Nurse Education in Practice 16 (2016) 176e181

Contents lists available at ScienceDirect

Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

The outcome of interprofessional education: Integrating

communication studies into a standardized patient experience
for advanced practice nursing students
Nicole Defenbaugh a, 1, Noreen E. Chikotas b, *
a
Department of Family Medicine, Lehigh Valley Health Network, USF Morsani College of Medicine e SELECT Program, Allentown, 18105, PA, USA
b
Bloomsburg University, Bloomsburg, 17185, PA, USA

a r t i c l e i n f o a b s t r a c t

Article history: The purpose of this qualitative study was to examine the impact of standardized patient experiences
Accepted 10 June 2015 (SPE) in the education of the Advanced Practice Nurse (APN). The education of the APN requires edu-
cators to make every attempt to promote competency in the areas of communication and clinical-
Keywords: decision making. SPE programs have been found to improve the interpersonal, problem solving, and
Standardized patients critical thinking skills of nursing students. For this research twenty-nine APN students participated in
Interprofessional education
SPEs over the course of two semesters. Fifteen student volunteers of those 29 participants were then
Advanced practice nursing
interviewed three months after the experience. Results revealed that having an expert in the field of
Communication
Clinical decision making
communication studies increased awareness of communication skills and how to improve nurse-patient
Qualitative research encounters in the clinical setting.
The interprofessional collaboration during the SPEs assisted in facilitating the application of learned
communication skills into patient-centered care of the APN student.
© 2015 Elsevier Ltd. All rights reserved.

Introduction been found to integrate a communication expert. This research article

discusses the use of SPEs in an Advanced Health Assessment course
For nearly fifty years standardized patient experiences (SPEs) for advanced practice nursing students (nurse practitioner and nurse
have been utilized as a teaching tool in healthcare education. Stu- anesthesia) and how communication skills at the advanced level are
dents in various programs such as psychology (O'Connor et al., learned and later applied to current and future clinical advanced
1999; Shawler, 2008), geriatrics (Nagoshi et al., 2004), speech- practice. The article examines how those communication skills are
language pathology (Hill et al., 2010), genetics (McGovern et al., further developed with a skilled Communication Studies scholar as
2006), trauma (Ali et al., 2009) and hematology-oncology one of the faculty developers and assessors in the SPE.
(Ahmed et al., 2009) have incorporated SPEs into their program
of study. Standardized patient experiences have also been used for
evaluating students in specific areas of care: end-of-life (Smith- Background
Stoner, 2009; Shawler, 2011), cultural competency (Rutledge
et al., 2004), individuals with disabilities (Long-Bellil, 2007), and In nursing the use of standardized patients has received
ethics (Haddad, 2010). More recently, SPE programs are being used extensive examination and continued attention because of its
to educate students for clinical examinations (May, 2008; Sadeghi usefulness as an instructional strategy for improving learning
et al., 2007; Hauer et al., 2009; McWilliam and Botwinski, 2010). outcomes (Seibert et al., 2004). Specific to the realm of nursing,
One aspect of utilizing SPEs in the education of healthcare pro- standardized patients have been used in a variety of contexts:
viders is the evaluation of communication skills. Although many gerontology (Shawler, 2011), distance learning (Seibert et al., 2004),
programs utilize the instructional strategy of SPE, no programs have pediatrics (Lambdon, 2008), end-of-life care (Smith-Stoner, 2009),
HIV prevention (Carney and Ward, 1998), psychiatric-mental health
(Shawler, 2008), and issues relating to psychosocial behavior
* Corresponding author. Tel.: þ1 570 389 4609; fax: þ1 570 389 5008.
E-mail addresses: Nicole.Defenbaugh@lvhn.org (N. Defenbaugh), nchikota@
(O'Connor et al., 1999) and culture (Rutledge et al., 2004). Stan-
bloomu.edu (N.E. Chikotas). dardized patient experiences enable nursing faculty to assess spe-
1
Tel.: þ1 610 969 4948. cific competencies in an evaluative format.

http://dx.doi.org/10.1016/j.nepr.2015.06.003
1471-5953/© 2015 Elsevier Ltd. All rights reserved.
 N. Defenbaugh, N.E. Chikotas / Nurse Education in Practice 16 (2016) 176e181 177

One competency in particular that has received notable atten- specialist, and nurse anesthesia options) of the Master of Science
tion in the last decade is communication. The popularity of SPEs program at the university where the study was conducted are
and recognition of its measured benefits in the area of communi- required to take the AHA. This course is designed to teach advanced
cation continues to rise. As a creative strategy employed by nearly history taking and physical assessment to the student who will be
30% of faculty who teach Advanced Health Assessment (Kelley et al., making medical diagnostic decisions as an Advanced Practice Nurse
2007), the use of SPEs in teaching competencies to nursing students (APN). There were a total of 29 APN students (20 nurse practi-
has numerous benefits, especially in improving communication tioners and 9 nurse anesthetist students) in the AHA course, which
skills. And although communication skills are taught at the un- was offered in both the fall and spring semesters. All APN students
dergraduate level, graduate nursing students entering into the were Registered Nurses licensed in the state of which they reside
realm of advanced practice (nurse practitioner, clinical nurse and had various years of experience (2e25 years) in the acute care
specialist, etc) need to have excellent communication skills to assist setting. Of the 29 students (27 female and 2 males) who partici-
in the process of diagnostic reasoning. pated in the SPE sessions, 15 students (all female) volunteered to
Specific communication skills or subcategories have been identi- participate in the study. Of those 15 female participants 11 of the
fied as interpersonal, listening, critical thinking, and empathy. These participants were nurse practitioner students and four were nurse
communicative skills are of particular interest to evaluators in SPEs anesthetist students. Fourteen respondents were Caucasian and
because of the need for nurses to effectively interact with their pa- one respondent was African American, with the mean age of the
tients creating a positive, engaging, and supportive encounter. participants being 30 years (range 24e43) and a mean of six years
Rutledge et al. (2004) state the importance of using SPEs in nurse in practice as a registered nurse. None of the participants had been
practitioner (NP) education is because the safe learning environment exposed to a standardized patient experience before.
helps them “be prepared to be better communicators, and ultimately,
better NPs” (2004, p. 3). Yet the following questions remain: What Procedure
does it mean to be an effective communicator? What does it mean to
possess “good” communication skills? And how are communication The SPE sessions took place in the health assessment laboratory
skills assessed without the use of a trained communication educator? of a northeastern university. The cases and sessions were devel-
One way to assure that communication skills are being oped and proctored by the authors of this study, a senior graduate
addressed within the instructional strategy of SPEs is to have a nursing professor and a senior health communication professor/
communication expert (scholar) involved, someone educated in the communication studies scholar at the university where the SPE
health communication field to assist in developing, implementing took place.
and evaluating the SPE process. This can be accomplished through The two primary roles of the Communication Studies (CS)
interprofessional education of disciplines. scholar were to examine the nursing students' use of nonverbal and
Over twenty years ago the World Health Organization (WHO) verbal communication skills and provide feedback regarding the
called for a need for collaboration across medical professions and application of these skills in the patient encounter. The CS scholar
wrote Learning Together to Work Together for Health Report in 1988 had experience in assessing SP sessions at a local health care
(Lapkin et al., 2013). Interprofessional education (IPE) was listed by network. The CS scholar worked alongside the Nursing faculty as an
WHO “as a way to enhance collaboration and interprofessional observer and facilitator of the SPE sessions. The scenarios were
teamwork” (Lapkin et al., 2013, p. 91). It is defined as “different evenly divided so that both the CS and Nursing faculty were able to
professions working together as a team toward a common goal of observe and watch each student at least once to provide a dual
providing optimal patient care using the skills/expertise of other perspective. The use of a CS scholar allowed for a richer, more in-
professions” (Wu et al., 2012, p. 4). Interprofessional education depth discussion about effective communication practices in
seeks to join individuals from various professionsdwithin the field obtaining a detailed history for the purpose of diagnostic reasoning.
of healthcaredto share their unique skills, knowledge, and talents All of the standardized patient (SPs) actors were recruited
with the unified vision of improving patient care. In so doing, through a local theater company and had prior experience as
collaborative work has the potential to revolutionize patient care. trained professional actors in the health care industry. Since the
Complementary medicine (Steel and Adams, 2012), nursing, hired SPs had significant prior professional training as health care
respiratory therapy (King et al., 2013), and mental health (Kinnair actors, minimal training was required. For this experience SPs were
et al., 2012), are just a few of the many health professional pro- contacted by the author and given the script/scenario one month
grams that have incorporated IPE in their curriculum. With an in- prior to the session. Actors were then asked to solicit any questions
crease in preventable medical errors (King et al., 2013) and growing or concerns about the script. Questions of clarification about the
need for improved communication skills and teamwork (Lapkin script (e.g., patient background) were the primary focus. On the day
et al., 2013), collaborative efforts in healthcare have become more of the session, actors were asked to meet in advance to have any
important than ever. Through IPE, learners have the potential to further questions answered, review the format/structure of the
increase their collaboration, teamwork, and communication skills. sessions (e.g., length of time for each nurse encounter and group
A study evaluating the importance of interprofessional simulation, debrief), be introduced to the physical space of the scenarios (e.g.,
for example, reported 44% of the students' answers related to the patient beds, curtains/dividers) and assist as co-facilitators of the
importance or need to improve communication (King et al., 2013). sessions.
Incorporating collaboration in IPE has shown to positively effect Utilizing four SPs actors, four different cases were utilized. These
teamwork, patient-centered care, and communication. cases included breaking bad news, cessation of smoking, request
for assistance with weight loss, and chronic headaches (domestic
Research design abuse issue). Over a two-week time frame each student had the
opportunity to rotate through all four cases. The students were
Sample provided with information on the patient they would be inter-
viewing and examining prior to the experience. The student was
The course in which the SPE was performed was an Advanced then given 20 min to complete the history and physical examina-
Health Assessment (AHA) course. All students in the advanced tion related to the patient's concern, and develop a plan with the
practice clinical specialties (nurse practitioner, clinical nurse patient for treatment and management. During this time the
178 N. Defenbaugh, N.E. Chikotas / Nurse Education in Practice 16 (2016) 176e181

researchers evaluated the student through observation and note Data analysis
taking. Upon completion of the 20-min session the student was
then debriefed on their overall presentation, communication skills, Thematic coding was utilized in analyzing the data for patterns
and physical exam techniques by the researchers and the actors. and themes. Defined by Boyatzis (1998) as “a process for encoding
The debriefing process included two parts: individual and qualitative information [that] requires an explicit ‘code’” (1998, p.
group. The first part of the debriefing occurred immediately after 4), thematic analysis involves seeing patterns, interpreting infor-
the scenario. Actors began by offering one-on-one feedback to the mation, and developing themes into meaningful knowledge. Given
nursing students and faculty provided comments to the sessions the diverse background of the two researchers, this particular
they observed. During the second part of the debriefing, all par- method of analysis was appropriate since it “can be a beneficial
ticipants sat in a circle to discuss the session. The group debrief bridge between researchers of varying orientations and fields”
began with feedback from the students. The CS scholar asked the (Boyatzis, p. 6). Each author coded and compared patterns indi-
students to articulate 1) what they did well and 2) what they will vidually and then together to refine and integrate as many themes
take away from the session. Although many students struggled as possible. This process, known as check coding, “not only aids
listing positive behaviorsdmany began with what they did not do definitional clarity but also is a good reliability check” (Miles and
welldevery student was able to articulate at least one. The CS Huberman, 1994, p. 64). These patterns and themes were then
scholar reminded students that recognizing one's strengths allows further compared and analyzed into categories by the two authors
increased awareness of those behaviors and an increased likelihood with further additions, deletions, and refining as information was
of repeating those behaviors. After the students spoke, faculty clarified and follow-up interviews occurred.
offered general comments about the session. These comments
varied depending on what themes emerged during the session (e.g., Findings
talking less and listening more to a patient after a cancer diagnosis).
This process was not meant to be summative in nature and From the face to face interviews with the 15 APN students three
the students were not graded on the process. Rather, the sessions categories were extracted from the data and illustrate the phe-
were formative in nature to help students improve in the area nomenon of the lived experience of having been exposed to SPEs
of communication while obtaining a history and physical as APN students as well as how that experience impacted their
examination. communication skills in both their clinical practicum as APN stu-
dents and their current practice as registered nurses. These cate-
Data collection gories included increased awareness, communication skills, and
clinical practice. And although practicing registered nurses, such as
The four main questions guiding the research were: How does our students in this study, are often well versed in therapeutic
the APN student make meaning of her/his standardized patient communication skills, they are being educated to utilize those
experience? What impact has the experience with the standardized skills to perform diagnostic reasoning, something they were not
patients had on his/her current clinical nursing practice? What taught as an undergraduate nursing student. So within the find-
impact does the inclusion of a Communication Studies scholar have ings listed here the responses relate to the process of arriving at a
on the assessment of communication skills in the standardized diagnosis for a patient, for which a higher level of communication
patient experience? What effect does the standardized patient is needed.
experience have on teaching the competency of communication? In the first category, increased awareness, the increase in
The research questions called for a qualitative investigation of the awareness of self and other became evident and was believed to
lived experiences, personal meaning, and outcomes in the com- have occurred as a result of the interactive and dialogic nature of
petency of communication. SPE sessions. One student commented,
Three months after the standardized patient experience, indi-
“There were some things that they [actors and facilitators] told me
vidual face-to-face interviews were conducted in the university
that I did that I didn't realize that I did”. Another student
offices of the researchers. An interview guide was utilized using
remarked, “…they [actor] kind of show you things that you didn't
semi-structured, open-ended questions to assist in focusing on key
even realize that you were even doing”.
areas, yet permitting for flexibility. Interviews were conducted over
a two-week period, until theoretical saturation was reached at a
sample size of 15. With permission from the respondents, in- Students not only increased their awareness of their own
terviews were recorded and transcribed. Prior to the initial in- thoughts and behaviors, they also learned new skills. For example,
terviews, a pilot study of the questions was conducted with five one student learned the importance of using the patient's own
participants to provide information on how well the questions words and not her own words when summarizing what the pa-
could elicit the information requested. From the pilot study no tient said. Another student learned to be aware of differing
restructuring occurred to the interview questions. agendas (nurse vs. patient), specifically that the patient's agenda
may not be the same as the nurse's. The student also stated the
Ethical considerations importance of “making] sure that we [nurse and patient] are on the
same page”.
Ethical approval was sought at the authors' home institution Other comments pointed to an awareness of the nurse-patient
through the University Wide IRB Committee. Since students are encounter and issues of control. In relation to end-of-life care,
considered a vulnerable population, a full committee approval was one student realized,
required and obtained prior to the start of the research. Participa-
“I think it is really key in end of life because they [patients] have lost
tion was voluntary and participants were provided information on
control of most other things. The one thing they should have control
the full nature of the research project including informed consent,
over is what they want from me and not what I want to give them”.
which was obtained prior to the first SPE session. Participants were
informed of their right to withdraw at any point from the research
and that individual responses would not be traceable in data There also was an awareness of the limitations in the nurse-
reporting. patient encounter. For example, students commented on an
 N. Defenbaugh, N.E. Chikotas / Nurse Education in Practice 16 (2016) 176e181 179

increased awareness of “noncompliant” patients and the nurse's “It is something I have to practice because I wasn't a natural at
desire to fix the patient's health issue. As one student noted, really listening...You shouldn't rush to the advice because people
need to feel and express their feelings.”
“I think that has helped me and made me realize I need to be a little
bit more realistic because sometimes you can lead a horse to water
but you can't make him drink”. Finally, students recognized the impact listening had on their
own clinical practice and how this impacted their overall nurse-
patient encounters.
In the second category, communication skills, the students
frequently commented on the various communication skills they “I deal with that every day trying to make sure that I am really
learned during the SPE sessions and how many of them had listening and not putting my own agenda into the whole situation
incorporated these skills into their practice. This was believed to and my own personal needs as well, which is sometimes hard”.
occur as a result of having a Communication Studies scholar co-
facilitating the SPE sessions.
In the third category of clinical practice, two themes were pre-
Twelve of the students mentioned an increased awareness of
sented: real life experience and safe environment. When asked to
their communication skills listing specific aspects of communica-
describe the experience, students believed it would be “phony” in
tive acts (e.g., allowing patients to talk, awareness of posture, vol-
nature but were surprised at how real it felt.
ume level of voice) in their responses. When asked what evidence
of professional development (SP experience) the nursing student “I thought oh this really won't be real, but I really felt like I was very
observed in his/her clinical practice since participating in the pro- present and all the actors were very good in making me feel that I
gram, eleven of the students mentioned “communication” directly was in a real situation”. “I wasn't sure if it would be realistic, but I
or as a specific communication skill (e.g., listening). When initially found it to be very realistic!”
asked to comment on the overall standardized patient experience
one student stated,
The students were also able to correlate the SPE to the recent
“It was good because it pointed out what I did verbally and clinical practicum in a primary health care setting, which they were
nonverbally. Kind of gave me an outside view of how I could currently doing at the time of the interviews.
improve from my communication skills and the way I looked at
“I started clinical this semester and I was not so nervous entering
patients and things like that”.
the exam room, since I felt like I had been there done that, and it
helped!”
Two themes emerged in the communication skills category:
nonverbal communication and listening. Students experienced Eight of the fifteen students interviewed commented on how
increased consciousness of their own body language and the the experience provided them with a safe environment to practice
nonverbal traits of others. communication skills, make mistakes, reflect on those mistakes,
Examples of their own body language included, and begin the process of becoming an APN. As described by two
“I think it [SPE session] pointed out a lot of body language. I learned respondents:
how important and aware patients are of your body language and “It was a good experience; it took you out of your comfort zone and
different gestures you make or what you are doing with your hands somewhat made you uncomfortable, but in a safe environment”.
if you're nervous or moving papers around”.
“Definitely being able to practice giving someone bad news when it
“It makes me more consciously aware of how I am sitting, how I am is really not bad news. It was really hard and it wasn't even real.
communicating with the patient, and trying to make the patient But being able to practice that for the first time was a great
more comfortable”. experience”.

Additionally, students had an increased awareness of their pa- And within that safe environment the student was comfortable
tients' body language. in transitioning into the role of an APN.
“I could tell just by their [patient and patient's daughter] responses “I feel better prepared now. It's such a profound role change to be
to me and their posture that they were a little resistant with able to sit there and actually discuss the problem with the patient.
sharing information with me.” It prepared me to do that in the clinical setting I am in now”

Listening, the second theme of communication skills was the The structure of the SPEs allowed for practicing clinical and
most cited communication tool listed by students. Responses communication skills in a safe environment. Through the re-
included an increase in the amount of listening, ways in which spondents answers to questions on the experience it was found
students listened, and accounting for patient silence (knowing that the informal non-summative evaluation of the sessions then
when not to talk). One student when asked how the SPE session enabled students to make mistakes, practice feedback given, and
helped him/her in clinical, commented on the importance of test different communication strategies in a supportive environ-
listening in relation to time. ment to prepare for future clinical practice.
“It's really important to just let them do that [talk to the nurse]…
taking the time and letting them talk to you about things instead of
rushing through” Discussion

In the study we discovered that APN students make meaning of

Students also gained an increased awareness of the skill their SPE through an increased awareness of their own thoughts
involved in listening and its importance to the patient. and behaviors in relation to the nurse (provider) e patient
180 N. Defenbaugh, N.E. Chikotas / Nurse Education in Practice 16 (2016) 176e181

encounter. This included an understanding of the importance of many, not only for students but also for the facilitators and actors
using the patient's own words, the existence of differing agendas, involved in the process. Standardized patient experiences allow for
issues of control, and other nuances of the nurse (provider) e pa- engaged, practical, embodied learning in a safe and supportive
tient encounter including noncompliance. environment. Feedback from facilitators and actors can be useful to
Additionally, the SPE provided a safe environment for the stu- students in future patient encounters. Through collaboration,
dent to practice her/his clinical skills in a more realistic format. As however, additional skills such as effective communication can be
Rutledge et al. (2004) previously stated, allowing the student to learned.
learn in a safe environment ultimately helps her/him to be a better Inviting a Communication Studies educator to co-facilitate the
NP. In regards to communication skills, the SPE resulted in an in- SPE resulted in valuable insight, knowledge, and skills about the
crease in the incorporation of and assessment of these skills. process and application of communication skills in the clinical
During the debrief, students repeated the feedback they received setting. By inviting other professionals from both within and
and offered their own assessments of how well they did/did not outside nursing to participate in the SPE, students have the op-
address specific communication skills, particularly nonverbal cues portunity to learn about other aspects of clinical care (e.g. psy-
and effective listening. The APN student demonstrated specific chological, community/social, religion/spirituality, familial) and
communication skills they learned to apply in their clinical how to treat and effectively care for the ‘whole person’.
encounter to better perform diagnostic reasoning. Being able to
read a patient's non-verbal cues (e.g., avoidance of eye-contact),
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