Research article
Open Access

Interprofessional Collaborative Practice in Graduate Medical Education: Where We Stand

Rachel Marie E Salas[1][a], Kate Allman[2], Leah Mische[3], Elizabeth Tanner[4], Jessica Bienstock[1][b], Antoinette Ungaretti[5], Paula David[1], Laura Hanyok[1][c]

Institution: 1. Johns Hopkins School of Medicine, 2. Towson University, 3. Mayo Clinic, 4. Johns Hopkins School of Nursing, 5. Johns Hopkins School of Education
Corresponding Author: Dr Rachel Marie E Salas ([email protected])
Categories: Postgraduate (including Speciality Training)
Published Date: 21/01/2021

Abstract

Context

The Core Competencies for Interprofessional Collaborative Practice (IPCP) provide goals for collaboration among health professionals, framing approaches for team-based patient care to enhance patient and population health outcomes. IPCP falls under the umbrella of health system science and is now regarded as the third pillar of medical education, providing an opportunity for teaming more effectively to provide high-value care. Graduate medical education national entities now describe the necessity of providing trainees opportunities for interprofessional work that meets the competencies for IPCP.

 

Objective

In this article, the authors explore the baseline understanding of IPCP across program leaders and trainees, identify the prevalence of IPCP activities, and determine the challenges/barriers to IPCP in GME at one institution.

 

Methods

An electronic survey polled medical program directors and trainees across specialties between January and February 2018. The survey was completed by twenty-two (of thirty-six) program leaders from seventeen departments (61% response rate). Sixteen faculty leader participants (73%) serve as Program Directors, and six (27%) serve as Assistant Program Directors. Three hundred and sixty-seven (367) trainees (21.9% response rate) completed the survey.

 

Results

Findings indicate that IPCP is valued in the preparation of residents, with 82% of program leader participants and 59.1% of trainees reporting. Most program leaders (63%) and trainees (n= 227, 61.85%) reported that their programs are facilitating IPCP activities (e.g. rounds, conferences with presenters/trainees from other professions). However, survey findings reflect a wide variety of definitions of IPCP across program leaders and trainees.

 

Conclusion

The meaning of IPCP, as a concept, remains ambiguous within the graduate medical community. IPCP is not ubiquitously defined with standardized educational expectations for all residency/fellowship training programs. An intervention to target teamwork and communication skills early in residency would likely benefit trainees to become better physicians and healthcare, team members.

 

Keywords: Interprofessional Collaborative Practice; IPCP; Graduate Medical Education; GME; trainee; residents; teamwork; interprofessional education; IPE; multidisciplinary

Introduction

Delivery of high-quality patient-centered care requires members of healthcare teams to be skilled in interprofessional teamwork. Following reports published by The Committee on Quality of Health Care in America, recommendations were made for how the health care system and related policy environment must be radically transformed to close the chasm between what we know to be good quality care and what exists in practice. Early reports of that committee were released--To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century stressing that “reform around the margins is inadequate to address system ills” (Kohn, 2000).

 

Since that time, efforts have been made to meet the demands of healthcare delivery with the development of recommendations and guidelines for attaining competencies needed to function on interprofessional collaborative teams. Not surprisingly, interprofessional education (IPE) is now mandated by accrediting bodies of all major health professions’ prelicensure programs (LCME, 2018; ACPE, 2015; AACN, 2008). Through IPE, learners understand the value, education, and clinical expertise that each healthcare team member brings to the delivery of high-quality patient care. Schools of nursing, medicine, pharmacy, and other health professions have incorporated new IPE approaches, starting in the pre-licensure years, to better prepare the next generation of clinicians. However, from the perspective of post-licensure learners, there remains a need to develop, implement, and foster more structured interprofessional collaborative practice (IPCP) opportunities (Fox et al., 2018).

 

Concerning the definitions of interprofessional collaboration, according to the Interprofessional collaboration, according to the Interprofessional Education Collaborative Expert panel, IPCP is defined as “care delivery by intentionally created, usually relatively small workgroups, whose members recognize themselves as having both a collective identity and a shared responsibility for a patient or group of patients (IPEC, 2016; Golom, 2018). Importantly, IPCP is differentiated from interdisciplinary and multidisciplinary teams by its lack of hierarchy and a focus on mutual respect and trust. This difference is analogous to the distinction in organizational psychology between “a group” versus “a team.” Whereas a group is a collection of individuals who work in parallel without interdependence, and a team requires coordination of multiple individual inputs to deliver a product that could not be constructed by any one individual given the time and resources (Golom, 2018).

 

In graduate medical education (GME), IPCP has become more relevant as trainees are interacting and working with other healthcare team members, patients, and carers daily. With that said, there have been a variety of obstacles to integrating IPE and IPCP in a more thoughtful and standardized manner. These include time constraints, limited resources, conflicting goals, educational approaches and program environments (Fox, et al., 2018).

 

The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements describe the necessity of providing trainees with opportunities for interprofessional work (ACGME, 2018). The ACGME’s Clinical Learning Environment Review (CLER) provided six areas (i.e., patient safety; health care quality; care transitions; supervision; well-being; and professionalism) that embody opportunities for IPCP in the clinical learning environment to provide safe, high-value patient care.

 

Achieving this vision requires the attainment of interprofessional competencies by trainees so that they enter the workforce ready to practice effective teamwork and team-based care.

 

While the GME community recognizes the importance of interprofessional exposure for trainees, with many training programs incorporating interprofessional opportunities in a variety of ways (Achkar, 2018) questions remain about how to effectively implement such opportunities in an already tightly packed curriculum (Gupte, 2016). Furthermore, and perhaps more important, is how to incorporate IPCP-centric opportunities for trainees from various specialty programs of different sizes, at different levels of training, and in a variety of learning environments (e.g., outpatient, inpatient, surgical, etc.) in a meaningful and standardized manner, as well as how to measure success. Thus, the goal of this study was to examine the current support implemented for IPCP by program directors and trainees within Johns Hopkins GME training programs. The study’s specific objectives were to 1) assess baseline understanding of IPCP across program directors and trainees (i.e., residents and fellows); 2) identify the prevalence of IPCP activities, and 3) determine the barriers to IPCP in GME at one institution.

Methods

Design

After receiving approval by the hospital Institutional Review Board for this cross-sectional study, data were collected by distributing an anonymous survey (see supplemental file 1 and 2) through the Johns Hopkins Office of Assessment and Evaluation to all program directors and trainees at Johns Hopkins School of Medicine. Faculty leaders of the institution’s Interprofessional Collaborative and other institutional faculty leaders worked together to identify the following research questions:

  • How do program directors and trainees across the target institution define IPCP?
  • How do program directors and trainees across the target institution integrate IPCP?
  • What barriers do program directors and trainees report in integrating IPCP at the target institution?

The research team developed and revised questionnaires that included closed-ended and open-ended questions. Once finalized, the electronic survey was distributed using Qualtrics online survey software. The survey was pre-tested with a small group of medical school faculty who were not program directors (n=5). Pre-test results were analyzed and survey wording and question formats were revised to clarify a sub-set of questions so that they more closely addressed the research questions.

 

Participants

Prospective participants from twenty-seven departments included 1674 trainees from 129 programs (both ACGME-accredited and non-ACGME accredited programs) and thirty-six residency program leaders (i.e., program directors, assistant directors) were invited by email to participate in the survey. Two email reminders were sent to non-responders; one was sent 12 days after the initial email invitation, the second sent 11 days later. Trainees were incentivized with being entered into a raffle for a food delivery gift card of 150 dollars.

 

Of thirty-six program leaders, twenty-two from seventeen departments responded to the survey (61% response rate). Sixteen faculty leader participants (73%) were identified as Program Directors and six (27%) as Assistant Program Directors. Three hundred and sixty-seven (367) trainees (21.9% response rate) participated. Of these respondents, thirty-three respondents chose not to identify their race. Of the total number of respondents, 60.7% (n=223) of trainee respondents were White, 22.3% (n=82) were Asian, 5.7% (n=21) identified as Black or African-American, 1.4% (n=5) White/Asian, and 0.8% (n=3) White/Black. Demographic data on the program leaders were not provided to maintain anonymity.

Results/Analysis

Analysis

Data were analyzed using a side-by-side, mixed-methods analytic approach (Creswell, 2011). Categorical survey questions were analyzed using descriptive statistical methods to identify counts and percentages of responses. Ordinal and ordered categorical survey questions were analyzed by assigning a numeric value to each response and descriptive statistics were used to summarize and compare responses.

 

Open-ended survey questions were analyzed by content analysis of the data and by collapsing codes into broad themes. Themes were then quantified to enumerate the frequency of themes among the respondents and the percentage of people identifying specific themes in their responses (Onwuegbuzie, 2003). Themes were refined and additional (new) themes were incorporated into the analysis, as needed.

 

RESULTS

 

IPCP Value and Definition

Our findings showed that both program leaders and trainees at the surveyed institution place a high value on Interprofessional Collaborative Practice (IPCP), with 82% of program leader participants and 59.1% of trainee participants identifying IPCP as a very important component of training. Despite the high value placed on IPCP integration, respondents differed widely in their definition of IPCP.

 

Program Leader Definitions of IPCP

Program leaders were asked the following open-ended question: “What does interprofessional collaborative practice (IPCP) mean to you? Think about how you would describe IPCP to others, how you would envision it occurring in an ideal situation or elements that create IPCP practice, or other elements that lead to how you think about IPCP.” Sixty-eight percent (n=15) of program leaders defined IPCP generally as a professional practice in which professionals with different areas of expertise “work together." Eighteen percent (n=4) of program leaders described IPCP as a collaborative practice between healthcare workers of different training. Five percent (one respondent) of program leaders defined IPCP as a professional practice in which professionals from different areas of expertise “learn” together. No program leaders identified patients, carers, families, or community members as part of this collaborative practice, which is important to the IPCP components of the definition (Gilbert, 2010). One program director responded with the comment: “[IPCP] is not a concept that I use, mostly because I am not familiar with it.” Thirty-two percent (n=7) of program leaders, chose not to provide a personal definition of IPCP. Sixty-four percent (n=14) of the program leaders described IPCP as producing an outcome, varying from patient care (n=9), productive teamwork (n=4), education (n=2), or a general goal” (n=1). Only 27% (n=6) of program leader participants defined IPCP in terms of method or process. Twenty-seven percent (n=6) of respondents described IPCP in terms of the quality of collaborative practice (“work well,” “work efficiently,” “respectful”), and one respondent specifically stressed that IPCP “must include ‘non-hierarchical’ mutual respect.” No program leader defined IPCP correctly by specifically including the three processes for promoting collaborative practice: shared decision-making, regular communication, and community involvement (Gilbert, 2010) (See Table 1).

 

Trainee Definitions of IPCP

Thirty-four percent (n=125) of trainee respondents identified IPCP as a collaborative practice that involves “talking to” or “working with” others. Only 22.6% (n=83) of trainees defined IPCP as a collaborative practice among healthcare professionals, and only 6% (n=22) of trainees described IPCP as a collaborative practice among health care professionals with different training backgrounds. Two respondents (0.5%) mentioned patients and families as partners in the IPCP process, and no trainees identified carers or community members as IPCP partners (Gilbert, 2010). Notably, 48.8% (n=179) of trainees did not provide a personal definition of IPCP, and of those who defined IPCP (n=190), eight (4.2%) reported they did not know what IPCP was or “never heard it before.” (See Table 1)

 

Table 1: Interprofessional Collaborative Practice Definitions (Program Leaders and Trainees)

 Program Leaders identified IPCP as:  Trainees identified IPCP as:
 “a professional practice in which professionals with different areas of expertise work together”  “a collaborative practice, involving talking to or working with others”
 “a collaborative practice between healthcare workers of different training”   “a collaborative practice among healthcare professionals”
 “a professional practice in which professionals from different areas of expertise learn together”  “a collaborative practice among health care professionals with different training backgrounds”
 “[IPCP] is not a concept that I use, mostly because I am not familiar with it”  “patients and families as partners in the IPCP process”
 “producing an outcome, varying from patient care, productive teamwork, education or a general goal”  
 “defined IPCP in terms of method or process”  
 quality of collaborative practice (“work well,” “work efficiently,” “respectful”  
 “IPCP must include non-hierarchical mutual respect”  

 

Table 1 lists examples of responses from both program leaders and trainees to the question “What does interprofessional collaborative practice (IPCP) mean to you? Think about how you would describe IPCP to others - how you would envision it occurring in an ideal situation, or elements that create IPCP practice, or other elements that lead to how you think about IPCP."

 

Integration and Partnerships

Both program leaders and trainees identify similar opportunities for interprofessional experiences and with whom those experiences involve. Sixty-four percent (n=14) of program leaders reported that their program currently integrates IPCP. Program leaders who integrated IPCP programmatically reported collaborating with twelve different professional areas, most commonly: Nursing (n=14, 64%), Pharmacy (n=12, 55%), Social Work (n=12, 55%), and Allied Health disciplines, including physical therapists, occupational therapists, and speech-language pathologists (n=11, 50%). Only one program director reported collaborating with public health professionals, and no program directors reported working with dentistry professionals.

 

Sixty-two percent of trainee participants (n=227) reported that they had participated in IPCP during their GME program training. Trainees reported collaborating with a variety of professionals from over twenty-four professional backgrounds in IPCP, most commonly: nursing (n=198, 54%), pharmacy (n=176, 48%), social work (n=174, 47.4%), and allied health (n=130, 35.4%). Trainee respondents reported collaborating least often with public health (n=20, 5.5%) and dentistry (n=3, 0.8%).

 

From the program leadership perspective, program leaders reported facilitating IPCP activities most commonly through rounds (n=12, 55%), conferences with presenters/trainees from other professions (n=12, 45%), and structured IPCP activities (n=12, 45%). Moreover, trainees reported that they participate in IPCP most often during “rounds" (n=189, 51.5%), "conferences with presenters/trainees from other professions" (n=157, 42.8%), "structured IPCP activities" (n=157, 42.8%), and "grand rounds" (n=152, 41.4%). Other IPCP activities mentioned more than once by trainee respondents included: tumor boards (n=4, 1.1%) and clinics (n=3, 0.8%).

 

Challenges/Barriers to IPCP Integration

Program leaders and trainees identified lack of time, lack of understanding of IPCP, and lack of relationship-building resources as the most significant barriers to integrating IPCP.

 

Figure 1 depicts the number of program leaders identifying the stated challenges/barriers listed.

 

Figure 1: Challenges/Barriers to IPCP Integration Identified by Program Leaders

 

 

Figure 2 depicts the number of trainees identifying the stated challenges/barriers listed. 

 

Figure 2: Challenges/Barriers to IPCP Integration Identified by Trainees

 

Time

Both program leaders (Figure 1) and trainees (Figure 2) identified a lack of “time” as the most significant barrier to effectively integrating IPCP. Ten faculty leaders (45%) identified the lack of “protected faculty time” as a significant or strong barrier to implementing IPCP. Program leaders recommended funding opportunities and greater institutional support to help support faculty understanding of IPCP and systematic, programmatic integration of IPCP. A total of one hundred and nine trainee participants (29.7%) identified a lack of “protected time” as a significant or strong barrier to implementing IPCP. Seventy-six (18%) respondents identified a lack of“protected time” as a moderate barrier. Twenty trainees (5.5%) expressed the need for a protected time during the workday to participate in structured IPCP activities. Two trainees (0.5%) voiced that it is “not a realistic possibility” to incorporate IPCP activities on “our own time.”

 

Improving IPCP in GME training

Faculty and trainees also identified that a general lack of knowledge about how to successfully engage in IPCP is a significant barrier to integrating IPCP. Sixty-four percent of program leaders (n=14) and 39.2% (n=144) of trainees identified lack of “knowledge about how to successfully engage in IPCP” as a moderate to a significant barrier to incorporating IPCP. Thirty-two percent (n=7) of faculty respondents and 12.5% (n=46) of trainees expressed the need for more training, examples, or other resources to support the integration of IPCP. Specifically, the need for examples, best practices, funding, making IPCP an institutional priority, providing more training/education, allowing dedicated time, and having more contact/point persons were listed as ways to enhance IPCP by program leaders.

 

Similarly, trainees reported recommendations. Sixteen trainees (4.4%) expressed the need for more resources (e.g., time, financial, established curriculums) related to IPCP. One trainee (0.3%) recommended “facilitating… point persons for each department (faculty and trainees).” Four additional trainees (1.1%) suggested the need for good examples of IPCP, and two others (0.5%) recommended sending out “best practice reminders.” Two trainees (0.5%) recommended creating and sharing “goal sheets” or a “best practice check-list” that could be completed during rounds.

 

Relationship-Building Resources for Trainees

Trainees expressed a unique need for more opportunities to connect with individuals from diverse training backgrounds interested in IPCP. Sixteen trainees (4.4%) expressed the need for more opportunities to connect with those from different professions. More specifically, eight trainees (2.2%) expressed the need for a contact list or directory that could be used to connect with people in other disciplines interested in IPCP (e.g., social and networking opportunities). Five trainees (1.4%) recommended the integration of more multidisciplinary rounds. Two trainees (0.5%) recommended fostering multidisciplinary clinics. Others recommended events or introductory e-mails where trainees can meet multidisciplinary providers who interface with specific divisions.

Discussion

IPCP is a necessary component of medical training; however, there are challenges to effectively integrating IPCP into the clinical arena where GME education occurs. The current study surveyed program directors and trainees at a large academic institution to examine their understanding of IPCP and if/how IPCP is currently incorporated into training programs. Additionally, barriers to effective IPCP integration into medical training were also probed.

 

Not surprisingly, program director and trainees, both identified IPCP as important and generally defined it as clinicians “working together” in some capacity. Interestingly, a larger percentage of program leaders identified IPCP as important, when compared to trainees. This may be related to a difference in understanding of the fundamental importance of IPCP and may relate to the impact of professional experience on appreciating the value of effective teamwork in the clinical setting. In defining IPCP, across the spectrum of both program leaders and trainees, very few respondents identified it as including family members, carers, or patients as members of the team. Neither did the greater majority define IPCP as an ongoing process, with responses tending to focus on outcomes rather than team development. This may reflect a view that respondents thought of IPCP as a consequence of professionals working together, rather than a conscious effort to build an effective team structure. The cumulative responses to the question of how to define IPCP suggest that there is a general misunderstanding of what effective IPCP looks like. It is important to note that almost 50% of trainees did not enter a response when asked the definition of IPCP. Further 32% of program leader respondents also failed to answer this question. While there is no way to know for sure why the question was unanswered, it is plausible that it was intentionally left blank as an indication that the respondents were unsure of the answer. This is backed by both groups indicating a need for more knowledge about IPCP and strongly supports developing an initiative to educate faculty and residents on IPCP.

 

In asking program leader respondents about IPCP opportunities within their training program, about 50% of program leaders reported facilitating an IPCP experience - e.g., rounds and interdisciplinary conferences. However, an activity or experience that is truly an IPCP project would be founded not just on a collection of individual members of the healthcare team working together toward a common goal. It would require intentionality, a focus on the goals, roles, processes/procedures of all team members, and, importantly, it would include the patient as a member of the team (IPEC, 2016). For example, while multidisciplinary rounding is a relatively common practice in the hospital setting, interprofessional rounds with a focus on collaborative care and performance improvements via communication development have been shown across studies to improve patient outcomes (Ashcraft, et al., 2017).

 

There were some barriers that program leaders and trainees identified as precluding successful integration of IPCP opportunities – in particular, time, understanding of IPCP, and how to integrate it into training, and relationship-building resources (i.e., opportunities to facilitate more direct interaction between team members). Postgraduate training is a particularly busy period in physician training with work expectations of up to 80 hours a week and single shifts as long as 24 hours. That being said, training is also a prime period for teamwork and communication skill development, because this is likely to be the most clinical-heavy time in a physician’s career. Making time and providing the resources for IPCP activities or opportunities within training programs would ensure that trainees complete training with the necessary competencies to work effectively in IPCP teams throughout their careers. 

 

This study which included 26 program leader respondents and 367 trainee respondents, is limited because it took place in a single institution. Additionally, not all specialties participated in the survey, which may have skewed our results based on the multitude of team cultures present across different fields of medicine. Finally, while this study was designed to evaluate knowledge of IPCP and its barriers among trainees and program leaders, the results would be more meaningful and robust if the voices of other stakeholders were included as well (e.g., nurses, pharmacists, and social workers on the units). While there were certain limitations, this paper represents important information regarding the IPCP in GME at an academic institution, as well as approaches that are recognized as valuable for building IPCP skills within GME programs. Future studies, including the views of the team members including all health professions as they relate to the responses acquired from the physician (including those in training), would help elucidate differences in team-based perspectives and cultures, to build and expand programs for trainees and health care team members to master interprofessional competencies.

 

Future studies should examine known barriers to IPCP as well as efficacious methods to address barriers to effective IPCP. Additionally, the methodology should include in-depth interviews with program directors, trainees, and institutional administrators to assess barriers to these interventions and to develop methods to overcome them when expanding residency education to meet IPCP competencies.

Conclusion

While there has been more emphasis on IPCP within GME programs, as a concept, it remains ambiguous and unclear within the physician community, with physicians not being fully aware of the IPCP definition and what activities truly represent IPCP, there is more work to be done. Thus, there is a need for more focused education on a grander scale (Zabar, et al., 2016; Gordon, 2018). This study highlights that this need extends into training programs as well. Currently, IPCP does not ubiquitously exist in a structured, standardized educational format within all residency/fellowship training programs. An intervention to target teamwork and communication skills early in residency would likely benefit trainees to become better physicians and healthcare team members and improve patient outcomes, which would ultimately benefit patients and carers. There are many barriers to improving the goal of offering more IPCP activities and opportunities. However, with institutional and financial support, instituting IPCP as a part of training is necessary and possible.

Take Home Messages

  • Often, the meaning of Interprofessional Collaborative Practice (IPCP) is not known or not clear.
  • Program leaders and trainees alike have conflicting definitions of IPCP.
  • Patients, families, and carers are an integral part of IPCP.
  • Interventions that target interprofessional teamwork and communication skills early in training will improve patient outcomes.
  • There are challenges to improving IPCP opportunities in medical training.

Notes On Contributors

Rachel Marie E. Salas, MD, MEd, FAAN is an Associate Professor, Neurology and Nursing at Johns Hopkins Medicine Director of Interprofessional Education and Interprofessional Collaborative Practice for the School of Medicine; Director, Neurology Clerkship Director.

 

Kate Allman, PhD is an Assistant Professor at Towson University and served as an Evaluation Specialist in the Office of Assessment and Evaluation at the Johns Hopkins School of Medicine during data collection and analysis.

 

Leah Mische, MD is a first-year medical resident in the Department of Internal Medicine at Mayo Clinic in Rochester, Minnesota.

 

Elizabeth (Ibby) Tanner, Ph.D., RN, FAAN is a Professor in the Johns Hopkins School of Nursing and School of Medicine, Community Public Health Nursing, Division of Geriatric Medicine and Gerontology Core Faculty, Center on Aging and Health Principal Faculty, Center for Innovative Care of Aging.

 

Jessica Bienstock, MD, MPH is Professor of Gynecology/Obstetrics and Associate Dean and Designated Institutional Official at Johns Hopkins School of Medicine.

 

Antoinette Ungaretti, Ph.D. is an Assistant Professor and Director of the Master of Education in the Health Professions (MEHP) Program, an interprofessional partnership of the Johns Hopkins University Schools of Medicine, Nursing, Education, the Bloomberg School of Public Health, and the Carey Business School.

 

Paula David, is a Senior Administrative Program Coordinator at Johns Hopkins University, School of Medicine, Department of Neurology.

 

Laura A. Hanyok, MD is an Associate Professor of Medicine and Nursing and Assistant Dean for Graduate Medical Education at Johns Hopkins School of Medicine.

Acknowledgements

The table and figures are original work of the authors. There was no funding associated with manuscript.

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Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

Johns Hopkins Institutional Review Board approved this cross-sectional study, on July 19, 2018, #IRB00176455.

External Funding

This article has not had any External Funding

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