In the field of mental health care, professionals from different backgrounds work in teams to plan, deliver, and evaluate interventions and care (1). Interprofessional practice occurs when multiple health workers from different professional backgrounds work together with patients, families, carers, and communities to deliver the highest quality of care (2). Increasing evidence demonstrates that collaborative mental health care can improve the quality of mental health services and contribute to positive patient outcomes (3, 4). Collaboration can improve access to mental health care, streamline intake procedures, improve coordination between mental and primary health care, and facilitate knowledge transfer (5).

Interprofessional education (IPE), is defined as students (or practitioners) from two or more professions learning about, from, and with each other (2). It is recommended at both pre- and post-licensure levels as a key means to promote and foster collaborative mental health practice (6, 7). Emerging evidence suggests that pre-licensure IPE can contribute to raising knowledge of roles and responsibilities, the enhancement of students' attitudes toward each other, enhanced interprofessional communication, and better preparation for interprofessional practice (8). Reeves' (9) review of post-licensure IPE in adult mental health reports a number of positive outcomes, including an increase in use of practice guidelines, the development of better support systems for staff, and cost-savings resulting from improved collaboration. Other studies have demonstrated the effectiveness of IPE experiences in increasing knowledge and skills in working as a team and mental health collaboration, and improving outcomes for patients with severe mental health problems (3, 10).

Memorial University, the only university in the Canadian province of Newfoundland and Labrador, offers programs leading to professional degrees in medicine, nursing, pharmacy, social work, and, since 2009, clinical psychology. The IPE Program at Memorial University initiated a comprehensive IPE curriculum-development project in 2005, with the goal of expanding and promoting IPE activities in both education and practice settings. This article summarizes how IPE in collaborative mental health practice has been integrated into the pre- to post-licensure continuum of medical education at our institution and its reception at each stage of professional development.

The Memorial University Interprofessional Education Curriculum Framework (11), encompasses key curriculum components across the broad developmental stages of a health professional (12). Collaborative mental health care was integrated into IPE activities at all stages along the pre- to post-licensure educational continuum. At the Pre-Clinical Stage the learner has limited clinical exposure, which restricts knowledge of the realities of professional roles and practice situations (12). This stage of learning typically occurs in North American medical schools in the preclinical, undergraduate phase. A series of IPE modules on health-related topics, including a Collaborative Mental Health Practice IPE Module, was introduced across undergraduate curricula and involved students from at least two professional programs. These modules are affiliated with existing courses within the curriculum structure of each academic unit and scheduled in a common time-slot.

The Clinical Novice developmental stage involves exposure to clinical learning in practice settings (12) and, for North American medical schools, refers to the clinical component of undergraduate medical education. The mandatory 2-month psychiatry rotation was selected for implementation of Interprofessional Practice-Based Learning (IPPL). The IPPL curriculum includes workshops, printed guides on interprofessional practice, and a Competency Reflection Journal (CRJ), organized around the CanMEDS Collaborator Role competencies (13). The CRJ is designed to stimulate discussion between the precepting resident and clerks about the barriers and enablers to collaboration in the psychiatry settings in which they are learning.

As learners develop comfort in their own professional role, they make the transition from clinical novice to the Probationer Stage. The probationer is a senior trainee familiar with the clinical environment in general, but not yet fully trained (12). A 1-day Interprofessional Collaboration Workshop has been introduced in partnership with a local regional health authority (14), and participants include nursing, allied health staff, and psychiatric postgraduate residents. A main emphasis of the learning is on developing CanMEDS Collaborator Role competencies (13). Learning methods include a combination of didactic presentation, small- and large-group discussion, videos, and reflective case-study exercises.

The Practitioner Stage includes those professionals who are fully qualified to practice independently in a clinical/practice environment. The Rural Mental Health Interprofessional Training Program (RMHITP) is a post-licensure IPE program that uses a blended learning approach combining face-to-face learning and videoconferencing (15). The main purpose of this program is to develop collaborative mental health practice skills and enhance confidence in providing specific mental health interventions. A total of 10 modules were offered across six rural communities, with two of these modules held face-to-face and the remaining delivered by videoconference. The videoconferencing sessions included didactic presentations on the various interventions and skill-building, case-based exercises.

A systematic evaluation of IPE activities was conducted utilizing a combination of evaluation study designs, including: pre-test–post-test control group, one-group pretest–posttest, and one-shot case study. Participant satisfaction, attitudes toward teamwork, and self-reported teamwork abilities were key evaluative outcome measures. All students completing the Collaborative Mental Health Practice IPE Module between 2006 and 2009 were invited to complete a student evaluation survey (e.g., one-shot, case-study evaluation design). The Student Satisfaction section comprised 15 five-point Likert scale items (1: strongly disagree to 5: strongly agree). Respondents were asked to rate their level of satisfaction with the module and the extent to which the module had enhanced their understanding of the subject area, interprofessional teamwork, their own role, and that of other professions.

Evaluation of the Interprofessional Collaboration Workshop included a one-group pre-test–post-test study design (14). Participants were asked to complete a pre-workshop survey immediately before each workshop, a satisfaction survey after each workshop, and a post-workshop survey was administered via telephone 6–8 weeks after workshop completion. The satisfaction survey consisted of 12 five-point Likert items (1: strongly disagree to 5: strongly agree) and open-ended questions concerning likes/dislikes, changes/improvements, and commitment to change. Both the pre- and post-workshop surveys included the Attitudes Toward Interprofessional Health Care Teams scale (16), consisting of 14 five-point Likert items (1: strongly disagree to 5: strongly agree) assessing the quality of care and teamwork of health professionals, and the Perceptions of Effective Interprofessional Teams scale (17), consisting of 17 five-point Likert items (1: poor to 5: excellent) measuring self-reported ability to function as part of an effective team. Both scales have demonstrated strong internal-consistency reliability, with a Cronbach α of 0.83 (Attitudes Scale) and 0.95 (Perceptions Scale), and previous research has demonstrated the construct validity of the adapted scales (18).

Evaluation of the Rural Mental Health Interprofessional Training Program utilized mixed methods, including pre- and post-training surveys, interviews, and focus groups with participants 6–12 weeks post-training. The pre- and post- surveys measured attitudes toward interprofessional collaboration in mental health care and perception of self and others in collaborative mental health care. The attitudes scale consisted of 14 five-point Likert items (1: strongly disagree to 5: strongly agree) and was adapted from the Attitudes Toward Interprofessional Health Care Teams scale (16). The Perception of Interprofessional Collaboration scale consisted of 16 semantic-differential items and was adapted from the Interdisciplinary Team Weekly Inventory scale (19). Participants were also asked to complete a feedback form after each session to rate their level of satisfaction on a Likert scale from 1 to 5 (1: very dissatisfied to 5: very satisfied).

The impact of the IPPL intervention (e.g., workshops, guides, and CRJ) is currently being evaluated and will be presented in a future article.

Pre-Clinical Stage: Collaborative Mental Health Practice IPE Module

The overall participation rate in the IPE Mental Health module ranged from 93% to 100% across professions, with the majority of professions reporting 100% participation for undergraduate students between 2006 and 2009. The mean response rate to the satisfaction survey for the 4 years was 90.75% (range: 84% to 98%). Ratings for the 2008 and 2009 version of the module reflected a significant (p<0.0001) increase in satisfaction across professions as instructional changes had been introduced. For 2009 satisfaction ratings, 98% agreed/strongly agreed that the learning experience had enhanced their understanding of interprofessional teamwork, and 90% agreed/strongly agreed this learning experience had enhanced their understanding of the mental health subject area. Overall, 97% of respondents agreed/strongly agreed that this module was a meaningful learning experience. The mean scores of each of the participating academic units were compared across the 4 years, using an ANOVA. In both 2006 and 2007, nursing, social work, and pharmacy students reported significantly higher mean scores than students in medicine (F [3, 204]=14.23; p<0.0001 and F [3, 167]=13.27; p<0.0001, respectively]. In both 2008 and 2009, however, students did not differ significantly in their mean satisfaction levels across academic units.

Probationer Stage: Interprofessional Collaboration Workshop

A total of 39 professionals participated in the two offerings of the interprofessional collaboration mental health workshops. Overall, participants expressed high levels of satisfaction (mean: 4.18/5.00); 90% agreed/strongly agreed that the workshop enhanced understanding of interprofessional collaboration, and 85% agreed/strongly agreed that they would recommend the workshop to others. Pre- to post- responses to the Attitudes Toward Interprofessional Health Care Teams scale (16) were analyzed by paired-samples t-test. There were no significant differences from the pre-survey (mean: 4.09/5.00; standard deviation [SD]: 0.34) to the post-survey (mean: 4.10/5.00; SD: 0.33; t [15] = –0.142; NS. Pre- to post- responses to the Perceptions of Effective Interprofessional Teams scale (17) were also analyzed by paired-samples t-test. There were no significant differences from the pre-survey (mean: 3.67/5.00, SD: 0.52) to the post-survey (mean: 3.77/5.00; SD: 0.61; t [15] = –1.040; NS). At post-workshop follow-up (response rate: 100%) participants did report practice changes in team meetings and rounds, and being more aware of professional roles with regard to patient referrals.

Practitioner Stage: Rural Mental Health Interprofessional Training Program (RMHITP)

Satisfaction ratings (response rate: 89.1%) for the sessions were very high across all topics and all aspects of the presentations (mean: 4.54/5.00). The highest average rating was for “opportunity for interaction provided” (mean: 4.70/5.00), and the lowest average rating was for “technical factors; signal delay” (mean: 4.27/5.00). The pre–post questionnaires were analyzed with paired-samples t-tests, and results revealed a statistically significant improvement in attitudes toward interprofessional collaboration in mental health care from pre-test (mean: 4.04/5.00; SD: 0.415) to post-test (mean: 4.21/5.00, SD: 0.377; t [48] = –3.02; p=0.004. The η² statistic (0.16) indicated a large effect size. There was no significant change in perceptions of collaboration in mental health care, pre-test (mean: 5.85/7.00; SD: 0.684) to post-test (mean: 5.99; SD: 0.702; t [48] = –1.63; NS. Qualitative data analysis revealed a reported increase in interprofessional referrals, interagency linkages, and collaborations (20).

IPE in collaborative mental health practice was well received at both pre- and post-licensure levels. At the pre-licensure level, students reported greatest satisfaction with the use of standardized patients (SPs) as a learning method. This finding supports previous research that has also highlighted the value of SPs in interprofessional learning (8). Post-licensure IPE in mental health was also offered with a high level of satisfaction even when using distance-learning technology (21), an important consideration for IPE delivered to professionals in rural and remote locations.

The results from the evaluation of the interprofessional collaboration workshop (Probationer Stage) suggest that a possible ceiling effect may have influenced the study findings. However, a follow-up post-workshop survey of participants did identify a number of areas of self-reported change in collaborative mental health practice. Similarly, RMHITP participants' self-assessed team skills did not increase significantly and also likely reflected a ceiling effect of high levels of self-assessed skills among seasoned practitioners. A lack of perceived change in self-assessed teamwork abilities at the probationer and practitioner stages may be attributable to the difficulty that trainees and health practitioners often experience in identifying their own weaknesses and the tendency to overestimate one's abilities (22).

Several limitations to the evaluation findings reported in this article should be noted. The majority of the findings are largely based on satisfaction ratings and self-reported measures of attitudinal or practice change. Although measuring satisfaction is only the first step in a comprehensive evaluation, it is a critical one. Completion of the attitudinal and satisfaction surveys was voluntary, and it is possible that the opinions reported may not be representative of all participants from each cohort surveyed. There were no true experimental control groups across the programming levels, and this was a limitation to the evaluation study designs used. Future research should consider how IPE at pre- and post-licensure affects student, trainee, and practitioner abilities and brings about behavior change in collaborative practice, and the ultimate impact of such change in mental health practice settings and on patient outcomes. The study also reports on the experiences at only one university.

The findings from our evaluation and experiences with implementing the reported IPE curriculum model in collaborative mental health suggest that learning experiences from pre- to post-licensure levels are feasible and valuable, and mental health settings offer practical and useful learning experiences for students and practitioners in interprofessional collaboration.

This project was funded through the Interprofessional Education for Collaborative Patient-Centred Practice (IECPCP) Initiative, Health Human Resources Strategies Division, Health Canada.