- Interprofessional
The terms ‘interprofessional education/practice/teamwork’ etc. have been defined by various groups. These terms are often used interchangeably. Where we simply use the term ‘interprofessional’, we do so when two or more professions are working collaboratively together.
Respectful working relationships with shared decision making, shared leadership and shared learning are the hallmarks of interprofessional practice (IPP). In addition to specific professional competence, other skills are required: the ability to work collaboratively; to take responsibility for your own actions and the actions of the team as a whole; to take a leadership role or follow the lead of others depending on circumstances; and the ability to provide a consistent service while under pressure.
The care of a person with dementia and their families is complex. Dementia is an umbrella term to describe many different causal diseases and processes, resulting in complex challenges associated with accurate diagnosis and treatment. Dementia is a progressive and life limiting condition with an unpredictable and variable trajectory from diagnosis to death. Dementia affects cognitive functions so that decision making, memory and praxis (performance of action) abilities change over time and the person requires assistance to use their remaining abilities and support to compensate for losses. This context challenges everyone’s knowledge, skills and attitudes.
- Dementia
Dementia is now referred to as a neurocognitive disorder (NCD) (American Psychiatric Association, 2013), that is, the result of chronic or progressive damage to the brain.
This chapter will outline some of the developments that have taken place internationally, not only in interprofessional competencies, but in competencies for dementia care, and provide a model that seeks to combine the two sets of competencies in order to provide a person-centred interprofessional model.
- Competencies
Forman, Jones & Thistlethwaite (2014) define competency as the ability to ‘identify specific knowledge, skills, attitudes, values and judgements that are dynamic, developmental and evolutionary’.
Models of interprofessional education and practice
The first step to interprofessional education (IPE) and practice is to identify and reach agreement on the specific knowledge, skills and attitudes required. Constructing a model or framework to demonstrate the multidimensional and interconnectedness of the elements helps to explain and understand the concept; to incorporate the acquisition of skills and capabilities into undergraduate, postgraduate and professional development programs; and to adapt or modify systems and processes to incorporate IPP into the workplace. Models and frameworks can also be used to develop tools to review or evaluate the capabilities of students and practitioners to ‘work towards a common goal, to communicate and share responsibility’ (Atkinson et al., 2002).
- Interprofessional education (IPE)
Interprofessional education occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care (http://www.caipe.org.uk/about-us/defining-ipe/).
When students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes (WHO, 2010).
- Capabilities
Forman, Jones and Thistlethwaite (2014) define capability as ‘has been used in preference to competence in one IPE framework, as it is considered by some educators to reflect more optimally the necessity that learners and professionals respond and adapt to health care and systems changes’.
Assessing interprofessional capabilities
Assessment of interprofessional capabilities is complex and multidimensional. Any health care educator is aware of the need to ensure that graduates entering the profession can apply evidence-based practice knowledge and skills beyond theoretical knowledge learned at university, and implement newly acquired competencies (Higgs, Andresen & Fish, 2004). As this learning is context based in the community of practice (Dahlgren, Richardson & Sjostrom, 2004), peers, role models, mentors and supervisors can significantly influence the quality of learning (Ajjawi & Higgs, 2008; Goldenberg & Iwasiw, 1993; Johnsson & Hager, 2008). Successful adaptation relies on social learning and active participation in reflection, and feedback from reliable others to judge actions and decisions (Regehr & Eva, 2007). Self-directed learning, critical thinking, reflective practice, and adaptability and flexibility are highlighted as skills for lifelong learning (Barr, 2002; Smith & Pilling, 2007). The development of these skills in the practice environment during this critical transition time facilitates graduates’ successful transition to the workforce (Johnsson & Hager, 2008; Smith & Pilling, 2007). Documentation of such continuing education practice after graduation is essential to retain professional registration. The following headings may be used as a guide under which evidence could be given to demonstrate continuing practice education:
- Client/patient/person/family/community-centred care that is effective, efficient and culturally appropriate within available resources is the primary driving force behind IPE and IPP.
- Sound socially responsibleethical principles and values guide service provision. Respect for autonomy, quality of life, equity and maximising benefit, and minimising harm are key principles.
- Collaborationand collaborative practice is strongly emphasised. The increasingly complex world of health practice means that no one person can possibly hold all the requisite knowledge, skills and attitudes to address client needs. Collaboration is more effective than teamwork, implying mutual respect, and shared leadership and authority.
- Communication is the most useful and effective tool to ensure collaborative practice and effective client outcomes.
- Professionalism includes organisational competence, reflection and conflict resolution.
- IPP requires practitioners to establish and maintain the evidence-based knowledge, skills and attitudes appropriate for professional registration. This encompasses the abilities to recognise limits to scope of practice and personal expertise, to seek appropriate consultation, and refer to other professionals with the required knowledge and skills.
All attributes, with the exception of the last, are generic; that is, are required by all people involved in the health needs of an individual client or client group to create a strong, flexible context in which the delivery of effective health services can occur. Facilitating the development, and evaluation, of interprofessional capabilities is complex and multidimensional.
- Evaluation
Appraisal or value of something.
Learning and applying these skills in the workplace is further complicated because not all health care environments practise within an interprofessional approach. Whilst it can be claimed that most health care is now delivered by teams, not all teams are inclusive or work collaboratively towards a common goal, communicate effectively and share responsibility. Students and practitioners alike often find themselves in health settings where systems and processes structure practice along hierarchical and siloed lines.
Is the context in which interprofessional education and practice occurs relevant?
Health services are provided within a variety of contexts, such as:
- geographical; for example, inner city, suburban, rural or remote communities;
- service delivery; for example, acute care, emergency department, community service, rehabilitation;
- specialty; for example, orthopaedics, oncology, mental health;
- by age; for example, paediatrics, adolescence, adult and aged care services;
- funding source; for example, state government, federal government, private for profit, not-for-profit.
Likewise, preparation for professional practice occurs in many contexts, such as at universities at undergraduate and postgraduate levels, within specific professional schools and departments, and across faculties. Within each context, or combination of contexts, IPE brings great benefits to clients and service providers alike. IPE models to date reflect the health education environment in which each was developed. Methods of evaluation and standards of achievement reflect the needs of that environment. While many of the elements within the models are universal, the interaction between elements may not be, making the transfer across different working situations difficult. Each context brings with it benefits and challenges to the process. The social and physical environment, like the air we breathe, can become so familiar that it almost becomes invisible and its influences become unnoticed unless and until something major, like toxic fumes, focuses our attention. This state of invisibility removes the potential to modify the environmental contexts as important areas of service provision and improvement.
Specific capabilities for the client with dementia
The differences within dementia care contexts must be recognised if a model of interprofessional practice and education is to make a beneficial contribution to the discussion. First, such a model must acknowledge the real-world nature of clinical practice and service delivery, in addition to the realities of educational institutions. Second, the model must address the social, emotional, medical and psychological complexities that living with dementia brings.
Dementia is a complex syndrome of cognitive, behavioural and psychological symptoms with many different, and largely not understood, causations. This complexity is evident by the varying presentations and individual variations in when and how the disease affects each person with dementia. The focus on measuring and accommodating losses in function blinds us to remaining abilities. Every person is different and any intervention or treatment needs to reflect individual needs, desires and abilities. Dementia is progressive and life limiting so a palliative approach is required. Some medications may improve symptoms for some; however, at the current time, non-medical management and lifestyle adaptation are the principal means of support.
Development of interprofessional competencies for the client with dementia
The capabilities of both current and future practitioners need to be considered for two reasons: first, in terms of the environment, in which the care of clients with dementia is delivered; second, in terms of the number of clients with dementia, with an anticipated 20% increase in people with the disease in 10 years’ time (Australian Bureau of Statistics, 2014). The development of interprofessional capabilities internationally is outlined in Chapter 3. By reviewing these developments, with a thorough literature review and consultation with practitioners and researchers, the following four interprofessional concepts or capabilities have therefore been highlighted as essential considerations:
By reviewing the latest research, and in collaboration with Dementia Training Study Centres throughout Australia, we derived the following additional four interprofessional concepts or capabilities for consideration in dementia care:
- Personhood
Thestate or fact of being an individual or having human characteristics and feelings.
In the care of a client with dementia both the dementia and interprofessional capabilities are intricately interwoven. This is demonstrated in the following model.
Model of Interprofessional Practice and Education – Dementia
The structure of the Model of Interprofessional Practice and Education – Dementia (MIPPE-D) resembles a rope or cord, comprising eight strands that reflect the eight concepts or capabilities which require consideration for effective interprofessional dementia care (see Figure 1.1). By interweaving each strand with the others, the rope increases strength and durability. A missing strand weakens the rope and increases the risk of failure while under tension.
Figure 1.1 The Model of Interprofessional Practice and Education – Dementia (MIPPE-D)
The following chapters will explore these strands further and how they work together using case study examples.
Dawn Forman and Heather Freegard
This case study has been adapted from a case study developed by the Western Australian Dementia Training Study Centre. Dementia Training Study Centres are funded by the Australian Government Department of Social Services. Visit http://www.dss.gov.au for more information.
This case study particularly highlights the journey of dementia, the importance of person- and relationship-centred care and the need for collaborative skills as taken from the MIPPE-D. Other aspects from the model are indicated just prior to each set of questions to help the reader.
Phoebe’s life before dementia
Mary and Fred were married in a quiet ceremony in St Aloysius Anglican Church, Guildford, in March 1932. Fred was 48 and Mary 33. Fred, a quiet, shy man, was determined to have a good home before he married. His skills as a carpenter/furniture maker, and his frugal lifestyle, meant that he was able to purchase a block of land, and build and furnish a modest home during the Depression. He was also a skilled fiddle player and was in demand to play at local dances.
Mary was vivacious and outgoing. She left school at 14 and worked at the local telephone exchange. She was 18 when she married her sweetheart – a friend from childhood. She was a widow at 20, her husband dying as a result of a work injury (asphyxiation caused by the collapse of the side of the well that he was digging). She returned to her work at the telephone exchange and was relatively content with her lot in life. Her status as widow provided her with the freedom to engage in social activities denied to single women. She read avidly and widely – ancient history, politics and philosophy were her particular passions. She joined the local repertory club and became a skilled actress. One drama production required someone to play the role of a mute fiddle player and Fred was approached, and agreed. Mary and Fred met, fell in love and married.
The home established by Fred was at Guildford, at this time a small township near the river surrounded by market gardens and orchards. It linked to Perth via a railway and narrow road, and was a resting place for those travelling east from the city to the wheat belt and goldfields.
Phoebe was born at 3 am on 11 December 1937, the fourth child of Mary and Fred. She was born at home, her birth assisted by her maternal grandmother. She had two elder brothers – Jack Frederick (born 1933) and Stephen John (born 1935). Her elder sister, Joan Elizabeth (born 1936), lived just three months, contracting pertussis (whooping cough). The two boys were also very ill but recovered. The advice of the day was to have another child quickly as a means of overcoming the grief associated with the death of a child, so Phoebe was born just 10 months following Joan’s death. There were no more children (as Mary was 40, and Fred 55).
Home was a happy place, full of laughter and music. Learning was valued and scholarly success was well regarded. All children were welcome in the carpentry workshop and learnt the skills and respect for tools from their father. As older parents, Fred and Mary encouraged conversation and debate at the dinner table. Phoebe, as the youngest child and only girl, felt very special and had a special bond with her father, often spending time in his presence in a companionable silence. From this secure place, the children were free to roam and explore their environment, and play with their friends, with one exception – they were forbidden from going into the town centre or railway station precincts alone. Mary wanted to protect her children from the many desperate strangers who were travelling as they sought work.
There was a shadow in the home. While unspoken, there was a sadness, especially within Mary. Several times each week, she could be found sitting quietly under the frangipani tree that had been planted in remembrance of Joan. When seen unawares, her body was drooped, her face slack, with tears silently rolling down her cheeks. On becoming aware that she was being observed, she would immediately brighten and make some excuse for her being there. ‘Gosh, the heat has made me tired,’ or ‘I have a slight headache and thought the quiet would help it go away.’ Phoebe always felt that her mother, while being loving and inclusive, also treated her with a reserve, and was both more protective and more demanding of academic excellence from her compared with her brothers.
The house and workshop were the hub of the repertory club activities, with friends and acquaintances coming and going. While the children were little, Mary did not take an active part in the repertory club, although she contributed by making and mending costumes, which she could do at home. Fred continued, happy to work backstage on set construction and props management. As the children grew up, they also became involved with front-of-house activities, handing out programs, ushering and assisting their parents in their respective chores.
Phoebe attended a small two-teacher primary school run by the State Education Department. Years 1–3 were in one classroom and Years 4–7 in the second. The family school years occurred during World War II, and the period of post-war construction. For the children, the war was an exciting backdrop and the theme for many mock war games where the brave Brits and Aussies defeated the Nazis and the Japs in the air, on the battlefield and on the seas. At the movies, newsreels of the day showed the patriotic and heroic deeds of the Allied Forces as they fought against the Nazis in Europe and the urgent need to stop the ‘Yellow Peril’ in their tracks before they reached Australian soil. Fred was too old to enlist and he became the surrogate father figure to many children in the district as he quietly attended to the many home maintenance tasks for the women whose husbands were away. Mary had to contend with some rationing of food and other daily resources. Otherwise the war had little impact on daily life.
After the war, some fathers did not return. Others returned wounded or emotionally scarred. Anger and resentment towards the Japanese, for their treatment of prisoners of war, and praise for the Americans, for finishing the war, was a common topic in social discussion and newspapers of the day.
Phoebe excelled at school academically and socially. She was a natural leader, sensitive to the needs of her fellow students. As a small school, with fewer than 70 students, all students were required to mix and interact with younger and older children, as well as those of their own age. The teacher would give individual attention to the older students in the classroom, and often relied on Phoebe to assist and supervise the younger students in class. Phoebe won a prestigious scholarship to further her education and, unlike the majority of her girlfriends, she continued to attend school to matriculation (Year 12). Going to high school was exciting and challenging, for the first time in her life mixing with others of similar intellectual capacity and interests. Teachers encouraged her abilities, treated her as an equal to the boys and challenged her to excel. Going to high school was also time-consuming and exhausting. Travel by train from Guildford to Perth Modern School in Subiaco was a slow and tedious journey by steam train, hot in summer and cold in winter. Phoebe often left home just as the sun was rising and arrived home after sunset. She was expected to take her share of the household chores and complete her homework. This left little time to maintain her old friendships and interests. However, she did continue with the repertory club on weekends.
Phoebe matriculated with distinction in English literature, European history, geography, chemistry and mathematics, and was offered a scholarship to the University of Western Australia. However, Phoebe chose a teachers’ training college and, three years later, graduated as a primary school teacher. At 19, her first posting was to a small country town, teaching Years three and four. She shared a house with three other female teachers and became active in the local repertory club. There she met Joseph, then 25, the eldest son of a well-to-do wheat and sheep farmer.
Joseph (Joe) and Phoebe were married two years later and they set up a home together on the farm in a modest newly built house, 100 metres from the main house. The farm was large and prosperous, producing wheat and wool. Ten km of gravel road, and a further 800-metre entry road, separated the homestead from town. Joseph, the eldest child and only son, was destined to take over the farm from his father, in due course. His three younger sisters had married farmers and settled outside the district.
Joe and Phoebe were the perfect couple, well-liked, attractive and deeply in love. However, on the farm, away from public gaze, life was very different. Joe was a strict supervisor with high expectations of Phoebe’s efforts both within the home and on the farm. He discouraged Phoebe from inviting friends to the farm and also from leaving the farm except for essential business. In addition to establishing the gardens, keeping the home spotless and providing well-cooked meals, Phoebe was required to drive the tractors, feed the stock and be a roustabout in the shearing shed. Even while pregnant, her workload did not decrease. At eight-months’ pregnant she took the evening shift to make sure that the wheat crop was seeded before the rains came.
They had been married for three years when twins, Frances and Luke, were born. Tensions between Phoebe and Joe increased. Phoebe was no longer able to continue with all her farming chores, and Joe became angry with her for shirking her responsibilities and spoiling the children. He became very jealous of the attention Frances and Luke were given. Verbal abuse escalated to physical abuse directed towards Phoebe, made worse by Joe’s increasing reliance on alcohol. Joe’s parents were aware of Phoebe’s increasing unhappiness but could not see their son’s behaviour as contributing to the situation.
When the twins were six months old, Phoebe received a telephone call from Mary. Fred, now 78, had had a heart attack and was not expected to live. Phoebe, with the babies, rushed to Perth in time to say goodbye to her father and promise to take care of his Mary. Phoebe stayed in the family home with Mary in the weeks following Fred’s death to support her mother, and assist her brothers in arranging the funeral and settling the estate.
Although this was a sad and busy time, Phoebe became less weary. It soon became apparent that Phoebe was loath to return to Joe and the farm. One evening she broke down and disclosed her unhappiness to her brother Stephen. He was appalled at Joe’s behaviour, so he, with Mary and Jack, encouraged Phoebe to remain in the family home and live with her mother. Mary was experiencing shortness of breath and high blood pressure.
Joe was angry at Phoebe’s desertion. During the acrimonious divorce proceedings, Phoebe was deemed to be 100% to blame for the breakdown of marriage and received no financial support. Because of their young age, the twins were allowed to remain with Phoebe.
With Mary’s support with child care, Phoebe (who had been required to resign from the education department when she got married) sought employment. As a divorced woman, all she could find was part-time relief teaching.
Five years later, after a rapid decline, Mary died of cancer of the bowel and liver. To settle Mary’s will, it was necessary to sell the family home. Phoebe used her part of the bequest to purchase a unit in Coolbellup. The suburb had a similar market garden–urban feel about it. Next to the small block of units, the Boden family, her Italian neighbours, lived on a large block and, in addition to providing Frances and Luke the experience of being part of a large extended family, also kept the small family generously provided with fresh vegetables, fruit and eggs. Phoebe continued her teaching and provided a stable home for herself, Frances and Luke. Phoebe was able to give maximum energy to parenting and work.
For the first time in her life, Phoebe had a period of self-efficacy and autonomy. The life of a single mother was difficult, although the rise of feminism, and changes to family law and social policy, were beginning to destigmatise the experience. The security of home ownership freed Phoebe of immediate financial worries. When her children started school, she was able to combine her roles as single mother and professional woman and increased her working hours. Phoebe became well-known for her in-school drama programmes for primary school children, especially in the areas of language development and social inclusion. Mrs Boden was a loved and reliable backstop on the rare occasions that Phoebe could not be at home on time.
When the twins were 13, Joe demanded that he have contact with the children. Reluctantly, Phoebe sent them to the farm for a two-week stay during the school holidays. Luke settled into the farming routine easily, with a natural talent for stock work. In his eyes, his father was an ideal role model. He wanted to stay. Phoebe and Joe finally agreed that Luke would finish school at agricultural college and on graduation return to the farm. From this point on, Phoebe and Frances saw little of Luke – the occasional affectionate visit, or warmly expressed messages on birthday and Christmas cards and rare phone calls.
Between Frances and Joe, there was an instant and deep antipathy. They did not get on at all; there was much bickering and arguing between them. At the end of the holiday period, Frances vowed never to go back to the farm. Joe disowned his daughter, happy that his son wanted to continue the family tradition on the farm.
Back in the city, Frances thrived, becoming a confident and competent young woman. At 18, when Phoebe was 43, she left home to attend university and live in shared accommodation.
Phoebe enjoyed living alone; she had a satisfying teaching career and spent her leisure time in repertory – and discovered the joy of travel. Her saving and holiday routine became established, embarking on a major trip abroad every three years – to India, Peru, Madagascar, Italy and Finland.
On retirement at 60, Phoebe planned to continue her travels to exciting and out-of-the-way places. Her health was good, rarely succumbing to coughs and colds, although having annoying bouts of urinary tract infections. She had become more sedentary, preferring to read in preparation for her next holiday and watch television. The degenerative changes in her shoulders, knees and hips, as a result of the heavy farm work, became bothersome. She still enjoyed eating and gained weight. When she went for her annual check-up with her GP, he warned her that she had developed hyperlipidaemia and encouraged her to exercise more and reduce her weight. He prescribed cholesterol-lowering medication and a mild analgesic to relieve joint pain, and discussed the possibility of hip replacement surgery in the future.
Phoebe continued to travel; now joining travel groups, and choosing less physically demanding destinations to accommodate her physical abilities. She found companionship among the other tour members and her extensive Christmas card list grew. For her 65th birthday, Frances gave her mother a computer as a means of managing her extensive social contacts and introduced her to email. Phoebe took to the new technology with enthusiasm and quickly became proficient at word processing and emailing.
Gradually her enthusiasm for travel and keeping in contact with friends waned. She lost her car no claim bonus following a series of minor but costly traffic incidents: running into the back of a Porsche at traffic lights; side swiping a four-wheel drive as she backed out of a parking bay; mistaking first gear for reverse and driving into a ditch; and driving over the speed limit on the freeway. Frances was called to reset her computer settings and demonstrate how to complete steps that Phoebe had previously done easily. She began to blame the computer for mistakes that occurred. Plans for her trip to New Zealand became complicated. She had difficulty choosing an itinerary, deposits were not confirmed. Her self-confidence waned. She frequently consulted her daughter, something she had rarely done previously.
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