Applications of ICF Framework
6.5 Barriers and enablers to IPECP and ways to address these challenges
6.5.1 Barriers
IPE barriers are not mutually exclusive and are constantly interacting to exert a negative effect on embedding IPE into curricula. Missen et al. (2012) point to a lack of government and political encouragement; insufficient organisational and administrative support; regulatory requirements; and, resistance from higher education institutions to implement curricula change (ginsburg and Tregunno, 2005; kvarnstrom, 2008; Stone (2007) in Missen et al., 2012).
6.5.1.1 Summary of main barriers
a Governmental and the organisational barriers
At government and professional level, direct policy development is often either lacking or uncoordinated, creating uncertainly and role confusion. Maintaining links between partners and stakeholders is vital for coordinated efforts in IPE.
However, these links are often challenged by organisational change (Lawlis et al., 2014), of which a leadership void can be catastrophic. These changes can disrupt communication, diminish enthusiasm, break continuity and erode ownership, which may result in abdication of responsibility. On the other hand, planned organisational change relooks at practices, procedures, policies and routines. These processes need to include modifying attitudes to embrace the benefits of collaboration, modifying practices and routines to reflect the new organisational culture and beliefs, creating strong leadership and redistributing resources to bring about new practices and policies that support IPE (ginsburg and Tregunno, 2005; Ho et al., 2008).
• Government funding
• Shared ownership and unifed goals
• Strong organisational leadership and commitment
• Policies, procedures and legislation that eliminate barriers
• Intersectoral collaborative groups that include HEIs and professional bodies
GOVERNMENT
&
PROFESSIONAL
• Institutional funding
• Supportive leadership and management practices
• Faculty development and support programmes
• Will and capacity for curricular review and change
• Changing the culture and attitude of health professionals
• Shared interprofessional vision
• Good interprofessional relationships
• Dedicated, knowledgeable and skilled staff
• Enthusiasm and positive attitude of staff
• Positive role-modelling of IPECP
• Respect and equal regard for other professions INSTITUTIONAL
INDIVIDUAL
b Regulatory barriers
Regulatory and licensing restrictions are also highlighted by Missen et al. (2012:
193). They point to the uk National Health System as an example of where regulatory, governing and accrediting bodies have assisted in facilitating change. Similarly, the lack of recognition of IPECP competencies by regulatory bodies and HEIs is a major barrier. Murray-Davis et al. (2012) in a uk-based study with midwifery students identified that competencies for IPECP were not assessed the same as clinical competencies.
c Funding barriers
Funding constraints straddle government and institutional levels and are a pervasive challenge. Embarking on sustainable IPE is resource-intensive (Lawlis et al., 2014). Traditional competitive funding models do not encourage IPC and increase staff perceptions about the lack of rewards and incentives for IPE.
d Institutional barriers
At institutional level, the 2013 wHO case-study report identifies the lack of a shared vision, professional cultures and stereotypes, use and understanding of language including communication, accreditation and curricula as important IPE barriers (WHO, 2013b).
An institutional culture – faculty and health services – that is not patient- centred and does not give patients decision-making power was also identified as a barrier (Daly, 2004). In some health services in the uk where IP care is well established and IP care pathway groups exist, an expert patient board governs such groups. Daly (2004) believes that this is one of the ways that real power is given to patients. For the successful implementation of IP care and collaboration a payment system that emphasises quality and incentivises collaboration is essential (Brown, 2009).
e Curricular barriers
With regard to educational programmes, Newton et al. (2015) add the following barriers: overloaded, inflexible curricula; lack of credit portability between courses, lack of alignment of clinical placements; lack of facility and preceptor development for IPE; IPE not mainstreamed or prioritised; human, financial and space resource constraints; (outmoded) education policies and overall lack of commitment. In particular, curricula are criticised for being rigid, ‘siloed’ and timetable bound.
f Staff and students as barriers
At an individual level, the preparedness and commitment of staff, students and clinical staff is key to embedding IPE into the curriculum. Often ‘buy-in’ is determined by attitudes towards IPECP. Negative attitudes are disabling and are mainly around issues of added workload, lack of appreciation of the value of IPE, lack of knowledge and skill, devaluing other professions and their role in the health team, and lack of rewards for IPE activities. Negativity also stems from staff not being involved in planning IPE initiatives (Lawlis et al., 2014). A clear, shared vision and staff involvement is essential.
These barriers pose major challenges to IPECP and the embedding of IPE into curricula. We summarise the main challenges and offer suggestions to address these.
6.5.1.2 Ways to address the main challenges
a Policy level issues – no political commitment and national co-ordination The lack of sustained political commitment and integrated health and education policies are major obstacles to IPECP. The wHO (2010), Steketee et al. (2014) and Lawlis et al. (2014) all identify the need for closer and sustained links between the education and health sectors. Some ideas to address high- level policy and political issues include, first, direct IPE policy development between the national education and health departments, regulatory and accreditation bodies. Policy processes include aligned legal, regulatory and accreditation frameworks (wHO, 2010). Coordinated policy development should involve health consumers and national academic/higher education structures. Health workforce planning is an essential convergence point for health and education (gilbert et al., 2010). If health workforce planning and policymaking is integrated IPE can be fully supported to produce graduates ready to practice collaboratively in teams.
Second, HEIs as change agents have the capacity to advocate for and facilitate intersectoral policy development (Lawlis et al., 2014). Funding is also an important catalyst for policy implementation and sustainability. Unless there is adequate funding and resources, policy on its own cannot enable IPE initiatives.
b No shared vision, co-ordination and collaboration across sectors
It is problematic when the IPECP agenda is not given the same priority in different settings and sectors, or when there is no shared jurisdiction. There is thus a need for HEIs to work closely with stakeholders to develop IPE placement opportunities; use of the best-available IP student mix; facilitating the inclusion of medical students in IPE with nurses and other HPs; and, authentic IPE materials (Derbyshire and Machin, 2011).
As Marshall and gordon (2010) point out: “The favourable learning environment for IPE created within universities may be fruitless if it is not supported within the clinical setting (Murray-Davis et al., 2012). They also emphasise that the extent to which the clinical workplace promotes IPECP influences the sustainability of these skills following graduation/qualification. In this regard, Missen et al. (2012) believe that the inclusion of IPECP in the mission statements of health services is important. This, in addition to a clear university/health sciences faculty vision and mission statement that espouses IPECP, is crucial for staff buy-in and retention, and for students when choosing an institution at which to study. It is essential that the faculty vision is shared by staff, which will assist in removing professional boundaries and increasing respect and equality of treatment of all professionals (McNair et al., 2001). Ways to do this include setting up regular forums at which guided discussions occur with steps or action plans to manage issues that threaten IPC. Opportunities for professional showcasing and team role enactment are also important.
c Funding and resource issues
IPECP may require additional funding (wHO, 2010) or reallocated financial and other resources like infrastructure, time and human resources. In the light of declining government subsidies it is not possible for universities to carry the costs associated with IPE. Earmarked grants allocated by the New Funding Formula in South Africa may have to include IPECP in the same way it does for community development and the teaching of foundation programmes.
HEIs too will have to find innovative ways to fund IPE, which could include raising grants. However, as Daly (2004) points out “Increased budgets alone are not sufficient. Localisation of budgets, use of resources for generic skills acquisition, auditing and improvement of multi-professional care as part of budget allocation, and the broadening of the research arena to include all professional groups would be a step forward” (Daly, 2004:79).
Other logistical issues such as geography, timetabling, classroom space and limited availability of staff also hinder IPE implementation (Freeth and reeves, 2004; Solomon and Missen et al., 2012). IPE in clinical placements that are at a distance from the HEI incur costs associated with transport, travel time, off- site supervisor/facilitator time and internet connectivity. Institutions need to develop appropriate organisational structures and administrative support to facilitate and coordinate IPE activities across programmes (Lawlis et al., 2014).
Processes that will require support include curriculum review, administration (calendars, timetables, placements, etc.), staffing and logistics. Although an IPECP champion may be required to lead the IPE processes it is essential to include the implementers.
Funding concerns are amplified in staff perceptions that there are no rewards or incentives associated with IPE involvement. The literature (Clifton et al., 2006; Lawlis et al., 2014; WHO, 2010) points to the need for management to recognise and support IPE with appropriate remuneration, reward, and related structures.
d Professional and communication issues
Maintaining professional relationships with colleagues from other disciplines is essential for the success of IPE (Lawlis et al., 2014) and is a significant enabler of IPECP. Through these relationships academics transfer their enthusiasm for IPE to students, fostering student engagement and promoting the transfer of IPE knowledge and skills (Forte and Fowler, 2009; Ho et al., 2008; McNair et al., 2001). Direct communication between team members is also an issue because different disciplines use different language (jargon) and meanings. However, this also encompasses broader communication in the sense of power struggles and hierarchy between team members as well as professional boundaries (stereotypes), and different ethics and care models. Clark, cited in Murray- Davis et al. (2012), points to professional socialisation as a way of emphasising common ground between professions rather than divisions. This can be a tool for creating a new, shared perspective that fosters collaboration, rather than the historical, divisive professional ideologies. Morgan et al. (2015:1218) also emphasise the need for informal communication. Communication issues include using ICT solutions.
e Staff development and training issues
Staff development programmes are key for the successful implementation of IPE, however, they must go hand-in-hand with adequate funding, organisational support and recognition to ensure sustainability (Lawlis et al., 2014). In clinical placement sites, IP training of clinical preceptors, mentors or clinical facilitators helps to increase student confidence and acceptance of IPE.
The lack of a continuum of IPE training – pre and post-qualification with clinical mentors who are able to teach and assess IPE skills was also highlighted by Murray-Davis et al. (2012). Caldwell and Atwal (2003) suggest that the best areas for shared learning are those that present complex patients, where professionals are required to work together in well-established teams who hold regular meetings, involving patients in care decisions (cited in Derbyshire and Machin, 2011). At student level, IPE opportunities in small, interactive groups are acknowledged as the most effective learning and teaching approach, especially where this learning focuses on practice realities. Research indicates that IPE is most effective when it is based on adult learning principles, when learning situations reflect real-world practices and when students interact (WHO, 2010). Teaching-learning approaches that support adult learning include, problem-based learning, case-based learning and other forms of active learning. Coupling these with e-learning goes a long way to appeal to a new generation of students. Staff development in these progressive pedagogies is essential but the content of such programmes must be adapted to staff needs and IPE context.