Upon graduation, newly licensed RNs (NLRNs) are expected to function not only within the scope of practice of a licensed RN, but also as a member of an interprofessional collaborative team (American Nurses Association, [ANA] 2015; Interprofessional Education Collaborative, 2016). In addition, how novice nurses are socialized or welcomed into the hospital environment directly impacts their capacity to collaborate with other health care professionals (Fowler et al., 2018). Unfortunately, not every prelicensure nursing student is exposed to interprofessional education (IPE) with other health professions students or provided mentoring on role socialization skills. As academia is attempting to identify optimal teaching methodologies to create interprofessional interactions, it is recommended that health care institutions evaluate the effectiveness of nurse internship programs in facilitating the acquisition of an interprofessional collaborative practice (Institute of Medicine, 2015). Two interprofessional core competencies recognized as essential to an interprofessional collaborative practice are communication and collaboration. Interwoven within these core competencies is role socialization, whereby NLRNs become familiar with the interprofessional norms of an organization (Houghton, 2014). Nurse internships that offer early integration of education focused on inter-professional communication and collaboration increase the potential to ensure NLRNs acquire the skills necessary to develop interprofessional collaborate practice (ANA, 2015; Labrague et al., 2018).
Many internship programs are centered on delivery formats of didactic theory and skill acquisition activities at the bedside. It is necessary to explore the effectiveness of alternate teaching methodologies to deliver IPE concepts. This research addressed the call to identify effective teaching methodologies that allow NLRNs to develop an interprofessional collaborative practice when transitioning into the practice setting (ANA, 2015; National Council of State Boards of Nursing, 2016). Specifically, this study explored the effectiveness of simulation-based education (SBE) compared with online education on interprofessional socialization and collaboration among NLRNs transitioning into medical-surgical practice.
Early identification of expected role behaviors is essential for novice nurses entering a dynamic work environment where complex patients require the collaboration of an interprofessional team to provide safe patient care (Foronda et al., 2013). Nurse internship programs, also referred to as residency programs, often are incorporated by health care institutions to transition the novice nurse into practice (Rush et al., 2013). Elements such as a work-force orientation, didactic content, role socialization, and customization of an internship program have the capacity to impact the transition process (Meyer et al., 2014; Spector, 2015). Unfortunately, similar to prelicensure nursing education, many internships segregate NLRNs into orientation programs emphasizing unit-specific teaching-learning experiences and the demonstration of nurse-only skill competencies (Zigmont et al., 2015). Any formal introduction of interdisciplinary education is more likely to occur after the first 6 to 9 months of entry into the clinical setting (Rhodes et al., 2016). During a time when NLRNs entering the medical-surgical practice setting are encountering the necessity to clearly articulate individual role attributes and expected nurse practice behaviors, it is essential to commence the simultaneous learning of interprofessional collaboration and teamwork (Interprofessional Education Collaborative, 2016; Pfaff et al., 2014; Posenau & Peters, 2016; Rush et al., 2013).
The teaching methodologies of SBE and online education noted in this study are recognized strategies that can be used to facilitate IPE (Foronda et al., 2016). As experiential learning with high-fidelity human patient simulation has been acknowledged as a clinical practice strategy, outcome measures connecting transition to practice in a formal nurse internship program with SBE are still reported as deficient in the literature (Edwards et al., 2015; Rush et al., 2013). There is an emphasis to conduct research evaluating the effect of IPE in relation to outcomes within health care systems (Institute of Medicine, 2015). A gap linking patient health care outcomes with successful internship programmatic or interprofessional collaboration competency outcomes subsists along with defining how to effectively integrate SBE within the health care setting as a strategy to address such outcomes (Cantrell et al., 2017; Meyer et al., 2014). This research study addressed the health care industry movement centered on identifying effective teaching strategies promoting the development of an interprofessional collaborative practice by comparing SBE to independent computer-based online educational modules (ANA, 2015; Posenau & Peters, 2016; Rhodes et al., 2016).
The research questions for this study were:
Do interprofessional role socialization attributes change among NLRNs who participate in high-fidelity SBE sessions compared with NLRNs who complete online modules in a nurse internship program?
Do perceptions of interprofessional collaboration, communication, role responsibility, and teamwork skills change among NLRNs who participate in high-fidelity SBE sessions compared with NLRNs who receive online education training in a nurse internship program?
An experimental repeated-measures design examined professional nursing practice attributes of values, attitudes, and behaviors along with interprofessional collaboration core competencies. A nonprobability, purposive convenience sample of NLRNs hired into a 6-week graduate nurse internship program during the winter 2017 cycle were selected as potential study participants. Inclusion criteria were newly licensed or prelicensure graduate nurses who were waiting to take the NCLEX-RN® examination, were hired to practice on a medical-surgical practice unit, and had attended either three SBE sessions or completed online modules conducted during the 6 weeks of the existing nurse internship program. An a priori power analysis was conducted using G*Power 18.104.22.168 (Heinrich-Heine-Universität Düsseldorf, 2017) to determine the minimum sample size required to achieve significance with a desired power level set at .80, an alpha level of .05, and a moderate effect size of .20 for this proposal. Based on the analysis, it was determined that a minimum of 44 participants (22 in each group) was required.
Research processes were conducted at a university medical center located in the southwestern United States. Designated as a Magnet® facility, the medical center embraces innovative teaching strategies within a traditional nurse-focused internship program. This research study incorporated strategies that reflected both the study site's professional nursing practice model and experiential learning theory (Baylor Scott & White Health Nursing Professional Practice Model, 2016; Kolb, 1984). Experiential learning theory offers learners a means to interact between persons through a cyclical process of 1) adaptation, 2) knowledge transformation, and 3) learning. The study site's professional nursing practice model aligns with experiential theory whereby the novice nurse interacts in a synergistic manner to adapt to a new environment while simultaneously learning role behaviors of the RN (Baylor Scott & White Health Nursing Professional Practice Model, 2016; Kolb, 1984). The educational formats in this study offered participants opportunities to learn role socialization and interprofessional attributes central to this research.
Demographic Data. Participants' degree program of study, age, gender, and medical-surgical practice unit were collected at the commencement of the study.
Interprofessional Socialization and Valuing Scale (ISVS). The ISVS was developed to measure students' values, attitudes, and beliefs about the professional roles of different health professionals in a pre- and posttest format. Data captured measurements of interprofessional role socialization necessary for preparing students to become a member of an interprofessional team. The ISVS includes nine statements rated on a 7-point Likert scale ranging from 1 = not at all to 7 = a very great extent, with higher scores demonstrating more positive perceptions about interprofessional socialization and value. Interclass correlation coefficient was 0.97, with a confidence interval ranging from 0.96 to 0.98. The ISVS was administered via pencil and paper at three time points (baseline, week four, and week six) to align with the delivery of educational content already embedded within the internship program and to capture progress within the program (King et al., 2016).
Interprofessional Collaborative Competency Attainment Survey (ICCAS). The ICCAS was developed to measure self-reported attitudes toward attainment of interprofessional competencies. This survey instrument aligns closely with attributes of an evaluation tool historically used by the study site to assess the readiness of NLRNs to exit the internship program and commence solo bedside practice. However, the researchers selected the ICCAS as a recognized instrument with validity and reliability data, and other psychometric properties essential for conducting research related to IPE. The ICCAS includes 20 statements rated on a 7-point Likert scale ranging from 1 = strongly disagree to 7 = strongly agree, with higher scores indicating a more positive attitude toward attaining interprofessional behaviors. Six subscales include communication, roles and responsibilities, collaboration, family-centered approach, conflict resolution, and team functioning. Cronbach's alpha was 0.91 for all factor items. This survey was administered via pencil and paper in a pretest-posttest format to capture data from the NLRNs' initial entry into (baseline) and exit (week six) from the internship program (Archibald et al., 2014). The pretest-posttest timing of data collection aligned with the existing internship program routine of assessing the readiness of NLRNs to commence solo practice.
Research processes commenced after receiving Institutional Review Board approval and completion of informed consent. Participants were randomized into either a control group (nurse internship with addition of IPE online modules) or experimental group (nurse internship with addition of simulation-based IPE). At week one, participants completed a demographic data form, the ISVS, and the ICCAS. Participants then began completing study-related procedures, which followed the systems-based curricular content of the internship program. Overarching objectives for IPE education content included recognizing and demonstrating interprofessional collaboration, communication, role responsibility, and teamwork skills. Participants were provided 2 hours of education time and a rotation schedule that allowed for participation in the study-related procedures.
Control Group. The control group completed online IPE modules based on interprofessional collaborative practice every other week for 6 consecutive weeks. The modules included: 1) Institute for Healthcare Improvement (2016) teamwork and communication module, 2) IPE for Healthcare education modules offered by Loyola University (2016), and 3) QSEN (2016) IPE modules. The modules were completed on either privately owned computers or in a designated nursing computer laboratory.
Experimental Group. Experimental group members were divided into session groups based on practice unit. Each group contained three to four NLRNs who worked within their scope of practice to provide care as a member of a collaborative team to a simulated patient. The following IPE simulation sessions were developed from existing National League for Nursing (2007) patient scenarios and consisted of representation from one interprofessional health care professional acting within a recognized scope of practice: 1) acute myocardial infarction (code team leader), 2) respiratory distress (respiratory therapist), and 3) gastrointestinal disease (medical practitioner).
All IPE simulation sessions followed the curricular content of the internship and lasted approximately 1.5 hours. Sessions were facilitated in a nursing simulation laboratory located on the study site. Designed to replicate a patient hospital, the simulation laboratory also contained a control room, prebriefing and debriefing room, medical equipment, electronic health record access, and demonstration medications for use during each IPE simulation session. A high-fidelity human patient simulator realistically portrayed the hospitalized patients identified in the simulation scenarios. INACSL Standards of Best Practice: SimulationSM were followed with a prebriefing inclusive of patient information and learning objectives, as well as a formal debriefing (INACSL Standards Committee, 2016; Lioce et al., 2015).
Prior to analysis, data were explored for any missing values, and normality testing was conducted. Missing values were noted at the end of the study to equate with participants who opted out of the study. Nonparametric statistical analyses were conducted secondary to sample size. Quantitative data were analyzed using SPSS® version 24. Quantitative analysis incorporated descriptive statistics for all demographic, independent, and dependent variables. Frequencies and percentages were calculated for categorical variables (e.g., gender). Means and standard deviations were calculated for continuous variables (e.g., age and instrument sub-scale scores). The Friedman Test, a nonparametric equivalent of a one-way analysis of variance, was used to examine the ISVS scores for a change in scores across the three time points. In addition, post-hoc tests of individual Wilcoxon signed rank tests for each study group were computed. To account for type I error, a Bonferroni adjusted alpha value was used with statistical significance set at .025. A Wilcoxon signed rank test was used to examine change over time in the ICCAS from baseline pretest to week six posttest for both groups.
Thirty-eight of the 39 NLRNs hired into the internship were eligible to participate. A total of 29 participants (n =13 for the control group and n = 16 for the experimental group) began the study. At week four, 22 participants completed the study procedures (n = 9 for the control group and n = 13 for the experimental group). A total of 18 participants (n = 7 in the control group and n = 11 in the experimental group) completed all of the study procedures, demonstrating an overall attrition rate of 38% for the study duration. Demographic data are presented in Table 1.
Demographic Data from Baseline to Week Six
Interprofessional Socialization and Valuing Scale
Change in the NLRNs' interprofessional role socialization attributes of values, attitudes, and behavior was measured with the ISVS (King et al., 2016). Reliability statistics for the ISVS demonstrated internal consistency with a Cronbach's alpha of .91 for the pretest and .82 for the posttest. The Friedman test demonstrated changes in interprofessional role socialization and valuing across the three time points (baseline, week four, and week six; χ2 [2, n = 18] = 18.9, p < .005) for all of the study participants in both groups. Review of the median values showed an increase in interprofessional role socialization and valuing from baseline (Mdn = 48) to week four (Mdn = 49) to week six (Mdn = 55) for all participants. Post-hoc tests of individual Wilcoxon signed rank tests for each study group was conducted with an increase in interprofessional role socialization and valuing from week four to week six noted for the experimental group (Z = −2.95, p < .003), with a large effect size (r = .80).
Interprofessional Collaborative Competency Attainment Survey
Change in the NLRNs' perceptions of collaboration, communication, role responsibility, and teamwork skills were measured using the ICCAS (Archibald et al., 2014). Reliability statistics for the ICCAS demonstrated internal consistency with a Cronbach's alpha of .96 for the baseline pretest and .94 for the posttest at week six for all sub-scale items. For all items on the ICCAS, findings were Z = 2.20, p < .028, and large effect size r = .69 for the control group and Z = 2.67, p < .007, large effect size r = .68 for the experimental group. When data from both the control and experimental groups were combined, more positive attitudes were noted toward attaining interprofessional behaviors in subscale areas of collaboration (Z = 3.4, p < .001), roles and responsibilities (Z = 3.03, p < .002), family-centered approach (Z = 2.60, p < .010), and team functioning (Z = 3.16, p < .002). No change occurred in communication (Z = .000, p = 1.0) and conflict resolution (Z = 1.23, p = .22).
This study examined the effectiveness of SBE compared with online education on interprofessional socialization and collaboration among NLRNs transitioning into medical-surgical practice. Although study participants' attitudes and beliefs about the value of interprofessional role socialization increased during the study, the participants who received SBE demonstrated an increase from week four to week six. In addition, the competencies of interprofessional collaboration, roles and responsibilities, family-centered approach, and team functioning changed in a positive direction over time for both groups. These findings align with systematic and integrative reviews noting how positive interorganizational collaborative interactions lend support for the creation of a well-functioning health care system in which all members are appreciated (Foronda et al., 2016; Verhaegh et al., 2017).
From an experiential learning theory standpoint, findings suggest how learning of IPE core competencies impacted practice behaviors of the participating NLRNs (Kolb, 1984). When added to a nurse internship program, IPE can be a conduit for NLRNs to experience authentic interactions with one another and their new team members where determinants of collaboration such as trust, mutual acquaintanceship, and respect can flourish. These attributes align with the Baylor Scott and White Health Nursing Professional Practice Model (2016), in which skilled communication and collaboration can transform the learner during the learning process. Regarding role socialization, findings resonate with how an appreciation for learning not only how the role of the nurse is vital to a team, but also how gaining an understanding of roles of other professions takes time.
Continuation of a supportive internship program supplemented with IPE created a hybrid experience, which also could have circumvented the occurrence of abandonment and components of transition shock often expressed by NLRNs (Fowler et al., 2018). The study procedures for this internship program occurred over a time span of six weeks, which allowed for repeated exposure and capturing of data from entry to exit from the internship program. In general, IPE with simulation research describing the amount of time necessary to demonstrate achievement of outcomes in both academia and practice settings is lacking (Labrague et al., 2018). This research adds support for clinical practice educators deciding on approaches to teach core concepts related to interprofessional collaboration and role socialization.
By contrast, no noteworthy changes in communication or conflict resolution were noted in the study findings. However, health care professionals and administrators have a long-standing knowledge of how interprofessional communication plays a crucial role in quality and safety practices. Effective communication is a core essential competency taught within nursing programs. Nursing programs that also incorporated simulation to teach inter-professional communication techniques noted substantial improvements in communication skills with both health care team members and patients (Labrague et al., 2018). Findings from this research may suggest how participants appeared to carry over communication and leadership skills pertaining to conflict resolution learned in preli-censure programs prior to entering professional practice. Findings also suggest how key attributes of true communication and collaboration within the organizational professional practice model reinforced during the internship program might have supported maintenance of existing interprofessional communication skills. The interprofessional modules and SBE used in this study created learning exchanges that promoted opportunities to sustain learned communication behaviors.
As clinical educators and administrators assess past and current methodologies used to transition NLRNs while introducing necessary interprofessional attributes of practice, SBE should be at the forefront. Although online training modules provide educational content, living out interprofessional care exchanges around a human patient simulator realistically portraying a hospitalized patient can address diverse learning styles of NLRNs. In addition, taking time to ensure NLRNs are supported with experiential learning strategies that promote interprofessional role socialization and collaboration can positively impact the institution (Innes & Calleja, 2018).
The sample size for this study was dependent on both the numbers of NLRNs entering the internship program and the participation of the NLRNs after enrollment in the study. The sample size did not meet the criteria identified from the power analysis. Thus, the power necessary to demonstrate significance was lacking. Across the time span of the study, the participants verbalized how schedule changes, opportunities to gain exposure to procedures not yet encountered during their undergraduate program of study, bedside rounds, and medication administration responsibilities conflicted with their ability to attend the prescheduled SBE sessions. In addition, influence by preceptors as to how staying on the practice unit was most beneficial to learning impacted the decision to opt out of the study for some participants. Maintaining interest and taking time out to complete the online modules were rationales for control group participants to opt out. It is proposed that more experimental group participants completed all procedures secondary to being more familiar with the research team.
This study provided an opportunity to use the ISVS (King et al., 2016) and ICCAS (Archibald et al., 2014) within the health care practice setting. Although reliability statistics for both instruments were satisfactory, prior or limited use of the instruments within the health care setting does not allow for a comparison of data. Future incorporation of these instruments and testing would be necessary.
This research has the potential to influence the direction of future medical-surgical nursing orientation practices through early integration of IPE concepts into an existing nurse internship program. As a result of this research, the study site has added interprofessional simulation education, 2-hour interprofessional clinical rotations, and interprofessional team debriefings to the nurse internship program. Study limitations draw attention to potential barriers that health care educators can assess for, as well as to choose from when seeking to conduct IPE research using reliable and valid study instruments. In addition, this article offers direction for future research pertaining to interprofessional training of new health care professionals and continuing competency education for existing team members within a health care institution.
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Demographic Data from Baseline to Week Six
|Characteristic||Baseline (N = 29)||Week 6 (N = 18)|
| 18 to 27||21||72.4||11||61.1|
| 28 to 37||6||20.6||5||27.7|
| 38 to 47||2||6.8||2||11.1|
|Program of study|
| Accelerated baccalaureate||10||34.4||7||38.8|