Interprofessional Education and Practice in Athletic Training

History

Though the impetus to use an IPE model to prepare future health care workers may be novel to athletic training and some health profession educators in the United States, it is certainly not a new concept.⁷ In 1910, in his address to the graduates of Rush Medical College, Dr. William Mayo stated, “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary.”^8(p1) The movement of IPE and IPP is a worldwide movement that has been in existence for over 30 years.^7,9 The World Health Organization (WHO) has recently fostered the focus on IPE, as historically, European and other countries have influenced IPE though coordinated initiatives.³ The models developed have been adopted and implemented in the United Kingdom, Australia, and Canada. In comparison, the United States' implementation of IPE initiatives has traditionally occurred in response to the unique needs of specific educational situations,¹⁰ resulting in discrete curricular events, such as the creation of interdisciplinary health care courses.^11,12 However, as governmental focus on and incentives for IPE in the United States have increased, the number of IPE investigations originating there have also noticeably increased, adding to scholarship produced in Canada, Australia, Sweden, Belgium, and the United Kingdom.¹³

Historically, there has been very little scholarship on athletic training and IPE. The continued development and promotion of athletic training as a health profession has been a professional concern, and the further evolution of educational programs is regarded as a key to continued improvement.¹⁴ “To protect the viability of our professional roles within a changing health care market, we must critically and strategically evaluate the strengths and weaknesses of our current model of pre-professional, professional, and post-professional education in relation to those of other health professions.”^15(p40) One of the most significant developments in athletic training occurred on June 22, 1990, when the American Medical Association House of Delegates officially recognized athletic training as an allied health profession.¹⁶ A related major milestone in the professional preparation of certified athletic trainers occurred when the NATA Education Task Force recommended in 1996 the elimination of the apprenticeship-based route to earn the ATC credential to “standardize athletic training education and enhance consistency with professional preparation in other allied health disciplines.”^16(p60) The Board of Certification formally eliminated the internship route to certification after the 2003 exam cycle. Despite these changes and the persisting stakeholder desire for athletic trainers to be universally recognized as health care providers, many in the medical community remain ignorant of the profession's evolution and educational standards. “Maintenance of the status quo might be very attractive to a large segment of our profession, but the prevailing model is unlikely to promote athletic training in the eyes of the medical community or advance the knowledge base of the profession.”^15(p40)

Organizational Recognition

Interprofessional education and IPP have been recognized as effective means of improving health care by the Institutes of Medicine,^17–19 the National Health Service,¹⁹ the Association for Prevention Teaching and Research,¹⁹ the National Academies of Practice,¹⁸ the American Public Health Association,^17–19 and the WHO.^17–19 Although IPE has been defined by a variety of professional groups,^4,19,20 the definition developed by the WHO is most frequently used: IPE is “an action that occurs when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.”^4,19(p76) Both IPE and IPP initiatives are grounded in the theory that patient care will improve as health care professionals work in a collaborative manner.^4,17–20 Table 1 includes terms commonly used in IPE and IPP and their definitions.

Table 1. Definition of Terms^1,2,25,26

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Societal Needs for IPE and IPP

Interprofessional education can be a useful vehicle to ensure understanding different health care professions' scopes of practice, effective collaboration methods, and potential patient benefits. Societal changes have contributed to an increased need for IPE and IPP by allowing for more health care specialists to emerge and contribute to efficient care coordination, reduced medical errors, improved patient advocacy, and reduced health care costs. Furthermore, increasing numbers of chronic condition diagnoses have stimulated the need for preventative practice across multiple health care professions, which, in turn, requires technological advancements to allow for more accurate analysis of patient outcomes and easier communication among health care team members.^4,19 Therefore, as expansion and overlap in care provided by health care professionals continues to increase, effective collaboration among health care teams has gained critical importance.⁴

Current literature and health care organizations have identified the need for interprofessional care as a means to enhance patient care. The WHO developed the foundational theory of IPE, which was then expanded into a set of core competencies to facilitate implementation and assessment in professional programs. Likewise, implementation of IPP in the workforce requires that students become acculturated through the educational process. A framework has been designed to assist in the interprofessional socialization (IPS) process by integrating social identity theory and intergroup contact theory.^21,22 This IPS process enables educators and students in multiple health professions to identify common concepts that may affect patient outcomes. It also helps students work with and learn from other professions. The model builds collaborative health professionals who can identify patient needs and follow through with specific team based interventions. Furthermore, integrating IPE and addressing its core competencies may prepare graduates to enhance clinical practice as interprofessional team members.²³ These core competencies, developed by the Interprofessional Education Collaborative Expert Panel, are based on the 4 domains listed in Table 2.²⁴

Table 2. Interprofessional Collaborative Practice Core Competencies

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The IPE sequence can be described as a continuum with 3 progressive steps. The first step, interprofessional preparation, drives the second step, effective teamwork, which in turn may produce an outcome of improved service and patient care.³ Interprofessional education programs “should reinforce preparation for teamwork and encourage students to be responsive to innovative, flexible and change-oriented practice.”^3(p77)

Involvement of Athletic Training Programs in IPE

Athletic training faculty and students could enhance both the athletic training programs and the IPE programs. The CAATE's Accreditation Standard 44 states, “Students must interact with other medical and health care personnel.”^5(p6) Participation in an IPE program is a viable option to assist in compliance with that standard and may also help socialize athletic training students as health professionals. Furthermore, IPE may help improve the athletic training program's recognition as a health profession program at its institution, by peer professionals, and by the public in general.

To date, there is very little evidence regarding the nature of IPE in athletic training. In 2011, Breitbach and Cuppett²⁷ surveyed the program directors at all CAATE-accredited athletic training programs about their institution's and program's involvement in IPE. Of 365 potential respondents, 169 program directors (46%) completed the survey. When asked if IPE initiatives were occurring on their campuses, 112 (66%) reported no, 32 (19%) reported yes, and 25 (15%) were not sure. These data show that athletic training program involvement in IPE was limited in 2011.²⁷

Traditionally, the professions of nursing and medicine have been the driving force behind advances in IPE and clinical practice. The American Association of Colleges of Nursing identifies interprofessional learning as an expected competency for baccalaureate (2008), masters (2011), and doctoral preparation.⁵⁰ Along with nursing, pharmacy also includes IPE in its accreditation guidelines.⁵¹ The American Association of Colleges of Pharmacy advocated that “all colleges and schools of pharmacy provide faculty and students meaningful opportunities to engage interprofessional education, practice and research to better meet health needs of society.”^52(p5) The National League of Nursing recommends repeated and systematic IPE experiences, matching student levels across disciplines, where the gold standard for implementation of these experiences is carefully planned and developed simulations in order to gain appreciation for all skills the various professions provide in an environment where discussions can take place.⁵³

In a study assessing commonalities in IPE accreditation mandates across professions, Zorek and Raehl⁷ reported that accrediting agencies lack a collective mandate for IPE. Although health professions identify and recognize the importance of IPE and IPP, the current approach to IPE standards across health professions is uniprofessional. The authors recommended that establishing common IPE standards could provide a baseline preparation of IPE across the health professions. This approach offers a way to address the challenge of IPE for graduates to experience and appreciate other health profession roles and responsibilities, and the added ability to collaborate to improve the delivery of health care to patients effectively.⁷ Similarly, Hertweck et al⁴¹ suggested that educational programs should require each applicant of a health professions program to shadow different health care providers/professionals in varied health care settings as part of the admissions process. Furthermore, Jones et al⁵⁴ performed a review of the status of IPE in the first clinical experience of pharmacy students. Their review indicated schools with multiple health profession programs have more success with integration of IPE into the clinical environment. The review also identified a lack of tools to assess the efficacy of IPE integration into pharmacy practice experiences.

Physical therapy accreditation standards do not yet specifically require IPE. However similar to the CAATE standard for athletic trainers, these standards require that physical therapists collaborate with physicians, dentists, nurses, educators, social workers, occupational therapists, speech-language pathologists, audiologists, and any other personnel involved with the patient/client.⁵⁵ The physical therapy accreditation standards also state that (1) “the academic environment must provide students with opportunities to learn from and be influenced by knowledge outside of, as well as within, physical therapy;” and (2) “the physical therapist professional curriculum includes clinical education experiences for each student that encompasses opportunities for involvement in interdisciplinary care.”^55(p5)

A challenge athletic trainers must address is to develop a more universally known understanding of their professional role. It is important in IPP that each discipline can come to the table with the ability to articulate their discipline's knowledge base to others.⁵⁶ Health professions pursue increasing educational preparation and consequent recognition of their clinical abilities. An important concept in the establishment of IPE and IPP in athletic training is the ability to communicate the scope of our knowledge, skills, and abilities and value as part of the health care team with others.

The athletic training profession can also learn from nursing and medicine in its IPE journey.⁵⁷ Answers to the major questions as to when to implement, how long, and what is required are crucial to the success of IPE. Interprofessional education experiences can vary, and can be adapted to institutional needs and resources. Examples of the possible learning activities are listed in Table 3. Athletic trainers should be committed to understanding the capabilities of the various health professionals, respect and recognize their value, share a common vision, and communicate goals for better health care and education.⁵⁸ In return, athletic trainers must provide the best care possible in all situations and be open to and embrace collaborative efforts in both educational and clinical environments to further solidify our place as part of the interprofessional team.

Table 3. Interprofessional Pedagogy Matrix

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Students

It is reported that students' participation in IPE increases their understanding of (1) scope of practice of theirs and others' health professions, (2) values of health professions, (3) language and actions appropriate for patient/client–centered care, and (4) skills required in effectively working in an interprofessional team.⁵⁹ Health profession students in IPE initiatives favor IPE more when the experiences are directly relevant to their current or future practice,¹⁰ and collaborative practice increases efficiency and understanding of interprofessional roles.⁶⁰ Further benefits include deconstruction of negative stereotypes, improvement in level of confidence for communicating across professions, and a positive influence on students' willingness to continue learning together throughout their professional preparation.⁵⁹ Interprofessional education helps students understand their own professional identity while gaining an appreciation for other professionals' roles on the health care team.⁶¹ Additionally, students perceive that the team approach benefits their patients, keeps them more enthusiastic, and helps them make better patient care decisions.⁶² The ultimate goal of IPE is to prepare preservice students to work effectively in interprofessional teams once they become in-service practitioners. The goal of IPP, on the other hand, is to provide an approach to care that improves patient outcomes.⁵⁹

There are contradictory approaches in the literature as to when to start IPE. For example, IPE may not be beneficial early in preservice education because students need to develop a clear sense of their professional identities before fully understanding the professional identity of others.⁶³ Others, however, postulate that it is important to develop a common framework of best practices early during professional preparation, even though students may not initially understand the complexities of interprofessional relationships.⁶¹

Early IPE experiences must be positive in order for participants to be successful.¹ Additionally, students must have a nonthreatening learning environment,¹⁰ and group balance, group mix, and group stability should be considered when developing IPE initiatives.¹⁰ Interprofessional education experiences that are real, are memorable, and enhance students' access to patients, caretakers, and communities are the ones found to stimulate and maintain interest and develop relationships among participants.⁴

Interprofessional education helps students understand their own professional identity while gaining an appreciation for other health care team professionals' roles.^61,64 During the IPE experience, roles for each profession should be clearly defined so that all students have the opportunity to engage as members of the interprofessional team. For example, athletic training students at a clinical site need to know their specific roles and responsibilities within a given team community to feel accepted into that community.²² This desire to be included in the team may also be true for IPE and IPP initiatives as well. Students must also be given the opportunity to socialize outside formal instruction to develop greater interprofessional awareness and bonding,^63,65 as socialization, where students learn how to work together in synergy rather than parallel to each other, is an important component of IPE.¹⁰

Faculty

Faculty members are critical stakeholders in IPE, and report benefits such as increased collegiality with other team members, greater opportunity to model interprofessional collaboration in the classroom and community, and increased scholarship opportunities.⁵⁹ However, there are also barriers that affect IPE and faculty, which should be acknowledged and discussed when constructing IPE experiences. A significant obstacle for faculty involved in IPE includes understanding the full scope or breadth of the other professions. For example, faculty from different health professions may come into the experience with different professional values, cultures, and biases that affect their personal perception of professional roles in a collaborative environment.⁶⁶ Therefore, it is important that faculty develop professional trust among team members⁴ and work to model interprofessional collaboration by developing, supporting, and sustaining collaboration across participating disciplines. Many faculty and preceptors have not been formally instructed in team approaches during their professional education; therefore, they likely do not have explicit training in leading, or being part of, collaborative efforts.⁶³

Common collaborative methods to enhance and forward goals of IPE include formal coursework, clinical/fieldwork (practice) education, and information technology.^10,63 Interprofessional education is more than just putting multiple disciplines into the same class. These activities must include specific and measurable objectives and evaluation metrics to assess outcomes.⁶³ Unfortunately, there is uncertainty about how to measure IPE competency-based models. One school of thought postulates that a multi–point-of-view approach should be used to plan and evaluate the outcomes and value of IPE.⁴ When used correctly, community-based health professionals can help faculty understand patients' and future employers'⁴ needs and priorities in order to identify purposeful goals during the planning phases. Faculty members may also need training and development in the construction, implementation, and assessment of IPE learning experiences based on input provided by health care providers.

Faculty support from higher-level administration can facilitate a culture shift that embraces IPE organizationally. Examples of organizational barriers administrators can help overcome include class scheduling and facility availability.^4,59,66 Additionally, IPE can be very time intensive for faculty members to develop and deliver⁵⁸; therefore, administrators can adjust workload to compensate.⁶⁷ Interprofessional education initiatives are further enhanced when academic administrators support faculty involvement in IPE through appropriate merit increases and recognition of IPE activity during the promotion and tenure process.⁶³

Preceptors

Although preceptors are important stakeholders in IPE, there is little documented evidence in the literature that discusses the effects of IPE on them. However, it is likely that preceptors experience similar benefits and barriers to those epxerienced by faculty, and have also likely not had any IPE experiences during their professional education or training in leading or participating in collaborative efforts.⁶³ Because supervision during an IPE activity was found to be the most important contribution to student satisfaction during IPE experiences, interprofessional facilitation and leadership training may be an important preceptor development activity.²⁰ Furthermore, students learning from and with each other often stimulate greater IPP in their preceptors,¹¹ and IPE may increase IPP for preceptors. Lastly, future research on IPE should include the effects on preceptors.

Professional Identity and Communication in IPP

Much of the literature on interprofessional teams identifies the key barrier to team functioning as role confusion and medical dominance among the professions. Different beliefs or values can trigger a professional identity and therefore divergent interpretations of appropriate patient treatment and care. When there is confusion and tension, conflict, lack of respect among the professions, and professional stereotyping may arise.⁷⁴ Essentially, a balance must be met between the need for interdependence and the desire for professional autonomy.⁷⁵ Interprofessional practice provides the opportunity for professionals to describe their own roles and responsibilities to team members. Having mutual respect for and understanding of each other's expertise and strengths can enhance the delivery of patient care. Furthermore, sharing an understanding of each other's roles provides an opportunity to improve communication and collaboration, with an expected improvement in patient care.²⁴

Meaningful formal and informal communication among providers, as well as among providers, patients, and their families, is key to mutual understanding and collaborative patient-centered care.⁷⁵ Specifically, with the goal of eliminating role confusion, using skillful negotiation to overcome differences in viewpoints arising from different professional cultures is imperative.⁷⁵ Likewise, communication breakdowns, a lack of teamwork, and the creation of a hierarchical process can lead to fatal errors in patient management.¹⁹

Teamwork and Collaboration in IPP

Teamwork and competent collaboration add value by bringing about patient/family and community/population outcomes.²⁴ Finding one's own place within a team and recognizing each other's strengths fosters trust and respect among professionals, which allows for the provision of safer, more efficient patient-centered care.⁷⁵ Additionally, commitment and attraction to the team enhances members' abilities to work together cooperatively.⁷¹ For example, teamwork training during an interprofessional CE course improved perceived knowledge of other professions' competencies and participants' own professional competence and role, and profoundly contributed to the understanding of the importance of communication and teamwork to patient care.⁷⁰

There are some settings where athletic trainers and physical therapists have worked side by side with team physicians and other medical professionals with the objective to seamlessly provide health care. A successful working relationship is largely based on excellent communication and an overall understanding and appreciation for each other's role in delivering health care.⁷⁶ A growing number of orthopaedic physicians look to employ athletic trainers as physician extenders to increase practice efficiency, revenue, and productivity while ensuring patient education and satisfaction.⁷⁷

Learning Theory

There are many different pedagogical models in IPE initiatives, which often reflect the mission, context, and scope of their respective organization or institution. Ideally, models should connect learning theory to practice.^10,78 However, a review of IPE models published between 2005 and 2010 revealed that only 47% of the studies reported using learning theories in the development and implementation of an IPE program.¹³ Additionally, how the theories were used and which theories were most effective in IPE development was not always clear.^13,79 One of the most commonly used theories in IPE pedagogy is the adult learning and contact hypothesis, yet the link between IPE theory and IPP has not been well established in the literature.^13,79

Pedagogical Components

Much like the competency-based educational model used in health professions preparation, a similar approach is discussed for grounding interprofessional behaviors within a program or curriculum. Interprofessional education competencies should be agreed upon by the curriculum committee before curricular design begins.¹⁰ Frequently cited strategies for determining competencies included a review of the Core Competencies for Interprofessional Collaborative Practice,^24,67 a review of the accreditation requirements from the various professional health care programs that will be represented in the IPE program,¹⁰ and brainstorming the specific type of skills the IPE should be designed to foster in students.¹⁰ Examples of desired skills found in the literature included team building and clinical team skills,^{12,19,61,68,80} knowledge of the various professional roles and responsibilities,^61,67,80,81 professional responsibility, accountability, communication, and coordination,^12,19,61,80 service to others,^59,61,67 cultural competence,^61,80 ethical decision making,^12,59,67,80 shared decision making,¹⁹ conflict management and negotiation,¹⁹ leadership,^19,61 and patient-centered care.^19,59,61

Learning Experiences

Interprofessional education learning experiences can vary and be adapted to accommodate institutional needs and resources. Some IPE programs outlined in the literature were created by designing entirely new coursework.¹² However, more frequently, IPE programs used a mixture of existing and new courses to create the curriculum. Existing courses that were frequently embedded with IPE competencies and learning strategies included introduction to health professions, current issues in health care, scholarly inquiry/research, ethics, evidence-based practice, and practicum/clinical.^23,59 Most IPE curricula included 2 or 3 phases. Early phases were often more didactic⁶⁷ and emphasized the roles and responsibilities of the student's own profession and other professions,^61,67,80,81 communication,^12,19,61,80 collaboration and team building,^{12,19,59,61,80} ethics and morals,^12,59,67,80 legal issues,⁶⁷ and/or patient safety.⁶⁷ A model also exists for an interprofessional simulation experience during this introductory phase.²³ Late phases were often more clinically based,^13,67 and in addition to the early-phase goals, emphasized patient-centered care in professional practice,^19,59,61 leadership,^19,61 behavior demonstration in professional practice,⁸¹ advocacy through group community-based projects,^59,67 and/or prevention through group community-based projects.^61,67 Table 3 lists examples of IPE learning activities arranged by educational context and resources required for implementation.

Teaching Strategies

The literature offered a wide variety of teaching strategies used to deliver IPE. These teaching strategies included both small-^10,13 and large-group formats,¹³ as well as didactic (both face to face and online),⁶⁷ observational learning/analysis,¹⁰ and experiential learning techniques.¹⁰ Teaching strategies found in the literature included reflection exercises,^{10,13,20,67,80,81} small-group discussion,¹⁰ case studies,^10,13 problem-based learning,^10,13 simulation,¹³ community projects,^13,59 vignettes,⁶⁷ role play,¹⁹ and literature review projects that require evidence from various professions' research sources.⁵⁹ Many authors emphasized that regardless of the format or specific learning strategy used, reflection is particularly important to the IPE process.^{10,13,20,67,80,81}

Service Learning

Service learning, as an IPE experience, may maximize the opportunity to understand patient-centered care and the importance of collaboration among health professionals.⁸¹ Collaborative work among health care professions is key to quality interprofessional patient/client care, and is now considered a high priority, as concerns about patient safety, health and human resources shortages, and effective and efficient care have reached epic proportions. Service learning is an easy way to overcome many of the IPE challenges such as varying schedules, while providing the students opportunities for collaborative learning outside the traditional academic setting.⁶¹

Facilitation of IPE Learning Activities

Emanating from pedagogical theory are instructional practices, and in the case of IPE, this means effective facilitation.^10,63 Because IPE can occur in both didactic and clinical settings, traditional instruction by the “expert teacher” rarely occurs.¹⁰ As such, faculty development is necessary to provide the requisite facilitation skills.⁸¹ Freeman et al⁸² describe several components of facilitator training: (1) agreement of the learning objectives; (2) presentation of the underlying theory, background, and context; (3) small-group work; (4) role play of the learning group; (5) discussion and reflection on the facilitator's role and skills; (6) effective training material; (7) ongoing support and opportunities for development; and (8) evaluation and review. Although this theory has not been evaluated specifically, similar studies have validated several of the aforementioned principles.⁸³ In particular, facilitators appreciated ongoing support and regular contact with other facilitators to reflect and debrief on their activities.⁸³ Effective IPE facilitation requires increased faculty meeting times outside of class to ensure grading consistency, modeling of interprofessional collaboration, and currency of content.⁵⁹ As with any instructional practice, the need to evaluate effective facilitation also exists. Sargeant et al⁸⁴ developed and validated an instrument that reliably evaluated the ability of facilitators to contextualize and encourage IPE interaction after the completion of a training program.

Pedagogical Barriers in IPE

Despite being recognized as a valued mechanism for communication, collaboration, cooperation, and improved patient outcomes, IPE is not without barriers that can significantly impact a program's success and sustainability. Such barriers or inhibitors can be categorized as intrainstitutional or extrainstitutional.⁸⁵ As with other educational programs, a lack of financial support for IPE can significantly impact implementation. In many cases, funding for IPE is derived from grants or similar initiatives. Once the grant expires, the program will often falter because of limited institutional resources.^66,86,87 Thus, it is critical that IPE programs receive consistent, long-term financial support from the institution.^{12,64,65,81,82} A second potential barrier to IPE implementation is the need for administrative support.^{6,13,66,67,86,87} Specifically, dedicated advocates or champions should be identified to steer interdisciplinary programming,^66,86 determine curricular changes to allow for IPE coursework and scheduling,^13,59 develop the IPE infrastructure,⁶¹ and manage faculty workload issues to allow for implementation of IPE initiatives^59,86 and faculty development.⁶⁶

Other major barriers from a personnel perspective stem from a failure of faculty to identify with other professions and a hesitancy to change coursework.^59,88 In order for IPE to prosper, it is important to have faculty buy-in.⁵⁹ Proposed techniques to encourage faculty involvement include exploring common goals, values, beliefs, and accreditation requirements with other professions^10,66; and establishing relationships with other health care programs, along with working to identify interprofessional support and a sense of community.^18,61 It is also noteworthy to remind faculty of the importance of modeling behavior expected of the students, as this further reinforces a culture of interprofessionalism.⁷⁸