VOL: 98, ISSUE: 41, PAGE NO: 30
Sarah Sheets Cook, MEd, RNC, DPNAP, is vice-dean, Columbia University, New York City, USA
Dorothy M. Rogers is professor of clinical nursing, Columbia University, New York City, USAEnthusiasm about interdisciplinary education for students in the health care professions comes in waves. The current wave dates back to the late 1990s, and has been widely discussed in the UK (Barr et al, 1999; Cooper et al, 2001; Glen, 2001; Hammick, 1998; Munro, 1998; Zwarenstein, 1999).
Enthusiasm about interdisciplinary education for students in the health care professions comes in waves. The current wave dates back to the late 1990s, and has been widely discussed in the UK (Barr et al, 1999; Cooper et al, 2001; Glen, 2001; Hammick, 1998; Munro, 1998; Zwarenstein, 1999).
Defining the term
The term 'interdisciplinary education' is often used interchangeably with 'multidisciplinary education'. However, there are important differences between them. Multidisciplinary learning is defined as 'learning together', while interdisciplinary education conveys the idea of learning together to promote collaborative practice (Cooper et al, 2001; Glen, 2001).
Even within the education sector there is often confusion about the terms, or about how to make educational provision interdisciplinary rather than multidisciplinary. For example, the Health Sciences Campus of Columbia University in New York City has made a number of attempts to provide interdisciplinary education, but these programmes have often turned out to be multidisciplinary instead.
The campus is a busy, urban and ethnically diverse academic health centre catering for almost 2,000 students. It comprises colleges and schools providing education for nurses, physicians and surgeons, public health professionals and dental and oral surgeons, and also has a number of institutes and centres of specialist study. All are affiliated to New York Presbyterian Hospital, and the University Hospitals of Columbia and Cornell.
The campus first attempted to develop interdisciplinary education in the 1970s, encouraged by a forward-thinking dean of the College of Physicians and Surgeons. Subject areas relevant to the range of health care professional students taught on the campus were identified, with the intention of teaching them in an interdisciplinary manner. Topics initially identified were:
- Anatomy and physiology;
- Human life-span growth and development;
- Students' responses to clinical encounters.
Of these subject areas, a truly interdisciplinary course was developed only in human life-span growth and development and it was successfully taught to nursing, occupational therapy and physical therapy students for 17 years.
A second effort in the early 1990s involved first-year medical, nursing and dental students (Cook and Drusin, 1995). This focused on combining the science and art of health care, blending traditional 'hard' topics such as epidemiology and nutrition with components of caring such as effective communication and empathy. All students had at least a baccalaureate degree from another academic institution, high average grades and successful scores on national testing examinations.
Interdisciplinary collaboration in clinical practice is not only useful but essential to providing high-quality, seamless health care, and it should be facilitated by interdisciplinary education. However, the influence of interdisciplinary programmes on the outcomes of health care, especially with regard to improving quality in a cost-effective manner, have not been tested consistently.
Schmitt (2001) argues that this is an opportune time to study the outcomes of interprofessional delivery of education and health care. She also points out that the medical profession has not been as keen on interprofessional collaboration as have other health professions.
Our experience corroborates Schmitt's observation: in the last interdisciplinary educational initiative in the 1990s, we found one of the largest barriers to success was faculty resistance. This persisted among both medical and some nursing faculties, despite a survey demonstrating that their students valued the course (Box 1).
Responses to questions relating to the concept of interdisciplinary education (questions 1, 2, 8, 9, 10 and 12) are relatively congruent between the two groups. Questions dealing with the actual operation of the course (questions 3, 4, 5, 6 and 7) received more negative ratings, which was not surprising since we had experienced problems with implementation.
Interestingly, students felt that the responsibilities of physicians and nurses in the delivery of health care overlapped significantly (question 15), which did not seem to distress them as much as it did their teaching staff. They also disagreed with the idea that informal contact between medical and nursing students was the best way to learn about collaboration (question 14).
In a survey of medical, nursing and pharmacy students involved in interdisciplinary education, Horsburgh et al (2001) also found that they generally agreed that collaboration in the delivery of health care was beneficial, although there were some interprofessional differences of opinion.
Assessing the outcome
The change in the nature of health care delivery during recent years and the apparent comfort among health professional students in learning together might provide the impetus for revisiting - or more importantly for initiating and sustaining - interdisciplinary educational programmes.
Schmitt (2001) points out that there are compelling reasons to refocus on interdisciplinary education and practice. These include:
- Increases in illness acuity and co-morbidities;
- Interest in health promotion and disease prevention;
- Age-related population-based health care;
- New technologies;
- Introduction of business models for the delivery of health care services;
- Emphasis on access and quality.
While all these topics were included in the Columbia Health Sciences interdisciplinary education in the 1990s, the outcomes and effectiveness of these programmes were not tracked consistently.
Barr et al (1999) discussed the difficulties of evaluating outcomes in interdisciplinary teaching. A Cochrane Collaboration process, which has very precise criteria for inclusion of studies in its evidence base, revealed that none of the papers for consideration were suitable.
Of the traditionally accepted research protocols - randomised clinical trials, controlled before and after studies and interrupted time series studies - the controlled before and after studies seem the most appropriate for Cochrane Collaboration reviews. However, it is difficult to apply such criteria to evaluating the outcomes of interdisciplinary teaching because it does not lend itself to a concrete yes/no measurement and has too many confounding variables. Barr et al note in their 'parallel study' that analysing such studies may depend on choosing an approach that reflects these contextual variables.
We found this to be true in trying to evaluate the results of our interdisciplinary education. We also found it exceptionally difficult to plan, implement and test an interdisciplinary teaching initiative and evaluate it concurrently. Implementation never worked as smoothly as planned and this threw off the accuracy of the expected plan of evaluation. Enthusiasm for pursuing the initiative waned as its complexity increased and extramural funding disappeared.
Facing the problems
Ruebling et al (2000) identified administrative, educational and professional factors relevant to the success of interdisciplinary education. Adequate funding, existing successful interdisciplinary education and high-ranking administrative support are essential, while a lack of rewards and faculty incentives are strong obstacles to success.
Educational requirements include a common aim and shared goals between faculties, to enable them to function as an interdisciplinary team. It is also important that each health care discipline involved in the initiative is acknowledged to have something unique to offer interdisciplinary teaching efforts.
Educational barriers include disparity among student credentials, scheduling conflicts, and conflicting educational styles and philosophies. Professional issues include 'turf guarding', status, role ambiguity, resistance to change and insistence on traditional hierarchies. In our experience, all these factors were present except disparity among student credentials.
As traditional efforts have not been successful in achieving truly interdisciplinary education, it might be necessary to think laterally and to identify non-traditional ways of promoting collaborative practice. Maurana and Cauley (1999) describe a non-traditional approach centred on changes in health care delivery. This approach shifts the focus to:
- Health promotion and disease prevention;
- Community-based rather than institutional teaching;
- Collaboration through efforts to solve community problems related to access, quality and cost-effectiveness.
While this might not work easily in other settings, the idea of pursuing completely non-traditional educational methods is promising. Despite having tried to control for consistency in credentials among students, scheduling of classes, using individual faculty strengths, and involving stakeholders in development and evaluation, some faculty members felt that the classroom, especially in the early part of professional education, was not the best place for students of different professions to mix.
Efforts are currently under way to place medical and nursing students together in community-based clinical sites to assist with solving identified community health problems. Third-year medical students beginning clinical rotations and nursing students gaining experience in community health care will pursue learning objectives related to identifying community strengths and liabilities. This should help improve communication between and among stakeholders (both professional and service users), determine a common intervention and eventually enable implementation and evaluation of the project.
Another point of collaboration between medical and nursing students may be in the postgraduate arena. Newly graduated doctors completing residency experiences and postgraduate/master's level nursing students completing advanced practice nursing programmes may be better able to appreciate and benefit from interdisciplinary education, especially in the clinical area.
In US hospitals, nurses have traditionally introduced new doctors to the practical realities of providing safe health care, both in hospitals and in the community. Organising and formalising this into focused, goal-oriented continuing education programmes is another way of fostering interdisciplinary learning and collaboration.
A third way of providing interdisciplinary education involves using materials developed by interdisciplinary teams and used with students in the manner most relevant to particular student groups.
At the health sciences campus of Columbia University, an interdisciplinary team is developing a DVD on clinical assessment. This explains how to perform a complete and accurate physical examination, and contains links to explanations, resources and additional information for students to enable them to understand the underlying knowledge base and differentiate between normal and abnormal findings. The DVD can be used by individual students, by groups of students or in organised tutorial sessions in classrooms or in clinical units.
Another academic health centre in the USA is engaged in the Duke (University) Interdisciplinary Faculty Development in Genetics project. This brings together the interdisciplinary expertise of genetic health professionals to develop innovative interdisciplinary educational and experiential training. Both these initiatives focus on bringing together faculties for interdisciplinary education.
Overcoming the obstacles
It is possible to make progress in developing interdisciplinary health care education, and work has been undertaken in many centres to define the ways and means of fostering this collaboration between health disciplines. A number of factors are important for projects to succeed. These include joint planning, shared goals, open communication and creative management of barriers. Mutual respect of professional roles and contributions to health care, sufficient motivation and direction to overcome resistance to change and reality-based methodologies are also important.
It is not acceptable to give up trying to develop interdisciplinary collaboration because of past problems. People throughout the world have increasingly significant health care needs and more co-morbidities and acuity. These factors, as well as increased cost constraints and a focus on delivering quality, demand effective collaboration among health care providers. The best way to foster genuine collaboration in practice is by nurturing it in education.