Promoting diverse teams in rehabilitation through adaptive digital diversity training: A study on participatory development, implementation and evaluation - A Study Protocol

doi:10.21203/rs.3.rs-4868278/v1

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Promoting diverse teams in rehabilitation through adaptive digital diversity training: A study on participatory development, implementation and evaluation - A Study Protocol

https://doi.org/10.21203/rs.3.rs-4868278/v1

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Background: The integration of foreign staff, upon whom rehabilitation facilities are increasingly dependent, poses numerous challenges. The primary challenge is effectively integrating new staff members into existing teams, ensuring smooth work processes. This project, with its pivotal goal of developing and evaluating a fully digital training program for rehabilitation facility healthcare staff and HR managers, underscores the crucial role of professionals in promoting diversity within teams. The training content will be tailored to meet the needs of both existing staff, including those with and without a migration history, and newly recruited staff from abroad. It will consider additional diversity characteristics such as culture, origin, gender, and age while ensuring objectivity and avoiding biased language.

Methods: The program will be developed using a participatory approach in collaboration with three rehabilitation facilities and their staff. The framework conditions and content of the training program will be developed using qualitative research methods. The initial stage will comprise three development workshops with 6 to10 target group representatives. To evaluate the process, a 'cognitive walkthrough' will be conducted with 8 to 12 individuals, while a qualitative evaluation of the effectiveness will be based on 8 to 10 problem-centered interviews.

Discussion: Adaptive learning may be an effective method for digitally delivering diversity training and assist in onboarding. This approach could be used to provide dynamically and automatically tailored learning paths that are made available as nudges, potentially allowing staff with limited time and budget to participate in diversity training.

Diversity

Rehabilitation

Personnel

Training

Online Training

Adaptive Learning

The German state of North Rhine-Westphalia is currently experiencing a significant deficit in the availability of skilled labor, particularly within the healthcare sector (1). The vacancy periods for physicians are x days, for specialist nurses y days, and for physiotherapists z days (2). As indicated by the Federal Employment Agency, the situation in Germany is anticipated to deteriorate further by 2025 (3). A similar situation has been described for other Western countries. Furthermore, health care facilities are encountering challenges in recruiting qualified medical professionals, resulting in a significant reliance on foreign staff. While hiring personnel from abroad is a viable strategy, the integration process is not always effective. The primary challenge is integrating the new staff members effectively into existing teams in order to ensure a smooth workflow (4). The challenge of rapid and efficient workforce integration can be addressed through the implementation of a structured onboarding process that encourages both professional and personal integration (5–7). It is therefore important for organizations to receive support in initiating such onboarding processes. A review of studies from Germany and other countries reveals a clear need for adequate support for culturally diverse teams in the healthcare sector. Healthcare organizations that lack appropriate support may face a number of challenges, including discrimination and stigmatization (8–10), inequality of opportunities (9, 11), and exclusion (12, 13). Additionally, language barriers (14) and communication problems (9, 14, 15) occur more frequently in such cases. A study from Germany on cultural diversity in hospitals describes issues concerning the transfer of information within teams, and difficulties in the execution of tasks due to cultural differences (15). Measures of support for diverse teams, on the other hand, can have a positive impact on the intention to stay (12, 16), job satisfaction (17), team performance (18, 19) and quality of care (15, 17, 19, 20).

In comparison to other healthcare sectors, rehabilitation facilities rely more heavily on the recruitment of foreign workers to address the deficit of skilled personnel (21). New employees in rehabilitation centers encounter numerous challenges when integrating into existing teams. These include the completion of paperwork, the documentation of treatments, adherence to planned workflows, collaboration across professional groups, and interaction with patients (4). Additional challenges emerge from the distinctive features of rehabilitative care in Germany, whose structures and processes differ significantly from those in nearly all other countries (4). The necessity for additional time to integrate new personnel from overseas impedes seamless collaboration within the organization, resulting in various issues.

Specific measures that facilitate collaboration in a diverse healthcare team include diversity trainings (19, 22, 23), diversity-sensitive leadership (13, 18), and mentoring programs (24, 25). Jansen and Hänel (26) investigated the integration of migrant doctors in rehabilitation facilities and developed training programs, demonstrating the significance of intercultural training, leadership training, structured initial interviews, and peer support programs. However, the implementation and maintenance of these measures requires substantial resources in terms of staff, time and finances. Furthermore, Jansen and Hänel (26) highlight the practical challenges of implementing time-intensive, face-to-face training courses, given the competing demands on the time and resources of already overburdened staff.

The present study addresses this issue. The development of a low-threshold digital training program focusing on diversity training, onboarding, and integration will be facilitated by the support of jointly developed content and digital learning units along individual learning paths. These units will utilize adaptive learning and nudging. The program will be qualitatively evaluated for rehabilitation personnel and HR managers. In addition, the digital training program will take into accountthe diversity characteristics of culture, origin, and migration history and their interaction (intersectionality) with other characteristics such as gender and age.

Diversity training is an effective tool for developing communication skills and working on personal attitudes to increase awareness and understanding of diversity measures. This has the effect of reducing stereotypes, prejudice, and discrimination (27). Furthermore, these courses facilitate the formation of more intimate relationships between individuals from disparate groups (27). The effectiveness of diversity training has been demonstrated across a range of industries (27, 28). In particular, during the period of the pandemic, scientists and trainers collaborated to develop methods for the online instruction of diversity skills. Diversity training programs have been demonstrated to foster enhanced confidence in navigating diversity among medical personnel, even when only consisting of brief online interventions (29, 30). While the use of static training content that is not adapted to participants may be perceived as a disadvantage compared to face-to-face events (29), this limitation can be overcome by the implementation of adaptive digital training programs. In addition to diversity training, a training tool for HR managers will be developed to support the onboarding process for employees. According to Bröckermann (2020), an onboarding process comprises eight stages: preparation, welcome, information, introduction, orientation, social integration, training, and assessment. These stages are interlinked and address both private matters, such as finding accommodation, and professional aspects, including behavior in the workplace (31).

The adaptive online tool will employ a variety of strategies to facilitate the transfer of knowledge and skills. The distinction between these approaches hinges on whether the content is conveyed through events with a certified educator (either in person or online) or in an online setting without the guidance of a professional instructor. Online learning environments (e-learning) with standardized training courses are frequently designed and structured in a similar manner for all learners. Such environments are non-adaptive e-learning contexts in which all users undergo the same training in a predetermined sequence and with identical content (32). Such solutions are, therefore, "one-fits-all" in nature, failing to account for the varying levels of knowledge among individual learners or the effectiveness of different learning strategies.

Furthermore, the concept of "nudging" will be incorporated into the instructional content of the digital training program. Nudging is a method that employs subtle cues, or "nudges," such as visual or textual incentives, to facilitate decisions that align with long-term goals or societal benefits (33). The design of such prompts should facilitate rapid comprehension of complex information and enable long-term adjustments to decisions or behavioral intentions based on facts (33). A nudge must be open to all available decision options. Rather, it should be conceptualized as a motivational stimulus that ultimately addresses an individual's behavioral tendencies (33). As part of the digital training program to be developed, the use of nudges will be employed with the aim of enhancing awareness of diversity-relevant topics. Furthermore, the objective is to prepare the learning content in a concise manner in order to minimize the time required by staff members.

The participatory development and qualitative evaluation of a fully digital training program for healthcare staff and HR managers in rehabilitation facilities aims to promote diverse teams. The training content will be designed for existing staff members with and without a migration history, as well as for newly recruited staff from abroad. The digital program provides adaptive learning, diversity training, onboarding, and integration guidelines for rehabilitation centers, with the aim of dynamically tailoring the content to the individual, resulting in individual learning paths.

The training tool will be developed using different methodological approaches. The initial phase of the study will comprise a scoping review of the existing literature on online diversity trainings for healthcare professionals. This will facilitate an examination of the various approaches that have already been utilized and evaluated in this context. The potential challenges and opportunities for the development of the new online training tool will be considered. Subsequently, the design of the learning program will be the focus of Development Phase 1. The concept, content, and utilization parameters will be jointly developed with a group of rehabilitation representatives (Group A) and researchers from the field. The program will then be evaluated with a second group of participants from rehabilitation facilities in Phase 2 (Group B). Finally, a qualitative evaluation of the results will be conducted by means of guided interviews, in which the usability and acceptance of the tool will be assessed using a third group (Group C) of participants. The following research questions that will be addressed during the development and evaluation of the program:

What methods should be employed to ensure that digital training content is as appealing and informative as possible for rehabilitation staff?
What elements should be included in the content of diversity training and the integration guidelines to provide practical added value for rehabilitation centers without overwhelming them with content?
What is the subjective impact of the individual learning paths on the self-assessment of the team's handling of diversity?
How do users perceive the program's acceptance and comprehensibility?

Figure 1: Work package of the study in different work packages of the Beyond Boundaries research project.

Scoping Review

The scoping review will include empirical studies conducted between 2014 and 2024. Given the focus on digital training programs, the period will be limited to 10 years. Additionally, only studies written in German or English will be considered. Both online and hybrid training programs, as well as those conducted synchronously or asynchronously, will be considered. The search will be conducted in PubMed, Business Source Premier, PsycInfo, and PsycArticle.

The search strategy will comprise four sections, each linked with the operator “AND”. The variables/keywords in question are “online platforms”, “trainings”, “diversity”, and “health personnel”. The complete search strategy is provided in the following:

(“Online” OR "E-Learning" OR "virtual*" OR "Web-basiert" OR "digitale Plattformen" OR "Internet-basiert" OR "Cyber Training" OR "Virtual Classroom" OR "Digital Learning") AND (Training OR Schulung OR Weiterbildung OR "Fortbildung" OR "Lehrprogramm*" OR "Bildungsprogramm*" OR "Education" OR "Training program*" OR "Professional development" OR "Skill development") AND (Diversität OR "kulturelle Kompetenz" OR Inklusion OR "soziale Gerechtigkeit" OR "interkulturelle Kompetenz" OR "Vielfaltstraining" OR "Anti-Bias-Training" OR "Diversity" OR "Cultural competence" OR "Inclusivity" OR "Social justice" OR "Intercultural" OR "Equity" OR "Anti-discrimination") AND (Gesundheitspersonal OR "medizinisches Personal" OR Ärzte OR Pflegekräfte OR "Gesundheitsfachkräfte" OR "klinisches Personal" OR "Gesundheitsdienstleister" OR "Healthcare professionals" OR "Medical staff" OR Doctors OR Nurses OR "Clinical staff" OR "Health practitioners")

Development Phase 1

The development of a digital training concept will be based on existing concepts from literature and practice (34–37) and will utilize a participatory approach, taking into account the professional life of the target group. This will be done in collaboration with three rehabilitation facilities and their staff. The participatory approach is based on existing recommendations from literature, pertaining to levels 6 and 7 (co-determination and partial decision-making authority) according to the definition by von Unger (38). To this end, three development workshops will be conducted, with approximately six to ten representatives of the target group (Group A) participating in each workshop. The composition of this group of individuals remains consistent throughout the three workshops. At the inaugural development workshop (kick-off event, project commencement), the preceding results from literature will be presented, and the concept of the program will be defined in collaboration with the participants. The second development workshop, scheduled approximately eight months after the initial meeting, will focus on the specific content of the program, including the topics of short videos and case studies. The third development workshop, held approximately 12 months after the initial meeting, will address the design aspects of the program and various usage parameters, such as usage times, duration, and locations.

Development Phase 2

Following the development of the alpha version, a process evaluation of the digital training will be conducted. For this purpose, a cognitive walkthrough as part of a think-aloud approach will be carried out with 8 to 12 representatives of the target group (Group B, i.e., employees who have not participated in previous steps). The recruitment of participants for the cognitive interviews will be based on purposive sampling with maximum contrastive comparison, with the aim of collecting qualitative material representing the broadest possible range of information. The planned recruitment strategy is designed to circumvent a potential systematic error in the selection of study participants, which is commonly observed in qualitative studies and is referred to as self-selection bias (39). The participants will have the opportunity to test the tool's functions and evaluate its elements and content. The acceptance of the alpha version by each user will be operationalized based on the unified theory of acceptance and use of technology (UTAUT), and recorded discursively during the interviews (40). In this context, the term "discursive" denotes that the acceptance of the alpha version will be recorded not only on the basis of quantitative data, but also on that of a qualitative approach based on open discussions, opinions, and detailed answers. Participants will be encouraged to share their thoughts, opinions, and experiences in detail in order to gain a comprehensive understanding of their attitudes and the reasons behind their acceptance or rejection of the alpha version.

Qualitative Evaluation of Results

Eight-to-10 problem-centered guided interviews will be conducted with representatives of the target group (Group C) and evaluated using summarized qualitative content analysis (41). The usability and perceived effectiveness of the digital training program (beta version) will be evaluated, and the participants will be given the opportunity to make recommendations regarding possible changes to the tool. The evaluation guideline, developed by the project team, is structured in a manner that guides the participants through the developed training program and incorporates elements of the UFE questionnaire (42). The problem-centered interviews are planned to last approximately 45–60 minutes.

Data Analysis

Cognitive interviews will be digitally recorded and subsequently transcribed upon completion. In accordance with Kuckartz, the method of summarized qualitative content analysis will be employed (41). The statements provided by study participants obtained through the think-aloud approach and verbal probing will be analyzed (39). The research team will be responsible for the collection, analysis, and interpretation of the qualitative material. A research workshop will be held to discuss the survey instruments and results with researchers from a range of different disciplines. To ensure communicative validity, individuals from Group A will also be invited to participate in the interpretation group (43).

The joint evaluation by the project team and the inclusion of other employees and individuals from Group A in the interpretation of the qualitative material serve to enhance the quality of the evaluation procedure and to reduce the potential for researcher bias in the evaluation by avoiding a one-sided subjective view (39). The number of interviews is an estimate and will be subject to adjustment depending on the degree of information saturation achieved (39). Furthermore, the socio-demographic information of the interviewees will be collected and considered in the analysis and interpretation of the material.

Considering previous findings, it is reasonable to hypothesize that the digital training program will prove more effective in addressing the needs of the target groups than previous tools. This is attributed to three key factors: (a) a participatory development approach and (b) customized and individualized provision through adaptive learning and nudging through which the program is expected to demonstrate high usability. (c) The low-threshold, accessible, and sustainable availability as a digital tool will enable better integration with minimal use of resources in everyday practice. It helps to ensure that the digital training program is better adapted to the needs of the target groups than existing tools. The training program will be implemented via the open-source learning platform Canvas and will remain available free of charge for an unlimited period after the project is completed. During the project, a dissemination strategy will be developed in collaboration with the cooperation partners to make the training program known in all rehabilitation facilities throughout Germany.

Ethics approval and consent to participate

A positive ethical approval has been obtained from the University of Witten/Herdecke, approval number S-109/2024.

Consent for publication

Not applicable

Availability of data and materials

All data generated or analyzed during this study will be included in future publications.

Competing interests

The authors declare that they have no competing interests.

Funding

This project is funded by the Society for Rehabilitation Research North Rhine-Westphalia (GfR NRW e.V.) as part of the Network Rehabilitation Research North Rhine-Westphalia initiative.

Authors' contributions

CK developed the conceptual idea, wrote the first draft and finalised the manuscript. TA and YA jointly developed the practical and theoretical implementation and contributed to the writing of specific methods. PB provided oversight and coordination, as well as content and methods review. All authors read and approved the final version of the manuscript.

Acknowledgements

Not applicable

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Promoting diverse teams in rehabilitation through adaptive digital diversity training: A study on participatory development, implementation and evaluation - A Study Protocol

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