Challenges to and Resources for Participation in Interprofessional Collaborative Practice: Perceptions of Collegiate Athletic Trainers

After obtaining institutional review board approval, we purchased a census sample of members of the National Athletic Trainers' Association practicing in the collegiate setting (N = 6313). Exclusion criteria were ATs not certified by the Board of Certification, Inc, and those not employed in the collegiate setting. Recruitment e-mails were sent to 6313 ATs in the collegiate setting, and a total of 739 ATs completed the survey. Participants were excluded from qualitative data analysis if they self-identified as not participating in direct patient care: that is, if they identified their role as a full-time academic or administrative appointment without patient contact. Based on this exclusion criterion, 223 participants were removed from the analysis, leaving a total of 513 participants included in the analysis of qualitative responses (8% response rate). Although the response rate was low, this was one of the first assessments of collegiate ATs' perceptions of IPCP and therefore may serve as a foundation of knowledge in this area of research.

The researchers (D.A.H., S.A.M.) contacted potential recruits via e-mail about participating in this study. The purpose of the study, informed consent procedures, a hyperlink to the online survey, and contact information for the researchers were included in the e-mail invitation. Recruits were offered the opportunity to enter a drawing for 1 of 23 cash prizes as an incentive to participation.

The Clinician Perspectives of Interprofessional Collaborative Practice survey was used to collect participant responses.¹⁴  This survey has 2 primary sections: (1) perceptions of IPCP and (2) clinical setting perspectives. The clinical setting perspectives section evaluates the experiential aspects of IPCP as assessed via a combination of Likert-scale items and 4 open-ended questions. These open-ended questions aim to capture ATs' perceptions of the challenges to, resources for, benefits of, and drawbacks to participation in IPCP. In this manuscript, we present the responses to the open-ended questions related to challenges to and resources for participation in IPCP. Further details regarding survey development and reliability (Cronbach α = 0.698–0.854 for all constructs) are available in a previous study.¹⁴ 

Data were collected in Qualtrics software (Provo, UT) and stored on a secure university server. Responses to the open-ended questions were analyzed using a general inductive approach. Initially, we conducted open coding by identifying recurrent words within responses. These key words were then compared to established guiding codes for the next review of responses. In subsequent readings of the data, we assigned labels to responses according to the established coding guide. This process continued until all data were categorized into appropriate thematic areas.^18,19  An outside auditor reviewed the responses and corresponding thematization.²⁰  The few discrepancies were discussed among the research team and the auditor until consensus was reached.

During the data analysis, strategies to improve the trustworthiness of the data included determination of coding saturation, external auditing of themes and categories, and triangulation. The research team and the outside auditor agreed that the emergent themes were in fact evident throughout all aspects of the data set, thereby establishing coding saturation. For triangulation, multianalyst evaluation occurred as both members of the research team were involved in all aspects of the data analysis, and the outside auditor provided added perspective for consideration.^19,20  Additionally, Likert-scale items²¹  were compared with open-ended responses to confirm the connection¹⁸  of the related information on perceptions and perspectives of IPCP.

Of the 513 participants, more than half (54%, n = 278) were female. On average, participants had 10.69 ± 9.33 years of experience in clinical practice, mostly in the athletic model (n = 325). Further demographic information is reported in Table 1. Responses to the Likert-scale items suggested that ATs perceived IPCP as beneficial to patient care but did not consistently practice in this manner; these results are presented in a separate manuscript.²¹  Responses to the open-ended questions relating to perceptions of challenges to and resources for participation in IPCP revealed several themes, categories, and subcategories related to each topic. Emergent themes and associated categories are identified in the following paragraphs; thematic frameworks with sample quotations from participants are also included by topic in table format.

Four themes emerged from the topic of challenges to participation in IPCP: (1) ability to engage in IPCP, (2) knowledge of roles and scope of practice, (3) factors affecting team collaboration, and (4) time to participate in IPCP (Figure 1). Within the theme of ability to engage in IPCP, 2 categories were identified: access to other health care professionals and structure of the health care team (Table 2). Within the category of access, participant descriptions related to geographic location and opportunities (or both) to meet and collaborate with each other. The category of structure of the health care team was further delineated into 2 subcategories: a defined IPCP process and continuity of care. Participant responses within the theme of knowledge of IPCP related to a perceived lack of knowledge of the roles and scope of AT practice by other health care professionals. For the theme of factors affecting team collaboration, responses were divided into the categories of communication, opinions, and respect for those on the health care team (Table 3).

Analysis of participant responses revealed 2 primary themes related to resources perceived as helpful to participation in IPCP: (1) means for improved communication and (2) educational opportunities (Figure 2). Participants' responses indicated that accessibility to other members of the health care team, shared medical records, and improved communication strategies would be helpful as they pursue IPCP. Within the area of shared medical records, an electronically based documentation system that was accessible to all members of the health care team was beneficial to keeping members of the team on the “same page” regarding patient care. In relation to resources for IPCP development opportunities, collegiate ATs noted that education for other professionals regarding the scope of practice of ATs as well as opportunities to participate in interprofessional education alongside other health care professionals would be beneficial (Table 4).

The purpose of our study was to describe collegiate ATs' perceptions of the challenges to and resources for participation in IPCP. When considering IPCP, participants perceived the areas of communication, knowledge, time, and opportunities as both challenges and resources. Although these findings are the first established data regarding IPCP among the collegiate athletic training population, the results are similar to those of previous authors¹⁴  among a larger, more generalized population of ATs.

Health outcomes are typically influenced by more than 1 profession or practitioner.^22,23  Therefore, health care professionals should appreciate their own skills, knowledge, and abilities and be able to describe these characteristics to others, while also learning this information about peer professions, with the aim of improving patient outcomes.²⁴  This goal of collaborative practice is relevant to participants in this study who identified a lack of knowledge as a challenge to IPCP. More specifically, these collegiate ATs cited a lack of knowledge by other health care professionals regarding the AT's scope of practice as a challenge. This perceived lack of knowledge was similar to previous findings in athletic training¹⁴  and various disciplines that showed professionals were not well versed in the skill set, roles, and practice patterns of other health care professions.²⁵  The Interprofessional Education Collaborative¹  domain of roles and responsibilities encourages health care providers to not only know their own role but also to understand the roles of others in order to best address patient needs. Early clarity about what each member of the team brings to the table, as well as the expectations for collaborative practice, should help to determine an effective patient care plan.^26,27  When participating in IPCP, ATs should capitalize on the opportunity to educate our health care counterparts about our professional scope and skills. Perrin¹⁷  summarized the challenges related to the scope-of-practice knowledge at the local or institutional levels as including patterns of clinical practice within teams and varying perspectives of team members regarding health care provider status, authority, and power, all of which may be present within the collegiate practice setting.

Although initiatives for improving awareness of the athletic training profession may occur at the local, regional, and national levels, individual efforts by ATs within their personal practice networks may be the best place to begin to see change. It is unrealistic to expect health care professionals to become fully knowledgeable about all other health care professions on their own, so ATs need to purposefully communicate their specific skill set within the IPCP team while advocating for the profession. Collegiate ATs typically work regularly with a structured health care team, which should increase the opportunities to inform the other members of the team about the athletic training skill set. In alignment with the interprofessional competencies, communication of these roles and responsibilities should be part of the early discussions on team expectations.^26,27  These discussions may lead to identified areas of overlap in care, which may result in role confusion rather than role clarity if appropriate modifications are not made.²⁸ 

One aspect of the AT's role in many situations, particularly in the collegiate setting, involves serving as the primary health care provider for the patient and the primary point of contact for the other members of the health care team.¹³  Furthermore, the AT often serves as the referral point for the rest of the health care team, thus enabling the AT to educate these other professionals on our scope of practice, skill set, and appropriate involvement in patient care. Ideally, ATs should make a distinct effort to discuss these roles early and often in an effort to achieve increased quantity and quality of interactions among members of the interprofessional team.²⁹  This emphasis on interprofessional knowledge should help to foster a respectful and collaborative approach to patient care.¹⁷ 

Interprofessional collaborative practice emphasizes a team approach to patient care that accentuates communication and cooperation.³  The ability of an interprofessional health care team to provide quality care is directly linked to the extent to which the members of this health care team work well together; if communication is a problem during team interactions, patient care may be negatively influenced.³⁰  In our study, communication was identified not only as a challenge to team collaboration in the collegiate setting when it was lacking but also as a resource for enhancing participation in IPCP when performed consistently.

Respondents in this study referenced personality differences and the perception of egos within the interprofessional team as communication-related challenges to IPCP. Previous literature³¹  supports these findings by identifying challenges and barriers to interprofessional communication as including (though not limited to) personal values and expectations, personality variances, and varied levels of preparation and qualification among professions. An additional communication challenge that exists in IPCP is the need for all members of the team to establish and use a shared language.^23,32  It is vital for all members of the health care team to understand each other's professional language, communicate using common terminology, and work in a coordinated manner to accomplish patient care goals.²³  For ATs at the collegiate level, mechanisms targeted at enhancing this common language and communication are seen in the recommendation for regular interprofessional meetings to reinforce collaboration through targeted verbal communication.³³ 

Collegiate ATs in this study also identified a common meeting space, shared medical records, access to electronic forms of documentation, and other communication tools as perceived resources for IPCP. Participants desired closer access to members of the team, including on-site interactions and space for collaboration. These results closely overlap with the World Health Organization's environmental recommendations for working culture, such as shared facilities and space design.⁶  In regard to shared medical records, information technology that is available to all members of the interprofessional team has also been cited¹⁷  as a way to increase collaboration and communication. Furthermore, this framework⁶  suggests that improved communication may be actualized through institutional support, a working culture that values IPCP, and environmental mechanisms that emphasize appreciation of IPCP. Specific to institutional support, structured protocols, administrative-level support, and shared operating resources may serve as positive contributors to collaborative practice.^6,16  This institutional support was recognized by our participants as a potential resource in terms of more accessibility to the IPCP team, shared medical records, support from administrators, and a more structured network of care providers. Consideration may be given to adjusting the working culture of the institution by defining communication strategies and policies for IPCP.⁶ 

Such policy development may entail a structural evaluation of the interprofessional teams to permit 1 entry point for the patient to access the care team.³³  Given the current structure of most collegiate athletic training departments, the AT may serve as this common entry point for patients to receive care from the interprofessional team.³³  Having 1 common entry point, as well as consistent communication among all members of the health care team, could help to enhance the continuity of care, which was cited as a challenge in this study. As IPCP in the collegiate setting increases, it will become more important for the reporting structure for ATs and other members of the health care team to follow the guidelines set forth by the National Collegiate Athletic Association for independent medical care.³⁴  Too often, collegiate ATs report to individuals who do not possess knowledge of medical decision making and health care administration.^16,34  When this occurs, communication is challenged, and patient safety is put at risk.¹⁶ 

Additional communication concerns were that participants perceived conflicting opinions and a lack of respect for all members of the team as challenges to IPCP. Challenges to communication may occur in the form of a perceived threat to one's professional identity or the perceived hierarchy of professionals on the health care team.^35,36  Headrick et al identified “fears of diluted professional identity”^32(p773) as a barrier to interprofessional collaboration, and this closely matches the previously mentioned potential for perceived power and authority imbalances to manifest as challenges to successful interprofessional collaboration.¹⁷  We propose that a strategy to decrease the perceived threat to professional identity may be to educate health care professionals early regarding roles and responsibilities, clearly defining such roles in the beginning of team-based patient care, thus enhancing the established trust among team members. Establishing trust is vital to the success of the health care team.²⁷  All members of the team must be willing and able to overcome personal differences, put the needs of the patient first, and work toward the common goal of improved patient care,²⁷  even if that means recognizing that another professional may have a more appropriate skill set relevant to the patient's goals. In concert with regular meetings to reinforce collaboration, more consistent opportunities to work together, while advocating for the role of the AT, should enhance the overall confidence, respect, and trust among the team members.

To overcome each of these perceived challenges, time is needed. As time was identified as a perceived challenge to ATs' participation in IPCP, collegiate ATs should consider how they might dedicate time to accomplishing IPCP. Although few participants specifically delineated which aspects of time were relevant to their perception, we suggest that time is a concern on multiple levels. Specifically, ATs may have difficulty identifying ample time to meet and collaborate with others, communicate, build relationships, and learn about the roles and responsibilities of other disciplines. One way to combat this challenge may be to set regular meeting times for the health care team aimed at enhancing member collaboration.³³  Also, explicitly making time for collaboration, thereby increasing contact time among team members, may increase the level of trust and confidence among providers.²⁷  For ATs who want to provide patient-centered care, collaborative practice will need to become a dedicated priority as they take the time necessary to establish relationships with other members of the IPCP team. Although it may be more time consuming at the beginning, ultimately it should allow for a more streamlined and effective delivery of patient care once the roles of each of the team members are established.

Our findings indicate significant potential for developing continuing professional education opportunities for ATs and other health care providers that may address the gap in knowledge of other professions' roles and responsibilities³²  while increasing awareness of and participation in IPCP. Similar to other literature,³²  these findings support a broader vision of continuing professional education by establishing practice-focused sessions with the goal of directly affecting specific outcomes for patients. Expanded opportunities to bring interprofessional teams from health care organizations at the state, regional, or national level to participate in cross-organizational, collaborative focused education sessions on a specific topic, such as concussion management, could be evaluated. Such interprofessional learning opportunities that allow health care professionals to better understand the scope of practice of others while addressing effective collaborative methods could be beneficial in enhancing ATs' participation in IPCP.⁹ 

As the results of this study show, collegiate ATs perceived access to the health care team, shared medical records, and communication mechanisms as resources beneficial to IPCP. When IPCP opportunities are identified and available, they may be facilitated via proximity to other providers, dedicated time to collaborate,²⁷  and mechanisms by which to collaborate.

In an effort to expand collegiate ATs' participation in IPCP, several possibilities may be examined regarding resources. In addition to the previously identified areas of institutional support, working culture, and environmental mechanisms, health care providers and policy makers may consider performing an internal evaluation of their health services.⁶  A needs analysis to ascertain the local, or internal, capabilities and requirements of their institution would be useful to begin this process. The World Health Organization framework⁶  also recommends making a commitment to fostering IPCP opportunities within both newly developed and existing programs. Establishing management practices that support IPCP while recognizing champions of IPCP initiatives may help to shift the culture and attitudes toward IPCP. Specifically, supporting and recognizing successful collaborations, teams, and collaboratively achieved patient outcomes should help to further foster IPCP practices and participation by ATs. An example of this successful collaboration may be seen in the medical model, where ATs report directly to a health care entity or physician rather than having direct oversight from an athletic department.¹⁶  The medical model may directly benefit participation in IPCP, as it would provide ATs with more consistent opportunities for integration into the health care team.^9,17 

This study had limitations. Given the self-report structure of the questions, we assumed that participants' responses were honest and represented their perceptions of IPCP. Although some participants referenced their personal experience with IPCP, we do not know if respondents were reporting their perceptions based on actual IPCP experience or projected perceptions on practicing in an interprofessional manner. The low response rate is also a concern because of the possibility of sampling bias. Although the level of error resulting from those who responded to the survey is unknown, we note that this study is the first of its kind among the collegiate athletic training population and provides insight into how ATs perceived participation in IPCP. Future researchers may benefit from increasing the number of participating ATs in the collegiate setting to more broadly capture the perceptions of this population.

Participation in IPCP by a health care team is being emphasized nationally. Athletic trainers in the collegiate setting perceived challenges and benefits to participating in IPCP. Specifically, challenges were cited in the areas of the ability to participate in IPCP due to physical location, available members of the team with whom to communicate, and general knowledge of the AT skill set by other health care professionals. Advocacy by ATs regarding their own skill set and role on the interprofessional team should occur with their direct health care team members. One resource for IPCP is administrative support by way of shared medical records. In general, these findings lend support to the need for continuing interprofessional education opportunities aimed at increasing knowledge of the skill sets of other health care professions, especially other professionals' knowledge of the AT skill set.

We thank Kelley Henderson, EdD, LAT, ATC, for her contribution as an auditor for review of the qualitative data.