A competent, collaborative, interprofessional team centered on the patient is necessary
for quality pain care; however, interprofessional collaborative practice is not yet
an integral part of all health professions education programs.
Interprofessional education involves 2 or more professions learning “with, from, and
about” to enable effective collaborative practice and improve health outcomes.
Core competencies and curricular resources are available for interprofessional education
and pain and can be adapted for use at all levels of health professions education.
Pain is a complex experience that impacts health, productivity, and well-being. It
requires a collaborative team approach with a common language and clear understanding
of roles and responsibilities. With few exceptions, a minimum amount of pain content
has been documented in health sciences curricula, and much of that has been fragmented
by profession and delivered within a crowded agenda of conventional course topics
such as anatomy and physiology.
Most health professionals learn pain management on the job and are often ill-prepared
to function as a team member in the real world. Despite documentation of the need
for improved education on pain of all types, consistent professional training in pain
is not widespread and innovation is warranted. The 2018 IASP Global Year for Excellence
in Pain Education is a call to action on multiple levels. The purpose of this report
is to describe opportunities for mutual learning through interprofessional (IP) pain
education. Interprofessional education (IPE) is a growing trend across health professions
and has been defined (Table 1) as when 2 or more professions learn with, from, and
about each other to improve collaboration and the quality of care.
For IP learning to occur, all 3 “with, from, and about” must be present.
2. With others–learning together to facilitate interprofessional collaborative practice
The complexity of health care across the globe, technological advances, and modern
models of care delivery has created demand for a practice-ready workforce and effective
Medical errors often result from poor communication within and across teams; high
functioning teams improve outcomes of care.
Professional education has not kept pace with increasing demands for collaboration-ready
health workers in part because of disjointed, outdated, and static curricula; furthermore,
a glaring mismatch of competencies to patient and population needs persists.
We educate students most often in uniprofessional settings (silos) with little opportunity
to learn and practice together. Although learning experiences in the clinic or on
a ward offer more opportunities to learn with, from, and about other health care professionals,
there may be few role model IP teams in the real environment. Uniprofessional education
is inadequate to prepare health care trainees to work in teams and can spur competition
rather than cooperation between the professions.
Recognizing this struggle, the World Health Organization (WHO) issued a Framework
for Action on Interprofessional Education and Collaborative Practice in 2010.
The report contextualizes existing health systems, commits to implementing principles
of IPE and collaborative practice, and champions the benefits of IP collaborations
with regional partners, educators, and health workers. Contemporaneously, the Lancet
Commissions issued a foundational report
developed by 20 health profession leaders from diverse countries advancing a common
strategy for educational reform in medicine, nursing, and public health. The Lancet
Commission calls for education reform that is guided by the desired outcomes of transformative
learning and interdependence in education. Transformative learning involves fundamental
shifts from fact memorization to synthesis of information for decision making; from
seeking professional credentials to achieving core competencies for effective teamwork
in health systems; and adaptation of global resources to address local priorities.
Interdependence stresses the system approach that offers insights into the dynamic
and nonlinear nature of a complex system that cannot be gained by studying components
of the environment in isolation. This report also underscores the pace, scale, and
intensity of globalization impacting interactions of health systems and education.
In several countries, collaboration of national associations of health profession
regulatory bodies has given rise to recommendations for core competencies for IP collaborative
practice designed to guide curriculum development in interactive learning. For example,
developed by the Interprofessional Education Collaborative (IPEC) in the United States
have become part of the global conversation (Table 2). The Global Forum on Innovation
in Health Professional Education has hosted a series of meetings engaging stakeholders
and policymakers through linked projects and networks in Uganda, South Africa, India,
Updated in 2016, the IPEC competencies integrate explicit population health outcomes
with individual care competencies to form an expanded model that targets desirable
health system goals. Interprofessional collaboration, in this framework, is the central
domain under which the original competencies are arranged. Similarly, the Canadian
IP Health Collaborative developed the National Interprofessional Competency Framework
in 2010, which has been used in various countries and academic settings.
Interprofessional collaborative competency domains.
Interprofessional collaboration occurs when learners/practitioners, patients/clients/families,
and communities develop and maintain working relationships that enable optimal health
Interprofessional collaborative practice occurs when multiple health workers from
different professional backgrounds work together with patients, families, and communities
to deliver the highest quality of care. Interprofessional core competencies build
on modern educational theory and practice to bring together all health professions
with shared language, vision, and goals (Table 3). These competencies are important
for positive outcomes, including those we aim for in quality pain care.
Characteristics of health-focused interprofessional core competencies.
3. From others—learning from different professions to facilitate collaboration and
Collaborative approaches are invaluable when pain management is complex, requiring
the knowledge and skills of more than one profession. It is logical then, that to
work together, future health care workers would benefit from learning together to
understand each other's roles and responsibilities and how to communicate using common
language. The provision of opportunities for student interaction is fundamental to
the learning experience to develop an understanding of the perspective of various
professions and to foster a climate of mutual respect and relationship-building values.
Interprofessional education requires active learner participation and case-based content
that is authentic and foundational to many health professionals.
Although most IPE is focused on prelicensure students, literature is emerging in post
graduate clinical education. Themes in the context of back pain in a primary care
setting included the context, value of involving the patient, listening, time and
The intent is to impact practice and improve quality of health care.
4. About others–attaining competence to use knowledge of one's own role and those
of other professions to address pain care needs
Pain experience is multidimensional; therefore, pain education draws on not only mechanisms
but also a variety of theories such as relational, professionalism, and social constructivism
and is grounded in adult learning theory.
The concept of communities of practice and situated learning is also important as
students move from learning about their own profession to other professions and members
of a team.
These concepts reinforce a model of multiprofessional team management of pain championed
long ago by John Bonica. Learners need to become self-directed, critical thinkers
and reflective practitioners, able to function as members of teams, and be good communicators,
adaptable to change and continuing to learn through professional experiences.
Interprofessional education is not a replacement for education specific to each profession,
a reason to lose individual professional identity, the only innovation needed in the
health system, and an end in itself. We do not do IPE for its own sake; we do it to
help understand each other's roles and contributions to work together in a real-world
5. Barriers to overcome
A number of significant barriers must be overcome to successfully implement and sustain
a culture of IPE.
Leadership at the highest level is needed for a culture change to be successful. For
example, licensure and accreditation requirements do not currently reinforce preparation
for collaborative practice in most countries. A survey of 41 countries from WHO's
6 regions representing various income economies reported IPE was often voluntary.
Moreover, the lack of compulsory IPE and pain competencies for entry-to-practice graduates
has implications for advancing skillful and ethical practice; it can limit the capacity
of health care professionals to alleviate suffering, foster autonomy, and use resources
As well, many faculty are trained and familiar with the didactic teacher role rather
than how to be an effective IPE facilitator and are not comfortable teaching pain
; faculty education and development are needed. Faculty and clinician composition
in the development and implementation of IPE activities may influence the outcomes
of the learning activities.
Evidence is scarce in developing countries, but challenges may be similar including
curriculum structure and complexity. It has been suggested that barriers be taken
as opportunities to transform approaches to core health problems in developing countries.
Modifications in physical classroom space, competition for curriculum hours, and coordination
of schedules can be challenging. Ideally, students should be introduced to IPE early
with learning activities that build on competencies. Curriculum design is an iterative
process necessitating modifications of complexity in patient cases and also the challenges
of integrating clinical content to meet the needs of all levels of learners.
Perceived differences in hierarchy, power status, and unequal participation rates
among certain health professions have also been described as challenges.
However, IPE can provide an opportunity to transform the way we socialize students
by improving the understanding and respect of each other's unique roles and responsibilities
within the team. Of course, the ultimate challenge is to harmonize learning experiences
with well-functioning IP teams in clinical practice. Involvement of clinicians in
curriculum development and implementation can help to insure real-world pain care
and patient-centered modeling.
6. Defining components of interprofessional education–competencies (learning outcomes),
curriculum (learning plans), and content (learning objectives)
Competency is the desired outcome of education. Distinct from learning objectives
that emphasize gains in factual knowledge, attitudes, and skills, competency places
emphasis on students' capacity to act effectively in relevant clinical situations.
Competency generally includes observable phenomena such as being able to demonstrate
the ability to explain a treatment or educate a patient about relevant treatment adverse
effects. It also includes appropriate attitudinal and affective qualities to the extent
that such are observable, eg, being able to maintain perceptibly compassionate communication
while examining a painful part, potentially gauged through the use of interpersonal
skills checklists. Core competencies in pain management for health professional education
have been established.
These pain competencies address the fundamental concepts and complexity of pain; how
pain is observed and assessed; collaborative approaches to treatment options; and
application of competencies across the life span in the context of various settings,
populations, and care team models (Fig. 1). A set of values and guiding principles
is embedded within each domain. These competencies can serve as a foundation for developing,
defining, and revising curricula and as a resource for the creation of IP learning
activities across health professions designed to advance care that effectively responds
Core competencies for pain management. These core competencies pain assessment and
management were developed through an interprofessional consensus process
to address prelicensure pain management education in all major health care professions
that are consistent with the IASP pain curricula outlines. Graphic created by Ian
Koebner, PhD. Used with permission University of California Regents or Graphic courtesy
of University of California Regents.
Pain curricula outlines provide the template that helps to structure learning. Curricula
include considerations of sequencing material, developmental appropriateness, and
coordination of different health professions' learning activities, so that students
from different health profession programs will learn about for IPE at the same time.
The IASP Pain Curriculum Outlines
provide recommended curricula for pharmacy, psychology, physical therapy, occupational
therapy, nursing, medicine, dentistry, social work, and IPE. Each is arranged to address
4 main domains and related core competencies including (1) the multidimensional nature
of pain, (2) pain assessment and measurement, (3) the management of pain, and (4)
pain in specific clinical conditions. The outlines are helpful for establishing courses
that provide an integrated foundation in pain at both the undergraduate and graduate
levels. With this foundation, students are prepared to understand and approach patients
with many forms of pain, as well as provide support to families and caregivers. All
IASP curricula outlines including IPE were updated in 2017 for the Global Year for
Excellence in Pain Education.
Content is the description of what is being taught at the most granular level, eg,
what are the learning objectives. Content serves as an important common language necessary
to effectively communicate with each other about the specific elements of our uniprofessional
and IP learning plans.
Three teaching modules that address a number of IASP topics and are adaptable for
IPE are available on the Portal of Geriatric Online Education (POGOe.org).
In the United States, the National Institutes of Health has created a freely accessible
portal of pain education online learning modules. Based on a variety of local models
of IP collaboration, these modules demonstrate that IPE can take various forms depending
on the specific professions engaged and the goals for learning.
A unique and perhaps most comprehensive program is the 20-hour University of Toronto's
Pain IP Curriculum involving students from 7 professional programs. The program's
design and implementation components are described in the Pain IP Curriculum Model
as (1) dynamic, (2) competency-based, (3) interrelated, and (4) collaborative with
the patient focus at the center.
Experience with the program has informed the creation of an eLearning Pain Education
Interprofessional Resource that is internet accessible and available on request.
As a blended eLearning program, Pain Education Interprofessional Resource has been
designed as a self-learning resource to be coupled with facilitated small group, IP,
7. Outcomes of interprofessional education
Measuring outcomes of IPE can be quite challenging. Large gaps regarding methods,
theory, and context remain, and most studies focus on short-term results. The heterogeneity
of contexts, variety of interventions, and methodological limitations makes it difficult
to draw generalizable inferences about key elements and effectiveness of IPE.
Evaluation should ideally link to clinical practice, but there is a paucity of contextually
and synthesized literature regarding outcomes, particularly for pain management.
University-based IPE using patient scenarios and group work in small teams, as contrasted
to didactic lectures, has been shown to be feasible and has led to improved attitudes
toward IP interaction and teamwork and improved understanding of health professional
Studies of IPE have found differences between professions, with students in professions
deemed psychosocial were more positive about IPE than students in biomedical career
Similarly, Erickson et al.
found that IP mentorship and group participation improved first year medical students'
pain management skills but did not have the same effect on fourth year nursing student
performance. Differences were attributed in part to experience in clinical settings
but also suggested that combining different levels of students is acceptable if they
are of similar age and life experience. A significant positive shift in the pain knowledge
and attitudes toward collaboration has been demonstrated through IPE.
Simko et al.
reported an increased knowledge and understanding of the importance of other profession's
role in pain management in an IPE course for nursing and pharmacy students. Other
studies have reported high student satisfaction and significant improvement in self-efficacy
as well as respect for each other's roles and responsibilities.
Positive changes have also been reported in pain assessment and documentation behaviors
The delivery of effective pain management can be complex, requiring collaborative,
team approaches that exceed the expertise of any one profession. Interprofessional
collaboration is increasingly recognized as a core skill for all clinicians and is
beginning to be required by some accrediting bodies for medical, nursing, pharmacy,
physician assistant, and social work programs. However, IP collaborative practice
is not yet an integral part of all health professions education programs. Recommendations
of the WHO
and other leading organizations recognize IP collaborative practice and education
as a central component of transformative improvements in health care. Based on work
in a number of global settings, recommendations for educational change to incorporate
IP collaboration into practice are available and undergoing further development.
Creating IPE learning opportunities is important. The intent of IPE is to produce
a collaborative practice-ready workforce to improve the quality of health care. Students
should be introduced to IPE early and have developmentally appropriate opportunities
throughout a curriculum program. Students can change agents in the real world to continuously
improve the way health professionals work together, mentor students and improve the
quality of pain care. The quality and rigor of IPE research is inadequate, and research
needs to move beyond feasibility and attitudes toward long-term improvements in clinical
When focused on pain, IPE is likely to provide substantive benefits in the real-world
practice setting, but barriers to IPE adoption, including slow adoption of pain-focused
competencies and cultural habits, limit uptake. When able to overcome these obstacles,
IPE has the capacity to harmonize learning experiences and promote patient-centered
socialization of health profession trainees at all levels. Importantly, communicating
and assessing innovation in IPE relies on understanding the conceptual education framework
built on key elements of competencies (learning outcomes), curriculum (learning plans),
and content (learning objectives). Although more work is needed to identify the most
effective approaches, and even fundamentally to define meaningful approaches to outcomes
assessment, models of education such as IP workshop training and online education
exist with positive impact. We leave readers with a brief table of actions they can
take to advance and transform health professions' education (Table 4).
Suggested actions individuals can take to promote IPE.
The authors have no conflict of interest to declare.
D.B. Gordon and B. Hogans hold positions of leadership in their University's NIH Pain
Consortium designated Centers of Excellence in Pain Education (CoEPEs). J.Watt-Watson
is a principal leader in the University of Toronto's IP curriculum program.