Health Services Executive

1. Health Services Executive Interprofessional Learning Master Class 20th June 2012 Helena Low

2. Health Services Executive CAIPE Interprofessional Learning Master Class Learning Together to Work Together, Working Together to Learn together’ The foundations for collaborative Care Helena Low Vice Chair Centre for the Advancement of Interprofessional Education

3. Themes and Questions What is interprofessional collaborative practice / interprofessional collaborative care - what do we actually mean when we use these terms? What difference does it make? Why the global emphasis on it? What are the competencies required? Why do we need interprofessional learning to develop collaborative practice ? What do we mean by interprofessional education? Why is it essential for professional education?

4. Aims of the Master class Foster a greater and shared understanding of what collaborative care means and what is involved within the Irish context Generate interest and engagement in interprofessional learning for collaborative practice Encourage you to consider practical application in the workplace Encourage you to identify further areas of interest in relation to taking forward collaborative initiatives

5. Interprofessional learning and collaborative practice in the context of global health International / global trends Economic factors – limited Resources Modernisation Ageing population Integration, Collaboration, Decentralisation Service User focus Community participation Emphasis on patient safety H. Low

6. Drivers of change • resource constraints • Rising cost of care, Increasing demand, diminishing resources • demography • Ageing population, Movement of people • technological advances • More people surviving defects, Illness, disease, accidents • consumer expectations • more informed recipients of care. • loss of confidence in professionals • Medical errors, lack of communication between professionals

7. Global picture Modernisation essential to deal with: • inequalities in access to health and care, • growing pressures of chronic non communicable illnesses • services for the vulnerable, older people and children suffering • Issues around patient safety Health systems worldwide are struggling with: • increasingly complex and costly challenges, • ever more demands on health workers • patients needs have become more complex and more - challenging.

8. ‘In a world of radically increased interdependence, health nearly everywhere is being shaped by the same powerful forces, like demographic ageing, rapid urbanization, and the globalization of unhealthy lifestyles.’ Dr Margaret Chan Director-General WHO 2012

9. The impact of globalisation - the international movement of professionals and professional knowledge and the resulting cross cultural transition of ideas are all manifestations of the global interdependence in health and education. Lancet Commission (2010)

10. World Health Reports A series of reports produced regularly by the World Health Organization (WHO). Published annually or biennially in multiple languages, Each report includes an expert assessment of a specific global health topic, relating to all countries that are Member States of the organization. Learning Together to Work Together for Health. World Health Organisation (1988) Report of a WHO Study Group on Multiprofessional Education for Health Personnel. The Team Approach Technical Report Series 769. Geneva: WHO

11. World Health Report ‘Working Together for Health’ WHO (2006)

12. WHO significant Reports World Health Report (2006) ‘Working Together for Health’ Highlighted a "global health workforce crisis". an estimated shortage of almost 4.3 million doctors, nurses, midwives, and other health human resources worldwide. World Health Report (2008) Primary Health Care (Now more than ever)’ ‘Now, more than ever, the health of people worldwide depends on health professionals working together across the boundaries of disciplines, professions and conventions’ Framework for Action on Interprofessional Education & Collaborative Practice (2010)– Report to the WHO The WHO and its partners acknowledge that there is sufficient evidence to indicate that effective interprofessional education enables effective collaborative practice.’

13. In response to these challenges: • In countries across the world government policies on workforce development have focused on the need for - collaborative frameworks for education and practice; - integrated approaches to care; - co-operation, - working across professional and organisational boundaries • Internationally, IPE and collaborative practice are seen as potential strategies to mitigate global health workforce crisis • An effective, interagency, interprofessional workforce is seen as critical for the health and welfare of future generations.

14. Impact of this approach • Modernisation is about looking at the workforce in a different way, as teams of people rather than as different professional ‘tribes’ • Global modernising politics reshaping healthcare relationships • Health and social care professions are faced with substantial changes in the pattern of their relationships.

15. Response to the Challenges by Governments around the world Some examples • United Kingdom • Canada • Japan • Australasia

16. In Ireland ? ‘Our Health services are facing challenges on a scale never experienced before’ ‘ Programme of reform • Universal health insurance • Community based services through a primary care setting • New models of care • National Clinical Care Programmes designed and implemented by clinically led multidisciplinary teams • Emphasis on standards and patient safety • greater flexibilities in work practices and rosters to achieve more efficient delivery of services ‘Implementation of the National Clinical programmes is driving a re engineering of traditional models of care and of service delivery’’ ‘All of these are being designed and implemented by clinically led multidisciplinary teams.’ HSE Report 2011

17. Health systems • are social institutions. Properly managed and adequately funded, a well-functioning health system contributes to social cohesion and stability. • In a world beset by one global crisis after another, social cohesion and stability are prized assets. • Health systems are highly context-specific. Dr Margaret Chan Director-General WHO 2012

18. Interprofessional Learning and Collaborative Practice

19. No one profession can respond adequately to the multiplicity of problems that many patients present, be they children at risk, alienated young people, members of dysfunctional families, chronically sick and disabled people living longer, or amongst the growing number of old people surviving to an advanced age. H. Low

20. Patient Safety Inquiries into medical errors, e.g. the United States (Institute of Medicine, 2001) and the United Kingdom (Kennedy, 2001), have attributed failure to problematic communications and relationships between professions (Meads & Ashcroft, 2005). WHO (2011) Patient Safety Curriculum Guide: Multi-professional Edition For the past three years, the World Health Organization has been exploring the links between education and health practice – between the education of the healthcare workforce and the safety of the health system. As an outcome, it has developed this multi-professional Patient Safety Curriculum Guide, which addresses a variety of ideas and methods for teaching and assessing patient safety more effectively.

21. Modernisation is about cultural change • Professionshave to work in a different way – and make collaboration a normal part of professional practice. • Collaboration is easy to say, but working together with other professions, new partners and in different ways is not easy. H. Low

22. Collaboration complex process with multiple components • can be a process, product or both connecting, cooperating, consulting, - encompasses: coordinating, co-locating, community building and contracting. - Is more than the sum of its parts H.Lawson (2004)

23. Connections for Collaboration Policy makers International, national, regional and local government Health & Care Services based on people’s needs Health & Care Employers / managers new organisations and agencies Independent sector Health & Care Professions new roles, new occupations, new professions Communities Voluntary organisations Service users and carers Academic institutions Higher & Further education new partnerships

24. Patient Voices Why Collaborate? A Video

25. The Lancet Commission Report – Health professional for a new century: transforming education to strengthen health systems in an interdependent world (2010) Increasingly interdependent in terms of key health resources, especially skilled workers’ ‘imperative to align professional competencies to changing contexts’

26. What are the competences of interprofessional learning and working • ‘soft skills’ and complex achievements • social practices that are highly context dependent, • team working, • developing supportive relationships, • reflection and self awareness, • working across boundaries, • communication, • interpersonal skills Mix of dispositions, understandings, attributes and practices

27. Competencies for Interprofessional Collaborative practice CUILU (2006) Interprofessional capability framework. Sheffield: The Combined Universities Interprofessional Learning Unit. Interprofessional Education Collaborative Expert Panel (2011) Core competencies for interprofessional collaborative practice: report of an expert panel. Washington D.C.: Interprofessional collaborative Canadian Interprofessional Health Collaborative. A national competency framework for interprofessional collaboration.www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf ‘Core Competencies for Interprofessional Care’ in Healthforce Ontario (2010) Implementing Interprofessional Care in Ontario: Final Report of the Interprofessional Care Strategic Implementation Committee. Ontario

28. Why do we need inter-professional education • Learning for working across professional, organisational and agency boundaries, together, is essential • ‘Inter-professional working must be grounded in inter-professional learning’John Horder 2005 • A flexible collaborative ready workforce is dependent on the way in which professionals are educated Lancet Commission 2010 H. Low

29. Interprofessional education • ‘Occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care’ (CAIPE 2002) • Principles • CAIPE commends a number of principles, drawn from the experience of its members and the interprofessional literature. These highlight the: values • process and • outcomes • deemed essential for effective interprofessional learning and working (CAIPE 2011)

30. The Evidence Base? • Patients report higher levels of satisfaction, better acceptance of care and improved health outcomes following treatment by a collaborative team. • There is now sufficient evidence to indicate that interprofessional education enables effective collaborative practice which in turn optimizes health services, strengthens health systems and improves health outcomes.World Health Organisation 2010

31. Hammick et al (2007) 21 studies discussed of the 399 reviewed (UK 11, USA 7, Canada 1, Finland 1, Sweden 1) 15 of the studies (72%) considered undergraduate IPE. All peer reviewed papers and reports, quantitative and qualitative approaches included Considered the following outcomes of learning: learners reactions; changes in skills, knowledge, perceptions of and attitude to others; changes in behaviour as well as impact on service users

32. Findings • Competent facilitation of IPE essential • Learner reaction to IPE is related to multiple factors • IPE needs to reflect appropriate and relevant service delivery settings • Principles of adult learning are key • IPE generally well received and enables learning of the knowledge & skills for collaborative working • In the context of quality improvement initiatives IPE frequently used to enhance development of practice & improvement of services

33. Cochrane Systematic Review (Reeves et al 2009) • Six studies met the inclusion criteria (small but first IPE review in 2000 found none) • 4 RCTs and 2 Controlled Before and After (CBA) Studies • Five studies conducted in the US, one in the UK • All studies undertaken with groups of qualified staff in established teams eg A&E, PHC

34. Findings • Four of the studies indicated that IPE produced positive outcomes in the following areas: • emergency dept culture and pt satisfaction; • collaborative team behaviour & reduction of clinical error rates in emergency dept teams; • management of care to domestic violence victims; • mental health practitioner competencies related to the delivery of patient care • Two studies reported mixed outcomes (positive and neutral) • Two studies reported that IPE had no impact on either professional practice or patient care

35. Outcomes, Effectiveness & Evaluation Outcomes: what you intend to achieve by the end of the Project Effectiveness: the extent to which your outcomes have been achieved Evaluation: process of looking at the evidence / data, to determine whether something has made a difference, ie; to measure any changes that have occurred from the initial situation.

36. Outcomes of Interprofessional Education • Reaction Learners’ view on the learning experience and its interprofessional nature • Modifications of attitudes / perceptions Changes in reciprocal attitudes or perceptions between participant groups. Changes in perception or attitude towards the value and/or use of team approaches to caring for specific client group • Acquisition of knowledge / skills Including knowledge and skills linked to interprofessional collaboration

37. Outcomes of Interprofessional Education • Behavioural Change Identifies individuals’ transfer of interprofessional learning to their practice setting and changed professional practice • Change in organisational practice Wider changes in the organisation and delivery of care • Benefits to patients / clients Improvements in health or well being of patients and carers Freeth et al 2003 (modified from Kirkpatrick 1967

38. Move towards competency based professional education – outcomes expressed as competences • contemporary professional education has adjusted and changed to meet workforce requirements; • so interprofessional education has been seen as necessary to equip professionals for multi dimensional collaboration • Standards and outcomes set by regulatory body and others eg, national occupational standards • Different types, different level. • Common, complementary and collaborative competences

39. Professionalism • Initial growth of professionalism mid 19th Century • Uni professional education, • By mid 20th Century professions being challenged • Attempts to bring health and social care professions in general and medicine in particular under greater control • Growing concerns about public safety and professional powers in light of, e.g. tragedies of Bristol Royal Infirmary events and Victoria Climbie • Reform of Professional Regulatory bodies • Establishment of Council for Healthcare Regulatory Excellence

40. Lancet commission Report (2010) Idea of professions and professionalism beginning to change New professions emerging Attempts to break down the barriers between professions Move towards interprofessional practice and interprofessionalism Need for reforms guided by transformative learning and interdependence Competency-based education transprofessional teamwork that includes non-professional health workers

41. Challenges for IPE in professional education • Professional socialization • Professional culture • Professional language / jargon • Organizational difficulties • Lack of service support • Lack of equality and reciprocity

42. Challenges for IPE in Professional Education • Different educational and social backgrounds • Fear of dilution of professional role / loss of professional identity • Separate professional education – stereotyping • Perceived different status and power • Poor communication • Poor facilitation of IPL Professionalism - key element in agendas related to interprofessional education in the UK

43. Professions as regulatory bodies assume different degrees of significance in different societies These set the parameters at national international level for the operation of specific professions, including in education. Opportunities for creating interprofessional education for practice are not just shaped by the educational institutions concerned and employer partners, but also by professional bodies.

44. Challenges re the practicalities Fitting IPE into a full curriculum – issues of ‘add on’ / integration Timetabling and logistics Resistance from colleagues and students Hierarchies between professions Silos and territorialism in universities and in practice Lack of support from professional organisations Poor communication systems

45. Interprofessional learning and working • Works to improve the quality of care • Focuses on the needs of service users and carers • Encourages professions to learn with, from and about each other • Respects the integrity and contribution of each profession • Enhances practice within professions H. Low

46. Benefits of Inter-professional Learning and Working Shifts focus from professional roles to patient needs Implicitly builds inter-professional team learning/working Demonstrates the power of sharing knowledge and experience It fosters innovation and capacity for change H. Low

47. Interprofessional Education • Applies principles of Adult Learning • Is practice led • Includes common and comparative learning • Is interactive • Involves service users • Is competency based • Is assessed • Improves practice • Is evaluated

48. Facilitating Interprofessional Learning Evidence indicates that the success of interprofessional learning is dependent to a significant extent on the effectiveness of those who facilitate it, at every level.

49. Facilitation of interprofessional learning Individuals may be experienced clinicians, practitioners and / or educationalists, but may lack the particular knowledge, skills and confidence to facilitate learning with groups of people from diverse professional backgrounds Even very experienced teachers find the challenges of multi professional teaching difficult to manage. Preparation is crucial Facilitation of interprofessional learning requires a level of expertise which builds on but extends beyond the range of knowledge, skills and attitudes required for uni professional teaching.

50. Facilitators of interprofessional learning of multi professional groups must: • Have the ability to discern and address a range of complex issues, such as different professional cultures. perceived power and status of different professions and professional language. • They must also have the sensitivity required to work across professional and organisational barriers to achieve change.