Appendix B
Synthesis of Interprofessional Education (IPE) Reviews
Scott Reeves, Ph.D.; Janice Palaganas, Ph.D., R.N., N.P.; Brenda Zierler, Ph.D., R.N.
INTRODUCTION
In 2010, a review of reviews was published that examined the “meta-evidence” for the effects of interprofessional education (IPE), including changes to collaborative practice and patient care (Reeves et al., 2010). The authors identified 6 IPE reviews published from 2000 to 2008, containing 174 studies. The results indicated that IPE varied in terms of content, duration, and professional participation. It was also found that studies evaluating this form of education were of variable quality and captured a range of different outcomes—from reports of learner satisfaction to changes in the delivery of care. While a number of methodological problems were identified, in general IPE was well-received by learners and enabled the acquisition of knowledge and skills necessary for collaborative work. There was also some evidence suggesting that IPE can improve collaborative practice and the delivery of patient care. To generate an understanding of the latest evidence of the impact of IPE on collaborative practice and patient care, we updated this review of reviews. This latest effort identified eight IPE reviews published from 2010 to 2014, containing 407 studies.1 The findings from this review of reviews are summarized below in three main sections: methods overview, summary of results, and concluding comments.
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1 Although 407 is the total count of included studies from these 8 review papers, it is highly likely that there is multiple reporting of studies in this work due to their overlapping focus. However, it was not possible to identify this overlap because of the limited information contained in the review papers with respect to details of the included studies.
OVERVIEW OF METHODS
To update the 2010 review, we initially searched PubMed for any reviews of IPE published from 2009 to 2014. This search produced 16 published reviews. Each review was assessed independently by the team to determine whether it focused on reporting IPE study outcomes related to collaborative practice and patient care. After this assessment, eight reviews remained.
To help understand the differences among these eight reviews, they were categorized into (1) systematic reviews that report directly on included studies, provide detailed information on interprofessional collaboration (IPC)/patient care outcomes, and provide methodological quality ratings; and (2) narrative/scoping reviews, which provide a more indicative overview of studies, with no formal assessment of the quality of included studies. Based on this categorization, the included reviews were divided into the following groups: systematic reviews included Pauze and Reeves (2010) and Reeves et al. (2013); and scoping/narrative reviews included Abu-Rish et al. (2012), Brandt et al. (2014), Brody and Galvin (2013), Broyles et al. (2013), Reeves et al. (2011), and Sockalingam et al. (2014).
Steps were then undertaken to analyze and synthesize the evidence contained in the included IPE reviews: (1) familiarization, which entailed a close reading and rereading of reviews to provide an in-depth understanding of the review contents; (2) initial synthesis, which involved a grouping of review data (e.g., search processes, quality assessment techniques, reported outcomes); (3) secondary synthesis, which involved a comparison of research designs and study methodologies used in the reviews to enable an appraisal in these areas; and (4) final synthesis, in which the findings from the previous two steps were combined. This process enabled a critical appraisal and the generation of key synthesized themes.
SUMMARY OF RESULTS
Key results from the synthesis of the included reviews are presented below in two main sections. The first presents general information from the studies included in the systematic and scoping/narrative reviews. The second section presents the key results and describes issues related to the quality of the IPE evidence presented in the reviews.
General Review Information
As noted above and outlined in Table B-1, of the eight included reviews, two were systematic (containing a formal assessment of the quality of included studies), and six were scoping/narrative (providing more descriptive insight into the nature of the included studies).
TABLE B-1 General Review Information
| Systematic Reviews | |||
| Review | Details | Methods | Inclusion Criteria |
| Pauze and Reeves, 2010 |
Update of 2001 systematic review of the effects of IPE on mental health professionals
16 studies included |
Searches: 1999-2007 Medline, CINAHL, PsycInfo
Quality: studies scored (1-4) based on assessment of methods, outcomes, and overall clarity of information |
Mental health staff involved in delivery of care to adults with mental health issues
All research designs included Use of Kirkpatrick outcome typology |
| Reeves et al., 2013 |
Update of 2008 systematic review that assessed effectiveness of IPE interventions
9 new studies included (added to 6 studies from 2008 review for a total of 15 studies) |
Searches: 2006-2011 Medline, CINAHL, EPOC; reference lists of included papers; manual searches of journals; searches of conference websites
Quality: used standard Cochrane criteria to assess quality of included studies |
Any IPE intervention
Experimental research designs: randomized controlled trial (RCT), controlled before-and-after (CBA) study, and interrupted time series (ITS) study Outcomes: professional practice, patient care, health outcomes, or patient satisfaction |
| Narrative/Scoping Reviews | |||
| Review | Details | Methods | Inclusion Criteria |
| Abu-Rish et al., 2012 |
A narrative review exploring IPE models to identify emerging trends in strategies reported in published studies
83 studies included |
Searches: 2005-2010 Pubmed, ISI Web of Knowledge, EMBASE, CINAHL, ERIC, Campbell Collaboration
Quality: No assessment of studies undertaken |
Qualitative, quantitative, and mixed-methods IPE studies published in peer-reviewed journals
All reported IPE outcomes |
| Review | Details | Methods | Inclusion Criteria |
| Brandt et al., 2014 |
A scoping review to determine the success of the IPE/interprofessional collaboration (IPC) studies in achieving the Triple Aim outcomes
496 papers included. (sub-analysis of 133 research papers) |
Searches: 2008-2013 Ovid Medline
Quality: No assessment undertaken |
Qualitative, quantitative, and mixed-methods studies reporting an IPE/IPC evaluation
Outcomes: studies that reported Triple Aim outcomes |
| Brody and Galvin, 2013 |
Systematic review to examine IPE studies reporting patient and provider outcomes related to dementia care
18 articles included (reporting 16 studies) |
Searches: 1990-2012 Medline, CINAHL, PsycInfo, and EMBASE
Quality: No assessment of studies undertaken |
Qualitative, quantitative, and mixed-methods IPE studies reporting dementia intervention
Outcomes: health professional knowledge, behavioral changes, or patient outcomes |
| Broyles et al., 2013 |
A scoping review to provide an overview of the state of collaboration in addiction education
30 studies included |
Searches: 1990-2012 PubMed, Medline, CINAHL, PsychInfo, Google Scholar
Quality: No assessment of studies undertaken |
Qualitative, quantitative, and mixed-methods IPE studies in the field of addiction education
Outcomes related to addiction education |
| Reeves et al., 2011 |
Scoping review to help understand clarity of different interprofessional (IP) interventions
104 studies included |
Searches: database of IPE studies, Medline, reference lists from IP reviews, manual journal searches
Quality: No assessment of studies undertaken |
Qualitative, quantitative, and mixed-methods IPE studies published in peer-reviewed journals
All reported IPE outcomes |
| Review | Details | Methods | Inclusion Criteria |
| Sockalingam et al., 2014 |
A review aimed at identifying evidence for the value of IPE in delirium programs
10 studies located |
Searches: 1965-2013 Medlne, PsychINFO, EMBASE, Web of Science, ERIC, MedEdPortal, BEME
No quality assessment undertaken |
Qualitative, quantitative, and mixed-methods IPE studies involving delirium care
Outcomes: Barr et al. expanded Kirkpatrick typology |
NOTE: BEME = Best Evidence Medical Evaluation; CINAHL = Cumulative Index to Nursing and Allied Health Literature; EMBASE = Excerpta Medical Database; EPOC = Effective Practice and Organization of Care; ERIC = Education Resources Information Center; IPE = interprofessional education.
Most of the included reviews shared similar inclusion criteria, which resulted in the inclusion of qualitative, quantitative, and mixed-methods studies. In addition, most employed an expanded Kirkpatrick outcomes typology (Barr et al., 2005), consisting of six different types of outcome (reaction, modification of attitudes/perceptions, acquisition of knowledge/skills, behavioral change, change in organizational practice, and benefits to patients/clients). Only one of the included reviews was more restrictive, limiting included studies to quantitative designs—randomized controlled trials (RCTs), controlled before-and-after (CBA) studies, and interrupted time series (ITS) studies—and reporting only validated professional practice and health care outcomes.
The range of IPE activities reported in these reviews includes different combinations of professional groups involving different activities and time periods, and delivered in different education and clinical practice settings.
Key Findings and Quality of Evidence
Table B-2 provides an overview of the key results and quality of evidence in the IPE reviews. As indicated in the table, the majority of reviews contain IPE studies that found positive learner-focused outcomes, usually linked to reactions, changes of perception/attitudes, and/or changes in knowledge/skills. Fewer studies found outcomes related to individual behavior. A small proportion of studies in the reviews found positive changes in organizational practice resulting from the delivery of IPE. A smaller number of studies contained in the reviews found changes in the delivery of care to patients/clients, typically in terms of changes in clinical outcomes.
TABLE B-2 Key Review Findings and Quality of Evidence
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Systematic Reviews |
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| Review | Key Findings | Quality of Evidence |
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| Pauze and Reeves, 2010 | All studies postlicensure IPE. Range of programs (most centered on small-group activities); outcomes focused on improving team functioning, collaboration, empowering consumers, enhancing integration of services. All but one study report positive outcomes; nine studies report outcomes at level 3, six studies at level 4b, and four studies at level 4a. | Overall improvement in methodological rigor of research designs from the previous 2001 review, with use of more mixed-methods approaches and more complex levels of education outcomes; however, quality of studies still uneven for identifying the effects of IPE for mental health providers. Five studies assessed as “good quality,” five studies as “acceptable quality,” four studies as “poor quality,” and two studies as “unacceptable quality.” |
| Reeves et al., 2013 | All studies postlicensure IPE. Seven studies report positive outcomes: diabetes care, emergency department culture and patient satisfaction, collaborative team behaviour and reduction of clinical error rates for emergency department teams, collaborative team behavior in operating rooms, management of care delivered in cases of domestic violence, mental health practitioner competencies for the delivery of patient care. Four studies had mixed (positive and neutral) outcomes; Four studies found IPE had no impact on either professional practice or patient care. | General limitations: small number of studies; heterogeneous IPE interventions, research designs, and outcome measures. The quality of evidence was “low” in the following areas: patient outcomes (six studies), adherence rates to clinical guidelines/standards (three studies), patient satisfaction (two studies), clinical process outcomes (one study). The quality of evidence was “very low” for collaborative behavior (three studies), error rates (one study), practitioner competencies (one study). |
|
Narrative/Scoping Reviews |
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| Review | Key Findings | Quality of Evidence |
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| Abu-Rish et al., 2012 | All studies include IPE outcomes. Sixty-seven studies report more than one outcome. Following outcomes included students’ attitudes toward IPE (n = 64), knowledge of collaboration or clinical systems (n = 33), student satisfaction with IPE (n = 30), team skills (n = 25). Patient/clinical outcomes reported in 6 studies, “other” (not specified) outcomes in 30 studies. | No formal assessment of quality undertaken. Authors note a rare use of longitudinal designs and use of surveys (63 studies) and/or interviews/focus groups (37 studies) in most of the included studies. |
| Brandt et al., 2014 | Of 133 research papers included 71 studies based in practice, 42 studies in education, and 14 in mixed setting. Level of analysis for study results: 79 studies report practice-based focus; 28 studies report individual-level knowledge, skills, attitudes focus; 22 studies report organizational-level change. Papers scored for attention to Triple Aim (0 = no Triple Aim outcome; 1 = one outcome; 2 = two outcomes; 3 = all outcomes). 81.2 percent of studies scored 0; 16.5 percent scored 1; 2.3 percent scored 2; none scored 3. |
No formal assessment of quality undertaken. Authors note that 67 studies used qualitative methods, 41 quantitative methods, and 24 mixed methods. Approximately 62 percent of the studies report sample sizes of less than 50, and 17 percent report sample sizes of more than 300. |
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| Review | Key Findings | Quality of Evidence |
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| Brody and Galvin, 2013 | Based on 16 included studies, authors note that IPE in dementia has potential to provide improved knowledge and attitudes for staff; IPE and structural reform have the potential to improve patient outcomes; IPE interventions that include structural reforms within institutions have the potential to sustain long-term change in practice. Most of the studies were multidisciplinary, not interprofessional in nature. | No formal assessment of quality undertaken. Authors note methodological limitations (i.e., underpowered studies) related to outcome measures in four studies. It is also noted that four studies were sufficiently powered, and that varying methodologies and foci of IPE interventions did not allow for meta-analyses or direct comparison. |
| Broyles et al., 2013 | Based on analysis of 30 studies, reported outcomes are limited to participants’ general satisfaction with IPE and/or self-reported confidence/self-efficacy in applying new knowledge and skills. A few studies (numbers not given) report changes in health professionals’ and health professional students’ substance abuse knowledge. It is noted that only three studies report practice changes. | No formal assessment of quality undertaken. Authors note a lack of conceptual and terminological clarity; wide range of different IPE programs and activities used. |
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| Review | Key Findings | Quality of Evidence |
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| Reeves et al., 2011 | One hundred four studies met the criteria and were included for analysis. Studies were examined for their approach to conceptualization, implementation, and assessment of their interprofessional (IP) interventions. Half of the studies were used for IP framework development and half for framework testing and refinement. All studies report some form of “intermediate” outcome (related to the expanded Kirkpatrick typology); 17 studies report changes in patient care; 4 studies report changes in system outcomes (economics). |
No formal assessment of quality undertaken. Authors note studies were used to map the literature to identify key concepts, theories, and sources of evidence in order to develop a theoretically based and empirically tested understanding of IPE/interprofessional collaboration (IPC). Authors note limited use of theory in the studies, so theoretical aspects were not incorporated into the framework. A range of research designs were used, including pre/post (n = 51), poststudy (n = 18), randomized controlled trials (RCTs) (n = 10), and qualitative methods (n = 8). Some mixed methods were used and some longitudinal designs. |
| Sockalingam et al., 2014 | Combined IPE and interprofessional practice (IPP) approach to delirium education can result in higher-order education outcomes (e.g., changes in team behaviors in clinical settings and improved patient outcomes). IPP interventions with higher-level education outcomes are most likely to be associated with interventions that integrate interactive instructional methods and practice-based interventions that are consistent with enabling and reinforcing strategies. |
No formal assessment of quality undertaken. Authors note a lack of RCTs and qualitative studies on IP in delirium education resulted in less conclusive recommendations. Expanded Kirkpatrick levels of studies: 1 = two studies; 2a = no studies; 2b = three studies; 3 = six studies; 4a = two studies; 4b = five studies. At the behavior level, two studies self-report an increase in team competence and performance. |
Many of the IPE studies in the included reviews contain methodological weaknesses. For example, a number of studies offer only limited or partial descriptions of their IPE programs. Many studies provide little discussion of the methodological limitations of their research. Identification of changes in individual collaborative behavior is particularly poor, often relying on
self-reported accounts of this form of change. Most change recorded in the studies was self-reported by learners themselves.
Across the studies, most report the short-term impacts associated with their varying IPE interventions in relation to changes in learner attitudes and knowledge. As a result, understanding of the longer-term impact of IPE on collaborative practice and patient care continues to be limited. Most of the IPE studies contained in the reviews were undertaken at a single site, in isolation from other studies, limiting the generalizability of the research.
Despite a number of weaknesses in the quality of evidence offered by the IPE reviews, there are some encouraging findings in terms of quality. Most notably, there was a fairly common use of quasi-experimental research designs, which can provide some indication of change associated with the delivery of IPE. In addition, most studies included two or more forms of data, and there was continuing use of longitudinal studies to begin to establish the longer-term impact of IPE on organizations and patient care.
CONCLUDING COMMENTS
This work updated a previous synthesis of reviews (Reeves et al., 2010). As indicated above, the evidence for the effects of IPE continues to rest on a variety of different IPE programs (e.g., in terms of learning activities, duration, and professional mix) and evaluation/research methods (experimental studies, mixed methods, qualitative studies) of variable quality. Nevertheless, this updated review of reviews revealed that IPE can nurture collaborative knowledge, skills, and attitudes. It also found more limited, but growing, evidence that IPE can help enhance collaborative practice and improve patient care.
REFERENCES
Abu-Rish, E., S. Kim, L. Choe, L. Varpio, E. Malik, A. A. White, K. Craddick, K. Blondon, L. Robins, P. Nagasawa, A. Thigpen, L. L. Chen, J. Rich, and B. Zierler. 2012. Current trends in interprofessional education of health sciences students: A literature review. Journal of Interprofessional Care 26(6):444-451.
Barr, H., I. Koppel, S. Reeves, M. Hammick, and D. Freeth. 2005. Effective interprofessional education: Argument, assumption, and evidence. Oxford and Malden, MA: Blackwell Publishing.
Brandt, B., M. N. Lutfiyya, J. A. King, and C. Chioreso. 2014. A scoping review of interprofessional collaborative practice and education using the lens of the triple aim. Journal of Interprofessional Care 28(5):393-399.
Brody, A. A., and J. E. Galvin. 2013. A review of interprofessional dissemination and education interventions for recognizing and managing dementia. Gerontology & Geriatrics Education 34(3):225-256.
Broyles, L. M., J. W. Conley, J. D. Harding, Jr., and A. J. Gordon. 2013. A scoping review of interdisciplinary collaboration in addictions education and training. Journal of Addictions Nursing 24(1):29-36; quiz 37-38.
Pauze, E., and S. Reeves. 2010. Examining the effects of interprofessional education on mental health providers: Findings from an updated systematic review. Journal of Mental Health (Abingdon, England) 19(3):258-271.
Reeves, S., J. Goldman, A. Burton, and B. Sawatzky-Girling. 2010. Synthesis of systematic review evidence of interprofessional education. Journal of Allied Health 39(Suppl. 1):198-203.
Reeves, S., J. Goldman, J. Gilbert, J. Tepper, I. Silver, E. Suter, and M. Zwarenstein. 2011. A scoping review to improve conceptual clarity of interprofessional interventions. Journal of Interprofessional Care 25(3):167-174.
Reeves, S., L. Perrier, J. Goldman, D. Freeth, and M. Zwarenstein. 2013. Interprofessional education: Effects on professional practice and healthcare outcomes (update). Cochrane Database of Systematic Reviews 3.
Sockalingam, S., A. Tan, R. Hawa, H. Pollex, S. Abbey, and B. D. Hodges. 2014. Interprofessional education for delirium care: A systematic review. Journal of Interprofessional Care 28(4):345-351.
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