Interprofessional Education,Collaborative Practice and Primary Care

The rationale for interprofessional education

Increasingly, people are living longer which may lead to health needs that cannot be met by any single profession. As a result, a plethora of health and social care professionals may be involved in the care of each person. If these professionals work independently of each other, the quality and continuity of care experienced by a patient can be affected, in some cases with tragic consequences (Laming, 2003). Interprofessional education (IPE) has been identified as providing professional groups with the opportunity to learn about the roles, responsibilities and skills of other professionals involved in health and social care. The underpinning belief is that by learning and training together, professionals will be more likely to understand each other's perspectives, values and skills, which will lead to increased collaborative practice and improvements in team and patient care (Barr and Waterton, 1996), preventing further tragedies as well as meeting new government policies (Department of Health, 2000). IPE is therefore not exclusive to undergraduate learning, being considered a key feature of continuing professional development.

Defining IPE

There has been, and perhaps still is, confusion about the definition of IPE. Frequently, this is because words such as multiprofessional, interdisciplinary, interprofessional and intraprofessional are used interchangeably. We now generally accept that these words mean different things; for example, ‘multidisciplinary’ is used to describe activities where individuals from two or more professions learn side by side but not in a collaborative manner, and ‘interdisciplinary’ relates to the specialities (for example, surgery, medicine, general practice) within a single professional group. Even with this clarification, there is still no single definition of IPE: for example, Reeves et al. (2008) suggest that an IPE intervention ‘occurs when members of more than one health and/or social care profession learn interactively together, for the explicit purpose of improving interprofessional collaboration and/or the health/wellbeing of patients/clients’.

The Centre for the Advancement of Interprofessional Education (CAIPE) provides a slightly different definition of IPE as ‘occurring when two or more professions learn with, from and about each other to improve collaboration and the quality of care’. This definition allows for inclusion of those professionals not usually included in a health and social care profession—for example, professionals involved in education and law—who may be involved in meeting patient/service user needs.

Importantly, both definitions offer the idea that IPE should be an interactive form of learning. Many professionals can learn with (alongside) each other—for example, different professional groups may share a lecture theatre to complete some ‘common’ or ‘shared’ areas of learning — but learning from each other suggests that learning is a two-way interactive process. Learning about each other implies that it is more than just learning about each other's roles and goes further to include responsibilities, cultures, values and beliefs. By going this bit further, a deeper understanding of, and respect for, different professions can be achieved. Such learning has been associated with better patient care (Rubenstein et al., 1984), increased patient satisfaction (Mickan, 2005), increased job satisfaction (Howie et al., 1992) and cost-effective care (Harris et al., 2003).

General practice and IPE

IPE is not a new concept within primary health care, with evidence of interprofessional activity and learning in the 1960s. Barr (2009) suggests that this is because the multidisciplinary context of health and social care professionals working in community settings provides a medium for improving collaboration and improving patient outcomes.

The primary health care team (PHCT) has long been considered a key aspect of general practice with GPs, practice nurses, receptionists and administrators making up the core part of the team. In reality, though, GPs are expected to and do work within a much larger team. Over time, with changes in government and consequently policy, the PHCT has become larger and more diverse as the need to communicate and work with professionals from education, local authorities, secondary care sectors, primary care trusts and complementary therapists has become the norm. Working and communicating effectively and efficiently with such a wide range of professionals scattered across a wide geographical area is very challenging. Effective training through IPE may foster teams which are able to optimize the skills of each profession and which have the ability to share case management in order to provide better health services to patients and the local community (World Health Organization (WHO), 2010).

The RCGP and teamwork in primary health care

While the number of professions GPs have contact with increases, some of that contact may be sporadic and infrequent, given that it depends entirely on individual patient needs. The forum on team working in primary health care (RCGP, 2000) ‘examined the practical aspects of team working in primary health care’ in order to suggest ways in which national organizations could ‘support and promote’ the concept of team working. It suggested that primary health care teams tend to be ‘dynamic’ rather than ‘static’ and identified that effective teamwork is most likely to occur where ‘each team member's role is seen as essential, roles are rewarding and there are clear team goals’ (Box 1).

The forum recommended that undergraduate and postgraduate training and educational opportunities should facilitate interprofessional collaboration as well as understanding and recognition that team working is a skill that needs to be taught. Education on team working would, however, require extra resources to ensure the ‘most effective use of professionals in primary health care'.

IPE, collaborative practice and team working

We have already suggested that working in teams is, or needs to be, an important aspect of delivering care in primary care. There are key factors that promote team working (Box 2).

Many of these factors are dependent on education—for example, shared learning processes, understanding and recognizing each other's roles and skills, communication, knowing how to identify clear goals as a team. Some are more difficult—for example, finding enough time and resources and keeping the team size manageable. If we accept that the PHCT is dynamic, and therefore frequently changing, it could be argued that IPE offers an opportunity to develop effective team working. Learning interactively with and about other professions during undergraduate training will equip students with a basic understanding of a wide variety of professionals' roles and responsibilities; professionals with whom they may work at some point in their careers.

When medical students and other health professional students are attached to general practices, both GP tutors and GP registrars should ensure that the students recognize the teamwork taking place in the practice and are familiar with the communications processes between the various health professionals. Practice settings need to embrace and model interprofessional collaborative practice if students are to be able to see theory in practice. Continuing professional development within primary care offers the opportunity to develop interprofessional activities aimed at increasing collaboration, communication and coordination. Providing uniprofessional activities is unlikely to improve outcomes (Nahrwold, 2005), while collaborative approaches can result in change and innovation. In this way, IPE at undergraduate level has the potential to produce a ‘collaborative practice ready workforce’ (WHO, 2010), where professionals are skilled and able to work together in teams at the point of qualification; at postgraduate level there is the opportunity to reinforce prior learning and instigate change. There should also be interprofessional learning activities during the protected time for education that is enjoyed by general practice staff.

Collaborative practice can overcome the fragmentation in the current health system so that GPs and GP registrars are able to work effectively with the wide range of professionals involved in delivering health and social care.

Is team working the same as collaborative practice?

Team working is a key element of collaboration but collaboration is more than just team working. Team working can consist of cooperative behaviour, where each team member performs his or her own task in developing high-quality patient care. Collaborative working can be viewed as bringing together the knowledge, experience and skills of multiple team members to contribute in developing high-quality patient care (Jackson and Bluteau, 2009).

A collaborative workforce is one where providing care for patients does not just involve a referral from one service to another but where care is delivered with a sense of shared responsibility, with some level of concurrent treatment and where professionals view patients as ‘ours’ not ‘mine’ (Simon, 1998). It works best when it is organized around the needs of the population being served and takes into account the way in which local health care is delivered involving ‘a collaborative practice-ready health workforce, poised to take on complex or emergent problems and solve them together’ (WHO, 2010).

Making time and space to facilitate learning within practice settings at both undergraduate and postgraduate levels is valuable and offers the opportunity to encourage collaboration enhancing a shared vision using the team's combined skills and perspectives to improve patient care. D'Eon (2005) suggests that there are five elements crucial to successful collaborative working (Box 3).

Using a case-based approach has been shown to encourage focused discussion on realistic patient-centred problems that are familiar to most participants and provide a common ground, which encourages flattening of traditional hierarchies.

Barriers to IPE

The recommendations of the Royal College of General Practitioners link well with the aims of IPE but the barriers to IPE are many. Teamwork does not necessarily occur because professionals are working alongside each other (RCGP, 2000). Teamwork is a skill and needs to be learned. Teamwork is an essential component of collaborative practice. The barriers to team working are similar to those in IPE. Bringing together professionals with historical differences in culture, status and power leads to tensions which can result in ‘increased defensiveness when situations demand team work’ (Nolan, 1995). Perceived threats from the integration of different professional groups can result in tribalism (Pirrie, 1999). Elston and Holloway (2001) found that conflict during education and training of practice nurses, GP and practice managers related in part to each profession's interpretation of collaboration. Nurses welcomed the blurring of boundaries, doctors feared it and practice managers took a wider view. However, it may be that these interpretations are influenced by the differing levels of accountability and professional regulations, which are also known to act as barriers. Differences in language, jargon, schedules and professional routines are just a few other barriers and these are before considering the challenges associated with the physical environment, time and human resources. Such challenges serve to hinder the implementation of IPE and subsequent collaborative practice.

Finding evidence to support IPE

Systematic reviews of the few robust studies show that IPE and collaboration lead to improvements in a wide variety of areas as well as optimizing health services (Table 1). IPE, especially within practice, is viewed as a positive learning experience by some students and facilitators (Harris et al., 2003) and collaborative practice achieves changes in professional behaviour and organizational practice.

Classification and principles of effective IPE

In 2005, based on findings from a systematic review, Barr et al. suggested that IPE appears to focus on three areas of which the last two are more likely to occur after qualification and are therefore of more relevance to GP registrars (Box 4).

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Table 1.

Improvements associated with collaboration

Topics	Authors
Patient care and satisfaction	Mickan (2005), Harris et al. (2003)
Treatment	Schmitt (2001)
Access to, and coordination of, health services	Lemieux-Charles et al. (2006)
Health outcomes and strengthening of health system	Department of Health (2001), Reeves et al. (2008), Hammick et al. (2007)

Facilitating IPE

Facilitating interprofessional learning is an important aspect of IPE, both at undergraduate and at postgraduate level (Marshall and Gordon, 2010). Training facilitators to support IPE have been shown to be key to success—poor facilitation of IPE activities can result in confirmation of stereotypes (Newell Jones, 2008).

IPE, general practice and the future

Currently, the strategic health authorities and primary care trusts are responsible for workforce development, which includes education and training. GP practices have great involvement with the education and training of professions in the medical field but less so with nursing and allied health professions. It is possible, however, that with the changes proposed in the white paper ‘Equity and Excellence’ GP consortia will find themselves faced with deciding how best to meet the needs of local communities within tight financial constraints.

Perhaps it is timely for professionals working in the community to review the barriers to IPE and to consider how these might be managed. The diverse lines of management, organizational structure, size and location of teams might be redesigned through collaborative teamwork. While status, gender and personality may always remain issues within teams, interprofessional learning has been shown to lessen these and empower lower status professions. These changes may present an opportunity for community-based professionals to collaborate and consider whether IPE will help primary health care teams communicate and collaborate to work effectively to deliver high-quality cost-effective and efficient care to their local communities. Inviting practitioners who generally sit outside of the core team into practice meetings may be one step to forging shared understanding of differing roles and responsibilities, which will encourage more seamless working with each other and most importantly the patient and the patient representative. Alternatively, practice meetings could incorporate interprofessional learning activities, for example, learning about common conditions from different professionals' viewpoints (e.g. leg ulcers, childhood illnesses) and/or significant event analysis.