across Western Europe (England, France, Norway, Sweden), the USA and Australia (Areskog et al., 1995; Freeth et al., 2002; McNair et al., 2005; Pollard et al., 2006). The main advantage of introducing interprofessional education within undergraduate curricula is the opportunity it provides to quash negative stereotypes at an early stage in an individual’s professional socialisation (Barr, 1996; Barr et al., 2000; McMichael and Gilloran, 1984; Miller et al., 1999). However, numerous authors consider it inappropriate to introduce interprofessional education at such early stage, given that most students in this category have not acquired a sense of their own professional identity or sufficient practical experience to be able to take full advantage of the interprofessional initiatives offered (Carpenter, 1995; Fraser et al., 2000; Mariano, 1989; Miller et al., 1999). Similarly, many critics warn the premature introduction of interprofessional education is not only inefficient but negative, as it interferes with the establishment of distinct professional identities by preventing individuals from focusing on the uniprofessional elements of their role (Areskog et al., 1995; Miller et al., 1999; WHO, 1988). The predominance of such opinions delays the introduction of interprofessional education until students have reached a more advanced stage of their education, perhaps until they become postgraduates (Barr, 2000b; Carpenter, 1995; Miller et al., 1999). Currently there are no studies demonstrating that early exposure to interprofessional education leads to the dilution of professional identity. Conversely Pollard et al. (2005, 2006) in their longitudinal multimethod study involving students from 10 undergraduate health and social care programmes provide evidence to suggest that interprofessional education does not interfere with the development of distinct professional identities. Perhaps more importantly they found those students exposed to interprofessional curricula held more positive perceptions of their own professional relationships than those exposed only to uniprofessional curricula (Pollard et al., 2006). Nevertheless, Spanish educators need to exercise caution when drawing on international literature particularly when the evidence for

M.J. Pumar Me ´ndez et al. introducing interprofessional education at the undergraduate level is scant. As yet the impetus for introducing interprofessional education in Spain is slow to gather momentum. Despite this measured approach, there is a genuine desire to break down auxiliary cliques and traditional power distributions to enable nursing and allied health professionals to become autonomous practitioners (Consejo General de Enfermerı´a, 2003; Davies, 2002; Gonzalez Jurado, 2006; Macia ´ Soler et al., 2006). To facilitate attainment of this ambitious objective the nursing and allied health education institutes and professional bodies have indicated that reconfiguration of traditional professional identities should be seen as a top priority (Consejo General de Enfermerı´a, 2003). Despite the above, traditionally dominant professions such as medicine tend to adopt defensive attitudes particularly when they perceive their customary professional boundary and/or status is being threatened (Davies, 2002). Thus, if interprofessional education is viewed in such a way medical faculties will be less than willing to participate. Hence, the key to success depends on the commitment of all educational stakeholders. Consequently, it would seem the introduction of interprofessional education in Spain might be better received if it were targeted towards postgraduate study. The reasons for this proposition are explored in the subsequent section.

Interprofessional education at postgraduate level Interprofessional learning initiatives at postgraduate level have been implemented within an international context in the form of joint short courses (Areskog et al., 1995; Barr, 2000b; Miller et al., 1999). The advantage of introducing interprofessional education at this level is that it is simpler to organise and opportunities for interaction are easier to facilitate (Miller et al., 1999). Furthermore, participants are better able to take advantage of the learning opportunities offered, as they possess considerable practical experience on which to base their discussions (Barr, 1996; Barr et al., 2000; Barr, 2000b; Miller et al., 1999). Postgraduate education for healthcare professionals in Spain varies according to each discipline. Whilst postgraduate education in the form of doctorates and/or specialist clinical programmes are imbedded within disciplines such as medicine, pharmacy and psychology, they are less well developed in nursing, physiotherapy, dietetics and social work (Ministerio de Sanidad y Consumo, 2006a). How-

The potential advantages and disadvantages of introducing interprofessional education ever, the forthcoming Spanish University reform will eliminate these differences. In fact, it is proposed to have two forms of postgraduate study available for health and social care professionals: clinical specialist programmes and Masters Certificates (Ley 44, 2003; Real Decreto 56, 2005; Real Decreto 450, 2005). These changes provide an opportunity to push for the introduction of interprofessional education within postgraduate curricula in Spain. Furthermore, as Masters programmes are now being re-designed, interprofessional education initiatives could be included from the outset.

Interprofessional education as a continuum in healthcare professional curricula Despite the debate concerning the introduction of interprofessional education at undergraduate level, many agree this type of learning may achieve maximum efficacy when applied within the context of a continuum (Areskog et al., 1995; Barr, 2001; Freeth et al., 2002; Miller et al., 1999; WHO, 1988). In Spain introduction of interprofessional learning on the basis of a continuum currently remains a utopian vision. First, evidence of the benefits of this educational initiative must be gathered from appropriate sources to engage the interest of educationalists and those in authority thereby raising their awareness of its potential to improve healthcare outcomes. Thus commencing the implementation process at Masters level may generate a series of positive experiences that could be cascaded down to other stakeholders, so that interprofessional education might subsequently be expanded across all curricula.

Table 1

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Designing interprofessional education activities When designing new educational initiatives the questions outlined in Table 1 need to be answered in order to determine how best to introduce interprofessional education into healthcare curricula. In respect of the first two questions, consensus has yet to be agreed regarding when and how interprofessional learning initiatives should be introduced and how long they should last. As a result, the question that is perhaps easier to answer relates to the type of learning methods educators should employ when implementing interprofessional learning. To date, a wide range of teaching and learning methods have been adopted (Freeth et al., 2002; Goosey and Barr, 2002). These are best summarised by Barr (1996) and outlined in Table 2. Each of these learning strategies balances the participants’ active and interactive involvement by the sharing of experiences, with the educators’ level of input. Therefore, when engaging in interprofessional learning the choice of method should reflect the experience of the audience, their capacity to share and their need to be guided (Barr, 2000b; Miller et al., 1999). Indeed, joint visits, problem-based learning and placements are generally preferred by undergraduates, while focus groups, collaborative inquiry and joint research are more appropriate for postgraduates (Areskog et al., 1995). Similarly, the time allocated to interprofessional initiatives influences the selection of teaching methods and type of content imparted. Short

Questions educationalist need to ask when considering implementing interprofessional education

 When is the best time to introduce students to such initiatives?  How long should the initiative(s) last?  What are the best learning methods to use so that students can derive the maximum benefit from the learning opportunity?  Which disciplines should be involved in such initiatives?  Which resources are necessary to develop and sustain interprofessional education initiatives? How will the general budgets be re-distributed?

Table 2

Classification of learning methods used in interprofessional education programmes

Classification of the type of learning

Learning methods used

Exchanged based learning Observation based learning Action based learning Simulation based learning Practice based learning

Debates, games, role plays, case study Joint visits, shadowing Collaborative inquiry, joint research, problem-based learning Experiential groups Work related assignments, placements

334 initiatives require greater content selection and more intensive teaching methods, while longer initiatives allow more detailed exploration of the same topic and the employment of interactive methods (Barr, 2001). Perhaps more importantly, when delivering interprofessional education careful consideration needs to be given to the range of disciplines from which students are drawn. Hence, if the majority of students are drawn from one particular discipline, the interactive and interprofessional focus will be lost, rendering the initiative no more effective than uniprofessional learning (Miller et al., 1999; WHO, 1988).

M.J. Pumar Me ´ndez et al.  mix of persons who should be involved in interprofessional learning,  type of learning methods most suited to interprofessional education, However, if such questions are to be adequately addressed rigorous investigational methods need to be employed in order to generate the necessary evidence based body of knowledge on which to build and implement such far reaching educational reforms.

References Conclusion This evaluation of interprofessional education, suggests there is an emerging body of knowledge pointing to both its feasibility and value as an educational method. In particular, interprofessional learning has the potential to facilitate more positive attitudes towards teamwork and collaboration among health and social care professionals. The development of this more helpful mind-set may in turn influence behavioural changes to help reduce the likelihood of fragmented healthcare leading to improved patient outcomes. Despite there being little evidence to support the latter, some would argue that careful evaluation of both the process and learning outcomes of well designed initiatives could strengthen the evidence to underpin such ideas (Barr, 2000b; Freeth et al., 2002; Zwarenstein et al., 2001). However, the debate on the features that should guide the design of a successful interprofessional education programme remains unresolved. Hence, it is suggested that interprofessional education should be orientated towards meeting the needs of the audience for which it is provided. Consequently, the timing, learning methods and length of the initiative should be adapted according to the audience’s specific needs. Thus, if interprofessional education is to be seen as a way forward for Spanish healthcare education, educators need to identify the:  extent to which interprofessional education can influence teamwork and healthcare outcomes,  most suitable educational methods to use when implementing interprofessional education in order to evaluate its impact on learning, professional socialisation and patient care,  best time to introduce interprofessional education,  type of topics that would benefit from being taught using interprofessional approaches,

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