Interprofessional Education: Principles and Application A Framework for Clinical Pharmacy

Interprofessional Education: Principles and Application.A Framework for Clinical Pharmacy

American College of Clinical PharmacyRobert Lee Page II, Pharm.D., FCCP, Anne L. Hume, Pharm.D., FCCP, Jennifer M. Trujillo, Pharm.D.,

W. Greg Leader, Pharm.D., Orly Vardeny, Pharm.D., Melinda M. Neuhauser, Pharm.D., M.P.H.,Devra Dang, Pharm.D., Suzanne Nesbit, Pharm.D., and Lawrence J. Cohen, Pharm.D., FCCP

With the increasing prevalence of chronic diseases, advancements in healthcare technology, and growing complexity of health care delivery, the need forcoordination and integration of clinical care through a multidisciplinaryapproach has become essential. To address this issue, the Institute ofMedicine has called for a redesign of the health professional education processto provide health care professionals, both in the academic setting and inpractice, the knowledge, skills, and attitudes to work effectively in amultidisciplinary environment. Such programmatic redesign warrants theimplementation of interprofessional education (IPE) across health caredisciplines. Pharmacists play a critical role not only in the provision ofpatient care on multidisciplinary teams but also in the delivery of IPE.National pharmacy organizations have endorsed IPE, and several havearticulated specific policies and/or initiatives supporting IPE. However, IPEhas not yet been implemented effectively or consistently; moreover, theinability to effectively deliver IPE in the classroom and clinic has beencorrelated with a decrease in the quality of patient care provided. In addition,the incorporation of interprofessional patient care into daily practice has beencompromised by workforce shortages within respective health care fields.This white paper from the American College of Clinical Pharmacy (ACCP)addresses terminology, levels of evidence, environment-specific models,assessment methods, funding sources, and other important implications andbarriers as they apply to IPE and clinical pharmacy. Current instruments thathave been tested and validated in the assessment of IPE are reviewed,including the Readiness for Interprofessional Learning Scale, theInterdisciplinary Education Perception Scale, and the Attitudes Toward HealthCare Teams Scale. Finally, strategies are suggested that ACCP might pursue toassist in the promotion and implementation of IPE both within and outsidethe pharmacy profession.Key Words: clinical pharmacy, interprofessional, interprofessional education,education, multidisciplinary, pharmacy practice, teamwork.(Pharmacotherapy 2009;29(3):145e–164e)

Advances in health care have made it virtuallyimpossible for a clinician practicing alone tomaintain the knowledge and skills necessary toprovide optimal care. This fact, coupled with the

increased prevalence of many chronic diseases,which require coordination of treatmentinvolving multiple health care professionals andclinical settings, has led to an appreciation of the

A C C P W H I T E P A P E R

PHARMACOTHERAPY Volume 29, March 2009

need for an interdisciplinary approach to provideappropriate patient-centered care. Both the PewCommission report, “Critical Challenges:Revitalizing the Health Professions for theTwenty-first Century,”1 and the Institute ofMedicine (IOM) report, “Crossing the QualityChasm: A New Health System for the 21stCentury,”2 recognize this problem and call for adrastic restructuring of our current health caresystem. Part of this restructuring will require thecoordination and integration of clinical care.One way to accomplish this is the provision ofcare through interdisciplinary teams.Unfortunately, however, many currentpractitioners are trained in educational programsisolated from other health care professionals.This isolation may negatively affect practitioners’beliefs and values regarding other health careprofessionals and their contributions to patientcare. To address this issue, the IOM report on“Health Professions Education” recommends aredesign of the health professional educationprocess to provide health care professionals, bothin the academic setting and in practice, theknowledge, skills, and attitudes to workeffectively in a multidisciplinary environment.Such programmatic redesign will require healthprofession academic programs to train studentsin an interdisciplinary environment.3

When evaluating, interpreting, and applyinginterprofessional theory, the conceptualframework can seem overwhelming. This whitepaper addresses the terminology, levels ofevidence, environment-specific models,assessment methods, funding sources, and otherimportant implications and potential barriers asthey apply to IPE and clinical pharmacy. Thiswhite paper should be used to assist in thepromotion and implementation of IPE bothwithin and outside the pharmacy profession.

Furthermore, it is our hope that the paper willfacilitate the development of a future vision forapplying IPE to clinical pharmacy practice,research, and education.

Definitions and Terminology

Interpretations of the terms multidisciplinary,interdisciplinary, and interprofessional with respectto clinical practice and education vary in theliterature. Table 1 identifies definitions of theterms used in this paper.4–6 Althoughinterdisciplinary and interprofessional are oftenused interchangeably, either term can be usedwhen referring to health professions educationand practice; however, the former term may bepreferred when individuals such as nursingassistants are included on teams such as in thenursing home care setting. Nonetheless,distinctions between multidisciplinary andinterprofessional are important. Whereas amultidisciplinary approach is simply additive andnot integrative, an interprofessional approachrequires integration and collaboration toincorporate the perspectives of several disciplinesto gain unique insights and foster innovativehealth care solutions.7–9 The provision of trueinterprofessional patient-centered care, andultimately transdisciplinary care, will requirepractitioners and students to learn skills thatmake them productive in this setting. Inaddition to clinical competence, communication,and conflict resolution skills, an understandingof group dynamics and a respect for theknowledge and contribution of other health careprofessions are important for success. Thiscombination of knowledge, skills and attitudesshould be taught by interdisciplinary teams inmixed settings and will thus require areexamination of clinical curricula, educationalfunding, and faculty preparation.2, 3, 10 With thisin mind, IPE, for interprofessional education, willbe used throughout this paper.

Supporting Evidence for IPE

Many articles have been published addressingthe implementation of IPE. Although thisapproach to training health care professionalsseems intuitive, strong evidence is lacking as tothe actual effectiveness of such an approach onhealth care outcomes. The National Academiesof Practice (NAP)11 provides a bibliography ofmore than 100 articles published from 2000 to 2005related to IPE on its Web site(http://www.napnet.us/files/Interdisc_Edufinal.pdf).

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This document is from the 2007 Task Force onInterprofessional Education: Christine K. Choy, Pharm.D.;Lawrence J. Cohen, Pharm.D., BCPP, FASHP, FCCP; DevraDang, Pharm.D., BCPS, CDE; Christa George, Pharm.D.,BCPS; Anne L. Hume, Pharm.D., FCCP, BCPS; W. GregLeader, Pharm.D.; Suzanne Nesbit, Pharm.D., BCPS;Melinda M. Neuhauser, Pharm.D., M.P.H., BCPS; Robert L.Page II, Pharm.D., FCCP, FAHA, BCPS; Therese Poirier,Pharm.D., MPH, FCCP, FASHP; Jennifer M. Trujillo,Pharm.D., BCPS; and Orly Vardeny, Pharm.D., BCPS.Approved by the American College of Clinical PharmacyBoard of Regents on June 5, 2008.Address reprint requests to the American College of

Clinical Pharmacy, 13000 W. 87th St. Parkway, Suite 100,Lenexa, KS 66215; e-mail: [email protected]; or downloadfrom http://www.accp.com.

IPE: PRINCIPLES AND APPLICATION ACCP

Many of these manuscripts describe thedevelopment and implementation of IPEprograms or use a subjective self-assessment oflearning or attitudes in a pre- and posttest design.In addition, the NAP12 provides a bibliography ofmore than 140 articles that addressinterdisciplinary practice (http://www.napnet.us/files/Interdisc_Practicefinal.pdf). In 2008, theauthors of a meta-analysis on the effects of IPEon professional practice and health careoutcomes identified more than 1000 studies inthe literature that addressed IPE.13 However, theauthors were unable to identify any studies thatmet a priori inclusion criteria for quality studiesand thus found no evidence linking IPE to thedesired clinical outcomes. A 2006 review ofevidence for IPE identified 13 articles that met apriori inclusion criteria; however, the authorscame to a similar conclusion: “There is littleevidence from controlled trials related tointerprofessional teams to guide rapidly changingeducational models and clinical practice.”14

Despite their findings, these authors identifiedstudies in which clinician attitudes, knowledge,skills, and behavior were changed after subjectswere provided clinical training in combinationwith the acquisition of skills necessary foreffective teamwork in an interprofessionalenvironment.14 In 2007, Hammick andcolleagues15 collated and analyzed the bestavailable contemporary evidence from 21 of thestrongest evaluations of IPE to assess whetherlearning together helps practitioners and agencies

work better together. The authors found that IPEis well received and is a conduit for “enablingknowledge and skills necessary for collaborativeworking to be learnt.”15 However, theyconcluded that IPE is less able “to positivelyinfluence attitudes and perceptions toward othersin the service delivery team.”15

Although data documenting the effectivenessof IPE overall are unavailable, evidence doessuggest that an interprofessional approach tohealth care improves the quality and decreases thecost of care; therefore, practitioners shoulddevelop the knowledge, skills, and attitudes toprovide effective interprofessional care.3 In 2007,the American Association of Colleges ofPharmacy (AACP) Professional AffairsCommittee advocated that “all colleges andschools of pharmacy provide faculty and studentsmeaningful opportunities to engage in education,practice, and research in interprofessionalenvironments to better meet the health needs ofsociety.”16 In addition, the requirement for IPE isembedded in the Accreditation Council forPharmacy Education 2007 AccreditationGuidelines.17 As IPE is implemented morewidely, a rigorous evaluation will be needed tofully assess its effects on outcomes inprofessional practice.13

IPE Initiatives Within the Pharmacy Profession

Many pharmacy organizations have endorsedthe concept of IPE. The AACP 2004 Strategic

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Table 1. Definition of Terms4–6

Term Definition(Uni)Disciplinary One provider working independently to care for a patient. There is little

awareness or acknowledgment of practice outside one’s own discipline.Practitioners may consult with other providers but retain independence

Multidisciplinary Different aspects of a patient’s care are handled independently by appropriateexperts from different professions. The patient’s problems are subdivided andtreated separately, with each provider responsible for his/her own area

Interdisciplinary/interprofessional The provision of health care by providers from different professions in acoordinated manner that addresses the needs of patients. Providers sharemutual goals, resources, and responsibility for patient care. The terminterprofessional is used to describe clinical practice, whereas the terminterdisciplinary is often used to describe the educational process. Either termmay be used when referring to health professions education and practice

Interdisciplinary/interprofessional education An educational approach in which two or more disciplines collaborate in theteaching-learning process with the goal of fosteringinterdisciplinary/interprofessional interactions that enhance the practice ofeach discipline

Transdisciplinary Requires each team member to become familiar enough with the concepts andapproaches of his/her colleagues to “blur the lines” and enable the team tofocus on the problem with collaborative analysis and decision-making


Plan included a goal to provide leadership for thedevelopment of interprofessional andmultidisciplinary educational, research, andpatient care opportunities for all colleges andschools of pharmacy. In 2005, AACP’s Council ofFaculties task force analyzed the opportunitiesand challenges of using IPE throughout thedoctor of pharmacy (Pharm.D.) curriculumregardless of the type of academic institution.Core definitions and competencies were also setforth. The 2007 Professional Affairs Committeeof AACP addressed IPE in its report titled,“Getting to Solutions in InterprofessionalEducation.” The committee stressed that IPEshould occur in settings other than theclassroom, such as laboratories and introductoryand advanced practice experiences. Theyrecommend that students demonstrateinterprofessional competencies through sharing acommon language among health careprofessionals, understanding the value of eachhealth care profession, learning to workeffectively as a team, and promoting theinterprofessional delivery of health care in allpractice settings. The committee’s reportendorsed the IOM’s competencies for healthprofessions education, urged all pharmacyschools and colleges to provide IPE, andprovided a series of specific recommendations forAACP’s consideration.16

In addition, AACP participates in the Institutefor Healthcare Improvement Health ProfessionsEducation Collaborative (HPEC).18 EighteenU.S. medical schools and their local schools ofnursing, pharmacy, and health careadministration programs are involved in thisinitiative. The AACP is collaborating with theHPEC in areas where schools of pharmacy are co-located to advance IPE opportunities.The Standards and Guidelines for Accreditation

for the Pharm.D. degree that went into effect in2007 include a curriculum goal in agreementwith the IOM report, affirming that “all healthprofessionals should be educated to deliverpatient-centered care as members of aninterdisciplinary team, emphasizing evidence-based practice, quality improvement approaches,and informatics.”2, 17 The new standards listinterprofessional teamwork as an area ofemphasis in the revision process. It is an integrallearning experience to be promoted in a college’sor school’s mission, curriculum, andadministration.17 These changes are inaccordance with the Accreditation Council forGraduate Medical Education’s newly adopted

General Competencies, which expect medicalresidents to work in interprofessional teams toenhance patient safety and improve patientand/or population-based care.19

It is not enough for pharmacy education aloneto advocate for IPE. Practicing pharmacistsshould promote interprofessional practice modelsand continuing education. To that end, theAmerican Society of Health-Systems Pharmacistsendorses IPE in a specific position policy. Thekey elements of the policy call for the followingactions:

• To encourage colleges of pharmacy and otherhealth professions schools to teach studentsthe skills necessary for working with otherhealth care professionals and health careexecutives to provide patient care; further,

• To encourage the Accreditation Council forPharmacy Education to includeinterdisciplinary patient care in its standardsand guidelines for accreditation of Pharm.D.programs; further,

• To encourage and support pharmacists’collaboration with other health professionalsand health care executives in thedevelopment of interdisciplinary practicemodels; further,

• To urge colleges of pharmacy and otherhealth professions schools to includeinstruction, in an interdisciplinary fashion,about the principles of performanceimprovement and patient safety and to trainstudents how to apply these principles inpractice; further,

• To foster the documentation anddissemination of the outcomes achievedbecause of the interdisciplinary education ofhealth care professionals.20

IPE Promotion and Implementation

Historical Perspective

An understanding of the history of IPE isimportant to promote, implement, and, mostimportantly, sustain this approach. Although IPEand practice may be considered a new concept orsolely in response to the recent IOM report,multiple distinct phases have existed for over 50years, with development beginning in the late1940s. The second phase was linked to the riseof the health center movement in whichimproving primary care within the communitywas the focus in the 1960s. During the 1970s,federal funding spurred the development of 20

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interdisciplinary programs around the countryand fostered early initiatives in team training.After federal funding waned, manyinterdisciplinary programs ended unless they hadbeen incorporated into the culture of theeducational institution. In the 1980s,recognition within the Veterans Administration(VA) medical system that older adults withcomplex medical needs required a morecomprehensive approach stimulated thedevelopment of the Interdisciplinary TeamTraining in Geriatrics program.21 In the fifth andsixth phases, the emphasis of federal programshas shifted to include students from disciplinesother than medicine and to increase collaborationwith existing programs such as Area HealthEducation Centers and Health CareerOpportunity Programs. In addition, the RobertWood Johnson Foundation and HartfordFoundation, as well as other organizations, haveemphasized the need for the interdisciplinaryeducation of students in the health professions.21, 22

Core Characteristics of an Ideal IPE Model

The development of the ideal model for IPEmust begin with the recognition that this is justthe first step toward the ultimate goal ofimproving patient-centered care. Aninterprofessional approach may better facilitatestudents from one discipline learning from otherdisciplines, both to specifically develop newskills that will enhance their own discipline-specific skills and to better work together in anintegrated team environment. As a result,students, practitioners, and faculty in the healthdisciplines must be socialized to their owndiscipline as well as to the team environment. Inaddition, given the inconsistent history of IPEimplementation, a commitment must be made toinstitutionalize interprofessional learning withinthe curricula of all health care programs toensure its long-term continued existence.

Student Perspective

The first issue in defining the corecharacteristics of the ideal IPE model is toconsider which health disciplines are “essential”to the educational process and intendedoutcomes. Recognition that the pharmacist hasnot always been considered an essential teamparticipant is important, especially when thepotential contributions of other professions areevaluated in developing the respective model. Ata minimum, an IPE team of students should

include medicine, nursing, pharmacy, clinicalsocial work, and dietetics/nutrition. Dependingon the specific focus of the IPE program,students from other health disciplines may beessential. For example, if the program focuses onimproving the care of individuals who havemental health issues or who are frail older adults,clinical psychologists or physical therapists maybe needed.The stage of socialization and other

developments of the respective discipline’sstudents must also be given carefulconsideration. Socialization of students in thehealth professions has been defined as “theacquisition of the knowledge, skills, values, roles,and attitudes associated with the practice of aparticular profession.” Among themanifestations of professional socialization arethe language, behavior, and demeanorcharacteristic of the profession.22, 23 A traditionalconcern with IPE models is that a student mightlose his or her professional identity. In addition,student teams must be carefully balanced withrespect to their stage of professional socializationand education. A fourth-year medical studentteamed with a first-year undergraduate nursingstudent or Pharm.D. student may inhibit effectivelearning if the medical student has already beenprepared to assume the leadership role.Finally, although much of the literature has

focused on IPE in the classroom, the theory ofIPE transcends all aspects of the educationalenvironment from the classroom to the patientcare setting. The IPE model may be tailored to fitthe needs of a specific learning environment.6

Instructor Perspective

Clinical faculty and other practitioners withextensive experience in interprofessionalpractices serve in critical roles as mentors androle models. Active and engaged clinicians fromdiverse disciplines are essential in IPE models,and these individuals must be fully committed tosharing patient care roles and responsibilitiesbecause bringing different viewpoints will likelyimprove patient care. In addition, the informalinteractions and active listening betweenclinicians who respect one another and who haveworked together effectively may be just aseducational for students and residents as formalinstructional programs.

Educational Environment

Models for IPE may be present in diverse

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learning environments in either the classroom orexperiential setting. The key element is thatactivities reflect, as much as possible, a “real-world” experience. This may be accomplishedusing carefully constructed patient case studiesor other simulations that encourage and supportcontributions from all disciplines and that arefacilitated by experienced faculty. For studentswho are academically more advanced, theexperiential setting is better at providing the real-life experiences they need to gain confidencewith their own skills as well as their skills as partof a team.

Basic Process Considerations for IPE Models

A fundamental consideration in IPE is thatstudents have a basic understanding of theknowledge and skills each profession brings tothe team. Discussion and reflection onpreexisting stereotypes regarding otherprofessions is an essential first step becausestudents may not be fully aware of the expertiseand perspectives that other disciplines bring topatient care. Of note, clinical faculty andpractitioners involved with IPE may not be fullyaware of student or trainee hidden orsubconscious beliefs about other professions.Faculty and students must recognize that

approaches to communication and conflictresolution can differ between professions andthat these skills are essential to developing acohesive IPE program. The professional“language” of different disciplines varies; this isbest illustrated by the simple example of what tocall the person who is to receive care. Is theindividual a “patient,” “client,” or someone else?Moreover, conflict within teams is oftenunavoidable, even on high-functioning teams,and students must recognize and develop anapproach to addressing conflict before they canestablish trusting and respectful relationships.

Discipline-Specific Issues

Students and faculty engaged in IPE andlearning must recognize that health disciplinesvary in their approach to clinical patient careissues. Clark described four major areas inwhich professions diverge in their methods foraddressing clinical problems.22, 23

First, and perhaps most fundamental, healthdisciplines assess the nature and scope of clinicalproblems from different perspectives.Traditionally, medicine and pharmacy have a“rule-out” approach to a given patient’s problem

such as insomnia, in which they focus oneliminating medical, dietary, andpharmacotherapy causes of the sleep disorder.Other professions, such as nursing and socialwork, have been described as having a broader“rule-in” approach that specifically considers theperson, his or her family, and his or herenvironment in a more holistic manner. Fromthis perspective, these health professionals givegreater consideration, for example, to emotionaland financial contributing factors that might bethe source of the insomnia.Second, health disciplines differ in how they

determine when their “work” has beencompleted. Traditionally, medicine andpharmacy have followed a more acute care“medical” model with a diagnosis made and atreatment prescribed, with the emphasisessentially being on the patient to follow “theplan.” When the patient’s behavior varies fromthe prescribed plan, the individual is likely to beidentified as “nonadherent” or “noncompliant.”In social epidemiology, this concept is referred toas the “sick role,” which has become an integralpart of the foundations of medicine.24 Accordingto this concept, the sick role evokes a set ofpatterned expectations that define the norms andvalues appropriate to being sick, both for theindividual and for others who interact with theperson. In theory, the sick person is exempt from“normal social roles,” is not responsible for his orher condition, should within his or her power tryto get well, and must seek technically competenthelp and cooperate with his or her provider. Anydeviation from these principles labels the patientas nonadherent.24

In contrast, those who practice clinical socialwork or psychology characteristically continue theirinvolvement with an individual or family for aprolonged period. For example, patients in thisthird health care model are viewed through thetranstheoretical model of change.25, 26 Based on thismodel, behavior change is a process, not an event.As a person attempts to change a behavior, he orshe moves through the five stages ofprecontemplation, contemplation, preparation,action, and maintenance; relapse may occur at anypoint on this continuum. Patients at differentpoints on the continuum have differentinformational needs and can benefit frominterventions designed for their particular stage.25, 26

Finally, the locus of responsibility for clinicalproblems may also vary with students inmedicine, traditionally taught to be the leaders ordecision-makers compared with nursing, which

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emphasizes patients’ self-determination andengagement in their own care. Although thisconcept may seem an unfair overgeneralization,the IOM has suggested that such a culture ofmedicine does exist and is deeply rooted, both bycustom and training, in high standards ofautonomous individual performance.27

Multidisciplinary Education and Practice

In describing IPE and practice, attention mustalso be given to models that do not reflect thisapproach. Deployment of multidisciplinary“teams” in which professionals from differentdisciplines work essentially independently of oneanother is not an interprofessional approach.Clinicians must be aware of, value, and respectone another’s contributions. Learning from otherdisciplines is essential to improving one’s skills aswell as enhancing the function and outcomes ofteam-based care.

Examples of Health Care IPE Models

Interprofessional Team Training and Development

As mentioned previously, an early model of IPEand practice was the Interprofessional TeamTraining in Geriatrics program that was funded in1979 by the VA health system. The program wasdeveloped to educate clinical staff and studentsregarding the unique needs of aging veterans andto foster teamwork in geriatrics. Eventually, itwas expanded under a new name, theInterprofessional Team Training andDevelopment Program. During the ensuingyears, 12 model programs were developed, whichcontinue to train VA clinical staff.

Collaborative Interprofessional Team Education

The Collaborative Interprofessional TeamEducation (CITE) program is a 3-year managedcare initiative of the University of MichiganHealth System that is funded by the Partnershipsfor Quality Education. As part of a 4-hourweekly clinic, older patients who have at leasttwo of the following conditions—diabetes,hypertension, or polypharmacy—are targeted forinterventions by interprofessional students andtheir faculty mentors. A care plan is developedthat includes specific interventions and identifiesresponsible team members and dates for review.The CITE program also includes didacticsessions on interdisciplinary geriatric assessmentand care planning, as well as reviews of patientsevaluated by the trainees.28

Geriatrics Interdisciplinary Team Training Initiative

The Geriatric Interdisciplinary Team Training(GITT) program was originally funded by theJohn A. Hartford Foundation in 1995. Thepurpose was to support demonstration projectsto develop and disseminate new national modelsfor team training between 1997 and 1999. Themodels represent partnerships between real-world providers and educational institutions.Advanced practice nurses, social workers, andprimary care medical residents were targetedinitially in the GITT program, although about20% of trainees now come from 13 distinctdisciplines, including pharmacy.29

Geriatric Education Centers

Geriatric Education Centers (GECs) have beenfunded by the Bureau of Health Professions since1995. Traditionally, each GEC varied in itsspecific area of concentration, with somefollowing a more medically focused “geriatrics”model and others having a “gerontological”perspective with participants from a broaderrange of disciplines outside medicine. Until2007, GECs were permitted to provide IPE onlyfor individuals who were currently in practice,not to pre-licensure students in the healthprofessions. This limitation was removed withthe last round of GEC grant applications. TheBureau of Health Professions now expects acomponent of interdisciplinary training ofstudents in the health professions.30

Key Strategic, Cultural, and Technical Elementsto Promote IPE Implementation

Strategic Elements

A key strategy for promoting IPE is to developa common sense of purpose and clearunderstanding of the rationale for IPE.31 Teammembers must believe that collaborationultimately results in improved patient care andtangible benefits to its members.32 Issues thatshould be addressed entail determining the goalssought by having students learn together and thebest time to introduce IPE initiatives, as well asthe best strategy of learning to accomplish thesegoals.A four-stage model to form interprofessional

collaboration has been proposed that identifiescollaborative perspectives from individual toindividual, individual to organization,organization to organization, and collaboration tocommunity.33 This model facilitates an earlier

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identification of barriers to collaboration, such asagency or system challenges.34 Strategies canthen be implemented to strengthen collaborativeties at each level. An example of individual-to-individual collaboration is the evaluation of anIPE module for medical, nursing, and dentalstudents, which reported that some studentslinked differences in entry qualifications withperceptions of inequality between professionsand retained a low opinion of other students’academic abilities.35 Negative perceptionsoccurred among students who had moreextensive educational experiences. Thesenegative perceptions may impair students’ abilityto enhance their own learning from otherdisciplines, thereby affecting collaboration fromindividual to individual. A potential solution isto introduce IPE earlier in the students’curriculum, at the preprofessional level, thuslessening the influence of stereotypical attitudesreached by their professional years.36 Opponentsof this argument believe that individuals need tobe secure in their professional roles before theycan function effectively as team members andthat IPE should therefore be introduced later inthe learner’s education. Regardless, for effectiveinteractive learning, the learning group must bebalanced by assembling an equal mix ofprofessionals per group. Faculty facilitators playa key role in creating an environment supportiveof IPE. As discussed previously, they act as rolemodels and, as such, need to be cognizant of thepotential consequences of expressing negativeopinions about other health professionals.37–39

An example of an individual-to-organizationissue is the manner by which IPE isimplemented. Offering relevant learningexperiences creates a more favorable reaction toIPE if a direct correlation is realized betweeneducational experiences and current or futurepractice. Hence, many IPE initiatives useapproaches that are based in clinical practice orthat use problem-based learning.40, 41 Group sizealso affects the quality of learning. Mostliterature supports limiting small group learningsizes to 10 learners.42 Another controversialissue is whether to mandate IPE courses or offerthem instead as electives. An elective course maysend the message that IPE is not essential forhealth professionals. Others argue that a choiceshould be given to participate in IPE activitiesbecause those involved may be more committedand interested.41

An example of organization-to-organization, aswell as organization-to-community, collaboration

is service-learning through communitypartnerships. Health professionals are exposed toservice-learning activities early in theircurriculum based on a community-service model.Service-learning meets the demands of both thecommunity and the student through theprovision of structured learning opportunitiesthat promote IPE. The community benefits by anincreased awareness and treatment of a multitudeof health conditions.43

Cultural Elements

Factors that promote a culture that welcomesIPE include role socialization, clarification, andvaluing, as well as the development of trustingrelationships and power sharing.44 As discussed,professional socialization involves acquiring theknowledge, skills, values, roles, and attitudesspecific to a particular profession; in essence, it isthat profession’s culture. In an interprofessionalsetting, role socialization, or “re-socialization,”should be expanded to include collaborationwith other health care professionals in a mannerthat respects differences in values and beliefs.44

Role clarification enhances socialization andbuilds confidence by attaining a clearunderstanding of roles and expertise, recognizingprofessional boundaries, and promotingcommitment to the values and ethics of one’sown profession. Role valuing encourages a showof respect and requires an understanding of eachprofession’s unique contributions to patient care.Trusting relationships among an interprofessionalgroup create a synergistic environment thatfosters a tolerance of assertiveness and shareddecision-making. Implicit in power sharing isthe notion that group consensus need not beunanimous but that an opportunity should existfor each member to influence the outcome.

Technical Elements

Implementing IPE often requires theenthusiasm and expertise of thought leaders inthis area. These “champions” play a key role ineffecting change; they are usually well-established, highly visible individuals withintheir academic institutions or communities andin positions of leadership.45 Although theseleaders are passionate in spearheading IPEinitiatives, with little or no funding, they cannotact alone to sustain new programs. Externalsupport is desirable, especially from academicinstitutions and government, accreditation, andother regulatory bodies. However, understanding

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the history of IPE underscores the importance ofhaving the higher administration commit to“institutionalizing” IPE programs into the cultureof the educational and/or health care institutions.In addition, governmental funding priorities arecyclical and, regardless of the political partiesinvolved, federal legislative and executiveperspectives focus on the actual outcomesassociated with any educational initiativesrequiring funding. Potential funding sources will

be described later in this paper.

Examples of Potential Assessment Instrumentsfor IPE

Assessment instruments should be designed tomeasure the desired outcomes of a learningexperience objectively. More importantly, theassessment of IPE should mirror thecompetencies of teamwork (Table 2).46 Examples

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Table 2. Competencies for Interprofessional Education6, 46

Competency DefinitionKNOWLEDGE COMPETENCIESCue/strategy associations The linking of cues in the environment with appropriate coordination

strategiesShared task models/situation assessment A shared understanding of the situation and appropriate strategies for coping

with task demandsTeammate characteristics familiarity An awareness of each teammate’s task-related competencies, preferences,

tendencies, strengths, and weaknessesKnowledge of team mission, A shared understanding of a specific goal(s) or objective(s) of the team

objectives, norms, and resources as well as the human and materialresources required and available toAchieve the objective; when change occurs, team members’ knowledgemust change to account for new task demands

Task-specific responsibilities The distribution of labor, according to team members’ individual strengths andtask demands

SKILL COMPETENCIESMutual performance monitoring The tracking of fellow team members’ efforts to ensure that the work is being

accomplished as expected and that proper procedures are followedFlexibility/adaptability The ability to recognize and respond to deviations in the expected course of

events or to the needs of other team membersSupporting/back-up behavior The coaching and constructive criticism provided to a teammate, as a means of

improving performance, when a lapse is detected or a team member isoverloaded

Team leadership The ability to direct/coordinate team members, assess team performance,allocate tasks, motivate subordinates, plan/organize, and maintain a positiveteam environment

Conflict resolution The facility for resolving differences/disputes among teammates withoutcreating hostility or defensiveness

Feedback Observations, concerns, suggestions, and requests, communicated by teammembers in a clear and direct manner, without hostility or defensiveness

Closed-loop communication/ The initiation of a message by a sender, the receipt andinformation exchange acknowledgment of the message by the receiver, and the verification of the

message by the initial sender

ATTITUDE COMPETENCIESTeam orientation (morale) The use of coordination, evaluation, support, and task inputs from other team

members to enhance individual performance and promote group unityCollective efficacy The belief that the team can perform effectively as a unit when each member is

assigned specific task demandsShared vision The mutually accepted and embraced attitude regarding the team’s direction,

goals, and mission

PRIMARY TEAMWORK COMPETENCIESTeam cohesion The collective forces that influence members to remain part of a group; an

attraction to the team concept as a strategy for improved efficiencyMutual trust The positive attitude that team members have for one another; the feeling,

mood, or climate of the team’s internal environmentCollective orientation The common belief that a team approach is more conducive to problem solving

than an individual approachImportance of teamwork The positive attitude that team members exhibit with reference to their work as

a team


of possible outcomes related to IPE includeattitudes toward other disciplines,communication skills, acquisition of knowledge,and group behaviors. The specific outcomesadopted at any given institution likely stem fromgoverning bodies, accreditation criteria, missionstatements, and programmatic goals. One of themost important outcomes to measure in medicaleducation is the impact on patient care.40, 41

Although a common set of outcomes has notbeen universally adopted for IPE, manysystematic reviews use a similar classification ofIPE outcomes (Table 3).4, 47, 48 Typical measuresused to evaluate pre-licensure IPE (i.e.,university-based) outcomes focus on learners’reactions, attitudes, perceptions, knowledge, andskills. Typical measures used to evaluate theoutcomes of post-licensure IPE (e.g., professionaldevelopment programs, continuous qualityinitiatives [CQIs]) focus more on behavioralchange, organizational change, and patientbenefit.48 With outcome measures ranging fromchanges in perceptions to improvements inpatient care, selecting or developing apsychometrically sound assessment instrumentthat matches the desired outcomes becomeschallenging.Several systematic reviews of the literature

have been conducted to identify valid andreliable evaluative studies of IPE. Many,particularly those with robust methodology, haveindicated that the evidence documenting theeffect of IPE on outcomes is limited.13, 14 Mostpublished articles on IPE are descriptive and donot include objective outcome measures.Consequently, few validated IPE assessment tools

have been described in the literature. Studiesthat have documented outcomes typically usedquasi-experimental designs, most of whichinvolve the administration of a non-validatedpre- and postsurvey of students’ attitudes andperceptions toward the IPE intervention. A morerobust assessment strategy would measurehigher-level outcomes using a control group,although identifying control groups is among themany challenges encountered in developinghigh-quality assessment tools for IPE.14, 49

Examples of assessment tools that have beentested and validated in more than one studypopulation and that can be administered to morethan one group of learners are described below.

Readiness for Interprofessional Learning Scale

The Readiness for Interprofessional LearningScale (RIPLS) is a 19-item questionnaire firstreported by Parsell and Bligh50 in 1999(Appendix 1) that uses a 5-point Likert-like scale(1 = strongly disagree, 5 = strongly agree)designed to measure attitudes towardinterprofessional teams and readiness for IPEexperiences. The measure consists of threesubscales: teamwork and collaboration (items1–9), professional identity (items 10–16), androles and responsibilities (items 17–19). Themeasure was originally tested and validated in120 undergraduate students representing eighthealth care professions. Since then, otherresearchers have used the questionnaire in avariety of populations, including bothundergraduate and graduate students as well aspracticing professionals.51–56

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Table 3. Expected Outcomes for Interprofessional Education4, 47, 48

Level Level Description Educational Outcome1 Reaction Learners’ views on the learning experience and

its interprofessional nature2a Modification of attitudes Changes in reciprocal attitudes or perceptions

and perceptions between participant groups.Changes in perception or attitude toward the valueand/or use of team approaches to caring for a specificclient group

2b Acquisition of knowledge Including knowledge and skills linked toand skills interprofessional collaboration

3 Behavioral change Identified individuals’ transfer ofinterprofessional learning to their practice settingand their changed professional practice

4a Change in organizational practice Wider changes in the organization and deliveryof care

4b Benefits to patient and clients Improvement in health or well-being ofpatients/clients

IPE = interprofessional education.


Interdisciplinary Education Perception Scale

The Interdisciplinary Education PerceptionScale (IEPS) is an 18-item self-report of attitudestoward interprofessional teamwork that wasdeveloped by Luecht and colleagues.57 The IEPSuses a 6-point Likert-like scale (1 = stronglydisagree, 6 = strongly agree) and contains foursubscale measures: competence and autonomy,perceived need for cooperation, actualcooperation, and understanding others’ value(Appendix 2). The IEPS was tested in a sampleof 143 trainees, and content validity and internalconsistency were reported by the authors. Sincethen, the IEPS has been used in the evaluation ofdifferent IPE programs, and participants haveconsisted of medical, nursing, pharmacy, socialwork, occupational therapy, physical therapy,physician assistant, chiropractic, osteopathy, andpodiatry students.47, 58–60

Attitudes Toward Health Care Teams Scale

The development and validation of theAttitudes Toward Health Care Teams Scale wasreported by Heinemann and colleagues in 1999.61

This is a 21-item self-report designed to enablecomparisons of attitudes of different members of

health care teams (Appendix 3).62 The scale’sreliability and validity were tested in a nationalsample of 973 health care professionalscomprising 111 geriatric health care teams in theVA health system. This assessment tool can bedivided into two subscales: the 14-item Quality ofCare/Process subscale, designed to measure“team members’ perceptions of the quality of caredelivered by health care teams and the quality ofteamwork to accomplish this,” and the 6-itemPhysician Centrality subscale, designed tomeasure “team members’ attitudes towardphysicians’ authority in teams and their controlover information about patients.”61 The twosubscales can be scored separately, and theauthors note that scores for the PhysicianCentrality subscale should be expected todecrease over time and that scores for the Qualityof Care/Process subscale should increase overtime when used to evaluate IPE programs.Many other instruments assessing team

performance in health care have been reviewedby Heinemann and Zeiss.62 In their review,instruments are categorized into four groups(focused, middle range, broad spectrum, and fullspectrum) based on the breadth of outcomesassessed. Each instrument is summarized and

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Appendix 1. Readiness for Interprofessional Learning Scale

1. Learning with other students will help me become a more effective member of ahealth care team 1 2 3 4 5

2. Patients would ultimately benefit if health care students worked together to solvepatient problems 1 2 3 4 5

3. Shared learning with other health care students will increase my ability tounderstand clinical problems 1 2 3 4 5

4. Learning with health care students before qualification would improverelationships after qualification 1 2 3 4 5

5. Communication skills should be learned with other health care students 1 2 3 4 56. Shared learning will help me think positively about other professionals 1 2 3 4 57. For small group learning to work, students need to trust and respect each other 1 2 3 4 58. Team-working skills are essential for all health care students to learn 1 2 3 4 59. Shared learning will help me understand my own limitations 1 2 3 4 510. I don’t want to waste my time learning with other health care students 1 2 3 4 511. It is not necessary for undergraduate health care students to learn together 1 2 3 4 512. Clinical problem-solving skills can only be learned with students from my

own department 1 2 3 4 513. Shared learning with other health care students will help me communicate better

with patients and other professionals 1 2 3 4 514. I would welcome the opportunity to work on small-group projects with other

health care students 1 2 3 4 515. Shared learning will help clarify the nature of patient problems 1 2 3 4 516. Shared learning before qualification will help me become a better team worker 1 2 3 4 517. The function of nurses and therapists is mainly to provide support for doctors 1 2 3 4 518. I’m not sure what my professional role will be 1 2 3 4 519. I have to acquire much more knowledge and skills than other health care students 1 2 3 4 51 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree.Used with permission from: Parsell G, Bligh J. The development of a questionnaire to assess the readiness of health care students forinterprofessional learning (RIPLS). Med Educ 1999;33:95–100.


critiqued individually and compared with otherinstruments in its group. Summaries include theconceptual framework, description of measure,target group, psychometric testing, evaluation,and availability of each instrument. This text isan invaluable resource for anyone participating inIPE assessment.These instruments are useful to assess

outcomes related to perceptions and behaviors,and many also measure team performance andbehavior changes; however, they do not assessthe impact of IPE on patient care outcomes.Although the Cochrane Database systematicreview of IPE literature showed that no studieshad been published evaluating the effect of IPEon patient care outcomes, other systematicreviews, with the development and refinement ofmore comprehensive methodology, identifyseveral studies that report changes in servicedelivery or patient care.15, 48 These reviews

illustrate that the instruments used to assesspatient care outcomes are often simply clinicaloutcome audits. Such audits may detect theoccurrence of clinical outcomes such as infectionrates, clinical error rates, or length of patient stay.The most appropriate clinical outcomes tomeasure may be derived from positionstatements, clinical guidelines or standards,national mandates (e.g., Agency for HealthcareResearch and Quality), or accrediting bodies suchas the Joint Commission on Accreditation ofHealthcare Organizations. For example, adiabetes self-management education team ofnurses, dieticians, pharmacists, and physiciansroutinely participates in IPE initiatives. A logicalassessment tool to evaluate these IPE initiativescould come directly from the “Standards forOutcomes Measurement of Diabetes Self-Management Education” (DSME).63 Twoexamples of IPE initiatives that have measured

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Appendix 2. Interdisciplinary Education Perception Scale and Subscale

Strongly Somewhat Somewhat StronglyAgree Agree Agree Disagree Disagree Disagree

1. Individuals in my profession are well trained. 6 5 4 3 2 12. Individuals in my profession are able to work closely with

individuals in other professions. 6 5 4 3 2 13. Individuals in my profession demonstrate a great deal

of autonomy 6 5 4 3 2 14. Individuals in other professions respect the work done

by my profession 6 5 4 3 2 15. Individuals in my profession are very positive about their

goals and objectives 6 5 4 3 2 16. Individuals in my profession need to cooperate with other

professions 6 5 4 3 2 17. Individuals in my profession are very positive about their

contributions and accomplishments.. 6 5 4 3 2 18. Individuals in my profession must depend on the work of

people in other professions.. 6 5 4 3 2 19. Individuals in other professions think highly of my profession. 6 5 4 3 2 110. Individuals in my profession trust each other’s

professional judgment. 6 5 4 3 2 111. Individuals in my profession have a higher status

than individuals in other professions.. 6 5 4 3 2 112. Individuals in my profession make every effort to understand

the capabilities and contributions of other professions. 6 5 4 3 2 113. Individuals in my profession are extremely competent.. 6 5 4 3 2 114. Individuals in my profession are willing to share

information and resources with other professionals.. 6 5 4 3 2 115. Individuals in my profession have good relations

with people in other professions. 6 5 4 3 2 116. Individuals in my profession think highly of other

related professions.. 6 5 4 3 2 117. Individuals in my profession work well with each other.. 6 5 4 3 2 118. Individuals in other professions often seek the advice

of people in my profession.. 6 5 4 3 2 1Subscale: Competence and autonomy (items 1, 3, 4, 5, 7, 9, 10, 13); perceived need for cooperation (items 6, 8); actual cooperation (items 2,14, 15, 16, 17); understanding others’ value (items 11, 12, 18).Used with permission from: Luecht RM, Madsen MK, Taugher MP, Petterson BJ. Assessing professional perceptions: design and validation ofan Interdisciplinary Education Perception Scale. J Allied Health 1990;19:181–91.


patient care outcomes are described below.Crawford and colleagues64 evaluated a series of

1-hour interprofessional workshops for doctorsand nurses in a hospital accident and emergencyworkshop. The goal was to improve the care ofdeliberate self-harm patients presenting to thedepartment. The authors audited patient notesbefore and after the educational workshops andfound that the notes were completed in a moreaccurate and comprehensive fashion after thesessions.Horbar and colleagues65 conducted the

Neonatal Intensive Care Collaborative Quality(NIC/Q) Project, a collaborative quality

improvement project for very low birth weightinfants. Interprofessional teams worked togetherfor a 3-year period, receiving instruction onquality improvement, reviewing performancedata, setting goals, and modifying practices. Theoutcome measured was the rate of infection afterthe third day of life with coagulase-negativestaphylococcal or other bacterial pathogens. Acontrol group of neonatal intensive care units(NICUs) that did not participate in the initiativewas used for comparison. The study found thatinfection rates were lower in the NICUsparticipating in the initiative (p=0.007). Basedon these data, the authors concluded that a

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Appendix 3. Attitudes Toward Health Care Teams Scale

Strongly StronglyAttitudes Toward Health Care Teams Scale Disagree Agree1 Working in teams unnecessarily complicates things 1 2 3 4 5 6

most of the time2 The team approach improves the quality of care to patients 1 2 3 4 5 63 Team meetings foster communication among team 1 2 3 4 5 6

members from different disciplines4 Physicians have the right to alter patient care plans 1 2 3 4 5 6

developed by the team5 Patients receiving team care are more likely than other 1 2 3 4 5 6

patients to be treated as whole persons6 A team’s primary purpose is to assist physicians in achieving 1 2 3 4 5 6

treatment goals for the patient7 Working on a team keeps most health professionals 1 2 3 4 5 6

enthusiastic and interested in their jobs8 Patients are less satisfied with their care when it is 1 2 3 4 5 6

provided by a team9 Developing a patient care plan with other team members 1 2 3 4 5 6

avoids errors in delivering care10 When developing interdisciplinary patient care plans, 1 2 3 4 5 6

much time is wasted translating jargon from other disciplines11 Health professionals working on teams are more responsive 1 2 3 4 5 6

than others to the emotional and financial needs of patients12 Developing an interdisciplinary patient care plan is 1 2 3 4 5 6

excessively time-consuming13 The physician should not always have the final word in 1 2 3 4 5 6

decisions made by health care teams14 The give-and-take among team members helps them make 1 2 3 4 5 6

better patient care decisions15 In most instances, the time required for team meetings 1 2 3 4 5 6

could be better spent in other ways16 The physician has the ultimate legal responsibility 1 2 3 4 5 6

for decisions made by the team17 Hospital patients who receive team care are better prepared 1 2 3 4 5 6

for discharge than other patients18 Physicians are natural team leaders 1 2 3 4 5 619 The team approach makes the delivery of care more efficient 1 2 3 4 5 620 The team approach permits health professionals to meet

the needs of family caregivers as well as patients 1 2 3 4 5 621 Having to report observations to the team helps team members

understand the work of other health professionals 1 2 3 4 5 6Used with permission from: Heinemann GD, Schmitt MH, Farrell MP, Brallier SA. Development of attitudes toward health care teams scale.Eval Health Prof 1999;22:123–42; Heinemann GD, Zeiss AM. Team performance in health care: assessment and development. New York:Kluwer Academic/Plenum Publishers, 2002.


multidisciplinary collaborative qualityimprovement approach has the potential toimprove patient outcomes. Although the NIC/Qis considered a seminal study and a foundationfor IPE, heterogeneity did exist between studygroups (p=0.04), and without adequatematching, it is problematic to assume that thebenefit is solely due to the application of IPEtheory.65

Currently, studies demonstrating a positiveeffect of IPE on patient care outcomes are in thepost-licensure collaborative setting (e.g., CQIworkgroups). The effects of pre-licensure IPE(i.e., university classroom setting) on patient careare still unknown.49 Research in developinghigh-quality assessment tools to evaluate patientcare outcomes, particularly in the pre-licensuresetting, is still needed.Regardless of setting, the assessment plan and

instrument chosen must match the purpose ofthe IPE initiative and should objectively measuredesired outcomes. For example, if the IPEinitiative is an introductory course for first-yearpharmacy, nursing, and medical studentsdesigned to improve perceptions of the roles ofdifferent professions in patient care, then aninstrument such as the RIPLS or the IEPS thatassesses attitudes and perceptions would be anappropriate assessment tool. Ideally, theassessment tool would be administered to aparticipant group and a control group, but itcould also be administered before and after theactivity if a control group was not feasible. If theinitiative is an IPE workshop series provided to agroup of diabetes educators including nurses,pharmacists, and dieticians as part of a CQIinitiative to improve the number of patients whoreceive dilated eye examinations each year, thenthe obvious assessment is the change in rate ofeye examinations. This important patient careoutcome would more likely be taken directlyfrom the standards for outcomes measurementsof the DSME than be developed specifically forthe assessment of IPE.

Implications of IPE

Education

The provision of optimal patient care requiresknowledge and contributions from manydisciplines. Increasingly, the required body ofknowledge may be borrowed from disciplinesother than one’s own, and some belongs to acommon body of knowledge about a particulartopic. Lines between these domains are difficult,

if not impossible, to draw, emphasizing thenecessity of incorporating IPE in the academicsetting.34 Traditional “silo” methods of learningresult in students in the health professionsentering the workforce poorly prepared forclinical practice and the inevitable teamwork inwhich they will be required to participate.Difficulties encountered in working withmultiple professions stem from a lack ofknowledge of different roles and a relativeabsence of teamwork skills., Both of these deficitscan be corrected through proper education (Table1). Students participating in IPE report an easiertransition from professional school to practice.In addition, their ensuing practices incorporategreater use of interdisciplinary treatmentapproaches and referral sources.34

Research

Limited financial resources continue to plaguehealth care facilities and educational institutionsas they seek to fully achieve their missions. Inaddition to caring for more patients by workingfaster, better, and more efficiently, research isrequired to improve patient care interventionsand document the outcomes of IPE.One strategy to combat limited resources is to

form research partnerships that include multipleprofessions. The benefits of this approachinclude a broader perspective when conductingresearch, the development of new or expandedclinical knowledge, professional collaborativeactivities in clinical and research areas, and agreater understanding and respect for theprofessional roles of others.66 This tactic allowsthe research team to address more complexresearch questions using the unique areas ofexpertise of its members, enables the pooling ofresources, and potentially leads to greater accessto data collection and dissemination.The National Institutes of Health (NIH)

recognizes the importance of forminginterprofessional research teams. Thisperspective stems from the realization thatbiomedical research is increasingly complex,requiring scientists to move beyond their owndisciplines and explore new organizationalmodels incorporating multiple areas ofexpertise.67 Moreover, new discoveries must betranslated from basic science to human studiesand, eventually, to tests and treatments thatimprove patient care.68 In the past 5–7 years, theNIH has been encouraging innovative approachesfor combining skills and disciplines through the

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NIH Roadmap and Clinical and TranslationalScience Award (CTSA) initiatives. These fundingmechanisms support collaborative partnershipsbetween academia and community centers andfocus on clinical research.In addition, key components of the CTSA are

graduate degree-granting programs and otherpostgraduate programs in clinical andtranslational science, designed to trainindividuals from multiple disciplines together(www.ncrr.nih.gov). This is yet another way tofacilitate the formation of interprofessionalresearch teams.In 2004, the Association of Academic Health

Centers69 recommended that the federalgovernment create new funding to research, test,and evaluate various models of IPE and practice.During the past decade, funding that addressesthese critical issues has increased from bothgovernmental and nongovernmental agencies.Depending on the focus of the project orresearch, Table 4 details potential fundingopportunities.

Patient Care

Health disparities remain common in theUnited States. A known challenge is the limitednumber of health care workers who choose towork with patients from underservedcommunities. One way in which IPE can servethe community is through student-staffed freeclinics in partnership with academic medicalcenters. These programs are mutually beneficialbecause students sharpen their clinical skills andhave opportunities to work with different health

professionals while providing health care servicesto populations with limited access to health care.Mobile interprofessional services using thismodel have also developed, with the goal ofreaching underserved patients in rural areas.70

Most students in the health professions areboth passionate and compassionate, with a desireto serve society and make a difference in others’lives. They possess leadership skills, which theymay have demonstrated even before enteringtheir degree programs. The setting describedherein affords opportunities for these qualities tostrengthen and thrive. A benefit to the patient isthat his/her care setting often incorporates amultitude of clinical services such as casemanagement, dental care, and mental health care.In addition, licensed clinical practitionerssupervise the students who provide care in thesesettings.71 Studies evaluating the attitudes ofstudents who participated in a free clinic electivefound that they were more likely to acquirepositive attitudes when working with theunderserved and homeless compared withstudents who did not complete the elective. Aspreviously discussed, these future practitionerslearn to consult each other more often, therebyperceiving themselves as professionals workingtogether, focused on the well-being of the patient.Future studies will assess the success of theselearning environments in increasing the pool ofpractitioners who focus on treating underservedpopulations.An important implication of IPE is that it can

lead to the formation of more efficient patientcare teams. This includes the incorporation of

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Table 4. Potential Granting Agencies and Foundations Funding Interprofessional Education Research6

Source Comments Web siteBill and Melinda The Gates Foundation provides funding for research www.gatesfoundation.org/UnitedStates/Gates Foundation that evaluates educational programs Education/ResearchAndEvaluation/

in the United States default.htm

Department of This governmental agency provides funding for projects http://www.ed.gov/index.jhtmlEducation that enrich and enhance education and its outcomes

Health Resources This governmental agency provides funding www.hrsa.gov/grants/and Services opportunities for health professionals with particularAdministration emphasis on medically underserved areasAgency

Josiah Macy, Jr. The Macy Foundation provides funding for projects www.josiahmacyfoundation.orgFoundation focused on the education of health care professionals

in the United States

Robert Wood The Building Human Capital program provides www.rwjf.org/applications/Johnson Foundation funding opportunities that focus on the training of

professionals

W.K. Kellogg Funding opportunities focus on education and www.wkkf.org/default.aspx?LanguageID=0Foundation general health


crucial health care services that can be neglectedif students are not exposed to them during theirtraining. Examples are services to older adultpatients such as advanced care planning and end-of-life decision-making.72 Older adults are alsomore likely to have one or more chronic illnesses,necessitating the need for coordinated care.Although many members of the health care teamare capable of discussing advance directives,patients identify social workers as the preferredprofessionals to discuss end-of-life familyplanning issues because of their specializedcounseling skills. Social workers are oftenknowledgeable about and appreciative of diversecultural norms, issues, and values anddemonstrate this insight in their assessments ofand interventions with culturally diversepopulations.73 An interprofessional teamtherefore benefits the patient by providing a morecomprehensive service offered by clinicians whoare trained for specific roles.There is also merit to sharing roles within an

interprofessional team. A nurse case manager,social worker, and pharmacist can work togetherto facilitate an effective discharge plan from thehospital. This team can link patients tocommunity resources, educate them about theimportance of medication adherence andprovider follow-up after hospital discharge, assistthem in identifying and locating a primary healthprovider, and ensure that their dischargemedications are appropriate. Studies have shownthat these strategies effectively decreasereadmission rates, improve patient satisfactionwith care, and save health care dollars.74, 75 In theend, assessing the impact of IPE on patient careand outcomes requires data from rigorousrandomized, controlled studies.13 This approachwill need to be investigator initiated because theoverall impact of IPE is hard to detect usingcurrent national statistics.27

Barriers to IPE

Although IPE initiatives have beenimplemented during the past decade, manybarriers have been identified.76 These barriersexist on a variety of levels and can beorganizational, operational, communicational,cultural, or attitudinal. It is crucial to overcomethese barriers to better prepare healthprofessional students and practitioners forcollaborative practice within a changing healthcare system. Table 5 addresses potential barriersto IPE and their possible solutions within

academic and patient care settings.

Potential Role of ACCP

Interprofessional education represents acommon thread that connects the threedimensions of pharmacy—education, practice,and research. National pharmacy organizationsendorse IPE, and several have articulated specificpolicies and/or initiatives supporting IPE.However, the inability to recognize theimportance of IPE and to effectively deliver itwithin the classroom and clinic has beencorrelated with a decrease in the quality ofpatient care provided. In addition, theincorporation of interprofessional patient careinto daily practice has been compromised byworkforce shortages within respective health carefields.13, 69 From the data presented in this whitepaper, IPE appears to be a critical element inhealth system reform that has not beensufficiently addressed. The mission of ACCP isto advance human health and quality of lifethrough fostering education, research, andclinical practice. The College can further thismission by pursuing several steps towardpromoting and implementing IPE within thepharmacy profession. First, the National StuNetAdvisory Committee should develop ACCPmeeting programming and educational materialsspecifically addressing the role of pharmacystudents in facilitating, promoting, andimplementing IPE in the classroom andexperiential learning environment. Second, toimplement IPE in practice settings, pharmacypractitioners, residents, and educators should betrained in the theory and application of IPE. TheACCP Academy’s Teaching and Learning Programand its Leadership and ManagementDevelopment Program could address these issuesin their respective curricula. Third, a majorbarrier to IPE is the lack of funding for well-designed IPE research. We suggest that theACCP Research Institute support studies to testand evaluate various IPE models and assessmenttools. Fourth, ACCP Focus Sessions during itsnational meetings could be delivered jointly withmedicine and other health disciplines to facilitateadvocacy and communication. Finally, theCollege should propose the formation of a jointcommission by national pharmacy organizationsto develop a consensus vision for theimplementation of IPE across the pharmacyprofession.

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IPE: PRINCIPLES AND APPLICATION ACCP 161e

Table 5. Potential Barriers to Interprofessional Education and Possible Alternativesa,6

Barriers Solutions and AlternativesAcademic calendars Integrate calendars (and catalogs) into one calendar (or, at most, two academic and

professional)Schedule IPE courses and activities in the “core” months of a semester

Academic requirements Develop a distinct grading system that would allow any school to use a conversionprotocol to translate IPE grades to the grading system of the school

Academic reward structure Recruit faculty to IPE activities whose primary distribution of effort is not directedtoward promotion/tenureParticularly with junior faculty who would like to teach in this environment, ensurethat IPE work is linked to his or her faculty development plan in his or herdepartmentCreate a separate merit pool related to IPE activitiesContinue to promote efforts for APT committees to recognize the expanded view ofscholarship, particularly as demonstrated in IPE activities

Clinical practice sites Forge alliances with external organizations that use interdisciplinary approaches tohealth care delivery

Communication issues Coordinate program communications among the schools/departments through IPEorganizational unitsCoordinate program marketing among the schools through IPE organizational units

Cost issues for students Add required IPE course at the expense of one elective course; devise a means ofproviding this course at no cost to the student

Disciplinary/departmental Create a separate organizational entity for IPE activities; allocate FTEs to thatorganization and structure organizationReimburse school/department for faculty FTEs allocated to the IPE unit

Disciplinary and professional Devote significant implementation planning to faculty and staff communication andtraditions and cultures developmentReinforce that a major goal of IPE is to mediate differences

Evaluation Design a rigorous, programmatic evaluation plan for any IPE courses

Faculty development Ensure that the IPE office collaborates with each school’s or department’s faculty/staffdevelopment efforts

Fiscal resources Fiscal wherewithal probably lies within current operating budgets; thus, funds couldbe reallocatedAssign IPE curriculum highest priority for state/institutional funds requestRedeploy faculty or staff from current assignments

Geographic separation Provide “universal parking privileges” for IPE facultyEnsure that faculty time agreement includes not only accommodation for teachingtime, but also class preparation and travel time

Insufficient interdisciplinary faculty Define competencies desired in IPE faculty and develop/offer training in those skillsRecruit initially from PBL-trained facultySeek preceptors from the practice community to assist in IPE teachingUse advanced-level students as facilitators

Leadership and administrative support If leadership moves forward with planning for implementation of IPE activities, thereshould be support at the university, school, or institution administration levelsLeadership within upper administration (e.g., deans) must work to ensure support atthat level

Levels of student preparation Categorize the courses, practicum, and rotations that are developed and implementedin and maturity terms of appropriate student readiness for that materialEstablish pre/post assessments and relate to student performance in year 1 andmodify prerequisites if neededMonitor, during registration, class mix for student preparation and maturity ofstudents’ own advisersEstablish all IPE courses as competency-based

Logistics Hold classes at every academic building on campusOffer flexible schedules for group sessions including a variety of options such asmonthly, weekly, weekends, early mornings, or late eveningsEstablish a faculty advisory board for the IPE curriculumCharge the IPE faculty with leadership of recruitment

Power dispositions and This will change only as IPE activity becomes more commonplaceterritorial imperatives


Acknowledgments

The Task Force would like to acknowledge StuartHaines, Pharm.D., FCCP, FASHP, FAPhA, BCPS, andRobin Ann Harvan, Ed.D., for their assistance withthis white paper.

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Table 5. continued

Barriers Solutions and Alternatives

Promotion and tenure considerations Promote efforts for APT committees to recognize the scholarship of teaching asdemonstrated in IPE activitiesCreate an IPE career path and recruit junior faculty

Recognition and reward Develop a means of recognizing the contributions of the faculty who participate inIPE, which includes both tangible and intangible rewards

Recruitment Create a separate office for IPE activities; allocate faculty FTE on IPE efforts to thatorganization

Resistance to change Create seed grants to faculty for the development of coursesContinue leadership efforts to stimulate interest in teaching including facultydevelopment plans

Reimbursement mechanisms and Include on-site IPE activities as part of negotiation and renegotiation of affiliation andschedules for clinical positions other agreementsInfluence state legislation regarding reimbursements of IPE teams for care

Scholarship Continue to promote efforts for APT committees to recognize the scholarship ofteaching as demonstrated in IPEIPE office should be responsible for assisting faculty with grantopportunities/publishing associated with IPE activities

Time commitment Create a separate organizational entity for IPE activities for bookkeeping purposes;allocate faculty FTEs to that organizationReimburse school/departments for faculty FTEs allocated to IPE units

aThese barriers are derived from the University of Texas Health Sciences Center: Interprofessional Education for Health Professions–SACSAccreditation Site Visit.APT = advancement, promotion, and tenure; FTE = full-time employee; IPE = interprofessional education.


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Interprofessional Education: Principles and Application A Framework for Clinical Pharmacy

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