1
1
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The Need for Interprofessional Collaborative-Ready Nutrition and Dietetics
3
Practitioners
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Key words: Interprofessional, collaborative, teamwork, dietetics, education
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Kathrin A. Eliot, PhD, RDN, FAND, Assistant Professor, Saint Louis University,
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3437 Caroline Street, Room 3076, St. Louis, MO 63118
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314-977-8669 (phone), 314-977-8520 (fax), keliot@slu.edu
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Kathryn M. Kolasa, PhD, RDN, LDN, Professor Emeritus and Affiliate Professor
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Brody School of Medicine at East Carolina University, 3080 Dartmouth Drive
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Greenville, NC 27858, 252.917-1290 (cell phone) 22.756.5487 (home phone)
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252.744.3079 (fax) kolasaka@ecu.edu
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15
Introduction
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Registered Dietitian Nutritionists (RDNs) are integral members of many health care and
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health prevention teams particularly when addressing issues such as eating disorders,
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HIV/AIDs, coronary heart disease, diabetes, maternal and infant health, pediatrics and
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exercise/sports. Despite their key positioning on these teams, graduates of nutrition and
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dietetics programs are rarely educated in a manner that would develop the soft skills
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needed to become an effective team member. Nutrition and dietetics graduates are not
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unique in this omission. Developing collaborative skills that emphasize communication
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and equity are often neglected by other health professions’ education as well.
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25
This paper calls upon the leadership of nutrition and dietetics education programs to
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increase the number of experiential opportunities for their students/interns to learn from
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and with students of other health professions. These opportunities would include
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facilitated discussions that make explicit the implicit competencies that were addressed
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during the learning exercise. The value of educating interprofessionally is three-fold.
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First, students graduate with collaborative skills that can be applied in many aspects of
31
life. Second, universities will better position their graduates for employment as
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organizations switch to team-based approaches. And third, learning from and with other
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health professions provides a greater understanding of the overall health system
34
students will be operating within.
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In this paper we hope to create greater awareness of IPE and encourage dietetic
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educators to respond to the call for action and educate students/interns
38
interprofessionally.
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Background
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The growing complexity of issues facing the healthcare system in the United States and
42
around the globe has led to the pursuit of innovative education models for future health
43
practitioners. One of these innovations is interprofessional education (IPE). Although
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IPE has been around in some form for over fifty years, more recently there has been a
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resurgence of interest as findings from the Institute of Medicine (IOM) commissioned
46
reports have become known publicly.1,2 Specifically, these reports highlight an
3
47
unacceptable number of medical errors, inadequate communication among healthcare
48
providers, and a lack of coordination in medical care resulting in poor health
49
outcomes.1,2
50
51
In response, the IOM recommended an overhaul of the healthcare system, including
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that “all health professionals should be educated to deliver client-centered care as
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members of an interdisciplinary team”.3 And, because there are substantial costs
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associated with retraining new graduates to be able to act collaboratively across
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professions, employers and payers of health care are demanding educators to teach
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both the specifics of their discipline and also team based competencies. 4 IPE is an
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approach to educating future health professionals that addresses these changing needs
58
of the health system and ultimately aims to better prepare students for becoming
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collaborative health professionals.5
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Defining Interprofessional Education
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A commonly accepted definition of IPE is that it “occurs when students from two or more
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professions learn about, from, and with each other to enable effective collaboration and
64
improve health outcomes”.6 Though no standard pedagogy for the delivery of IPE
65
exists, common iterations include workshops, didactic courses, and practical
66
experiences. Typically these encounters have been carefully designed to promote
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collaboration among team members with an emphasis on providing patient and person-
68
centered care.7
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4
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IPE differs from multiprofessional education in that multiprofessional education only
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provides the opportunity for students to learn in tandem and often leads to co-located,
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siloed care, lacking in effective collaboration to improve patient outcomes.6 True
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interprofessional education brings students out of their professional silos and aims to
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demonstrate to these future health care professionals how to engage in collaboration.
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D’Armour et al. suggest that the key components of collaboration include shared
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responsibilities, collaborative decision-making, shared values, and mutual
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perspectives.8 These interactions often include discussions run by a trained facilitator
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who makes explicit the learning that takes place during the interprofessional experience
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so as to move beyond asynchronous independent judgments to a higher level of shared
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decision making to benefit the patient. D’Armour and Oandasan coined the term
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“interprofessionality” to describe and define these interactions as “the development of a
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cohesive practice between professionals from different disciplines.”9
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As the concept of interprofessionality evolved, the Interprofessional Education
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Collaborative (IPEC) was formed to serve as a resource for developing IPE best
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practices and collaborations. IPEC is a national organization consisting of
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representatives from health professions (nursing, medicine, dentistry, pharmacy and
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public health) with the overarching goal of improving collaboration and patient-centered
89
care.10 The core competencies for interprofessional collaborative practice put forth by
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IPEC emphasize the importance of values and ethics in interprofessional practice,
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professional roles and responsibilities of team members, interprofessional
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communication, and effective teamwork.11 Some professions are taking ownership of
5
93
these competencies by incorporating them into their education requirements. For
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example, The American Association of Medical Colleges (AAMC) released new
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competencies in fall, 2013 (Table 1). While designed for medical students, AAMC
96
leaders suggest they can be used by all health professions. The eight domains include:
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patient care, knowledge for practice, practice based learning and improvement,
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interpersonal and communication skills, professionalism, system-based practice,
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interprofessional collaboration, and personal and professional development.12
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101
Current Landscape of IPE in Nutrition and Dietetics Education
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Many health professionals addressing chronic and acute health conditions have general
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knowledge of nutrition and make general dietary recommendations to their patients.
104
From our experience as RDNs, we realize that general dietary recommendations rarely
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produce effective change. Few professions may really understand the breadth and
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scope of what RDNs contribute to patient care and outcomes. Engaging in IPE is an
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opportunity to actively promote a broader understanding and appreciation for the RDN.
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Additionally, it provides a forum to develop much needed skills in our students to be
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strong advocates for how an RDN differs from someone providing general nutrition
110
advice.
111
112
The benefit of IPE in health care education as a whole has been well studied though
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few mention specifically how dietetics has been involved. Hind et al., assessed student
114
attitudes within 6 weeks of starting an IPE program.13 Dietetics students were
115
significantly more likely to rate themselves as good communicators than students from
6
116
other health care professions (medicine, nursing, pharmacy and physiotherapy).
117
Students from all professions, including dietetics, showed a willingness to engage in
118
IPE.
119
120
Research suggests that dietetics students are ready for and excited about engaging in
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IPE. Students from a dietetics education program that integrated an interprofessional
122
workshop reported that they wanted more information on the roles and responsibilities
123
of other health professions and that they enjoyed interacting with students from other
124
health professions.14 A similar response is seen in programs outside the US such as in
125
the UK where dietetics students participate in on-line IPE. These students reported that
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participation in IPE increased their knowledge of other professions and awareness of
127
interprofessional issues.15
128
129
Despite student interest, there are no formal guidelines for incorporating IPE
130
components into dietetics education programs in the US. The current program
131
standards for core knowledge (KRD) and competencies (CRD) from the Accreditation
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Council for Education in Nutrition and Dietetics (ACEND) only generally refer to
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concepts that are related to IPE (Table 1).16,17
134
135
Incorporation of IPE into the curricula
136
One approach to training nutrition and dietetics students to become collaboration-ready
137
is to include interprofessional courses, simulations and workshops as part of the
138
curriculum. We attempted to identify examples of nutrition and dietetics education
7
139
programs that were incorporating IPE into their curricula but unfortunately identified only
140
a few. We conducted a literature search, queried several DPG electronic mailing lists
141
reviewed FNCE abstracts and inquired of Academy staff. Table 2 includes examples of
142
programs that incorporate IPE as part of their curricula at both the undergraduate and
143
graduate level.
144
145
These programs cite benefits of incorporating IPE into the curricula for both students
146
and faculty. As a result of IPE, students develop increased communication, acquire
147
greater knowledge of healthcare systems, develop an increased understanding and
148
awareness of professionalism, and improve their confidence in working as part of a
149
team.13,18,20, 21, 22 Students also report that engaging in IPE is enjoyable and appear to
150
recognize benefits to their futures as professionals.13, 18, 20
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152
Faculty run and faculty assisted student run interprofessional clinics
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Experiential learning is a critical component of IPE.26 While dietetic students and
154
interns are often engaged in community based education, most do not appear to have
155
the opportunity to learn interprofessionally. Participating in student run clinics may be
156
one way dietetic students could work collaboratively with other health professions. In
157
addition to our search for components of IPE in dietetics programs, we reviewed
158
abstracts at the website for student run clinics (www.studentrunfreeclinics.org) to
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identify participating dietetic programs (Table 3). Anecdotally we heard from other
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health care professions that since dietetic programs often are not in an academic health
161
center, they are not approached as potential partners in these enterprises. Where these
8
162
volunteer clinics operate successfully, students comment that they experience real
163
interprofessional practice and help them become “team ready”. There are many
164
challenges such as institutional support, accreditation standards, sustainability and
165
fairness to patients and the community. We encourage dietetic educators to reach out
166
to other faculty involved in both required and volunteer clinics where students learn
167
about the unique needs of special populations while engaging in the real work in
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community settings. It also is important for faculty to role model interprofessional
169
practice.
170
171
Academy Involvement in IPE
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Global Forum on Innovation in Health Professional Education. The Academy is a
173
member of the Institute of Medicine’s Global Forum on Innovation in Health Professional
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Education (IHPE) created in 2012. (second author - blinded) represents the Academy
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in the Forum. In addition to the Academy, the American Society for Nutrition represents
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nutrition interests in training for medical and health professionals.
177
178
IOM uses Forums to provide a neutral platform for various sectors and professions to
179
come together to discuss topics of shared concern. This structure provided the
180
framework for all interested stakeholders to continue a dialogue that started following
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publication of two landmark reports. The first was published as a Lancet report titled
182
“Health Professionals for a New Century: Transforming Education to Strengthen Health
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Systems in an Interdependent World”.27 The second was a report from the Institute of
184
Medicine titled “The Future of Nursing: Leading Change, Advancing Health”28. These
9
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two reports provided strategic level thinking about innovative health professional
186
education within a changing, globalized health system. The Global Forum is the
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mechanism for ongoing dialogue, networking and information sharing at the
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organizational level.
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190
Starting initially with 34 members that included the Academy, the Forum has now grown
191
to more than 60 members with 46 member/sponsors who financially support the work of
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the Forum, its open workshops and consensus studies. There are 18 different
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professions represented on the IHPE drawn from 9 developed and developing
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countries. The thread of innovation, transformative learning, interprofessional practice
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and global health pervade all workshops. Although the workshops are not specific to
196
dietetics education, it is critical for our educators to be involved in the conversation.
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198
Since 2012, the Forum has held 5 workshops (Table 4). The summaries of these
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workshops as well as video recording of presentations are available at the Forum’s
200
website (iom.edu/IHPEglobalforum). In the first year, the discussions focused on
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aligning health professional education with the needs of clinical practice, students,
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consumers and the health care delivery system through the use of IPE. Physicians,
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nurses and pharmacists were dominant players in these workshops but the other health
204
professions were active in the discussions. Many voiced support for the inclusion of
205
nutrition in training of health professionals. The workshop summary provides an
206
excellent base for understanding IPE.4 In the second year, the focus was on
207
professionalism and then on assessment of individuals and teams.29,30 In 2014 it
10
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focused on community based education. It is clear that the US is increasingly focusing
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on community based health care yet much of health professions education and training
210
continues to be siloed in academic health centers.31 There is not a common
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understanding of community and community based education across the health
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professions. Additionally there are many barriers to scaling up programs recognized as
213
best practices. Those barriers include availability of training sites, financing and staffing,
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faculty development and assessment of outcomes for students and patients/clients.
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The second author (blinded) had the opportunity to plan a session discussing ways to
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scale-up best practices in community based experiential learning using examples of
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programs where nutrition services were provided by dietetic, medical, and dental
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medicine students in different interprofessional settings.
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220
In 2014, the Forum members voted to host one workshop and one fast-track study. The
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study will look beyond classroom impacts of IPE to see what if any evidence there is
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linking IPE to actual patient outcomes. Unlike workshops that are designed to inspire
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robust discussions, studies are designed to provide evidence-based advice from a
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diverse group of experts. Recommendations from the committee are expected to be
225
released in the spring 2015. Once published, the IHPE Forum members will come
226
together to discuss how best to take the recommendations of the expert committee
227
forward.
228
229
Academy leadership and relevant groups are kept abreast of these and other activities
230
of the IHPE by its representative. Workshops and select sessions of the consensus
11
231
studies are free and open to the public and webcast for those who are unable to attend
232
in person.
233
234
Academy IPE Task Force. The development of an IPE task force within the Nutrition
235
and Dietetics Educators and Preceptors Council is another Academy initiative to
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increase involvement in the IPE movement. The first author (blinded) is a member of
237
this task force which was charged with leading the effort for IPE by: sharing IPE
238
practices in the NDEP newsletter and FNCE; devising a plan where dietetic educators
239
have a presence in IPE; helping educators become more involved in IPE; and plan an
240
article on IPE to be submitted in NDEP’s section of JAND. Three members of the task
241
force were sponsored to attend the 2013 Collaborating Across Borders IV (CAB-IV)
242
meeting in Vancouver as representatives of the Academy. CAB-IV was the fourth
243
installment in a series of conferences designed to promote IPE, practice and policy in
244
North America.32 CAB-IV specifically addressed concepts and theories for preparing
245
collaborative-ready healthcare professionals.
246
247
Recommendations
248
The field of nutrition and dietetics interacts with other healthcare professions in unique
249
and complex ways making the IPE movement rich with opportunities for our students
250
and interns to become involved. A first step may be for nutrition and dietetics educators
251
to consider reviewing the AAMC competencies for relevancy in the field and
252
incorporating or adapting the competencies for use in their programs. Interprofessonial
253
collaboration competencies embedded into healthcare professional education programs
12
254
can help broaden professional teamwork beyond the scope of the individual
255
profession.25 When more explicit interprofessional collaboration competencies are
256
incorporated into ACEND competencies, programs will need to be creative with
257
developing ways of achieving these competencies. There are resources that dietetic
258
educators can draw from and should consider contributing to: 1) the National
259
Coordinating Center for IPE and Collaborative Practice (http://nexusipe.org) and 2) the
260
Directory & Repository of Educational Assessment Measures
261
(www.mededportal.org/dream). Based on our investigation, nutrition and dietetics
262
education programs as a whole are only participating in IPE in limited ways. As a
263
starting point, one suggestion is to build on community-based events that are already
264
occurring (i.e. health fairs, student run clinics, National Nutrition Month activities) by
265
inviting other healthcare professions to join in and creating opportunities for students to
266
work collaboratively. For more in-depth collaborations, nutrition and dietetics education
267
programs could partner with other healthcare professions on their campuses to identify
268
common coursework, missions and accreditation standards with the potential to be
269
taught in an interprofessional environment.19
270
271
Incorporating IPE into dietetic programs comes with challenges. In particular, for
272
programs that are not located on campuses with other healthcare professions, face-to-
273
face interprofessional interactions may not be feasible. Interprofessional simulation
274
training is an alternative that could provide opportunities for the development of
275
collaboration skills. Additionally, synchronous and asynchronous web-based
13
276
interprofessional interactions can be successful ways to promote collaboration beyond
277
geographical locations.33
278
279
Conclusion
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There is growing IPE movement. To date, dietetic educators and students and interns
281
appear to have minimal participation in IPE. This is a call for the Academy, the
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Commission on Dietetic Registration and all the educational institutions offering dietetic
283
education to explore ways to facilitate IPE.
284
285
References
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1. Institute of Medicine. To Err Is Human: Building a Safer Health System.
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2. Institute of Medicine. Crossing the Quality Chasm. Washington, DC: National
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3. Institute of Medicine. Health Professions Education: A Bridge to Quality.
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4. Institute of Medicine. Interprofessional Education for Collaboration: Learning How to
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Improve Health from Interprofessional Models Across the Continuum of Education
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to Practice: Workshop Summary. Washington, DC: The National Academies Press;
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2013.
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5. World Health Organization. Framework for Action on Interprofessional Education
and Collaborative Practice. Geneva: WHO; 2010.
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6. Centre for Advancement of Interprofessional Education. Defining IPE. London:
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7. Ruebling I, Carlson J, Cuvar K, et al. Interprofessional Curriculum: Preparing Health
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Sudbury, MA: Jones Bartlett; 2009.
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8. D’Amour D, Ferrada-Videla M, San Martin Rodriguez L, Beaulieu M. The conceptual
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9. D’Amour D, Oandasan I. Interprofessionality as the field of interprofessional practice
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10. Interprofessional Education Collaborative. Six Leading Health Education
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Associations Unite to Form a New Organization on Interprofessional Education and
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Practice. Press Release. https://ipecollaborative.org/uploads/IPEC-PR-2-14-12-
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Updated-Version.pdf
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11. Interprofessional Education Collaborative Expert Panel. Core competencies for
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interprofessional collaborative practice: Report of an expert panel. Washington, DC:
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Interprofessional Education Collaborative; 2011.
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12. Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener CA. Toward a
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common taxonomy of competency domains for the health professions and
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13. Hind M, Norman I, Cooper S, et al. Interprofessional perceptions of health care
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15. Earland J, Gilchrist M, McFarland L, Harrison K. Dietetics students’ perceptions and
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16. ACEND Accreditation Standards for Dietitian Education Programs.
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http://www.eatright.org/ACEND/content.aspx?id=7877. Accessed Aug 4, 2014.
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17. ACEND Accreditation Standards for Didactic Programs in Nutrition and Dietetics.
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http://www.eatright.org/ACEND/content.aspx?id=7877. Accessed Aug 4, 2014.
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18. Smith AR, Christie C. Facilitating transdisciplinary teamwork in dietetics education:
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19. Breitbach T, Sargeant D, Gettemeier P, et al. From buy-in to integration: melding an
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transforming education to strengthen health systems in an interdependent world.
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28. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health.
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interprofessional understandings through online learning: A qualitative examination.
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Nurs Health Sci. 2014. doi: 10.1111/nhs.12105
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Table 1. Selected IPE-related competencies and/or core knowledge requirements from
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AAMC and ACEND
AAMC Interprofessional Collaboration Competencies, Domain 7a
Demonstrate the ability to engage in an interprofessional team in a manner that
optimizes safe, effective patient and population centered care.
7.1
Work with other health professionals to establish and maintain a climate of
mutual respect, dignity, diversity ethical integrity and trust.
7.2
Use the knowledge of one’s own role and the roles of other health professionals
to appropriately assess and address the health care needs of patients and
populations served.
7.3
Communicate with other health professionals in a responsive and responsible
manner that supports the maintenance of health and the treatment of disease in
individual patients and populations.
18
7.4
Participate in different team roles to establish, develop and continuously
enhance interprofessional teams to provide patient and population centered
care that is safe, timely, efficient, effective and equitable.
ACEND Standards for Core Knowledge and Competencies
KRD The curriculum must include opportunities to understand governance of
2.3
dietetics practice, such as the Scope of Dietetics Practice and the Code of
Ethics for the Profession of Dietetics; and interdisciplinary relationships in
various practice settings.
CRD Establish collaborative relationships with other health professionals
2.10
and support personnel to deliver effective nutrition services.
377
a
378
CA. Toward a common taxonomy of competency domains for the health professions and
379
competencies for physicians. Academic Medicine. 2013. 88(8):1088-94.
380
381
382
383
384
385
386
Quoted with permission from Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener
19
387
388
389
390
391
392
393
Table 2. Examples of Programs with Interprofessional Education components
394
incorporated into the curriculum
395
Program
Components incorporated into
Other professions
the curriculum
involved
University of
Half-day workshop
Nursing, pharmacy,
Cincinatti13
2 hour observation field experience
communication sciences
and disorders, genetic
counseling, advanced
medical imaging, medical
technology, physical
therapy
University of North
Florida18
Case-studies discussed face-to-face
Physical therapy
20
Interview student from other
profession
Saint Louis
Five interprofessional courses (11-
Physical therapy, nursing,
University19,20,21
credits) embedded in professional
occupational therapy,
curricula
athletic training, clinical
Interprofessional Grand Rounds
laboratory science, radiation
Presentations
therapy
Georgia State
One day IPE workshop:
Nursing, physical therapy,
University22
Interprofessional teams
respiratory therapy
complete case studies
Iinterprofessional Simulations
The Ohio State
Interprofessional Simulations
University23
Nursing, respiratory
therapy, physical therapy,
pharmacy, medicine
St. Catherine
Half-day workshop:
Nursing, occupational
University24
Case-studies
therapy, respiratory care,
public health, physical
therapy, social work
21
Drexel University25
Research initiative: collect and
Nursing, rehabilitation
analyze data as an interprofessional
sciences, creative arts
team
therapy, couples’ and family
therapy
396
397
398
399
Table 3. Examples of programs where dietetic interns/students are involved in
400
Interprofessional Clinics
Program
Dietetic Student Participation
Rutgers (UMDNJ)
Interns teach medical students about role of RDN;
Attend Student Family Health Care Center
www.njms.rutgers.edu
Tufts
With medicine, PT, dental, nursing, podiatry
Interns work with dental group
Dietetic interns complete oral health/dental rotation
paired with dental students
22
Idaho State University,
Interdisciplinary (public health, dental, dietetics
Meridian
labs, nursing) health screenings every 6 weeks;
dietetic students do BMI and nutrition assessments;
University of Cincinnati
Interprofessional student-driven Saturday community
clinic
Open School Clinic
University of Memphis
www.ucopenschool.org
Dietetic interns work with adjunct health care workers
During two week rotation.
www.churchhealthcenter.org/wellness
401
402
403
404
405
406
407
408
409
23
410
411
412
413
414
415
416
417
Table 4. Topics and key concepts addressed by IHPE workshops
Workshop
Aug 2012
Key Concepts
Educating for Practice.
Defining interprofessional education
Part 1.
Nov 2012
Educating for Practice.
Implementing IPE. Measuring impact. IPE
Part 2.
Within the Health System. Learning
From students, patients and communities.
May 2013
Establishing
How the different professions might work
Transdisciplinary
effectively together and with society in creating
Professionals for Health
a social contract; ethical implications of and
barriers to transdisciplinary professionalism
24
Oct 2013
Assessing Health
Current state of assessment of
Professional Education
Competencies in IPE, team based care,
And patient centeredness; technology
And innovation in assessment
May 2014
Scaling up Best
Responsibilities of health professions,
Practices in Community-
institutions, and students to communities they
based Health
serve; terminology; competencies needed to
Professional Education
engage communities; gaps and best practices
in community based experiential learning
418