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Interprofessional education: effects on professional practice and health care outcomes

Interprofessional education: effects on professional practice
and health care outcomes (Review)
Reeves S, Zwarenstein M, Goldman J, Barr H, Freeth D, Hammick M, Koppel I
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2009, Issue 1 Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
PLAIN LANGUAGE SUMMARY AUTHORS' CONCLUSIONS CHARACTERISTICS OF STUDIES CONTRIBUTIONS OF AUTHORS Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Interprofessional education: effects on professional practice
and health care outcomes
Scott Reeves1, Merrick Zwarenstein2, Joanne Goldman3, Hugh Barr4, Della Freeth5, Marilyn Hammick6, Ivan Koppel7 1Li Ka Shing Knowledge Institute & Centre for Faculty Development, St Michael's Hospital, Wilson Centre for Research in Education,Department of Psychiatry, Toronto, Canada. 2Continuing Education, University of Toronto, Senior Scientist, Institute for ClinicalEvaluative Sciences, Toronto, Canada. 3Continuing Education and Professional Development, Faculty of Medicine, University ofToronto, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada. 4Visiting Professor, King's College London;Kingston University with St George's University of London; , University of Greenwich, Cranmer Terrace, London, UK. 5Health CareEducation Development Unit, Institute of Health Sciences, City University, London , UK. 6 Seacole 457, Faculty of Health, BirminghamCity University, Birmingham, UK. 7Centre for Community Care and Primary Health, University of Westminster, London, UK Contact address: Scott Reeves, Li Ka Shing Knowledge Institute & Centre for Faculty Development, St Michael's Hospital, WilsonCentre for Research in Education, Department of Psychiatry, University of Toronto, 30 Bond Street , Toronto, Ontario, M5B 1W8,Canada. Editorial group: Cochrane Effective Practice and Organisation of Care Group.
Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 11 November 2007.
Citation: Reeves S, Zwarenstein M, Goldman J, Barr H, Freeth D, Hammick M, Koppel I. Interprofessional education: effects on
professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD002213. DOI:
10.1002/14651858.CD002213.pub2.
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Patient care is a complex activity which demands that health and social care professionals work together in an effective manner. Theevidence suggests, however, that these professionals do not collaborate well together. Interprofessional education (IPE) offers a possibleway to improve collaboration and patient care.
To assess the effectiveness of IPE interventions compared to education interventions in which the same health and social care professionalslearn separately from one another; and to assess the effectiveness of IPE interventions compared to no education intervention.
We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE and CINAHL, for theyears 1999 to 2006. We also handsearched the Journal of Interprofessional Care (1999 to 2006), reference lists of the six includedstudies and leading IPE books, IPE conference proceedings, and websites of IPE organisations.
Randomised controlled trials (RCTs), controlled before and after (CBA) studies and interrupted time series (ITS) studies of IPE inter-ventions that reported objectively measured or self reported (validated instrument) patient/client and/or healthcare process outcomes.
Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Data collection and analysis
Two reviewers independently assessed the eligibility of potentially relevant studies, and extracted data from, and assessed study quality of,included studies. A meta-analysis of study outcomes was not possible given the small number of included studies and the heterogeneityin methodological designs and outcome measures. Consequently, the results are presented in a narrative format.
Main results
We included six studies (four RCTs and two CBA studies). Four of these studies indicated that IPE produced positive outcomes in thefollowing areas: emergency department culture and patient satisfaction; collaborative team behaviour and reduction of clinical errorrates for emergency department teams; management of care delivered to domestic violence victims; and mental health practitionercompetencies related to the delivery of patient care. In addition, two of the six studies reported mixed outcomes (positive and neutral)and two studies reported that the IPE interventions had no impact on either professional practice or patient care.
This updated review found six studies that met the inclusion criteria, in contrast to our first review that found no eligible studies.
Although these studies reported some positive outcomes, due to the small number of studies, the heterogeneity of interventions, andthe methodological limitations, it is not possible to draw generalisable inferences about the key elements of IPE and its effectiveness.
More rigorous IPE studies (i.e. those employing RCTs, CBA or ITS designs with rigorous randomisation procedures, better allocationconcealment, larger sample sizes, and more appropriate control groups) are needed to provide better evidence of the impact of IPE onprofessional practice and healthcare outcomes. These studies should also include data collection strategies that provide insight into howIPE affects changes in health care processes and patient outcomes.
Training health and social care professionals to work together effectively
Health and social care professionals, such as doctors, nurses, physiotherapists and social workers, need to work together effectively totake care of patients effectively. Unfortunately, professionals may not always work well together. Training and educational programmeshave been developed as a possible way to improve how professionals work together to take care of patients. Interprofessional education(IPE) is any type of educational, training, teaching or learning session in which two or more health and social care professions arelearning interactively.
This review found six studies that evaluated the effects of IPE. Four of these studies found that IPE improved some ways in howprofessionals worked together and the care they provided. It improved the working culture in an emergency department and patientsatisfaction; decreased errors in an emergency department; improved the management of the care delivered to domestic violence victims;and improved the knowledge and skills of professionals providing care to mental health patients. But two of those four studies alsofound that IPE had little to no effect on other areas. Two other studies found that IPE had little to no effect at all.
The studies evaluated different types of IPE and were not of high quality. It is, therefore, difficult to be certain about the effect of IPEand to understand the key features of IPE to train health and social care professionals to work together effectively.
B A C K G R O U N D
This is an update to a previous Cochrane IPE review ) which found no studies that met the inclusion criteria.
The continued interest in IPE is unsurprising, given the increasing Since the publication of that review, interest in IPE as a means complexity of the organisation and delivery of health care. A num- to cultivate collaborative practice and enhance care has continued ber of factors, such as an ageing population and the shift of the to grow amongst policy makers, educators, and researchers burden of illness from acute to chronic care, require a number of Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
different health and social care professions to be involved in the de- 2.To assess the effectiveness of IPE interventions compared with livery of care. As a result, the need for good interprofessional com- control groups which received no education intervention.
munication and collaboration to help coordinate patient care in In the first objective we are seeking to better understand the ef- an effective manner is critical. Despite this need, research indicates fects of IPE in relation to the current dominant uniprofessional that such communication and collaboration can be problematic.
education model, where ideally the control group should receive For example, studies have shown that effective interprofessional the same education in a uniprofessional manner. We included the collaboration can be undermined by boundary infringements, a second objective as there was a lack of studies addressing the first lack of understanding of one another's roles, limited communica- tion and poorly coordinated teamwork (; ; IPE aims to encourage different professionals to meet and interact in learning to improve collaborative practice and the health careof patients/clients, and therefore has more potential for enhancingcollaborative practice than a programme of multiprofessional edu-cation (where professionals share their learning experiences but do Criteria for considering studies for this review
not interact with one another, such as a joint lecture) or uniprofes-sional education (where professionals learn in isolation from oneanother).
Types of studies
Given that our earlier Cochrane review found no IPE studies Randomised controlled trials (RCTs), controlled before and after employing randomised controlled trials (RCTs), controlled be- (CBA) studies, and interrupted time series (ITS) studies.
fore and after studies (CBAs), and interrupted time series stud-ies (ITSs), some researchers have adopted broader methodological Types of participants
and outcomes criteria to provide an indication of the wider effectsof this type of education. Results from these reviews have pro- Health and social care professionals (e.g. chiropodists/podia- vided some insights into the impact of a range of IPE studies on trists, complementary therapists, dentists, dietitians, doctors/ a number of outcomes, including changing learners' attitudes to- physicians, hygienists, psychologists, psychotherapists, midwives, wards one another's profession; improving knowledge of interpro- nurses, pharmacists, physiotherapists, occupational therapists, ra- fessional collaboration; enhancing collaborative behaviour; and diographers, speech therapists, and social workers).
making gains in the delivery of patient care (; ; ; While the studies in thesereviews indicate positive outcomes for IPE, most did not address Types of interventions
the question of the impact of IPE as defined by this review. In An IPE intervention occurs when members of more than one addition, most did not use rigorous research designs and objec- health and/or social care profession learn interactively together, tive or well validated measures of improved professional practices for the explicit purpose of improving interprofessional collabora- or improved patient morbidity, survival or satisfaction, making it tion and/or the health/well being of patients/clients. Interactive difficult to attribute reported changes directly to IPE.
learning requires active learner participation, and active exchangebetween learners from different professions.
The development and delivery of IPE can require significant All types of educational, training, learning, or teaching initiatives, amounts of resources. Any large-scale changes to adopt and imple- involving more than one profession in joint, interactive learning, ment this educational approach should be based on evidence of its as described in the above IPE definition.
effects to current uniprofessional models of education. Thus, thisreview seeks to update the existing evidence from rigorous studiesin this field.
Types of outcome measures
1. Objectively measured or self-reported (validated instrument)patient/client outcomes in the following areas: health status mea- O B J E C T I V E S
sures; disease incidence, duration or cure rates; mortality; compli-cation rates; readmission rates; adherence rates; satisfaction; con- The two objectives of this review are: tinuity of care; use of resources (i.e. cost-benefit analyses).
1.To assess the effectiveness of IPE interventions compared to ed- 2. Objectively measured or self reported (validated instrument) ucation interventions in which the same professions were learning health care process measures (e.g. skills development, changes in separately from one another.
practice style, interprofessional collaboration, teamwork).
Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Search methods for identification of studies
reviewed proceedings from the 'All Together Better Health') and 'Grounding Action in Theory' ( Effective Practice and Organisation of Care Group (EPOC) spe- ) conferences; and reviewed the grey literature cialised register (see Specialised held by the Centre for the Advancement of Interprofessional Ed- Register under Group Details), 1999-2006, searched 18 Septem- ucation, accessible on the internet (In addition, we drew upon other related work, in particular systematic reviews The search strategy from the previous IPE Cochrane review, shown ; ), as well as our below, was adapted for each of the following databases searched: international networks, to ensure that all relevant published and MEDLINE, 1999 to 2006, August week 4 2006.
unpublished work in the field would be identified.
CINAHL, 1999 to 2006, September week 1, 2006.
MEDLINE search strategy (adapted for Cinahl) used was:1 (interprofession$ or inter-profession$).tw.
2 (interdisciplin$ or inter-disciplin$).tw.
Data collection and analysis
3 (interoccupation$ or inter-occupation$).tw.
Two authors (SR and JG) independently reviewed the 1801 ab- 4 (interinstitut$ or inter-institut$).tw.
stracts retrieved in the searches to identify all those that suggested 5 (interagen$ or inter-agen$).tw.
6 (intersector$ or inter-sector$).tw.
1. there was an intervention where interprofessional exchange oc- 7 (interdepartment$ or inter-department$).tw.
8 (interorgani?ation$ or inter-organi?ation$).tw.
2. education took place; 9 interprofessional relations/ 3. professional practice, patient care processes or health and satis- 10 team$.tw.
faction outcomes were reported; 11 (multiprofession$ or multi-profession$).tw.
4. the intervention was evaluated using a RCT, CBA or ITS design.
12 (multidisciplin$ or multi-disciplin$).tw.
We identified 56 studies from this abstract search as potentially 13 (multiinstitution$ or multi-institution$).tw.
meeting these criteria (11 from EPOC, 23 from MEDLINE, 22 14 (multioccupation$ or multi-occupation$).tw.
from CINAHL). We then obtained the full text of these articles.
15 (multiagenc$ or multi-agenc$).tw.
The same two authors independently assessed each full text article 16 (multisector$ or multi-sector$).tw.
to further examine whether it met all of the criteria. We resolved 17 (multiorgani?ation$ or multi-organi?ation$).tw.
any disagreements and uncertainties by discussion, with the input 18 exp professional-patient relations/ of a third author (MZ), who also reviewed all of the final papers as a further quality check for inclusion in the review.
20 (education$ or train$ or learn$ or teach$ or course$).tw.
21 exp education, continuing/22 exp education, graduate/ Study quality assessment
We used the quality criteria recommended by EPOC to assess study quality of all studies included in the review (EPOC Review 25 program evaluation/ Group Checklist, 2002).
26 "health care outcome?".tw.
The criteria used to assess RCTs were: 27 (education$ adj outcome?).tw.
1. concealment of allocation; 2. follow up of professionals; 3. follow up of patients or episodes of care; 30 limit 29 to yr="1999 - 2006" 4. blinded assessment of primary outcomes(s); We placed no language restrictions on the search strategy.
5. baseline measurement; The search generated a total of 1801 abstracts (201 from EPOC, 6. reliable primary outcome measure(s); 1157 from MEDLINE, 443 from CINAHL). While the abstract 7. protection against contamination.
search was sensitive to identifying a high proportion of relevant IPE The criteria used to assess CBA studies were: intervention studies, it was not specific in relation to differentiating 1. baseline measurement; between IPE interventions and other interprofessional teamwork 2. characteristics for studies using second site as control; interventions, such as continuous quality improvement and total 3. blinded assessment of primary outcome(s); quality improvement initiatives.
4. protection against contamination; We also searched ISI Web of Science for papers which cite studies 5. reliable primary outcomes measure(s); included in the review; hand searched the Journal of Interprofes- 6. follow-up of professionals; sional Care (1999 to 2006); and reviewed reference lists of the 7. follow-up of patients.
included studies and two leading IPE books ; No ITS studies were identified so these criteria are not relevant.
Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
We assigned an overall quality rating (high, moderate, low protec- physicians), 37 were randomly assigned to receive the intervention tion against bias) to each study. We gave a high quality rating if all and 32 were assigned to the control group (who received the IPE criteria were rated as done (or not applicable); we gave a moderate intervention after the study). A questionnaire was sent to patients quality rating if one or two criteria were not done or not clear; and within ten days of their visit. Data collection occurred during a we gave a low quality rating for studies if three or more criteria six month follow-up period.
were not done or not clear.
The second study () was a group RCT that evalu-ated an interprofessional training program for emergency depart-ment physicians, nurses, social workers, and health administrators, along with representatives from local domestic violence service Two authors extracted the following information from included organisations, to improve the effectiveness of their collective re- sponse to intimate partner violence. The emergency departments 1. Type of study (RCT, CBA, ITS); were in hospitals in the United States. The two-day education pro- 2. Study setting (country, health care setting); gram, developed and implemented by violence prevention organi- 3. Types of study participants; sations, involved didactic instruction, role playing, team planning, 4. Description of education program; and teamwork to develop a written action plan. The program ad- 5. Description of any other interventions in addition to the edu- dressed systems change and coalition building, as well as provider attitudes and skill building. The attendees were expected to col- 6. Main outcome measures; laborate in order to implement system changes in their respective 7. Results for the main outcome measures; emergency departments. The instructors were available for tele- 8. Any additional information that potentially affected the results.
phone assistance during the implementation phase. Six emergencydepartments were randomly assigned to receive either the IPE in-tervention (three hospitals) or to be in a control group which re- ceived no intervention (three hospitals). Data were collected at 9- Ideally, we would have conducted a meta-analysis of study out- 12 months and 18-24 months; although only 19 individuals at- comes for this review. This however was not possible due to the tended the education sessions, data were collected from the whole small number of included studies and the differences in relation to methodological design and outcome measure across the studies.
The third study (was a CBA study to evaluate the Consequently, we have presented the results in a narrative format.
effectiveness of a program to improve collaborative behaviour ofemergency department staff physicians, nurses, technicians, andclerks. The emergency departments were all located in hospitalsin the United States. The intervention consisted of an emergency team coordination education course, as well as implementationof formal teamwork structures and processes. A physician-nursepair from each emergency department was involved in develop- Description of studies
ing and implementing the curriculum. The course consisted ofeight hours of instruction in one day. The format was lecture, dis- cussion of behaviours, practical exercises, and discussion of video segments. Teamwork implementation involved forming teams by Six studies met the inclusion criteria; all of the studies addressed shift and delivering care in a team structure. Each staff member objective number two, to assess the effectiveness of IPE interven- completed a four-hour practicum in which teamwork behaviours tions compared with control groups which received no education were practiced and critiqued by an instructor. Staff coached and intervention. Given the major differences between the included mentored teamwork behaviours to all staff during normal shifts.
studies, a description of each is provided below.
This teamwork implementation phase lasted six months. Nine The first study () was a RCT to examine whether a hospital emergency departments self-selected either to receive the communication skills training program for physicians, physician IPE intervention (six emergency departments, 684 clinicians) or assistants, nurse practitioners, and optometrists increased patients' to act as a control (three emergency departments, 374 clinicians).
ratings of clinicians' communication skills. The healthcare pro- Control group departments received the intervention at a later fessionals worked at a not-for-profit group-model health mainte- date. Data were collected at two four-month intervals following nance organisation in the United States. The IPE intervention, the training.
led by two physicians, consisted of two four-hour workshops de- The fourth study (was a group RCT to evaluate livered a month apart, with two hours of homework in between.
the effectiveness of IPE and a clinical practice guideline to im- The intervention involved didactic components, role playing, and prove recognition and management of depression in primary care interactive dialogue. Of the 69 participants (75% of whom were Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
practices in the United Kingdom. A primary care physician, prac- one study (one study had two not clears and a second study had tice nurse and community mental health nurse delivered the four- one not clear). For the two CBA studies, both had baseline mea- hour IPE seminars to general practitioners and practice nurses in surements, blinded assessment of primary outcomes, protection groups of two to three practices when convenient. Teaching was against contamination, and reliable primary outcome measures.
supplemented by videotapes, small-group discussion of cases, and One study was not clear and one study did not adequately follow- role play. The educators were available for nine months after the up of professionals. Characteristics of study and control providers seminars to facilitate guideline implementation and promote use were reported and similar in one study and not similar in the sec- of teamwork. Fifty-nine primary care practices were assigned to ond study. One of the CBA studies contained a self-selection pro- the intervention group (29 practices) or control group (30 prac- cess for experimental and control groups, and the other CBA study tices). Practices in the control group received the IPE intervention selected experimental groups by convenience and enthusiasm.
after the study had been completed. Data were collected six weeks Results from five of the studies were based on small sample sizes.
and six months after patient visits.
Of these five studies, one study had 69 individually randomised The fifth study undertook a group RCT to ex- practitioners and four studies had a range of 5 to 12 clusters amine the effectiveness of a one-year intervention to improve iden- (emergency departments (two studies), community mental health tification and management of domestic violence in primary care provider organizations, primary care practices). The small sample clinics in the United States. The intervention, for teams of physi- sizes limit the sensitivity in detecting an effective intervention.
cians, nurse practitioners, physician assistants, registered nurses, The sixth study had a larger size sample with 59 primary care practical nurses, and medical assistants, consisted of two half-day practices. In addition, there was not always a balanced number of IPE sessions, a bimonthly newsletter, clinic educational rounds, control and experimental groups: the study by had system support (posters, cue cards, questionnaires), and feedback six experimental groups and three control groups, and the studies of results. Five primary care clinics were randomly assigned to re- by and had two intervention and ceive the intervention (two clinics) or to the control group (three three control groups.
clinics). Data were collected at baseline, 9-10 month, and 21-23month points.
The sixth study (was a CBA study that evaluated ef- Effects of interventions
fects of a consumer-led innovation to improve the competence of In the study by , the communication skills training mental health practitioners working in community mental health program did not improve patient satisfaction scores. Based on an provider organisations in the United States. The practitioner in- average of 81 responses for each of the 69 participating clinicians, tervention for psychiatrists, nurses, therapists, case managers, res- the mean score on the Art of Medicine survey improved more idential staff, mental health workers, and administrative support in the control group (0.072 (95% CI, -0.010 to 0.154)) than involved six educational components held over a one-year period in the intervention group (0.030 [CI, -0.060 to 0.120]). This that included presentations, discussions, small groups, and role- improvement, however, was not significant.
playing techniques, as well as three or four full-day detailing visits The results in indicated that the emergency de- to sites. An additional 16 hours was also spent with staff at the partments which received the intervention to improve responses to sites. The intervention was developed and delivered by two people battered women recorded significantly higher levels on all compo- who are consumers of mental health services. The innovation also nents of the "culture of the emergency department" system-change involved a consumer-focused intervention. The study was con- indicator (e.g. appropriate protocols, materials such as posters, ducted at five organisations in two states; one organisation in each brochures, medical record intervention checklists and referral in- state received the intervention (total of 269 mental health practi- formation available to staff, and staff training) (F = 5.72, P = 0.04) tioners, 151 in intervention groups and 118 in control groups).
and higher levels of patient satisfaction (F = 15.43, P < 0.001) Data were collected at baseline and one year.
than the emergency departments in the control group. There wereno significant differences in the identification rates of domesticviolence victims (F = 0.411, P = 0.52) in the medical records of Risk of bias in included studies
the experimental and control groups. In this study, it was unclear Of the six studies, we have rated one study as high quality, and whether there were unit of analysis errors for the identification the remaining five studies are rated as moderate quality (see rates outcome. The differences in this comparison were not sig- and For the four RCTs, concealment of allocation was nificant, though, and would remain non-significant even if an ad- done in two studies and not clear in two studies; blinded or ob- justment for unit of analysis errors was possible.
jective assessment of primary outcomes was done in all studies; In evaluation of the effectiveness of an interprofes- and baseline measurement was done in all studies. Follow up of sional teamwork training program on collaborative behaviour in professionals, reliable primary outcome measures, and protection emergency departments, results showed a statistically significant against contamination were done in three studies and not clear in improvement in quality of observed team behaviours between the Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
experimental and control groups following training (P = 0.012).
domestic violence between their intervention and control groups.
The clinical error rate significantly decreased, from 30.9% to 4.4% found that documented asking about domestic in the intervention group (P = 0.039).
violence significantly increased, yet the increase in case finding was In the evaluation of the effectiveness of an IPE not significant.
and clinical practice guideline intervention reported no differences Although overall the results indicate some positive outcomes re- between the intervention and control groups in relation to the lated to IPE, a clearer understanding of the IPE itself, as well as its recognition of depressive symptoms. The outcome of depressed effectiveness, remains unclear at this time due to the heterogeneity patients at 6 weeks or 6 months after the assessment did not sig- amongst the six studies as well as their methodological limitations.
nificantly improve.
In the study by documented asking about do- The studies were heterogeneous in relation to the objectives and mestic violence was increased by 14.3%, with a 3.9-fold relative format of the educational intervention, the existence of other in- increase at 9 months in intervention clinics compared to controls.
terventions in addition to the education, and the clinical areas Overall case finding increased by 30% (OR 1.3), but this was not and settings. The interprofessional education component in these statistically significant. Recorded quality of domestic violence pa- studies ranged from four hours to multi-day programs over a one- tient assistance did not change.
year period. The rates of participation also varied; for example,noted that only one experimental hospital sent In the study by mental health practitioners in the a complete team to the two-day training. (In this study, a small intervention group, in comparison to practitioners in the control number (17) of participants participated in the education com- group, reported significantly higher scores in relation to the fol- ponent and were expected to make changes in their departments, lowing competencies: teamwork (R = 0.28, P = 0.003); holistic yet data was collected from the entire department.) approaches (R = 0.17, P = 0.06); education about care (R = 0.22, P reported that the percentage of clinicians who participated in each = 0.03); rehabilitation methods (R = 0.25, P = 0.007); and overall intervention component varied among sites, with most clinicians competency (R = 0.21, P = 0.02).
in the intervention group participating in at least one component.
In the study by , the emphasis was on communica-tion between clinicians and patients, whereas other studies (e.g.
and ) explicitly focused on inter- D I S C U S S I O N
professional team work in the context of particular settings (emer-gency department, primary care) and healthcare goals (error rates, This IPE review update located six eligible studies, an improve- domestic violence). These few examples are some indication of ment from our previous review that found no studies that met the the existing heterogeneity and why it is difficult to summarise and inclusion criteria (Four of the studies reported identify key elements of successful IPE.
positive outcomes in the following areas: culture of emergency de- Four of the studies partment and patient satisfaction (collaborative ; ) contained multi-faceted interventions, of team behaviour and reduction of clinical error rates for emergency which the interprofessional education was only one component.
department teams (); management of care delivered to The other interventions included team restructuring, tools such as domestic violence victims ); and mental health posters, cue cards and questionnaires, measurement and feedback, practitioner competencies related to the delivery of patient care and consumer-directed interventions. In these studies, the authors (). Three of the studies also reported that the gains commented on the importance of system change and the time and attributed to IPE were sustained over time: eight months ( resources required to facilitate it (as well as the ); 18 months (); and 21 months ( need for leadership supportive of teamwork at various organisa- tional levels (). The lack of more rigorous method- Two studies reported that the IPE interventions had no impact ological designs, as well as additional qualitative data, limits our on either healthcare processes or patient health care or outcomes; understanding of how the IPE affected change, including its role reported that patient satisfaction mean scores im- in relation to other components of the intervention. The lack of proved more in the control group than in the intervention group, positive outcomes might not be attributable to the lack of IPE while reported that there were no differences be- effectiveness, but to the nature of the particular healthcare issue; tween the intervention and control groups in relation to the recog- for example, notes that the program might have a nition or treatment of patients with depression. In addition, two greater impact in relation to the care of 'more difficult' patients studies reported a mixed set rather than on routine patient visits. comments of outcomes. As well as reporting positive outcomes in relation to that the pragmatic evidence base of the CPG for treating represen- changes in professional practice and patient satisfaction, tative depressed patients in primary care is weak. Better research found no differences in the identification rates of victims of designs incorporating quantitative and qualitative data collection Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
strategies would further address our understanding of how IPE on interprofessional interactions and communication and quanti- leads to changes in practice behaviours and processes, and its most tative data on patient satisfaction, readmission rates, patient length of stay, and waiting times ).
Methodologically, the studies all shared a common key limitation.
All six studies compared the effects of the IPE interventions with control groups which received no educational intervention. As aresult, it is difficult to assess the effects of the interprofessional Implications for practice
learning compared to the predominant uniprofessional educationmodel. In addition, most of the included studies involved small While our first IPE review found no eligible studies, this update samples (individual healthcare professionals or clusters), which located six studies. Although these studies reported a range of limited their ability to provide a convincing level of generalisable positive outcomes, the small number of studies, combined with evidence for the effects of the IPE interventions.
heterogeneity of IPE interventions, means it is not possible todraw generalisable inferences about the effects of IPE. Despite Given the small number of studies and their heterogeneity, it is marking a step forward in beginning to establish an evidence base difficult to conclude whether any of these IPE approaches are bet- for IPE, more rigorous IPE research (those employing RCTs, CBA, ter than others, and it is still unclear what are the defining and or ITS designs) is needed to demonstrate evidence of the impact instrumental elements of IPE. It is recommended that future ran- of this type of intervention on professional practice or healthcare domised controlled studies have a clearer and explicit focus on outcomes or both.
IPE, better randomisation procedures and allocation concealment,larger sample sizes, and more appropriate control groups. Given Implications for research
that IPE occurs in groups of more than one provider, future trialsshould have cluster randomized designs, and we urge researchers Despite a growth of IPE studies in the past few years, most of to be thoughtful about and avoid unit of analysis errors. In addi- this research does not employ rigorous designs. Future randomised tion, an evaluation of the impact of IPE on resources (i.e. cost- controlled studies explicitly focused on IPE with rigorous ran- benefit analysis) is also needed. The feasibility of such interven- domisation procedures and allocation concealment, larger sample tions also needs to be considered, given the challenges described sizes, and more appropriate control groups, would improve the in these studies of securing health professionals' commitment and evidence base of IPE. A focus on understanding the use of IPE in relation to resources is also needed. These studies should alsoinclude data collection strategies that provide insight into how Although this review located only six eligible IPE studies whose IPE affects changes in healthcare processes and patient outcomes heterogeneity limits possible conclusions, it marks an improve- as research to date has not sufficiently addressed this critical issue.
ment from our first review which found no studies that met the in-clusion criteria ). In the absence of this type ofevidence, the findings from other IPE reviews, which have adoptedbroader methodological and outcome criteria, provide some in- sight into the impact of IPE on changing learners' attitudes, im-proving their knowledge of collaboration, enhancing their collab- We would like to thank Laure Perrier, University of Toronto for her orative behaviour and improving the delivery of patient care assistance with the searches for this review. We would also like to ; ; ;Nevertheless, thank Martin Eccles, Jeremy Grimshaw, Luke Vale, Craig Ramsay, the future development of this type of rigorous IPE evidence ap- Doug Salzwedel, Tanya Horsley, Craig Campbell, and Susanne pears to be underway; an example is a multi-method RCT of an Lindquist for their helpful comments on this review. We would IPE intervention involving general and internal medicine depart- also like to thank Alain Mayhew for his assistance in preparing ments within five hospitals which aims to gather qualitative data this review for publication.
Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
R E F E R E N C E S
References to studies included in this review
Bashir 2000 {published data only}
Bashir K, Blizard B, Bosanquet A, Bosanquet N, Mann A, Brown 1999 {published data only}
Jenkins R. The evaluation of a mental health facilitator in Brown JB, Boles M, Mullooly JP, Levinson W. Effect general practice: effects on recognition, management, and of clinician communication skills training on patient outcome of mental illness. British Journal of General Practice satisfaction: a randomized controlled trial. Annals of Belardi 2004 {published data only}
Campbell 2001 {published data only}
Belardi FG, Weir S, Craig FW. A controlled trial of an Campbell JC, Coben JH, McLoughlin E, Dearwater S, advanced access appointment system in a residency family Nah G, Glass N, et al.An evaluation of a system-change medicine center. Family Medicine 2004;36(5):341–5.
training model to improve emergency department response Bell 2000 {published data only}
to battered women. Academic Emergency Medicine 2001;8
Bell CM, Ma M, Campbell S, Basnett I, Pollock A, Taylor I. Methodological issues in the use of guidelines and audit Morey 2002 {published data only}
to improve clinical effectiveness in breast cancer in one Morey JC, Simon R, Jay GD, Wears RL, Salisbury United Kingdom health region. European Journal of Surgical M, Dukes KA, et al.Error reduction and performance improvement in the emergency department through formalteamwork training: evaluation results of the MedTeams Bellamy 2006 {published data only}
project. Health Services Research 2002;37(6):1553–81.
Bellamy A, Fiddian M, Nixon J. Case reviews: promotingshared learning and collaborative practice. International Thompson 2000 {published data only}
Journal of Palliative Nursing 2006;12(4):158–62.
Thompson C, Kinmonth AL, Stevens L, Peveler RC, StevensA, Ostler KJ, et al.Effects of a clinical-practice guideline Benjamin 1999 {published data only}
and practice-based education on detection and outcome of Benjamin EM, Schneider MS, Hinchey KT. Implementing depression in primary care: Hampshire depression project practice guidelines for diabetes care using problem-based randomised controlled trial. Lancet 2000a;355(9199):
learning: a prospective controlled trial using firm systems.
Thompson 2000a {published data only}
Bluespruce 2001 {published data only}
Thompson RS, Rivara FP, Thompson DC, Barlow WE, Bluespruce J, Dodge WT, Grothaus L, Wheeler K, Sugg NK, Maiuro RD, et al.Identification and management Rebolledo V, Carey JW, et al.HIV prevention in primary of domestic violence: a randomized trial. American Journal care: impact of a clinical intervention. AIDS Patient Care & of Preventive Medicine 2000b;19(4218):253–63.
Young 2005 {published data only}
Boyle 2004 {published data only}
Young AS, Chinman M, Forquer SL, Knight EL, Vogel Boyle DK, Kochinda C. Enhancing collaborative H, Miller A, et al.Use of a consumer-led intervention to communication of nurse and physician leadership in two improve provider competencies. Psychiatric Services 2005; intensive care units. Journal of Nursing Administration 2004; Buck 1999 {published data only}
References to studies excluded from this review
Buck MM, Tilson ER, Andersen JC. Implementation andevaluation of an interdisciplinary health professions core Antunez 2003 {published data only}
curriculum. Journal of Allied Health 1999;28(3):174–8.
Antunez HG, Steinmann WC, Marten L, Escarfuller J. Amultidisciplinary, culturally diverse approach to training Burns 2003 {published data only}
health professions students. Medical Education 2003;37
Burns JP, Mello MM, Studdert DM, Puopolo AL, Truog RD, Brennan TA. Results of a clinical trial on care Barrett 2001 {published data only}
improvement for the critically ill. Critical Care Medicine Barrett J, Gifford C, Morey J, Risser D, Salisbury M.
Enhancing patient safety through teamwork training.
Buxton 2004 {published data only}
Journal of Healthcare Risk Management 2001;21(4):57–65.
Buxton L, Pidduck D, Marston G, Perry D. Developmentof a multidisciplinary care pathway for a specialist learning Barton 2006 {published data only}
disability inpatient treatment and assessment unit. Journal Barton C, Miller B, Yaffe K. Improved evaluation of Integrated Care Pathways 2004;8(3):119–26.
and management of cognitive impairment: results ofa comprehensive intervention in long-term care [see Carew 2001 {published data only}
comment]. Journal of the American Medical Directors Carew LB, Chamberlain VM. Interdisciplinary update nutrition course offered to educators through interactive Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
television. Journal of Nutrition Education 2001;33(6):
improvement. Quality Review Bulletin 1993;19(1):8–16.
[MEDLINE: 93205371] Cobia 1995 {published data only}
Fields 2005 {published data only}
Cobia DC, Center H, Buckhalt JA, Meadows ME. An Fields M, Peterman J. Intravenous medication safety system interprofessional model for serving youth at risk for sustance averts high-risk medication errors and provides actionable abuse: the team case study. Journal of Drug Education 1995; data. Nursing Administration Quarterly 2005;29(1):78–87.
25(2):99–109. [MEDLINE: 95387218]
Hanson 2005 {published data only}
Coggrave 2001 {published data only}
Hanson LC, Reynolds KS, Henderson M, Pickard CG. A Coggrave M. Care of the ventilator dependent spinal cord- quality improvement intervention to increase palliative care injured patient. British Journal of Therapy & Rehabilitation in nursing homes. Journal of Palliative Medicine 2005;8(3):
Connolly 1995 {published data only}
Harmon 1998 {published data only}
Connolly PM. Transdisciplinary collaboration of academia Harmon RL, Sheehy LM, Davis DM. The utility of external and practice in the area of serious mental illness. Australian performance measurement tools in program evaluation.
& New Zealand Journal of Mental Health Nursing 1995;4
Rahabilitation Nursing 1998;23(1):8–11. [MEDLINE:
(4):168–80. [MEDLINE: 97241876] Cooper 2005 {published data only}
Hayward 1996 {published data only}
Cooper H, Spencer-Dawe E, McLean E. Beginning Hayward KS, Powell LT, McRoberts J. Changes in student the process of teamwork: design, implementation and perceptions of interdisciplinary practice in the rural setting.
evaluation of an inter-professional education intervention Journal of Allied Health 1996;25(4):315–27. [MEDLINE:
for first year undergraduate students. Journal of Hook 2003 {published data only}
Corso 2006 {published data only}
Hook AD, Lawson-Porter A. The development and Corso R, Brekken L, Ducey C, KnappPhilo J. Professional evaluation of a fieldwork educator's training programme for development strategies to support the inclusion of infants allied health professionals. Medical Teacher 2003;25(5):
and toddlers with disabilities in infant-family programs.
Zero to Three 2006;26(3):36–42.
Hope 2005 {published data only}
Crutcher 2004 {published data only}
Hope JM, Lugassy D, Meyer R, Jeanty F, Myers S, Jones Crutcher RA, Then K, Edwards A, Taylor K, Norton P.
S, et al.Bringing interdisciplinary and multicultural team Multi-professional education in diabetes. Medical Teacher building to health care education: the downstate team- building initiative. Academic Medicine 2005;80(1):74–83.
Dalton 1999 {published data only}
Dalton JA, Blau W, Lindley C, Carlson J, Youngblood R, Horbar 2001 {published data only}
Greer SM. Changing acute pain management to improve Horbar JD, Rogowski J, Plsek PE, Delmore P, Edwards patient outcomes: an educational approach. Journal of Pain WH, Hocker J, et al.Collaborative quality improvement for and Symptom Management 1999;17(4):277–87.
neonatal intensive care. NIC/Q project investigators of
the Vermont Oxford Network. Pediatrics 2001;107(1383):
DeVita 2005 {published data only}
DeVita, Schaefer J, Lutz J, Wang H, Dongilli T. Improving Hughes 2000 {published data only}
medical emergency team (MET) performance using a novel Hughes TL, Medina Walpole AM. Implementation of an curriculum and a computerized human patient stimulator.
interdisciplinary behavior management program. Journal of Quality & Safety in Health Care 2005;14(5):326–31.
the American Geriatrics Society 2000;48(5):581–7.
Dienst 1981 {published data only}
Dienst ER, Byl N. Evaluation of an educational program in James 2005 {published data only}
health care teams. Journal of Community Health 1981;6(4):
James R, Barker J. Evaluation of a model of interprofessional 282–98. [MEDLINE: 82120622] education. Nursing Times 2005;101(40):34–6.
Dobson 2002 {published data only}
Jones 2006 {published data only}
Dobson S, Upadhyaya S, Stanley B. Using an Jones D, Bates S, Warrillow S, Goldsmith D, Kattula A, interdisciplinary approach to training to develop the quality Way M, et al.Effect of an education programme on the of communication with adults with profound learning utilization of a medical emergency team in a teaching disabilities by care staff. International Journal of Language & hospital. Internal Medicine Journal 2006;36(4):231–6.
Jordan-Marsh 2004 {published data only}
Falconer 1993 {published data only}
Jordan-Marsh M, Hubbard J, Watson R, Deon Hall R, Falconer JA, Roth EJ, Sutin JA, Strasser DC, Chang RW.
Miller P, Mohan O. The social ecology of changing pain The critical path method in stroke rehabilitation: lessons management: do I have to cry?. Journal of Pediatric Nursing from an experiment in cost containment and outcome Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Ketola 2000 {published data only}
Price 2005 {published data only}
Ketola E, Sipil R, M'kel M, Klockars M. Quality Price D, Howard M, Shaw E, Zazulak J, Waters H, Chan D.
improvement programme for cardiovascular disease risk Family medicine obstetrics: collaborative interdisciplinary factor recording in primary care. Quality in Health Care program for a declining resource. Canadian Family Landon 2004 {published data only}
Rogowski 2001 {published data only}
Landon BE, Wilson IB, McInnes K, Landrum MB, Rogowski JA, Horbar JD, Plsek PE, Baker LS, Deterding Hirschhorn L, Marsden PV, et al.Improving patient J, Edwards WH, et al.Economic implications of neonatal care: effects of a quality improvement collaborative on intensive care unit collaborative quality improvement.
the outcome of care of patients with HIV infection: the EQHIV study. Annals of Internal Medicine 2004;140(11):
Rubenstein 1999 {published data only}
Rubenstein LV, Jackson-Triche M, Unutzer J, Miranda Lawrence 2002 {published data only}
J, Minnium K, Pearson ML, et al.Evidence-based care Lawrence SJ, Shadel BN, Leet TL, Hall JB, Mundy LM.
for depression in managed primary care practices. Health An intervention to improve antibiotic delivery and sputum procurement in patients hospitalized with community- Ryan 2002 {published data only}
acquired pneumonia. Chest 2002;122(3):913–9.
Ryan A, Carter J, Lucas J, Berger J. You need not make Lia-Hoagberg 1997 {published data only}
the journey alone: overcoming impediments to providing Lia-Hoagberg B, Nelson P, Chase RA. An interdisciplinary palliative care in a public urban teaching hospital. American health team training program for school staff in Minnesota.
Journal of Hospice and Palliative Care 2002;19(3):171-80,
Journal of School Health 1997;67(3):94–7. [MEDLINE:
Smarr 2003 {published data only}
Llewellyn-Jones 1999 {published data only}
Smarr KL. The effects of arthritis professional continuing Llewellyn-Jones RH, Baikie KA, Smithers H, Cohen education in vocational rehabilitation [unpublished Ph.D.].
J, Snowdon J, Tennant CC. Multifaceted shared care University of Missouri, Columbia 2003.
intervention for late life depression in residential care: Smith 2005 {published data only}
randomised controlled trial. BMJ 1999;319(7211174):
Smith C, Rebeck S, Schaag H, Kleinbeck S, Moore JM, Bleich MR. A model for evaluating systemic change: McBride 2000 {published data only}
measuring outcomes of hospital discharge education McBride P, Underbakke G, Plane MB, Massoth K, Brown redesign. Journal of Nursing Administration 2005;35(2):
R, Solberg LI, et al.Improving prevention systems in primary care practices: the health education and research Taylor 2002 {published data only}
trial (HEART). Journal of Family Practice 2000;49(2707):
Taylor BL, Smith GB. Trainees' views of a multidisciplinary training programme in intensive care medicine. Care of the Nash 1993 {published data only}
Nash A, Hoy A. Terminal care in the community -- an Trummer 2006 {published data only}
evaluation of residential workshops for general practitioner/ Trummer UF, Mueller UO, Nowak P, Stidl T, Pelikan district nurse teams. Palliative Medicine 1993;7(1):5–17.
JM. Does physician-patient communication that aims [MEDLINE: 94115720] at empowering patients improve clinical outcome? A O'Boyle 1995 {published data only}
case study. Patient Education & Counseling 2006;61(2):
O'Boyle M, Paniagua FA, Wassef A, Hoizer C. Training health professionals in the recognition and treatment Tschopp 2005 {published data only}
of depression. Psychiatric Services 1995;46(6):616–8.
Tschopp JM, Frey JG, Janssens JP, Burrus C, Garrone S, [MEDLINE: 95368428] Pernet R, et al.Asthma outpatient education by multiple Ouslander 2001 {published data only}
implementation strategy: outcome of a programme using Ouslander JG, Maloney C, Grasela TH, Rogers L, a personal notebook. Respiratory Medicine 2005;99(3):
Walawander CA. Implementation of a nursing home urinary incontinence management program with and Umble 2003 {published data only}
without tolterodine. Journal of the American Medical Umble KE, Shay S, Sollecito W. An interdisciplinary MPH via distance learning: meeting the educational needs of Phillips 2002 {published data only}
practitioners. Journal of Public Health Management and Phillips M, Givens C, Schreiner B. Put into practice: impact of a multidisciplinary education program for children and Unutzer 2001 {published data only}
adolescents with type 2 diabetes. Diabetes Educator 2002; Unutzer J, Rubenstein L, Katon WJ, Tang L, Duan N, Lagomasino IT, et al.Two-year effects of quality Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
improvement programs on medication management for Best Evidence Medical Evaluation Review Guide 9.
depression. Archives of General Psychiatry 2001;58(10233):
Health Canada 2003
Ward 2004 {published data only}
First Minister's Acord on Health Renewal. Health Canada, Ward C, Wright M. Fast-track palliative care training to Ottawa (2003).
bridge the theory-practice gap. Nursing Times 2004;100
IPE Conference 2005
Interprofessional Education: Grounding Action in Theory.
Wells 2000 {published data only}
Toronto, 2005 May 26–27.
Wells K, Sherbourne C, Schoenbaum M, Duan N, McKeown 2005
Meredith L, Unutzer J, et al.Impact of disseminating quality McKeown M, Blundell P, Lord J, Haigh C. Organic improvement programs for depression in managed primary training and development: working with mental health care: a randomized controlled trial. JAMA 2000;283
teams directly in the workplace. In: Carlisle C, Cooper H, Mercer D editor(s). Interprofessional education: an agenda for healthcare professionals. Salisbury: Quay Books, 2005.
Barr 2002
Pethybridge J. How team working influences discharge Barr H. Interprofessional education: today, yesterday and planning from hospital: a study of four multi-disciplinary tomorrow. Learning and Support Network: Centre for teams in an acute hospital in England. Journal of Health Sciences and Practice. London 2002.
Barr 2005
Reeves 2001
Barr H, Koppel I, Reeves S, Hammick M, Freeth D.
Reeves S. A review of the effects of interprofessional Effective interprofessional education: assumption, argument education on staff involved in the care of adults with mental and evidence. London: Blackwell, 2005.
health problems. Journal of Psychiatric and Mental Health Better Health 2006
All Together Better Health III: Challenges in Reeves 2004
Interprofessional Education and Practice. Proceedings Reeves S, Lewin S. Hospital-based interprofessional of the 3rd conference. 2006 Apr 10–12. Available: collaboration: strategies and meanings. Journal of Health Services Research and Policy 2004;9:218–25.
LH1259&content=social.(accessed 2006 Sept 04). [:Available: www.event–solutions.info/pages/forum.asp? SCRIPT 2007
ecode=LH1259&content=social.(accessed 2006 Sept 04)] SCRIPT. Structuring communication relationships forinterprofessional teamwork (SCRIPT): A Canadian CAIPE 2006
initiative aimed at improving patient-centred care. Journal Centre for the Advancement of Interprofessional Education.
of Interprofessional Care 2007;21:111–4.
www.caipe.org.uk (accessed 2006 Sept 04).
Cooper 2001
Skjorshammer M. Co-operation and conflicts in a hospital: Cooper H, Carlisle C, Gibbs T, Watkins C. Developing an interprofessional differences in perception and management evidence base for interdisciplinary learning: a systematic of conflicts. Journal of Interprofessional Care 2001;15:7–18.
review. Journal of Advanced Nursing 2001;35(2):228–37.
Zwarenstein M, Reeves S, Barr H, Hammick M, Koppel I, Working Together -- Learning Together: A Framework for Atkins J. Interprofessional education: effects on professional Lifelong Learning for the NHS. Department of Health, practice and health care outcomes. Cochrane Database London (2001).
of Systematic Reviews 2000, Issue 3. [DOI: 10.1002/ Freeth 2005
Freeth D, Hammick M, Reeves S, Koppel I, Barr H.
Effective interprofessional education: development, delivery Zwarenstein M, Reeves S, Perrier L. Effectiveness of pre- and evaluation. London: Blackwell, 2005.
licensure interprofessional education and post-licensure Hammick 2007
collaborative interventions. Journal of Interprofessional Care Hammick M, Freeth D, Koppel I, Reeves S, Barr H. A best evidence systematic review of interprofessional education.
∗ Indicates the major publication for the study Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Characteristics of included studies [ordered by study ID]
Brown 1999
RCT where clinicians were randomly assigned to attend immediate (intervention) or later sessions of theprogram (control group) Physicians, nurse practitioners, physician assistants, optometrists Two physicians gave a communication skills training program consisting of a four-hour interactive work-shop, two hours of subsequent homework, and a four-hour follow-up workshop Patient satisfaction; self-reported ratings of communication skills Mean scores of patient satisfaction increased more in the control group than the intervention group,although this change was not statistically significant. The study authors state that longer and more intensivetraining, performance incentives, ongoing feedback, and possibly practice restructuring may be neededto improve general patient satisfactionStudy Quality: Moderate Risk of bias
Allocation concealment? RCT with baseline (pre-test), immediate (9-12 months), and long term (18-24 months) post assessments.
Hospitals randomly assigned to experimental and control groups Emergency department teams (physicians, nurses, social workers, administrators) and local domesticviolence advocates Two-day information and team planning intervention Rates of reported domestic violence, patient satisfaction, audit of clinical documentation Only one hospital sent a complete team as requested; two hospitals did not send a physician; socialworker sent from five of six hospitals. Limited institutional support for IPE noted as a possibility for pooroutcomes in this studyStudy Quality: Moderate Risk of bias
Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Allocation concealment? Morey 2002
CBA study with data gathered eight months after the intervention. Six emergency departments receivedthe intervention, while three emergency departments acted as the control group Physicians, nurses, technicians, and clerks based in nine teaching and community hospital emergencydepartments Eight-hour intervention delivered to groups of physicians, nurses, technicians and clerks involving lectures,discussion of videotaped segments of teamwork and clinical vignettes and interactive teamwork exercises Collaborative behaviour, clinical error rates Also gathered survey data which indicated no change in attitudes for participants following the deliveryof the IPE interventionStudy Quality: Moderate Risk of bias
Allocation concealment? RCT involving 59 primary care practices who were randomly assigned to an intervention group (29practices) or a control group (30 practices) Physician and nursing teams from the participating primary care practices Four-hour seminar delivered to the primary healthcare teams. The seminars included videotapes, smallgroup discussion of cases, and role play Recognition and treatment of patient depression.
While actual number of physicians is reported (n=152), actual number of nurses is not recorded. Qualitativedata relating to participants' views of the intervention were also gatheredStudy Quality: High Risk of bias
Allocation concealment? Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
RCT involving five clinics who were randomly assigned to two intervention groups and three controlgroups. Follow-up data were gathered at 9-10 months and 21-23 months Primary care practice teams; physicians, nurse practitioners, physician assistants, registered nurses, licensedpractical nurses, medical assistants Two half-day training sessions based on Precede/Proceed model for behaviour change; three extra trainingsessions for opinion leaders, newsletter, four additional educational sessions, system support (e.g. postersin waiting areas, cue cards for providers) Provider knowledge, attitudes and beliefs; rates of asking; case finding; quality of assistance Unvalidated survey and qualitative data on provider views of the intervention were gatheredStudy Quality: Moderate Risk of bias
Allocation concealment? Young 2005
CBA study. Two mental health provider organisations received the intervention, while three acted as thecontrol group Psychiatrists, mental health nurses, therapists, case managers Six educational components delivered over one year involving presentations, small group discussions, roleplay and 3-4 day detailing visits. 16 hours of follow-up discussions to monitor progress Practitioner professional competencies Semi-structured interviews were gathered to qualitatively explore the effects of the intervention in moredetailStudy quality: Moderate Risk of bias
Allocation concealment? Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Characteristics of excluded studies [ordered by study ID]
Reason for exclusion Post-intervention study design.
Description of IPE intervention that reports no outcomes.
Not an IPE intervention. One group pre-/post-test study design Not an IPE intervention.
Not an IPE intervention.
Not an IPE intervention.
One group pre-/post-test study design.
Not an IPE intervention.
One group pre-/post-test study design.
One group pre-/post-test study design.
Post-intervention study design.
Not an IPE intervention.
Not an IPE intervention.
Post-intervention study design.
Before and after study with no controls.
Not an IPE intervention.
Post-intervention study with no controls.
A CBA study which gathered self-report data related to attitudes and knowledge change One group post-intervention study design.
A clinical controlled trial of an IPE intervention. Reports outcomes related to self-reported knowledge change Not an IPE intervention.
One group post-intervention study design.
Controlled before and after study. Failed to meet comparison group criteria Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
One group pre-/post-test study design Post-intervention study with control group. Failed to meet comparison group criteria Not an IPE intervention.
Not an IPE intervention.
Five-year longitudinal study with no controls.
Before and after study with no controls.
One group post-intervention study design.
One group pre-/post-intervention study design.
Not an IPE intervention.
Descriptive study.
One group pre-/post-intervention study design.
Not an IPE intervention.
Jordan-Marsh 2004 One group pre-/post-test study with follow-up data collection points Not an IPE intervention.
Not an IPE intervention.
Not an IPE intervention.
Lia-Hoagberg 1997 Before and after study with no controls.
Llewellyn-Jones 1999 Not an IPE intervention.
Not an IPE intervention.
Before and after study with no controls.
Before and after study with no controls.
Not an IPE intervention.
Not an IPE intervention.
Not an IPE intervention.
Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Not an IPE intervention.
Not an IPE intervention.
Not an IPE intervention.
Not an IPE intervention.
One group pre-/post-intervention study design.
Not an IPE intervention.
No control group.
One group pre-/post-intervention study design.
Not an IPE intervention.
Not an IPE intervention.
Not an IPE intervention.
Not an IPE intervention.
Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
This review has no analyses.
Table 1. Quality assessment of included studies (RCTs)
Conceal al- Prof follow- Patient fol- Blind
nation pro- quality
Table 2. Quality Assessment of included studies (CBA designs)
Patient fol- Overall
nation pro- outcome
F E E D B A C K
Lack of Evidence
Received 20/04/2003 13:47:02I am assuming this excellent work is a follow up from earlier published material from 1999 (J. Int. Care 13 (4)417-4). What Icannot understand is why, therefore is IPE still 'flavour of the month'? We wouldn't push ideas forward without adequate evidenceof effectiveness first! Isn't anyone else out there brave enough to concur with the authors? I certify that I have no affiliations with orinvolvement in any organisation or entity with a direct financial interest in the subject matter of my criticisms.
Thank you for your positive comment. The article to which you refer is indeed a print version of this Cochrane review, and we will notethat in the review. We would like to stress that the 'absence of evidence of effect is not evidence of absence of effect' (Cochrane Reviewers'Handbook 4.1.5, section 9.7). We therefore suggest that interprofessional education (IPE) interventions ought to be implemented Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
widely, but ONLY in the context of rigorous evaluations, ideally randomised controlled trials of their effects. This is not as difficult asit might at first seem, and we would encourage those who are interested enough in IPE to want to subject it to reliable test to contactus or other groups of researchers with randomised controlled trial experience for advice and help.
Merrick Zwarenstein [on behalf of the reviewers.]The most recent update to this review is published in Issue 1, 208. The update now has 6 studies. However, it still remains very difficultto draw conclusions about the effectiveness of this intervention and we continue to require further research in the area.
Alain Mayhew [on behalf of the authors and the editorial staff and team] Jane Warner, Practice Nurse W H A T ' S N E W
Last assessed as up-to-date: 11 November 2007.
Protocol first published: Issue 3, 2000 Review first published: Issue 1, 2001 Converted to new review format.
New citation required and conclusions have changed Substantive amendment There was a joint effort to conceiving, designing, co-ordinating and collecting data for the review. SR, JG and MZ analysed andinterpreted the data and wrote the review, with input from HB, DF, MH and IK. MZ is guarantor for the review.
Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
• Li Ka Shing Knowledge Institute of St Michael's Hospital, Canada.
• Continuing Education and Professional Development, Faculty of Medicine, University of Toronto, Canada.
• Institute of Health Sciences, City University, UK.
• Centre for Community Care and Primary Health, University of Westminster, UK.
• Canadian Institutes of Health Research, Canada.
I N D E X T E R M S
Medical Subject Headings (MeSH)
∗Interprofessional Relations; ∗Patient Care Team; ∗Professional Practice; Attitude of Health Personnel; Health Personnel [∗education];Randomized Controlled Trials as Topic; Treatment Outcome MeSH check words
Interprofessional education: effects on professional practice and health care outcomes (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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