Members of interprofessional teams collaborate to meet complex needs in health care and to promote quality care. This article reports findings from an inquiry on the impact of high-fidelity simulation (HFS) on team skills and attitudes in an undergraduate population. There are various methodologies to deliver interprofessional education (IPE) to enhance collaborative competence, one approach being HFS. HFS can apply to any mode or method of simulation, including human, manikin, or virtual reality, and is known to offer "learners an extraordinarily realistic experience, as well as involving them as much as possible in simulation" (Lopreiato et al., 2016, p. 14). Undergraduate students can especially benefit from HFS: They can practice clinical skills and build confidence through realistic patient scenarios in safe environments, which also enhances critical thinking and decision-making skills (Paige et al., 2014). In contrast to other levels of fidelity, HFS is more effective in enhancing teamwork and participants' problem-solving abilities (Adamson, 2015).
A scarce amount of literature was found that documents outcomes of IPE via HFS (IPE HFS) in undergraduate (prelicensure) health care trainees. Most reported positive outcomes, such as improvement in collaborative behavior (Paige et al., 2014), participants' increased awareness of knowledge gaps in interprofessional care (Stewart, Kennedy, & Cuene-Grandidier, 2010), and appreciation for other disciplines' roles (Rossler, 2013). Of note, most studies on prelicensure interprofessional HFS examined changes in either teamwork skills or attitudes; only one examined both (Stewart et al., 2010). Because learning outcomes include knowledge, skills, and attitude (Warren, Luctkar-Flude, Godfrey, & Lukewich, 2016), evidence for the impact of HFS on all aspects of learning outcomes is needed to advance IPE. Accordingly, this pilot study aimed to examine the effectiveness of an interprofessional HFS workshop in enhancing both interprofessional competence (team skills) and attitude among prelicensure medicine and nursing trainees.
METHOD
A quasi-experimental pilot study was conducted to compare teamwork skills and attitudes before and after IPE HFS. The study took place in the simulation center at a publicly funded university in Southern California in 2014. We recruited a convenience sample of fourth-year undergraduate nursing students (n = 32) and third-year undergraduate medical students (n = 19) from two simulation sessions to participate in our study, which was approved by the university's research ethics board. A sample size of 10 percent of the target population was deemed adequate for a pilot study (Connelly, 2008). With each professional group having approximately 100 students enrolled in each academic program, our sample size of 32 and 19 from each group was adequate.
The study's two dependent variables, teamwork skills and perception of IPE, were assessed via two previously validated instruments: the TeamSTEPPS Teamwork Perception Questionnaire and the Interdisciplinary Education Perception Scale (IEPS). The TeamSTEPPS Teamwork Perception Questionnaire has 16 items that measure communication and mutual support (American Institutes for Research, 2010). IEPS has 18 items measuring four factors: competence and autonomy, perceived need for cooperation, perception of actual cooperation, and understanding others' value (Luecht, Madsen, Taugher, & Petterson, 1990). Cronbach's alpha values ranged from .75 to .79. The independent variables were profession (nursing vs. medicine) and time (before vs. after).
Although simulation training was a course requirement at the university, students were not required to participate in the study, which involved completion of a survey before and after simulation training. Recruitment took place prior to each simulation session and was conducted by a trained researcher who was not involved in simulation or course teaching. Following informed consent, participants were organized into groups of four to seven. One to three nursing students and two medical students participated in one of the two concurrent group sessions, along with nonparticipants, with each participant assigned a unique role on the health care team (e.g., student, staff nurse, staff physician).
Participants rotated as the main health care provider in each of the three emergency scenarios that were relevant to their concurrent clinical placements: cardiogenic shock, septic shock, and asthmatic shock (each lasted 30 minutes). When students were not the main health care provider, they took the role of observer. All participants were involved in debriefings after each scenario (about 30 minutes in duration), which were conducted by facilitators with accredited simulation and IPE training. Participants completed study surveys before simulation and after debriefing. This was done when instructors were not in the room to ensure confidentiality of participation. Following data screening and descriptive analysis, multivariate analysis of variance (two-tailed, p set at .05) was conducted to identify differences in perceived teamwork and interprofessional competence between nursing and medical students and before and after simulation.
FINDINGS
Our sample consisted of 32 fourth-year undergraduate nursing students and 19 third-year medical students. Participation rates were 94.1 percent and 95 percent, respectively. Demographics were not collected. Results showed significant differences in several domains of interprofessional perception (IEPS) before and after the simulation, F(8, 81) = 12.01, p < .0001. Post hoc Scheffe test revealed that students' perceptions of interprofessional competence (4.43 vs. 4.09 out of 5), F(1, 88) = 12.18, p = .001; needs for interprofessional cooperation (4.76 vs. 3.82 out of 5), F(1, 88) = 63.83, p < .001; and perceived cooperation (4.47 vs. 4.17 out of 5), F(1, 88) = 6.97, p = .01, were all higher before simulation. No significant differences in team skills or interprofessional perceptions were noted between nursing and medical students.
DISCUSSION
The average scores for teamwork competence and interprofessional attitude were moderately high at both measurement times (pre- and postintervention). The high ratings may have reflected confidence about interacting with members from another profession and indicated prior IPE (Rossler, 2013).
The second key finding concerns the decline in positivity toward IPE after HFS. Although this is unexpected, such declines were reported in older IPE literature, and several explanations were offered: a) Learners are enthusiastic at the start of new learning (Coster et al., 2008), b) learners become more critical about IPE after training (Pollard & Miers, 2008), and c) learners' views about professional stereotypes become more exaggerated after IPE (Tunstall-Padoe, Rink, & Hilton, 2003). All three explanations require that learners gain awareness about collaborative competence during learning activities; such awareness supports the impact of our study intervention. Pollard and Miers (2008) contend that, although learners who have experienced IPE may grow critical of it, these experiences help to "produce and sustain positive attitudes toward collaborative working" (p. 399).
Our inconsistent findings of declining IPE perception with no change in team skills are congruent with Pollard and Miers' (2008) argument that attitude toward IPE may not align with collaborative skills due to the different factors that affect attitude and skills. One reason for the null result in teamwork skills may be the short duration of our intervention. Adamson (2015) reported a dose-response relationship between simulation and learning outcomes and recommended exposure throughout the training program with longer duration each time. However, there remained a lack of consensus on the appropriate amount of exposure needed to yield favorable outcomes.
This pilot study is limited by its small convenience sample from only two professional groups and the collection of self-reported measures in evaluating team skills and attitude toward IPE. Despite these limitations, the findings indicate that use of HFS leads to increased awareness of interprofessional care principles and informs change.
From key study findings, the authors recommend the following. First, more exposure to IPE through simulation and other methods (e.g., didactic course-based teaching, clinical rounds, case conferences) should be available to undergraduate health care trainees. Equipping learners with team skills and positive attitudes toward IPE requires appropriate content and theories for both IPE and simulation (e.g., through tools such as the NLN Jeffries Simulation Theory; Jeffries, 2015) and addressing various simulation variables (such as characteristics of learners, facilitators, and education practices) while developing IPE HFS. The simulation design should involve experts from IPE, simulation, and each intended professional group. Such experts are invested in IPE success and can anticipate external influences on collaborative skills and attitudes. It is also important to note that technology merely promotes interactions between learners and facilitators; it does not replace the need for good pedagogy (e.g., structured debriefing, active listening).
Future IPE initiatives, regardless of delivery method, should take into account learners' preexisting interprofessional competence to keep activities engaging for participants. Development of guidelines on the integration of IPE and simulation concepts would be helpful. Finally, future studies should examine an integrated program of IPE HFS and control for other factors that affect attitude and skills for teamwork (e.g., contact outside classrooms between health care trainees, educational background; Coster et al., 2008; Pollard & Miers, 2008) in assessing the impact of IPE HFS.
CONCLUSION
This study provides evidence for the use of HFS as one means to promote interprofessional learning among undergraduate nursing and medical students. Because nurses play a central role in the health care team and HFS is widely adopted in nursing curricula, HFS holds promise as a pedagogical tool for enhancing collaborative competence.
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