Global interprofessional education: is the time now?
Across the globe great interest exists in the revitalization of the concept of interprofessional health professions training. Frenk et al. (2010) reported in Lancet that health systems and health professions education systems have not kept up with ‘new infections, environmental, and behavioural risks, at a time of rapid demographic and epidemiological transitions, (which) threaten the health security of all’ (p. 1923).
The Robert Wood Johnson Foundation has supported advancing interprofessional education through funding the work of developing core competencies. The Interprofessional Education Collaborative Expert Panel (2011) recommended core competencies in four domains: Values/Ethics for Interprofessional Practice; Roles/Responsibilities; Interprofessional Communication; and Teams and Teamwork. Participants in another meeting that took place in 2011 developed five action strategies to achieve interprofessional collaboration in education and practice (Conference Proceedings 2011). These strategies are: Communicate and Disseminate; Develop Interprofessional Faculty and Resources; Strengthen Metrics and Research; Develop New Collaborative Academic Practice and New Collaborative with Community Learning Site; and Advance Policy Changes.
From my perspective as a nurse administrator and researcher, these competencies and strategies have always been core to nursing education at the collegiate levels. It certainly may be the case that the individuals participating on these panels were unaware of the content of nursing education. I am pleased that perhaps they had an opportunity to learn more about how nursing focuses on patient-centred care, highly values honest and therapeutic communication, embodies strong ethical values, and has an ongoing commitment to quality, safe, and cost effective care.
In my opinion the articles, proceedings and calls for transformation cited above tend not to address several critical issues. I believe these neglected issues are at the core of why it has been so difficult to implement interprofessional practice.
It is interesting to read the documents to explore how they approach the concept of a team leader for interprofessional education and practice. Often, this complicated issue is not addressed. In some cultures, it is simply assumed that the team leader would be the physician, whether or not he or she has the best qualifications. This is often the case in my environment. Nursing professionals will be more likely to embrace collaborative, interprofessional training when they see collaborative teams that vary leadership depending upon the demands of the clinical situation.
The vast differences in salaries among health care workers in many developed countries create a socio-economic class system that is an obstacle to interprofessional practice. We see many examples of how this tension can work itself out in the educational and practice arena. For example, while many nurses will volunteer for short overseas community service assignments, it is usually much more difficult for them to get away from family obligations, unlike physicians who can afford to employ help to keep their homes running. Linked to this class difference is the fact that medicine remains an income generator, while nursing is typically viewed as a cost centre. It is challenging to develop interprofessional collaboration when one group of health professions is viewed as enhancing the bottom line of the care setting and another is viewed as a cost. To implement interprofessional education and thereby enhance the quality of patient care, we must address the dramatic salary differences among health care professionals and the resulting perceived differences in importance and worth.
The World Health Organization (WHO), headquartered in Geneva, Switzerland, sets a terrible example. WHO rarely uses the title of nurse in position job announcements, and less than one percent of all WHO employees globally are nurses. The WHO Chief Nurse Scientist, the one position offering international visibility for nursing, is vacant ‘due to budget constraints’. I believe that the person holding this position was probably always a figurehead and had so few resources that it was impossible to provide global leadership for nursing and interprofessional education. WHO should be held publicly accountable for how few nurses they hire for their high-salaried positions in Geneva and around the globe. The WHO employment policies demonstrate that this major global health organization does not support interprofessional training, education, and service.
Recently in the United States, the newly authorized PEPFAR (President's Emergency Plan for AIDS Relief) legislation supported the preservice training of health care professionals, rather than continuing to provide only continuing education and retooling workshops. As a result, several U.S. agencies combined resources to strengthen health professions education in Africa. They awarded approximately US$ 300 million to ten medical schools and only three million dollars to three nations to improve nursing education. (See WHO 2006 for available data on the nursing workforce.) This is an outrageous policy decision. The same individuals who called for interprofessional training in the Lancet article (2010) cited above advised PEPFAR, the National Institutes of Health, and the Health Resources and Services Administration to fund medicine and nursing with such disparate amounts. The existing number of physician and nursing training programs would have justified actually reversing the two funding levels.
Medical education in many countries continues to be funded at a much higher level, and physicians significantly supplement their salaries with income from clinical practice. In contrast nursing education is separated from practice and funded at inadequate levels. These facts make it impossible to imagine how we can begin to develop interprofessional health training and practice. The realities of interprofessional service delivery, as demonstrated by WHO employment patterns, prove that many leaders in health care do not truly embrace the call for interprofessional education.
William L. Holzemer, RN, PhD, FAAN is Dean and Professor of Rutgers University College of Nursing in New Jersey, USA.