Perceptions of Developing Cohort Cohesiveness within an Interprofessional

Distance Learning Doctoral Program

Angela Adair Burrell

A dissertation submitted to the faculty of the

Joseph and Nance Fail School of Nursing
in partial fulfillment of the requirements for the
Doctor of Philosophy in Nursing Education and Administration

William Carey University

2018

Approved by Committee:
Alicia Lundstrom, Ph.D., Chair
Jude Haney, Ph.D.
Ken Tillman, Ph.D.
Jalynn Roberts, Ph.D.




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 iii

ABSTRACT
Angela Adair Burrell
Perceptions of Developing Cohort Cohesiveness within an Interprofessional
Distance Learning Doctoral Program

This study explored students’ perceptions of developing cohort cohesiveness while

progressing through a doctoral level interprofessional health administration program.

Drawing upon Tuckman and Jenson’s Theory of Group Development (1977), this study

specifically emphasized the group development process and its inherent relationship to

achieve cohesion within a group. To better understand this process, an in-depth

qualitative research design, using semi-structured interviews, was implemented to

illustrate the experiences of an interprofessional group of students enrolled in a distance

learning program that utilized a closed cohort model. Emerging from the data was the

core category of shared experiences, supported by main categories of collegiate unity,

required interactions, group maturation, and interprofessional appreciation. The

significance of interaction between students and faculty emerged as fundamental and

inseparable to students’ achievement of cohort cohesion. The data suggest the value of

group development within these types of programs as well as how cohesive groups

enhance the learning experience and contribute to student success. Results of this study

have implications for the promotion of educational programs to foster group development

within distance learning cohorts. Attention should be given to a broad base of

understanding by faculty of the development of cohort cohesion and the value of

cohesion in higher-level education. Findings of this study support the notion of faculty

involvement in cohort cohesion and the importance of helping students make connections

as a group.
 iv

DEDICATION
First and foremost, this dissertation is dedicated to my Lord and Savior Jesus

Christ, whose promises are always Yes and Amen. Also, to my entire family who have

supported me down every educational pathway I have pursued and I am forever indebted.

To my husband, Shane Burrell, who was no doubt created to be my earthly

partner. You are the person I share everything with and I am blessed to wake up every

day beside my best friend.

To my mother, Jeanette Adair, who is a constant example of strength, patience,

selflessness, and generosity. You are so beautiful and I am so grateful for your

unconditional prayers.

To my father, Lamar Adair, who remains my example of a Kingdom Man. You

are a provider, protector, champion, and Godly leader for our family.

To my brother, James Adair, whose precious family provided me the escape I

needed when I felt overwhelmed. Thank you Mary Margaret, Hutchinson James, Lulie

Frances, and Charlie.

I love you all.

 v

ACKNOWLEDGEMENTS

This endeavor is not the work of one, but rather the efforts of many. I am

especially thankful for my committee: Dr. Alicia Lundstrom, Dr. Jude Haney, Dr.

Tillman, and Dr. Roberts. Your expertise, time, and patience will forever be treasured.

Conducting a study of this nature that is so closely connected to my full-time job

required the support of my administration, Dr. Jessica Bailey, Dr. Mark Gray, and Kim

McGaugh. I am so blessed to have Christian leaders who pray for their faculty. I also

want to express my appreciation for Dr. Elizabeth Franklin, Kimbra Bass, Robin Benson

Thompson, and Colleen Kelly. Without each of you, this would not have been possible.

To the graduates and students who participated in this study, thank you for sharing your

thoughts and time.

I also want to thank my loyal Chesapeake Bay retriever, Harley, who I lost during

this process. For 14 years, she was the first happy face I saw when I pulled into my

driveway.

Last, but not least, I want to acknowledge my classmates. Each of you have

shared with me your expertise and encouragement along the way. Particularly, I want to

thank Michael Roberson and Tammy Windham. The two of you were key to my success

in this program and I look forward to our continued friendship.

 vi

TABLE OF CONTENTS
ABSTRACT……………………………………………………………………………...iii

DEDICATION……………………………………………………………………………iv

ACKNOWLEDGEMENTS…………………………………………………………….....v

LISTS OF FIGURES…………...……………………………………………...…….…...ix

LISTS OF ABBREVIATIONS……………………………………………………..…….x

Chapters
I. INTRODUCTION………………………………………………………….…1

Statement of the Problem & Significance…………………………………3

Purpose of the Study………………………………………………...…….7

Research Questions………………………………………………………..7

Theoretical Framework……………………………………………………7

Definition of Terms………………………………………………………13

Assumptions……………………………………………………………...14

Limitations……………………………………………………………….14

Summary………………………………………………………………....15

II. LITERATURE
REVIEW……………………………….……...…………………….……….17
Interprofessional Groups……………………………………...….………19

Group Development…………………………………………….......……30

Role of Cohesion in Groups……………………………………………...37

Distance Education Considerations……………...………….…………...47

The Effect of Group Size……………………………...……….………...50

Summary……………………………………...……………….…………54
 vii

III. METHODOLOGY………………………………………………………….57

Purpose of the Study & Research Questions…………………………….57

Research Design…………………………………………………………57

Setting……………………………………………………………………61

Sample……………………………………………………………………62

Human Subjects Protection…………………………….…..…………….63

Instrumentation…………………………………………………………..64

Procedure for Data Collection…………………………………………...65

Procedure for Data Analysis……………………………………………..67

Summary…………………………………………………………………68

IV. RESULTS……………………………………………………………………70

Description of Subjects…………………………………………………..70

Research Questions and Findings………………………………………..71

Collegial Unity…………………………..……...……….……………….73

Required Interaction……………………………………………………...77

Group Maturation……………………...…………………………….…...80

Interprofessional Appreciation…………………………………………...82

Summary…………………………………………………………..……..85

V. DISCUSSION………………………………………………………………..86

Summary of the Study…………………………………………….……..86

Discussion………………………………………………………………..87

Conclusions………………………………………………………………95

Implications………………………………………………………………96
 viii

Recommendations……………………………………………………......97
 ix

LIST OF FIGURES
1 Tuckman and Jenson’s Theory of Group Development Revisited………………12

2 Participant demographics………………………………………………………...71

3 A model of shared experiences…………………………………………………..88

 x

LISTS OF ABBREVIATIONS
ATG-S Individual Attractions to Group Social…………………………………..37
ATG-T Individual Attractions to Group-Task……………………………………37
GI-S Group Integration-Social………………………………………………...37
GI-T Group Integration-Task………………………………………………......37
IOM Institute of Medicine………………………………………………….…...3
IP Interprofessional………………………………………………………......1
IPE Interprofessional Education…………………………………...…….…….1
NP Nurse Practitioner………………………………………………………...21
PLS Partial Least Squares……………………………………………………..33
WCU William Carey University……………………………………….……….63
WCU IRB William Carey University Institutional Review Board……………….….63
 1

Chapter I

INTRODUCTION

In today’s rapidly changing healthcare environment, educational programs must

incorporate an interprofessional (IP) team approach in disciplines that, until now, have

practiced independently. To achieve this, modifications in program curricula have been

implemented that support IP practice by including activities that require collaborative

thinking and foster effective group behavior (Institute of Medicine, 2001;

Interprofessional Education Collaborative Expert Panel, 2011; Zorek & Raehl, 2013). In

recognition of the value of interprofessional education (IPE), programs integrating

multidisciplinary and multiprofessional groups of students have evolved with a mission

of preparing graduates to assume upper level managerial and leadership roles within the

healthcare delivery system.

In order for students to complete this type of program successfully, each must

effectively work within a group to complete projects and assignments with real-world

application dispersed throughout the coursework. To achieve program outcomes, a

process must occur whereby students actively participate in constant dialogue and depend

upon one another as group members. However, this level of dependency varies among

the group members, and the strength of the group is constantly tested (Bonebright, 2010;

Tuckman, 1965; Weber & Karmen, 1991). The construct of group development and

member behavior is well documented in the literature but an overall consensus of how it

is achieved remains confounding (Alle-Corliss & Alle-Corliss, 2009; Miller, 2003;

Mullen & Copper, 1994; Ohrt et al., 2014; Tuckman, 1965; Tuckman & Jensen, 1977;

Wolf, Eys, Sadler & Kleinert, 2015). Although researchers do not concur with the stages
 2

of group development, researchers agree that effective group practice is difficult without

achieving cohesion.

Distance learning doctoral level health administration programs recognize the

need for IPE with a focus on advanced educational opportunities in health care

leadership. Students progress through these programs together, learning as a group or

cohort from the rich milieu of their student colleagues and faculty. This study will focus

on one program of this design, the Doctor of Health Administration (DHA) Program,

offered at a large metropolitan academic medical center in the southern region of the

United States. This program has created an avenue for students across the nation to

pursue this type of degree. The 3-year program is devised for part-time, non-traditional

students who can continue to work in their areas of expertise while enrolled. The program

is primarily online with minimal residency requirements.

Using a closed cohort model, students are required to work collaboratively

sharing knowledge and expertise while developing the skills necessary to function

effectively as a group. Although group productivity and effectiveness is directly

correlated to the groups’ ability to achieve cohesiveness (Mullen & Copper, 1994; Wolf

et al., 2010), a review of the literature shows no research specifically focused on group

cohesion in IP distance learning doctoral level programs.

Through semi-structured interviews, this study aims to explore student

perceptions of developing cohort cohesiveness while progressing through a doctoral level

interprofessional health administration program offered via distance learning and

utilizing a closed cohort model. In addition, this study will explore the role of faculty in

the development of cohesion among the cohort. Findings from this study may be used to
 3

determine the value of cohesion in higher-level education IP cohorts and how cohesion

affects cohort members individually and as a group. Additionally, findings may be used

by faculty to enhance course development and residency opportunities that foster the

development of cohesive groups.

Statement of the Problem and Significance

For many decades medical, dental, nursing, and allied health programs operated in

separate “silos” with little or no collaboration and IP teaching methodologies. In 2001,

The Institute of Medicine (IOM) published their executive summary agenda outlining

recommendations for the future of health care delivery systems in the 21st century. The

IOM recognized the changing needs of the health care population and identified that

innovative approaches were necessary to support this redesign (IOM, 2001).

One approach identified by the IOM was Recommendation 12, which proposed a

need for new strategies to better prepare the health care workforce that would be

consistent with the changing health care system. With this approach, IP leaders were

asked to develop strategies that included educating health care professionals at the

undergraduate, graduate, and continuing education level to work collaboratively. In 2011,

these recommendations were implemented by six IPE collaborative sponsors who

developed the core competencies for IP collaborative practice (Interprofessional

Education Collaborative Expert Panel, 2011). Since that time, additional disciplines have

adopted or mandated the use of these competencies.

To function effectively, IP group members must establish both a trust and a

willingness to work together. Research suggests that cohesion among group members

produces a higher level of satisfaction, commitment, encouragement, and performance.

 4

This is evident across various entities such as sports, education, psychology, business

management, and health care (Akcaoglu & Lee, 2016; Hurlock-Chorostecki, Forchuk,

Orchard, Soeren, & Reeves, 2014; Mullen & Copper, 1994,; Tekleab, Karaca, Quigley, &

Tsang, 2016; Wolf et al., 2010). According to Zander (1982), cohesiveness remains the

most essential component of group behavior.

Although cohesion has been a topic of discussion among researchers for decades,

a review of the literature shows no research specifically focused on group cohesion in IP

distance learning doctoral level programs. To effectively measure the level of

cohesiveness of members in a group has proven to be a challenge. Salas, Grossman,

Hughes, and Coultas (2015) suggest that due to the inherent complexity of the task,

researchers should use a multidimensional definition of cohesion. Within these

dimensions, group cohesion is demarcated as the degree to which individuals belonging

to a group were attached to one another and motivated to maintain their status within the

group (Organ & Hammer, 1950). Carron (1982) described cohesion as group members’

inclination to establish social bonds, an interpersonal fondness between group members,

and a dynamic process reflected in a group’s tendency to remain united in pursuit of a

specific objective and to satisfy member affected needs. Despite its complexity, more

than 30 years of research appears to support cohesion as one of the most critical variables

within small groups (Eys, Loughead, Bray, & Carron, 2009). Therefore, high functioning

cohesive groups are vital for successful health care systems to maintain a competitive

advantage.

A higher impact of cohesiveness on performance has been repeatedly linked to

smaller groups versus larger groups (Mullen & Copper, 1994; Mullen, Johnson, & Drake,
 5

1987). As IP leadership programs have increased across the United States, more

institutions have embraced a model that encourages a smaller class student number,

providing an avenue for cohesive development (Pemberton & Akkary, 2010). This

model, known as the cohort model, has been used in higher education since the 1940s (as

cited in Maher, 2005). The model encourages collaborative learning and group learning

among students. Research has specifically indicated a higher rating of cohesion

developed from individuals belonging to a cohort in comparison to individuals in a non-

cohort group (Greenlee & Karnxha, 2010). Higher education programs utilizing the

cohort model enroll students in a predetermined course sequence in which they progress

together from start to finish. McCarthy, Trenga, and Weiner (2005) identified two themes

that emerged from the cohort learning model. The first theme, cohort as a group,

recognized stages of group development and the effects each stage had on the group. The

second theme, cohort as a culture, found that members belonging to a cohort stopped

viewing themselves as an individual and more so as a part of a community (McCarthy et

al., 2005). Overall, these findings suggest not only the significance of a cohort for the

growth of the individual, but also for the transitioning and transformation of the entire

group as part of a unified community.

Today, advances in technology have created new pathways for academic cohorts

and other interprofessional groups to communicate at a local, national, and global level.

Instant messaging videos, webinars, and other device applications have enabled

organizations and institutions to transfer collaborative knowledge promptly into action.

Institutions utilize this same technology to develop distance-learning programs that allow

working adult learners the opportunity to complete advanced professional degrees.

 6

Students enrolled in these programs have limited campus visits with some requiring little

to no on-campus activities. Therefore, collaborative team building that promotes

cohesiveness is an ongoing challenge (Palloff & Pratt, 2007 & Waugh & Jian, 2016).

Among these challenges, Waugh and Jian (2016) identified online attrition, online

collaboration, social cognition, and social presence as elements most affected by this

method of delivery among graduate level students.

Research supports that combining and sustaining IP teams has many challenges

(Clark, 2011; Clark, Leinhass, & Filinson, 2002; Freeth, 2001; & Holley, 2009).

Particularly identified by these researchers are a sense of magnetism to one’s own

profession and a lack of respect for other diverse professions within the group. However,

as these IP programs become institutionalized, additional studies must be conducted to

determine what contributes to student success. This success extends further than

programmatic outcomes and reaches the need for cohesive group modeling that continues

beyond graduation.

Nationally, graduate program completion rates continue to struggle. According to

the Council of Graduate Schools (CGS; 2008), completion rates for both male and female

students average 58% to 55% respectively. Research also indicates that external factors

such as family responsibilities, professional obligations, and lack of support contribute to

high attrition rates in graduate level education (Castro, Garcia, Cavazos, & Castro, 2011;

Pemberton & Akkary, 2010). While some research has focused on other factors such as

characteristics and internal and external influences on student completion rates, little to

no research has focused on cohesion as a determinant of academic success.

 7

Furthermore, past research has focused on many facets of IP groups to include:

roles, trust, culture, task outcomes, faculty attitudes, perceptions by the workforce,

student perceptions, and on-line IPE and training programs (Clark et al., 2002; Dallaghan,

Hoffman, Lyden, & Bevil, 2016; Ebert, Hoffen, Levett-Jones, & Gilligan, 2014; Gregory

& Austin, 2016; MacDonald et al., 2010; Myers & O’Brien, 2015). However, a review of

the literature revealed no studies specifically aimed toward the development of group

cohesiveness or its influence in IP distance learning doctoral programs. In fact, limited

literature exists examining cohesion among any distance learning educational programs.

Purpose of the Study

The purpose of this study is to identify student perceptions of developing cohort

cohesiveness within an IP doctoral level distance learning program at a large academic

medical center.

Research Questions

Questions that will guide this study include:

1. What are the perceptions related to the development of cohort cohesiveness

among graduates and students pending graduation within an interprofessional

distance learning doctoral program?

2. What are the perceptions related to the role of faculty in the development of

cohort cohesiveness among graduates and students pending graduation within an

interprofessional distance learning doctoral program?

Theoretical Framework

This study examines a group’s ability to achieve cohesiveness, including the

perceptions of this process and its overall significance. The study requires a theoretical
 8

framework that models the stages of group development and identifies at what point in

this process cohesion occurs. Tuckman and Jensen’s (1977) revisited theory of group

development is used as a model for the developing sequence of groups, particularly those

that are smaller in number.

Bruce W. Tuckman (1965) published an article entitled Development Sequence in

Small Groups. This article was the foundation for the coined terms used to describe his

four stages of group development: forming, storming, norming, and performing

(Tuckman, 1984). Later, Tuckman and Mary Ann Conover Jensen (1977) collaboratively

revised the original model and identified a fifth stage coined adjourning. Although this

stage commonly is excluded from research investigations and the 1965 model is

referenced, it will be considered an important element in this investigation in order to

better understand what occurs to the cohesiveness of the study participants at the end of

the program.

Tuckman’s (1965) four stages of group development proposed that over time

groups move through these stages while resolving both interpersonal relationships and

task activities. According to Tuckman (1965), interpersonal relationships refer to the way

in which groups act together and relate to one another as individuals. The task activities

throughout each stage of development will refer simply to the task at hand and be

identified by its appropriate parameters.

During the first stage of the Tuckman’s model, also referred to as testing and

dependence or forming stage, the group is introduced to the task, begin to establish

ground rules, and attempt to discover what information will be needed to accomplish this

task (Tuckman, 1965; Bonebright, 2010). While in this stage, individual relationships are
 9

characterized by dependence. Members cautiously examine responses, behaviors, and

actions of other individuals. They seek acceptance, searching for similarities and

differences amongst one another, potentially exploring the possibility of subgroups.

Parker (1958), credited in Tuckman’s original work, described this stage as cohesive

organization, explaining that subgroups are formed, rules are followed, and harmony is

maintained.

The task activity within the forming stage is similar to that of the group structure.

During this period of time an orientation to the task occurs in which expectations are

defined, boundaries are expressed, ideas of how to approach the task are discussed, and

some environmental and behavioral concerns directly related to the task are made known

(Tuckman, 1965; Tuckman, 2001). Within this stage, group members establish

relationships with the leaders, faculty or administrators, and become aware of

organizational or institutional standards (Bonebright, 2010).

During the second stage of Tuckman’s model, also referred to as intragroup

conflict or storming stage, the group begins to organize the task functions and thus

conflict arises within their interpersonal relationships (Tuckman, 1965). Members are

forced to reconsider their own feelings, thoughts, attitudes, and beliefs in order to create

organization within the group. A fight-flight period could occur in which conflicts over

leadership, power, or structure emerge, or the opposed in which members digress and

become withdrawn (as cited in Tuckman, 1965). Although this lack of member

functionality is not always felt as an entire group, they certainly exist.

Related to the task, this conflict begins to become apparent. Questions arise

concerning responsibility of group members, initial boundaries and rules, the effect on
 10

the overall evaluation of performance, and the individual value of the task and the group

(Bonebright, 2010; Tuckman, 1965). During this period, members must self-evaluate and

embrace a problem-solving mentality that will allow them to shift discerningly to the next

stage.

The third stage, also referred to as development of group cohesion or norming, is

characterized by cohesiveness. During this stage group members become unified,

acknowledging a common goal, embracing a sense of group spirit, and egalitarian style of

leadership (Tuckman, 1965; Weber & Karman, 1991). Members begin to identify with

one another, trusting relationships are formed, and a mutual consensus and cooperation

perpetuates group integration and unity (Bonebright, 2010; Tuckman, 1965). At this point

interpersonal conflicts are being resolved and members begin to experience belonging

and a sense of family is postulated. Tuckman (1965) describes this notion as a

“simulation of the family constellation… with unity and cohesion accepted in that

structure” (p. 72).

The task function during this stage is group dynamics at work. Members are able

to comfortably share feelings and ideas, explore effective ways to work together,

creatively brainstorm actions that could proliferate success, and preemptively avoid

conflict (Bonebright, 2010; Tuckman, 1965).

The fourth stage, also referred to as functional role relatedness or performing, is

marked by interdependence in task processes and group relationships (Tuckman, 1965).

Although some researchers fail to identify a difference between the third and fourth

stages of this development, Tuckman (1965) determined the performing stage represented

the transitioning of the “development of cohesion to the use of cohesion” (p. 390). It is
 11

within this stage that members are intrinsically motivated to produce optimal solutions

and highly function as a group (Bonebright, 2010; Tuckman, 1965; Weber & Karmen,

1991). Group members are able to function independently, in subgroups, or the group in

its entirety, modeling flexibility and functionality in any role (Bonebright, 2010).

In Tuckman’s original work, the fourth stage was the final stage of group

development; however, Jenson, along with Tuckman, revisited the original model and

reviewed subsequent group development literature that led to the fifth stage (see Figure

1). This stage, referred to as adjourning, involves the termination of the group and the

disengagement process (Tuckman & Jensen, 1977). Inclusion of this stage will be

instrumental in identifying what occurs to group cohesion at the end of the program.
 12

Figure 1

Tuckman and Jenson’s Theory of Group Development Revisited (figure designed

by the researcher on the basis of Tuckman and Jensen, 1977)
 13

Definition of Terms

For the purpose of this study, the following terms are defined:

1. Closed cohort: A group of selected doctoral students who progress through

a distance-learning program together while completing all required

coursework in a pre-arranged sequence designed to prohibit any new

student from joining the group throughout their entire 3-year enrollment.

2. Cohort model: A group of students who enter and progress through a

program of study together to improve teaching and learning outcomes

(Greenlee & Karanxha, 2010).

3. Cohesion: The extent to which members of the group felt they belonged,

had a sense of ownership regarding group decisions, and whether they

wanted to maintain affiliation with the group (Greenlee & Karanxha, 2010).

In addition, a comprehensive definition describes cohesion as group

attractiveness, belonging, and member similarity (Hansen, 2016).

4. Distance learning: A remote teaching and learning system utilizing the

Canvas platform and other forms of technology to provide a specialized

curriculum for doctoral level students from various geographical locations

within the United States.

5. Faculty: Persons who hold specialized expertise in administrative entities

within the healthcare industry who provide instruction, research, or service

as a principal activity (or activities) for the institution and who hold

academic rank titles of professor, associate professor, assistant professor or

instructor.
 14

6. Interprofessional education (IPE): The process of collaboratively

educating students from various healthcare professions who hold a master's

degree or professional doctorate from a regionally accredited institution of

higher learning in a healthcare related field; or, hold a master's degree from

a regionally-accredited institution of higher learning and 5 or more years of

experience in health care management, health care policy, or clinical

medical specialty.

7. Perceptions: Insight or interpretation of knowledge gained by students

related to their ideas or experiences while enrolled in an interprofessional

distance learning doctoral program.

8. Student: Individuals from various healthcare professions who hold a

master's degree or professional doctorate from a regionally accredited

institution of higher learning in a healthcare related field; or, hold a

master's degree from a regionally-accredited institution of higher learning

and 5 or more years of experience in health care management, health care

policy, or clinical medical specialty. This includes professionals such as

physicians, nurses, allied health professionals, business and finance majors,

information technology majors, and attorneys.

Assumptions

It is assumed that participants responded honestly, openly and without bias. In

addition, it is assumed that participants were sincere and lacked ulterior motives for

personal gain.

Limitations
 15

In order to respond accurately during the interviews conducted, some participants

must recall experiences that occurred 2 to 5 years previously. In addition, the research is

restricted to a single institution, which potentially limits transferability to dissimilar

settings. Lastly, one cohort of participants attended an additional 8-hour on-campus

residency that included no group activities.

Summary

Collaboration in IP groups is essential to prepare the healthcare workforce of the

21st century. Because of recommendations made from the IOM, healthcare disciplines

were mandated by their accrediting bodies to incorporate competencies for IP

collaborative practice. Leadership programs integrating collaborative and group learning

now exist to prepare administrators and educators in these competencies. These programs

are designed for graduates, who traverse through the stages of group development,

acquire cohesive characteristics, to model IP collaboration among colleagues.

Cohesion is well-documented in the literature, and is commonly referred to as the

glue that holds a group together, a bond that allows members to freely express

themselves, a connectedness manifested by collaboration to achieve a shared goal, and

the sum of why members choose to stay in a group (Budman, Soldz, Demby, Davis, &

Merry, 1993; Donigan & Malnati, 2006; Henry, 1992). For decades, cohesion has been

widely recognized for its role in group development, and research supports its need for

effective IP groups in practice (Hurlock-Chorostecki et al., 2014; Tekleab et al., 2016).

However, limited research exists to determine its significance in distance learning IPE

groups.
 16

Measuring cohesion among group members remains cumbersome due to its

multidimensional definition (Eys et al., 2009; Salas et al., 2015). Because this study seeks

to understand the perception of student experiences, rather than a specific outcome or

product, a qualitative approach will offer the researcher the most descriptive and

meaningful data. By examining the experiences of students currently enrolled and those

who have completed a distance learning doctoral level IP health administration program,

the researcher seeks to contribute to the understanding of the significance of cohort

cohesion and how the faculty support or hinder its development.

 17

Chapter II

LITERATURE REVIEW

The review of the literature provides supporting evidence of the need for cohesive

IP groups and associated challenges of IP group development. Interprofessional

education has increasingly been recognized for its value and the literature identifies its

integration into the majority of academic medical centers across the United States (Greer,

Clay, Blue, Evans, & Garr, 2014). In order for this integration to be successful, health

care professionals must be able to understand their role in building IP cohesive teams,

appreciate the role of other professionals within these teams, identify how their specific

discipline influences IP work, and recognize barriers to IPE (Dallaghan et al., 2016; Ebert

et al., 2014; Hurlock-Chorostecki et al., 2014). Further exploration of the literature

indicated a need for faculty to develop coursework and activities that focus on the

enhancement of professional identity and exposure to health care professionals in practice

(MacDonald et al., 2010). Students with an enhanced professional identity tend to view

other disciplines favorably and possess more receptiveness and readiness for IP learning

(Hind et al., 2003; MacDonald et al., 2010).

Developing cohesive IP groups means learning how members must function

effectively within these groups and understanding the process of group development.

Tuckman and Jenson’s Theory of Group Development provides the researcher the

theoretical framework for this investigation by establishing a sense of structure for the

research and comprising relationships sought to be better understood by the researcher. In

conjunction with this theory, literature supports that specific stages exist in which groups

experience a process of development and within this process cohesion should occur,
 18

resulting in meaningful and effective task accomplishment (Erdem Aydin & Gumus,

2016; Haines, 2014; Ohrt et al., 2014; Tuckman & Jensen, 1977). Researchers continue to

refer to Tuckman and Jenson’s theory and use it as a framework for group development

research.

According to the literature, the same group development process occurring in

traditional groups must occur in distance learning groups whereby a connection or a

sense of community with other group members must form in order to achieve successful

group development (Erdem Aydin & Gumus, 2016; Haines, 2014). Research emphasizes

the role of faculty in assuring groups at a distance have a solid understanding of group

goals, individual roles are clearly defined, instructions to complete tasks leave little room

for interpretation, and formative assessments are ongoing (Erdem Aydin & Gumus, 2016;

Gallagher-Lepak, Reilly, & Killion, 2009).

Cohesion is widely accepted as a determiner of teamwork and a significant

indicator of how a task will be accomplished (Mullen & Copper, 1994; Wolf et al., 2015).

However, research indicates that certain factors must exist for cohesion to develop among

group members, which include trust, competence, social presence, caring, supportive

environment, personal significance, and a shared task attainment (Gregory & Austin,

2016; Plante & Asselin, 2014; Wolf et al, 2015). While the research is limited related to

group cohesion in distance learning environments versus a traditional setting, evidence

exists that group cohesion can be developed in distance learning and that these groups

can actually outperform traditional teams, have a higher degree of group satisfaction and

develop a higher level of trust and stronger social indenture (Hansen, 2016).
 19

To support the development of group cohesion and optimal learning, faculty must

create online/distance learning courses that incorporate structural, processual, and

emotional factors in order to foster online communities successfully. Online interaction

and engagement play a significant role in student success. Faculty must consider how

both are affected by course design, online discussions, technical support, student

feedback, academic support, task type and pedagogical support (Gallagher-Lepak et al.,

2009; Purarjomandlangrudi, Chen, & Nguyen, 2016).

In order for educational programs to support the development of group

cohesiveness, group size must be considered. To achieve this, programs establish cohort

models consisting of approximately 10-25 students. The literature suggests that group

size is a direct determiner of member participation, engagement, and a feeling of

connectivity. In addition, this model fosters components suggested to build cohesion

within a group such as a sense of shared learning, focused discussion, and increased trust

(Akcaoglu & Lee, 2016; Maher, 2005).

The literature examined in this chapter will offer a better understanding of the

research problem being studied by further exploring the significance and challenges of

developing effective IP groups, the process of group development, the role of cohesion

within groups, factors to consider in distance education, and the effect of group size. In

addition, it will disclose gaps that exist in the literature and reveal the relationship of each

work to the significance of this study.

Interprofessional Groups

In 2014, Greer et al. conducted a descriptive statistical analysis to determine the

prevalence and nature of IPE and IP prevention education at academic medical centers
 20

across the United States. According to the researchers, in lieu of recent health care

reforms, prevention has never been more important, and this approach to health care can

greatly benefit from IP teams. Past research has included specific disciplines and their

role in IPE, but the authors agree that research is lacking in determining the overall state

of IPE and IP prevention in academic health centers across the nation.

The researchers identified a tool, rigorous in its reliability, known as the

Assessment and Planning Instrument. The instrument was published in 2010 and was

designed as a self-assessment tool to plan and/or evaluate the progress toward academic

institutions IPE goals (Greer et al., 2014). Ten items were extracted from the survey

focused on basic IPE elements. A qualitative approach using triangulation of feedback

from various groups engaged in IPE initiatives tested the instrument’s dependability and

pilot-tested with individual familiar with IPE concepts.

A database was constructed of colleges and schools using the Association of

Academic Health Centers (AAHC) and the survey was distributed to the highest-raking

individual who could delegate completion using SurveyMonkey (Greer et al., 2014).

Additionally, a proprietary process for systematic review was outlined prior to data

analysis. Of the 168 accessed surveys, 129 were completed and two were withdrawn,

leaving a total of 127 respondents.

Results indicated that health professions courses, along with clinical

rotations/internships are more prevalent than IP infrastructure. The results provided

evidence that IPE activities and IP coursework have been developed at the majority of the

68 universities represented (Greer et al., 2014). The results also suggested that more

emphasis should be placed on infrastructure, resources, and policies that support IPE
 21

models. The overall shift of creating synergy for IP education and IPE initiatives is

indicated. Many respondents reported that their institutions have designated specific

personnel responsible for IPE coursework design and clinical opportunities.

The survey results indicated a lower prevalence of IP prevention education than that of

IPE. According to the researchers, this may be due to the instillation of IPE core

competencies and accreditation standards in most health care disciplines (Greer et al.,

2014). These findings and the newly adopted competencies and standards, creating new

IPE models is not necessary.

Limitations identified by the researchers included the probability that respondents

who have IPE activities under way were more likely to complete the survey than that of

non-respondents, and that some of the institutions who participated were presented by

multiple respondents. The authors also identified the need for ongoing surveillance of

institutions in order to track new and improved IPE models and outcomes that could be

attributed to IPE and IP prevention education (Greer et al., 2014).

In 2014, Hurlock-Chorostecki et al. conducted a two-phase study using the

constructivist grounded theory approach to explore the hospital-based (HB) nurse

practitioner (NP) role value. Two research questions were posed: what is the hospital

team members’ shared perception of the value of the NP role working within hospital

teams; and how do the shared perceptions relate to the socio-political influences and

position of the NP role within hospital teams?

Seventeen NPs (15 females, two males) from seven Ontario hospitals participated

representing 12 different specialty practices. A two-phase study was completed using the
 22

perceptions of team members’ and NPs’ perceptions of the value of the NP within an

interprofessional team (Hurlock-Chorostecki et al., 2014).

Because the constructivist grounded theory approach is interpretive, it was

deemed appropriate for this study (Hurlock-Chorostecki et al., 2014). Group and

individual interviews were audio-recorded and transcribed verbatim. The analysis

included line-by-line coding within each interview and between interviews. A qualitative

computer software program was used to aid in constant comparison and regular principal

research reflections and expert reviewers ensured scrutiny from personal preconceptions.

Analysis was completed in five linear steps and the final product resulted in three

categories of actions and eight related sub-categories.

The category most intensely and frequently expressed was evolving the NP role

and advancing the specialty. The sub-categories that emerged included creating and

evolving the NP role, specifically in leadership, and responding to program gaps by

including NPs in strategy planning. The other two categories included focusing on team

work, and holding patient care together. The data indicated this could be accomplished by

bridging role boundaries and making full use of NPs expertise. In addition, reducing

patient/family burden and being available to the patient and family is necessary to ensure

quality care (Hurlock-Chorostecki et al., 2014).

Extant IP theories provided a framework for focused exploration of sensitizing

concepts of IP collaboration and teamwork. Moreover, to further explore the IP

perspective of the HB NP practice, the Reeves’ contingency framework was used as a

comparator. In comparing this model with the new findings, the HB NP actions related

to teamwork focused on fostering clear roles and goal, interdependence, and shared
 23

accountability. The perspective from the NPs in this study clearly identified their roles as

being valuable beyond simply labor savers. Limitations did exist in that NPs were not

asked to share their exposure to IP education, and different jurisdictions and varying

regulations governing NP practice may alter role enactment. Also, these findings were

explored using only one IP teamwork model. Exploration with another model may raise a

different relationship and understanding (Hurlock-Chorostecki et al., 2014).

This study indicated the benefit of including IP theory within NP education such

that NPs could more effectively assert their legitimate role within a team (Hurlock-

Chorostecki et al., 2014). It also emphasized the role of the NP as central to the

development of cohesive teams and highlighted their influence in IP work further

solidifying the need and desire for this type of team modeling among individual

disciplines.

In 2014, Ebert et al. published an interpretive study that focused on the

experiences of new graduate nurses, doctors and pharmacists in relation to “knowing

about” and “working with” other health care professionals. This was a part of a larger

research project in which a range of interdisciplinary, multimedia teaching and learning

resources for nursing, medical and pharmacy students were developed and evaluated.

Sixty-eight participants, making up 12 focus groups were recruited from three

Australian States. The age of the participants ranged from 21-45 years. Approval by the

university’s Human Research Ethics Committee was obtained and focus groups were

then conducted by an experienced facilitator. Each focus group lasted approximately 1

hour and was audio-recorded and transcribed with the participants’ permission (Ebert et

al., 2014).
 24

Data were analyzed using iterative thematic analysis and the researcher then

identified sets of themes and sub-themes. Data were coded and reviewed by six members

of the research team. A second level of coding and theming occurred within three sub-

groups of researchers. This followed with whole group discussion around theming and

concepts to identify final themes accepted.

Two themes emerged from analysis of the data: roles and responsibilities; and

working with: collaborative relationships. Roles and responsibilities were related to the

participants’ knowledge and understanding of other health professional roles within

health care (Ebert et al., 2014). Specifically, during the focus groups nurses and

pharmacists expressed that their role was not valued by other health professions and there

is a lack of appreciation. Interestingly a similar contradiction was expressed by doctors

who felt that other health professional had a limited understanding of their role and

responsibilities. Nurses expressed that they often felt caught in the middle of professional

interaction with neither medical nor pharmacy colleagues demonstrating respect for their

role (Ebert et al., 2014).

The collaborative relationship focused on interpersonal interactions between

health professions. Doctors within these focus groups expressed that in order to function

effectively, they need to develop relationships with nurses. Many of them felt ill-prepared

to work as part of an IP team and attributed this to limited experience in their program’s

curriculum. Emerging from all professions within the focus group was a concern over

how to effectively communicate as a team. All of these groups expressed the need to

round table group discussion about their roles, formal interaction as students, role

reversal simulations, and collaborative case studies (Ebert et al., 2014).

 25

Limitations to the study included sampling form only three Australian states and

may not be representative of other states or countries. Participants also had varying IPE

experiences and program preparations which could potentially make drawing definitive

conclusions difficult (Ebert et al., 2014).

In 2016, Dallaghan et al. conducted a mixed method investigation to identify

faculty attitudes regarding IPE and what barriers they perceive to participating in IPE

campus-wide activities. Despite documented benefits, the authors identified a gap in the

literature specifically regarding the attitudes of faculty members and its effect on

participation.

Two-hundred and eighty-five faculty representing all colleges on the University

of Nebraska Medical Center (UNMC) Omaha campus completed the Nebraska

Interprofessional Education Attitudes Scale (NIPEAS) 19-item questionnaire assessing

attitudes related to IP collaboration. The items are rated form 1 = Strongly Agree to 5 =

Strongly Disagree. The items stem from the Interprofessional Education Collaborative

(IPEC) Competencies published in 2011 (Dallaghan et al., 2016). Faculty were also asked

to provided narrative comments pertaining to perceived barriers to participating in IPE

activities and suggestions on how to improve IPE on campus.

The Kruskal-Wallis test was conducted to identify differences among colleges for

NIPEAS items and descriptive statistics and Chi-square analysis were calculated for

questions about perceived barriers to participating in these activities. In addition, the

narrative comments were analyzed for themes using a crystallization/immersion method

(Dallaghan et al., 2016). These comments were analyzed separately by the researcher and

consensus was made on their meaning.

 26

The quantitative results indicated that faculty agreed with 13 of 19 items on the

NIPEAS. When comparing three items that were statistically different the faculty in the

College of Public Health rated understanding various roles of the health care team and

degree of appreciation of team members’ efforts higher than other faculty (Dallaghan et

al., 2016). The data also revealed that Medicine faculty actually rated making group

decisions higher than the other colleges, even though they are considered the natural team

leaders. In summary of this data, it does not appear that faculty attitudes create a barrier

to participation or engagement into IPE activities. Scheduling conflicts and lack of

departmental support were the most common barriers identified by Medicine faculty. In

addition, lack of relevance of the topics created a barrier of the College of Public Health.

From the analysis of the qualitative data emerged four themes, priorities,

relevance, location, and negative experience (Dallaghan et al., 2016). Taking time away

from clinics and lack of administrative support were captured in the priority theme.

Several faculty commented that the sessions did not match their discipline and, therefore,

made participation difficult. Location was simply faculty being off campus and lacked

accessibility. Some faculty reported negative past experiences with students being

disrespectful by displaying attitudes of superiority and that the events were unrealistic.

Because responses were anonymous, the study was reviewed and deemed exempt

by the UNMC Institutional Review Board. This study is limited by being a single

institution investigation and using a locally developed attitude scale. Further research

could include multiple colleges participating in these IPE activities while alternating

campuses to assure accessibility (Dallaghan et al., 2016).

 27

In 2010, MacDonald et al. conducted a qualitative study utilizing a Grander

Theory approach to identify competencies of IP collaborative practice for patient-

centered care. By using these competencies, the author’s purpose was to determine the

basis for the preparation of students, preceptors, and faculty for interprofessional practice

(IPP) and to develop a tool for assessing student performance in such practice.

After ethical approval was obtained from the Research Ethics Board, the research

began to determine the extent of competencies identified in a thorough literature search,

identify additional competencies, and seek clear descriptions of these competencies. The

setting for the study was a Canadian medical-doctoral university with nine health

sciences professional colleges (MacDonald et al., 2010). A total of 24 participants

consented to an audio-taped interview lasting approximately 30-90 minutes in length and

using a semi-structured interview guide. Interviews were audiotaped, transcribed

verbatim and analyzed to identify recurring themes and behavioral indicator of the

relevant competencies. After the analyzation and coding of the findings, experts were

consulted to validate these competencies and their behavioral indicators.

From these interviews emerged six key competencies that include:

communication; strength in one’s professional role; knowledge of professional role of

others; leadership; team function; and negotiation of conflict resolution (MacDonald et

al., 2010). The authors chose to focus on the behavioral indicators of knowledge of the

professional role of others and a total of seven competencies emerged that included:

1. Describes where the scope of one’s own profession ends and another begins.

2. Open to/seeks out the contributions of other team members.

3. Addresses misconceptions/stereotypes among team members.

 28

4. Respects the roles, expertise, and unique contributions of other team members.

5. Identifies common/overlapping professional skills amongst team members.

6. Values the enhanced benefits of the collaborative efforts of the team.

7. Describes the different perspectives and knowledge of other professions

(MacDonald et al., 2010).

From these, the authors further discussed how each behavior is associated with

this competency as well as on the impact of each on nursing education and practice. They

found that in order to collaborate in an effective manner, specific role competencies must

be clearly delineated. It is necessary to identify unique difference in, and to understand,

the roles and contribution so other team members. They also identified that all team

members must have an understanding of the knowledge and skills that teach team

member can contribute in any given situation. Faculty should provide learning

opportunities for student to student to become knowledgeable about the roles,

responsibilities and contributions of other team members (MacDonald et al., 2010).

In addition, MacDonald et al. (2010) identified a need for faculty to develop

curriculum that has a strong focus on courses that enhance nurse’s professional identity

as well as expose the students to the practice of other healthcare professionals. Nursing

students must also be given the opportunity to discuss team relationships openly in a

supportive environment. The importance of IP group interactions combined with

problem-based learning experiences are instrumental in their development. Students

should also be exposed to the opportunities to practice in IP teams to hone their skills and

become more mature within their professional roles.

 29

In 2003, Hind et al. conducted a longitudinal study to increase the understanding

of students’ attitudes towards their own and other professional groups. Although many

social psychology theories exist to explain inter-group dynamics and relationships, the

authors chose to apply the Social Identify Theory and the Self-categorization Theory as

their theoretical framework for the study.

A total of 933 students, ranging from 19.9 to 23.9 years of age and entering a

multi-faculty United Kingdom university, completed a questionnaire within six weeks of

starting their chosen healthcare program. More specifically, these programs consisted of

medical, nursing, pharmacy, physiotherapy, and dietetic programs. The questionnaire

included items to collect demographic data and items from three other existing scales.

These included the Health Care Stereotypes Scale, the Professional Identify Scale, and

the Readiness for Interprofessional Learning Scale (Hind et al., 2003).

Once approved by the ethics committee of Higher Education Institution, the

questionnaires were distributed. The data analysis included calculation of mean and

standard deviation and these scores were compared using one-way between-subjects

analysis of variance (ANOVA) with post hoc analysis (Scheffe test). The hypothesized

relationships between variables were tested using Pearson’s product moment correlation

test and data was managed and analyzed using Statistical Package of the Social Sciences

(SPSS; Hind et al., 2003).

The hypothesis stated that there would be a positive relationship between positive

autostereotyping and strength of professional identity. This hypothesis was supported.

The findings showed a low positive correlation for the total sample, which was

nevertheless highly significant (p = 0.000). Subgroup analysis showed that this

 30

relationship was weaker for nursing students (p = 0.028) than for dietetic, pharmacy,

physiotherapy, and medical students (Hind et al., 2003).

More specifically, the findings indicated that students who were positive about

their own group viewed other groups favorably. These findings also showed that low-

positive correlations were found between the strength of group identification and inter-

group differentiation (Hind et al., 2003). In fact, most scores were fairly close to the top

end of the professional identity range indicating that the students all identified strongly

with their professional group in this early stage of their program. Similarly, the readiness

for IP learning scores were at the top end for each group, indicating that the students in

all groups were positive about engaging in IP learning at this stage of the their program.

This study suggests that faculty should try to capitalize on the early stage of professional

education while these groups are receptive to IP learning (Hind et al., 2003).

Limitations within this study included the number of group participants. An

overwhelming number of medical and nursing students participated in this study in

comparison to the rest of the programs. Suggested future research includes the same

study with a similar number of students but focused on the end-of-program timeframe. If

results are significantly different, a qualitative study would be helpful in determining the

reasons for the attitude changes and discover predictors of this change (Hind et al., 2003).

Group Development

Ohrt et al. (2014) conducted a phenomenological study exploring group

development among master’s level counseling students. These counselors-in-training are

expected to learn many aspects of group counseling that included the stages of group

development and factors affecting the group process.

 31

The participants consisted of 52 of these students, 85% identifying as female and

15% as male. Additionally, multiple races were represented including White (75%),

Black (2%), Hispanic (7.6%), Asian (11.5%), and multiracial (2%; Ohrt et al., 2014). The

students were divided into seven experimental groups, each co-led by doctoral students

majoring in counselor education. The group participants were randomly assigned and

spent 90 minutes together each week for a total of 10 weeks. The groups focused on

interpersonal growth and interpersonal goals of the group. Each member completed a

demographic questionnaire and were required to complete a journal reflection

electronically within 48 hours of the weekly group meeting.

Ohrt et al. (2014) used a phenomenological data analysis and through a series of

familiarizing themselves with the data independently developed a list of statements

related to group development and member development. The researchers then broke into

two separate teams to code the journals. Each team developed lists using the same

instructions as when they created their independent lists, eliminating those statements

which were similar among members. From there, the researchers created a textual

description of the meaning statements, using specific examples from the transcripts, and

gained a consensus from an outside peer debriefer. Subsequently, clusters of common

themes emerged and were checked with participants to ensure accuracy of the

interpretation by the researchers.

The horizontalization of statements related to both group development and

member development produced four overarching themes as well as 25 subthemes

specifically for member development and 19 for group development. The first theme

identified, “exploration,” included subthemes for member development such as “anxiety”

 32

and “monitoring disclosure” while group development subthemes included “feelings of

initial silence and awkwardness” but a “positive and respectful environment.” The second

theme, “transition,” included subthemes for member development such as “finding a role

in the group” and “increased disclosure with reluctance,” clearly exemplifying “trust vs.

mistrust” (Ohrt et al., 2014).

The third theme identified, “working,” included subthemes for member

development such as “insight and awareness,” “personal growth,” and “empathy for other

team members.” Subthemes identified with group development included “connection

among members,” “meaningful work,” and “cohesion.” The final subtheme, “closure,”

included “anticipating termination” and “continued connection” as member development

subthemes; and, “less emotional sharing” and “staying in touch” as subthemes for group

development (Ohrt et al., 2014).

The findings of this study were generally consistent with literature and proposed

models of group development from past research, specifically Tuckman and Jensen. The

researchers acknowledged that the number of female participants was a limitation of the

study and that future research should be done to explore a replication among more

diverse groups and populations (Ohrt et al., 2014). Additionally, the researchers

identified a possible weakness in data collection being specifically articulated through

writing and not collected verbally or through recorded sessions in order to triangulate the

data.

In 2014, Haines conducted a mixed methods study investigating the development

of virtual teams. Because virtual teams are thought to have poorer outcomes because of

little or no face-to-face interaction and use alternative techniques for communication,

 33

moving through process of group development may be both difficulty and different. The

researcher reported four possible hypothesis for the study. They included:

1. (H1) In virtual teams, the level of sense of belonging at one time period is

positively linked with goal commitment at a later time period.

2. (H2) In virtual teams, the level of goal commitment at one time period is

positively linked with trust in peers at a later time period.

3. (H3) In virtual teams, trust in peers, at one time period positively influences team

performance of a virtual team.

4. (H4) In virtual teams, team performance during one time period positively

influences decision scheme satisfaction at a later time period (Haines, 2014).

Using a microcomputer application, Haines (2014) conducted an experiment

using six virtual teams comprising five members and requiring the completion of 10

information-sharing tasks. These teams were given a chat mode capability available

through this application and an email mode for team communication. Throughout the

working process of the assigned tasks, the computer system administered questionnaires

to the participants following completion of the first, third, sixth, and tenth task.

Two separate partial least squares (PLS) models were used to analyze the data,

examining group development over time and the predictor of trust at each measurement

period (Haines, 2014). The first PLS model revealed that upon completion the first task

sense of belonging was significantly linked (p < .01) with goal commitment, upon

completion of the third task goal commitment was significantly linked (p < .001) with

trust in peers, following the sixth task completion trust in peers was significantly linked
 34

(p < .05) with performance, and after the tenth task was completed team performance

showed a significant link (p < .01) with decision scheme satisfaction.

The second PLS model further analyzed trust in peers (Haines, 2014). Following

the first task completion task faithfulness showed a significant relationship (p < .001)

with trust in peers and after the completion of the third task (p < .001). However, trust in

peers and goal commitment was not significant at these times (p = .20, p = .41). Upon

completion of the sixth task, a reversal occurred in which goal commitment had a

significant relationship (p < .01) with trust in peers, while task faithfulness and trust in

peers’ relationship was insignificant (p = .07). The relationship reversed again after the

completion of the tenth task with task faithfulness having a significant relationship (p <

.01) and goal commitment’s relationship having an insignificant (p = .27) result.

Haines’s (2014) findings indicate that traditional group development can also be

applied to virtual teams, signifying that they evolve over time. Additionally, a sense of

belonging developed in the early stages of the team life is needed to carry through the

entire life of the team. Virtual teams also view sense of belonging, goal commitment,

decision scheme satisfaction, and trust in peers as important and these are directly linked

to team performance and team satisfaction.

The qualitative portion of the study involved the researcher analyzing the chat

messages among the teams. The results of the chat messages indicated that team members

conformed to the norm which revealed task readiness. In the later rounds the teams had

similar messages of encouragement, with very little discussion necessary. This indicated

that the groups followed a sequential development process. A deeper analysis by Haines

(2014) suggests that teams that overreach tend to exhibit low trust and commitment,
 35

therefore it is imperative that managers help them maintain a specific pace. In addition,

teams that initially struggle with organization or are slower learners would benefit from

early guidance.

In 2016, Erdem Aydin and Gumus conducted a descriptive quantitative study to

examine online learners’ perceptions of sense of community in relation to success in team

development. The study focused on Alfred Rovai’s sense of classroom community and

members’ need to feel connected in order for a strong sense of community to form among

online learners. For this to occur, cohesion, trust and team spirit must exist between

members of the online community.

Participants included 118 second year students enrolled in an online Information

Management (IM) Associate Degree Program (Erdem Aydin & Gumus, 2016). The

survey instrument used for the quantitative study was composed of three main sections.

In the first section, Clark’s Teamwork Questionnaire addressed learner attitudes in the

Tuckman’s team development process and Rovai’s Classroom Community Scale was

used to determine perceptions of the sense of community. The second section of the

instrument evaluated participants’ satisfaction with teamwork and included four open-

ended questions addressing preferences of learning.

According to the results of the Rovai’s Sense of Classroom Community scale,

online learners’ level of sense of classroom community is lower (X = 1.98) than the

average (Erdem Aydin & Gumus, 2016). This score revealed that the program failed to

build a good sense of classroom community among the learners. Additionally, scores

from the team development instrument revealed that the program was not helpful in

facilitating good teamwork among the learners, scoring generally low (X = 1.32).
 36

A Pearson correlation analysis was conducted to see whether a relationship

existed between online learners’ perception of sense of classroom community and

success in team development. The results indicated a positive significant relationship (p <

0.01, r = 0.27) was observed (Erdem Aydin & Gumus, 2016). The strongest relationship

was observed during the norming and performing (.785) stages of team development, and

with noticeably stronger interactions between the storming and norming stages (.636) and

the performing and adjourning stages (.663). The survey instrument revealed that these

specific learners would generally prefer individual study rather than work as a team (X =

2.69, SD = 1.34).

From the open-ended questions, participants that prefer to work individually

revealed reasons to be largely due to difficulty communicating and meeting with team

members and lack of team members to fulfill assignment obligations. Those participants

who preferred to work in a team reported they learned better using a team approach,

preferred shared responsibilities, and that the team approach better mimicked real

business life. Additionally, these participants reported that in order to improve the

teamwork in the IM Program team members must be able to fulfill their assigned

obligations, work in harmony with one another, select his/her own team members, and

allow all members to have an equal opportunity to serve as the team leader (Erdem Aydin

& Gumus, 2016).

Lastly, the study revealed online learners who had a higher level of teamwork

preference experienced a feeling of being more connected in their courses than other

participants are. This team development began emerging in the storming stage, and

continued to be significant through the last stage of development, adjourning. However,

 37

the majority of leaners indicated a low tendency to stay in contact with their team

members post completion of the assignment (Erdem Aydin & Gumus, 2016).

Relevant recommendations from this study included assuring course

designers/instructors establish common goals within assigned teams, alternating roles for

each assignment, clearly defining instructions to complete the task, and ongoing

formative team assessments (Erdem Aydin & Gumus, 2016). Additionally, relevant

recommendations for future research included a closer look at variables affecting the

team development process and a qualitative approach to gather more in-depth insight.

Role of Cohesion in Groups

In 2015, Wolf et al. conducted a series of multiple regression analyses to

determine whether team cohesion in relation to a social context is associated with

appraisal. Using the conceptual model of cohesion, four dimensions were determined:

group integration-social (GI-S); group integration-task (GI-T); individual attractions to

group-social (ATG-S); and individual attractions to group-task (ATG-T).

Participants were part of a purposive-convenience sample that included 386

athletes, whose mean age was 20.32 years and belonged to 27 different teams, 14 of these

being men’s teams (Wolf et al., 2015). To measure team cohesiveness, the researcher

used the Group Environment Questionnaire that consisted of 18 statements that measure

the four cohesion dimensions mentioned above. The athletes then rate these statement on

a 9-point Likert-type scale ranging from 1 = strongly disagree to 9 = strongly agree.

Precompetitive appraisal was assessed using the Precompetitive Appraisal Measure that

measures three primary appraisal statements and three secondary appraisal statements.
 38

In addition to the questionnaires above, the participants completed a short

demographic survey. Appropriate institutional ethics review board approval was

obtained, along with consent from the athletes following obtained permission by the

coaching staff.

Two multilevel models and two multilevel moderation models were used to

obtain appropriate estimates for all predictors associated with precompetitive primary

appraisal. In addition, the ordinary least squares (OLS) regression model was used to

predict precompetitive secondary appraisal and the OLS moderation model to examine

whether gender had any effect on the results (Wolf et al., 2015). The researchers then

used SPSS software to run the specified multilevel regression analyses and determined

descriptive statistics for precompetitive appraisal (primary and secondary), individual-

level predictors (ATG-S, ATG-T, GI-S, and GI-T), contextual predictors, and gender

(Wolf et al., 2015).

The results indicated that perceptions of cohesion amongst teams predicted both

the personal importance of the competition (precompetitive primary appraisal) and the

perceived prospect for coping with demands of the competition (precompetitive

secondary appraisal). In addition, the results indicated that most relationships were

similar for all genders. With regard to primary precompetitive appraisal, the researchers

identified that the athlete’s perception of higher task cohesion was related to the

increased personal importance of a pending competition (Wolf et al., 2015). With regard

to precompetitive secondary appraisal, the researcher identified that the athlete’s higher

individual attraction to the group resulted in a more positive ability to come with

demands of a pending competition. The authors concluded that their findings support the
 39

literature suggesting that perceptions of a supportive environment are directly related to

the individual’s performance when faced with opposition, and can lead to decreased

anxiety and disengagement, ultimately evading suboptimal performance (Wolf et al.,

2015).

This study was limited to an intercollegiate sample and the potential for

indirectness in cohesion-appraisal relationship did clearly exist. However, the study

provided opportunities for future research to identify likely mediators between cohesion

and primary appraisal, along with social support as a cohesive factor of secondary

appraisal. Also, the authors mention the need to examine perception based upon the

position held on the team in relationship to cohesion (Wolf et al., 2015).

Mullen and Copper (1994) conducted a meta-analytic cross-lagged panel

correlation analysis to determine the relationship between group cohesiveness and

performance. The researchers suggest that the nature of the group, including reality of

the group, degree of interaction, and group size, could influence the cohesion and

performance relationship. Due to the multidimensionality of group cohesiveness, a

precise and experimental integration of temporal patterns in the cohesiveness-

performance effect was reviewed to determine relative contributions.

The study had three major goals (Mullen & Copper, 1994). The first attempted to

provide a precise summary of the cohesiveness-performance effect and its overall

significance and strength. The second effort was to determine variations in the

cohesiveness-performance effect, specifically whether research models, interaction,

group reality, group size and cohesive components moderate or control the cohesiveness-
 40

performance effect. The third goal was to determine temporal patterns in the

cohesiveness-performance effect.

Standard literature search techniques were used with key words related to

cohesion and performance and the criteria determined by the researcher rendering 49

studies (Mullen & Copper, 1994). The hypotheses were coded and a questionnaire was

used to score predictors, resulting in three additional predictors including interpersonal

attraction, commitment to task, and group pride. Information was entered into the meta-

analytic database and results were determined.

Of the 66 hypothesis tested, 92% (61) determined a positive cohesiveness-

performance effect. The results indicated a significant effect (p = 3.94E-6) on

cohesiveness-performance effect in real groups versus artificial groups. There were

inconsistencies among group sizes in the study but following a correction for restriction

of range and utilizing standard deviation of group sizes, the results revealed that the

cohesiveness-performance effect was generally stronger among smaller groups and larger

groups showed a weaker effect. Surprisingly, the results indicated that groups with higher

interaction requirements did not exhibit a stronger cohesiveness-performance (p =

0.4717) effect (Mullen & Copper, 1994).

The cohesiveness-performance effect decreased when examining interpersonal

attraction and group pride (p = 0.00627, p = .0549), but increased when examining

commitment to task (p = 1.74E-6). The researcher indicated that despite differences

between research models, types of groups, levels of the cohesiveness-performance effect,

commitment to task repeatedly emerged the critical element of group cohesiveness

(Mullen & Copper, 1994).

 41

Mullen and Copper (1994) concluded that although inconsistencies emerged from

the various scholarly articles, the analyses completed in this study document that the

cohesiveness-performance effect does exist but that it varies in predictable ways.

However, the temporal patterns in the cohesiveness-performance effect seem to be

stronger for performance to cohesion, rather than cohesion to performance. This suggests

that teams who perform well may not interact with seamless coordination, have a likeness

towards one another, or are notably proud of their group, rather they are committed to the

task at hand and adjust their behaviors accordingly.

Future research suggests addressing specific mechanisms affecting different types

of groups or strategically engaging task commitment as a critical component of group

cohesion. In addition, attention should be placed on mutual influences of cohesiveness

and performance when studying the relationship between the two (Mullen & Copper,

1994).

In 2016, Gregory and Austin conducted a qualitative study to characterize the

construct of trust in IP collaboration for primary care. A snowball sampling technique

was used to identify participants and double-coding of recorded transcripts was used to

enhance the analytical rigor. Specifically, this study was conducted amongst a

community of pharmacists and family physicians in the greater Toronto area who were

co-involved in caring for a group of patients in a primary care setting.

Following the recruitment tactics and informational sessions, 11 pharmacists and

8 family physicians agreed to participate. Semi-structured telephone interviews were

conducted resulting in three major themes:

 42

1. Pharmacists demonstrate implicit trust of physician based on their professional

status/degree/role.

2. Physicians do not demonstrate implicit trust of pharmacist simply based on their

status/degree/role.

3. Differences in psychological construct of trust between pharmacists and

physicians may produce or exacerbate IP tensions (Gregory & Austin, 2016,

p.238).

The results indicated the pharmacists within the study expressed that collaborative

relationships were best facilitated by specific characteristics seen in the physicians they

worked with including, confidence, energy, and knowledge level. The process of forming

trust within this relationship was characterized as implicit, meaning positional authority,

physician status in the health care hierarchy, and academic qualifications guided the

trusting factor in decision-making and judgement calls (Gregory & Austin, 2016).

The results also indicated that family physicians within the study expressed that

collaborative relationships were best facilitated by different characteristics than

mentioned by the pharmacists. These included being helpful, available, nice, and keeping

them on their toes. Also, the study found that when forming a relationship of trust with

the pharmacists, they relied on some kind of proof or track record of their success. Unlike

the pharmacists interviewed, the physicians clearly expressed that a degree of

competence must be observed before that trusting bond could be formed (Gregory &

Austin, 2016).

Lastly, the study revealed a difference in cognitive models of trust in comparison

between pharmacists and family physicians. This implicit or conferred trust created short-
 43

term trust issues accompanied by some degree of resentment. Due to this finding, the

researchers identified the need for these groups to recognize and find a mutual respect for

these differences in order to facilitate the formation of a collaborative relationship

(Gregory & Austin, 2016).

Although saturation of themes was achieved, the number of participants was

relatively small and member checking with participants could not be completed due to

logistical constraints. The snowball sampling technique used for this study to determine

participants denotes the group was not representative of the general population of

pharmacists and physicians. The researchers concluded that further studies were

necessary that invited a different population of participants and that used alternative

techniques to draw conclusions (Gregory & Austin, 2016).

In 2014, Plante and Asselin conducted a literature review to determine whether

within a virtual environment, where visual and verbal cues and behaviors are nonexistent,

it is possible for caring and social presence be demonstrated. Fostering a social presence

is challenging for faculty, but the authors found, the literature reveals common

characteristics for models of caring in the context of an online community.

Caring is considered the essence in nursing. This article identifies best practices

and evidence based strategies for creating an online learning environment that

encompasses caring behaviors and promotes social presence. Over a 5-year period, a

Cumulative Index to Nursing and Allied Health Literature search was conducted using

key words relevant to the criteria for review (Plante & Asselin, 2014). Eleven articles

were identified that met the specific criteria the authors determined were relevant to
 44

address the aim of the study. Within the 11 articles, commonalities were extracted and

themes were identified to develop best practices.

Within the literature, practices to promote caring and social presence were found

in both qualitative and quantitative studies. Best practices were identified from data

analysis, specific feedback from study participants, satisfaction scores, narratives, and

behaviors. The authors identified a multitude of overlapping themes to create interactions

that promote a sense of belonging and a sense of community. These best practices

included utilizing a language that exhibited a sense of value and respect between student-

faculty exchanges and student-student exchanges. Encouraged interactions through

teamwork, frequent contact, prompt feedback, tones of appreciation, and synchronous

open dialogue were additional themes discovered (Plante & Asselin, 2014).

Several themes for best practices employed a humanistic approach that included a

welcoming introduction by both faculty and students, tones of appreciation, opening and

closing messages with greetings and encouraging idioms. Students appreciate interactions

that share personal stories and reflection, problem-solving and an understanding of the

significance of these experiences (Plante & Asselin, 2014). The authors emphasized that

caring, as a partnership between the student and faculty member, is the foundation and

commitment to best practices for teaching.

Future research needs were noted on ways to advance social presence and caring

in the online environments, communication styles, transferability of caring to the patient

care setting, and consequences of uncaring behaviors. In addition, more clarity is needed

to understand how positive outcomes can be further achieved in the online setting by

faculty intentionally facilitating engagement. Lastly, further exploration of the Social

 45

Presence Scale is needed in regard to online communication, faculty performance, and

course satisfaction (Plante & Asselin, 2014).

In 2016, Hansen conducted a nonrandomized, quasi-experimental study to

determine whether online student teams demonstrated more cohesion than traditional

teams. The input-process-output model served as the framework connecting team

cohesion with teamwork. The study identified cohesion as being widely accepted as a

determiner of teamwork and a significant indicator of how a task will be accomplished.

The researcher identified this type of research was limited, and that a direct comparison

was necessary to better understand its effect on performance and overall satisfaction.

The study participants were business majors enrolled in a Principles of Marketing

course in a midsized state university located in the United States. The first year enrolled

25 online students and 23 traditional students and second year enrollments included 25

online students and 15 traditional students. All four sections of the course were assigned

the same primary faculty; and age, nationality, and gender of the participants were

evaluated for significance with no statistically significant differences found between the

groups (Hansen, 2016).

The researcher suggested five hypothesis and the participants were provided a

survey through Blackboard utilizing a Likert scale to determine perceptions of the team

experience. Multivariate analysis of variance (ANOVA) models were used for the

estimation of variance that existed (Hansen, 2016).

The results for the first hypothesis, which suggested that online team participants

would experience more positive communication than traditional team participants, were

supported with substantial effect sizes of 1.28 and 1.30. The second hypothesis, which
 46

suggested that online teams would show a higher level of cohesions than the traditional

team, was also supported as evidenced by the 0.74 substantial effect (Hansen, 2016).

The third set of measure were concerned with styles used to manage conflict.

Neither the equity style of conflict management nor the equality style was significant,

which failed to support the third hypothesis, suggesting online teams would have a more

group-focused approach. The fourth hypothesis, which was related to student

satisfaction, was supported with p = .031. This hypothesis suggested that online team

members would be more satisfied with their teams than those participants in the

traditional setting (Hansen, 2016).

The final hypothesis, related to objective performance, suggested that online

teams would perform at a higher level than traditional teams in the proposal, planning,

and presentation stages of the task assigned. The results of this study found that when

compared to traditional teams, the online teams performed at a higher level during the

proposal (p =.031) and planning (p =.003) stage of the task; however, there was no

statistical significance during the presentation (p =.150) stage (Hansen, 2016).

This research found that team cohesion was evident in online teams in the form of

positive communication and team-focused interaction. In addition, evidence suggested

improved objective outcomes for online teams when compared to traditional teams. In

addition, the online team participants seemed to have a higher level of trust and a stronger

social indenture (Hansen, 2016).

Limitations of the study were identified as the small sample size used for this

quantitative approach and the ability to obtain reliable measures for the process variables

included. Hansen (2016) also acknowledged the lack of a definitive test to determine
 47

differences in online and traditional teams. It was concluded that a need for further

studies aimed at online student teams is merited for faculty to better understand the

overall benefits and limitations associated with this learning format (Hansen, 2016).

Distance Education Considerations

Gallagher-Lepak et al. (2009) conducted a qualitative study exploring students’

perceptions of community in online learning environments. The researchers emphasized

that a sense of community in an online learning environment in needed to enhance

student engagement and improve learning outcomes.

Eighteen participants, predominately female, Caucasian, and who attended a

Registered Nurse (RN) transition program consented to join the focus groups. Five focus

groups were conducted via teleconference in order to include greater geographic

participation, and approval was obtained from the Institutional Review Board (IRB).

Each focus group lasted approximately 90 minutes and was facilitated by two

experienced moderators. Key questions focused on participant experiences of community

and isolation, actions take to build community and value of community in online courses

(Gallagher-Lepak et al., 2009).

Focus groups were digitally recorded and transcribed verbatim into print. Using a

modified version of LaPelle’s technique and Microsoft Word, data tables were created for

each focus group and coded appropriately. After multiple re-readings and in Nvivo

coding of the data, themes evolved. A total of 15 themes emerged reflecting factors that

supported and/or detracted from sense of community (Gallagher-Lepak et al., 2009).

Findings were then clustered into structural, processual, and emotional.

 48

Structural themes included class structure, required participation, teamwork and

technology. Within these themes, participants specifically reported that instructor

presence and style, mandatory group activities and team scenarios, and knowledge of

computer technology were necessary for community development. The processual factors

identified themes that included commonalities and disconnects related to interests and

experiences with the group, having real conversations, using proper online etiquette, and

casual chatting outside of the course. Lastly, emotional factors emerged, which included

a sense of aloneness, apprehension of online learning, intimidation by overachievers, lack

of nonverbal communication, and being uncomfortable sharing too much personal

identity online (Gallagher-Lepak et al., 2009).

The focus group participants provided good examples of what did and did not

work, along with ideal conditions they wish they would have had. It was evident that

increasing levels of communication and interaction are heavily supported in the

promotion of online learning communities. Results further suggest that innovative

approaches to bridge the virtual and real environments are necessary for social capital

and optimal learning.

This study adds depth and detail to the limited body of research related to sense of

community in distance education. The study was limited to transition nursing students

and was limited in the number of participants. The need to further explore how best to

build community in online education that transmits the core constructs and values of

health care professions is vital (Gallagher-Lepak et al., 2009).

In 2016, Purarjomandlangrudi et al. conducted a systematic literature review to

determine drivers of student interaction and student engagement in online courses.

 49

Because online learning has become the widespread method of all different types and

levels of education, the researchers’ aim was to provide a better understanding of the

various characteristics and elements and their impact on interaction and engagement of

online students.

An extensive search in numerous databases, specifically limited to studies

conducted after 2000, was done using four phrases associated with online interaction and

engagement in education, producing 362 studies (Purarjomandlangrudi et al., 2016).

After close consideration and evaluation of the articles to assure relevance to the area, 66

studies remained. The literature included was for studies conducted within higher

education organizations and overwhelmingly conducted within the United States. They

were then classified into five main categories: university post-graduate, college

undergraduate, university graduate, college graduate and university graduate.

Additionally, the studies included in the systematic review used primarily a quantitative

methodology approach, but qualitative and mixed-method approaches also were well

represented.

The researchers identified two main categories following the review of the

literature: students’ positive outcomes and factors affecting online interaction. According

to the review, past research indicates online interaction and engagement has a significant

impact on positive outcomes of the student and overall student satisfaction and

motivation. The researchers identified that instructional interaction was perceived as

having a higher impact on achievement than social interaction, while recognizing that

social intimacy could negatively affect desired outcomes. Also determined was that

Facebook and Twitter were used minimally by the students for course work and academic
 50

purposes. Additionally, it was determined from past literature that opportunities of

interactivity among the students was not sufficient to engage student interest

(Purarjomandlangrudi et al., 2016).

In regard to factors impacting online interaction, four main groups of factors were

determined: (a) Student’s individual characteristics, (b) Student’s behavioral factors, (c)

Course design factors, and (d) Administrative factors (Purarjomandlangrudi et al., 2016,

p. 276). Characteristics extracted from the literature included student expectations, self-

expression, cognitive abilities, creativity, confidence level, learning flexibility, and

sharing of knowledge. Behavioral factors included social intimacy, student readiness,

attitude, interaction, group functioning, collaboration, cooperation, and participation.

Course design factors extracted from the literature included clarity, task design,

and academic integrity (Purarjomandlangrudi et al., 2016). The administrative factors

affecting online interaction included active discussion, feedback, technical support,

academic support, and pedagogical support. Specifically mentioned by the researchers

was the relationship between task design and learner behaviors in online courses,

meaning the volume of interaction is highly determined by task type.

Future research identified by the authors included the exploration of different

parameters and factors contributing to effective interaction by the students, and further

investigation of specific student behaviors, course designs and administrative factors are

needed to improve and enhance student interaction and engagement. The researchers

repeatedly emphasized the essentialness of student interaction and its impact on student

engagement and attrition (Purarjomandlangrudi et al., 2016).

The Effect of Group Size

 51

In 2016, Akcaoglu and Lee, conducted a mixed-methods study to examine the

effect of group size on students’ perceptions of social space, group cohesion and

sociability in an asynchronous online discussion environment. The researchers wanted to

point readers to instructional design decisions regarding social aspects of the online

learning environments (Akcaoglu & Lee, 2016).

Thirty-three participants enrolled in a graduate program in education were

distributed a survey composed of three different instruments. These instruments included

the Work Group Cohesion Index, which uses a 5-point Likert scale, the Sociability Scale

consisting of 10 separate items, and the Social Space Scale composed of 10 separate

items (Akcaoglu & Lee, 2016). The students were placed in whole class discussions for

the first part of the semester and then randomly placed into permanent groups of four to

five members for the remaining weeks. Students were required to post on the topic posed

by the faculty and make one initial post in response to classmates. After experiencing

both versions of the class discussions, an online survey was distributed to the students

with instructions to compare the large and small groups (Akcaoglu & Lee, 2016).

Independent t-tests were run to compare the two implementations. The results

indicated that student perceptions of the three constructs did not vary among large and

small groups (cohesion: whole class, p = .703, small, p = .493; sociability: whole class, p

= .703, small: p = .315; and social space: whole class, p = .346, small p = .427). Based on

these findings, the researchers merged the data from the two implementations and

conducted the remaining between-subjects analyses on the combined sample (Akcaoglu

& Lee, 2016).

 52

The results of this quantitative analysis revealed that a statistically significant

difference was observed between the small group and large group discussion in terms of

students’ perceptions of sociability (p = .001), indicating that students perceived small

discussion groups facilitated higher levels of social interactions. There was also a

statistically significant difference between small and large group discussion in relation to

social space (p = .005), indicating small discussion groups led to more positive

perceptions of social space. Also, the results revealed similar findings in regard to group

cohesion (p = .001; Akcaoglu & Lee, 2016). This indicated that students perceived small

groups to be more conducive to cohesion than large groups.

At the end of the survey, the students were asked to explain their preferences

regarding group size discussions. These responses were analyzed using deductive coding

and categorized into themes. The themes from the small group included being sensitive to

member participation, getting to know classmates better, easy focus, or engaged and a

connection to previous conversations. For the whole group, themes emerged reflecting

more feedback options, less personalized, left replies unread, and time wasted replying to

others (Akcaoglu & Lee, 2016).

This study had several limitations, one being that is was not an experimental study

and was conducted using a small sample. Also, the order in which the students

experienced the small/large group may have had some influence on survey responses.

Lastly, these were graduate students and may differ from other learner populations. The

researchers agree that future research should focus on the impact of social presence and

student learning outcomes (Akcaoglu & Lee, 2016).

 53

Maher (2005) conducted a qualitative study to determine the evolving meaning

and influence of cohort membership. In the researchers’ introduction, a cohort is defined

as “a group of about 10-25 students who begin a program together, proceed together

through a series of developmental experiences in the context of that program of study and

end the program at approximately the same time” (p. 195).

The study was conducted in a master’s level educational program in a closed

cohort design. Thirteen participants were included in the study, one male and 12 female.

The investigation spanned 10 months and across four overlapping courses. Semi-

structured interviews were conducted on the students’ thoughts and feelings about

participating in a cohort model (Maher, 2005). These interviews were conducted at

various times throughout the students’ enrollment, specifically at the 1st, 5th, and 10th

month of the program. In addition, the researcher conducted observations of the classes

throughout the different semesters.

Data were collected and transcribed into NVivo qualitative analysis software.

Descriptive coding was used to identify the themes that emerged from the interview and

observational transcripts (Maher, 2005). Miles and Huberman’s illustration of pattern

codes was referenced as a guide for refining the descriptive codes based on the researcher

becoming more familiar with the participants and setting (as cited in Maher, 2005). The

researcher presented these results chronologically across the semesters in which the data

were collected.

The findings suggested that cohort membership is a fluid process, evolving

throughout group participation. Students acknowledged that at the start of the first

semester, they felt the cohort membership would have a modest effect on their
 54

educational experiences, later realizing the extent and impact that was underestimated

(Maher, 2005). Comments by the students toward the end of the cohort membership

courses and reported by the faculty were, “You mean after we get through the core

program, you’re going to turn us loose? Where’s our next cohort? What are we going to

do without our cohort?” (Maher, 2005, p. 201). In addition, characteristics were reported

by the group reflecting a sense of “shared learning, focused discussion, and increased

trust” (Maher, 2005, p. 207). Regarding cohesion, the researcher identified that many of

the students felt that more time was needed to become comfortable with the entire group

and to allow for cohesive development.

Limitations of the study reported by the researcher include the fairly limited

sample size, unique factor of the program limiting generalizability, and participant

stressors caused by their professional roles. Recommendations included further

investigation of benefits and drawbacks associated with the cohort membership and the

need to investigate what occurs after the dissemination of the cohort (Maher, 2005).

Summary

Within Chapter II relevant literature was presented to offer a better understanding

of the problem statement and research questions to be answered. The significance and

challenges of developing effective IP groups, the process of group development, the role

of cohesion within groups, factors to consider in distance education, and the effect of

group size were reviewed. Cohesion among groups has been validated as a factor

influencing group performance, group satisfaction, group participation, and member

engagement (Gallagher-Lepak et al., 2009; Mullen & Copper, 1994; & Wolf et al., 2015).
 55

Regarding the theoretical framework for this study, the process of group

development is relevant to all literature reviewed. First, this process directly affects IP

groups through role establishment and identity, group readiness, respect among the

group, and contributions of group members (Dallaghan et al., 2016; Ebert et al., 2014;

Greer et al, 2014; Hind et al., 2003; Hurlock-Chorostecki et al., 2014; MacDonald et al.,

2010). Secondly, Tuckman and Jensen have been widely recognized for decades

throughout the literature and their theory of group development continues to be a relevant

framework for researchers today (Erdem Aydin & Gumus, 2016; Haines, 2014; Ohrt et

al., 2014). Thirdly, the theoretical framework identifies where in the group development

process cohesion should occur and stages where cohesion is challenged. (Gregory &

Austin, 2016; Hansen, 2015; Mullen & Copper, 1994; Plante & Asselin, 2014; Wolf et

al., 2015). Fourthly, distance learning has become an important consideration in group

development. Literature suggests that the same process of group development must occur

in online groups as it does in traditional groups (Gallagher-Lepak et al., 2009;

Purarjomandlangrudi et al., 2016). Lastly, group size has been identified as a contributor

to the success of group development and cohesion, and was a consideration in the

original theory developed by Tuckman in 1965 (Akcaoglu & Lee, 2016; Maher, 2005).

The literature supports the importance of IP groups in today’s healthcare

environment and the significance of understanding member roles within these groups

(Dallaghan et al., 2016; Ebert et al., 2014; Greer et al., 2014; Hind et al., 2003: Hurlock-

Chorostecki et al., 2014; & MacDonald et al., 2010). In addition, literature suggests that

factors such as group size, distance learning, and stages of group development influence

cohesion (Akcaoglu & Lee, 2016; Erdem Aydin & Gumus, 2016; Gallagher-Lepak et al.,
 56

2009; Haines, 2014; Ohrt et al., 2014; Maher, 2005; & Purarjomandlangrudi et al., 2016).

To date, no literature specifically aimed at developing group cohesiveness or its influence

in IP distance learning doctoral programs exists.

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Chapter III

METHODOLOGY

This chapter provides a rationale for choosing a grounded theory approach as the

research design. A description of the study’s setting, along with the participants to be

included, is discussed in detail. Methods used for data collection and data analysis are

explained, as well as the researcher’s approach to ensuring the credibility and

trustworthiness of the findings.

Purpose of the Study and Research Questions

The purpose of this study was to identify student perceptions of developing cohort

cohesiveness within an IP doctoral level distance-learning program at a large academic

medical center.

Questions that guided this study included:

1. What are the perceptions related to the development of cohort cohesiveness

among graduates and students pending graduation within an interprofessional

distance learning doctoral program?

2. What are the perceptions related to the role of faculty in the development of

cohort cohesiveness among graduates and students pending graduation within an

interprofessional distance learning doctoral program?

Research Design

Due to the focus on social processes and understanding the development and

influences of these processes, grounded theory methodology was adopted for this study.

Grounded theory was designed to build a theoretical explanation for studying social

phenomena and to provide techniques and procedures for gathering and analyzing
 58

qualitative data (Corbin & Strauss, 1990, 2015; & Glaser & Strauss, 1967). Data

collection procedures were derived using semi-structured interviews with questions

created using Tuckman and Jenson’s Theory of Group Development, which provided the

framework for this study (see Appendix F). Specific procedures existed for data analysis

and began immediately upon the first collection of data. Corbin and Strauss (1990)

outlined these procedures and canons and they are as follows:

1. Data collection and analysis are interrelated processes and concepts brought into

the study or discovered in the research process that are initially considered

provisional;

2. Conceptualization of data is the basis for analysis and becomes more abstract

throughout the analyzation process;

3. Categories, or grouping of concepts, must be specified, defined and given

explanatory power;

4. Incidents should be identified and a constant comparison for similarities and

differences should be conducted;

5. Patterns must be regularly examined for variation and thus accounted for;

6. Processes must be analyzed to determine stages, phases, or steps in the

phenomenon;

7. Memo writing should begin during the first coding session and continue until the

end of the research process;

8. Hypotheses emerging from categorical relationships should be developed and

continually verified throughout the research process;

 59

9. Collaborative analysis of data is suggested to avoid bias and provide additional

insight; and

10. Specific linkages of conditions, actions, and consequences is a responsibility of

the researcher.

Understanding the subjective experiences and identifying the perceptions of the

participants within the social context of a distance-learning program was of paramount

importance. Because of the nature of qualitative research, particularly grounded theory,

the researcher sought to gain insight that was less rigid and more intuitive of what was

occurring in the data collected (Corbin & Strauss, 2015). Due to the complexity of group

development, specifically the point at which cohesion occurs, the use of grounded theory

was employed. Using Tuckman and Jensen’s model as the theoretical framework for this

study, the identified stages of group development were defined. In order to understand

better how cohesion occurred within these defined stages, the researcher investigated the

inner experiences of the participants and determined the impact of their experiences

within this context. Also, the impact of cohesion on the group and individual group

member, as well as external influences that affect this cohesion, were of interest to the

researcher. An insider perspective provided a better construct of meaning and

understanding of interprofessional relationships. The use of grounded theory inquiry

allowed the researcher to capture participants’ idioms, behaviors, and social context. This

further confirmed the need for a qualitative framework, specifically grounded theory, and

was necessary to understand how these individuals perceived cohesiveness among their

interprofessional cohorts (Fossey, Harvey, McDermott, & Davidson, 2002).

 60

According to Glaser (1978), “The generative nature of grounded theory constantly

opens up the mind of the analyst to a myriad of new possibilities (p. 6).” However, for

this to occur authentically the researcher stayed aware of the advantages and

disadvantages of grounded theory. Researchers rely on grounded theory to collect rich,

thick descriptive data that is not well described through other methodologies. Although

some qualitative approaches allow researchers to collect and analyze data with little

direction, grounded theory provides explicit guidelines for these processes, making it

more prescriptive for the novice qualitative researcher (Charmaz, 2006; Corbin &

Strauss, 2015). Grounded theory does not hypothesize expected outcomes of the research,

therefore bias from previous assumptions or previous similar works was minimized.

Although the researcher was directly involved in the program of interest, creating the

potential for researcher bias, the use of grounded theory’s coding paradigm sensitized the

researcher and allowed the data to be the researchers’ guide. This enhanced creativity by

the researcher and allowed for the development of new emerging categories and

interpretations. The systematic approach to data analysis ensured rigor and

trustworthiness in the theories that emerged from the data by iteratively collecting and

analyzing findings for comparative logic and an original analysis to occur (Charmaz,

2006).

A novice researcher using grounded theory should remain cautious of other

potential limitations with this approach. Grounded theory can be an exhaustive process in

which the researcher becomes inundated during the coding process (Myers, 2009).

Therefore, a peer coder experienced in grounded theory methodology assisted the

researcher through this process of inquiry. According to Corbin and Strauss (2008),
 61

researchers should be guarded when reviewing the literature and careful not to allow

“predetermined explanations” or assumptions that could threaten the rigor of the study.

An additional challenge of grounded theory is its limited generalizability. The

issue remains a controversial discussion among researchers and theorists but is rarely

discussed in qualitative research due to its complicated nature. Polit and Beck (2010)

argue that regardless of the language used, the end product of qualitative research is to

further knowledge through the confirmation of systematic replication and that

quantitative testing of new theories does not always result in the growth of knowledge.

Setting

This study took place within a distance learning administrative doctoral program

at a large academic medical center in the southern region of the United States. This

particular program began August 2012 in response to a need for a doctoral level program

designed to prepare midlevel administrators and clinical mangers for upper level

administration within today’s health care industry. The program has a limited residency

requirement, with cohorts meeting only two times face-to-face within a 3-year

enrollment. Students are exposed to multiple synchronous and asynchronous

opportunities to communicate and discuss various content topics throughout each

semester. In addition, the students are encouraged to find additional technological

resources to stay connected or use the communication tools available via the distance-

learning platform. Students are required to complete multiple assignments and projects

throughout the 3-year enrollment period in groups varying in size with members being

either assigned or chosen at their discretion. The program enrolls students nationwide

with competitive admission standards requiring a face-to-face interview and an on-

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campus writing assessment. To date, the program has admitted six cohorts, with two of

these cohorts admitted in Fall 2012 and Fall 2013 and the remainder in Summer 2014,

2015, 2016 and 2017.

Sample

The participants were selected based on their relationship with the distance

learning administrative doctoral level program, representing both current students and

graduates from four specific cohorts. Due to the qualitative nature of this study,

purposive sampling was used to assure the participants were knowledgeable and

experienced with the phenomenon of interest. Purposive sampling is used often in

qualitative research to assure participants are selected according to the needs of the study

and that they are able to provide a rich context of information suitable for the

phenomenon of interest (Corbin & Strauss, 2008). Participants for this study were

selected based upon completion level of the administrative doctoral level program. This

occurred by selecting participants who had completed the program, or had completed all

coursework and were scheduled to defend the required doctoral project. Interviews were

conducted with individuals who were willing and available to participate during the data

collection process. This required the researcher to accommodate the participants’ and

research teams’ professional and personal obligations, varying time zones, and work

schedules.

Selection of participants for interviews was purposefully conducted to offer

maximum variation sampling of the total population. The researcher included a sample of

participants representing various demographic locations, disciplines and professions,

years of healthcare experience, generations of learners, genders, and ethnic backgrounds.

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All participants were taught using the same practices with the exception of one cohort

that was required to attend an additional 8-hour on-campus residency.

Purposive sampling dictates only four of the six cohorts accepted into the program

of interest were eligible to participate in this study. This ensured that the participants had

ample time to go through the stages of group development outlined in the theoretical

framework. Furthermore, it provided a sample of participants that experienced or are

experiencing the adjourning phase of group development described in the revisited model

used and outlined in Chapter I. The 42 participants who met inclusion criteria received an

invitation to participate. Twenty-two signed consent letters were received and 19

participants were interviewed. Eight interviews were conducted face to face, and 11 were

conducted via telephone conference. Theoretical saturation was reached after the 19th

interview and appreciation emails were sent to the remaining three eligible participants.

Human Subjects Protection

This study was conducted using the ethical principles for research outlined by the

William Carey University Institutional Review Board (WCU IRB), and the program of

study’s external review board. The participants were provided information regarding the

study and notified of their right to withdraw participation from the study at any time or

decline to answer any questions during the interview process. The researcher obtained

informed consent from each participant in the study (see Appendix A) and formal written

permission from the Dean of the program of study (see Appendix B) prior to starting the

data collection process. In addition, participants were provided information to contact the

researcher, William Carey University (WCU) Dissertation Committee Chair, or the WCU

IRB Chair, if warranted.

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The researcher successfully completed all Collaborative Institutional Training

Initiative (CITI) modules required for both WCU IRB and program of study’s external

review board. Approval from the WCU IRB was obtained on October 31, 2017 and

identified as IRB #2017-57 (see Appendix C). Also, approval by the External Review

Committee of the program of study’s parent institution was obtained on December 13,

2017 and identified as ERR-1043 (see Appendix D).

Instrumentation

Unlike validity and reliability used in a quantitative approach to gather data, a

qualitative approach is concerned with issues of credibility, dependability, authenticity,

and trustworthiness established simultaneously throughout the collection and analysis

process of the data (Corbin & Strauss, 2015). According to Silverman (2004), validity in

qualitative research is equivalent to “truth” or “trustworthiness of the findings.” Several

steps were outlined to assure this was maintained throughout the collection and analysis

of the data and were used by the researcher to uphold quality of the study.

The interview guide consisted of seven open-ended questions (see Appendix F)

that were created using Tuckman and Jenson’s Theory of Group Development and

reviewed by a colleague highly experienced in qualitative research. Due to the

exploratory nature of the study, the lack of parameters of the research required questions

that would generate descriptive responses. The interview guide was designed using the

theoretical framework of the study, the research questions, and the sample participants,

but left latitude for the interviewer to ask and sequence questions without forcing an

absolute answer.
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Two mock participants were interviewed to determine whether questions were

adequately structured and focused to capture the participant’s view and to achieve the

purpose of the study. Following the mock interviews, it was confirmed no changes were

necessary to the interview tool. These data were not recorded.

Probing questions were used when clarification of information was needed or the

participant’s response was vague or shallow. In addition, demographic data were

collected that identified participant age, gender, occupation, and years of experience in

health care.

Procedure for Data Collection

The researcher sought approval from the WCU IRB and the External Review

Committee of the program of study’s parent institution. The Dean of the school offering

the program of study was hand-delivered a letter seeking written approval to contact the

participants and provided an opportunity to ask any questions related to the study.

Permission was granted by the Dean, and an email inviting eligible study participants (see

Appendix E) was distributed to their preferred email addresses recorded within the

program’s database. Included in the email was a letter that disclosed the purpose of the

research, length of the interview, confidentially statement and point of contact

information. Students and graduates who did not respond to the initial email were sent a

follow-up email and/or attempted to be contacted via telephone.

Nineteen interviews were conducted between January 18, 2018 and March 9,

2018. All participants signed a letter of consent prior to their interview. Graduates of the

program who participated were informed that an assistant note taker would be present

during the interview process. Currently enrolled students who participated were informed
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that a peer interviewer and assistant note taker would conduct their interview. Practice

sessions were incorporated to allow the peer interviewer time to become familiar and

comfortable with the interview guide and process.

Interview methods were based upon participant location. A combination of

telephone conferences and face-to-face interviews were used to collect the data. Face-to-

face interviews were conducted in an informal, neutral setting convenient to the

interviewee. The researcher transcribed all interview responses using handwritten notes

and immediately recorded reflections related to participant behavior and responses

allowing for simultaneous analysis of the data. Also, an assistant note taker transcribed

interview responses using short-hand and collected intonations of the spoken words. For

each interview conducted by the peer interviewer and note taker, a debriefing session

immediately followed each interview to ensure consistency of the data and begin the

analysis process. A comparison of the data collected was used to derive a final draft of

the interviewee’s responses.

Due to the complexity and cumulative thought processes required for qualitative

data analysis, memo writing was utilized to track and reflect on the interview and coding

sessions that allowed clarity and accuracy as the research progressed (Corbin & Strauss,

2015). Immediately following each interview and data coding process, the researcher

carefully recorded notes, dates of participant interviews and coding sessions, and

researcher impressions, resulting in a chronological collection for concept comparison

and interpretation of participant responses.

The researcher protected participant anonymity by removing any identifiable

information from the data collected and ensured documented information regarding the
 67

study was securely maintained in a password-protected computer. To ensure the

trustworthiness of the data, the mechanism of member checking was used by the

researcher. Following the scheduled interview and preliminary analysis, participants were

sent a summary of their responses for review and confirmation of accuracy. Participants

were asked to verify or correct misconceptions or misinterpretations of the summary

provided.

Following conversion of the handwritten copies into an electronic format, the

original handwritten copies were destroyed. All interview transcriptions will remain

secured for a period of 6 years after which it will be destroyed.

Procedure for Data Analysis

In qualitative research, data collection and analysis is described as an iterative

process creating a cycle of comparison of new results and findings that further data

collection (Corbin & Strauss, 2015; Miles & Huberman, 1994). The use of grounded

theory allowed both deductive and inductive reasoning to occur, contributing to the

theoretical depth of analysis.

The coding process was initiated shortly after the first interview. Codes were

assigned to words or statements by the participants and used for concept development

(Corbin & Strauss, 2015). This first interview was the foundation of the data collection

and analysis process serving as the first concepts to build upon. Open coding allowed the

researcher to begin verifying initial concepts, using a constant comparative analysis, and

to remain open to all possibilities from the data. Subsequently, open coding led to axial

coding, and allowed the researcher to construct categories and relate subcategories

captured from the data. This was accomplished by determining the conditions, context, or
 68

action/interactions that occurred, and their relationship to one another (Corbin & Strauss,

2015). During the data collection process, concepts and categories either became relevant

through repeated appearances or significant due to their absences. The researcher

captured reoccurring patterns from the constructed categories that resulted in categorical

integration (Corbin & Strauss, 2015). This process was repeated until no new categories

emerged, indicating that saturation was attained.

Duplicates were provided to a peer coder knowledgeable and experienced in the

qualitative data analysis process. Comparison of the data was performed by the

researcher and peer coder to authenticate findings to decrease the threat of bias and allow

an impartial analysis of the data. Along with the WCU dissertation committee, the peer

coder served in an inquisitorial role to ensure the analytical process was preserved.

The researcher used memo writing to record relevant information during the

methodical process that included specific dates and times of interviews, initial thoughts

following the interview sessions, and thoughts and ideas throughout the analytical

process. These reflective memos were frequently revisited during the collection and

analysis process to better define codes or categories, make comparisons, offer

conjectures, and identify possible gaps in the analysis (Charmaz, 2006; Corbin & Strauss,

2015).

Summary

Grounded theory, based on Corbin and Strauss (2015), was used to identify

student perceptions of developing cohort cohesiveness within an IP doctoral level

distance learning program. This chapter began with an explanation of the purpose of the

study and questions to be answered. The researcher followed with an argument of why
 69

grounded theory was chosen for this study and specifically discussed the design along

with strengths and limitations. The setting, sample selection, instrumentation, procedure

for data collection, and procedure for data analysis were described in detail. The

researcher also discussed methods used to enhance the trustworthiness and authenticity of

the data collected. Using Tuckman and Jensen’s model as the theoretical framework for

this study, the identified stages of group development were defined and interview

questions were derived using this model.

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Chapter IV

RESULTS

The purpose of this study was to identify student perceptions of developing cohort

cohesiveness within an IP doctoral level distance-learning program at a large academic

medical center. This chapter focuses on the results of a grounded theory study and

provides the reader sufficient evidence of the findings while including direct quotations

from the participants interviewed.

Description of Subjects

The 19 participants interviewed for this research study represented four cohorts of

a distance learning administrative doctoral level program. Figure 2 provides an

illustration of the participant demographics. All participants in this study had either

completed the program, or had completed all coursework and were scheduled to defend

the required doctoral project. Data were collected from 11 female students and eight male

students. Ages ranged from 32 to 64 years with a mean age of 45.5 years. All participants

have been involved in some aspect of health care delivery, with years of experience

ranging from 9 to 45 years. The study participants represented various demographic

locations, disciplines and professions, generations of learners, and ethnic backgrounds,

maximizing the diversity relevant to the research questions.

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Figure 2

Participant demographics

Research Questions and Findings

Research Questions

Using in-depth, semi-structured interviews, this study began with two questions

designed to open an exploration of student perceptions of developing cohort cohesiveness

within an IP doctoral level distance-learning program:

1. What are the perceptions related to the development of cohort cohesiveness

among graduates and students pending graduation within an interprofessional

distance learning doctoral program?

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2. What are the perceptions related to the role of faculty in the development of

cohort cohesiveness among graduates and students pending graduation within an

interprofessional distance learning doctoral program?

The first question regarding perceptions related to the development of cohort

cohesiveness among graduates and students pending graduation was supplemented with

open-ended interview questions. These questions intended to describe cohesion within

the student’s cohort in the first 3 years of the program, discuss how cohesion affected

them individually, and identify ways program design impacted cohesion. The second

question intended to discover perceptions related to the role of faculty in the development

of cohort cohesiveness. However, in the interviews, students’ opinions and perspectives

of the role of faculty emerged in questions intended to supplement the first research

question.

A shared experience was identified as the core category of student perceptions of

developing cohort cohesiveness within an IP doctoral level distance-learning program. As

data from the interviews unfolded, students overwhelmingly discussed how cohesion

developed while accomplishing similar tasks and experiencing positive and negative

events as both an individual and a group member. Integrated within the core category of

shared experience were four additional categories: collegial unity, required interactions,

group maturation, and interprofessional appreciation. The use of grounded theory enabled

the researcher to identify shared experience, along with its components, as the primary

theoretical construct of the study.

As analysis of the data proceeded, the researcher began identifying connections

and linkages between the emerging categories and both research questions. A general
 73

awareness among the students’ perceptions revealed the role of faculty could not be

separated from the development of cohort cohesiveness; therefore, findings will be

reported collectively. The researcher will discuss this interconnectivity and its

relationship as the student participants described during the interview process. Responses

to both research questions will be reported within each category.

Collegial unity.

Students reported that challenges and adverse situations as well as achievements

and life celebrations that occurred while enrolled in the program created and strengthened

a sense of collegiate unity. Throughout the interview process, the students discussed

multiple concepts that formed three specific subcategories: (1) program design; (2)

program challenges; and (3) personal challenges.

Program design.

Students discussed an expectation to progress together, enrolling in the same

courses throughout each of the nine semesters. The lock-step curriculum prevents new

students from joining the courses, allowing a continuity of those enrolled and shared

expectation for success. Students expressed how a closed cohort model helped to build

relationships between cohort members and unity to accomplish expected outcomes.

Students discussed how faculty encouragement and their course requirements

discouraged the exclusion of students from the group.

 “We all got to know each other better as we went along.…we had a continuity and

knew each other better because of that continuity.” (P05)

 “We were on the same page and the same journey.” (P09)
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 “Faculty encouraged us to get to know one another. It [program] was like a

support system….our family and friends don’t always understand.” (P14)

 “Program design encouraged cohesiveness and sharing ideas. Unless it is required

[by faculty], I may not make that extra step.” (P15)

Students perceived this model as beneficial to group unity and their overall success.

Under the concept of program design, the overall support system within the cohort was

compared to being like a family.

 “We were like a family…it was like no student left behind.” (P10)

 “Typically I have not seen this model in other programs…it almost forces

cohesion through the cohort model.” (P19)

Program challenges.

The program created challenges for the students that strengthened collegial unity.

These challenges were voiced as confusion or concern with faculty assignments,

increased workload within courses, proximity of the students, and overall exhaustion.

Students expressed that during these times, they were able to lean on each other to find

ways of overcoming these challenges, provide an avenue of therapeutic release, and offer

words of encouragement or a colloquial phrase of support.

 “It is nice to know you are not alone, with questions, concerns, or even gripes

about the program. We are a support system for each other….it is a comic relief

because it [program] is stressful. It is okay to laugh at yourself when you don’t

understand directions from faculty….it leads to comfort knowing others have the

same concerns.” (P12)

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 “We also have been burned out together. We listen and have given support…and

sometimes tough love, like suck it up buttercup.” (P16)

 “…challenges exist for distance learning. The university provided a lot of tools to

make distance learning feel like we are all together.” (P15)

As program assignments intensified, students recognized they were

overwhelmed. Instead of allowing division among the group, students cited these

challenges represented opportunities to draw closer together.

 “The work [assignments] picked up and pressure was felt from the program…that

brought us closer together.” (P02)

 “It [program] was challenging and demanded a lot of work. It’s like going through

a fire or traumatic event, it brings you closer together.” (P02)

Personal challenges.

Students were faced with personal challenges during the program that created

opportunities for collegiate unity to occur. It became evident to the researcher that these

events, although difficult, were perceived as an avenue to embrace that student and grow

as a collective group.

 “We were a shoulder for one another if we were struggling and at one time we all

have struggled.” (P16)

 “When I just wanted to scream, I would talk to someone and they would talk me

through it.” (P04)

Specifically, the students discussed personal illnesses, the loss of a family

member, professional onuses, and other private struggles that fostered a sense of familial

responsibility or friendship to one another. Initially, these interactions appeared to be

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student-student centered, however, faculty involvement became significant within their

conversations.

 “We all got to know each other better as we went along.…we had a continuity and

knew each other better because of that continuity.” (P05)

 “We were on the same page and the same journey.” (P09)

 “Faculty encouraged us to get to know one another. It [program] was like a

support system….our family and friends don’t always understand.” (P14)

 “Program design encouraged cohesiveness and sharing ideas. Unless it is required

[by faculty], I may not make that extra step.” (P15)

 Let’s see, I lost my mother during the first year, was diagnosed with a major

illness…had a site visit and self-study. Through all of those circumstances, they

were my friends. There was no one that didn’t call or express concern, including

the faculty. I could call anyone at any time and they’d be there for me.” (P02)

 “One member of our cohort faced a major sickness and the others rallied behind

her. On another occasion, a member of our cohort needed help personally and we

made sure they knew we were there for them.” (P11)

 “We made sure the individual knew what was needed and the rest of the team

know what was needed to accomplish the goal….everybody has stuff, someone in

the program had a baby. All sorts of stuff happens.” (P17)

Sharing these experiences coupled with program commitments resulted in a

deeper desire to remain united. Students recognized this unity as advantageous both

personally and professionally.

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 “If anything slowed one of us down it bothered us all….we wanted to finish

together and walk together [commencement].” (P11)

 “If someone was struggling we would bring it to light in order to help. It was very

non-judgmental. It was like a family.” (P10)

 “I think we probably have been more personable with one another because we’ve

shared our lives with our cohort.” (P16)

Required interaction.

Students clearly articulated that required interaction, both formal and informal, is

necessary to establish cohesion. This interaction took many forms, whether designed by

faculty to be face-to-face or from a distance. Students expressed the need for this

interaction to be both frequent and purposeful. During these times, students were able to

share their professional expertise, personal attributes, and areas of concern or challenges

within the group. They also discussed the role of faculty during these interactions.

Through the interviews, the researcher identified numerous references of how these

formal and informal interactions affected group development and how the absence of

these interactions could have impeded this development.

Formal.

The formal interactions discussed by the students included a required a two-day

on-campus orientation process whereby students interacted with faculty and their new

cohort while becoming acquainted with school policies, procedures, and expectations.

Students shared that this on-campus time was needed to make initial connections and

determine their best modes of communication throughout the program.

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 “Cohesion is what helped me get through…if we would have started solo, I don’t

know if I would have made it through.” (P17)

 “We kicked off all on campus together and had a chance to put a face with a name

and to learn about each other.” (P18)

 “We had everyone’s email, and phone numbers. We all communicated in group

texts and group emails. We had everyone’s home, cell, and school email. We all

got together and made a spreadsheet and google doc and saved it.” (P14)

 “What helped the most was meeting in that first go-around during orientation.”

(P03)

Their responses revealed activities designed by faculty using the learning management

system and group projects that involved other members of the cohort became essential in

the development of cohesion. Students expressed how the incorporation of these

assignments became an avenue for developing group cohesion.

 “The cohesive feeling began with a group project. I got to know my partner

professionally a little more...his intellectual strengths and weaknesses and he

mine” (P04)

 “Group projects…I had the opportunity to work with different people in the

cohort and I don’t know if I would have reached out to them with that.” (P03)

 “…got to know each other more. We got to know each other’s jobs and

personality more. Through discussion boards that just started to pick up.” (P19)

 “Spirit of community was encouraged. The challenge of distance learning…it

takes time and intentionality. With online learning you will see really task

oriented people, and cohesion was facilitated by projects together. The faculty
 79

made it so we could learn as much from each other as we did from the

assignments….unless it is required, I don’t think it will naturally happen in

cohorts.” (P15)

 “I think the assignments that forced you to interact with different people through

the semester led to cohesiveness…I wouldn’t been naturally drawn to (members

of the group) without the forced interaction of the group projects. I wouldn’t have

picked them naturally, but I pick them to be in my group today.” (P12)

Informal.

Student responses woven into the discussion also revealed an array of informal

methods of interaction necessary to build relationships between group members and

faculty. Students considered the formal requirements as the key component to

maintaining these relationships; however, these relationships were initially ignited during

informal social interactions at the beginning of the program and refueled during

subsequent interactions. Students explained these informal events, attended by both

faculty and students, were held at a faculty member’s residence.

 “We went to a faculty member’s house for a barbeque social to get to know each

other professionally and socially and so we could meld together as a cohort and

find likeliness with one another.” (P04)

 “…were able to visit and socialize….social time is critical in that first year. I

hadn’t thought of this a lot about cohesion being online, but programs that don’t

[socialize], that is a risk.” (P07)

 “Teambuilding…occurred within an opportunity to meet and talk about our

backgrounds after hours in a casual environment and have some food.” (P05)
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 “We had an opportunity to meet off campus. This was provided by the program

and was a great introduction. It was well thought out and peppered with games. It

was a low stakes weekend.” (P10)

Group maturation.

Many powerful examples were given by the students that foreshadowed group

development or maturation. The idea emerged in the first year of the program whereby

students referenced similarities and differences among each other, relationships were

pioneered, and program expectations were established.

 “First year was more of a grooming process…or sort of a courting process.”

(PO8)

 “We were learning to work well together…developing connections with

people.”(P07)

 “We were getting to know each other’s faces, names, and jobs and also becoming

familiar with what there is to accomplish.” (P09)

 “It takes time to get to know everyone.” (P13)

 “We didn’t know what to expect” (P18)

Stories were repeatedly shared of a transition that occurred among the students as

the program progressed, bringing them closer together as a group, allowing them to

embrace a degree of comfort, and motivating them to accomplish the task at hand.

 “…more of an understanding of how we work. We were more comfortable

offering insight.” (P07)

 “I think we got closer. We got closer with certain class members but we always

knew we could ask anyone a question.” (P14)

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 “Definitely better. More interactions, more dialog…a level of comfort comes with

that communication.” (P12)

 “In the second year, we had the mindset that we should complete the task…we

experienced some groupthink…people were like, ‘let’s just roll with it and get it

done’.” (P16)

 “We were very honest and very constructive and it was typically well-received.”

(P10)

While these relationships were forming between students, faculty and student

relationships also emerged that were perceived as significant to group maturation.

Students acknowledged these relationships invited a more open conversation that was

described as a mutual respect from the faculty.

 “By and large they [faculty] respected the students and were supportive and didn’t

discourage anyone from sharing and discussing in discussion boards. They

recognized we were professionals in our field and looked at us as peers and they

were more than their title of instructors, they were mentors. They listened to us.”

(P02)

 “They [faculty] were open and made it clear we could always come to them with

questions.” (P14)

 “Cohesion comes from a shared struggle that you have. The program gives

enough struggle and the faculty give enough guidance. The cohesion occurs when

you make an emotional connection when you are feeling heartburn and angst. The

common struggles force us to talk to each other and resolve it.” (P12)
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While students expressed that more individualized work at the end of the program

resulted in less communication, an underlying sense of genuine concern and support for

one another continued to exist, affecting their sense of togetherness. This time was

perceived by some students as a disengagement as a group; however, their discussions

displayed a sense of unity continued to exist.

 “Cohesiveness was not as evident because there are no tasks bringing us together.

The spirit of congeniality to be there for one another is still there. We are

encouraging and supportive of each other, but we are working on our own

separate tracks.” (P15)

 “Relationships, though the final project was individualized, was more like that of

‘you can make it’. The cohesive times were not scheduled, it was more check in

text in the middle of the night or the middle of the day, just randomly. I think that

illustrates that there was still cohesion of the group towards the end.” (P09)

 “We were still a very cohesive group but by this point it is more individual work.”

(P01)

 “I think that because everyone was focused on the individual project, you do not

have as much cohesion. We did communicate with each other for mutual support.

I think it is what helped me get through. I always knew there was someone to

reach out to.” (P17)

Interprofessional appreciation.

During the interview process, students often referred to the idea of

interprofessional appreciation and the group enrichment offered by the professional

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diversity of its members. The students voiced an expectation of the faculty to seek the

perspective of other group members and to remain open to differing viewpoints.

 “We were encouraged to start the conversation and think about problems from a

different angle.” (P04)

 “The faculty made it so we learn as much from each other as we did from the

course.” (P15)

Findings indicate that students valued the opportunity to share their own

professional experiences and examine the perspectives of others. Students felt this

deepened their discussions, enhanced their group assignments, and broadened their

individual viewpoints.

 “We had such a diverse cohort where people were in different areas [professions].

We learned a lot from everyone by reading their responses and talking about

things I would not have thought about.” (P17)

 “For myself, I have a lot I can learn…by the positions they hold, I can really learn

a lot. The variety of experiences from really smart people showed me my

weaknesses” (P16)

 “Relationships are very important especially in administration. Learning from one

another and enhancing your ability to communicate with people professionally.”

(P18)

 “I would not have picked them naturally but I pick them to be in my group

today.” (P12)

 “…genuine respect for each other and an appreciation for the knowledge each one

of us possessed.” (P02)
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 “You get to see all different points of view. If you talk about it, you can see the

material more clearly…it you look past your own way of thinking.” (P01)

Students viewed their interprofessional experiences as not only beneficial while

enrolled in the program, but also as translated into their professional practice. Several felt

this removed them from the silos of their professions and allowed them to pursue

collaborative opportunities that were unfamiliar.

 “I would reach out to them for my job. So, it went over from cohesiveness in the

program to cohesiveness in real life. We learned respect for others whether we

agreed with them or not.” (P13)

 “I was the only clinical [member of the group] but others were administration,

education, and had all different views. At the end we could see people, accept

other sides or perspectives. Our cohort went from silos to very cohesive, but it

was a process. I don’t know if it was random or intentional, but it [assigned

groups] forced us to work with people from a different vantage point. …we had

gotten over the ‘my way is the right way mentality’…considering another view, it

really opened my eyes as a result of working with others. It started opening doors

to other jobs and other pathways I would not have considered. Not only that, but it

yielded actual results.” (P10)

While the exposure to varying professional backgrounds was considered a key

component of the group experience, geographic diversity was the precursor in many

conversations.

 “It was good to have diversity and a cohort that has people in LA and North

Carolina, and the Deep South.” (P16)

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 “…different geographic areas represented, health care takes different forms in

different places in the United States. It was nice to see that.” (P15)

Summary

The students provided the researcher insight regarding the development of cohort

cohesion within an interprofessional distance learning program. The rich data provided in

the interviews identified the core category of a shared experience and four additional

categories of collegial unity, required interaction, group maturation, and interprofessional

appreciation. In addition, several subcategories were discussed. The researcher provided

invaluable perspectives, in the students’ own words, to enhance the findings from the

analysis. Chapter V will provide further discussion of these findings and offer

conclusions grounded in the theory of the research study.

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Chapter V
DISCUSSION

This chapter presents a summary of the study and a further discussion of the

findings presented in Chapter IV. The researcher will present areas of the findings better

informed by the literature and theoretical framework. The discussion of results are

structured around the model of shared experiences and guided by the research questions.

A conclusion, synthesizing key points will be included, along with implications for use of

the research. Finally, recommendations for enhancement and future research

opportunities will be addressed.

Summary of the Study

Programs integrating multidisciplinary and multiprofessional students have

evolved with a mission of preparing graduates to assume upper level managerial and

leadership roles within the healthcare delivery system. For students to successfully

complete this type of program, each must effectively work within a group to complete

projects and assignments with real-world application dispersed throughout the

coursework. To achieve program outcomes, a process must occur whereby students

actively participate in constant dialogue and depend upon one another as group members.

This level of dependency varies among the group members and the strength of the group

is constantly tested (Bonebright, 2010; Tuckman, 1965; & Weber & Karmen, 1991).

Furthermore, challenges exist to create opportunities for groups to work together

collectively, coupled by proximity challenges of a distance-learning environment. The

construct of group development and member behavior is well documented in the

literature but an overall consensus of how it is achieved remains confounding (Alle-

Corliss & Alle-Corliss, 2009; Miller, 2003; Mullen & Copper, 1994; Ohrt et al., 2014;
 87

Tuckman, 1965; Tuckman & Jensen, 1977; Wolf et al., 2015). Although researchers do

not concur with the stages of group development, researchers agree that effective group

practice is difficult without achieving cohesion.

This qualitative study set out to determine student perceptions of developing

cohort cohesiveness while progressing through a doctoral level interprofessional health

administration program offered via distance learning and utilizing a closed cohort model,

and the role of faculty in the development of cohesion among the cohort. The setting for

the study was a program offered by a large metropolitan academic medical center in the

southern region of the United States. Using semi-structured interviews, the researcher

explored the experiences of students who are near completion or have graduated from a

distance learning doctoral level interprofessional (IP) health administration program to

determine the significance of cohort cohesion and how the faculty support or hinder its

development.

This study addressed gaps in the literature identified regarding group cohesion

and its influence in IP distance learning doctoral level programs. Furthermore, this study

provided additional insight into cohesion within distance learning programs, adding to a

limited collection of existing literature. It also offers a useful framework for future

research in this area of inquiry.

Discussion

This discussion of results is structured around the model of shared experience.

The findings are presented as a combination of the two research questions that dovetailed

during the data analysis process. The dynamic nature of cohesion prohibited the

separation of the developed categories, requiring the researcher to report the data results
 88

in unity. These categories and the relationship between them are interwoven and

encapsulated within the core category. Figure 3 offers a model representing this

relationship and its interrelated categories that comprise the core category of shared

experience.

Figure 3

A model of shared experience

 89

The researcher will present the categories, subcategories, and relationships derived from

the students’ experiences within the program of study and their perception of cohesion

within their group.

A shared experience was identified as the core category emerging from student

perceptions within the IP doctoral level distance learning program. In conjunction with

Tuckman and Jenson’s Theory of Group development, literature supports that specific

stages exist in which groups experience a process of development and within this process

cohesion should occur, resulting in meaningful and effective task accomplishment

(Erdem Aydin & Gumus, 2016; Haines, 2014; Ohrt et al., 2014; & Tuckman & Jensen,

1977). This same process became evident throughout the data but the idea of a shared

experience became uniquely central to the development of cohesion within the distance-

learning program of study. The shared experience emerged throughout the data analysis

process and was further supported by the categories of collegial unity, required

interactions, group maturation, and interprofessional appreciation.

Collegial Unity

Findings of the study revealed several aspects of collegial unity, further supported

by program design, program challenges, and personal challenges, encouraged the

development of cohesion. Students described the significance of having the common goal

of successfully completing the program and expressed empathy for others in the group

who desired the same goal. In conjunction with the theoretical framework of the study,

literature supports the need for groups or teams to have a mutual goal or task

commitment in order for group development to occur (Haines, 2014; Tuckman & Jenson,

1977; Wolf et al., 2015).

 90

Program design.

Findings of this study revealed the students’ perception of the program design

resonated with Maher’s (2005) findings suggesting that the cohort membership is a fluid

process. Within this study, students reflected upon starting the first semester of the

program and how they felt the cohort would have only a modest effect on their

educational experience, later realizing the extent of that impact was underestimated. In

Maher’s (2005) study, the idea of shared learning and increased trust were reported by

the students; however, students felt more time was needed to achieve cohesion. Contrary

to Maher’s (2005) research, the students interviewed by the researcher for this study were

together approximately 2 years longer. The students were also acutely aware of faculty

encouragement and expectations that aided in uniting them as a group. The researcher

perceived faculty support and the closed cohort model were conducive to the

development of cohesion.

Program Challenges.

The students’ perceptions of program challenges further solidified the category of

collegial unity. Many of the students interviewed voiced times in which frustration or

confusion related to the program created opportunities for them to rely on each other

more to find ways to overcome these challenges. This idea is exemplified in a study by

Wolf et al. (2015), whereby a supportive environment is directly related to the

individual’s performance when faced with opposition. Challenges such as increased

course workload, assignment confusion, proximity in distance learning, and exhaustion

were perceived by the researcher as an avenue of developing cohesion due to the

dependence required between group members during these times.

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Personal Challenges.

Echoing the students’ perceptions of program challenges were additional personal

challenges. Students recalled personal and family illnesses, death of a loved one, and

private struggles that ultimately aided in a familial responsibility or friendship with one

another. Sharing these experiences coupled with program commitments resulted in a

deeper desire to remain united. Although limited research exists regarding social presence

and caring in the online environment, Plante and Asselin (2014) emphasized that caring

between students and between students and faculty is the foundation of best practices for

teaching. Even though most students offered examples of student-student caring

interactions, several offered examples of faculty-student caring interactions experienced

during the program and how having both were significant.

Required Interaction

Both formal and informal interaction were revealed in students’ perceptions of

developing cohesiveness within the group. Purarjomandlangrudi et al. (2016) concluded

that instructional interaction was perceived as having a higher impact on success than

social interaction in a distance-learning environment. However, students in this study

perceived both the formal and informal interactions as crucial for group development and

the absence of these interactions could have impeded this development—in short,

affecting the development of cohesion. In Tuckman and Jenson’s (1977) Theory of

Group Development, during the stages of forming, storming, and norming, groups are

encouraged to come together periodically to work on common tasks and take team time

together.

Formal.
 92

Formal interactions of the program were perceived by students as an opportunity

to intermingle with faculty and group members while becoming acquainted with program

expectations. Students explained activities created by faculty to interact or work as a

group became essential to the development of cohesion. These opportunities were both

face-to-face and via the learning management system. Gallagher-Lepak et al. (2009)

explained how class structure, class participation, teamwork and use of technology were

necessary to foster a sense of community in distance learning. Student perceptions within

this study echoed these findings, indicating that increased communication and interaction

were necessary to promote connections between faculty and students and create a shared

sense of togetherness.

Informal.

Informal interactions were also discussed by the students and perceived by the

researcher as equally significant in the development of cohesion. However, these

interactions all occurred face-to-face, starting at the beginning of the program and at

subsequent times throughout the program. Students perceived these times as an

opportunity to ignite a relationship among group members and faculty and refuel these

relationships as time passed. Some students emphasized the detrimental consequences of

a distance-learning program that does not incorporate these informal opportunities.

Waugh and Jian (2016) identified social presence as one element most affected by

distance learning among graduate level students. The lack of required online socialization

examples by the students was perceived by the researcher as a hindrance of group

development in distance learning and a confirmation that some required face-to-face

interaction is necessary for this type of socialization to occur.

 93

Group Maturation

The students offered powerful examples of group maturation mirroring the

theoretical framework used for this study. During the interview process, students

referenced the initial stage of Tuckman and Jenson’s (1977) Theory of Group

Development as they spoke of similarities and differences among group members,

forming relationships within the group, and discovering the expectations of the task at

hand. According to the literature, the same group development process occurring in

traditional groups must occur in distance learning groups whereby a connection or a

sense of community with other group members must form in order to achieve successful

group development (Erdem Aydin & Gumus, 2016 & Haines, 2014).

Repeatedly, the students offered the researcher more insight into a transition that

occurred as the program progressed. Students discussed their relationships with other

students in the group and how faculty and student relationships also had emerged. The

transition brought the students closer together as a group and created a sense of comfort

and motivation to accomplish the ultimate task of program completion. In Tuckman and

Jenson’s (1977) theory, these stages of group development are recognized as norming,

followed by performing, and are characterized by the development of cohesion and the

use of this cohesion. At this point, group members begin to identify with one another,

trust is established, and teamwork perpetuates group integration and unity—in short, a

sense of family is being postulated.

During the interviews, most students cited more individualized work towards the

end of the program. Less communication and group work occurred during this stage;

however, an underlying sense of genuine concern existed among the students, and
 94

support for one another remained as individual tasks were accomplished. Although this

was perceived by the students as separation of the group, a sense of togetherness

continued to be evident within their comments. During the adjourning stage of Tuckman

and Jenson’s (1977) Theory of Group Development, the group begins the disengagement

process. However, this stage was unique for several of the students interviewed in that a

sense of togetherness, both professional and personal, remained after program

completion.

Interprofessional Appreciation

Throughout the interview process, the implication of interprofessional

appreciation was voiced by the students. The students explained an enrichment offered by

the professional diversity of its group members and how pursuing the perspective of other

group members was expected by faculty. MacDonald et al., (2010), indicated the need for

faculty to develop coursework and activities that focus on the enhancement of

professional identity and exposure to other health care professionals.

A study by Hurlock-Chorostecki et al., (2014) supported the need to bridge role

boundaries among interprofessional groups and make full use of members’ expertise.

These sentiments were similar in a study by Ebert et al. (2014), which reported the lack

of ability to communicate effectively as an IP team member was directly attributed to

limited experience in the group members’ program curricula. This further captures the

need for IP exposure and highlights the role of each member and their contribution to the

group development process. These findings are also consistent with the norming and

storming stage of Tuckman and Jenson’s Theory of Group Development, where role

identity is cautiously examined and members are forced to reconsider their own feelings,
 95

thoughts, attitudes and beliefs, establishing a base level for cohesion to occur (Tuckman

& Jenson, 1977).

Conclusions

In recognition of the value of interprofessional education, distance-learning

programs have evolved with a mission of preparing graduates to assume upper level

managerial and leadership roles within the healthcare delivery system. To achieve

program outcomes, a process must occur whereby students actively participate in

constant dialogue and depend upon one another as group members. The construct of

group development and member behavior is well documented in the literature, but an

overall consensus of how it is achieved remains confounding (Alle-Corliss & Alle-

Corliss, 2009; Miller, 2003; Mullen & Copper, 1994; Ohrt et al., 2014; Tuckman, 1965;

Tuckman & Jensen, 1977; Wolf et al., 2015). Although group productivity and

effectiveness is directly correlated to a group’s ability to achieve cohesion (Mullen &

Copper, 1994; Wolf et al., 2015), no known literature exists specifically focused on group

cohesion in IP distance learning doctoral level programs.

Using Tuckman and Jenson’s (1977) Theory of Group Development, along with a

grounded theory approach to analyzing students’ perceptions, the study found that shared

experience emerged as the essential component in the development of cohesion.

Encapsulated within this shared experience, the ideas of collegial unity, required

interactions, group maturation, and interprofessional appreciation became equally

influential to the process. As the students progressed through the varied stages of group

development, they recognized the faculty as an inseparable part of the process, drawing

attention to the significance of their role in promoting cohesion.

 96

Implications

Results of this study have implications for the promotion of educational programs

to foster group development within distance learning student cohorts. Attention should be

given to a broad base of understanding by faculty of the development of cohort cohesion

and the value of cohesion in higher-level education. Findings of this study support the

notion of faculty involvement in cohort cohesion and the importance of helping students

make connections as a group.

Findings support the benefits of a closed cohort model for this type of educational

program whereby adult learners from various professional backgrounds are expected to

function as a group. The results of this study also suggest incorporating connection

opportunities, both online and face-to-face at the beginning of the program and

subsequent times throughout the program. Although the face-to-face times may be

minimal in number, they are necessary to ignite a relationship and refuel these

relationships as time evolves. During face-to-face required interactions, attention should

be given to create both formal and informal activities for the students and faculty.

Findings also suggest that faculty must create activities online requiring group or cohort

participation to preserve the group development process essential to attaining cohesion.

These activities must be both frequent and purposeful.

Today, advances in technology have created new pathways for educational

programs to promote group development at a distance. Students enrolled in these

programs have limited campus visits, thus faculty must be prepared to use this technology

to promote group development and strengthen student-faculty relationships. It is

imperative both faculty and students recognize the value of group development within
 97

these types of programs and how the cohesiveness of groups enhances the learning

experience and contributes to student success. The consequences of ignoring the value of

cohesion in higher education or impeding its development could have detrimental effects

for distance learning programs.

Recommendations

This study was conducted within an interprofessional administrative doctoral program

at a large academic medical center in the southern region of the United States. This raises

questions about whether the role of group cohesion is valued in a discipline-specific

program of this nature. In addition, none of the four cohorts participating in the study

exceeded 14 students. Issues related to larger size cohorts or groups in distance learning

are yet to be investigated. Further research might address:

1. Faculty perceptions of cohesion within distance learning programs,

2. Specific design of distance learning assignments to encourage group

development and promote cohesion, and

3. Interprofessional group performance of students as it translates into

interprofessional group practice.

 98

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APPENDICES
 97

APPENDIX A
Consent to Participate

To: Doctor of Health Administration Student/Graduate

From: Angela A. Burrell
Subject: Informed Consent to Participate in Study
Dear: _______________________

My name is Angela A. Burrell, and I am a PhD student at William Carey University. I am researching
Perceptions of Developing Cohort Cohesiveness within an Interprofessional Distance Learning Doctoral
Program. I am requesting your participation and permission to be interviewed for this study.

Your participation in this study is voluntary and your time and involvement is appreciated. You should not
feel compelled to answer any questions you do not want to answer. During the interview process, you may
decline to continue at any time. The interview will take approximately 30 minutes to an hour. To maintain
the essence of your words for the research, both a note-taker and the interviewer will record the information
using handwritten notes. The information collected is available for you to review at any time. Once I
receive your consent, I will call you within 3 days to set up a convenient time for the interview.

The interview will be electronically stored in a password-protected computer with all identification
removed and the hard copy will be destroyed. All remaining data collected will be remain secured for six
years and ultimately destroyed.

Excerpts from the interview may be included in the final dissertation or used for later publications.
However, your name and all identifying characteristics will remain confidential in these writings.

I would be grateful if you would sign this form on the line provided below to show that you have read and
agree with the contents. Please return it by email to me at aburrell345749@student.wmcarey.edu.

____________________________________________________
Your signature above

This study is being conducted in part to fulfill requirements for my Doctor of Philosophy in Nursing
Education and Administration degree at William Carey University, Hattiesburg, Mississippi.
 98

The study has been approved by the Institutional Review Board of William Carey University and The
University of Mississippi Medical Center. The Chair of William Carey University’s Institutional Review
Board is Dr. Jalynn Roberts. Dr. Roberts can be reached at (601) 318 – 6778 and his email address is
jroberts@wmcarey.edu. The chairperson of this dissertation is Dr. Alicia Lundstrom. Dr. Lundstrom can be
reached at (601) 318-6709 for further questions or concerns about the research.

Sincerely,

Angela A. Burrell
William Carey University
Aburrell345749@student.wmcarey.edu
(601) 573-9690
 99

APPENDIX B
Letter of Permission to Dean

Date
Dr. Jessica H. Bailey
Dean, School of Health Related Professions
University of Mississippi Medical Center
2500 North State Street, Jackson, MS, 39216

RE: Permission to Conduct Research Study

Dear Dr. Bailey:

I am writing to request permission to conduct a research study at the School of Health Related
Professions, University of Mississippi Medical Center. I am currently enrolled in the Doctor of
Philosophy in Nursing Education and Administration Program at William Carey University in
Hattiesburg, MS, and am in the process of writing my dissertation. The study is entitled
Perceptions of Developing Cohort Cohesiveness within an Interprofessional Distance Learning
Doctoral Program.

I hope that you will allow me to recruit students currently enrolled in the last year of the Doctor
of Health Administration Program and those that have graduated. They would be participating in
a qualitative interview via face-to-face, phone conference, or web conference. Interested students,
who volunteer to participate, will be emailed a consent form to be signed and returned to the
primary researcher at the beginning of the interview process (copy enclosed).

The interview process should take no longer than one hour to complete. The data collected will
remain confidential and anonymous. Should this study be published, only pooled results will be
documented. No costs will be incurred by either your school/institution or the individual
participants.

Your approval to conduct this study would be greatly appreciated. I will follow up with a
telephone call next week and would be happy to answer any questions or concerns that you may
have at that time. You may contact me at my email address:
aburrell345749@student.wmcarey.edu.

If you agree, kindly submit a signed letter of permission on your institution’s letterhead
acknowledging your consent and permission for me to conduct this study at your school.

Sincerely,

Angela A. Burrell, MSN, RN

Enclosures
 100

APPENDIX C
WCU IRB Approval Letter
 101

APPENDIX D
External Review Board Approval Letter
 102

APPENDIX E
Email Invitation to Participate
 103

APPENDIX F
Interview Guide

1. How would you describe cohesiveness within your cohort during the first year of
the program?
2. How would you describe cohesiveness within your cohort during the second year
of the program?
Probe: Explain how the first year was different than the second year.
3. How would you describe cohesiveness within your cohort during the third year of
the program?
Probe: Explain how the third year was different than previous years.
4. Tell me how cohesion affected you individually within the cohort.
5. In what ways did the program design impact cohesion?
6. Describe ways in which the faculty may have influenced cohesion.
7. Any other comments?