Interprofessional education (IPE) is key to developing the interprofessional teams that are considered vital to improving our healthcare system and bridging well-known quality gaps.1 Preclinical IPE, or IPE outside of the clinical learning environment, is relatively well established and implemented with varying levels of authenticity, sophistication, and effectiveness at most health professions schools, in part driven by educational regulatory requirements. More recently, there has been an increasing recognition that IPE, in order to fully realize its benefits in practice transformation and improved patient care, needs to move beyond the classroom to the clinical learning environment.2 Calls for innovation within this intersection of IPE and interprofessional collaborative practice (IPCP) speak to the national urgency in moving IPE beyond the classroom.

Implicit in the idea that IPE is necessary to transform our clinical environments is the underlying recognition that current healthcare systems are inadequate: physician-centric, silo’ed, fragmented, and insufficiently responsive to the totality of patient needs. IPCP could address these shortcomings. While there are many encouraging clinical models that encompass aspects of the World Health Organization’s definition of IPCP, widespread adoption of transformational, patient-partnered IPCP, which meaningfully involves patients and families, remains elusive.

We created such an IPCP environment on our adult inpatient medicine teaching service.3 Workflows on these teams were interprofessionally integrated, requiring significant changes in daily activities for all involved professions. Rounds were collaborative and patient partnered at the bedside, and additional workflows, including dedicated time for team reflection and learning, were built into the day. While the experience was not perfect, we found that learners appreciated patients’ roles on the team3 and we observed modest process improvements. Ultimately, with the pandemic, our IPCP initiative ceased. With the recognition that creating patient-partnered IPCP environments is challenging, we reflect below on lessons learned and implications.

First, patient-partnered IPCP does not represent an incremental improvement on the status quo of inpatient adult medicine. Rather, it represents complete system redesign.

In our case, the redesign required had consequences at the system, team, and individual levels. Acknowledging this multi-level system complexity at least partially explains why implementation of transformational, patient-partnered IPCP remains a wicked problem and why typical quality improvement efforts, such as Plan-Do-Study-Act (PDSA) cycles, are ill-suited for this transformation. It also makes apparent why such tremendous energy is required from all involved in such initiatives to make and then sustain the redesign. While we are not suggesting that incremental improvements on our current healthcare delivery systems are without value, we are concerned that they may not be sufficient for the transformational change that patient-partnered IPCP requires.

To successfully accomplish the needed transformation, IPCP teams (and well-functioning teams in general) require partnership and input from all healthcare system stakeholders, leveling of hierarchy, and unwavering leadership support. This inclusive, constructivist approach is necessary, time-intensive, and, at times, exhausting. Consideration for appropriate, potentially reduced clinical workload in the context of transition to an IPCP care model is necessary. IPCP models, and subsequently teams, that emerge in conducive environments will be quite different across contexts. Even within our healthcare system, new patient-partnered IPCP teams with the same underpinnings functioned differently on different inpatient units within a single hospital. Because these IPCP team differences may reflect important differences in each care setting (i.e., spatial layout, staff deployment and availability), they should be respected and not necessarily considered implementation flaws.

Second, the skill set required for successful IPCP is greater than that for which team members are currently equipped.

As the Interprofessional Educational Collaborative’s (IPEC) core competencies for interprofessional practice (interprofessional practice, roles and responsibilities, interprofessional communication, and teams and teamwork—with 39 interrelated subcompetencies) make explicit, providing optimal care in IPCP settings requires additional knowledge, skills, and attitudes than that required in traditional care models.5 This is not an “either/or,” it is a “both/and;” health professionals practicing in these settings need to develop both profession-specific and interprofessional competency. Patients and families, as vital team members, require guidance as well.

Even with training, expectations, and iterative feedback to promote team member skills and team effectiveness, IPCP creates challenges with cognitive load for team members, and particularly learners, when engaged in true collaboration with patients and families at the bedside. Care conversations at the bedside are dynamic and rich, but also unpredictable; their complexity invariably leads to increased extraneous cognitive load (while variably affecting intrinsic cognitive load); this increased cognitive load will be more challenging for less experienced team members and learners to overcome.

Sensemaking, a social act of developing a shared mental model about what is happening and acting in a coordinated way based on that understanding, is a necessary team skill for managing the dynamic and often unpredictable nature of IPCP; further, it offers a framework to think through best practices for IPCP creation and support. In prior work, we noted that inpatient teams with observable behaviors that promote team sensemaking (e.g., defining the task at hand, clearly articulating the intent of care plans, soliciting concerns), have improved patient outcomes.4 Incorporating design elements that promote effective sensemaking (e.g., time for teams to reflect and learn together) could allow IPCP teams greater capacity to engage in sophisticated sensemaking required for working within contemporary, complex healthcare systems. Building teams’ sensemaking capacity, particularly across professions, takes time. This is another reason to consider clinical workload when introducing new systems of care to allow interprofessional teams time and space to develop and grow.

One challenge that quickly becomes apparent when building and growing IPCP teams is that while the interprofessional group tasked with disrupting the care environment evolves together, the interprofessional team members that form the actual teams delivering care are, in contrast, transitory, especially in teaching environments. As organizations move towards IPCP models of care, it will be essential to examine how to increase stability of teams through exploring staffing models that allow for increased continuity. Because discontinuity cannot be eliminated, however, strategies to rapidly orient and engage transient individual team members meaningfully in the constructivist team creation/maintenance process are needed. Creating a scaffolding for new team members is critical. This scaffolding can take many forms: team reflections, overlap of team members, simulation of IPCP activities, real-time coaching, and scripts and educational tools. All these approaches promote the specific behaviors that enable effective IPCP sensemaking. Our experience suggests that using multiple approaches is more likely to be successful.

Our healthcare system’s status quo is not acceptable for patients, learners, or care professionals. IPCP represents an important opportunity to meaningfully engage patients, families, and a diverse group of health professionals to develop the individualized, inclusive care plans that are necessary to improve outcomes. IPCP must be recognized as a fundamental redesign of our current system that requires an expanded skill set from clinicians and learners across the health professions. Our experience speaks to the importance of (1) recognizing the magnitude of the task of implementing IPCP and adjusting team clinical workload accordingly over time; and (2) recognizing the importance of sensemaking as a critical IPCP and system transformation skill, using purposeful strategies and scaffoldings to teach and promote effective sensemaking behaviors.

References

  1. Gilbert JHV, Yan J, Hoffman SJ. A WHO report: Framework for action on interprofessional education and collaborative practice. J Allied Health. Fall 2010;39 Suppl 1:196-7.
  2. Lutfiyya MN, Brandt BF, Cerra F. Reflections from the intersection of health professions education and clinical practice. Acad Med. 2016;91(6):766-771.
  3. Ding A, Ratcliffe TA, Diamond A, et al. Ready to collaborate?: Medical learner experiences in interprofessional collaborative practice settings. BMC Med Educ. 2020;20(1).
  4. Leykum LK, Chesser H, Lanham HJ, et al. The association between sensemaking during physician team rounds and hospitalized patients’ outcomes. J Gen Intern Med. 2015;30(12).
  5. Interprofessional Educational Collaborative, Practice IC, Values U. Core competencies for interprofessional collaborative practice : 2016 Update. Interprofessional Educ Collab. 2016;(May 2011):10-11.

Issue

Topic

Clinical Practice, Health Policy & Advocacy, Leadership, Administration, & Career Planning, Medical Education, Research, SGIM

Author Descriptions

Dr. Ratcliffe (ratcliffe@uthscsa.edu) is an associate professor in the Department of Medicine at The Joe R. and Teresa Lozano Long School of Medicine at the University of Texas Health San Antonio and the South Texas Veterans Health Care System and a 2016 Josiah Macy Jr. Foundation Faculty Scholar. Dr. Leykum (luci.leykum@austin.utexas.edu) is a professor in the Department of Medicine at the Dell Medical School at the University of Texas at Austin and the center lead for the Elizabeth Dole Center of Excellence for Veteran and Caregiver Research in the Department for Veterans Affairs. Dr. Pugh (pugh@uthscsa.edu) is a professor in the Department of Medicine at The Joe R. and Teresa Lozano Long School of Medicine at the University of Texas Health San Antonio.

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