Interprofessional Education: Roles and Models

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1 Interprofessional Education: Roles and Models CILT Training Session C118 17th February 2016 Dr Celia Woolf

2 Interprofessional Education Occasions when two or more professions learn with, from and about each other to improve collaboration and the quality of care (Freeth et al., 2005) Shared Learning Interprofessional Learning

3 Activity 1: Reflections on Interprofessional Teamwork Discuss examples of interprofessional teamwork from your own experience, both positive and negative Identify Factors that facilitated interprofessional teamwork Barriers to interprofessional teamwork

4 Airline Disasters Case 1 Korean Air flight 801

5 Korean Air flight 801, Guam, August 6 th 1997 Crashed into hillside 3 miles SW from Guam International airport when approaching to land Plane broke up and caught fire 254 passengers and crew on board, 228 were killed

6 Why did Korean Air flight 801 crash? Post-crash analysis revealed no mechanical defects with the aircraft Poor weather & visibility Pilot fatigue Pilot Error Descent towards airport too steep Flew into top of Nimitz Hill If a few feet higher would have cleared the hill

7 Why did Korean Air flight 801 crash? Flight recorder revealed poor team collaboration Co-pilot and engineer were both monitoring equipment readings and aware of the error Neither informed the pilot clearly not in sight let s make a missed approach Inadequate team training Cultural sensitivity about criticising a superior? NB. Korean Air had more plane crashes than almost any other airline in the world at the end of the 1990s

8 What have airplane crashes got to do with interprofessional education? Human Factors

9 Human Factors in healthcare A human factors approach to system design considers the characteristics and abilities of the people who work in the system and how to organise them effectively so that the system works (Royal College of Nursing)

10 Failures of Care Poor interprofessional communication and teamwork is often identified as a contributory factor in inquiries into failures of care deaths of infant heart patients at Bristol Royal Infirmary (Kennedy, 2001) death of Victoria Climbié (Lord Laming, 2003) deaths in maternity care at Northwick Park Hospital (Healthcare Commission, 2006) death of Baby P (Care Quality Commission, 2009)

11 Just a Routine Operation rs.html

12 What makes MDT working so challenging? boundary disputes status issues language barriers competing practice models complex accountabilities disputed decision making powers imported inequalities Littlechild & Smith, 2013

13 Boundary disputes Unclear or overlapping role boundaries between professions e.g. Problematic tasks may be shunned by both parties Tension over colonisation of tasks

14 Status issues Some professions assume authority over other disciplines rather than agreeing collective solutions Reluctance of individuals to raise concerns or share information with MDT members perceived to have higher status

15 Language barriers Specialist terminology and acronyms help establish professional identities and credibility Differences in terminology between professions can be divisive and lead to miscommunication

16 Competing practice models e.g. Social vs Medical models of Disability Social Model interventions may focus on reducing disabling barriers in environment Medical Model interventions may focus on reducing impairment in individual Can create conflicting approaches to care planning.

17 Complex accountabilities Managers may not share an individual s professional skills and expert knowledge Management may be shared across departments and/or organisations Who is accountable if things go wrong?

18 Disputed decision making powers Who has authority to make decisions? e.g. Nurse prescriber having to wait for doctor to sign off their prescriptions

19 Imported inequalities External social divisions may be imported into MDT relationships Gender Ethnicity Culture Socioeconomic status

20 Activity 2: Professional stereotypes Discuss what stereotypes exist about Nurses Social workers Occupational therapists Speech & language therapists Doctors/specialties Dentists GP receptionists How might these affect interprofessional collaboration?

21 Changing professional stereotypes IPE can change attitudes and perceptions by countering prejudice and negative stereotypes (Barr et al, 1999) Assumption that bringing different groups together allows them to learn about each other and dispel negative stereotypes that hamper interprofessional collaboration.

22 Contact Hypothesis Reduce hostility by bringing groups together (Allport, 1954) But contact is not enough (Dickinson & Carpenter, 2005) Alarming degree of negative stereotyping following integrated lecture and seminar programme for education and social work students (McMichael & Gilloran, 1984) Majority showed positive change but 19% of social work, medical and nursing students increased negative stereotypes of each other following interprofessional education (Carpenter & Hewstone, 1996)

23 Facilitating conditions for changing intergroup stereotypes Equal status within contact situation Common goals Institutional support Cooperation Participants have positive expectations Joint work is successful Similarities and differences are acknowledged Participants perceive each other as typical group members (cf. Dickinson & Carpenter, 2005)

24 Getting back to airplanes

25 Crew Resource Management

26 Crew Resource Management Training for cockpit crew to enhance safety and improve efficiency: Communication Situational awareness Problem solving Decision making Teamwork Cognitive and interpersonal skills

27 Crew Resource Management Assertive statement process Opening or attention getter - Address the individual. "Captain Smith," or "Bob," or whatever name or title will get the person's attention. State your concern - Express your analysis of the situation in a direct manner while owning your emotions about it. "I'm concerned that we may not have enough fuel to fly around this storm system" State the problem as you see it - "We're only showing 40 minutes of fuel left." State a solution - "Let's divert to another airport and refuel." Obtain agreement - "Does that sound good to you, Captain? (Bishop)

28 MDT Training and Patient Safety A. Morey et al 2002 Research Study involving 9 hospital emergency departments ETCC Emergency Team Coordination Course CRM training adapted for hospital emergency department teams Six hospitals received training Three hospitals used as experimental controls

29 MDT Training and Patient Safety Outcomes of training (compared to control group): Collaborative team behaviours increased (p =.012*) Perceived workload did not change (p =.668) Attitudes towards teamwork were more positive (.047*) Clinical error rates decreased from 30.9% to 4.4% (p =.039*)

30 MDT Training and Patient Safety B. Neily et al., JAMA 2010; 304: Team training intervention; briefings, debriefings, preparatory work, 1 day conference, 1 year of quarterly coaching Included teams of surgeons, anesthesiologists, nurse anesthetists, nurses, and technicians Retrospective health services cohort study with contemporaneous control

31 MDT Training and Patient Safety Analysis of 182,409 procedures from 108 VHA facilities Surgical mortality declined 18% in the 74 hospitals that had implemented Team training (RR=0.82, 95% CI , p=0.01) 7% in the controls (RR=0.93, 95% CI , p=0.59) There was a dose-response relationship. More team training greater reduction in mortality Absolute reduction in mortality from 17/1000/year procedures at baseline to 14/1000/year after training

32 Drivers of Interprofessional Education in UK Government policy Public Inquiries Regulatory bodies

33 Government Policy National Health Service Plan (DoH, 2000) called for: Better integration of services Working across professional boundaries by practitioners Better communication between those caring for the patient Working Together, Learning Together (DoH, 2001) All health professionals should receive common learning with other professions From pre-registration through to CPD Classroom and practice based elements Centred on needs of patients

34 Recommendations of Public Inquiries Poor interprofessional communication and teamwork is often identified as a contributory factor in inquiries into failures of care

35 Regulatory Bodies Regulatory Bodies for each health and social care profession require IPE as part of pre-registration education

36 Tomorrow s Doctors (GMC) Doctors must understand and respect the roles and expertise of health and social care professionals in the context of working and learning as a multi-professional team. understand the contribution that effective interdisciplinary teamwork makes to the delivery of safe and high quality care. Medical schools must ensure that students work with and learn from other health and social care professionals and students. Opportunities should also be provided for students to learn with other health and social care students.

37 Preparing for Practice (GDC) Dentists must: Describe and respect the roles of dental and other healthcare professionals in the context of learning and working in a dental and wider healthcare team Co-operate effectively with other members of the dental and wider healthcare team in the interests of patients Explain the contribution that team members and effective team working makes to the delivery of safe and effective high quality care

38 Activity 3: Planning classroom based IPE As a team, plan a session to teach undergraduate students about interprofessional teamwork: Group 1: First year medical, dental and nursing students in classroom setting Group 2: Final year audiology, podiatry, speech & language therapy & medical students in classroom setting Group 3: 4 th year medical and final year midwifery students in practice setting

39 IPE Models in Context IPE Models are diverse e.g. Philosophies and Aims Nature of learning activities Context dependant One size does not fit all (Miller, Woolf & Mackintosh, 2006)

40 Logistics & Resources Timetabling is a nightmare! Taught curriculum and Practice Placement patterns vary between professions Organisational barriers e.g. separate communication systems for each profession IPE Champions essential Administrative resources required

41 Professional Groupings Natural teams e.g. doctors, nurses & radiographers Contrived teams e.g. midwives, dentists & chiropodists

42 Implications of natural v contrived groupings The role of the patient / client Relationship of student with peers IPE Activity Exploration of professional roles and identities

43 Generic tasks Generic focus may be more appropriate for contrived professional groupings students explore professional roles and team-working in general topics selected are of equal relevance to all professions e.g. communication skills professional ethics infection control measures Pre-cursors to specific professional roles

44 Patient/Client focused tasks Explore professional roles and team-working in relation to individual patient/client Hypothetical patient/client E.g. case scenarios, patient actors, high-tech simulations Real patient/client E.g. patient journeys, students involved in real care delivery

45 Interprofessional learning is optimised when. Real patients/clients involved in care IPE Activity Professional status with peers Exploration of professional roles in relation to patient care

46 Activity 4: Planning practice based IPE As a team, plan practice based training to address interprofessional teamwork issues in one of your settings: - Specify: - Learning objectives - Participants - Teaching activities - Consider logistics (when, where, resources etc)

47 Dr Celia Woolf Senior Lecturer in Interprofessional Teaching & Learning Barts & The London School of Medicine & Dentistry