Promoting Cultural Competence in Athletic Training Education: An Intergroup Dialogue Approach
Sport is an increasingly diverse context. This reality has prompted clinicians and educators to emphasize cultural competence education in athletic training. However, few efforts go beyond traditional, didactic methods and teach cultural competence in practically meaningful ways. One evidence-based approach that has potential to promote cultural competence in athletic training education is intergroup dialogue. To describe intergroup dialogue in concept and research, demonstrate why this pedagogy can support cultural competence in athletic training education, and detail what such an approach looks like in practice. Intergroup dialogue has origins in critical pedagogical philosophies and emerged as a part of broader social and political movements in the United States. Over the last 30 years, scholars have systematically employed and studied the approach in higher education. Intergroup dialogue is an interdisciplinary approach that teaches people how to communicate across differences. Guided by trained facilitator(s), this method can help participants develop an understanding of diversity and practical skills to constructively navigate social-cultural differences in order to improve relationships and effect positive social change. Intergroup dialogue can address the critical need for engaging pedagogy that helps athletic training students and practitioners develop cultural competencies. This method can equip those in athletic training with a critical awareness of social-cultural differences and practical skills to provide culturally sensitive care and promote equity. Athletic training educators can consider intergroup dialogue as a promising pedagogical approach to promote cultural competence in athletic trainingContext
Objective
Background
Description
Clinical Advantage(s)
Conclusion(s)
KEY POINTS
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Intergroup dialogue is a research-informed approach that can be used to address the critical need for promoting cultural competence in athletic training.
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Intergroup dialogue has potential to equip future and current athletic trainers with critical knowledge, awareness, and skills to provide quality care to athletes with diverse identities.
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The sequential design and reflective and experiential activities integral to intergroup dialogue align with and could enhance existing educational initiatives in athletic training.
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This paper details the 4 key elements of intergroup dialogue and describes a step-by-step guide on how to implement this educational technique along varied time frames.
INTRODUCTION
Sport is an increasingly diverse context.1,2 Demographic information from the National Collegiate Athletic Association (NCAA), for example, shows a greater representation of student-athletes with diverse identities and backgrounds.3 This trend necessitates that future and current athletic training professionals possess culturally relevant knowledge and skills in order to provide effective care.4 Although cultural competence is an educational standard of the Commission on Accreditation of Athletic Training Education, efforts to teach this concept in practically meaningful ways can be improved.4,5Cultural competence in athletic training concerns practitioners' capacity to assess, appreciate, and respect individuals' unique backgrounds (eg, race, ethnicity, gender, sexual orientation, and religion) in order to make medical decisions and minimize inequities in health care.5 While athletic training students and professionals recognize that cultural differences exist, research shows that they are less confident about and capable of translating awareness into action.4 Moreover, limited evidence supports the efficacy of current approaches to integrate cultural competence curriculum into athletic training education.6–9 This paper presents intergroup dialogue as 1 promising method to do so. Definition of cultural competence and background information will set up an explanation of what intergroup dialogue is and how this approach may be used in athletic training education to promote cultural competence.
BACKGROUND
Cultural Competence
Cultural competence is an ongoing, iterative process through which individuals first develop a greater awareness of their own and others' social location.5Social location refers to an individual's social position given how certain social identities—such as race, gender, and religion (and their intersections)—afford them privilege. Thus, cultural competence includes, but is not limited to, knowledge of culture and ethnicity. Scholars credit transcultural nursing for pioneering the application of cultural competence within health care delivery.10 From this initial work, many cultural competence models for health care professionals emerged. Campinha-Bacote's10,11 framework is prevalent among sport medicine scholarship and educational texts on cultural competence. Specifically, this model posits that practitioners must develop a critical understanding of the self (ie, social location, beliefs, and biases), sensitivity to diverse identities of patients, and culturally responsive skills to effectively engage with others across differences. The model also asserts that cultural competence requires health care providers to gain a broader, critical awareness of systems of oppression (eg, health care inequalities) and their potentially marginalizing effects on individuals and communities with whom they work. While Campinha-Bacote's model and educational texts offer some conceptual and practical guidance on how athletic trainers might adopt a culturally competent practice, literature on effective training programs and specific pedagogical approaches that support athletic trainers' developmental process are less instructive. This paper aims to fill this gap and offer 1 innovative, practical approach—intergroup dialogue—for cultural competence development in athletic training.
An Intergroup Dialogue Approach
Intergroup dialogue is an interdisciplinary approach that blends theory and experiential learning to teach people how to communicate across differences.12,13 This structured process of social and intellectual interactions helps individuals of different social identity groups gain an understanding of diverse identities, critical awareness about biases and social inequities, and practical skills to strengthen interpersonal relationships and promote social justice. Intergroup dialogue has origins in critical pedagogical philosophies14 (eg, Paulo Freire15) and emerged as a part of 20th-century social and political movements in the United States. This approach also stems from Gordon Allport's (1954)16 theoretical and empirical work on positive intergroup contact. As such, the dialogue space ideally has an equal representation of social identity groups (eg, race) in order to balance power and voice and nurture positive intergroup interactions.17 More recently, scholars and practitioners have systematically employed and studied the approach within higher education—with pioneering work done through the University of Michigan's Program in Intergroup Relations.12–14
Prior research indicates that intergroup dialogue facilitates critical thought about social identity and justice issues among undergraduate students.18,19 A multi-university study of intergroup dialogue lends further support to its efficacy to promote critical cultural awareness and action.12,13 The study showed that, when compared with control groups, students who engaged in classes that adopted a dialogic framework improved their intergroup understanding, relationships, and collaboration. They showed improvements in their knowledge about different social-cultural identities (eg, race, gender, and class); empathy and motivation to engage across differences; and commitment to social justice action. Intergroup dialogue programs and studies (eg, MSU Dialogues at Michigan State University) have been developed from this large-scale effort and corroborate these effects.14,17,20 Specific to health care education, an exploratory study of intergroup dialogue as pedagogy for promoting cultural competence among medical students offers preliminary evidence of positive participant experiences,21 and thus may have a place within athletic training education.
THE EDUCATIONAL TECHNIQUE: INTERGROUP DIALOGUE IN ATHLETIC TRAINING EDUCATION
This section outlines the “what” and “how” of an intergroup dialogue approach applied to athletic training education. After providing detail on the 4 key elements of an intergroup dialogue approach, this paper will describe a step-by-step guide on how to implement this educational technique (along varied time frames) according to its sequential design. The paper will conclude with a discussion of advantages and challenges of using intergroup dialogue to promote cultural competence in athletic training.
Key Elements of Intergroup Dialogue
Gurin and colleagues12,13 have done seminal work on intergroup dialogue in research and practice. They outline 4 key elements of intergroup dialogue that underpin existing practical models. These foundational aspects include emphasis on dialogue over debate; reflection and communication practices; engagement in a 4-stage sequential process; and trained facilitators.
Dialogue Over Debate
Dialogue requires learning to listen, asking questions, and committing to understanding the perspectives of others, even if not agreeing.12,13,17 Distinct from debate, dialogue is a style of interactive communication that facilitates understanding, rather than dismissal, of other perspectives. While disagreement can take place during dialogue, the underlying purpose is to add diverse perspectives to build a shared understanding (and broader pool of knowledge) rather than convincing others that one side of an argument has more merit (ie, debate). In intergroup dialogue, participants communicate with one another by asking questions to gather more information about another person's experience rather than invalidate other perspectives (eg, “Your perspective is different from my own. I have never thought about what my preferred gender pronoun is. Can you tell me more about your experience?”).
Reflection and Communication Practices
Through intergroup dialogue, participants engage in ongoing intra- and interpersonal reflection and communication through which they learn across differences.13 Reflective and communicative practices include thinking about and sharing one's own perspective, appreciating differences by actively listening to others; critically examining historical context, individual biases, taken-for-granted social norms and their potentially marginalizing effects; and building alliances with others to solve conflict. These iterative practices are intended to support intergroup understanding, relationships, and action. Research has supported these practices as central to the efficacy of dialogue programs.13,14,17,20
Within the context of athletic training education, for example, participants might reflect on a meaningful aspect of their identity (different from their professional role) and then take turns sharing that significant identity characteristic with a partner and actively listening to their partner's perspective. From this reflection and communication practice can follow a discussion about similarities and differences across pairs and the group, and how individuals' identity characteristics may affect their athletic training practice.
Four-Stage Sequential Process
Intergroup dialogue consists of a 4-stage sequential process.14,17 In Stage 1: Dialogue Foundations and Forming Relationships, participants get acquainted with one another and fundamental concepts and assumptions regarding dialogue. Stage 2: Exploring Differences and Commonalities concerns understanding social identity differences and similarities within and across groups, and how institutions afford power and privilege to certain social identity groups and disadvantage others.14,17 In Stage 3: Exploring and Dialoguing Hot Topics, participants reflect and dialogue about controversial social issues and consider how institutional inequities and individual biases operate in real-world contexts. Stage 4: Action Planning and Collaboration guides participants to consider how to apply their knowledge and skills learned through dialogue to promote social justice in their professional and personal lives. Further explanation of these stages and their application is provided in the step-by-step guide that follows.
Trained Facilitators
Facilitators play the most significant role in creating a successful learning experience for dialogue participants.13,17 For intergroup dialogue to achieve its intended effects, trained facilitators must uphold its key elements and guide knowledge sharing among participants through its sequential design over a designated time frame.9,10,13 Effective facilitators support participant learning (and their own) by properly framing the space for deep reflection and discussion that challenges status quo assumptions. They pose open-ended questions that provoke critical thought among participants, and structure and reinforce the intergroup setting to be a brave space. A brave space encourages participants to “stretch” themselves by sharing their perspective, embracing mistakes as learning opportunities, and considering points of view different from their own.22 Facilitators must also ensure that socially marginalized voices are heard so as not to enact existing social inequities and power dynamics.20 Having 2 facilitators who represent different social identity groups (eg, race) to guide the dialogue can best ensure power is balanced. And, while not always possible, having facilitators with 2 distinct social identities (eg, race and gender) is ideal in order to attend to the multiple, intersectional nature of our identities. Within this learning environment, facilitators can productively engage participants in experiential and dialogic activities (and serve as a model) to achieve desired outcomes.
Facilitator training may take various formats and lengths—from a full-day retreat (such as at a professional development conference) to semester-long commitment. Training focuses on learning about intergroup relations and facilitation techniques through experience as an intergroup dialogue participant.17 Thus, training may—in part—occur through participation. Some universities and colleges offer intergroup dialogue participation and facilitator training opportunities (typically supported by their inclusion and intercultural initiatives offices), which athletic training educators and practitioners can explore. While Kaplowitz and colleagues17 recommend that formal training programs best prepare facilitators, they acknowledge that educators may not have such programs available to them and support those who may choose to start facilitating after reading about intergroup dialogue and training guides on facilitation.
Using Intergroup Dialogue in Athletic Training Education: A Step-by-Step Guide
This section features a step-by-step guide for implementing intergroup dialogue in athletic training education. The 4-stage sequential process (listed above) can take place over varying time frames and consist of single or multiple sessions.17 The Table overviews one 90-minute session including workshop components, description of activities along with facilitator notes, and debrief questions. While short-term interactions can be educational and raise awareness, recurring experiences are most effective to build intergroup trust, deeply explore identity differences and similarities, and hone practical skills. The curriculum for this single session is meant to serve as an example and can be built out and extended over a longer time period. Just as specific activities can pertain to 1 stage (or many stages) of the sequential design, so too can whole sessions. It is also important to note that stages are not necessarily discrete, but are interrelated. Regardless of program length, each dialogue meeting begins with a group relationship building exercise and then engages participants in key concepts, main activities, and a closing.17 Content (eg, social-cultural topics) may vary based on participants' prior knowledge and experience.
Stage 1: Dialogue Foundations and Forming Relationships
Facilitators first frame the dialogic space as brave by working with students to co-create ground rules: communally agreed-upon ways of being and interacting in a group. They regularly refer back to these group norms throughout their participation and emphasize that all participants have the option to opt in or out of any activities at any point. In a multisession program, facilitators could devote more time in initial sessions to familiarizing participants with foundational dialogue concepts and engaging group members in trust building activities compared with the brief time allotted for these components in a single session.
Stage 2: Exploring Differences and Commonalities
Facilitators introduce students to relevant concepts related to diversity, cultural competence, social identities, privilege, oppression, and historical, systemic (health care) inequity. Concepts are meant to give participants common terms to critically think and dialogue about individual and institutional forms of privilege and oppression generally and how these play out in athletic training specifically. Protected time during multisession programs can allow facilitators to provide greater depth of information on historical content and complex concepts (eg, implicit biases, microaggressions, and deconstructing whiteness). Participants then engage in self-reflection, active listening, small- and large-group discussions, and problem-based activities to elucidate key terms. These exercises encourage students to (a) think critically about their own identities and privileges (or lack thereof); (b) listen to others' lived experiences; and (c) problem solve situations of social and cultural difference. These exercises foster perspective taking and group cohesion.
Stage 3: Exploring and Dialoguing Hot Topics
Prevalent “hot” topics and “challenge moments” involving social-cultural differences that might arise in athletic training are most effectively addressed once participants have built trust and understand key concepts and dialogue practices. Facilitators along with participants can identify critical issues and challenging real-world scenarios that are significant to their health care context and work through strategies to resolve these in culturally sensitive ways. Discussion of prevalent issues involving individual and institutional privilege and oppression can be challenging, but these difficult conversations present valuable learning opportunities to reinforce dialogic concepts, group norms, and communication skills previously learned. Sample scenarios might include addressing how to avoid and/or interrupt harmful racial or gender stereotypes and honor others' (and communicate about) religious beliefs and health-related preferences. Lengthier dialogue curricula can devote whole sessions toward the end of their programming to more fully attend to “hot” topics.
Stage 4: Action Planning and Collaboration
Facilitators conclude dialogue with a closing activity that gives participants an opportunity to reflect on what they have learned and apply that knowledge to their professional and personal life for cultural competence promotion. Structured debriefs (listed below) can also take place after activities within a given session to guide critical reflection and learning that can later inform action. Within lengthier programs, facilitators can devote a final “closing” session to action planning that allows participants to identify short- and long-terms goals and foreseeable challenges.
Preliminary Evaluation
Intergroup dialogue, considered in light of the extant peer reviewed literature, has yet to be systematically applied to athletic training education to teach cultural competence. In an exploratory project, the author employed an intergroup dialogue approach among athletic training undergraduates (from 1 university in the Midwest region of the United States), which offers initial evidence for its feasibility and potential utility.23 The pilot study examined students' perceptions of their experience through participation in a 90-minute, in-person workshop using qualitative study design. The workshop was designed around 3 learning objectives for students, define concepts related to cultural competence, apply concepts to deepen students' understanding of themselves and others, and develop practical skills to support cultural competence in athletic training. After the workshop, students (more than half of workshop participants, or n = 12) participated in semistructured focus group interviews of 3 to 5 students each. Abductive analysis of qualitative data revealed key themes specific to 2 sensitizing concepts: workshop impact and process outcomes. Specifically, participants expressed experiencing improvements in their knowledge, practical skills, and behavioral intentions regarding cultural competence because of participating in the intergroup dialogue workshop. While a more rigorous evaluation is necessary, findings serve as preliminary evidence for the efficacy of using intergroup dialogue to promote cultural competence in athletic training.
Advantages
Intergroup dialogue is a promising, research-informed approach that can address a critical need within athletic training: the lack of educational techniques to promote cultural competence. Previous research6–9 in athletic training education calls attention to the inadequacies of traditional, didactic learning of cultural competence to bridge the education-to-practice divide. Researchers explore and point to promising educational avenues, such as curricular integration of study away/abroad experiences.6 While cross-cultural exchanges may valuably increase students' cultural awareness, alternative approaches are worth exploring—in particular, those that minimize significant travel and cost requirements for students. An intergroup dialogue initiative would place minimal travel or financial burden on students and attend to recommendations to use varied tools and teaching styles so that “students can safely explore different cultures and values.”7 Thus, although systematic research and practice is necessary, intergroup dialogue aligns with and could enhance existing educational initiatives.
Conceptual and empirical work lend further support to the use of intergroup dialogue in athletic training and health care education. Reflective and experiential learning activities integral to this approach are shown to be effective among athletic training students.9 Given the few studies on educational techniques for the promotion of cultural competence in athletic training, drawing on research from other health care professions (eg, nursing) is helpful. For example, Cueller et al24 put forth curricula for cultural competence training among undergraduate nurses. Their sequential design aimed to help students understand diversity concepts, foster critical inquiry about institutional oppression and health care inequities, and navigate context-specific issues. Recent studies also demonstrate the efficacy of critical self-reflection and active engagement of learners in using real-life experiences to expand participants' perspectives.25 Last, Bristol and colleagues26 employed interdisciplinary training on gender identity and sexual orientation among health care providers. Their curriculum involved a 2-hour facilitator-led session with varied instructional, interactive methods. Results showed that their program increased awareness, attitudes of openness and acceptance toward patients, and knowledge and skills related to sexual identity and orientation. Taken together, research demonstrates that a sequential design and pedagogical strategies of various cultural competence training programs in health care are in keeping with an intergroup dialogue approach.
Challenges
Despite the promise of an intergroup dialogue approach, 2 potential challenges are important to consider for effective integration in athletic training education: the need for trained facilitators and dedicated curricular time and space for programming. First, trained facilitators are vital to successfully deliver the dialogue curriculum. Facilitators must be familiar with intergroup relations and use strategies to invite and sustain all voices, especially those of socially marginalized groups, to create a healthy dialogue environment. Without trained facilitators, instructors may risk marginalizing already minoritized individuals/groups and reproduce oppressive power dynamics.13,17 Facilitator training programs (of varying durations) exist in many US universities and colleges. However, access to training opportunities for athletic training educators is a practical challenge, and perhaps most accessible if professional conferences were to offer training. Second, while short-term interactions can be impactful, intergroup dialogue—like cultural competence—is a process. Sequential, recurring experiences and allocation of sufficient time for foundational dialogue stages are needed to effectively engage future and current practitioners in their cultural competence process. Young and Guo27 similarly remark on the difficulties of incorporating such training in nursing. But they implore that health care educators prioritize cultural competence—expanding roles of leaders in health care education and developing strategic planning for its wholescale integration. While protected time and space for such development (and training) are practical challenges, overcoming these barriers is essential to actually promote cultural competence.
CONCLUSIONS
Intergroup dialogue is a research-informed approach that can address the critical need for promoting cultural competence in athletic training. This framework has potential to equip future and current athletic trainers with critical knowledge, awareness, and skills to provide quality care to athletes with diverse identities and promote equity.
Contributor Notes