Examining Health Professional Students’ Attitudes on Interprofessional Education

............................................................................... ii ACKNOWLEDGEMENTS............................................................. iv DEDICATION ............................................................................. v TABLE OF CONTENTS................................................................ vi TABLES.................................................................................... vii CHAPTER 1...............................................................................

. Quality and Safety Education for Nurses (QSEN) has embraced the IOM and WHO reports and recommended effective teaching approaches to ensure that future graduate nurses develop competencies in patientcentered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007;IOM, 2010).

Education (IPE): A Report from the National League for Nursing's Think Tank on Using
Simulation as an Enabling Strategy for IPE, which described the importance of simulation and IPE in health education (Willhaus, 2012). This report described barriers to Simulation-Based IPE and implementation strategies for a successful program.
Willhaus, (2012) suggested, "Nursing think tank participants believe, simulation is a foundational component to bringing health professions educators together and allowing IPE to be started early and throughout the educational continuum in order to provide true interprofessional learning opportunities" (p. 12).
Simulation learning is not limited to manakin practice scenarios. Simulation is categorized according to levels of fidelity, beginning with low fidelity at one end of the continuum and high fidelity at the other (Jeffries & Rogers, 2007). Through the use of low fidelity simulated activities such as standardized patient assessment, case-base scenarios and role-playing, the facilitation of developing knowledge application, accurate clinical judgment, and skill development can be achieved. The utilization of simulation as a teaching strategy within IPE programs has been recommended (Willhaus, 2012).

Theoretical Framework
Kolb's Experiential Learning Theory (ELT) can be used to guide simulationbased IPE (Poore, Cullen, & Schaar, 2014). This theoretical framework is the underpinning for this study. Kolb's ELT defines learning as "the process to which knowledge is created through the transformation of experience" (Poore et al., 2014, p. 244). Kolb's theory offers a foundation and a process for knowledge acquisition based on the needs of each individual learner (Poore et al., 2014). Poore et al.'s (2014)  Nursing and healthcare research suggest social, behavioral, and Learning theories such as Kolb's are foundational to and have relevance for the health care environment and educational arena. ELT depicts a learning process within which knowledge is created through transformation of an experience (Kolb, 1984).
Experiential learning is an effective teaching strategy. The rationale for the use of experiential education is based on the purpose for the learning experience. These experiences provide relevant goals and objectives that the health professional participants will learn throughout the interprofessional experience. Poore et al.
states, "Kolb's Experiential Learning theory offers both a process for delivering IPE and a mechanism to maximize the learning of each individual student" (2014, p. 246). This theory also supports the components of designing and implementing IPE simulation activities.

Purpose of Research
The aim of this study was to examine the potential impact of IPE on health professional students' attitudes and perceptions towards other health professionals and to explore the utility of the Readiness for Interprofessional Learning Scale (RIPLS) in evaluating IPE programs in the United States. The two specific hypotheses were: (a) students will have an improved perception towards roles of other health professionals through IPE and simulation, and (b) students will have an increased value for Interprofessional Education through IPE and simulation.
This study was designed to answer the following research questions: 1. Does IPE impact students' attitudes towards the roles of other health professionals?
2. Does IPE change students' perceptions of interprofessional collaboration?
3. Does IPE affect students value for learning with other professionals?
In this study, health professional students from five professions (Medicine, Nursing, Pharmacy, Physical Therapy, and Social Work students) participated in a biannual IPE Program located at a private medical school in the Northeast. The program was comprised of simulated activities to include an Objective Structured Clinical Examination (OSCE) of a standardized patient, a case-based scenario, and a teambuilding exercise. Students voluntarily completed a pre-test and posttest utilizing the RIPLS questionnaire and four posttest open-ended questions. This questionnaire was designed to examine the impact of IPE on health professional students' attitudes and perceptions. Overall, the RIPLS is used to measure readiness of health care professional students to undertake shared learning activities (Parsell & Bligh, 1999). This measurement tool is known to be one of the most widely-used instruments in evaluating IPE programs.
Through a paired-sample t test, the pre-test and posttest scores were analyzed to evaluate changes in attitudes toward the IPE experience. The ordinal level of measurement for the RIPLS survey responses represented changes in attitudes for each of the four subscales (Role & Responsibility, Negative Professional Identity, Positive Professional Identify and Teamwork & Collaboration). The fours open-ended questions were analyzed using conventional content analysis.
The significance of this study is supported in the IPE and nursing literature. IPE is recognized as a strategy that can assist health professional students in developing the skills necessary for successful future collaboration in healthcare teams in order to ensure quality patient care. The gap that exists in the IPE research is the lack of understanding the impact of IPE on healthcare outcomes. Although a number of IPE research studies have been conducted, this study represents a unique collaboration of five professions that included health professional students from Medicine, Nursing, Pharmacy, Physical Therapy, and Social Work from two universities and one college. This was the first time these five specific professions collaborated in an IPE simultaneously and were evaluated using RIPLS. IPE is a strategy recognized by health organizations to assist health professional students in developing the skills necessary for successful future collaboration in healthcare teams.
This chapter provided a brief introduction to the literature and theoretical underpinnings to support the relevance to IPE and simulation in this study. The aim of the research study, followed by the research questions to be answered, were presented.
The significance of this research study was addressed. The following is an overview of the remaining chapters.
In chapter 2, a review of the literature on IPE and simulation provides a detailed description of the historical context and supportive research. The chapter examines the research for the relevance to IPE, simulation and practice. A review of various measurement tools in IPE and simulation are examined along with research implications.

Chapter 3 focuses on the theoretical underpinnings of this study and the utilization of
Kolbs's Experiential Learning theory. A detailed description of this theory and related research are explored. Chapter 4 describes the mixed method design of the study. A review of the research design, sample and setting, program description, measurement tool, and data analysis are discussed. The research findings are presented in chapter 5.
This chapter reports the quantitative data results from a paired-sample t test as well as a conventional content analysis allowing categories to emerge. The last chapter concludes with discussion of the findings and implications for nursing education, practice, and research.

Interprofessional Education
Interprofessional Education (IPE) continues to be supported by national organizations as an essential component of the education of healthcare professionals.
There is a growing consensus that the collaboration between healthcare professionals and students can impact learning. In addition to providing essential comprehension of IPE, simulation, as a component of IPE, provides an opportunity for students to engage in active learning strategies among health care professionals. This chapter explores the literature on IPE and its impact on health professional students' attitudes and perceptions towards other roles and collaboration among professionals. This chapter also reviews previous research focused on IPE. The IPE programs utilizing simulated activities are examined for relevance to this study.
According to the National Center for Interprofessional Education and Practice, the history of exploration of the need for health care providers to collaborate to impact practice began over 50 years ago. The leading national organizations have recognized and invested time in promoting an expanded understanding of IPE in practice and education (IOM, 2001(IOM, , 2003(IOM, , 2010National Center for Interprofessional Education and Practice, n.d.). To further elaborate on the history of IPE, the following timeline was adapted from the Interprofessional Education and Collaborative Practice Presentation by the Sage Colleges School of Health Sciences Interprofessional Education Committee (2012) and the work of Professor Dewitt C. Baldwin (1996) to capture the evolving interests and trends of IIPE. The timeline is divided into decades with primary accomplishments listed for each time frame.

1900-1950
The work of Professor Dewitt C. Baldwin (1996) investigated Royer's (1978) historical notes revealing that, prior to 1900, India's mission hospitals sent out teams of physicians, nurses, and "auxiliaries" to provide health services to remote communities (Fendall, 1972;Robinson & Fandall, 1976). In 1910, Abraham Flexner, an acclaimed reformer of medical education, criticized the splintering of education for health care professionals, especially medical education. After the Progressive Era in the 1920s, the interests in IPE waned in the United States, but research continued in Canada. Royer's notes quoted the Dawson Report (1920) which advocated a "team approach" to health care and the establishment of "health centers" in Great Britain (Baldwin, 1996). Baldwin (1996) also traced the development of interdisciplinary teams back to World War II. Teams were utilized in surgery, burns, rehabilitation, and long-term care.
Martin Cherkasky is credited with the development of primary care interdisciplinary teams at the Montefiore Hospital, New York in 1948 (Cherkasky, 1949;Baldwin 1996).
His efforts provided home care outreach services that included teams of physicians, social workers, and nurses to provide care within local communities.

1951-1979
The concept of teamwork in primary health care occurred during the 1960s.  (OEO, 1970).
In the 1970s, Laura Halsteadt, MD conducted the first systematic review of studies regarding the impact of team delivery of care in rehabilitation services (Baldwin, 1996). The recognition of IPE as a field of study was established through these efforts.
There continued to be an increase in global concerns regarding the delivery of health care and the role of interprofessional teams in reducing safety errors. The UK and Canada assumed leadership roles in IPE (Baldwin, 1996).
The first IOM conference in 1972 called "Education for the Health Team" produced a report that discussed the importance of establishing substantive relationships between educational programs for the health professions (IOM, 1972). This report supported the concept of interdisciplinary education for health science students: an educational experience can be interdisciplinary at the level of the student, faculty, or both (Baldwin, 1996;IOM, 1972;Pellegrino, 1972). The IOM (1972) report also recognized the definition of Interdisciplinary as: "Students from more than one health profession taught by faculty from one health profession; students from one profession taught by faculty from more than one profession; and students from more than one health profession taught by faculty by faculty from more than one profession" (p. 6).
In 1978, the WHO identified IPE as an important component of primary health care. This global organization's initiative built upon the considerable progress that had been achieved in the area of IPE.

1980-1989
In 1987, the Center for the Advancement of Interprofessional Education (CAIPE) was established in the UK. CAIPE is described as an independent "think tank" that collaborates with individuals, corporate, and student members to improve collaborative practice. The CAIPE (2002) initiative is to promote quality of care through health care professionals learning and working together to benefit patients and clients.
Another positive step for establishing support for IPE was the founding of the

1990-1999
The Canadian Interprofessional Health Collaborative (CIHC) was established in the 1990s. This national organization continues to promote IPE, collaboration in healthcare practice, and patient-centered care. According to CIHC, their goals include sharing knowledge with policy makers, planners in the health and education systems, health professionals, and educators to ensure that all Canadian citizens benefit from healthcare practice and patient-centered care. CIHC organization also assists health providers, teams, and organizations with the resources and tools needed to apply an interprofessional, patient-centered, and collaborative approach to healthcare. Health System (1999) report is that health care organizations and the professionals affiliated with them should make continually improved patient safety a declared and serious aim by establishing patient safety programs with defined executive responsibility.
The following includes a description of Patient Safety Program objectives: to provide strong, clear, and visible attention to safety; to implement non-punitive systems for reporting and analyzing errors within their organizations; to incorporate well-understood safety principles such as standardizing and simplifying equipment, supplies, and processes; and to establish interdisciplinary team training programs for providers that incorporate proven methods of team training such as simulation (IOM, 1999). This recommendation impacted the IPE community to enhance initiatives in healthcare and academic programs.

2000-2009
The IOM report Crossing the Quality Chasm: A New Health Care System for the 21st Century called for fundamental changes to the health care system to close the quality gap (IOM, 2001). The IOM identified six goals for improved delivery of patient care resulting in greater patient safety and attainment of positive health outcomes: (1) Safe: avoiding injuries to patients from the care that is intended to help them; (2) Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit; ( (Cronenwett et al., 2007;Cronenwett, Sherwood, & Gelmon, 2009a;Cronenwett et al., 2009b). The IOM's six aims are the foundation for QSEN's six competencies (QSEN, 2012a(QSEN, , 2012b (1) create a coordinated effort across the health professions to embed essential content in all health professions' education curricula; (2) guide professional and institutional curricular development in cooperation learning approaches and assessment strategies to achieve productive outcomes; (3) provide the foundation for a learning continuum in interprofessional competency development across the professions and the lifelong learning trajectory; (4) acknowledge that evaluation and research work will strengthen the scholarship in this area; (5) prompt dialogue to evaluate the "fit" between educationally identified core competencies for interprofessional collaborative practice and practice needs/ demands; (6)  History of simulation. Throughout the literature, simulation was interpreted and scrutinized as a theory-based practice. Simulation was a topic of theoretical debate as early as the times of Plato and Aristotle. Across the continuum of philosophy, simulation was utilized in different professions. Simulation continues to evolve and impact education as an innovative strategy to engage the learner. Some philosophers suggested a new fundamental philosophy of science was needed to understand simulation (Naylor & Finger, 1967). This different ontological focus of simulation would include a new theoretical foundation and a validated model of simulation.
This brief overview of simulation will be followed by a philosophical perspective.
Many resources define "Simulation" as a noun, meaning to pretend, imitate, to reproduce the conditions of a situation for training. Simulation in this study refers to activities or events replicating clinical practice using scenarios, fidelity manikins, standardized patients, role playing, skills stations, and computer-based critical thinking simulations (Hayden, Jeffries, Kardong-Edgren, & Spencer, 2009;Roh, Lee, Chung, & Parks, 2013). Jeffries (2005) defines simulation as activities mimicking the reality of the clinical environment. Simulation provides a realistic environment for students to practice skills without risk to patients and then apply these skills in practice (Wilford & Doyle, 2006). Overall, simulation was intended to provide an artificial world or learning environment for students; it was not meant to be an environment for participants to demonstrate perfect performances. The laboratory allowed simulation experiments of situations that occur in the real world to take place. This learning environment was conducted in a controlled environment, safe and neutral. Each different profession identified relevant objectives and goals. Simulations are often computer generated and alternated the degree of difficulty or circumstances.
The history of education has often used simulation activities such as role-playing and case studies to help develop critical thinking skills. These techniques are referred to as low fidelity simulation. Jeffries (2005) has described three key components in nursing simulation: the design, implementation, and evaluation phases. Jeffries' Simulation Model provides a foundation for simulation design in nursing curriculums and health education programs. There are five concepts in Jeffries' framework: educational practice, the teacher, the student, the design of characteristics of the simulation, and the outcomes (Jeffries & Rogers, 2007). During the simulation process, a facilitator is commonly used, referring to the person who conducts the process of simulation. Chapter

Types of analysis.
There are two types of analysis used to interpret simulation, descriptive and prescriptive. Naylor and Finger (1967) described an example of simulation using a descriptive and a prescriptive analysis. If faculty use a simulation model for descriptive analysis, they are interested in the behavior of the system being simulated and so would attempt to produce a model which would predict behavior. The use of simulation models for prescriptive purpose involves predicting the behavior of the system being studied under different combinations of environmental conditions. Another example of this type of modeling is the need to think critically to imitate health professionals caring for acutely ill patients in an emergency situation. This type of simulation experiment can evaluate predicted behaviors of the healthcare professionals.

Seamless Care Model
The Seamless Care Model is the educational concept for this IPE program The Seamless Care interventions were important for the individual and group processes of learning these skills to demonstrate an assessment and development of a joint patient transition care plan. The cooperative learning process was the foundation for reflective practice (Mann et al, 2009).
By forming small groups to receive education throughout the project, the Seamless Care approach engages students and preceptors to continue building on their knowledge and skills while working in interprofessional teams. Student objectives included collaboratively developing an interprofessional transition plan of care, setting goals with patient living with chronic illness, and monitoring the achievement of those goals. The student teams regularly conversed in person or via teleconference or further web-based communication. The teams also met regularly with the patient. Lastly, the preceptor guided and supported the student and student teams. The outcomes of the project included the recognition of challenges with the development of the interprofessional experience for the students and preceptors and the value of continuing such programs. Seamless Care continues to be a foundational framework on which multiple IPE programs are based. Interprofessional teams focus on developing knowledge and skills necessary to educate their patient improved outcomes.
The utilization of IPE and simulation in an academic setting is becoming more widely accepted by health care educators. The use of simulation within IPE has been identified as an effective teaching strategy in early co-education of students from different professions in the healthcare field (Baker et al., 2008;Dillon, Noble, & Kaplan, 2009;IOM, 2010 Another study that focused on attitudes of health professionals was conducted by van Schaik, Plant, Diane, Tsang, and O'Sullivan (2011). This study examined a simulation-based interprofessional team-training program with health professionals. This program was based on pediatric emergencies and evaluated self-efficacy in resuscitation skills. Medical residents and nurses' self-efficacy was measured using a pre- Throughout this literature review, the terms confidence and self-efficacy are used interchangeably (Lundberg, 2008). Confidence is described as a type of attitude that indicates a person has a belief in oneself and the abilities to accomplish specific goals.
This empirical evidence supports the relationship between attitudes and the performance of students in the clinical setting. A change in students' attitudes is often evaluated with the use of simulation learning. One of the major effects of simulation in nursing is the development of nurse's confidence in self-performance of skills (Goldenberg, Andrusyszyn, & Iwasiw, 2005;Cant & Cooper, 2010). Goldenberg et al. (2005) conducted a study with undergraduate nursing students participating in classroom simulation. This descriptive study investigated the effect of classroom simulation on a convenience sample of 22 third-year baccalaureate nursing students' self-efficacy in health teaching. The students completed a self-efficacy questionnaire before and after the simulation workshop sessions. The results indicated that the students' overall confidence scores increased significantly following the two sessions of role-playing case studies, suggesting more perceived self-confidence in performing health teaching.
In Brown and Chronister's (2009) comparative research study of senior nursing students, the effect of simulation activities on critical thinking and self-confidence in an electrocardiogram-nursing course were evaluated. The treatment group (n=70) received weekly simulation exposure in addition to lecture (500 minutes combined total), and the control group (n=70) received weekly lecture (400 minutes total didactic instruction). As reported, the results showed no significant differences in the critical thinking and selfconfidence measures between the groups, except when controlled by semester level. In the data from the second semester of simulation, scores of critical thinking and selfconfidence were significantly higher. The study also reported a pre-and post-simulation measure of self-confidence demonstrating statistically significant improvement following the simulation in the second semester.
Sinclair and Ferguson's (2009) study explored the effect of simulation learning in a nursing theory course on students' perceptions of self-efficacy, satisfaction, and effectiveness. While self-efficacy can be a challenge for students, they have often expressed concerns of anxiety regarding their abilities to apply learning to clinical practice. The findings suggested that nurses have reported improved self-efficacy in their skill performance following the simulation experience.
Kameg, Howard, Clochesy, Mitchell, and Suresky (2010)  An example of an individual's capacity to perform a task was described in the research study conducted by Cardoza and Hood (2012). This study focused on comparing baccalaureate nursing students' self-efficacy before and after simulation. A convenience sample of 52 senior baccalaureate nursing students was separated into two groups. Self-efficacy was measured using the General Self-Efficacy (GSE) scale (Jerusalem & Schwarzer, 1995). Data identified senior baccalaureate nursing students having unrealistic self-assessments of their clinical knowledge and performance capabilities before simulation. A significant increase in self-efficacy in the groups emerged over time. Improved self-knowledge by both groups regarding the limitations and perceptions of their clinical abilities increased after seven weeks. This study demonstrated the need for students to engage in simulated clinical scenarios. Simulated scenarios can lead to identifying levels of nursing knowledge and clinical skills, while further enhancing behaviors to improve students' critical analysis and learning outcomes (Cardoza & Hood, 2012).

Related simulation research in comparing knowledge and satisfaction was
conducted by Karong-Edgren, Lundstrom, and Bendel (2009). This research study compared student test scores and satisfaction outcomes when interacting with Vital Sim® and Simman®. The purpose of this study was to compare student knowledge and retention satisfaction scores between two fidelity levels of simulation manikins by using a paper and pencil test. This study employed an experimental 3x3 factorial with repeat measure design. One hundred and forty baccalaureate nursing students in a medical surgical course participated in this study as members of a convenience sample. Students were randomly selected to join three groups and three different levels of time on three campuses. They participated in a paper and pencil test that consisted of 15 multiple choice questions based on the AHA algorithm for ACS or from the selected medical surgical test bank. After the students participated in a 30-minute simulation scenario, satisfaction scores were measure by a faculty designed, seven-item Likert-type satisfaction questionnaire. The results indicate that there were no significant covariates and the simulator by time interaction was not significant (p>0.5) (Karong-Edgren et al.,

2009). Overall, results indicated significance in knowledge and satisfaction scores
between the pre-test and posttests. Faculty members further reported students' satisfaction with the simulation experience.

Interprofessional education research. Interprofessional teams involved in
simulation continue to be a growing trend in health care education (Willhaus, 2012).
There are combined efforts between medicine and nursing to engage in these programs to impact patient care. Other team dynamics have included Pharmacy, Nutrition, Physical Therapy, and Social Work. IPE is an avenue for changing attitudes of healthcare professionals and enhancing patient centered care during training (Rodehorst, Wilhelm, & Jensen, 2005;Rose et al., 2009). This continues to impact patient care by involving members that collectively participate in the decision making regarding the patient. Bray, Schwartz, Weeks, and Kardong-Edgren (2009) surveyed non-university healthcare educators after a high fidelity simulation demonstration, and found that this group was interested in employing patient simulation in student learning as an educational tool.
These findings support the use of high fidelity simulation in staff education in hospitals and other health care agencies. Incorporating interdisciplinary education with simulation in these settings would be a valuable addition to improving patient care (Bray et al., 2009).
The Another study also focused on the comprehension of the different roles of health professionals. Rodehorst et al. (2005) analyzed the efficacy of students from several disciplines working together to provide care to patients with asthma, and evaluated the interplay of overlapping roles in health care. Results indicated that interdisciplinary learning could clarify roles and enhance learning for students from different disciplines.
Interprofessional education can impact attitudes towards other professionals.
Woodroffe, Spencer, Rooney, Le, and Allen (2012)  training curricula models of collaborative and interprofessional education. Training future health care providers to work in such teams will help facilitate this model resulting in improved healthcare outcomes for patients. The models in the study were a didactic program, a community-based experience, and an interprofessional-simulation experience.
The study reported a common theme of the importance of helping students understand their own professional identities while gaining an understanding of other professionals' roles on the health care team. The authors summarized their report to include a recommendation for best practices such as the need for administrative support, interprofessional programmatic infrastructure, committed faculty, and the importance of recognition of student participation as key components in an IPE program. The General Self-Efficacy (GSE) scale has been used to assess self-efficacy of IPE students (Jerusalem & Schwarzer, 1995). This scale is considered a structured selfreporting instrument. The GSE is a 10-item scale designed to assess optimistic selfbeliefs. Participants use a four-point scale with 1=not at all true, 2=hardly true, 3=moderately true, and 4=exactly true. Responses are summed for a final score that range from 10-40. The higher score reflects students' greater belief in self-efficacy. This test requires 4 minutes to complete on average, according to the originators (Jerusalem & Schwarzer, 1995). The reliability has been established in 34 samples from 23 nations with Cronbach's values ranging from 0.76 to 0.90, with the majority in the high side of the range (Rimm & Jerusalem, 1999;Luszczynska, Scholz, & Schwarzer, 2005). This range indicates that some of the research is reporting internal consistency coefficients.

Review of Measurement Tools
This scale is considered unidimensional, meaning it has a construct and content validity.
The GSE scale will be at the interval level. Validity of the scale was confirmed by determining the relations between the GSE and other social cognitive variables (Luszczynska et al., 2005). This scale is widely used as a measurement instrument in education and applicable to the evaluation of nursing students and health professional.

Summary
Through the history and development of IPE and simulation, the importance of collaborative practice to reduce practice errors and improve quality of care and patient outcomes are evident. There are many studies that explored the effects of IPE and the use of simulation in health education. The impact of these teaching strategies continues to be utilized to enhance critical thinking, psychomotor skills, and communication.
Research supports the need to further investigate health professionals' attitudes and perceptions to improve education and future practice.

Chapter 3: Theoretical Framework
Health education theories provide a common lens for research that can describe,

Bandura's Social Learning Theory
Bandura's Social Learning Theory (SLT) has particular relevance to adult learning that accounts for both the learner and the environment in which he/she operates.
SLT emphasizes the importance of observing and modeling behaviors, attitudes, and emotional reaction to others (Bandura, 1977). Parcel and Baranowski (1981) described basic components of SLT and suggested ways for them to be utilized in planning and implementing health education. SLT is especially attractive to health educators because it approaches the explanation of human behavior in terms of a continuous interaction among cognitive, behavioral, and environment determinants (Parcel & Baranowski, 1981). Within the developmental stages of health education programs, SLT has been effective in influencing behavior change. Bandura (1977) has identified three elements to the SLT: (1) People tend to model those they admire or most closely identify with; (2) Observational learning follows a process of rehearsal, modeling the behavior symbolically, and then acting on it; and (3) People tend to model behavior that results in outcomes they value. Modeling reduced both the burden and the hazards of direct trial-and-error learning by enabling people to learn from example what they should do even before they attempt a given behavior (Bandura, 1977). Bandura (1977) also outlined a four-step, largely internal process that directs social learning, which included an attentional phase, retention phase, reproduction phase, and motivational phase. Attentional phase is the observation of the role model.
Retention phase involves the storage and retrieval of what was observed. Reproduction phase is where the learner copies the observed behavior. The last phase, the motivational phase, involves whether or not the learner is motivated to perform a certain type of behavior.
In general, understanding the learning process is helpful to the educator. SLT can be used singularly or with other learning theories to help the educators acquire new information and modify existing thoughts, feelings, and behaviors of the learner. The educator can model behavior and create opportunities for students to serve as models to each other. By incorporating learning activities, the educator provides opportunities for practice and collaborative group learning. The educator also strives to form a positive and supportive interpersonal relationship with every student. Braungart and Braungart (1997) stated that the social learning perspective is a simple theory to use, stressing the importance of effective role models who, by their example, demonstrate exactly what behavior is expected.
The strength of Bandura's SLT (1977) as a framework for educational programs is evident in many research studies. Social learning programs encourage behavior changes to take place, which can lead to a desirable outcome. IPE programs have strong foundations of observational learning, followed by motivation and reinforcement interventions encouraging participants to model favorable behaviors and enhance decision-making skills. Bandura (1977) proposed that the environment and internal events that influence perceptions and actions affect complex behaviors. In other words, people influence their environment, which in turn influences the way they behave. Simulation activities provide a practical environment to focus on intrinsic and extrinsic factors that can influence behaviors of the health professional.
SLT has been used as a framework for simulation educational programs (Sinclair & Ferguson, 2009). Sinclair and Ferguson's (2009) research explored the effects of simulation learning on students' perception of self-efficacy, satisfaction, and effectiveness. Qualitative data showed students reported that working with their peers during simulated learning activities was effective in promoting their learning. Nurses reported improved self-efficacy in their skill performance following the simulation experience.
Williams et al.'s (1993) examined a collaborative approach among health care professionals in the development of a preceptor program by using social learning theory.
Through the evaluation of nursing student behaviors, the authors suggested that change can impact future nursing practice leading to better patient outcomes.

Knowles' Adult Learning Theory
The second theory widely used in IPE and simulation is Knowles' Adult Learning Theory (1990). This theory relates to concepts of adult learning that exist with five of Knowles assumptions: self-concept, experience, readiness, orientation, and motivation.
Simulation is based on adults who are learning in an environment relevant and applicable to their set of experiences. IPE and simulation scenarios are designed to have adult learners critically reflect on their experiences. According to Knowles (1990), this is an important element in fostering a positive effective learning experience. Campbell, Themessl-Huber, Mole, and Scarlett (2007)  Jeffries' underlying assumptions depict a "how to" of planning, designing, and implementing simulation in a clinical setting (Jeffries & Rogers, 2007). For instance, the framework guides the simulation scenarios by creating and planning the events according to the needs of the education program or practice environment. This framework is essential in the organizational development of simulation education to improve the nurse's actions in providing care to patients. Another component of Jeffries Simulation Framework is nursing students connecting simulation within the nursing curriculum as well as student satisfaction with simulated situations.

Smith and Roehrs (2009) utilized Jeffries' design characteristics and included five
variables: clear objectives and information, support during the simulation, a suitable problem to solve, time for guided reflection/feedback, and fidelity or realism of the experience. This framework directed the research needed to address the questions related to the outcomes and efficacy of the author's simulation-based education.

Kolb's Experiential Learning
Through a detailed examination of relevant theories to IPE and simulation, the theoretical framework of Kolb's Experiential Learning guided this study. This social theory is defined as a learning process in which knowledge is created through transformation of an experience (Kolb,1984). Kolb's ELT has been utilized in multiple disciplines as an approach to learning such as nursing, business and education (Baker et al., 2008;Lisko & O'Dell, 2010).
Interprofessional Education is built on social and experiential learning (Reeves et al., 2007). Kolb (1984) suggested that immediate or concrete experiences lead to observations and reflection. These are relevant goals and objectives that the participants will learn throughout an interprofessional experience. This theory also supports the components of designing, implementing, and debriefing of simulation. Throughout the simulation experience, students interact with each other and the environment while exploring beliefs and ideas (Poore et al., 2014). Kolb (1984) suggested that learning is a process through which simulation can affect how individuals develop and employ knowledge they gain through experiential learning cycle.

Assumptions of Kolb's Experiential Learning Theory. Kolb's ELT identifies
learning styles of each individual learner. ELT has two assumptions to guide the learner: (1) the learner can adapt and change their knowledge, skill, and attitude through experiential learning; and (2) learning continues to evolve after the completion of the learning cycle to a more complex level (Davies & Gidman, 2011). This completion directs the learner to another set of experiences, which in turn directs him or her to another cycle of learning (Poore et al., 2014). The learner's knowledge is focused between personal and social knowledge.
The following section provides some background information to explain Kolb's earlier work. Kolb's theory pulls from the original work of experiential learning from the scholars Dewey, Lewin, and Piaget (Kolb, 1984 formation of abstract concepts based upon the reflection, (4) testing the new concept, and (5) repeat (Kolb, 1984).
Kolb's learning styles model gave rise to the Kolb's Learning Style Inventory (LSI) and Experiential Learning Theory (ELT) (Kolb, 1976(Kolb, , 1984. His Learning Style Inventory (LSI) was based on the notion that learning styles can be described in two continuums. The focus of LSI is to determine the learning styles of an individual. The model works on two levels or continua, active experimentation-reflective observation and abstract conceptualization-concrete experience (Kolb, 1976(Kolb, , 1984. The ELT was a model of learning that utilized role experience in the learning process (Kolb, 1984). This theory further emphasizes the combination of experience, perception, cognition, and behavior as a perspective on learning (Kolb, 1984 The propositions are: Learning is a process, All learning is relearning, Learning is a dialectic process, Learning is holistic and integrative, Learning results from interaction between person and environment, and Learning is a process of creating knowledge (Kolb, 1984).
In addition to contributing to understanding the process for experiential learning, the following describes Kolb's four learning styles, to which each has a combination of learning preferences (Kolb & Kolb, 2005). The first is the Converger (active experimentation-abstract conceptualization), which represents the learning style of solving problems to practical issues that involve technical tasks and social issues. The second learning style is the Accommodator (concrete experience-reflective observation) or the hands-on style of a learner that prefers to take a practical, experiential team approach to completing a task. The third style is the Assimilator (abstract conceptualization-reflective observation) or the logical approach learner that focuses on the ideas and abstract concepts of the learning situation. Lastly, the Diverger (concrete experience-reflective observation) learning style is described as the watching rather than the doing action of a task. This is the "gathering of information to solve problems, preferably in groups" (Kolb & Kolb, 2005, p. 5). The learning cycle represents a studentcentered focus that enhances active learning such as reflection to increase critical thinking skills. Kolb (1984) suggested that the learner, as a reflective practitioner, watches, listens, and views issues from different points of view and discovers meaning in the learning material.
Kolb's three stages of a person's development improve as he or she matures through the development stages as illustrated in Table 1 (Kolb & Kolb, 2005). The development stages are identified as Acquisition, Specialization, and Integration. Kolb (1984) further explained these stages as (1) Acquisition stage occurs from birth to adolescence, and is where basic abilities and cognitive structures develop; (2) Specialization occurs from the beginning of formal schooling through the early work and personal experiences of adulthood; and (3)  Central to IPE is the relevance to various theoretical frameworks. The utilization of Kolb's ELT in conjunction with IPE and simulation continues to impact the educational research of health care professionals and students to improve future practice.
Incorporating this theoretical framework provides a foundational component, which can lead to a credible evaluation of IPE programs.

Chapter 4: Methodology
This study utilized mixed methods to explore interdisciplinary health students' readiness, attitudes, value, and understanding of interprofessional roles. Furthermore, the utility of the Readiness for Interprofessional Learning Scale (RIPLS) was evaluated by using a descriptive analysis and a paired-sample t test. This study examined the potential impact of Interprofessional Education (IPE) on health professional students' attitudes and perceptions. In addition to the RIPLS questionnaire, evaluation of the IPE program was conducted by using a qualitative method of three-open ended questions intended to reveal a greater understanding of the IPE students attitudes on role and interprofessional collaboration.

Research Questions
This descriptive study was designed to answer the following research questions: 1. Does IPE impact students' attitudes towards the roles of other professionals?
2. Does IPE change students' perceptions of interprofessional collaboration?
3. Does IPE affect student's value for learning with other professionals?

Research Design
The study design was a pretest-posttest descriptive design utilizing a 15-item

Sample and Setting
A convenience sample (n=524) of health professional students (Medical, Nursing, Pharmacy, Physical Therapy, and Social Work) from a state university, a state college, and the medical school of a private university in the Northeast participated in a mandatory, bi-annual IPE program.
The sample consisted of 121 second-year medical students, 120 senior nursing students from two different programs, 120 fifth-year Doctorate in Pharmacy students, 37 second-year Physical Therapy students and 126 graduate Social Work students. Faculty randomly assigned students into one of the 17 equally blended interprofessional teams.
Each team had 5-7 members. Three breakout sessions labeled by color (Green, Red, and Blue) were conducted. An attempt was made to have an equal representation of students from each profession. Students were given an assigned color group at the time of checkin. Throughout the program, students rotated throughout the breakout rooms, also referred to as "Academies," to complete the simulated activities.

Description of the IPE Program
Health professional students participated in a bi-annual IPE Program located at a private medical school in the Northeast. In an effort to provide IPE across professions, reported to their assigned "Academies" for an introduction, breakfast, and a brief orientation to the IPE. Program facilitators provided students with IPE program objectives that explained the importance of interprofessional teams in health care and described the roles of nurses, pharmacists, physicians, physical therapists, and social workers in health care in working as a team to problem solve a non-medical situation.
Emphasis was placed on devising a care plan for a complicated patient and implementing care for a patient. A detailed description of the program follows.
Initial breakout sessions focused on an OSCE of a patient diagnosed with pneumonia (Appendix K & M). The OSCE was originally designed as a form of performance-based testing used to measure candidates' clinical competence. IPE programs currently use this strategy to observe and evaluate health care students who conduct a simulated patient interview, perform a physical examination, and treat standardized patients who present with a medical problem.
Next, students arrived to the patient rooms as a team to begin discussions for a plan of action for a patient complaining of a cough. Prior to the start of this first session, students received a packet of patient information. Upon entering the room, the team was expected to conduct an interview and assess the patient while collectively gathering information. After the assessment phase, the team discussed plan of care and discharge strategies. At the conclusion of this session, a debriefing phase was held and led by a faculty member representing one of the participating professions.
A case-based scenario was the format for the second breakout session. Casebased scenarios continue to be an educational strategy to enhance IPE. Scenario for this session focused on a recurrent admission of a patient from the Emergency Department, named "The Complicated Patient" (Appendix I). Each student received a packet of information that included patient information of demographics, history, and physical and group discussion questions. Students collectively participated in a team discussion for 30 minutes. Students were encouraged to participate in their designated teams to further discuss a detailed plan of action according to a set of discussion questions. Each reported a problem list and a projected plan of action according to their role. A debriefing phase concluded the session to elaborate on the findings and further discuss each professions action plan.
In the last breakout session, student teams participated in a team building exercise consisting of building a spaghetti tower. This 30-minute exercise encouraged teams to experience a lesson in collaboration, innovation, and creativity. Team participants were challenged to practice teamwork skills by working together to build the tallest tower. Student teams were instructed to build a freestanding structure using 20 sticks of spaghetti, one yard of tape, one yard of string, and one marshmallow. Learning objectives for this experience were: (1) to complete a task, (2) to demonstrate effective communication, and (3) to practice creative thinking and problem solving. Students received a detailed instructional sheet at the beginning of the session. Each group was instructed to develop a detailed overall design concept for the tower. Teams were encouraged to pick a team leader, collaborate on a design, and listen to each member's best thinking and recommendations. Prior to beginning to build, each team was instructed to come to a consensus on the design, and each team leader needed to assign specific tasks to each member. Completed structures were compared and among groups to determine the tallest structure. Each group described their process of communication.
Students elaborated on creative thinking ideas and problem solving strategies used to complete the activity in the time allotted. A debriefing phase concluded the session to discuss the teams experience in collaboration, innovation, and creativity.

Instrumentation
Based on a thorough review of IPE, an adapted version of RIPLS was used to examine the potential impact of IPE on health professional students' attitudes and perceptions (Appendix I). The RIPLS is used to measure readiness of health care professional students to undertake shared learning activities (Parsell & Bligh, 1999).
Because it attempts to allow for flexibility and application across professions, this instrument is widely used in evaluating IPE programs. Parsell and Bligh (1999) (Parsell & Bligh, 1999). Parsell and Bligh (1999) have identified four key dimensions that relate to the outcomes of interprofessional learning. These dimensions arise from characteristics and practical application of the theories. The first dimension is the relationships between different professional groups (values and beliefs people hold); second, the collaboration and teamwork (knowledge and skills needed); third, the roles and responsibilities (what people actually do); and, fourth, the benefits to patients, professional practice, and personal growth (what actually happens). The purpose of this scale was to rate the desires outcomes of shared learning; or, in other words, to assess the readiness of health care students that engage in shared learning activities (Parsell & Bligh, 1999).

Data Analysis
Quantitative data was collected using the RIPLS (Appendix I). Data was analyzed using the IBM SPSS statistical software, version 21. Descriptive statistics analyzed the pre-test and posttest RIPLS results of student subjects. This ordinal scale measured univariate means, standard deviations, frequencies, and percentages. Change score analysis determined the differences between paired pre-test and posttests of the heath professional students. Subjects were also asked if the RIPLS was completed prior to this IPE experience and if they participated in any prior experiences. ANOVA was used to assess the difference in mean scores for each subscale of the RIPLS. These methods are appropriate when testing the differences between group means. ANOVA tests for significance (p=0.05) in the potential effect of the IPE program on attitudes.
Further analysis was conducted using a paired-sample t test to determine significant differences between the pre-test and posttest of the RIPLS survey. For this study, the ordinal level of measurement of the RIPLS survey response categories were Strongly agree, Agree, Undecided, Disagree, and Strongly Disagree.

Ethical Considerations
Approval was obtained from the universities and college's IRB prior to conducting this study. The timeline for the study included dissertation proposal approval from the author's dissertation committee, IRB application for exemption, and data collection in October 2013 (Appendix A). Permission was granted by Survey Monkey® to utilize this service as a platform in collecting data. There was little to no risks to the subjects throughout this project. Students were required to attend the IPE program within the curriculum separate and apart from this study. Students were asked to voluntarily participate in this study through completion of the survey. This was an anonymous survey. Anonymity was protected with the only identifiers being the student's first three letters of mother's maiden name and first three digits of a childhood address. Subjects were also asked to identify to which of the five professions of Medical, Nursing, Pharmacy, Physical Therapy, and Social Work, they belonged. This investigator shared no responsibility for student grading. Through the method of content analysis, the questions were further evaluated to answer the qualitative research questions of this study. Content analysis is described as a research methodology that examines words or phrases within a wide range of texts. As analysis and interpretation continued, the researcher and qualitative expert examined the data and began to identify categories in an attempt to draw whatever conclusions and generalizations were possible. Content analysis is considered to be a widely used qualitative research technique. There are three approaches to the application of content analysis: conventional, directed, or summative. Each approach is used to interpret meaning from the content of text data. Hsieh and Shannon's (2005) described the different methods of conducting a content analysis on qualitative data. In conventional content analysis, coding categories are derived directly from the text data. With a directed approach, analysis starts with a theory or relevant research findings as guidance for initial codes. A summative content analysis involves counting and comparisons, usually of keywords or content, followed by the interpretation of the underlying context.

Qualitative Data Analysis
Qualitative research needs to demonstrate trustworthiness of the data by accurately reflecting the experience of the participants and not of the researcher. The participants' actual responses can potentially lead to supporting the quantitative finding of the study and further answer the research questions of this study. For the purpose of this study, the researcher and qualitative expert conducted a conventional content analysis of the data. The analysis conducted is an attempt to achieve credibility for this study. Hsieh and Shannon's (2005) article presented a detailed description of the approach to conventional content analysis. The following section addresses the process of conducting a qualitative analysis through the approach of Conventional content analysis for this study. Conventional content analysis is generally used with a study design, which aims to describe a phenomenon. Researchers allow for categories and names for categories to emerge from the data (Hsieh & Shannon, 2005). Hsieh and Shannon (2005) described the process of data analysis as follows: Data analysis starts with reading all data repeatedly to achieve immersion and obtain a sense of the whole (Tesch, 1990). Then, data are read word by word to derive codes (Miles & Huberman, 1994;Morgan, 1993;Morse & Field, 1995) by first highlighting the exact words from the text that appear to capture key thoughts or concepts. Next, the researcher approaches the text by making notes of his or her first impressions, thoughts, and initial analysis. As this process continues, labels for codes emerge that are reflective of more than one key thought. These often come directly from the text and are then become the initial coding scheme.
Codes then are sorted into categories based on how different codes are related and linked. These emergent categories are used to organize and group codes into meaningful clusters (Coffey&Atkinson, 1996;Patton, 2002). Ideally, the numbers of clusters are between 10 and 15 to keep clusters broad enough to sort a large number of codes (Morse & Field, 1995). Depending on the relationships between subcategories, researchers can combine or organize this larger number of subcategories into a smaller number of categories. A tree diagram can be developed to help in organizing these categories into a hierarchical structure (Morse & Field, 1995). Next, definitions for each category, subcategory, and code are developed. To prepare for reporting the findings, exemplars for each code and category are identified from the data. Depending on the purpose of the study, researchers might decide to identify the relationship between categories and subcategories further based on their concurrence, antecedents, or consequences (Morse & Field, 1995). (p. 1279) Hsieh and Shannon (2005) described an advantage and challenge to the conventional approach to content analysis. An advantage is gaining direct information from study participants without imposing preconceived categories or theoretical perspectives. The challenge is failing to develop a complete understanding of the context; or, in other words, failing to identify key categories. Hsieh and Shannon (2005) referenced the following: Lincoln and Guba (1985) Poole and Folger (1981) described a coding scheme as a translation device that organizes data into categories. A coding scheme includes the process and rules of data analysis that are systematic, logical, and scientific (Hsieh & Shannon, 2005). The development of a good coding scheme is central to trustworthiness of content analysis (Folger, Hewes, & Poole, 1984). In summary, the type of approach to content analysis used can provide a universal language for health researchers and strengthen the method's scientific base (Hsieh & Shannon, 2005).

Chapter 5: Results
This study was designed to examine the potential impact of Interprofessional

Qualitative Analysis
After completion of the program as well as the post RIPLS questionnaire, 132 students from all five professions (Medical, Nursing, Pharmacy, Physical Therapy, and Social Work) completed the four open-ended qualitative questions via Survey Monkey.
Participants were encouraged to write in one or two sentences, the answer to the following four questions: 1. Describe your confidence level in communicating with other disciplines.
2. How has your participation in this IPE changed your understanding of roles of the other health disciplines?
3. What was the most helpful thing you learned with this IPE?

Would you recommend IPE to other members of your discipline?
Student responses were analyzed by using the conventional content analysis evaluation through coding categories derived directly from the text data (Hsieh & Shannon, 2005). The researcher and qualitative expert analyzed students' responses to the questions and categories were identified.
Analysis for Question 1. Participants (n=132) responded to Question 1, Describe your confidence level in communicating with other disciplines. Students described their confidence level in communicating with other professionals by using words such as "comfortable," "being confident," "very confident," or "having increased with people in other disciplines, and feel confident doing so," and "I feel more confident communicating with other disciplines after this IPE." Most participants described themselves as confident or highly confident in communicating with other professionals after the IPE program. (Table 3). Highly confident was coded for comments that included "pretty high," "high confidence," "strongly confident," and "very confident." Comments that were identified as Confident often stated "confident" with no qualifiers. 17.8 % or 17 students identified having a Fair level of confidence and stated that their confidence level was "okay" or "fair." Most Comments categorized as Confident among Pharm D students included: "I was very nervous but realized that I know more than I think. I was confident with the other students and felt comfortable asking them for recommendations on the areas I was uncomfortable with. I was also confident in saying I didn't know and answer and looking it up to ensure that patient got the best recommendation".
And another Pharm D student responded, "I feel confident communicating with other disciplines. It allows for better outcome for the patient." A student was identified as Fair level of confidence if the student used the terms such as "not so confident," "okay," "fair," or "could be better  (7) reported that they experienced no change. Increased knowledge of roles/ expertise. The second most frequent response was related to learning about the expertise/role of other disciplines. The Medical students expressed their discovery that pharmacists play an important role in the health care team.
Medical students' comments regarding pharmacists included, "I learned to ask a pharmacist before I prescribe medications. They know much more than we do." One Medical student described "a new found respect for pharmacists," and another, "I don't have to do this alone. Someone will double check the drugs I prescribe." Students commented on the importance of role from this IPE experience. They Analysis for Question 4. Question 4 asked Would you recommend IPE to others? The participants answered overwhelmingly "yes" with only one (1) "no" from a social work participant.
An answer was categorized as Strongly/Absolutely yes if participants used the same words or if they bolded or placed exclamation marks with their "yes" answer.
One Medical student responded, "Absolutely! Doctors are not superhuman and omniscient. They need support from nurses, pharmacists, and social workers to manage patient care." Others responded with such comments such as "It was a great experience on collaborative approach" and "The IPE session at (X) University was a very beneficial experience." The no response by the Social Work student was "if they would like to go into the social work field in a medical setting or work with older populations, then yes, but beyond that, not particularly." Profession and experience of the students shape attitudes toward IPE. The findings from both quantitative and qualitative data suggested that the majority of students' attitudes towards interprofessional learning were positive and students were willing to engage in IPE. Overall, a majority of participants in all professions displayed a positive response to having an increased confidence level in communication, an improved understanding of roles, and a stronger sense of value towards IPE. The next chapter will address a discussion of the study's results, limitations, and future research and educational direction for IPE.

Chapter 6: Discussion
Interprofessional Education (IPE) is an important strategy that can assist health professional students in developing the skills necessary for successful future collaboration in healthcare teams in order to ensure quality patient care. National organizations recognized that interprofessional collaborative practice reduces practice errors and improves quality of care and patient outcomes (IPEC Expert Panel, 2011;IOM, 2010;The Joint Commission, 2010;WHO, 2010). This study provided support for IPE using simulation to enhance health professionals in communication, role awareness, and confidence to work in interprofessional teams.  (2010) report recommended the need for interprofessional practice to be integrated into health professional educational curriculums. Simulation provided a safe environment for this IPE experience. This study examined the potential impact of IPE on health professional students' attitudes and perceptions and the utility of the Readiness for Interprofessional Learning Scale (RIPLS) in IPE.

Quantitative Analysis
Prior exposure to IPE. In this study, the students reported little to no exposure (1%) to the RIPLS pre-test prior to the IPE experience. In addition, 30 or 18.29% response to the open-ended qualitative questions from Pharmacy, Nursing, and Medical students. In contrast, Gallagher et al. (2010) reported student attitudes toward a team approach to health care did not significantly change as a result of this experience.

Qualitative Analysis
The next section will discuss the qualitative finding through the lens of Additional research studies revealed an increase in confidence in Nursing students after the participation of simulation experiences. Goldenberg et al.'s (2005) research on undergraduate Nursing students who participated in classroom simulation also found that the students' overall confidence scores increased significantly following the sessions of role-playing case studies. Brown and Chronister's (2009) research on Nursing students also reported a post-simulation measure of self-confidence with statistically significant improvement. Kameg et al. (2010) found that senior Nursing students' confidence was enhanced in communicating with patients who are experiencing mental illness after the simulation experience. Cardoza and Hood (2012) also found that baccalaureate Nursing students' self-efficacy had a significance increase after simulation.
A few students in this study expressed feelings of being less confident and nervous going into the program, but this changed to confident after the IPE. This was also found by Sinclair and Ferguson (2009), who reported that nurses expressed concerns over anxiety regarding their abilities to apply learning to clinical practice; however, after the simulation experience, nurses reported improved self-efficacy in their skill performance.
The common categories that emerged throughout the student responses included:

Teamwork/Collaboration, Increased Knowledge of Role/ Expertise, Respect, and
Communication. The IOM (2003) report concurs with the student opinions to further validate the need to increase communication by using IPE.
Teamwork/Collaboration. The student responses in this study indicated the increased knowledge of importance with teamwork and collaboration. Lumague et al.'s (2006) findings also suggest that students reported that all health care education should include opportunities enabling them to develop the skills, behaviors, and attitudes needed for interprofessional collaboration. Woodroffe et al.'s (2012) research concurs with positive attitudes towards team learning and enhanced learning and benefits of IPE.
Increased knowledge of role/ expertise. The qualitative findings in this study indicated that learning professional roles were understood after the IPE experience. This was also found by Gallagher et al. (2010) on an interdisciplinary project using volunteer students from Physician Assistants, Nursing, and Pharmacy programs. The authors suggested students have an increase in understanding of strengths and skills of other members of the health care team and gained experience in working with other disciplines. Rodehorst et al.'s (2005) findings concur with Gallagher et al. (2010), and this study identified that interdisciplinary learning can clarify roles and enhance learning for students from different disciplines. The heath professional students in this study, as well as Lumague et al.'s (2006)  Most student responses indicated a positive expression of "Yes" to "Absolutely." Some students indicated a response of "definitely" to "highly recommending IPE." This concurs with the research of Baker et al. (2008); Dillon, Noble, and Kaplan (2009);and IOM (2010), who recognized the use of simulation and IPE as an effective teaching strategy in early co-education of students from different professions in the healthcare field. Interprofessional activities can and should be an essential part of nursing and allied health professional educational curriculums (Titzer, Swenty, & Hoehn, 2012). The review of the Interprofessional literature supports the need to further develop programs and examine the impact of IPE on health professional students. The findings from this study provide additional support for using simulation and IPE as teaching modalities.
Because most participants stated that they would recommend IPE to others, health professional education should consider a combination of IPE and simulation education.

Limitations
One limitation of this study was that the health professional students were

Future Direction
Implications for education. Interprofessional education is essential for students to develop the skills necessary for successful collaboration in health care teams to ensure quality patient care. As IPE programs expand, simulation designed to promote teamwork and collaboration needs to be evaluated with regard to both short-and long-term effects, in particular the impact on practice in the clinical setting (Scherer et al., 2013). The findings of Hertweck et al.'s (2012) concur with the need to examine the impact of students' attitudes and perceptions towards IPE and the roles of other professionals and suggests more IPE is needed to enhance collaboration and safe practice. The knowledge of the professional role of others had been identified as a significant element in IPE and the potential to improve healthcare outcomes through communication and collaboration. Source : Kolb, (1984). Table 2.

Propositions of Kolb's Experiential Learning Theory
Learning is a process Engaging students in an active experience enriches their learning.
All learning is relearning Relearning is the best expedited using a process that offers students the opportunity to examine their beliefs and ideas and integrate them with new ideas that are more advanced.
Learning is a dialectic process Students shift between the varying modes of reflection, action, feeling, and thinking.
Learning is holistic and integrative Learning takes into account the whole person, including how they think, feel, perceive, and behave when solving problems and making decisions.

Learning results from interactions between person and environment
Learners process the possibilities of an experience based on their lived experience.
Learning is the process of creating knowledge Social knowledge is generated based on personal knowledge of the student.
Source: Kolb (1984). Table 3.  Table 4.  This letter is being produced in response to a request by a student at your institution who wishes to conduct a survey using SurveyMonkey in order to support their research. The student has indicated that they require a letter from SurveyMonkey granting them permission to do this. Please accept this letter as evidence of such permission. Students are permitted to conduct research via the SurveyMonkey platform provided that they abide by our Terms of Use, a copy of which is available on our website.

RIPLS Scales
SurveyMonkey is a self-serve survey platform on which our users can, by themselves, create, deploy and analyze surveys through an online interface. We have users in many different industries who use surveys for many different purposes. One of our most common use cases is students and other types of researchers using our online tools to conduct academic research.
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Examining Health Professional Student's Attitudes on Interprofessional Education
Dear Participants, You have been invited to take part in the research study described below.
The purpose for this research study is to examine the attitudes of health and social care students and professionals towards interprofessional learning.
Before and after your collaboration experience, you will be asked to voluntarily and anonymously complete; The Readiness for Interprofessional Learning Scale (RIPLS) and three written response questions via survey monkey.
This research has been reviewed according to University of Rhode Island IRB procedures for research involving human subjects.
If you decide to take part in this study, the survey will be provided to you via survey monkey that will take approximately 15 minutes.
Your part in this study is anonymous. Your responses will be confidential and we do not collect identifying information such as your name, email address or IP address. That means that your answers to all questions are private. No one else can know if you participated in this study and no one else can find out what your answers were. Scientific reports will be based on group data and will not identify you or any individual as being in this study. All data is stored in a password protected electronic format.
YOU MUST BE AT LEAST 18 YEARS OLD to be in this research project.
Although there are no direct benefits of the study, your answers will nurture additional research ideas in promoting IPE programs to enhance professional collaborations and safe practice. The decision to participate in this research study is up to you. You do not have to participate and you can refuse to answer any question. There will be no penalty if you choose to not participate in this study. Choosing not to participate will not affect your grade in the workshop.

Summary of Case
The patient is a 45-year-old male (or female; gender is not important) who presents to the Emergency Department with four days of increasing shortness of breath, fever and cough productive of yellowish sputum.
Students will be asked (in teams comprised of at least one medical student, one nursing student and one pharmacy student) to work the patient up (history, physical examination, laboratory data and x-ray); make the diagnosis of pneumonia and come up with a treatment plan for the patient.

Description of Patient
Mr. Jones (gender, ethnicity and age can vary in this case based on the availability of standardized patients) is a 45-year-old male. The patient is dressed in a hospital gown (having already been placed in a room by ancillary staff in the Emergency Department). The patient has lived in Rhode Island for the last twenty-five years (the patient is originally from Massachusetts but moved here after attending college at the University of Rhode Island). The patient is a marketing executive at a local company and has worked there for the last ten years. The patient lives in the Elmwood section of Cranston. The patient is married and has three children (all boys, ages 15, 13 and 7). The patient does not smoke (never has); occasionally drinks red wine with dinner (once or twice per week; all CAGE questions are negative if asked) and does not use recreational drugs.
The patient looks somewhat uncomfortablehe appears to be in tripod position to aid with taking deep breaths. He also coughs occasionally through the patient encounter.

History of Present Illness
The patient was in his usual state of health until approximately three weeks ago when he came down with flu like symptoms (at that time, he had fever with body aches and an occasional headache). The patient states the symptoms lasted about three days and then they gradually improved. However, four days ago, the patient states that he developed a fever (up to 103.3 at home) along with shortness of breath and a cough productive of yellowish sputum. The patient states that he has worsened each day. He had called his primary care physician earlier in the day and described his symptoms and the PCP referred the patient to the ED for a workup. The patient states he also been having chills and night sweats. The patient also states that he has been wheezing occasionally over the last four days as well.
On review of systems, the patient denies any visual changes, conjunctivitis, ear pain, congestion, rhinorrhea, throat pain, chest pain, palpitations, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, hematuria, melena or bright red blood per rectum.

Medications
Lisinopril 10mg by mouth once daily Simvastatin 40mg by mouth once daily Aspirin 81mg by mouth once daily Multivitamin by mouth once daily Allergies Penicillin (The patient developed urticaria and throat tightness after using as a child)

Social History
The patient lives with his spouse in the Elmwood section of Cranston. They are in a monogamous relationship. He has lived in the same house for the last twenty years. He has three children (age 15, 13 and 7all boys). The patient does not smoke (never has); occasionally drinks red wine with dinner (once or twice per week; all CAGE questions are negative if asked) and does not use recreational drugs. He exercises about three times per week (elliptical machine mostly at the local YMCA). He is a marketing executive for a company in Providence and has worked there for ten years. There are no occupational exposures. The patient has had no recent foreign travel. He goes to church on a weekly basis.

Family History
The patient's mother is sixty-three years old. She is a retired school teacher. She has a history of hypertension which is controlled on medication and osteoporosis for which she takes calcium, Vitamin D and Alendronate.
The patient's father is also sixty-three years old. He is a former smoker and suffers from chronic obstructive pulmonary disease (he quit smoking about five years ago). He otherwise has no health problems.
The patient's children are all healthy except the seven year old has asthma.
The patient has two siblings (a brother and a sister) who are both healthy and both live in Massachusetts.

Patient Concerns
The patient is concerned because he has never been this sick before. He is nervous that he will miss work (he has a big deadline coming up in trying to secure a new client for his company). He is also worried about not being able to coach his youngest son's soccer match this upcoming weekend.

Patient Behavior
The patient is pleasant and friendly throughout the patient encounter although he is clearly having some respiratory distress. The patient will answer questions but will progressively become more uncomfortable the more he has to talk.

Issues Explored with the Case
The main issue to explore with this case is the ability of the nursing student, medical student and pharmacy student to work together effectively as a team. Of particular interest is how the students negotiate roles (for example, does the nursing student assume the lead in taking vitals and getting some of the patient history versus the medical student doing a physical examination and chest radiograph results versus the pharmacy student analyzing the patient's medicine list and developing an appropriate treatment plan or is the effort put forth disjointed and haphazard).
Other issues to explore with this casedo the students who have worked together in the small group settings first (on the PBL cases) work together better than students who have not had an opportunity to work together on a separate project first.
Finally, can students come up with a diagnosis of pneumonia for this patient (based on history and chest radiograph findings mainly) and a proper therapeutic plan.

Props Needed for Case
Students should be asked (if they have them) to bring their stethoscopes to class. An online chest radiograph will be provided. A blood pressure cuff along with a clock should be in each room (to take blood pressure and pulse respectively). The patient should be dressed in a hospital gown.

Opening Scenario
Mr./Mrs. Jones presents to the Emergency Room with increasing shortness of breath, cough and fever.

Tasks
As a team (please be sure that all team members contribute to the following): Take the patient's vital signs (including temperature and pulse oximeter).
Take a focused history and perform a lung examination. Interpret the chest x-ray and laboratory data on this patient.
Describe to the patient the diagnosis and treatment plan (you may confer about the diagnosis and treatment outside of the room first if the team wishes).
Tony lives alone. He does not smoke or drink alcohol. He does not drive. He goes to the local grocery store once or twice a month to stock up on food. He lives in a two story house. There are throw rugs throughout. He does not exercise much. He receives a check for $500 per month from Social Security. He has no other income. He has no family. He lives in senior housing in Central Falls. His apartment is infested with bed bugs, but his landlord refuses to hire an exterminator.
Tony visits his primary care physician (PCP) every six months and usually spends about fifteen minutes with his PCP. He otherwise has little to no contact with his physician's office. His last blood pressure at that visit was 96/52. The rest of his exam was unremarkable. He does however admit to feeling sad about living alone and not getting out much. He does not remember the last time he had labwork done.
Your assignment is to design a care plan for Tony that improves his health and prevents him from being hospitalized as often as he currently is. Consider the medical, nursing, pharmacy, social work and physical therapy aspects to his care.

Problems Relating to: Potential Solutions
Medicine: Nursing: Pharmacy: Physical Therapy: Social Work: Facilitator guide: Medicine: The patient is admitted about once per month to the hospital but is only seeing his PCP every 6 months. He needs to be seen more frequently (initially every 6 weeks until his medical problems are under control, but no less frequently than every 3 months). He needs more frequent monitor of his labwork (for example, when was the patient's last HgBA1C or cholesterol checked). Additionally, his blood pressure is low but he is on at least three blood pressure lowering medications (Isosorbide/Carvedilol/Terazosin). One or more of these medications should be stopped.

Questions to consider:
Is the physician utilizing a team to take care of this patient? Could a nurse care manager call the patient to check on the patient's blood sugars more regularly? Could a pharmacist help manage the multiple medications the patient is on. Could a social worker help with what seems like limited financial resources? Could the physical therapist help with the patient's mobility (or lack thereof)?
Pharmacy: The patient is on multiple medications that could be causing more harm. For example, the case tells us the patient was admitted with acute renal failure and has chronic kidney disease, yet he is still on Metformin. The patient is also on both a sulfonylurea and insulin (increasing the risk of hypoglycemia). He is on Warfarin/Aspirin/Clopidogrel. The case gives us no indication the patient has an indication for all three and he was admitted for a gastrointestinal bleed in the past. He is on two medications for benign prostatic hypertrophy (with one of these potentially causing falls).
Nursing: There are multiple avenues for nursing to get involved in this case. As mentioned previously, a nurse care manager could call the patient frequently (every week) to track his blood sugars and report those sugars to a physician for adjustment of the insulin dose. A home care nurse could visit the patient and conduct a home safety evaluation (the patient lives on two floors and yet has limited mobility; he has multiple throw rugs throughout the house that he could be tripping on). Based on the results of this, the nurse could make suggestions for the patient to prevent the falls. A home care nurse could also help the patient manage his medications if he is having difficulty doing so. Finally, it is possible that the patient is confused on discharge from the hospital about post-discharge instructions. A nurse could help him with this as well.
Social Work: There are also multiple avenues for a Social Work to get involved in this case. The patient is on multiple medications. Is he able to afford them? If not, could the social worker help in obtaining the medications? Are there other community resources the social worker could help the patient obtain? Is he getting SNAP for example (he is living on only $500 per month). Are there other social supports the patient has such as neighbors, friends, clergy, etc? Could the social worker help the patient find more suitable housing (or at least advocate for the patient with the landlord regarding the bedbugs)? Finally, could the social worker discuss the patient's mood and screen for depression or other mental illness (reporting the findings back to the physician and potentially also offering therapy to the patient)?
Physical Therapy: The physical therapist has many opportunities to work with the healthcare team to improve this patient's quality of life. He is having knee pain and issues with balance and falls. In addition to a full musculoskeletal exam of the knee, screening the visual, sensory, and vestibular systems (particularly as they relate to DM and fall history) is warranted.
Consider environmental factors in relationship to his fall history. A physical therapist could assess home safety and access, in addition to transportation needs (are recommendations for adaptive equipment and home modifications indicated? Footwear? Orthoses?). What is the therapist's role in educating the healthcare team on fall prevention for this individual?
Given the patient's cardiovascular and pulmonary status, would an endurance, or strengthening, program be valuable? Energy conservation? Paced breathing? Assess posture and candidacy for pulmonary rehab. Consider patient education on wellness and prevention (i.e. bronchial hygiene, timing exercise/activity with medication, meals, time of day). Discuss need for pelvic floor training exercises. Could the physical therapist design and monitor a safe exercise program-particularly given his history of hypoglycemia, hypotension/HTN, and a-fib? How might this patient's psychosocial needs be addressed through exercise prescription?