AACN Issue Bulletin
July 1997

Although the actual practice of pairing providers of different professions into health care teams can be traced to the beginning of the 20th century in the U.S. and Great Britain, teaching them to think and perform as teams didn't emerge until more recently. As early as the 1950s, nursing, medical, and other health professions students were sharing coursework and clinical experiences at such campuses as the University of Washington.

What's new, observers say, is the incentive. Tighter funding supplies, scarcer resources, and more complex health care delivery have given interdisciplinary education new drive as health care projects must demonstrate to federal and state governments, foundations, and other backers that they are making the wisest use of the expertise and dollars at hand. What used to be just a good idea -- pooling the labor and skills of different health professions toward a common goal -- has become, in the eyes of many educators and health policymakers, an essential tool for the times.

Indeed, in a 1993 report calling for major changes in how health professionals are educated, the Pew Health Professions Commission included "interdisciplinary team arrangements" as a core competency providers will need as the new century dawns. Among several federal efforts already in place, the Department of Health and Human Services in April awarded a three-year grant to the Association of Academic Health Centers to establish a center to develop model interdisciplinary curricula in the health professions and promote delivery of community-based services, "particularly in underserved areas," an AAHC statement says. A 1996 survey by the organization, which represents the health complexes of the nation's major universities, found that more than half its member institutions had designated staff to coordinate interdisciplinary activities on their campuses.

Pointing to a "dearth" of substantive health care literature on interdisciplinary education and practice, the American Association of Colleges of Nursing (AACN) has urged nursing schools to provide students with interdisciplinary experiences that enhance the practice of each profession. Unlike multidisciplinary training, where several professions work in parallel and often with separate goals, interdisciplinary education coordinates health care and other fields in collaborations that include joint planning, decisionmaking, and responsibility.

AACN issued its call amid the health industry's accelerating move to scrutinize costs and maximize efficiency by shifting "from an environment of competition to one of collaboration," AACN explained in a recent position statement. "The complex health needs of society exceed the capability of any single discipline," the Association said, noting that interdisciplinary education is "a vital step in the movement toward coordinated systems of efficiently delivered, cost-effective, high-quality health care."

Not every health care problem needs an interdisciplinary approach. As Patricia Maguire Meservey, director of the Graduate Medicine and Nursing Education Initiative at Northeastern University, warned a conference of health professions educators in Washington, D.C., recently, "Don't force feed it." Still, she says, as managed care dominates, seamless provision of care across disciplines becomes essential, a change that will compel all providers to know how to practice as part of an interdisciplinary team or at least how to draw on the resources of other professions. Moreover, as nurses, physicians, and other new recruits take more than a year to learn the workings of managed-care organizations that hire them, it strengthens the case that providers will need to adopt interdisciplinary mindsets as students, "not when they begin to practice," Meservey adds. In her view, interdisciplinary practice works best when the patient care required is complex, the need and role for each provider are clear, and when certain conditions that would otherwise thwart collaboration -- such as regulations covering financial reimbursement for each discipline -- are loosened. Such openness also has been urged by a panel of the National League for Nursing, which noted in a recent consensus paper that "interdisciplinary education is better served by a health, rather than a medical model."

As late as 1995, when AACN issued its policy statement, interdisciplinary experiences in the classroom or at clinical sites were by far the exception for nursing, medical, and other health professions students, not the rule. Within nursing, a host of new efforts are creating models of collaboration in a variety of forms. Several, like the graduate nursing school at the Uniformed Services University of the Health Sciences -- the nation's only federal medical university which prepares advanced practice nurses for the military -- do joint curriculum planning and share joint faculty appointments with other departments such as physiology, anatomy, pharmacology, and family practice.

But some programs even stretch beyond the boundaries of health care. The Professional Schools' Neighborhood Clinic, a combined endeavor of the Yale School of Nursing and other departments across the university, joins students from seven different graduate and professional schools to address the future of neighborhoods in cities. Students and faculty from nursing, architecture, management, law, public health, forestry and environmental studies, and Yale's Child Study Center work with a New Haven neighborhood in implementing the neighborhood's action plan.

"Students need to know how an environmental impact statement, business plan, or community assessments relate to the task of community development, but not every student will be taught how to develop an environmental impact statement, business plan, or a community assessment," explains Donna Mahrenholz, director of Yale's Nursing Management and Policy Program. Though collaboration across professions is one goal, the clinic also aims "to generate a deeper, more unified, more concrete, and more practical understanding of the prospects for urban revitalization than is available at present," Mahrenholz says.

One of the biggest efforts -- seven projects funded in 1992 by the W.K. Kellogg Foundation -- has sought to boost the number of primary care providers by establishing academic primary care centers in localities from rural Michigan to Atlanta's inner city. Funded at $6 million each, the programs are partnerships of health professions schools, local governments, and area health centers aimed at shifting health professions education out of hospitals and into community-based sites that provide primary care training and services in an interdisciplinary approach. Among the current projects at one of the Kellogg sites -- East Tennessee State University -- is the teaming of family practice residents, master's-degree family nurse practitioner students, and graduate public and allied health students in interdisciplinary experiences in rural, underserved communities.

Meanwhile, nursing schools at Ball State University in Indiana and the University of North Carolina-Charlotte have paired with their campuses' architecture schools to teach courses on nursing home design. At Villanova University's College of Nursing, where advanced nutrition concepts are included throughout the curriculum, interdisciplinary experiences are provided by a faculty member, who is also a registered dietitian, during her visits to training sites in hospitals and home care agencies. Nursing students at the suburban Philadelphia school are required to complete a nutrition assessment on their patients and present findings in a post-conference with the clinical group and nursing and nutrition professors.

Elsewhere, offerings range from a bioethics course taught jointly by the Schools of Nursing and Medicine at Georgetown University to the University of Virginia's recent course on wound healing co-taught by nursing faculty and the Department of Biomedical Engineering. UVA's School of Nursing, together with the university's new Department of Health Evaluation Sciences, is also developing courses to bring a multidisciplinary approach to managing large health care data bases. Further west, a class on multiculturalism and health care -- co-taught by a nursing faculty member and a campus anthropologist at Indiana University last summer -- looked at the nation's changing demographics and the need for health care that is culturally appropriate. "My caveat to students is that most of the world is not white, most of the world does not speak English, most of the world is not Christian, and most of the world does not believe in the theory of germs," explains Barbara Ann Ross, the course's nursing instructor and director of IU's nursing programs in Columbus.

Nursing students at Wilkes University take up to six credits in core interdisciplinary studies. One class, ICS 210: Marx, Darwin, and Freud and co-taught this spring by faculty from nursing, history, and psychology, aimed at developing students' critical thinking and communication skills. Planners of the course, which was billed as "writing intensive," sought to help students in discussions, readings, and written papers to "discover how the ideas of these three thinkers influence us today," notes Ann Kolanowski, chair of the Department of Nursing at the Wilkes-Barre, Pennsylvania school.

While the skills needed for collaboration -- negotiation, team building, joint decisionmaking, and problem solving --are learnable, "the content and methods to best teach these skills are rare in current curricula," AACN's position statement points out. Still, the foundations for interdisciplinary education not only can be laid at the outset of graduate training, but are best introduced early in the liberal arts core of undergraduate studies, AACN urges.

Recent progress has been significant. Last fall, Philadelphia's Thomas Jefferson University established a core interdisciplinary curriculum required of all health professions undergraduates, who include students from nursing, occupational and physical therapy, diagnostic imaging, and laboratory sciences. Coursework focuses on health care systems, research, and data management, and puts students in small teams to devise interdisciplinary care plans. At Boise State University, all nursing, radiological science and respiratory therapy students take an interdisciplinary patient care skills course taught by faculty from each discipline, while at the University of New Mexico College of Nursing, grant programs teach team building as students from several disciplines meet each week to develop case studies, then practice together for eight weeks in the summer during clinical rotations in a rural area.

Other changes are happening university-wide. At the University of Florida, deans of the colleges of health professions, nursing, medicine, dentistry, pharmacy, and veterinary medicine put forward a joint legislative budget request this year to enhance interdisciplinary education. "The initiative received $1 million, and we are in the process of determining how the funds will be used to support both increased enrollment in selected health professions -- nursing is one -- and the further development of interdisciplinary teaching," says nursing dean Kathleen Long.

Meanwhile, as part of a new strategic plan announced in 1992, the University of Texas Health Sciences Center in Houston is creating interdisciplinary clinical experiences for students in its schools of nursing, medicine, dentistry, allied and public health, and biomedical sciences. The program includes an elective course currently offered to all students, Frontiers of Interdisciplinary Health Care, that emphasizes group interaction and gives students opportunity to "develop composite approaches to health care problems," says Mary Ann Neeley, assistant professor at the School of Nursing. In Washington, D.C., students at Howard University's colleges of nursing, medicine, pharmacy, dentistry, and allied health take a health care ethics course taught by faculty across schools and do problem solving in interdisciplinary teams. Georgia State University's School of Nursing not only has created an interdisciplinary student council, but offers interdisciplinary teams of undergrads the opportunity to assess a community health problem and present testimony at the State Capitol on health policy changes needed to address it.

At the graduate level, Montana State University continues work towards a planned fall 1998 opening of an interdisciplinary program that will award a master's degree in health administration. The joint program will be administered by the College of Nursing in conjunction with the College of Business and College of Education, Health and Human Development. In addition, research tracks are witnessing their own interdisciplinary evolution. All doctoral students at the School of Nursing at the University of North Carolina - Chapel Hill, for instance, are required to take at least 15 credits of coursework in other departments and must have one member of their five-person research supervisory committee come from another department. Meanwhile, community health research by collaborations among the University of Hawaii's professional schools -- nursing, medicine, social work, and public health -- has led to new services, such as resource lists for pregnant teens and a substance abuse prevention curriculum for elementary schools which is being used as part of a statewide program.

Roadblocks remain, however. Besides needing to resolve scheduling and timing differences throughout an institution's various colleges, trying to distribute tuitions and credits fairly across programs, and finding space for new electives in already full programs, schools must grapple with deeper issues. "There is incredible territoriality that is difficult to overcome. In some instances, we just went ahead and started initiatives under nursing, otherwise they would have died at the table," says Pamela Webber, dean of the Division of Nursing at Shenandoah University. Part of the solution may be in the "Frontiers" course at the University of Texas. "The proposed clinical site is also a newly opened health care facility where territory has not been established, explains Mary Ann Neeley. Moreover, as some community-based programs also become community-driven, concerns over philosophy have emerged. "Direct-care providers, including some grad nurses and MPH students, as well as medical residents, are uncomfortable with a philosophy that puts the community in the driver's seat" in determining health care priorities, says Wendell Oderkirk, associate professor at New Mexico State University's Department of Nursing.

While few long-term studies have looked at education's effectiveness at generating interdisciplinary practice, "it's a self-evident truth" that practitioners trained that way are more open to new approaches, says DeWitt C. Baldwin, Jr., professor emeritus at the University of Nevada Medical School and scholar in residence at the American Medical Association. In areas such as geriatrics, comprehensive team care has resulted in lower mortality, fewer hospitalizations, shorter hospital stays, fewer drug prescriptions, and greater satisfaction among patients and caretakers, Baldwin notes in a recent review in the Journal of Interprofessional Care. In Massachusetts, Worcester-based Fallon Healthcare System, an HMO, found that the average cost to care for nursing home patients was 42 percent lower when care was provided by a team of a physician and geriatric nurse practitioner than by a physician alone. Costs were kept trim largely because patients received "good episodic care" by NPs on site and were followed so closely by the teams that fewer referrals to specialists were needed, according to a recent study in HMO Practice.

"The best example of collegiality I have seen for years is the cheering of the nursing students when their classmates from medicine received their hoods at graduation last week," says nursing dean Joellen Edwards of East Tennessee State University. Still, other watchers say a sea changes is needed before interdisciplinary training can realize its full rewards. "Most nursing faculty 'allow' for the ideas of [such fields as] medicine and social work after they are fully assured the student knows nursing," explains Eileen Zungolo, dean of the College of Nursing at Northeastern University. But, she adds: "If we are to develop ways of functioning that are truly interdisciplinary, then we will need to allow our students to formulate a 'vision' of nursing as an interdisciplinary craft. In so doing, they may come up with a whole new idea of what nursing practice is -- we should not be afraid to let that happen."

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