Abstract
Background/Objective
The purpose of this study is to develop and validate an instrument to assess interprofessional collaboration by occupational therapists, physical therapists, and speech-language therapists.
Methods
Item development consisted of a review of interprofessional collaboration and group interviews with occupational therapists, physical therapists, and speech-language therapists. The developed items were surveyed on a 4-point Likert scale among occupational therapists, physical therapists, and speech-language therapists. Ceiling effects, floor effects, and item-total correlation analysis for each item, as well as constructs, internal consistency, and cross-cultural validity of the scales were evaluated.
Results
A total of 47 items were extracted for evaluation and 28 items with five factors (“team-oriented behavior,” “exchange of opinions,” “flexible response,” “sharing the whole picture of the patient,” and “coordination of support methods”) were retained after the evaluation. The correlation coefficients of the five factors ranged from 0.48 to 0.72. The total score of each factor and the total score of all 28 items were compared for occupational therapists, physical therapists, and speech-language therapists, and the result showed that was no statistically significant difference between the total scores of all factors and the job titles. The Cronbach’s alpha coefficients for the five factors are 0.842, 0.840, 0.805, 0.732, and 0.734 for the first, second, third, fourth, and fifth factors, respectively.
Conclusions
The developed scale includes items aimed at facilitating patients' activities of daily living through interprofessional collaboration, and its content reflects the expertise of occupational therapists, physical therapists, and speech-language therapists.
Introduction
Interprofessional collaboration is important to meet the diverse needs of patients in the healthcare industry. World Health Organization (2010) emphasizes that interprofessional collaboration is an essential skill for healthcare professionals to engage with patients and families in their daily work. The main purpose of interprofessional collaboration is to share the common goals of support, clinical decision-making, knowledge, and information among professionals to provide high-quality support to patients and families, and work in a multifaceted manner (Petri, 2010; Sargeant, 2009). The implications of interprofessional collaboration have been reported in a variety of primary care settings. Recent research on interprofessional collaboration has reported its effectiveness on patient health outcomes and safety (Walters et al., 2016). The field of research on interprofessional collaboration also includes care for patients with chronic diseases in clinics where primary care is provided (Black et al., 2013), care for patients with chronic obstructive pulmonary disease and femoral neck fractures (Deneckere et al., 2013), geriatric care (Tsakitzidis et al., 2016), and many more.
However, a review on interprofessional collaboration and healthcare outcomes (Reeves et al., 2017) reported that there is not enough evidence to draw conclusions about the effectiveness of interprofessional collaborations. In addition, few appropriate methods to evaluate interprofessional collaboration for healthcare industry settings have been identified (Deneckere et al., 2013; Strasser et al., 2008), and researchers and practitioners have reported difficulties in researching, evaluating, and improving the quality of collaboration. Therefore, it is important to identify instruments to evaluate interprofessional collaboration in the healthcare industry.
Peltonen et al. (2020) conducted a comprehensive review of instruments designed to assess interprofessional collaboration in healthcare settings and ultimately identified 29 such instruments. The identified scales focused on similar elements such as professionalism, teamwork, communication, support factors, collaboration, and conflict. The study reports that the focus is on assessing interprofessional collaboration between nurses and physicians, who comprise the majority in the medical field (Peltonen et al., 2020). However, because the existing scales consists of questions that are designed to be used by nurses and physicians, they are not an optimal tool for evaluating interprofessional collaboration practiced by other healthcare professionals in terms of content validity. Therefore, the authors believe that the content of a tool for evaluating interprofessional collaboration in a medical institution should reflect the characteristics of the professionals who use the tool. In particular, this study hypothesized that assessing the interprofessional collaboration by occupational therapists, physical therapists, speech-language therapists—who provide rehabilitation services to patients for the purpose of improving their physical functions and activities of daily living—may have a different perspective from that of nurses and physicians. In addition, the recovery rehabilitation ward is a unique medical system in Japan that provides interprofessional collaboration and intensive rehabilitation to improve patients’ physical functions and activities of daily living. Occupational therapists, physical therapists, and speech therapists in the recovery rehabilitation ward play a role in improving the physical and mental functions of hospitalized patients, and promoting their activities and participation through the provision of intensive rehabilitation by a team. Therefore, to improve the quality of support for hospitalized patients, it is necessary to improve the quality of interprofessional collaboration among occupational therapists in recovery rehabilitation wards.
The purpose of this study was to develop a tool to assess the interprofessional collaboration that reflects the professional characteristics of occupational therapists, physical therapists, and speech-language therapists in recovery rehabilitation wards. In addition, the reliability and validity of the developed scale were verified.
Methods
The scale development in this study consisted of three steps. In Step 1, the literature on interprofessional collaboration practiced by occupational therapists, physical therapists, and speech-language therapists in recovery rehabilitation wards was referred to and the questionnaire items were drafted. In Step 2, interviews with professionals were conducted to verify the content validity of the draft questions. In Step 3, the validity and reliability of the scale were verified by following statistical procedures.
Step 1: Drafting the questionnaire items
First, a literature review to develop a draft questionnaire was conducted. The databases used for the literature review were PubMed, Medical Journal Web, and MEDLINE. The keywords used in the search were (interprofessional OR multiprofessional OR multidisciplinary OR interdisciplinary), (collaboration OR collaborative), (team work OR teamwork), (physical therapist OR occupational therapist OR speech-language therapists), and (recovery rehabilitation ward). Duplicates and commentaries were excluded from the literature retrieved from the database, and the abstracts and text of the articles were carefully read to extract the target literature. To indicate the framework related to interprofessional collaboration among occupational therapists, physical therapists, and speech-language therapists in recovery rehabilitation wards, all codes were grouped based on similarity of meaning, referring to Mayring’s (2004) method of qualitative descriptive analysis, and abstracted through discussions among researchers.
Step 2: Verifying the validity of the draft content
Next, interviews were conducted to verify the validity of the draft created in Step 1. The inclusion criteria for the interviewees were that they worked in recovery rehabilitation wards and practiced interprofessional cooperation on a daily basis, such as sharing information with other professionals and participating in conferences. There were no restrictions on the number of years of experience, age, or gender of the subjects. However, managers whose regular work was administrative work were excluded. The content validity of the draft scale was assessed using a Likert scale, and questions were added, modified, or excluded accordingly. Data were analyzed using a four-point Likert scale (4 = very appropriate, 3 = appropriate, 2 = slightly inappropriate, 1 = inappropriate), and the content validity ratio (CVR) was calculated as (Ne-N/2) or N/2, where N is the total number of raters and Ne is the number of experts who rated the item as “necessary” (3 or 4 points). The criterion of CVR was based on Lawshe’s (1975) criterion of 0.99 when there were five raters, and if the value was less than the criterion, the item was not adopted. The content validity was verified through interviews until no items needed modification or exclusion.
Step 3: Evaluation of validity and reliability
In Step 3, the validity and reliability of the scale were evaluated. Inclusion and exclusion criteria were the same as in Step 2. For the recruitment of participants, questionnaires were distributed by research collaborators. The questionnaires were returned voluntarily by respondents without their names. The responses to the questionnaire were recorded using a Likert scale (4 = always, 3 = almost, 2 = rarely, 1 = never). Five analyses were conducted: (1) ceiling effect and floor effect of each item, (2) item-total correlation analysis, (3) exploratory factor analysis for construct validity, and (4) calculation of Cronbach’s alpha for reliability assessment, and (5) cross-cultural validity by comparing scores across jobs. In each analysis, the following specific processes were implemented: (1) For the ceiling and floor effects of each item, if the mean ± standard deviation did not fall within the range of response options (1–4 points), the response was considered to be distorted and was excluded. (2) In the item-total correlation analysis, items with an absolute value of correlation less than 0.3 with the overall items were judged to be inconsistent with the overall scale and were excluded. (3) The maximum likelihood method was used for factor extraction, with promax rotation (commonality of 0.16 or more) and factor loading of 0.40 or higher as criteria. Each time an item was excluded, the factor analysis was repeated until all factor loadings were 0.40 or higher. (4) For internal consistency, Cronbach’s alpha of each factor was calculated, and the criterion was 0.7 or higher. (5) For cross-cultural validation, the scale scores were compared among occupational therapists, physical therapists, and speech-language pathologists. One-way analysis of variance was used to calculate the mean, standard deviation, and 95% confidence interval. The significance level was set at 5%. Statistical analysis was performed using SPSS Ver. 25.0 (IBM Corporation, Tokyo, Japan).
Ethical considerations
This study was approved by the Ethics Committee of Kanagawa University of Health Services. The study participants were invited to participate in the study as volunteers. Although the gatekeepers handled the questionnaires, none of the participants’ data were disclosed to the hospital staff. The healthcare professionals who participated in the study were provided with a document explaining the ethical considerations of the study.
Result
Step 1: Drafting the questionnaire items
As a result of the database search, 547 documents related to interprofessional collaboration in recovery rehabilitation wards were retrieved. Duplicates and commentaries were excluded from the retrieved literature, and the abstracts and text of the articles were carefully read and selected, resulting in a total of 24 literature. As a result of qualitative content analysis, 360 codes were extracted, and 35 medium categories were generated based on semantic similarity. To indicate framework related to interprofessional collaboration among occupational therapists, physical therapists, and speech-language therapists in recovery rehabilitation wards, the 35 medium categories were further abstracted to generate the following seven large categories: “structures for practicing collaboration,” “ways to communicate in formal settings,” “ways to communicate in informal settings,” “opportunities for communication in informal settings,” “management and leadership,”" knowledge sharing”, and “sharing clinical decision making”. The seven large categories were used to explain the framework of interprofessional collaboration to the participants in the Step 2 interviews, and 35 categories of items were adopted as the draft of the questions in this study.
Step 2: Verifying the validity of the draft content
Four occupational therapists (mean years of experience: 5.3), four physical therapists (mean years of experience: 4.5), and two speech pathologists (mean years of experience: 4.0) participated in Step 2. In the first and second sessions, a group interview was conducted with two occupational therapists, two physical therapists, and one speech-language therapist as the members (each session had different members) (supplemental material 1 and 2). In the first session, 12 questions (No. 36 to No. 46) were added, and the wording of the other items was modified as necessary. Nine question items were excluded because their CVRs were below the reference values (supplemental material 1). In the second session, 10 questions (No. 38 to No. 47) were added, and the wording of other items was modified as necessary. Since there were no more items whose CVR fell below the criterion in the second session, the content validation was completed (supplemental material 2). Finally, 47 items were extracted for evaluation.
Step 3: Evaluation of validity and reliability
Characteristics of study participants
Of the 70 participants in the survey, 29 (41.4%) were occupational therapists, 33 (47.1%) were physical therapists, and 8 (11.4%) were speech pathologists. The gender of the respondents was 33 (47.1%) males and 37 (52.9%) females. The number of years of experience was 22 (31.4%) for less than 3 years, 31 (44.3%) for 3–5 years, 15 (21.3%) for 5–10 years, and 2 (2.8%) for more than 10 years. There were no items that met the exclusion criteria for ceiling effect, floor effect, or item summation correlation analysis.
Construct validity
Exploratory factor analysis of items assessing collaboration among occupational therapists, physical therapists, and speech-language therapists.
Maximum likelihood method was used to extract the factors, followed by promax rotation. The rule of commonality >0.16 was used to select the number of factors. Factor 1 was named “team-oriented behavior,” Factor 2 was named “exchange of opinions,” Factor 3 was named “resourcefulness,” Factor 4 was named “sharing the whole picture of the patient,” and Factor 5 was named “adjustment of support methods.” Factor loadings greater than 0.40 in absolute value are indicated by shaded lines.
Items that were not adopted for assessment based on validity and reliability.
Reasons for not adopting a scale (X, Evaluation of a ceiling and/or floor effect; Y, correlation in item-total correlation analysis was less than 0.3; Z, based on the results of factor analysis).
Correlation coefficient between factors (r).
Differences in the total score of each factor among job classifications.
SD: standard deviation; CI: confidence interval; OT: occupational therapist; PT: physical therapist; ST: speech-language therapist.
Reliability
To evaluate the internal consistency of the scale, Cronbach’s alpha coefficients for each factor were calculated. The results were 0.842, 0.840, 0.805, 0.732, and 0.734 for the first, second, third, fourth, and fifth factors, respectively.
Discussion
The purpose of this study is to develop a new scale to evaluate interprofessional collaboration among occupational therapists, physical therapists, and speech-language therapists in a recovery rehabilitation ward. The following is a discussion of each stage and the limitations of the study.
In Step 1, 35 medium categories and 7large categories were generated from the reviewed literature. The seven broad categories, which provide a framework for interprofessional collaboration by occupational therapists, physical therapists, and speech-language therapists in recovery rehabilitation ward, were “structures for practicing collaboration,” “ways to communicate in formal settings,” “ways to communicate in informal settings,” “opportunities for communication in informal settings,” “management and leadership,” “Knowledge Sharing”, and “Sharing Clinical Decision Making”. In previous studies, it was reported that the most compassionate factor in successful interprofessional collaboration is the compatibility of organizational structure and frequent informal communication (Morgan et al., 2015), which supports the results of this study. It has been reported that organizational structure is necessary to allow time for teamwork in interprofessional collaboration and to clarify roles and responsibilities (Munday et al., 2007). It has also been noted that informal communication, when brief and frequent, fosters the team itself and is effective in clinical decision making and knowledge sharing (Bunniss & Kelly, 2008). Therefore, it was reiterated that in the interprofessional collaboration by occupational therapists, physical therapists, and speech-language therapists in a recovery rehabilitation ward, both securing time for teamwork, such as organizational structure and conference opportunities, and sharing knowledge and creating tacit knowledge through informal communication among the staff are important.
In Step 2, the following items were added through group interview: “I exchange opinions with other professions and patients/families about tips on how to provide support related to ADLs” and “I explain how to provide support related to activities of daily livings from the perspective of each profession.” In a previous study (Booth et al., 2005) comparing the support provided by occupational therapists and nurses to patients, it was shown that occupational therapists used “Promoting and Instructing” and nurses used “Supervision” highly often. In other words, the support provided by occupational therapists tends toward facilitation, while the support provided by nurses tends toward a compensatory style of “doing for them” or “adding physical assistance. This suggests that occupational therapists, physical therapists, and speech-language therapists in recovery rehabilitation wards practice interprofessional collaboration, while always being aware of facilitating patients' activities of daily living as a background for the adoption of items focusing on it.
As a result of the factor analysis conducted in Step 3, five factors and 28 items were extracted as a scale. The factors comprising the scale devised in this study were “team-oriented behavior,” “exchange of opinions,” “flexible response,”" sharing the whole picture of the patient,” and " coordination of support methods.” The extracted question items included many contents related to support for patients' activities of daily living. As a characteristic of the questions in this scale, the occupational therapists, physical therapists, and speech-language therapists in the recovery rehabilitation wards recognized that not only medical information about the patients, but also the personal background and intentions of the patients and their families was the information that should be shared with the other professionals. Existing scale questions include questions about the supporters' conflicts (Rothermund et al., 2018), but do not include items about the patients' feelings. It is also unique in that it employs many questions that focus on facilitating the patient’s activities of daily living. From these findings, it can be inferred that the interprofessional collaboration emphasizes the importance of coordinating the content of support by exchanging opinions with other professionals, while respecting the will of patients and their families, and always being aware of facilitating patients' activities of daily living.
Regarding internal consistency, the alpha coefficients of Factors 1, 2, and 3 were calculated to be over 0.80, indicating high internal consistency. The alpha coefficients for Factors 4 and 5 were lower than the other factors at over 0.70, indicating a relatively high degree of internal consistency. In the cross-cultural validation, the total score of the scale was compared among jobs. The results showed that there were no differences in any of the factors of the scale among the professionals, suggesting that this scale is a common tool for occupational therapists, physical therapists, and speech-language therapists in rehabilitation wards to evaluate interprofessional collaboration.
Limitation
There are several limitations to this study. First, the occupational, physical, and speech-language therapists included in the data collection were sampled for convenience. Moreover, this study was conducted as a small pilot study to clarify the psychological characteristics of interprofessional collaboration by occupational, physical, and speech-language therapists in a recovery rehabilitation ward. To determine the feasibility of a large-scale study in the future, future adjustments such as increasing the sample size and modifying, adding, or excluding the wording of the questionnaire items may be necessary. Additionally, criterion-related, predictive, and intra-examiner validities by test-retest are also necessary. These validations of reliability and validity are recommended for scale development and should be considered for future research in the area.
Conclusion
The purpose of this study was to develop an interprofessional collaboration scale from the perspective of occupational therapists, physical therapists, and speech-language therapists in Japanese recovery rehabilitation ward, and to test its validity and reliability. As a result, a five factor and 28-items interprofessional collaboration scale was developed. In terms of construct validity and internal consistency, the pilot version of the scale shows a number of promising results. Based on the findings of this study, further multi-centers large scale surveys should be carried out to use the scale for the evaluation of the interprofessional collaboration among healthcare disciplines. The developed scale has potential to improve interprofessional collaboration in the area of support, clinical decision-making, as well as knowledge and information sharing among professionals to provide high-quality support to patients and their families.
Supplemental Material
Supplemental Material - Development of a new scale for the measurement of interprofessional collaboration among occupational therapists, physical therapists and speech-language therapists
Supplemental Material for Development of a new scale for the measurement of interprofessional collaboration among occupational therapists, physical therapists and speech-language therapists by Kohei Ikeda and Satoshi Sasada in Hong Kong Journal of Occupational Therapy
Supplemental Material
Supplemental Material - Development of a new scale for the measurement of interprofessional collaboration among occupational therapists, physical therapists and speech-language therapists
Supplemental Material for Development of a new scale for the measurement of interprofessional collaboration among occupational therapists, physical therapists and speech-language therapists by Kohei Ikeda and Satoshi Sasada in Hong Kong Journal of Occupational Therapy
Footnotes
Acknowledgments
We would like to thank the occupational therapists, physical therapists, and the speech-language therapists who contributed to this study. We would also like to thank the staff at Editage for their proofreading services. This study was approved by the Ethics Committee of Kanagawa University of Health Services 2019 (No. 7169).
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant from JPSP KAKENHI (Grant number: JP20K19452).
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References
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