The design of an interprofessional objective structured clinical examination (iOSCE) approach

Developing an iOSCE presents unique challenges. For example, there is a need to balance the inclusiveness of participating professions in each scenario with realism, and the need to ensure that learners have opportunities to demonstrate their different interprofessional skills within scenarios. Nevertheless, this initial work has helped to ensure that the perspectives of the professions involved in the IPE curriculum were captured in a fair and equitable manner. In addition, we found that the modified Delphi process was an effective tool to obtain consensus amongst the professions for the foundational work required for this study. The next steps in this study involve two full-day writing workshops to develop the top five topic themes into clinical scenarios for use in the iOSCE that could accommodate any 5 of the 10 health professions at the study site. Participants will work in small, interprofessional groups led by a facilitator to accomplish this task. An iterative process of scenario review, refinement, pilot testing and evaluation for validity and reliability will be used to address challenges, with the help of clinical subject matter and OSCE experts, confederates (trained actors to role play scenarios), and student volunteers. Finally, a series of focus groups will be held with purposefully selected faculty, students, and standardized patients involved in this process to evaluate their experiences in the development of the iOSCE.

Scott Reeves (Editor-in-Chief)

For more information read: Journal of Interprofessional Care (January 2011), 25 (1), pg. 73-74.

The role of nurse practitioners in hospital settings: implications for interprofessional practice

Expansion of the nurse practitioner (NP) role worldwide indicates a need to understand how the role functions in interprofessional healthcare teams. Through the adoption of a mixed methods approach that gathered on-site tracking and observation, self-recorded logs of consultations and focus group interviews of team members and NPs, we describe the extent of role activity and the nature of interprofessional practices of 46 NPs and their team members in nine hospital sites across the province of Ontario, Canada. Findings outline the nature of the NP role activities, which largely focused on providing clinical care, with the support of their team, to a range of patients across the study settings. We discuss how ‘‘embedding’’ the NP in this way appears to contribute to utilization of expertise of all professions as well as enabling team members to promote evidence-based practices. We argue that the use of NPs augments interprofessional role utilization through their desire to consult with a range of professionals and the capacity to perform holistic care for patients that is not limited to traditional nursing boundaries.

(Scott Reeves, Editor-in-Chief)

For more information read: Mary Van Soeren; Christina Hurlock-Chorostecki; Scott Reeves

Journal of Interprofessional Care (July 2011), 25 (4), pg. 245-251.

A scoping review to improve conceptual clarity of interprofessional interventions

Interprofessional education (IPE) and interprofessional collaboration (IPC) have been identified in health education and health care as playing an important role in improving health care services and patient outcomes. Despite a growth in the amount of research in these areas, poor conceptualizations of these interprofessional activities have persisted. Given the conceptual challenges, a scoping review of the interprofessional field was undertaken to map the literature available in order to identify key concepts, theories and sources of evidence. The objective of this review was to develop a theoretically based and empirically tested understanding of IPE and IPC. A total of 104 studies met the criteria and were included for analysis. Studies were examined for their approach to conceptualization, implementation, and assessment of their interprofessional interventions. Half of the studies were used for interprofessional framework development and half for framework testing and refinement. The final framework contains three main types of interprofessional interventions: IPE; interprofessional practice; and interprofessional organization; and describes the nature of each type of intervention by stage, participants, intervention type, interprofessional objectives, and outcomes. The outcomes are delineated as intermediate, patient, and system outcomes. There was very limited use of theory in the studies, and thus theoretical aspects could not be incorporated into the framework. This study offers an initial step in mapping out the interprofessional field and outlines possible ways forward for future research and practice.

(Scott Reeves, Editor-in-Chief)

For more information read: Scott Reeves; Joanne Goldman; John Gilbert; Joshua Tepper; Ivan Silver; Esther Suter; Merrick Zwarenstein

Journal of Interprofessional Care (May 2011), 25 (3), pg. 167-174. 

Liberating the NHS: Developing the Healthcare Workforce

Workforce planning is an ongoing discussion for health and social care policymakers across the world. Attempting to educate different professional groups to equip them with a suitable skills mix to meet the growing and evolving demands of patients/clients and their families is clearly no mean feat. It is certainly one which needs to be continually reviewed and revised in response to changing demographics and availability of (limited) resources.

This consultation document builds upon the UK government’s recently published white paper Equity and Excellence: Liberating the NHS (Department of Health, 2010) which outlined an ambitious set of principles for shifting the balance of workforce planning, education and training from a ‘‘top-down’’ to a more ‘‘bottom-up’’ approach. In essence, these reforms will mean that workforce planning and education activities will no longer be the responsibility of centralized strategic health authorities (SHAs), rather they will be the responsibility of local networks of health professionals working together in a ‘‘multi-professional’’ manner. The rationale for this shift is that localized ‘‘bottom-up’’ planning will be more effective as professions, engaged in delivering clinical services, are the best placed to decide collaboratively about the workforce planning.

Specifically, this document outlines a new framework which will be crucial for the Department of Health to meet the goals it articulated in the earlier white paper. The document itself is divided into 11 chapters which outline background context issues for the shift in workforce planning, review the underpinning ideas for the new framework, describe the framework, outline funding and incentive issues and describe a range of transition plans. The document also contains 46 consultation questions which invite comments on a range of issues based in each of the chapters.

The final date for responses to this consultation document was March 2011. While we are still waiting to see the official summary of responses from the Department of Health, it is possible to read a number of responses from a range of bodies including the British Medical Association, British Dental Association, Charted Association of Psychotherapists and the UK Clinical Pharmacy Association, which outline a mixed range of reactions relating to the economic, professional, educational and organizational issues related to the proposed reforms. (Scott Reeves, Editor-in-Chief)

For more information read: Journal of Interprofessional Care (July 2011), 25 (4), pg. 312-313.

Exploring power in interprofessional education

As we know, IPE is considered a key mechanism in enhancing communication and practice among health care providers, optimizing participation in clinical decision making and improving the delivery of care. An important, though under-explored, factor connected to this form of education is the unequal power relations that exist between the health and the social care professions. In a study which analyzed data from the evaluation of a large multi-site IPE initiative, we used Anne Witz's model of Professional Closure to explore the perspectives and the experiences of participants and the power relations between them. Findings from this study really highlighted how professionals' views of interprofessional interactions, behaviours and attitudes tend to either reinforce or attempt to restructure traditional power relationships within the context of an IPE initiative.

For more information read: Baker, Egan-Lee, Martimianakis, Reeves – Journal of Interprofessional Care, Vol. 25, pages 98-104

Appreciative inquiry within interprofessional education: how it overlooks the influence of social structures

Appreciative inquiry (AI) is a relatively new approach to initiating or managing organizational change that is associated with the ‘positiveness’ movement in psychology and its offshoot positive organizational scholarship. Rather than dwelling upon problems related to change, AI encourages individuals to adopt a positive, constructive approach to managing change. In recent years, AI has been used to initiate change across a broad range of public and private sector organizations. In a recent interview-based study which explored how AI was employed as a change agent for implementing an IPE initiative across a number of health care institutions we found a strong resonance and fit for AI both among the health and social care professionals who participated in this initiative. Numerous individuals commented on the enthusiasm and energy AI engendered, while praising its ability to enhance their working lives and interprofessional relationships. Yet a number of difficulties were also reported. These focused on problems with the translation of the AI process into achievable structural level (e.g. professional, cultural) changes. Based on these findings, we go on to argue that the use of AI can overlook a number of structural factors, which will ultimately limit its ability to actually secure meaningful and lasting change within health care.

(Scott Reeves, Editor-in-Chief)

For more information read: Dematteo & Reeves – Journal of Interprofessional Care, Vol. 25, pages 203-208 

Interprofessional simulated learning and sociological fidelity: Part 2

As noted in the last blog entry (see May 2, 2011), the use of interprofessional simulation based on psychological conceptions of non-technical skills tends also to emphasise the individual as the site of the ‘problem’ and ‘solution’ to communication and collaboration.  As a result, there appears to be a disconnect between the theoretical and methodological approach underpinning simulation – that emphasises individual skill acquisition – without adequately acknowledging the subsequent complex clinical context in which individual practitioners must perform their newly acquired collaborative skills. One could also posit that current interprofessional simulated learning brings the notion of interprofessionalism back to an issue of  'correcting' the individual to become more 'team' oriented and ‘collaborative', thereby exacerbating culturally held, highly valued and behaviorally expressed notions of individualism which can exist within some professions.  This would seem fundamentally in tension with the premise of interprofessionalism which is a relational one.  It is not just grounded within uni-dimensional ideas of effective communication, but within an understanding of one's role in relation to others that are pertinent to a given health care task, with an appreciation of the context in which it occurs.

The application of a sociological approach can also encourage a reconsidering of the notion of ‘non-technical’ (collaborating, negotiating and communicating) skills, which within the simulation literature are usually demoted to ‘soft’ and secondary to clinical skills.  Not only are collaborating and negotiating processes essential to effective interprofessional practice, they are also complex technical activities in their own right. They involve the integration of a complicated range of skills, attitudes and behaviours, which require a firm understanding as to how factors such as imbalances of authority and influence, differing educational backgrounds, disparate ways of constructing professional identity, gender and socio-economic inequalities, can affect and often undermine interprofessional interactions.  

It seems therefore that whilst the simulation literature is acknowledging the importance of using an interprofessional approach, the best way to incorporate such an approach and empirically study its impact on collaboration, teamwork and patient care, is still unknown. 

Whilst recognising the issues affecting interprofessional collaboration in healthcare are complex, historical, and culturally and socially engrained, we strongly believe that such issues must be addressed if meaningful and relevant team-focused, rather than individually-focused, training programs are to become a reality.  Incorporating the ever-present, but seldom explicitly addressed sociological issues (e.g. power, hierarchy, professional boundaries, gender) into interprofessional team training simulations will certainly be no easy task.  Operationalizing concepts which are complex and nuanced will be challenging, but if our ultimate goal is to improve interprofessional collaboration in clinical practice to enhance patient care, then this is a necessary next step.  

The introduction of ‘sociological fidelity’ will inevitably have many implications for the design and practice of interprofessional simulated learning.  Undoubtedly, scenarios will become more complex to produce.  As a result, rich qualitative data gathered from various clinical settings will be needed to ensure that the interprofessional scenarios are truly contextual and provide an effective reflection of the lived realities of different professionals.  The aim of such scenario development is to reveal and explore real life interprofessional tensions, hierarchies and boundaries, and thus facilitators will need to anticipate potential consequences of sometimes difficult discussions which may emerge during the enactment of the scenarios.  Despite these additional challenges, the use of sociological theory in the development of interprofessional scenarios, combined with careful assessment and evaluation, will improve the quality of interprofessional simulation-based education. 

(Scott Reeves, Editor-in-Chief)

For more information read: Sharma, Boet, Kitto & Reeves – Journal of Interprofessional Care, Vol. 25, pages 81-83.