Creating a utopian future by asking uncomfortable questions

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KEYWORDS:

• interprofessional education
• interprofessional practice and education
• collaborative practice
• workplace learning

The interprofessional movement thrives where conditions are conducive; where openness and mutual support in the workplace characterize relations; where democratization in universities liberalizes learning; where the need for change to improve health and social care is addressed. Sustaining progress depends … on the readiness of interprofessional exponents to set aside professional protectionism and academic rivalry as they support each other across borders and boundaries

Hugh Barr, Interprofessional Education: The Genesis of a Global Movement (Barr, 2015, p. 2).

This special issue of the Journal of Interprofessional Care focuses on the United States (U.S.) National Center for Interprofessional Practice and Education as we observe our 10th year. In 2012 after a national peer-review, five U.S. funders selected the University of Minnesota (UMN) to create a public–private collaboration to advance interprofessional education and collaborative practice (IPECP) in the U.S. (Chen et al., 2013). Historically, healthcare in our country is distinct from others globally. It is business driven, characterised by fee-for-service payment models that favor some professions over others. For decades, the U.S. has struggled with implementing universal healthcare that is a right not a luxury. As a result, overall U.S. health outcomes fall far below those of the other countries represented by international readers of this journal (Commonwealth Fund, 2020).

The year 2012 was the right time and conducive environment in the U.S. to invest in IPECP to change healthcare. The stimulus traces to the year 1999 when health systems began to address medical errors by implementing patient safety and quality improvement initiatives (2001; Institute of Medicine, 2000). In 2003, the Institute of Medicine proclaimed “interdisciplinary” teams as one of five competencies for health professions education as a “bridge” to healthcare quality (Institute of Medicine, 2003). In 2010, Congress passed the Patient Protection and Affordable Care Act signaling new models of healthcare and access. In 2011, the Interprofessional Education Collaborative, representing six health professions education associations, released national core competencies for interprofessional collaborative practice (Interprofessional Education Collaborative Expert Panel, 2011).

However, this time was not the first that major investments were made in interprofessional work to improve the U.S. healthcare system. The 2012 multi-million-dollar U.S. investment to the UMN was intended to kickstart and re-energise IPECP that had essentially gone dormant. After decades of surviving but not thriving, U.S. IPECP could be characterised as at its nadir of investment and commitment. Major IPECP developments in the early 2000s, particularly by our neighbors in Canada, were far surpassing efforts in the U.S.

In a personal conversation in 2021, Dr Dewitt C. Baldwin, Jr., a U.S. IPECP pioneer, described to me that he estimated that in the 1970s U.S. public and private funders had provided over $100 M for interprofessional work to transform healthcare throughout the nation (D. Baldwin, personal communication, 2021). These investments were used to develop healthcare and higher education infrastructure, fund multiple interprofessional curricula in the U.S., and supported new professions with the eye towards educating the health team to transform healthcare. The evidence of this major investment lay in Dr Baldwin’s own 60-year collection of papers that have now been archived by the National Center at the UMN Library Archives.

Given this reality, one could conclude that if advancing IPECP was only about money, the U.S. would have implemented it and transformed healthcare decades ago. When funding nearly ceased in the early 1980s, the advancement of the U.S. interprofessional movement was left to enthusiasts who worked with global colleagues as their own IPECP developments accelerated. These include notably the launch of the United Kingdom (UK) Centre for the Advancement of Interprofessional Education, a rallying definition of interprofessional education, and the Journal of Interprofessional Care.

In 2012, the UMN senior leaders who wrote the proposal for funding the National Center had a bold vision not just for interprofessional work but also for redesigning the relationship between healthcare and higher education. With substantial experience at all levels and environments of the two systems, we proposed the Nexus vision. Every day we saw the same issues as Baldwin: education alone cannot be the “fulcrum of change” for healthcare (Baldwin, 2013, p. 196). Rather, we must work on changing the underlying ideology and culture that crosses professional and institutional borders and boundaries. We need a new mental model about the professions themselves, how they work together, and how today’s disparate systems function optimally together.

We can no longer ignore that the centuries-old guild mentality codified in the early 20th century is alive and well today. Into the 21st century the professions have increasingly strived for protecting their turf through accreditation, certification, licensure, and competencies for their own professions, all in the name of quality and patients. While common wisdom speaks of collaboration within our current constructs, we in the National Center are learning that until we question the very principles and structures of the professions, how they learn, healthcare and higher education systems, and their inter-relationships, we will not make progress. From the outset of the National Center’s founding, we understood that to truly transform healthcare for health outcomes that incorporate interprofessional work, what was needed is a bold vision, patience, taking the road less traveled with a long-view, and asking uncomfortable questions. This mind-set has not been easy, or often makes us popular, but it continuously informs our current perspectives that we offer in this issue.

Three new papers in this issue portray our story of the National Center since its inception: the background, how it was operationalised within the expectations of funders, the international reach of services and platforms, the nature of work with collaborators, and our observations about the interprofessional movement. We also offer our thinking for the next decade. Importantly, based upon what we are learning with many collaborators, we propose the NexusIPE™ model to guide interprofessional practice and education that places the focus first on what matter most: people/patients, families, and communities. This model suggests a framework for implementing interprofessional practice and education with a laser focus. Then, we can intentionally design the Nexus relationships between the healthcare and higher education systems for how professionals and others, including student and patients, work and learn together in practice and community-based settings every day.

The other articles in the issue are those that we requested some of our collaborators write because we believe their experiences tell important stories about specific phenomena to advance aspects of the Nexus concept and its implementation. These articles were previously published by the Journal online. In our article on the NexusIPE™ model, we highlight the features of these authors’ work that importantly clarified our thinking. Readers of these articles should view them as a mosaic that bring to life aspects of the NexusIPE™ model. Because the authors’ interprofessional experiences occurred over time, we benefit, learning from their efforts that mirror the historical trajectory of predictably fluid interprofessional work. Since online publication of these articles, some programmes and initiatives have thrived, while others are no longer in existence. When senior leaders transition, we know that support and investment often stop as new leaders have their own agendas. When IPE champions leave, often programmes change focus or cease. Our reality begs us to reflect: What are the uncomfortable questions we should be asking now to understand and prevent the predictable ebbs and flow phenomenon of our century-long interprofessional movement?

Thistlethwaite and Xyichris have asked whether the future of interprofessional work will be dystopian or utopian (Thistlethwaite & Xyirichis, 2022). Today, this question is the same one that we have, and we believe the interprofessional movement is at a crossroads because the celebratory rapid and exponential growth over the past decade may cloud our understanding of the current situation. There is much to learn outside of our own sphere to form and answer uncomfortable questions. Authors of recent provocative books lay out the premise that there are flashing warning signs for the future of the professions themselves, healthcare and education (Levine & Val Pelt, 2020; Susskind & Susskind, 2022; Wears & Sutcliffe, 2019). The external destabilizing drivers for the professions and how they are educated include technology such as artificial intelligence, public distrust, fractured political systems, war, climate change, health inequities, and the pandemic aftermath. We are all experiencing these disturbing influences on our personal and professional lives.

In The Great Upheaval, Levine & Van Pelt describe higher education for the professions as built upon the 1910s Industrial Era scientific management mentality with emphasis on standardisation, common processes, or the “one right way” (Levine & Val Pelt, 2020). The 1910 U.S. Flexner Report personifies the Ford Automobile Production model of educating physicians that influenced the education of other health professions and the relationships between them. This foundational framework further developed throughout the 20th century and into the 21st in accreditation, licensure, the competency movement, certification, and hour-based continuing education units to assure competence. Have the standardisation structures led professionals to become self-assured in their own knowledge and expertise? These authors describe the need to leave the Industrial Era behind and move into the 21st century Knowledge Era to humbly learn every day.

Conventional structures and mind-sets are holding us back from being nimble and responsive to the rapidly changing and disorienting realities of today’s global crises. Evidence for the limits of Industrial Era framework comes alive in Wears¹ and Sutcliffe’s book, Still Not Safe, in which they critique the state of the today’s patient safety movement (Wears & Sutcliffe, 2019). These patient safety experts, and now others, provide ample data and evidence that after the billions of U.S. dollars investment to work on the process of care for a safer healthcare system, very little has changed (Padula & Pronovost, 2022). If it was about money alone, we would have had the medical error problem solved years ago. Similar to observations about Industrial Era thinking, these authors describe the limits of technical rationality (Schon, 1987) with its checklists and standardisation alone to make a difference. We need to take note that, as previously described, the patient safety and quality movements laid the foundation for recharging the U.S. interprofessional movement.

In the National Center, we assure readers that we are well positioned to create a utopian future for our work. It is within our reach because in the global interprofessional movement we have come so far by learning together. How do we meld the best of the “standardisation” model to create a new reality in the Knowledge Era? In 2016, our team did not have the benefit of the recent provocative thinkers as we too began to question our work and direction. We recognised the limits of traditional, evidence-based research models to accomplish our goals to assure what matters most to people/patients, families, and communities. Our article on knowledge generation describes the journey of assembling a team of scholarly thinkers and researchers from other fields to critique our work and make recommendations.

During this time, we had many uncomfortable conversations that led to questioning our basic assumptions and values about healthcare, health professions education, and interprofessional work. Our collaborations have resulted in identifying an IPE core data set and building the National Center Interprofessional Information Exchange (NCIIE) to move data tools into practices to enable new ways of learning together every day. An example of important future collaboration is interprofessional workplace learning and expansive learning theory contributed by our colleagues at the University of Bergen that sets the stage for cutting-edge perspectives that align with our current thinking (Baerheim & Raaheim, 2020). Today, the National Center knowledge generation work is ongoing as we implement and scale the NCIIE and IPE Core Data Set in health systems, setting the stage for our next 10 years. We recognised that for the readers of this issue, the knowledge generation approach represents our most unconventional thinking, but it has piqued interest in other sectors, notably the health informatics community.

Today, 2023 marks the first year of our new decade after an intense 10 years of implementation of IPE that was originally defined by our funders in a specific era, as described. Using the prophetic words of Hugh Barr, we look forward to continuing to learn together across many borders and boundaries to contribute what we have learned over the past decade.

Disclosure statement

No potential conflict of interest was reported by the author.

Additional information

Funding

The National Center for Interprofessional Practice and Education has received funding from the Josiah Macy Jr Foundation, Robert Wood Johnson Foundation, Gordon and Betty Moore Foundation, and the John A. Hartford Foundation, the University of Minnesota, and was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under HRSA Cooperative Agreement [UE5HP25067]. The content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government or private foundations. 

Notes on contributors

Barbara F. Brandt

Barbara F. Brandt is the founding director of the National Center for Interprofessional Practice and Education and professor, pharmaceutical care and health systems, University of Minnesota College of Pharmacy. She and served as the Associate Vice President for Education at the University of Minnesota Academic Health Center, overseeing the implementation of interprofessional practice and education programs from 2000 – 2017. She has served on the strategic advisory board of the Journal of Interprofessional Care and on the editorial board of the Journal of Continuing Education in the Health Professions.

Notes

1. Sadly, Dr Robert L. Wears, coauthor of Still Not Safe and an international expert in health informatics, patient safety and emergency medicine, died of complications from surgery in 2017. Dr Sutcliffe carries on his work. https://med.jax.ufl.edu/news/story/?id = 1943.