STUDENT PERCEPTIONS OF SOCIALSIM FOR SIMULATION-BASED   INTERPROFESSIONAL EDUCATION IN HEALTHCARE   By  Mary Kathryn Smith           A DISSERTATION  Submitted to Michigan State University in partial fulfillments of the requirements for the degree of  Higher, Adult, and Lifelong Education-Doctor of Philosophy  2016           ABSTRACT  STUDENT PERCEPTIONS OF SOCIALSIM FOR SIMULATION-BASED   INTERPROFESSIONAL EDUCATION IN HEALTHCARE  By  Mary Kathryn Smith  This descriptive qualitative study investigates perceptions of students regarding the use of SocialSim, a tool designed to deliver simulation in a virtual environment using social media as a platform to facilitate inteprofessional education. There have been exponential changes in U.S. healthcare system in recent years, prompting the need for institutions in higher education to prepare students to function effectively as members of an inteprofessional team.  Coinciding with this is advancement in the field of healthcare simulation and virtual methodologies.  The incorporation of these three into a learning experience for IPE has not been previously explored and became the impetus for my study.  I developed SocialSim as a novel tool using social media as a platform to deliver a simulation facilitating interprofessional education.  I examine the use of this tool and experiences of twenty healthcare professional students at a major public university.  Through the analysis of semi-structured interviews, this study examines student perspectives related to the use of SocialSim as a new tool for IPE.  The results can inform administrators and faculty decisions in addition to expanding the field of healthcare simulation.                                  Copyright by MARY KATHRYN SMITH 2016            iv      To my family my husband Timothy James Smith, Jr. my children T.J., Jolynne, Megan and Danny and my first grandchild James                v  ACKNOWLEDGEMENTS    Michaelangelo said on his eighty-Emerson late These statements resonate with me as I have traveled this journey on a somewhat crooked path.  I began my career as a nurse and discovered the world of healthcare simulation simply by fate.  After pursuing a career in academia, I was intrinsically motivated to pursue my doctorate in higher education administration. Juggling a career, family and doctoral studies was no easy task.  I most definitely did not travel this road alone and have many individuals to thank who helped me along the way.  I wish to thank my dissertation committee, particularly my Chair, Dr. John Dirkx.  Dr. Dirkx provided the freedom I needed to explore what must have seemed like a crazy idea to him at the start.  On the other hand, he kept me on task and focused on my goals with the utmost of kindness particularly at critical times when it would have been easy for me to walk away.  Dr. Marilyn Amey continued to be interested and engaged every time we met.  Her leadership in the College of Education and enthusiasm continued to inspire me throughout my program.  Dr. Ann -on-the- in her course.  Her advice and encouragement as I began with big ideas and eventually honed in on my plan was invaluable.  o continuously find relevance of my study to the greater arena of healthcare education.  Her energy was contagious and often  needed. College of Education Research Practicum/Dissertation Development Fellowship. vi    I could not have completed my degree without the support of so many at Michigan State University (MSU).  The Deans of the four healthcare professional colleges, particularly Dr. William Strampel, emulate what leaders in healthcare education should be. They each have unique leadership styles from which I learned so much and they never ceased to be interested in and supportive of my progress toward degree. Members of the Learning and Assessment Center  Steering Committee, particularly Dr. Terrie Wehrwein, Dr. Mark Notman and Dr. Rebecca Henry,  supported and contributed to my growing body of knowledge related to research and higher education administration.  The core LAC team, especially my peer debriefer Kimberly Patterson, is the best group of individuals I could work with in the field of simulation.    My colleagues in the Society for Simulation in Healthcare (SSH) are my superheroes.  Their collective wisdom and commitment to the field of healthcare simulation is unmatched and I am privileged to have so many experts in my corner. I consider myself blessed to have such a wonderful circle of friends & extended family including my brothers (Steve Gaumer and Matt Gaumer), in-laws, colleagues, peers in my cohort, and lifelong friends. Their constant encouragement helped tremendously.      My father, Stuart James Gaumer, earned his PhD at MSU in 1973.  He instilled the value of doctoral education during my formative years and I still believe he was the smartest man who ever lived. While he is no longer with me in this physical world, he has been with me every step of my journey.   Last but not least, my husband Tim provided continuous support, unconditional love and never doubted for a minute that I would reach the finish line.  My children T.J. (spouse Jolynne), vii  believed in me and my dreams.   My first grandchild, James, was born while I was in the program and has so much joy during this period and I look forward to spending more time with him and my future grandchildren now that I am through.    viii  TABLE OF CONTENTS   ..........xi  ...  CHAPTER 1: INTRODUCTION ..  .               .    CHAPTER 2:  REVIEW OF LITERATURE                14        18            Use of Simulati            Social Media and Microblogging as 25                    ..                                             Implementation  Data Collection  Data Analysis                          CHAPTER 4: 47                   ix         .        Affordances   Accessibili   Enhanced Fide   Transfer to Pr        Technical Is   Lack of Priv   .   Lack of Personal      Influence on Interprofessiona   .   Communicat                                    .     Technical Issue  Use of Informat90        Faculty Affordances            ...      ...    Technical Soluti  Development of Fid  Hybrid Model            Suggestions for Future Re      06         APPENDIX A:  IPEC Core Competencies for Interprofessional Education109      APPENDIX B:  SocialSim Faculty Case Scenario and Debriefing Guide      APPENDIX C: SocialSim Student Informati      ... x       .125  APPENDIX F:  Background Quest.      APPENDIX G:  Research Participant Information and Consent Form.      APPENDIX H:  Faculty SocialSi      APPENDIX I:  Interview Pro      APPENDIX J:  Simulation Fiction                                                xi    LIST OF TABLES  Table 3.1 Description of Study .40  Table 3.2   Table 4.1                                      xii  LIST OF FIGURES  Figure 2.1   Figure 2.2 Interrelationship between processes and IPE   Figure 2.3   Figure 2.4 In...  Figure 2.5 2  Figure 4.1 ...  Figure 4.2 ..  Figure 4.3 .  Figure 4.4 ...  Figure 4.5 Self-described Twitte  Figure 4.6 ..  Figure 4.7 Prior collaboration wit  Figure 4.8 Prior communication with students of                    1   CHAPTER 1:  INTRODUCTION AND PROBLEM STATEMENT  The U.S. health system is one of the most expensive in the world.  According to 2015 statistics, the U.S. spends twice what other developed countries spend per person on healthcare (Organisation for Economic Co-operation and Development, 2015).  Amidst the high costs of healthcare, quality of care has come under intense scrutiny within the past 15 years.  Beginning in 1999, the Institute of Medicine disclosed that nearly 100,000 people die each year because of medical errors.  This report served as a catalyst for review of medical and nursing education and a call for significant revision.   The Triple Aim initiative is a national plan developed by the Institute for Healthcare Improvement (IHI, 2010) intended to improve patient care and reduce healthcare costs.  The Triple Aim outcomes encompass the domains of quality (the delivery of safe and effective care by healthcare teams as well as patient outcomes); cost (total cost and measures of utilization that drive costs); and experience including pworking in interprofessional teams (Berwick et al., 2008).  The Triple Aim (Berwick et al., 2008) has become a galvanizing force drawing attention to a generalized approach needed to fix the United States healthcare system by simultaneously improving patient experiences of care, improving the health of populations, and reducing the per capita cost of healthcare (Brandt, Lutfiyya, King & Chioreso, 2014).   The Affordable Care Act (ACA) of 2010 has also had a dramatic impact on U.S. many provisions, perhaps the least discussed are those reforms directly targeting primary care. The Affordable Care Act realigns incentives within the health system and create opportunities 2  for providers to be rewarded for delivering high value, patient-centered primary care. Such a transformation is intended to improve outcomes for patients, increase job satisfaction among physicians and encourage more sustainable levels of health spending for the nation (According to Lathrop & Hodnicki (2014), the ACA primary care, funds community health initiatives, and promotes quality care. These changes increase the need for well-   As a result of national policies driving reform in healthcare, there is need for strategic changes in professional healthcare education programs to respond to both current and future healthcare needs (Dahlberg, Falk, Kjellgren & Dahlgren, 2014).  At the forefront of this movement is the need for an interprofessional approach to patient care.  The need for healthcare providers to deliver interprofessional care has and will continue to require dramatic changes in healthcare education and transition from professional silos to an integrated approach to education and practice.  Thistlewaite (2012) defines this concept as follows:    If we expect students to learn about teamwork and professional roles,  and to be ready for collaborative practice, it seems both logical and  educationally necessary that we include teamwork in health professional  curricula and, critically, that we also explore the most effective way of              delivering learning activities to promote future collaboration (pg. 60).  For the purpose of this study, interprofessional education (IPE) is defined as  ach p. 7).  It includes all such learning in academic and work-based settings before and after qualification, adopting an inclusive view of "professional" (Center for the Advancement of 3  Interprofessional Education, 2002).  As with many other behaviors, skills and attitudes expected to be taught and learned in higher education, there are many decisions to be made with regard to methodological approach to IPE in healthcare professional education. Exponential growth in various technologies presents options for administrators and faculty in higher education that could not have been considered until recent years.  One example imitation or representation of one act of system by another.  Healthcare simulations have four main purposes:  education, assessment, research, and health system integration.  Simulation education is a bridge between classroom learning and real-Simulation in Healthcare, n.d.).  Healthcare simulation provides a safe environment for learners to apply skills without threat of harming patients.  It also affords the opportunity for formative and summative assessment of learners to ensure acceptable professional competencies prior to applying in real clinical environments.   Higher education institutions face major challenges in keeping pace with the evolution of technology, not the least of these is financial.  Challenges resulting from fluctuating financial resources are not new to universities as this issue has been present since the 1800s (Thelen, 2011).  However, the situation that universities find themselves in now is different.  Multiple conditions contribute to a cost model that has been prevalent in the past in order to operate is no longer sustainable (Kirshstein & Wellman, 2012).  The rule of thumb of most institutions is that to stay abreast of technology requires an annual investment of 10 percent of the operating budget.  For a large research institution, the investment in technologies can amount to hundreds of millions of dollars per year (Duderstadt, 2000).  Universities have begun and will continue 4  examining ways to deliver high-quality and affordable higher education with the use of technologies (Kirshstein & Wellman, 2012).   A significant advance in technology providing innovative and cost-effective options for the manner in which web pages are made and used and differs from the static web sites of earlier times.  Key attributes of Web 2.0 applications include: 1) users as independent entities within the system, 2) ability to form connections between users, 3) ability to post content in multiple forms, and 4) ability to embed various rich content types (e.g., Flash videos, YouTube, etc.).  According to Greenhow, Robelia and that travel across physical and cyber spaces.  Learners have more choices about how and where  Because of the evolution of Web 2.0 and associated capabilities, social media soon exchange information and ideas in vir2010).  Recent studies related to the use of social media in higher education present compelling evidence supporting it as a viable teaching and learning strategy.  The number of social media platforms is increasing exponentially and each presents affordances for education.  One such platform, Twitter, has been used in both formal and informal learning settings.  Kuh (2009) r of positive education outcomes including fostering rich discussion of literature by direct conversation with other students, peer questioning, reflection, and engagement.    5  Statement of the Problem While interprofessional education (IPE) is not new, it is apparent that attention to IPE education has increased dramatically in recent years.  Despite policy and social forces exerting pressure on the response to these needs, healthcare professional educaThere are a number of significant barriers noted in the literature that explain the lack of progress in interprofessional education over the years.  According to the National League for Nursing (NLN, 2011) the varieties of factors limiting the ability of educators to incorporate simulation-based IPE include:     - to partner           -- Horsbough (2001) points to divergent learning and assessment styles, different curricular periods, lack of commitment of faculty and students and limited resources as being primary barriers.  Curran, Deacon and Fleet (2005) claim that the lack of willingness of faculty and students to experiment with new methods of teaching and learning contribute to lack of progress.  Additional barriers identified are lack of institutional flexibility with regard to financial and 6  human resources needed to implement IPE activities, turf battles among faculty in different disciplines, rigid curricula and lack of administrative support (Ho, 2006).   Because of shifts in patient populations, specifically the number of aging baby boomers, increase in chronic diseases, and longer life spans, there is a demand for more healthcare professionals.  Shorter hospital stays add complexity to the situation as hospital censuses are lower and learners have less access to patients for clinical practicums.  Higher education institutions have responded to this demand by increasing enrollments in healthcare professional programs further compounding the issue related to access.  Therefore, alternatives to traditional clinical rotations will need to be considered to prepare healthcare professional students for the workforce. The complex issues related to changes in healthcare, policy changes, calls to higher education to respond and associated barriers related to implementing interprofessional education have resulted in slow progress and present challenges to educators.  New technologies and platforms by which teaching and learning can be accomplished offer viable options for implementing IPE in healthcare education and therefore warrants inquiry.   Purpose Statement The purpose of this study is to investigate the efficacy of SocialSim as a simulation-based intervention to facilitate IPE and as a means to overcome some of the identified barriers associated with IPE implementation.  SocialSim was developed by the research as a means to triangulate the need to develop IPE communication and collaboration skills, healthcare simulation and use of social media, specifically microblogging (e.g., Twitter), as a mode of pedagogical delivery.  SocialSim is defined as a simulation tool using a social media platform for 7  delivery and encompasses a patient care scenario by which learners will interact with the patient, and collaborate with students of other disciplines while allowing scaffolding and guidance of the instructor.  The purpose of SocialSim is to provide an opportunity for students of multiple disciplines to communicate and collaborate with each other within the context of patient care delivery thereby facilitating implementation of interprofessional education and preparing students for the workforce. Research Questions 1. -  2.   3.   Statement of Significance            As higher education institutions are compelled to answer the call for IPE by developing the competencies of healthcare professional students for contemporary practice, it is important to identify effective teaching methods to accomplish this.  There is little evidence guiding healthcare professional programs as to how to integrate IPE and even less as to how to overcome associated barriers.  It is imperative that higher education address these gaps through inquiry that informs the development and use of evidence-based teaching practices.               Simulated activities are increasingly viewed as viable options for educators to consider as they provide a safe environment for students at no risk to patients.  The emergence of social media and recent applications to pedagogy illuminate possibilities for IPE.  This study aims to 8  explore the use of social media microblogging (e.g., Twitter) as a platform to facilitate IPE and potentially overcome some common barriers currently prohibiting implementation.  Evidence provided by this study will contribute to the current body of knowledge related to effective teaching methods for IPE in the healthcare professions in addition to the field of healthcare simulation.  Findings from this study may also inform other disciplines as to the effectiveness of social media to facilitate communication and collaboration among diverse groups of learners within the context of simulation.  Due to web-based nature of delivery, the study outcomes may also have relevance to distance and online education.           Lastly, results of the study may provide insight as to whether simulations delivered via social media may be considered as a method to provide opportunity for students to apply knowledge to clinical situations.  While it is impossible to replicate real patient encounters, alternative methods such as SocialSim may be able to supplement noted decreases in clinical access. Dissertation Structure      This dissertation contains five chapters.  The purpose of this chapter is to introduce the problem, significance and situate the research questions within the problem as a means to explore a potential strategy from the student perspective.  Chapter 2 will explore relevant literature informing the inquiry.  Chapter 3 presents methodological approach and  research design applied.  In Chapter 4, the results of the study are presented including analysis followed by Chapter 5 which provides a discussion of the results and implications for curriculum and further research. 9   -     10   --  -11    12    13          - - 14  -    -15   - 16               Figure     Common Competencies Collaborative Competencies  Complentary Compentencies 17  ---  Figure 2.2 Interrelationship between processes and IPE competencies.   Informatics Interprofessional Team Patient-Centered Care Quality Improvement Evidence-Based Practice  18     19    T-   20       -Medical & Nursing Education IPE: Communication & Collaboration Improved Patient Care 21     -- 22   Figure 2.4 Interprofessional education and healthcare simulation               23      -- The cost of simulation activities varies widely and likely influences the decision or ability plausible responses, plausible intChen, Honkanen, Hackel & Golianu, 2010, p. 114; Seropian, M., 2003).  The cost depends greatly on the mix of target population, purpose of simulation and technology used.  It also depends on how educational and clinical organizations succeed in reorganizing their structures of work to incorporate simulation-based learning (Gaba, 2004).  The cost assigned to personnel, whether faculty or staff, is also an important factor.  Human capital or personnel costs are associated with simulation staff, which may include faculty simulation experts, clinical educators, and instructional technology technicians, simulation technicians in addition to other support staff such as finance officers, secretaries, and custodians (Tuttle, 2014).    24   ----  demonstrated that Second Life can be an effective option for interprofessional case discussions or communication but the technical issues and learning curve necessary for faculty and students proved to be challenging (Seefeldt, Mort, Brockevelt, Giger, Jordro, Lawler, Nilson & Svien, 2012).     25    Literature indicates social media is more than an emerging technology platform or cultural trend, but a method of communication that is changing the way individuals transmit and receive information.  -- ----26  - --- - - 27     28    -29   -  30    31     32      ---- Clinical Practice Interprofessional Education Virtual Environment Educator Student Student 33   --- 34  CHAPTER 3:  METHODOLOGY The purpose of this descriptive study was to explore how a simulation methodology I developed, SocialSim, might facilitate simulation-based interprofessional education (IPE) activities for medical and nursing students including the ability of SocialSim to facilitate collaboration and communication skills, affordances and challenges of delivery via a social media microblogging platform and associated perceptions regarding benefits and barriers to the use of SocialSim. As a result of my inquiry, I was able to provide a thematic description of findings to best explain the perceptions of participants in my study.     Quantitative research is associated with experimental science which begins with a theory or hypothesis about the world and operates under the assumption that by setting up the appropriate intervention, evidence can be collected to support or reject the hypothesis (Creswell, 2009).  as I assert that students are at the core of teaching and learning and therefore, an essential first step prior to testing or using the tool more broadly.   35  Research design  In an effort to facilitate interprofessional education (IPE) and overcome barriers identified in the literature, I developed a new method of delivery to explore.  -Actual implementation of the study was situated within a virtual setting, specifically a social media microblogging platform, Twitter.  Simulation Description   -First, I developed a simulated case scenario representing a realistic clinical situation appropriate for the level of students in the study and their assumed clinical decision-making abilities. The case centered on a middle- 36  aged female in the primary care setting with chronic diseases presenting with an acute condition (see Appendix B). The case was reviewed by experts in primary care in order to validate the fidelity of the scenario.  These experts included two primary care physicians and one doctorate of nursing practice, all of whom are faculty in the medical and nursing colleges that participants were recruited from.   Next, I chose the social media platform I felt most suited to deliver the simulation. There were multiple alternative platforms to consider, however, I chose Twitter due to innate features I believed conducive to delivering an engaging simulation. These included the ability to embed media such as audio and visual clips within tweets, alerts that would be translated when learners received tweets and the ability to easily isolate the case scenario to a pair of students versus a larger group.  Twitter is also amenable to an ongoing dialogue than other types of social media such as Facebook because Twitter is a microblogging platform (Ebner, Lienhardt, Rohs & Meyer, 2010).   In order to promote a realistic experience while minimizing technological challenges that might occur, I distributed supporting documents and references on the first day of the simulation to students via email.  These included an electronic patient chart with lab reference (see   Lastly, I developed a set of guiding questions included in the case scenario document to be used during the debriefing session (see Appendix B).  The intent was to provide a reference for the simulation educator who debriefed the students as a means to facilitate discussions focused on the research questions and objectives of the case.   Participants - 37  - -------  38   - 39  --  -  40    the experiential learning process and helps learners develop and integrate insights from direct experience into later action  - 41                     -                 Data Collection  ------  42  ---     - -              43  -  Data Analysis   44    --    45   Trustworthiness Creswell (2009) has identified several strategies that researchers can employ in order to ensure the credibility and trustworthiness of qualitative data analysis. Those used in my study included peer review, debriefing, and clarification of researcher bias.   Review and debriefing was a continuous process accomplished regularly with my advisor, dissertation committee members and peers. The peer debriefer was asked to review the case and associated debriefing questions after which some minor revisions were made.  My dissertation advisor served as an external auditor of study findings.  Study participants also had the opportunity to provide feedback to ensure that their perspectives were represented accurately.   Consideration of Human Subjects  46    -  -         47  CHAPTER 4:  FINDINGS  The primary aim of my study was to explore  medical and nursing regarding the use of SocialSim for simulation-based interprofessional education (IPE) activities, particularly collaboration and communication skills, in addition to the affordances and challenges of delivery via a social media microblogging platform (e.g. Twitter).  In this chapter, I present and interpret the findings in an integrated manner within each section. I argue that the use of SocialSim presents a viable option to be considered by administrators and faculty when integrating interprofessional education into curriculum.  A deeper understanding of how students perceived this methodology underpins my approach and analysis.  This chapter uses examples from the students interviewed in this study in order to describe perceived benefits, challenges and application of social media-facilitated simulation, SocialSim, to interprofessional education.   I begin this chapter with an introduction to the terminology used in Chapters 4 and 5 resulting from themes and topics that emerged during analysis in addition to review healthcare simulation definition previously presented.  Demographic information is then presented with the intent of providing a schematic representation of the subject population as a whole and insight as to how certain characteristics may have influenced their perceptions. The data revealed from the pre-survey suggests some characteristics of the subjects influenced perceptions and also provided a baseline or reference as to what prior experiences of the subjects were. The remaining sections the research questions.  The overarching areas to be explored include affordances, challenges and influences of SocialSim on interprofessional education, particularly collaboration and communication.     48  Definitions Healthcare Simulation hnique that uses a situation or environment created to allow persons to experience a representation of a real event for the purpose of practice, Maxworthy, Epps & Mancini, 2015; Society for Simulation in Healthcare Accreditation, 2014). Healthcare simulation can be manifested in multiple forms such as human patient simulators, standardized patients, partial-task trainers, haptic devices, computer-assisted instruction, gaming and virtual reality. Fidelity or Realism Fidelity, also simulated experience approaches reality.  The level of fidelity can involve a variety of dimensions including (a) physical factors such as environment, equipment and related tools; (b) psychological factors such as emotions, beliefs and self-awareness of participants; (c) social factors such as participant and instructor motivation and goals; (d) culture of the group; and  Dieckmann et al., 2007; National League for Nursing Simulation Innovation Resource Center [NLN-SIRC], 2013). Healthcare Informatics Healthcare informatics refers to the application of computer and information science in basic and applied biomedical sciences in order to facilitate the acquisition, processing,  49  interpretation, optimal use, and communication of health related data.  The focus is on the patient and the process of care with the goal to enhance the quality and efficiency of care provided  Interprofessional Education Interprofessional educatio from two or more professions learn about, from and with each other to enable effective is unplanned and may occur serendipitously.  Formal IPE aims to promote collaboration and enhance the quality of care.  It is a planned and purposeful effort that brings learners from different professions together to engage in activity (ies) that promote inteprofessional learning.  The intention for formal IPE is for curricula to achieve this goal (Palaganas, et al., 2015). Transfer to Practice Transfer to practice is relevant in this study as situated within transformative learning.  Transformative learning (Mezirow, 1991, 1995, 1996, 19cognitive, conative and emotional components (Mezirow, 1997).  When considering transfer to practice, learners transfer a change in frame, or way of knowing, to their practice or work.  In the case of healthcare education, the medical and nursing students would apply newly learned skills, behaviors and attitudes to the clinical setting to improve patient care.       50  Subject Demographics This study explored the perceptions of 10 third-year medical students and 10 fourth-year nursing students regarding the use of social media as a mechanism to deliver a simulated clinical experience to facilitate interprofessional education.  All students were at similar stages in their academic trajectory having completed a medical-surgical rotation caring for patients with histories of chronic disease.  I am grateful to the students who chose to participate and share their valuable time and perspectives with me multiple times over the course of the study, which equated to a total of approximately 6 hours.  In describing the participants, my primary concern is that they remain unidentifiable.  Therefore, I will approach the presentation of data and discussion surrounding their perspectives thematically and with the use of pseudonyms as indicated in Table 4.1. Table 4.1 Student Pseudonyms and Associated Discipline. Medical Student Pseudonyms Amber, Darlene, Erik, Maria, Mark, Martha, Maya, Miranda, Tanya, Zach Nursing Student Pseudonyms Abby, Alexis, Ann, Audrey, Dawn, Eva, Francine, Lori, Nancy, Paul  The subjects were recruited via email through their respective college faculty and administrators. From the 42 medical students and 26 nursing students who responded, 22 were selected based on scheduling availability.  Informed consent was obtained at the same time as the demographic survey.  The demographic survey elicited characteristics of the participant population and affirmed diversity of the subjects in an effort to broaden range of perspectives and substantiate a pool somewhat representative of the larger student population.   51  It was noted there were more female participants which correlates proportionately with nursing enrollment at the respective institution.  In contrast, gender distribution of medical students was skewed since enrollment is more equalized with regard to gender (see Figure 4.1).  Thelwall, Wilkinson and Uppal (2010) found that social media is an emotion-rich environment where females give and receive more positive comments. They did not find any differences between genders in negative comments. Their findings also suggest that females are more successful social media site users because of their ability to better textually harness positive affect.  Thomson (2006virtual environment.  Gender differences were found to be more salient in same-gender electronic discussions versus mixed-gender discussions and that gender affects how we produce and interpret these communications.  Whether or not the disproportionate number of females had actually impacted my results is beyond the scope of this study.  However, considering the literature, this dynamic may be worthy of consideration and future inquiry.   Figure 4.1 Subject gender distribution The age of students was more homogenous with 75% in the 20-25 range and 25% students aged 26 or older (see Figure 4.2).  This would be expected considering nursing students  52  were recruited from a traditional program meaning they typically pursue their degree immediately following high school graduation and would be approximately 22-23 years old in their fourth year.   The older students were noted to be medical students with 5 being traditional and 5 pursuing medical education later than what is typical.   Figure 4.2  Subject age distribution. A prerequisite for participating in the study was to have had a Twitter account for at least 6 months to ensure basic understanding of Twitter and thereby facilitating the ability to engage in the simulation, particularly given the short span of the study period.  As illustrated in Figure 4.3, all students met this criterion.  Figure 4.3  Length of time possessing a Twitter account.  53  I was also interested in frequency of use since the length of time a student had their account as it would serve as an indicator of their experience with Twitter which is illustrated in Figure 4.4.  It also helped me gain a sense of how often they might be accessing their Twitter account during the period of the study so that I would know what to expect and could plan accordingly.  The number of students that used Twitter less than twice per month was greatest and represented a third of the subject population. Two thirds of the students used Twitter multiple times per day, week or month.   Figure 4.4  Frequency of Twitter Use.  Another characteristic of interest was how the students perceived their Twitter expertise to be.  This self-perception could have an impact on self-efficacy of students with regard to using ssment of their Twitter expertise was quite variable as seen in Figure 4.5.    54  Figure 4.5  Self-described Twitter expertise. The final areas of interest prior to implementation of the simulation were whether students had prior experience with interprofessional education (IPE) learning activities during the course of their curriculum and if they had opportunity(ies) to communicate or collaborate with students of the opposite discipline (e.g. medicine or nursing).  Figure 4.6 indicates almost all students had prior IPE experience.  This could be beneficial by providing safety for students within the context of a virtual IPE experience as they might feel more comfortable interacting with each other than not having had prior experience. Figure 4.6  Prior experience with IPE.  55  As would be expected, students reported opportunities to collaborate and communicate with students of another discipline correlated with prior experience with IPE with the exception of one student who reported that they had not had an opportunity to communicate (see Figures 4.7 and 4.8).  I assume this discrepancy was in error as it would not be possible for a student to collaborate without communication and I did not probe the student further. Figure 4.7  Prior collaboration with students of other discipline. Figure 4.8  Prior communication with students of other discipline. After collection of information related to demographics, prior IPE experience and Twitter usage, students were paired based on their availability and scheduled for the SocialSim experience and debriefing session. Following the simulation and debriefing session, semi- 56  structured interviews were scheduled and conducted at which time the students shared their personal perspectives regarding their experience which are presented in the next section.   Thematic Presentation       The primary aim of this study was to elicit student perceptions regarding the use of SocialSim as a method for delivering interprofessional education, specifically as it relates to communication and collaboration. The time spent during the semi-structured interviews proved to be insightful as students shared their individual experiences and thoughts.  I continue this chapter by introducing the themes that emerged relative to the research questions. These themes are organized into three sections: (1) Affordances, (2) Challenges and (3) Influence on interprofessional education.  The descriptive nature of these findings are intended to  inform administrators and faculty as to how SocialSim may facilitate interprofessional education in addition to  contributing to the broader field of healthcare simulation.   Affordances Accessibility   Within the context of this study, accessibility refers to the ability of students to access or connect to the learning activity in addition to others (e.g. partner, patient, faculty, patient) using SocialSim.  Given a traditional simulation activity, students are expected to physically locate to wherever it might occur.  Typically this means students go to a campus-located simulation center or skills laboratory during specific operational hours.  Often, students in healthcare professional programs are not geographically proximate (NLN, 2011).  Mark was one of these students who exemplified the geographical challenge of being physically located at a site distant from campus  57  and other students, particularly those in different programs.  Mark was assigned to a hospital two hours from campus for his third and fourth-year clinical rotations.   You can be anywhere , the nursing student was in Detroitthink you were in East Lansing and we were able to all collaborate and work through the  What Mark did not know was that I was in a different city 90 miles from campus during the period of his simulation. SocialSim allowed the students and educator (i.e. myself) to interact in was on a weekend during a time when he did not have competing demands on his time.         Another issue relative to access brought forth numerous times was the ability of of being able to connect to Twitter any time of the day and subsequently, their partner, patient and myself.  Abby, a nursing student, describes the benefit of SocialSim and accessibility as related to time: I thought it was cool how Twitter specifically, was at our own schedule.  We could tweet online at a specific moment to receive the information. The information would come to  had time. I thought it was also cool that we had, you know, a partner that we could tweet back and forth and share both of our views on the scenario. As indicated in the literature, confounding schedules of healthcare professional students presents a sign 58  SocialSim to provide an accessible means for her to engage with her partner whenever her schedule allowed.   One of the medical students, Maria, expressed similar sentiments: still communicate with the patient and my partner which was very nice. It was different to do that while  While there is much debate in the literature regarding the impact multitasking has on learners, SocialSim is conducive to it.  Maria expanded upon her thoughts related to access by addressing efficiency of the access:  I do use social media to look for information quickly and for emails or whatever it is  nursing student was great; we talked back and forth through messaging and discussed what we thought was going on and which way to go and what to do and had that open line of communication.  It was nice to communicate quickly and efficiently. In terms of the patient, they were able to get feedback in the appropriate time versus waiting and being unsure. It is noted from the background questionnaire that most of the students in the study would fall in the Millennial generation which includes those born 1977 and 1992 (Noren, 2011).,,. According to the Nielson Report (2014), Millennials expect everything from smartphones to websites to mobile apps, to provide the most usable, self-guided, hiccup-free, efficient user ects the millennial attributes as she describes  59  SocialSim being able to facilitate continuous access, engagement and fun.   As she references her other students would feel the same way.   But I thought it [SocialSim] was very interactive, engaging and fun.  I liked anticipating what videos or pictures would be uploaded and then tweeting after with my partner.  I thought it was a fun exercise. As far as education is concerned, I found this to be a really great tool for that.  Enhanced Fidelity  According to the literature, students have repeatedly stated that they prefer high levels of fidelity when reporting their level of satisfaction with simulated learning activities (Jeffries & Rizzolo, 2006; Lapkin, Levett-Jones, Bellchambers & Fernandez, 2010).  The students participating in my study varied in their views as to whether SocialSim enhanced or lacked realism or fidelity. While fidelity was not specifically addressed in my research questions, it became apparent in the interviews that students valued fidelity as contributing or enhancing the learning experience and therefore considered an affordance.  Lack of fidelity as a perceived barrier will be discussed in the respective section.   In primary care, the norm is for patients to have a healthcare record which is accessed by providers in the interest of formulating diagnoses, treatment interventions and promoting optimal health and quality of life for their patients.  The SocialSim experience began with dissemination of an abbreviated patient record with the goal of providing students an opportunity to learn about and care for their virtual patient as the simulation evolved.  Nancy represents a number of  60  students who articulated the impact of this type of reality-experience and how this may replicate a realistic experience. My thoughts after looking at her chart and her phone call were immediately about teaching and planning nursing interventions, so it was pretty similar to how I approach things in the real life clinical setting.  t having that face to face was a lot different doing it by social media.  I actually did think it helped to have a picture was different from a face-to-face encounter, but yet appreciates the pictures embedded in tweet links as enhancing the reality of the case. These comments are congruent with the concept of that a case or situation is not real, yet for the duration of the simulation, cognitive engagement and emotional responses occur. The concept of environment includes not only the physical setting but also the equipment, teammates, and other individuals involved in reproducing the desired situation. It also includes elements necessary to the way it is perceived and experienced (eventually even believed) by participants (Dieckmann, Gaba & Rall, 2007).  simulation can overcome the reality that the situation is not real and the experience can ultimately promote an enriching learning experience.    Twitter allowed for embedding links to audio and visual clips into the tweets which had  the benefit of not only enhancing fidelity but also appealing to students whose learning preferences emphasize auditory or visual components.  Dawn describes her thoughts regarding these embedded links as follows:  61  I liked having had her actual voice on there.  That made the patient come to life, I guess you could say. I also liked how it seemed very realistic managing her diabetes and providing proper education. So I really like real voice was used which made it life-like. the medical field, which I liked.   Hayes (2005) found that some virtual environments are not solely text-based and provide opportunity for learning via a wider range of modalities such as visual and auditory.  There is an infinite number of pictures, audio and video available to embed into tweets.  Therefore, SocialSim would offer an opportunity or affordance for educators to respond to student preferences.   Lastly, I argue that the perceived fidelity could be advantageous as a way to establish face and content validity of the case.  For example, although I had sought input from multiple experts, if the case was designed in such a way that students did not find it plausible, it could be an indicator regarding the validity and subsequently have an impact on engagement and use of SocialSim.  Transfer to Practice  It is imperative for medical and nursing students to transfer learning to the practice environment.  It is sometimes difficult to differentiate between the fidelity of a learning experience and transfer to practice as they can be so tightly coupled.  For example, if an experience has a high level of fidelity, one might expect that acquired learning would naturally transfer to practice. I assert that they are different and that a learning activity with a high level of fidelity does not necessarily guarantee that students transfer behaviors to the clinical  62  environment. Therefore, I opted to separate perceptions related to the level of fidelity from those related to skills they thought they would use in the real world.     Paul shares his thoughts regarding the use of the chart as correlating with other realities of his as a student in the clinical setting: gation portion, or the pre-assessment. I like looking over the labs and understanding the pathogenesis outside of my physical assessment and trying to understand, you know, from all the different resources. Then I can coordinate this with my physical assessment and go from there.  I think it [SocialSim] was really similar.   Paul comments reflect the ability of SocialSim to replicate what he would expect in a real patient record. It is interesting considering recent attention focused on the viability for healthcare simulation to replace actual clinical experiences. In a recent study conducted by the National State Board of Nursing, results indicate that up to 50% of clinical experiences for nursing students can be replaced with simulation.  The authors describe conditions necessary to exist in this situation including faculty members who are formally trained in simulation pedagogy, an adequate number of faculty members to support the student learners, subject matter experts who conduct theory-based debriefing, and equipment and supplies to create a realistic environment (Hayden, Smiley, Alexander, Kardong-Edgren & Jeffries, 2014). The ability for simulation to transfer directly to clinical practice is compelling and the degree to which it can debatable. Nevertheless, the use of modalities such as SocialSim to accomplish this objective may be more realistic in the future.  63  Zach describes yet another aspect of how SocialSim might serve as impetus to reflect on prior learning, assess current knowledge and apply to practice: probably could be researching, especially when I got the initial case. Just seeing the amount of problems that Wanda [simulated patient] had going on.  It was kind of in my mind that I should look up guidelines and things. I thought it was good that I was able to while, like the 10-was a good incentive to kind of look up guidelines and things like that. Zach recognized the need to reference prior learning in addition to the need to access additional information regarding what was going on with the simulated patient and SocialSim provided an opportunity to reinforce and contextualize key concepts. Mayer (1983) found that postsecondary students were able to recall conceptual principles and related information at a significantly higher rate when they were presented repeatedly.  Thus, SocialSim can provide a venue to repeat and reinforce previously learned concepts in a different way.  Use of Informatics  An interesting and unanticipated affordance of SocialSim that emerged was the potential for SocialSim to facilitate learning related to healthcare informatics.  Multiple students felt that it would prepare them for what they believe is the future of healthcare, specifically related to the use of technology to augment care of the patient. While the design and objectives of the simulation were not specifically intended to teach informatics, students repeatedly referenced  64  this in multiple interviews.  As is often the case in healthcare simulation, secondary objectives emerged which warrants discussion.    type of medicine that  people might  technology to interact with patients, in this case SocialSim, seemed to provide a glimpse into the  future and what her work might look like.  Lori generalized the prevalence of social media use and is perplexed that it is not used more often in healthcare: becoming one of  the primary ways to keep in contact with people...I think that our generation is becoming such  Given that the majority of students in the study fall within the Millennial generation,  it is not surprising that she would respond in this manner. SocialSim provided the opportunity for Lori to conceptualize the use of social media in practice and has difficulty comprehending why it is not in the real world. According to Nelson (2007), the preferred learning environment of Millennials combines personal challenge comments, she exemplified how SocialSim supported teamwork and technology: helpful for the patient because it lets them know if they should come in or if they should not come in which we see a lot of times in like hospital settings and primary care settings.  65  should.  So if they have the option to just post a picture on social media or tweet to their nurse, physicians and nurses might be able to catch something before it becomes even worse than it already was. As previously defined, the use of technology to support care of patients falls within the realm of healthcare informatics.  I assert that  SocialSim provided an opportunity for students in the study to use technology to care for a patient in a virtual environment as evident in the interviews. This suggests that SocialSim can provide a venue for students to practice their informatics skills. It is also interesting to consider that SocialSim prompted students to reflect on what they envision the use of technology for patient care to be in the future.  Challenges Technical Issues            Despite careful planning and piloting the simulation prior to broad implementation of the study, there were some technical issues that originated both from me and the students.  The technical issues did seem to decrease significantly over the course of the study with students participating mid to end of the study having less technical issues than at the beginning.             One of the common issues at the beginning was the need to include the assigned hashtag and designated Twitter handle in every tweet in order for the students, patient and myself to with itme or their partner and upon investigation. I found most issues related to not including handles  66  their partner, patient or me) they were isolated from the activity. Another issue contributing to of assigned hashtag and permission, the students could not access the case.             Given that these functions are considered basic to the use of Twitter and I had distributed considering the Millennial-affinity to technology.  Upon review of the background questionnaire results, I noted the disparity in self-described Twitter expertise in the study population and therefore, should not have assumed a higher level of technological ability than what actually was.  Schaffhauser (2015) asserts that Millennials are not as tech-savvy as they think they are. Results from his study indicate that while the Millennials internet access, but all that competence. While they spend an average of 35 hours every week on digital media, nearly six a -solving using technology must become the rule rather than the exception and it is time for government, educators and other STEM advocates to ensure that all young people have the opportunity to become tech savvy. Lack of Privacy  Students referenced privacy as being an issue in two different ways:  1) social media as public platform may violate privacy of the patient and, 2) student privacy was compromised.  Zach shared his thoughts regarding his work being visible:  67  Just the idea of putting information out there that is going to stay out there and then could potentially see that information, so it made me think a lot more even though it's a would put out there and versus what I would maybe want to send in a direct message or, or make a phone call or see somebody in persure.    It appears Zach contemplated whether he should tweet information related to the patient or not.  Regardless of the fact that the patient was not real, he still felt an ethical obligation to protect his patient.  Alexis brought specifically referenced the Health Insurance Portability Act encrypted and I was afraid everyone was seeing what I was tweeting with my patient.  So that students, Audrey, was able to acknowledge the fact that while HIPPA is an issue to consider, when considering the context and fact that this was a simulated educational experience, it was  A major goal of HIPPA is to assure allowing the flow of health information needed to provide quality care (United States Department of Health and Human Services, 2003).  Healthcare students are required to participate in HIPPA training early in their curriculum (American Association of Colleges of Nursing, 2008).  It is apparent that students internalized their knowledge related to HIPPA and  68  subsequent need to protect the privacy of their patient, even though she was not real.  Miranda, was concerned about privacy regarding others who might see her tweets: It was uncomfortable  because I was thinking from my end whenever I tweeted I wondered if  my friends could read it or who else could see this even though I, you know tagged Wanda in with the program and how to use it.  I also wondered if my other patients are reading this.  Those are the things that I was thinking about.   Another medical student, Amber, was concerned about future implications of her tweets what if I was doing something wrong?  What if I ordered the wrong thing?  They might not want pite careful planning of the simulated experience and setting the security within Twitter to private in an effort to sequester any and all SocialSim communications, it seemed to still be a concern for students.  I am not certain if they remembered or understood the security settings that did, indeed, protect all information and communications related to the case.  My primary motivations for private settings were to comply with the Family Educational Rights and Privacy Act (United States Department of Education, 1974) and protect intellectual property.  I had not considered future professional ramification for the students or at least, their perception that it would have an impact on their reputation or future.  Lack of Fidelity  Contrary to prior discussion related to enhanced fidelity of SocialSim, there were some students who felt the fidelity of the simulation was not plausible as compared to real clinical situations. Paul shares his thoughts:  69  I felt like it was a lot harder to get information.   And then the information I needed now asking questions and getting immediate responses.  So that was a little difficult. You  that was a little difficult, too. lSim reflected the difference in provider-patient interactions using SocialSim than those in real life that elicit immediate responses. Due to the nature of Twitter, unless all parties are accessing at the same moment, the communications will be asynchronous in nature.  In addition, the lack of human emotion with SocialSim was perceived by Paul as problematic and not typical of real life.  One of the nursing students, Eva, describes her perception that SocialSim was significantly different from real life: I think that the audio and the picture really helped but I think that it also was very essing in real life and SocialSim you really kind of   Eva appreciated the audio and visual clips that were embedded in the tweets, however, still felt the need to have a comprehensive and holistic view of the patient that was not possible in segmented tweets.   suggests that the fidelity of SocialSim may be conditional: I think that in this case from my experience with the family med docs, they probably precursory information that we had.  But for things that are recurrent, if she had had this  70  several times before and it's the same kind of thing, then I think that something similar could happen in a primary care office.   would be cared for in the same manner as with SocialSim.  However, given certain circumstances such as a recurrent health issue, it seemed plausible.   There is widespread belief that simulation experiences (and effectiveness) improve proportionately as the precision of the replication of the real world improves. Under this assumption, a perfectly realistic simulation becomes the gold standard. This view has been criticized early and repeatedly in various fields working with simulation. Some studies have failed to show positive effects of higher fidelity on training outcome, and others have shown that relatively low fidelity simulations can be effective (Dieckmann, et al, 2007).  Consideration of affordances, are important when identifying the simulation method during the curriculum design phase and weighing these against the desired outcomes.  The decrease in fidelity may not be relevant or prohibitive to a positive learning experience.  Regardless of the chosen method, artificial or virtual patients cannot entirely replace real-life patient experiences, however may be able to augment. Lack of Personal Contact Another theme that resonated among multiple students was their need for more personal ching the patient and making them feel comforted, and  71  had an effect on the fidelity of the case: hat something looked like in the past but you also have them there to kinda check up on how it looks now. So just not verything  just through tweeting back and   Audrey thought the lack of physical presence prohibited the need to physically assess the patient and hindering the quality of care: them.  A lot of what my assessment skills are based on physical findings, so it was sort of hard to just go by the subjective information I was given and not physically assess the patient. When I probed further and reoriented Audrey to the fact that the context was within the primary times doctors and nurses care for patients over the phone in the office or when  Given the nature of practice-oriented healthcare professions and need for physical contact in order to perform important basic skills such as physical assessment, it is not surprising that the students recognized and missed the personal contact that is not possible via a social media platform.     72  Text Limits  When I asked students to recall some of their challenges, most prevalent was the text or character limitations of Twitter.  In fact, during analysis, I was surprised at the magnitude of this complaint as being unanimous.  The text limit of Twitter is 140 characters per tweet and includes the handle, body and hashtag(s).  This is a unique feature of Twitter and is mentioned in the literature as being a limitation with Twitter.  However, there are other functions built within Twitter that support other means of connection allowing more text, such as direct text messaging.  first day of the study with the goal of minimizing this potential barrier.  There were a number of consequences noted by students resulting from the text limitation.  Tonya expresses concerns about missing important information as a result of the limitation: I think it was difficunibe missing details using social media and communicating.  Tonya does recognize a benefit of the text limitation as prompting prioritization of issues to discuss with theithe necessity to embed hashtags and handles within a tweet:  73  With the um hashtags and handles and everything, it took a lot of your characters away and so not being able to like explain why I was thinking things or why I would want a certain test  was kind of frustrating. impact on how many remaining character spaces are available for the tweet.  The ability for students to completely convey thought processes, share information and ask comprehensive questions could be therefore be hindered by the text limitation.  Eva exemplified this: and my partners handle in there and then also the hashtag which took up more than half of the characters and so the character limit was my biggest problem in terms of communication I would say.   The text limitation inhibiting communication could have a direct impact on interprofessional interactions which will be discussed in the next section.   Influence on Interprofessional Education The last area of interest relative to the third research question is how SocialSim influenced interprofessional education, specifically communication and collaboration between disciplines (e.g. medicine and nursing).  Literature suggests that other simulation methods have a direct impact on learning since simulation and is often a shared, social experience, contrary to other instructional media (Dieckmann et al. 2007). I was particularly interested as to whether SocialSim as a simulation method may have a perceived effect on interprofessional education specifically related to collaboration and communication skills that underpin effective interprofessional care of patients.  I found during the interviews and analysis that often times  74  these two skills were interwoven and interdependent. For example, students needed to communicate in order to collaborate and expressed as such in the interviews. Elements of collaborative practice include responsibility, accountability, coordination, communication, cooperation, assertiveness, autonomy and mutual trust and respect (Brown, Lewis, Ellis, Beckhoff, Stewart, Freeman, & Kasperski, 2010).  Because it is difficult to segregate collaboration and communication completely, some elements of each will be found in the next two sections.   Collaboration  The attribute of SocialSim that students seemed to appreciate the most was the opportunity to collaborate with one another. It was an interesting and rewarding experience to observe the collaboration that occurred between pairs of students during the simulation experience followed by their perceptions shared during the interviews. The nature of the collaborations varied among the pairs.  Typically, the students collaborated with each other aints followed by their agreed upon plan of care.  Mark describes the collaborative nature of interactions with his partner as:  direction but then looking at the second video, I asked the nursing student, This I think and this is what I think we should do, what do you think?  And then she said, think we should also do this. We both had our own things and came together.  We were both discussing and agreeing on what we should do and so forth. Some students appreciated SocialSim as promoting a team-  75  d the other brought it up as an issue, you start thinking about other things that might be going on  Considering once again the age group of the participants and the tendency for Millennials to thrive with team-oriented activities, it is not surprising that the students enjoyed working as a team with SocialSim.  Zach takes this concept further and elaborates by sharing his thoughts.  What I liked was that she [partner] had a different perspective than I did.  I felt like when I pulled up the case [Twitter] I was quickly thinking about disease states and med changes and diagnoses and she [partner] was thinking more along the lines of education and lifestyle kind of things,  I thought tlittle lower on my list than it should be, so it was nice to have somebody with a little bit involve them was helpful.  I would have liked more of a kind of bouncing ideas back and forth, but it was nice to feel like there was a team there so if I said something that was kind of off the wall, she could at least check it and we could correct each other.  Not that this happened  but iable to have, a team approach and a patient case because I know that personally I can that I want to work on with the patient.    76  These examples suggest that SocialSim provided a platform and case scenario conducive to collaboration and problem-solving.   Also frequently shared by students during the interviews was that the opportunities to collaborate with students in other disciplines was lacking and SocialSim provided a means to overcome this deficiency.  An example of this is reflected by Alexis: I thought it was cool to talk to, like get that chance to like collaborate with nursing my first two years of school we never talked about like what kind of things that we needed to tell nurses or what their education level is or how, what they know and what they, they can teach us.  So I thought that was really helpful. As evidenced by the background questionnaire, most students had previous opportunities to collaborate with students of the opposite discipline. It is interesting to note  the number of times students mentioned the lack of opportunity to collaborate with other disciplines during the interviews which I found was not congruent with the background questionnaire.  This may be indicative of a lack of consistency or standardization on the part of academic programs to provide collaborative opportunities for students.  It may also be that the frequency of opportunity was such that it did not have a significant impact. For example, while they reported on the survey that they had previous opportunity, it may have only one time or not significant.   Communication  Effective communication across multiple healthcare disciplines and professions is critical to ensure the delivery of safe and efficient care (Abu-Rish, Kim, Choe, Varpio, Malik, White, Craddick, Blondon, Robins, Nagasawa, Thigpen, Chen, Rich & Zierler, 2012; Greiner & Knebel,  77  2003).  The study participants shared differing perspectives regarding the ability of SocialSim to promote communication with each other.  The majority of students felt that SocialSim was able to support their ability to communicate with each other. Conversely, a few students felt communications were more parallel than bidirectional as  I was hoping that there would be more back and forth, more um kind of discussing what we thought was going on and I felt like we were kind of at parallels at times.  I was talking to the patient and was thinking through some of these things.  She [partner] was discussing them together and, and coming up with a plan of action or maybe even a how are we going to move forward, what kind of follow-up do we want with the patient.  Unfortunately, one student, Paul, conveyed his partner had not interacted or responded to him throughout the entire simulation.  While I had observed this from the periphery and attempted to prompt his partner to communicate via tweets, she did not respond.  What was particularly compelling and interesting was that Paul, despite participating in SocialSim unilaterally, was still able to communicate with the patient and ultimately gain something from the experience.  He  healthcare simulation (Fanning & Gaba, 2007).  It is during this period that guided reflection, processing of information and sharing among participants occurs. There is an abundance of literature supporting the value and importance of quality debriefing in simulation, however, very  78  little related to promotion of quality debriefing for inteprofessional simulation (Littlewood & Szld, 2015).  The comments expressed by Paul suggest that the quality of the debriefing may have an effect on the SocialSim experience and consequential learning. -in-the Nielson Social Media Report (2014), Millennials have different communication habits, and are way more connected and in-tune with technology and online culture. Growing up with access to information at their fingertips, they have become accustomed to an on-demand lifestyle, expect a seamlethey need.  Martha exemplifies many of the students in the study who had an affinity for -in- r people do.  I look for information through messaging and we discussed what we thought was going on [with the patient], ike that but just  it worked out for us.  We were both able to communicate quickly and efficiently. In terms of the patient they were able to get feedback in the appropriate time versus waiting and being unsure. It is interesting given that some students expressed frustration with the asynchronous nature of SocialSim and lag time as discussed previously but yet others perceived SocialSim as providing  79  of my own home but then I would sometimes have to wait a few hours for responses and then  Lastly, many students perceived social media as a futuristic method to communicate with each other in addition to their patients.  Dawn shares her prediction: I could see in the future this kind of communication coming to the healthcare setting.  I healthcare is now and how social media and just everyone is, seems to be connected all the time that this is kind of where healthcare is headed a little bit in terms of communicating with people. not, it is certain that social media is here to stay in one form or another. The use of social media as a vehicle to support interprofessional education communication skills appears to have both pros and cons. Summary   I have presented multiple perspectives of medical and nursing students regarding the affordances and challenges related to the use of SocialSim.  I developed SocialSim with the intent to facilitate a simulated interprofessional education experience situated within a virtual environment; in this case, using social media (Twitter). My primary interest given the early stage of SocialSim, was how the students felt about this tool prior to pursuing further development and subsequent inquiry.  As evidenced in the interviews, there are many factors to be considered.   It is also important to consider the broader arenas of healthcare delivery and higher education.  The current crisis in primary care in the United States presents challenges to  80  healthcare leaders and policy makers.  Unprecedented demand for care coupled with poorly Everett, 2010).  This creates opportunity for administrators and faculty in higher education to better prepare healthcare professional students for contemporary healthcare by developing interprofessional education to prepare students to deliver quality care is not new, progress has been slow considering the roots of IPE dating to the 1980s (IOM, 2009).  Innovative methods such as SocialSim to ignite progress and overcome barriers are desperately needed.   There are two primary contributions of this study.  First, it provides an understanding of and faculty as to how this type of methodology it may be integrated into interprofessional education.  Second, it contributes to the broader field of healthcare simulation.  What began as an idea during an elective course came to fruition as I pursued my inquiry.  Many lessons were learned from the students who shared and contributed to my journey.  The next chapter will focus on further discussion of the results, implications for practice and suggestions for further research 81  CHAPTER 5:  DISCUSSION AND CONCLUSIONS  This descriptive study examined the potential for SocialSim to facilitate simulation-based interprofessional education from the perspective of medical and nursing students.  In light of increased need to integrate interprofessional education (IPE) into curriculum, I sought to answer the following research questions: 1. -  2.   3.   The conceptual basis for my study is underpinned by the framework that I developed based on review of literature and my professional experience (Figure 6).  The inner circle represents faculty and students engaged in teaching and learning within a virtual environment with bidirectional arrows indicating communication and collaboration among all. The faculty member transforms from teacher to learner and together with the learners, co-creates knowledge (Lave & Wegner, 2008). Using SocialSim, I was able to interact between students and observe them interact between themselves.  Components of the simulation activity were scaffolded in such a manner that allowed systematic presentation of information at intervals promoting the ability of learners to process, communicate, collaborate and formulate a plan of care.  I was able to systematically send this information in tweets via Twitter, ask questions and encourage students to probe deeper into the case. The middle circle represents interprofessional education  82  and that the learning activity is situated within the IPE domain.  Lastly, the large circle represents the larger arena of clinical practice. The assumption is that the learning activity will prepare students for an interprofessional approach to patient care.  Underpinning the conceptual framework are experiential and situated learning theories. In my study this experiential learning activity is SocialSim and it is situated within a virtual environment-social media.   SocialSim was designed to facilitate faculty-guided teaching and learning within a virtual environment in order to teach interprofessional skills to prepare learners for contemporary clinical practice.    In this chapter, I will present the discussion in sections correlating with the research questions.  I will make connections to the conceptual framework and literature within each section in an effort to promoting deeper meaning and understanding of the major findings.  I will then discuss implications for practice specifically as it related to higher education and the field of simulation.  Lastly, I will present specific recommendations and limitations learned from this study.   Discussion Research Question 1  Question 1 sought to answer what students thoughts were regarding the influence of SocialSim on simulation-based interprofessional learning.  The majority of students expressed appreciation regarding the opportunity it provided to interact with students of a different discipline.  While most of them had previous IPE experiences prior to the study, it was often described as a one-time activity.  The SocialSim activity influenced interprofessional learning by providing a structured and carefully designed opportunity to incorporate interprofesional learning simply by providing a venue for them to interact.    83   Students detailed their interactions with each other and how they approached the care of their simulated patient.  Though they were not in the same physical space, the shared virtual space SocialSim is situated in provided an opportunity to work together centered by a shared case.    The students also referenced application of previously learned skills such as gathering of patient information, diagnosis and discipline-on five assumptions. The assumptions most relevant to this discussion are the adult learner is -concept and who can direct his or her o-  Thus, according to the theory of andragogy, the students are self-directed, have prior knowledge to draw upon, enjoy problem-solving and appreciate relevance and immediate application.  Inteprofessional education relies upon many different theories to substantiate learning activities.  Drawing from andragogy, SocialSim influences interprofessional education since students need a certain degree of self-direction in order to actively participate, immediately apply previously learning knowledge and approach the case in an effort to problem-solve.  According to the literature review conducted by Issenberg, McGaghie, Petrusa, Gordon and Scalese (2005) under the Best Evidence Medical Education (BEME) Collaboration, ten consistent features and uses of simulation were found to be beneficial to the development of every healthcare professional and include:    84                  When considering the features of SocialSim, most of the above would apply. It is possible for faculty to provide feedback via tweets at any time in addition to the debriefing.  I argue that the potential for SocialSim to be integrated into the curriculum would be comparable to other simulation methods.  It is also possible for SocialSim cases to be designed for varying levels of difficulty and variety of clinical scenarios. Standardization would be facilitated as multiple pairs or groups of students could be exposed to the same clinical experience which is impossible in actual healthcare environments.  Most importantly, the students can practice interprofessional and clinical decision making skills without the risk of harming real patients.  The one use of SocialSim for development of healthcare professionals that would be difficult to determine is clear outcomes.  This is term is ambiguous since outcomes can be measured by many different benchmarks. Students often referenced their belief that the SocialSim activity prepared them for what they foresee as the future of healthcare and their respective role within that arena.   The Quality and Safety Education for Nurses (QSEN) project addresses the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work. QSEN articulates that effective simulations being able to engage students in realistic problems that require clinical data  85  and decision-making, along with the opportunity to reflect on their practice. QSEN further recommends that when designing simulation scenarios, an effort be made to thread elements of patient-centered care, teamwork and collaboration, evidence-based practice, safety, and informatics (Jarzemsky, 2010). SocialSim demonstrated the ability to engage the students centered around a realistic problem that included clinical data and supported decision-making. Again, the debriefing provided an opportunity for reflection. At the Interprofessional Education and Healthcare Simulation Symposium (2012), known as IPEC, 29 leaders representing 27 key healthcare professional organizations, including those from nursing (i.e. American Academy of Colleges of Nursing and National League for Nursing) and medicine (i.e. Association of American Medical Colleges and The American Association of Colleges of Osteopathic Medicine), presented research findings substantiating healthcare simulation as an effective vehicle for interprofessional education.  In summary, there was agreement that simulation in all of its modalitiestask training, team training, immersive experiences using standardized patients or manikins, screen-based simulations, virtual reality, serious gamingis a powerful tool that should be leveraged in IPE. Lastly, considering historical aspects of both healthcare simulation and interprofessional education, there has been a logical synergy between them.  According to Palaganas, Epps & Raemer (2014), healthcare simulation has features which are advantageous over other educational techniques such as:        86           Based on results of my study combined with the current body of research substantiating simulation for interprofessional education, SocialSim influences interprofessional education by providing a platform or venue for students to interact, apply knowledge and skills, problem-solve and engage in reflective practice.  I argue that it is a new addition to the menu of healthcare simulation options administrators and faculty may consider.  As presented in this section, SocialSim has the ability to influence interprofessional education in many ways.  Research Question 2    In order to answer question 2, the students shared valuable insight regarding the affordances and challenges of the chosen social media platform, Twitter, to deliver SocialSim.  Collectively, they provided the perspective I needed to critically examine SocialSim through the eyes of the student.  This information is important to consider as choices are made regarding the methodologies best supporting a specific population of students in addition to programmatic objectives. In this section, I will discuss the affordances and barriers identified by students in an  87  effort to answer the second research question.   Some of the themes that emerged were very similar and intertwined and therefore will be combined in the following sections.   Accessibility.  The ability of SocialSim to facilitate access to learning was appreciated by most of the students.  The concept of accessibility was manifested in my study in a variety of ways: (a) access to the information or case using technology, (b) access to each other in the interest of inteprofessional encounters, and (c) and timeliness or flexibility of the access.  Online learning environments provide an unprecedented opportunity for students to access learning in higher education. According to Adams, DeVaney and Sawyer (2009), the design of virtual learning environments for post-secondary instruction is rapidly increasing among public and private universities.  The social aspects of teaching, learning and educational practice are changing to accommodate rapidly emerging communication technologies and there is a growing demand from students for delivery of educational activities not tied to a physical place or set time.  In recent years, online learning practices have evolved into virtual learning environments. The positive side of this is the ability to create high quality, responsive, and engaging learning environments that foster engagement between faculty and students (Topper, 2007).  There are a variety of reasons for the increased demand and use of learning activities in higher education facilitated by educational technologies, which include the need to expand access, offer students greater scheduling flexibility, the freedom to work at their own pace and curb increasing cost (Bell & Federman, 2013).   In contrast to students appreciating the access and flexibility afforded by SocialSim, a few students indicated that they did not like the lag time or having to wait for their partner to respond.  Dziuban, Moskal, Brophy and Shea (2007) attribute this attitude as being typical of Millennial students as they have been accustomed to a hyper- 88  not involve their preferred modality. The authors suggest that development of instructional asynchronous nature of the microblogging platform, Twitter, to be problematic while others did not was left unanswered and is an area for further exploration.  Fidelity.  Fidelity was perceived as both an affordance and a challenge. While some students conveyed that SocialSim was realistic and similar to caring for a patient in real life, other students did not.  The underlying issue related to the lack of realism seemed to be the inability to see or touch their patient.  When probed, the students typically conceded that it is plausible in primary care for healthcare providers to care for their patients without seeing or touching them. For example, a patient may call a clinic complaining of back pain. A healthcare provider can gather information over the phone and suggest interventions without the patient having to be seen face-to-face in the clinic.  lation occurs at three levels of fidelity:  physical fidelity (how real the environment and people appear), (the interactive impetus that creates the emotions SocialSim does have the ability to replicate realistic clinical situations, however, is dependent upon the context of the case, engagement of the students in addition to their commitment to interacting in a virtual environment.    89  Privacy.  A significant number of students expressed discomfort with regard to the lack of privacy SocialSim provided for their patient and for themselves as learners.  Despite that fact that I had utilized the privacy settings within Twitter, it was nevertheless still an issue for the students.  While I would like to attribute some of this to the fidelity of the simulation in that they I cannot dismiss their concerns.   they were tweeting on social media is problematic on multiple levels.  A fundamental characteristic of simulation-based learning is the establishment of psychological safety (Council for the Accreditation of Healthcare Simulation Programs, 2012).  For students to fully engage in simulation, their fears and insecurities need to be addressed (Palaganas, 2012).  Gaba (2013) and Truog and Meyer (2013) state that anyone who has a role in simulation needs to consider the psychological effects of simulation on leaners and be responsible to themselves and the learners.   Another issue is the potential for giving students mixed messages.  HIPPA compliance is emphasized and expected in face-to-face experiences.  If sensitive health information related to the simulated patient is shared in the virtual setting, students may experience confusion as the behavior is accepted in one context and not another. The perceived lack of privacy definitely impacted the psychological safety of the students and was unanticipated on my part.  This had an adverse effect for some students as they did not feel comfortable posting tweets, which could have inhibited their desire to fully engage and interact in the simulation. I will never know what they might have posted had they not had these concerns.     90  Technical issues.  There was a general dissatisfaction regarding the character limit (e.g. 140) allowed on the Twitter platform.  While a few students acknowledged that it prompted them to be more succinct in their communications, most found this to stifle their ability to express complete thoughts and interact with each other. This challenge could have been circumvented by using the direct-messaging feature available within Twitter, however, only one pair of students document (see Appendix D).   Twitter users are reliant upon the product as is, barring any periodic updates.  Therefore, educators are not able to revise or customize the platform.  There were a few technical issues, however, which may be overcome. First, simply the inexperience of the students and myself with SocialSim hindered the ability of SocialSim to facilitate the interprofessonal education activity for those participating at the beginning even after the pilot. This did improve over the course of the study as I became more experienced and was able to assist the students more effectively as time went corrected.  Once I had figured this out, I was able to avert this with subsequent pairs by including it in information provided on Day 1. Use of Informatics.  Students expressed appreciation for SocialSim to provide an opportunity for them to use technologies that they will use in the future.  Engelbardt and Nelson (2002) asserted over a decade ago that planning and implementation of educational activities to teach informatics skills to healthcare professionals is necessary.  Since then, the accrediting bodies for nursing (American Colleges of Nursing, 2013) and medicine (American Osteopathic Association, 2015; Accreditation Commission on Colleges of Medicine, 2016) articulate an expectation that  91  informatics knowledge be integrated into baccalaureate nursing and medical education.  In addition, the Institute of Medicine (2003) identified the use of informatics as one of five competencies necessary to work in interprofessional teams.    While the initial intent of SocialSim was not designed to facilitate integration of informatics in healthcare curriculum, it is apparent that it may warrant consideration based upon  Transfer to practice. Arguably, the primary goal of any experience in healthcare education is to prepare students for clinical practice.   Maginnis & Croxon (2010) found that there needs to be parity between what is taught and what is experienced to ensure safe practice. While I did find an abundance of literature related to the use of simulation to promote self-efficacy, acquisition of psychomotor skills, and installation of interprofessional team skills in order to promote safe care, literature was scant with regard to how these acquired skills directly translate to practice and even less to the degree that it affects patient outcomes.  Based on findings in my study, SocialSim can provide a platform for students to practice, apply and reflect on learning generated by the case and interactions with their partner. The students were able to make a connection between the simulated case and real clinical care.  However, it is unclear to me as to whether they would transfer learning specifically from the use of SocialSim to real clinical practice and would be an area for further inquiry.  There are a few theories to consider with regard to the ability of SocialSim to support the transfer of knowledge acknowledges the experience followed by reflection and application to practice.  Another theory  92  that may be considered  is Transformative Learning.  Jack Mezirow described a transformation of perspective as going through ten ordered phases (Cranton, 2006, p. 20):      -                          problem is shared                     As students participated in the SocialSim activity, they shared a problem (i.e. case) which presented an opportunity for them to self-examine how they would approach the problem, conducted critical assessment of how they might have approached interprofessional care in the past, recognized the shared experience, explored new options to approach the care of the patient, planned a course of action and tried out new roles.  The ideal would be for students to become more confident as a result of the learning activity (SocialSim), become competent members of an interprofessional team and then integrate this into their future practice.  93   Lastly, when considering the conceptual framework, SocialSim was effective in providing a platform for faculty and two students to interact bidirectionally during the simulation and then as a group during debriefing.  This was situated within the context a realistic primary care case scenario using a virtual environment (Twitter) to facilitate interprofessional communication and collaboration.  The desired outcome, while not measured, would be for the students to be able to transfer knowledge gained from the activity to their clinical practice.  Given the nature of social networking platforms such as Twitter, SocialSim promotes the social aspects of learners constructing their own knowledge through their experience(s).  The students shared many examples of how they were able to apply previously learned skills to their simulated virtual patient.  Multiple studies support simulation as preparing students for clinical practice whether it is psychomotor skills, attitudes or behaviors.  One of the most notable and debated studies in recent time is the National Council of State Boards of Nursing (2014). This was a multi-institutional randomized controlled study with 666 nursing students comparing varying percentages of simulation replacing hours in a real clinical environment on clinical competency and nursing knowledge.  The researchers found no significant difference in these skills when replacing 25% and 50% of real clinical experiences with simulation.  In a systematic review, Zendejas, Brydes, Wang and Cook (2013) concluded that there were moderate patient benefits when simulation was incorporated into medical education.  Therefore, SocialSim may provide an opportunity for students to apply didactic knowledge with the hope that it has a positive impact on actual clinical practice. Measuring this would warrant further inquiry outside the scope of my study.   94  Faculty Affordances Over the course of implementation of the simulation, I noted some affordances for the faculty. Even though my stuthis section since they may have had an impact on the experience. First, I was able to facilitate the simulation from locations varying within a 120 mile radius at any time of the day.  I also appreciated the ability to scaffold the simulation in a customized manner according to what each pair of learners was doing. For example, one pair of students progressed quickly through the simulation arriving at a diagnosis and appropriate interventions quicker than other pairs. I was able to tweet probing questions prompting them to focus on underlying issues with the patient.   Finally, I was able to monitor activity using Hootsuite, which is an online social media management program.  This enabled me to visualize frequency of interactions between student oal of increasing engagement.  Research Question 3  The third research question was intended to explore how the students perceived the influence of SocialSim on communication and collaboration between them.  There are many skills integral to effective interprofessional care; however, these two were identified most frequently in the literature as being fundamental to interprofessional education and therefore were the skills I focused on in my study.      It became apparent that SocialSim did influence the communications and collaboration between the students, both positively and negatively.  Overall, the students appreciated the opportunity SocialSim provided for both interprofessional communication and collaboration.   95  -in- the asynchronous nature of Twitter prohibited immediate access to their partner that they would have -in-r interactions with each other but yet missed the face-to-face contact with the patient.   According to Palaganas (2012), the social process of students working together to find new ways of doing things may be the most important characteristic promoting positive outcomes of inteprofessional simulation.  This was exemplified by my study as SocialSim facilitated the collaborative efforts of students to identify what the underlying issues were (i.e. problem-solving) with their patient followed by an interprofessional approach to care.  Principles of social constructivism discussed in Chapter 3 are relevant given the manner in which the students collectively constructed their own knowledge rooted in a realistic case, using technology and yet also considered the cultural elements of their own professions.  Microblogging platforms such as Twitter, are hybrids that facilitate both online and offline communication (Gao, Luo & Zhang, 2012; Antenos-Conforti, 2009). Such an environment is particularly suitable for designing social learning experience grounded in social constructivism (Gao, Luo & Zhang, 2012; Vygotsky, 1978), distributed cognitions theory (Gao, Luo & Zhang, 2012; Pea, 1997) and connectivism (Gao, Luo & Zhang, 2012; Siemens, 2005).  Implications for Practice The overarching impetus for my study was to explore the possibility for SocialSim as an innovative tool to be added to the growing list of options administrators and faculties have to integrate IPE into curriculum. First and foremost, I wanted to explore student perspectives since  96  they are central to any educational activity. The answers to the research questions provide compelling evidence to consider.  While my study focused specifically on education in the fields medical and nursing, I argue that there are many similarities and lessons learned that would be of value to other disciplines and programs.    Significant barriers to interprofessional education, specifically geographical locale of student and competing demands of scheduling are not insurmountable.  Leaders in higher education will need to consider nontraditional methods requiring face-to-face participation in order to implement IPE overcome these barriers.  At this point in time, the advancement of technologies should be leveraged as a promising option in which to circumvent these particular barriers.   During my study, I noted interesting similarities and differences between SocialSim and face-to-face simulations intended to facilitate interprofessional interactions with students.  The primary difference was the lack of physical connection which offers the advantage of immediate exchange of information and conversation.  While SocialSim overcomes geographical barriers, it cannot overcome the lack of being in the same physical space.  Careful consideration needs to be made as to when face-to-face is more appropriate and when SocialSim would be able to achieve the intended outcomes.  I believe novice students would benefit most from face-to-face IPE activities, whereas upper-level students with previous IPE experiences would be able to use SocialSim most effectively. One of the more interesting similarities was student comments during the debriefings.  Based on my prior experience with debriefing IPE simulations, I did not reactions.     97  While I have argued that SocialSim has potential to contribute in many ways to IPE, I do -utilizes a mixture of online and in-person methods for IPE over the entire curricular trajectory is worth consideration and further study. The Horizon report (2015) examined face-to-face, dents felt the faculty member was more accessible and that there was altogether more persistent communication through the use of virtual learning when integrated with current classroom and clinical practice experiences.    Social media is here to stay in one form or another.  Programs such as educational technology, marketing and communications integrate the use of social media throughout the curriculum.  There is very little evidence in the literature and practice that healthcare professions use social media as a pedagogical tool and no evidence to suggest it has been used to facilitate simulation.  This arena is essentially untapped and ripe for exploration not only to deliver simulation but also to communicate with students, network with experts or share and disseminate scholarship.   There has been some work in healthcare education regarding the use of technology as a means to promote reflective practice.  Reflective writing is widely-accepted as a means to integrate theory with experience (Boyd & Fales, 1983).  Study findings by Chretien, Goldman and Faselis (2008) suggest that blogging is an effective way to integrate reflective writing into clinical practice.  Since Twitter is a form of blogging, specifically microblogging, SocialSim may be a method to facilitate reflective writing as it provides the opportunity for reflective writing via tweets and direct messaging.   98   Another important consideration for administrators is the cost to deliver educational experiences.  Balancing a budget while providing optimal learning for students has become more challenging today than ever before.  While a comprehensive cost analysis comparing the multitude of educational methodologies is beyond the scope of my study, a simple cost comparison for implementing IPE between traditional simulation methods and SocialSim is appropriate.  Typically, costs for a face-to-face IPE experience include high fidelity simulators at $50,000-250,000, faculty and staff time prior to, during and after the experience, medical supplies relevant to the case which are variable, technologies including audio-visual and computer devices and adequate space to accommodate the number of learners.  Cost to implement my study was limited to gift cards for students and transcription which totaled $1451.50. Under normal circumstances, SocialSim would not require incentives for students or transcription.  While not to discount the amount of time necessary to develop a robust case, supporting materials and all that is involved with implementation (e.g. tweets, monitoring students, debriefing), it is safe to assume the cost is much less than other methods most often used for IPE, specifically, high fidelity immersive simulation.   A cost-benefit analysis of face-to-face experiences as compared to SocialSim would be valuable for administrators as decisions regarding teaching methods are made.  I posit that it would make sense to invest more financially in higher impact IPE simulations where students from multiple disciplines (e.g., more than two disciplines) participate and might benefit collectively from the IPE event.  These situations would ideally occur earlier in the curriculum.  Another investment to consider is that of faculty as integral to delivery of SocialSim.  The role of faculty is not limited to facilitating interactions between students.  It is necessary for faculty to develop the case and simulation script prior to implementation.  This required  99  approximately eight hours of my time including the supporting documents and noted that I have extensive experience developing simulation cases.  Over time, SocialSim cases could be developed and shared in an effort to minimize time.  Scheduling, pairing and organizing student pairs took approximately four hours.  Implementation of the SocialSim scenario for twelve pairs consumed a moderate amount of time.  It is possible to schedule tweets in advance for multiple pairs, which I would recommend for larger groups.  Debriefing also requires time on the part of faculty.  I recommend debriefing a group of 6-8 for 30-45 minutes.  The group needs to be large enough to facilitate multiple perspectives, however, not too large to manage using technology.  Although the development and implementation of SocialSim does require a significant amount of time, I equate it to other forms of simulation based on my experience.    While it is premature to suggest that SocialSim can replace actual clinical experiences, conceptually, administrators and faculty may want to consider virtual options to deliver IPE.  As a result of the groundbreaking National Council of State Boards of Nursing (NCSBN) study (Alexander, et al, 2014), outcomes of simulation in prelicensure education have come under scrutiny.  Their findings indicate that up to 50% of real clinical experiences may be replaced with simulation.  It is important to note that the simulation method used in the study was high-fidelity immersive and those implementing the simulations and study have a high level of expertise.  Nevertheless, it is likely that the debate will continue and all modalities will be considered.  I believe it is likely that in the future, virtual simulation will be included in the conversations.    As evidence in the literature, there are specific IPE competencies expected of healthcare professionals.  I did not specifically explore IPE competency outcomes.  However, I propose that these be explored in the future.  It would be important for administrators and faculty to know if  100  SocialSim was an effective method to achieve specific competencies.  I would recommend quantitative inquiry to address these questions.  Lastly, I propose that an interprofessional approach of administrators and faculty is warranted.  In order to best represent appropriate learning objectives for an interprofessional group of learners, an interprofessional approach to integration is necessary. Support by leaders of multiple disciplines and commitment by faculty charged with incorporating IPE is imperative.  In addition, role modeling of faculty for their respective groups of learners is important.  Role modeling has been shown to be effective to inculcate professional values, attitudes and behaviors in healthcare professional students (Paice, 2001). How can administrators and faculty fail to model the same communication and collaborative behaviors expected of learners? This will most definitely require openness to change for everyone and a collective commitment to navigating the IPE process.  As progress. Working to Recommendations  Given that I navigated uncharted waters with regard to the use of social media to deliver an interprofessional education activity, there were many lessons to be learned. Based on my experience with SocialSim and study results, I present some recommendations in this section which may benefit administrators and faculty as they consider methods to incorporate IPE into curriculum.    101  Briefing and Debriefing   Briefing in healthcare simulation is similar to orientation.  It is important for learners to be pre-briefed in order to provide psychological safety and preparation for the case (Smith & Lammers, 2015).  More attention to privacy and HIPPA in the orientation or briefing could help students avert their expressed concerns regarding lack of privacy and fear of their actions being visible in a public forum.  It would also provide an opportunity for faculty to reinforce the importance of HIPPA compliance and settings in place to ensure privacy of the simulated patient.   It is also important to inform students that their privacy is ensured by the settings and reassure them that their simulation interactions are not visible to others.  The debriefing would present another opportunity for faculty to review importance of privacy for the patient and students and how these were protected during the simulation. Technical Solutions  minimized by addressing in the pre-should be made other, how to incorporate links to assist with text limitations and how to more effectively use hashtags would likely improve the experience.  Another technical issue experienced by myself is related to managing multiple pairs of over the course of a few weeks and often times the pairs overlapped. While I was ultimately able to engage, monitor and interact with all pairs, it was no easy task.  Considering cohorts of medical and nursing students often equate to 100 or more, I would recommend orchestration of SocialSim for multiple groups consecutively. In other words, begin on the same day and progress  102  through the simulation similarly, but yet still customized for all pairs.  It may require repeated iterations of the simulation or multiple faculty members sharing the workload.   Development of Fidelity The fidelity of the simulation could be enhanced with more video or audio-enhanced clips since the students indicated that they liked them and they were fairly easy to develop and embed.  Another strategy to address any lack in fidelity could be addressed in the pre-briefing students (participants) to mutually agree on the conditions related to the simulation.  Each party brings a set of responsibilities to the table to promote a positive learning experience.  The agreement can range from implicit to explicit, but when they exist and are adhered to will allow the recognition of value arising from the simulation (Phrampus, 2015).  The fidelity or realism can be explained in the fiction contract as exemplified in Appendix J.   Hybrid Model Considering the literature supporting a blended learning approach in education and some with other methodologies. In blended learning, traditional methods such as face-to-face are blended with technology-supported methods such as online.  In the field of healthcare simulation, this often referred to as a hybrid model.  For example, IPE integration could incorporate multiple simulation methods including standardized patient interactions, immersive high-fidelity combined with SocialSim.   Leaders of higher education are challenged to position their institutions to meet the connectivity demands of prospective students and meet growing expectations and demands for higher quality learning experiences and  103  that blended learning is consistent with the values of traditional higher education institutions and has the proven potential to enhance both the effectiveness and efficiency of meaningful learning experiences.   I recommend consideration of simulation-based technologies such as SocialSim to be integrated with traditional methods of  IPE instruction in an effort to meet the connectivity demands of learners while providing a quality learning experience. Limitations          The most significant limitations were related to the study subjects.  The subjects in my study represented only medical and nursing students.  A more robust interprofessional education activity would include students of other disciplines such as pharmacy, respiratory therapy, social work. SocialSim should have the capacity to accomplish this and in fact, would allow students of different disciplines at other institutions to participate together.  The study sample was also small and from one institution, and therefore, not necessarily indicative of the greater population of medical and nursing students.  In addition, the subjects volunteered and were self-selected according to their availability.  Therefore, they may represent a highly motivated strata within the greater population of students.  Lower motivated students could potentially have entirely different experiences and perceptions of SocialSim.  Lastly, the subjects were all approximately the same age and generation.  Considering characteristics of Millennials, it could have influenced how they utilized SocialSim and what their perceptions were. The perspectives of older students would also be of interest.             SocialSim is limited in its ability to be used for every context of healthcare. For example, it would be extremely difficult to facilitate a simulation situated in an operating room using  104  SocialSim.  It would also be unlikely to simulate the delivery of a baby using SocialSim.  Like any other simulation modality, the objectives and context of learning should underly the chosen method.           SocialSim is also reliant on connectivity to be effective. If faculty or students had limited connectivity at any time during the simulation, it could alter the experience. By using hashtags, faculty and students could reconnect later with the case; however, it would not be as interactive or collaborative.            For my study, prior experience with Twitter was a prerequisite for participation.  It is conceivable that in a typical medical or nursing cohort that  not everyone would have experience with social media.  This would result in a significant learning curve from the start which might present a barrier for the student(s) and faculty.           Another limitation of my study is that I used Twitter as the only option for microblogging.  There are a number of other social media platforms available to educators, each with their own unique feature, that were not explore in this study.            Lastly, a limitation of my study is that I considered perceptions of all students collectively and globally.  I did not compare or contrast perceptions of medical and nursing students.  Therefore, I do not have insight as to if perceptions were related to one discipline or the other which could have more specific programmatic implications.   Suggestions for Future Research  While my study results were compelling, I became more interested in the potential for future research as my study commenced.  I challenge not only myself, but others in higher  105  education to respond to the need for further inquiry related to IPE and new methods to facilitate it. I propose suggestions for further inquiry in this section.      Considering the magnitude of the impact of text limitations of Twitter, exploration of other social media platforms to deliver SocialSim is warranted.  Facebook, in particular, may provide similar abilities to communicate and collaborate without the constraints of character limits. A qualitative inquiry exploring faculty perceptions of SocialSim would also contribute to broader understanding.  This would be relatively simple from a logistical perspective as the same case and interview protocol would be appropriate.  It would be helpful to know how effectively faculty in general can facilitate a SocialSim experience since literature varies regarding technical abilities of healthcare program faculty.  Following expanded qualitative study, I recommend inclusion of quantitative inquiry.  Use of analytics provided by programs such as Hootsuite may provide more insight as to variables such as frequency of student interactions, length of time spent communicating and what types of information are exchanged during interactions.  Randomized controlled studies comparing groups and disciplines of students regarding use, preferences, feasibility, etc. would also be of interest. Themes identified in my study could serve as a foundation for these inquiries.   Lastly, initial or repeat studies related to types of simulation used for IPE would be beneficial.  Previous studies (Palaganas, 2012) have compared the use modalities such as high fidelity, partial task trainers and standardized patients for IPE, however, have not considered virtual environments or social media. Of further interest may be a combination or blend of these modalities in an effort to determine what options might be with regard to blending of  106  methodolgoies for IPE.  Cost analysis of these would further inform administrators and faculty as to what the best options for IPE are to achieve programmatic objectives, accreditation standards, respond to student needs and most importantly, improve the future of healthcare delivery. Conclusion  The integration of interprofessional education into healthcare curriculum is no longer an option, but a requirement.  How to best accomplish this given the numbers of barriers is a challenge for administrators and faculty.  While it is certainly possible to accomplish this in clinical care environments, a simulated environment offers opportunity for students to practice and apply interprofessional skills without risk to patients.  Most traditional simulation methodologies require face-to-face interactions such as immersive or high fidelity and use of standardized patients. I argue that we must explore beyond traditional methods of interprofessional education and develop new innovative modalities not as a replacement for all other methods, but to augment.  In other words, we will have more tools in our toolbox to choose from.  This will allow administrators and faculty to align interprofessional learning objectives to resources and make informed decisions.    My study confirms that SocialSim is a viable consideration for interprofessional would be possible to deliver a simulated case similar to what could be replicated from real life using social media.  I found that it was, however, knowiprior to pursuing further inquiry. I found there are some affordances and challenges which need to be taken into account when faculty are choosing the most appropriate tool to use given the  107  intended outcomes.  I also that this is the case with any teaching method.    There are many implications for further inquiry regarding the use of social media to facilitate interprofessional education.  Until this occurs, my hope is that my study may challenge administrators and educators to think outside the box as external forces mandate the integration of interprofessional education.  The barriers are not insurmountable. I also hope that my study contributes to the field of healthcare simulation.  This field is in its infancy as compared to others and ripe for individuals to develop and test new methods. According to Smith and Lammers imulation education to determine the methods and techniques to help students understand retain concepts, to identify whether the knowledge, behaviors, skills and attitudes learned and practiced in the simulated environment translate to practice at the bedsI designed SocialSim was to prepare healthcare professional students to function in a world in which inteprofessional care is essential for safer, better quality patient care.           108          APPENDICES          109  APPENDIX A:                                                                                                                            IPEC Core Competencies for Interprofessional Education (Interprofessional Education Collaborative Expert Panel, 2011) The four domains of interprofessional education competencies are identified below with correlating skills within each section.  Highlighted skills are those SocialSim may most effectively support as a teaching method. Competency Domain 1: Values/Ethics for Interprofessional Practice   Place the interests of patients and populations at the center of  interprofessional health care delivery.    Respect the dignity and privacy of patients while maintaining  confidentiality in the delivery of team-based care.   Embrace the cultural diversity and individual differences that  characterize patients, populations, and the health care team.   Respect the unique cultures, values, roles/responsibilities, and expertise of other health professions.    Work in cooperation with those who receive care, those who  provide care, and others who contribute to or support the delivery  of prevention and health services.    Develop a trusting relationship with patients, families, and other team members    Demonstrate high standards of ethical conduct and quality of care in  -based care.   Manage ethical dilemmas specific to interprofessional patient/ population centered care situations.   Act with honesty and integrity in relationships with patients,  families, and other team members.    of practice.      110  Competency Domain 2: Roles/Responsibilities   s, families, and other professionals.      professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs.   Explain the roles and responsibilities of other care providers and how the team works together to provide care.   Use the full scope of knowledge, skills, and abilities of available health professionals and healthcare workers to provide care that is safe, timely, efficient, effective, and equitable.     responsibility in executing components of a treatment plan or public health intervention.   Forge interdependent relationships with other professions to improve  care and advance learning.   Engage in continuous professional and interprofessional development to enhance team performance.   Use unique and complementary abilities of all members of the team  to optimize patient care   Competency Domain 3: Interprofessional Communication  Choose effective communication tools and techniques, including  information systems and communication technologies, to facilitate  discussions and interactions that enhance team function.   Organize and communicate information with patients, families, and  healthcare team members in a form that is understandable, avoiding  discipline-specific terminology when possible.    patient care with confidence, clarity, and respect, working to ensure  common understanding of information and treatment and care  decisions.  111    Listen actively, and encourage ideas and opinions of other team  members.    Give timely, sensitive, instructive feedback to others about their  performance on the team, responding respectfully as a team member  to feedback from others.   Use respectful language appropriate for a given difficult situation,  crucial conversation, or interprofessional conflict.   Recognize how o expertise, culture, power, and hierarchy within the healthcare  team, contributes to effective communication, conflict resolution,  and positive interprofessional working relationships.   Communicate consistently the importance of teamwork in patient- centered and community-focused care   Competency Domain 4: Teams and Teamwork   Describe the process of team development and the roles and practices  of effective teams.   Develop consensus on the ethical principles to guide all aspects of  patient care and team work.    Engage other health professionalsappropriate to the specific care  situationin shared patient-centered problem-solving.   Integrate the knowledge and experience of other professions appropriate to the specific care situationto inform care decisions,  while respecting patient and community values and priorities/ preferences for care.   Apply leadership practices that support collaborative practice and  team effectiveness.   Engage self and others to constructively manage disagreements  about values, roles, goals, and actions that arise among healthcare  professionals and with patients and families.   Share accountability with other professions, patients, and   112  communities for outcomes relevant to prevention and health care.   Reflect on individual and team performance for individual, as well as  team, performance improvement.   Use process improvement strategies to increase the effectiveness of  interprofessional teamwork and team-based care.   Use available evidence to inform effective teamwork and team-based  practices.   Perform effectively on teams and in different team roles in a variety  of settings                 113  APPENDIX B: SocialSim Faculty Case Scenario and Debriefing Guide  Case Scenario name:  Wanda LaFleur Target Audience:   3rd Year Medical Students and 4th Year Nursing students  Purpose:  The purpose of the simulation is to give students an opportunity to apply interprofessional core competencies by collaboratively developing a plan of care for a virtual patient with situated within the primary care setting.  Although a patient plan of care may be a  Objectives:   During the simulated encounter, learners will:  1.  Develop an interdisciplinary, patient centered plan of care  2.  Demonstrate effective communication skills with learner colleagues   Competencies:   1.  Utilize the full scope of knowledge, skills and abilities of available health team members to establish       an interdisciplinary patient plan of care  2.  Choose effective communication tools and techniques to facilitate interdisciplinary team discussions  3.  Engage team members in shared patient-centered problem solving  4.  Apply leadership practices that support collaborative practice and team effectiveness  5.  Reflect on individual and team performance   Simulation Set Up:  1.  Virtual patient 2.  Patient characteristics:  [60] year old female       Healthy appearing; no weight issues  3.  Technologies:  Email,  Social media platform/Twitter (delivery of simulation) and web-based video-conferencing/Zoom/Skype (debriefing and/or interviews) 4.   Patient Chart (or EMR)   Learner Preparation:   1. Assembly of teams and introduction to each other 2. document) 3. Welcome and Orientation to the patient (email patient chart) 4. Information:  You are a [role] in a busy primary care clinic.  You and your team member will be assessing [patient or patients] and planning care for your patient, Wanda LaFleur based on information provided via social media.    Case Information Demographics, Financial & Insurance Status:   Wanda LaFleur is a [60] year old, married female   She is currently employed full time as a bank teller at the credit union  she has worked since  114  graduation from high school Wanda is insured through Blue Cross Community Blue  Wanda completed a high school education  Social:   Wanda lives with her husband in a suburban neighborhood in the home they built in 1968.  Wanda likes to travel, however, her husband does not.  They spend a lot of time at their lake cottage during the summer.  Wanda has 3 married sons, 5 grandchildren, and 1 great-grandchild.  Besides spending time at the cottage, Wanda enjoys reading and gardening. Health Habits / Lifestyle:   Wanda has a 40-year history of smoking 1ppd, husband smokes non-filtered cigarettes.  She rarely drinks alcohol other than occasional wine or margaritas.  She has been physically active until the last year by gardening and walking.  Diet:  Wanda prepares all the meals, which typically consist of meat, vegetables, and starches.  She goes out to eat with her husband approximately 3 lunches and 4 dinners per week.   ADLs & Exercise:   Wanda used to walk every day; she has not been able to for the past year.  Other:   Wanda denies exposures to communicable diseases and has never travelled internationally.     Spiritual:   Wanda attends mass at the Catholic church nearby every week. Family History:   Father Deceased (age 76); History of HTN, diabetes and colon cancer Mother Deceased (age 88); History of diabetes, dementia and coronary artery disease  Past Medical History:   Hypertension (diagnosed 2006)   Diabetes (diagnosed 2005)  Coronary Stenting (June, 2012; drug eluting stent placement in right coronary artery); routine pre-op EKG prompted the cardiac catheterization and resulting stent; mild MI noted  Chronic back pain due to Degenerative Spondylolisthesis in lumbar vertebrae (diagnosed 2010); treatments have included NSAIDS, physical therapy, epidural injections (x8) and spinal fusion  Past Surgical History:    Hysterectomy (1978)  Spinal fusion of L4 & L5 (2014)  Allergies:   NKMA Prescribed Medications:   Norco 7.5 mg/325 mg; 1 tablet orally every 6 hours prn    Zestril (Lisinopril) 10 mg 1 tablet orally daily    115   Humalog 10 Units tid at mealtimes  Plavix (clopidogrel) 75 mg 1 tablet orally daily   Over the Counter Medications:   Aspirin 81 mg orally daily   Motrin 600 mg orally every 6 hours as needed for pain    Vaccines:   Influenza (2014)   Zostavax (January, 2015) Preventative:    Colonoscopy at age 52 (negative)   Mammogram; last 12/2014 (negative) Vital Signs:  Last visit (10/14/2015);     Significant Lab Results (10/14/2015): A1C  7.1 FBS  188 mg/dL Na 137 mmol/L K  4.2 mmol/L Cl  101 mmol/L Creat   2.2 mg/dL Alb  6.9 g/dL T.bili  1.6 mg/dL Direct bili  0.6 mg/dl Uric Acid  .56 mmol/L Total Protein 8g/dl Calcium 10.3 mg/dL Hgb   14.2 g/dL Hct  38% Platelets   330,000 x103/mL HgbA1c   WBC   8,000/ml aPTT   32.0 sec PT  12.0 INR  1.0 Fibrinogen   1.9 g/L Triglycerides   101 mg/dL Total cholesterol  4.0 mmol/L HDL  121  mg/dL LDL   167 mg/dL Amylase   111 u/L Lipase <95 U/L    116    Simulation Script 1.  Day 1-Email patient chart, normal lab value reference and initial instructions 2. Day 2 a.  Tweet 1 (both students)-What are primary concerns for this patient? b. Tweet 2-(nrsg. Student) Send audeo; patient complains of toe pain x2 days c. Tweet 3-To nrsg. Student:  Increased pain; send picture of toe d. Subsequent tweets based on exchange and any requested pt. info 3.  Day 3 a.  Tweet 1-(both students)-send audio; pt. called office during night and left message c/o increased pain, drainage from toe, redness up to knee.  Office schedule is overbooked for the day. b. Tweet 2-(both students)-What are primary concern(s) for this patient?  Priorities?  What treatment options?  Plan of action? c. Subsequent tweets based on exchange and any requested pt. info   Debriefing  Overview:   1.  Welcome students to the debriefing session and introduce faculty who will be conducting the debrief 2.  Outline the debriefing process  3.  Identify the simulation objectives       a.  Using social media platform, primary care of patient with chronic disease      b.  Explore interprofessional  team interactions, communications & collaboration Potential Debriefing Questions:   1.  How well do you think you worked together as a team?   2.  Overall, what went well? 3. If you have a patient like this in real life, what might you do differently ?  4. If you have a similar situation in real life, how might you improve team communication and collaboration?  5.  As a team, how did you decide the plan of care?  Did one team member take primary responsibility or did you distribute equally?  How did that work for you? 6.  What priorities did you identify for the pat 7.  What did you learn about other team members?  8.  What one thing will you integrate into practice?       117  APPENDIX C:                                                                                                                    SocialSim Student Information I. Day 1:  General information and instructions distribited via email A bit of background:   Assume you are both working in a primary care office or clinic.  You will note that your patient has chronic conditions which you will be able to identify given the information provided and in discussing with each other.  There will be an issue that emerges r/t your patient that will be delivered via Twitter.  I have attached a ce) with patient information to provide some background for your patient, Wanda LaFleur.  I have also attached a lab results reference to save time as well.   Pertinent Twitter Handles: Alex: @______ Dawn:  @______ Mary Kay:  @MaryKaySmith2 Wanda:  @WandaLaFleur  Please use the hashtag   #SocialSim___(insert number associated with pair here) Guidelines: 1. The goal is to facilitate a patient case oriented interaction via social media to see if this might be a way to incorporate required interprofessional activities in healthcare education.  learning from each other. 2. I may tweet one or both of you. Hint:  think about that because you may choose to share pertinent information regarding your patient. 3.  Feel free to share any resources with each other via Twitter (e.g. articles, web links, etc.).  There is no minimum or maximum amount of tweets between the two of you; you decide what is necessary to care for your patient. 4. You may email me with any difficulties you may be having. My interactions will be  You can expect tweets from Wanda today and tomorrow. Again, please use Twitter with each other as your primary means of interaction.   Mary Kay Smith (mksmith@msu.edu)  118   II.     Patient :   Wanda LaFleur Demographics, Financial & Insurance Status:  Wanda LaFleur is a [60] year old, married female   She is currently employed full time as a bank teller at a local credit union  and has worked there since graduation from high school Wanda is insured through Blue Cross Community Blue  Wanda completed a high school education  automotive company Social:   Wanda lives with her husband in a suburban neighborhood in the home they built in 1968.  Wanda likes to travel, however, her husband does not and she has not been able to for over 5 years d/t back pain.  They spend a lot of time at their lake cottage during the summer.  Wanda has 3 married sons, 5 grandchildren, and 1 great-grandchild.  Besides spending time at the cottage, Wanda enjoys reading and gardening. Health Habits / Lifestyle:   Wanda has a 40-year history of smoking 1ppd, husband smokes non-filtered cigarettes.  She rarely drinks alcohol other than occasional wine or margaritas.  She has been physically active until the last year by gardening and walking. Diet:  Wanda prepares all the meals, which typically consist of meat, vegetables, and starches.  She goes out to eat with her husband approximately 3 lunches and 4 dinners per week. ADLs & Exercise:   Wanda used to walk every day; she has not been able to for the past year. Spiritual:   Wanda attends mass at the Catholic church nearby every week. Family History:   Father Deceased (age 76); History of HTN, diabetes and colon cancer Mother Deceased (age 88); History of diabetes, dementia and coronary artery disease Past Medical History:   Hypertension (diagnosed 2006)   Diabetes (diagnosed 2005)  Coronary Stenting (June, 2012; drug eluting stent placement in right coronary artery); routine pre-op EKG prompted the cardiac catheterization and resulting stent; mild MI noted  Chronic back pain due to Degenerative Spondylolisthesis in lumbar vertebrae (diagnosed 2010); treatments have included NSAIDS, physical therapy, epidural injections (x8) and spinal fusion Past Surgical History:    Hysterectomy (1978)  119   Spinal fusion of L4 & L5 (2014)  Other:   Wanda denies exposures to communicable diseases and has never travelled internationally. Allergies:   NKMA Prescribed Medications:   Norco 7.5 mg/325 mg; 1 tablet orally every 6 hours prn    Zestril (Lisinopril) 10 mg 1 tablet orally daily    Humalog 10 Units tid at mealtimes  Plavix (clopidogrel) 75 mg 1 tablet orally daily   Over the Counter Medications:   Aspirin 81 mg orally daily   Motrin 600 mg orally every 6 hours as needed for pain  Vaccines:   Influenza (2014)   Zostavax (January, 2015) Preventative:    Colonoscopy at age 52 (negative)   Mammogram; last 12/2014 (negative) Vital Signs:  Last visit (10/14/2015);     Significant Lab Results (10/14/2015): A1C  7.1 FBS  188 mg/dL Na 137 mmol/L K  4.2 mmol/L Cl  101 mmol/L Creat   2.2 mg/dL Alb  6.9 g/dL T.bili  1.6 mg/dL Direct bili  0.6 mg/dl Uric Acid  .56 mmol/L Total Protein 8g/dl Calcium 10.3 mg/dL Hgb   14.2 g/dL Hct  38% Platelets   330,000 x103/mL HgbA1c   WBC   8,000/ml aPTT   32.0 sec  120  PT  12.0 INR  1.0 Fibrinogen   1.9 g/L Triglycerides   101 mg/dL Total cholesterol  4.0 mmol/L HDL  121  mg/dL LDL   167 mg/dL Amylase   111 u/L Lipase <95 U/L  III. Day 1:  Lab reference distributed via email Test Abbreviation Normal Ranges Hematology White Blood Cell WBC Non-Blacks: 4000 - 10,000/ml  (4-10K/mL) Blacks 2800 - 10,000/mL (2.8 -10K/ul) Hemoglobin Hgb M: 13.5-17.5 g/dL F: 12.0-16.0 g/dL Glysolated hemoglobin HgbA1c 5.6 - 7.5 % of total Hgb Hematocrit  Hct M: 41-53% F: 36-46% Red blood cell  RBC M: 4.5-5.9 x 106 cells/mL F: 4.0-5.2 x 106 cells/mL Mean corpuscular volume MCV 80-100 fL Mean corpuscular hemoglobin MCH 26-34 pg/cell Mean corpuscular hemoglobin concentration MCHC 31.5-36.3 gm/dL Reticulocytes Retic 33-137 x 103 cells/mL  121  Platelets Plt 150-400 x 103/mL Erythrocyte sedimentation rate ESR 0-20 mm/hr       Coagulation Parameters Prothrombin time PT 11-14 seconds Partial thromboplastin time PTT 25-35 seconds International normalized ratio  INR 0.8 to 1.2       Chemistry Tests     Sodium  Na+ 136-146 mEq/L Chloride C1- 98-106 mEq/L Potassium K+ 3.5 - 5.0 mEq/L Bicarbonate HCO3 23-29 mEq/L Glucose Glu 70 - 105 mg/dL Creatinine Cr 0.5-1.2 mg/dL Blood urea nitrogen BUN 7-18 mg/dL Calcium Ca2+ 8.5 - 10.5 mg/dL Inorganic phosphorus (phosphate) PO4 3.0 - 4.5 mg/dL Urate (Uric Acid)   M: 3.5 - 7.2 mg/dL F: 2.6 - 6.0 mg/dL Lactate dehydrogenase LDH 88-230 U/L  122  Iron Fe 50 - 175 ug/dL Total iron binding capacity TIBC 250-460 ug/dL Ferritin   20-300 mg/mL Albumin Alb 3.5-6.0 g/dL Total Protein   6-8g/dl Alkaline phosphatase Alk phos 40 - 130 U/L Aspartate aminotransferase AST (SGOT) 12-37 IU/L Alanine aminotransferase ALT (SGPT) 3-25 IU/L Total bilirubin T.bili 0.1-1.2 mg/dL Direct bilirubin   0- 0.2mg/dl Amylase   0 - 130 U/L Lipase   <95 U/L Thyroid stimulating hormone TSH 0.5 - 4.6 uU/ml Thyroxine free FT4 9 - 24 pmol/L Tri-iodothyronine  Total T3 70 -132 ng/dL Cholesterol   <200 mg/dL Fasting triglycerides   <250 mg/dL High density lipoprotein HDL M: 40-50 mg/dL F: 50-60 mg/dL Low density lipoprotein LDL <130 mg/dL Osmolality   270-290 mOsm/kg (L)  123  Urine Analysis     Urine electrolytes Na+, K+, Cl+ variable, wide range Urine osmolality Uosm 38-1400 mOsm/L                    124  Appendix D:   Tweets: A tweet is a message. You have 140 characters, including spaces, to put down your thoughts. send a tweet.  Link shorteners: If you have 140 characters, you don't want to use 50 of them by including a long URL. You need to shorten the URL so that you can save yourself some characters. Most URL shorteners shrink the links to anywhere from 16 to 20 characters.  @ Reply: Your ndle one day prior to start of your simulation. DM: DM stands for direct message.  It is a way to hold a private conversation with another Twitter user, but you can only DM people who are already following you. To send a direct message, type the letter D followed by the username of the twitterer you want to reach, and then messages directly to the individual through your Messages Inbox on your profile. Feel free to  RT: RT stands for retweet.  If you like what someone says on twitter, You can retweet it to spread the message to your followers as well. Note:  Please do not retweet interactions r/t your   Hashtag (#): If you see the pound symbol (#) before a word or phrase, it is essentially a keyword tag for the tweet so that others can find it more easily.  On Twitter, this is called a hashtag, and they can be serious, to help people search for your tweet (like #advice or #blogging) or funny stream of everyone talking about a specific subject. We will use the hashtag #SocialSim Twitter Chat: A Twitter chat happens when several people get on Twitter at once to share ideas with one another.  They do this by using a specific hashtag.  For example, every Sunday, bloggers participate in #blogchat.  Etiquette:  Remember that you are on a public forum. Dotweets.  If you use an affiliate link on Twitter, tweet something sponsored, or link to an ad, make sure you note that in the tweet.    Credit/cite sources. 125  APPENDIX E: Recruitment Flier       I (Mary Kay Smith) am recruiting third year medical students and fourth year nursing students to participate in my study as a component of my doctoral study in the College of Education.    Problem:  Medical and Nursing accrediting bodies require interprofessional education to be included in all programs.  There are many barriers, specifically scheduling students to be in the same place at the same time for simulation.    My study:  I am exploring whether social media can be used as a vehicle to deliver a sivirtually care for.    What would be involved for you:    Participants will be grouped in pairs of one medical and one nursing student  I will send a short pre-questionnaire (10 questions) gathering basic information (program, age, gender, how long you have used social media, etc.)    I will tweet to you and your partner over the course of two days   You will participate in a debrief session using Zoom  I will follow up with a post-interview to gather your thoughts regarding your experience  You will receive a $25.00 Amazon gift card and certificate of participation as a THANK YOU!           PLEASE CONTACT Mary Kay Smith via email (mksmith@msu.edu) or phone (517-353-5162) if interested.  126      1.  a.    2.  a. - b. - c. - d.  3.  a.  b.  4.  a. - b. - c.  5.  a.  b.  c.  d.  e.     127  6.  a.  b.  c. - d. - 7.  a.  b.  c.  d.  e. - 8.  a.  b.  9.  a.  b.  10.  a.  b.   128  APPENDIX G: Research Participant Information and Consent Form    1.  EXPLANATION OF THE RESEARCH and WHAT YOU WILL DO:      You are being asked to participate in a research study regarding the use of social media to deliver an interprofessional simulation.  Your input regarding the usefulness of this method is extremely valuable as it will contribute to healthcare professional education and the field of healthcare simulation.  You will complete a survey collecting basic information related to demographics, previous participation in interprofessional education and use of social media.  A small group of participants (twelve pairs of one medical and one nursing student) will be selected to participate in the simulation and follow-up interview based on this information.  If you are selected for the simulation phase, you will schedule a time to participate in a virtual simulation delivered via Twitter intermittently over the course of two days.  Total time commitment is expected to be approximately two hours.  The primary investigator will interview you after the simulation for approximately 30 minutes.  You must be at least 18 years old to participate in this research.  2. YOUR RIGHTS TO PARTICIPATE, SAY NO, OR WITHDRAW:   Participation in this research project is voluntary.  You have the right to say no. You may change your mind at any time and withdraw. You may choose not to answer specific questions or to stop participating at any time.   3.  COSTS AND COMPENSATION FOR BEING IN THE STUDY:         There are no costs associated with participating in the study. o You will be compensated for your time with a $25.00 Amazon gift card, which will be emailed directly to you after the interview has been completed.  4.  CONTACT INFORMATION FOR QUESTIONS AND CONCERNS:      If you have concerns or questions about this study, such as scientific issues, how to do any part of it, or to report an injury, please contact the researcher:  Mary Kay Smith, PhDc, MSN, RN, CHSE  HALE Doctoral Candidate 965 Fee Rd., A601 E. Fee Hall mksmith@msu.edu 517-353-5162  Or  Dr.  John M. Dirkx, Ph.D.  Professor, Higher, Adult and Lifelong Education Michigan State University 517-353-8927   If you have questions or concerns about your role and rights as a research participant, would like to obtain information or offer input, or would like to register a complaint about this study, you may contact, anonymously if you wish, the Michigan State Un-355-2180, Fax 517-432-4503, or e-mail irb@msu.edu or regular mail at Olds Hall, 408 West Circle Dr Rm 207, East Lansing, MI 48824.   129     I.  A.  1.  2.  II.  A.  B.  C.  D.  E. -    130  III.  A.  B.  C. - D.  IV.  A. -   131     1.  a.  b.  2.  a.  b.  3.  a.  b.  c.  4.  a.  b.  c.  5.  a.  b.  c.   6.   132  7.  8.  a.  9.  a.                   133  APPENDIX J:                                                      Simulation Fiction Contract   The purpose of simulation-based healthcare training is intended for you to develop skills, including judgment and reasoning, for the care of real patients. Using patient simulators and/or other simulation teaching techniques, faculty will recreate realistic patient care situations. The realism of each simulation may vary depending upon the learning goals for the session. The simulated environment and patient(s) have certain limitations in their ability to exactly replicate real life.  When participating in the simulations, your role is to assume all aspects of a practicing healthcare provider professional behavior. Additionally, when a gap occurs between simulated reality and actual reality, it is expected that you try to understand the goals of the learning session and behave accordingly.  All patient information is to be kept confidential and reproduction and/or sharing with others is not permitted.  Faculty Responsibilities:   Create goal-oriented, practical simulations based upon measurable learning objectives.   Add enough realism to each simulation so that the learner receives enough clues to identify and solve a problem.   Set and maintain an engaging learning environment.   Provoke interesting and engaging discussions and fosters reflective practice.   Identify performance gaps and helps close the gaps.  Learner Responsibilities:   Suspend judgment of realism for any given simulation in exchange for the promise of learning new knowledge and skills.   Maintain a genuine desire to learn even when the suspension of disbelief becomes difficult.   Treat the simulated patient with the same care and respect due an actual patient.       Learner Signature                                         Faculty Signature  Date________________________________ Date__________________________________   134                            135    -      -  Adams, N.B., DeVaney, T.A., & Sawyer, S.G. (2009). Measuring Conditions Conducive to Knowledge Development in Virtual Learning Environments: Initial Development of a Model-Based Survey. Journal of Technology, Learning, and Assessment, 8(1), 4-24.    American Association of Colleges of Nursing (2013). Standards for accreditation of  baccalaureate and graduate nursing programs. Washington, D.C.: Commission on Collegiate Nursing Education.      -   -------  Atherton, J. (2013) Learning and Teaching; Constructivism in learning. Retrieved  from   http://www.learningandteaching.info/learning/constructivism.htm     -  -    -    -    -          136      -   -             -    -      -    -  --    -  --         -  Creswell, J.W. (2009). Research design: Qualitative, quantitative and mixed     methods approach. Thousand Oaks, CA: Sage Publications.     -            137               -    -    -    -    -  -    -      -  -        -  Gaba, D. (2008). What does simulation add to teamwork training? AHRQ morbidity and mortality. Retrieved from http://www.webmm.ahrq.gov/perspective.aspx?perspectiveID=20&researchStr=Gaba+DM         138   -   - -      -  -  -  Gilles, C., Cole, G., Brisbin, K., Huffman, D., Cragg, B., Lamacchia, M., Norman,  D. (2013) Simulation in healthcare: A taxonomy and a conceptual framework for instructional design and media selection. Medical Teacher. Retrieved from http://www.tandfonline.com/doi/pdf/10.3109/0142159X.2012.733451        -    -  -   -    --  -   -           139         -    -                                  -  -                140          -                     -  -         -             ------------         141               -    -    -  Merriam, S. (2004). The changing landscape of adult learning theory. In J. Comings, B. Garner,  & C. Smith (Eds.). Review of adult learning and literacy: Connecting research, policy, and practice. Mahwah, NJ: Lawrence Erlbaum Associates.    -    -       -            ---        142   ------   ------  -    ----- -       ---      -        -  -      -------  -             143    -  -  --------    --    -   --------   -            -            -   -        144               --  -    -               -           -  -    -