Chapter 2: Review of the Literature
This literature review focuses on a review of interprofessional education, a history and review of the use of simulation in the education of medical and health professional students and a review of collaborative learning. This review also includes a summary of the learning theory that bridges interprofessional and simulation education, and finally, identifies the gaps in the literature.
The review of literature for this study was conducted to address these goals:
1. To determine the goals and barriers to interprofessional education, especially in the area of collaboration
2. To determine how patient simulation is used in interprofessional health care education
3. To identify gaps in the existing literature pertaining to interprofessional education, simulation and respiratory therapy.
The MEDLINE (1985-December 2008), CINAHL (1985-December 2008), ERIC and COCHRANE REVIEW data bases were reviewed using various combinations of the following key words: interprofessional education, interdisciplinary education, human patient simulation, respiratory therapy education, interprofessional collaboration, interdisciplinary collaboration, perception of collaboration, medical education and simulation. Research studies focusing on the use of human patient simulation in medical education were used for this review of literature. Additionally, articles and research studies focusing on interprofessional/interdisciplinary education were reviewed and included in this literature review. Books were reviewed to understand more fully the pedagogy of interprofessional education and simulation. The following section summarizes the relevant literature on interprofessional education, collaboration and the use of human patient simulation in health care education.
The need for interprofessional education in health care can be traced back in history to the increasing difficulty of health care delivery (Baldwin, 2007). At the turn of the 20th century, health care was primarily an interaction between a doctor and patient. From that point on there has been a steady increase in the number of people and professions involved in that patient's care. Hospitals became a strong institution with increasing amount of technology and more professions attending to that patient. Each profession developed their own curriculum and struggled for its own identity. Within each profession new roles are acquired and new professions, such as Respiratory Therapy, have developed because of the increase in technology.
Interprofessional education and collaboration in the health professions are often identified in many reports as a means to overcome the issues of complexity and to ensure safe and effective health care(Romanow, 2002; Kirby, 2002; Health Canada, 2004; O'Neil, 1998 ). A common theme among these reports is the need for health professionals to work more effectively and collaboratively in interdisciplinary teams. Related literature on interdisciplinary/interprofessional education will be discussed in the next sections of this chapter. I will use the term interprofessional instead of interdisciplinary because it more accurately describes the elements under study.
For many years, the World Health Organization (WHO) has promoted interprofessional models of care internationally (Oandasan & Reeves, 2005). In 1999, the Institute of Medicine (IOM) estimated that 44,000 deaths per year occurred directly as a result of human error (Kohn et al, 1999). Based on these findings, the IOM recommended that medical professionals develop ways to increase patient safety and decrease the risk of human error (Kohn et al, 1999).
Interprofessional education has been identified as a way to address current and future health human resource issues (Health Canada, 2003). In particular, IPE has been said to: 1) enhances understanding of roles and responsibilities of other health professionals; 2) provide mechanisms for continuous communication and improvement of interpersonal skills of participants; 3) develops skills in teamwork and clinical decision-making and 4) foster respect for the disciplinary contribution of all professionals (Kipp et al, 2007; Curran, 2004).
There is a belief that starting interprofessional learning as early as possible in undergraduate courses will change negative attitudes or prevent stereotyped views from forming and that students will be better prepared for team working and collaboration after graduation (Parsell et al, 1998).
In recent years, national healthcare systems have begun to incorporate more collaborative models of healthcare delivery and interprofessional education is identified as a necessary basis for collaborative patient-centred practice systems to succeed (Romanow, 2002). The purpose of this study will be to bring together two developments in healthcare professional education: interprofessional collaboration and the use of high-fidelity simulators.
History and Development of IPE
The United Kingdom (UK) was one of the first countries to initiate Interprofessional Education (IPE) development in the 1960's for the purpose of improving working relationships among social work, health care and other professionals (Oandasan & Reeves, 2005). This development continued through to the 90s and the Center for the Advancement of Interprofessional Education (CAIPE) in the UK was founded in 1987. CAIPE is now the central resource for health care educators that provides an outlet for the exchange of ideas and the creation of new initiatives (Oanadan & Reeves, 2005; Barr, Koppel, Reeves, Hammick & Freeth, 2005)
In Canada, there have been a number of initiatives supported by Health Canada related to collaborative care since the 1990s. In 2002, Roy Romanow declared that if health care providers are expected to work together and share expertise in a team environment, it makes sense that their education and training should prepare them for this type of working arrangement (Health Canada, 2002).
The 2003 First Ministers' Accord on Health Care Renewal (Health Canada, 2003) highlighted that fundamental changes are necessary to deliver effective primary health care. This accord identified that a key component of health system renewal is to change the way health professionals are educated. In response to this report, Health Canada explored national and international trends in interprofessional education and collaborative patient-centered practice (IECPCP) (Health Canada, 2004) in order to develop a framework to define the main features and determinants of interprofessional education for collaborative patient-centered practice (Oanadasan & Reeves, 2005; Phillippon et al, 2005).
As reported in a Canadian Interprofessional Health Collaborative (CIHC) report (Curran & Orchard, 2007), various government documents have called for joint training or common learning across health professions to ensure and promote seamless patient-centered care (Health Council of Canada, 2005; Health Council of Canada, 2006).
There is a great deal of diversity in how this joint training is accomplished both within and across countries (Cook, 2005). A recent international review commissioned by the Royal College of Nursing in the UK examined literature published between 2000 and 2006 on interprofessional education from the United Kingdom, Canada, United States, Finland, Australia and New Zealand (Clifton et al, 2007). There was a wide range in the content of the programs reviewed, types of learners, professional mix, teaching methods, and the duration of the curriculum. Until recently, most interprofessional programs were developed for postlicensure or postgraduate learners (Barr, 2005). In the last few years, governments in many countries have been calling for the development of new approaches to interprofessional education for undergraduate students (Barker et al., 2005).
Interdisciplinary is a term that has been used to describe collaborations of students from different health professions since the 1970s but the use of the term interprofessional is a recent development. The broader term of interdisciplinary is now more commonly used outside of health profession education. Multiple definitions of interprofessional education have been put forward but there is a growing consensus that it is defined as joint learning by practitioners or students of more than one profession to enhance collaborative practice (Barr, 2005; Clark, 2006; Goelan et al, 2006). In this section I will address the operational definitions of the term interprofessional and the current definitions of interdisciplinary and other terms.
The term interdisciplinary is an adjective describing the interaction between two different disciplines (McCallin, 2001). The World Health Organization (1988) defines interdisciplinary education in health sciences as “the process by which a group of students (or workers) from the health-related occupations with different educational backgrounds learn together during certain periods of their education, with interaction as an important goal, to collaborate in providing preventative, curative, rehabilitative and other health-related services” (WHO, 1988, p.2). This interaction may range from the simple communication of ideas, to the integration of concepts, methodology, terminology, data and organization of research.
In Canada and Europe, the term ‘interprofessional' is often used to refer to health professions education. In a review of the literature on the subject, Oandasan and Reeves (2005) state that there is a move towards use of the suffix “-professional”. While a discipline is defined as a field of study, a profession is a calling requiring specialized knowledge (Barr, 1996). Oandasan and Reeves (2005) found that educators in the health professions searched for ways to prepare practitioners who can work in a collaborative way by emphasizing interprofessional education, or programs that join the efforts of departments and training courses that have traditionally been separate.
Both the Pew Foundation Report (O'Neill, 1998) and the Institute of Medicine Report (IOM, 2003) use the term interdisciplinary, instead of interprofessional education. Interdisciplinary teams in the IOM report are “composed of different professions and occupations with varied and specialized knowledge, skills, and methods. The team members integrate their observations, bodies of expertise and spheres of decision-making to coordinate, collaborate and communicate with one another to optimize care” (IOM, p.54).
Change this para if including The common themes of these definitions are the concepts of cooperation, integration, and an effort to look at problems from many angles by those with different backgrounds and trained in various disciplines. In the medical profession, the term interdisciplinary often refers to one clinical specialist, for example, a respirologist working with another specialist such as an endocrinologist. Using the term interdisciplinary in reference to health professions education would be confusing to those accustomed to this understanding of the term. The term interprofessional has become the customary way to define health profession education involving many professional schools by those writing internationally (Gilbert, 2005).
This study will use the term interprofessional as it clearly describes the environment of students from different professions and is the current term used by those most familiar with the field of research. It will avoid confusion and debate surrounding the term interdisciplinary.
Definition of other terms used in literature reviews:
Multidisciplinary: students from different disciplines learn the same subject at the same time, then share the information with each other (Gilbert, 2005; McCallin, 2001).
Multiprofessional learning - “describes any occasion when members of 2 or more professions learn side by side (Mattick & Bligh, 2003, p. 1008)”.
Barriers to IPE
“Changing a college curriculum is like moving a graveyard - you never know how many friends the dead have until you try to move them” (variously attributed to Calvin Cooledge or Woodrow Wilson as cited in Gilbert, 2005).
Numerous studies (Hammick et al, 2007, Kipp et al, 2007, Hall, 2005, Gilbert, 2005, Pullon & Fry, 2005) have suggested reasons for the lack of implementation, or lack of success of existing interprofessional programs in health care education. In a best evidence systematic review of interprofessional education, Hammick et al (2007) reviewed 21 studies published between 1981 and 2005, divided between Europe and North America. Their findings revealed that formal IPE could be restricted by factors such as space, timetabling of curriculum and held up by a lack of administrative support. In the studies reviewed, funding was not mentioned as a barrier but 13 studies did acknowledge they received funding from external sources (Hammick et al, 2007). Another finding from Hammick et al's (2007) review was that undergraduates have prior perceptions and attitudes to IPE and collaborative work. These perceptions are formed by a combination of factors including gender, age, and prior work experience (Hammick et al, 2007).
Some of the barriers to interprofessional education (IPE) are generic and would be present regardless of context or human resources. These barriers include attitudes and cultural aspects. This points to a need to recognize the range of interprofessional education understanding that everyone involved in the education of health professionals have their own objectives and priorities which results in different approaches and perspectives.
There are many and varied articles of literature on the effects of attitude in attempts to promote and develop interprofessional education and collaboration (Mattick & Bligh, 2003; Gilbert, 2005; Bassoff, 1983; Buck, 1999; Mu, 2004) pertaining to both faculty and students.
Within a post secondary institution, there are instructors who have been educated in close disciplinary bounds and display attitudes that do not always correspond with an interprofessional view. When a broad perspective is missing from the students' education, the effects are unfortunate for attempts at IPE. Despite well-intended efforts to educate students in the principles of interprofessional collaborative care, when students leave for clinical education, the practitioners by whom they are mentored are frequently unaware of the potential for understanding and working with other health care professionals. This lack of awareness then reinforces stereotypes. Stereotyping during professional education is a major barrier that both campus-based education and clinical education will need to address with new and innovative approaches, including educating the educators about the most effective ways to implement and practice IPE.
Stereotyping by students of one discipline, about the other has been well documented in the literature (Parsell & Bligh, 1998; Tunstall-Pedoe, 2003). Authors have argued for interprofessional education to occur in the undergraduate setting to prevent stereotyping from developing. The Tunstall-Pedoe study showed that “students arrive to start their training with stereotyped views of each other already firmly established (2003, p. 170)”.
Harden (1998) noted that if the goal of IPE is to teach collaborative practice, then, the content must be on interprofessional knowledge, skills and attitudes. He maintains that one must not confuse teaching profession specific content with the primary goals of collaborative practice. For example, health professional students may be brought together to study about asthma management, but unless they are learning “how to work together” in the management of asthma they will be learning in parallel. This is a classic example of multi-professional learning. When students use a topic, like asthma management, as a way to learn how to work in collaboration with one another, they are engaged in interprofessional learning. The primary goal of IPE is therefore to develop students who have the knowledge, skills and attitudes to become collaborative practitioners who work together in an effective collaborative fashion (Harden, 1998).
Culture is defined as “the knowledge, values, customs, attitudes, language and strategies that enable individuals and groups to adapt and survive in their environment” (Egbo, 2009, p.3). Each health care profession has a different culture, including values, beliefs, attitudes, and behaviours. This culture is passed on to the learners in the profession (Hall, 2005).
Hall (2005) defines the knowledge base underlying a particular profession as its “cognitive map”. This map represents the standard and theoretical methods used by a profession and includes its basic concepts, modes of inquiry, problem definitions, observational categories, types of explanation, and general ideas of what represents a profession. In addition to cognitive maps, different professions have differing normative maps (Hall, 2005). These are similar to cognitive maps, and include basic values, modes of moral reasoning, and methods of resolving ethical dilemmas.
The gaining of cognitive and normative maps is learned by the process of professional socialization. Becoming a health care professional means acquiring the particular traditions, customs, and practices; knowledge, beliefs, morals, and rules of conduct; and linguistic and symbolic forms of communication and the meanings they share that are associated with the practice of that particular profession (Clark, 2006). If members of an interprofessional team do not have a basic understanding of the cognitive and normative maps of other professions, then they may look at the same thing but not see the same thing.
Faculty development barriers
Although there was only one article that specifically addressed faculty development for IPE (Steinert, 2005), a number of authors did highlight the need for faculty development in this area (Freeth et al, 2003; Jeffries, 2005). There is a need to provide teachers, in both the clinical and the classroom setting, with the knowledge, skills and attitudes to foster IPE. In particular, training faculty for interprofessional education needs to focus on a change in attitudes, increased understanding of the roles and responsibilities of other health care professionals and skill acquisition in the areas being taught to students (Jeffries, 2005).
As Parsell and Bligh (1998, p. ) have noted, we must “develop a context in which learning together becomes a vital part of working together”.
A major barrier to the integration of IPE in health care is the use of a multitude of descriptions to define this pedagogy of practice. In education, the language used by health professions regarding the same procedure, operation and method of treatment delivery is quite different at a number of points. Each academic discipline tends to use its own jargon. Language difficulties are compounded by the academic fact that “interprofessional” is now routinely applied to learning and research activities that are not interprofessional in their intent. For example, interdisciplinary work can be conducted within one department, interprofessional work cannot (Parsell, Spalding & Bligh, 1998; gilbert, 2005)
Health care programs are strongly influenced by barriers created by external agencies. The majority of health faculties are members of professional associations that have a long history. Professional associations seek autonomy and respect for their members, which can establish barriers against acknowledging the full place of other health care workers and the skills that they bring with them. An examination of the scopes and standards of practice and competencies claimed by professions is evidence of this point (Gilbert, 2005; CRNBC, 2009; CSRT, n.d.).
Professional associations are the authority of whether interprofessional education move forward as these associations establish the criteria for practice within a particular profession. They develop guidelines for curriculum and the amount of contact that students will have with patients prior to graduation. They establish the ethical boundaries of their members and are instrumental in developing the set of competencies for practice. Curricular guidelines are almost always established in collaboration with post-secondary institutions (CSRT, n.d.). If a list of disciplinary competencies is large, then the time spent to establish IPE in the curriculum may be small or nonexistent (Gilbert, 2005). Because of this low level of professional support for interprofessional experiences, professional associations in conjunction with the academic institutions may be seen as a barrier to the development of good pedagogic practice in IPE.
The number of curriculum barriers within and across the post-secondary and clinical education systems are enormous. The amount of time spent on developing and delivering curricula, and the associated costs, indicate that the curriculum is a massive economic endeavour. The curricular implications of IPE do not seem to be fully understood with respect to Full time Equivalent (FTE) costs, curriculum development and evaluation tools (Gilbert, 2005; Oandasan & Reeves, 2005b; Paylor, 2008). Whichever way it is viewed, developing and delivering an interprofessional curriculum is expensive. When individual disciplinary programs are asked to consider either implementing a part of an interprofessional curriculum or contributing to it either through faculty support or by curricular materials, barriers become evident. Examples of these barriers include how to appropriately recognize faculty participation within departments and faculties, and how to reward faculty through merit review, promotion, and tenure. Finally, for students, curriculum changes that include IPE must be seen as part of the evaluation and assessment of student learning within the curriculum of a discipline, otherwise IPE has no currency and no uptake. There is also an expense to incorporating the evaluation into the curriculum. (gilbert, 2005)
Best Evidence of IPE
There have been several systematic reviews of the outcomes of IPE however, there is little indication about the types of pedagogy utilized and their effectiveness (Payer et al, 2008).
Several reviews of IPE have been carried out over recent years. Zwarenstein et al. (2000) in their review from 1999 (updated in 2000) concluded that in a search yielding over 1000 studies, none convincingly showed an impact of IPE on professional practice or healthcare outcomes. The review, however, was limited to randomized trials, controlled before and after studies, and interrupted time-series studies of IPE interventions. The interventions were designed to improve collaborative practice between health and social care practitioners, yet no simulation was used as an intervention (Reeves, 2008). Outcomes included objectively measured or self-reported patient/client outcomes and healthcare process measures (Zwarenstein et al, 2000). Four of the six studies that met study criteria indicated that IPE produced positive outcomes in Emergency departments culture and patient satisfaction; collaborative team behaviour and reduced clinical error rates. Two of the six reported mixed outcomes and two studies reported that IPE interventions had no impact on professional practice or patient care (Reeves, 2008).
Cooper et al (2001) reviewed 30 studies of the effectiveness of undergraduate IPE. Again, none of the studies involved simulation. They concluded that although the students benefited, there was little evidence of any impact on professional practice. Cooper (2001) summarized that educational and psychological theories were rarely used to guide the development of the educational interventions.
There is significant interest in research on IPE because there is a belief that it can promote teamwork and collaboration, which in turn will hopefully lead to better patient care. There seems to be little evidence existing to date that supports this belief. (mattick & bligh, 2003) The need for more and better quality research into IPE becomes increasingly important as more resources become available to academic and health care organizations for such learning. (mattick & bligh, 2003)
Gaps in the research (incorporate into Best evidence section)
The major gap in the current body of literature on interprofessional education in the health professions is that the articles are not research based. The majority of the writings are descriptive reporting of programs, the majority of those originating from England and Canada. Research-based articles that were found focused primarily on structural issues like schedules, faculty incentives and administrative support.
Interprofessional education (IPE) seems to be facing two opposing dilemmas. On one side there are increasing calls for expanding teamwork training in the health professions in order to address problems facing health care systems (Barr et al., 2005). On the other side, much of the IPE literature is descriptive and provides little in the way of clear or theory-driven guidance that is essential for growth to occur (Barr et al, 2005). (clark, 2006)
One might assume that IPE does improve health care by improving collaboration between the health professions, but the evidence that has been gathered to support this position is limited (Zwarenstein et al, 2000; Mattick & Bligh, 2003). The gathering of this evidence will require a long term research effort. IPE is bound to affect knowledge and skills as well as attitudes, but it is the latter that are considered the most difficult to affect, which may add to their interest for assessing outcomes. (goelen et al, 2006)
There is some evidence that training programs can improve team performance and lead to improved patient outcomes (Zwarnstein et al, 2000). Interventions to improve teamwork should be based on a thorough understanding of how teams function. A systematic review in the Cochrane database (Zwarenstein et al, 2000) concluded that randomized trials or forms of controlled before-and-after studies to evaluate interventions aimed at improvement of interprofessional teamwork are usually of limited value, and suggest that qualitative study in this area should be carried out before any further quantitative work is done.(weller et al, 2008)
Hall (2005) advances the notion that interprofessional learning models have shown that positive attitudes between professions can be fostered, but only when these interventions are provided early in the professional's education. She notes that this serves to build bridges between the learners before the walls of their barriers become so thick and high that reaching across the professions becomes too difficult. The gap in the interprofessional education literature is clearly around explaining the successful ways to teach interprofessional team skills and documenting outcomes of these lessons. Theories and barriers are repeatedly described, but demonstrated steps toward success are rarely published. (kipp et al, 2007)
However, published reports of interprofessional education in North America and elsewhere have mainly described or evaluated single courses or short-term programs (Gilbert et al, 2000; Horsburgh et al, 2001; other resources that fall into this category ), rather than an entire initiative devoted to fostering interprofessional education, research and practice as a core competency for health professionals. (Philippon et al, 2005)
If you are the original writer of this essay and no longer wish to have the essay published on the UK Essays website then please click on the link below to request removal:
More from UK Essays
- Free Essays Index - Return to the FREE Essays Index
- More Nursing Essays - More Free Nursing Essays (submitted by students)
- Example Nursing Essays - See examples of Nursing Essays (written by our in-house experts)
Need help with your essay?
We offer a bespoke essay writing service and can produce an essay to your exact requirements, written by one of our expert academic writing team. Simply click on the button below to order your essay, you will see an instant price based on your specific needs before the order is processed: