Interprofessional Education in Canadian Nursing Programs and Implications for Continuing Education

In 2010, the Canadian Association of Schools of Nursing, the accrediting body for nursing programs in Canada, became part of the Accreditation of Interprofessional Health Education initiative. In turn, interprofessional education (IPE) is now a requirement in nursing curricula. Although the requirement is formally in place, how it is achieved varies substantially. This paper explores how IPE has been integrated within Canadian nursing programs. Implications for the continuing education of nurses and other health professionals in order to achieve excellence in interprofessional practice are also considered.


Abstract
In 2010, the Canadian Association of Schools of Nursing, the accrediting body for nursing programs in Canada, became part of the Accreditation of Interprofessional Health Education initiative. In turn, interprofessional education (IPE) is now a requirement in nursing curricula. Although the requirement is formally in place, how it is achieved varies substantially. This paper explores how IPE has been integrated within Canadian nursing programs. Implications for the continuing education of nurses and other health professionals in order to achieve excellence in interprofessional practice are also considered.

Introduction
Interprofessional education (IPE) "occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care" (Centre for Advancement of Interprofessional Education, 2002). Identifi ed in the Romanow Report (2002) as critical to the delivery of health services and programs in contemporary Canada, IPE and collaborative patient care became the basis of the Interprofessional Education for Collaborative Patient-Centred Practice (IECPCP) Strategy (Gilbert, 2010). In 2006, the Canadian Interprofessional Health Collaborative (CIHC) was developed to ensure that IPE and collaboration occur across the health professions (CIHC, 2010;Gilbert, 2010).
Later, in July 2007, Interprofessional Care: A Blueprint for Action in Ontario was released by Health Force Ontario (Interprofessional Care Steering Committee). This document provided information and recommendations about how to enhance the functioning of the Ontario healthcare system through the practice of interprofessional care. The report further identifi ed that it had been diffi cult to integrate IPE into curricula, due to the lack of accreditation standards for IPE. The lack of best practices in IPE within the curricula of health sciences programs has also been noted in the literature (Abu-Rish et al., 2012).
Interprofessional instructional and institutional strategies are quickly becoming a major focus of professional health and social education programs in order to better prepare health professionals for safe, competent, and collaborative practice (Frenk et al., 2010;Interprofessional Care Strategic Implementation Committee, 2010;Reeves et al., 2010;Reeves, Tassone, Parker, Wagner, & Simmons, 2012; World Health Organization Study Group on Interprofessional Education and Collaborative Practice, 2010). Further, the World Health Organization recently recommended that IPE needs to be implemented in programs to prepare health professionals for intercollaborative practice in the pre-licensure period, and it emphasized that research is required to examine the relevance of IPE for communities served, cost-eff ectiveness, and sustainability (World Health Organization, 2013). Continuing education for health professionals is likewise vital to achieve the benefi ts of collaborative, team-based care founded on an interprofessional model. en soins infi rmiers du Canada. L'article aborde également ce que cela implique en matière de formation continue pour les infi rmiers et autres professionnels de la santé, afi n qu'ils atteignent l'excellence dans leur pratique interprofessionnelle.
This paper describes the state of IPE in nursing education in Canada since 2012. In addition, it explores the role of continuing education in sustaining interprofessional learning and care in practice. Continuing educators are challenged to refl ect on how they can support this critical practice.

Interprofessional Education in Nursing Education in Canada
While IPE emerged over 30 years ago on the international level, it has become particularly important in educational, research, policy, and regulatory activity in the past 10 years (Reeves et al., 2012). Formal inclusion of IPE activities in Canadian nursing programs has likewise developed recently, particularly over the last fi ve years. Most signifi cant is that the Canadian Association of Schools of Nursing (CASN) now includes IPE as an accreditation standard (CASN, 2012). CASN is a member of the Accreditation of Interprofessional Health Education initiative (AIPHE), which has brought together the accreditation bodies for medicine, nursing, occupational therapy, social work, pharmacy, and physiotherapy in order to develop principles, practices, and competencies for the integration of IPE within accreditation standards (AIPHE, 2011).
In the case of nursing, CASN has indicated that "learners [need to] develop functional working relationships, including intra/interprofessional and intersectoral collaboration" (2012, p. 1). Given this requirement, Canadian nursing programs must now formally demonstrate the integration of IPE in their curricula.
Nursing schools have had a myriad of experiences-positive and negative-in the eff ort to embed IPE within programs. The objective of this paper is to: (i) review the literature to discern how and to what extent IPE is supported by nursing programs; (ii) share important themes; (iii) consider areas for further study; and (iv) refl ect on the role of continuing education in supporting interprofessional learning and practice.

IPE and Nursing Curricula since 2012
The principal theme identifi ed in a review of IPE and nursing programs in Canada was that interprofessional education is occurring in classrooms and in clinical practice settings. These circumstances have been associated with positive outcomes, including improved perceptions of other health professionals as team members. Benefi ts of the interprofessional learning process have also been identifi ed. Several studies of IPE in Canadian nursing programs occurring prior to 2012 found similar results (Ateah et al., 2011;Basran et al., 2012;Bilodeau et al., 2010;Cooper, Macmillan, Beck, & Paterson, 2009;Graybeal, Long, Scalise-Smith, & Zeibig, 2010;Dobson et al., 2009;Meff e, Moravac, & Espin, 2012;Salvatori, Berry, & Eva, 2007;Sommerfeldt, Barton, Stayko, Patterson, & Pimlott, 2011). Fortugno, Chandra, Espin, and Gucciardi (2013) examined an interprofessional placement in a Canadian urban secondary school where four students from nursing, early childhood education, child and youth care, and nutrition programs worked together to deliver "healthy living" modules. A focus group was conducted with the students from nursing, early childhood education, and nutrition; another focus group was conducted with two preceptors. Refl ections were completed by the students on a weekly basis throughout the seven-month placement. Two themes emerged from the fi ndings: team functioning and a shift in perspectives, which suggested a positive interprofessional experience in the school setting. The idea that interprofessional skills and experiences would enhance future participation in teams was also identifi ed (Fortugno et al., 2013).
Variety in learning strategies was also a theme. Interprofessional learning through simulation, modelling, and combined learning strategies was noted. These strategies have been associated with improved perceptions of professionals from other backgrounds as team members.
A non-experimental, pre-test / post-test study at the University of Manitoba investigated the interprofessional knowledge, skills, and attitudes of nursing, medical, and pharmacy students involved in a simulated night shift (Joyal, Katz, Harder, & Dean, 2015). Forty-fi ve students (n = 12 medicine, n = 23 nursing, n = 10 pharmacy) responded to the pre-event survey, while 11 students (n = 5 medicine, n = 6 nursing) responded to the post-event survey. In the pre-event survey, students reported having a positive perception of interprofessional education and how it could improve patient care through teamwork and improved communication. In the postevent survey, students indicated that they valued the interprofessional simulation experience J P C O E . n e t A r t i c l e I n t e r p r o f e s s i o n a l E d u c a t i o n i n C a n a d i a n N u r s i n g P r o g r a m s 5 and had an improved understanding of the roles of other professions and the importance of each team member, as well as increased confi dence about working as a team member.
An exploratory descriptive ethnographic study investigated the experiences of nursing and pharmacy students who took part in three simulation learning activities over a six-hour period during their fi nal year (Paul, Olson, Sadowski, Parker, & Alook, 2014). The focus of the study was to determine how the interprofessional simulation learning experience assisted the students in learning both discipline-specifi c and interprofessional skills. Results indicated that the simulation experience was positive, increasing confi dence, improving students' understanding of their professional roles and the roles of others, and leading to a valuing of interprofessional teamwork and relationship-building. Ruiz, Ezer, and Purden (2013) employed an exploratory case-study design to investigate pedagogical strategies used in IPE as well as modelling of interprofessional behaviour by faculty over two years. They paid attention to a number of required learning activities for fi rst-year students in medicine, nursing, occupational therapy, physiotherapy, and communication sciences at McGill University, in Montréal, Québec. A total of 11 university IPE facilitators and 97 students from across the professions were video-and audio-taped in several learning situations. Findings confi rmed that strategies such as creating a supportive learning environment, modelling interprofessional collaboration, and using open-ended questions improved interprofessional learning. Faculty development was identifi ed as important to this type of teaching role, although it is time-intensive and requires support.
Some of the studies examined the integration of IPE in clinical settings (Basran et al., 2012;Fortugno et al., 2013;Sommerfeldt et al., 2011;Vanderzalm et al., 2013). By contrast, two studies focused solely on classroom learning (Cooper et al., 2009;Dobson et al., 2009), while three others focused on the inclusion of IPE in both classroom and practice settings (Ateah et al., 2011;Meff e et al., 2012;Salvatori et al., 2007). Strategies identifi ed as facilitators of J P C O E . n e t A r t i c l e I n t e r p r o f e s s i o n a l E d u c a t i o n i n C a n a d i a n N u r s i n g P r o g r a m s 6 interprofessional learning included patient care simulation activities (Joyal et al., 2015;Paul et al., 2014), modelling, and other supportive learning strategies (Ruiz et al., 2013). Factors reported to enhance IPE were faculty development, faculty champions, and administrative supports and resources (Basran et al., 2012;Bilodeau et al., 2010;Graybeal et al., 2010;Ho et al., 2008;Ruiz et al., 2013;Sommerfeldt et al., 2011;Vanderzalm et al., 2013). The identifi ed challenges included the time-intensive nature of IPE activities, diffi culties with scheduling, and lack of professional identity in junior-year students (Basran et al., 2012;Bilodeau et al., 2010;Graybeal et al., 2010;Ho et al., 2008;Ruiz et al., 2013;Sommerfeldt et al., 2011;Vanderzalm et al., 2013). These fi ndings are consistent with the fi ndings of Reeves et al. (2012) and another recent literature review that explored the barriers to and enablers of sustaining IPE (Lawlis, Anson, & Greenfi eld, 2014). No studies indicated that IPE should not be included in health profession programs, despite the barriers and challenges, and no studies suggested that the inclusion of IPE in curricula makes no diff erence at all. There was a limited amount of research demonstrating the integration of IPE across all years of programs (Bilodeau et al., 2010;Ruiz, et al., 2013).

IPE and Continuing Education
Continuing interprofessional education occurs when members of two or more health and/or social care professions learn with, from, and about each other in practice settings after graduation/post-licensure to improve collaboration and the quality of care (Reeves, 2009). The literature identifi es two strategies for facilitating interprofessional learning: modelling of interprofessional behaviour and care by faculty, and faculty development with respect to IPE (Basran et al., 2012, Bilodeau et al., 2010, Graybeal et al., 2010, Ho et al., 2008, Ruiz et al., 2013, Sommerfeldt et al., 2011, Vanderzalm et al., 2013. These two fi ndings point to the signifi cance of continuing IPE occurring with healthcare professions in practice, and with educators in the learning arena, be that a classroom, simulation laboratory, or clinical practice setting. Continuing interprofessional education for those involved in the education of nursing undergraduate students is crucial to the successful integration of interprofessional learning pre-licensure, and to the support of interprofessional learning in practice post-licensure. Reeves (2009) conducted an overview of continuing interprofessional education and identifi ed faculty development as one of seven trends emerging in the past several years, thus confi rming the importance of IPE faculty development in the last several years.
There is additional evidence that, for some health professions, limited interaction with other professions and lack of knowledge and experience with IPE reduces their support for IPE when it is involved in pre-licensure education in a practice setting (Sommerfeldt et al., 2011). These limitations directly aff ect how students perceive and learn about interprofessional interactions and practices in the clinical setting, since, as stated previously, modelling is an infl uence on student learning. Further, the process of continuing IPE necessitates that mutual respect and trust exist within the group and context involved (Legare et al., 2011). If teams of healthcare professionals do not know how to work with each other due to a lack of knowledge about or respect for each other's professions, interprofessional learning will not be successfully demonstrated to students. This reality builds the case for ensuring that continuing IPE takes place in practice settings and that content includes materials directly relevant to IPE. Such learning opportunities assists health professionals in becoming more knowledgeable about other professions and contribute to safe team-based practice and care. Finally, the development and delivery of interprofessional continuing education programs also require consideration of the varying learning needs of the healthcare professions involved (Zwarenstein & Reeves, 2006).

Final Thoughts
Although IPE curriculum is being integrated within Canadian nursing programs in diverse ways, further programming and research are required. Among other things, this work needs to investigate the experiences of nursing faculty and program administrators in advancing IPE. The resources required to support IPE likewise require particular consideration. In this way, strategies for integrating IPE within curricula and ways for overcoming barriers can be determined, thus enabling nursing programs to meet the IPE accreditation requirement more eff ectively.
At the same time, there is considerable work to do in the continuing education sector to ensure that the learning initiated at the undergraduate level is sustained and advanced when nursing graduates and graduates from other health programs begin practice. Moreover, it is important to recognize that practicing nurses experience teamwork and collaboration in ways that are similar to but also diff erent from how nursing students do. Because of this, continuing educators are encouraged to work closely with nurses and other members of interprofessional care teams to ensure that IPE theory and practice are complementary and that identifi ed IPE gaps are addressed. Acknowledging that Canadian health systems are increasingly dependent on high-functioning interprofessional teams, there is important work to be done by continuing educators, including administrators, program planners, instructional designers, instructors, and others. With Canada's healthcare system experiencing the stressors of an aging population, the health impacts of globalization, escalating infrastructure costs, and shrinking budgets, now is a critical time for continuing education to support and advance interprofessional knowledge and practice in the health setting.