Keywords
collaboration - interprofessional practice - IPEC competencies - Collaborative Practice Assessment Tool - behavior analyst
Learning Outcomes: As a result of this activity, the reader will be able to:
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Describe the categories of the Collaborative Practice Assessment Tool (CPAT) and how they relate to the four Interprofessional Education Collaborative (IPEC) competencies.
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Identify areas of similarity where health professionals across various settings indicate effective interprofessional practices are occurring.
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Analyze where relevant challenges still exist in the interprofessional collaboration space according to healthcare professionals.
Across the lifespan, individuals with disabilities obtain healthcare services from a variety of different professionals. Services can include those provided by speech-language pathologists (SLPs), behavior analysts (BA), psychologists, educators, occupational therapists, and mental health providers, among others. Please note, this article will use the term “behavior analyst” as opposed to using acronyms more commonly associated with the licensing components of BAs (i.e., BCaBA, BCBA, BCBA-D). These practitioners support clients to develop a variety of skills through interventions targeting areas of language, social skills, activities of daily living, and academics. Due to the complexity of needs presented by individuals with disabilities and goals for comprehensive and well-rounded outcomes, it is common for clients to receive services from multiple professionals across fields, and at the same time. Collaboration among these professionals is thought to ensure complementary and coordinated care.
Despite the importance of coordinated care, research suggests that interprofessional practice (IPP) is an area where many professionals across fields continue to struggle. For example, school-based SLPs have reported that they engage in minimal collaborative practice during evaluations, meetings, and intervention (Pfeiffer et al., 2019). Similarly, BAs working in public schools and home settings have reported that although they have almost daily opportunities to collaborate with other professionals, they adopt only minor changes to programming based on those collaborations and they are more likely to adopt recommendations that come from other BAs as opposed to practitioners outside of their discipline (Kelly & Tincani, 2013).
There are a multitude of reasons practitioners may fail to engage in IPP. These can range from a lack of time (Kelly & Tincani, 2013; Pfeiffer et al., 2019) to a lack of training on the importance of IPP or how to engage in IPP (Kelly & Tincani, 2013). Cardon (2017) indicated that theoretical differences across fields can lead to disparities in collaborative practices, as professionals experience a mismatch in the ways that they approach assessment and intervention with their clients. Similarly, the use of technical jargon and inconsistencies in terminology can result in difficulties communicating and coming to common understandings (Cardon, 2017; Critchfield et al., 2017). This may be compounded by the general lack of training and understanding related to the roles that other practitioners can play in supporting their common clientele.
IPP Definition and Competencies
Due to the importance of IPP for efficient and effective care, several groups have turned their attention to the topic. In 2010, The World Health Organization (WHO) put forth their Framework for Action on Interprofessional Education and Collaborative Practice. They defined collaborative practice as “multiple health workers from different professional backgrounds working together with patients, families, carers, and communities to deliver the highest quality of care” (Gilbert et al., 2010, p. 7) and the organization went on to issue a call to action for interprofessional education (IPE) and collaborative practice to support overwhelmed health systems with the goal of improving patient outcomes. With this in mind, in 2011 the Interprofessional Education Collaborative (IPEC), supported by an expert panel of health care professionals and institutions, put forth guidelines to guide curriculum and interprofessional collaboration across health professions. These competences were revised in 2016 (IPEC, 2016) and included the four following domains: values/ethics for interprofessional practice, roles/responsibilities, interprofessional communication, and teams and teamwork.
Researchers have attempted to translate these IPEC competencies into practice to improve understanding and to provide guidelines for practitioners from various health professions as they navigate the growing need for evidence to support IPP (Kirby et al., 2022; Ludwig & Kerins, 2019; Kester, 2018; Musaji et al., 2019). Research focused on improving understanding of practitioner's perception has been an important initial step in the movement toward development and betterment of IPP in practice, at both levels of education and implementation. Perception can be both a strong descriptor and an influencer of the experiences of practitioners (Jussim, 1991); therefore, it is key to learn how practitioners perceive their experiences with IPP in their work settings.
Measures about knowledge, skills, and attitudes toward IPE and IPP are few, and the ones that have been validated for use are limited to contexts of healthcare. Another important consideration for the furtherment of IPE and IPP in practice is to demonstrate measurement and report finding using these tools.
The Collaborative Practice Assessment Tool
The Collaborative Practice Assessment Tool (CPAT; Schroder et al., 2011) is one tool that has been used to assess practitioner's perceptions of IPP in practice. The CPAT was originally designed for use in healthcare settings, such as hospitals or primary care centers, to evaluate eight domains of IPP (Medves et al., 2008; Schroder et al., 2011): (1) relationships among team members; (2) barriers in team collaboration; (3) team relationships within the community; (4) team coordination and organization; (5) decision-making and conflict management; (6) leadership; (7) mission, goals, and objectives; and (8) patient involvement, responsibility, and autonomy. Scores on the CPAT focus on overall perception of IPP in the respondent's workplace and their perception across each of the eight domain subscales.
Several studies have been conducted using the CPAT and have found that the measure is psychometrically sound across populations and settings and that it can be used with confidence to gain insight into practitioner's perception of IPP (e.g., Findyartini et al., 2019; Fisher et al., 2017; Yusra et al., 2019). In general, these studies have been conducted with healthcare professionals working in healthcare settings, including primary care centers and hospitals. Findings using the CPAT have indicated that practitioners largely report positive perceptions of collaboration, but that some domains may contribute more to this perception than others. In addition, these studies have found that perceptions differed within domains based on demographic characteristics of the respondents, including respondent's profession, suggesting that different practitioners may have different experiences with IPP even within the same setting.
The Current Study
Given that individuals with disabilities often receive support from multiple professionals, IPP and care coordination is necessary to support intervention and well-rounded client outcomes. In order to move from IPE to IPP, it is important to measure knowledge, skill, and attitudes about IPP in practicing professionals. While the CPAT has been used in research to examine practitioner's perception of IPP across a variety of healthcare settings (e.g., Findyartini et al., 2019; Yusra et al., 2019), the perceptions of other professionals, including SLPs and BAs who work in schools, private clinics, or home-based settings with clients with developmental disabilities, are lacking. IPP for these groups is important however, as clients with developmental disabilities often have complex needs for which they require the support and expertise of multiple professionals across fields. To better understand how IPP is developing between these practitioners, it is helpful to understand how they perceive IPP to be working in various environments. Therefore, the purpose of this study was to expand research on IPP for a broad sample of disciplines representing different clinical practice settings using the CPAT as an assessment tool for this group. In this way, this study contributes to directly understanding IPP in a sample of SLPs and BAs; and also contributes to further demonstrating the validity of using a tool such as the CPAT to understand IPP for practitioners.
Method
This study was a cross-sectional survey design whereby individuals who were health care professionals working in a variety of settings with individuals with disabilities were invited to complete an online survey. This study was deemed exempt by a university institutional review board (#IRB-21-01-0025).
Sampling Strategy
Participants were recruited using purposive sampling, a nonprobability sampling procedure that targets potential participants with specific characteristics (Gentles et al., 2015). Inclusion criteria required that participants work with clients with developmental disabilities in one of the following roles: BAs, educators/teachers, occupational therapists, mental health providers, psychologists, social workers, or SLPs. Participants were recruited by the research team who posted advertisements about the study on social media (e.g., Facebook, LinkedIn) and shared with personal and professional contacts via email. The advertisement for the study included a link to the survey, which could be accessed by anyone interested in participating. Recruitment information could also be shared with any others who may be interested in the study, allowing for snowball sampling to increase exposure to potential participants (Rea & Parker, 2014). Although snowball sampling limits information on response rates, it increases the exposure to potential participants, is consistent with sampling strategies used in previous research in the social sciences (e.g., Taylor et al., 2018), and is consistent with the purpose of the current study.
Data Collection
The survey was developed in Microsoft Forms and included three parts. The first part included informed consent, screening questions, and demographic information. The second part comprised the CPAT (Schroder et al., 2011). The third part included five open-ended questions: the first three were tethered to the CPAT and the second two were included to support the study's purpose.
Survey Part 1: Informed Consent, Screening Questions, and Demographic Information
Informed consent was achieved by displaying an IRB-approved informed consent letter on the first page of the survey where respondents answered three screening questions, one question about age of participants and the other two questions directly asking for consent to participate in the study. This screen also included contact information for the study patient's involvement (PI). A series of demographic questions asked about professional licensure, years in practice, and descriptive information about the participant's current workplace.
Survey Part 2: CPAT
The CPAT (Schroder et al., 2011) assesses knowledge, skills, and attitudes about IPE and practice in health care professionals. It includes 57 items spanning 8 subscales related to interprofessional collaboration and practice. Respondents rate agreement with each statement using a Likert-type rating scale ranging from 1 (strongly disagree) to 7 (strongly agree). Reliability for items by subscale was established by Schroder et al. (2011) using Cronbach's alpha and are reported here: (1) mission, meaningful purpose, and goals (α = 0.88); (2) general relationships (α = 0.89); (3) team leadership (α = 0.80); (4) general role responsibilities, autonomy (α = 0.81); (5) communication and information exchange (α = 0.84); (6) community linkages and coordination of care (α = 0.76); (7) decision-making and conflict management (α = 0.67); (8) PI (α = 0.87). Two questions from the CPAT were not included, as these made direct reference to physicians and were not appropriate for the target audience.
Survey Part 3: Open-Ended Questions
The CPAT also includes three open-ended questions which were included in the current survey (questions 1, 2, and 3, below). Finally, two open-ended questions were developed by the researchers for this study (questions 4 and 5, below). Each question included space for participants to note their narrative response. The open-ended questions were as follows:
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What does your team do well with regard to collaborative practice?
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In your practice, what are the most difficult challenges to collaboration?
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What help does your team need to improve collaborative practice?
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What do you think your professional organizations can do to promote positive collaborations in the future?
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Have you noticed specific barriers to IPP and collaboration?
Data Analyses
Data were analyzed in two phases. First, quantitative analyses were conducted, to examine participant characteristics and to summarize the quantitative data collected using the CPAT. Second, the open-ended CPAT questions and the open-ended questions that were developed for this study were analyzed to examine themes across participants' responses.
Quantitative Analyses
Quantitative analyses were conducted in two parts. First, descriptive analyses (e.g., frequencies and percentages; Gravetter & Wallnau, 2017) were conducted to provide a summary of the characteristics of the professionals who participated in this study. Second, descriptive and inferential analyses were conducted to summarize participant's responses on the CPAT and to examine possible differences between professional groups. Prior to the analyses, CPAT data were cleaned to reverse code three items and to ensure data met assumptions for the planned analyses (Gravetter & Wallnau, 2017). Descriptive analyses for the CPAT included ranges, means, and standard deviations, which were calculated for the participant group as a whole and for the subgroups of respondents (e.g., BAs, SLPs). Inferential statistics included a series of independent t-tests (Gravetter & Wallnau, 2017; Tanujaya et al., 2022) that were conducted to determine statistical significance of any differences between groups. To control for type 1 error, the Bonferroni correction method was used to adjust the alpha values to 0.006. For those differences that were deemed to be statistically significant at the adjusted alpha level, Cohen's d effect sizes were also calculated to determine the magnitude of the differences. These were interpreted as small (0.02), medium (0.05), and large (0.08), consistent with industry standards.
Qualitative Analysis
Qualitative data were analyzed using thematic analysis to identify, analyze, and report the themes (Braun & Clarke, 2006) provided by respondents to the open-ended questions. A deductive, top-down analysis of the open-ended question responses was conducted using the four IPEC competencies (IPEC, 2016) as a framework for coding response types. The IPEC competencies were chosen as the conceptual framework because of the competencies' established relevance across numerous disciplines. A procedure for the top-down, deductive analysis was adapted from An Illustration of Deductive Analysis in Qualitative Research (Pearse, 2019), and consisted of the following steps:
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Establish a conceptual framework (i.e., IPEC competencies).
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Identify the proposed components from the conceptual framework (ethics/values, roles and responsibilities, interprofessional communication, and teams and teamwork).
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Establish the code book and guidelines to support the coding definitions.
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Organize the data (i.e., spreadsheet of questions and responses).
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Analyze the data via code and theme.
Data were coded by four authors, in pairs; each pair included one SLP and one BA. Responses for each open-ended question were collated into a spreadsheet by question. Researchers reviewed responses by question and coded each of the responses, placing them into one or more of the following four IPEC competency domains: values/ethics for IPP, roles/responsibilities, interprofessional communication, and teams and teamwork. To establish a code book to guide the coding process, each of the IPEC competencies' associated subdomains were reviewed and on hand during coding. The research teams also had on hand a coding sheet with the four IPEC competencies and “keywords” that were coordinated with each competency. After the two teams coded all of the open-ended responses, the five members of the research team reviewed any discrepancies and consensus coded items where needed. Interobserver agreement for the total number of open-ended responses was 88%. The percentage of responses categorized by theme was reported to represent the findings of this deductive, top-down approach. Word clouds (see [Figure 1]) generated by MS Forms were used to visually represent keywords indicated in responses. Word clouds are generated by artificial intelligence and based on response rate frequency whereby the larger the word in the cloud, the more frequently it was referenced across responses and participants. Duplicate words were removed from the word clouds to focus response rates on similar words, thereby increasing the word size, as opposed to diluting the word size with similar words. For example, collaboratively was left in the word clouds, while similar terms like collaborate, collaboration, and collaborating were removed.
Figure 1 Word clouds for qualitative Collaborative Practice Assessment Tool (CPAT) questions.
Results
Quantitative Data
Participants
Sixty-six professionals completed the survey: including 25 BAs, 26 SLPs, 9 psychologists/counselors, and 6 participants who were categorized as “other” and included special educator, service coordinator, or early intervention specialist. As the majority of respondents identified as either BAs or SLPs, the sample was truncated to only these respondents to allow for a comparison across professionals from two primary fields. Descriptive information for the entire sample is available as a [Supplementary Appendix] (available in the online version only). Descriptive information about the truncated groups is presented in [Table 1]. Fisher's exact tests were run to determine if there were any statistically significant differences between SLPs and BAs. No differences were found in any of the variables, including highest degree earned (p = 0.37), current work environment (p = 0.73), years in their current work environment (p = 0.09), and years in their professions (p = 0.11).
Table 1
Demographic data by total sample and specialty
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SLPs (n = 26)
n (%)
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BAs (n = 25)
n (%)
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Overall (n = 51)
n (%)
|
|
Highest degree
|
|
PhD/EdD
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4 (14%)
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5 (19%)
|
9 (18%)
|
|
Masters
|
19 (76%)
|
17 (65%)
|
37 (71%)
|
|
Bachelor's
|
0 (0%)
|
3 (12%)
|
3 (6%)
|
|
Other
|
2 (8%)
|
1 (4%)
|
3 (6%)
|
|
Current work environment
|
|
School
|
9 (36%)
|
11 (42%)
|
20 (39%)
|
|
Clinic
|
12 (48%)
|
13 (50%)
|
25 (49%)
|
|
Hospital or residential facility
|
4 (16%)
|
2 (8%)
|
6 (12%)
|
|
Colleagues with similar degrees
|
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< 10%
|
11 (44%)
|
14 (53%)
|
25 (97%)
|
|
25%
|
5 (20%)
|
4 (15%)
|
9 (35%)
|
|
50%
|
7 (28%)
|
7 (27%)
|
14 (54%)
|
|
100%
|
2 (8%)
|
1 (4%)
|
3 (12%)
|
|
Years in current work environment
|
|
1–5
|
11 (44%)
|
12 (46%)
|
23 (45%)
|
|
6–10
|
4 (16%)
|
7 (27%)
|
11 (22%)
|
|
11–15
|
7 (28%)
|
2 (8%)
|
9 (18%)
|
|
16–25
|
1 (4%)
|
5 (19%)
|
6 (12%)
|
|
25+
|
2 (8%)
|
0 (0%)
|
2 (4%)
|
|
Years in profession
|
|
1–5
|
0 (0%)
|
3 (12%)
|
3 (6%)
|
|
6–10
|
2 (8%)
|
6 (23%)
|
8 (16%)
|
|
11–15
|
9 (36%)
|
7 (27%)
|
16 (31%)
|
|
16–25
|
9 (36%)
|
9 (35%)
|
18 (35%)
|
|
25+
|
5 (20%)
|
1 (4%)
|
6 (12%)
|
CPAT Summary and Comparisons
[Table 2] presents the data collected using the CPAT. For each subscale and for the total score, the means and standard deviations are presented for the full sample of SLPs and BAs, and for each professional group individually. t-Test values are also provided for the comparisons between professional groups, along with the degrees of freedom and the p-values. Effect sizes were not calculated, as there were no statistically significant differences found between professional groups for any of the CPAT domains or for the total score.
Table 2
Means, standard deviations, and t-test results comparing CPAT responses by domain between SLPs and BAs
|
Domain
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SLPs
M (SD)
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BAs
M (SD)
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t-Value
|
Degrees of freedom
|
p-Value
|
|
Mission, meaningful purpose, goals
|
5.36 (1.17)
|
5.40 (1.07)
|
0.13
|
47
|
0.89
|
|
General relationships
|
6.04 (0.91)
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6.05 (0.87)
|
0.01
|
47
|
0.99
|
|
Team leadership
|
4.92 (1.18)
|
4.91 (1.15)
|
−0.04
|
48
|
0.97
|
|
General role responsibilities, autonomy
|
5.01 (0.94)
|
5.15 (0.99)
|
0.53
|
47
|
0.60
|
|
Communication and information exchange
|
4.99 (1.55)
|
5.31 (1.24)
|
0.80
|
47
|
0.43
|
|
Community linkages and coordination of care
|
4.71 (1.05)
|
4.59 (1.38)
|
−0.36
|
49
|
0.72
|
|
Decision-making and conflict management
|
3.84 (0.58)
|
4.16 (1.09)
|
1.31
|
49
|
0.20
|
|
Patient involvement
|
5.98 (0.85)
|
5.65 (0.98)
|
−1.25
|
49
|
0.22
|
|
Total
|
40.70 (6.85)
|
41.11 (6.23)
|
0.21
|
41
|
0.84
|
Abbreviations: CPAT, Collaborative Practice Assessment Tool; BAs, behavior analysts; SLPs, speech-language pathologists.
Note: Likert-type rating scale ranging from 1 (strongly disagree) to 7 (strongly agree).
CPAT data suggest that, on average, participants responded positively to questions gauging their perception of IPP. Specifically, average ratings across seven of the eight CPAT domains indicated that participants agreed to at least some level with positive statements about their experiences with collaborative team practices in their workplace (i.e., means that are rounding to or over 5). Only the domain of “decision making and conflict management” had average scores indicating disagreement (i.e., scores rounding to or that are below 4).
Qualitative Data
Five open-ended responses from the 66 participants who completed the survey were analyzed for thematic analysis using the IPEC competencies: values/ethics for interprofessional practice, roles/responsibilities, interprofessional communication, and teams and teamwork. Word clouds (see [Figure 1]) were also used to visualize and highlight key words identified from responses to each question.
Question 1: What Does Your Team Do Well with Regard to Collaborative Practice?
The majority of respondents indicated communication and team meetings were key with 29% of responses related to interprofessional communication and 39% of responses indicated teaming and team-based factors. Selected responses demonstrating this include “Our team is united in wanting best outcomes for our clients,” “regularly check with other team members regarding next steps to care planning,” and “Twice a week collaboration meetings are held.” Fifteen percent of responses were coded as values and ethics and focused on “mutual respect among team members,” and creating relationships where “people feel safe, ask for help, share openly” as contributing factors. Finally, 17% of responses focused on roles and responsibilities as a supporting component of collaborative practices going well with example responses of: “Seek out other professional opinions when it's beyond their scope of practice,” “work together to implement interventions,” and “Very supportive of each other and unique roles.” These findings are supported by word clouds (see [Figure 1]) which indicate that practitioners report holding client-focused meetings, setting goals, and sharing information contributed to teams doing well with collaborative practice.
Question 2: In Your Practice, What Are the Most Difficult Challenges to Collaboration?
Responses to this question indicated that practitioners struggled with limited time for meetings, planning, and training and 44% of respondents indicated concerns with teaming and team-based aspects of collaboration. One respondent summed up the challenge by stating, “Time to clearly and effectively communicate regarding all cases with ALL team members present.” Twenty-three percent of respondents indicated struggles with roles and responsibilities with some frustrations being expressed as, “lack of explicitly defined team member roles and responsibilities,” “recognizing when to bring in other disciplines,” and “unbalanced work load and responsibilities.” Difficulty with interprofessional communication was expressed by 22% of respondents with some indicating: “Differences in clinical language or understanding and theoretical perspective can lead to misunderstandings or lack of effectiveness,” or “Professional disagreements about teaching procedures and strategies.” With regard to values and ethics, 12% of respondents reported struggles, such as “long-standing teams are not welcoming to new members” or “misunderstanding and poor adherence to competence within a scope of practice.”
Question 3: What Help Does Your Team Need to Improve Collaborative Practice?
Responses to this question suggested that practitioners need more time and training, support from leadership, and more research and resources to help improve collaborative practice. An overwhelming number of respondents (52%) indicated that teaming and team-based components were needed, including “regular meetings with structure,” “more systematic and proactive processes,” “agreed upon decision-making, training, and implementation procedures,” and “research-based models of collaborative teams.” Similarly, 19% responded that more support for interprofessional communication was needed: “listening to others perspectives and communication,” “more communication, direct instruction about roles.” Values and ethics (14%) and roles and responsibilities (16%) were similar in that some respondents suggested areas for improvement including “understanding of other people's disciplines,” “finding/hiring providers with the right skill set and motivation,” and “know that we both have expertise.”
Question 4: What Do You Think Your Professional Organizations Can Do to Promote Positive Collaboration in the Future?
Three keywords that were indicated on the word cloud analysis (see [Figure 1]) of what professional organizations can do to promote positive collaborations indicated that practice, training, and techniques are needed in the future. The importance of values and ethics was highlighted by 44% of respondents, with one suggesting that professional organizations “sponsor research that explains models/frameworks of collaborative teaming within different settings and populations” and another identifying “more training in undergraduate and graduate degrees,” and “stronger guidance for collaboration in our professional guidelines” as an area of need. Teaming and team-based support was highlighted by 30% of respondents, many of who stated, “provide time for collaboration” or “advocate for dedicated time to collaborate as a team and with other teams.” One respondent summed up the feelings of the 18% whose comments reflected the need for more interprofessional communication when they stated, “more frequent, effective, and timely communication.” And a need for clearer roles and responsibilities was highlighted by 8% of respondents with one commenting, “many times the client/family gets disjointed service” when there is a lack of “interconnected goals and plans.”
Question 5: Have You Noticed Specific Barriers to Interprofessional Practice and Collaboration?
Forty-four percent of respondents indicated specific barriers related to teaming and team-based aspects of IPP. The overwhelming keyword highlighted on the word cloud (see [Figure 1]) was “time” with one respondent stating one specific barrier as, “time management and expectations around billable hours. If payors reimbursed collaboration, I believe clinicians would prioritize collaboration more.” Similar barriers were reported around values and ethics (20%) and roles and responsibilities (22%). Several respondents indicated, “Poor incentives to collaborate. Hubris and pride within providers” and a “lack of understanding between professionals about what they can contribute to one another.” Additional barriers reported include a “lack of theoretical understanding” and a “preference for one way of thinking.” Finally, 13% of respondents indicated issues specific to interprofessional communication with comments indicating struggles with “the effort and time needed to develop integrated care models” and a sense of “unwillingness to have tough conversations.”
Discussion
The purpose of this study was to survey practitioner knowledge, skills, and attitudes about IPP across disciplines and clinical practice settings, using the CPAT as an assessment tool supporting a mixed method analysis. The findings add to a growing body of research using tools, such as the CPAT, to document knowledge, skills, and attitudes toward IPP—an important consideration in the validation of measurement. Since the majority of respondents were from the fields of BA or SLP, the findings from the survey allowed for a comparison between the two disciplines regarding their views of IPP. In short, both quantitative and qualitative findings indicate that this sample of professionals was far more alike in their response pattern than unalike. The finding that both SLPs and BAs see the same strengths and weaknesses in IPP allows for a launch point for subsequent discussion, collaboration, and professional development.
Overall, results indicated that practitioners across disciplines are more similar than they are different, with positive perceptions of IPP including collaborative team meetings, shared goals, mutual respect, and open communication. Similarly, barriers to IPP, such as time and lack of communication, were also consistent across practitioners. The lack of time and communication is an all too consistent finding across studies (e.g., Kelly & Tincani, 2013; Pfeiffer et al., 2019) and is something that organizations must address, perhaps through policy as many respondents cited billing and insurance as a limitation to collaboration. There was a general sense that IPP was perceived as necessary and positive and would support client outcomes. Given that perception can influence actual day-to-day experiences of practitioners (Jussim, 1991), one potential takeaway from this research is an openness to abandon territorial thinking and collaboration blind spots (Kwan, 2019) to improve IPP and support improved client outcomes.
One such framework for collaboration that focuses on the primary respondents in this study (i.e., BAs and SLPs) was put forth recently by Lane and Brown (2023). Lane and Brown identified key areas of overlap between SLPs and BAs (e.g., teaching early communication skills, supporting social interactions, understanding child interests to promote understanding), and highlighted the different ranges and scope of competence each practitioner brings to the table. They then suggest a framework for IPP that focuses on the recipients of service and includes obtaining preservice and ongoing in-service education, an ongoing process-orientated approach to collaboration, demonstrated cultural competence and humility, adopting and maintaining a family-centered approach, and maintaining respect and adopting shared values and principles. Furthermore, it would be beneficial for BAs to have access to and partner with the Interprofessional Education Collaborative and adopt the IPEC competencies for BAs as highlighted by Kirby et al. (2022).
Using a mixed methods approach across an interprofessional research team was the strength of the current study. First, the CPAT included quantitative and qualitative data, the latter of which was used to better contextualize the findings from response rate to items. Second, the deductive analysis approach used in this study required that one BA and SLP pair to interpret open-ended responses, which allowed for opportunities for interprofessional communication in research. The authors learned more from one another about each other's profession by using a shared starting point for discussion. For this article, the tool was the CPAT; however, a similar approach to addressing client's needs in practice may help support practitioners engaging in IPP. For example, the findings from this study suggest that values and ethics was one of the least frequently coded examples in our qualitative analysis yet is an important consideration for any practicing professional. One way to start interprofessional conversations and professional development might be to discuss an ethically challenging case study and brainstorm how as a team one might address the challenge. The Kirby et al. (2022) framework discussed earlier could be used as a model for the discussion.
Relevant Challenges Contributing to Current Practice
A key struggle that was pointed out in various ways and by multiple respondents was the lack of billing support for IPP. Specifically, insurance billing regulations limit collaborative assessment and practice, and, even worse, may actually contribute to competition between practitioners. Another component related to billing is the lack of time to support case coordination. One participant commented, “I would like to see the service coordinators have an office hour each day. Team members can come to collaborate with the service coordinator about any student on their caseload during that time. I think this will allow for more frequent, effective, and timely communication about potential challenges to student progress.” A suggestion as such, generated by a practitioner, could serve as a starting point for organizational discussions about policy and practice.
Another area of struggle that was highlighted in a few of the open-ended responses involved the concept of encroachment. While licensure exists in many states, not all practitioners are guided by licensing boards or have clear-cut realms of intervention. Several practitioners indicated that codes billing for communication intervention or skill building were available to multiple practitioners. In our view, this is another area where co-treating and care coordination support from payers would be a huge benefit to both practitioners and clients. At the very least, practitioners within an agency or organization can establish policies and procedures within their organization to address this issue, allowing for another entry for interprofessional collaboration.
Limitations
Several limitations were noted with regard to the use of the IPEC competencies as a coding tool. First, there is significant overlap across categories. While sub-competencies were used to further define each competency and assist with coding, the descriptions of the sub-competencies often used the same terms. For example, the word “relationship” appears across descriptions in three separate competencies. Descriptions of how and what to communicate appear across all four of the competencies in some format. While there is an expectation of crossover between competencies, our research team had to discuss each of these points of overlap to refine our coding tool. This exercise served as a launch point for IPP discussion and could be something that is used as a source of professional development by agencies or organizations. Surprisingly, the research team was underwhelmed with the inclusion of caregivers and families in the IPEC competencies, as there were very limited references into how to include caregivers/families as part of the team. It is worth noting that the IPEC recently revised the competencies after seeking input from practitioners (November, 2023). The revised competencies may address some of these concerns and should be considered in future studies.
A second limitation, though not detrimental to the findings of the study but worth mentioning, involved the open-ended responses from the participants. As would be expected, some respondents used this survey as a platform to rant or vent about their own frustrations with their organization and other professionals. Both SLPs and BAs took aim at the other profession, clearly creating lines in the sand. As a research team, we read these responses and discussed their utility in our analysis but ultimately determined they were combative or accusatory, and not constructive. These few examples were more indicative of a comment on a social media platform than a research article and as such we chose to keep our focus on the “what's working” components of the research. In practice, these strong feelings held by practitioners must be addressed and not allowed to fester which can weaken team relations. In other words, team members need a way to rant and vent without retribution and in a manner that allows for interprofessional discussion about roles and responsibilities. Again, we are more alike than we are unalike.
While it was not possible to complete direct comparisons across environments due to sample size, it was noted that SLPs and BAs both reported that only 10% of their colleagues had degrees similar to them. This indicated that participants were working with teams who were different in terms of educational experience. This demonstrates a limitation of this research in that more diverse samples need to be evaluated in larger numbers. However, it is also the case that organizations would include teams of diverse practitioners, which is why it is important for these teams to regularly meet and discuss practice issues related to values/ethics, roles and responsibilities, interprofessional communication, and teams and teamwork.
Directions for Future Research
The current analysis is based on a self-report from survey respondents. Future observational and transactional research analyzing collaborative practice in multidisciplinary settings would be beneficial and could contribute to the respondents' suggestions for more training and relevant research directed at real world, collaborative settings. For example, combining the results of a self-report survey tool such as the CPAT, which is the primary measure for IPP currently, with direct observation of interprofessional engagement would strengthen these findings.
One comment that came up multiple times (n = 12) in the analysis of the open-ended responses was the lack of collaboration or co-treatment opportunities, specifically as they relate to insurance billing. In fact, billing practices seemed to be counter to collaboration and co-treating. Future research to analyze the role that insurance billing has on collaboration and teaming across disciplines is needed to further explore this concern. This could be tested experimentally whereby the cost–benefit of providing reimbursement for interprofessional activities could be assessed in a prospective manner.
While this research was not able to draw conclusions based on participant-reported settings, it would be beneficial to determine if collaborative practices are more prevalent in different settings (e.g., schools vs. private clinics or hospitals vs. public schools) and what can be done to support and accelerate collaborative practices in locations that are lagging behind. Dually important is the impact of IPP and measurement therein on client outcomes, which would require data collected from both the professionals and the clients they serve. Findings from studies as such would only help policy makers better understand the role of IPP on client outcomes and how to account for this for insurance billing and other related purposes.
Conclusion
The idea of IPP is not new or genuine to the current times; it has been a longstanding factor in healthcare and education since practitioners began practicing. At the very least, one therapist working with one client can be considered an interprofessional group. We as SLPs and BAs have worked with one another as part of education and well into practice, and we have become better at it over time. The current emphasis on IPP is a rebranding of what we already know, that when we work together in collaboration with other professionals and with our clients (not at our clients) outcomes are better. Findings from this study do not speak to outcomes, but they do highlight, in boldface and underline (perhaps with some blinking), that SLPs and BAs are more alike than unalike. Common across both disciplines is the desire to help clients improve functional outcomes, also common across disciplines are the barriers of time, communication, and language. Using the findings from this study, organizations can provide professional development that centers across the IPEC competencies as a launch point for interprofessional development.
