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Mar 12, 2018 - wileyonlinelibrary.com/journal/eje. Eur J Dent Educ. 2018;22(Suppl. .... as a part of students' clinical experience.5,6 The American Dental. Education Association (ADEA) reported substantial progress by. U.S. dental schools in ...
Accepted: 12 March 2018 DOI: 10.1111/eje.12341

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Interprofessional education in dental education: An international perspective J. M. Davis1 | J. Janczukowicz2 | J. Stewart3 | B. Quinn4 | C. A. Feldman5 1

Missouri School of Dentistry and Oral Health, A.T. Still University, St. Louis, MO, USA

2

Centre for Medical Education, Medical University of Lodz, Lodz, Poland 3

American Dental Education Association, Washington, DC, USA

4

King’s College London Dental Institute, Guy’s Hospital, London, UK 5

School of Dental Medicine, Rutgers, The State University of New Jersey, Newark, NJ, USA Correspondence Joan M. Davis, Missouri School of Dentistry and Oral Health, A.T. Still University, St. Louis, MO, USA. Email: [email protected]

Abstract Interprofessional collaborative care (IPC) is defined as working within and across healthcare disciplines and is considered essential to achieve a more inclusive, patient-­ centred care, provide a means to support patient safety and address global healthcare provider shortages. Interprofessional education (IPE) provides the knowledge and experience students need to achieve these goals. ADEE/ADEA held a joint international meeting 8-­9 May 2017, with IPE being one of four topic areas discussed. The highly interactive workshop format, where “everyone was an expert,” supported discussion, sharing and creative problem-­solving of over seventy-­one participants from twenty-­nine countries. IPE participants broke out into five groups over a two-­day period discussing three main areas: challenges and barriers to implementing IPE within their institution or country; discussion of successful models of introducing and assessing IPE initiatives, and exploring best practices and next steps for implementation for each group member. A mind-­mapping model was used to graphically display participants’ thoughts and suggestions. Key themes, revealed through the visual mind maps and discussion, included the following: IPE should lead to and enhance patient-­centred care; student involvement is key to IPE success; faculty development and incentives can facilitate adoption and implementation of IPE; the role of a “champion” and leadership structure and commitment is important to move IPE forward; and IPE must be tailored to the unique issues found in each country. Overall, there was a high level of interest to continue both collaboration and discussion to learn from others beyond the London meeting. KEYWORDS

dental education, international, interprofessional collaborative care, interprofessional education

1 | OV E RV I E W

practice allows for optimisation of expertise, resulting in anticipated cost savings, increased access to care and fewer patients “falling

Interprofessional collaborative practice (IPC) is widely viewed as an

through the cracks” as a result of numerous referrals.

essential paradigm shift needed in health care to improve patient and

For more than forty years, healthcare educators have explored

population health outcomes, achieve reduced healthcare costs and

interprofessional education (IPE) as a means of achieving a collabo-

address global workforce challenges.1-3 An interprofessional team

rative workforce. The importance of moving from practising in iso-

approach is needed when providing comprehensive care for patients

lation to a team approach was recognised early on. The Institute of

experiencing chronic diseases such as diabetes, coronary heart

Medicine (IOM) 1972 report, Educating for the Health Team, stated

disease and chronic obstructive pulmonary disease. Collaborative

“[we will] begin to explore together the ways in which health care

10  |  © 2018 John Wiley & Sons A/S. wileyonlinelibrary.com/journal/eje Published by John Wiley & Sons Ltd

Eur J Dent Educ. 2018;22(Suppl. 1):10–16.

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DAVIS et al.

teamwork might be taught.”.4(p8) The World Health Organization’s

to address the often-­cited barriers of scheduling issues, space and

(WHO) 2010 Framework for Action on Interprofessional Education and

workforce requirements at all levels, none of which could be real-

Collaborative Practice provides clear IPE guidelines and strategies

ised without vision and commitment from the highest level of the

on how to implement interprofessional collaboration on educator,

administration.

curricular, management, and policy levels, leading to a “practice-­ ready health workforce”. 2(p7) The WHO’s Framework defined IPE as occurring when “students from two or more professions who

1.1.2 | Actively engaged students

learn about, from, and with each other to enable effective collab-

Health care and social service students need to be actively engaged

oration and improve health outcomes” and IPC as “multiple when

with students from other disciplines, not only didactically but also

health workers from different professional backgrounds who work

clinically, to provide integrated, patient-­centred care experience.13,14

together with patients, families, carers and communities to deliver

Enlisting student input and involvement early in the planning and

the highest quality of care.”. 2(p7) Collaborative care in action could be

throughout the implementation phase not only supports buy-­in but

as basic as a discussion between a physician and pharmacist over

also enthusiastic participation. Collaborative care activities can en-

a contraindication of a medication, or as complex as an oncology

able students to develop communication and leadership skills as well

team composed of medical, nursing, dental, nutrition, social work,

as create self-­awareness on how various disciplines fit into overall

pharmacy and mental health professionals creating a comprehen-

patient-­centred care. Both inter (within the same field)-­and intra

sive, long-­term treatment plan for a patient recently diagnosed with

(outside the field)collaborative clinical care and public health activi-

oral pharyngeal cancer.

ties should start very early in the undergraduate sequence and be

Educators have made varying levels of progress towards adopting IPE, ranging from shared basic science courses to cre-

woven throughout the all phases of training, culminating in formally assessed clinical competencies.

ating collaborative patient or community healthcare experiences as a part of students’ clinical experience. 5,6 The American Dental Education Association (ADEA) reported substantial progress by

1.1.3 | Interdisciplinary competencies

U.S. dental schools in offering IPE experiences. Researchers in-

In healthcare education, competencies drive curriculum develop-

dicated that over 61% of responding dental schools required ac-

ment, mapping and assessment at all levels. The inclusion of in-

7

tual IPE activities. When surveyed, dental faculty and students

terprofessional competencies at both the didactic, clinical and

often report a positive attitude towards IPE, but go on to share the

community service levels is of the highest importance if students

need for authentic experiences; constructive, faculty-­led clinical

are to be prepared for collaborative practice upon graduation. In

environments; and important small group work. 8,9 In a recent sur-

2011, and later in a 2016 update, the Interprofessional Education

vey of Canadian undergraduate medical schools, both faculty and

Collaborative, composed of educators from dental, medical, nursing,

students reported interest in moving forward with the integration

pharmacy and public health fields, published the Core Competencies

of IPE into medical education.10 Unfortunately, as with many IPE

for Interprofessional Collaborative Practice.15,16 The IPEC core compe-

studies, the Canadian respondents reported implementation bar-

tencies are composed of four subcompetencies: values/ethics; roles/

riers including issues with scheduling and funding limitations for

responsibilities; interprofessional communication; and team and

actual implementation. Although healthcare educators affirm the

teamwork. These provide educators with an essential framework to

value of collaborative care, the complexity of integrating multi-

navigate IPE adoption and implementation.

ple disciplines across multiple units continues to be daunting for many.

In a series of IPE Guides, the Association for Medical Education in Europe (AMEE) has provided resources to inform the development of interprofessional education with discussions of educational

1.1 | Lessons learned 1.1.1 | Strong administrative support

theories, elements of learning and other educational concepts that may assist educators in the development of IPE curriculum.14,17 These and other resources provide a wealth of inspirational, theoretical and practical information from which educators can learn

Strong and sustained commitment from institutional administrators

and which they can use in the development of their interprofessional

at a systems level is essential.6,11,12 The visionary leadership of deans,

curriculum.

chairs and program directors is needed to facilitate policy and curricular and scheduling changes. An exemplary model of institutional commitment in action is the unique partnership between the New

1.1.4 | Rigorous IPE/IPC research

York University’s Dental and Nursing Schools.13 Deans, associate

Initially, IPE/IPC research focused on student/faculty perceptions

deans, directors and key members from both schools created several

and satisfaction with IPE experiences, which supported collabora-

organisational structures, including a joint administrative leadership

tive skills and were generally well received by learners.18 Over time,

team and an office of interprofessional education, and the joint

administrators started to ask—given the large investment of time,

development of an IPE strategic plan. This required a commitment

resources and effort to implement IPE—whether it actually improves

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DAVIS et al.

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patient outcomes. In 2015, the IOM published a committee report: Measuring the Impact of Interprofessional Education on Collaborative

2.2 | Pre-­conference survey

Practice and Patient Outcomes. The Committee found that “In light

A total of 60 participants were emailed a short online survey

of these, the committee found it necessary to highlight four areas

designed to assess their level of interest, expertise and expecta-

that, if addressed, would lay a strong foundation for evaluating the

tions for the IPE workshop. The results were then used to inform

impact of IPE on collaborative practice and patient, population, and

the focus and direction of the two-­day IPE workshop format and

system outcomes: (1) more closely aligning the education and health

process.

care delivery systems, (2) developing a conceptual framework for measuring the impact of IPE, (3) strengthening the evidence base for IPE, and (4) linking IPE with changes in collaborative behavior.”.19(p3)

2.3 | Online digital abstracts and posters

Establishing collaborative care as an evidence-­based model of pa-

To support additional participation, poster submissions were sought,

tient care provides a foundation for Institutions to dedicate the

twenty to thirty per stream, with the intent of broadening the dis-

needed resources to implement IPE and overcome implementation

cussion and reach of information for both those in attendance and

barriers.

interested parties unable to attend. An online poster presentation format was used, and these submissions were not physically dis-

1.2 | An international perspective After more than forty years of discussions, reports, research and model IPE programs highlighted, the integration of team-­based care

played during the conference.

2.4 | Workshop format

on a universal scale has yet to be realised. Educational and health-

The IPE workshop format was designed to be highly interactive

care institutions continue to struggle with the common barriers of

where “everyone was an expert.” The intent was to support dis-

scheduling, funding and the tendency of people to drift back into a

cussion, sharing and creative problem-­solving. IPE participants

discipline-­centric patient care model. Worldwide, the principles of

broke out into five groups over a two-­d ay period, discussing three

IPE and IPC are reported as being valued but are at varying levels

main areas: challenges and barriers to implementing IPE within

of adoption and implementation. This report provides a glimpse into

their institution or country; discussion of successful models of

two days of discussions by seventy-­one participants from twenty-­

introducing and assessing IPE initiatives; and exploring best prac-

nine different countries sharing best practices, learning from each

tices and next steps for implementation for each group member.

other, and brings home ideas on how to be a part of the IPE/IPC

A mind-­m apping model was used to graphically display partici-

paradigm shift in health care.

pants’ thoughts and suggestions using white paper and markers. Each discussion group reported out to the whole IPE group at the

2 |  M E TH O DS/ WO R K S H O P 2.1 | Areas of focus

completion of three discussion sessions. The IPE Chair shared key IPE themes with all conference members at the end of each day. Workshop discussions were encouraged via breaks and working lunches.

Although there have been numerous IPE conferences, papers and

Multiple qualitative artefacts were employed to identify IPE

resources generated over the past 20 years, to our knowledge, this

themes generated during all aspects of the conference. These

was the first international oral health educators’ workshop designed

artefacts include notes taken during group discussions, post-­its,

to bring together a wide-­range of experiences, best practices and

whiteboards, chair report-­ o uts with power points and poster

implementation strategies.

abstracts.

IPE Workshop Goals: • Discuss challenges and barriers to implementing IPE around the world • Learn about successful models for introducing and assessing IPE programs • Describe best practices and next steps for implementation

3 | R E S U LT S/ WO R K S H O P O U TCO M E S A N D TH E M E S 3.1 | Pre-­conference survey Of the sixty pre-­conference surveys emailed to the IPE registrants, thirty-­four responded for a return rate of 57%. When asked to rank

The IPE organisational or workgroup members included a chair, two

in order of importance what they would like to see as a part of the

facilitators and two rapporteurs. Pre-­conference, the workgroup

workshop (1 being the highest, 5 being the lowest), most respond-

reviewed existing IPE and IPC literature in order to identify key

ents indicated an interest in a “Presentation of best practices/

documents that were then emailed to all registered IPE conference

lessons learned from around the world” and least interest in “A

participants. This list can be found with a (*) in the REFERENCE list

literature review/annotated bibliography on the workshop topic.”

at the end of this article.

(see Figure 1).

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DAVIS et al.

F I G U R E   1   IPE participants (n 21) Pre-­Conference Survey Question 5: Please rank in order of importance what you would like to see as a part of the workshop (1 being the highest) [Colour figure can be viewed at wileyonlinelibrary. com]

3.2 | IPE abstracts overview The conference posters are displayed electronically and can be found at http://www.adee.org/meetings/london2017/poster.php

3.3 | IPE workshop themes There were 71 participants from 29 countries participating in the IPE workshop. The qualitative data are presented on three levels: (i) Conference topics, (ii) Major themes, and (iii) Subthemes based on all identified artefacts (see Figures 2-4 for a sampling of artefacts).

3.3.1 | Specific barriers and challenges to IPE (Day One) Administrative issues

F I G U R E   2   End of day one: identification of barriers and challenges to IPE [Colour figure can be viewed at wileyonlinelibrary. com]

a. The lack of upper administrative support; resources are not dedicated to IPE b. Lack of programmatic administrative support and faculty incen-

e. IPE is often classroom lectures or is combined with other healthcare students and lacks any clinical application

tives are barriers c. Administration, faculty and staff must understand, value, sup-

Faculty issues

port and be involved with IPE; otherwise, the initiative will not work.

a. Faculty often lacks IPC training and experience to teach or assess IPE b. Faculty attitudes can be a barrier; resistance to change; biases

Curriculum challenges and concerns

and stereotypes of other professions; lack of interest c. Poor faculty-to-faculty communication or interprofessional culture

a. IPE lacks credibility, must demonstrate that it is evidenced-based; needs more research

Practical challenges

b. IPE must be patient-centred or it misses the reason for doing interprofessional care c. Students focus on practising technical skills rather than “soft skills” such as communication skills; they have limited interest in IPE because it is not formally assessed d. Assessments that do not include the patient’s perspective will miss the key rationale for IPC

a. Different professional programs’ schedules, academic calendars can conflict with each other; scheduling can be very complex b. In smaller institutions, there may be a lack of natural collaboration partners c. Having shared curriculum and competencies inter- and intraprofessional

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DAVIS et al.

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3.3.2 | Defining the future and exploring best practices (Day 2, morning) Key IPE principles a. Learning how to effectively listen and communicate is key to the

b. IPE should lead to and enhance patient-centred care c. Student involvement is an important element in the adoption of IPE d. IPE must be integrated into all levels of didactic, patient assessment and clinical care; all levels of IPE must be formally assessed

success of IPE and IPC

Key IPE components a. Faculty development and incentives can facilitate adoption and implementation of IPE b. The support and leadership of Deans and Chairs can facilitate adoption and implementation of IPE c. There needs to be a “Champion” to move IPE through the school and system d. There needs to be a way to connect and learn best practices from others around the globe

Compelling reasons to support IPE and IPC a. Increases patient’s safety, outcomes and satisfaction due to patient-centred care b. The focus is on medically and socially compromised patients c. Increases student and faculty communication skills, professionalism and job satisfaction d. Increases knowledge, skills and attitudes

3.3.3 | Strategies for adoption and implementation (Day 2, afternoon) Best practices F I G U R E   3   End of day two: IPE implementation strategies [Colour figure can be viewed at wileyonlinelibrary.com]

a. Upper and middle administration need to demonstrate commitment through faculty development and needed resources

F I G U R E   4   Final IPE mind-­map [Colour figure can be viewed at wileyonlinelibrary.com]

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DAVIS et al.

b. Provide IPE faculty development (professionalism, communication, intercultural skills), resources and incentives c. Include IPE activity in the annual appraisal of faculty for tenure and promotion d. Identify and support the IPE “Champion” within the educational system

The governance and organisational structure of academic institutions, including dental schools, and the governance and organisational structures of health delivery systems will also have a large impact on how a school implements IPE. Much discussion focused on the expectation that the leadership and implementation of IPE in systems where various professionals are under one reporting struc-

e. IPE should be integrated throughout the educational experi-

ture will likely be easier than in an environment where the health de-

ence from classroom to clinical experience to externship; as-

livery organisation and the academic institutions are under different

sessment should be based on knowledge, communication skills

governance and organisational structures.

and patient outcomes f. Involve patients and students in all aspects of IPE development, implementation and evaluation; patient-based learning

Schools represented were at dramatically different stages of implementation. Several had well-­developed programs but others were at the beginning stages of implementation. For those just beginning,

g. Start with small, simple steps (as you build capacity for change)

starting small will enable success to be more easily achieved. Learning

h. Share positive IPE experiences with students, faculty and the

from programs which are more developed can save missteps. Programs

administration; inspire and lead by example

can then be built upon others’ failures and successes. Barriers and

i. Utilise existing online IPE/IPC resources and conference meetings

challenges abound, but there are ways to overcome these challenges

j. Develop shared curriculum and competencies across all profes-

with a clear articulated message describing the benefits of IPP, a strong

sions; focus on effective implementation k. Promote IPE/IPC research

central commitment to IPE, strong central leadership, passionate local champions and a culture of ownership and accountability. Many delegates reported that their institutions had been talking

Examples of cooperation

about IPE for several years, yet had made limited progress in implementing programs which enable students to get hands-­on experi-

a. Partnerships within the European Union and other governing or

ence. For those beginning this journey, there is often no incentive to

association bodies; working towards including IPE into accredi-

engage in IPE and no penalty for not engaging. Assembling a com-

tation standards

mitted and passionate team is therefore critical to success. Thus, del-

b. Inter- and intra-institutional instructor (and student) exchanges

egates agreed to a call for action—let’s stop talking about doing IPE

c. Involvement of all healthcare professions in school committee

and let’s begin to move forward with implementing IPE.

meetings; developing a culture of cooperation and communities of practice

In designing IPE programs, consider starting with health programmes which value IPP and IPE and later expand to those which are somewhat resistant. Cases to illustrate the need for and ben-

4 | D I S CU S S I O N , CO N C LU S I O N S A N D N E X T S TE P S

efit of IPP should be developed involving all professionals to be involved in the IPE program. Consideration in case development must be given to the types of practitioners and their scope of practice, particularly when designing cases involving the health-­related

As a result of our discussions, there were several key themes which

professions and various types of nurses, therapists and assistants.

emerged.

This will ensure engagement by all students, highlighting that a

Optimising patient health and patient satisfaction is the goal to be

team maximums[?] the quality of care and patient satisfaction and

achieved. Whilst IPE is what many educators focus on, IPE is only im-

outcomes. Involve students in planning and [?]wide stakeholder in-

portant because interprofessional practice (IPP) is considered by most

volvement, including consultation with students. Do not forget that

health systems to be the best way to provide the best quality care at

patient wellness is driven not just by medical and dental services

the least cost with the highest patient satisfaction. If IPP was not a

received but by considering social determinants and technological

goal, there would be no reason for IPE. As a result, as IPE programs are

advancements also. So when developing interprofessional teams, re-

developed, the goal of IPP must be kept in mind.

member that non-­healthcare workers—such as social workers, urban

Different health systems will implement IPP differently; thus, IPE

planners, teachers, clergy, lawyers, community workers, computer

will look different and will be implemented differently. For example,

scientists and engineers—could also be included, providing a very

IPE in countries with a private health system will need to teach about

rich and engaging experience.

incentive systems and payment mechanisms to incentivise healthcare

The need to provide patient-­centred care, improve patient safety

providers to work in collaborative teams. In such a system, the educa-

and address healthcare shortages is shared concerns worldwide.

tional programmes must teach about the incentive and payment sys-

Interprofessional education and interprofessional care have been

tems and the ways in which social workers, healthcare coordinators

promoted as a meaningful way to address these issues. IPE has been

and others can help with collaboration and communication activities. In

adopted by educators with varying degrees of implementation and

public systems, efforts will need to be made to ensure that incentives

success. The ADEE/ADEA joint meeting provided a place to bring to-

align with public system values to emphasise public health outcomes.

gether oral health faculty from around the globe to share, discuss and

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DAVIS et al.

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create meaningful connections with educators, generate best practices

KE Y IPE/IPC ARTICLE S SENT TO THE IPE

and look towards the future of interprofessional education and care.

PA R T I C I PA N T S P R E - ­C O N F E R E N C E

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WHO. Framework for Action on Interprofessional Education & Collaborative Practice. Geneva: World Health Organization; 2010. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: National Academic Press; 2003. Institute of Medicine. Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes. Washington, DC: National Academic Press; 2015. Reeves S, Fletcher S, Barr H, et al. A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39. Med Teach. 2016;38:656‐668. Reeves S, Tassone M, Parker K, Wagner SJ, Simmons B. Interprofessional education: an overview of key developments in the past three decades. Work. 2012;41:233‐245. Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: A Report of an Expert Panel. Washington, DC: Interprofessional Education Collaborative; 2011. https://ipecollaborative.org/uploads/IPEC-Core-Competencies. pdf Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: 2016 Update. Washington, DC: Interprofessional Education Collaborative; 2016. https://ipecollaborative.org/uploads/IPEC-2016-Updated-Core-CompetenciesReport__final_release.pdf El-Awaisi A, Wilby KJ, Wilbur K, El Hajj MS, Awaisu A, Paravattil B. A Middle Eastern journey of integrating interprofessional education into the healthcare system: a SWOC analysis. BMC Med Educ. 2017;17:1‐10. Palatta A, Cook B, Anderson EL, Valachovic RW. 20 years beyond the crossroads: the path to interprofessional education at U.S. dental schools. J Dent Educ. 2015;79:982‐996. Buring SM, Bhushan A, Brazeau G, Conway S, Hansen L, Westberg S. Keys to successful implementation of interprofessional education: learning, location, faculty development, and curricular themes. Am J Pharm Educ. 2009;73:1‐11.

KE Y IPE/IPC RESOURCES Center for the Advancement of Interprofessional Education (CAIPE). https://www.caipe.org Center for Interprofessional Education (University of Toronto). http:// www.ipe.utoronto.ca Interprofessional Education Collaborative: Connecting health professions for better health (IPEC). https://ipecollaborative.org National Center for Interprofessional Practice and Education (Nexis). https://nexusipe.org Journal of Interprofessional Education and Practice—Elsevier

How to cite this article: Davis JM, Janczukowicz J, Stewart J, Quinn B, Feldman CA. Interprofessional education in dental education: An international perspective. Eur J Dent Educ. 2018;22(Suppl. 1):10‐16. https://doi.org/10.1111/eje.12341