ORIGINAL REPORTS

Attitudes Toward Communication and

Collaboration After Participation in a
Mock Page Program: A Pilot of an
Interprofessional Approach to Surgical
Residency Preparation
Angela J. Arumpanayil, MSN, AGACNP,* Chris Winkelman, PhD, ACNP, FAANP, FCCM,*
Kelly K. McConnell, DNP, MSN, AGACNP,* Michael R. Pelyak, MN, RN,*
Christopher P. Brandt, MD, FACS,†,‡ and Jeremy M. Lipman, MD, FACS†,x

*
Case Western Reserve University, School of Nursing, Cleveland, Ohio; †Case Western Reserve University,
School of Medicine, Cleveland, Ohio; ‡MetroHealth Medical Center, Cleveland, Ohio; and xCleveland Clinic,
Cleveland, Ohio

OBJECTIVE: A source of insecurity among new physi-
cians and new nurses is communicating and managing
acute changes in patient condition. Mock page programs
are an effective method for teaching communication and
clinical decision-making skills to medical students. Joint
participation in a mock page program provides a unique
opportunity for medical and nursing students to practice
communication, collaboration, and clinical decision-
making in a low-risk learning environment. The purpose
of this pilot study was to examine attitudes toward com-
munication and collaboration among medical and nurs-
ing students after participation in a mock page program.
DESIGN: Twenty-four medical students participating in
a surgical residency preparatory course were paired
with 24 senior level nursing students. Over a period of 3
weeks, nursing students delivered 5 mock pages to the
medical students. Mock pages consisted of peer-
reviewed, prescripted scenarios depicting patients
experiencing common postoperative complications. A
12-question survey measuring attitudes toward commu-
nication and collaboration between physicians and
nurses was administered prior to delivery of the first
page and after delivery of the last page. A dependent
sample t test was used to perform item analysis.
RESULTS: Individual item analysis of medical student sur-
veys indicated significant improvement in attitudes toward
Correspondence: Inquiries to Angela J. Arumpanayil, MSN, AGACNP, Frances
Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid
Ave, Cleveland, OH 44106; e-mail: ajm10@case.edu
Funding: This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.
communication and collaboration with nurses in 12 out of
12 survey items (p < 0.05). Individual item analysis of nurs-
ing student surveys indicated significant improvement in
attitudes toward communication and collaboration with
physicians in 6 out of 10 survey items (p < 0.05). There
was no decline in attitudes among any of the survey items.
CONCLUSIONS: The results from this study suggest that
an interprofessional mock page program improves atti-
tudes toward communication and collaboration
between medical and nursing students. This program
has the potential to improve the quality of education
and increase confidence among medical and nursing stu-
dents as they prepare for their professional roles. ( J Surg
Ed 75:14911497. Ó 2018 Association of Program
Directors in Surgery. Published by Elsevier Inc. All rights
reserved.)
KEY WORDS: Medical student, Nursing student, Resi-
dency preparation, Surgical education, Interprofessional
education, Mock page
COMPETENCIES: Interpersonal and Communication
Skills, Professionalism, Systems-Based Practice, Medical
Knowledge, Patient Care
INTRODUCTION
Surgical residency preparatory courses improve the con-
fidence, knowledge, and skill of entering residents.16
In 2014 the American Board of Surgery, Association for
Surgical Education (ASE), and Association of Program

Journal of Surgical Education  © 2018 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 1491
Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsurg.2018.04.023
Directors in Surgery (APDS) issued a joint white paper
stating that “requiring all matriculants of surgery residen-
cies to successfully complete a multidimensional prepa-
ratory course before residency should accelerate the
speed at which trainees acquire basic clinical and techni-
cal skills and reduce variability in these skill sets among
entering residents.”7 This has led to the collaborative
creation of a “Resident Prep Curriculum” by the Ameri-
can College of Surgeons, ASE, and APDS.8
A key component of many residency preparatory
courses is a mock page program. This has been shown
effective in teaching interprofessional communication
skills and clinical decision-making to medical students.9
At our institution, like many others, the mock page com-
ponent of our surgical residency preparatory course has
been delivered by advanced practice registered nurses
(APRNs) with focused training to support this offering.
The program has consistently been highlighted by par-
ticipants as a critical component of the course.
We hypothesized that the mock page program could
be an opportunity for interprofessional education of
both medical and nursing students at our institution.
Specifically, if nursing students delivered the pages,
rather than APRNs, this program would offer experien-
ces in interprofessional communication and shared deci-
sion-making to both participants. The purpose of this
pilot study was to explore attitudes toward communica-
tion and collaboration among medical and nursing stu-
dents, before and after participation in a mock page
program. Also, this pilot was designed to determine the
feasibility of transitioning to senior nursing students for
delivery of pages.
METHODS
This was a prospective repeated measures study in which
online surveys were administered at baseline and repeated
at the conclusion of the mock page program. Twenty-four
medical students in their fourth year participated in the
mock page program as a component of their month long
surgical residency preparatory course, based on the ACS/
APDS/ASE Resident Prep curriculum. Fourth year Bachelor
of Science in Nursing students at the same institution were
recruited to participate in the mock page program and
research study on a voluntary basis. There were no exclu-
sion criteria. Thirty-three Bachelor of Science in Nursing stu-
dents volunteered and 24 were selected at random using
the lottery method. Each nursing student was randomly
paired with a medical student. University Institutional
Review Board approval granted exempt status.
A standardized approach to the mock page program
previously published in the literature was adapted for
this project.10 Details pertaining to the mock page
1492 Journal of Surgical Education  Volume 75 /Number 6  November/December 2018
process are provided in Appendix A. One of our unique
adaptations to this program was using nursing students
rather than APRNs to deliver pages and feedback to the
medical students. A total of 5 pages were delivered in
this program.
Nursing students had 2 roles for each of the 5 mock
pages. The first was to initiate the page and deliver
patient information provided in a standardized script.
The second was to provide immediate feedback to the
medical student using a standard rubric. Nursing student
participants were prepared for both roles with 3 training
sessions over the course of 4 weeks. Participation in the
mock page program was not a required component of
coursework for nursing students. Nursing students were
compensated with a $10 retail gift card. Institutional
funding for gift cards was provided by the School of
Medicine.
Prior to the start of the mock page program, all stu-
dents were asked to complete a 12-question online sur-
vey. The “Communication, Collaboration and Critical
Thinking = Quality Patient Outcomes” survey tools are
freely available on the Institute for Healthcare Improve-
ment website11 and were adapted for this study with
permission from the original authors. Medical students
were asked to complete the “Communication, Collabora-
tion and Critical Thinking = Quality Patient Outcomes
Physician Survey Tool” and nursing students were
asked to complete the “Communication, Collaboration
and Critical Thinking = Quality Patient Outcomes
Nurse Survey Tool." All participants were invited to
complete the survey a second time at the end of the
mock page program. A third invitation to complete
survey tools occurred 8 days after the second survey
was completed, as a test-retest measure of reliability.
Each survey completion required approximately 5
minutes of student time. Upon completion of the 5
mock pages and after administration of the posttest
surveys, medical and nursing students gathered for a
group dinner and debrief.
Item analysis comparing pretest and posttest
responses was performed through the use of the depen-
dent samples t test. Cronbach’s a was performed as a
test of reliability for the survey tools. All surveys were
administered through REDCap secure online survey soft-
ware. SPSS version 23 statistical software was used to
analyze the data.
A final component of the mock page program was
debriefing. Nursing school faculty attended weekly med-
ical student debriefing sessions. Additionally, a com-
bined debriefing with both medical and nursing
students was held upon conclusion of the program, a
second unique component of this activity. The com-
bined debriefing included collection of comments for
qualitative summary.
RESULTS
All 24 medical students enrolled in the surgical residency
preparatory course participated in the mock page pro-
gram as a required component of the course. Twenty-
three students consented to participate in the research
component of this program, agreeing to complete 2 sur-
veys. The average age of medical students was 26.6 years
and 78% were male (n = 18). Nineteen medical students
completed both pretest and posttest surveys (82.6%).
Item analysis of medical student surveys indicated signifi-
cant improvement in attitudes toward communication
and collaboration with nurses in 12 out of 12 survey
items (p < 0.05, Table 1).
Twenty-three nursing students completed delivery of
the mock pages; 1 nursing student withdrew due to
schedule conflict prior to the delivery of the first mock
page. The average age of nursing students was 21.3 years
and 8% were male (n = 2). Nineteen nursing students
completed both pretest and posttest surveys (82.6%). A
total of 6 items in the nursing student survey demon-
strated significant improvement from baseline (p

0.05, Table 2). There was no decline in the mean scores
in survey items.
Differences in the scores of 2 items in the nursing stu-
dent survey were not analyzed due to low response rates
(Table 2). The low response rates appeared to have
resulted from an error in administration of the online
survey. Survey items were analyzed independently and it
is unlikely that the lack of response to these 2 items had
an effect on responses to the remaining items.
Cronbach’s a for pretest, posttest, and retest of the
medical student survey was 0.79, 0.90, and 0.87, respec-
tively. Cronbach’s a for pretest, posttest, and retest of
the nursing student survey was 0.77, 0.87, and 0.74,
respectively. These results support moderate-to-strong
reliability of the survey tools.
Informal qualitative observations were collected at
debriefing sessions for both medical and nursing stu-
dents. Both groups of students verbalized nervousness
surrounding the initial mock pages and described less
nervousness over time. Themes gathered from medical
student debriefings for the mock page program included
concerns around not knowing when pages would be
delivered, not having a hand-off report with basic patient
information, and a desire to provide evaluation of the
nursing student’s ability to communicate effectively.
Nursing students expressed some frustration over using
prescripted scenarios and not being able to formulate
their own Situation, Background, Assessment, and Rec-
ommendation (SBAR) statement. They also had concern
that medical students may be sharing information regard-
ing the particular scenarios among each other.
Both medical and nursing students voiced apprecia-
tion for the opportunity to engage in this interprofes-
sional education activity before assuming postgraduation

TABLE 1. Physician Survey Tool-Comparison of Results at Baseline and After Completion of 5 Mock Pages
Paired Differences
Item n Mean T1 Mean T2 Mean SD t df p Value*

Nurses and physicians 19 3.47 4.00 0.526 0.513 ¡4.472 18 0.000

understand each other’s roles
Physicians are respected by nurses 19 3.58 3.95 0.368 0.684 ¡2.348 18 0.031
Nurses and physicians plan together 19 3.00 3.84 0.842 1.119 ¡3.281 18 0.004
before making decisions
There is open communication between 19 3.26 3.89 0.632 0.761 ¡3.618 18 0.002
physicians and nurses in making decisions
I feel confident speaking with nurses 19 3.37 4.32 0.947 0.848 ¡4.869 18 0.000
on the phone
I am confident clarifying unclear information 19 3.68 4.47 0.789 0.855 ¡4.025 18 0.001
with nurses
Nurses clearly convey the purpose of 19 3.37 4.11 0.737 0.872 ¡3.684 18 0.002
their call
I am comfortable acknowledging my 19 3.37 3.95 0.579 0.838 ¡3.012 18 0.007
inexperience to nurses
I have good communication with nurses 19 3.53 4.32 0.789 0.713 ¡4.825 18 0.000
I feel certain about accuracy of information 19 3.32 3.95 0.632 0.831 ¡3.314 18 0.004
from nurses
It is easy to ask the nurses questions 19 3.79 4.21 0.421 0.769 ¡2.388 18 0.028
I enjoy collaborating with nurses 19 3.95 4.37 0.421 0.692 ¡2.650 18 0.016
T1 = baseline, T2 = after completion of 5 mock pages, SD = standard deviation.
Items were scored using a 5-point Likert scale (5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, 1 = strongly disagree).
*Significance set at 0.05.

Journal of Surgical Education  Volume 75 /Number 6  November/December 2018 1493

TABLE 2. Nurse Survey Tool-Comparison of Results at Baseline and After Completion of 5 Mock Pages
Paired Differences
Item n Mean T1 Mean T2 Mean SD t Df p Value*
Nurses and physicians understand each 19 3.11 3.21 0.105 0.567 ¡0.809 18 0.429
other’s roles
Nurses are respected by physicians 19 3.16 3.26 0.105 0.567 ¡0.809 18 0.429
Nurses and physicians plan together 7y 2.71 3.43
before making decisions
There is open communication between 19 3.16 3.53 0.368 0.684 ¡2.348 18 0.031
physicians and nurses in making
decisions
I feel confident speaking with physicians 19 2.84 4.05 1.211 0.713 ¡7.398 18 0.000
on the phone
I am confident clarifying unclear 7y 3.14 4.00
information with physicians
Physicians return calls in a timely manner 19 3.16 3.58 0.421 0.607 ¡3.024 18 0.007
I am comfortable acknowledging my 19 3.00 3.53 0.526 1.124 ¡2.041 18 0.056
inexperience to physicians
I have good communication with 17 2.94 3.65 0.706 0.849 ¡3.429 16 0.003
physicians
I feel certain about accuracy of 14 3.57 3.57 0.000 0.961 ¡0.000 13 1.000
information from physicians
It is easy to ask the physicians questions 19 2.84 3.84 1.000 0.816 ¡5.339 18 0.000
I enjoy collaborating with physicians 14 3.43 3.86 0.429 0.646 ¡2.482 13 0.028
T1 = baseline, T2 = after completion of 5 mock pages, SD = standard deviation.
Items were scored using a 5-point Likert scale (5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, 1 = strongly disagree).
*Significance set at 0.05.
†
Due to low response rates, analysis of these 2 items was excluded.

roles. Many students expressed the desire to have this
program offered earlier in their education. Medical and
nursing students both shared that this was a valuable
learning activity that improved their abilities to com-
municate and collaborate over the course of 3 weeks.
During the final, shared debriefing participants brain-
stormed ways in which this activity could be enhanced
for future interprofessional education. One suggestion
was to “reverse” a scenario, creating a page where the
medical student possessed patient information and ini-
tiated the call to the nursing student, increasing oppor-
tunity for the nursing student to engage in critical
thinking and decision-making. Additional suggestions
included providing feedback to nursing students about
the quality of communication and revising scenario
delivery to reflect best practices such as the use of
SBAR.
DISCUSSION
The implementation of a mock page program as an
interprofessional education opportunity was success-
ful in improving attitudes toward communication and
collaboration among both medical and nursing stu-
dents, with medical students demonstrating more con-
sistent improvement in individual scores. Experiences
such as these are valued in health care education, as
patient safety relies upon effective communication
and collaboration within interprofessional teams. The
positive change in attitude among medical students,
noted by responses to all 12 survey items, supports
the continuation of this unique adaptation of the
mock page program.
Analysis of nursing student surveys demonstrated
significant improvement in half of the items, with no
responses declining. Consideration should be given to
the small sample size and likelihood of error in survey
administration with the nursing students. It is also pos-
sible that the exposure our nursing students have to
nurse-physician relationships through weekly clinical
experiences over the course of 4 years could impact
these results. Both groups of students affirmed that
the mock page program provided a rich learning
opportunity with benefits for both medical and nurs-
ing education.
When initially considering the use of nursing students
to deliver mock pages, there was concern that neither
group of students possessed mastery over content cov-
ered in individual scenarios. The phrase “the blind lead-
ing the blind” arose during conversations surrounding
this concern. By the fourth year of their education, nurs-
ing students at our University have accumulated over
1000 hours of clinical time but have little real-world

1494 Journal of Surgical Education  Volume 75 /Number 6  November/December 2018

experience paging physicians with patient concerns.
The purpose of the training sessions for nursing students
was to increase knowledge of postsurgical complica-
tions and build confidence in communication effective-
ness. Having prescripted scenarios and providing
information sessions pertaining to postsurgical compli-
cations was deemed essential to the success of the learn-
ing for both nursing and medical students.
It was understood from the beginning that the mock
page program provided greater learning opportunities
and feedback on performance for the medical students.
The intention was to conduct this program similar to the
traditional approach developed by Southern Illinois Uni-
versity School of Medicine and determine if nursing stu-
dents were effective in delivering mock pages. If
successful, future mock page programs would incorpo-
rate increased learning opportunities and provision of
feedback to the nursing students, providing a more bal-
anced approach.
Adaptation of the mock page program to include nurs-
ing students was effective in that each medical student
received all 5 pages and immediate feedback was pro-
vided upon the completion of each page. Training was
accomplished for both medical and nursing students but
the time to train nursing students to deliver pages was
significantly greater than the amount of time to train
medical students. Delivery of all 5 pages and feedback
required about 75 minutes of nursing student’s time.
Nursing students attended weekly training and debrief-
ing sessions totaling 3 hours. Efficiencies may occur as
nursing faculty repeat this program or incorporate
online modules to prepare nursing students.
Future directions for this program include an opportu-
nity for medical students to offer feedback on effective-
ness of nursing student communication. Consideration
will be given to randomizing rather than pairing students
for each mock page, minimizing the potential for acqui-
escence bias. We are also developing real-time scenarios
using manikins to simulate common postoperative com-
plications, allowing nursing students to incorporate
assessment skills and formulate their own SBAR state-
ments prior to delivering pages. We anticipate that
incorporating an evaluation of nursing student commu-
nication and manikin simulation could enrich the learn-
ing experience for nursing students.
In particular, the flexibility of the students to deliver
or receive pages at random during a 3-week time frame
overcame some of the traditional barriers to interprofes-
sional education, such as time and schedule constraints.
In future mock page programs, we would like to exam-
ine whether improvement in attitudes toward communi-
cation and collaboration could be strengthened with
additional pages, or the same results seen with fewer
interactions. We consider this a preliminary report and
Journal of Surgical Education  Volume 75 /Number 6  November/December 2018
anticipate using this program in additional classes and
among additional students, which will improve the abil-
ity to generalize findings.
One limitation of this study is that it is a single site, sin-
gle course report. It may be that different settings or dif-
ferent populations of students would have unique
outcomes. However, our medical and nursing students
are similar to other medical and nursing students in
research-intensive environments and we used a stan-
dardized program with established reliability and validity
in teaching and training. An additional limitation is our
small sample size. An error with pretest survey adminis-
tration for the nursing students additionally limited the
sample size for 2 of the items. Nonetheless, 6 of the
remaining 10 items provided data to suggest that atti-
tudes about communication and collaboration do posi-
tively change in nursing students following a mock page
program.
While paired medical and nursing students did not
meet until the final debriefing, we recognize that pairing
the same students together for all 5 pages may have
increased familiarity with each other, potentially intro-
ducing acquiescence or habituation bias. However,
pages were spaced over time and scenarios were varied
to reduce fatigue or autopilot responses. Further, medi-
cal and nursing students did not meet or have direct con-
tact with each other, except during the scenario
delivery, until after program completion; so acquain-
tance was not expected to influence response to the atti-
tude surveys.
CONCLUSIONS
A mock page program as a component of surgical resi-
dency preparatory courses provides medical students
with the opportunity to build competence and confi-
dence in communication and management of common
postoperative complications. Adapting this program to
include nursing students for the delivery of mock pages
and subsequent feedback about performance has poten-
tial to provide rich interprofessional education by
allowing students from both professions to communi-
cate and collaborate while working together through
patient scenarios. At our institution, this program
improved attitudes toward communication and collabo-
ration between medical and nursing students.
ACKNOWLEDGMENTS
We would like to sincerely thank Maggie Boehler and Cathy
Schwind from Southern Illinois University School of
Medicine, Department of Surgery. Their generosity in
1495
sharing time, knowledge, and resources has been invalu-
able as we developed this interprofessional education
program for medical and nursing students at our Univer-
sity.
APPENDIX A
The Mock Page Program at Case Western
Reserve University
Well-tested mock page scenarios developed by Southern
Illinois University School of Medicine (SIU) with validity
evidence for this purpose were used with their permis-
sion. Five scenarios were selected by faculty from the
medical and nursing schools based upon patient prob-
lems commonly encountered by surgical residents and
nurses. Selected scenarios included wound infection,
dyspnea and hypoxia, nausea and vomiting, fever, and
abdominal distention. As a prior participant in the SIU
mock page program, course faculty from the medical
school were accustomed to this framework and content.
Preparation of medical students
Medical students were prepared for mock pages during
the introduction to their surgical residency preparatory
course. This training took about 1 hour and was led by
course faculty. Training included content about goals
and objectives of the mock page program, the logistics
of how mock pages would be conducted, and how feed-
back would be provided. Students worked as a group
through a series of simulated pages similar to those they
would receive throughout the course. A group discus-
sion on how to best approach the scenarios was fol-
lowed by guided feedback from a physician faculty
member. Medical student preparation also focused on
closed-loop communication, clinical decision-making,
and time management.
Preparation of nursing students
Nursing faculty leading the mock page program were
trained by Advanced Practice Registered Nurses from
SIU familiar with the development and delivery of the
scenarios and feedback. This training was then used to
develop content to train nursing students. Each of the 3
training sessions for nursing students lasted for approxi-
mately 1 hour and occurred outside of the regularly
scheduled class. Training included identification and
management of common postoperative complications,
closed-loop communication, specifics pertaining to the
delivery of mock pages, and opportunities to rehearse.
Delivery of pages
Five mock pages were delivered over the first 3 weeks of
the surgical residency preparatory course. A mock page
consisted of a nursing student sending a text page to the
1496 Journal of Surgical Education  Volume 75 /Number 6  November/December 2018
designated medical student requesting the medical stu-
dent to call. A prescripted case scenario was delivered
when the call was returned. Mock pages were delivered
at the convenience of nursing students between the
hours of 8 a.m. and 8 p.m. Monday through Sunday. Late
night and early morning pages were not included due to
student schedules. Faculty and guest speakers for the
surgical residency preparatory course were supportive
of students excusing themselves from class or activities
to answer pages within 3 minutes of the initial text mes-
sage. Pages were not delivered during the fourth week
of the course as this was a dedicated cadaver week. Nurs-
ing students recorded the time of the page and were
asked to deliver a second or third page if a call was not
returned within 3 minutes. Text messages and calls were
delivered using students’ personal cell phones.
During the call, medical students would dialog with
the nursing students in order to better understand the
patient problem and determine a course of action. Medi-
cal students received consistent information from the
nursing students as the developed scenarios contained
details such as vital signs, lab values, medication lists,
and assessment findings. Total time for delivery of each
page including feedback and completion of the assess-
ment rubric was approximately 15 minutes.
Delivery of feedback
Nursing students completed an assessment rubric during
each mock page, evaluating medical student perfor-
mance regarding clinical management and communica-
tion effectiveness (volume, tone, clarity, appropriate
language, use of closed-loop communication, etc.).
Immediately following each mock page, nursing stu-
dents verbally shared this formative feedback using the
rubric as a guide. Upon the completion of the mock
page program, each medical student received a written
summary outlining their performance during each sce-
nario. The formative feedback rubric and summary
report followed a structured format developed by SIU.
Rubrics completed by nursing students about medical
student performance (i.e., request for additional infor-
mation, selection of interventions, presence of closed-
loop communication) were collected by a nursing fac-
ulty member and summarized. This summary of group
performance was the basis for the medical students’
weekly hour-long mock page debriefing session. Medical
student performance on individual case scenarios was
not a research component of this study.
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