Applied Nursing Research 27 (2014) 115–120

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Interprofessional health education in Australia: Three research projects informing curriculum renewal and development Carole Steketee, B.Ed. (Hons)., PhD a,⁎, Dawn Forman, PhD, MBA b, 1, Roger Dunston, PhD, BA Applied Social Studies/CQSW c, 2, Tagrid Yassine, MA Adult Education, BA Organisational Learning c, 3, Lynda R. Matthews, BHlthSc (Hons), PhD d, 4, Rosemary Saunders, MPH, BAppSc e, 5, Pam Nicol, MPH, BSc f, 6, Selma Alliex, PhD, MSc (Nursing) g, 7 a

School of Medicine Fremantle, The University of Notre Dame Australia, Fremantle, 6959, Australia Adjunct Professor Curtin University and Auckland University of Technology, Visiting Professor University of Derby and Chichester University Faculty of Arts and Social Sciences, University of Technology, Sydney, 2007, Australia d Ageing, Work and Health Research Unit, Faculty of Health Sciences, The University of Sydney, Sydney, 2006, Australia e School of Population Health, University of Western Australia, The University of Western Australia, Perth, 6009, Australia f School of Paediatrics and Child Health, The University of Western Australia, Perth, 6009, Australia g School of Nursing and Midwifery, The University of Notre Dame Australia, Fremantle, 6959, Australia b c

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Article history: Received 1 May 2013 Revised 16 August 2013 Accepted 8 March 2014 Keywords: Curriculum development Australia Collaboration Teamwork Nursing

a b s t r a c t Purpose: This paper reports on three interrelated Australian studies that provide a nationally coherent and evidence-informed approach to interprofessional education (IPE). Based on findings from previous studies that IPE tends to be marginalized in mainstream health curriculum, the three studies aspired to produce a range of resources that would guide the sustainable implementation of IPE across the Australian higher education sector. Method: Nine national universities, two peak industry bodies and a non-government organization constituted the study team. Data were gathered via a mixture of stakeholder consultations, surveys and interviews and analyzed using quantitative and qualitative methods. Results & Conclusion: An important outcome was a curriculum renewal framework which has been used to explore the implications of the study's findings on Australian nursing. While the findings are pertinent to all health professions, nursing is well placed to take a leading role in establishing IPE as a central element of health professional education. © 2014 Elsevier Inc. All rights reserved.

Australian health service providers are becoming increasingly receptive to interprofessional practice (IPP) as a means of addressing the challenge of delivering high quality, safe and patient-centred health care in a service environment that is changing constantly. Rising costs, an ageing population and increases in the prevalence of

⁎ Corresponding author. Tel.: +61 8 9433 023; fax: +61 8 9433 0250. E-mail addresses: [email protected] (C. Steketee), [email protected] (D. Forman), [email protected] (R. Dunston), [email protected] (T. Yassine), [email protected] (L.R. Matthews), [email protected] (R. Saunders), [email protected] (P. Nicol), [email protected] (S. Alliex). 1 Tel.: +44 1142 362142; +44 07872025462 (Mobile). 2 Tel.: +61 2 9514 3846; +61 402042772 (Mobile); fax: +61 2 9514 3939. 3 Tel.: +61 2 9514 4628; fax: +61 2 9514 3939. 4 Tel.: +61 2 9351 9537; fax: +61 2 9351 9672. 5 Tel.: +61 8 6488 8108; fax: +61 8 6488 1188. 6 Tel.: +61 8 9340 8943; fax: +61 8 9388 2097. 7 Tel.: +61 8 9433 0215; fax: +61 8 9433 0227. 0897-1897/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnr.2014.03.002

chronic and complex illnesses are making traditional uni-professional approaches to health care less viable (Dunston et al., 2009). IPP is a partnership between a team of diverse health professionals who work together in a collaborative, patient-focused and coordinated fashion to share in the decision making and overall care of the patient (Canadian Interprofessional Health Collaborative, 2010). The literature suggests that this form of practice leads to a more effective, efficient and safer model of patient care (Greiner & Knebel, 2003). The overarching aim of interprofessional education (IPE) is to equip health practitioners across all professions with a range of competencies that enable well developed and effective IPP. For example, communication, collaboration and teamwork skills, problem solving and quality improvement skills, patient and family centred care and an understanding of and respect for others' roles and responsibilities are integral to sharing patient care (Interprofessional Education Collaborative Expert Panel, 2011). The Centre for the Advancement of Interprofessional Education (2002) defines IPE as occurring when ‘two or more professions learn with, from and about

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each other to improve collaboration and the quality of care’. This definition emphasizes the central place of collaboration as the mediating factor in producing improved patient care outcomes. Whilst IPP is promoted globally as essential to the delivery of safe and effective patient care and, more broadly, to health system effectiveness and sustainability, a recent study reporting on IPE within Australian health professional education noted that it tended to be locally developed and, more often than not, exist with vulnerability on the margins of a curriculum (Dunston et al., 2009; Matthews et al., 2011). Examples of where it did exist were often as a result of ad hoc and often heroic initiatives to locate IPE within an already crowded curriculum. The need for a nationally coherent, better coordinated and evidence-informed approach to the development of IPE has been identified in Australia (and internationally) as critical in shifting IPE from its precarious curriculum position to one where it is accepted as fundamental to mainstream health professional practice, education and learning. This paper reports on three interrelated Australian studies that were conceived as a direct response to these findings. They are: • Curriculum renewal in interprofessional education in health, • Interprofessional education for health professionals in Western Australia: perspectives and activities, and • Interprofessional education: a national audit. Nine national universities, together with two peak industry bodies and one non-government organization, (the Australasian Interprofessional Practice and Education Network), became the overarching study team. A national and international reference group comprising leading scholars in the area of IPE was also established as a point of advice and feedback. The three studies produced a range of conceptual and practical resources that aim to guide and inform the development of IPE curriculum across the Australian higher education sector. While the findings and implications of the three studies are presented as relevant to all health professions, the final section of this paper explores the implications of the findings to IPE in Australian nursing. It is apparent that the ways in which the nursing profession position themselves to the idea and practice of IPE and IPP will, given its size, status and location within the higher education and health service sectors, have a significant impact on the future shape of IPE (Barnsteiner, Disch, Hall, Mayer, & Moore, 2007). 1. Research methods 1.1. Study design The design of three studies, and the overarching methodology, was shaped to address four major issues. Firstly, we believed it would be critical to develop a coherent and meaningful way of discussing the many and complex issues involved with IPE and its development across a diverse range of Australian universities. While we would be engaging with health provider organizations, government bodies, the professions and health consumers, our central focus was higher education and those involved with curriculum development. From an earlier study (Dunston et al., 2009), we were aware of major gaps and ambiguity in the ways in which IPE curriculum and IPP capabilities were conceptualized. If our work was to be relevant, meaningful, and have impact, it was clear to us that we needed a way to communicate with key stakeholders. This led to the development of what we termed the four dimensional curriculum framework (4DF). The 4DF has had great utility as a way of uniting the discrete work of the three studies. It has provided a meaningful framework and language through which all study activities have been mediated and interpreted. Additionally, the four dimensions of the framework have been used to design the national survey, to focus consultations, to organize and analyse data and to communicate with all stakeholder groups. This development activity and

the overall management of the three studies was taken on as part of the curriculum renewal study and funded by a peak national government body in Australian higher education, the Office for Learning and Teaching (www.ipehealth.edu.au). Summary details of this study and the development of the 4DF are presented and discussed below. Secondly, the studies aimed to be responsive to what was already occurring within Australian IPE, to build on strengths and address deficits. The problem we faced was a superficial understanding of what was occurring in each university. We knew little about design features, about the ways in which IPE and IPP were being conceptualized, about linkages between curriculum elements, and about assessment and evaluation. This major information deficit shaped what became one of the major foci of the studies – to produce a detailed profile of IPE activity in Australian universities during 2011 and 2012 (ICRC, 2013). The primary method through which this information was gathered was a national survey together with focused interviews with professional health, consumer and government stakeholders. A collection of exemplars of innovative and well-developed interprofessional practice and a broad-based review of the relevant literature provided additional data. A total of 26 Australian universities participated with 83 discrete interprofessional activities reported, two-thirds of which included activities for nursing students. The national audit was funded by a peak national body, Health Workforce Australia (www.hwa.gov.au). A substantial report detailing aims, methodology, data, findings and recommendations can be accessed at www.ipehealth.edu.au. Summary details of the national audit, its findings and recommendations are presented and discussed below. Thirdly, the information gathered by the national audit was clearly a critical point of departure. However, as we worked at the design of a major national survey it was clear to us that what this could not produce was an in-depth and narrative view of how IPE curriculum was being developed in local Australian universities. Our position as a study team is that curriculum is a socio-cultural formation, shaped by many social, cultural and historical factors. We felt it important to understand IPE as it currently exists through a socio-cultural lens. As such, four of the five universities in the state of Western Australia (WA) agreed to conduct a qualitative, ethnographically informed study of the development of IPE across their universities. This study aimed to develop a coordinated approach to mapping existing, and building future IPE activity in Western Australian universities and to examine and make visible cultural, logistical and strategic factors that impact on the development and delivery of IPE. This study has proved invaluable in building our understanding of the complex mix of factors intersecting in relation to IPE, its place and development within individual universities. Like the national audit, this study also provided us with an understanding of trends, patterns, challenges and opportunities in IPE. It was funded by the peak state government health body, Western Australian Health. A substantial report detailing aims, methodology, data and findings can be accessed at www.ipehealth.edu.au. Summary details of the WA qualitative study and its findings are presented and discussed below. Fourthly, our wish that the work of the studies have impact beyond the delivery of a number of reports led us to design in as much face-to-face consultation and discussion with key stakeholders as was possible. This work was designed to supplement the data from the national audit and the WA qualitative study. However, it differed in focus. Consultations sought to engage all key bodies in a process of collective and future orientated design. Our aim here was to strengthen and connect members of what might be termed an Australian IPE community of interest and practice. 1.2. The 4DF – Designing for change Project partners recognized early in the design of the studies that there was a need for a conceptually coherent understanding of, and

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approach to, curriculum renewal in IPE. Earlier studies had identified considerable variability in how curriculum is conceptualized. As Lee, Steketee, Rogers, and Moran (2013) note: The term ‘curriculum’ tends to be used in its limited sense, often referring to the development of written syllabi for courses where learning objectives, activities and assessment are identified for localised needs. In this regard, little systematic attention is paid to the curriculum development process and the impact of the curriculum decision on the health of citizens or the future development and sustainability of health professionals; that is, there is little theoretical framing of the curriculum development process. While the purpose of some training programmes, such as Tomorrow's Doctors, the General Medical Council, (2010) is to prepare students who can meet societal health needs, it is nonetheless difficult to identify a theoretical framework that might be replicated and used to guide curriculum development in general (p. 65). As a relatively new and “marginal” player in health professional curriculum, how IPE is viewed is crucial to whether (and how) IPE exists within the curriculum. For instance, many stakeholders expressed considerable concern that IPE and its educational outcome, IPP capabilities, was likely to diminish the importance of their uniprofessional or disciplinary knowledge and role. The need to find a mechanism and process through which to address, discuss and work with and through these issues within a curriculum context would be critical to what the studies could achieve. Such a framework would need to give the widest consideration to how the curriculum is developed and delivered. How interprofessional learning takes place within and between individuals, how understandings of each other's roles is achieved, how competencies are gained, and how continuous development facilitates an interprofessional, collaborative approach to the patient/client are fundamental in the consideration of a curriculum for an interprofessional health workforce of the future. The development of the 4DF was our attempt to articulate and use

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such a curriculum framework as the structure and process that framed and informed all study activities (see Fig. 1). The 4DF is described in detail elsewhere (Lee et al., 2013). Briefly, it is both a conceptual statement and, via the consideration of each dimension and the relationships between dimensions, also a reflexive and critical process through which organizations and educators can review existing curricula and develop new curricula. The four curriculum dimensions are: 1. Future orientation of health practices - the relationships that exist between curriculum and the social, economic and political conditions that are shaping what health services and health professionals are required to deliver. For example, changing demographics, technologies, community expectations and resources (dimension 1). 2. Knowledge, competencies and capabilities - the ways in which these requirements for current and future health practice, expressed in terms of competencies, capabilities and learning outcomes, are identified within the curriculum (dimension 2). 3. Teaching, learning and assessment - the kinds of pedagogies and educational practices required to achieve the specified learning outcomes and capabilities. This is particularly the case for pedagogies congruent with the achievement of interprofessional capabilities (dimension 3). 4. Institutional delivery - the ways in which local institutional factors are configured to enable or constrain achievement of the above - an area frequently neglected in curriculum development (dimension 4). 2. Results and discussion As noted previously, one of the most important findings and possibilities for the nursing profession in relation to IPE is leadership. The national audit confirmed that, as the largest health workforce, nursing is positioned as the largest cohort currently engaged with IPE. How nursing engages with, contributes to and demonstrates leadership is likely to become a major factor in determining the shape and future of IPE, certainly within Australia.

Fig. 1. Four‐dimensional curriculum development framework (4DF).

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At a generic level, the national audit and its related consultation findings confirmed what had been identified in previous projects engaging with Australian IPE, that is, that the development of IPE within Australian universities has been (a) localized, opportunistic, adaptive and creative, but existing on the margins of the curriculum, (b) minimally resourced and, as a consequence frequently unsustainable, (c) fragmented both within and across universities and the higher education sector, and (d) without mechanisms to share information, share learning, develop research and build knowledge and capacity. The National Audit also identified for nursing and other health professionals significant gaps in the specification of IPE learning outcomes and in the articulation of IPP capabilities. It seems there is a lack of alignment between IPP capabilities, learning outcomes and well conceptualized teaching methods and considerable diversity in the articulation and specification of what pedagogies and educational methods were most effective in achieving IPP learning outcomes (a significant gap in our knowledge base). Participants also identified considerable diversity and uncertainty in how best to assess student learning and to evaluate IPE programs. The WA qualitative study unpacked these more general issues revealing a wide range of (at times conflicting) views about IPE. These views appeared to be strongly influenced by the perceived different educational needs and learning potential of students from the various health professional disciplines, in particular, between nursing and medicine. The culture of the local environment and its mix of health professional disciplines also influenced these perspectives. Differing views as to the role, knowledge and capabilities of nursing and medical students were a constant theme that threaded through consultations and interviews. Such differences were also a part of other complex issues such as how and where in the curriculum to teach IPE and about how much is desirable at pre-licensure level. It was apparent that what is considered desirable not only depends on what is possible but also how the future roles and responsibilities of different groups of health professionals are perceived. This was also evident in a US study by Makary et al. (2006) that found that while nurses describe “collaboration” as having input into decision-making, doctors describe it as having their needs anticipated and directions followed. Another view that came down on the side of caution was that, although IPE appeared a worthy goal, it is doubtful whether the evidence for its benefits is sufficient to warrant the considerable effort and resources necessary to implement it. This is another reference to a lack in the knowledge base underpinning the legitimacy claims of IPE. There were also areas of consensus. For example, all participating universities valued clinical practice and placements, identifying them as arguably the most important IPE learning opportunity for students. Considerable consensus also existed in relation to the conditions that would be required for IPE to be positioned (and accepted) as a core element of the curriculum. Four key challenges were identified: 1. The need for dedicated funding for IPE curriculum development and implementation. 2. The critical impact of professional accreditation (and registration) on the extent to which IPE is seen as a priority. 3. The professional development of IPE educators. 4. Much closer and sustained links between the higher education and health sectors and a greater responsiveness from the higher education sector to what is occurring in the health sector and, more broadly, in the community. Interestingly, there was also much commonality about the ways in which participants thought about sustainability. The issue of sustainability (or the lack thereof), is typically discussed as a major concern in relation to the viability of IPE. Views about the conditions for sustainability were presented in complex terms. It was not just

having IPE champions and a responsive executive sponsor; rather, it involved a coalescence of factors – capacity, capability, policy, local context, health registration and accreditation. What was also a point of consensus, and noted across all the forms of information gathering methods, was the practical and logistical issues of attempting to generate curriculum synergies in institutions underpinned by uniprofessional practices. 2.1. Key areas for development As part of the curriculum renewal study and the national audit (ICRC, 2013 & 2014), we were asked to develop recommendations based on the findings. In this section we present a summary of these recommendations. They are useful in that they provide guidance in terms of capacity building and strategic directions. For the most part, the recommendations have applicability at a policy and institutional level – they define the kinds of activities and requirements that participants across the three studies indicated would be required to position IPE as a core element of curriculum and as part of a welltargeted health workforce capacity building strategy. 2.2. National leadership and a national approach The importance of building a connected, coherent and nationally coordinated approach to the development of IPE was one of the most consistently discussed themes across all consultations. What was also made clear to us was that national leadership and a nationally coordinated approach did not mean a prescriptive curriculum. On the contrary, the clear message was that curriculum had to be responsive at the local level. There was an obvious distinction made between work to be done locally and work to be done nationally. Agreed curriculum principles, guidance on appropriate pedagogies, learning networks, evaluation and research, knowledge sharing, were the kinds of conditions identified as required for the systematic development of IPE. The issue of an inclusive national approach to IPE is, we think, a critical issue and one not able to be well addressed solely through uni-professional mechanisms. Additionally, the importance of a national approach to specifying the capabilities or competencies that describe the capable interprofessional practitioner (dimension 2 of the 4DF) was identified. As noted earlier, the national audit identified how frequently IPP capabilities were not specified as part of IPE curriculum. This critical bridge linking the world of health practice (dimension 1) and health professional education (dimension 2) was rarely well articulated. The importance of this step in the development process is strongly identified in the international literature. The work of the curriculum renewal study has attempted to bring together a range of international and national IPP capability frameworks for consideration in the Australian context. The importance of profession-specific accrediting bodies identifying IPP and IPE as required practice and education elements of curriculum was again one of the most consistent themes raised by stakeholders. The view of many we spoke with was that unless this occurred IPE would remain on the margins of the curriculum; giving rhetorical support but not systematic implementation. This is a challenge for each profession, in particular medicine and nursing, two major gatekeepers of curriculum. However, we think nursing has immense opportunity to demonstrate a systemic commitment to IPE in accreditation standards, in curriculum development and, given its demographic and capacity, in knowledge building through evaluation and research. We have noted during the course of the studies significant movement in this area. Finally, building faculty capacity in IPE was a further consistent theme of stakeholder consultations. This task was broadly scoped. Comments often distinguished between designing or building curriculum and implementing curriculum. It was clear that for many

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educators socialized within uni-professional frameworks and with uni-professional pedagogies, the area of IPE was unfamiliar. In particular, aligning learning outcomes, pedagogy, teaching methods and assessment was developed differently across different institutions. The task of also specifying IPP capabilities in terms of learning outcomes was also little developed, little theorized and little researched. Building faculty capacity and building IPE curriculum and teaching capacity need to engage with: ▪ Building curriculum - theorizing and conceptualizing the nature of IPP and the kinds of pedagogy and educational methods suited to achieving IPE learning outcomes. ▪ Building delivery capacity – developing ways to add IPE capabilities to the uni-professional capabilities of educators. ▪ Significantly increasing evaluation and research into IPE and its relationship with IPP and interprofessional learning. Whilst there is indicative knowledge as to the effectiveness of IPE and IPP, our knowledge base can only be termed provisional and in its early stages of development. The need for new ways to think about and conduct educational and practice research were identified as major areas of need. 2.3. Implications of findings on IPE in Australian nursing The challenges related to IPE in nursing in Australia are many and varied and not unique to nursing. These challenges are similar to those identified by US researchers who concluded that the nursing profession could take the lead to work with colleagues in other health professions to deliver high quality, safe patient care (Barnsteiner et al., 2007). These issues were also highlighted in an Australian study of medical and nursing students' rural placements where the authors suggested the use of champions to minimize challenges (McNair, Brown, Stone, & Sims, 2001). The key challenges for developing IPE for nursing in Australia can be themed around the concepts of the 4DF. This framework supports the overarching philosophy of nursing programs which promotes holistic care with a patient/client centred focus within a collaborative model of care. The first dimension of the 4DF relates to connecting health professionals' practice needs to changing workplace demands and curriculum consideration needs to take into account global health and educational reforms. On a global perspective, the World Health Organization (2010) has stated the importance of IPE in order to strengthen the workforce for future generations. Royal College of Nursing Australia (2006) (now the Australian College of Nursing) has identified IPE and IPP as an important part of nursing education, and it acknowledges the importance of IPE and IPP for continuity of care. The introduction of a national nursing accreditation body (Australian Nursing and Midwifery Accreditation Council) in 2010 has provided national accreditation and competency standards for the nursing profession in Australia. Importantly, the standards require that education providers must demonstrate IPE as part of the curriculum framework and in teaching and learning approaches; and that IPE opportunities must be provided for collaborative practice as part of workplace experiences (ANMAC, 2012). This change has required all nursing programs, leading to registration, to embed IPE into nursing curricula. Owing to the 5 year accreditation cycle, the majority of nursing curricula are yet to meet the standard relating to IPE. Meeting this standard will see an increase in the number of nursing programs seeking to develop curricula that embed IPE, and may provide opportunities for all nursing students to interact with students in other health professions. The 4DF will provide a clear structure for nursing programs that are developing curricula to consider each dimension and the dimensional concepts in order to meet the accreditation requirements for IPE. The second dimension of the 4DF relates to the competencies of health professionals. One of the key challenges is how to meet the

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different discipline-specific IPE curriculum requirements when, in Australia, there are no common national competencies for IPE. This is clearly a major challenge for the nursing profession and, indeed, all other professions. In contrast, the Canadian Interprofessional Health Collaborative (2010) has assisted in the implementation of IPE with the development of national competencies. The identification of IPE competencies is an important part of curriculum development and also is critical to the preparation of students and facilitators for IPP. They provide the structure for assessing student performance in IPP. With regards to curriculum design and coordination, major challenges exist for individual institutions as they seek to develop and embed a well conceptualized, coherent and manageable approach to IPE across the professions. Given the relative size of the nursing cohort compared with other health professions this will require not only commitment from education providers but also commitment from the varying health professional disciplines teams involved planning curricula. O'Halloran, Hean, Humphris, and Macleod-Clark (2006) also recognized the enormous commitment required by organizations and academics in co-developing and implementing common IPE learning objectives for health and social care professions. Barr (1996, p. 343) also described the “need for joint planning between all the parties, for give and take, and for sensitivity regarding one another's preoccupations, before formulae can be found to which all can subscribe.” The third dimension of the 4DF pertains to the development of learning, teaching, assessment and evaluation experiences appropriate to IPE. This dimension needs to be considered with the fourth dimension as it focuses on the how of supporting institutional delivery. Curriculum development must also involve stakeholders in the curriculum development process and be considerate of future health care systems. There are also many other issues to consider in embedding IPE into curricula including, but certainly not limited to, student course level, numbers, access to different health professions, facilitation, resources and varied environments. These challenges have also been reported on by the social work discipline in Australia (Pockett, 2010). Often, the large cohorts of nursing programs add an additional challenge to the embedding of IPE across disciplines, and this requires a mix of approaches that are creative and build partnerships across disciplines and agencies external to educational providers. Salfi, Solomon, Allen, Mohaupt, and Patterson (2012) describe a framework for the implementation of IPE into a Canadian Bachelor of Science (Nursing) curriculum for nearly 2,000 nursing students that was delivered effectively across multiple sites, and has the potential to be utilized with other pre-licensure programs. Within the three Australian studies discussed in this paper, interprofessional simulation based education was described as one of the IPE activities that provide IPE opportunities for nursing students with students from other disciplines. Major financial commitments to the development of simulation technologies is now a feature of health professional education, with nursing playing a significant role in leading development and research in this area. The value of practice as part of learning experiences was identified as a key part of IPE activity in Australia. Howarth, Holland, and Grant (2006) emphasized the importance of providing opportunities for students to practice in interprofessional teams, with the ideal experience being in clinical settings. However interprofessional clinical practicums require collaboration and development of partnerships between tertiary institutions, health care providers and regulatory authorities (Missen, Jacob, Barnett, Walker, & Cross, 2012). Cross-institutional IPE learning opportunities also need to be considered to enable IPE. The WA qualitative study reported on a cross-institutional IPE initiative where two universities, in collaboration with a residential and community aged care provider, implemented IPE placements for nursing, medical, physiotherapy, occupational therapy, speech pathology, social work, dietetics, nursing and pharmacy students. However, the variability between each university's calendar

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requirements impacted on these IPE placements, which ultimately contributed to difficulties in timetabling. An important part of establishing interprofessional clinical practicums is to ensure that the work environment is adequately prepared to support student learning and that facilitators are experienced in interprofessional supervision. Health Workforce Australia have developed a National Clinical Supervision Competency Framework (Human Capital Alliance, 2012) that provides generic competency requirements associated with the roles and functions of clinical supervisors across the educational and training continuum, and this will also build interprofessional collaboration and teamwork. 3. Conclusion The narratives, statistical data and findings of the three studies present a rich, complex and evolving picture of IPE in Australia presently. This picture, we think, resonates globally. Whilst the picture is of conceptual and practical diversity, with major gaps in knowledge, curriculum and educational approach, the studies also identify areas of convergence and shared aspiration. Critically, they identify recognition across government, regulatory bodies, the professions, health service providers and universities as to the importance of IPP and the need for well conceptualized, well designed and effectively implemented IPE. Achieving this goal is clearly challenging, requiring work from all health professions. A significant outcome of this research has been the development of the 4DF. We have framed the key challenges for developing IPE for nursing in Australia around the dimensions of the 4DF. This framework articulates well with the philosophy of nursing which promotes holistic care with a patient/client centred focus within a collaborative model of care practiced in dynamic social systems. Nursing was discussed as having a central and leading role in this area. Its size, diversity and important role in all areas of health care practice position nursing as ideally placed to lead and model the professional, and interprofessional, in curriculum design and educational practice. Acknowledgments Support for this research has been provided by the Australian Government Office for Learning and Teaching/the Australian Learning and Teaching Council, Health Workforce Australia, and WA Health. We acknowledge the work undertaken by The Interprofessional Curriculum Renewal Consortium (Australia). References Australian Nursing and Midwifery Accreditation Council (ANMAC) (2012). Registered Nurse Accreditation Standards 2012. ANMAC. Canberra. Retrieved from. www. anmac.org.au Barnsteiner, J., Disch, J. M., Hall, L., Mayer, D., & Moore, S. M. (2007). Promoting interprofessional education. Nursing Education Outlook, 55(3), 144–150.

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