From the Nexus vision to the NexusIPE™ learning model

1

ABSTRACT

The Nexus vision of simultaneously transforming health professions education and healthcare delivery to achieve Triple (now Quadruple) Aim outcomes was first articulated in the 2012 proposal and funding of the National Center for Interprofessional Practice and Education (National Center). Over the past decade, the National Center has worked with over 70 sites implementing large scale and practice-based interprofessional practice and education (IPE) programs. Because what is needed to implement the Nexus to achieve Quadruple Aim outcomes was not well understood in 2012, the National Center took a social innovations and developmental evaluation approach. This iterative method led to the development of the National Center NexusIPE™ Learning Model that adapts the 3-P high-level stages (Presage, Process, and Product), proposed as a framework for IPE by Barr and colleagues. National Center collaborators’ lessons learned about the Nexus vision are highlighted in this issue and provide real-world examples of elements of the NexusIPE^TM Learning Model. Reflecting on ten years of experience, the National Center leaders recognize the need for Nexus transformation and the relevance of the NexusIPE^TM Learning Model today as education and health systems grapple with mounting workforce challenges. The model provides opportunities to address growing workforce shortages, provide equitable care that leads to health, and support the well-being of practice teams in the face of challenges such as the COVID-19 pandemic

KEYWORDS:

• Collaborative practice
• interprofessional education
• interprofessional practice and education
• workplace learning

Introduction

Since first articulating the Nexus vision in the 2012 University of Minnesota (UMN) proposal to the United States (U.S.) Department of Health and Human Services Health Resources and Services Administration (DHHS-HRSA), significant national interactions informed the evolution of the concept, leading to the NexusIPE™¹ Learning Model, described below (Brandt et al., 2023; Earnest & Brandt, 2013, 2014). The idea for the Nexus originated in 2011 when Minnesota health systems leaders approached the University of Minnesota Academic Health Center senior administrators. The health system leaders described a perceived gap between how graduates are prepared for practice and the transforming health-care delivery system. From 2008, implementing healthcare reform legislation that predated the passage of the 2010 U.S. Patient Protection and Affordable Care Act (PPACA) had been a priority for the State of Minnesota (Minnesota Health Care Reform Act, 2008; PPACA, 2010). Health system leaders questioned how UMN students were prepared to function in teams, understood patient safety issues, knew quality improvement processes, or were aware of the Triple Aim outcomes (improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care) (Berwick et al., 2008).

In response, UMN administrators described the 1Health interprofessional curriculum and other academic health center programs as well as teamwork, patient safety, and quality improvement concepts taught in the health science schools’ didactic curricula (Brandt et al., 2010). Recognizing a disconnect, leaders of the two systems held a retreat in September 2012 to discuss perspectives. A pre-retreat survey of university and health system participants used to plan the meeting demonstrated that each side saw the situation differently. The Nexus concept emerged from the realization at the retreat that, although faculty taught interprofessional content in the classroom, consistent role models were needed in everyday clinical practice to reinforce what students were learning. A disconnect can lead to student skepticism, or the hidden curriculum working against IPE (Hafferty, 1998; Leedham-Green et al., 2019). In other words, the transformative redesign of healthcare requires reconnecting the education and health-care delivery systems at the point of care using an interprofessional model. During a time of significant system change, the health professionals, who are the important role models, are also learners.

Creating the transformational nexus

The National Center senior leaders have written extensively about creating the transformational model of aligning interprofessional education with practice redesign in clinical and community-based settings in the U.S. represented by the Nexus vision (Earnest & Brandt, 2013, 2014; F. Cerra & Brandt, 2011). This vision incorporates new learning approaches into health professions education, a system that currently relies on the linear rational competency model (Figure 1) (Cerra & Brandt, 2015). Traditional U.S. formal health professions education is dependent upon the presence of community experiential rotation sites and practitioner educators who largely serve pro bono. Health systems hope that by providing clinical placements during this phase of health professionseducation, they will be more likely to recruit graduates to their workforce in the future. For example, half of the education and training of medical students occurs in these settings, often with little campus-based faculty interaction (Cerra & Brandt, 2015). Other professions are educated similarly, challenging IPE programming in practice as students are co-located in the same sites with little planned collaboration for learning together. Often clinical preceptors are unaware of other professions’ learners or that members of their own practice team are precepting students. Further, these preceptors may not have a firm understanding of the scope of practice or specific educational mandates of their professional colleagues that can cross multiple higher education institutions.

Figure 1. The rational competency model (F. B. Cerra & Brandt, 2015).

In contrast, creating a transformational Nexus, the cornerstone of the 2012 UMN proposal to the DHHS-HRSA, defines the National Center portfolio (Figure 2). The aim is to intentionally link health professions education and health-care systems for interprofessional workforce development of future and current health professionals to simultaneously demonstrate learning, organizational, health, and wellbeing outcomes. While doing so, the interprofessional collaboration involves students and current health professionals working on the same team toward achieving the same outcomes in clinical practice and community settings. The original 2012 proposal focus was achieving Triple Aim outcomes that over time expanded to the Quadruple Aim to include health and wellbeing of health professionals (Berwick et al., 2008; Bodenheimer & Sinsky, 2014; Delaney et al., 2020; Pechacek et al., 2015). An important conceptual shift, or “flip,” is moving from primarily collaboration-ready student learning for future practice to a more collaborative approach where education and health systems work closely as “Nexus teams” in clinical and community practice settings. There is an intertwining of the continuum of learners in foundational and graduate education and continuing professional development for their specific needs (Institute of Medicine [IOM], 2015). These teams create interprofessional workplace learning environments together to impact organizational, learning, health, and wellbeing outcomes simultaneously (Earnest & Brandt, 2013, 2014; Cerra & Brandt, 2015; Nisbet et al., 2013). Furthermore, this shift reinforces the National Center use of the term “interprofessional practice and education (IPE),” based upon the World Health Organization (WHO) definition, emphasizing target endpoints to enhance collaboration for health outcomes improvement. IPE, therefore, communicates that learning and health outcomes are inextricably linked in clinical practice and community-based settings (Brandt et al., 2023; WHO, 2010).

Figure 2. Creating the transformational nexus.

National center collaborators

Since 2013, U.S. collaborators have worked with the National Center on a variety of projects and activities in IPE implementation, data collection, scholarship, action research, and consultancies. The National Center staff has conducted visits to over fifty U.S. sites implementing large-scale institution-wide and practice-based IPE (Company, 2019; Delaney et al., 2020; Pechacek et al., 2015). These collaborators include the Nexus Innovation Network originally supported by the National Center funders, DHSS-HRSA grantees, the Accelerating Interprofessional Community-based Education and Practice Initiative (Accelerating Initiative) grantees, and others such as the U.S. Veterans Administration Centers of Excellence in Primary Care Education, the American Interprofessional Health Collaborative, the Train-the Trainer (T3) faculty development program (Summerside et al., 2018), and U.S. centers of interprofessional practice and education.

Because the Nexus phenomenon and what is needed to achieve Quadruple Aim outcomes were not well understood in 2012, the National Center took a social innovations and developmental evaluation approach (Brandt, 2014; Gamble, 2008; Patton, 2011). This strategy requires asking three questions: “What?” by studying plans and reviewing data, reports, and information in real-time; then “So What?,” interpreting the meaning in the specific situation; and followed by “Now What?” to make meaningful adjustments. By 2016, using these questions, lessons learned from these national large-scale IPE efforts emerged to inform the Nexus vision and the iterative creation of the NexusIPE™ Learning Model.

Accelerating interprofessional community-based education and practice initiative

From 2016 to 2019, the National Center staff learned a number of significant lessons about academic-community collaboration in sixteen implementation sites in the Accelerating Initiative. This initiative was an intensive three-year, externally evaluated program that provided a unique vantage point to study the Nexus and its phenomena in real-time. The National Center coordinated the initiative, which was funded in 2016 by the Robert Wood Johnson Foundation, the Josiah Macy Jr. Foundation, the Gordon and Betty Moore Foundation, and the John A. Hartford Foundation. The one-time Accelerating program was created to support and study the role of advanced practice nurses to develop and lead interprofessional collaborative care and education models. The initiative aimed to accelerate IPE through creative and sustainable partnerships in which advanced practice nurses and at least one additional profession (e.g., medicine, pharmacy, occupational therapy, social work, among others) actively learned and worked together with community-based partners.

Following a national call for proposals, sixteen sites were awarded $50,000 grants with a match requirement to address real community health needs while providing interprofessional learning opportunities for students. To support the work of these Nexus teams, the National Center developed a comprehensive program that began with a three-day intensive institute introducing the concepts and the tools. For more than two years, each site received technical assistance, expert coaching, resources, a community of practice as well as a two-day site visit to accelerate their interprofessional education and collaborative practice efforts. Working intensively with sixteen sites simultaneously during developmental stages from start-up to implementation to evaluation in light of other National Center experiences informed the framework and elements of the NexusIPE™ Learning Model.¹

An external research group conducted an implementation evaluation of the initiative by tracking program outcomes, achievement of implementation milestones, and documenting success and challenges of the Nexus approach (Harder+Company., 2019). The evaluators collected and analyzed data from a variety of sources including: team site progress reports; surveys of team members including measuring teamness (Tilden et al., 2016); and site visit documentation prepared by the National Center staff. They also conducted interviews with key stakeholders including funders, National Center staff, and Nexus teams’ principal investigators. The evaluation team also conducted in-depth interviews with Nexus team members in a sample of seven sites, selected to reflect a diverse array of program models, target populations and geographies. The Harder report, case studies, and webinars documenting the Accelerating Initiative are available at https://nexusipe.org/advancing/accelerating

At the end of the evaluation grant period in fall 2019 immediately prior to the COVID-19 pandemic, the external evaluators validated the approach, tools and strategies deployed by the National Center to support site development of effective impactful Nexus partnerships. Examples of promising early outcomes and Nexus benchmarks to continue to inform the NexusIPE™ Learning Model included:

• Sites engaged a total of 1,842 students in their Nexus programs by the end of the grant period, an average of 123 students per site.

• Between 2016 and 2019, the number of students increased across all professions, especially nursing, pharmacy, and medicine.

• Many sites started to see improved health outcomes for patients by the end of the two-year grant period.

• Many of the Nexus programs increased access to primary care for vulnerable populations.

• Some Nexus programs saw reduced readmissions and emergency room visits and improvements in health indicators.

• Working in a community-based setting gave students hands-on experience with the ways in which social determinants of health impact the lives of patients.

• Nexus programs allowed student interprofessional care teams to showcase how their expertise could aid specific vulnerable patient populations. (Harder+Company, 2019)

The NexusIPE™ learning model

National Center collaborators contributed to lessons learned and our understanding of the Nexus vision leading to the creation of the NexusIPE™ Learning Model (Figure 3). For this article, we cite real-world examples of our collaborators, many of which were invited to write articles for this special issue on the National Center (Appendix 1). The authors’ perspectives shed light on and illustrate the interconnected elements of the model. They also inform the importance of convening practice and education stakeholders as they focus on the people² (individuals, families, communities, and populations) served first and outcomes to guide IPE design. Using overarching design principles, Nexus teams can enter the model at any point that makes sense, given a specific situation, stage of development, timing, or when developmental progress is impeded. By using the model and related tools, Nexus team collaboration for shared understanding is iterative rather than completing a list of tasks, and provides a scaffold for developmental evaluation.

Figure 3. Moving from the rational competency model to the NexusIPE™ learning model.

Elements of the model

Based upon the evolution of the Nexus, the NexusIPE™ Learning Model adapts the Biggs 3-P high-level stages (Presage, Process, and Product), proposed as a framework for IPE by Barr and colleagues (Barr et al., 2005; Biggs, 1999; Tynjälä, 2013). During the presage stage, groups, taskforces, and steering committees are convened to implement IPE. At this stage, we propose design principles for creating NexusIPE™ programs to link practice and education, starting first with people who are served. During the process stage, those individuals designated to implement IPE strive to form a functioning Nexus team as they work together toward a shared understanding of their Nexus program. Developmental tasks include understanding and designing for their own ecosystem, weighing critical success factors of IPE, creating interprofessional workplace learning in practice, and collecting actionable data in real time. The product stage documents organizational, health, wellbeing, and learning outcomes to inform iterative developmental evaluation by asking the “what?,” “so what?,” and “now what?,” questions. The answers will continuously inform the implementation process to make necessary adjustments. For clarity, citations from this special issue are presented in Appendix 1, with NexusIPE^TM Learning Model design principles highlighted by each article noted.

Presage: using overarching NexusIPE™ design principles

Implementing IPE in classrooms, simulations, and practice settings is complex, requiring that IPE champions manage a myriad of details (e.g., curricula, logistics, accreditation, politics) to be successful. To complicate matters in Nexus implementation, practice and education stakeholders have different drivers and pressures such as their own regulatory requirements and resource constraints. As a result, the National Center staff observe that IPE champions and Nexus teams often get “lost in the weeds,” losing sight of the big picture and goal, or “what matters most” (Brandt et al., 2023). Instead, in the NexusIPE^TM Model presage stage, the primary developmental tasks create situational awareness for shared understanding among Nexus team members (i.e., IPE champions, senior leaders, learners, and people served) (Salas & Dietz, 2011). Using five overarching design principles helps to “zoom out” from details and day-to-day activities to provide structure in specific situations.

To initiate or restart IPE implementation with a fresh perspective, these five overarching design principles promote Nexus team development “to get on the same page:”

Intentionally connect practice and education

Use the Compass: The People North Star

Plan outcomes for what matters most

Anticipate critical events for success

Plan for sustainability and vitality

Intentionally connect practice and education

Foundational to Nexus collaboration is overtly expressing rather than inferring that the purpose is to create authentic partnerships that move beyond conventional health professions’ education, using volunteer clinical sites as placements for student rotations. As noted, the goal is to simultaneously and mutually benefit education and health systems emphasizing outcomes in clinical and community settings (Bradley et al., 2018; Brandt et al., 2020; Earnest & Brandt, 2013, 2014; Fowler et al., 2018; Guck et al., 2019; Lamb et al., 2018; Shrader et al., 2018). To do so, the education system needs to be attentive to the practice system to optimize the “under-leveraged education system” expertise to support health system goals (Earnest & Brandt, 2013, p. 46). For example, health systems administrators expect clinicians, especially in primary care, to be skilled in population health and manage panels of patients, but many have not been trained to do so (Dulay et al., 2018). In their article, the Medical University of South Carolina authors note the importance of being attuned to the needs of their clinical partner to create a purposeful academic-practice partnership (Brashers et al., 2015; Fowler et al., 2018). Once established, Nexus partnerships require actively developing and managing inter-organizational relationships to support logistics, resource sharing, innovation, faculty, health professionals and staff development, and educational/program evaluation (Bradley et al., 2018; Harada et al., 2018; Nagelkerk et al., 2021).

Use the compass: the people north star

In forming a Nexus, the single most important design principle is to focus intentionally first on the people who are served in the practice. Then, design, planning, and implementation considers learning needs of stakeholders (i.e., students, residents, health professional staff, and people served) (Fraher & Brandt, 2019). Effective partnerships engage the people in assessing needs and ongoing engagement to drive design (Company, 2019). For example, in this issue, Bradley and colleagues describe that what matters most to the communities they serve is the social determinants of health (SDoH) of housing, lack of insurance, and access to care. With this design principle in mind, a different type of program was created that impacts the SDoH, health equity, and interprofessional learning at the same time (Barton et al., 2020; Bradley et al., 2018; Company, 2019).

Define outcomes for what matters most

Once what matters most to the people in the specific practice setting is documented, intended targets (organizational, health, and wellbeing) and intermediary (learning) outcomes can be articulated to guide NexusIPE™ design and data collection (Delaney et al., 2020; IOM, 2015). Several authors in this issue describe NexusIPE programs created around target outcomes, rather than leaving them to chance. Examples include: the social determinants of health (Bradley et al., 2018); improving depression screening rates and HbA1c (Shrader et al., 2018); the 4 Ms of age-friendly health systems (Brandt et al., 2023); practice efficiencies (Harper et al., 2018; Nagelkerk et al., 2021), improving mammogram screening rates (Harper et al., 2018); and staff team performance (Fowler et al., 2018). To plan for outcomes, several authors describe using the Institute of Medicine Interprofessional Learning Continuum model as a framework for identifying target outcomes as well as planning for the array of learners and hierarchy of intermediary learning outcomes (reaction, attitudes/perceptions, knowledge/skills, collaborative behavior, and performance in practice) (Figure 4) (Brandt et al., 2023; Cox et al., 2016; Delaney et al., 2020; Dulay et al., 2018; Fowler et al., 2018; Harper et al., 2018; IOM, 2015). This model has been adapted and is foundational to the NexusIPE™ Learning Model strategy for documenting outcomes as described below.

Figure 4. NexusIPE™ design using the IPLCM.

Anticipate critical events for success

The National Center has studied the common, predictable, and pervasive barriers and obstacles of IPE experienced by our collaborators (Delaney et al., 2020). Bringing teams together for rapid innovation in chaotic times, developing a program in a complex environment, beginning a new grant-funded project, or starting an ambitious initiative can feel like flying the plane while building it. Authors of contributed articles describe how teams are frequently confronted with critical events, or unforeseen, unplanned occurrences that demand rethinking an original plan, often requiring a change in course (Brandon et al., 2021; Delaney et al., 2020; Dulay et al., 2018; Harada et al., 2018; Nagelkerk et al., 2021). We observe that this experience is very common and recommend that Nexus teams anticipate, document, and continuously manage them as they occur.

Plan for sustainability and vitality

An important area for future scholarship is understanding the nature of sustainability, growth, and vitality of IPE and Nexus programs. Because of the complex nature of IPE with its ever-changing ecosystem and leadership support, conversations about sustainability and vitality need to start early and be constant. Planning for sustainability takes into consideration more than financial resources including: maintenance of mission and activities, institutionalization of infrastructure, strategic response to change, and community visibility (Kennedy, 2021). Beyond minimal program sustainability, vitality can mean growth and expansion, building upon the original program (Shrader et al., 2018, 2022). Vitality can also mean a program has seeded ideas that are intended to live beyond the original program and scale in organizations (Fowler et al., 2018).

Process: next step: getting from here (people) to there (outcomes)

The steps in implementing the Nexus vision are an interplay between conceptually understanding the ecosystem surrounding the specific situation, outcomes, and the tasks to accomplish. People and teams live in systems that continuously impact outcomes. The overarching NexusIPE™ design principles frame the work of setting the stage for identifying, planning, and accomplishing what needs to be done. By understanding these influences, IPE champions can contextualize their work in their own specific circumstances to discern the specific enabling and interfering factors (i.e., professional culture, institutional culture, workforce policy, and financing policy) that may support and hinder implementation (Brandon et al., 2021; IOM, 2015). Using the design principles, five steps characterize the process stage to shape IPE to achieve defined outcomes:

• Develop Nexus teams for shared understanding

• Analyze success factors of IPE

• Understand the Nexus ecosystem

• Create the interprofessional workplace learning environment

• Collect real-time data for developmental evaluation

Develop nexus teams for shared understanding

Understanding the ecosystem and IPE success factors lays the foundation to expand the conventional rational competency approach that focuses on professionals and learners first to a Nexus approach for high impact for learning, people, and organizations (Dochy et al., 2022; Fraher & Brandt, 2019). Developing effective Nexus teams comprised representatives from academia, community/practice, and the people served raises the likelihood of success. We observe that U.S. school-based clinical faculty members who tend to rotate for a limited amount of time through clinics with primarily teaching responsibilities cannot speak for the everyday needs of the practice. Over time, the Nexus team develops a shared understanding of their work and are able to leverage their insight to enhance their ability to adapt. When Nexus teams adapt in real-time to circumstances and planned outcomes, the time between IPE implementation and outcomes can potentially be shortened and the number of confounding variables reduced, leading to continuously documenting learning, organizational, health, and wellbeing outcomes (Figure 2).

However, we have observed that the mental model shift from conventional thinking is difficult, and Nexus teams often get stuck at this stage, impeding progress. Therefore, members need to have dedicated time, energy, recognition, and rewards for their efforts (Reeves et al., 2016). Relationship building among team members and between organizations takes time and is important in developing an effective Nexus team. Once assembled, an early task is to come to agreement on a shared vision for the Nexus work that is turned into a compelling vision with frequent updates to inspire others (F. B. Cerra et al., 2015; Lamb et al., 2018). The articles in this special issue describe effective Nexus teams that work well together and demonstrate high performance. Nexus teams emulate teaming characteristics themselves (e.g., mutual trust, communication, interprofessional values and ethics, clearly defined roles) espoused and expected for future and practicing health teams (IPEC, 2016; Osborne et al., 2018). As noted, a goal is to develop shared mental models and understanding by fostering relationships, developing collaborative teamwork while anticipating conflict and developing resolution skills (Bradley et al., 2018; Brandon et al., 2021; Harada et al., 2018; Nagelkerk et al., 2021; Shrader et al., 2018).

Analyze success factors of IPE

Early review of data collected in the Nexus Innovation Network revealed success factors for interprofessional programs to demonstrate impact on student learning and patient outcomes (F. B. Cerra & Brandt, 2015; F. B. Cerra et al., 2015). In addition to grassroots IPE champions, these factors are: culture change, shifting the focus from process of care to interprofessional teamwork for health; a compelling vision; proactive senior leaders; and appropriate resources for and positioning of IPE efforts. As we defined these factors, the Arizona Nexus began to explicitly use the National Center lessons learned to guide their inter-institutional statewide development, paying attention to changing local ecosystem influences (Lamb et al., 2018). The authors share the story of each success factor and the stakeholders’ readiness for change, particularly initial lack of senior leadership readiness. The IPE champions were successful in garnering early grant resources stimulating Nexus programs and used relationship strategies to lay the foundation for success.

Understand the nexus ecosystem

IPE operates in an ecosystem of inter-connected organizations, networks, structures, and events (Brandt et al., 2023; Earnest & Brandt, 2013, 2014; Kennedy et al., 2021; Pechacek et al., 2015). The technical approach to IPE is to create strategic plans, logic models, checklists of tasks, and educational evaluation strategies (Brandt et al., 2023). However, the interplay and changes in the ecosystem constantly impacts IPE implementation such as national and state policies and regulations (e.g., accreditation, politics, healthcare finance), senior leadership and governance of education and health system decisions, the clinical and community practice settings, and teaching educational environments. These changes can quickly make a priori plans obsolete, and successful IPE champions are constantly managing them. As noted, this reality adds complexity to IPE work, requiring the need to continuously adapt plans in health system levels: microsystem (the point of care linked with education); mesosystem (health and education system leadership); and macrosystem (regulation and accountability) (Table 1) (Earnest & Brandt, 2013, 2014; Pechacek et al., 2015). In creating Nexus partnerships, the levels of system influences are in practice, education and the Nexus alignment between the two, each having their own enabling and interfering factors (professional culture, institutional culture, workforce policy, and financing policy) that continuously impacts IPE implementation (Brandon et al., 2021; IOM, 2015).

Table 1. Level of Change Defined by Context.

Change level	Practice	Education	Nexus relationships
Micro point of care/service delivery linked to education	Provides clinical and other services within its own environment and ecology; committed to interprofessional workplace learning environments with education partner; focused on intermediary and target outcomes	Builds upon curriculum for students for interprofessional and professional competencies; committed to interprofessional workplace learning environment with practice partners, focused on intermediary and target outcomes	Intentionally create Nexus teams to achieve intermediary and target outcomes
Meso organizational systems	Senior leadership and governing structures in healthcare and community systems, corporate offices, governing boards; responsible to macro system and for the bottom financial line	University/college presidents, deans, senior leadership with faculty governance; boards and trustees; responsible to macro system and bottom financial line	Greater understanding of synergies between meeting practice and education system needs and outcomes; engages macrosystem; supports the micro system
Macro state, regional and national	Regulation, payment systems, financial, health system accreditation, policy environment, professional associations, political, market forces	Higher education and professional school accreditation, financing models, market forces,	Players in practice and education systems participate in the macro systems, interpreting complex interplay

Adapted from: Pechacek et al. (2015), p. 148.

The Veterans Administration Centers of Excellence in Primary Care Education began with the national senior administration vision and response to implementation and study of 800 interprofessional teams throughout the U.S. (Dulay et al., 2018; Harada et al., 2018). This commitment to interprofessional teams led to the creation of the national and regional centers in seven systems partnerships between VAs and their primary care clinics and local academic institutions. The start-up phase revealed the necessity to monitor compliance with VA regulations while facilitating collaboration, innovation, and fidelity to project goals. The authors describe the continuous management of critical events between system levels of existing local and national VA policies and procedures, developing new IPE national policies, and advocating for ongoing resources through communication with the national Office of Academic Affairs.

Create the interprofessional workplace learning environment

The growing expertise in the IPE faculty ranks represents potential for the greatest impact to generate knowledge about clinical learning environments and learning health systems by revisiting the workplace learning literature (Brandt et al., 2023; Dochy et al., 2022; IOM, 2007; Nisbet et al., 2013; Weiss et al., 2019). The opportunity for advancing and studying interprofessional collaborative practice is in clinical and community practice settings. These environments are where students/trainees, health professionals, and staff, with the people they serve, are working and learning together (Arenson & Brandt, 2021; Cox et al., 2016; IOM, 2015). It also is where relationships are formed, influencing practice culture such as psychological safety and setting the tone for learning (i.e., “Everyone teaches and everyone learns”) (Brandon et al., p. 442). Favorable student evaluations infer that the lessons learned in practice shed light on the importance of mastering interprofessional competencies in practice settings where interdependence is readily evident, not theoretical (Collins et al., 2019; Fowler et al., 2018; Harada et al., 2018; Nagelkerk et al., 2021; Shrader et al., 2018).

The collection of articles featured in this special issue provides a portal into the nature of circumstances that arise in creating interprofessional workplace learning environments (with or without students), incorporating training for competencies into a learning in practice model. The authors’ experiences shed light on the importance of situated cognition in practice settings, the contributions of educators’ expertise, the potential of designing for impact, and the necessary continuous adjustments to keep attuned to the practice setting. Collectively, the articles inform us of themes for interprofessional workplace learning to consider for implementation, future scholarship, and action research. Examples of practical and scholarly themes follow.

IPE Learning In Practice Design. Based upon seven years’ experience documenting outcomes when implementing a patient-engaged teaching practice, Shrader and colleagues offer principles for real-time interprofessional learning in practice, as noted below.

Practice and Teaching Efficiencies and Continuous Learning. Several authors note the realities and impact of productivity pressures in the U.S. healthcare system in which physicians are primarily responsible for generating income in a fee-for-service model. Addressing concerns, some authors in this issue describe strategies for clinical workflow redesign that incorporates quality improvement and teamwork as well as students as value-added team members (Bradley et al., 2018; Brandon et al., 2021; Harper et al., 2018; Nagelkerk et al., 2021). Others provide practical interprofessional teaching tips specifically to address efficiencies, while documenting contributions to the practice and community, including the social determinants of health (Nagelkerk et al., 2021; Osborne et al., 2018).

Role Ambiguity and Conflict. An important observation by some of this issue’s authors is role ambiguity and confusion on the health-care team and the need for explicit expectations for clinical performance as a theme. Introducing teams into practices in several sites has implications for the hidden curriculum working against IPE and the potential for negative role-modeling for pre-professional and resident learners (Brandon et al., 2021; Dulay et al., 2018). After engaging the law school to offer conflict resolution training during the Accelerating Initiative start-up of a nurse practitioner-led team at Creighton University, a practice-based facilitator used the IPEC roles and responsibilities’ competencies in the practice to focus conversations while implementing a new primary care teaching clinic (Brandon et al., 2021; Company, 2019).

Formal Education and Informal Learning. Workplace learning builds upon formal curricula that are based upon standards of practice, what is taught in classrooms and simulations, and everyday informal opportunities that cannot be anticipated before they occur (Nisbet et al., 2013). The authors in this issue share a wide variety of formal, didactic curricula during experiential rotations and clinician education as well as informal opportunities for facilitating learning. These articles include a diversity of learner perceptions and evaluation results, primarily favoring learning in practice over required modules. The authors reflect upon such issues as what is foundational education; what is best learned in practice; and how, why, when and if academic content should be introduced in practice settings (Dulay et al., 2018; Fowler et al., 2018; Nagelkerk et al., 2021).

Types of Learners. Some authors’ experiences point to the impact of levels of learners on clinical practices such as preference for more advanced students who contribute clinically such as nurse practitioner, social worker, and physician assistant students rather than third- or fourth-year medical students who are novice clinicians (Nagelkerk et al., 2021; Osborne et al., 2018). In the Midwest Interprofessional Practice, Education and Research Center program, the clinic staff chose a preference for nurse practitioner and social work students who were placed longitudinally over several months. The organizational burden of monthly onboarding was considered onerous, no matter how valuable the clinical input of certain student learners such as pharmacy students (Nagelkerk et al., 2021). Comparatively, other clinical and community settings may be better positioned to take students who are early in their programs.

Learning Across the Continuum. Noted authors shed light upon issues related to balancing clinical and interprofessional competency mastery in practice settings for different stages of careers and developmental tasks (IOM, 2015). As a result, the articles elucidate both implementation and future research issues on interprofessional workplace learning design around the expanded Kirkpatrick typology for stages of careers in the learning continuum (foundational and graduate education to continuing professional development) (Barr et al., 2005; IOM, 2015). The primary purpose of educating pre-professional learners (foundational education) and residents (graduate education) in experiential rotations or placements is mastering their own discipline’s clinical competencies. If professionals are not competent members of their own profession, they cannot be effective team members. Experienced, current practitioners have other learning needs as they already demonstrate their clinical competence through many forms: continuing education, maintenance of certification, licensure, hospital privileges, and state boards. For interprofessional teamwork, practice workflow redesign and interprofessional precepting, what and how learning should be accomplished for the clinical setting present different issues (Fowler et al., 2018; Harada et al., 2018; Harper et al., 2018; Nagelkerk et al., 2020).

Collect real-time data for developmental evaluation

In two of the included articles, authors describe technology-assisted, practical strategies for collecting real-time, accessible, and actionable data in interprofessional workplace learning environments (Collins et al., 2019; Delaney et al., 2020). These tools have the power to inform teams’ learning with data for iterative, rapid-cycle improvement in performance that demonstrates meaningful outcomes. The NexusIPE^TM Learning Model is informed by the concept of the Learning Health System, first articulated by the IOM as an approach to “transform the way evidence is generated and used to improve health and health care” (IOM, 2007, p. xiii). The NCIIE and NexusIPE^TM Core Data Set have been developed based on experience working with many academic, clinical, and community partners, and leveraging the strengths of the UMN Clinical and Translational Science Institute information platform and expertise. These tools are described in detail in Delaney et al. (Delaney et al., 2020). The NCIIE provides a dashboard that gives real-time insight into actionable data to inform Nexus partnerships’ ongoing work. The NexusIPE^TM Core Data Set is a highly curated set of tools that provide an approachable, comprehensive strategy for measuring relevant intermediary and target Quadruple Aim outcomes. Use of standardized tools also supports a unique opportunity for knowledge generation across individual projects to develop new evidence. The tools provide effective strategies to develop and sustain meaningful transformation.

Collins et al. describe another model of real-time data collection, the Jefferson Team Observation Guide (JTOG) (Collins et al., 2019). JTOG provides a practical tool for measuring from the vantage point of the team, individual, patient, and/or support person to provide a 360-degree assessment of application of interprofessional practice competencies in real time. The JTOG also leverages technology, and provides an option to collect data in a smart-phone-based app and share real-time feedback to learners or practitioners, comparing their performance with that of peers. The collected data can be used to provide formative feedback for interprofessional teams and individual team members.

Product: documenting and communicating intermediary and target outcomes

As noted in defining outcomes that matter most, some special issue authors report documented intermediary (learning) and target (organizational, health, and wellbeing) outcomes using a variety of data collection and research methodologies. These articles represent early Nexus implementation at a time when the National Center was studying the Nexus vision and creating and stabilizing the NexusIPE^TM Core Data Set and the NCIIE, noted above (Brandt et al., 2023; Delaney et al., 2020). These tools are designed using the IOM IPLCM model as a foundation to drive measurement of meaningful outcomes from interprofessional education and practice transformation. Documenting and communicating high impact on what matters most, especially to senior leaders and other stakeholders, is important for IPE program sustainability and vitality. As senior leadership transitions, new leaders refresh their own agendas and visions, and IPE programs are the most vulnerable (Baldwin, 2013; Brandt et al., 2023). The early outcomes of Nexus development infer IPE that aligns practice and education can demonstrate opportunities for being part of the solution, rather than a cost center. Below are three illustrations to highlight from articles published in this special issue.

The Medical University of South Carolina Nexus team documented learning and organizational outcomes. Using the IPCLM as a shared mental model strategy, the team engaged health system leaders and a hospital unit to simultaneously educate staff and students. This model leveraged the substantial educational expertise of the Office of Interprofessional Initiatives. As a result, staff teamwork performance improved significantly across all TeamSTEPPS® Team Performance Observation Tool (T-TPO) domains (team structure, communication, leadership, situation monitoring, and mutual support) (Marlow et al., 2016). The success of the model allowed scaling across the health system (mesosystem) (Fowler et al., 2018).

Workforce and workflow redesign to incorporate medical assistants (MA) in more meaningful ways to benefit patient care drove the University of Minnesota team’s design of their interprofessional workplace learning implementation (Harper et al., 2018). Using the Share the Care^TM model in a primary care teaching clinic that incorporates medical residents and other pre-professional learners, the team assessed the impact on Quadruple Aim outcomes in real-time while adjusting workflows. Focusing on medical assistant enhanced rooming and visit assistance, the team documented health outcomes (increased mammogram ordering), organizational (visit summary print rates and improved workflows), learning and satisfaction (MA and clinicians). This learning microsystem created enough documentation that the process scaled to the other clinics in the Department of Family Medicine and Community Health mesosystem.

The Kansas University Medical Center team partnered with the National Center in a Josiah Macy Jr. Foundation-funded project to develop the “Preceptors in the Nexus” interprofessional teamwork project that has over 30,000 views on Nexusipe.org. Using the patient focus to drive their interprofessional “learning in practice” design of the interprofessional workplace learning environment in the clinic, as described in the article in this issue, the team documented student learning outcomes of satisfaction, increased interprofessional collaboration skills while demonstrating organizational outcomes of value-added benefits to improve patient outcomes (HbA1c values for patients with diabetes and significantly improved depression screening rates) (Shrader et al., 2018).

Creighton University’s program is another program highlighted in this issue (Brandon et al., 2021). In a separate publication, Creighton University’s program documented outcomes related to the Quadruple Aim by following a high-risk cohort of patients longitudinally. Outcomes showed reductions in emergency department visits, hospitalizations, hemoglobin A1c values, and patient charges (Guck et al., 2019).

Concluding reflections

The National Center has had a unique opportunity to observe and participate in IPE implementation in multiple situations with many collaborators and researchers, focused on a big vision, the Nexus. The 2012 charge to the National Center was to impact US healthcare by elevating the decades-old concept of interprofessional education and collaborative practice. Over time, we recognized that outcomes-based interprofessional education needed to expand beyond the learners, enriching their competence while simultaneously impacting organizational health and well-being outcomes. From the beginning, based upon our experience, we understood that our ideas defied conventional wisdom and thinking and needed to expand expertise beyond traditional collaborators such as incorporating interprofessional informaticians, computer scientists, and health services researchers.

In 2012, five U.S.-based public and private funders made the initial investment in the University of Minnesota to provide support specifically to improve the U.S. health system. To do so, their expectation was that the health system and clinical practice redesign must be intentionally focused first on achieving what matters most to the people served: their health (Cox & Naylor, 2013; Fulmer & Gaines, 2014). Their vision was that this goal can be achieved through implementing interprofessional collaborative practice and team-based workforce development in practice. The NexusIPE™ Learning Model emerged based upon over ten years of work with numerous U.S. and other collaborators in many environments. At the time world-wide acceptance of health teams and IPE was rapidly growing. The exponential growth of international discovery, scholarship, and research continuously informs our understanding. A core design principle of the model is the situation-specific application to any practice- and community-based setting within its own organizational or cultural context. For example, implementing the model focuses first on understanding what outcomes matter locally and the context during the Presage and Process stages. We look forward to learning together with collaborators by continuing to refine the NexusIPE™ Learning Model, the NexusIPE™ Core Data Set, and the National Center Interprofessional Information Exchange as we position our work for the next decade.

Disclosure statement

No potential conflict of interest was reported by the authors.

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 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 to 2017. She is a professor of pharmaceutical science and health systems in the University of Minnesota College of Pharmacy. 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.

Carla Dieter

Carla Dieter is the Coordinator of NexusIPE™ Programs at the National Center for Interprofessional Practice and Education and previously the Accelerating Initiative Project Coordinator with the National Center. Dieter has been in nursing for 45+ years with experience ranging from clinical practice as an RN as well as a certified Family Nurse Practitioner. Carla has served in numerous leadership positions including Coordinator of the Doctor of Nurse Practitioner Family Nurse Practitioner program at South Dakota State University and as Chair of Nursing at The University of South Dakota. Dieter ls a founding member and past chair for the South Dakota Nexus, also referred to as the South Dakota Interprofessional Practice & Education Collaborative (SD-IPEC). She is Professor Emeritus, Department of Nursing at The University of South Dakota.

Christine Arenson

Christine Arenson is the director of the National Center for Interprofessional Practice and Education and Professor in the Department of Family Medicine and Community Health at the University of Minnesota School of Medicine. Prior to joining the National Center, she served in a variety of academic and practice leadership roles at Thomas Jefferson University, including founding director of the Division of Geriatric Medicine and Palliative Care, founding co-director of the Jefferson Center for Interprofessional Practice and Education, and Chair of the Department of Family and Community Medicine. She has been engaged in academic-community partnerships and practice transformation at local and health system levels for over two decades.

Notes

1. The use of the term “Nexus” refers to the vision for aligning practice and education. In 2020, the University of Minnesota trademarked the term, “NexusIPE,” to be used for programs and services offered by the National Center.

2. The term “people” collectively refers to patients/individuals, families, communities, and populations. The local context determines which term may be more appropriate.

Appendix 1:

Special issue citations with Nexus principles exemplified

Table

Paper	Nexus principles exemplified
Bradley et al. (2018). The Interprofessional Care Access Network (I-CAN): achieving client health outcomes by addressing social determinants in the community. Journal of Interprofessional Care, 1–8. https://doi.org/10.1080/13561820.2018.1560246	Connecting education and practice; The people: North Star; planning for outcomes; develop Nexus team for shared understanding; creating interprofessional workplace learning in practice
Brandon et al. (2021). Creation of a primary care academic collaborative nexus: enabling and interfering factors. Journal of Interprofessional Care, 35(3), 438–443. https://doi.org/10.1080/13561820.2020.1749574	Anticipate critical events; develop Nexus team for shared understanding; understand ecosystem; creating interprofessional workplace learning in practice
Collins et al. (2019). A tool for assessing interprofessional collaborative practice: evolution of the Jefferson teamwork observation guide (JTOG)®. Journal of Interprofessional Care, 1–4. doi:10.1080/13561820.2019.1613967.	Collecting actionable data in real time
Delaney et al. (2020). National center for interprofessional practice and education IPE core data set and information exchange for knowledge generation. Journal of Interprofessional Care, 1–13. https://doi.org/10.1080/13561820.2020.1798897	Planning for outcomes; anticipate critical events; collecting actionable data in real time; learning, organizational, health and wellbeing outcomes; learning outcomes
Dulay et al. (2018). Interprofessional population health advocacy: Developing and implementing a panel management curriculum in five veterans administration primary care practices. Journal of Interprofessional Care, 1–11. https://doi.org/10.1080/13561820.2018.1469476	Connecting education and practice; anticipate critical events; understand ecosystem; critical success factors; creating interprofessional workplace learning in practice
Fowler et al. (2018). Alignment of an interprofessional student learning experience with a hospital quality improvement initiative. Journal of Interprofessional Care, 1–10. doi:10.1080/13561820.2018.1455649	Connecting education and practice; planning for outcomes; plan for sustainability and vitality; creating interprofessional workplace learning in practice; learning outcomes; organizational outcomes
Harada et al. (2018). Interprofessional transformation of clinical education: the first six years of the Veterans Affairs Centers of Excellence in Primary Care Education. Journal of Interprofessional Care, 1–9. doi:10.1080/13561820.2018.1433642	Connecting education to practice; anticipate critical events; develop Nexus team for shared understanding; understand ecosystem; critical success factors; creating interprofessional workplace learning in practice
Harper et al. (2018). Team-based care: an expanded medical assistant role – enhanced rooming and visit assistance. Journal of Interprofessional Care, 1–7. doi:10.1080/13561820.2018.1538107	Planning for outcomes; creating interprofessional workplace learning in practice; learning outcomes; organizational outcomes; health outcomes
Lamb et al. (2018). The Arizona Nexus: the first five years. Journal of Interprofessional Care, 1–4. doi:10.1080/13561820.2018.1505715	Connecting education and practice; develop Nexus team for shared understanding; critical success factors
Nagelkerk, J., Trytko, J., Baer, L. J., Tompkins, A., Thompson, M., Bouthillier, M., Booth, A., & Nagelkerk et al. (2021). Sustainability of an IPCP program within a federally qualified health center including interprofessional student team placements. Journal of Interprofessional Care, 1–9.	Connecting education and practice; planning for outcomes; anticipate critical events; develop Nexus team for shared understanding; creating interprofessional workplace learning in practice
Osborne et al. (2018). Training Health Professions preceptors in rural practices: A challenge for Interprofessional practice and education. Journal of Interprofessional Care, 1–3. doi:10.1080/13561820.2018.1458707	Develop Nexus team for shared understanding; creating interprofessional workplace learning in practice
Shrader et al. (2018). Determining the impact of an interprofessional learning in practice model on learners and patients. Journal of Interprofessional Care, 1–8. doi:10.1080/13561820.2018.1513465	Connecting education and practice; planning for outcomes; plan for sustainability and vitality; develop Nexus team for shared understanding; creating interprofessional workplace learning in practice; learning outcomes; organizational outcomes; health outcomes
Summerside et al. (2018). Early outcomes from a national train-the-trainer interprofessional team development program. Journal of Interprofessional Care, 1–4. doi:10.1080/13561820.2018.1538115	Connecting education and practice; creating interprofessional workplace learning in practice