The Modified Readiness for Interprofessional Learning Scale in Currently Practicing Athletic Trainers

INTRODUCTION

A focus on interprofessional practice (IPP) has occurred across health care disciplines with the impetus to improve the quality of patient care.¹ Interprofessional practice emphasizes collaborations among numerous health care professionals, patients, and their caregivers to deliver whole-person health care to improve patient outcomes.² However, IPP is a complex process that often requires formal training to optimally implement.¹ Interprofessional learning or education (IPE), defined as 2 or more professional groups learning with, from, and about each other, is a necessary form of training that should occur regularly in professional programming.³ It is through IPE activities that students from multiple disciplines can understand the complexities and benefits of working in a health care team and become effective at IPP postlicensure.³ Therefore, the Interprofessional Education Collaborative Expert Panel developed core competencies to facilitate effective development of IPE curricula across health care disciplines.²

Specific to athletic training education, the Commission on Accreditation of Athletic Training Education has standards delineated in the 2012 professional standards which address IPE specifically.⁴ In addition, 1 of the 6 core competencies implemented in the 2014 postprofessional standards⁵ for postprofessional programs is dedicated to IPE and IPP. These standards^4,5 demonstrate the value and importance of these concepts in athletic trainer education and the impact they will have on athletic trainers after graduation from a professional or postprofessional program. As continued advances in IPE in athletic trainer education are ongoing, thousands of credentialed athletic trainers are currently practicing in various settings who may need additional formal IPE opportunities. Most of the health care professionals with whom athletic trainers might collaborate need continuing education units (CEUs) to maintain their qualification(s).⁶ The development of interprofessional CEU opportunities, or continuing interprofessional education (CIPE) units, where “2 or more postlicensure health care professionals learn with, from, and about each other,”^6(p143) may be an avenue to further grow practicing athletic trainers' IPP abilities. Different types of CIPE activities can be offered including practice-based, distance-based, and electronic-based learning activities.⁷ In order to assess the effectiveness of CIPE units and to gauge attitudes and readiness of health care professionals for IPE and IPP, a developed outcome measure should be used. It is through the use of a reliable and valid instrument to compare IPE readiness, effectiveness of experiences across disciplines, and time that improved IPE methods are promoted.⁸ One of the early tools established for this purpose, the Readiness for Interprofessional Learning Scale (RIPLS) was developed for use in health professional students⁸ and has been adapted and widely used since.^3,9–15 Eventually, the RIPLS was modified (mRIPLS) for use in postcertification health care professionals as the need arose for an outcome measure which could assess postcertification or practicing health care professionals' beliefs toward IPP and IPE.¹⁴ Previous research has explored the use of the RIPLS and mRIPLS in students or practitioners from various health care professions, such as nursing,^3,9,10,14 physicians,^3,9,10,13,14 and pharmacists^3,9,10,13,14; however, little is known about the usefulness of this instrument in practicing athletic trainers. Therefore, the purpose of this study was to determine select psychometric properties of the mRIPLS in practicing athletic trainers. Specifically, we determined the internal consistency, performed an exploratory factor analysis, and examined the mRIPLS for ceiling and floor effects in practicing athletic trainers. This information will provide the impetus to further explore the use of this instrument in practicing athletic trainers who participate in CIPE learning activities or echo recent evidence which suggests the mRIPLS should not be used as an evaluative scale.¹⁶

METHODS

Participants

The population of interest was members of the National Athletic Trainers' Association (NATA) who are currently certified by the Board of Certification and practicing in the college/university, secondary school, clinic, hospital, and professional sports settings in the United States. The NATA identified the members who met the study inclusion criteria and randomly selected 2000 members to receive the survey via e-mail. This study sample was believed to be adequate since the purpose of this research study was to determine the internal consistency and examine the mRIPLS for a ceiling effect. A total of 8.7% (n = 173) subjects accessed the survey and participated to some degree. Of these 173, 83.8% (n = 145) completed the survey instrument entirely (92 females, 53 males). The participants were credentialed athletic trainers currently practicing in the collegiate (n = 143), physician's office (n = 1), or physical therapy clinic (n = 1) and members of the NATA. Additional demographic data can be found in Table 1.

Table 1.  Demographic Characteristics of the Participants (n = 145)

^a Urban defined as 50 000 or more people, urban cluster defined as between 2500 and 50 000, and rural defined as less than 2500 people.¹⁶

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RESULTS

Psychometric Properties

Reliability

The mRIPLS demonstrated acceptable internal consistency in a population of athletic trainers with a Cronbach α = 0.872. The TWC and PC subscales demonstrated acceptable internal consistency with α = 0.917 and α = 0.862, respectively. Professional identity had the lowest internal consistency with α = 0.632.

Factor Analysis

The results of the Kaiser-Meyer-Olkin curve verified the sample was adequate (0.845), and the Bartlett's test of sphericity verified the correlations between the items were adequate for the analysis (P < .001). There were a total of 6 factors that had eigenvalues of >1 and >5% of the variance (Table 2). Further examination of the scree plot confirmed 6 distinct factors. The results of the factor analysis indicate the 3 original subscales discussed in the mRIPLS (TWC, PC, and PI) were not able to be replicated in the practicing athletic trainer population; thus, we were unable to confirm the structure of each factor in the mRIPLS as previously described.

Table 2.  Rotated Component Matrix for the Principal Component Analysis

^a  Questions adapted from: Reid et al.¹⁴

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Ceiling Effect

A visual examination of the ceiling effect for each question on the instrument can be found in the Figure. For 10 questions, over 50% of respondents scored at the highest level of agreement (highly agree), indicating a ceiling effect. Six of these questions came from the TWC subscale, and the remaining 4 were from the PC subscale (Table 3). When subjects who scored highly agree or agree were totaled for each question, 22 of the 23 questions had >70% of respondents selecting 1 of these 2 options (Figure). Further analysis revealed 12 of the 23 questions had ≥90% of subjects select agree or highly agree with the statement.

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Table 3.  Results of the Examination of a Ceiling Effect for Each Individual Item on the Modified Readiness for Interprofessional Learning Scale

Abbreviations: PC, patient-centeredness; PI, sense of professional identity; TWC, teamwork and collaboration.

^a Questions adapted from: Reid et al.¹⁴

^b Agreement indicates those that selected either agree or strongly agree.

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DISCUSSION

An increased emphasis has been placed on IPP in health care in recent years as a means to improve patient outcomes, reduce medical errors, and increase job satisfaction among practitioners.^1,18 Before IPP can successfully occur in the workforce, health care practitioners must learn interprofessionally. These IPE experiences can occur precertification or postcertification as part of the CEUs many health care professions require to maintain certification.⁶ Prior to development of IPE opportunities, in either the professional or postprofessional learner, the attitudes of potential students should be accessed to determine their level of interest in this style of learning and also to measure change in their attitudes post-IPE event. While previous literature discusses the inclusion of a needs assessment prior to the implementation of IPE, the assessment of the learner's readiness is often not included.¹⁹ The mRIPLS¹⁴ is one tool designed to fill this gap and assess the attitudes of postqualification health care practitioners toward IPE experiences.

The findings of this study contribute to existing literature exploring the use of the mRIPLS in practicing health care clinicians prior to formal IPE. The present study demonstrates acceptable overall internal consistency of the mRIPLS when used in certified athletic trainers. The TWC subscale in the present study had the highest internal consistency amongst subscales, which has also been reported previously for other types of learners.^14,15 The PC subscale in the present study (α = 0.862) demonstrated internal consistency, which was consistent with previous findings (α = 0.860).¹⁴ The lowest internal consistency subscale in the present study, PI, scored similarly low in existing literature in a professional population, with internal consistency estimates of α = 0.63 and 0.69, respectively.¹⁴ Therefore, this study demonstrates overall acceptable internal consistency for the mRIPLS in practicing athletic trainers. However, as identified previously, it is problematic when one subscale's internal consistency is not acceptable, such as the PI scale.¹⁶ Due to issues with subscale internal consistency in previous versions of the RIPLS, changes such as removal of the roles and responsibilities and addition of the PC subscale were made, which are also included in the mRIPLS used in this investigation.¹⁶ However, even with omissions and modifications to the subscales, the results of this investigation demonstrate the current reconfiguring of subscales currently used in the mRIPLS still does not elicit acceptable internal consistency, which remains problematic when examining the use of this instrument in IPE learning environments.

We also performed an exploratory factor analysis to examine the construct validity of the 3 subscales for the mRIPLS when used in a practicing athletic trainer population. The results of the factor analysis revealed 6 factors, only 1 of which mimicked the original reported PC subscale (factor 2). The items in the PI subscale, the subscale with the lowest internal consistency, were divided among 3 factors (factors 4, 5, and 6). Finally the TWC items were divided between 2 factors (factors 1 and 3). Therefore, the construct validity of the mRIPLS proposed subscales were unable to be replicated in practicing athletic trainers, which has been reported previously for versions of the RIPLS.¹⁶ These data in combination with the internal consistency values suggest the psychometric properties of this instrument are not sufficient for future use.

The results of our study demonstrated a ceiling effect for questions throughout all subscales. The researchers hypothesize this could be because a majority of the athletic trainers who responded practice within the collegiate setting and are already practicing collaboratively, as demonstrated in Table 1, and thus are more likely to see the value in IPP. Because of the large number of respondents who scored in agreement with each statement, the mRIPLS is unable to dichotomize respondents into those who are ready or not for IPE/IPP. In addition, the ceiling effect makes the mRIPLS limited in its ability to show improvements in attitudes toward IPE/IPP over time and specifically after learning activities. For these reasons and the previously discussed consistency issues, the mRIPLS, like the RIPLS, may not be suitable for use in assessing attitudes toward IPE in practicing athletic trainers.

LIMITATIONS

This study is not without limitations. First, other psychometric properties such as test-retest reliability and responsiveness of the survey instrument were not assessed. In addition, this research study had a small sample size largely due to the small response rate. The response rate for recent surveys which include athletic trainers as participants varies greatly across the literature. Surveys examining concussion practices have reported a high response rate of 25%.^20,21 Recent surveys that examined burnout²² or evidence-based practice²³ report smaller responses rates of 15% and 11.67%, respectively. These findings illustrate the variability of response rates of online surveys. The authors acknowledge the response rate of the present survey is low, and the small sample size necessitates all results be interpreted with caution. Furthermore, there was limited variation in age, years credentialed, and degree obtained for the participants that responded. Therefore, the generalization of these results to all practicing athletic trainers is cautioned. Additionally, the use of the RIPLS, and indirectly the mRIPLS, has been critiqued for issues involving reliability and validity.¹⁶ While studies on the psychometric properties of the RIPLS are prevalent, they still remain inconclusive.¹⁶ In addition, because of changes from the RIPLS to the mRIPLS, most notably a change in population from health care students to practicing clinicians, it is unclear to what extent the concerning properties of the RIPLS are echoed in the mRIPLS.

Future studies should examine other instrument(s) that might better assess health care students' and practitioners' attitudes toward IPP and CIPE. Many instruments have been proposed, with varying levels of usage, which assess similar properties as the RIPLS and mRIPLS. For example, the Interdisciplinary Education Perception Scale has been used to assess perceptions of IPE programs.¹¹ This original 18-item scale, and its modifications, has been well studied in a variety of undergraduate students as a way to assess the effectiveness of IPE in this population.^12,24,25 While the Interdisciplinary Education Perception Scale has not been studied on a postcertification cohort, and it was not selected for this research study, determination of the psychometric properties of this scale in postcertification learners could be beneficial in the development of future CIPE programs. In addition, the Attitudes Toward Health Care Teams Scale has potential use for future CIPE program in the athletic trainer field. This 20-item measure was designed to measure changes in attitudes toward health care teams pre-IPE and post-IPE or CIPE programing.^26,27 Future research on the Attitudes Toward Health Care Teams Scale in practicing athletic trainers could be beneficial when determining the effectiveness or promotion of IPE or CIPE programs. While there are many instruments proposed in IPP literature, it is crucial to select a validated and reliable instrument to ensure quality IPP research.

Future studies should also examine ways in which the previously discussed evaluative scales can be interpreted as standalone instruments to examine which learners are ready for IPE or CIPE so the educational sessions can specifically target these populations of health care workers. For health care workers who are not ready for IPE, steps could be taken to improve their attitudes toward IPE before the individual attends a CIPE event. Using the scale in this manner can allow for an individual assessment of the needs of each learner and only implement IPE or CIPE events when the learner is ready and will be more likely to gain knowledge from the event.

CONCLUSIONS

For current athletic training students, the Commission on Accreditation of Athletic Training Education standards^4,5 and postprofessional core competencies mandate IPE and IPP experiences. A recent summary by the Interprofessional Education and Practice in Athletic Training Working group²⁸ reminded us that IPE experiences for students will provide them with the knowledge, skills, and abilities to understand their roles and the roles of other health care professions and how, together, they will contribute to effective, patient-centered care. However, IPE is similarly important for practicing clinicians and must be stressed postcertification as well. Continuing IPE events may provide learning activities that specifically focus on collaborative practice for those athletic trainers that are already practicing, along with the health care professionals in which they collaborate. While the majority of research on IPE focuses on prequalification, CIPE is not a new concept, but has yet to be ideally implemented.²⁹ Further research efforts should encourage the formal implementation of CIPE and the planning processes involved in the design, implementation, and evaluation of each program.²⁹ The use of evaluative scales to determine the readiness of the learners and the effectiveness of the education experience, through a tool like the mRIPLS, is a necessary. However, the mRIPLS does not appear to be an outcome measure that should be used in practicing athletic trainers.