Abstract
The author created a new course, called “Seminar in Public Health Law and Policy in an Interprofessional Setting” to address the need for interprofessional education (IPE) to equip graduate and professional students for collaborative practice at the systemic and policy (i.e., macro”) levels in the health care and public health fields. Despite important work being done at the clinical practice level, limited existing IPE models examine larger systemic issues. The course is designed specifically to enable students in social work, law, and public health to recognize the reciprocal relationships between policy and interprofessional collaborative practice, including the need for understanding of the impact of team-practice work at the system and policy levels.
Course Design
In 2014, the Robert Wood Johnson Foundation and Georgia State University launched The Future of Public Health Law Education faculty fellowship program with the goal of creating innovative opportunities for interprofessional training in the field of public health law. 1 As a fellow in this program, I developed a new course, called “Seminar in Public Health Law and Policy in an Interprofessional Setting.” The course included students from the professions of law, social work, and public health at the graduate level. I offered it as a pilot course for the first time in the spring semester 2015.
The course was created to address the need for interprofessional education (IPE) to equip graduate and professional students for collaborative practice at the systemic and policy (i.e., “macro”) levels in the health care and public health fields. To train students for doing effective policy work in these fields, IPE will need broad involvement across multiple professions, including those outside the usual IPE clinical practice settings (e.g., medicine, nursing, allied health sciences). Despite important IPE work being done at the clinical practice level, 2 limited existing IPE models examine larger systemic issues. The course is designed specifically to enable students in social work, law, and public health to recognize the reciprocal relationships between policy and interprofessional collaborative practice, including the need for understanding of the impact of team-practice work at the system and policy levels. This course is the first step in a longitudinal process to clarify the specific competencies needed to equip students as practice leaders who are able, upon graduation, to identify and address policies and organizational structures to support interprofessional practice in health care and public health settings.
Student Learning Objectives
As outlined in the syllabus, 3 this interdisciplinary course was designed to help develop professionals who can: (1) understand and analyze public health law and regulations as appropriate to the discipline; (2) work as a part of a collaborative team of public health, social work, and legal professionals to analyze different options for action; and (3) learn from a team of public health, social work, and legal professionals to better understand social determinants of health in order to advocate for clients and for more effective public health policies. Developing the teamwork skills for effective interprofessional collaboration was a primary focus of this course.
Students were assessed for baseline public health and law knowledge, but coverage of subject matter content was generally driven by the particular substantive information the students would need to perform the work that they would be doing for two community organizations in the public health law field during the semester. The course was designed to provide the skills needed to work in interprofessional teams to ensure that the work for these two experiential-learning sites benefited from all the different disciplinary backgrounds and perspectives of the professional students involved in the work, rather than be dominated by a uniprofessional framework with the different professional students' work cobbled together at the end of the project in the final paper.
Group Projects
The two community agencies for the pilot course were the Indiana Health Advocacy Coalition (IHAC) 4 and the Riley Child Development Center (RCDC). 5 IHAC is a non-profit organization which seeks to reduce the negative effects of the social and economic determinants of health by supporting organizations, such as interprofessional medical-legal partnerships (MLPs), which work to address unmet legal and social needs that can adversely impact people's health. RCDC is a federally funded Leadership Education in Neurodevelopmental Disabilities (LEND) program. RCDC trains 17 different disciplines in an interprofessional manner and works to create leaders in the field of neurodevelopmental disabilities.
The students in this course worked on specific policy-based questions for these organizations. For IHAC, the two teams of students worked on two specific questions. The first group examined current legislation regarding MLP in Georgia and New York. They provided a comparative analysis of enabling legislation in those two states and discussed the process each state used to get the legislation passed. That team then analyzed the political landscape in Indiana and provided recommendations for IHAC to consider as its leaders discussed potential legislation regarding MLP implementation in Indiana. The second team researched possible reimbursement avenues for the work of MLPs in Indiana. They examined what other states have successfully achieved to ensure financial stability for MLPs and made recommendations for consideration by IHAC.
For RCDC, a team of students examined possible funding mechanisms for coverage of Applied Behavioral Analysis (ABA) for children with autism in Indiana. Students reviewed current coverage options available in Indiana, then did a national search for other state programs providing coverage for these services. The students ultimately provided the organization with an issue brief entitled “Rethinking Indiana's financial reimbursement for Autism Spectrum Disorder under Medicaid as mandated by Centers for Medicare & Medicaid Services.” The issue brief was designed to be used with those who may be in the policy field, but not necessarily well versed in the needs of those with autism. It provided information on the current services for children with autism covered by public and private insurance in Indiana, the mandate from the federal government, a description of model programming in two other states, and brief information on advocacy methods effective for influencing policy.
All three teams of students worked in interprofessional groups at the experiential-learning sites to apply the skills from the classroom setting. In addition to the final product delivered to the agencies, the students had the opportunity to create posters representing their work for presentation at a statewide conference. They also presented the findings of their projects to the board of directors for IHAC and to the leadership team at RCDC. The different audiences and methods of presenting their work provided students with multiple experiences to negotiate how their teams would perform in different settings.
Student Assessment
Because the focus of the course was on developing interprofessional teamwork skills, assessment was different than it would have been if learning the substantive content were the primary goal. Students were assessed using reflection papers, concept mapping assignments, 6 in-class discussion, and a final product deliverable for their agency. There are few tools specifically designed to measure the interprofessional competencies that were targeted in this course. It is the goal of the research described below to create an assessment tool specifically for this purpose to use in future iterations of this course.
Benefits
For Students
The students reported benefits primarily relating to working with students from other professions. Following the final project and grades, one student said that it had been a favorite course she had taken because it allowed her to put her skills to work on real-world issues. The same student reported that she enjoyed working on the team in this course because they concentrated on communication and consensus building, rather than each person on the team doing their own work then putting it together at the last minute.
There were three dual-degree students in the course: two students were earning a master's degree in public health (M.P.H.) and master's degree in social work (M.S.W.), and one was pursuing a law degree (J.D.) and M.P.H. One of the M.P.H./M.S.W. students reported that before this course she had seen the two degrees as separate. She said that the course helped her blend the two degrees. The same student reported that this was her best group project experience, due largely to the course's focus on developing effective interprofessional teamwork skills.
One of the law students observed that she believed law students often saw themselves as the hardest working professionals and at the top of the social hierarchy among the professions. She said that she had no idea prior to this class what social workers did, particularly in the policy arena. She also said that not only had she learned a lot about the expertise and perspectives that social workers can bring to the policy table and that she would be incorporating their insights in her work, but also she had brought these perspectives back to other students in her law classes.
For the Home Institution
Indiana University has been moving towards integrating interprofessional education into the health curriculum. It has shown a strong support to this movement by funding a Center on Interprofessional Health Education and Practice. Originally including the professions of medicine, nursing, dentistry, social work, and allied health, this movement has been expanded to include public health professionals. The law school has also begun working with these efforts. A group of lawyers who work both in the law school and throughout campus met and discussed ways for law to participate in these IPE efforts. These legal academics will become more involved in initiatives as appropriate. The new course has been a positive way to show the institution that law and public health professionals are key collaborators in this work in addition to other efforts across campus.
For the Public Health Law Community
The agencies with which the students worked reported positive results from the students. For example, IHAC representatives asked one of the student groups to serve as resources for the organization based on the high quality of their work. The board recognized the importance of the diverse backgrounds of the inter-professional group. The students in the course all reported feeling that they learned skills in collaborative teamwork which would allow them to create better policies once they leave the academy.
Opportunities and Challenges
Getting the schools of law, social work, and public health all to allow the course for their students was a new process, as the course was the first on our campus that would be offered to students in all three schools on an interprofessional basis. The school of social work course-approval process was made more difficult with the curriculum tracks that the school offers. The school offers five tracks, which are areas of concentration for students. Each track has its own course requirements. For three of the five tracks, students must take a very specific set of classes, with no room for elective classes of their own choosing. Due to the absence of electives for these students, though the faculty approved the new course, it was available only to the health and leadership track students, who have electives available.
It was more difficult to get the course approved at the law school. We ultimately got it approved as a two-credit-hour course. The number of minutes required for a credit hour at the law school was different than at the social work and public health schools. The course ended up being a three-credit-hour course for social work and public health students and a two-credit-hours course for the law students. The course itself was very work intensive, particularly because of the group projects for the community agencies. Law students typically have only a final exam at the end of the semester, with some classes having a midterm, unless it is specifically a writing class. This course, with ongoing writing assignments and weekly field work, is a different type of course for the law students. The law students particularly discussed the amount of work feeling quite heavy compared to other two-hour law courses. In the future it will be important to figure out a way to ensure that the workload is commensurate with the credit hours for each of the professional schools, particularly law.
The public health school allowed its students to register in the social work course and count it towards the M.P.H. degree, thanks to the guidance of one of the mentors in the faculty fellowship program who works in that school. Preexisting relationships with faculty and administration at each of the schools was helpful with expediting the process.
Community Opportunities and Challenges
It was important to find community agencies that had genuine organizational system or policy issues they wanted to have addressed. The two organizations chosen were a good fit for a couple of reasons. First, they were agencies with whom I had previously worked, and I had good working relationships with the student contacts there. For a pilot program and all the work involved, it was important to have good communication with the sites, and currently existing relationships with the sites facilitated our communication. Second, both sites already had an interprofessional focus.
Though we worked hard to ensure the topics and deliverables were well defined before the start of the semester, in the next iteration, we will ensure additional clarity. A question arose for some student groups about who the audience would be for their deliverables. For some it was to be the agency itself. For others, the agency hoped to use the students' work product with outside parties. I had not thoroughly vetted this question prior to assignment to the students groups and was left wishing that I had done so. It is particularly important that the projects be well defined so that the students are able to do this work in the time provided.
Other Opportunities and Challenges
Despite its strong conceptual support for interprofessional education, the university system can create administrative or logistical barriers or disincentives to actually implementing interprofessional courses. For example, the flow of tuition dollars from student enrollment may be an impediment for some schools. At our university, the tuition from the students goes to the school in which the student registers. However, the school where the professor has the appointment pays the salary of the faculty member who teaches the course. It was clear that to resolve this potential problem and to get the new course approved, the support of the faculty dean in the school of social work (where I have my primary appointment) was crucial. If he had been less supportive, it would have been difficult to gain cross-school acceptance. In the future, it may be necessary to work with the schools either to provide for co-teaching with faculty members from each of the schools so that one faculty member does not have the whole course responsibility, or to provide for each school with registering students to assist in the cost of offering the course.
Meeting promotion and tenure standards can pose challenges for faculty members who want to teach or write on an interprofessional basis. Though the academy generally supports the idea of interprofessional work, and in fact Indiana University has IPE as a key part of its strategic plan, many schools' or departments' promotion and tenure guidelines within the university may reflect a preference for single-authored scholarship in the schools' particular disciplinary fields. If the schools do not “count” interprofessional work for promotion and tenure purposes, many junior faculty on the tenure track will be left to decide between single-discipline work and interprofessional work.
Lessons Learned
Each student has different needs, styles, and strengths. In future offerings of this course, I plan to give a questionnaire or request a writing sample that is less about content knowledge and more about working styles and skill level prior to the assignments of teams. It is important to ensure that the groups have a mix of stronger students and those who need more assistance in each group. When working with community agencies, it is important that the final product (here white papers and issues briefs) be something of benefit to them. We want to ensure continued positive relationships with the community. When there is not a balance of strengths and backgrounds within each team, it is possible to end up with some excellent projects and some which are not as strong. Additionally, along with discussion of interprofessional collaboration skills, I would like to spend more time on developing conflict resolution skills. Though we discussed managing conflict during our class, I received feedback that for some teams, more time spent on this topic would have been beneficial.
Lastly, I believe it will be important to give attention to the balance between lecture time in the classroom and time for students to work on their group projects for their community agencies. I had packed the syllabus with content I believed would be useful to the students, and I had planned to do at least half of each class period on the topics I had chosen. I heard early on from students that, while they needed some of this content, they also wanted to be able to drive the content by asking for lectures on issues as they arose at the experiential-learning sites. In the future, I will continue to include important content on interprofessional collaborative teamwork, but I will leave more room for both group work and open topic time where content can be driven by student questions.
Impact
On Students
Student reflections provided a good source of information regarding the impact of this course on their learning.
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An MSW student spoke specifically to the interprofessional aspects of the course, saying: Although I believe that a uniprofessional team of social workers could have completed this project and created a quality product, working as an interprofessional team has been invaluable. [The law student's] legal skills have been invaluable as we have analyzed the legislation from other states, and [the public health student's] public health education has provided a unique perspective to the team. I think our product is better because it was completed by an interprofessional team.
A good illustration of the impact of the course on students happened at one team's final presentation to the board of directors of their agency. The students were able to present a professional and thought-provoking set of facts and recommendations. The students answered the board's questions in a thorough and positive way. At the end of the presentation, I asked the students to talk about what it was like to learn in an interprofessional manner. The students each spoke about how important the learning had been. The law student discussed specifically how she had spoken with other law students about what she had learned, not in terms of content, but in terms of inter-professional process. The social work students talked about how empowering it had been to be able to share expertise within their purview, and also what they had learned about law and public health. The professionals in the room expressed strong interest in the inter-professional process. I was amazed. I wanted to take that group of students around our campus to demonstrate how IPE should be the way of the future! This course has affirmed my hypothesis that interprofessional work could truly benefit the policy process.
At the end of the presentation, I asked the students to talk about what it was like to learn in an interprofessional manner. The students each spoke about how important the learning had been. The law student discussed specifically how she had spoken with other law students about what she had learned, not in terms of content, but in terms of interprofessional process. The social work students talked about how empowering it had been to be able to share expertise within their purview, and also what they had learned about law and public health. The professionals in the room expressed strong interest in the interprofessional process. I was amazed. I wanted to take that group of students around our campus to demonstrate how IPE should be the way of the future! This course has affirmed my hypothesis that interprofessional work could truly benefit the policy process.
Institutional Impact
In addition to the classroom impact, this course will have an impact on interprofessional learning and scholarship at the macro level. I applied for and received a curriculum enhancement grant from the university for 2015-2016. This grant provides me with release time and technical support to use the information received from students during the course to provide in-depth analysis of their learning in the course. The grant includes the provision that I write an article regarding this research. The university's process for approval for human-subjects research from its Institutional Review Board has been completed, and a qualitative analysis of concept maps and reflection papers is underway. The information will be used both to add to the scholarship of teaching and learning and to inform the creation of a framework for working in interprofessional teams to create public health policy.
Reflections on Personal Impact
This year was challenging and thought-provoking. One of the most important things for me was that I was able to truly integrate my social work frameworks, methods, and skills to the benefit of a public health law course. It has been fantastic to be accepted to this fellowship program as a social work faculty member. Though I have a law background and have been teaching in the law school longer than at the school of social work, it was daunting to be the only fellow in the fellowship program without a primary faculty appointment in a school of law or public health.
It was interesting to see that the other disciplines in the course and in the community agencies, particularly the legal professionals, articulated the usefulness of the social work professional background. Social workers are trained in systems theory with a person-in-environment perspective. This means that social workers highlight “the importance of understanding an individual and individual behavior in light of the environmental contexts in which that person lives and acts.” 8 Additionally, social workers are trained in executive leadership, including leading groups. One legal professional, after the student presentation, said that he was amazed that the social work students mentioned having specific coursework in collaboration and group dynamics. He said that having worked in the MLP field, he could see how beneficial that could be.
Course Follow Up and Future Planning
The pilot course is in the process of a funded in-depth evaluation. The course will be offered again in the spring of 2016, using any lessons learned from the pilot course to inform the teaching and content from the initial evaluation.
I will be using my work from this course in two distinct ways. One will be the scholarship of teaching and learning. I will be working on the course evaluation with the goal of publishing at least one article to guide others wanting to do similar work. The other goal will be to use what was learned while teaching this course to help develop a framework for thinking about interprofessional work with public health systems and policies. We have competencies developed for interprofessional work at the clinical level, 9 and I would like to examine the similarities and differences when working at the macro (policy or systemic) level.
Anyone wanting to design a similar course in the future should work to ensure that the community experiential-learning sites are prepared to work with the students. In the future, I will work to provide more frequent interaction with the agencies. It is important both from the perspective of providing more guidance and of providing students the opportunity to interact more with the community.
I will also explore co-teaching this class in the future. If we expect students and future professionals to work as collaborative teams, we, as faculty, should model these behaviors. Team teaching is time consuming when done well, but it is anticipated that the results will be worth the effort.
I would encourage anyone who is interested in interprofessional engagement in public health law to design a course in this field, using mine or others fellows' projects described in this supplement issue of JLME as guides. Our collective experiences mean that others teaching in the field do not have to reinvent the wheel. Public health is inherently a multifaceted profession. Public health law should be no exception. This faculty fellowship program provided the mechanism for a strong set of model programs to help those wanting to begin this work. The experience for me has been well worth it both personally and as a faculty member who enjoys seeing students excel.