Interprofessional education – still more questions than answers?

The importance of co-operation between the professions in the provision of health and social care is well recognised and has been provided for in UK policy planning since the early 1960s.1 By the late 1970s, specific programmes for interprofessional training to underpin this goal began to appear and the concept of ‘learning together to work together’ received further impetus from the 1988 WHO publication of that name.2 At the start of the 21st century, as medicine changes to deal with the demands of society, differing global public health concerns, an ageing population and an increased emphasis on long-term management of chronic illness, the delivery of care by a range of professionals who can cooperate in the best interests of the patient is essential. This reality of working practice within the healthcare professions has provided the major stimulus for interprofessional education.3 In the UK, development of a format of interprofessional education which recognises the unique contribution of each individual profession towards improved patient care4 is high on the government’s agenda.5,6 The parallel, more radical, proposals for a multiskilled NHS workforce, educated and trained to function across the traditional healthcare boundaries, continue to attract interest.4,7 The benefits of interprofessional education are perceived to be an increased ability to share knowledge and skills, enhanced personal confidence and professional development, greater respect between the professions and the encouragement of reflective practice.2,8 These are clearly desirable goals, but numerous questions are raised about the timing, content and delivery of such educational programmes. Furthermore, data relating to the outcome of these courses, both in terms of educational achievement and potential affects on patient care, remain scarce. Two papers in this month’s issue of Medical Education add to the debate from a non-UK perspective. Hall and Weaver9 provide a review of literature, mainly taken from North American sources. Horsburgh and colleagues from Auckland describe their use of the Liverpool ‘Readiness for Interprofessional Learning Scale’ to establish the attitudes of first year healthcare students towards shared learning.10 In some respects these papers encapsulate many of the frustrations encountered in this field of medical education. In the first paper the authors reviewed numerous small studies describing interprofessional interventions at the undergraduate and postgraduate level. However, as they point out, there is little about learning outcomes in these papers and even less about cognitive learning theory. Most of the major issues relating to interprofessional learning remain unanswered – indeed, having reviewed much of the literature, the penultimate paragraph of their paper contains 16 sentences, 15 of which end in a question mark! It is clear that a large amount of research remains to be done before interprofessional teaching and learning can be established as the most effective way to educate the healthcare staff of the future. The second paper describes a study at the University of Auckland to investigate the attitudes of first year medical, nursing and pharmacy students to interprofessional learning. This is of interest particularly in terms of the timing of their investigation as optimum timing of the introduction of interprofessional learning remains one of the major unresolved issues in the field. It may be argued that interprofessional education should commence early in training at the undergraduate level.11 However, there is little research evidence to support this theory and most relates to senior students.12-14 In view of the large numbers of students and staff engaged in education in the healthcare professions and the massive organisational change required to bring about large-scale interprofessional learning programmes, the assumptions underlying the development of interprofessional education at the undergraduate level merit further scrutiny. Students entering any of the healthcare professions not only have to acquire a large range of knowledge, skills and attitudes during their course, but have to do this partly within learning environments where the principal activity is the delivery of health services. Such clinical areas are initially unfamiliar and to some students may remain hostile and frightening. Furthermore, much of the classroom teaching early in traditional curricula (particularly in medicine) may appear remote from the student’s goals on entering the course, which are usually highly altruistic. It is not surprising that students develop strong academic and social support systems within their peer groups as part of the process of professional socialisation. These activities are fostered by role models provided by their tutors and form a way in which the student can create a ‘safe’ environment within which to function. Appropriate professional socialisation may be beneficial, contributing towards successful performance in a professional group within a healthcare system. Indeed it could be argued that students need to gain confidence in their own professional identity before being able to undertake interprofessional learning and moving on to successful teamwork in clinical practice. The conflict between teamwork and uniprofessional practice was highlighted in a study of an interprofessional training ward at the Faculty of Health Sciences in Linkoping, Sweden.15 Informal discussions with students involved in the pilot study of a similar training ward at my own medical school revealed similar conflicts. However, it is important to recognise that adverse perceptions of other healthcare professionals can have detrimental effects in the long term and ultimately may impair patient care.16 The perception that successful interprofessional education only occurs at the postgraduate level may merely reflect the paucity of evidence for earlier educational interventions, particularly in the early years of undergraduate curricula.17 Horsburgh and colleagues’ study10 would suggest that junior students (before being subjected to professional socialisation) may be highly receptive to interprofessional education. In our own study of an education programme for pre-registration house officers and newly qualified staff nurses,18 the benefits of learning together were recognised by the participants and many regretted the lack of similar programmes in their undergraduate courses. Conceptually, interprofessional education for the healthcare professions has high validity, mainly due to the influence of working conditions prevailing in health service provision. In the postgraduate field, educational programmes to improve the generic skills required to function in effective teams are likely to prove successful. However, advocates of interprofessional learning for undergraduates must show advantages of this method over the traditional uni-professional learning methods leading to multiprofessional working at a later stage. Ultimately the goal of improved patient care must be addressed. If one accepts that health care delivery is a multiprofessional activity dependent upon the actions of teams rather than individuals, then one might postulate that early exposure to students in different disciplines might enhance understanding of the complex processes involved in patient care. There is a pressing need to provide the evidence to support or refute this theory.