Interprofessional Education for Collaborative Patient-Centered Chronic Disease Care

Interprofessional Education for Collaborative Patient-Centered Chronic Disease Care

Dalhousie University Faculty of Medicine

New Brunswick Community College
Table of Contents

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Overview (from section 5.2) Principal Applicant Organization Partner Organizations Patients and Learners Steering Committee Co-Chair : Keith De’Bell Co-Chair : Barbara McGill Project description 5.1 Title 5.2 Overview 5.3 Context 5.4 Conceptual Framework 5.5 Change in Culture and Attitude 5.6 Barriers and Challenges 5.7 Primary Target Audience 5.8 Integration of the Learning into Educational and Clinical Settings 5.9 Bibliography Project Objectives Tentative Timelines Evaluation Knowledge Transfer, Networking and Dissemination Sustainability Appendix: Project Summary

3 5 6 7 9 10 11 12 12 12 13 14 17 17 18 18 19 20 21 23 27 28 29

Overview

Four partners have come together on this project:

• 
  University of New Brunswick (UNB) that offers a Bachelor of Nursing, a Bachelor of Nursing for Registered Nurses and Bachelor of Health Sciences degree programs at its Saint John Campus;
  
• 
  New Brunswick Community College (NBCC) that offers Practical Nurse program and parts of BHS programs at its Saint John Campus;
  
• 
  Atlantic Health Sciences Corporation (AHSC) that is a practice setting including a tertiary care hospital and a primary care Community Health Center;
  
• 
  Dalhousie University that offers medical education practice through distributive learning experiences to Family Medicine residents through the St. Joseph’s Community Health Centre (SJCHC) of AHSC and undergraduate clinical clerkships in Saint John through the AHSC facilities.
  

Each partner has varying degrees of experience with Interprofessional Education (IPE). This concept is new to faculty and students in the education programs at UNB Saint John and NBCC Saint John. Interdisciplinary teams can be found at AHSC, but need to be developed to a higher level. SJCHC is on the cutting edge of interprofessional primary care and provides workshops based on the “Building a Better Tomorrow Initiative” (BBTI) to education health care providers in interprofessional care. Dalhousie University Faculty of Medicine is a partner in the Tri-faculty Interprofessional Program that includes mandatory seminars for students in all health disciplines on this important new concept (Cycle I of IPEPCC).

• 
  Increase the capacity of health educators to promote IPE with pre-licensure students through faculty development and strengthening liaison with partners already engaged in IPE. Faculty development will include both workshops to familiarize educators with IPECPCP concepts and benefits and active engagement in the curriculum development;
  
• 
  Increase the capacity of pre-licensure students and post-licensure professionals to deliver interprofessional care through curriculum development including interprofessional experience leading to participation in a “capstone” workshop on chronic care, and practice experience in clinical settings at AHSC and CHC;
  
• 
  Strengthen the functioning of post-licensure interprofessional teams across medical-surgical units of AHSC to ensure that pre-licensure students have opportunities to participate in high functioning teams in practice for the benefit of patients receiving integrated clinical care;
  
• 
  Evaluate each component of the program for its effect on educators, pre-licensure students, post-licensure professionals, and patient care.
  

The work already done at the SJCHC with the BBTI will be used as a starting point for the project. BBTI is a modular program developed in Atlantic Canada through the PHCTF, addressing the various aspects of IPE. Facilitators have been trained to deliver the program components to primary care providers at AHSC working in CHC, public health, and community mental health. Currently BBTI is being offered for these groups through AHSC. We will build on this work including preparation of other clinical areas for IPECPCP, and develop complimentary new tools for IPECPCP delivery and evaluation.

• 
  The three facilitators;
  
• 
  Representatives from the faculty/educators and pre-licensure students of each partner;
  
• 
  Representatives from the practice partners and post-licensure professionals;
  
• 
  Patients with chronic illness (e.g., Diabetes).
  
• 
  Administrative representatives of the partners
  

The unique features of this program are:

• 
  The provision of IPECPCP in the unique health/medical education environment of New Brunswick;
  
• 
  The inclusion of PN students with BN, and Medical students in an IPECPCP initiative;
  
• 
  The development of a “capstone” workshop/simulation of interprofessional management of chronic illness patients.
  

Tucker Park Rd,

Saint John,

New Brunswick. E2L 4L5

FAX: (506) 648 5784

E-Mail: kdb@unbsj.ca

Organization mission, goals and objectives

The University of New Brunswick is a national comprehensive university providing high quality and innovative programmes in both education and research. Its mission includes both

• 
  Serving New Brunswick, the Atlantic Region and Canada through the provision of broadly educated graduates and through the development of applied programmes,
  

and

• 
  Co-operating with governments and post-secondary institutions in developing a coherent system of advanced education (University Mission Statement, UNB Calendar).
  

The University’s commitment to applied programmes in health care education and to innovative partnerships with other institutions are reflections of its goal of carrying out its fundamental role in the economic, social and cultural well being of the province and of Atlantic Canada, as a national university and as a learning institution (UNB President’s report 2003-4, p.3).

Dalhousie University Faculty of Medicine (Dal)

New Brunswick Community College (NBCC)
The partners have a history of working together and maintaining communication both formally and informally. Previous formal agreements have typically been either bilateral (e.g. AHSC and Dalhousie University for the family practice residents programme at the St. Joseph’s Community Health Centre) or trilateral (e.g. AHSC, UNB, and NBCC for the Nuclear Medicine Stream of the BHS programme). To the best of our knowledge this will be the first formal multi-institutional education programme agreement that all of the partners have been involved in. It reflects the shared vision of the institutions involved in this proposal of increased capacity in health education through multi-institutional collaboration.
The working relationships amongst the partners have demonstrated their ability to work collaboratively while maintaining their separate governance structures. In particular, curriculum changes and new courses referred to in this document will be developed subject to the normal approval processes of the appropriate partner institution.

3. Patients and Learners
Patients: This programme will be constructed around a patient-centered approach to care for patients with a chronic disease. One of the advantages of building the programme around a chronic disease is that it will allow us to examine and discuss interprofessional interaction in the continuum of care along the illness trajectory. This will involve consulting with patients at different stages of the disease to inform curriculum development. Patients with a chronic disease will be involved throughout the construction of the pre-licensure and post-licensure (including continuing education) curriculum and faculty development programme, and throughout the running of the project. (Details are given in the project description below). Patients will also contribute to the evaluation component by providing feedback on the degree to which the interprofessional training has addressed patient needs.

Regarding the recruitment of patients, an obvious choice would be persons with diabetes. Opportunities for involvement in the programme will be advertised to the client population of the diabetic teaching programme of the St. Joseph’s Community Health Centre. As we wish to include interprofessional issues that may arise for patients in rural settings, patients living in rural southwest New Brunswick (Health Region 2- from Sussex to St. Stephen including the Fundy Isles), as well as those living in urban settings will be included.

In keeping with the objectives of the programme stated below (Section 6) the principal learner groups will include faculty/health educators, pre-licensure students, and post-licensure health professionals.

Faculty development to increase the number of health educators able to facilitate IPECPCP is a core aim of this programme. Faculty in the Department of Nursing UNB Saint John, Faculty in the Faculty of Health Sciences, NBCC, and Faculty affiliated with Dalhousie University Medical Faculty will have access to this training. However it is understood that changing the attitudes and education strategies of all health care educators, including those who may act as preceptors or mentors for students in a clinical setting, to include interprofessional team work and patient centred practice is necessary. Therefore the faculty development stage of the programme will include workshops on interprofessional approaches and patient centred practice open for participation to all health care professionals having a role in clinical site education.

Students

The pre-licensure core learners groups include pre RN Bachelor of Nursing (BN) students (UNB Saint John), and practical nurse (PN) students (NBCC). (See proposal description below). Approximately 40 students per year in each of the PN and pre RN BN programmes will take the IPECPCP programme. Pre-licensure students will typically take the course in the upper years of their programme.
The core learners will also include 10 post graduate family medicine residents from SJCHC. At present, residents at the SJCHC are students in the Dalhousie Medical School postgraduate programme however they will have taken their undergraduate medical training at medical faculties across Canada and in some cases outside Canada. Consequently not all residents will have received the same IPE as undergraduates and in some cases may not have received any IPE. We believe this reinforces the need for an IPE programme at the postgraduate level immediately prior to licensure.
The core learner groups as identified above reflect the education qualification which each group has before licensure (i.e. certificate for LPNs, Bachelors degree for RNs, and postgraduate training for MDs). It is therefore appropriate to develop interprofessional experiences that bring together these core groups as outlined in this proposal. At present, undergraduate MD students from New Brunswick are primarily educated at Dalhousie University (Halifax, Nova Scotia) and Memorial University (St. John’s, Newfoundland). Undergraduate MD students may return to New Brunswick for part of their clinical rotation however the numbers and areas of specialization are difficult to predict under the current system. However, it is also recognized that this programme provides an opportunity to provide undergraduate MD students with IPECPCP during their clinical rotation at AHSC. For the purposes of this pilot study we have focused on the students in the internal medicine clinical rotation and there is agreement in principle to develop an IPECPCP component for these students. Because of the nature of the clinical rotation this will, in general, be asynchronous with the other core learner groups however it will be designed to build on the other IPE components that these students receive as part of their undergraduate training at Dalhousie Medical School. We will also attempt to establish links with those programmes that undergraduate New Brunswick MD students enter to establish better integration of IPECPCP at all levels of the MD education path.
Similarly IPECPCP training will also be made available to social work, dietician, pharmacy and other health profession students placed at SJCHC.
This pilot project will also provide opportunities for the integration of IPECPCP into other health care programmes shared by the partners including the BHS/diploma programmes for Nuclear Medicine, Radiography, Radiation Therapy, and Respiratory Therapy.

Within the AHSC system an interdisciplinary team environment has been developed in units such as the SJCHC. However few of the AHSC staff have had formal IPECPCP training currently. AHSC staff will be provided with access to IPECPC through a continuing education programme. This component of the pilot project is intended to effect the workplace environment for interprofessional patient centred practice (see section 5).

For the purposes of the pilot project the language of instruction will be English (following the normal practice of the educational institution partners) and both patients and learners will be communicated with in English. However, the final report will be translated into French and disseminated in both official languages. We expect to develop Faculty Development packages and Curriculum packages in both official languages.

4. Steering Committee
The steering committee will ensure continued communication between the partner institutions at the appropriate level, will continue to monitor the programme is matching the model of IPECPCP, and will ensure that appropriate and sustained evaluation is in place.
Co-chairs (one page descriptions follow this section): Keith De’Bell (Special Advisor to the President and Vice President (Saint John), UNB) and Barbara McGill (Vice President (Community) and Chief Nursing Officer, AHSC).
The steering committee membership has been chosen to address the various roles necessary within the Committee to ensure a sustainable programme consistent with the IPECPCP model. These include ensuring on-going support of the programme and liaison from the education institutions and practice sites. The Steering Committee composition has also been chosen to reflect the interactions between groups within the IPECPCP model and therefore includes representatives of patients, educators, and learners. The Steering Committee composition is also consistent with our view that interprofessional education should reflect the continuum of care throughout the illness trajectory required for patient centred care as well as the interdisciplinary team approach for specific interventions.
Nine members of the Steering Committee are persons with administrative responsibilities such that they will be able to ensure the required attention to liaison between the partners and regard for sustainability occurs. The representative from the Faculty of Education will be able to advise the Committee on education models and best practice and will ensure the Committee has access to other members of the Education Faculty when specific expertise is required. The current Education Faculty representative has considerable expertise in evaluation practice.
The remaining members of the Steering Committee will ensure that the programme development is guided by input from the core centres of the education and practice areas of the IPECPCP model and the interaction between them.
The three facilitators will be appointed following approval of the proposal. They will be drawn from front line educators/practitioners and their roles within the project will include IPECPCP curriculum development and integration (see below for a detailed description). Within the steering committee they will provide an essential connection between the administrative oversight and the “on the ground” practice of the programme.
The patient representatives will normally be drawn from the population of knowledgeable chronic disease patients and these interact in the practice setting with post-licensure professionals which are also represented in the Committee. (We use ‘practice setting’ here in the broadest sense of where health care is delivered). We recognize that the learner at the centre of the interdisciplinary education system may be a pre-licensure student or a post-licensure professional whose interdisciplinary education is a response to the need for collaborative care in patient centred practice; thus there is an interaction through the post-licensure professionals between the patient centred professional system and the learner centred education system. Both pre and post-licensure groups of learners are represented. The Committee also has representation from the educators who facilitate the enculturation of the learners in their professional beliefs and attitudes. The representatives of the learners, in-practice professionals and educators will be chosen to ensure a broad representation of the professions in the Committee.
Co-Chair: Keith De’Bell

Institution: University of New Brunswick

Position: Special Advisor to the President and Vice-President (Saint John), Health Care Education and Research

Education: B.Sc. (Physics, London, 1976), M.Sc. (Solid State Physics, London 1977), Ph.D. (Mathematics, London, 1980)

Experience

• 
  Teaching: Range of teaching experience in statistics, mathematics and physics including the development of innovative curricula for the teaching of physics to elementary school teacher candidates and for in-service development of elementary school teachers.
  
• 
  Research : Funded by Natural Sciences and Engineering Council of Canada since 1985, published articles in refereed journals 78
  
• 
  Administrative Experience : Associate Dean of Arts and Science (Trent University, 1993-1998), Dean of Science, Applied Science and Engineering (University of New Brunswick in Saint John, 1999-2004), Special Advisor to the President and Vice President (Saint John), (University of New Brunswick 2004-)
  
• 
  Other recent relevant experience Member (1999-) and Chair (2005-) of the Atlantic Science Council (APICS), Member, Management Board, Canadian Rivers Institute (2001-2004), Chair, Evaluation Subcommittee, and member, Implementation Committee, St. Joseph’s Community Health Centre (2002-3), Chair, Research and Evaluation Committee, and member, Leadership Roundtable, Vibrant Communities Saint John (2005).
  

Comments: As Dean of Science, Applied Science and Engineering (1999-2004), Keith De’Bell had Faculty level responsibility for the Department of Nursing at UNB Saint John. He was also responsible for the Bachelor of Health Science programmes which report directly to the Dean. As Dean of the Faculty and Chair of the Bachelor of Health Sciences Advisory Committee he developed a strong working relationship with partners in the BHS programme, i.e. a community college and two regional health authorities. He was closely involved in developing the formal agreements, which underpin the BHS partnerships and in developing the “integrated programme” model of the BHS degree. He has also developed a health research partnership between the University, the New Brunswick Community College, the National Research Council Institute for Information Technology and the Atlantic Health Sciences Corporation. His present position of Special Advisor includes building collaborative partnerships amongst educational institutions, health care authorities, government departments, and NGOs to increase the University’s capacity to deliver innovative health care education programmes and national standard research.

Co-Chair: Barbara J. McGill

Institution: Atlantic Health Sciences Corporation, (Region Health Authority 2, NB)

Position: Vice-President, Community Programs and Chief Nursing Officer

Education: MN (Dalhousie University, Halifax, NS) 1983. BN (University of New

Brunswick) Fredericton, NB, 1984, RN (St. Joseph’s Hospital School of Nursing) Saint John, NB, 1969

Experience:

• 
  Research: Site Coordinator, Atlantic Health Sciences Corporation, Understanding the Costs and Outcomes of Nurses Turnover in Canadian Hospitals (in progress) 2005 - 2006. Nursing Effectiveness, Utilization and Outcomes Research Unit, University of Toronto (CHSRF funded) 2005 - 2006, Nursing Environments: Knowledge to Action ñ The Centre for Organization Research and Development, Acadia University, Wolfville, NS (in progress, Health Canada funded), Evaluating Implementation and Integration of the Nurse Practitioner Role in BC and NB. (Letter of intent approved - awaiting funding in August, CIHR funded), 2005, Effective mechanisms for establishing, monitoring and predicting the needs for Nursing services in the Atlantic Provinces, Atlantic Consortium on Research Utilization for Nursing, (CHSRF funded), 2003, Communaute vertielle de pratique en sante du coeur – L’ordre des infirmire, et infirmiers du Quebec, 2003, Evidence-based standards for measuring nurse staffing and Performance ñ Nursing Effectiveness, Utilization and Outcomes Research Unit, University of Toronto, (CHSRF funded), 2003
  
• 
  Administration: Vice-President, Community Programs and Chief Nursing Officer, Atlantic Health Sciences Corporation, Saint John, NB, 2003- present, Vice-President, Planning and Chief Nursing Officer, Atlantic Health Sciences Corporation, Saint John, NB, 2000 ñ 2003, Adjunct Professor, Nursing, UNBSJ, 1998-present, etc
  
• 
  Other Recent Relevant Experience: President, Academy of Canadian Executive Nurses, 2005 - 2006, Chair, Nursing Resources Advisory Committee to the Minister of Health and Wellness, NB, 2001 ñ present, Chair, Integration and Coordination of Care and Services Committee, Region 2, NB, 1999-present, Surveyor, Canadian Council on Health Services Accreditation, 1995-present, Member, NB Steering Committee ñ Transition of Community Mental Health / Public Health to RHAs, 2004-present
  

Comments: Barbara McGill brings a progressive perspective to the integration and coordination of care and services to patients and clients between AHSC and the health and community sectors of Region 2. This perspective is honed through active involvement in the development, implementation and evaluation of patient care delivery efforts at the local, provincial, and national levels. The challenges of regionalization provided her the opportunity to explore the application of an integrated interdisciplinary patient-centred, outcome-oriented approach to care delivery within a program management context. Ms. McGill has been providing nursing professional practice leadership to Atlantic Health Sciences Corporation since 1993.
5. Project description
5.1 Title: Interprofessional Education for Collaborative Patient-Centered Chronic Disease Care
5.2 Overview.
The benefits of interprofessional teams in patient centred practice have multiple potential benefits:

• 
  for the patient (increased coordination of services, integration of health care for a wide range of health needs, empowerment as an active partner in care),
  
• 
  for health care delivery professionals (increased professional satisfaction, (where appropriate) shifts emphasis to long term preventative care, allows professionals to focus on individual areas of expertise),
  
• 
  and for the health care delivery system (more efficient delivery of care, decreased burden on acute facilities as a result of increased prevention and patient education interventions)[1].
  

In order to ensure that these potential benefits of this model of health care are realized it is necessary to ensure that the education model reflects the practice model.

The complex interactions described in the interprofessional education for patient centred practice (IPECPCP) model of D’Amour and Oandasan [2] require a multifaceted approach which affects the education system, the learner, and the workplace.
Education system: The proposed project will increase the capacity for IPECPCP through a faculty development programme for university and community college faculty, and for in-practice health care providers (health educators) who act as mentors for students during their practice experience. A component of this faculty development programme will be joint development of the interprofessional experience for students.
Students: Integration of IPECPCP materials into the curricula of the partner institutions and provision of common experiences which reflect the interprofessional environment will provide students with opportunities to learn about each others distinct professional roles while developing experience with interprofessional team work in a patient centred practice context.
Workplace: In addition to providing a development programme for health educators, the proposed project will develop a programme of training for in-practice health professionals who have not previously received formal IPECPCP.
Evaluation: An effective evaluation programme is essential to assess the effectiveness of the programme both in terms of process and outcome, and to inform further development for a sustainable IPECPCP programme. The programme will build on existing evaluation tools including those that have been developed for the BBTI programme, to assess the effectiveness of the workshops employed. New evaluation tools designed to assess changes in approaches to practice will also be developed.
While the pilot project is intended to provide experience that may be useful in other regions of Canada, the details of the proposal reflect some of the context of the particular model of health care education used in New Brunswick. This context is described in the following subsection. A detailed description of the proposal is then provided.

5.3 Context

At the present time no medical school exists in New Brunswick however components of the medical education programmes are provided in Saint John through clinical rotations for undergraduate MD students and residencies for postgraduate students (see below). This places limitations on the opportunities for IPECPCP including MD students however these opportunities will be utilized as described below.

New Brunswick uses a variety of inter-provincial agreements and in-province programs to provide education for health professionals. There are a number of excellent programs providing education to health professionals here in the province. The University of New Brunswick Saint John offers a four-year Bachelor of Nursing degree, a part-time Bachelor of Nursing degree program for Registered Nurses, and a Bachelor of Health Sciences degree (Radiography, Respiratory Therapy, Nuclear Medicine, and Radiation Therapy). The New Brunswick Community College at Saint John offers a Practical Nurse (PN) Programme, a Respiratory Therapy program, a Nuclear Medicine Technology programme, a Medical Laboratory Technology programme and a number of health care support worker programs. The Atlantic Health Sciences Corporation also provides programs for health disciplines such as Radiography and Radiation Therapy.
The Region 2 Health Authority (AHSC) serves south western New Brunswick from St. Stephen to Sussex, including the Fundy Isles. The Saint John Regional Hospital is a large tertiary care hospital which provides cardiac services to the province and is one of two centres in New Brunswick for neuroscience and oncology. The region also includes a number of smaller hospital and health centers, the Extramural Hospital program, and an urban Community Health Center. Public Health Services and Community Mental Health Services are being incorporated into the Health Authority. A full range of patient/client services are provided by health care professionals from various disciplines within the Region. The Health Authority accepts students for clinical placements from the Nursing programs at UNB Saint John, from the PN and health programs at NBCC-SJ, and from a variety of other professional education programs from other parts of Canada. The Medical Faculties of Dalhousie University and Memorial University are affiliated with the Health Authority for clinical placements of medical students and residents and many of the medical staff at AHSC have academic appointments with these universities. The Health Authority also hosts students from other disciplines for clinical placements such as physiotherapy, occupational therapy, psychology, social work, and clinical dietetics. Clinical placements for students from UNB Saint John and NBCC-SJ are coordinated so as not to overwhelm clinical areas, but each educational program functions independently.
Currently the students in these programs may receive some content related to team function and/or development of skills essential to effective team membership. In addition some of the B.N. students obtain multi-disciplinary points of view through classes shared with other health care professionals in classes such as “Health Ethics” and “Health Research”. Students have varying degrees of exposure to teamwork among health care professionals within clinical placements, e.g., some attend team conferences or rounds while a few may prepare a patient assignment for colleagues. However, there are currently few opportunities to examine roles and responsibilities, explore differences in care frameworks or philosophies, or develop advanced skills for effective interprofessional practice. The proposed IPECPC programme will provide a systematic and comprehensive approach to interprofessional education for all of the learner groups identified in this proposal.
5.4 Conceptual Framework: The conceptual framework for this pilot study incorporates key features of the interprofessional education for collaborative patient centred practice model of D’Amour and Oandasan [2]. In particular it reflects the fact that to be effective as an education programme for patient centred care the interprofessional education must be informed by the patient’s view of the trajectory of the illness. Therefore we have structured the programme development so that it will be informed by articulate patients at various stages of the chronic disease, moreover patients will be involved in the steering committee and their assessments will be used as part of the evaluation process. For the purposes of this pilot study, patients can be invited to participate through the SJCHC diabetes management programme.
The framework also notes that the work of D’Amour and Oandasan [2] identifies the role of the workplace culture in making interprofessional education either effective or ineffective. Moreover, it takes into account the role of faculty within the student centred education component, in the enculturation of students in their discipline. Therefore we will develop both an interprofessional education component of the AHSC continuing education programme, for in-practice professionals who have not previously had exposure to (formal) interprofessional education for patient centred care, and a faculty development package for educators both within the education institutions and within the clinical setting. Our proposal includes design and implementation of interprofessional experience for students and practitioners in the examination of professional roles and barriers to collaboration, and in development of advanced skills to enhance effective teamwork.
The conceptual framework outlined above has lead to the project being developed as four phases:

1. 
   Resource Identification
   
2. 
   Faculty Development
   
   • 
     Orientation and Awareness
     
   • 
     Joint Curriculum Development
     
   • 
     Curriculum Materials and Reports
     
3. 
   IPECPCP Implementation
   
4. 
   Final Report and Evaluation
   

A more detailed description and tentative timelines are given below (sections 7 & 8). Each phase develops a foundation for the following phase and concurrent with these phases an evaluation process which interacts with the phase and informs the development of the next phase, is carried out.

While the project will include interprofessional team experience in the practice setting it will also provide simulations to facilitate understanding of interprofessional practice including the distinct but interacting roles of the team members. The evaluation process will also use simulations to assess the effect of the programme.

Simulations can take a variety of forms, such as computer programs, physical models, and problem-solving exercises on CD-ROM or DVD. Nursing faculty at UNB Saint John use situational simulations of case studies, as well as interviews of patients and families, and actors taking on roles. Simulations are also used in upper year medical programmes although traditionally the use of simulated patients by actors is primarily used for the final assessment process and does not include a collaborative care team of students. For the purpose of this project, we are proposing a combination of all three of these methods. Simulation experiences can be used to explore student attitudes and values as well as to practice decision-making and communication skills. Simulations have the advantages of being repeatable, predictable and schedulable. In addition, the ability to tailor the simulation provides an opportunity to explore different health care issues in the rural and urban settings.

A “capstone” simulation is to be delivered in a workshop format with the core audience being BN and PN Students in the later parts of their programs, as well as family practice MDs in the residency component of their programme where possible. In a patient-centred continuum of care model, after graduating from their respective programs, these students will work together in patient care delivery teams in the workplace. These are chosen as the core professions for the study as the numbers of students is predictable and large enough to allow some quantitative analysis. Within the New Brunswick model of health care education provision the numbers and specializations of other students may vary; however, this model has the advantage that over time many different professions and specializations will be involved in the programme. Inclusion of post-licensure health professionals in the workshops will be through the AHSC continuing education programme.
We expect the workshop to take 1.5 days with all students brought to a single site for the duration of the workshop. The workshop will include an orientation session, interviews and practice setting simulations with students in small interdisciplinary groups (maximum of eight students per group), post practice setting simulation discussion and analysis in small interdisciplinary groups, large group comparison and discussion including comparative analysis by groups working at different stages in the trajectory of illness. (For the interviews and practice setting simulations actual patients and simulated patients will be used depending on the availability and appropriateness of actual patients).
Simulated practice setting situations have been used previously for inter-disciplinary education [3] [4] [5] [6]. Generally speaking these have shown that this education model is effective for identifying differences in perception of issues through, for example, differences in approaches to ethical issues in the cultures of different disciplines. It is also effective for enhancing students’ awareness of differences in roles and scope of practice. The proposed programme specifically incorporates the model of interprofessional education for collaborative patient centred practice by looking at the interaction of the patient view of the illness trajectory and the practice setting culture, with the interprofessional education model.
In preparation for the simulation workshops, students will participate in learning experiences that will be integrated into their existing course work at their own institutions and which will include interprofessional workshops. They will then come together for a planned simulation experience to work in teams to address patient case studies. To create the interprofessional experience, students from other professional disciplines involved in clinical placements in the Health Authority will be invited to participate in the simulation as they are available. When students are not available, then practicing members of the professional group will be invited in to provide additional professional perspectives. As described below, health care practitioners who have not previously had access to formal health care education will take part in the simulation exercises and as part of their formal preparation prior to the simulation exercises will be provided with learning materials on collaborative team practice relevant to in-practice professionals.

The case studies used in the preparatory work and simulation exercise will be based on chronic illness experiences and management. This is supported by the fact that population health studies indicate that there are high rates of many chronic illnesses in the local area[7], and complex chronic illness or multiple co-morbidities lend themselves to team interventions. For the purposes of the pilot project discussed here we anticipate using diabetes as the main chronic illness on which to base the case studies. Centering the case studies used in the realization of the education model on a chronic illness, such as diabetes, is informed by the interaction between the education model and patient centred care model identified by D’Amour and Oandasson[2]. In particular, this provides access to a substantial number of patients whose experience in managing their disease and in interacting with health care professionals, will inform the development of the programme.

The simulations will be based on a combination of stimuli, including written case descriptions related to chronic illness, actors who will take on the role of patients with this condition, and/or interviews with patients and families who are experiencing a complex chronic health challenge. Patients experiencing the specific conditions under discussion in the simulation will be consulted as a part of the planning process. The theory component of the programme will be packaged into an independent study that will be completed in preparation for participation in a simulation.
A programme for practicing professionals in collaborative care and interprofessional practice will be established. This is consistent with the observation by D’Amour and Oandasan [2] that “it is important to have clinical settings where collaborative practice is modeled” and that “institutional factors (meso level) can influence the professional beliefs and attitudes of faculty and learners towards interprofessional ways of learning and practicing”. Existing practitioners in the profession may be either formal or informal mentors to new practitioners in the workplace and, in particular, may either reinforce or diminish the role of interprofessional practice and collaborative care as part of the workplace culture. We hypothesise that new recruits will be either positively or negatively influenced by in-practice individuals in their profession according to their degree of developed interprofessional education and practice of professionals already established in the workplace. A study of this will require a longer period of research than can be incorporated in the two year pilot programme and, therefore, will form part of the long term evaluative research for the interprofessional programme beyond the term of this pilot project. However during the pilot project we shall be able to assess the role of in-practice professionals in the groups and to assess models for the inclusion of such professionals in the full programme (see Section 6.8 below). The senior administration of AHSC has given its support to developing such a programme as part of its continuing education programme.
5.5 Change in culture and attitude
As noted above the programme will address IPECPCP both for pre-licensure students and post-licensure in-practice health care workers. In doing so it will effect both the education setting centred on the student and the practice setting centred on the patient. This recognizes the point made by D’Amour and Oandasan [2] that interprofessional education will not be effective in changing the model of patient care if it is not supported by the practice setting culture.
5.6 Barriers and Challenges
Implicit assumptions of hierarchy. The core learner groups in this programme are PN students, BN Students and MD residents. These groups have different types of education experience (certificate, undergraduate degree, and post-graduate training) and this is often accompanied by different types of life experience (typical ages may vary significantly among the groups). Historically health care has used a hierarchical structure amongst health professions and even within professions. However effective teamwork has been shown to positively affect health care practice and outcomes and has been associated with trust and mutual attunement in shared time and space even in stressful healthcare situations [8]. We will address any implicit assumptions of hierarchy that may be associated with the differences in educational experience by placing emphasis on mutual respect for the distinct but interacting roles of team members.
Limited number of full health education programmes. We deliver full education programs for only a small number of health care disciplines in our geographic area, so in order to create a true interprofessional education experience we are proposing an innovative collaboration to overcome this barrier. A particular difficulty in this context is that undergraduate MD students receive most of their undergraduate training outside New Brunswick. At present undergraduate students are present in Saint John only during certain of their clinical rotations and therefore both the exact number and area in which they work is unpredictable. We intend to liaise with the Dalhousie University and Memorial University programmes so as to understand and build on the IPE that they provide for undergraduate MD students.
Faculty Experience with IPECPCP. While some of the faculty who will be involved with this project have experience with multi-disciplinary programmes and there is some experience with simulations within specific discipline contexts, there is a need for a larger number of faculty who can integrate inter-disciplinary team patient centred health care into their classes and who can facilitate the inter-disciplinary workshop. This will be addressed through a faculty development package as described above.
Student Assessment. The issue of student assessment may prove difficult because of different methodologies in the different programmes. However, experience with multi-institution programmes such as the Bachelor of Health Sciences programme indicates that this can be addressed through the steering committee.
Limited numbers of students in some disciplines For some disciplines the numbers of students may be very small even after the programme has been run several times. For this reason, quantitative analysis will be used primarily in the case of the core groups of learners as identified above however qualitative data will be collected from all groups including facilitators and patients. (See section 8).
5.7 Primary Target Audience: The primary target audience is those entering or in-practice in the professions of practical nurse, registered nurse and MD. These have been chosen as they form core components of the interdisciplinary teams for patient centred practice. Secondary audiences are undergraduate MD students during clinical rotation, other health professions and, through the faculty development package, health educators.



5.8 Integration of the Learning into educational and clinical settings
As described above the integration into the educational setting will be by weaving the interdisciplinary team for patient centred care approach into the curriculum of existing courses (PN, BN, and post graduate MD). Students in the PN and RN groups are provided with clinical experience during the course of their programme therefore they will have an opportunity to apply education in interdisciplinary team patient centred care in the clinical sites used for this clinical experience. The SJCHC environment in which the MD residents work is based on patient centred practice through interdisciplinary teams. Residents will receive orientation and workshops (BBTI based) which provide IPECPCP. Depending on where the resident previously studied, this will either supplement and reinforce previous IPECPCP training or introduce this training to the resident. A specific objective of this proposal is the integration of interprofessional team experience into the practice setting placements of students (objective 3 see section 6).
Atlantic Health Science Corporation is the main practice setting provider for the PN and BN programmes and is committed to interdisciplinary practice to support patient centred care. The health educator component of the faculty development phase and continuing education programme described above will accelerate the integration of this model into the practice settings where the BN and PN students receive their clinical training.
5.9 Bibliography
[1] Grant RW, Finnocchio LJ, and the California Primary Care Consortium Subcommittee on Interdisciplinary Collaboration. Interdisciplinary Collaborative Teams in Primary Care: A Model Curriculum and Resource Guide. San Francisco, CA: Pew Health Professions Commission, 1995. (As quoted in Building a Better Tomorrow materials).
[2] D. D’Amour and I Oandasan, Interprofessional Education for Collaborative Patient-Centred Practice : an evolving framework, Interprofessional Education for Collaborative Patient-Centred Practice, Chapter 10 (Health Canada 2004)
[3] O. Wahlstrom and I. Sanden, Multiprofessional training ward at Linkoping University: Early Experience, Education for Health: Change in Learning & Practice v.11 p231-236 (1998)
[4] G.J. Mires et al., Multiprofessional Education in Undergraduate Curricula can work, Medical Teacher v.21 281-285 (1999)
[5] J. Ker, L. Mole, and P. Bradley, Early Introduction to Interprofessional Learning: A Simulated Ward Environment, Medical Education v.37 248-255 (2003)
[6] C. Edward and P. E. Preece, Shared Teaching in Health Care Ethics: A Report on the Beginning of an Idea, Nursing Ethics v.6 299-307 (1999)
[7] K. Hayward and R. Colman, The Tides of Change: Addressing Inequity and Chronic Disease in Atlantic Canada. A Discussion Paper. prepared for the Population and Public Health Branch (Health Canada 2003)
[8] H. Menzies, Nurses and Health Care (Chapter 5); No Time: Stress and the Crisis of Modern Life (2005 Pub Douglas and McIntyre, Vancouver)

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