Executive Summary

Interprofessional Education for Collaborative Patient-Centred Practice: An Evolving Framework

Prepared and Submitted by:

Ivy Oandasan, MD, CCFP, MHSc, Project Leader, Assistant Professor and Research Scholar at the Department of Family & Community Medicine, University of Toronto and Toronto Western Hospital, University Health Network.

Danielle D'Amour RN, PhD , Associate Professor, Faculty of Nursing at Université de Montréal, Director of FERASI Centre and Researcher at Groupe interdisciplinaire de recherche en santé (GRIS).

Merrick Zwarenstein, M.B., B.Ch., M.Sc., M.Sc (Med.), Senior Scientist, Institute for Clinical & Evaluative Sciences; Principal Investigator, Knowledge Translation Program, Continuing Education, and Associate Professor, Department of Health Policy, Management and Evaluation, at the Faculty of Medicine, University of Toronto.

Keegan Barker, BA, M.Ed, Research Associate, Department of Family & Community Medicine, Toronto Western Hospital, University Health Network.

Margaret Purden R.N., Ph.D, Assistant Professor, School of Nursing, McGill University, and Director of the Centre for Nursing Research, Jewish General Hospital.

Marie-Dominique Beaulieu MD, MSc, CCMF, Professor, Chaire Dr Sadok Besrour en médecine familiale, Department of Family Medicine, Université de Montréal and Researcher, Centre de recherche du Centre hospitalier de l'Université de Montréal.

Scott Reeves, BSc, MSc, PGCE, Research Fellow, City University, UK and Senior Research Fellow, South Bank University, UK.

Louise Nasmith, MDCM, MEd, CCFP, FCFP Professor and Chair, Department of Family and Community Medicine, University of Toronto.

Carmela Bosco, BA, Health Policy Consultant and Managing Director, CBR Consulting.

Liane Ginsburg, PhD, Assistant Professor, School of Health Policy & Management, Atkinson Faculty of Liberal & Professional Studies, York University.

Deborah Tregunno, RN, PhD, CHSRF Post-Doctoral Fellow, Faculty of Nursing, University of Toronto.

Interprofessional Education for Collaborative Patient-Centered Care

Definitions

It is recognized at this time that there are many terms being used amongst those who are advancing the areas of interprofessional education and collaborative practice. The authors of this report respect the use of other terms intended to convey the same meaning. As the most controversial terms being used are "interdisciplinary versus interprofessional education", the authors initially chose to use these terms interchangeably. However, in consultation with the National Expert Committee on Interprofessional Education for Collaborative Patient-centred Care, consensus was reached that the use of the term "interprofessional education" should be adopted by Canadians working in this domain. Therefore, interprofessional education for collaborative patient-centred care will be used henceforth in this report and will be given the acronym of "IECPCP".

Interprofessional/Interdisciplinary Education

"occasions when two or more professions learn from and about each other to improve collaboration and the quality of care"

(CAIPE, 1997, revised)

Collaboration

"an interprofessional process of communication and decision-making that enables the separate and shared knowledge and skills of health care providers to synergistically influence the client/patient care provided"

(Way & Jones, 2000)

Collaborative Patient-centred Practice

"is designed to promote the active participation of each discipline in patient care. It enhances patient- and family-centred goals and values, provides mechanisms for continuous communication among caregivers, optimizes staff participation in clinical decision making within and across disciplines and fosters respect for disciplinary contributions of all professionals"

(Health Canada, 2003)

Executive Summary

About the Research Report

Across Canada, there has been much dialogue about the affordability and sustainability of the country's health system for more than a decade. As there are many facets to health system renewal, one of the goals of the First Ministers of Health is to achieve an integrated and interprofessional approach to primary care.[1] This approach would ensure timely access to appropriate health care providers, 24 hours a day, 7 days a week for all Canadians who require health care services regardless of where they live. The 2003 First Ministers' Accord on Health Care Renewal provided the direction for change. The consensus was that fundamental changes are necessary in order to deliver an effective primary health care system that would see improvements to continuity and coordination of care.

Under this direction, the 2003 First Ministers' Health Accord identified that changing the way health professionals are educated is a key component of health system renewal. This change will be mobilized through the development and implementation of an initiative on interprofessional education for collaborative patient-centred practice (IECPCP). A team of health researchers with expertise and experience in the field of interprofessional education and collaborative practice was assigned the task of examining this issue. The team explored current national and international trends impacting interprofessional approaches to primary health care, reviewed existing models of interprofessional education and collaborative patient-centred care practice frameworks, and provided an analysis of their findings to determine what Canada must do to advance IECPCP in our health care system. Under the guidance of the National Expert Committee (NEC) on Interprofessional Education for Collaborative Patient-Centred Care and the Office of Nursing Policy of Health Canada, the research team proposed recommendations that take into consideration the current realities both at the policy and organizational level. It is hoped that the recommendations can assist in driving interprofessional health care change forward.

The research team explored both successful and unsuccessful interprofessional education and collaborative practice initiatives within health care practice settings and academic institutions. The findings from a literature review and an environmental scan conducted for this report provided the necessary information to develop a framework to define the essential features and determinants for IECPCP.

The report covers:

• Current trends of interprofessional education for collaborative patient-centred practice in Canada and abroad and what are best practices for patient outcomes.
• A review of existing studies on the effects of interprofessional education and collaborative practice for quality of care and patient outcomes.
• Key features in the relationship between, and elements for, successful interprofessional education and collaborative practice models.
• Barriers to implementing interprofessional education and collaborative practice and descriptions of change management strategies to overcome these barriers.
• Enablers that influence interprofessional education and collaborative practice.
• Current policies, programs and strategies in health and education that support IECPCP.
• Recommendations on how to advance IECPCP in Canada, including research priorities.
• A conceptual framework to consider the essential elements and determinants for IECPCP based on available evidence and theoretical considerations.

A database is included with this report highlighting examples of interprofessional education and collaborative practice initiatives that currently exist in Canada and abroad. As well, a listing of published articles is provided.

Findings and recommendations of this report will be used as the basis for further deliberations by the First Ministers, of Health, the NEC and Health Canada as a priority for health system renewal.

Overview Research Methodology

The research methodology employed in exploring models of interprofessional education and collaborative practice was a literature review and an environmental scan. The research team, leaders in interprofessional education and collaborative practice, contributed significantly to the research. These individuals were core contributors to the literature review and were instrumental in other studies involving IECPCP. These include:

• the Zwarenstein and Bryant Cochrane Reviews on Nurse - Physician Collaboration Interventions.
• the Zwarenstein, Reeves, Barr, Hammick, Koppel and Atkins Cochrane Review on Interprofessional Education and Patient Care Outcomes.
• a review on Interprofessional Education conducted by the Joint Evaluation Team (JET) in association with the Centre for Advancement of Interprofessional Education (CAIPE) in the United Kingdom.
• expertise from the Université de Montréal in studies related to collaboration mainly at the primary care level.

With the researchers' combined extensive background, the team was able to build upon and share their knowledge of existing resources in order to begin building a Canadian database on the literature related to this field. In addition, the authors (team members) of each chapter of this report executed their own research activities to address specific issues about IECPCP. Their specific research methodologies are described in their chapters.

The literature review examined existing interprofessional education and collaborative practice models within government, health care facilities, educational institutions, professional and health care associations, and professional licensing bodies in Canada and internationally, including the United States and the European Community.

Literature Review

Sources for the literature review included:

• published literature (national and international, health sector and non-health sector);
• "grey" (see below) literature, including: government policy documents, including health and education departments (national, provincial, municipal, as well as international governments);
• doctoral dissertations;
• position papers and policy statements of professional, health, education, and voluntary associations;
• Primary Health Care Transition Fund, and Health Transition Fund literature; and
• an Internet and Web site search.

The grey literature consisted of a collection of policy papers, reports, articles, and summaries that are generally considered non-scientific. The process used to identify this body of literature was through contacting members of two listserves, CanMedLib (Canadian Medical Librarians listserve) and MedLib (Medical Librarians listserve) to ask to identify and forward any key documents. This generated only one recommendation that was not appropriate and could not be used. Subsequently, searches were conducted on GoogleT, PubMed and Medline search engines.

Key Web sites were then identified by team members working on the project. The following Web sites were specifically sought out:

• Health Canada;
• Health and Education Departments for each Canadian province and territory;
• World Health Organization;
• National, state and territorial government Departments of Health and Ageing in Australia;
• United States Department of Health and Human Services;
• New Zealand Ministry of Health;
• United Kingdom Department of Health;
• National Institutes of Health; and
• Canadian Health Care Associations.

The following keywords were entered separately into the "Search" box for each individual Web site: multidisciplinary, interdisciplinary, interprofessional and primary care reform.

A research librarian was hired to ensure that all literature, both English and French languages, was collected and collated by each team member and entered into an electronic database. The librarian acted as the central information resource. For this initiative, the research librarian conducted an examination of the mechanisms used for the literature searches by the team members from their past work to ensure that all published and non-published information was identified and distributed to team members for their evaluation. An inventory of program initiatives in interprofessional education and collaborative practices database was created and is housed within Health Canada. This inventory will be a resource for individuals embarking upon innovations in the field of interprofessional education and collaborative practice. A second database of those individuals and organizations contacted for participation in the environmental scan provides a registry of key individuals with experience in this field. This database is also housed within Health Canada. Third, a database of key literature in the field of IECPCP based on published articles and grey literature was generated and is appended to this report.

Environmental Scan

The environmental scan provided information about what is currently being done in the country related to interprofessional education and collaborative practice. The environmental scan accomplished the following objectives:

• highlighted supportive policies in governments, health service and educational organizations;
• indicated emerging trends and innovations; and
• provided a sense of the readiness for interprofessional education and collaborative practice at the macro-, meso- and micro-levels in Canada.

Three methods were executed to gain such comprehensive information:

• an on-line survey of identified key informants;
• a focus group with NEC-IECPCP committee members; and
• in-depth interviews with individuals involved in representative interprofessional education and collaborative practice initiatives.

Sources for the environmental scan included key informants (including national and international contacts), with relevant sources identified by:

• Health Canada staff from the Health Human Resource Strategies Division, the Office of Nursing Policy, and the Primary and Continuing Health Care Division;
• the National Expert Committee;
• provincial/territorial government officials;
• international initiatives;
• educators;
• health provider organizations;
• professional associations;
• Primary Health Care Transition Fund/Health Transition Fund initiatives and projects; and
• authors of grey literature.

Key Chapter Findings/Highlights

The researchers were divided into teams to address specific themes and tasks related to IECPCP. Each of their findings is highlighted in separate chapters within the report. The following provides the highlights of each of the chapters.

Effectiveness of IECPCP Interventions

• To date, evidence has been found that collaborative practice initiatives, which occur at the post-licensure level of training (with practitioners in clinical practice) improve quality of care and patient outcomes in specific populations. The authors of the chapter consider that post-licensure collaboration interventions have the highest priority for research and implementation. The fact that they are workplace-based ensures that stakeholders, in addition to the professions or their organizations, have an interest in supporting these interventions.
• Research conducted at the pre-licensure level of training has lacked the rigour needed to understand its impact on patient care outcomes. There is no empirical evidence to date that interprofessional education can improve patient care outcomes. Thus, more research is needed. The authors strongly recommend that a number of approaches to interprofessional education should be tested using contextual, qualitative studies and rigorous quantitative studies to develop models of educational interventions that can be pilot-tested and have their effectiveness evaluated. Given the urgent need to develop educational models, caution is recommended against widespread intervention programs until the findings of the effectiveness and feasibility of implementing them are tested.
• The research to date measuring the effectiveness of collaborative practice initiatives has been found primarily in hospital-based settings. There is a need to develop interprofessional collaboration interventions in primary and ambulatory care settings. They should be pilot-tested and moved rapidly into rigorous large scale trials in order to understand outcomes.

Elements for Collaborative Practice

A literature review was conducted on the conceptual basis of collaboration. Findings reveal that collaboration is a complex, voluntary and dynamic process involving several skills. The complexity of the task at hand translates into different levels of collaboration intensity in a constantly evolving fashion. For example:

• Collaboration is related to other concepts such as sharing, partnership, interdependency and power. Teamwork is the main setting in which collaboration takes place.
• In none of the available research papers did we find a true reflection of how to integrate patients in the care team despite the fact that patients are recognized as the ultimate justification for collaborative care.
• Only a few reviewed papers proposed models with a sound theoretical and empirical basis. Three models stand out as possible references for future education and research initiatives.
• The stronger theoretical models of collaboration propose an understanding of the processes of collaboration on hand and the components of the structure influencing the processes.
• Three main types of determinants were identified: interactional, organizational and macrostructural determinants. Interactional determinants have been studied more extensively than organizational and macrostructural determinants; the latter have been particularly ignored.
• It has been shown that within the organizational determinants, formal regulation (definition of rules to be followed by the teams) and leadership have an impact on measured outcomes.
• The policy levers that appear the most likely to help reduce some of the barriers to implementing collaborative care include changes to health profession regulation policies, funding mechanisms and professional compensation methods.

Elements for Interprofessional Education

• A literature review was conducted to obtain insight on the elements for interprofessional education with respect to competencies, attitudes, values, teaching methodologies, learning practice settings, and faculty development. Findings from the literature review point towards information related to educational processes for interprofessional education. However, more research is needed to link the effectiveness of these processes with successful outcomes of interprofessional education. There is also a need for more process-oriented research to help address the complexities involved in interprofessional education.
• The notion of a spectrum of learning is introduced where pre-licensure students are gradually introduced to concepts related to collaborative practice competencies. Differences between uniprofessional, multiprofessional and interprofessional teaching strategies need to be understood in order to consider when to use these teaching strategies within the spectrum of learning.
• There is a call for competency-based interprofessional education in which the development of specific knowledge, skills, attitudes and behaviours can guide the teaching strategies employed.
• Teaching strategies should consider the use of educational theory and established models to provide the foundation for the initiatives developed. In addition, factors related to the setting of interprofessional education, the learners and their readiness or resistance to interprofessional education, and the form of facilitation used by educators to teach interprofessional education should be accounted for.
• Currently, there is little in the literature to help educators understand how to facilitate interprofessional education in a successful manner and hence there is an urgent need for faculty development in this area.
• Evaluation methods are lacking for both program and student assessments related to interprofessional education. These methods need to be developed using techniques to measure established educational outcome measurements. Currently, the literature reveals most assessments primarily measure attitudes. As such, there is a need to look at other competency measurements and ultimately link the outcome of interprofessional education to its effects on patient outcomes.
• While there is no evidence to date that interprofessional education improves patient outcomes, no evidence does not mean ineffectiveness (Hammick 2000). Therefore, we need urgently to develop studies to pilot interprofessional education initiatives, which can help us to understand the educational processes related to successful methodologies (using qualitative research), and then create methods to further test educational initiatives that can measure its impact on patient outcomes. By doing so, we will finally come to the answer of whether there is evidence that interprofessional education does affect patient outcomes.

Environmental Scan Findings

On-line Survey

• Surveys were e-mailed to 550 individuals; 316 responses were received, resulting in a response rate of 57%. One hundred and seventy-seven (177) respondents reported that they had knowledge of an interprofessional education (IPE) program, and 91 respondents reported knowledge of a collaborative practice (CP) initiative. One hundred and sixty-two (162) people went on to describe the interprofessional program, and 86 described a collaborative practice initiative.
• Interprofessional education initiatives took place almost equally in higher education settings (50%) as in service or mixed settings (49%; a clinical setting with higher education links or vice versa). The majority of successful collaborative practice initiatives took place most often in service or mixed settings (92%) and rarely in higher education settings (7%).
• Seventeen professions were common amongst programs and initiatives, 27 professions were unique to interprofessional education, and 11 were unique to collaborative practice.
• Primary care settings and "other" settings had more instances of interprofessional education and collaborative practice than either tertiary care or rehabilitative care. Specifically, 40.9 % of interprofessional education programs and 41.9% of collaborative practice initiatives were primary care; tertiary care was 8.5% IE and 14.5% CP; and rehabilitation was 7% IE and 6.5% CP.
• In both education and practice initiatives, the majority of these programs ran for more than three years, and more than three times. Funding has a slight effect on length of time a program ran in interprofessional education, but was not statistically significant.
• Curriculum development was the impetus that drove interprofessional education, while continuous quality improvement was a driver for collaborative practice initiatives.
• A large variety of patient populations were involved in programs and initiatives, with slightly more practice initiatives involving patients.
• There was virtually no comparison made to non-participants of the survey nor was there random assignment in evaluations.
• Programs and initiatives were more often presented at conferences than published.

In-depth Interviews

• In the 12 in-depth interviews (10 English and 2 French) that were conducted, participants described both successful and unsuccessful IECPCP examples and/or initiatives as well as provided their insight and knowledge concerning the enablers for, and barriers to, IECPCP development and implementation. The interview findings concluded that:
  • Interprofessional education and collaborative practice are priorities and funding is available at the macro-level from governments and institutional leaders.
  • Interprofessional education and collaborative practice require commitment and support from leaders, in particular, champions, but the sustainability of these programs also requires secondary support.
  • Interprofessional education and collaborative practice are linked to health reform initiatives and address patient and population needs.
  • There is a willingness for change amongst those involved in interprofessional education and collaborative practice over a period of time.
  • There is a high level of interest in IECPCP-related programs and initiatives.
  • Although there is a wealth of information existing on current IECPCP initiatives, this information is not readily accessible concerning specific progress.
• Consensus from the in-depth interview participants revealed that more needs to be done to move IECPCP forward in placing it in the mainstream of health care delivery. Suggestions included:
  • conducting evidence-based research on the integration of IECPCP in all practice settings;
  • exploring new funding models for collaborative practices;
  • effectively addressing social and cultural issues of population groups; and
  • developing mechanisms to ensure the sustainability of IECPCP program initiatives.

Cultural Diversity in IECPCP

• The lessons learned from the literature with respect to promoting cultural competence in practice settings include the following:
  • Effective cross-cultural caregiving requires that interprofessional collaboration be extended to pararprofessionals or health care providers and key community workers who are not currently part of the traditional health care team.
  • Promoting cultural competency in practice calls for learning opportunities that bring professionals and health care providers (traditional/non-traditional) together to explore ways to collaborate on actual patient care situations.
  • Securing the support and participation of the community is vital to the sustainability and relevance of health programs and services. The Participatory Action Research model describes a process of building community partnerships and may be adapted to health promotion activities. A successful collaboration is likely to result in the development of innovative services that are an eclectic blend of ideas and perspectives from traditional healing practice and conventional western health care.
• The prominent themes that emerged from the literature on promotion of cultural competency in interprofessional education include the following:
  • Opportunities for interpersonal skill development from an interprofessional or transcultural perspective are lacking or are inadequate in most professional programs. Classroom teaching of cultural content does not address how to provide culturally sensitive care and may in fact oversimplify the cultural care needs of patients. Pedagogical initiatives need to incorporate culture-fair assessment workshops, case-based formats, and interactive sessions with patients and families.
  • Professional schools should include clinical experiences where students from the different professions work collaboratively in teams providing care to culturally diverse populations.
  • Students in health care need to be made aware of the contributions of all health care providers, particularly the non-traditional health care providers, and how to work more collaboratively with them.
• The review of the literature and the national survey results provide increasing evidence that an interprofessional collaborative approach among professionals, health care providers (traditional/non-traditional) and the community is desirable and possibly the only feasible way in which health care can be delivered in Canada's northern native communities and remote settings. Moreover, the principles underlying such an approach an approach as, mutual respect, inclusiveness, responsiveness and understanding one another's roles should be fundamental to the delivery of culturally competent services to all ethnic minority communities throughout Canada.

Health Policy in IECPCP

• Time constraints, budget allocation, infrastructure, institutional climate and culture are all factors impacting policy issues that need to be discussed in order to move IECPCP forward in the Canadian health care system. There are policy opportunities that can make interprofessional education for collaborative patient-centred care a reality. However, they need to emerge from federal, provincial and territorial legislative changes through coordination of existing policies in order to make decisions applicable in each jurisdiction.
• Based on the review of both published and unpublished literature, a number of critical barriers have been identified that hamper effective collaboration in primary health care delivery within a health renewal system. An overview of the current systemic barriers at the government, organizational and individual level is provided as well as specific policy barriers that impede IECPCP, including legislative and regulatory frameworks, human health resources, economic, educational and medico-legal liability issues.
• Funding, research, best practice tools, political, education, and legislation are examples of policy enablers/levers that have been used to facilitate IECPCP. While most of these policy enablers/levers have been identified, they have not been fully employed and evaluated to determine (either positively or negatively) their effectiveness in advancing IECPCP .
• Identified policy issues that must be taken into consideration to further advance IECPCP include:
  • reviewing current health and education training programs;
  • developing strategies for effective health human resource planning;
  • reviewing the current regulatory and legislative frameworks on new approaches to integrate collaboration for health disciplines;
  • establishing funding priorities for education, research and practice;
  • addressing cultural and political diversity issues; and
  • exploring alternative health care delivery concepts.
• Despite increasing calls for interprofessional collaboration, particularly in relation to primary health care, there is limited research on effective ways of implementing new mixes of skills and providers in health care delivery settings. New work environments and new divisions of labour call for new approaches to collaboration among health care providers in order to maximize the use of the health workforce. There also is limited information about the health care workplace in terms of its organization, planning, the nature of group practice, payment mechanisms and incentives, and professional responsibility.
• The consensus with many health policy reports is that, in formulating policies on IECPCP, there is a need to expand our knowledge-base on what is feasible within the current health care and education framework. Although we currently have had sufficient health research expertise that has explored collaborative primary health care, it has only peripherally addressed the impact of IECPCP on human and financial resources. To move IECPCP forward, efforts should be made to evaluate our current policies that frame our health and education systems.

Change Management Strategies for Enablers/Barriers

• The literature on organizational behaviour reveals that moving from existing models to new models of interprofessional education and collaborative practice poses multiple challenges. For change to occur for IECPCP, the following measures are recommended:
  • Change required in the academic and practice setting to implement and evaluate IECPCP will require challenging professionals' underlying values, assumptions and cognitive maps.
  • Experimentation with different forms of interprofessional education and collaborative practice requires managers and practitioners to develop a culture supportive of risk-taking and shared leadership.
  • Approaches to learning vary, and so successful implementation of interprofessional education will require both individual and collective learning.
  • There is no one best model of change that can be applied in this area. Interprofessional education and collaborative practice require change in different domains (education and practice) and at different levels within the system (individual/team, organizational, system/policy).
  • More radical changes involving new programs, curriculum changes, and accountability requirements (e.g., accreditation standards) would require substantially more time and would face more substantial barriers. However, it can be argued that these types of structural changes are required to entrench interprofessional education and promote collaborative practice over the long term.
• Reorganization into a framework where IECPCP becomes the norm will necessarily require clear policy direction, support and incentives (financial or otherwise) to bring key players on board. However, consistent with suggestions for bringing about change in the area of restructuring primary care, policy "direction" must be balanced enough to provide local agents with sufficient flexibility to implement changes in a manner that is consistent with the unique needs and interests of various settings.

Synthesis and Analysis of Findings

Building a Body of Knowledge

While there is promise for the advancement of IECPCP in Canada, there is still much to be learned concerning its true impact on improving quality of care and patient outcomes. From the literature and environmental scan, available evidence, although limited, supports the finding that collaborative practice can improve patient outcomes in specific patient populations and practice settings. In particular, there is a limited understanding of the impact of collaborative approaches on patient care outcomes at the primary care level of our health care system. There is a need to conduct research with sufficient rigour to provide an understanding of the effect of formalized interprofessional education and its outcomes with both learners (students and practitioners) and patient care. We recognize that a body of knowledge in the area of IECPCP is still growing. Canadian educators, researchers, practitioners and policy-makers can make significant contributions in increasing our understanding of the essential elements and impact of IECPCP. Through this body of knowledge better models and theoretical frameworks can be developed to advance IECPCP in a way that is based on best evidence.

Towards Common Terminology

Based on the experience from international jurisdictions, it is evident that there is a need for common terminology in using the words "interprofessional" or "interdisciplinary" education for collaborative practice among the providers and users of the health care system. The authors have decided to use the term "interprofessional" based upon discussions with the NEC. Consensus has been reached by them adopting the term "interprofessional education" as defined by the Centre for Advancement of Interprofessional Education (CAIPE) in the United Kingdom. It defines "interprofessional education" as "occasions when two or more professions learn from and about each other to improve collaboration and the quality of care" (CAIPE, 1997, revised). Collaboration is defined as an interprofessional process of communication and decision-making that enables the separate and shared knowledge and skills of health care providers to synergistically influence the client/patient care provided. Mechanisms must be in place that will enhance better collaboration and communication between health care providers and with patients. A common value system would result in the creation of a common vision for collaborative health and education, thus enhancing collaborative practice (Way & Jones 2000).

Clarifying Interprofessional Education and Collaborative Practice Outcomes

Through our research efforts, it was recognized that there is a need to distinguish the types of outcomes from educational interventions that are conducted. For educators, learner outcomes are of most importance. For health service researchers and policy-makers, the interest is more likely to be concerning quality of care and patient care outcomes. Although it is recognized that one of the ultimate goals for educational interventions in the health professions is to improve patient outcomes for IECPCP, we realized improving patient outcomes is not solely determined by the formalized educational interventions employed. With this realization in mind, the authors decided that there would be value in distinguishing categorizations for IECPCP related to the following defined outcomes:

• Educational Interventions to Enhance Learner Outcomes; and
• Collaborative Practice to Enhance Patient Outcomes.

Although the categorizations separate practice and education, we recognize that they are interdependent upon each other.

The Interdependency Between Interprofessional Education and Collaborative Practice

It is noted that interprofessional education and collaborative practice may be categorized separately but they are interdependent upon one another. To advance IECPCP, interprofessional education and collaborative practice cannot work in isolation. Their interdependence must be clearly understood and consciously promoted. Interprofessional education conducted at the pre-licensure level of training must take place in settings that house successful collaborative practices by practicing health professionals who can act as role models and provide experiences for students to work collaboratively. Thus, there is a need to identify and foster collaborative practices for which practitioners have both competence and the willingness to work collaboratively. Developing collaborative practices will entail the need not only for formalized competency training in collaboration but also organizational and systemic realignment to prioritize collaborative practice in appropriate settings and patient situations.

A Vision of Interprofessional Education for Collaborative Practice

Efforts should be focused on developing teaching processes to develop collaborative competencies (knowledge, skills and attitudes) necessary for our current and future health professionals to work in collaborative practices. It is hypothesized that if health professional trainees and those in practice are provided formalized training related to collaborative competencies (knowledge, skills and attitudes), the potential for a change in workforce patterns may occur. It is, however, recognized that competency alone is not enough for practice change to materialize. Within the workforce there is a need to understand the processes involved at both the organizational and the individual team levels to encourage and sustain collaboration. There needs, therefore, to be a vision of how we train health professionals and how health professionals should work together in their clinical settings. The elements of collaboration need to be understood, promoted and sustained throughout the continuum of learning and within the workforce of health professionals practising in Canada. Competencies related to collaboration will not be enough to change the "silo-like" practices that health professionals are accustomed to. The need to address the complex factors that influence the opportunities to advance IECPCP in Canada is pressing.

Determinants Affecting IECPCP at the Macro-, Meso-, and Micro-levels

As we have seen, interprofessional education and collaborative practice are linked. Thus, IECPCP cannot be achieved without addressing the issues arising from the following levels:

• systemic (macro);
• organizational/institutional (meso); and
• health professional practitioner/learner (micro).

It is recognized that at the systemic level, decisions made by government (in the areas of education, health and social policies) as well as profession-specific policies (like those from regulatory bodies) all influence the chances for IECPCP advancement since these decision-making bodies can structurally make it possible for IECPCP to become a reality in Canada. At the organizational and institutional levels, leaders and champions can enable change to take place and encourage interprofessional education and collaborative practices to be priorities. At the practitioner/learner micro-level, the influence of professional cultural values embedded amongst the identities of health professionals cannot be underestimated for they can either enable or impede the actualization of IECPCP. Professional cultural values are systemic. Often learners entering their training programs already have pre-existing stereotypes developed about other health professionals; these beliefs may be further consolidated through exposure to learning experiences and educator role models. Thus, there is a need to consider techniques of influencing the professional cultural values of health professionals to ensure that collaborative means of working are considered a priority. If we are to advance IECPCP, a collaborative venture must be undertaken by educators, practitioners, researchers and policy-makers. Therein lies the means in which the macro-, meso- and micro-level determinants for IECPCP can be addressed in a coordinated, sustainable fashion.

The Patient/Client's Role in IECPCP

Practising in a patient-centred and collaborative manner is valued by many who are advancing this area forward. The patient's well-being is central to the notion of IECPCP. Although available evidence to date is limited, it is increasingly evident that collaborative practice does enhance patient outcomes. We know that some specific patient populations and health problems benefit from a collaborative approach to care by health professionals working together in teams, but more research needs to be conducted to identify further when this approach provides best optimization of outcomes. We do know that the complexity of the patient's health care issues affects the need for a collaborative approach to care. Patients are thus at the centre of collaborative care since they are the very reason behind the interdependency of the professionals. This explains the terminology of "Collaborative Practice Patient-centred Care Practice" used in this report. Patients are simultaneously active members of the teams and recipients of the team care. Their privileged position in the team still depends on their willingness and ability to participate in the planning and delivery of health care. It is unclear at this time how we can best engage patients in our collaborative health care ventures. As IECPCP is advanced, it would be worthwhile to investigate this further, especially taking into account patient and provider cultural and socio-demographic considerations.

Research Opportunities

Research is needed to understand the complexities related to collaborative practice and how it can be taught or developed amongst health care providers. Much of this explanatory and exploratory research will need to use qualitative research methodology. In addition, clearly developed outcomes or benchmarks for IECPCP need to be established and measured. These include educational competencies (knowledge, skills and attitudes) and collaborative practice outcomes involving patients, professionals, the organization and system. The evaluative evidence to support collaborative practice and its impact on defined outcomes will arise from rigorous evaluation designs such as randomized controlled trials. A research program incorporating and integrating both qualitative and quantitative research methodology should be launched with studies emphasizing different components of the proposed framework (see Chapter 10) within diverse practice settings and different patient populations. In particular, the primary care setting should be a priority as studies to date are lacking in this area. The findings of the research conducted in this field must be transparent and disseminated in order for learned lessons to be shared. It will be imperative that duplication of research be kept to a minimum and that opportunities to build upon research work conducted are optimized if we are to advance IECPCP in a coordinated and timely fashion across disciplines, jurisdictional sectors and among health and education sectors.

An IECPCP Framework

From the synthesis of the environmental scan and literature review, this report presents an innovative conceptual framework developed by the researchers that can be used as a template to encourage dialogue among decision-makers, educators, researchers, health providers and Canadians toward the advancement of IECPCP. It provides an understanding of the complexities that will be involved in moving IECPCP forward and the need for all key stakeholders to work together. The framework can be seen in its entirety in Chapter 10.

Recommendations

1. Adopt a common language for IECPCP.
1. Develop terminology for IECPCP.
2. Make explicit at what level of training interprofessional education interventions are being implemented. Using the term "pre-licensure" denotes learners from both the undergraduate and postgraduate levels of training who are unable to practise their professions independently without a licence. "Post-licensure" learners would be described as health professionals who are able to practise independently and are licenced to practise independently. The distinction between these terms is important as it has implications on describing the types of interprofessional or collaborative practice interventions and aids in providing uniformity when comparing research interventions in the future.
3. Make explicit the types of outcomes that are being considered in any initiative embarked upon.
4. Clearly identify types of interprofessional education initiatives particularly to level of training.

2. Advocate and support for the education of health professionals that values collaborative patient-centred care.
1. Coordinate government activities to address barriers to IECPCP.
2. Consult with professional bodies on IECPCP standards and competencies.
3. Develop operating principles of IECPCP.
4. Coordinate academic institutes across disciplines to enhance IECPCP.
5. Review current education and training programs.
6. Identify teaching strategies to be employed that will define outcomes.
7. Develop IECPCP faculty development initiatives.
8. Create ways to address socialization factors to remove barriers and enhance opportunities for IECPCP.
9. Develop role models for collaborative practice.

3. Advocate and support for patient-centred collaborative practice.
1. Research and identify collaborative practice interventions that achieve improved patient outcomes.
2. Identify determinants that affect processes of interprofessional collaboration.
3. Determine the patient's role in IECPCP.
4. Develop evidence-based interprofessional collaboration inventions, particularly in the primary care settings.
5. Identify the organizational determinants that impact collaborative practice.
6. Identify role and responsibilities of health professionals in IECPCP.
7. Explore incentives that will foster collaboration.

4. Explore policy initiatives that will advance IECPCP.
1. Consult and explore with professional bodies on the impact of scope-of-practices in IECPCP.
2. Review legislation on current and related IECPCP initiatives.
3. Review current scope-of-practice rules and determine implications for malpractice liability within an IECPCP framework.
4. Determine the benefits of informatics in IECPCP.
5. Explore funding models for IECPCP.

5. Use change management strategies that will facilitate collaboration amongst health care professionals.
1. Initiate dialogue with stakeholders in exploring necessary changes to advance IECPCP.
2. Determine successful models of change management approaches to IECPCP.
3. Identify change management approaches that can be easily implemented.
4. Consider change management models and determine their application in the current health care system.
5. Develop change management policy strategies for IECPCP.

6. Address socio-cultural and diversity issues among population groups with special consideration for Aboriginal health when advancing IECPCP.
1. Address cultural and political diversity issues among population groups in advancing IECPCP.
2. Explore models that will foster collaboration in culturally diverse communities.
3. Develop IECPCP mandate for Aboriginal health.
4. Provide research funding for Aboriginal health in IECPCP.

7. Build upon current federal/provincial/territorial initiatives that facilitate the development and implementation of IECPCP.
1. Identify current federal, provincial, and territorial initiatives that can be leveraged to achieve and promote the goals of the IECPCP initiative.
2. Solicit feedback from stakeholders on the impact of IECPCP in their environments.
3. Develop and implement a policy process for IECPCP.
4. Consult with community leaders and communities to foster IECPCP.
5. Develop a public awareness campaign.

8. Create a national centre of excellence for IECPCP in Canada.
1. Explore strategies to effectively develop and support IECPCP knowledge transfer.
2. Establish a repository or a central resource to house key information (publications, research, databases) to advance IECPCP.
3. Create a forum for information exchange and knowledge transfer.
4. Establish a "Research Outcomes Commission" to aid in overseeing research that is conducted to build a body of knowledge for IECPCP.

9. Build a body of knowledge by funding IECPCP research initiatives based on criteria that will facilitate an understanding of the processes and outcomes related to models for IECPCP.
1. Actively engage in the establishment of linkages and partnerships with other health research stakeholders.
2. Build a body of knowledge related to IECPCP using well-designed qualitative and quantitative research methodologies.
3. Develop and conduct randomized control trials to test new interprofessional education and collaborative practice models.

Future Research Priorities

Priorities for conducting and funding IECPCP "Request for Proposals" include:

1. Post-licensure collaborative interventions: Recommend studies be conducted measuring:

Outcomes

a) The Patient: What health problems and/or practice settings (e.g. primary care) do collaborative practice models improve both individual patient and population health outcomes?

b) The Professionals: How does collaborative practice effect job satisfaction and well-being, recruitment and retention, productivity, efficiency, and professional development? Gaining a perspective from both patients and providers concerning their views on IECPCP and its personal impact on them should also be included.

c) The Organization: How does collaborative practice impact quality of services in terms of efficiency of health care services (i.e., reduce waiting lists and duplication of services), recruitment and retention, patient safety, evidence-based practice and cost effectiveness?

d) The System: What cost-benefit does IECPCP contribute to the entire health care system? What is the effectiveness of IECPCP in improving efficiencies? What are the population health outcomes?

Processes

As important to outcome measurements is the need to conduct research that looks at the dynamic processes that occur related to organizational factors and interactional factors affecting IECPCP.

2. Pre-licensure educational interventions: Recommend studies that address:

Outcomes

a) What are the competencies that can be taught to learners?

b) What methods can be used to assess students' competencies?

Process

a) Teaching Factors: What models for teaching collaborative competencies show the most promise? How can teaching strategies be developed based on theoretical models focusing on the context of learning and drawing on the role of facilitation?

b) Institutional Support: What methods can be measured to demonstrate the effect of institutional/organizational levers to impact interprofessional education? How can these methods be developed and implemented?

c) Educators: Acknowledging the impact of professional beliefs and attitudes that may be imparted to trainees from educators, what faculty development methods can be developed in order to impart the values of collaborative practice to learners?

3. Address interprofessional collaboration and education within the context of culturally diverse communities. Recommend research be conducted to determine:

a) What does collaborative practice mean to different communities, i.e., what is their understanding and vision of culturally specific collaborative patient-centred care? How it is received by them? Who would be the health practitioners involved?

b) How would collaborative practice best be implemented in various communities?

c) What are the distinct features of IECPCP that may or may not work for certain population groups?

d) How can IECPCP address gaps in health care access and the provision of continuity of care for certain population groups?

e) How can we build bridges between traditional and western medicine for collaborative practice?

f) What is the patient's role in patient-centred collaborative practice and how can we best involve the patient while taking into consideration the patient's views and cultural factors?

4. Research teams must demonstrate collaboration between educators, practitioners, institutional/organizational leaders and policy-makers who have expertise and experience in IECPCP and/or similar initiatives.

5. To ensure sustainability of research on IECPCP beyond this initiative, there is a need for consultation with other major research granting agencies to fund interprofessional education/practice initiatives in the future.

6. To reduce duplication in research efforts and to ensure that the science of IECPCP is based on rigorous empirical work, we support the establishment of a permanent "Outcomes Commission" under the auspices of a national centre for excellence in IECPCP that should be developed.

Canada's Readiness

In Canada, there is substantial momentum for change given the current health reform achievements and initiatives that have taken place over the past decade. All levels of governments, health and education sector institutions and health providers are committed to the need for change, however, implementation is gradual. Canadians are ready for health system renewal. Everyone has a role in deciding how services are organized and delivered in their health care system, including interprofessional care. There is considerable room for collaboration and cooperation. For many years, the provinces and territories have worked together on common issues of concern, sharing ideas and learning from each other's experiences; the area of IECPCP is one that is fertile for such collaboration to occur. Furthermore, the potential for primary health care reform and the important role it can play in transforming the health care system demands national leadership and national action.

An IECPCP policy directive that is patient-centred will play a critical role in developing the health care renewal framework. Timely action is imperative to obtain the commitment and resources that are needed to move IECPCP forward. Governments, institutions, health care providers, educators, researchers, decision-makers and Canadians must work collaboratively to prioritize the policies and determine what should be done to achieve interprofessional education for collaborative practice.

Researchers of the report concur that despite the limitations of the research, the current literature review demonstrates that it is feasible to develop an IECPCP framework as part of health system renewal. Findings from the literature review and environmental scan indicate that there are opportunities for creative, more focused research strategies to acquire the answers we need to develop a comprehensive IECPCP framework. Emphasis should be placed on the development and implementation of an IECPCP policy framework by leveraging existing federal/provincial/territorial initiatives. This would take into account the policy levers and enablers necessary to overcome the barriers that have been identified, bringing us closer to a health care system that practises and values IECPCP.

[1] Health Canada. Interprofessional Education for Collaborative, Patient-Centred Practice. Discussion Paper & Research Report Request for Proposal. October 2003.