Interprofessional and Collaborative Practices of Athletic Trainers in the Secondary School Setting

KEY POINTS

• Secondary school athletic trainers have positive perceptions and regular engagement in interprofessional and collaborative practice.

• Secondary school athletic trainers perceive many challenges to interprofessional and collaborative practice including communication, trust and respect, and health care providers identifying secondary school athletic trainers' roles.

• Secondary school athletic trainers report interprofessional and collaborative practice can be a benefit to patient outcomes.

• Communication is critical to interprofessional and collaborative practice, and a unified software system may help to enhance the network of communication with health care providers.

• Interprofessional and collaborative practice is thought by secondary school athletic trainers to create idea sharing to identify issues or limitations in patient care.

INTRODUCTION

Collaborative practice, according to the World Health Organization, “happens when multiple health workers from different professional backgrounds work together with patients, families, careers and communities to deliver the highest quality of care across settings.”^1(p7) Interprofessional and collaborative practice (IPCP) has gained greater focus in health care since the Crossing the Quality Chasm report in 2001² along with the development of core competencies for IPCP by the Interprofessional Education Collaborative.³ Interprofessional and collaborative practice is thought to increase quality patient-centered care and improve patient outcomes and quality of life.^1–3

Previous research on IPCP has spanned across health care professionals (HCPs) and among athletic trainers across settings, specifically in the college and university setting. In nursing and medicine, IPCP has been shown to improve patient outcomes and health care efficiency.^4–6 Among primary care teams, frequent informal communication has been vital for effective IPCP.⁷ Collaboration allows teams to offer more comprehensive care,⁸ and often patients experience greater levels of satisfaction.⁹ Athletic trainers in the collegiate setting reported they had opportunities to collaborate with HCPs and found those experiences beneficial to patient care but inconsistent.^10,11 Athletic trainers across 8 different practice settings identified benefits of IPCP such as comprehensive care, building understanding of other HCPs, and professional growth.¹² The athletic trainers also reported knowledge limitations about other HCPs, inadequate communication, work setting, scheduling, and attitudes as barriers to collaboration.¹² While this research did incorporate secondary school athletic trainers (SSATs), the results were generalized across several different practice settings, and noted specifically that setting may impact the ability to deliver IPCP.¹²

There may be more nuanced differences between SSATs' practices and perceptions of IPCP and other athletic trainers' practice and perceptions of IPCP due to specifics of the practice environment. SSATs that have been credentialed for less than 1 year experience a sense of isolation and little support, likely because they do not have other HCPs in proximity.¹³ The growing demand for SSATs^13,14 and the benefits of IPCP demonstrated in other health care disciplines^4–6 highlight a need to better understand SSATs' current perceptions and use of IPCP. The unique combination of high patient load, sense of isolation, lack of support, and increased demand in a different practice environment may alter SSATs' ability to practice IPCP. Currently, no researchers have specifically explored IPCP with SSATs, and we do not know to what extent they are practicing in a collaborative manner. The purpose of this study was to investigate the perceptions of SSATs regarding IPCP and determine how and if they engage in IPCP in the secondary schools. Additionally, we explored how formal interprofessional education, having a directing physician affiliated with the clinical site, and working directly with other HCPs at the clinical site affected perceptions and implementation of IPCP.

METHODS

Data Analysis

We used descriptive statistics to compute the mean, standard deviation, and frequency of the demographic data and independent variables. The independent variables included prior formal interprofessional education (yes or no), number of HCPs collaborated with on patient care (physician, physical therapists, occupational therapists, nurse, chiropractor, or physician assistant), and relationship with directing physician (no directing physician, directing physician working for the same educational and/or health care organization as SSAT, or directing physician not working for the same organization as SSAT but has/does not have formal relationship with the school where SSAT provides care). For each construct, we calculated composite scores by averaging the Likert scale scores of all items in 1 construct. We compared construct scores from different groups (of unequal sizes) of those who have engaged in formal interprofessional education, their directing physician's structural affiliation to the clinical site, and the number of different HCPs the athletic trainer collaborates with using Mann-Whitney U and Kruskal-Wallis nonparametric tests. When appropriate, we used Mann-Whitney U tests for post hoc comparisons. Significance was set at P < .05 a priori (SPSS, Chicago, IL).

The data analysis team composed of 2 experienced qualitative researchers and the primary investigator (a novice qualitative researcher) analyzed participant responses to the open-ended questions using a general inductive coding approach. The data analysis team conducted open coding by identifying recurrent words and phrases within 50 surveys. The team then compared key words and phrases to establish coding guidelines. The primary investigator used the coding guidelines to label all the remaining participant responses. The remaining members of the data analysis team reviewed the labeling and met to meet consensus. An external auditor reviewed the responses and themes, and the research team then discussed discrepancies until the research team and auditor reached a consensus. The data collection and analysis process is depicted in Figure 1.

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RESULTS

Of the 379 SSATs that completed the survey in its entirety, 232 (61.2%) were female, and 257 (67.8%) had earned a master's degree (Table 1). Secondary school athletic trainers reported that 65.0 ± 21.9% of patient care was independent, and 20.2 ± 14.9% was done collaboratively with another HCP that was not an athletic trainer. Secondary school athletic trainers agreed to statements regarding athletic trainers' perceptions of working with other HCPs (construct 1 = 3.4 ± 0.3), engaging in collaborative practice (construct 2 = 3.3 ± 0.4), influence on collaborative practice (construct 3 = 3.4 ± 0.4), and influence on roles, responsibilities, and autonomy in collaborative practice (construct 4 = 3.1 ± 0.3; Table 2). Secondary school athletic trainers marked statements indicating their perspective about their practice of communication in collaborative practice (construct 5 = 2.1 ± 0.5) and patient involvement in collaborative practice (construct 6 = 1.9 ± 0.5) were either always occurring or sometimes occurring in their clinical setting (Table 3).

Table 1 Demographic Characteristics

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Table 2 Highest and Lowest Rated Statements for Participant Selections in CPICP Survey Section 1^a

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Table 3 Highest and Lowest Rated Statements for Participant Selections in CPICP Survey Section 2^a

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We found no significant differences for each of the constructs between those with and without formal interprofessional education training (P = .151–.963) and between those with no relationship, same-system, or external-system relationship with their physician (P = .070–.866). We identified a significant difference for SSATs' perceptions of working with other HCPs (construct 1) based on the number of different HCP associations (P = .033). Secondary school athletic trainers that work with more than 4 and 5 different kinds of HCPs shared a significantly higher perception of working with other HCPs than those having relationships with 1, 2, or 3 different kinds of providers. While the clinical usefulness of this data is minimal, as the differences are nominal and within the standard deviation, this finding is beneficial for discussion on how to possibly increase IPCP perceptions with SSATs.

The research team identified the 3 main themes of communication, learning, and infrastructure from the 4 open-ended questions. We used specific subthemes to build the 3 main themes outlined in Figure 2.

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DISCUSSION

The purpose of our study was to investigate the perceptions of SSATs regarding IPCP and determine how and if they engage in IPCP in the secondary school setting. Overall, participants agreed with statements in all 4 constructs of the first section discussing perceptions of IPCP, like previous research conducted on athletic trainers in the collegiate setting.^10,11 Participants had higher levels of agreement about working with other providers when they worked with more than 4 different kinds of HCPs. In previous research, SSATs reported a significantly lower frequency of interactions with other HCPs than other athletic training settings such as the college, clinic, and nontraditional settings.¹² The SSATs occasionally interacted with strength and conditioning coaches, Doctor of Osteopathic Medicine, general surgeons, and registered nurses,¹² while participants in our study also interacted with physical therapists and physician assistants consistently. However, SSATs reported less than a third of the time spent in patient care was collaborative with another HCP or athletic trainer. Current literature has shown that HCPs have benefitted from IPCP through increased efficiency and better patient care,^4–6 and because SSATs report low IPCP, there is the potential for SSATs to not access the benefits of IPCP while SSATs' patient loads increase.¹⁴ The low reported IPCP frequency is likely from the many challenges and drawbacks that SSATs experience in their practice setting.

Participants identified a lack of frequent communication with HCPs as a challenge, and communication was harder with no prior relationship with the HCP. Improved communication between nurses and physicians can help provide better care to patients.¹⁷ Similar outcomes, hypothetically, could be achieved with athletic trainer and physician communication, but athletic trainers need to take on a bigger role of initiating the relationship building and IPCP. With 33% of secondary schools not having an athletic trainer either full time or part time on staff,¹⁸ SSATs need to embrace initiating IPCP with other HCPs. Secondary school athletic trainers need to become comfortable with initiating conversations with overseeing physicians because it is a poor assumption that the physician will know the SSAT is available. Previous research has supported this concept, with athletic trainers stating that an effective strategy for implementing IPCP was to reach out, initiate, and develop the relationships with providers.¹² Athletic trainers indicated face-to-face meetings during the year are important to start and maintain IPCP, and these meetings could then be used to help educate other HCPs on the athletic trainer's scope of practice and role in patient care.¹²

Medical errors have a direct effect on patient health, and they are often the result of poor communication.^19,20 In previous research, SSATs strongly agreed inadequate communication with other health care providers hindered collaborative practice.¹² Similarly, Kraemer et al¹² found athletic trainers strongly agreed interprofessional meetings foster communication among members from multiple professions or disciplines, and working interprofessionally improved the efficiency and quality of patient care. Meaningful and intentional communication is needed for collaborative care.²¹

Secondary school athletic trainers identified that a unified software system would be a helpful resource to improve communication. Previous researchers also found athletic trainers agreed inadequate access to non-athletic trainer HCPs hinders collaborative care, which could be remedied with a unified software system.¹² Researchers have found athletic trainers use both electronic and paper documentation, and there are many barriers to the use of electronic documentation in secondary schools.^22–24 Secondary school athletic trainers have noted privacy issues in communication with HCPs. The use of a system-wide electronic medical record (EMR) could diminish both perceived challenges. Reduced documentation time, higher quality of documentation, and improved communication are benefits of EMR use.^17,25,26 Traditionally, SSATs and school nurses have shared responsibilities of treating concussions, evaluating orthopaedic injuries, and communicating with physicians and other HCPs.²⁷ Secondary school athletic trainers have the potential to engage school nurses in interprofessional care, and the use of similar or compatible systems to improve communication and documentation could increase quality of patient care and IPCP. Previous researchers used an EMR to improve communication between the school nurses and physicians for an asthma care plan.¹⁷ For students whose nurse used the EMR to communicate to the physician, there was a decrease in hospital admissions.¹⁷ A system-wide EMR would provide a resource SSATs need to improve communication and could integrate SSATs as part of the health care team, potentially diminishing the privacy concerns that result from the perception that the athletic trainer is ancillary to the team.

Sharing an understanding of roles can help communication and collaboration.³ Participants stated HCPs do not understand SSATs' roles, which can lead to their underutilization. Participants identified education as a resource needed to help HCPs understand the roles and utilization of SSATs. Interprofessional education seminars have benefitted others HCPs with developing professional identity,²⁸ role clarity,^28,29 and better attitudes toward HCPs.²⁸ When examining a 10-week interprofessional gross anatomy dissection course with students from medicine, midwifery, nursing, physician's assistant, physiotherapy, and occupational therapy programs, researchers found improvements in professional identity, role clarity, and attitudes toward other health professions.²⁸ However, while SSATs identify a need for more interprofessional education and the Interprofessional Education Collaborative¹⁶ identifies the need for role clarity to help develop IPCP, we found the interprofessional education did not result in significant differences in perceptions of IPCP in SSATs. In this research, we focused on the general completion of interprofessional education with SSATs and further research should be conducted on the specifics of interprofessional education sessions with SSATs to identify the specific effects on perceptions of IPCP.

Participants identified access to HCPs as a challenge to IPCP. While this study did not compare experiences of SSATs in different geographical locations, participants stating they worked in an urban environment experienced saturation of providers and difficulty finding consistency in collaboration, and participants stating they worked in a rural environment indicated a concern about accessing providers. The use of telehealth has the potential to help with both challenges of access. Previous researchers have identified telehealth can help HCPs improve systems in remote areas, reduce costs, improve clinician efficiency, have better communication, and increase convenience for providers.^30–32 Telehealth benefits of improving communication and improving clinician efficiency have the potential to also reduce the challenge of communicating with physicians outside of the team physician.

CONCLUSIONS

Secondary school athletic trainers could use IPCP to benefit patient care and increase efficiency as demand for them grows. We discovered SSATs have low reported collaborative practice with other HCPs along with perceived challenges to implementing IPCP, but they also proposed resources like EMRs, telehealth services, and interprofessional education sessions to increase access to other HCPs and improve role clarity, trust, and respect between providers. Secondary school athletic trainers should focus on implementing EMR and telehealth systems to overcome many of the challenges and drawbacks of IPCP. Additionally, SSATs must become more comfortable in initiating IPCP with HCPs around them to develop relationships and improve IPCP for the benefit of their patients.