Attitudes Toward Communication and Collaboration After Participation in a Mock Page Program: A Pilot of an Interprofessional Approach to Surgical Residency Preparation

ARTICLE IN PRESS ORIGINAL REPORTS

Attitudes Toward Communication and Collaboration After Participation in a Mock Page Program: A Pilot of an Interprofessional Approach to Surgical Residency Preparation TagedPAngela J. Arumpanayil, MSN, AGACNP,* Chris Winkelman, PhD, ACNP, FAANP, FCCM,* Kelly K. McConnell, DNP, MSN, AGACNP,* Michael R. Pelyak, MN, RN,* Christopher P. Brandt, MD, FACS,†,‡ and Jeremy M. Lipman, MD, FACS†,x TagedP Case Western Reserve University, School of Nursing, Cleveland, Ohio; †Case Western Reserve University, School of Medicine, Cleveland, Ohio; ‡MetroHealth Medical Center, Cleveland, Ohio; and xCleveland Clinic, Cleveland, Ohio *

OBJECTIVE: A source of insecurity among new physi-

cians and new nurses is communicating and managing acute changes in patient condition. Mock page programs are an effective method for teaching communication and clinical decision-making skills to medical students. Joint participation in a mock page program provides a unique opportunity for medical and nursing students to practice communication, collaboration, and clinical decisionmaking in a low-risk learning environment. The purpose of this pilot study was to examine attitudes toward communication and collaboration among medical and nursing students after participation in a mock page program. DESIGN: Twenty-four medical students participating in a surgical residency preparatory course were paired with 24 senior level nursing students. Over a period of 3 weeks, nursing students delivered 5 mock pages to the medical students. Mock pages consisted of peerreviewed, preD67X Xscripted scenarios depicting patients experiencing common postD68X Xoperative complications. A 12-question survey measuring attitudes toward communication and collaboration between physicians and nurses was administered prior to delivery of the first page and after delivery of the last page. A dependent sample t test was used to perform item analysis. RESULTS: Individual item analysis of medical student sur-

veys indicated significant improvement in attitudes toward Correspondence: Inquiries to Angela J. Arumpanayil, MSN, AGACNP, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106; e-mail: [email protected] Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

communication and collaboration with nurses in 12 out of 12 survey items (Dp 2X7 X < 0.05). Individual item analysis of nursing student surveys indicated significant improvement in attitudes toward communication and collaboration with physicians in 6 out of 10 survey items (Dp 4X7 X < 0.05). There was no decline in attitudes among any of the survey items. CONCLUSIONS: The results from this study suggest that

an interD75X Xprofessional mock page program improves attitudes toward communication and collaboration between medical and nursing students. This program has the potential to improve the quality of education and increase confidence among medical and nursing students as they prepare for their professional roles. ( J Surg Ed 000:17. Ó 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) TAGEDPKEY WORDS: Medical student, Nursing student, Resi-

dency preparation, Surgical education, InterDprofessional 7X X education, Mock page

TAGEDPCOMPETENCIES: Interpersonal Skills and Communica-

tion, Professionalism, Systems-Based Practice, Medical Knowledge, Patient Care

TAGEDH1INTRODUCTIONTAGEDN TagedPSurgical residency preparatory courses improve the confidence, knowledge, and skill of entering residents.16 In 2014 the American Board of Surgery, Association for Surgical Education (ASE), and Association of Program Directors in Surgery (APDS) issued a joint white paper

Journal of Surgical Education  © 2018 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsurg.2018.04.023

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ARTICLE IN PRESS stating that “requiring all matriculants of surgery residencies to successfully complete a multidimensional preparatory course before residency should accelerate the speed at which trainees acquire basic clinical and technical skills and reduce variability in these skill sets among entering residents.”7 This has led to the collaborative creation of a “Resident Prep Curriculum” by the American College of Surgeons, ASE, and APDS.8 TagedPA key component of many residency preparatory courses is a mock page program. This has been shown effective in teaching interD79X Xprofessional communication skills and clinical decision-making to medical students.9 At our institution, like many others, the mock page component of our surgical residency preparatory course has been delivered by advanced practice registered nurses (APRNs) with focused training to support this offering. The program has consistently been highlighted by participants as a critical component of the course. TagedPWe hypothesized that the mock page program could be an opportunity for interD80X Xprofessional education of both medical and nursing students at our institution. Specifically, if nursing students delivered the pages, rather than APRNs, this program would offer experiences in interDprofessional 81X X communication and shared decision-making to both participants. The purpose of this pilot study was to explore attitudes toward communication and collaboration among medical and nursing students, before and after participation in a mock page program. Also, this pilot was designed to determine the feasibility of transitioning to senior nursing students for delivery of pages.

TagedPThis was a prospective repeated measures study in which online surveys were administered at baseline and repeated at the conclusion of the mock page program. Twenty-four medical students in their fourth year participated in the mock page program as a component of their month long surgical residency preparatory course, based on the ACS/APDS/ASE Resident Prep curriculum. Fourth year Bachelor of Science in NursingD83X X students at the same institution were recruited to participate in the mock page program and research study on a voluntary basis. There were no exclusion criteria. Thirty-three Bachelor of Science in Nursing students volunteered and 24 were selected at random using the lottery method. Each nursing student was randomly paired with a medical student. University Institutional Review Board approval granted exempt status. TagedPA standardized approach to the mock page program previously published in the literature was adapted for this project.10 Details pertaining to the mock page

process are provided in Appendix A. One of our unique adaptations to this program was using nursing students rather than APRNs to deliver pages and feedback to the medical students. A total of 5 pages were delivered in this program. TagedPNursing students had 2 roles for each of the 5 mock pages. The first was to initiate the page and deliver patient information provided in a standardized script. The second was to provide immediate feedback to the medical student using a standard rubric. Nursing student participants were prepared for both roles with 3 training sessions over the course of 4 weeks. Participation in the mock page program was not a required component of coursework for nursing students. Nursing students were compensated with a $10 retail gift card. Institutional funding for gift cards was provided by the School of Medicine. TagedPPrior to the start of the mock page program, all students were asked to complete a 12-question online survey. The “Communication, Collaboration and Critical Thinking = Quality Patient Outcomes” survey tools are freely available on the Institute for Healthcare Improvement website11 and were adapted for this study with permission from the original authors. Medical students were asked to complete the “Communication, Collaboration and Critical Thinking = Quality Patient Outcomes Physician Survey Tool” and nursing students were asked to complete the “Communication, Collaboration and Critical Thinking = Quality Patient Outcomes Nurse Survey ToolD93X X." All participants were invited to complete the survey a second time at the end of the mock page program. A third invitation to complete survey tools occurred 8 days after the second survey was completed, as a test-retest measure of reliability. Each survey completion required approximately 5 minutes of student time. Upon completion of the 5 mock pages and after administration of the postD96X Xtest surveys, medical and nursing students gathered for a group dinner and debrief. TagedPItem analysis comparing preD97X Xtest and postDtest 98X X responses was performed through the use of the dependent samples t test. Cronbach’s a was performed as a test of reliability for the survey tools. All surveys were administered through REDCap secure online survey software. SPSS version 23 statistical software was used to analyze the data. TagedPA final component of the mock page program was debriefing. Nursing school faculty attended weekly medical student debriefing sessions. Additionally, a combined debriefing with both medical and nursing students was held upon conclusion of the program, a second unique component of this activity. The combined debriefing included collection of comments for qualitative summary.

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TAGEDH1METHODSTAGEDN

ARTICLE IN PRESS TAGEDH1RESULTSTAGEDN TagedPAll 24 medical students enrolled in the surgical residency preparatory course participated in the mock page program as a required component of the course. Twentythree students consented to participate in the research component of this program, agreeing to complete 2 surveys. The average age of medical students was 26.6 years and 78% were male (n = 18). Nineteen medical students completed both preD10X Xtest and postD10X Xtest surveys (82.6%). Item analysis of medical student surveys indicated significant improvement in attitudes toward communication and collaboration with nurses in 12 out of 12 survey items (D103X Xp < 0.05, Table 1). TagedPTwenty-three nursing students completed delivery of the mock pages; 1 nursing student withdrew due to schedule conflict prior to the delivery of the first mock page. The average age of nursing students was 21.3 years and 8% were male (n = 2). Nineteen nursing students completed both preD105X Xtest and postD106X Xtest surveys (82.6%). A total of 6 items in the nursing student survey demonstrated significant improvement from baseline (p
0.05, Table 2). There was no decline in the mean scores in survey items. TagedPDifferences in the scores of 2 items in the nursing student survey were not analyzed due to low response rates (Table 2). The low response rates appeared to have resulted from an error in administration of the online

survey. Survey items were analyzed independently and it is unlikely that the lack of response to these 2 items had an effect on responses to the remaining items. TagedPCronbach’s a for preD109X Xtest, postD10X Xtest, and retest of the medical student survey was 0.79, 0.90, and 0.87, respectively. Cronbach’s a for preD1X Xtest, postD12X Xtest, and retest of the nursing student survey was 0.77, 0.87, and 0.74, respectively. These results support moderate-to-strong reliability of the survey tools. TagedPInformal qualitative observations were collected at debriefing sessions for both medical and nursing students. Both groups of students verbalized nervousness surrounding the initial mock pages and described less nervousness over time. Themes gathered from medical student debriefings for the mock page program included concerns around not knowing when pages would be delivered, not having a hand-off report with basic patient information, and a desire to provide evaluation of the nursing student’s ability to communicate effectively. Nursing students expressed some frustration over using preD13X Xscripted scenarios and not being able to formulate their own Situation, D14X X Background, Assessment, and Recommendation (SBAR) statement. They also had concern that medical students may be sharing information regarding the particular scenarios among each other. TagedPBoth medical and nursing students voiced appreciation for the opportunity to engage in this interDprofes6X1 X sional education activity before assuming postDgraduation 7X1 X

TABLE 1. Physician Survey Tool-DComparison 1X X of Results D2X X at Baseline D3X X and After D4X X D5X X Completion of 5 D6X X Mock D7X X D8X X Pages Paired Differences Item

n

Mean T1

Mean T2

Mean

SD

t

df

* D9X X 10X XValue pD D1 X

Nurses and physicians understand each other’s roles Physicians are respected by nurses Nurses and physicians plan together before making decisions There is open communication between physicians and nurses in making decisions I feel confident speaking with nurses on the phone I am confident clarifying unclear information with nurses Nurses clearly convey the purpose of their call I am comfortable acknowledging my inexperience to nurses I have good communication with nurses I feel certain about accuracy of information from nurses It is easy to ask the nurses questions I enjoy collaborating with nurses

19

3.47

4.00

0.526

0.513

D12X X ¡4.472

18

0.000

19 19

3.58 3.00

3.95 3.84

0.368 0.842

0.684 1.119

D13X X ¡2.348 D14X¡3.281 X

18 18

0.031 0.004

19

3.26

3.89

0.632

0.761

D15X X ¡3.618

18

0.002

19

3.37

4.32

0.947

0.848

D16X X ¡4.869

18

0.000

19

3.68

4.47

0.789

0.855

D17X X ¡4.025

18

0.001

19

3.37

4.11

0.737

0.872

D18X X ¡3.684

18

0.002

19

3.37

3.95

0.579

0.838

D19X X ¡3.012

18

0.007

19 19

3.53 3.32

4.32 3.95

0.789 0.632

0.713 0.831

D20X X ¡4.825 D21X¡3.314 X

18 18

0.000 0.004

19 19

3.79 3.95

4.21 4.37

0.421 0.421

0.769 0.692

D2X X ¡2.388 D23X¡2.650 X

18 18

0.028 0.016

T1 = baseline, T2 = after completion of 5 D24X X mock pages, SD = standard D25X X D26X X deviation. Items were scored using a 5-point Likert scale (5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, 1 = strongly disagree). *Significance set at 0.05.

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ARTICLE IN PRESS

TABLE 2. Nurse Survey Tool-DComparison 27X X of Results D28X X at Baseline D29X X and After D30X X D31X X Completion of 5 D32X X Mock D3X X D34X X Pages Paired Differences Item

n

Mean T1

Mean T2

Mean

SD

t

Df

* D35X X 36X XValue pD D37 X

Nurses and physicians understand each other’s roles Nurses are respected by physicians Nurses and physicians plan together before making decisions There is open communication between physicians and nurses in making decisions I feel confident speaking with physicians on the phone I am confident clarifying unclear information with physicians Physicians return calls in a timely manner I am comfortable acknowledging my inexperience to physicians I have good communication with physicians I feel certain about accuracy of information from physicians It is easy to ask the physicians questions I enjoy collaborating with physicians

19

3.11

3.21

0.105

0.567

D38X X ¡0.809

18

0.429

19 7y

3.16 2.71

3.26 3.43

0.105

0.567

D39X X ¡0.809

18

0.429

19

3.16

3.53

0.368

0.684

D40X X ¡2.348

18

0.031

19

2.84

4.05

1.211

0.713

D41X X ¡7.398

18

0.000

7y

3.14

4.00

19 19

3.16 3.00

3.58 3.53

0.421 0.526

0.607 1.124

D42X X ¡3.024 D43X¡2.041 X

18 18

0.007 0.056

17

2.94

3.65

0.706

0.849

D4X X ¡3.429

16

0.003

14

3.57

3.57

0.000

0.961

D45X X ¡0.000

13

1.000

19 14

2.84 3.43

3.84 3.86

1.000 0.429

0.816 0.646

D46X X ¡5.339 D47X¡2.482 X

18 13

0.000 0.028

T1 = baseline, T2 = after completion of 5 D48X X mock pages, SD = standard D49X X D50X X deviation. Items were scored using a 5-point Likert scale (5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, 1 = strongly disagree). *Significance set at 0.05. † Due to low response rates, analysis of these 2 D51X X items was excluded.

roles. Many students expressed the desire to have this program offered earlier in their education. Medical and nursing students both shared that this was a valuable learning activity that improved their abilities to communicate and collaborate over the course of 3 weeks. During the final, shared debriefing participants brainstormed ways in which this activity could be enhanced for future interD19X Xprofessional education. One suggestion was to “reverse” a scenario, creating a page where the medical student possessed patient information and initiated the call to the nursing student, increasing opportunity for the nursing student to engage in critical thinking and decision-making. Additional suggestions included providing feedback to nursing students about the quality of communication and revising scenario delivery to reflect best practices such as the use of SBAR.

TagedPThe implementation of a mock page program as an interD120X Xprofessional education opportunity was successful in improving attitudes toward communication and collaboration among both medical and nursing students, with medical students demonstrating more consistent improvement in individual scores. Experiences

such as these are valued in health care education, as patient safety relies upon effective communication and collaboration within interD12X Xprofessional teams. The positive change in attitude among medical students, noted by responses to all 12 survey items, supports the continuation of this unique adaptation of the mock page program. TagedPAnalysis of nursing student surveys demonstrated significant improvement in half of the items, with no responses declining. Consideration should be given to the small sample size and likelihood of error in survey administration with the nursing students. It is also possible that the exposure our nursing students have to nurse-physician relationships through weekly clinical experiences over the course of 4 years could impact these results. Both groups of students affirmed that the mock page program provided a rich learning opportunity with benefits for both medical and nursing education. TagedPWhen initially considering the use of nursing students to deliver mock pages, there was concern that neither group of students possessed mastery over content covered in individual scenarios. The phrase “the blind leading the blind” arose during conversations surrounding this concern. By the fourth year of their education, nursing students at our University have accumulated over 1000 hours of clinical time but have little real-world

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TAGEDH1DISCUSSIONTAGEDN

ARTICLE IN PRESS experience paging physicians with patient concerns. The purpose of the training sessions for nursing students was to increase knowledge of postD124X Xsurgical complications and build confidence in communication effectiveness. Having preD125X Xscripted scenarios and providing information sessions pertaining to postD126X Xsurgical complications was deemed essential to the success of the learning for both nursing and medical students. TagedPIt was understood from the beginning that the mock page program provided greater learning opportunities and feedback on performance for the medical students. The intention was to conduct this program similar to the traditional approach developed by Southern Illinois University School of Medicine and determine if nursing students were effective in delivering mock pages. If successful, future mock page programs would incorporate increased learning opportunities and provision of feedback to the nursing students, providing a more balanced approach. TagedPAdaptation of the mock page program to include nursing students was effective in that each medical student received all 5 pages and immediate feedback was provided upon the completion of each page. Training was accomplished for both medical and nursing students but the time to train nursing students to deliver pages was significantly greater than the amount of time to train medical students. Delivery of all 5 pages and feedback required about 75 minutes of nursing student’s time. Nursing students attended weekly training and debriefing sessions totaling 3 hours. Efficiencies may occur as nursing faculty repeat this program or incorporate online modules to prepare nursing students. TagedPFuture directions for this program include an opportunity for medical students to offer feedback on effectiveness of nursing student communication. Consideration will be given to randomizing rather than pairing students for each mock page, minimizing the potential for acquiescence bias. We are also developing real-time scenarios using manikins to simulate common postD13X Xoperative complications, allowing nursing students to incorporate assessment skills and formulate their own SBAR statements prior to delivering pages. We anticipate that incorporating an evaluation of nursing student communication and manikin simulation could enrich the learning experience for nursing students. TagedPIn particular, the flexibility of the students to deliver or receive pages at random during a 3-week time frame overcame some of the traditional barriers to interD13X Xprofessional education, such as time and schedule constraints. In future mock page programs, we would like to examine whether improvement in attitudes toward communication and collaboration could be strengthened with additional pages, or the same results seen with fewer interactions. We consider this a preliminary report and

anticipate using this program in additional classes and among additional students, which will improve the ability to generalize findings. TagedPOne limitation of this study is that it is a single site, single course report. It may be that different settings or different populations of students would have unique outcomes. However, our medical and nursing students are similar to other medical and nursing students in research-intensive environments and we used a standardized program with established reliability and validity in teaching and training. An additional limitation is our small sample size. An error with preD135X Xtest survey administration for the nursing students additionally limited the sample size for 2 of the items. Nonetheless, 6 of the remaining 10 items provided data to suggest that attitudes about communication and collaboration do positively change in nursing students following a mock page program. TagedPWhile paired medical and nursing students did not meet until the final debriefing, we recognize that pairing the same students together for all 5 pages may have increased familiarity with each other, potentially introducing acquiescence or habituation bias. However, pages were spaced over time and scenarios were varied to reduce fatigue or autopilot responses. Further, medical and nursing students did not meet or have direct contact with each other, except during the scenario delivery, until after program completion; so acquaintance was not expected to influence response to the attitude surveys.

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TAGEDH1CONCLUSIONSTAGEDN TagedPA mock page program as a component of surgical residency preparatory courses provides medical students with the opportunity to build competence and confidence in communication and management of common postD139X Xoperative complications. Adapting this program to include nursing students for the delivery of mock pages and subsequent feedback about performance has potential to provide rich interDX140 Xprofessional education by allowing students from both professions to communicate and collaborate while working together through patient scenarios. At our institution, this program improved attitudes toward communication and collaboration between medical and nursing students.

TAGEDH1ACKNOWLEDGMENTSTAGEDN TagedPWe would like to sincerely thank Maggie Boehler and Cathy Schwind from Southern Illinois University School of Medicine, Department of Surgery. Their generosity in

ARTICLE IN PRESS sharing time, knowledge, and resources has been invaluable as we developed this interDprofessional 3X41 X education program for medical and nursing students at our University.

TAGEDH1APPENDIX ATAGEDN The Mock Page Program at Case Western Reserve University TagedPWell-tested mock page scenarios developed by Southern Illinois University School of Medicine (SIU) with validity evidence for this purpose were used with their permission. Five scenarios were selected by faculty from the medical and nursing schools based upon patient problems commonly encountered by surgical residents and nurses. Selected scenarios included wound infection, dyspnea and hypoxia, nausea and vomiting, fever, and abdominal distention. As a prior participant in the SIU mockD14X X page program, course faculty from the medical school were accustomed to this framework and content. TagedPPreparation of medical students TagedPMedical students were prepared for mock pages during the introduction to their surgical residency preparatory course. This training took about 1 hour and was led by course faculty. Training included content about goals and objectives of the mock page program, the logistics of how mock pages would be conducted, and how feedback would be provided. Students worked as a group through a series of simulated pages similar to those they would receive throughout the course. A group discussion on how to best approach the scenarios was followed by guided feedback from a physician faculty member. Medical student preparation also focused on closed-loop communication, clinical decision-making, and time management. TagedPPreparation of nursing students TagedPNursing faculty leading the mock page program were trained by Advanced Practice Registered Nurses from SIU familiar with the development and delivery of the scenarios and feedback. This training was then used to develop content to train nursing students. Each of the 3 training sessions for nursing students lasted for approximately 1 hour and occurred outside of the regularly scheduled class. Training included identification and management of common postD148X Xoperative complications, closed-loop communication, specifics pertaining to the delivery of mock pages, and opportunities to rehearse.

student to call. A preD150X Xscripted case scenario was delivered when the call was returned. Mock pages were delivered at the convenience of nursing students between the hours of 8 a.m. and 8 p.m. Monday through Sunday. Late night and early morning pages were not included due to student schedules. Faculty and guest speakers for the surgical residency preparatory course were supportive of students excusing themselves from class or activities to answer pages within 3 minutes of the initial text message. Pages were not delivered during the fourth week of the course as this was a dedicated cadaver week. Nursing students recorded the time of the page and were asked to deliver a second or third page if a call was not returned within 3 minutes. Text messages and calls were delivered using students’ personal cell phones. TagedPDuring the call, medical students would dialog with the nursing students in order to better understand the patient problem and determine a course of action. Medical students received consistent information from the nursing students as the developed scenarios contained details such as vital signs, lab values, medication lists, and assessment findings. Total time for delivery of each page including feedback and completion of the assessment rubric was approximately 15 minutes. TagedPDelivery of feedback TagedPNursing students completed an assessment rubric during each mock page, evaluating medical student performance regarding clinical management and communication effectiveness (volume, tone, clarity, appropriate language, use of closed-loop communication, etc.). Immediately following each mock page, nursing students verbally shared this formative feedback using the rubric as a guide. Upon the completion of the mock page program, each medical student received a written summary outlining their performance during each scenario. The formative feedback rubric and summary report followed a structured format developed by SIU. TagedPRubrics completed by nursing students about medical student performance (i.e., request for additional information, selection of interventions, presence of closedloop communication) were collected by a nursing faculty member and summarized. This summary of group performance was the basis for the medical students’ weekly hour-long mock page debriefing session. Medical student performance on individual case scenarios was not a research component of this study.

TagedPDelivery of pages TagedPFive mock pages were delivered over the first 3 weeks of the surgical residency preparatory course. A mock page consisted of a nursing student sending a text page to the designated medical student requesting the medical

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