Interprofessional Education

Transcription

1 Interprofessional Education American Association of Colleges of Nursing March 19, 2011 Linda Cronenwett, PhD, RN, FAAN Beerstecher Blackwell Term Professor Linda Cronenwett, PhD, RN, FAAN Beerstecher School Blackwell of Nursing Term Professor School of Nursing University of North Carolina at Chapel Hill University of North Carolina at Chapel Hill

2 Institute of Medicine Health Professions Education: A Bridge to Quality (2003) All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidencebased practice, quality improvement approaches, and informatics.

3 World Health Organization Framework for action on interprofessional education and collaborative practice (2010) * Collaborative practice happens when multiple health workers from different professional backgrounds work together with patients, families, carers and communities to deliver the highest quality of care. *After almost 50 years of enquiry, the World Health Organization and its partners acknowledge that there is sufficient evidence to indicate that effective interprofessional education enables effective collaborative practice.

4 World Health Organization Framework for Action on Interprofessional Education and Collaborative Practice (2010) * Interprofessional education occurs when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes. A collaborative practice-ready health worker is someone who has learned how to work in an interprofessional team and is competent to do so. Interprofessional education is a necessary step in preparing a collaborative practice-ready health workforce that is better prepared to respond to local health needs.

5 Logic Model Education Interprofessional education Interprofessional teamwork and team-based care competencies Practice High functioning teams that include patients and families Patient-centered, coordinated team care Outcomes Safe, reliable, effective, efficient care Patient satisfaction Professional joy in work 5

6 IPE National Initiatives Josiah Macy 2010 report recommendation: Inter-professional education should be a required and supported part of all health professional education. This change is especially important for primary care. Regulatory, accreditation, reimbursement, and other barriers that limit members of the healthcare team from learning or working together should be eliminated. Macy/Carnegie initiative to stimulate IPE seven AHC s with SON/SOM partnerships HRSA and partners (Macy, RWJF, IPEC) initiative to identify interprofessional team and team-based care competencies and fund grants to stimulate learning about effective pedagogy

7 Interprofessional Education A means to an end or an end in itself? What learning objectives make IPE efficient and effective? How will we know if IPE has an impact on effectiveness of interprofessional teamwork and collaboration? 7

8 Theories About Interprofessional Education If students learn together as health professions students in common before they are in role, we will achieve better collaboration in patient care. By what mechanism? Will it reinforce or dispel stereotypes? Could students of one profession learn as well (or better) with professionals from other disciplines?

9 Theories About Interprofessional Education If students learn more about each others roles, we will achieve better collaboration. Which roles, of the many? Are students good informants about roles? Is the aim knowledge or attitude/values?

10 Theories About Interprofessional Education If students experience IPE team training, we will provide better, safer patient care. With whom do they team for training? What are effective teaching strategies? Will knowledge and attitudes change?

11 Health Professions Education IPE Clinical Microsystem Teamwork/ Collaboration Patientcentered care Evidence-based practice Quality improvement/safety Informatics 11

12 IPE and Health Professions Education Clinical IPE T/C IPE courses students learn common content in ethics, QI, safety cultures, disease prevention, genetics, etc. IPE courses students learn about patientcentered care from perspectives of patients, faculty and students in multiple roles, for instance through courses about patient conditions (AIDS, diabetes), team training IPE low/high fidelity simulations students learn about patient-centered, team-based care through simulations and de-briefs (from case studies, role play, patient actors, computer-based manikins) IPE service learning 12

13 IPE and Health Professions Education: What keeps me awake? What incentives/rewards will attract faculty to inter-professional (rather than individual) work? What university infrastructure will support efficient review/approval of courses, alignment of schedules and sharing of resources to support this work? What happens when medical or nursing schools or their students do not enjoy geographical proximity? 13

14 IPE and Clinical Microsystems Clinical IPE T/C Learners from multiple professions are trained in clinical inter-professional micro-systems Focus of learning is intra-professional Interactions almost completely intraprofessional Licensure and accreditation requirements reinforce intra-professional focus Early foci consist mainly of obtaining what I need to complete my work and frustration with other professionals who, in doing their work (whatever that is), get in the way of reaching my goals 14

15 IPE and Clinical Microsystems: What keeps me awake? What could be accomplished with: Common orientation Common language Common conferences analyzing safety culture, quality of teamwork, and error/qi data from micro-system Common rounds patients, families, MDs, RNs, learners Involvement in common QI initiatives 15

16 IPE and Teamwork and Collaboration Clinical IPE T/C IPE as means to an end development of specific competencies Issues with improving training for working in interprofessional teams Different meanings of teamwork and collaboration Unique meaning of collaboration in state regulatory language Culture of autonomy Different labeling of competencies across medicine and nursing 16

17 Clinical Different Labels IPE T/C IOM Health Professions Education Report Interdisciplinary teams Canadian IP Health Collaborative Framework Team functioning Interprofessional conflict resolution WHO Framework on Inter-professional & Collaborative Practice Teamwork ACGME Communication Quality and Safety Education for Nurses (QSEN) Teamwork and collaboration 17

18 Definition of Teams How often do health professionals actually work in teams? Does the language matter?

19 Individual to High-performance Team Continuum Complexity and Commonality of Goal Individual Workgroup Collaborative Workgroup Team Highperformance Team Degree of Interdependence and Collaboration Kossler & Kanaga, Center for Creative Leadership,

20 Individual to High-performance Team Continuum Complexity and Commonality of Goal Individual Individual One person has all the expertise, knowledge and skills needed to do the job Is solely accountable for getting the job done Degree of Interdependence and Collaboration Kossler & Kanaga, Center for Creative Leadership,

21 Individual to High-performance Team Continuum Complexity and Commonality of Goal Workgroup Group of people who work together May do essentially the same kind of work Not dependent on each other for information and skills Workgroup Degree of Interdependence and Collaboration Kossler & Kanaga, Center for Creative Leadership,

22 Individual to High-performance Team Continuum Complexity and Commonality of Goal Collaborative Workgroup Individuals need information from one another in order to achieve results Collaborative Workgroup Each person completes one step in a complex process One person s error of execution affects ability of others in the group to do their work Each person is rewarded for individual performance Degree of Interdependence and Collaboration Kossler & Kanaga, Center for Creative Leadership,

23 Individual to High-performance Team Continuum Complexity and Commonality of Goal Team Small group of interdependent Team people who collectively have the expertise, knowledge, and skills needed to complete a task or ongoing work Clear roles and responsibilities Shared vision and sense of purpose Collectively accountable for completing tasks Harder to create especially in cultures that prize individual achievement Degree of Interdependence and Collaboration Kossler & Kanaga, Center for Creative Leadership,

24 Individual to High-performance Team Continuum Complexity and Commonality of Goal High-performance Team Highperformance Team Unusual degree of synergy among members Exceeds performance expectations Personal commitment of each member to other members personal growth and success is extraordinary Members may sacrifice individual rewards to secure success and rewards for the team The degree of coordination and interdependency is such that members anticipate what each other will need and provide it in advance Degree of Interdependence and Collaboration Kossler & Kanaga, Center for Creative Leadership,

25 Qualitative Analysis of Resident MD-Nurse Collaboration Stories McGrail, Morse, Glessner & Gardner (2008) Sample: 25 medical residents (many IMGs), 32 nurses, 5 MD and 5 nurse faculty members Method: Appreciative inquiry - wrote narratives in response to prompt: Think of a time when you experienced nurse-physician collaboration at its best, resulting in either better care, greater satisfaction on your part or an unexpected good result. It could be an experience you had personally or one you observed. It could have occurred in the clinical, administrative, research or teaching arenas. 25

26 Qualitative Analysis of Resident MD-Nurse Collaboration Stories McGrail, Morse, Glessner & Gardner (2008) Conclusions: Despite the prevailing wisdom that nursing and medicine are qualitatively different, the stories from this study illuminate surprising commonalities in the collaboration experience, regardless of gender, age, experience, or profession. 26

27 Elements and Levels of Collaboration McGrail, Morse, Glessner & Gardner (2008) Unconscious incompetence Doesn t know what collaboration is Doesn t know that he/she doesn t know Low level collaboration -jobs done in complementary ways on parallel tracks Little or no interaction Smooth hand-offs Use of protocol or pathway Little affective component

28 Elements and Levels of Collaboration McGrail, Morse, Glessner & Gardner (2008) Mid level Collaboration Give and take interactions Use of other s abilities to jointly problem solve Active listening regarding patient care issues Satisfaction with job well-done Some appreciation of the other

29 Elements and Levels of Collaboration McGrail, Morse, Glessner & Gardner (2008) High level (high order) collaboration Fluid, repetitive interactions Flexible use of one another s abilities and talents On-the-spot collaborative problem solving Intuitive appreciation of others needs and use of that knowledge Potential for high level affective outcomes

30 IPE and Teamwork/Collaboration: What keeps me awake? What could be accomplished if we: Shared a vision of knowledge, skills, and attitudes required of all health professionals Were clear about the collaboration continuum and the KSAs needed to be effective in each type of interprofessional effort Focused student attention on interprofessional as well as intra-disciplinary teamwork and collaboration 30

31 IPE and Teamwork/Collaboration: What keeps me awake? What could be accomplished if we: Discovered what to teach students about dealing with asymmetry in education, authority, intelligence (all types), or available time Didn t assign team projects without knowing teamwork would add value 31

32 Clinical IPE Clinical Microsystems and Teamwork/Collaboration T/C One vs. many clinical micro-systems and the impact on teamwork and collaboration Relationships between health care errors and quality of team communications Lack of shared mental models Recent increased attention to: SBAR training for nurses (after debates about the R ) Use of checklists to reduce reliance on memory Policies to handle disruptive behaviors Common language for stopping the process 32

33 Clinical Microsystems and Teamwork/Collaboration What keeps me awake? What could be accomplished if we: Consistently role modeled effective conflict resolution involving patient/provider or interprofessional differences Accepted greater standardization of roles (less autonomy) Improved routine handoffs Didn t rotate so much Everywhere and always included the patient and family as members of the team 33

34 Clinical Microsystems and Teamwork/Collaboration What keeps me awake? Do we celebrate teams or only team leaders? What can be accomplished if we do not find common ground on definitions of authority, accountability, and roles? 34

35 The Hidden vs. Formal Curriculum A marked divergence between the formal and informal curricula is likely to lead to cynicism amongst professional trainees. In order for interprofessional education initiatives to have a significant impact on the ongoing interactions between health care professionals, the values that are promoted in formal courses must be reflected in clinical practice settings. Whitehead, C. The doctor dilemma in interprofessional education and care: How and why will physicians collaborate? Medical Education 2007: 41:

36 Pushing the Envelope Link nursing faculty members to the clinical enterprise Build interprofessional relational trust so that can create satisfying roles, teams and workgroups Experiment with different approaches to IPE: Develop the outcome measures for assessing learning 36

37 Qualitative Analysis of Resident MD-Nurse Collaboration Stories McGrail, Morse, Glessner & Gardner (2008) Sample: 25 medical residents (many IMGs), 32 nurses, 5 MD and 5 nurse faculty members Method: Appreciative inquiry - wrote narratives in response to prompt: Think of a time when you experienced nurse-physician collaboration at its best, resulting in either better care, greater satisfaction on your part or an unexpected good result. It could be an experience you had personally or one you observed. It could have occurred in the clinical, administrative, research or teaching arenas. 37

38 Qualitative Analysis of Resident MD-Nurse Collaboration Stories McGrail, Morse, Glessner & Gardner (2008) Conclusions: Despite the prevailing wisdom that nursing and medicine are qualitatively different, the stories from this study illuminate surprising commonalities in the collaboration experience, regardless of gender, age, experience, or profession. 38

39 Elements and Levels of Collaboration McGrail, Morse, Glessner & Gardner (2008) Unconscious incompetence Doesn t know what collaboration is Doesn t know that he/she doesn t know Low level collaboration -jobs done in complementary ways on parallel tracks Little or no interaction Smooth hand-offs Use of protocol or pathway Little affective component

40 Elements and Levels of Collaboration McGrail, Morse, Glessner & Gardner (2008) Mid level Collaboration Give and take interactions Use of other s abilities to jointly problem solve Active listening regarding patient care issues Satisfaction with job well-done Some appreciation of the other

41 Elements and Levels of Collaboration McGrail, Morse, Glessner & Gardner (2008) High level (high order) collaboration Fluid, repetitive interactions Flexible use of one another s abilities and talents On-the-spot collaborative problem solving Intuitive appreciation of others needs and use of that knowledge Potential for high level affective outcomes

42 Defining the Learning Aims QSEN - funded by the Robert Wood Johnson Foundation (RWJF) Interprofessional Team-Based Competencies: Building a Shared Foundation for Education and Clinical Practice meeting held in Washington D.C., February 16-17, 2011, supported by HRSA, RWJF, the Josiah Macy, Jr, Foundation and ABIM

43 QSEN Competency Aims Teamwork and collaboration: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decisionmaking to achieve quality patient care Knowledge, skills, and attitudes for basic and advanced practice nursing students outlined in: Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P, & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), Cronenwett, L., Sherwood, G., Pohl, J., Barnsteiner, J., Moore, S., Sullivan, D.T., Ward, D., & Warren, J. (2009). Quality and safety education for advanced nursing practice. Nursing Outlook, 57(6),

44 IPEC (Interprofessional Education Collaborative) Amer. Assn of Colleges of Nursing Amer. Assn of Colleges of Osteopathic Medicine Amer. Assn of Colleges of Pharmacy Amer. Dental Education Association Assoc. of American Medical Colleges Assoc. of Schools of Public Health Expert Panel Chair: Madeline H. Schmitt, PhD, RN, FAAN, FNAP

45 IPEC 2011 Interprofessional Team and Team-based Care Competencies Values/Ethics for Interprofessional Practice Work with individuals of other professions to maintain a climate of mutual respect and shared values Roles/Responsibilities for Collaborative Practice Use the knowledge of one s own role and the roles of other professions to appropriately assess and address the health care needs of the patients and populations served

46 IPEC 2011 Interprofessional Team and Team-based Care Competencies Interprofessional Communication Communicate with patients, families, communities, and other health professionals in a responsive and responsible manner that supports a team approach to maintaining health and treatment of disease Interprofessional Teamwork and Team-based Care Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan and deliver patient/populationcentered care that is safe, timely, efficient, effective and equitable

47 Teaching Strategies TeamSTEPPS AHRQ curriculum and materials SBAR training and cards Exposure to MD-RN communication listen in when staff RN makes call, include in simulations, involve physicians in classroom case studies or invite to postconference Reflection and journaling on instances of professional communications that enhanced quality, efficiency, safety, timely and evidence-based care

48 Teaching Strategies Watch for opportune teaching moments when can reflect on good or poor teamwork examples or make it an assignment Reinforce good role modeling by faculty Expect attendance at interprofessional rounds Spend a day with someone from another discipline Apply learning to student team projects Ensure exposure to teams that include patients and families

49 Teaching Strategies Consider different strategies for schools with/without medical schools or residents nearby Use of retired physicians Use of simulation In same room vs. virtual case studies Team-based learning (e.g. Clarion competition or quality improvement projects) Service learning Observational experiences of other health professionals in their roles

50 Teaching Strategies Consortium of 4 universities (McMaster University, University of Western Ontario, University of Ottawa-Elizabeth Bruyere and Laurentian University) that have combined their expertise, knowledge and skills to create an online virtual network of Interprofessional Education (IPE). Modules are asynchronous, problem-based and interactive, able to be inserted into a variety of curricula Each module package includes: DVD to be installed in your own learning management system (LMS) Facilitator and Installation Manuals One printed copy of the courseware

51 Comments from the HRSA Conference Important factors in enacting successful IPE: Leadership at the top Faculty attention and development Careful, thoughtful IP planning and rigor Not viewed as a single event but a continuum of experience Technology can be an aid Humility about what we don t know yet Simultaneous work and learning across education and practice

52 Comments Ideas Concerns? How can we enhance the reinforcing factors? How can we mitigate the restraining factors? What should be the priorities for nursing education leaders and deans?