ADEPT: Building a Model of Communication for Athletic Training Students

Key Points

• Patients evaluate their healthcare professionals on both their level of medical expertise and on their social skills. However, patients prioritize their healthcare providers ability to connect on a relational level over their medical competence.

• Effective communication within healthcare encounters comprehends both the medical needs of the patient as well as the socio-relational aspects of the interaction.

• By learning to include appropriate self-disclosures during their patient interactions, Athletic Trainers can demonstrate empathy, foster trust, and encourage more positive patient health outcomes.

Context

Athletic trainers need strong communication skills to evaluate, treat, and progress patients. Furthermore, researchers have found that communication skills are among the most important characteristics when hiring an athletic trainer.¹ Despite the integral role of communication to the practice of athletic training, research indicates newly certified athletic trainers often lack vital communication skills and sometimes are even sent for communication skills training remediation.^2–6 Supervisors of newly credentialed athletic trainers (NCATs) expect the NCATs to be able to communicate professionally, calmly, and respectfully while also identifying that NCATs with communication skills better adapt to the setting and are more successful.⁶ However, many NCATs state they lack communication skills because they did not experience effective communication with coaches and physicians as a student, although communication and interactions with patients and other athletic trainers was part of their educational experience.^4,5,7 In contrast, a more recent survey of NCATs found that 85.9% of participants believed they were comfortable and ready to communicate with patients.⁷ This indicates that, while the NCATs feel they have communication skills, employers report otherwise.⁶ Patients themselves have also stated that effective communication, feedback, and personal connections are essential for developing trust with athletic trainers.^8,9

In July 2020, new standards adopted by the Commission on Accreditation of Athletic Training Education (CAATE) went into effect.⁹ Table 1 displays the standards that relate to communication; these 3 standards fall under the core competency of patient-centered care. The CAATE uses the following definition of patient-centered care:

Table 1.CAATE Standards Related to Communication

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Care that is respectful of, and responsive to, the preferences, needs, and values of an individual patient, ensuring that patient values guide all clinical decisions. Patient-centered care is characterized by efforts to clearly inform, educate, and communicate with patients in a compassionate manner. Shared decision making and management are emphasized, as well as continuous advocacy of injury and disease prevention measures and the promotion of a healthy lifestyle.⁹

Thus, the CAATE also views communication as an essential skill and one that must be included and taught in athletic training curricula.

The World Health Organization’s International Classification of Functioning, Disability and Health (ICF) model was adopted as the disablement model for the National Athletic Trainers’ Association in 2015.^10,11 The components of the ICF model are described in Table 2. Most of what is taught in athletic training focuses on the function and disability components. However, the contextual factors can greatly impact patient-centered care and vary from patient to patient. It is important that athletic trainers understand how to properly communicate with patients to determine how the contextual factors affect the individual patients and the care they require.

Table 2.ICF Organization (WHO)¹⁰

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It is evident that communication skills are important for athletic trainers and, as of July 2020, must be included in athletic training curriculum. Intentionally adding communication skills training to the curriculum offers the ability to give students multiple opportunities to practice communication skills with different patient populations, various stakeholders, and different situations demanding varying degrees of urgency. The ADEPT model presented in this paper is one way to help students better understand and practice communication that facilitates patient-centered care.

Objective: Development of a Patient-centered Communication Model

Much work has been devoted to identifying and describing patient-centered communication but little done to operationalize it.^12,13 Because patient-centered communication involves the provider effectively assessing patients’ preferences for their level of participation and amount of information, the challenge is to develop a model of communication that incorporates a relational approach to the interaction, understands the patients’ needs and motivations, and allows for flexibility in the use of a variety of communication behaviors and messages to support both relationship-building and information-gathering.¹⁴ Thus, the ADEPT model, as presented here, is designed to teach athletic training students communication behaviors that fall in line with a patient-centered approach while also encouraging patients to perform communication behaviors that help them achieve their goals and fully participate in the medical alliance. The objective of this paper is to present a communication model that works in conjunction with injury assessment protocols currently taught as part of the athletic training curriculum and that addresses the environmental and personal factors associated with the interaction between the athletic trainer and the patient as identified in the ICF model. The ADEPT model seeks to address the following:

1. Provide a memorable construct that is easy to recall.

2. Focus on communication behaviors designed to assess patients’ preferred communication styles, elicit patient disclosure, demonstrate empathy, and increase the athletic trainers’ ability to understand patients’ perspectives.

3. Foster a sense of connection between athletic trainers and their patients built on trust.

4. Complement the necessary information-gathering techniques taught as part of the assessment and diagnostic protocols.

Background

With patient-centered care being highlighted as a core competency under CAATE standards, it is helpful to consider specific communication concepts to help guide athletic trainers as they interact with patients and work toward better health outcomes. The literature on interactions between patients and health care providers has primarily focused on identifying communication skills and behaviors that contribute to an improvement in a variety of patient outcomes including patients’ satisfaction with their health care encounter, patient compliance with health care instructions, and ultimately, improved health outcomes for the patient.¹⁵ Interpersonal communication is an interactive process with 2 or more active participants performing communicative behaviors and exchanging messages in a variety of modes. However, authors of most studies within the context of interpersonal health communication have looked at the communicative behaviors of either the health care provider or the patient in isolation; authors of studies rarely perform conversation analysis on a particular interaction between the patient and provider.¹² However, patient-centeredness dominates the literature on patient-provider communication and, as a construct, identifies various communication behaviors that consider both patient and provider perspectives.¹²

Patient-Centeredness

Patient-centeredness acknowledges that patients bring concerns beyond just the biomedical aspects of illness and injury.¹⁶ With nearly 40 years of research, patient-centeredness has shaped most modern studies on patient-provider communication.¹² While definitions vary, in their literature review, Mead and Bower identify 5 key dimensions of patient-centered care: a biopsychosocial perspective, recognizing the patient as a person, sharing power and responsibility, fostering a therapeutic alliance, and considering the provider’s personal influence.¹⁵ This definition emphasizes providers’ roles, assuming that improving their communication skills and behaviors can enhance patient outcomes. While no agreed upon operational definition of patient-centered communication exists, Cegala and Street recommend health care providers to engage in communicative behaviors designed to elicit the patient perspective, gain an understanding of the patient’s feelings and concerns, identify the preferences the patient has for the health care encounter, and encourage the patient to take an active, involved role in his or her health care.¹²

Provider Training

Much of the communication-related training provided by medical schools and other professional programs is focused on teaching diagnostic skills and patient management techniques designed to gather symptomatic information from patients regarding the specific health-related condition they are experiencing.¹⁸ Communication is then focused on performing behaviors to facilitate information gathering such as listening, asking the patient questions, clarifying understanding, responding to patient emotions, providing information, and shared decision-making.¹⁸ In addition, communication training efforts have tended to focus on very specific health contexts. For example, researchers at Sloan Kettering have developed and assessed provider communication training within the context of oncology and cancer care.¹⁹ Due to the complexity involved with diagnosing and treating cancer, along with the accompanying emotional considerations and uncertainties involved, much of this training has focused on providing physicians and nurses with specific protocols and reminders to ask patients questions about what they are thinking and feeling as well as to deliver information about patients’ diseases and treatment options with patient satisfaction as the goal.¹⁹ In the context of athletic training, much of the curricula focuses on the diagnostic aspects related to injury and illness. Athletic training students are taught essentially communication protocols designed to gather symptomatic information from the patient, to use that information to assess and diagnose a particular problem and then prescribe a course of treatment based on their assessment of that information. Certainly, this type of information exchange is vital to the work performed by the athletic trainer; however, few relationship-based aspects are comprehended in these diagnostic exchanges.

Patient Relational Preferences

Much of the communication training efforts within health care focus on the goal of getting patients to be active participants in the interaction and on getting providers to perform communication behaviors to elicit that patient involvement. However, providers are not often taught to first understand patients’ relational needs. A patient’s willingness to disclose personal information is often affected by the patient’s affective feelings and attitudes about the provider. While patients base their evaluations of their health care provider’s competence on both medical and affective-relational characteristics, patients prioritize the affective-relational dimension.²⁰ Patients look for health care providers that are encouraging, demonstrate empathy, have confidence, show concern for the patients’ progress and outcomes, and allow for shared decision making.²¹ Athletic trainers that communicate well, use positive nonverbal communication, are approachable, and make personal connections develop stronger trust with their patients.²² Because the relational dimension of health care encounters is prioritized by the patient, provider communication training should comprehend those relational factors and seek to incorporate communication behaviors designed to convey those characteristics.

With patients prioritizing affective-relational aspects, trust, liking, and a comfortableness with discussing topics deemed intimate in nature are the hallmarks of an effective patient-provider relationship.²³ These relational qualities are in turn fostered by the provider’s ability to perform communicative behaviors designed to demonstrate empathy and allow the patient to develop a more intimate understanding of or knowing about the provider. For example, the ability of the athletic trainer to demonstrate empathy in a way the patient understands has become an important skill that communication training programs should attempt to teach.²⁴ However, directing an athletic trainer to demonstrate empathy is very different from and far more abstract than describing specific behaviors that reveal how to demonstrate empathy. To bring more concreteness to the abstract directive demonstrate empathy, provider communication training often focuses on listening as a communicative behavior that demonstrates the provider’s empathy and leads to trust between patient and provider. For example, the COMFORT Model curriculum identifies a variety of contextual cues and situations that palliative care nurses should be listening for when interacting with patients and their families.²⁵ Within the realm of athletic training specifically, Davlin-Pater and Rosencrum identify listening as a key component necessary to develop effective communication skills.²³

However, the ability to listen and demonstrate empathy is not sufficient for the development of trust. Trust is defined as the willingness of a person to make oneself vulnerable to another based on the expectation of a favorable outcome.^26,27 Trust then is an active decision to take the inherent risk in making oneself vulnerable in some way to another. As people know more about one another, this in effect increases intimacy, and the willingness to take the risk and disclose more intimate, personal information is bolstered by this increased knowing of the other. A patient’s trust in his or her health care provider increases over time and with more frequent visits.^28,29 This suggests that, as the patient interacts more frequently with the health care provider, the patient knows the provider more intimately, and increasing amounts of information are shared over time. Trust is fostered through this increased knowing and intimacy.

The implication of knowing and its effect on trust is that disclosure becomes an important part of patient-provider interaction. While many provider training protocols focus on the importance of interpersonal communication, developing rapport, active listening, and demonstrating empathy as central to patient-centered communication, none mention the role of provider self-disclosure.^19,23,30,31 However, reciprocal self-disclosures help develop social relationships, and physician self-disclosure can be key to the demonstration of empathy and the development of intimacy between patients and providers.^32,33 Traditionally, physician personal self-disclosures have been characterized as inappropriate within medical practice; however, some level of provider self-disclosure is fairly common in medical encounters.^34,35 Indeed, it is impossible to extricate the sociorelational aspects of communication from the more commonly thought of instrumental communication related to patient health within the medical encounter.³⁶ Because of this, the ADEPT model presented here incorporates the identified aspects of listening and demonstrating empathy found in previous provider training programs but adds in appropriate provider self-disclosure as part of the communication process. The act of disclosing helps build knowing, which in turn facilitates rapport-building and leads to trust.

Description of the ADEPT Model

The ADEPT model was designed around communication concepts to bridge athletic trainers’ treatment goals with a patient-centered approach. The ADEPT model focuses on 4 constructs: (1) appraisal, (2) disclosure, (3) empathy, and (4) perspective-taking. ADEPT was designed in such a way to overlay the diagnostic and treatment process already in practice but asks providers to attend to relational elements present within the interactions.

When first interacting with the patient, athletic trainers need to conduct a patient appraisal. Understanding a patient’s injury is just a portion of this appraisal. What other concerns does the patient have beyond the injury that may impact treatment? What socioemotional factors are present that need to be addressed? This requires the athletic trainer to observe the patient’s emotional state, ask questions, and demonstrate that he or she perceives the patient as a full person rather than just an injury. As part of this appraisal, it is important to allow the patient to tell his or her story in his or her own words. Allowing the patient to express his or her narrative not only relates the physical aspects of his or her illness or injury but also puts the athletic trainer in a position to effectively attend to the patient’s sociorelational needs as well.³¹

Treating patients means building relationships which is central to the patient-centered approach. As previously noted, healthy relationship- and intimacy-building requires appropriate self-disclosures. Athletic trainers are encouraged to disclose personal yet appropriate information about themselves. For self-disclosure to be considered appropriate and still maintain a patient-centered approach, it is important for the athletic trainer to be conscious of the timing, relevance, and how personal the information is. These disclosures should reveal a bit about who we are without being too personal or too removed from the other aspects of the encounter. In this way, self-disclosure enables the patient to see the athletic trainer as a person as well as a provider. For example, the athletic trainer may observe that the patient is wearing a shirt showcasing a team he or she also follows. The athletic trainer might note that he or she is also a fan or inquire if the patient caught the last game. Appropriate disclosures are used to find common ground and establish or maintain a relationship.

When centering the patient in a health encounter, it is helpful to demonstrate empathy. Often, a gap exists between how providers perceive they are demonstrating empathy and how patients perceive empathy within the course of the encounter.³⁷ Empathic understanding is the understanding of another person by placing oneself imaginatively in her or his experiential world.³⁸ Actively employing empathy by using specific communication techniques can bridge this perception gap. Providers should assess their verbal and nonverbal signals given to patients when they are listening. Are providers using backchannel cues such as nodding, asking clarifying questions, and paraphrasing client response? In addition to active listening, the provider needs to demonstrate he or she is present in the moment and care about patient concerns as much as his or her own.

The final concept asks athletic trainers to consider environmental factors beyond the injury that may impact the patient’s ability to progress by engaging in perspective-taking. Perspective-taking asks the athletic trainer to step into his or her patient’s shoes for a moment to consider other viewpoints. Perspective-taking is a form of empathy that requires the athletic trainer to assess all information about the patient and his or her situation to develop an understanding of the patient’s feelings and needs. This requires athletic trainers to be willing to question their own understanding of the situation to properly assist the patient. Any one of these constructs may be useful in interactions, but practicing them all together strengthens a provider’s ability to create an effective relationship with patients.

Teaching ADEPT

Faculty from the Communication Department and Athletic Training Program developed the model and lesson plan described here. The initial lesson was originally delivered over a 3-hour class session. Subsequent lessons were completed in two 1.5-hour sessions. Faculty implementing this lesson can choose to do either one 3-hour session or two 1.5-hour sessions. As noted in this article, partnering with faculty from the university’s Communication Department will enhance the learning experience for students by offering an interdisciplinary perspective on relational communication knowledge and theories. Partnering with Communication Faculty early will deepen the Athletic Training Faculty’s knowledge base in health communication so later sessions may be conducted without the assistance of Communication Faculty. Table 3 outlines a lesson plan designed to teach the ADEPT model and includes 2 modules. In teaching the ADEPT model to athletic training students, faculty focused on 3 main topics: (1) what is communication, and what role does it play in athletic training, (2) perspective-taking, and (3) managing uncertainty. Focusing on these 3 areas enabled faculty to unpack elements of ADEPT and explain the usefulness of the model to everyday athletic training interactions. Furthermore, the model is introduced after students have had their initial clinical experience and before their full semester immersive clinical rotation. This timing allows students to have some experience in the field but leaves room to add further education. By placing this education module between clinical experiences, students can have some practical experience that enables them to recognize the value of the model and perhaps how they might best use the information in future settings.

Table 3.ADEPT Lesson Plan

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Faculty began the training with a discussion of what communication is and the role it plays in athletic training interactions. This discussion started with basic communication concepts such as the transactional model of communication and its various components such as senders, receivers, feedback, and noise (Figure 1). Reminding students of the basics of communication and how each part functions allows students to engage in a fruitful discussion of the communicative challenges and how to improve communication overall. As we shifted the conversation to athletic training, we discussed their experiences from their first clinical rotation. This allowed students to see how communication is used, specifically in athletic training interactions that they each experienced.

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As students discussed their experiences from their first clinical rotation, instructors identified specific instances from students’ examples to highlight how to address the challenges using ADEPT. Inevitably, in these discussions, uncertainty was a common theme athletic training students identified as a struggle, both with their uncertainty in interactions with patients as well as the uncertainty they observed within their patients. While managing uncertainty is not a part of the ADEPT model, it is the well from which ADEPT sprang. We manage uncertainty through communication, specifically with the 4 constructs included in the ADEPT model. Faculty walked students through each component of ADEPT and showed how it can be used in interactions (See Figure 2). After the discussion, students were split into pairs to practice what they learned. Pairs were given scenarios in which they took turns being in the roles of patient and provider. Scenarios involved the use of injury assessment protocols students were familiar with (ie, shoulder or knee assessments) while also incorporating the ADEPT model. Instructors moved throughout the room observing the assessments in progress, offering feedback on identifying windows of conversational opportunity, how to structure statements, and asking appropriate follow-up questions. Training usually wrapped with a discussion of the practical challenges from practice in class and how these issues might translate to clinical practice. As noted in the Table 3 lesson plan, partnering with faculty from the university’s Communication Department can enhance the learning experience for students by offering an interdisciplinary perspective on relational communication knowledge and theories while also allowing athletic training faculty and communication faculty to contribute their expertise.

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Clinical Advantages

Previously, athletic training students were exposed to very little communication training, usually a single communication class that is part of the general education (liberal studies) university requirements. While valuable, these kinds of classes are introductory in nature and often focused more on public speaking rather than professional relationship-building skills. Often, students struggle to apply knowledge learned in these classes to their field, as they are taken early in the academic career and make use of content separate from the field of athletic training and devoid of any clinical context. Embedding relational skill-building in athletic training curricula highlights the importance of these skills for both instructors and students alike. Furthermore, it provides clearer guidelines for direct applications in clinical settings that meet demands for patient-centered care.

As noted in the literature, this model highlights the importance of empathy and perspective-taking in professional settings as a function of patient-centered interactions. However, many communication training programs discuss empathy without concrete suggestions as to how the provider may demonstrate an empathic understanding to the patient. If the patient does not recognize the empathy of the provider, empathy serves no communicative benefit. With ADEPT, appropriate self-disclosure on the part of the athletic trainer becomes the key to demonstrating empathy and encouraging reciprocal disclosure by the patient. When this reciprocal disclosure process involves disclosures that are personal in nature, relevant within the context of the interaction between the athletic trainer and his or her patient, and done at appropriate levels of intimacy, it helps the patient develop a sense of knowing his or her athletic trainer. In turn, this signals to the patient that the athletic trainer is listening to his or her concerns, carries the message the athletic trainer cares about him or her as a person, and fosters a sense of trust in the athletic trainer. While other health protocols focus on communication such as SBAR and SPIKES, these models are limited. SBAR is focused on provider-to-provider interactions.³⁸ While SPIKES does focus on patient-provider communication, it is focused on breaking bad news.³⁹ ADEPT is a more comprehensive communication model that may be used for everyday situations.

Much like athletic skills are mastered through continuous coaching and practice, communication skills must be developed and mastered in a similar fashion. Davlin-Peter and Rosencrum advocate for communication skills training before athletic training students enter their clinical experiences.²³ This highlights the importance of communication skills to clinical practice and prompts students to keep the practice of communication top of mind as they enter clinical rotations. Deveugele et al argues that communication skills training should occur throughout a clinician’s education.⁴⁰ With communication skills incorporated continuously throughout the curriculum, students needing remediation can be identified early, and ongoing practice improves students’ skills over time.⁴⁰ The ADEPT model offers enough flexibility that it can be introduced before clinical experiences and continue to be used throughout the program as students progress through the curriculum. The ADEPT protocol as outlined here begins with the basic transactional model of communication that can refresh and reinforce communication concepts first introduced as part of a university’s general education requirements. ADEPT was developed using an acronym to aid in retention and recall. As students then move into their clinical experiences, ADEPT provides a memorable mnemonic device enabling students to keep communication concepts top of mind as they navigate their first clinical rotations. With the partner simulation component, ADEPT provides students the opportunity to practice diagnostic assessments while also incorporating the protocol, helping them prepare for patient encounters. After the initial clinical experiences, ADEPT can then be repeated and reviewed with students having a better understanding of the context in which it applies. With these recent experiences fresh in their minds, discussion related to ADEPT concepts and principles is better informed, allowing for students to adjust their approaches, help them process the challenges they encountered, identify ways to take corrective actions, and share success stories related to specific practices and techniques. The ADEPT acronym provides a valuable framework for athletic training students to communicate effectively with patients, leading to better patient experiences, improved outcomes, and the development of essential health care communication skills. A summary of student responses to instruction related to ADEPT can be found in Table 4.

Table 4.Student Response to Instruction

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Conclusion

As the medical establishment increasingly understands the impact communication has on individual health and well-being and calls for clinicians to improve their relationship-building skills, the ADEPT model offers an easy-to-remember communication protocol that athletic trainers can adapt to a variety of clinical encounters and circumstances. Training programs involving simple, low-demand, patient-provider interpersonal interventions have shown improvements to patient health outcomes, patient involvement and satisfaction with providers, and reductions in provider burnout and depersonalization.³⁰ Because ADEPT is designed to complement and be used with existing diagnostic assessments already being taught, it is easily incorporated into existing athletic training curricula without adding significant amounts of time or additional coursework. In addition, ADEPT helps bridge the varying levels of abstraction (and potential confusion) among terms like communication, empathy, and interpersonal skills. Communication is an umbrella term that can pertain to a variety of behaviors that involve the exchange of messages between 2 or more parties. Researchers investigating the effectiveness of communication training programs often attempt to categorize communication skills, interpersonal skills, listening, empathy, rapport, patient management, and relationship-building as separate, discrete behaviors and characteristics, when in fact they all function as communication. By combining more abstract directives (ie, demonstrate empathy) with more concrete behaviors (ie, appropriate self-disclosure), ADEPT guides the athletic trainer through the more abstract notions of communication to specific behaviors that can be enacted within the context of patient-provider relationships.