ICLE Interprofessional practice education : is the ‘ interprofessional ’ component relevant to recruiting new graduates to underserved areas ?

Introduction: Globally, there has been a serious health human resource (HHR) shortage for underserved populations in and outside of urban centers. This article focuses on practice education, specifically interprofessional (IP) practice education, and its impact on recruiting new health sciences graduates to populations in underserved areas as an important HHR outcome. The authors reviewed 16 articles on prelicensure practice education to identify whether (1) IP practice education is a successful recruitment strategy to for graduates to underserved communities and (2) the IP component provides an important recruitment incentive over uniprofessional practice education. Methods: A scoping review was conducted for the time period from 2004 to 2012 yielding 1245 articles of which 16 studies were selected for this review. Results: Out of these 16 studies, the following HHR outcomes were reported: practice uptake by new graduates with underserved populations (eight studies), interest in working with underserved populations after graduation (eight studies), and residency requests for IP sites (three studies). These results show that IP practice education has a modest influence on recruitment to underserved areas. The impact of the IP component as an added recruitment incentive over practice education alone was not assessed in any study. Therefore, it remains uncertain whether the IP component offers an added benefit to successful recruitment. Conclusions: Given the shortage of healthcare providers in rural and urban underserved populations, innovative recruitment and retention strategies to these areas must be developed and evaluated. This review of the literature suggests that IP practice education experiences offered to students may influence their first place of employment at graduation, especially in rural and urban primary


Introduction
Globally, there has been a serious health human resource (HHR) shortage for underserved populations in and outside of urban centers [1][2][3] .The greatest demand for health service providers is in sectors such as primary care, medical and hospital services, and long-term care 4 .Health and education systems need to develop strategies that draw various healthcare providers to these less desirable settings.This article focuses on practice education, specifically interprofessional (IP) practice education, and its impact on recruiting new health sciences graduates to practice in underserved areas as an important HHR outcome.HHR have been described as the human capital needed to design healthcare systems and to implement health service delivery models that are cost effective 5 .IP practice education refers to any type of practice placement where learners from two or more different health professions learn about, with and from each other.Sixteen articles were reviewed to identify whether (1) IP practice education is a successful strategy to recruit graduating students to underserved communities and (2) the IP component provides an important recruitment incentive over uniprofessional practice education.
The awareness of provider shortages in underserved communities has motivated many academic institutions with IP health sciences programs (IP courses in combination with uniprofessional and practice courses) to acknowledge their social responsibility and address the issue through explicit objectives and innovative recruitment strategies 1,2,[6][7][8][9] .Some programs require a stated commitment by their applicants to work with underserved communities or a desire to serve community health needs as essential admission criteria 2 .These education programs have attempted to capitalize on factors that are seen as influencing career choice in favor of underserved communities 1,2,6,[8][9][10][11][12] .Minority ethnic background, family of origin from underserved communities, or residency training/clinical placements in underserved communities are seen as strong influences on taking up practice there 1,2,4,[13][14][15] .Some critics question the influence of these factors, in particular rural exposure, largely due to confounding variables 3 .
Since the 1970s, many IP health sciences programs in the USA, Canada and Australia have encouraged students from underserved communities to apply to their programs 2,7 .For example, evaluations of the Martin Luther King Jr. Health Center, New York City, showed that minority physicians with a higher percentage of minority residency colleagues (from New York's urban underserved populations in the Bronx) were significantly more likely (p=0.04) to practice in underserved communities 2 .This study argued that a commitment to practice in these communities after graduation 'accounts for much of the success that the [IP program] has had in recruiting, training and graduating physicians of color' 2 , even though some lack of followthrough has also been observed once participants from these areas have experienced an urban lifestyle 2,4 .
Practice education opportunities in rural areas are also intended to expose urban participants to these settings with the hope of practice uptake after graduation 3,14,16 .Wilkinson et al 14 .argued that 'medical students that receive rural undergraduate training are more likely to become rural doctors'.The significance of this factor is shown in some partnerships between academic institutions and underserved communities that offer extensive practice education options in underserved communities to accommodate the large number of students in these programs 7,17 .In 1991, the Community Partnerships in Health Promotion initiative funded by the W.K. Kellogg Foundation with $6 million for each of the seven participating sites has created practice education opportunities in hundreds of underserved communities 7,8,17 .With support from the initiative, some academic institutions have completely restructured their curricula to create rural IP practice opportunities 7,17 despite inconclusive evidence of their impact on graduate student recruitment.
While some influences have been discussed to impact recruitment of graduates to underserved areas, there appears to be a lack of evidence about the influence of the IP component in these programs.This review examines whether IP practice education is a successful recruitment strategy, in particular what the IP component adds to the placement experiences of students.This objective leads to a closer examination of the evaluations of the intervention studies with particular focus on the assessment of the IP component.

Definition of interprofessional practice education
Currently, there is no consensus on the definition of IP practice education.Depending on the discipline, academic departments use terms including clinical placements, fieldwork, clerkships, rotations, externships and internships to describe 'that special part of a professional educational programme in which students gain 'hands-on' experience of working with clients under the supervision of a qualified practitioner' 18 .Others refer specifically to service learning as a different form of practice education where placements occur in community settings primarily focussing on prevention as a major benefit to the communities 19 .For this review, Alsop et al.'s definition of practice education for interprofessional practice education has been adapted as 'that special part of a professional educational program in which students learn with, from and about each other while gaining 'hands-on' experience working with clients under the supervision of qualified practitioners from any discipline' (emphasis added).

Literature searches
An initial literature search on peer-reviewed articles on interprofessional interventions and HHR outcomes from 2004 to 2009 was conducted in Medline, Embase, CINAHL, ABI Inform and Web of Science for a related project.The search terms related to quality workplace, staff satisfaction, recruitment, retention, turnover, career choice and cost combined with terms relating to collaboration, teamwork and interprofessional; English and French language abstracts were considered.Standard steps were followed for selecting, rating and classifying articles 20,21 .Abstracts and full articles were rated for relevancy by three authors who discussed any discrepancies in ratings to reach a consensus 22 .For this review, with its specific focus on students and their career choices as a result of IP practice interventions, eight intervention studies (out of 1184 abstracts) met the inclusion criteria.These articles measured outcomes related to recruitment or interest of new graduates in choosing work or placements in underserved communities 1,7,[9][10][11]13,23,24 . By screeing the reference lists of the articles and hand searching a few relevant journals, five more studies outside of the time period for this review were found 6,8,12,17,25 .
Since this comprehensive search was not specifically directed at IP practice education, it was supplemented with a scoping review of peer-reviewed studies in Medline for January 2004 to August 2012.The search terms comprised synonyms for practice education including clinical, practice or community placements, fieldwork, clerkship and others combined with IP or related terms.HHR-related terms for outcomes included recruitment, interest or intent to practice in underserved communities or related terms.Out of 61 abstracts, three more relevant studies were found 2,26,27 .While this was not an exhaustive search of all databases, Medline indexes approximately 5600 journals with a strong focus on health administration matching the topic of interest.

Review of studies
In total, 16 studies evaluating 12 IP practice education initiatives for prelicensure learners were included in this review.Table 1 summarizes key features of included studies.Most IP practice education interventions were conducted in rural settings and the primary care sector.Besides medical students, students from nursing, social work and various allied health disciplines were most frequently involved in these studies.Most evaluation designs were cohort or case studies without controls.

Human health resource outcomes of interprofessional practice education interventions
The primary focus of this review was to establish whether IP practice placements had a discernible effect on recruitment of new graduates to less desirable settings.Three types of result were found to relate to the career choices of students: • practice uptake in underserved communities (eight studies) • intent/interest to return to underserved areas (eight studies) • residency requests for IP sites (three studies).
The total number of articles is greater than 16 studies because some measured more than one outcome (Table 1) 7,9,10 .

Practice uptake in underserved communities
Interprofessional training in community-based primary care settings showed a limited degree of success on the recruitment of former students to these environments.Of the 16 articles included in this review, only eight measured actual recruitment of graduates to underserved areas.Oneha et al 8 .reported that after 6 years of placing students at three primary care centers in rural and urban areas in Hawaii, four new graduates (total student numbers not provided) from nursing and social work were recruited back to these settings.The program at Creighton University in Omaha, Nebraska resulted in three graduates (out of 111 occupational therapy, physical therapy and pharmacy students in the program) taking up work with First Nations communities 24 .These graduates also became clinical instructors for entry-level university students at these sites.
Rhyne et al 1 .found that pharmacy, occupational therapy, physical therapy and speech language pathology students with IP rural placements chose rural employment as their first job more often than controls.Rhyne et al 1 .also reported that 'practitioners who had participated in a rural practicum, practiced in rural and underserved locations significantly more often than those who had not'   program had a positive influence on their interest in urban underserved practice.A comparison between SPARX and non-SPARX students showed that the program succeeded in increasing primary care choices among its graduates (62% of medical graduates as compared to 50% of controls at p<0.01).The study did not report whether primary care practice was taken up mainly in underserved areas.

Residency requests for interprofessional sites
Only three studies showed an increased uptake of primary care-or acute care-related residency training opportunities for medical students in rural areas.In 1991, 27 schools in seven US states initiated an extensive redesign of their health profession curricula toward multidisciplinary instruction to increase primary care residency rates in community settings.The evaluations of the residency rates over 5 years (1991 to 1996) involving approximately 2500 students showed an average increase from 17% to 28% in primary care residency rates as compared to the national average (14% to 22%) 17,25 .Most importantly, one of the seven sites had transferred a major portion of the education program to rural, underserved communities comprising more than 100 rural centers and small rural hospitals.Therefore, the increased uptake in primary care specialities also spread to a greater number of rural communities (no specific data provided).Baldwin 7 presented outcomes from the Interdisciplinary Health Sciences Program at the University of Nevada on choice of residency training for medical students attending the program between 1972 and 1977.He argued that students from this program were twice as likely to select primary care residency training than students from other programs (80% as compared to 44% of students from other programs).Given that some of these sites are in Native communities, the evidence suggested that underserved communities also benefitted from this program 7 .

Design of interprofessional practice education
In this review, the design of the IP practice education in each study was carefully examined to understand which design elements, if any, might be associated with positive graduate recruitment.Particular attention was paid to curriculum context, format of practice education experience, and the theoretical underpinnings driving the IP practice education.

Curriculum context of interprofessional practice education interventions
The curriculum context of the IP practice education experiences took many forms and was often poorly described.In some studies, student applications for IP programs were reviewed by community representatives and/or program faculty 8,10,11,17,25 .For one program, the application process involved students presenting at various health organizations to publicly show their commitment to promoting social justice 2 .Several studies described IP placements as voluntary practice education opportunities outside of the regular core curriculum involving smaller numbers of students 6,8,10,11,27 .Two programs made rural practice placements mandatory to all or at least some of their health sciences students outside of their core curriculum 1,26 .
Other studies described mandatory sessions embedded within the entire learning continuum of students' core curriculum 2,7,25 .These embedded IP practice education experiences were therefore offered alongside disciplinespecific learnings.Overall, existing studies involved students in practice education opportunities at various points in their learning continuum.In relation to recruitment impact of IP practice education, Rhyne et al 1 .argue that practice education opportunities have greater effect closer to graduation when practice decisions are made, while other authors promoted them at the beginning of students' programs before students' individual professional identities are solidified 13 .For a few programs, the students were the driving force behind planning and design of their learning opportunity 2,6,23 .

Format of interprofessional practice education experiences
All practice education experiences were set up as placements of IP student teams.As a variation on the team placement, two projects paired up two students under the co-preceptorship of two different or the same profession 2,11 .These teams of students provided health and social services to individuals in clinical and community environments.The IP clinical skill development varied between studies but included case management or total patient care 1,6,13,17,24,25 , case presentations and clinical rounds 9,11 and patient screenings and in-services 6,7,24 .Clinical observation experiences (eg shadowing home care providers and other professionals) were another type of IP practice experience 10,11,24 .One study emphasized observations of alternative therapies (eg acupuncture, biofeedback training, guided imagery and herbal therapies) as part of the IP practice education experience 2 .Other student activities involved observations of community-based interdisciplinary team meetings and panel discussions 27 .Tutorials or other sessions to discuss principles of IP practice and working in rural communities were often integrated in the practice education experiences 1,6,8,9,11,24,26 .Two studies did not provide much detail on the practice learning activities 7,26 .
Community-based projects, which are largely service learning opportunities, were integral to IP practice education in several studies 2,6,8,11,13,25 .The projects were primarily health education (eg substance abuse, HIV/AIDS,) to various community subgroups including elementary/high school students, residents of shelters and other individuals 2,6,8,13 , development of health promotion information 9,11 , health needs analyses 11 , information sessions with community members (eg local youth) on future careers in health care 9 ), social activities with communities 11 ), community health assessments 8,17,25 , healthcare policy research 17,25 , and designing interventions with/for the community 25 .

Theoretical underpinnings
Few reports described theoretical underpinnings for the interventions.Two intervention studies explicitly referred to adult learning theory to endorse their IP education programs 2,27 .Baldwin and Baldwin referred to a philosophy of learning together where 'students and faculty are companions in learning' 23 .In the other studies, implicit references were found to experiential learning theory, adult learning principles and the contact theory to explain the ways in which students were brought together in active learning sessions.While not being theories per se, four studies specifically referred to pedagogical approaches about types of interactions that should be designed to make IP practice education meaningful to learners.McNair et al 11 .emphasized approaches promoting interactive learning among professionally diverse learners: exchanges, actions, simulations, observations and experiences.Rhyne 1 described problem-based learning as a key learning approach to the educational experience.Meyer et al 27 .mentioned active and adult learning activities including reflection, discussion, analysis and working in teams.All of these approaches showed awareness among curriculum planners to align successful IP learning strategies with theoretical underpinnings.

Evaluating the interprofessional component
The second focus of this review was to identify whether the IP component provides an important recruitment incentive.All studies emphasized that IP practice education is ideal for learning healthcare practice, particularly in rural areas.Some authors argued that it better addresses the limited resources including chronic staffing shortages and the complexities of community settings requiring people to work together in ways that are not typical for urban centers 6,8,9,24 .Added perceived benefits from IP practice education included the improvement of the working environment for providers 11 , gaining role clarity and greater comfort in working with interdisciplinary teams 1,8,13 , and familiarity with underserved communities 13,25 .IP training may also lessen professional isolation and conflict between the professions as argued by Hays et al 28 .While teamwork or collaborative practice has become important to provide better patient care regardless of location 6,24 , the consequences of not collaborating may be more disastrous in rural areas 9 .
Besides gaining important IP competencies such as role clarity and improving collaborative practice, Harris et al 17 .stated that 'little is known about the value of a multidisciplinary component to health professions education', in particular

Discussion
This review of IP practice education studies and their impact on attracting new graduates to underserved populations in rural and urban areas is timely given the global workforce challenges, particularly in underserved settings.The review found 16 studies that implemented IP practice education for prelicensure learners and reported HHR outcomes.While most IP practice education interventions were intended as recruitment strategies, only eight studies demonstrated some success and numbers were small.Two of the most comprehensive programs embedding IP practice courses in their core curricula had increased residency requests in primary care specialities, some of which were also in underserved areas.Another eight studies reported interest by students to work in these areas after graduation.The findings about the career choices of students in this review are modest given the overall numbers of students that attended these programs and the considerable resources involved in creating such practice education opportunities.Some authors found the current evidence on the impact of IP practice education on graduate recruitment encouraging.Mu et al 24 .suggested that the positive experiences of the students in rural placements 'may help increase the recruitment and retention of health care providers (from various professions) to underserved rural areas'.The lack of sound theoretical models supporting the design and outcomes evaluation of IP practice education reduces the ability to clearly explain the impact of current interventions, especially the impact of the IP component, which was not evaluated in any of the studies.To better understand the impact of IP practice education programs as a recruitment strategy, more rigorous study and evaluation designs are required.The lack of longitudinal studies to measure the impact on future actions becomes particularly apparent 29 .The weak evaluations of the interventions are compounded by the use of different terminology without clear definitions (eg clinical placement, community project, fieldwork and clerkship).
Descriptions of IP education interventions were incomplete with important details often omitted, which also applies to strategies that did not work well.This is a common problem in implementation science 30 , creating a barrier to replicating these studies and understanding their impact.
With the exception of a few methodologically more rigorous studies 1,2,11,24 , the existing evidence is based primarily on small, non-controlled, non-randomized studies and on mostly anecdotal evidence.Self-selection bias of students entering these programs may be a confounding factor and has not been adequately addressed in these studies.

Conclusions
Research about recruitment of healthcare providers to rural and urban underserved populations is important and must be continued to address the current HHR challenges in these areas.The studies examined offer some evidence that IP practice education experiences may influence graduates' decisions to work in healthcare specialties such as primary care for underserved populations in rural and urban areas.However, the current evidence is inadequate to understand the key features of a successful IP practice education experience in enhancing new graduate recruitment.

Recommendations
To enhance conceptual clarity and methodological rigour, the following recommendations are made for researchers in this area: • Clearly describe the IP practice education interventions to make them replicable for others and to develop theoretical explanations for the current evidence.
• Design longitudinal studies that track actual employment of former students in IP practice education experiences.
• Develop methodologically and theoretically rigorous intervention studies and evaluation designs to measure the impact of IP components.
whether it contributes to recruitment.None of the studies in this review contributed to evidence, currently lacking, that the IP component is an influence leading to recruitment of healthcare providers to underserved areas.With several types of IP interventions occurring at the same time, Oneha et al 8 .evaluated the 'combined curriculum objectives'.Yamada et al13 .pointed to 'the difficulty of identifying the influence of a particular element of curriculum on temporally remote behaviour (e.g.employment choice)'.Rhyne et al1 .also stated that it was difficult to differentiate the effects of the practice education experience from the other components of the program.While their evaluation of the IP program used controls for comparison, self-selection for the IP program versus random selection for the control program may have skewed the higher uptake in underserved communities among the IP program participants 1 .The gap in evaluating the IP practice component is a significant shortcoming of the reviewed studies given the extensive planning and resources that are invested in IP practice education to address workforce shortages.

Table 1 :
1,2,[6][7][8][9][10][11][12][13]17,[23][24][25][26][27][9][10][11][12][13]17,[23][24][25][26][27] 9,10ithout providing exact figures, the study on the Interprofessional Rural Program of British Columbia (IRPbc) referred to greater practice uptake in five rural communities by nurses, social workers, speech language pathologists, pharmacists and medical lab technicians at graduation9,10.In total, 67lbourne agreed that it had increased the possibility for them to practice in rural Australia 26 .Meyer et al27.reported the outcomes from an elective interdisciplinary mental health course in rural Appalachian areas as offered by the University of Ohio.Out of three student cohorts comprising 38 participants, six (16%) strongly agreed with the statement 'because of this class, I am more likely to work in a rural area'27.It cannot be determined from the article whether these respondents were representative of the participants.Program evaluators of the Student Providers Aspiring to Rural and Underserved Experiences (SPARX) program at the University of Washington conducted a followup survey of former students enrolled in this extracurricular IP program6.Of 38 students responding (112 students did HHR, health human resource, IP, interprofessional.†Totalnumber of articles is higher since some reported more than one outcome.Intent/interest to return to underserved areas not reply), 24 students reported that SPARX had increased their interest in rural practice 'quite a bit' or 'very much'.Thirteen students (out of 38) reported that the SPARX This supports McNair et al.'s 11 statement that 'the results strongly support the argument to continue to develop rural IPE programs at undergraduate level'.Other authors expressed more caution towards the influence of IP practice education on the recruitment of new 11aduates to rural areas.While achieving positive attitudes about rural communities through these placements is a step forward, these attitudes 'do not necessarily translate to an intention to enter [such] practice long-term' 11 .Thus, merely expressing an interest in future rural employment is too tentative to be seen as strong evidence.McNair et al11.noted discrepant results between students' high level of interest to 'spend some time in a rural health setting' as compared to their commitment to practicing in the rural setting (implying more permanent rural work).