Health Services Executive Interprofessional Learning Master Class 20th June 2012 Helena Low

Health Services Executive The foundations for collaborative Care CAIPE Interprofessional Learning Master Class Learning Together to Work Together, Working Together to Learn together’ The foundations for collaborative Care Helena Low Vice Chair Centre for the Advancement of Interprofessional Education 2 2

Themes and Questions What is interprofessional collaborative practice / interprofessional collaborative care - what do we actually mean when we use these terms? What difference does it make? Why the global emphasis on it? What are the competencies required? Why do we need interprofessional learning to develop collaborative practice ? What do we mean by interprofessional education? Why is it essential for professional education?

Aims of the Master class Foster a greater and shared understanding of what collaborative care means and what is involved within the Irish context Generate interest and engagement in interprofessional learning for collaborative practice Encourage you to consider practical application in the workplace Encourage you to identify further areas of interest in relation to taking forward collaborative initiatives

Ground Rules Respect differences Value all contributions equally Confidentiality Avoid jargon Check understanding Important - Mutual trust Mutual respect Mutual support

Economic factors – limited Resources Modernisation Ageing population Interprofessional learning and collaborative practice in the context of global health International / global trends Economic factors – limited Resources Modernisation Ageing population Integration, Collaboration, Decentralisation Service User focus Community participation Emphasis on patient safety H. Low 6

Drivers of change resource constraints demography Rising cost of care, Increasing demand, diminishing resources demography Ageing population, Movement of people technological advances More people surviving defects, Illness, disease, accidents consumer expectations more informed recipients of care. loss of confidence in professionals Medical errors, lack of communication between professionals

Global picture Health systems worldwide Modernisation essential to are struggling with: increasingly complex and costly challenges, ever more demands on health workers patients needs have become more complex and more - challenging. Modernisation essential to deal with: inequalities in access to health and care, growing pressures of chronic non communicable illnesses services for the vulnerable, older people and children suffering Issues around patient safety

‘In a world of radically increased interdependence, health nearly everywhere is being shaped by the same powerful forces, like demographic ageing, rapid urbanization, and the globalization of unhealthy lifestyles.’ Dr Margaret Chan Director-General WHO 2012

The impact of globalisation - the international movement of professionals and professional knowledge and the resulting cross cultural transition of ideas are all manifestations of the global interdependence in health and education. Lancet Commission (2010)

World Health Reports A series of reports produced regularly by the World Health Organization (WHO). Published annually or biennially in multiple languages, Each report includes an expert assessment of a specific global health topic, relating to all countries that are Member States of the organization. Learning Together to Work Together for Health. World Health Organisation (1988) Report of a WHO Study Group on Multiprofessional Education for Health Personnel. The Team Approach Technical Report Series 769. Geneva: WHO

World Health Report ‘Working Together for Health’ WHO (2006) You will note that in all regions of the world except Europe, there is a critical shortage of doctors, nurses and midwives – other figures shoe a similar situation for other health and social care professions. Migration of health professions from developing to developed countries is a major issue.

WHO significant Reports World Health Report (2006) ‘Working Together for Health’ Highlighted a "global health workforce crisis". an estimated shortage of almost 4.3 million doctors, nurses, midwives, and other health human resources worldwide. World Health Report (2008) Primary Health Care (Now more than ever)’ ‘Now, more than ever, the health of people worldwide depends on health professionals working together across the boundaries of disciplines, professions and conventions’ Framework for Action on Interprofessional Education & Collaborative Practice (2010) – Report to the WHO The WHO and its partners acknowledge that there is sufficient evidence to indicate that effective interprofessional education enables effective collaborative practice.’

In response to these challenges: In countries across the world government policies on workforce development have focused on the need for - collaborative frameworks for education and practice; - integrated approaches to care; - co-operation, - working across professional and organisational boundaries Internationally, IPE and collaborative practice are seen as potential strategies to mitigate global health workforce crisis An effective, interagency, interprofessional workforce is seen as critical for the health and welfare of future generations.

Impact of this approach Modernisation is about looking at the workforce in a different way, as teams of people rather than as different professional ‘tribes’ Global modernising politics reshaping healthcare relationships Health and social care professions are faced with substantial changes in the pattern of their relationships. Politics is about relationships

Response to the Challenges by Governments around the world Some examples United Kingdom Canada Japan Australasia

In Ireland ? Programme of reform Universal health insurance ‘ Programme of reform Universal health insurance Community based services through a primary care setting New models of care National Clinical Care Programmes designed and implemented by clinically led multidisciplinary teams Emphasis on standards and patient safety greater flexibilities in work practices and rosters to achieve more efficient delivery of services ‘Our Health services are facing challenges on a scale never experienced before’ ‘Implementation of the National Clinical programmes is driving a re engineering of traditional models of care and of service delivery’’ ‘All of these are being designed and implemented by clinically led multidisciplinary teams.’ HSE Report 2011

Health systems are social institutions. Properly managed and adequately funded, a well-functioning health system contributes to social cohesion and stability. In a world beset by one global crisis after another, social cohesion and stability are prized assets. Health systems are highly context-specific. Dr Margaret Chan Director-General WHO 2012

Interprofessional Learning and Collaborative Practice The first thing we need to do is to be clear about what we / you mean by the terms interprofessional learning / interprofessional education / collaborative practice

No one profession can respond adequately to the multiplicity of problems that many patients present, be they children at risk, alienated young people, members of dysfunctional families, chronically sick and disabled people living longer, or amongst the growing number of old people surviving to an advanced age. No one profession can meet the needs of every patient H. Low

Patient Safety Inquiries into medical errors, e.g. the United States (Institute of Medicine, 2001) and the United Kingdom (Kennedy, 2001), have attributed failure to problematic communications and relationships between professions (Meads & Ashcroft, 2005). WHO (2011) Patient Safety Curriculum Guide: Multi-professional Edition For the past three years, the World Health Organization has been exploring the links between education and health practice – between the education of the healthcare workforce and the safety of the health system. As an outcome, it has developed this multi-professional Patient Safety Curriculum Guide, which addresses a variety of ideas and methods for teaching and assessing patient safety more effectively. Medical errors attributed to the failure of problematic communications and in effective relationships between profession.

Modernisation is about cultural change Professions have to work in a different way – and make collaboration a normal part of professional practice. Collaboration is easy to say, but working together with other professions, new partners and in different ways is not easy. Collaboration essential but not easy H. Low

Collaboration complex process with multiple components can be a process, product or both connecting, cooperating, consulting, - encompasses: coordinating, co-locating, community building and contracting. - Is more than the sum of its parts H.Lawson (2004)

Academic institutions Connections for Collaboration Policy makers International, national, regional and local government Health & Care Employers / managers new organisations and agencies Independent sector Health & Care Services based on people’s needs Health & Care Professions new roles, new occupations, new professions Communities Voluntary organisations Service users and carers Academic institutions Higher & Further education new partnerships

Patient Voices Why Collaborate? A Video

The Lancet Commission Report – Health professional for a new century: transforming education to strengthen health systems in an interdependent world (2010) Increasingly interdependent in terms of key health resources, especially skilled workers’ ‘imperative to align professional competencies to changing contexts’

What are the competences of interprofessional learning and working ‘soft skills’ and complex achievements social practices that are highly context dependent, team working, developing supportive relationships, reflection and self awareness, working across boundaries, communication, interpersonal skills Mix of dispositions, understandings, attributes and practices Consider these competences – You need them for any kind of professional practice, but especially interprofessional practice

Competencies for Interprofessional Collaborative practice CUILU (2006) Interprofessional capability framework. Sheffield: The Combined Universities Interprofessional Learning Unit. Interprofessional Education Collaborative Expert Panel (2011) Core competencies for interprofessional collaborative practice: report of an expert panel. Washington D.C.: Interprofessional collaborative Canadian Interprofessional Health Collaborative. A national competency framework for interprofessional collaboration. www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf ‘Core Competencies for Interprofessional Care’ in Healthforce Ontario (2010) Implementing Interprofessional Care in Ontario: Final Report of the Interprofessional Care Strategic Implementation Committee. Ontario  

Why do we need inter-professional education Learning for working across professional, organisational and agency boundaries, together, is essential ‘Inter-professional working must be grounded in inter-professional learning’ John Horder 2005 A flexible collaborative ready workforce is dependent on the way in which professionals are educated Lancet Commission 2010 . We need interprofessional education – we have to learn how o work across professional, organisation and agency boundaries H. Low 29

Interprofessional education ‘Occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care’ (CAIPE 2002) Principles CAIPE commends a number of principles, drawn from the experience of its members and the interprofessional literature. These highlight the: values process and outcomes deemed essential for effective interprofessional learning and working (CAIPE 2011)

The Evidence Base? Patients report higher levels of satisfaction, better acceptance of care and improved health outcomes following treatment by a collaborative team. There is now sufficient evidence to indicate that interprofessional education enables effective collaborative practice which in turn optimizes health services, strengthens health systems and improves health outcomes. World Health Organisation 2010

Hammick et al (2007) 21 studies discussed of the 399 reviewed (UK 11, USA 7, Canada 1, Finland 1, Sweden 1) 15 of the studies (72%) considered undergraduate IPE. All peer reviewed papers and reports, quantitative and qualitative approaches included Considered the following outcomes of learning: learners reactions; changes in skills, knowledge, perceptions of and attitude to others; changes in behaviour as well as impact on service users

Findings Competent facilitation of IPE essential Learner reaction to IPE is related to multiple factors IPE needs to reflect appropriate and relevant service delivery settings Principles of adult learning are key IPE generally well received and enables learning of the knowledge & skills for collaborative working In the context of quality improvement initiatives IPE frequently used to enhance development of practice & improvement of services

Cochrane Systematic Review (Reeves et al 2009) Six studies met the inclusion criteria (small but first IPE review in 2000 found none) 4 RCTs and 2 Controlled Before and After (CBA) Studies Five studies conducted in the US, one in the UK All studies undertaken with groups of qualified staff in established teams eg A&E, PHC

Findings Four of the studies indicated that IPE produced positive outcomes in the following areas: emergency dept culture and pt satisfaction; collaborative team behaviour & reduction of clinical error rates in emergency dept teams; management of care to domestic violence victims; mental health practitioner competencies related to the delivery of patient care Two studies reported mixed outcomes (positive and neutral) Two studies reported that IPE had no impact on either professional practice or patient care

Outcomes, Effectiveness & Evaluation Outcomes: what you intend to achieve by the end of the Project Effectiveness: the extent to which your outcomes have been achieved Evaluation: process of looking at the evidence / data, to determine whether something has made a difference, ie; to measure any changes that have occurred from the initial situation.

Outcomes of Interprofessional Education Reaction Learners’ view on the learning experience and its interprofessional nature Modifications of attitudes / perceptions Changes in reciprocal attitudes or perceptions between participant groups. Changes in perception or attitude towards the value and/or use of team approaches to caring for specific client group Acquisition of knowledge / skills Including knowledge and skills linked to interprofessional collaboration

Outcomes of Interprofessional Education Behavioural Change Identifies individuals’ transfer of interprofessional learning to their practice setting and changed professional practice Change in organisational practice Wider changes in the organisation and delivery of care Benefits to patients / clients Improvements in health or well being of patients and carers Freeth et al 2003 (modified from Kirkpatrick 1967

Move towards competency based professional education – outcomes expressed as competences contemporary professional education has adjusted and changed to meet workforce requirements; so interprofessional education has been seen as necessary to equip professionals for multi dimensional collaboration Standards and outcomes set by regulatory body and others eg, national occupational standards Different types, different level. Common, complementary and collaborative competences

Professionalism Initial growth of professionalism mid 19th Century Uni professional education, By mid 20th Century professions being challenged Attempts to bring health and social care professions in general and medicine in particular under greater control Growing concerns about public safety and professional powers in light of, e.g. tragedies of Bristol Royal Infirmary events and Victoria Climbie Reform of Professional Regulatory bodies Establishment of Council for Healthcare Regulatory Excellence

Lancet commission Report (2010) Idea of professions and professionalism beginning to change New professions emerging Attempts to break down the barriers between professions Move towards interprofessional practice and interprofessionalism Need for reforms guided by transformative learning and interdependence Competency-based education transprofessional teamwork that includes non-professional health workers

Challenges for IPE in professional education Professional socialization Professional culture Professional language / jargon Organizational difficulties Lack of service support Lack of equality and reciprocity

Challenges for IPE in Professional Education Different educational and social backgrounds Fear of dilution of professional role / loss of professional identity Separate professional education – stereotyping Perceived different status and power Poor communication Poor facilitation of IPL Professionalism - key element in agendas related to interprofessional education in the UK

Professions as regulatory bodies assume different degrees of significance in different societies These set the parameters at national international level for the operation of specific professions, including in education. Opportunities for creating interprofessional education for practice are not just shaped by the educational institutions concerned and employer partners, but also by professional bodies.

Challenges re the practicalities Fitting IPE into a full curriculum – issues of ‘add on’ / integration Timetabling and logistics Resistance from colleagues and students Hierarchies between professions Silos and territorialism in universities and in practice Lack of support from professional organisations Poor communication systems

Interprofessional learning and working Works to improve the quality of care Focuses on the needs of service users and carers Encourages professions to learn with, from and about each other Respects the integrity and contribution of each profession Enhances practice within professions Just to reinforce what I have been saying about IPE H. Low

Benefits of Inter-professional Learning and Working Shifts focus from professional roles to patient needs Implicitly builds inter-professional team learning/working Demonstrates the power of sharing knowledge and experience It fosters innovation and capacity for change As above H. Low 47

Interprofessional Education Applies principles of Adult Learning Is practice led Includes common and comparative learning Is interactive Involves service users Is competency based Is assessed Improves practice Is evaluated These are the principles of IPE. As long as these are in place, iy does not matter which model, or theory you use.

Facilitating Interprofessional Learning Evidence indicates that the success of interprofessional learning is dependent to a significant extent on the effectiveness of those who facilitate it, at every level.

Facilitation of interprofessional learning Individuals may be experienced clinicians, practitioners and / or educationalists, but may lack the particular knowledge, skills and confidence to facilitate learning with groups of people from diverse professional backgrounds Even very experienced teachers find the challenges of multi professional teaching difficult to manage. Preparation is crucial Facilitation of interprofessional learning requires a level of expertise which builds on but extends beyond the range of knowledge, skills and attitudes required for uni professional teaching.

Facilitators of interprofessional learning of multi professional groups must: Have the ability to discern and address a range of complex issues, such as different professional cultures. perceived power and status of different professions and professional language. They must also have the sensitivity required to work across professional and organisational barriers to achieve change.

Members of different professions have different Styles of learning Patterns of thinking Attitudes to authority and therefore different constructions of reality. Different professionals have different skills, knowledge, concepts and therefore different value systems

Values and relationships The values that are part of professional culture will be reflected in the way professionals perceive other professions and affect the way relationships are (or not) developed. These relationships are crucial to effective interprofessional working and collaboration and influence the way in which interprofessional education is taken forward. H. Low

IPE is not achieved by structural and systems change alone It relies on the development of collaborative relationships, changed attitudes and behaviours for the long term, to develop a culture of IPE is an applied discipline dependent on the context where it takes place learning is transferable to new contexts and dependent on reinforcement

agreed aims, objectives and values Some Key Factors for effective Interprofessional Learning and Interprofessional working agreed aims, objectives and values address anxieties regarding any perceived reduction of standards and dilution of professional service. recognise issues of status and authority equity – all contributions are valued, individual and professional confidence enhanced respect differences Mutual respect and mutual support are important Recognise own and others’ knowledge and expertise Recognise where these are different and where they overlap Shared Learning: A Good Practice Guide ENB/CCETSW (Low.H, Weinstein.J)

Key factors for successful planning & delivery of an IPE initiative identify and get support of key stakeholders strong leadership identify enthusiasts/ champions for IPE work in a partnership of educators and service providers, plan together involve staff at all levels involve service users resources Start with what you have! Shared Learning: A Good Practice Guide ENB/CCETSW (Low.H, &Weinstein.J)

Academic institutions Connections for Collaboration Identifying stakeholders potential partners Policy makers International, national, regional and local government Health & Care Employers / managers new organisations and agencies Independent sector Health & Care Services based on people’s needs Health & Care Professions new roles, new occupations, new professions Communities Voluntary organisations Service users and carers Academic institutions Higher & Further education new partnerships

Global Interprofessional networks - connections and relationships CAIPE UK CENTRE FOR THE ADVANCEMENT OF INTER-PROFESSIONAL EDUCATION EIPEN EUROPEAN INTER-PROFESSIONAL EDUCATION NETWORK IN HEALTH & SOCIAL CARE INTERED THE INTERNATIONAL ASSOCIATION FOR INTER-PROFESSIONAL EDUCATION & COLLABORATION JAIPE THE JAPANESE ASSOCIATION FOR INTER-PROFESSIONAL EDUCATION 58

Interprofessional learning & working is not just about individuals, groups and organisations coming together and redesigning the way they do things. It is also about reflecting on the quality of relationships with each other