June 1, 2013 Features

So Long, Silos

Interprofessional care benefits patients, but teaching future clinicians how to provide it can be challenging. Follow these guidelines to "de-silo" your academic program.

Fred Astaire and Ginger Rogers. Wilbur and Orville Wright. Lewis and Clark. Steve Jobs and Steve Wozniak. King George VI and Lionel Logue.

What do these names have in common? We may recognize some of these people and their individual accomplishments, but it is their success as part of a dynamic collaboration that we remember most. The results of creative, interprofessional collaboration are all around us: a Pixar movie, pictures from Mars, a cochlear implant, an iPad app, a laryngeal transplant. These accomplishments are possible only because of the efforts of multiple disciplines working together to create art, expand knowledge, solve a problem or help others.

As communication sciences and disorders professionals, it's not enough to demonstrate the value of interprofessional collaboration to future clinicians—we need to teach them how to work with other professionals to achieve better outcomes for patients.

Why collaborate?130601_Silos.jpg

In her book "Creative Collaboration," Vera John-Steiner writes that most meaningful artistic and scientific achievements result from creative interprofessional collaborations, rather than solitary acts from great, individual minds. Positive outcomes emerge from joint thinking, passionate conversations, emotional connections, and shared struggles common in meaningful relationships. The late Mark Ylvisaker, then College of Saint Rose professor of communication sciences and disorders, revolutionized services for people with traumatic brain injury, in large part because of his philosophy of collaboration in assessment and intervention. In 2007, in an interview conducted as part of the International Brain Injury Association's 25th anniversary, he said that in an exceptional rehabilitation team for people with traumatic brain injury, the team members:

  • Learn from one another and share skills.
  • Do not function in a pecking order or hierarchy.
  • Understand that many critical client needs are not discipline-specific.
  • Are willing to blur professional boundaries, respecting one another.

In the context of health care, these powerful ideas are gaining momentum in clinical education.

Research in health care indicates that interprofessional collaboration enhances patient care by increasing efficiency, improving continuity of service, reducing errors, and providing a context for sharing increasingly scarce resources (see sources list online). Interprofessional collaboration in health care mirrors the real world in many ways and, given technological advances, global learning and economic pressures, interprofessional collaboration is becoming the societal norm. The World Health Organization discusses the global significance of interprofessional collaboration in the 2010 document, "Framework for Action on Interprofessional Education and Collaborative Practice". It points out the critical need to educate the next generation of health care providers in principles of interprofessional collaboration to support health care around the world.

Learning to collaborate across disciplines

As the U.S. health care system strives to become more interprofessional and collaborative, policy makers are urging higher education institutions to teach students how to work in teams. We are seeing significant changes in medical and nursing education to address this need. Recently, eight professional organizations that represent educators of health care providers came together to generate core competencies [PDF] that can facilitate interprofessional collaboration in the classroom, clinic and community. This collective, the Interprofessional Education Collaborative, generated the competencies to help future doctors, nurses, dentists, pharmacists and other providers gain the skills needed to work in an increasingly collaborative, team-based, health care arena. The competencies are arranged around four domains: values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork.

The framework for implementing these competencies and responding to calls for action is interprofessional education. IPE requires students in multiple disciplines to learn together with intention, mutual respect and commitment. It requires continuous interaction, coordinated effort and knowledge sharing, activities consistent with person-centered clinical practice, and Mark Ylvisaker's characteristics of an exceptional team. As appealing as these principles sound, activities that promote this type of learning typically are not found in the clinical education of speech-language pathologists or audiologists.

Difficulties implementing IPE

Ample evidence supports interprofessional collaboration. To provide this collaboration effectively, we need to educate future health care providers in team-based service delivery and to establish a framework for teaching interprofessional collaboration. However, inherent tendencies in higher education pose barriers to its implementation. Broadly speaking, these barriers include the tendency to reward individual achievement, insufficient funding for interprofessional activities, and, importantly, differences in terminology and professional cultures among disciplines. Further, academic programs are usually organized in silos, independent of other disciplines in administrative function and curriculum. Coursework is often disorder-specific, with an awkward separation between academic knowledge and clinical skills.

These challenges make it difficult to expose students to meaningful interprofessional collaboration during their course of study. But overcoming them yields many benefits. Exposure to interprofessional partnerships broadens students' knowledge and experiences in our increasingly team-based, collaborative health care system; faculty members have opportunities for meaningful, contextualized scholarship that can enhance program viability and visibility; and, most important, the implementation of team-based, interprofessional collaboration improves the care we provide in clinical practice.

We can take 10 steps to cultivate interprofessional collaboration in our classrooms, clinics and communities.

  1. Scan the internal and external environment to see what is available. There may be collaborative opportunities within your department or unit with colleagues you know, and you may be able to capitalize on affiliations already established. However, partnerships that extend outside your unit—whether on campus or beyond—also may provide unique chances for interprofessional collaboration. Community-based organizations that serve our clients may be worth considering, particularly if such projects would fill unmet needs in your clinic, hospital, local schools and community. One example is the Rockcastle project, a collaboration among a rural hospital in Eastern Kentucky and students and clinical supervisors in occupational therapy, physical therapy and speech-language pathology from two Kentucky universities.
  2. Find a willing colleague. Planning and implementing interprofessional partnerships require considerable effort and time, so it's important to share the experience with a colleague. This colleague is not necessarily someone with whom you always agree or share a style. Rather, a working relationship that can facilitate open dialogue and debate can lead to creative problem solving. Critical conversations may be necessary to move your ideas forward. Explore opportunities to share ideas and leadership roles with other team members to maintain a sense of empowerment, trust and respect by all involved.
  3. Identify a shared vision and tap into individual strengths. Each person brings strengths to the process of developing and implementing a collaborative partnership. Use those strengths to identify a shared vision for the project. These two ideas go hand in hand. Successful interprofessional teams appreciate, understand and accept the individual contributions of their collaborative efforts and goals, and then re-envision them as part of a collective. Regardless of the discipline, ask: What do you hope to accomplish on behalf of the people being served by the collaboration?
  4. Enhance core competencies for collaboration. To explore ideas that enhance collaboration among students, consider using the Interprofessional Education Collaborative's core competencies as a guide. Each of the four domains in the document includes specific objectives that can be applied to the collaboration. Include these ideas, as well as the discipline-specific content that team members need to share to make the collaboration successful.            
  5. Plan carefully. One of the main pitfalls of developing and implementing a successful interprofessional collaboration is rushing to start. The collaborating faculty/clinical supervisors need time to develop a curriculum, consider space and learn the language of one another's disciplines. Trust and respect take time to cultivate, but are essential in promoting shared decision making in the collaborative process.
  6. Engage stakeholders in planning and evaluation. Do not do the work on your own. Encourage feedback from others—including students and clients—who will make the project better. A focus group or evaluation team can consider critical features of the collaboration; ideal team members would include professionals in the field who could support and be supported by such collaborations.
  7. Get administrative support. Administrative support goes beyond finances. A department chair or college dean who supports your project can open the door for creative ways to maximize time and departmental resources. In addition, the positive public relations generated by administrators often can garner positive attention to the partnership. Keep your chair and dean apprised of the project to help sustain the collaboration.
  8. Seek funding and share resources. We have each received internal professional development funding to initiate, assess, and/or improve our collaborations. Additional support, including access to other professionals and various medical settings and community centers, followed in response to our successes. Health care and education settings require professionals to share resources—including space and time—and the same is true for interprofessional education. Institutions that provide clinical services can generate income. Translational research supported by the National Institutes of Health or the National Science Foundation often includes the expectation of collaboration, so creative partnerships can be folded into grant opportunities (see ASHA's information on collaboration in research, on.asha.org/inter-collab), yielding a great way to integrate academic and clinical education.
  9. Share what you are doing. Let others know of your collaborative efforts, through public relations and scholarship. Well-planned collaborations with an evaluation component facilitate research that can be shared in conference presentations and scholarly articles. The potential for student research is great, and there are avenues for sharing creative interprofessional collaboration beyond our discipline. Also, successful collaborations that support real people in the real world make good stories in an alumni newsletter, internal correspondence, local newspapers and professional association news.
  10. Follow up, evaluate, improve. Do not rest on success! Constantly evaluate the partnership with a focus on the individuals served. At the end of the class, semester or treatment period, sit down with your collaborators and discuss the project outcomes and strengths and weaknesses. Think big and outside the box when considering next steps. Involve students, clients and professionals in your follow-up and modify goals for the next opportunity, if necessary. 

Collaborative work in clinical education takes vision, time, effort and creativity, but if done effectively, has far-reaching impacts that may exceed your initial expectations. When we present information about interprofessional collaboration, we often refer to the original "Saturday Night Live" as a quintessential creative collaboration that ultimately changed the face of late-night television. The cast, partnered with the talents of the writers, musicians, technicians and directors, made us look differently at entertainment.

In an increasingly complex, global professional environment, we give our students a distinct advantage when we cast them in interprofessional teams that mirror the interprofessional clinical services they will provide. Helping them become part of a creative team of professionals allows them to see their work in a different, client-centered way.

Jack Pickering, PHD, CCC-SLP, is professor of communication science and disorders at the College of St. Rose in Albany, N.Y., and co-director of the department's Transgender Voice and Communication Program. He is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders. pickerij@mail.strose.ed

Erin Embry, MS, CCC-SLP, is the associate director of the communicative sciences and disorders graduate program at NYU Steinhardt School of Culture, Education, and Human Development. ee28@nyu.eduv

cite as: Pickering, J.  & Embry, E. (2013, June 01). So Long, Silos. The ASHA Leader.

Silo Buster One

Take a snapshot look at what health sciences faculty at three institutions—New York University, the College of Saint Rose and the Medical College of South Carolina—are doing to bring together students across specialties.

Small Idea, Big Changes at NYU-Steinhardt

An interprofessional nutrition and speech-language pathology class at NYU-Steinhardt proved valuable not only for students, but also for patients with swallowing difficulties—who now have tastier and more varied food choices.

Recognizing the need for educational and clinical training that more closely mirrors real experiences, Communicative Sciences and Disorders and Nutrition were the first departments at NYU-Steinhardt to offer an interprofessional course promoting collaborative approaches to care. Given that the keys to effective interprofessional case management are understanding and valuing the contribution of each discipline, the primary focus of the course was to foster a comprehensive, evidence-based and person-centered team approach to care for individuals with swallowing disorders.

We conceived the course as including multiple disciplines as part of the learning experience. However, the logistical barriers of creating a first-time course with so many key players proved too overwhelming, so we narrowed the focus to swallowing issues and their impact on nutrition. Primary learning methods include the use of problem-based learning—including complex individual case studies (based on real patients)—student-led discussions, and exercises to apply the information taught in class.

As with a real case, information related to the "patient" unfolds over time. CSD students are responsible for interpreting and explaining information from the clinical and objective swallowing evaluations. In turn, nutrition students discuss methods for determining and analyzing nutrition lab values and non-oral feedings. Collectively, students review and critique evidence-based treatment and management practices, discipline-specific standards of care, and problem-solving approaches to ethical decision-making and case management. From these interactive learning opportunities, students identify intersecting aspects of the assessment and treatment process that may affect several aspects of their interactions with patients—their individualized approaches, written and verbal communication, and clinical recommendations—and that may lead to a more comprehensive, efficient and effective plan of care.

More recently we added simulated real-world opportunities to the course. At NYU Langone Medical Center and Beth Israel Medical Center, speech-language pathologists allow students to be part of the collaborative process by observing videofluoroscopic swallow studies. Physicians from Rusk Institute of Rehabilitation Medicine also participate by leading our students in simulated team rounds specific to their cases. The culminating experience includes a "Quick Fire" mocktail and "Iron Chef" dysphagia cooking competition, in which student groups select and prepare a beverage and a meal specific to each patient's swallowing and nutritional needs. Guest judges rate each group's creations based on taste, appearance, appropriateness, rationale and best use of a secret ingredient.

Students, department faculty, administration and the affiliated medical community support the idea of creating an interprofessional course with a common vision. Students generally are surprised and impressed by sharing discipline-specific knowledge and responsibilities, and refer to this unique learning opportunity as one of the highlights of their academic career.

As a result of this course, NYU Langone Medical Center modified its dysphagia menus last year. It now offers patients chef-inspired meals and uses food molds to improve the taste, consistency and presentation of food. In addition, students in the hospital's culinary academy will soon learn how to enhance textured foods for people with swallowing disorders. What began as a collaborative, team-based learning experience became a source of significant change at a major medical center.

This course, its impact on the community and what it represents for clinical education and training programs on a larger scale are more than my collaborator and I ever could have imagined. It has inspired us to challenge conventional ideas about learning in ways that benefit students, educators, organizations, health care providers and, most important, the patients we serve. Each year the course continues to evolve and we are having fun exploring where it goes. Maybe a show on the Food Network is next?

Erin Embry



Silo Buster Two

Transforming Support at the College of Saint Rose

Speech-language pathology and counseling students join in a voice modification program for people who are transgender.

Five years ago, I received a call from a local mental health counselor about services for two transgender women interested in modifying their voices. With the help of these clients, The College of Saint Rose established a voice and communication program for people in the transgender community. Initially the program focused on voice, but expanded to include nonverbal communication, language and articulation.

Collaboration has been an integral part of this program from the start. Each semester, graduate student clinicians in speech-language pathology provide services to five to 10 transgender clients using an apprenticeship model in which supervisors and clients serve as "master craftspeople" supporting the students. A team-based approach fosters collaborative decision-making between clinicians and clients. Participants discuss the collaborative partnership during weekly group supervisory meetings.

A lynchpin of the program is collaboration with counseling, as mental health counselors play an integral role in gender transition. Counselors support people as they work through a significant and often stressful life change and connect them with providers who address primary health care, hormone therapy, surgery and other aspects of transition. We encourage students to explore their role as clinician-counselors. And we include activities that allow student clinicians and clients to experience interprofessional collaboration between speech-language pathology and counseling. These include:

CLASSROOM PRESENTATIONS. Clients and student clinicians visit counseling and communication science and disorders classes to practice communication skills, evaluate communication in a functional context and teach others about the transgender experience [PDF]. In two graduate classes, "Counseling for SLPs" and "Multicultural Counseling," faculty and students also use the visits to practice counseling skills (such as active listening and facilitating the client's story), creating a dynamic collaboration between the two disciplines.

MISSION AND MINDFULNESS. Two years ago, a counselor specializing in transgender health came to the group to discuss ways of creating a more positive culture. The counselor helped us craft a mission statement and determine principles of effective communication. The counselor also provided guidance on using mindfulness to enhance the group experience. Feedback from clients and student clinicians, who provide mindfulness activities, indicates that this is an important component of the program.

A LEARNING MODULE IN COUNSELING SKILLS. With a small grant from the college, two communication sciences and disorders faculty members, a mental health counselor, CSD students, and program clients collaborated to create a video designed to teach CSD students about counseling for individuals in the transgender community. The video focuses on gender transition, the role of the mental health counselor, group therapy and the speech-language pathologist's role as clinician-counselor.

STUDENT PROJECTS IN MULTICULTURAL COUNSELING. Two students in multicultural counseling have completed projects on counseling people who are transgender. Part of their project research involved engaging in the group's activities and interviewing clients.

VISITING MENTAL HEALTH COUNSELOR. During the past semester, a mental health counselor from a large community-based counseling center came to the group, observing activities and providing support. She also presented to the student clinicians about gender change and the emotional aspects of transition. This arrangement will continue in an effort to foster more regular interprofessional collaboration between our program and the counseling center.

The transgender voice and communication program at Saint Rose has received considerable support from students, faculty, administrators and our primary referral source—mental health counselors. The program has a relationship with the local lesbian, gay, bisexual and transgender community center, which extends our reach beyond the campus. Continued collaboration with mental health counselors and students studying counseling will ensure that our services meet the needs of people undergoing an extraordinarily life-changing physical and social transformation.

Jack Pickering



Silo Buster Three

The New Face(s) of Training at MUSC

The Medical University of South Carolina is a leader in providing interprofessional education and training. Here's a snapshot of its IPE program.

At the Medical University of South Carolina, we've required students to participate in interprofessional education since 2007—when we focused on IPE as part of university-wide reaccreditation. All first- and second- year students participate in an Interprofessional Day, where they learn more about the necessity and value of interprofessional collaboration. 

First-year students learn more about one another's professions through an interactive small-group exercise. The second-year experience builds on that experience through discussion of cases designed to showcase the value of collaboration. Students also complete an interprofessional course, in which they learn about the complexities of the health care system—including cultural and ethical issues—and work in small interprofessional groups to analyze a fictional sentinel event. The intent is that they apply teamwork skills when working together.

Because problems can emerge when bringing together different professionals and personalities, we incorporate training on effective teamwork behaviors when encountering challenges: respect for others, listening to different perspectives, clear communication, encouraging others to participate, negotiating differences to be inclusive, and resolving conflict productively.  Interprofessional challenges typically relate to respect issues, a need to break down the traditional hierarchy in medicine, and confidence in reaching out to other professions—a trait that is often not role-modeled by faculty or preceptors. We sensitize our students to all of this.

As students progress to clinical rotations, each program requires them to purposefully interact with other professions to improve a patient's care—not simply stand side by side during patient rounds and never interact. Our goal is for students to apply teamwork skills and their knowledge of others' professions in multiple learning and practice settings before they graduate. Students report confidence in seeking help from other professionals during patient care. Ensuring that  students can collaborate and truly understand what different professions contribute to health care is the new direction in health professions education.

Amy Blue, PhD, assistant provost for education and professor of family medicine, Medical University of South Carolina.



Sources

Alberto, J., & Herth, K. (2009). Interprofessional collaboration within faculty roles: Teaching, service and research. OJIN: The Online Journal of Issues in Nursing, 14(2).

ASHA (2008, June). Why is greater emphasis being placed on interprofessional education in health care? Access Academics and Research. Retrieved July 20, 2011, from http://www.asha.org/academic/questions/Interprofessional-Education.

Durkin, T,. & Vescovich, M. (2011, November). The SLP: A valued member of the hospice interdisciplinary team. Paper presented at the 2011 Annual ASHA Convention, San Diego, CA.

Embry, E., & Pickering, J. (2012, November). Cultivating creative, interdisciplinary collaboration in academic & clinical education. Paper presented at the 2012 ASHA Annual Convention, Atlanta, GA.

Embry, E., & Pickering, J. (2012, April). Cultivating creative, interdisciplinary collaboration: Perspectives from two institutions. 2012 Council of Academic Programs in Communication Sciences and Disorders Annual Convention, Newport Beach, CA.

Hagstrom, F. (2010). Establishing interdisciplinary collaborations for international education. SIG 10 Perspectives, 13(1), 13–17.

Harvard Medical School (n.d.). Academics: Cambridge Integrated Clerkship. Cambridge Health Alliance. Retrieved on July 19, 2011, from http://www.challiance.org/academics/integrated_clerkship.shtml.

Huff, E. G. (2009, November). Incorporating Medical Setting Interdisciplinary Experiences into a Graduate SLP Program. Paper presented at 2009 Annual ASHA Convention, New Orleans LA.

International Brain Injury Association. (2007). On neurorehabilitation: A conversation with Mark Ylvisaker, PhD. Retrieved June 16, 2011, from http://www.internationalbrain.org/?q=node/71.

Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative. Available at http://www.aacn.nche.edu/education-resources/ipecreport.pdf.

John-Steiner, V. (2006). Creative collaboration. New York: Oxford University Press.

Kirch, D. G. (2011). Higher education and health care at a crossroads. Trusteeship, 2(19), 1–7.

MMC/Tufts Medical School (n.d.). Milestone: About us. Maine Medical Center/Maine Health. Retrieved July 19, 2011, from http://www.mmc.org/mmc_milestone.cfm?id=6239.

Page, J. L. (2010). The Rockcastle Project: A model for interprofessional clinical education in a rural medical center. Access Academics and Research. Retrieved July 20, 2011, from http://www.asha.org/Academic/questions/rockcastle-project.

Page, J. L., & Morris, D. S. (2012). Whole patient, whole team. The ASHA Leader , 17(6).

Perry, C., Hall, B., & Tiongco, C. (November, 2011). Interdisciplinary teamwork: Making IT work. Paper presented at the 2011 Annual ASHA Convention, San Diego, CA.

Pickering, J., Bloom, C., Luna, A., & Selmon, S. (November, 2011). The clinician-counselor with transgender clients: An instructional video. 2011 ASHA Annual Convention, San Diego, CA.

Stemple, J. C. (2006). Personnel shortages in speech language pathology: Doctoral Collaborations. Retrieved June 16, 2011, from http://www.asha.org/uploadedFiles/slp/Stemple.pdf [PDF].

Strober, M. H. (2011, January 2). Communicating across the academic divide. The Chronicle of Higher Education. Retrieved June 16, 2011, from http://chronicle.com/article/Communicating-Across-the/125769/.

Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press.

Weinstein, D. (2011, February 14). Students prepare for your final class! The Iron Chef challenge: NYU Steinhart News. Retrieved from http://steinhardt.nyu.edu/site/ataglance/2011/02/students_prepare_for_your_fina.html.

Wertheimer, J., Constantinidou, F., Raymer, A., Turkstra, L., & Paul, D. (2008, November). Promoting effective interdisciplinary collaboration. Paper presented at the 2008 Annual ASHA Convention, Chicago, IL.

Williams, L., Marks, L., Barnhart, R., & Epps, S. (2011, November). ICF-CY: Basis for a conceptual model for interprofessional education. Paper presented at the 2011 Annual ASHA Convention, San Diego, CA.

World Health Organization. (2010). Framework for action on interprofessional education and collaborative practice. Geneva, Switzerland: World Health Organization Press. Available at http://www.who.int/hrh/resources/framework_action/en/index.html.

Ylvisaker, M. (1994). Collaboration in assessment and intervention after TBI. Topics in Language Disorders, 15(1).

Ylvisaker, M., & Feeney, T. (1998). Collaborative brain injury intervention: Positive everyday routines. San Diego: Singular Publishing, Inc.



  

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