Interprofessional learning--the solution to collaborative practice in primary care: when health professionals from different disciplines truly understand each other's roles, responsibilities and challenges--through interprofessional education--the the potential of genuine teamwork can be fully realised.

"The combined skills of a nurse and a doctor together create a team much more than the sum of its parts". (1)

Worldwide, there are increasing options available at postgraduate level for health professionals to undertake interprofessional education. Interprofessional education provides a route to improved interdisciplinary health professional teamwork; (2) an imperative of all health and social services. (3)

New Zealand authorities, such as the Ministry of Health (4) and District Health Boards New Zealand (DHBNZ) (5,6) endorse the value of teamwork both to improve the quality of care through complementary disciplinary skills and to ensure supportive workplaces. Despite this apparent support, opportunities to undertake interprofessional education are limited. Where they exist, however, they are well accepted and commended by students and teachers alike.

This article outlines the basis of interprofessional education, its relationship to interdisciplinary teamwork in primary health care (PHC) clinical practice and describes a New Zealand model of postgraudate interprofessional education. It identifies barriers to the implementation of interprofessional education, as well as possible solutions.

Interprofessional education is when two or more health or social service professionals learn with, from and about each other (2); or a group of students from different health-related occupations with different educational backgrounds, learning together, with interaction as an important goat. (7) It is education which uses interactive learnings and puts a premium on innovative approaches. (3) Interprofessional education is not different disciplines sitting together, passively listening to the same lecture or listening to a lecturer of a different discipline than the students. (9) Neither is it professionals learning alongside each other but not discussing roles, contributions or disciplinary perspectives. (10)

Interprofessional education differs from other forms of learning because, although the focus is still on content, there is another level of learning about professional roles and interactions. As well as focusing on subject matter (generally clinical), students are challenged to critique traditional role definitions. Because of the dual focus, interprofessional education increases the complexity of the learning activity and outcome.

In comparison, uniprofessional learning involves one discipline and is predominantly content or subject based, with little or no emphasis on interactive learning. Neither of these are to be confused with multiprofessional learning, which involves members of more than one discipline, but disciplinary contributions, similarities and differences are seldom discussed.

Ongoing learning opportunities currently offered for qualified health professionals fall along a continuum: the majority are uniprofessional (eg continuing medical or nursing); some are multi-professional (eg continuing professional development); but very few are interprofessional (eg structured inter-professional postgraduate courses, courses where interdisciplinary practice is integral to practice eg palliative care). Effective teamwork in clinical practice leads to continuity of care, the capacity to take a comprehensive view of patients' problems, the availability of a range of skills, synergistic working between providers via mutual support and reciprocal education, higher productivity, innovation because of cross fertilisation of approaches and skills, and finally it prevents professional isolation. (11,12,13)

But teamwork in clinical practice does not always work. A recent Health and Disability Commissioner's report highlighted poor inter-professional communication noting "team work is critical" (14) with an expert witness saying "it is likely that communication problems are systemwise and not confined to doctors and nurses ..." (14) One study found one third of nurses unable to speak up in an interdisciplinary forum when they found a patient problem. (15)

So, why does poor teamwork occur when all disciplines have the best intentions at heart? Hall and Weaver describe how health professionals enter health care teams with preconceived maps of their roles based on their learned culture, beliefs and cognitive approaches. The type of uni-disciplinary education most health professionals have undertaken results in poor understandings of each others roles, causing stress, anxiety, conflict and ineffectiveness in the team. (16)

International research suggests interprofessional education results in effective clinical teamwork by enabling students of different disciplinary backgrounds to engage in learning designed to lead to collaborative problem-solving approaches, mutual decision-making and team work. (9) Importantly, it increases and enhances understanding of each other's professional roles and activities. (17)

Recognition of each other's strengths

New Zealand research has found inter-professional education fosters "... recognition by each health care worker of the strengths that other professionals bring to the clinical team, with respect for other members of the team and trust to allow open discussion ... and translation of this discussion into action. (18)

Interprofessional education also values disciplinary difference. "... it is not what people have in common but their differences that make collaborative working more powerful than working separately. Working together means that all participants bring equally valid knowledge and expertise from their professional and personal experience ... but it is the questions and challenges that arise from the differences that are vital". (19)

Interprofessional education leads to collaborative clinical practice by building effective teams, establishing common values, knowledge and skills, fostering an understanding, not only of students' own professional roles, but also enhancing understanding of others' roles. It strengthens professional identities so negotiation of work roles at the boundaries is successful and mutually respectful, which is crucial in primary care. This enhances the repertoire of knowledge, skills and attitudes of professional practitioners responding to changing practice and changing professional roles. (20,21,22)

Flexible learning formats

In the Wellington Department of Primary Health Care and General Practice, an interprofessional, postgraduate programme has been developing and expanding steadily. Qualifications in primary health care, travel medicine and general practice offer advanced learning for doctors, nurses, pharmacists and other PHC professionals. The courses are delivered in flexible, distance learning formats that allow students to study while in clinical practice anywhere in the country. Audioconferencing and use of asynchronous e-learning discussion boards support the face-to-face residential block components, which enable students to interact with each other and teachers. Papers include New Zealand contemporary PHC, Te Tuhauora: Maori health, sexual health, mental health issues, chronic conditions management, addictive behaviour management, travel medicine, tropical and migrant medicine, and wilderness medicine.

Content is targeted to the educational needs of the workforce, so is constantly updated and changed every semester; e-learning allows these changes to be easily incorporated. Each year, regardless of discipline, all students follow the same course content and undertake the same assessments; academic achievement is impressive in all disciplinary groups. A variety of intentional activities using different technologies (e-learning platform, audiconferencing, face-to-face) foster reflection and support the practice of working in teams. The residential block courses held once or twice a semester are the highlight of every course; nurses and doctors, with a small number of pharmacists and health managers, welcome the chance to learn with, from, and about each others' work.

Over the nine years the programme has been running, the disciplinary mix has included about one-third nurses and two-thirds doctors, with total numbers increasing and the proportion of nurses steadily growing in the last three years. Nearly all students are working as full time PHC professionals; either as GP, practice nurses, or other PHC nurses, so their study is part time, and often progresses slowly over several years. Five years to complete a diploma part time is not uncommon. But students' commitment to PHC is huge, and often given as an important reason for undertaking study. Of the 250 or so students enrolling over the last nine years, about two thirds have already completed a postgraduate certificate and/or diploma, and some are now completing masters qualifications.

Improving professional practice

In an earlier graduate survey (22), students told us that interprofessional study specifically encouraged them to stay in a sector they would otherwise leave (77 percent of nurses, 35 percent of doctors); and for most (88 percent) the interdisciplinary postgraduate study improved their own professional practice. But just as importantly, for a majority, postgraduate study improved workplace practice (68 percent), and for nearly half (45 percent), their study directly increased collaborative practice in their workplace.

This programme has shown that interprofessional education can be successfully applied in a whole variety of content areas, and is especially suited to those working in primary care. When programmes such as this one go well, the rewards are huge, not just for students but also for teachers, and even though challenging, it can be a tot of fun, and satisfying for everyone. Despite the fact interprofessional education improves clinical teamwork and thus quality of care, PHC professionals face significant barriers in accessing it. Some barriers also affect secondary care colleagues. Direct financial costs, travel, internet access, replacement of staff while studying and attending in-course requirements, and little or no protected study time are all barriers. There is also a lack of recognition, let atone active promotion, of interprofessional education courses by professional and regulatory organisations for accreditation, re-accreditation, and for validated funding via district health boards (DHB). What little funding there is, depends on this recognition. Sadly, people tend to think a course, even one based in a university and mandated by the Committee on University Academic Programmes, is not appropriate to undertake, if not funded by a body like the Clinical Training Agency or endorsed by regulatory bodies such as the Medical or Nursing Councils.

New Zealand is not alone in this experience. In the United Kingdom, barriers to successful implementation of interprofessional education for postgraduate health professionals were noted to be political, organisational educational and cultural. To remove these barriers, success and sustained delivery has been required, along with organisational support and active promotion. (3) Within New Zealand, separate government funding streams, such as Vote Health, Education or Social Development, result in a lack of cohesion when considering health and social services postgraduate education needs. In turn, separate disciplinary regulatory bodies, as well as the various colleges, further fragment this, together with a final layer of tertiary and other education providers, DHBs, primary health organisations and management services organisations. These barriers also work in concert with other high level barriers. (See table one.)

BARRIERS TO INTERPROFESSIONAL EDUCATION

Political: High-level
policy supports ongoing professional development, collaborative
practice, interdisciplinary teamwork, interprofessional education.
But the MoH appears to promote interdisciplinary teamwork only in
principle and leaves implementation to chance. For example, those
working in health recognise the integral nature of health and
social welfare/social service yet there is no Ministry of Social
Development involvement in any health-related education

Organisational: Professional and other organisations are largely
silent or pay lip-service to interprofessional education. Because
their mandate, as membership organisations, is to represent a
single disciplinary group, professional organisations have few
mechanisms for recognising interprofessional education and few
drivers for doing so. The clinical training agency (Vote Health)
that has largely disbursed funds for uni-disciplinary vocational
training. In particular CTA funding for clinical training has been
largely directed at vocational training for doctors, with the bulk
of funding going to secondary care training. For GPs, this funding
has only provided for a single year of uni-disciplinary early
vocational training for an inadequate number. For PHC nurses the
very limited funds avaialbe are disbursed through DHBs.

Educational: Educational institutions have limited drivers to
offer interprofessional education as opposed to regular
uni-disciplinary courses. Some tertiary education providers do
offer interprofessional education for health professionals, but
this is usually only because of individual staff initiative, but
student numbers remain smell, making sustained course viability
difficult.

Cultural: Increasing numbers of students are seeking-out
interprofessional education. But mistrust between
professional groups can put some students off participating and
mistrust between professional groups can put some tutors and
institutions off developing and/or participating in
interprofessional education.

Table one: High level barriers to interprofessional education

High level change is needed. A report to the Minister of Health in 2006 on quality in health care stated: "In the past, most training and education in health care has been delivered and governed from within each specific discipline. This mono-discipline approach does not match the delivery of health care approaches where interdependence, complexity and technology are the norm. Not only do health workers require an in-depth understanding of their own specialty, they must also know how to work in teams and how to improve the processes within which they work." (5) Despite these recommendations and those of the now dissolved Health Workforce Advisory Committee, (23) nothing has changed to address the barriers at different levels.

A number of solutions are required which, if implemented together, would enable increasing interprofessional education opportunities.

* Formation of a single national organisation to promote and manage integrated workforce planning and education, both interprofessional and uni-disciplinary education, with representation from professional and regulatory organisations and education institutions

* All regulatory organisations should have to facilitate and promote interprofessional education at postgraduate level, by requiring a proportion of interprofessional learning for accreditation, reaccreditation and Health Practitioners Competence Assurance Act professional development requirements.

* Vote Education and Vote Health should both contribute to educational funding streams for postgraduate education, especially for the PHC workforce.

* DHBs and PHOs should be required to support ongoing education, but not necessarily provide it.

* Tertiary education providers should have to provide interprofessional education options for health professionals, at least at postgraduate level.

Conclusion

Interprofessional postgraduate education provides experienced PHC professionals with subject and content and enables enhanced interdisciplinary practice. The University of Otago's Department of Primary Health Care and General Practice, has developed a distance learning interprofessional education which is a pragmatic solution for busy PHC health professionals, who wish to upskill and foster interdisciplinary skills. It uses a variety of technologies and intentional processes to build interdisciplinary practice, despite limited face-to-face time.

Despite health authorities advocating clinical teamwork and interprofessional education, a variety of structural and attitudinal barriers challenge its development and practice. Only when PHC professionals from different disciplines have an indepth understanding of each other's roles, responsibilities and challenges, nurtured through interprofessional education, will the furl potential of clinical teamwork be realised for clients and health professionals alike.

This paper is based on addresses given at the Workforce Action Conference, Wellington, June 2007 and the Primary Health Care Nurses' Conference, Auckland, August 2007.

It is also being published in the New Zealand Family Physician next month.

References

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(14) Report of Health and Disability Commissioner. (2007) Capital and Coast District Health Board. Wellington: Health and Disability Commissioner.

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(20) Barr, H. (2003) Unpacking Interprofessional Education in Interprofessional Collaboration. In: Leathard A, (eds.). Interprofessional collaboration: from policy to practice in health and social care. Hove, United Kingdom: Brunner-Routledge.

(21) Pullon, S. (2006) Primary trust in primary care: an exploration of interprofessional relationships between nurses and doctors in New Zealand. (Master in Primary Health Care unpublished thesis) University of Otago, Wellington.

(22) Pullon, S. & Fry, B. (2005) Interprofessional education in primary health care. Is it making a difference? Journal of Interprofessional Care; 19: 6, 569-579.

(23) Health Workforce Advisory Committee. (2003) The New Zealand Health Workforce: Future Directions--Recommendations to the Minister of Health Wellington: The Author.

Eileen McKinlay, RN, ADN, HA (Apptd) and Sue Pullon, MBChB, MPHC, FRNZCGP, are both senior lecturers in the Department of Primary Health Care and General Practice, Wellington School of Medicine and Health Sciences. McKinlay and Pullon teach programmes for undergraduate students and teach together in the interprofessional postgraduate programme.