Nurse Educator Vol. 40, No. 1, pp. 16-20 Copyright * 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nurse Educator
Infusing Interprofessional Education Into the Nursing Curriculum Joan Sistrunk Cranford, EdD, RN & Teresa Bates, MSN, RN Education for interprofessional collaboration should begin early in the nursing program with a gradual infusion of interprofessional competencies into the curriculum. The faculty developed an interprofessional education program for students in nursing, physical therapy, nutrition, and respiratory care, which focused on sharing knowledge about each discipline, developing respect and value for each other’s disciplines, and emphasizing techniques to improve communication and teamwork. Keywords: collaboration; interprofessional competencies; interprofessional education; nursing curriculum
N
urses work with a variety of disciplines every day in various health care settings. Each discipline has a specific set of skills, and different disciplines bring different viewpoints, values, and beliefs even when the central goal is quality care for the patient. These differences can become a source of conflict, resulting in adverse outcomes for the patient.1 For patient care to be effective, disciplines must work together to make decisions and plan care. When there is effective interprofessional collaboration, patient outcomes improve.2 Nevertheless, collaboration does not come easy to all professionals; therefore, interprofessional education (IPE) is necessary to teach health and social care professionals about the benefits and skills required for collaboration.3 Interprofessional education has been defined as engagement of students from 2 or more professions associated with health care in learning with, from, and about each other to enable effective collaboration and improve health outcomes.4 Interprofessional education is designed to prepare health care students to work in interprofessional teams on graduation and is characterized by principles of partnership, communication, collaboration, shared decision making, relationships, and respect.4 The goal of IPE is to improve collaboration between team members by focusing on cooperation, trust, and respect while advancing skills in the use of collective knowledge and decision making in academic and clinical
experiences. This article describes the steps involved in implementation of IPE in a nursing curriculum.
Background Education is 1 of the best interventions for increasing skills in teamwork, cultivating an appreciation for diversity, and developing mutual respect for colleagues.5 Inspired by a vision of interprofessional collaborative practice, an expert panel of representatives from the American Association of Colleges of Nursing (AACN) and 5 other disciplines issued a set of core competencies in a report entitled Core Competencies for Interprofessional Collaborative Practice.6 The AACN has now included IPE as a basic essential for baccalaureate, master’s, and doctor of nursing practice graduates.7 However, if nursing faculty members are to accept IPE as a necessary part of the nursing curriculum, they must understand its foundational tenets. Interprofessional education includes 4 core competency domains: values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork.6 These domains include basic concepts of relationship building, team dynamics, assertive communication, and knowledge of one’s own role and the roles of other professionals.6
Theories and Frameworks Author Affiliations: Clinical Associate Professor (Dr Cranford), Clinical Assistant Professor (Ms Bates), Byrdine F. Lewis School of Nursing and Health Professions, Georgia State University, Atlanta. The authors declare no conflicts of interest. Correspondence: Dr Cranford, Byrdine F. Lewis School of Nursing and Health Professions, Georgia State University, 140 Decatur St, Room 918, PO Box 4019, Atlanta, GA 30311 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: July 6, 2014 Published ahead of print: August 22, 2014 DOI: 10.1097/NNE.0000000000000077
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Volume 40 & Number 1 & January/February 2015
A number of frameworks, theories, and models can aid nursing faculty as they begin to explore IPE and the infusion of this type of learning into the nursing curriculum. In some theories, social identity is viewed as belonging to a profession. Thus, professional socialization teaches members of a profession to hold certain goals and maintain shared values as part of their professional identity. This can be a positive influence, or it may result in barriers to change and an inability to work collaboratively.8 Another theory from social psychology addresses the influence of situational factors on behavior. For example, learning in IPE is influenced by team members and their Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
different interpretations of the same event or situation. Finally, situated learning is often used to explain certain beliefs and behaviors. The view that the medical profession holds a place of privilege may lead medical students to believe that they should take on the role of leader; similarly, respiratory therapists may hold the idea that they should lead patient ventilation therapies. In contrast, interprofessional collaboration is characterized by flexible leadership shared by the health care team8 and by leadership based on the situation at hand rather than based on the beliefs and interpretations of a discipline. Transformative learning theory also can be used to frame IPE. This theory is based on the belief that transformative learning shapes people so that they are different in ways both they and others can recognize after learning takes place.9 To transform long-held beliefs and values, the values of the profession to which an individual belongs must be examined and reexamined.10 Transformative learning involves learning from experience, critical reflection, and personal development. Understanding the meaning of experience provides an opportunity for change in perspective and revision of assumptions.11 The student in IPE who experiences transformation will be better prepared to question existing knowledge, develop new ways of learning, and change roles, relationships, ideas, and perceptions to heighten collaboration among all providers.12 Several models of IPE have been implemented based on learning theories. They include the centralized and decentralized models used to describe the interprofessional activities of medical and physical therapy students at a south Florida university. The centralized model was implemented in year 1 of the curriculum, with IPE concentrated in a core set of courses for students from both disciplines and faculty oversight from each of the professions. Years 2 and 3 were decentralized with interprofessional learning experiences designed by IPE champions without core courses or centralized oversight. The focus of IPE activities was on professional issues, primary care, and special populations. The centralized model, however, was found to have the greatest potential for sustainability.13 Scarvell and Stone14 implemented an educational intervention for clinical educators in nursing, biomedical and sports sciences, nutrition and dietetics, pharmacy, and physiotherapy. Students were placed together in clinical facilities, and the IPE didactic included a variety of teaching models and teaching/learning philosophies. All of these frameworks, theories, and models emphasize relational capacities and abilities, competence in one’s profession, respect for others’ roles and perspectives, and knowledge of group process skills, which align with the IPE competencies.15 Implementation of an IPE program, however, must begin with culture change and the education of faculty on strengths, weaknesses, barriers, and opportunities.
Implementation Our university’s strategic plan includes interprofessional collaboration as 1 of its major initiatives. The School of Nursing and Health Professions (SNHP) faculty, in alignment with the strategic plan, developed an innovative model that infused IPE into the curriculum for nutrition, physical therapy, respiratory therapy, and nursing. To begin the process, Nurse Educator
faculty from the 4 disciplines in SNHP each sent 1 member to the Interprofessional Education Collaborative (IPEC) Institute— Building Your Foundation for Interprofessional Education, a national interprofessional conference. The IPEC conference provided the faculty with ideas about team building and the need to stimulate enthusiasm among the health professions. As the faculty began to reflect on adoption of new ideas and changes in behavior, a decision was made to introduce IPE and frame it in Diffusion of Innovations Theory.16 The aim was to spread IPE throughout the SNHP and, later, to the Schools of Law and Social Work. The first step in the process was to educate the educators. Faculty members are key to the success of IPE. However, focus group interviews with faculty revealed a lack of respect between professionals and a ‘‘silo’’ approach to health education. Most faculty members were products of an educational system whose perspective was limited to that of their discipline, and they were not practicing in an interprofessional environment. Therefore, faculty needed to learn together about the skills required to be effective.17 The work began with a business proposal to support the case for a program of IPE in the curriculum. The proposal included background information about IPE and an explanation of factors promoting IPE at the university. The phases of the proposed work were outlined and presented to the dean of the SNHP for approval. A group was then formed with members from each of the 4 disciplines, and they reviewed the IPE competencies and identified competencies specific to their individual disciplines. This was followed by review, merging, and adoption of a set of competencies that would be appropriate for all students. In the process, SNHP faculty discovered that dissonance existed between faculty values and educational practice and transformation would be required to change faculty attitudes. The 4 faculty members reviewed different frameworks, theories, and models for implementing a program and, on that basis, developed an interprofessional course that would cross all 4 disciplines. The Figure reflects the educational process that served as a guide. The 4 faculty members who had attended the IPEC conference then expanded the team to include other faculty members who expressed an interest in IPE. This broader team adopted a working definition of IPE from the Center of Advancement for IPE.18 The decision was made to infuse IPE into an existing course in each discipline. This led to a process of curriculum mapping to determine which courses had the flexibility to delete some existing content and add a new component. The faculty team decided that incorporating IPE into the curriculum should be similar to a continual infusion rather than a bolus. Just as patients often cannot tolerate a bolus of fluids, faculty and students do not tend to accept a large bolus of change as well as a more gradual process of change. The team also decided to begin with a 1-day class event and, in addition, to have students engage in a shared clinical experience that would include simulation. Given time constraints, the 1-day seminar was agreed on as the least difficult method of providing a community of learning while also providing a forum for practicing communication skills. The Figure, Supplemental Digital Content 1, summarizes the process model, http://links.lww.com/NE/A163. Volume 40 & Number 1 & January/February 2015
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
17
Figure. Educational process for IPE. IPEC, Interprofessional Education Collaboration.
Goals were set and a course proposal was drafted that included team-building exercises, video, introduction to IPE competencies, group assignments, and case studies. During the combined class, students would be randomly selected and asked to describe the role of another profession. This would be followed by a PowerPoint presentation highlighting the 4 disciplines. A proposed implementation date was set and the team developed a timeline. Faculty assignments involved work on simulation, including scenario development; formulation of plans for the class day, including individual session tasks such as teambuilding exercises and jeopardy games; logistics and facilities; and development and implementation of an evaluation of the interprofessional experience. The final course plan included classroom teaching, simulations, and real-world practice in the use of interprofessional collaboration.
was a heightened awareness that faculty buy-in would be key to success. Two nursing faculty were identified who were using simulation activities that could easily be adapted to incorporate IPE. The nursing faculty members learned that nutrition faculty in the SNHP were interested in highfidelity simulation and collaboration. This led to the development of an initial collaboration, which enhanced the realism of the simulated experience and increased awareness of the innovation.14 This joint effort became the foundation for a much larger endeavor.
The development of the interprofessional curriculum for nursing and health professions students was championed by the representatives from the 4 departments within the SNHP. The team engaged in refining, restructuring, and developing the implementation plan. Each team member role was identified at the formative stage, so all members were aware of expectations and goals. Communication and cooperation among members were necessary to persuade faculty and students to participate in a new innovation. This was accomplished through a 6-step educational program.
Building an Interprofessional Team Because the SNHP contains 4 health care professions, nutrition, respiratory therapy, nursing, and physical therapy, finding other professional partners to work with nursing and nutrition faculty was not difficult. Within 2 semesters, the innovation had diffused to all of the disciplines, and they were ready to work collaboratively. The team demonstrated compatibility in values and experiences that supported initial implementation of the innovation. Early in the process, it became apparent to the team that faculty involvement at all levels would be essential to success. There were numerous activities for faculty members, including participating in the class agenda and welcoming and signing in students for the simulation event, observing a simulation group and assisting with debriefing, and observing faculty and critiquing their work. Faculty participation created an atmosphere for sharing knowledge and skills to influence student learning and generate a sense of excitement and interest.
Accepting the Challenge The first step was to gain momentum.14 After setting the expectation that IPE would be a priority at our school, there
Creating the Objectives To keep our endeavors manageable, nursing and nutrition faculty initially agreed to 2 simple collaborative objectives.
ABCs of Infusing IPE into the Curriculum—6 Steps to Success
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Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
First, students would increase their knowledge of the educational requirements and function of each health profession in patient care. Second, students would demonstrate effective communication with the interprofessional team to improve patient outcomes. As other SNHP disciplines adopted the innovation and became involved, those 2 objectives remained the same for all IPE initiatives.
Developing the Game Plan The initial IPE endeavor between nursing and nutrition faculty involved a high-fidelity gunshot wound simulation that nursing faculty had been using with senior undergraduate students. The nursing faculty worked with nutrition faculty to modify the simulation by changing the patient from a new admission to the emergency department to a 2-day postoperative patient who experienced hemorrhaging during the simulation. Nutrition students began the simulation with an alert, stable patient to interview. In a room adjacent to the patient’s room, nutrition students and nursing students collaborated on the dietary plan of care. Faculty members assessed the students’ communication style and respect for diverse opinions. When respiratory therapy and physical therapy faculty joined nursing and nutrition faculty in the school-wide IPE effort, a decision was made to change the simulation activity and to implement 3 learning activities over the course of the semester. Planning time for the IPE activities was limited. Therefore, faculty had to learn quickly and adopt team collaboration as a personal value to role model the desired behaviors for students. The final plan for implementation of IPE in the SNHP included the 1-day 6-hour class event in addition to simulation activities that were scheduled at the beginning of the semester. At the 1-day event, students were divided into small groups that included students from each profession. The session began with an ice breaker that promoted communication and teamwork within the groups. Two prerecorded patient care skits were created for the students to discuss; 1 demonstrated good communication and the other demonstrated very poor communication. A second learning activity during the semester involved collaborative work to answer questions about 2 case studies (Table). The students worked with other students from their previously assigned seminar group to complete this activity outside the classroom. The final activity of the semester was a high-fidelity simulation. The students continued with their same group and
provided care for the 2 patients in the case studies they had worked on during the semester. Both patients required all 4 professions to work collaboratively to achieve optimal patient outcomes.
Evaluating the Collaborative Effort The desired outcome was a change in student behavior from a shared experience. This could only be determined through some type of evaluative process. Students from the 4 disciplines took part in a preimplementation assessment to determine their level of preparedness to meet the overall learning outcomes. Because of time constraints, a tool developed by the faculty allowed students to self-evaluate their ability to communicate their professional role and responsibilities; engage other health care professionals in developing a plan of care; explain the roles and responsibilities of other health care providers; manage disagreements about values, roles, and goals for the patient and family; and share accountability with other professions for patient outcomes. The evaluation tool also afforded students an opportunity to give feedback and input for redesigning or changing the current course. Thus, the evaluation was used to identify deficiencies as well as to determine the usefulness of the program. Students were asked to identify the most meaningful components of the course. Students rated the opportunity to learn about other disciplines and the explanation of professional roles, team-building exercises, communication, and simulation exercises as the most useful components of the 1-day session. Simulation activities were rated highly effective even though they were time-consuming. One suggested change made by most students was to provide the course earlier in their program of study and make it a separate credit-hour course. Other evaluation methods included completion of an anonymous evaluation form after the last simulation activity. Faculty from the 4 disciplines also conducted a faculty debriefing to determine what changes need to be made and what opportunities for improvement were apparent. Following up and Going Forward It is important to keep the momentum going. This program was implemented in fall 2012 with the 1-day seminar, group assignments throughout the semester, and simulation activities as a final component. Each semester’s course activities build on the previous semester’s accomplishments and on information gleaned from the evaluation forms. To infuse
Table. Sample Case Studies Used for IPE Simulations Case Study 1
Case Study 2
Mrs Multie was admitted 4 days ago with bronchitis, severe constipation, and Mr Aire is an intensive care patient. He was admitted with pneumonia, decreased appetite related to lower abdominal fullness. She has a complex AIDS, chronic diarrhea, wasting syndrome, peripheral neuropathy, and medical history of respiratory difficulties related to multiple sclerosis, an unhealed ankle fracture from 5 weeks past. The patient experienced swallowing difficulties, decreased appetite, vegetarian diet, chronic muscle respiratory failure and was intubated overnight. During morning fatigue and nocturnal cramping, progressive weakness of extremities, and mild interprofessional rounds, a new plan of care needs to be devised incontinence. The patient is scheduled for discharge later in the day. The and implemented by the team. interprofessional team needs to assess the patient’s and family’s readiness for discharge and provide any teaching deemed necessary.
Nurse Educator
Volume 40 & Number 1 & January/February 2015
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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IPE throughout the curriculum, specialty lectures have been conducted by faculty from other disciplines at all levels of the program, and student-led skills demonstrations are held in Fundamentals of Nursing and Nutrition courses. For example, physical therapy students teach nursing students in the proper use of ambulatory devices, and nursing students teach the physical therapy and nutrition students about intravenous lines and tubes. One research course has been redesigned to make it interprofessional. This provides an opportunity for students to meet early in their program of study. In the coming semesters, the team will be expanding interprofessional activities for all disciplines in SNHP to include first responder and emergency department mass casualty simulations. The program will begin in the second semester of the curriculum with Disaster Preparedness Training. Students will practice mass casualty preparation in the third semester and participate in a mass casualty event in the fourth semester.
Conclusion The content and activities described here can be easily translated to other nursing and health professions curricula. A recent study by Hudson et al19 suggested that baccalaureate nursing students’ professional development may be enhanced through IPE, which also provides clarity on the unique contributions of nursing to health care. Interprofessional education allows for innovation and breaks down traditional disciplinespecific and institutional barriers. Student outcomes focus on acquisition of knowledge and an understanding of all the professions that are a part of the health care team. When embarking on the IPE journey, certain elements must be a part of the infusion process. Each discipline needs to evaluate the curriculum to determine where IPE best fits. There should be committed leadership from administration and faculty and adequate resources, including community and clinical partners, classroom space to accommodate a large class, and laboratory space for simulation. Scheduling issues also need to be resolved to provide adequate time in the curriculum. Simulation experiences should be created with interprofessional activities emphasized in the development of the scenarios. The institutional culture must be open to change and collaboration with multiple partners and willing to provide real-life clinical experiences where students work together in a respectful, honest, collaborative environment. Completion of the infusion will require follow-up evaluation to determine whether understanding of the functions of the health care team has changed and whether attitudes and values have been transformed. In our school, the evaluation process is ever-evolving. The goal of the team is to begin using a valid and reliable evaluation tool, the Interdisciplinary Education Perception Scale, which will be administered before the IPE classes (pretest) and on completion of the simulation activity (posttest) to rate students’ perceptions of their profession and other disciplines. Another tool, the Readiness for Interprofessional Learning Scale Questionnaire, will be administered at the beginning of the 1-day seminar to examine the attitudes of health care professionals toward interprofessional learning. These tools will assist in reshaping and improving the IPE program. Although barriers exist to the development of IPE, the positive outcomes for students are evident through their
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anecdotal comments and the debriefing sessions. Students describe the experience as having taught them how to work together in preparation for practice. They also report that they gained a clear understanding of the concept of working together to help the patient in the end.
References 1. Rose L. Interprofessional collaboration in the ICU. Br Assoc Crit Care Nurse. 2011;17(1):5-10. 2. Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: effects on professional practice and healthcare outcomes (update). Cochrane Database Syst Rev. 2013;3: CD002213. 3. Kenaszchuk C, Rykhoff M, Collins L, McPhail S, Van Soeren M. Positive and null effects of interprofessional education on attitudes toward interprofessional learning and collaboration. Adv Health Sci Educ. 2012;17(5):651-659. 4. Gilbert JH, Yan J, Hoffman SJ. A WHO report: framework for action on interprofessional education and practice. J Allied Health. 2010;39(3, pt 2):196-197. 5. Petri L. Concept analysis of interdisciplinary collaboration. Nurs Forum. 2010;45(2):73-82. 6. Interprofessional Education Collaborative Expert Panel. Core Competencies for Intercollaborative Practice. Washington, DC: Interprofessional Education Collaborative Expert Panel; 2011. 7. American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington, DC: American Association of Colleges of Nursing; 2008. 8. Sargeant J. Theories to aid understanding and implementation of interprofessional education. J Contin Educ Health Prof. 2009; 29(3):178-188. 9. Clark MC. Transformational learning. In: Merriam SB, ed. An Update on Adult Learning Theory, New Direction for Adult and Continuing Education. San Francisco, CA: Jossey-Bass; 1993: 318-321. 10. Merriam SB, Caffarella RS. Learning in Adulthood: A Comprehensive Guide. 2nd ed. San Francisco, CA: Jossey-Bass; 1999. 11. Mezirow J. A critical theory of adult learning and education. Adult Educ Q. 1985;35(3):142-151. 12. AACN Expands Its Leadership Role in the Area of Interprofessional Education as Nursing’s Representative to IPEC [news release] Washington, DC: American Association of Colleges of Nursing; February 15, 2012. http://www.aacn.nche.edu/news/articles/2012/ ipec. Accessed January 16, 2014. 13. Swisher LL, Woodard LJ, Quillen WS, Monroe ADH. Centralized and decentralized organizational models of interprofessional education for physical therapist and medical students. J Phys Ther Educ. 2010;24(1):12-18. 14. Scarvell JM, Stone J. An interprofessional collaboration practice model for preparation of clinical education. J Interprof Care. 2010;24(4):386-400. 15. Odegard PS, Robins L, Murphy M, Belza B, Schaad D, Mitchell P. Interprofessional initiatives at the University of Washington. Am J Pharm Educ. 2009;73(4):1-7. 16. Diffusion of Innovation Theory. Behavioral Change Model Web site. http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-Models/ SB721-Models4.html. Accessed July 1, 2014. 17. Numer M, Macleod DS, Blye F. Interprofessional education for faculty and staff—a review of the changing worlds: diversity and health care project. J Interprof Care. 2008;22(51):83-90. 18. Center for Advancement of Interprofessional Education. http:// www.caipe.org.uk. Accessed July 5, 2014. 19. Hudson CE, Sanders MK, Pepper C. Interprofessional education and prelicensure baccalaureate nursing students: an integrative review. Nurse Educ. 2013;38(2):77-80.
Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Nurse Educator
Infusing Interprofessional Education Into the Nursing Curriculum Joan Sistrunk Cranford, EdD, RN & Teresa Bates, MSN, RN Education for interprofessional collaboration should begin early in the nursing program with a gradual infusion of interprofessional competencies into the curriculum. The faculty developed an interprofessional education program for students in nursing, physical therapy, nutrition, and respiratory care, which focused on sharing knowledge about each discipline, developing respect and value for each other’s disciplines, and emphasizing techniques to improve communication and teamwork. Keywords: collaboration; interprofessional competencies; interprofessional education; nursing curriculum
N
urses work with a variety of disciplines every day in various health care settings. Each discipline has a specific set of skills, and different disciplines bring different viewpoints, values, and beliefs even when the central goal is quality care for the patient. These differences can become a source of conflict, resulting in adverse outcomes for the patient.1 For patient care to be effective, disciplines must work together to make decisions and plan care. When there is effective interprofessional collaboration, patient outcomes improve.2 Nevertheless, collaboration does not come easy to all professionals; therefore, interprofessional education (IPE) is necessary to teach health and social care professionals about the benefits and skills required for collaboration.3 Interprofessional education has been defined as engagement of students from 2 or more professions associated with health care in learning with, from, and about each other to enable effective collaboration and improve health outcomes.4 Interprofessional education is designed to prepare health care students to work in interprofessional teams on graduation and is characterized by principles of partnership, communication, collaboration, shared decision making, relationships, and respect.4 The goal of IPE is to improve collaboration between team members by focusing on cooperation, trust, and respect while advancing skills in the use of collective knowledge and decision making in academic and clinical
experiences. This article describes the steps involved in implementation of IPE in a nursing curriculum.
Background Education is 1 of the best interventions for increasing skills in teamwork, cultivating an appreciation for diversity, and developing mutual respect for colleagues.5 Inspired by a vision of interprofessional collaborative practice, an expert panel of representatives from the American Association of Colleges of Nursing (AACN) and 5 other disciplines issued a set of core competencies in a report entitled Core Competencies for Interprofessional Collaborative Practice.6 The AACN has now included IPE as a basic essential for baccalaureate, master’s, and doctor of nursing practice graduates.7 However, if nursing faculty members are to accept IPE as a necessary part of the nursing curriculum, they must understand its foundational tenets. Interprofessional education includes 4 core competency domains: values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork.6 These domains include basic concepts of relationship building, team dynamics, assertive communication, and knowledge of one’s own role and the roles of other professionals.6
Theories and Frameworks Author Affiliations: Clinical Associate Professor (Dr Cranford), Clinical Assistant Professor (Ms Bates), Byrdine F. Lewis School of Nursing and Health Professions, Georgia State University, Atlanta. The authors declare no conflicts of interest. Correspondence: Dr Cranford, Byrdine F. Lewis School of Nursing and Health Professions, Georgia State University, 140 Decatur St, Room 918, PO Box 4019, Atlanta, GA 30311 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: July 6, 2014 Published ahead of print: August 22, 2014 DOI: 10.1097/NNE.0000000000000077
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Volume 40 & Number 1 & January/February 2015
A number of frameworks, theories, and models can aid nursing faculty as they begin to explore IPE and the infusion of this type of learning into the nursing curriculum. In some theories, social identity is viewed as belonging to a profession. Thus, professional socialization teaches members of a profession to hold certain goals and maintain shared values as part of their professional identity. This can be a positive influence, or it may result in barriers to change and an inability to work collaboratively.8 Another theory from social psychology addresses the influence of situational factors on behavior. For example, learning in IPE is influenced by team members and their Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
different interpretations of the same event or situation. Finally, situated learning is often used to explain certain beliefs and behaviors. The view that the medical profession holds a place of privilege may lead medical students to believe that they should take on the role of leader; similarly, respiratory therapists may hold the idea that they should lead patient ventilation therapies. In contrast, interprofessional collaboration is characterized by flexible leadership shared by the health care team8 and by leadership based on the situation at hand rather than based on the beliefs and interpretations of a discipline. Transformative learning theory also can be used to frame IPE. This theory is based on the belief that transformative learning shapes people so that they are different in ways both they and others can recognize after learning takes place.9 To transform long-held beliefs and values, the values of the profession to which an individual belongs must be examined and reexamined.10 Transformative learning involves learning from experience, critical reflection, and personal development. Understanding the meaning of experience provides an opportunity for change in perspective and revision of assumptions.11 The student in IPE who experiences transformation will be better prepared to question existing knowledge, develop new ways of learning, and change roles, relationships, ideas, and perceptions to heighten collaboration among all providers.12 Several models of IPE have been implemented based on learning theories. They include the centralized and decentralized models used to describe the interprofessional activities of medical and physical therapy students at a south Florida university. The centralized model was implemented in year 1 of the curriculum, with IPE concentrated in a core set of courses for students from both disciplines and faculty oversight from each of the professions. Years 2 and 3 were decentralized with interprofessional learning experiences designed by IPE champions without core courses or centralized oversight. The focus of IPE activities was on professional issues, primary care, and special populations. The centralized model, however, was found to have the greatest potential for sustainability.13 Scarvell and Stone14 implemented an educational intervention for clinical educators in nursing, biomedical and sports sciences, nutrition and dietetics, pharmacy, and physiotherapy. Students were placed together in clinical facilities, and the IPE didactic included a variety of teaching models and teaching/learning philosophies. All of these frameworks, theories, and models emphasize relational capacities and abilities, competence in one’s profession, respect for others’ roles and perspectives, and knowledge of group process skills, which align with the IPE competencies.15 Implementation of an IPE program, however, must begin with culture change and the education of faculty on strengths, weaknesses, barriers, and opportunities.
Implementation Our university’s strategic plan includes interprofessional collaboration as 1 of its major initiatives. The School of Nursing and Health Professions (SNHP) faculty, in alignment with the strategic plan, developed an innovative model that infused IPE into the curriculum for nutrition, physical therapy, respiratory therapy, and nursing. To begin the process, Nurse Educator
faculty from the 4 disciplines in SNHP each sent 1 member to the Interprofessional Education Collaborative (IPEC) Institute— Building Your Foundation for Interprofessional Education, a national interprofessional conference. The IPEC conference provided the faculty with ideas about team building and the need to stimulate enthusiasm among the health professions. As the faculty began to reflect on adoption of new ideas and changes in behavior, a decision was made to introduce IPE and frame it in Diffusion of Innovations Theory.16 The aim was to spread IPE throughout the SNHP and, later, to the Schools of Law and Social Work. The first step in the process was to educate the educators. Faculty members are key to the success of IPE. However, focus group interviews with faculty revealed a lack of respect between professionals and a ‘‘silo’’ approach to health education. Most faculty members were products of an educational system whose perspective was limited to that of their discipline, and they were not practicing in an interprofessional environment. Therefore, faculty needed to learn together about the skills required to be effective.17 The work began with a business proposal to support the case for a program of IPE in the curriculum. The proposal included background information about IPE and an explanation of factors promoting IPE at the university. The phases of the proposed work were outlined and presented to the dean of the SNHP for approval. A group was then formed with members from each of the 4 disciplines, and they reviewed the IPE competencies and identified competencies specific to their individual disciplines. This was followed by review, merging, and adoption of a set of competencies that would be appropriate for all students. In the process, SNHP faculty discovered that dissonance existed between faculty values and educational practice and transformation would be required to change faculty attitudes. The 4 faculty members reviewed different frameworks, theories, and models for implementing a program and, on that basis, developed an interprofessional course that would cross all 4 disciplines. The Figure reflects the educational process that served as a guide. The 4 faculty members who had attended the IPEC conference then expanded the team to include other faculty members who expressed an interest in IPE. This broader team adopted a working definition of IPE from the Center of Advancement for IPE.18 The decision was made to infuse IPE into an existing course in each discipline. This led to a process of curriculum mapping to determine which courses had the flexibility to delete some existing content and add a new component. The faculty team decided that incorporating IPE into the curriculum should be similar to a continual infusion rather than a bolus. Just as patients often cannot tolerate a bolus of fluids, faculty and students do not tend to accept a large bolus of change as well as a more gradual process of change. The team also decided to begin with a 1-day class event and, in addition, to have students engage in a shared clinical experience that would include simulation. Given time constraints, the 1-day seminar was agreed on as the least difficult method of providing a community of learning while also providing a forum for practicing communication skills. The Figure, Supplemental Digital Content 1, summarizes the process model, http://links.lww.com/NE/A163. Volume 40 & Number 1 & January/February 2015
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
17
Figure. Educational process for IPE. IPEC, Interprofessional Education Collaboration.
Goals were set and a course proposal was drafted that included team-building exercises, video, introduction to IPE competencies, group assignments, and case studies. During the combined class, students would be randomly selected and asked to describe the role of another profession. This would be followed by a PowerPoint presentation highlighting the 4 disciplines. A proposed implementation date was set and the team developed a timeline. Faculty assignments involved work on simulation, including scenario development; formulation of plans for the class day, including individual session tasks such as teambuilding exercises and jeopardy games; logistics and facilities; and development and implementation of an evaluation of the interprofessional experience. The final course plan included classroom teaching, simulations, and real-world practice in the use of interprofessional collaboration.
was a heightened awareness that faculty buy-in would be key to success. Two nursing faculty were identified who were using simulation activities that could easily be adapted to incorporate IPE. The nursing faculty members learned that nutrition faculty in the SNHP were interested in highfidelity simulation and collaboration. This led to the development of an initial collaboration, which enhanced the realism of the simulated experience and increased awareness of the innovation.14 This joint effort became the foundation for a much larger endeavor.
The development of the interprofessional curriculum for nursing and health professions students was championed by the representatives from the 4 departments within the SNHP. The team engaged in refining, restructuring, and developing the implementation plan. Each team member role was identified at the formative stage, so all members were aware of expectations and goals. Communication and cooperation among members were necessary to persuade faculty and students to participate in a new innovation. This was accomplished through a 6-step educational program.
Building an Interprofessional Team Because the SNHP contains 4 health care professions, nutrition, respiratory therapy, nursing, and physical therapy, finding other professional partners to work with nursing and nutrition faculty was not difficult. Within 2 semesters, the innovation had diffused to all of the disciplines, and they were ready to work collaboratively. The team demonstrated compatibility in values and experiences that supported initial implementation of the innovation. Early in the process, it became apparent to the team that faculty involvement at all levels would be essential to success. There were numerous activities for faculty members, including participating in the class agenda and welcoming and signing in students for the simulation event, observing a simulation group and assisting with debriefing, and observing faculty and critiquing their work. Faculty participation created an atmosphere for sharing knowledge and skills to influence student learning and generate a sense of excitement and interest.
Accepting the Challenge The first step was to gain momentum.14 After setting the expectation that IPE would be a priority at our school, there
Creating the Objectives To keep our endeavors manageable, nursing and nutrition faculty initially agreed to 2 simple collaborative objectives.
ABCs of Infusing IPE into the Curriculum—6 Steps to Success
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First, students would increase their knowledge of the educational requirements and function of each health profession in patient care. Second, students would demonstrate effective communication with the interprofessional team to improve patient outcomes. As other SNHP disciplines adopted the innovation and became involved, those 2 objectives remained the same for all IPE initiatives.
Developing the Game Plan The initial IPE endeavor between nursing and nutrition faculty involved a high-fidelity gunshot wound simulation that nursing faculty had been using with senior undergraduate students. The nursing faculty worked with nutrition faculty to modify the simulation by changing the patient from a new admission to the emergency department to a 2-day postoperative patient who experienced hemorrhaging during the simulation. Nutrition students began the simulation with an alert, stable patient to interview. In a room adjacent to the patient’s room, nutrition students and nursing students collaborated on the dietary plan of care. Faculty members assessed the students’ communication style and respect for diverse opinions. When respiratory therapy and physical therapy faculty joined nursing and nutrition faculty in the school-wide IPE effort, a decision was made to change the simulation activity and to implement 3 learning activities over the course of the semester. Planning time for the IPE activities was limited. Therefore, faculty had to learn quickly and adopt team collaboration as a personal value to role model the desired behaviors for students. The final plan for implementation of IPE in the SNHP included the 1-day 6-hour class event in addition to simulation activities that were scheduled at the beginning of the semester. At the 1-day event, students were divided into small groups that included students from each profession. The session began with an ice breaker that promoted communication and teamwork within the groups. Two prerecorded patient care skits were created for the students to discuss; 1 demonstrated good communication and the other demonstrated very poor communication. A second learning activity during the semester involved collaborative work to answer questions about 2 case studies (Table). The students worked with other students from their previously assigned seminar group to complete this activity outside the classroom. The final activity of the semester was a high-fidelity simulation. The students continued with their same group and
provided care for the 2 patients in the case studies they had worked on during the semester. Both patients required all 4 professions to work collaboratively to achieve optimal patient outcomes.
Evaluating the Collaborative Effort The desired outcome was a change in student behavior from a shared experience. This could only be determined through some type of evaluative process. Students from the 4 disciplines took part in a preimplementation assessment to determine their level of preparedness to meet the overall learning outcomes. Because of time constraints, a tool developed by the faculty allowed students to self-evaluate their ability to communicate their professional role and responsibilities; engage other health care professionals in developing a plan of care; explain the roles and responsibilities of other health care providers; manage disagreements about values, roles, and goals for the patient and family; and share accountability with other professions for patient outcomes. The evaluation tool also afforded students an opportunity to give feedback and input for redesigning or changing the current course. Thus, the evaluation was used to identify deficiencies as well as to determine the usefulness of the program. Students were asked to identify the most meaningful components of the course. Students rated the opportunity to learn about other disciplines and the explanation of professional roles, team-building exercises, communication, and simulation exercises as the most useful components of the 1-day session. Simulation activities were rated highly effective even though they were time-consuming. One suggested change made by most students was to provide the course earlier in their program of study and make it a separate credit-hour course. Other evaluation methods included completion of an anonymous evaluation form after the last simulation activity. Faculty from the 4 disciplines also conducted a faculty debriefing to determine what changes need to be made and what opportunities for improvement were apparent. Following up and Going Forward It is important to keep the momentum going. This program was implemented in fall 2012 with the 1-day seminar, group assignments throughout the semester, and simulation activities as a final component. Each semester’s course activities build on the previous semester’s accomplishments and on information gleaned from the evaluation forms. To infuse
Table. Sample Case Studies Used for IPE Simulations Case Study 1
Case Study 2
Mrs Multie was admitted 4 days ago with bronchitis, severe constipation, and Mr Aire is an intensive care patient. He was admitted with pneumonia, decreased appetite related to lower abdominal fullness. She has a complex AIDS, chronic diarrhea, wasting syndrome, peripheral neuropathy, and medical history of respiratory difficulties related to multiple sclerosis, an unhealed ankle fracture from 5 weeks past. The patient experienced swallowing difficulties, decreased appetite, vegetarian diet, chronic muscle respiratory failure and was intubated overnight. During morning fatigue and nocturnal cramping, progressive weakness of extremities, and mild interprofessional rounds, a new plan of care needs to be devised incontinence. The patient is scheduled for discharge later in the day. The and implemented by the team. interprofessional team needs to assess the patient’s and family’s readiness for discharge and provide any teaching deemed necessary.
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IPE throughout the curriculum, specialty lectures have been conducted by faculty from other disciplines at all levels of the program, and student-led skills demonstrations are held in Fundamentals of Nursing and Nutrition courses. For example, physical therapy students teach nursing students in the proper use of ambulatory devices, and nursing students teach the physical therapy and nutrition students about intravenous lines and tubes. One research course has been redesigned to make it interprofessional. This provides an opportunity for students to meet early in their program of study. In the coming semesters, the team will be expanding interprofessional activities for all disciplines in SNHP to include first responder and emergency department mass casualty simulations. The program will begin in the second semester of the curriculum with Disaster Preparedness Training. Students will practice mass casualty preparation in the third semester and participate in a mass casualty event in the fourth semester.
Conclusion The content and activities described here can be easily translated to other nursing and health professions curricula. A recent study by Hudson et al19 suggested that baccalaureate nursing students’ professional development may be enhanced through IPE, which also provides clarity on the unique contributions of nursing to health care. Interprofessional education allows for innovation and breaks down traditional disciplinespecific and institutional barriers. Student outcomes focus on acquisition of knowledge and an understanding of all the professions that are a part of the health care team. When embarking on the IPE journey, certain elements must be a part of the infusion process. Each discipline needs to evaluate the curriculum to determine where IPE best fits. There should be committed leadership from administration and faculty and adequate resources, including community and clinical partners, classroom space to accommodate a large class, and laboratory space for simulation. Scheduling issues also need to be resolved to provide adequate time in the curriculum. Simulation experiences should be created with interprofessional activities emphasized in the development of the scenarios. The institutional culture must be open to change and collaboration with multiple partners and willing to provide real-life clinical experiences where students work together in a respectful, honest, collaborative environment. Completion of the infusion will require follow-up evaluation to determine whether understanding of the functions of the health care team has changed and whether attitudes and values have been transformed. In our school, the evaluation process is ever-evolving. The goal of the team is to begin using a valid and reliable evaluation tool, the Interdisciplinary Education Perception Scale, which will be administered before the IPE classes (pretest) and on completion of the simulation activity (posttest) to rate students’ perceptions of their profession and other disciplines. Another tool, the Readiness for Interprofessional Learning Scale Questionnaire, will be administered at the beginning of the 1-day seminar to examine the attitudes of health care professionals toward interprofessional learning. These tools will assist in reshaping and improving the IPE program. Although barriers exist to the development of IPE, the positive outcomes for students are evident through their
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anecdotal comments and the debriefing sessions. Students describe the experience as having taught them how to work together in preparation for practice. They also report that they gained a clear understanding of the concept of working together to help the patient in the end.
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