Dr. Salfi is Assistant Professor, Dr. Solomon is Professor and Associate Dean, and Ms. Patterson is Assistant Professor, School of Nursing, McMaster University, Hamilton; and Ms. Allen is Professor and Dr. Mohaupt is Professor, School of Nursing, Conestoga College Institute of Technology & Advanced Learning, Kitchener, Ontario, Canada.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Jenn Salfi, PhD, RN, Assistant Professor, School of Nursing, McMaster University, 1280 Main Street W–HSC 2J21D, Hamilton, ON, Canada L8S 4K1; e-mail: firstname.lastname@example.org.
It has been proposed that interprofessional education (IPE) is an essential step in preparing a collaborative practice-ready workforce that is better prepared to respond to and meet the health care needs of the population (World Health Organization, 2010). IPE occurs when students of two or more professions learn with, from, and about one another to improve collaboration and the quality of care (Centre for the Advancement of Interprofessional Education [CAIPE], 2010). CAIPE (2010) uses the term interprofessional education to include learning in both academic and clinical settings before and after licensure. Some of the key benefits to exposing nursing students, as well as other prelicensure students, to IPE is that it helps to cultivate mutual trust and respect, confronts misconceptions and stereotypes, and dispels prejudice and rivalry between professionals (CAIPE, 2010). The ability to communicate and collaborate in a respectful manner facilitates connectedness among members of a team, as it allows for an awareness of equal power and fosters shared decision making, responsibility, and authority (Sele, Salamon, Boarman, & Sauer, 2008).
Effective Interprofessional Education—Guiding Principles
CAIPE (2010) has published several key principles to assist in the development of effective IPE. A few key points should be upheld when designing and implementing activities and opportunities for IPE within a curriculum. IPE should (a) reinforce and provide the opportunity for students to develop and refine essential team-based skills; (b) provide an opportunity to learn about their own scope of practice and also learn the skills, languages, and perspectives of other health and social care professionals; and (c) be grounded in mutual respect, honoring the distinctive experiences and expertise that each participant brings to the health care team from their respective backgrounds (CAIPE, 2010). Embedded within these principles of effective IPE are several competencies (knowledge, skills, and behaviors) that are required for interprofessional collaborative practice. The number and specificity of interprofessional competencies may vary across academic institutions, but overall they can be summarized into four key domains (Table).
Table: Core Interprofessional Education Competencies
Another key principle of effective IPE is that it should not be viewed in isolation but rather as a continuum over a prelicensure curriculum. To increase the overall effects and benefits of IPE, it should be continuously revisited and reinforced as the student develops as a professional. This continuum should be planned with specific and shifting goals for each level of the learner and should use a variety of pedagogical methodologies (Thibault, 2011).
Challenges and Obstacles
Despite the many benefits of IPE, several challenges and obstacles are associated with implementing IPE initiatives. IPE can be costly and time consuming to arrange and sustain. Other possible barriers to the delivery of IPE include lack of faculty interest and expertise in IPE (Hammick, Freeth, Koppel, Reeves, & Barr, 2007), as well as incompatible clinical shifts and timetables and rigid curriculum schedules (Morison, Boohan, Jenkins, & Moutray, 2003).
Student numbers can also affect the ability to deliver effective IPE. Care is often taken to balance groups with representation from at least three or more professional bodies, thereby avoiding experiences that are dominated by any one profession. Because nurses are the most predominant professional group within the health care environment, the nursing undergraduate program also tends to be one of the largest student bodies within an academic institution; therefore, it is challenging to offer sufficient opportunities in IPE for all nursing students within a large program.
Another obstacle that many prelicensure programs (including nursing) face relates to the difficulty in securing clinical placement settings for students that are in close proximity to the academic institution. This difficulty stems in part from health care restructuring, health provider shortages, and increased student enrollment in health professional programs (Diem et al., 2005). To overcome this problem, one strategy that is commonly used is to expand traditional clinical placements to include rural, outpost, and international sites. However, this separates students from the academic institution, making it difficult for students to participate in IPE opportunities and activities (unless offered online). Certainly, it is possible for one to learn with, from, and about others via the Internet, but this learning format introduces a new set of challenges in itself—for example, finding reliable and stable Internet connections in remote settings and finding faculty experienced in facilitating both IPE and e-learning (Luke et al., 2009).
Another challenge with integrating IPE into a prelicensure program relates to the controversy of introducing IPE at the undergraduate level. One of the arguments against the introduction of IPE at the undergraduate level is that most students have not yet acquired a sense of their own professional characteristics, which might interfere with the establishment of a distinct professional identity (Miller, Ross, & Freeman, 1999). Regardless of this and other aforementioned obstacles, awareness of the importance of IPE on safe clinical practice and strong professional partnerships continues to build, as does the need to prepare all nursing students for interprofessional collaborative practice.
Framework for Integrating Interprofessional Education into a Bachelor of Science in Nursing Curriculum
As a strategy for preparing all students within a large school of nursing (approximately 2,000 students) for interprofessional collaborative practice, a framework was developed to guide the integration of effective IPE into a Bachelor of Science in Nursing (BScN) curriculum. With students dispersed across three academic sites (one university and two college sites), as well as placement in clinical rotations across the province and internationally, it was essential to think outside of the box because IPE activities and courses offered through the central university and college programs would not prepare all BScN students for interprofessional collaborative practice. The foundation for this framework is based on the original work of Vygotsky (1978), which reports that the cognitive process associated with collaboration and communication can be effectively developed in a clinical setting to promote higher-level learning among students. The framework is also based on Miller’s (1990) levels of competence (knows, knows how, shows how, does) in that levels of competence are much like steps—the underlying level is the building block for the next level.
Level 1 Focus: Intraprofessional Education; Foundation of Group Skills
As one of the main arguments against introducing IPE in the undergraduate program relates to students not having a sense of their own professional characteristics or sufficient practical experience to be able to understand the full benefits of IPE (Fraser, Symonds, Cullen, & Symonds, 2000), the decision was made to devote the first year of the program to learning about the profession of nursing, which includes brief exposure to the intraprofessional roles within the nursing profession. First-year BScN students learn about the scope of practice of the RN, and also learn about the many different roles of the RN in a variety of clinical contexts. Although students continue to build on this knowledge as they progress through the program, by the time they complete Level 1 they should know about their own professional role and are ready to begin learning about other professionals on the health care team.
Another main focus in level 1 is laying the foundation of group skills. Students learn about the different roles and tasks within a group and the dynamics of group functioning. Focus on such skills as collaborative problem solving, mutual goal setting, and shared decision making in a problem-based learning context aid in the development of key group (team) skills, such as effective communication, active listening, and giving and receiving feedback.
Level 2 Focus: Introduction to Interprofessional Education and Interprofessional Collaboration; Exposure to the Health Care Team
Role clarification is the focus in level 2, building on knowledge of the nurse’s role while also facilitating exposure to the many different professionals within a health care team. A key area for learning in this level is beginning knowledge about others’ scopes of practice, and when and how to collaborate with other professionals in patient care appropriate to their roles and responsibilities (knows how) (MacDonald, Bally, Ferguson, Murray, & Fowler-Kerry, 2010).
Building on the group skills acquired in level 1, students in level 2 are introduced to core concepts of interprofessional collaboration (IPC) and the importance of IPC in providing holistic and safe and seamless person-centered care. Advanced communication strategies are reinforced, and key principles of conflict management are introduced. By the end of levels 1 and 2, students in the BScN program know about the roles of many health and social care professionals, including the unique features of their own professional role, and they should have a basic understanding of the importance of interprofessional collaborative practice.
Level 3 Focus: Interprofessional Collaboration
In level 3, the goal is “knowledge to practice.” Students are expected to show what they have learned in the previous 2 levels through demonstration of the basic skills required for collaboration with other professionals. It is required that students begin to interact with other members of the health care team (other prelicensure students or health care professionals), and demonstrate they are capable of engaging in collaborative problem solving, mutual goal setting, and shared decision making. Students in this level show that they respect and value the unique perspectives of others within the team, and they must also demonstrate accountability to the team. Practice collaborating with others can be developed within their individual clinical settings and service learning placements with other health professionals. These skills can also occur through voluntary IPE activities organized through a central university or college program (e.g., through interprofessional online modules, workshops, or simulation experiences with students from other professional programs). The goal for students by the end of level 3 is to demonstrate some of the knowledge and skills required for effective collaborative practice.
Level 4 Focus: Becoming an Effective Member of the Health Care Team
By level 4, most students are immersed in the clinical setting, so it is expected that they are also participating and contributing to the overall effectiveness of a health care team. The knowing and showing becomes doing, and the more they do, the greater likelihood that attitudes and behaviors required for collaborative practice will be adopted. Also, through doing, confidence in collaborating with others continues to build. Depending on the student’s level of confidence and the organizational culture in the clinical practice environment, some students may also have the opportunity to develop advanced team skills (team leadership, team mentorship, and the ability to manage conflict within a team environment). By the time the students graduate from the BScN program and have progressed through the four levels of the framework (Figure), it is anticipated that they have acquired a basic knowledge and skill set essential for collaborative practice, which they can continue to develop and refine in the practice setting as a new health care professional. Currently, a variety of evaluation measures (scholarly papers, critical reflections, simulation demonstrations, oral synopses, and presentations) are positioned throughout the curriculum to assess the level of interprofessional learning and the effectiveness of each IPE learning experience. Also, there are plans to evaluate the effectiveness of the framework when the first cohort of students complete the 4-year, IPE-enriched curriculum (June 2013).
Figure. Integration of interprofessional (IP) compentencies in prelicensure (Bachelor of Science in Nursing [BScN]) curriculum. Adapted with permission from the Integrated Interprofessional Education Model, HealthForceOntario (2010).
This framework was developed specifically to overcome two unique obstacles: the sheer volume of students in a large BScN program and the many sites in which the students were located. The goal of this framework was to prepare all of the nursing students within a 4-year undergraduate program for interprofessional collaborative practice. Some key lessons learned during the implementation of this framework that could inform any prelicensure program—regardless of type, size, length, or complexity—are shown below.
Overcoming All Obstacles: Capitalize, Coordinate, Create, and Credit
Capitalize on What Already Exists
One lesson learned to ease the adoption of the framework into a curriculum was to capitalize on what already existed—whether it be experiences, assignments, or opportunities. For example, small group learning sessions (i.e., in this particular nursing program, it was problem-based learning) provide an ideal opportunity to develop and refine group skills, which are the same skills required for collaborative practice in a health care team setting. Of course, ideally, all students would have the opportunity to engage in interprofessional problem-based learning classes, but this can be difficult to coordinate in a large, multisite curriculum. Nonetheless, effective communication, respecting others’ opinions, shared decision making, collaborative leadership, problem solving, and conflict resolution are fundamental skills of an effective member of a health care team that can be developed in an uni–professional (i.e., related to a single profession versus multiprofessional, which relates to many professions) environment. The key in the successful utilization of this learning environment as a means to help prepare students for collaborative practice is that instructors need to make explicit the correlation between group skills and collaborative functioning within a health care team. When this association is consistently referred to (initially by the tutors and instructors and then eventually by the students as they adopt this way of thinking and behaving), small group learning sessions are the perfect venue for acquiring some of the knowledge and skills (interprofessional competencies) required for collaborative team functioning.
Another area in which educators can capitalize, and one that all nursing students have in common, is the clinical setting. Although specifically developed interprofessional clinical placements and internships with students from other professional programs would be the ideal IPE opportunity for each BScN student (especially in level 3), this is not an option for large, multisite programs. Therefore, maximizing opportunities for IPE within each student’s clinical placement becomes the next best alternative. This is usually a reliable strategy as most students interact with learners and professionals from other health professions during their clinical placements. For example, in the first 2 years of a prelicensure program (levels 1 and 2), activities and discussions can be built into the clinical practicum that involve knowledge acquisition; first learning about the many roles of the nurse and then learning about the roles and responsibilities of other professionals within the health care team. This may take the form of observing, shadowing, or interviewing exercises. Postclinical discussions and reflective journals are an effective means to assess what students know about their own role and the roles of others and whether they know how and when to collaborate with each professional.
During the final 2 years of the prelicensure program (levels 3 and 4), the focus switches to shows how and does, where the students can use their clinical practicum to demonstrate the knowledge and skills they have acquired that are essential for interprofessional collaborative practice. Activities involving communication (e.g., interprofessional rounds) and cooperative care planning (e.g., admissions, treatment plans, discharge planning) are effective in refining knowledge of others’ roles and improving collaborative team skills. More importantly, collaborative opportunities and experiences in the clinical setting help develop student confidence, help prepare the students for collaborative practice, and help ease the transition to professional practice.
Coordinate and Cooperate
To get a variety of professional student groups together so that they can learn with, from, and about one another, it is critical to have an interprofessional group or committee of faculty who are committed to developing, evaluating, and sustaining IPE initiatives. Another key lesson learned when trying to integrate IPE into a large, multisite program was the need for IPC at the faculty level. To facilitate the process of integration of IPE into a professional curriculum, at least one faculty member from each academic site had to be connected to or successfully collaborating with faculty from the other health and social care programs at their respective academic sites. This is essential because it provides a bridge between the programs. By connecting with the other prelicensure programs, faculty are able to share program-specific information and can work together toward the common goal of coordinating IPE opportunities that are effective and accessible for all students. Dedicated “IPE days” involving all prelicensure students within an academic institution are becoming more frequent occurrences as cooperation at the faculty level becomes more commonplace, which is a big step in breaking down the walls dividing the traditional professional programs.
Create New Opportunities
Another key lesson learned while trying to integrate IPE into a large BScN curriculum was the need to be creative. Several assignments were developed to help prepare students for collaborative practice and were incorporated into existing theory or professional practice courses. Most of the assignments involve a key reading related to collaboration, an interprofessional experience, and an evaluation measure. Another creative, yet effective, means of learning with, from, and about others within the setting of a required theory-based course is the option of inviting students or providers from other health professions to join in on the discussions. If the course utilizes problem-based or case-based approaches, collaborative care planning can be a goal of the discussion.
The use of high-fidelity simulation, virtual health care teams, avatars, and other new educational technologies can also help facilitate IPE (Thibault, 2011), with discussion forums or postconferences as a means for assessing or solidifying student learning. Service learning, community health, research courses, and even science-related courses can be tailored to recognize key knowledge and skills associated with IPC, as well as present opportunities for collaboration with other prelicensure students or professionals.
Credit for Extracurricular Activities
Finally, it is important to acknowledge and provide credit for participation in IPE activities and initiatives outside of one’s professional curriculum. Within this framework, there are opportunities for BScN students to participate in extracurricular IPE initiatives with students from other professional programs. Involvement in the planning of or participation in these extracurricular IPE activities are equally important for developing knowledge, skills, and behaviors required for collaborative practice. Some strategies for acknowledging extracurricular involvement in IPE are (a) students self-selecting extracurricular IPE activities based on individual interest and availability as part of the requirements for professional practice or clinical courses, (b) recognition of participation recorded on academic transcripts, or (c) making participation in a designated number of IPE events or activities outside of their professional curriculum mandatory to graduate from the program.
By embedding IPE within the content and the process of a prelicensure curriculum, there is a recontextualization of the traditional uni–professional knowledge into knowledge of collaborative practice, with a focus on one’s unique and valuable professional role within an interprofessional practice. A considerable benefit of fully integrating IPE into a BScN curriculum is the ability to overcome the obstacle of preparing nearly 2,000 nursing students dispersed across multiple sites for interprofessional collaborative practice. By weaving IPE threads throughout a curriculum, the expectation is that all students will accumulate essential knowledge and skills, as well as some of the attitudes, behaviors, and confidence necessary to be an effective member of a health care team upon graduation.
- Centre for the Advancement of Interprofessional Education (CAIPE). (2010). Defining IPE. Retrieved from http://www.caipe.org.uk/about-us/defining-ipe/
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Core Interprofessional Education Competencies
Knowledge of and the ability to clearly articulate one’s own professional role and responsibilities.
Knowledge of the roles and responsibilities of other health professionals, and knowing when to refer and/or collaborate with others, in order to provide optimal person-centered care.
Possession of the skills required for collaboration, and the ability to collaborate with other professionals to establish common goals (demonstrates effective communication, shared decision making, collaborative leadership, problem solving, and conflict resolution).
Contributes to team functioning by consistently exhibiting the following behaviors: sharing information, listening attentively, respecting others’ opinions, demonstrating flexibility and the ability to trust others, using a common language, providing and responding to feedback from others.