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A Working Relationship

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Seattle

Dana Doering had high hopes when she signed up for a pilot program here at the University of Washington that teaches professionals from different disciplines how to work together.

Doering, a nurse practitioner with a speciality in children and adolescents who is working on a graduate degree, was looking for ways to team up more effectively with educators, community members, and other professionals. The confidence and skills she has gained from the program--which combines academics and community work--are valued by her work colleagues. And she has ample opportunities to use them in her private therapy practice and her work at a children's hospital. "Now that I know what I know," she says, "it would truly be malpractice for me to try to work with a child in isolation."

Despite the program's good intentions, though, she sometimes gets mixed messages about the value of straying beyond one's professional boundaries here at the university. When an assignment in one of her nursing classes called for designing an intervention program for children, for example, it was only natural for Doering to propose linking up with students from schools such as education and economics.

But her professor wasn't buying it. Her attitude was "'Oh, you want someone else to do your work,"' Doering recalls. "It was real discouraging."

Doering's experience suggests that much remains to be done to infuse the spirit of collegiality that this program tries to foster into the ethos of the entire university. The problem is not unique to the University of Washington. To address it, institutions of higher learning throughout the country are testing models of what's known as interprofessional education.

The movement rests on the assumption that people who provide services to children and families can't do an effective job if they address only the piece of the problem that fits their training. Experts in education, health, and human services have been calling for collaborative approaches for years. But the schools that train these professionals have very different traditions, jargon, and requirements.

"What this project is trying to say is that we have to start further back in the process to get professionals to talk to each other," says Allen Glenn, the dean of the school of education at the university.

The Training for Interprofessional Collaboration program, now in its fifth year, draws its faculty and students from the graduate schools of education, public health and community medicine, nursing, social work, and public affairs. Students who enroll in the six-month program participate in a series of seminars and a team project in the community. They must also fulfill the requirements of their own graduate schools. Although the program doesn't confer any special certification, students earn six credits that can be applied toward their graduate degrees. On top of their graduate requirements, students devote five or six hours a week to the program over two quarters.

Some institutions, such as Ohio State University, have been promoting collaborative approaches for 20 years. But for the most part, the movement is relatively new. A 1995 Portland State University study identified 25 campus-based programs nationwide--most only a few years old--that offer some element of interprofessional training, mostly at the graduate level. Many are fairly small and targeted mainly to professionals in a given field, such as mental health. But some newer programs emerging on the scene are trying to bring students and faculty together across a wide span of disciplines not just for a single course but to break new ground in the delivery of services to children and families. A national network of experts, meanwhile, is working to gain more support for these programs from funders and accrediting bodies.

The University of Washington's program, which places more emphasis on the mechanics of working in groups than some of the emerging programs, is one of the best-known and most generously backed by foundations. The program has had a budget of about $500,000 for each of the past four years; its budget this year is $325,000. The program's major funders have been the Stuart Foundations, the Pew Charitable Trusts, and the DeWitt-Wallace Reader's Digest Fund.

Most of the program's grants are scheduled to run out in June, however, and pressure is mounting to contain the costs and faculty time associated with the program, which serves about 27 students a year and currently involves eight faculty members. The program is entering a new phase now as its founders seek ways to scale back the pilot while incorporating its philosophy throughout the university.

"The challenge for us," says Glenn, "is how do we take the core of this project and infuse it into the training of all principals, counselors, teachers, public-health people, and nurses?"

Even for the faculty members closest to the program, it's taken five years to smooth over the conflicts and contrasting rhythms that go with the territory when people from different schools of thought come together.

Some accreditation standards also discourage collaboration. That's especially true in social work, where standards restrict students from some courses or field placements not supervised by licensed social workers.

Other interventions will be needed, meanwhile, to retrain people already working in schools and social agencies to build a climate for collaboration.

"Something we know about interprofessional work is that it is very subject to the working conditions one is in," says Mike Knapp, an associate professor of education here. "One needs more than a well-trained individual to make a situation really function."

Rick Brandon, the faculty member who got the interprofessional-training program off the ground, moved here in 1989 after a long stint as the staff director for the U.S. Senate Budget Committee.

Brandon, now an associate research professor at the school of public affairs, switched coasts to "unhook from the political scene" and raise his children in a more hospitable setting. But he didn't leave behind the lessons he learned on Capitol Hill. Poring over budget laws convinced him how fragmented federal human-services programs are and "how difficult it is to get any relationship between programs," he says. "I was appalled by how many people writing national legislation had no idea how the laws they wrote translated at the community level."

Brandon spent his first couple of years in Seattle visiting schools, day-care centers, and nursing homes for a variety of research projects on state and local policy issues. Everywhere he went, he says, "I found people creating collaboration from the ground up." At the university, too, he found disparate groups of people involved in community projects designed to improve children's services. "I saw the opportunity to come up with something really striking if we brought all these people together."

Brandon's first step was to create a Human Services Policy Center to help faculty and community members involved in collaborative projects. But Brandon's colleagues in the community let him know that wasn't enough. "People said that sounds fine, but the university is the problem," he recalls. "You are training people to think differently and work differently."

By the time they reach the program, some of the students may have already formed their own biases. The average age of enrollees is 28, and many have been working in their fields for several years. A recent discussion after the opening lecture in a colloquium series on collaborative theory illustrates students' search for common ground.

An education student who teaches at a nearby school worries aloud that the added pressure on schools to address social problems will cut into his teaching time. "Other professionals feel that stress, too," counters a pediatric nursing student who tells of a pediatrician friend who had seen 58 patients in one day. He also mentions the overwhelming caseloads many social workers face. The end result is poor results for children, he says, and the issue for everyone is "how do we learn to produce different outcomes."

One social-work student describes a peer-mediation program she helped launch at a local school as an example of how other professionals can support teachers. The pediatric-nursing student tries to shift the focus from schools alone. "We should be discussing the health of the community," he says. A student who serves on a local school board brings it back, though, by insisting that teachers will have to change to respond to an increasingly volatile student population.

"The hope for that kind of change is in you," says Sue Lerner, a school administrator who supervises the program's community projects in her district.

Lerner, the director of educational support and human services for the South Central school district, has been involved in a number of efforts to link community groups with the schools in Tukwila, a suburban community facing many of the same social problems as Seattle.

Last year's students helped lay the groundwork for a community-advisory committee to offer support and ideas for new school-community projects, such as a campus-based family center. They also wrote a grant for a VISTA volunteer who could link up with local service providers to help the community group carry out its ideas.

Lerner admits, though, that it's taken several years for the student projects to bear fruit. The first school site the students paired up with--the Meany Middle School in Seattle--was so riddled with personnel conflicts and staff turnover that the district closed it down and is completely revamping it.

The first students placed in Tukwila, meanwhile, did a lot of valuable community networking but had trouble rallying around a concrete set of interventions.

Often, students set out with unrealistic expectations. "They start out great guns thinking they are going to save this community," Lerner says. "No matter how much you tell them it's going to be difficult, they are still disappointed" by the limitations that unfold.

Nathalie Gehrke, a professor of education with the program, recalls that in one of the early community projects she helped lead, students resisted her entreaties to bring more teachers on board until they heard the same message from a community leader.

"One of the things you have to become toughened to is the anger and frustration of students" when projects flounder, says Gehrke. "They don't realize that this is part of the difficulty of collaboration--they want to find someone responsible."

Doering, for one, says she expected that "anyone who would choose to be part of a collaborative project would be a real 'point person."' But the assumptions people brought with them from their fields got in the way, she says, and "some needed to be pushed to experiment."

Lerner describes one student who was wary about trying to track down hard-to-reach families for a community survey. But the group prodded her, Lerner says, and the experience "opened up her eyes."

Students also get a reality check when their plans go awry, notes Craig Shimabukuro, the project coordinator of the Mutual Partnerships Coalition, a neighborhood group that has worked with students. Last year's students had to shift gears when a youth group the coalition had planned a project around backed out. "It was a great piece of learning, because this kind of thing happens all the time," says Shimabukuro.

The group eventually formed a partnership with Seattle's Pratt Fine Arts Center that brought community residents of all ages together for art classes and culminated in an exhibition and community health fair.

Ron Yu, a student who participated in that project and is hoping to put his skills to use with a joint master's in education and business, says it was frustrating having to spend so much time learning to work together. "In the end, though," he says, "what I learned was that all the time we spent on group process really did assist us in getting the project off the ground."

To gauge how well students apply these lessons to their work, faculty members have begun compiling data on its graduates.

Knapp of the school of education cites the example of a police detective who has earned high marks for his emphasis on collaboration in a management fellowship with the National Institute of Justice. He tells of another student in the health field, though, who has not found a welcome climate for collaboration in the medical hierarchy she works in. But she's using her skills in other ways, like volunteering at her son's school. "She knows a lot about how to get different elements of the community together, which is something the principal wanted but didn't know how to do," Knapp explains.

This year's students are eager to find ways to spur teamwork in their own milieus.

"In my profession, a lot of programs and committees get started and then deflate," notes Carol Christensen-Boyt, a nurse manager in a clinic for AIDS patients at Seattle's Harborview Medical Center. "People come in with ideas, but they're not able to gather together and formulate a vision."

Tracy Beyer, an education student who is also the director of development for the university's school of nursing, is interested in partnerships between businesses and higher education that can bring new expertise and services to the community. She's excited about working on a project at the Ida Culver House Broadview, a privately owned retirement community. "This is an opportunity for our faculty and students to gain practice and access to a research population, while Ida Culver receives the benefit of the skills of the top-ranking nursing school in the country," she says.

As a single mother of three young children, Beyer understands how hard it is for many parents to negotiate schools and social-service agencies to meet their families' needs. With so many students juggling work, academics, and families, she says, "you feel the need to make every meeting count because it's so difficult just to get there."

A number of students, in fact, do drop out due to scheduling conflicts. Between student orientation in October and the first colloquium session in January, enrollment this academic year dropped from 47 to 27, which is fairly typical. Last year, which had the largest enrollment, 37 of 47 who started the program completed it.

While the community teams generally involve six to 12 students, the drop in numbers this year leaves the Ida Culver site with only two. So the staff and students have agreed to change the format for that group from a collaborative project to independent study work that will require less faculty time.

That shift in plans gets at the crux of what has become one of the biggest dilemmas for Brandon and his colleagues--how to justify devoting so much faculty time to so few students.

The steering committee that governs the program is trying to get it listed as a permanent course in each of the schools. But it is also looking at other less costly ways to foster interprofessional training. One option it's exploring is how to consolidate similar courses the different schools offer--from statistics to organizational theory--and teach them from an interdisciplinary perspective.

Ted Teather, an associate professor of social work, warns the group to anticipate that turf issues are apt to surface in any attempt to reshift faculty course loads. That kind of effort "would identify and run smack into the barriers of collaboration," he says.

The deans from the five schools involved have put their support behind the interprofessional-training program. But they worry about its long-term feasibility.

"We can't afford the luxury of that many faculty involved," says Nancy Hooyman, the dean of the school of social work. "Yet, without it, the program would lose its distinctive aspect."

While she favors trying to build more opportunities for collaborative work into her school's curriculum, Hooyman points out that social-work accreditation requirements are so numerous that "interdisciplinary seminars will always be viewed as an elective."

The standards reflect an increasing degree of specialization to treat a wide range of family-risk conditions, from AIDS to teenage pregnancy.

"The heart of the problem with the accreditation standards is that they are very segmented and categorized," observes Hooyman. The effort under way at the university, meanwhile, "is trying to break down those barriers."

Besides convincing national accrediting bodies to rethink some of their requirements that hinder collaboration, she says, "a crucial next step is getting more faculty to buy in."

Margaret Gordon, the dean of the school of public affairs, also stresses the need to find more cost-effective ways to support interprofessional education. But the program's national recognition and high approval ratings among students make it worth pursuing, she says.

"A worst-case scenario would be that when the funding ends, people go back to doing what they were doing before," reflects Glenn of the education school.

The leaders themselves, in fact, had to step back and bring in outside mediators to help them work through some of their own problems communicating and sharing power.

"I believe we are together five years later and still like each other and respect each other because we took some time and used our resources to focus on our own collaborative process the same way we expect others to," notes Gehrke.

The effort has also won the support of the university's new president, Richard L. McCormick. McCormick, who became president last fall, is interested in building stronger links between the university and the community. A new task force Gordon is chairing, for example, is exploring how the university can serve the community better and build more incentives for such service into its reward system.

The program may need to make its mission to the community clearer, however, if it is to make a significant contribution.

Lloyd Shelley, a senior citizen recruited to work on the art project with UW students, says the program taught students valuable lessons and benefited the community. But he's skeptical of any enduring effects. "Once the project was over, the community was right back where it was," he says.

To help them gauge how students, faculty, and community workers view the program, its leaders have developed an extensive evaluation component. Information derived from the evaluation's detailed interviews and reports has spurred several changes. This year, for example, all the colloquium sessions are taking place before students start their community projects so they won't be sidetracked. The faculty have also turned over more authority for supervising the student projects to community site leaders.

To ease the time constraints on faculty and students, meanwhile, the steering committee is looking at ways to refine the program next year so that students with packed schedules can do some form of community work without having to commit to projects as time-consuming as those in the past.

Brandon and others are pursuing more foundation funding and applying for federal aid. And in the spring, the national network of experts promoting interprofessional education will seek support from a large group of funders at the annual conference of the American Educational Research Association.

The network's leaders agree, however, that interprofessional training won't have a lasting effect without a well-defined mission tied to better outcomes for families and communities.

"A lot of this interprofessional work needs more clarity about what is going to be better as a result of our work," notes Katharine Hooper-Briar, the chairwoman of the department of family studies and social work at Miami University in Oxford, Ohio. She also argues that parents and other community members must play pivotal roles in planning and teaching these programs. "If we are not accountable to the consumer, interprofessional collaboration alone will not guarantee better outcomes."

Hal Lawson, a professor in the school of education and allied professions at Miami University, stresses that these programs should be grounded in community interventions that have proved successful in boosting family well-being.

But the University of Washington's effort, Lawson says, has made an important contribution. "They've done a better job than anyone in helping us understand what it takes to help people from diverse fields to collaborate," he says.

Brandon agrees, too, that the program should be viewed as only one strategy in an emerging field that needs much more experimentation. "The worst thing would be for people to say prematurely that this is the way to go," he says.

Universities looking for new angles might do well to take a lesson from Doering, who has learned that much can be accomplished by taking small steps toward collaboration.

Every faculty member, she says, could reinforce the value of collaboration: "All it would take would be introducing the subject and encouraging the process."

Communities is being underwritten by a grant from the Annie E. Casey Foundation.

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