Abstract
Background
Protocols instituted for behavioral treatment and skills training programs for the management of autism spectrum disorder (ASD) suffer from lack of collaborative approaches. The tenets of interprofessional collaborative practice (IPCP) focus on preparing a panel of health care professionals (HCPs) from different professions who can work together to enable the common goal of ensuring that children with ASD can participate in society. This study was designed to pilot this approach through an IPCP training module on ASD for care providers from multiple professions.
Methods
An interventional study with pre-post analysis began with formation of the interprofessional (IP) team, who developed an IPCP module, addressing the knowledge and skills needed for the collaborative management of neurodevelopmental issues of children with ASD. This module was delivered through an online training workshop using various teaching learning methods to the participants from seven different health professions after obtaining informed consent. Perceptions of interprofessional collaboration and competencies of IPCP were assessed using standard IP tools and reflective summaries and analyzed through a mixed-methods approach.
Results
A total of 42 HCPs from seven professions, including speech and hearing, occupational therapy, clinical psychology, physiotherapy, pediatrics, nursing, and pedodontics, participated in the study. Pre-post analysis of PINCOM-Q and Dow-IPEC data and thematic analysis revealed a significant difference in the perceptions of interprofessional collaboration and competencies’ levels of IPCP.
Conclusion
This study suggests that use of IPCP principles in the training of professionals working with ASD is a promising and feasible option to develop more competent health professionals. The training enhanced the abilities of professionals to work in field of ASD as conveyed by the participants. They also expressed confidence in the knowledge of IP core competencies after the completion of the module.
Keywords: Interprofessional, Collaborative practice, Training module, Autism spectrum disorder, Health care professional
Introduction
Autism spectrum disorder (ASD) is one of the most common developmental disorders globally and in India with the prevalence of 1 in 125 in children at 3–6 years and 1 in 85 in children at 6–9 years of age. Although this number has steadily increased in recent times, majority of them fail to get appropriate treatment.1, 2, 3, 4 The quality of life of children with ASD are compromised due to the current management protocols, which largely address the issues in professional silos.5 Protocols instituted for behavioral treatment and skill training programs also suffer from lack of collaborative approaches. Hence, collaborative care with an interprofessional (IP) focus sounds like an opportunity for treating neurodevelopmental delay with impaired cognitive and behavioral function.
World Health Organization (WHO) promotes interprofessional education (IPE) across the globe to enhance effective health care. This concept is well illustrated in its report, ‘Learning Together to Work Together for Health’. IPE occurs when members of two or more professions learn with, from and about one another to improve the quality of care through collaborative practice (CP). However, the real benefit of IPE and CP is, getting a work-force ready for CP based on the health needs with the available infrastructure.6,7
For this purpose, a well-planned systematic IPE program is crucial to prepare the health professionals from different disciplines to work together for a common goal.
It is still a challenging task for ensuring that children with ASD can participate fully in the society. This is partly due to a lack of effective interventions to address issues related to various neurodevelopmental domains. Available interventions often fail to reach the needy due to issues like lack of awareness, attitudinal issues, and noncompliance to the treatment regimen.5,8 IPE for CP is crucial for the creation of efficient and service-oriented health professionals and improved patient care and health outcomes. IP team-based, collaborative care is the way to provide comprehensive care to children with ASD and their caregivers. IPC is needed not only at the direct service delivery level but also at the level of policy and management.9,10 Hence, health care professionals (HCPs) need to be trained on interprofessional collaborative practice (IPCP) for the effective management and quality care of children with ASD.
Although IPCP for the care of children with ASD has been introduced in many countries, evidence for the same is very minimal in the Indian context.11, 12, 13 Educating the health professionals on IPCP is an area that looks promising and hence needs to be evaluated. This prompted us to design this study to develop and validate an IP training module on CP among the HCPs for the management of children with ASD.
Materials and methods
This study was designed as an interventional study with pre-post analysis, conducted on health care providers of seven diverse professions from different institutions. The selected professions of study participants included pediatrics, occupational therapy, clinical psychology, speech and hearing, physiotherapy, nursing, and pedodontics. An IP team was formed with 11 different professionals including, clinical psychologist, audiology and speech pathologist, occupational therapist, clinical biochemist, physiotherapist, public health expert, pediatrician, nursing professional, pedodontist, and IPEP consultant. A training session on IPE and CP was conducted for the IP team members after a brain storming session with pre-test. Feedback was collected to understand the effect of IPE and CP training workshop on the team members.
Development of the interprofessional collaborative practice (IPCP) module for autism spectrum disorder (ASD)
Six consecutive focus group discussions (FGDs) of the IP team were conducted to plan and prepare the contents of the IPCP module, addressing the knowledge and skills needed for the management of neurodevelopmental and nutritional issues of children with ASD through IPCP. The contents were finalized after fixing the learning objectives, teaching learning and assessment methods and course outcomes. The module was reviewed and validated by 12 experts both from IPE and CP as well as experienced professionals involved in the care of children with ASD. Then the evaluation of the module was carried out by delivering the module to HCPs through training sessions and assessing the outcome.
The training module was designed such that five strands of the module (Table 1) were scheduled in each day.
Table 1.
The five strands of the interprofessional collaborative practice (IPCP) training module.7
| Sessions | Competencies |
|---|---|
|
STRAND 1 Introduction to interprofessional education and collaborative practice |
To appraise the importance of interprofessional education and collaborative practice, to discuss the working models of collaborative care, and to identify the essential competencies in IPCP for the care of patients with autism spectrum disorder (ASD) |
|
STRAND 2 Values/ethics |
To work with individuals of other professions to maintain a climate of mutual respect and shared values during the collaborative practice for the management of ASD |
|
STRAND 3 Roles/responsibilities |
To use the knowledge of one's own role and that of other professions to appropriately assess and address the health care needs of patients with ASD |
|
STRAND 4 Interprofessional communication |
Communicate with children with ASD and their parents, families, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to enhance their participation in the society |
|
STRAND 5 Teams and teamwork |
To apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient-centered care |
The core competency on ‘Values and ethics’ is essential for maintaining the climate of mutual respect and shared values among team members providing care for children with ASD. The competency on ‘Roles and Responsibilities’ emphasizes that professionals use the knowledge of one's own role and those of other professions to suitably evaluate and address the healthcare requirements of the patients with ASD. The third core competency on interprofessional communication demands that health professionals involved with care of patients with ASD engage in responsive and responsible manner with patients, families, communities, and other health professionals. ‘Teams and teamwork’ competency highlights the relationship-building values and the ideologies of team dynamics to ensure efficient performance in different team roles while planning and delivering safe, timely, efficient, effective, and equitable patient-centered care for children with ASD.
A total of 42 study participants from seven different professions, including speech and hearing, occupational therapy, clinical psychology, physiotherapy, pediatrics, nursing and pedodontics, participated in the study after giving informed consent. The study was approved by the Institutional Ethics Committee.
The module was delivered to the study participants through the training sessions including interactive lecture, classroom activities, and small group discussions using case-based learning. The assessment was done using pre-post analysis using questionnaires and reflective summaries.
The introduction and core competencies of IPCP were taught by the national and international IP experts. The training for acquiring the skills of IPCP was given through small group activities and case-based learning sessions for each competency. The case-based learning sessions and small group activities were facilitated by all the members of IP team.
A mixed-method approach was adopted for the assessment. The pre-test and post-test for perceptions of IP collaboration and IP competencies were assessed using Perception of Interprofessional Collaboration Model Questionnaire (PINCOM-Q) and Dow, IPEC instrument, respectively.14,15 The participants were instructed to follow Bortons’ model for writing reflective summaries.16 Qualitative data analysis of the reflective summaries was performed by two independent investigators. Feedback was collected after the workshop incorporating questions for each strand separately.
The primary outcome measure is the mean difference in the pre- and post-score of each component of IPCP to assess the acceptability of the IPCP module for ASD among the HCPs to learn IPCP. A mixed-methods approach was used for the analysis. The pre-post analysis of the responses was done using a paired-sample t-test, p< 0.05 was considered as significant. The qualitative data including reflective summaries from the participants were analyzed using thematic analysis. All guidelines as per the Declaration of Helsinki and good clinical practice guidelines were followed.
Results
A total of 42 participants from seven professions, including speech and hearing (n = 7), occupational therapy (n = 7), clinical psychology (n = 6), physiotherapy (n = 7), pediatrics (n = 5), nursing (n = 4), and pedodontics (n = 6), participated in the study in which 40 participants submitted pre-tests, and out of these 40 participants, only 37 participants submitted the post-tests. Hence, only data from the 37 participants were included for further analysis. The overall post-test score for both PINCOM-Q and Dow, IPEC was significantly higher than the pre-test score (Table 2).
Table 2.
Comparison of overall scores of pre-tests and post-tests.
| Test tool | Pre-test mean | Post-test mean | p-value |
|---|---|---|---|
| PINCOM-Q | 5.115 | 5.377 | 0.009 |
| DOW,IPEC | 3.862 | 4.492 | <0.001 |
The pre-post analysis showed significant improvement in various factors of IPCP including motivation, role expectations, communication, social support, organizational culture, organizational goal, and organizational domain.
The changes in the post-test scores for factors including personality style, professional power, group leadership, coping, and organizational environment were not significant indicating the better understanding and realization of self-limitations in IPCP. The increase in the post score of interaction and values by the IPEC instrument was highly significant (Table 3).
Table 3.
Pre-post analysis of responses on interprofessional collaborative practice factors and interprofessional competencies.
| Parameter | Pre-test mean | Post-test mean | p-value |
|---|---|---|---|
| Motivation | 6.045 | 6.311 | 0.025a |
| Role expectations | 4.939 | 6.136 | 0.001a |
| Personality style | 5.530 | 5.386 | 0.297 |
| Professional power | 5.023 | 4.818 | 0.241 |
| Group leadership | 5.348 | 5.492 | 0.172 |
| Coping | 4.894 | 4.871 | 0.457 |
| Communication | 4.500 | 5.182 | 0.010a |
| Social support | 4.833 | 5.265 | 0.027a |
| organizational culture | 5.311 | 5.682 | 0.024a |
| organizational goal/aims | 4.750 | 5.280 | 0.014a |
| Organizational domain | 5.045 | 5.462 | 0.043a |
| Organizational environment | 5.167 | 5.258 | 0.305 |
| Interaction | 3.678 | 4.436 | <0.001a |
| Values | 4.045 | 4.549 | <0.001a |
Highly significant.
The feedback after the training sessions showed the positive effect on the attitude and understanding of the participants towards IPCP.
A total of 22 participants from all the seven professions submitted the reflective summary. After the review of the reflective summaries, the authors arrived at a consensus on the main themes and subthemes that emerged during analysis. Three main themes were established. Further 12 subthemes were also identified, which were linked to major themes. Table 4 provides a summary of these themes, subthemes, and selected responses from participants identified to support them.
Table 4.
Thematic analysis of reflective summaries.
| Main themes | Subthemes | Exemplars from participant reflections |
|---|---|---|
| 1. Perceived barriers |
|
Ego, withholding information, power struggle between care providers I have never involved in patient care of autism spectrum disorder (ASD) as a team Persistent hierarchy present in clinical setting can hamper collaboration among care providers Stereotyping can hamper any team-based interventions |
| 2. Anticipated benefits |
|
More confidence among parents as they are a part of decision-making process Active delegation at all levels reduces redundancy, making it cost effective and less risky for ASD patients Open and respectful communication is a hallmark of team-based care With child having ASD in the center stage, patient autonomy and safety is guaranteed Can help prevent medication errors Collaborative team-based care is likely to enhance health outcomes in ASD patient |
| 3. Action plans for future |
|
IPE and Interprofessional Practice (IPP) should be introduced in all health professions curricula Now while treating children with ASD, I need to consider perspectives of other professionals involved in care I need to unlearn to learn Sharing of knowledge and skills is important if this must work A team with clear vision, sense of purpose and situational leadership can help create client-centric care for ASD |
Discussion
The word ‘IP’ is defined as a group of individuals from different professions working and communicating with each other. In the environment of IP learning, every member provides his/her knowledge, skills, and attitudes to augment and support the contributions of others (Hall et al).17
Keeping these ideas about IP learning as a foundation, the current study focused on two objectives. One is the quality of the IPCP module that we developed for ASD, and secondly, if the effective delivery of the module to train the health professionals would contribute to developing efficient IP practitioners for the management of ASD. We investigated the knowledge, skills, and perception of IPCP in this group of participants and improvements after the training sessions if any.
The results indicate a positive change in the perceptions and understanding of the participated HCPs on IPCP. However, to develop a workforce ready for IP practice would need a provision to learn this in their own health professions curricula. This calls for interprofessional educational modules in the curricula that address cognitive, psychomotor, and affective competencies.
The competencies for IPE must be patient centered and must be applicable across the professions and practice settings. Educational initiatives of this kind can provide experience and expertise to enhance the coordination and capacity building on IP practice aimed toward enhancing health outcomes in patients with ASD.
Overall, our intervention could bring about a change, through the understanding of IPCP and its impact among the participants and increased their confidence in CP. The study also displays acceptability of the IPCP module for ASD among the participated HCPs as training tool for IPCP for ASD.
Apart from these benefits, we also recognize that including nutritionist and other professionals like special schoolteachers and care givers would have been more effective. Further studies to understand the other long-term benefits of such a training module for professionals also needs to be evaluated.
Conclusion
IPCP seems to be a feasible option in the management of ASD and in enhancing the quality of life of ASD patients as conveyed by the participants. They also expressed confidence in the knowledge of IP core competencies after the completion of the module. Comprehensive Interprofessional training programs developed by local experts, which are evidence-based, context-specific, learner-centered, and rigorously evaluated can be game changers in creating a sustainable impact in the management of children with ASD.
Patients/ Guardians/ Participants consent
Patients informed consent was obtained.
Ethical clearance
Institute/hospital ethical clearance certificate was obtained.
Source of support
Nil.
Disclosure of competing interest
The authors have none to declare.
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