Using a Standardized Patient Model for Interprofessional Team Training in Social Work

The purpose of this article is to describe the development of a single-session Interprofessional Team (IPT) Training that incorporates the practice of interprofessional teamwork using a health care case study. We will share how a large-scale training that requires interprofessional teams of students to create a treatment plan of care for a standardized patient developed over time and how this experiential learning activity affects learning outcomes for social work students related to interprofessional awareness and teamwork skills. Additionally, we will explore the use of video technology as a pedagogical approach to presenting standardized patients to students. Student responses from three IPT Training sessions provided the data discussed in this article. While overall results are mixed about students’ learning outcomes, trends in the data show this single-session, interprofessional training involving a standardized patient as a promising practice. Lessons learned for social work education are also discussed. The present study advances the field of interprofessional simulation by contributing to our understanding of how a team-based training combined with a standardized patient can be used to increase social work students’ professional awareness about interprofessional teamwork.

As defined by the World Health Organization (2010), interprofessional education (IPE) occurs when two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes for individuals and communities. IPE is now considered an essential part of the curricula in US colleges and universities that are educating the next generation of health care professionals, including social work education (Council on Social Work Education [CSWE], 2015; Interprofessional Education Collaborative [IPEC], 2019). While IPEC (2016) offers guidance for key competencies needed by students graduating from health care degree programs, the questions of how and when to incorporate IPE learning activities into curricula is a challenge for educators across all healthcare professions. In this article, we explore the development, implementation, and evaluation of an IPE learning activity at one university that uses a standardized patient model with large groups of students from nine professions including social work, nursing, and medicine, and report on how this activity affects social work students' perceptions of interprofessional collaboration.

Benefits and Challenges of IPE
Innovative interprofessional curriculum is critical for preparing a future healthcare workforce in the US that is capable of serving the increasingly complex needs of patients living in our community. Optimizing patient experiences, improving population health, and bettering the working lives of healthcare providers, while simultaneously reducing costs, known as the quadruple aim of healthcare delivery, necessitates working in highly functional interprofessional teams (Bodenheimer & Sinsky, 2014). Effective interprofessional communication, role clarity and teamwork are critical for patient safety. Higher team functioning in the context of interprofessional models of care is associated with lower mortality rates and better health outcomes for patients (Wu et al., 2018). Interprofessional healthcare teams, working within coordinated models of care, can reduce patient length of stay, improve patient health and health literacy and prevent readmission to hospital (Berwick & Hackbarth, 2012;Blewett et al., 2010).
Students in healthcare professions must be trained in effective, meaningful participation in interprofessional teamwork in order to provide them with the skills necessary to succeed in our current and future healthcare systems. Purposefully designed, interprofessional, team-based learning experiences, have demonstrated potential to improve student attitudes and skills in working with other professional groups (Kaminetzky et al., 2017;White et al., 2013;Wu et al., 2018). Additionally, high quality interprofessional educational experiences for interprofessional learners include a clear rationale, outcome-based goals, deliberate design, and coordinated assessment and evaluation (Health Professions Accreditors Collaborative, 2019). Educational experiences are capable of breaking down the traditional barriers to build mutual respect, appreciation for shared knowledge and shared experiences, while helping students to appreciate the roles and responsibilities each profession brings to the healthcare team (Homeyer et al., 2018).
Educators tasked with preparing students for the interprofessional healthcare workforce of the future, require resources and willingness to step outside traditional professional silos with the explicit goal of helping students learn from, with, and about other professions in the healthcare team. Logistic challenges can be significant and are often reported as key barriers limiting widespread use of interprofessional education across U.S. college campuses. Barriers to interprofessional education include lack of designated funding for activities, high volume of learners, space and time limitations, and diverse program curricula requirements (Freeth & Reeves, 2004). Interprofessional education programs should therefore be designed with the intent of overcoming known barriers and promoting enablers to developing skills in effective interprofessional teamwork and communication. In this paper, we share how a large-scale training that requires interprofessional teams of students to create a treatment plan of care for a standardized patient developed over time to address many of these common logistical challenges.

IPE in Social Work Education
The social work profession has long articulated the need for interprofessional education, especially for social workers practicing in settings where social work is not the dominant profession such as hospitals and schools. At the annual meeting of the Council on Social Work Education (CSWE) in 1968, Dana, along with colleague Dr. Sheps noted that "the successful outcome of new educational ventures into interprofessionalism will be dependent upon the degree to which professional schools themselves demonstrate the principles of interprofessional behavior in designing and implementing new ways for students to learn together" (Dana & Sheps, 1968, p. 41). More recently, this call to action has been operationalized by the CSWE's membership in the Interprofessional Education Collaborative (IPEC) in 2016 as well as CSWE's 2018 annual conference being devoted to the theme of interprofessional education. Further, current leaders in social work education have been calling for more emphasis on practical and meaningful educational experiences where social work students are at the same table as students from other professions, learning about other professions' roles as well as effective collaborative processes (Jones & Phillips, 2016;Rubin et al., 2018) Among social work curricula, IPE has been a growing area of educational innovation. Recent studies of various IPE activities with social work students have shown positive student learning outcomes associated with attitudes and beliefs toward interprofessional collaboration. For example, Wharton and Burg (2017) found that working with medical and pharmacy students on health-related cases increased social work students' confidence in their role on an interprofessional healthcare team. Others have found that social work students can learn about how poverty affects health outcomes by participating in a teambased poverty simulation with other professions such as nursing and occupational therapy (Hitchcock et al., 2018;Vandsburger et al., 2010). Additionally, the social work profession has demonstrated diversity in IPE by working with disciplines such as K-12 education, business, and social innovation as well as the traditional health care professions (Archibald et al., 2016;Lopez et al., 1998). As more social work educational programs expand their curricular efforts to incorporate interprofessional skills for teamwork, faculty will need to develop evidence-informed practices that promote positive student learning outcomes across a variety of educational activities.

Standardized Patient Model in IPE
One important modality of interprofessional education involves the use of standardized patients (SPs). SP methodology provides a gold standard for education and assessment of learner performance in a clinical health care setting (Palaganas et al., 2014). SPs are individuals who have been trained to portray a patient in a scripted case scenario and are able to consistently deliver a standardized performance when interacting with different students or groups of students. The use of SP methodology in formative educational activities and high stakes summative assessment has been extensively documented and its ability to bring the human touch to simulation is undeniable (Kaplonyi et al., 2017).
The use of SP methodology in IPE allows students to practice acquired skills and behaviors around patient care while gaining knowledge from the nuances associated with human interaction. In IPE, working with an SP while simultaneously interacting with other health professional students can foster insight and understanding into individual roles and tasks within the healthcare team (Wamsley et al., 2012). In addition, education around communication skills is a hallmark of SP methodology. It has been shown that practicing interpersonal communication with SPs results in better communication skill acquisition than practice with peers (Schlegel et al., 2012). While the use of SPs to enhance interprofessional communication and teamwork has been reported, this has commonly been done in small group settings (Bays et al., 2014;Foronda et al., 2016). Small group settings do aid in recreating the healthcare team approach by selectively limiting number and types of participants. However, small group formats do raise certain curricular design challenges when dealing with large numbers of students representing many schools. Designing large group interprofessional activities, particularly those involving considerable student cohorts, often come with logistical and financial challenges. The use of virtual patients or web-based SP encounters can provide a platform to assure learners are provided equal opportunity often at a lower cost to stakeholders (Lempicki & Holland, 2018;Reis et al., 2015). Here, we will report the use of videotaped patient interviews using a SP that combines patient history acquisition with continuum of care.

Standardized Patients in Social Work Education
Scholarship about the use of standardized patients or clients in social work education primarily follows two models -a formative SP-based learning experience, and summative encounters (e.g., objective structured clinical exams). The formative learning experience typically involves an actor or theatre student in the role of a client who is based on a case study developed by a faculty member with the goal of improving student skills and competency related to specific course content (Badger & MacNeil, 2002;Mooradian, 2008). Research on these learning experiences has found that the use of SP Methodology can increase interviewing and assessment skills as well as their knowledge about specific clinical situations such as domestic violence or adolescent sexuality (Forgey et al., 2013;Logie et al., 2015). Other examples of the formative use of a standardized patient model in social work includes virtual patients to increase knowledge about brief assessment skills in medical settings (Hitchcock et al., 2019;Washburn & Zhou, 2018), and live patients to practice interprofessional communication skills among a team of health care students (Wharton & Burg, 2017).
This article describes the development, implementation, and evaluation of a singlesession training that incorporates the practice of interprofessional teamwork using a SP health-based case. The authors will meet this aim in two ways. First, we will describe the large-scale training that requires interprofessional teams of students to create a treatment plan of care for a SP which has been developed over time and how this experiential learning activity affects learning outcomes for social work students related to interprofessional awareness and teamwork skills. We will also explore the use of video technology as a pedagogical approach to presenting standardized patients to students, which can provide efficiency in educational delivery and mitigate the need for multiple spaces and extensive human resources when providing valuable IPE content to hundreds of learners from multiple health professional schools. Second, we will share data about student responses from three Interprofessional Team Training (IPTT) sessions, providing a combination of quantitative and qualitative data that informs student learning. Lessons learned from IPTT are discussed for IPE generally and for social work education specifically.

Description of Interprofessional Team (IPT) Training Activity
The University of Alabama at Birmingham (UAB) IPTT was originally conceived and designed in 2009 as a part of the Health Resources and Services Administration-funded UAB Geriatrics Education Center (UAB GEC) to provide an opportunity for health professions students to experience interprofessional team-based care (Rothrock et al., 2013). In its earliest iterations, large groups of 300-350 students from nine health professions (Social Work, Nursing, Medicine, Pharmacy, Dentistry, Occupational Therapy, Physical Therapy, Optometry and Nutrition) gathered in a lecture hall for a 60minute presentation. After a brief introduction to interprofessional teamwork, a real patient was interviewed sequentially by a professional, typically a faculty member, from each of the nine different health professions, and students were tasked to take notes. Each professional had approximately 5-minutes to ask questions to complete their assessment and were asked to focus their questions on specific aspects of their scope of practice. For example, the social work faculty frequently asked questions of the real patient about family involvement and financial resources. distributed model. In this model, students reported to small group rooms at the start of the activity. The patient interview was replaced by a 4-minute video of a standardized patient talking about his various health-related problems. Table 1 provides a summary of the different models of this training for the following elements: 1) amount of time allotted for the training; 2) predictability of the standardized patient; 3) physical space requirements; and 4) proctor requirements. An overview of the Distributed Model for the IPT Training can be found in Table 2, from start to finish. The training starts with some preparatory information which is sent to students via email. They are given their group room assignments and are directed to resources to help them craft their "elevator speech". On the day of the event, students arrive directly to their assigned room. The faculty preceptor screens the video, and then students break into pairs to give a 30-second summary outlining their profession's scope of practice. The next part of the training is an interactive group discussion. Students then discuss the case in detail, and work as an interprofessional team to develop their own care plan for the patient. This new model takes about 90 minutes to complete, which considerably improved student satisfaction on a Friday afternoon and eliminated both the long-observed interview component, and the cumbersome transition times seen with the previous model.
Faculty preceptors for the small groups are recruited from a large pool of experienced faculty, many of whom have been with this activity since the beginning. Using a "train-the -trainer" approach to maintain quality and consistency, new faculty volunteers are paired with an experienced preceptor the first time they participate to get a realistic preview before they facilitate a small group on their own. The focus on preceptor training is to provide strategies that will enable preceptors to create opportunities for students to practice effective interprofessional communication and teamwork regardless of the mix of professions within the group. Learners watch standardized patient video 15 min.
Intraprofessional discussion for each group of professional students 5 min.
Consider what additional information might be needed. Reflect on role overlaps/differences 40 min.
Learners prioritize goals for patient care and develop a care plan 15 min.
Reflection: role similarities/differences, cross profession interaction, "takeaways" 10 days after activity Learners sent link to post-activity attitudes/skills evaluation

Standardized Patient
Because the original IPT Training was developed by the Geriatrics Education Center at (de-identified), the SP is an older adult with multiple health care problems. Along with watching the video of the patient talking about their health concerns, the students are provided with a two-page handout that includes: 1) past medical, surgical, vision and dental history; 2) a medication list and lab results; and 3) a social history. Table 3 provides some examples of the standardized patient's health concerns. Last saw a dentist four years ago

Participants and Setting
The Office of Interprofessional Curriculum at the University of Alabama at Birmingham hosted three IPT Trainings over three semesters during 2018 and 2019. During the Spring 2018, Fall 2018, and Spring 2019 semesters, a total of 1,015) from nine professional health care programs at UAB and Samford University were invited and participated in the IPT Training. These disciplines included dentistry, medicine, nursing, nutrition, optometry, occupational therapy, pharmacy, physical therapy, and social work. A total of 287 participants completed both the pre-and post-event surveys for a response rate of 28%. There were 77 social work participants and all of these students completed the pre-event survey, and only 20 students completed both the pre-and post-event surveys for a response rate of 26%. For this activity, small group rooms were used to comfortably accommodate groups ranging from 12 to 25 learners. The size of the small groups varies depending on the number of available preceptors and the number of students from each profession. Rooms were equipped with the necessary audio/visual systems.

Design
The IRB at the University of Alabama at Birmingham granted exemption for the study, "Effect of an Interprofessional Team Training Exercise on Attitudes towards Interprofessional Teams among Students in Health Professions" (IRB_300000478). A preand post-event survey design was used to collect data from the participants. A paper version of the survey was distributed to all participants at the beginning of the IPT Training, and they were asked to complete the survey before the event started. Post-event surveys were collected using Qualtrics, a digital survey tool, and were sent electronically to all participants via email approximately one week after the experience. Pre-and post-event responses were collected from 287 participants.

Measurements
Demographics and health profession major were collected from each participant. Quantitative measures were used to assess changes in student attitudes towards interprofessional teamwork. The revised version of Dow's IPEC Competency Self-Assessment Tool was used to assess overall attitudes toward interprofessional teamwork (Dow et al., 2014;Lockeman et al, 2019). The original version of this assessment tool consisted of a 42-item self-assessment questionnaire. The Dow Team revised the tool in 2015 and revalidated this version 3 in 2016. It now consists of 16 items assessed on a 5point Likert scale. The tool that was used consists of two domains, one to assess attitudes toward interprofessional interaction and one to assess interprofessional values. Additionally, three items were included to assess the participants overall satisfaction with the learning experience. The items were as follows: a) "This was a valuable learning experience;" b) "The preceptor was well prepared;" and c) "The preceptor effectively led the activity." These items were rated on a 5-point Likert-type scale (1= strongly disagree to 5= strongly agree). The participants were also given the opportunity to provide comments at the end of the survey using an open-ended prompt.

Analyses
Analyses were conducted using IBM SPSS Statistical Software (Version No. 25). The authors conducted univariate analyses to generate means, frequencies and proportions for the demographic and outcome variables. Because the data could not be matched by participant between pre-and post-event, to look at differences between the social work students' preand post-event scores, cross tabulations and T-tests for unequal variances were conducted. The analyses used an alpha level of .05 for all statistical tests. Because of the low number of qualitative comments, no thematic analysis could be completed, but representative comments are provided in the results section for context.

Results
While students from multiple professions participated in this event, we were interested in how the social work students' attitudes toward interprofessional teamwork changed due to this training. Table 4 provides demographic information of all the student participants who completed both the pre-and post-event survey, specifically, in terms of race, gender and major. Most of the participants identified as female (69%), white (54%), and between the ages of 20-29 years (93%). Additionally, Table 4 shows the demographic information for all social work students who completed both the pre-and post-event survey and the just the pre-event survey. Among all students participating in the IPT Training, a majority (78%) rated it a valuable learning experience. In Figure 1, 65% of social work students "strongly agreed" whereas only 32% of total participants "strongly agreed" the training was a valuable learning experience. One caveat is that the social work student data is included in the total participant data, thereby positively influencing the response pattern of the group. When social work students were excluded from all participants, only 30% of all participants found the event to be a valuable learning experience.

Figure 1. Reported Ratings of That IPT Training Provided a Valuable Learning Experience
In terms of specific learning outcomes, Table 5 shows the mean scores and standard deviations for pre-and post-event measures for the social work students for the interprofessional competency scale and each of the domains assessed within the tool. These means were compared using independent-sample t tests (alpha value of 0.05), and results found no differences between students' attitudes on interprofessional teamwork for the full scale as well as the two domains, interprofessional interaction and interprofessional values. A small number of all the participants (10%) provided written comments about their experience with the IPT training, and while the number does not reflect generalizable qualitative results, they do inform future topics for further exploration for similar interprofessional activities. Table 6 shows representative comments from the social work participants, mapped with possible themes for future exploration based on the Interprofessional Education Collaborative's Core Competencies for Interprofessional Collaborative Practice (IPEC, 2016). For example, Quote #1 from a social work student could represent that the social work student was apprehensive about working with interprofessional teams or that they embrace commonly held stereotypes about other health care professionals. Similarly, Quote #2, from another social work student, could reflect that the student had difficulty engaging with students from other health professions or perhaps is unclear about the role of social workers in medical settings. While these quotes are not generalizable, they suggest that rich learning can take place during the IPT Training. Additionally, there is a need for more mixed methodology when assessing student learning with interprofessional activities. Competency #4 -Team and Teamwork ▪ Engage health and other professionals in shared patient-centered and population-focused problemsolving (Sub-competency TT3) ▪ Reflect on individual and team performance for individual, as well as team, performance improvement (Sub-competency TT8) ▪ Perform effectively on teams in different team roles in a variety of settings (Sub-competency TT11)

Discussion
The present study advances the field of interprofessional education in two ways. First, this innovative program, using a video-based standardized patient, offers a viable interprofessional education experience for health care professions, including social work students, which could be replicated by other institutions. Second, it contributes to our understanding of how an assessment on the effectiveness of team-based interprofessional trainings need to be structured, especially to assess social work students' professional awareness about interprofessional teamwork.
While social work students did not demonstrate an improvement in attitudes towards interprofessional teamwork, we suspect this was due to the very positive attitudes students reported on our survey instrument before they began the training, possibly due to confidence in their knowledge and skills or wanting to provide socially desirable responses. Additionally, this lack of significant change in attitudes toward interprofessionalism between may be because of the low sample size for social work students. Future assessment of the effectiveness of the program will account for these limitations.
But written comments suggest that this experience may influence students' understanding of specific IPEC competencies and sub-competencies, and this worthy of further investigation. Combined, these data suggest that current scales to assess attitudes toward interprofessional teamwork may be too blunt to assess the complexity of interprofessional competencies across multiple professions. To further assess, in Fall 2019, the team is testing a different instrument, the Interprofessional Collaborative Competency Attainment Survey (Archibald et al., 2014), which uses a post-pre and post-activity methodology. Additionally, post-retrospective research designs may better compensate for the natural tendency of learners to rate themselves higher on attitudes and knowledge related to interprofessional competencies prior to an interprofessional learning activity. Future research studies should address these limitations.
Another interesting finding is the marked difference in the reported value of the IPT Training as a learning experience between social work students and all other health professional students, with a higher percentage of social work students reporting the IPT Training as a valuable learning experience. While this is an area for future exploration, one possible explanation for these differences is that social work students at UAB participate in fewer IPE events than the other health care students due to curricula differences and location of the program within the university's administrative structure. Social work students' higher satisfactions scores may be because IPE events are more novel for them. Adding questions about students' prior experience with IPE combined with an open-ended survey question could uncover reasons for this difference in satisfaction with the Training.

Lessons Learned
This study offers many lessons learned for social work and other health care educators interested in designing and implementing IPE activities. First, the use of a standardized patient model offers several advantages, such as: allowing for a more consistent and inclusive educational experience for this diverse group of learners; and providing a more condensed and efficient version of the training. Second, the transition to the video interview was a welcome change from the point of view of the standardized patient, who appreciated the improvement in role clarity. The individual in the role of the standardized patient reported it was challenging to prepare for the live interviews because of the diversity of clinical information they had to memorize, as well as the potential that they would be asked questions for which they were unprepared. Third, instruments designed to assess attitudes toward interprofessional teamwork are often not adequate to detect a change in attitudes or understanding. Research shows that students often overrate their abilities, thus, when using some pretest instruments they will rate themselves at the high end of the scale leaving little or no room for an increase to be measured post activity (National Association of Colleges and Employers [NACE], 2018). More collection of qualitative data may be needed to better understand the social work student experience in a large interprofessional training program. Finally, one potential area for further research is to assess if differences among the small group faculty preceptors have any effect on student learning outcomes. These individuals will have varying levels of comfort facilitating discussion of all aspects of the case and engaging learners from all different healthcare professions. Overall, interprofessional educational activities such as the IPT Training offer social work educators a rich opportunity to improve competencies among social work and other health care students related to teamwork and the contributions of the social work profession to the health care team.