1College of Nursing, Washington State University, Spokane, WA 99210-1495, USA
2Family and Child Nursing, University of Washington, Seattle, WA 98195, USA
3College of Nursing, Seattle University, Seattle, WA 98122, USA
Copyright © 2012 Cynthia Fitzgerald et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Nursing education programs may face significant difficulty as they struggle to prepare sufficient numbers of advanced practice registered nurses to fulfill the vision of helping to design an improved US healthcare system as described in the Institute of Medicine's “Future of nursing” report. This paper describes specific challenges and provides strategies to improve advanced practice nursing clinical education in order to ensure that a sufficient number of APRNs are available to work in educational, practice, and research settings. Best practices are identified through a review of classic and current nursing literature. Strategies include intensive interprofessional collaborations and radical curriculum revisions such as increased use of simulation and domestic and international service work. Nurse educators must work with all stakeholders to create effective and lasting change.
National and international reports, including one published recently by the Institute of Medicine , describe the potential for advanced practice registered nurses (APRNs) to contribute to the provision of high-quality healthcare as part of comprehensive healthcare reform [2, 3]. Preparing APRNs for practice and fostering the role of APRNs in a variety of educational, clinical, and research settings are necessary steps toward achieving this vision. Given the current economic and political climate in the United States, however, success may be elusive. At present, a shrinking number of nurse educators carry an increasingly large responsibility for educating a declining number of APRNs [4, 5]. In many settings, outdated regulations, policies, and biases prevent APRNs from practicing to the fullest extent of their education, skills, and competencies [6–8]. Some US-based physician organizations have mounted campaigns aimed at discrediting APRN education and practice and decrying the potential of APRNs to provide cost-effective and clinically efficient care [9, 10].
While barriers to practice are significant, innovative approaches to clinical education and curricular transformation offer promise to nursing administrators, nursing educators, and practicing APRNs who are committed to preparing a highly qualified APRN workforce that will serve future generations of Americans. The rapid development and establishment of the practice doctorate has generated cautious enthusiasm among many nurse educators who are eager to help APRNs achieve their fullest potential in clinical practice. The purpose of this paper is to describe challenges in providing APRN clinical education and to propose achievable strategies for educating future APRNs to participate fully in transforming the United States healthcare system. We argue that the time is right to identify and implement educational practices that will lead to the optimal development of clinical skills, knowledge, and practice acumen and help meet the goals endorsed by national nursing organizations and set forth in the “Future of nursing” report published in 2011 . While the IOM report is extraordinarily thorough, its scope does not include suggestions for specific strategies for improving APRN clinical education, a gap this paper seeks to fill.
Advanced practice registered nurses include nurse practitioners (NPs), certified nurse-midwives (CNMs), certified registered nurse anesthetists (CRNAs), and clinical nurse specialists (CNSs). APRNs represent an underutilized source of quality health care providers . Only 3.8% of the 2.4 million US registered nurses (RNs) are NPs, 0.3% are CNMs, 1.1% are CRNAs, and 0.9% (down from 1.2% in 2004) are CNSs . While the nurse anesthetist was the first advanced practice role to emerge in the late 19th century, formal APRNs education programs did not start until the 20th century. The first nurse-midwifery program began in 1932 at the Maternity Care Association in New York, and in 1954, Rutgers University offered the first CNS graduate program with a specialty in psychiatric and mental health. The role of the nurse practitioner then developed in the 1960s with the increase in federal funding for advanced nursing education in order to fill the need for primary care providers . Since the various roles have emerged, APRNs consistently provide high-quality, cost-effective patient care in a variety of healthcare settings . Today, the majority of APRNs are employed in primary care settings, with most providing women’s health, obstetrics, and mental health services . One hallmark of APRN practice is the provision of care directed at illness prevention, health promotion, and improved patient care outcomes . APRN practice represents one aspect of the nursing profession’s ongoing efforts to provide high-quality healthcare to diverse populations. Overcoming barriers to APRN practice in today’s healthcare environment will lead to improvements in health care for many, especially among traditionally underserved populations.
We define many challenges associated with providing effective APRN clinical education, particularly in clinical practice settings. Our analysis of the challenges in Table 1 led us to identify innovative educational and programmatic strategies with potential to improve APRN education. The strategies we present include both internal (those related to educational institutions) and external (those related to social, political, and interprofessional practice issues) factors.
Table 1: Challenges to effective APRN clinical education.
3. Internal Challenges
For the purpose of this paper, we defined internal challenges as those existing within the profession and/or within educational organizations responsible for preparing APRNs for practice. When considering these internal challenges, we discovered, not surprisingly, that the literature was dominated by information about the critical role of the growing nursing and nursing faculty shortages. Clearly, not enough qualified nursing faculty are available to meet the nation’s need for increased numbers of APRNs, and the projections describing future shortfalls are bleak [15, 16]. While the nursing faculty shortage has been well described in the literature, some aspects of it are germane in a discussion about APRN education, especially given the relatively large numbers of potential students unable to gain admission because of limited faculty resources .
Educational organizations find it increasingly difficult to attract qualified APRNs willing to serve in faculty roles. The demand for APRNs in both educational institutions and in a variety of practice settings has increased simultaneously, but educational institutions are disadvantaged by their inability to offer competitive compensation packages. Constrained budgets result in compressed salaries throughout higher education systems, increasing the gap between salaries available in practice and those offered for teaching positions.
When APRNs do pursue education at the PhD level, they often graduate only to face the reality of the tenure process in research-driven educational institutions. Emphasis on the role of faculty in conducting research and generating research-related revenue limits the availability of PhD-prepared APRN faculty to participate in direct clinical supervision of APRN students. One result is that the primary responsibility for APRN clinical education falls to faculty not eligible for tenure  and whose salaries are typically lower than those available for APRNs in clinical practice . Educational institutions without established faculty practice plans face additional barriers for supporting and retaining faculty who need to practice to maintain certification and licensure, in addition to teaching and meeting tenure criteria.
As many schools of nursing transition to the Doctorate of Nursing Practice (DNP), existing advanced practitioner faculty without a doctorate may find that they are underqualified . Institutional requirements for supervisory committees of doctoral students may require faculty to hold equivalent doctorates, and supervision of DNP students may increase faculty workloads. PhD-prepared nursing faculty may lack the advanced practice qualifications to teach specialty content in APRN programs. Smaller educational institutions may not have the institutional structures or additional faculty necessary to support the development of DNP programs . While the development of DNP preparation and practice offers much promise for preparing the future workforce, the transition process may temporarily exacerbate the shortage of available clinical faculty and result in decreased numbers of APRN graduates. It is too soon to tell whether these transitional challenges will affect the quality of APRN clinical education. The net result may be additional reductions in the available supply of APRNs at precisely the time when they are most needed to address the challenges of healthcare reform in the US .
The number of annual graduates from APRN programs has fallen from a peak in 1998 . This decline is multifaceted, relating to a variety of barriers facing nurses who might otherwise pursue graduate education. Admission to APRN educational programs can be difficult. As many as 17% of graduate nursing programs are highly selective, and there are insufficient openings for qualified applicants . Program costs present challenges to potential applicants whose educational plans are altered by the recent economic downturn in the US as well as by declines in available employer tuition-reimbursement programs; in 2009, 15% of masters of nursing programs cited affordability as a commonly stated reason for students not enrolling . Program location can be a deterrent to nurses who are place bound by responsibilities to support family and provide income. Although the need for more APRNs in rural communities is critical, APRN programs are less accessible to nurses in rural areas, where there are fewer nurses, and nurses must contend with lower salaries and longer commutes . In some areas, there are vacancies in some nursing programs, while others may turn away qualified applicants. Additionally, there are significant shortages of Hispanic, Native American, and men in nursing and in APRN programs. White, non-Hispanic women make up over 83% of APRN nurses . The result is a professional nursing community that does not reflect the diversity of the US population .
Since World War II, educational programs offering Associate Degrees have proliferated and graduates of those programs have become Registered Nurses (ADNs) in increasing numbers. In turn, this internal challenge has influenced the shortage of APRNs, given that nurses prepared in ADN programs are less likely than bachelor’s prepared nurses to obtain graduate degrees . If ADNs do pursue graduate education, time to completion of an APRN program expands, given the requirement for ADNs to complete bachelor’s education before entering a graduate nursing program. Such problems clearly bring the APRN supply needs back to nurse educators and leaders at all levels.
4. External Challenges
The primary challenge facing APRN education from outside educational institutions is the limited number of available clinical sites and preceptors . To increase the number of APRNs prepared to practice independently and to the fullest extent of their scope of practice, nursing education programs must increase both the number and quality of available preceptors and sites. Since many existing faculty practice settings are inadequate to meet this need, educational institutions must rely on cooperative, volunteer community preceptors. There is a shortage of APRN preceptors, particularly in acute care or hospital-based specialties (i.e., CNMs, neonatal nurse practitioners (NNPs), and acute care nurse practitioners). Often, APRN specialties require that preceptors hold the same specialty certification. For example, certified nurse-midwives (CNMs) must provide education to CNM students . While there is a great need for APRN graduates to serve rural areas, there are even fewer preceptors and role models available in these underserved locations.
The limited supply of potential preceptors and clinical sites is exacerbated by competitive forces. Medical resident preparation dominates the use of available clinical sites in hospitals. Federal funding through the Medicare program supports resident education, but not APRN preparation. In many academic medical centers, APRNs are employed for medical student and resident education, further reducing the field of potential preceptors for APRN students . Nursing educational institutions are concentrated in large urban areas near hospitals and may compete with other nursing educational institutions for clinical sites and preceptors.
State regulations and specialty certification agencies place additional requirements on educational institutions that further limit the capacity to prepare APRN students. Direct supervision of students limits the number of students individual preceptors may have at any given time. The requirement for low student-faculty ratios in clinical courses makes APRN education expensive. For example, the National Task Force on Quality Nurse Practitioner Education recommends faculty-to-student ratios of 1 : 6 in situations where there is indirect clinical supervision . Requirements for supervised student clinical practice in most APRN programs are typically established at a minimum of 500 hours, and the DNP requires at least 1000 hours of clinical practice . This increase in DNP student practice hours will increase the need for qualified and willing preceptors.
The limited availability of national funding poses a significant external challenge to successful APRN education. Increasing the capacity of educational institutions to educate APRNs requires additional funding. The current prioritization for medical education and residency training through federal support makes increasing funding for nursing education difficult. Furthermore, current research funding priorities by the National Institute of Nursing Research do not support the investigation of nursing education issues, nor do they support research about the implementation of innovative practice education models at the graduate level. In many research organizations, nursing faculty pursuing academic careers and tenure are discouraged from pursuing clinical education research as a funded line of inquiry. Among potential APRN preceptors, there may be a lack of willingness to precept APRN students due to a lack of incentives beyond the ideals of serving the profession. Most educational institutions are unable to compensate preceptors financially for their teaching roles and are limited in the nonfinancial benefits they may provide preceptors such as faculty titles and access to educational resources. Potential preceptors may see the challenges to practitioner productivity or the additional time commitments of being a preceptor as disincentives to assuming the role. The lack of formal preparation and support for the teaching role may further discourage APRNs from being a preceptor. While direct or graduate entry training is increasingly used as a mechanism for increasing the supply of APRN graduates, potential preceptors may be resistant to training students with little or no health care experience.
The final challenge to increasing the preparation of APRNs is closely tied to the profession’s relationship with the citizens who are served. Nursing continues to be a profession dominated by Caucasian women, a limitation that affects the profession’s negotiation of relationships with other more male-dominated professions. In addition to the chronic underrepresentation of men, diverse populations, and rural inhabitants in the nursing workforce, advanced practice nursing continues to contend with an identity crisis among the US population as a whole, who suffer from a knowledge deficit regarding the skills and abilities of APRNs. Historically, nurses work at the direction of physicians, and cultural and occupational patterns that reinforce this dependent relationship are slow to change. While it is not clear the American Medical Association’s efforts to counter the IOM’s Future of Nursing Report will be entirely successful , the lack of support for full-scope APRN practice from this influential organization is disappointing to those with a vision for the provision of collaborative care in an efficient and effective interprofessional model. Negotiating a new position in health care for nurses and APRNs will continue to be complicated by gender politics as well as power positioning.
5. Strategies and Solutions
The IOM report presents an unparalleled challenge to nursing educators, that is, to foster the development of an “improved education system that promotes seamless academic progression” [1, page 164]. Significant innovation and change are needed to accomplish this vision and to increase the number of APRN graduates. While some of what is required must be implemented on a nation-wide scale, there is strong potential for nursing education programs to implement local and regional strategies that will increase the numbers of APRN graduates prepared to practice at the fullest extent of their education and licensure.
In preparing this discussion of strategies and solutions described in Table 2, we considered our own experience as educators in graduate nursing programs and explored recommendations from multiple authors describing approaches that have been successful in enhancing the education of APRNs. Taken individually, each of these strategies has the potential to help programs make incremental improvements in the recruitment, retention, and preparation of graduate nursing students. In combination, these strategies offer the promise of helping nursing education affect transformation in the preparation and practice of APRNs.
Table 2: Solutions and strategies.
For the purposes of this paper, internal strategies are those that can be undertaken within nursing education programs and the universities that house them, while external are those that reflect some level of engagement with other organizations including other nursing education programs and healthcare organizations.
5.1. Internal Strategies
As noted above and in the IOM report, the expansion of advanced nursing education programs is hampered by a faculty shortage that represents the convergence of multiple factors. These include supply-side problems related to the nursing shortage itself as well as to competitive factors that reflect, among other things, the relatively high cost of graduate nursing education when compared to the earning potential of nurse educators. Like prelicensure nursing education, advanced practice nursing education is resource intensive, requiring sophisticated laboratory settings, computer equipment, and high faculty-to-student ratios.
One approach with potential to aid in the nursing faculty shortage and to make more clinical resources available for APRN education involves internal efforts by educational institutions to develop and strengthen collaborative partnerships. The American Association of Colleges of Nursing  and the Robert Wood Johnson Foundation  recommend that educational organizations work with one another as well as with hospitals and healthcare organizations to develop innovative capacity expanding approaches for preparing nurses and nurse educators and to foster the expansion of nursing education programs. These programs are likely to be costly, but if the benefits can be well-described, educational institutions, hospitals, and healthcare organizations may be willing to invest in their success. As one example of innovative collaboration between university programs, Siewert and her colleagues from the University of Iowa College of Nursing report on collaborative efforts with the University of Missouri at Kansas City that allows for dual enrollment of neonatal nurse practitioner students and helps to optimize faculty resources and enhance student learning opportunities at both institutions . An innovative array of academic and service partnerships linking Bassett Medical Center in Cooperstown, New York, with educational programs at the State University of New York Institute for Technology in Utica, New York now offers tuition support for advanced practice nursing preparation with an emphasis on improving care in a large rural community . These programs and others like them offer much promise in addressing faculty shortages and other challenges while offering innovative contemporary APRN education to place-bound students.
In almost every aspect, curriculum, teaching, and learning must undergo radical transformation, as Benner and her colleagues asserted in 2010 . Nursing programs have traditionally been content driven, but the needs of students and faculty are changing along with those of the workplace . At the core of these new and revised curricula is an emphasis on integrating established educational and professional competencies with educational strategies that encourage problem solving and that enhance students’ critical thinking abilities. Such curricula will encourage the simultaneous development of innovative learning activities, ensure effective student evaluations, and provide clinical experiences that emphasize the optimization of student practice outcomes . Competency-based education may have additional advantages including the development of more learner competence, confidence, and compassion [34, 35].
Problem-based learning can be integrated within a competency-based framework or as a stand-alone strategy to enhance the development of critical thinking and hypothesis-testing skills [36, 37]. Problem-based learning (also known by other terms with slightly different applications, including case-, practice-, or concept-based learning) helps students ground learning in relevant clinical experiences [38, 39]. As students engage closely with faculty in exploring new concepts and identifying new solutions, the process of discovery can lead to the development of improved clinical judgment .
The use of simulation in nursing education is becoming increasingly popular for its ability to enhance the critical thinking of advanced practice nursing students and because it provides a useful evaluative tool for faculty . Through the use of high-fidelity computerized simulation models, APRN students safely develop new knowledge and skills about high-risk, low-volume practices . Other simulation activities involving scripted patients or rotation through skill-based practice stations in laboratory settings also offer enhanced opportunity for student learning and faculty participation. Clinical simulation activities can add greater value by linking APRN students with medicine, pharmacy, and rehabilitation students across the health sciences .
Interprofessional education offers the potential to enhance efficiency in the provision of clinical education for all students  and fosters collaborative practice beyond the educational period. Success has been demonstrated when APRN education has been integrated with specialty and generalist physician practice in a mental health practice setting, as described by Roberts and her colleagues  and likely has much potential to improve education and patient care in a variety of other settings. While mistrust by physicians of the APRN role threatens to constrain the development of collaborative educational models, the promise of interprofessional education also has the potential to unite APRN and physician practice. Such efforts to integrate education and training hold much promise for the US healthcare system as a whole.
Distance education helps create opportunities for otherwise place-bound nurses to pursue graduate studies to become APRNs by extending the reach of nursing education programs beyond traditional boundaries. Improvements in online course management software and evidence-based distance teaching pedagogical approaches provide a foundation for the asynchronous delivery of high-quality and engaging course content. The use of streaming media and a wide range of unified communication technologies (e.g., video cameras, instant messaging, web-connected whiteboards, etc.) enhance faculty-student and student-student engagement. Despite the obvious challenges of providing adequate supervision for APRN students who may be completing coursework from remote areas and with little direct faculty contact, the rewards of accessing optimal professional education using distance education technologies can be great for place-bound students living in underserved communities. To help these programs and students to succeed, educational programs can develop innovative faculty hiring agreements, hiring APRNs who live in the students’ home communities to provide supervision for didactic learning experiences as well as for clinical practice and evaluation. The education and support these faculty members may require can be provided in part by professional development or continuing education programming.
5.2. External Strategies
Not all responsibility for enhancing advanced practice nursing lies with classroom or faculty-driven learning activities. As the number of available clinical sites and preceptors has declined, the need to consider effective alternatives for APRN clinical education has increased. Nursing education programs must “aggressively pursue alternative clinical learning sites and experiences” if they want to assure that students participate in appropriate patient-centered learning activities .
The development of partnerships with a broad range of community organizations and providers can create mutual benefits and provide additional learning opportunities for APRN students. While faculty may believe that an ideal clinical placement would pair students with preceptors in one-to-one relationships with clients arriving at set appointment times, there may be great value in developing partnerships with agencies and individuals who provide care in different models and settings . The development of community partnerships with a service-learning framework can provide APRN students with innovative opportunities to engage in health promotion, physical and mental health assessments, and intervention with individuals who might not otherwise receive healthcare services in a given setting. For example, assignment of students to a correctional facility could offer students the opportunity to engage with individuals in need of health assessment or behavioral intervention , even in the absence of a formally organized on-site health clinic. Assigning students to work with clients through a variety of community agencies can enhance learning opportunities for APRN students and improve care for individuals seeking nonhealthcare services such as meal delivery or day care . Facilitating student engagement in homeless centers can provide a variety of learning opportunities while serving to increase student understanding of social conditions and mental illness . These innovative learning opportunities can provide students with opportunities to build personally meaningful collateral skills even when the emphasis is on accomplishing practice-related learning objectives [50, 51].
In 2004, Connolly and her colleagues described the innovative creation of a collaborative approach to nursing education . Although writing about associate degree nursing education, key concepts have the potential for application in advanced practice education. These include the introduction of interprofessional collaboration that links nursing, medicine, and allied health personnel education within single community health settings, allowing the development of knowledge and skills that are essential to advanced practice nursing.
Academic health centers that integrate faculty practice opportunities with clinical education experience opportunities may well provide ideal environments for APRN education. Not all graduate nursing programs are situated on campuses that house such centers, however. Heller and Goldwater suggest that the development of innovative patient-driven programs, designed to improve access, may also offer enhanced clinical education opportunities for advanced practice students . Their experience with the development of a mobile clinic offering primary care services by APRNs and their supervising faculty, dubbed the “Wellmobile,” illustrates a comprehensive and innovative approach to clinical care. In addition to providing a structured environment that places emphasis on the clinical education of APRN students, the “Wellmobile” also offered students the opportunity to develop strong business and management skills .
Although they can be costly and somewhat difficult to coordinate and offer, domestic and international healthcare missions do offer APRN students and faculty innovative opportunities to provide care to the underserved. While many available international opportunities are useful for student enrichment alone, with secure funding, careful planning, and rigorous attention to the management of learning and evaluation, successful programs can extend clinical education beyond local limits . Participation in mission-driven clinical experiences offers students opportunities to provide care for vulnerable populations and can serve as cultural immersion experiences, enriching students’ cultural competence. They may also provide opportunities for students to develop skills in leadership and practice inquiry, cornerstones of DNP practice.
Finally, funding must be made available to support the vision that advanced practice nurses will assume a large measure of responsibility for the success of healthcare reform in the United States. Improvement in the healthcare system requires the collaborative effort of many disciplines. At present, the current “system of medical education and graduate training… is not aligned with the delivery system reforms essential for increasing the value of health care in the United States.” [54, page 103] The current system of funding graduate medical education does not provide sufficient resources to support the education of nurses in clinical practice settings. While it is typical for medical residents to be supported with salaries, stipends, living allowances, and even resources such as equipment and textbooks, responsibility for APRN clinical education rests solely with the students themselves. Educating an effective nursing workforce is a responsibility that must be shared by nursing programs, academic institutions, and government agencies with support from policy makers who will stand firm in sponsoring a coherent and appropriate approach to the education of a collaborative workforce . It will not be sufficient to simply provide increases in available loans or to improve loan repayment programs; for APRN clinical education to be on par with medical education, nursing classroom and clinical education must receive full financial support. Further, there must be improvements in Medicare compensation for services provided by APRNs, including those related to performance as clinical preceptors and research mentors. Funding for improved and financially supported residency programs for APRNs could come from federal programs that accept a mandate to provide healthcare services to all citizens or that compensate physicians at greater rates than APRNs for the provision of equal services .
The Institute of Medicine Report on The Future of Nursing  calls for increasing the supply of highly educated and clinically skilled APRNs who can practice to the fullest possible extent of their scope of practice. Clearly, APRNs have the potential to contribute to the provision of high-quality healthcare as part of comprehensive healthcare reform in the United States. If this vision is to be accomplished, however, numerous challenges inherent in the current APRN educational process and barriers in the practice environment must be overcome. This paper has identified challenges that specifically hinder the clinical education of APRNs and proposed strategies and solutions to help educational institutions address them. In preparing this paper, we considered our personal experience and explored the literature describing innovative approaches and strategies that have been successful for others. These approaches to APRN clinical education can affect a radical transformation in the preparation of APRNs and help ensure the healthcare needs of US citizens are met by a diverse and collaborative workforce of professionals united in a vision to optimize the practice potential of all practitioners. It is imperative that nurse educators work with all stakeholders to improve the education of APRNs through the identification and implementation of best practice clinical education strategies designed to overcome the current barriers to the provision of high-quality clinical experiences.
The authors would like to thank Dr. Ruth Bindler for her support.
Louder than words: power and conflict in interprofessional education articles, 1954–2013
Elise Paradis,Corresponding author
- Department of Anaesthesia, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Wilson Centre, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Postgraduate Medical Education, Faculty of Medicine, University of Toronto, Ontario, Canada
Correspondence: Elise Paradis, Wilson Centre, University of Toronto, 200 Elizabeth Street, Room 1ES559, Toronto, Ontario M5G 2C4, Canada. Tel: 00 1 416 340 3646;
Cynthia R Whitehead
- Wilson Centre, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Education, Women's College Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Ambulatory Care Education, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
Interprofessional education (IPE) aspires to enable collaborative practice. Current IPE offerings, although rapidly proliferating, lack evidence of efficacy and theoretical grounding.
Our research aimed to explore the historical emergence of the field of IPE and to analyse the positioning of this academic field of inquiry. In particular, we sought to investigate the extent to which power and conflict – elements central to interprofessional care – figure in the IPE literature.
We used a combination of deductive and inductive automated coding and manual coding to explore the contents of 2191 articles in the IPE literature published between 1954 and 2013. Inductive coding focused on the presence and use of the sociological (rather than statistical) version of power, which refers to hierarchies and asymmetries among the professions. Articles found to be centrally about power were then analysed using content analysis.
Publications on IPE have grown exponentially in the past decade. Deductive coding of identified articles showed an emphasis on students, learning, programmes and practice. Automated inductive coding of titles and abstracts identified 129 articles potentially about power, but manual coding found that only six articles put power and conflict at the centre. Content analysis of these six articles revealed that two provided tentative explorations of power dynamics, one skirted around this issue, and three explicitly theorised and integrated power and conflict.
The lack of attention to power and conflict in the IPE literature suggests that many educators do not foreground these issues. Education programmes are expected to transform individuals into effective collaborators, without heed to structural, organisational and institutional factors. In so doing, current constructions of IPE veil the problems that IPE attempts to solve.
Interprofessional education (IPE) has become a core curricular component in many health professions education programmes internationally. Learning with, from and about other health professions is widely considered to be an important – even an essential – step in order to be primed and readied to engage in collaborative practice. Collaborative practice, moreover, is deemed critical to the optimal functioning of health care systems as it is believed to reduce medical error, improve efficiency, patient safety and provider satisfaction, reduce health care costs and generally lead to improved health outcomes. Although the hopes for IPE are high and many, the current evidence to support its efficacy remains sparse, even while the number of articles about IPE initiatives published annually continues to grow (Fig. 1). Can IPE really be an antidote to longstanding professional conflict and power struggles, as some have suggested?
As faculties of medicine look to their curricular offerings and reconsider the importance of IPE for their trainees, taking stock of the IPE literature is of critical importance. The gaps between hope and evidence, and between rhetoric and reality, represented the starting point for the research presented here. Some in the IPE community suggest that IPE has become so normalised as a logical and sensible way to ‘do’ education that it may be that insufficient attention is paid to its theoretical underpinnings. This suggestion aligns with our individual experiences, developed from attending conferences and reading the literature. We were particularly interested in looking at the extent to which issues of power and conflict are described in the IPE literature. There exists a long sociological tradition of considering the effects of existing professional hierarchies,[6-13] and this literature suggests that professionals use demarcating strategies that divide rather than connect, and that institutional and organisational structures limit the ease with which collaborative practices can be implemented.
Although others before us have mapped medical education scholarship historically, their analyses did not cover IPE. Similarly, a recent review of the interprofessional literature did not delve into IPE. We felt this omission to be important and worth addressing. To surpass our individual perspectives, we set out to explore the extent to which these ideas have permeated IPE curricula and scholarship through a structured review of the published IPE literature.
Theoretically, this article is anchored in constructionism, which suggests that the rise or fall of specific educational objects or tools (here IPE) is contingent on historical and social factors. Therefore, by examining the ways in which educators and researchers describe IPE, including what types of IPE interventions are considered worthy of description in the academic literature, how educators evaluate IPE interventions and – more generally – what they consider to be legitimate research about IPE, it is possible to glean insights into how the field of IPE is framed and positioned. This framing and positioning provides a sense of what is considered ‘normal’ in IPE.
Inspired by Kuhn, we see ‘normal’ mainstream science as paradigmatic or, in other words, as clustering around a common set of theories, methodologies and questions. What paradigmatic science finds is thus defined by this common set and does not allow for explorations that contradict it. Evaluating the core concerns of IPE research thus offers a sighting of the paradigm. What the IPE research community chooses to study and, importantly, not to study reflects the research paradigm within which it works and the assumptions that underpin it, as well as the objects of knowledge that it deems legitimate.
Our research used metadata on articles published in the scientific literature to investigate – either deductively or inductively – the evolution of language in IPE research. The methodology used in this paper has enabled the investigation of a wide range of topics, from medical education to obesity[18, 19] and to interprofessionalism more broadly. Figure 2 provides an overview of the different steps we took, which included the generation of a dataset, automated deductive and inductive coding, manual coding, tabulation and content analysis.
Data for this paper were collected on 4 May 2014 by searching the Web of Science and PubMed databases for publications related to IPE. Our interest in the landscape of IPE research suggested an inclusive query, given the wide range of terms used across the interdisciplinary and interprofessional spectra. Albeit that we understand that research on interprofessional collaboration or on the nurse–doctor relationship is related to the IPE literature, our focus is on the scholarship produced by scholars who identify with the IPE paradigm and thus label their work as such. Consequently, our search, which yielded 1915 and 1411 articles, respectively, in Web of Science (as ‘Topic’) and PubMed (among ‘All Fields’) published between 1954 and 2013, used the following terms: (‘interprofessional education’) OR (‘inter-professional education’) OR (‘multiprofessional education’) OR (‘multi-professional education’) OR (‘multidisciplinary education’) OR (‘multi-disciplinary education’) OR (‘interdisciplinary education’) OR (‘inter-disciplinary education’) OR (‘transprofessional education’) OR (‘trans-professional education’) OR (‘transdisciplinary education’) OR (‘trans-disciplinary education’).
We merged both datasets.
We used two strategies to analyse publication metadata – deductive and inductive – and conducted them on a merged dataset of 2191 unique publications (Fig. 2). The deductive strategy used a Python code written specifically to generate frequency counts of the different words used by authors in their titles. Every word used in more than 1% of all articles was then reduced to its simplest root form. For example, ‘education’, ‘educate’ and ‘educational’ were all reduced to the root ‘educat’, which was used as a wildcard. The list of all root terms was then fed into another Python program that coded all titles to generate a binary matrix in which 0 signals ‘no match’ and 1 signals ‘match’. For instance, the title ‘The paradox of interprofessional education: IPE as a mechanism of maintaining physician power?’ matched the top 1% of keywords on ‘interprofessional’, ‘interprofessional education’, ‘IPE’ and ‘physician’, all of which were coded as ‘1’. Other top 1% keywords, such as ‘nursing’, ‘assess’ and ‘experience’, were coded as ‘0’. Data were then aggregated by word (column), by publication (row), and by year.
We deductively coded titles rather than abstracts or full articles for several reasons. Firstly, scientists choose titles to represent the content of the full article. Secondly, because the title serves as an attention-seeking device to draw the reader to read the full text of the article, word choice in titles illustrates which concepts and methodologies hold the most symbolic power in the field. Thirdly, and more pragmatically, using abstracts or full texts generates a messier portrait, increasing frequency counts and making it harder to detect the signal from the noise, especially in light of the fourth reason: only 1367 of the identified 2191 articles (62.4%) contained abstracts, and we did not want to miss potentially relevant articles without abstracts, nor bias results in favour of articles with abstracts.
The second Python code was used again to analyse publication metadata inductively. Given our concern with power in IPE, we developed a list of 144 power- and conflict-related keywords using a thesaurus (Appendix S1, online). This list was fed into the program to code titles, which generated another binary matrix as described above. Once the title coding was completed, we repeated the process with abstracts in order to ensure the fulsome capture of potentially relevant articles. After an initial reading of the abstracts of the articles thus identified, we elected to select only articles with abstracts that contained one or both of the two keywords most closely aligned with our research subject: ‘power’ and ‘conflict’. Indeed, the most frequently used keywords included ‘concern’, ‘influence’, ‘control’ and ‘power’, but their meanings often differed from those for which we were searching. For example, ‘control’ was used most frequently in the phrases ‘controlled trial’ or ‘controlled study’, or referred to symptom or infection control, or was used in the context of quality control, none of which had anything to do with the kind of sociological power we are interested in. A total of 129 articles were thus identified.
To identify which articles of these 129 made a sociological rather than statistical use of ‘power’ without being partial to researchers in our own circle, we blinded ourselves to the authors’ names, individually coded all articles as ‘Yes, about power’, ‘May be about power’ or ‘Not about power’, and finally discussed and resolved disagreements as a pair. A third party, external to the project, further reviewed the 129 articles; thus every article identified as ‘Yes’ or ‘May be’ about power was reconsidered by the authors. The six articles thus identified to be about power and IPE were then submitted to content analysis. We sought to identify the nature of the depictions and discussions of power and conflict, whether issues of power and conflict were integral to the articles, and whether power and conflict were theorised.
It is important to note that despite having blinded ourselves to the authors’ names while coding, four of the six papers in our final selection were written by teams that included either people we knew professionally or ourselves. We would like to point out that many of these authors have published extensively about IPE, yet none of their other papers made it into our final selection. Perhaps unsurprisingly, we found that birds of a feather flock together.
Quantitative textual meta-analysis
Deductive coding of the data suggested that interprofessional education as a research field is mostly concerned with education (58.0%), health (21.5%), students (14.5%), care or caring (13.8%), learning (9.8%), and collaboration (8.6%). Practices (8.9%) and programs (8.8%) are also prominent in the sample. Practice and students, in particular, have shown significant growth in the IPE literature since the mid- and early-nineties, respectively. Nurses and nursing (7.8%), as well as patients (6.0%) are also prominent in titles. Table 1 provides the full breakdown of keywords that figured among 5% or more of the articles in the sample, with their associated frequencies. As a proportion of the sample, communication (1.0%), leadership (0.7%) and professionalism (0.2%) were rarely present, despite being skills and attitudes that are commonly mentioned in the recent interprofessional education in the literature.22–24 Teaching was also relatively absent compared to learning, featuring in only 3.2% of articles. Mapping the use of these four keywords over time shows that they emerged on the IPE agenda only at the turn of the 21st century, and partly explains their low frequency overall.
|Interprofessional education/inter-professional education||677||30.9|
Inductive coding of article titles found only 29 of our 144 power- and conflict-related keywords (Table 2), and only 79 articles counted one or more of these keywords in their titles. Among abstracts, 77 of our 144 keywords were found, in a total of 555 articles. Keywords found in titles or abstracts in more than 1% of articles can be found in Table 2. As we have noted, several keywords were used in contexts that did not reflect a sociological understanding of the word, but rather often statistical or biomedical understandings. ‘Control’ was most often used in the phrases ‘controlled trial’ and ‘controlled study’, and in the context of symptom, infection or quality control; similarly, power often referred to statistical power. Most of these articles were thus false positives. Focusing on ‘conflict’ and ‘power’, the conceptual anchors of this paper, yielded 50 new articles to be coded, for a total of 129 in our power and conflict dataset.
To identify the articles that were truly about power and conflict (i.e. true positives) among the 129 identified inductively, we then independently read and coded them all in the three steps described above. Through these three steps, we agreed that only six articles specifically focused on issues of power or conflict. Our manual search yielded no further articles on power and conflict in the interprofessional education literature, but identified four articles on power relationships in the broader interprofessional care literature.
We conducted content analysis on the six articles identified inductively as explicitly addressing issues of power and conflict. Of these, two articles articulated the need to attend to notions of power and conflict, but were limited in their theoretical explication of issues. One of these articles provided a review of the medical and social science literatures to highlight tensions between desired notions of flattened hierarchies prevalent in IPE programmes, and medical socialisation and authority. Despite pointing out these discrepancies, it did not rely on a strong conceptualisation of power and conflict in its analysis. The second article used critical incident analysis to examine issues of collaboration among professionals treating eating disorders. The incidents described highlighted a variety of power and conflict issues, which were further elaborated in the discussion. Here again, the article's theoretical underpinnings were limited, leading the authors to make superficial suggestions, such as that better communication and conflict resolution may make power struggles disappear. These two articles[25, 26] represent tentative, initial explorations of power dynamics.
A third article described a study which involved interviews with newly qualified doctors about what they had learned from nurses in the workplace. The authors discussed issues of professional hierarchies, role negotiation and (inter)professional socialisation, and clearly articulated the importance of power, medical dominance, gender and professional conflict in how these issues played out. Despite this, the authors’ conclusion focused primarily on the importance of recognising the role that nurses play in the education of junior doctors, and called for more focus on informal learning opportunities. In the end, by diverting attention from (shying away from?) power-related issues, many of the implications of the article's fascinating findings were left undissected.
The other articles tackled issues of power more explicitly. One of these was an editorial, which positioned IPE as an ideology and boundary object. The authors commented:
Since the discursive logic of IPE positions it as ‘naturally’ and ‘inevitably’ leading to collaborative practice, the IPE discourse sets up an expectation that the structural changes required for effective collaborative practice will someday occur when we finally find the way to ‘do IPE right’.
This article invited more IPE research focusing on power and conflict to dissect and revisit the previously atheoretical literature that takes for granted the idea that IPE will lead to systems change.
Another article troubled the underlying assumptions of IPE by drawing upon activity theory and notions of boundaries. The authors argued that overly simplistic constructions of stable professional roles within teamwork models belie the complexity of interprofessional and interdisciplinary work in clinical care settings. In doing so, they also deconstructed the fallacy that simply aiming to provide excellent patient care will unite health care workers around a common goal and cause hierarchies, conflict and power dynamics to disappear.
The final article used Witz's theory of professional closure to elucidate group dynamics in an IPE initiative. The authors highlighted strategies used by different professional groups to exert power within interprofessional relations, and provided the most direct examination of power issues in IPE that we were able to locate. This study stands as an exemplar for future power-related research in IPE.
Interprofessional education has become a popular educational activity and, as our study shows, is an increasingly prevalent topic in the health professions education literature. The vast majority of articles about IPE, however, focus on curriculum and the design of specific IPE sessions or programmes and do not critically examine the power dynamics that IPE is meant to address. As our data demonstrate, notions of power and conflict are virtually absent from the IPE literature. Only six of 2191 (0.3%) articles on IPE made substantial reference to power, and only three articles integrated it throughout, which suggests that the paradigm that labels itself IPE has not capitalised on findings from other literatures, such as those in sociology, in the broader interprofessional care literature, or in the literature focusing on the doctor–nurse relationship. Although our initial impressions of the IPE literature did suggest that power would rarely be one of its central concerns, we were shocked by the scarcity of such research. Particularly given the commanding presence of power in the sociological literature, as well as its obvious presence in the interprofessional care literature, the absence of power from the IPE literature is both mysterious and disquieting. If issues of power are known and recognised in clinical practice, why then does the IPE literature fail to address them? And if the literature on IPE ignores these realities, how do we expect IPE to become an educational model that will better lead students in the health professions to collaborate?
The absence of power and conflict from the vast majority of the IPE literature suggests that most educators are not attending to these fundamental issues, or that they may be attending to them in a subdued manner, without using vocabulary that is ‘charged’ and that may alienate key stakeholders in the effort: physicians. Most articles seem to accept the assumption that IPE is an effective way to prepare learners to engage in collaborative practice. If it were effective, then there would be no need to pay heed to the structural, organisational or institutional issues that create and reproduce hierarchies among the health care professions. Instead, responsibility for change rests with educational programmes, which are expected to transform the minds, hearts and practices of individual learners, who will, in turn, change the system.
We do not need to look far to see the naivety of this approach. As far back as the 1970s, researchers in institutional theory suggested that educators make token or symbolic changes in response to institutional pressures but that these changes are decoupled from actual classroom practices.[31, 32] Moreover, practices imposed upon teachers from above have been shown to be often reconstructed and reshaped to align with teachers’ pre-existing beliefs and practices, demonstrating the difficulty of enacting change in large systems. Similarly, the reliance on curriculum as a corrective for social and structural problems has also recently been critiqued within medical education.
Much of IPE currently appears to be driven by the notion that there is a script – elusive thus far, but worth the continued quest to find – that, if sensitively adopted, will enable health professionals to enact their respective parts in cheery collaborative harmony. Once this is unearthed (presumably as a result of the various curricular pilots, programmes and experiments), it will provide educators with a recipe for successful and standardised collaborative practice. The appeal of a silver bullet with which to erase power and hierarchies from medicine is obvious, and the early success of surgical checklists[35, 36] or interventions to reduce catheter-related bloodstream infections created hope. Yet there is mounting evidence that context deeply influences outcomes, even for protocols at the sharp end or technical side of health care interventions.[38-40] One size may never fit all, especially when what is at stake is something as fragile and intangible as the quality of interactions among people, and its impact on care delivery.
The analysis presented here suggests that IPE is one area in which education has been misused as a ‘solution’ to structural, organisational and institutional issues. This is a phenomenon well known in the broader education literature: when confronted with an unmanageable issue (poverty, crime, sexism), we often turn to education as a solution of last resort in the hope that the next generation may fix it. We argue that it is not only unrealistic, but also inappropriate to expect learners to be catalysts for systems change. Health professions educators and leaders are shirking responsibility if they give up on currently practising generations of health care providers, cobble together an IPE curriculum and expect that a sprinkling of fresh faces with more egalitarian ideas will change the system for the better. The fact that power and conflict are absent from the vast majority of articles written about IPE suggests that educators and researchers are hesitant to engage with the difficult yet undeniable truth that power structures shape health systems and health professional interactions.[6-13] Failure to engage with power peculiarly positions IPE as a ‘solution’ to an amorphous and unarticulated problem. By ignoring power and conflict, the IPE literature obscures what exactly it is that IPE initiatives are theoretically aiming to correct. This absence speaks louder than words.
EP contributed to the conception and design of the work, and the acquisition, analysis and interpretation of data. CRW contributed to the conception and design of the work, and the analysis and interpretation of data. Both authors contributed to the drafting and critical revision of the paper, approved the final manuscript for publication, and agree to be accountable for all aspects of the work for accuracy and integrity.
We thank Sarah Wright, PhD, Scientist at the Toronto East General Hospital, for help with data analysis.
This research was supported by a Canadian Institutes of Health Research, Health Services and Policy Research grant to CRW: “Better education for better teamwork: Understanding the discourses to improve the practices of interprofessional education.”
Conflicts of interest
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