Integration of Interprofessional Education Within the Didactic Aspect of Athletic Training Programs

Research Design

This study was qualitative in nature, specifically using a consensual qualitative research (CQR) design.^17,18 The CQR approach is based in the qualitative traditions of grounded theory, phenomenology, and comprehensive process analysis.¹⁷ Using this approach allowed the researchers to explore data and the phenomenon naturally through an inductive process, thus allowing results to be discovered with little bias from the researchers.¹⁷ We chose the CQR approach to explore athletic training educators' experiences integrating IPE within the didactic curriculum of their academic programs. The CQR process requires a research team to work together and discuss opinions on the data to arrive at consensus throughout each stage of the data analysis process.¹⁷ The key component of CQR is the group dynamic of respect, and each individual must feel safe to speak up and give their opinions.¹⁷ The research team consisted of 4 athletic trainers. In addition to equal collaborations on study procedures and interview protocol development, 1 member served as the primary recruiting contact person (D.H.) while a second member (S.F.) conducted all phone interviews to ensure consistency in data collection. Three team members (D.H., S.F., J.K.) conducted the primary data analysis. The fourth member (S.M.) served as an internal auditor in addition to the development and initial analysis roles. An external auditor was recruited to serve solely in this role after data analysis. This approach allowed the research team to provide various perspectives to the data and have subsequent discussion about its meaning, thus resulting in a greater understanding of the data.¹⁸

Participants

In spring of 2018, the clinical education coordinators (CECs) for the 107 identified CAATE-accredited professional master's athletic training programs were invited to participate in this study. In the event the invited CEC felt another program faculty member would better be able to speak to the integration of IPE in their program, the invitation was passed to that faculty member. Regardless of program faculty member role, inclusion criteria established that all participants must have been employed in their current faculty role for at least 12 months before participation and that the program was currently accredited and in good standing with the CAATE.

The CQR process recommends using 8 to 15 participants to include in a study using 1 interview.^17,18 A total of 17 program faculty who met the inclusion criteria responded to the request for participation and were included in our study. Demographic information of the program faculty can be found in Table 1. All program faculty provided consent to participate via e-mail and again verbally prior to each individual interview. The study was approved by the university institutional review board as exempt research.

Table 1 Program Faculty Demographic Data

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Instrumentation

A semistructured interview guide was developed by the research team and was dichotomous in nature (Table 2). The initial question related to whether IPE was being integrated within the athletic training program or not. Based on response, participants were tracked toward 1 branch of interview questions aimed to ascertain how IPE was being integrated into the program or to the alternative branch aimed to ascertain why IPE was not being integrated. Additional questions determined demographic information related to program faculty as well as IPE resources available at the associated institutions. To assist in content validation after interview script development, 2 athletic training educators who had experience as CECs, but did not meet the inclusion criteria of the study, reviewed the interview guide and provided feedback and suggestions. Changes were made per their suggestions, and the process was repeated until consensus was reached regarding the interview guide as appropriate to the research questions. Before data collection, the researcher conducting the interviews engaged in 2 pilot interviews to test the order of the questions, gain experience, and increase confidence in conducting the phone interviews. After pilot interviews were conducted and reviewed, alterations were made to the interview guide, specifically reordering of questions and wording or grammatical revisions. Data from these pilot interviews were not included in the analysis of data. In addition to the qualitative data, demographic data about the participants and the affiliated athletic training programs were collected via a Qualtrics (Provo, UT) online survey. The demographic survey was developed by the research team.

Table 2 Interview Questions

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Procedures

One research team member (D.H.) contacted all potential participants via e-mail and requested program faculty respond via e-mail if they were interested in participating and met the inclusion criteria. Once program faculty responded, they were sent a link to a demographic survey and a request to schedule a 30- to 45-minute phone interview with the designated research team interviewer (S.F.). Due to the geographic locations of the participants, phone interviews were used to allow for the greatest amount of participation. Once a phone interview was scheduled, program faculty were assigned a pseudonym to protect their identity, and their demographic data were also assigned the same pseudonym. Each phone interview was audio recorded for accuracy, and informed consent was gained over the phone and audio recorded.

After verbal consent to participate in the recorded interview, program faculty were provided the definition of IPE according to the World Health Organization (2010), “[IPE] occurs when [students of] 2 or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.”^9(p13) After hearing the definition of IPE, the program faculty were asked whether or not they currently integrate IPE in their program, and their response dictated which set of interview questions they were asked, how they integrate IPE or why IPE has not been integrated.

Upon completion of each interview, audio files were transcribed verbatim by a research assistant. Any identifying information including proper names and places were removed to protect the identity of the participant. After transcription, the program faculty were sent their transcripts for member checking and allowed 1 week to review the transcript for accuracy. Data collection continued until data saturation was achieved.

Data Analysis and Trustworthiness Measures

The CQR process relies on consensus throughout the data analysis process. For our study, consensus in data analysis began with each research team member independently reading the same 3 transcripts and taking notes on recurrent topics that could be used as potential codes.¹⁷ Once the transcripts underwent an initial read through by each member of the research team, the entire team met to discuss their findings, reach a consensus on the identified topics, and ultimately develop a codebook for use in further analysis. After consensus was reached, the research team independently coded 1 more transcript with the established codebook. The full research team then met again to discuss the results and make modifications to the codebook as necessary. With the revised codebook, 3 members of the research team (D.H., S.F., J.K.) coded 4 more transcripts and compared the subsequent results to ensure code alignment. No further modifications were made to the codebook at that time. With the finalized codebook, 1 researcher (D.H.) coded the remaining 9 transcripts. One member of the research team (S.M.) served as the internal auditor who ensured consensus judgments were in line with the data.

The inclusion of multiple researchers in the CQR process ensures constant triangulation and peer discussion. This researcher debriefing aimed to diminish bias by using consensus and discussion between members of the research team. Finally, the external auditor, who did not have firsthand knowledge of the data or research design process, was sent the final themes and a sampling of quotations to support those ideas to confirm the alignment of themes and quotes.

Delivery Methods

Program faculty described the delivery methods used to integrate IPE into didactic aspects of the program. These methods varied from orientation activities or online modules, to use as part of applied scenarios in case-based activities such as simulation. Regarding online modules, Andrew stated:

We do an online module, which is about an hour, and then we have an in-person 2-hour workshop where they are at tables with the other disciplines and there is a little didactic part to it, but it is primarily a case-based presentation where they're discussing how each of the professions would fit into the care of the patient, the imaginary patient.

In relation to applied scenarios, Mimi stated:

We do 3 sessions where we've developed a case study for them, and then they work through that case study to talk about how each perspective would treat the patient and how they would work together to come up with a treatment plan, and then we have a handful of questions about interprofessional experiences and how one profession helps with the other and that kind of stuff.

Furthermore, some program faculty illustrated examples of cross-listed courses with other health care disciplines as well as full integration of IPE across the athletic training curriculum. Raoul indicated:

We have, I guess I would call it a parallel curriculum that happens in the College of Health and Rehab Sciences, where the [IPE] curriculum has its own syllabus and specific objectives and outcomes and things. It's been a component of students' coursework, so it's been embedded in one of the courses in each of the semesters in the program, essentially, that they complete the [IPE] curriculum that's happening in each semester of the program.

Educational Content and Objectives

Closely associated with delivery methods, but defined within its own theme in this study, is that of content related to IPE. Within this theme, program faculty identified learning goals and objectives as well as specific topics and content included in the various events and activities used to deliver IPE content. Such goals included an overview of what IPE is and is not, roles and responsibilities, teamwork, and communication. For example, Christine stated:

. . . prior to the module, we teach everyone the CUS acronym, which stands for, “I am concerned about the patient. I am uncomfortable with the current state of the patient. I believe the safety of the patient is at risk.” It's not only knowing each other's roles and responsibilities; it's getting them [students] used to being able to speak up and not just letting, more often times, not just letting the future physician be the ringleader of it all.

Participants also described incorporating the IPEC core competencies as goals for IPE integration. Maria indicated, “Each one [each workshop] has different IPEC core competencies that are addressed and different objectives, but they are typically doing some type of activity and discussion.”

Other program faculty identified goals related to navigation of the overarching health care system and patient-centered care. Mark, for example, explained:

In one of the IPE classes I teach, it's clinical decision making. Actually, it's applied clinical decision making, really. I have a group of 23 students. . . they are divided into 4 teams. Just last week, they did a standardized patient interview.

Maria described the incorporation of an online activity to help familiarize students with available health care resources for patients and health care providers:

The students, typically they have some prework they have to do. They will have some reading that they might do, modules on the Institute for Healthcare Improvement Web site. There are free modules on there. I think they do a patient centeredness one, and another one is the upstream thinking and thinking prevention.

Assessment

Data analysis also identified assessment approaches for IPE activities and objectives. Program faculty described using assessment for adapting the IPE events, evaluating learning, and allowing students to reflect on the experience. Tom stated:

Prior to the scenario, we have them do an IPE questionnaire about if they're ready for IPE or if they know what IPE is and if they know each other's professions. After, they take that same questionnaire so we can compare before and after just for data collection purposes for the program.

Andrew described how the assessment of their IPE offering has led to adjustments in the activity itself:

The feedback from how we did it last year or the last 2 years, getting a standardized patient, that's going to make it way better I believe. The case, the first time we had a case, it was too complicated. We were trying to tie everything, too many different variables, not even variables, there was too much. It was too detailed; it didn't need to be as detailed. This time around, it is way less detailed.

Program faculty emphasized that assessment is an ongoing process that adapts and changes each time an IPE activity is offered. Measures of assessment included pre-event and post-event surveys or interviews related to logistics, perceptions of the IPE activity, or both; reflection assignments; debriefs; and questionnaires aimed to attain levels of knowledge, application of IPE content, or both. For example, Maria described the type of assessment that members of the IPE organizing committee are conducting at her institution:

There is a group that's doing kind of a pre/post and some qualitative interviews for research more based on the poverty piece of it, and then we will also have a pre/post on the IPE objectives that we have.

Some program faculty indicated specific athletic training program level assessment in addition to that of the overarching IPE activity. Raoul described the nature of their IPE assessment:

One of our large program goals is to recognize the role of athletic trainers as health care providers within the larger context of a changing health care system through measuring how students demonstrate a collaborative approach to care through various assessments throughout the program. One assessment is by preceptors in their clinical experiences and the debrief, which students are practicing collaboratively with intra- and interprofessionally, then through alumni surveys, identifying graduates who describe an ability to work effectively and collaborate with other health care providers.

Logistics

During the interviews, program faculty discussed several logistical considerations that must be addressed during IPE integration in the didactic setting. One aspect program faculty commented on was the consideration for whether to require IPE activities for students or to make it optional. Raoul, for example, described how participation requirements of IPE could evolve over time:

I think early on, too, you want, as we start to develop these opportunities, these targeted interprofessional opportunities at our clinical sites. It's really hard to envision. We are never going to get all 500 students who are enrolled across all these programs to be able to have this experience. We got to start with something and let it grow from there. It's hard, I think, for people to wrap their heads around the fact that it's actually okay. We are looking for opportunities to be able to create, but it's not required of every single student to have that specific experience. We are just looking to build on something, and we got to start somewhere. There is always that, I think, tug of war between you start at the top and say this is what everyone is going to do, or you start at the bottom and say, see if we can get, next year, if we can get 5 students at this site to work together and collaboratively on 1 patient case. Let's start there.

Other considerations related to how often the IPE activities would be offered and what other health care disciplines would be included were discussed. For example, Andrew described how timing and disciplines of inclusion have changed:

We moved it from a 1-time workshop to a 2-time workshop, and meeting face to face twice instead of once. This is the second year we are doing that. We didn't have simulated patients last year. The faculty just did one of the simulated patients. This year, we have been collaborating with our theater department actually to help recruit simulated patients.

The availability of resources such as space, interprofessional groups or students for attendance, facilitators, and general organization or activity planning were also identified by participants as important for consideration. Joanne described the level of detail that is needed to successfully implement their IPE activity:

We have 14 different health care professions. We actually have an afternoon to where the students are divided up into groups. They start out with a keynote speaker, and that's about an hour, and then for the other 3 hours, they have 3 different rotations they go through, and they stay within your groups, and their groups are intentionally split to where there are multiple students from different health care professions together. . . making sure there is a student at least from the groups that are in there represented. They have to introduce themselves, tell what their profession is, and they have to work through the case study as far as what care they would provide for that particular patient, and they report back. Each group reports back to the actual larger group.

Resources for IPE Integration

It is apparent from our study that program faculty are seeking outside resources to support their IPE initiatives. For example, 1 method for incorporating IPE collaboration and communication identified by a participant in this study related to the acronym of CUS (“I am concerned. I am uncomfortable. There is a safety issue.”) from the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program from the Agency for Health care Research and Quality.²³ This curriculum is designed to improve collaboration and communication among health care professionals, leading to an ultimate goal of enhanced patient outcomes. While not a novel topic unto itself, the TeamSTEPPS approach provides an evidence-based framework from which to educate health care professionals, and the resources are free of charge. It is likely there are other programs besides TeamSTEPPS in which it may be appropriate for health care faculty to seek further education. In this vein, program faculty should continue to seek professional development opportunities to advance their knowledge and application of IPE to sufficiently model these behaviors for students.

Collaboration for IPE

In addition to the outlined themes, the results of our study provide a view into the health care disciplines that athletic training program faculty are engaging with to accomplish IPE. Participating programs in the described didactic activities included, though may not have been limited to, counseling, social work, nutrition and dietetics, occupational therapy, through to the more traditional collaborators of physician assistants, nursing, and medical students. These findings support survey data indicating athletic trainers perceive that the top 3 professions athletic training students should be educated to work with are physical therapists, emergency medical technicians, and physician assistants.²⁴ Although each of these 3 disciplines were not explicitly listed by participants in the current qualitative study, the associated learning opportunities involving these disciplines reinforce the recommendation for role delineation and appreciation of responsibilities outlined in previous literature.^8,25 It should also be considered that the school in which an athletic training program is housed may influence IPE collaboration. For example, those programs housed within schools of health, medicine, nursing, or similar likely offer more opportunities for IPE collaboration with other health care disciplines.

Recommendations for IPE Integration

For program faculty looking to integrate or expand integration of IPE within their didactic curriculum, there are several areas for consideration. Two early areas to evaluate may include (1) who is available for IPE collaboration, and (2) what are the objectives for the IPE collaboration? When beginning IPE, it is important to identify who will be involved to enable learning from, with, and about each other. More specifically, faculty should consider what health care professions or affiliated programs are available to engage in the learning activities. While it may be easy for some to identify these programs within their own academic unit or elsewhere on campus, it is also important to look to the local community or other connections for these opportunities. Once the programs have been identified, it may be helpful to establish who may have vested interest in IPE due to accreditation standards or other particular buy-in needs. Programs with these requirements may be more eager to engage in collaborations that can be recurrent or expanded.

After identification of appropriate people for collaboration in IPE, it is vital to establish the objectives for the collaboration. Considering the IPEC core competencies or an institution-derived strategic plan initiative, such as ethics or patient-centered care, may provide themes for faculty stakeholders to use as guidance, in general for the logistics and process of developing IPE opportunities and how that process should begin small and develop from there.

From an institutional standpoint, there are several areas that can be examined to demonstrate commitment to IPE. The Health Professions Accreditors Collaborative (2019)²⁶ recommends institutional leaders stimulate IPE by fostering collaboration and relationships both within and, when possible, beyond the institution. Specific recommendations to support IPE include the establishment of resources including logistical support, financial means, curricular planning, and policy establishment. For each of these areas to be successful, dedicated faculty must be in place to develop the IPE learning activities including designation of time, oversight, faculty development, and commendation of faculty effort when successful programs are achieved.²⁶ In relation to this study, these recommendations were not overly apparent, as only 5 of the 17 program faculty identified a dedicated coordinator for IPE on campus, while 10 of 17 indicated that there was an existing IPE committee. Our findings therefore support research stating that faculty who have institutional support for IPE are more likely to engage in IPE than those attempting more individualized approaches.²⁷ As athletic training program faculty are considering establishing or expanding their IPE integration, consideration of these recommendations may be beneficial.

Understanding of IPE

In addition to the identified themes of our study, it is important to note IPE is still not fully understood by all program faculty in athletic training. For example, during the interview process, several participants described learning activities that did not match the IPE process of 2 or more professions learning from, with, and about each other. One participant described a class activity where a guest lecturer from another health care discipline delivered content related to his or her profession. Another example depicted how students from several health care professions took an anatomy class together. While these classroom descriptions may provide some learning benefits such as introduction to other professions roles and understanding of the overarching health care system, they are not inherently IPE, as the students are not actively engaged in learning from, with, and about each other and their respective professions. These findings are not surprising, given that Breitbach et al¹⁶ noted that a majority of athletic training programs are not incorporating IPE initiatives into the curriculum. Many factors may contribute to the lack of IPE integration such as a dearth of knowledge of IPE, lack of affiliated programs at similar levels or within similar academic units, and historical factors at the institution.¹⁶