Transition from Uniprofessional Towards Interprofessional Education: The Malaysian Experience of a Pragmatic Model

Abstract

Changing from conventional uniprofessional education to interprofessional education (IPE) in health professions education requires strategic planning, especially in developing countries where resources are limited. Successful implementation of IPE is an important way to establish a foundation for interprofessional collaborative care that will improve the quality of health care. Although providing best quality of care is paramount, defining what is ‘best’ is contextual and is highly dependent on a national agenda (The WHO Framework for Action, 2010). Therefore, stakeholders and funders from developing countries need convincing data, particularly local data, before investing in an IPE approach. Piloting such initiatives on a smaller scale provides room for fine-tuning before it is implemented on a national or regional level. In this chapter, pilot projects for IPE initiatives in Malaysia are described. How interprofessional practices can pave the way for national policy change in IPE is also discussed. The framework for action on IPE and collaborative practice (CP) proposed by the World Health Organization (WHO) (The WHO Framework for Action, 2010) was used to guide the project. A brief account of Malaysian health care is given, followed by our experience of developing IPE and finally a leadership model is offered.

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Introduction

Changing from conventional uniprofessional education to interprofessional education (IPE) in health professions education requires strategic planning, especially in developing countries where resources are limited. Successful implementation of IPE is an important way to establish a foundation for interprofessional collaborative care that will improve the quality of health care. Although providing best quality of care is paramount, defining what is ‘best’ is contextual and is highly dependent on a national agenda (WHO 2010). Therefore, stakeholders and funders from developing countries need convincing data, particularly local data, before investing in an IPE approach. Piloting such initiatives on a smaller scale provides room for fine-tuning before it is implemented on a national or regional level. In this chapter, pilot projects for IPE initiatives in Malaysia are described. How interprofessional practices can pave the way for national policy change in IPE is also discussed. The framework for action on IPE and collaborative practice (CP) proposed by the World Health Organization (WHO) (The WHO Framework for Action, 2010) was used to guide the project. A brief account of Malaysian health care is given, followed by our experience of developing IPE and finally a leadership model is offered.

The Current Climate of Health Care Practice in Malaysia

Malaysian health care is largely uniprofessional in its approach. In some situations, a multiprofessional approach has been adopted, particularly for management of complex medical problems. Specialisation of health care occurs for both physicians and other health care providers due to the increasing complexity of health care needs. To a great extent this has resulted in the fragmentation of care, especially in the management of complex medical problems and chronic diseases. Holistic care and quality of care are compromised by this fragmentation. In order to bridge the gaps a truly interprofessional approach (not multiprofessional) is greatly needed.

Communication across specialties in health care relies heavily on appropriate written referrals. Knowledge of other professions’ roles is limited to the bare minimum. Patients who need further care from other health professionals are often referred by letter or phone call. Hence, at any one point of time, patients are seeing health care providers of one specialty and there is little dialogue between various professionals to discuss the best management strategy for individual patients. Although patients receive the services of multiple health professionals, these services are essentially fragmented in their approach, reflecting a multidisciplinary model of care that contrasts with interprofessional CP.

Collaboration between physicians and other health care professionals is still fairly superficial. For example, integration of pharmacists within the medical team was started only in about last ten years and now the pharmacists role has gone beyond dispensing medication. They provide medication counselling for patients and drug reconstitution services, and support doctors with detailed drug information. Pharmacists are gradually incorporated into the team during ward rounds to contribute to patient care in most major hospitals with sufficient manpower. Since 2007, pharmacist-run Medication Therapy and Adherence Clinics (MTAC) in various specialised areas such as diabetes, asthma, renal diseases, anticoagulant therapy and methadone replacement have been set up to optimise patients’ adherence to their medication regimes and achieve better clinical outcomes.

However, in the private sector, communication between Malaysian community pharmacists and general practitioners (GPs) is still rare (Hassali, Awaisu, Shafie & Saeed, 2009; Wong, 2001). Overall, discussion between health professionals in the presence of patients is uncommon. Interactions mainly occur when triggered by problems, for example when there are mistakes in the prescription or when patients complain of side effects. Therefore it becomes a multidisciplinary rather than interprofessional discussion to prevent potential problems.

Combined clinics have been created for specific complex disorders which require multi-professional care. For example, in cochlear implant clinics, otologists, audiologists and speech language pathologists are seeing patients in a single visit and centralised setting. Some specialised diabetic clinics in Malaysia are also jointly run by endocrinologists, dieticians and nurse educators. However, the problem of power dynamics may surface within the team. Physicians have traditionally had a more dominant voice because the various components of care are distributed by the physician to individual health care professionals rather than patient care being planned collaboratively. Greater effort is required to embrace the true values and beliefs of interprofessional care.

Moving On from Uniprofessional and Multiprofessional Education

Perhaps one of the main contributors to current practice is the traditional medical and health professional training, which is largely uniprofessional. Medical students are mainly taught by medical doctors during their undergraduate training. Other health professional faculties have similar educational models. Their exposure to other health care professions during the practice education phase of training is limited to ad hoc informal brief contacts with other health professionals in a clinical placement. These opportunistic contacts often represent multidisciplinary practice rather than interprofessional CP. Team discussions among different professionals are relatively uncommon. Actual learning about other professions often occurs when health care professionals engage with other professions in their daily work after graduation. Hence, professionals’ appreciation for interprofessional practice depends on the apprenticeship model they experienced and individual initiative.

Changing from traditional uniprofessional to interprofessional curricula requires a move to create formal opportunities for students to experience IPE, which is recommended as an element of transformative learning that breaks down professional silos while enhancing collaborative and non-hierarchical relationships in effective teams (Frenk et al., 2010). To foster effective interprofessional practices, continuity of IPE throughout the professional training and education period and beyond is necessary (Dent & Harden, 2009). Thus, implementing IPE curricula should span from pre- to post-licensure exposure. It should be a structured formal learning experience delivered collaboratively by different professions. For example, collaborative learning for medical students should engage physicians, nurses, pharmacists and students from these and other health and social care professions. Additionally, formal attachment to interprofessional practices can be incorporated into the curriculum to experience the actual advantages and challenges of the practice. Upon graduation, health care professionals need to be continually exposed to interprofessional practice in the early years of their career to further consolidate their learning experiences (Dent & Harden, 2009).

Requirement of the University Curriculum in Malaysia

The Malaysian Qualification Agency (MQA), a national higher education accreditation body, supports teaching multidisciplinary practices in local higher education curricula. This was explicitly stated in two of the three national higher education curricula development guidelines. Imparting skills of multidisciplinary collaboration is appreciated as a means of enhancing standards. This collaboration is not IPE per se. In the Code of Practice for Institutional Audit (MQA, 2009) and Code of Practice for Programme Accreditation (MQA, 2008), a curriculum teaching multidisciplinary practices may be placed under electives, study pathways or co-curricular activities. However, the MQA (2013) does not provide a detailed description of what a teaching and learning approach should be. Although the Guidelines for the Accreditation of Undergraduate Medical Education Programmes (Malaysian Medical Council, 2011) explicitly stated the need to inculcate an interdisciplinary approach, it lacks a definitive stance on interprofessional teaching and learning. In order to encourage interprofessional collaboration, there is a need to start introducing structured IPE.

Innovation in implementing IPE in Universiti Kebangsaan Malaysia (The National University of Malaysia) (UKM)

Although IPE is yet to be a requirement in the curriculum of university programmes in Malaysia, some universities have introduced IPE to improve the quality of graduates serving the needs of current and future health care systems and patient needs within these systems. Since 2007, in UKM, various innovations have been planned to incorporate IPE in our curricula. This was in conjunction with the restructuring of undergraduate curricula. The new curriculum was envisioned to be in line with learning outcomes recommended by the World Federation of Medical Education (WFME, 2015), with the emphasis on clinical problem solving and professional development. In order to achieve this, 11 learning outcomes were drafted (Table 9.1). Outcomes 3, 4 and 5 are directly aimed at interprofessional practice skills, and outcomes 6, 7, 10 and 11 are closely related to interprofessional practice. An integrated curriculum was designed to achieve the learning outcomes and includes modules to deliver the teaching of interprofessional skills. Within the faculty, the restructuring of curriculum took a top-down approach led by the Dean of Faculty of Medicine, assisted by Deputy Dean of Undergraduate Studies.

Table 9.1 The 11 learning outcomes of the UKM undergraduate medical programme Universiti Kebangsaan Malaysia, 2014

The strategy was to develop IPE modules and training of faculty members concurrently. Faculties from different professions were involved, as described below. Also, interprofessional collaborative practices and other faculty development programmes, such as a hospital home care programme and Citra UKM (explained below), were planned and would be further developed to support the ongoing efforts. The IPE initiative was spearheaded by the IPE working group, an ad hoc project team. The lead person was the Dean of Faculties involving Medicine, Pharmacy and Health Sciences. The innovations together with human resource development are described briefly below:

• 1. Comprehensive Health Care module (CHC) where the IPE concepts are explicitly introduced;

• 2. Working Together as a Health Care Team module; and

• 3. Interprofessional Problem-Based Learning (IPBL).

The Health Care Team module is a pilot project in co-curriculum activities, whereas the other two are part of modules in the main curriculum.

Comprehensive Health Care Module

The Comprehensive Health Care module (CHC) at UKM aims to introduce the concept of a holistic approach in managing the health issues of patients in the community. Introduced in 2007, CHC is the first IPE initiative by the Faculty of Medicine and Faculty of Pharmacy at UKM, and was chosen as the platform for IPE because the concept of a comprehensive approach to health care is relevant to both professions. The module is compulsory for second year medical students but offered as an elective for third year pharmacy students. Students are required to work together to identify the bio-psycho-social issues faced by the patients and to determine a potential community resource to provide relevant support for improving the health status of the patients.

Implementation

Both faculties collaborated to lay out the learning objectives during the initial stages of introducing the module. Logistic adjustments to programme schedules were required to allow participation by students of both faculties. Facilitators were appointed from different departments of the Faculty of Medicine, including family medicine, public health, medical education, parasitology and nursing, and the Faculty of Pharmacy. The different backgrounds and expertise of the facilitators was intentional to allow interprofessional exposure between the students and the teachers.

As part of faculty development, all facilitators attended a half-day workshop prior to the implementation of the module. During the workshop, they were introduced to the concept of IPE, the module objectives, activities and assessment. They were also given pointers on how to conduct small group discussions with students from other faculties, and were briefed on the importance and objectives of IPE to improve their receptivity to teaching students from other professions. Students were encouraged to discuss about the best management plan with their fellow group members, by considering the expertise of various health professions.

The usual cohort of students for every academic year consists of about 200 medical students and 50 pharmacy students. The number of pharmacy students is limited to 50 in order to minimise the logistics issues in the running the module. The imbalance of students from each programme is unfortunately necessary to ensure that the facilities and teaching resources are able to cater for the large number of students. Not all medical students had the opportunity to work with a pharmacy student in their own subgroup. Hence, the grouping of students is done with care to ensure opportunities for interprofessional exposure. Nursing students are not enrolled because of difficulties in adjusting the CHC schedule to nursing schedules.

Contents of Module

Within the module, students are taught the comprehensive approach to managing patients’ multiple health problems in a community setting. The ‘comprehensive approach’ is based on Engel’s bio-psycho-social model of health care (Engel, 1997). An optimal comprehensive approach to patients’ care commonly requires interprofessional services because of the complexity of their health care. Students are divided into small groups and each group is assigned a patient. Students are required to prepare a case study, which would include home visits. Arrangements are made to ensure each group includes students from medicine and pharmacy. Additional opportunities for interprofessional exposure are available through a learning visit to a community-based organisation which offers health care services relevant to the group’s assigned patient. At the end of the module, all students are required to complete a few assessments which include writing a reflective journal on their views regarding working with other professions in managing health care issues, a group case report and peer assessments of teamwork.

Evaluation

Thus far, the feedback from the students has been mainly positive. They have been enjoying the experiences during the module and have suggested that students from other health care programmes be included in the module. The visits to the community-based organisations have been beneficial in that they expose students to the available community resources which provide support for special groups of patients. As an evaluation of the programme, a qualitative analysis of the students’ reflective writing has found that the students improve their awareness of the roles of various other health care professions (Tan, Jaffar, Tong, Hamzah & Mohamad, 2014). This analysis did not affect the students’ grades/marks in the module, rather it evaluated the actual learning outcome of their experience. Awareness of the different professional roles has helped to foster respect for one another, which is a prerequisite for successful CP in the future. In fact, some medical students who did not have pharmacy students in their groups wished that they had pharmacy students in their own groups as well.

Working Together as a Health Care Team Module

The Working Together as a Health Care Team module was developed and piloted in 2011. It aimed at testing the feasibility of introducing the concept of IPE and CP for year one students of various health disciplines. Upon completion of the module, the students were expected to be able to describe the roles of different health professionals, communicate effectively and work together with students from different health professions.

Implementation

This course was offered as a two-credit-hour co-curriculum module to all first year undergraduate students from Faculties of Medicine (including nursing), dentistry, pharmacy and health sciences in February to April 2011. The professions under the Faculty of Health Sciences included rehabilitation science, health psychology, dietetic science, nutritional science, diagnostic imaging, forensic science, environment & industrial safety and health education. In the co-curriculum module, all undergraduate students have to complete eight credit-hours of university-approved co-curricular activities. They have the option of choosing from a list of modules or activities offered by the faculties, university centres and students' associations. Saturdays are specifically designated for co-curricular activities. Therefore, the policy for co-curriculum creates a common platform which allows for participation by students from different faculties. Recognition and approval of Working Together as a Health Care Team module was obtained from the Centre for Students’ Accreditation.

A total of 87 students from medicine, dentistry, pharmacy, nursing, medical imaging, audiology and speech therapy were enrolled in the pilot project. The students were divided into eight groups, consisting of nine to eleven students from different faculties. Each group was facilitated by lecturers from two different professions.

Content of the Module

In line with the characteristic of co-curricular modules, our teaching and learning activities were mainly student-centred, tapping into exchange-based, observation-based and action-based learning approaches. There was only a one-hour interactive lecture at the start of the module. Subsequently the students were given tasks to present their own profession’s roles and responsibilities to their group members. They were also given a case of CP in stroke management and were asked to identify the roles of different health professionals. The students visited a hospital department and observed the role of another health professional, which they self-selected. At the end of the module, the students planned and carried out a community project, such as a visit to one of the orphanages, nursing homes, shelter homes or health promotion campaigns. They were required to do a poster presentation at the end of the course.

Evaluation

The module had eight learning outcomes which focused on the attainment of generic skills. Assessments were done using the evaluation of personal and group portfolios, mentor and peer assessments, and poster presentations.

Eighty students successfully completed the course with good grades. Students observed 17 different health professions in practice and carried out eight community projects. Observation of another health profession was a real eye-opener for them.

Before this visit, I have no knowledge about the role of optometrists. I feel happy because I get the chance to learn about other health discipline.

JP, an audiology student.

I am very happy that we work as a team. We planned the visit to the orphans at a shelter home, baked and sold cupcakes to raise fund. We taught the children the proper way of brushing teeth with a video and did some games with them. It was fun for everybody.

CMN, a pharmacy student.

All students who participated in the programme reported increased understanding of interprofessional learning, and greater confidence to work with students from other health disciplines. The students favoured early introduction of IPE in their undergraduate study.

Interprofessional Problem-Based Learning (IPBL)

The UKM Faculty of Health Sciences introduced an Interprofessional Problem-Based Learning (IPBL) module in 2013 for students of various health professions. This module uses a problem-based learning approach to design tasks that mirror practice in diverse health settings. Three PBL packages are designed by members of the Faculties of Medicine, Pharmacy, Health Sciences and Dentistry. Scenarios pertaining to head and neck problems are selected as the background situations because they are the common scope of study for the programmes involved.

Prior to its introduction, institutional ethics approval (NN-18-2011) was obtained, followed by a survey on students’ and academics’ readiness for IPE. Favourable results from the survey provided the IPE working group with the confidence to introduce IPBL in 2013. A total of 150 students from different professions in the Faculty of Health Sciences (optometry, audiology, speech sciences, physiotherapy, occupational therapy, diagnostic imaging and radiotherapy) were enrolled in the module. Unfortunately, despite inter-faculty efforts in designing the initial module, it was only offered to students from the Faculty of Health Sciences in 2013 because of logistic and time constraints. The module was expanded to include students from the Faculty of Dentistry in 2014. Similarly to uniprofessional PBL, two hours were used for each session, giving a total of 12 hours for three modules. After the completion of two sessions or a module the lecturer evaluation and student self-evaluation were completed for assessment purposes. The lecturers utilised Bloom’s Taxonomy of higher-order thinking to evaluate the students at the completion of the course and the students were able to interpret evidence and justify key results (Bloom, 1956). At the end of the IPBL the students were given a 20-question questionnaire to measure their level of critical thinking and were invited to give feedback. About 85% of the students were able to identity the basic assumptions and make inferences justified by data, and 90% were able to appreciate differences in opinions (karim et al., 2014). Comments from students were generally positive: the module improved their confidence in communication skills and their ability to develop interprofessional relationships, self-directedness in learning and critical thinking

Diabetes causes blurring of vision and other complications. It is amazing how different professions manage a patient.

Audiology student

I assumed a speech therapist only guides the patient to speak correctly, well they assess the swallowing function and the dietician suggest the correct food intake for a nasopharyngeal carcinoma patient.

Physiotherapy student

Since I am in the IPBL group I have WA [Whatsapp—a mobile social networking application] group with students from all professions, which would be convenient in the future when I need to get further information from other professions.

Radiotherapy student

More efforts are required to resolve the logistic and scheduling issues and enable the participation of all students from the health cluster. As for this semester, commitment from all academics and early scheduling allowed students from more health professions to be included in the learning, and the Faculty plans to expand IPE in clinical practice in future years.

Challenges

The foremost challenge is to convince all stakeholders, ranging from faculties, programme coordinators, facilitators and students to embrace IPE as part of the curriculum. It is not easy to gain the academic support for IPE. Being products of uniprofessional education, they may be less receptive to the idea of allowing other health professionals to teach their students. Learning from other health professionals could be seen as deviating from the core objectives of their own programme. In order to facilitate IPE effectively, they need to set aside these reservations so that they can engage with students and ensure a healthy atmosphere for interprofessional learning.

The faculties within the health cluster operate independently from one another, despite being part of the same academic institution. This further strengthens the divide between the various academicians because most are not aware of the educational objectives and outcomes of other professions.

The group of medical educationists who pioneered IPE in the Faculty of Medicine started IPE on a small scale with CHC and IPBL of the head and neck. Although these modules constitute a small fraction of the main curriculum, they do represent an inroad for IPE into the mainstream education programmes of the health cluster. Academicians are given the opportunity to experience IPE for themselves, paving the way for greater engagement with the concept of IPE at the personal level. Support and recognition from the Deans of the respective faculties and Centre for Students’ Accreditation academics helped to promote IPE at a higher organisational level.

A staff development programme in IPE may be useful in the long run. The Department of Medical Education has proposed the formation of an interprofessional education unit. However, it is still very much in the planning stage. Ongoing feedback and evaluation of IPE modules will help to generate ideas for staff development. Involvement of the Faculty of Health Sciences and Faculty of Pharmacy in the proposed unit is also essential for future developments.

Although difficult, coordinating the logistics and proper scheduling of IPE initiatives are important to ensure successful implementation of the programmes. Well-coordinated scheduling between faculties is needed to accommodate important dates such as examinations and semester breaks. To achieve this, the various faculties need to specifically set aside time for IPE modules to allow their students to participate and benefit from them. Facilitators need to prioritise small group discussions of IPE in order to avoid disrupting the schedule of students from other health professional programmes. Without these efforts, implementation of IPE is neither feasible nor possible.

It is suggested that programme coordinators from the various faculties meet to plan the teaching-learning activities to avoid clashes with other programmes. Identifying ‘off peak’ times such as Saturdays, as done in the ‘Working With Other Health Care Professionals’ module, may ease coordination between programmes with very tight schedules.

Provision of sufficient facilities to conduct IPE was another challenge. Since many rooms and equipment were required for the activities, there were conflicts with other teaching-learning activities using the same facilities. To overcome this, the IPE working group had arranged for the Working Together as a Health Care Team module to run as a co-curricular activity on Saturdays, as mentioned earlier. However, given that it was a co-curricular activity, which was an optional module, not all students had the opportunity to participate.

The concept of IPE is also new to students who may be unaccustomed to accepting colleagues from other health professions. Their apprehension as to how students from other health professions could contribute to their learning needs created initial uneasiness during such activities. On the other hand, students also have the dilemma of whether to actively share information about their health profession with peers from other health professions or simply wait to be asked.

The social hierarchy of different professions could also adversely affect group dynamics within IPE sessions. In Malaysia, where doctors are highly esteemed and selection of medical students is based on excellent academic performance, some medical students may carry with them certain unspoken pride. Intimidating moments are real. In most instances, medical students are chosen as group leaders because they are perceived as more ‘credible’ and ‘capable academically’. Therefore, there is a need to cultivate healthy group dynamics with a free exchange of ideas. Here, the role of the facilitators in managing group dynamics during discussions is of utmost importance.

Given that concepts about IPE are relatively new, it has not been possible to measure some of the learning outcomes because valid outcome measures are not available as yet. ‘Collaborativeness’ in teamwork and ‘attitude towards IPE’ are two examples of this. At present, teamwork is assessed as part of the professional and personal development module in the curriculum using peer and facilitator feedback. But strictly, it does not focus on the degree of collaboration with other health professionals per se. Furthermore, evidence of the relationship between these outcomes and long-term benefit to patient care is also not available. The benefits of IPE to long-term health care outcomes are therefore still unclear and require further robust studies (Reeves, Perrier, Goldman, Freeth & Zwarenstein, 2013).

Opportunities for IPE

Opportunities for IPE should not be limited to classroom experiences as described above. Applying Bandura’s social cognitive theory, behaviour is learnt from observing others. Therefore, successful CP functions as a role model alongside classroom learning. If it is successfully implemented, it becomes evidence that different professions can work together to achieve similar goals. Teaching institutions should aim to design a service that demonstrates interprofessional CP in action. Future research should promote the development of IPE in evidence-based practice that is grounded in well-established theoretical concepts.

The Home Care Unit of Universiti Kebangsaan Malaysia Medical Centre (UKMMC), the teaching hospital for UKM, is a model for interprofessional CP. The unit provides home health services, led by a team of nurses. Cases receiving home care services are discussed at a fortnightly case conference attended by family physicians, nurses and dieticians. Patients’ problems are identified and prioritised during such discussions. Short- and long-term management plans are created for each patient based on input from the participants. Home visits are conducted by nurses, together with doctors or dieticians when necessary. Most importantly, management is planned in a collaborative manner. In future, it is hoped that more health care professions can participate in the case conferences and that this model will be developed in other health centres.

Postgraduate family medicine trainees have been assigned to the Home Care Unit as part of their programme. Besides learning about managing health problems in the home environment, they also learn to appreciate the roles of nurses and other health professionals better. In addition, they have the opportunity to contribute their knowledge and skills to the team. Verbal feedback from the trainees who have had the opportunity to join the unit has been encouraging. The benefits of home care placement may be extended to undergraduates and other postgraduate professional trainees.

At the university level, UKM has also launched the Citra UKM initiative (‘Citra’ is a Malay term for ‘image’), in which selected courses and programmes from individual faculties are offered to students from other faculties. The exposure of students to other professions in the Citra UKM project is consistent with IPE concepts. The Vice-Chancellor of the university has also encouraged an inter-faculty lecturer-exchange programme to provide the experience of working in a different field. This creates opportunity for academicians to ‘learn with, from, and about each other’. Such exposure will benefit both faculties by allowing health professionals to view health care from other perspectives.

Research on IPE is required to assess all aspects of IPE and its long-term outcomes in reducing mortality and morbidity of patients. Qualitative approaches can uncover the dynamics and processes within teamwork and health systems, which may not be tangible via quantitative approaches. The aim of IPE is to improve future teamwork dynamics and CP. Students or health care professionals who have completed IPE modules could be assessed for their attitudes towards other health care professionals as compared to those who did not experience IPE. In the long run, it is expected that better teamwork dynamics will lead to improved quality of health care services and health outcomes.

Leadership Model for Developing IPE in a Predominantly Uniprofessional Curriculum

This model was conceived from local experience of working in a resource-constrained setting. At UKM, IPE was initiated by an interest group with a bottom-up approach at the faculty level to convince the university leadership about the value of IPE (Fig. 9.1). At an early stage of IPE development, it is important to have a local champion of the bottom-up approach, such as one led by the Dean. This initial stage offers the advantage of testing the ground for challenges and threats to implementing IPE in order to propose realistic models of IPE at an organisational level. A functioning model with supporting data stands a better chance of convincing a national champion to initiate a top-down approach (Fig. 9.1). The national champion should be at the ministerial level. This would spark further interest and garner institutional support for implementation of IPE. Successful implementation of IPE initiatives requires changes to be made both at faculty level and at organisational level (Steinert, 2005).

Fig. 9.1

Leadership model for promoting interprofessional education in UKM (Interprofessional Education Working Group, UKM)

The Initial Bottom-Up Approach

The Medical Education Department formed an inter-faculty IPE research team in 2010 to support the implementation of IPE at the university level, particularly among faculties from the health cluster. UKM engaged an international IPE expert as an adjunct professor to advise on designing or improving existing IPE modules, and to stimulate further interest in IPE among other faculty members. Engaging other faculty members was important to ensure their support and collaboration in the delivery of IPE within the health cluster.

From 2010 to 2012, a series of skills transfer activities were organised, including an inter-university symposium on IPE. Besides disseminating knowledge and sharing experience, it aimed to build a network of IPE initiators. Four local universities (Universiti Malaya, UKM, Universiti Sains Malaysia and International Medical University) had initiated IPE in the medical and health sciences disciplines. Seminars and workshops giving an introduction to IPE and advice on its implementation were subsequently organised with other local higher education institutions, with key input from an adjunct professor.

Within UKM, IPE has been made one of the key topics in the annual UKM Teaching and Learning Congress since 2012. Development of IPE is stepped up with research on the approach at undergraduate and postgraduate levels. Research in IPE is needed to convince the university leadership of its value and to encourage the initiation of a top-down approach, and to widen the implementation of IPE. A study conducted at UKM Medical Centre involving medical, nursing and undergraduate emergency medicine students suggested IPE as an educational strategy should be introduced to nursing students in order to extend their understanding of the roles and responsibilities of other health professionals and to provide them with opportunities to work collaboratively with them (Karim et al., 2014). Understanding other health professions roles is more effective through experiential learning starting from the very first year of the undergraduate study as demonstrated in “Working Together as Healthcare Team” module (Efendie et al., 2015) and spiraled up to subsequent years as demonstrated in Comprehensive healthcare module at UKM (Tan et al., 2014) where 2nd year medical students and 3rd year pharmacy students work together in addressing community-based health issues. We are hopeful of convincing the policymakers and university leaders of the value of IPE with the skills transfer initiatives and initial evaluations of IPE outcomes.

Moving On to a Top-Down Approach

Formation of a national policy to encourage IPE is a vision that institutions of higher learning need to achieve. Initially, there is a need to spark interest among academicians nationwide and to enthuse local champions who can introduce IPE into their own respective institutions. The other stakeholders such as the health care industry and policymakers also need to be convinced regarding the value of IPE. In Malaysia, most universities manage their own programmes independently and each faculty also has its own level of autonomy in designing educational programmes. Hence, there is a need for a national guidance policy on how to implement IPE in the universities.

Round-table discussions involving the stakeholders, which include consumer groups and patients, are important in order to have buy-in from the Ministry of Health and Ministry of Education. Sharing of data becomes crucial. Feasibility and readiness for adopting IPE can be debated. Conferences at national level are often used as a platform to introduce IPE to a greater audience. A few conferences were organised in our effort to promote IPE, but have yet to engage with the Ministry of Health. Engaging the ministries will pave the way for the formulation of national policy.

The national policy should address three agendas:

• 1. Teaching of interprofessional skills;

• 2. Research in IPE;

• 3. Development of interprofessional collaborative practices.With the formulation of national policy, these agendas can be made part of the accreditation requirements of various agencies such as universities, research institutes and health service sectors.

Support from the university leadership (and ideally at national level) is necessary, because inter-faculty efforts are required to create a suitable environment for the implementation of IPE. At present, UKM has shown initial support for IPE via the Comprehensive Health Care module, IPBL and Citra UKM. The development and continuous improvement of workable interprofessional health care services in UKM’s teaching hospital (for example, the Home Care Unit) provides evidence that interprofessional collaborative practice is feasible, and hence there is a need for interprofessional education. At the level of the university administration, core support and guidelines for the implementation of IPE need to be developed and effectively implemented to facilitate the coordination of the logistics, scheduling and teaching methods. Recognition and support should be given to faculties who have successfully initiated IPE. For example, the Citra UKM programme catalysed the provision of such support because the participating faculties needed to revise their programmes to allow students from other faculties to participate. Without the call by the university leadership for such changes, implementation of IPE would be challenging. The importance of this leadership cannot be too heavily emphasised.

Further research in IPE at the institutional level is needed to provide evidence to support the allocation of resources to IPE. The findings from exploratory small studies (Tan et al., 2014; Karim et al., 2014; and written feedback collected for the various modules) evaluating our IPE modules have shown great promise. Future research in IPE in Malaysia should be more focused and theoretically-based, determining the factors and process leading to successful interprofessional CP. Adult learning theories and implementation science theories are likely to be a useful start (French et al., 2012). These include measuring learners’ and teachers’ interprofessional skills, the impact of IPE on health care outcomes, and measures of quality of interprofessional CP.

A major agenda item is the provision of true interprofessional CP within health care services. This will require support from the hospital administration and encompasses various health care services. The teaching hospital is a suitable platform for experimenting with models of interprofessional CP delivery, alongside education and research. It is important to nurture an interprofessional collaborative culture among health care professionals and break down the pre-existing social hierarchies of different health professions. Having a working model of interprofessional CP will erase previous psychological barriers and facilitate the seamless provision of health care services. Models of collaborative practice, such as the interprofessional outreach home care programme, that have been successfully piloted and implemented could motivate organisations to set up similar services in other settings nationwide. Evaluating the patient health outcomes and cost-effectiveness such as quality of life, admission rate, mortality rate and cost of care should be the next agenda of research in interprofessional practice.

Conclusion

Care of a patient should always focus on the patient as a whole, not in fragmented parts. Interprofessional collaborative practice and education represent a step forward in returning care to patient-centeredness as well as making the best use of various health professional disciplines. Therefore a shift from uniprofessional education to interprofessional education is needed. Although far from complete, we developed a workable leadership model that starts from the bottom up and is followed by top-down organisational change at the university level. So far, integration of CHC module and IPBL into the curriculum has been successful. However, the effective delivery of IPE content remains to be evaluated rigorously. Although faculty development and training programmes such as facilitator training workshops and the CITRA programme are in place, sustaining the interest of the faculties presents great challenges. Fundamental respect for one another’s professional knowledge and skills should be instilled within and across the training of all health professionals. Building respect and reducing the social hierarchies of different professions should be emphasised. Implementing IPE and interprofessional practice would be easier with a change in the education system, even before students enter tertiary education. However, changing societal perceptions remains a challenge. It will require the concerted efforts of various stakeholders, particularly national education system, health system and consumer groups.

There is also a need to produce convincing data for stakeholders to support IPE. It is difficult to attribute positive health care outcomes to IPE because the efficient delivery of health services takes more than interprofessional CP. Hence, the direct impact of IPE and interprofessional CP will take time, patience and effort to measure. Proponents of IPE are beginning to devise ways to measure the contribution of IPE to long-term health outcomes. Better measures of IPE need to be developed as current measures still lack sufficient theoretical and psychometric properties (Thannhauser, Russell-Mayhew, & Scott, 2010). Given the time and effort that has been committed to the promotion of better medical education, it is unsurprising that IPE in Malaysia is still at the beginning of a long journey.

Promoting a culture conducive to IPE requires time and taking small steps at a time can avoid the wastage of resources. Improvements along the way can be generated from small mistakes before turning the initiative into a large-scale programme. Given the rapidly developing research evidence that is supporting IPE, it is clear that with constant improvements and fine-tuning, IPE initiatives can be further optimised to ensure that the learning outcomes will truly leave a deep impact and continue not only to influence the students throughout their careers, but also to change the ways in which they practise, and lead to the goal of higher quality of care.