Interprofessional Education (IPE): A framework for introducing teamwork and collaboration in health professions curriculum

Teamwork in the curriculum: a case for interprofessional education and practice

Meaningful learning is intertwined with experiences that connect the learner with their professional world. These authentic encounters through potentially meaningful signs and concepts are assimilated within the cognitive structure of learners contributing towards transformative learning.¹ Health care delivery today is largely a team based and collaborative affair and therefore calls for learning opportunities that foster the knowledge base, skills, attitudes, and values that seek to transform learner attitudes which empower them to practice collaboratively towards the broader goal of enhancing health outcomes. This perspective review is based on our assumption that the framework for interprofessional education and collaborative practice may be useful in the context of introducing and sustaining tenets of teamwork and collaboration in the health professions curriculum.

Interprofessional education is the method of educating professionals together to obtain a common goal. The WHO states that, “Interprofessional education occurs when two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes”.² Interprofessional Education (IPE) of healthcare professionals is aimed to be a precursor for Interprofessional Collaborative Practice (IPCP). It is obvious that when students from diverse health professions learn and train together, they will be better equipped to work together. Interprofessional collaborative practice is “when multiple health workers from different professional backgrounds work together with patients, families, carers, and communities to deliver the highest quality of care”.³

However, learning opportunities that foster interprofessional education and practice remain largely sparse in our educational environments. With reports on the valued experiences of collaborative practice conducted by health care teams during the COVID-19 pandemic globally, interprofessional approach as a framework for introducing teamwork and collaboration in health professions curricula is worth exploring.⁴

Collaborative competencies of IPE: the inbuilt mechanisms offer a definite advantage

Interprofessional education by the very nature of its framework encourages collaboration and cooperation. Though various agencies and professional bodies have specified the competencies for IPE and IPCP in the past, the ones proposed by the Interprofessional Education Collaborative (IPEC) have gained wide global acceptance. IPEC articulated these competencies in 2011 which was subsequently updated in 2016.⁵ The 2011 document was a joint effort of American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association, Association of American Medical Colleges, and Association of Schools of Public Health. The 2016 document had representation from nine other professional bodies namely American Association of Colleges of Podiatric Medicine, American Council of Academic Physical Therapy, American Occupational Therapy Association, American Psychological Association, Association of American Veterinary Medical Colleges, Association of Schools and Colleges of Optometry, Association of Schools of Allied Health Professions, Council on Social Work Education and Physician Assistant Education Association. The collaborative consortium represents almost all the key professions involved in planning and delivery of health care.⁶

The competencies were developed with interprofessional collaboration as the centrepiece. Values and ethics, roles, and responsibilities, interprofessional communication, and teams and teamwork are the four key competencies outlined. Fig. 1 depicts how the competencies are an integral part of interprofessional collaboration and ensures that patient and family centered care is provided keeping in mind the needs of the community and population.⁶ By the very nature, all four competencies require collaboration. However, the one competency that makes collaboration imperative is the competency on teams and teamwork. This is listed as the fourth competency and is stated as “applying relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.” The competency on teams and teamwork has eleven sub-competencies and they cover the entire spectrum from team development to performing effectively in teams. They provide a framework both for education and practice.^5,6

Fig. 1.

Interprofessional collaboration competency domains.

Team competencies in the newly proposed competency based medical curriculum

Medical Education regulators in India introduced the new competency-based curriculum from the academic year 2019–2020. The undergraduate curriculum has been codified in three volumes and lists the various competencies and sub-competencies. A series of documents have been published outlining various modules.⁷ National and institutional goals have been specified. One among the institutional goal is to equip the learner with skills “to work as a leading partner in health care teams”. The major role of an Indian Medical Graduate is they be a member and leader of health care teams. In this assigned role, they need to “work effectively and appropriately with colleagues in an interprofessional health care team respecting diversity of roles, responsibilities and competencies of other professionals.” A key word search using ‘team’ and ‘teamwork’ yielded a total of eleven major results that evolved from the three volumes which is provided in Table 1.

Table 1.

Sub-competencies for Interprofessional Teamwork in the newly proposed Indian medical curriculum.

Subject	Number of sub-competencies	Sub-competencies (Number in the document)
Forensic Medicine	1	2.31
Internal Medicine	3	26.19, 26.24, 26.25
Paediatrics	1	27.34
Orthopaedics	5	1.6, 3.2, 3.3, 13.1, 13.2
Ophthalmology	1	7.5

These are merely the sub-competencies that specifically ask for team and/or teamwork. However, an in-depth analysis of the document reveals that many of the sub-competencies listed in the document would require the competence of either leading a team or working in teams traversing from the formative years to the phase of clinical practice, either in an overt or covert manner.

The AETCOM (Attitude, Ethics and Communication) module identifies three specific competencies detailing team and team work (serial numbers 22, 27 and 28) as delineated in the booklet.⁸ It has a specific component titled ‘Working in a health care team’ (Module 2.4) and has documented the importance of respect in relationship with fellow team members. Interprofessionality involves a paradigm shift as the practice domains present a unique set of values and codes of conduct. With a concrete plan and appropriate faculty development in place, opportunities for expounding collaborative competencies in the AETCOM module are huge.

It is obvious that the new competency based medical education curriculum in India without specifically expending the term interprofessional education has introduced elements of interprofessional collaborative practice and made it mandatory for learners to acquire the competencies linked to teamwork and collaboration to consider themselves fit for practice. In addition, the curriculum clearly identifies the need for medical students for deliberatively working together with other professions that would enable learning with, from and about each other. Precise planning would ensure that they are linked to educational strategies, learning activities, and behavioral assessments that are developmentally apposite for the learner in future. In addition, integration across the learning continuum would ensure accomplishing the common goal of building a safer and better patient-centered and community/population oriented Indian healthcare delivery system.

Examples from other health professions curricula

Examples for integrating core competencies of interprofessional education and collaborative practice are witnessed in many other health professions curricula. The Commission on Dental Accreditation (CODA) implemented new accreditation standards incorporating fundamentals of IPE and IPCP in their programs.⁹ The dentistry curriculum now specifically mandates graduates to be competent to communicate and collaborate with other health professionals which has necessitated dental educators to incorporate IPE and its assessment at their own institutions.

No curriculum effectively captures the interdependence between health professions’ education competency development for collaborative practice and practice needs, like the nursing does. According to the Quality and Safety Education for Nurses (QSEN) initiative, team work and collaboration are core pre-licensure competencies that nursing students should accomplish.¹⁰ Therefore, integrating interprofessional education has been identified as a key factor in transforming nursing education. Common courses that introduce nursing students to interprofessional concepts and behaviours, followed by strategically designed collaborative clinical rotations are now a feature in many nursing curricula.

Physiotherapists adopt a common approach for the development of interprofessional modules focusing on specific health problems/conditions/diseases or societal issues by the incorporation of the same in their curriculum using a team-based format.¹¹ Geriatric care is a brilliant example of how interprofessional education has been integrated in the physical therapy curriculum wherein a number of health professionals are expected to be involved in care delivery.¹² The trends in increasing life expectancy worldwide, concerns related to patients’ safety, and the complexity of the needs of geriatric population makes it an ideal mix for introduction of collaborative competencies in the allied health sciences curriculum.

The aforementioned educational approaches from various health professions curricula reinforce the philosophy cherished in the WHO report from the Interprofessional Education Collaborative which seeks collaborative designs for education and training of future healthcare professionals in a continuously evolving healthcare system.²

Learning with, from and about: the interprofessional learning experience

The interprofessional learning experiences are conventionally assigned to the categories of exposure, immersion, and mastery as a continuum of interprofessional education and practice.¹³ The exposure phase is primarily preparatory in its organization and intended for learners to come together with students who represent other health professions. Exposure phase helps in positioning the foundation for future partnerships. This phase employs common orientation programs, small groups discussions and social activities that foster the spirit of interprofessionalism. The interactions during exposure will set the stage for next phase, the immersion period which warrants collaborative interactions that help learners focus on learning with, from and about each other's profession. Immersion phase also helps the student understand interprofessional values and ethics along with role clarification which are deemed vital ingredients for effective team work and collaboration in healthcare. Learning is largely confined to the workplace/clinical setting with case rounds, bedside rounds and team meetings having a major role. Interprofessional simulation-based education (IPSE) that vary in relation to duration, fidelity and professions involved are found to enhance learner outcomes relating to teamwork, leadership, and communication skills.¹⁴ Common learning arenas or electives on topics such as doctor-patient communication, patient safety, chronic disease management and managing difficult conversations in clinical setting are good approaches that may be adopted during the integration phase. They not only assist in the indoctrination of collaborative competencies but also help in presenting certain sticky issues in the curriculum that are associated with modern health care delivery. The mastery phase necessitates the integration of critical thinking and problem solving in complex real-world situations. Examples of mastery activities involve team-based care focusing on areas of complex care such as mental health, reproductive health and life style disorders.

With the nature of learning approaches cited, it is evident that the role of an interprofessional facilitator will go way beyond the conventional roles of a health professions educator. An IP facilitator will often play a mediator's role helping learners resolve conflicts and settling miscommunication and misunderstandings that are likely impediments in smooth functioning of teams.¹⁵ This will be in addition to their regular roles of helping the team members acquire necessary knowledge, skills, and attitudes from resources within and beyond their teams.

It is evident that early introduction and implementation of a range of settings combined with diversity of instructional methods hold the key for promoting interprofessional learning. Incorporation of IPE into existing courses instead of a separate course is found more viable and sustainable for addressing teamwork and collaboration.

Assessment of interprofessional collaboration and teamwork: garnering evidence for effectiveness

Assessment is at the core of learning. The core concepts of assessment remain the same even for assessing interprofessional education and practice. It requires a combination of assessment for learning (formative assessment) with assessment of learning (summative assessment).

Some of the core principles include:

• 1.Continuous, timely summative assessments with thorough formative assessments to confirm continued progress
• 2.Best utilization of different assessors and assessments to empower the perfect appraisal to be made at the perfect time for the correct reason, while staying away from assessor exhaustion
• 3.Mechanisms for the synthesis of data gathered through different processes to reach competence decisions
• 4.Timely faculty training to equip them with the necessary skills for assessment

Optimizing assessment would require multiple methods, multiple assessors, proper selection and training of assessors, reconceptualization of the role of psychometrics and recognition of the importance of group process in reaching critical decisions about competence. It is important to use a mix of quantitative and qualitative data to derive valid interpretations so as arrive at a meaningful conclusion.¹⁶

For facilitating assessment, it is preferable that the competency be broken down into parts. For example, teamwork competency can be broken down into team/collective orientation, shared mental models, mutual trust, and closed-loop communication. It is important to develop behavioral examples for the competency. They include:

• ✓Facilitating team problem solving
• ✓Providing performance expectations and acceptable interaction patterns
• ✓Synchronising and combining individual team member contributions
• ✓Seeking and evaluating information that impacts team functioning
• ✓Clarifying team member roles
• ✓Engaging in preparatory meetings and feedback sessions with the team

The next step in assessment is deciding the level at which it would be assessed: individual, team and organization. It could be assessed at any one level or using different combinations. Once the level(s) has been decided, the appropriate assessment tool needs to be identified. A list of these tools are provided in Table 2 and can be accessed from https://nexusipe.org/.¹⁷

Table 2.

Assessment tools for interprofessional practice at individual, team and organizational level.

S. No.	Level of Assessment	Assessment Tools
1.	Individual	•Performance Assessment Communication and Teamwork Tools Set (PACT) •Index of Interdisciplinary Collaboration (IIC) •Individual Teamwork Observation and Feedback Tool (iTOFT) •Team Observed Structured Clinical Encounter (TOSCE) •Interprofessional Collaborative Competencies Attainment Survey (ICCAS) •Interprofessional Collaborator Assessment Rubric (ICAR)
2.	Team	•Performance Assessment Communication and Teamwork Tools Set (PACT) •Assessment of Interprofessional Team Collaboration Scale (AITCS) •TeamSTEPPS Team Assessment Questionnaire and Team Performance Observation Tool (TAQ-TPOT) •Communication and Teamwork Skills (CATS) Assessment •Observational Teamwork Assessment for Surgery (OTAS) •Assessment for Collaborative Environments (ACE-15) •Teamwork Assessment Scale (TAS) •Team Emergency Assessment Measure (TEAM) •Team Observed Structured Clinical Encounter (TOSCE) •Multidisciplinary Team- Observational Assessment Rating Scale (MDT-OARS) •Team Development Measure (TDM)
3.	Organizational	•Healthcare Team Vitality Instrument (HTVI) •Team Evaluation and Assessment Measure (TEAM)

What works and what doesn't: enablers and barriers in the Indian context

Enablers for introduction of collaborative competence in the curriculum using an interprofessional framework

Our experiences for the past five years organizing a fellowship program that focuses on Interprofessional leadership irrefutably identifies opportunities for learning from other professions and prospects for acquiring newer competencies as a reason for early adoption of interprofessional practices among enrolled fellows. The mandated requirement of collaborative competencies as stipulated by the regulators in the recent times can be a shot in the arm for making transformative changes within the curriculum.

We found that past experiences working with teams along with having clear goals and strategic plans, customarily enhanced the acceptance of team-based approaches among the faculty and students. Skills of managing change and communication are considered pivotal in this success formula. Hence awareness and positive attitude towards change process among faculty and students by training on attitudes, knowledge and skills required to work efficiently together with other professionals so as to deliver safe, high quality patient care must be considered a key step during implementation.

Potential barriers in adopting an interprofessional framework for introducing teamwork and collaboration in the curriculum

Invalid assumptions are often a cause for breakdown in collaboration and teamwork, be it education or patient care. Organizational barriers are largely related to the lack of understanding about IPE and IPCP. Power hierarchy prevalent in the institutions can underrate the knowledge and appreciation of other health professional's role, hindering adoption of curricular approaches that recommend transformative changes. As encountered with any academic reform, hesitancy on the part of major stakeholders for change has been identified as a major concern. The prevailing rigid academic policies and a health professions curriculum that is already intense is likely to discourage enthusiasts if any, leading to breach of confidence, creating fear in the success of a new module focusing on tenets of teamwork and collaboration.

In a nutshell, team composition, adaptability of the team members and administrative support are crucial factors that will determine the outcomes of such curricular interventions. Shared interprofessional vision regardless of position is an important factor that contributes to flawless implementation. Adequate number of orientation programs that help faculty and students understand the philosophy and concepts of collaborative practice are essential for developing and sustaining modules that address team work and collaboration, specifically while using an interprofessional framework in the health professions curricula.

Disclosure of competing interest

The author have none to declare.