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KEYWORDS Abstract
standardized patients; Background: There is limited research into the effectiveness of standardized patient experiences
teaching effectiveness; (SPEs) to teach therapeutic communication skills in undergraduate psychiatric nursing students.
psychiatric mental Method: A quasi-experimental, one-group, preepost evaluation design was used to examine the
health simulation; effectiveness of the use of SPEs to teach therapeutic communication skills in psychiatric nursing. Study
therapeutic participants included 89 senior nursing students enrolled in a psychiatric nursing clinical course in a
communication; baccalaureate nursing program.
communication skills; Results: Faculty provided formative evaluation on 14 criteria and group feedback early in the semester
nursing students; for students’ first interaction with a standardized patient (SP). During a second intervention at the end
quasi-experimental of the semester, with an SP, summative feedback was used to evaluate the student using the same
research; 14 criteria. Significant differences were noted in 12 of the 14 criteria demonstrating improvement
training in therapeutic communication skills.
Conclusion: Although further research is needed, this study suggests that the use of SPEs is an effec-
tive methodology for promoting therapeutic communication skills in undergraduate psychiatric
nursing students.
Effective communication skills are a core competency an increase in the severity of the illness of hospitalized indi-
for nurses. Without this essential skill, psychiatric nurses are viduals. In addition, a patient may refuse, be considered too
unable to build a therapeutic relationship and care for dangerous or fragile, or refuse to work with a student. This
individuals with mental illness. Providing students with may result in encounters with only certain patient diagnoses
opportunities to practice therapeutic communication with and no opportunity to interact with patients with common
individuals with mental illness can often be a challenge for psychiatric diagnoses. Nurse educators are therefore
nurse educators (Webster, 2010). Opportunities may be challenged to substitute other clinical teaching strategies
limited due to decreased patient census, length of stay, and that promote the use of therapeutic communication skills.
Simulation involving standardized patients (SPs) may be
an effective alternative method for teaching therapeutic
* Corresponding author: dawebster@salisbury.edu (D. Webster). communication skills in psychiatric nursing.
1876-1399/$ - see front matter Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2013.08.005
Standardized Patients and Therapeutic Communication e82
In addition to providing clinical activities when there identify the type of communication technique utilized, it
may be limited clinical options, SP experiences (SPEs) may not be accurate and is subject to distortion, because
allow faculty to control the types of patient interactions the student must rely on memory to document what was
(Founds, Zewe, & Scheuer, 2011; Parsh, 2010). This is of said and to identify nonverbal behaviors (Varcarolis &
great benefit, because providing a quality psychiatric Halter, 2010). Students may also document how they
nursing experience can be should have responded instead of what they actually said,
further complicated by fac- leading to many missed teachingelearning opportunities.
Key Points tors such as patient confiden- Because faculty do not have the opportunity to directly
Simulation involving tiality, aggression, and observe an entire studentepatient interaction in the psychi-
standardized patients unpredictability (Hermanns, atric setting, students are evaluated on brief observations
may be an effective Lilly, & Crawley, 2011). and written assignments, including the interpersonal pro-
alternative method for The use of SPEs allows fac- cess recording, both of which provide just a snapshot of
teaching therapeutic ulty to align clinical and di- the student’s ability to use therapeutic communication
communication skills dactic teaching giving skills.
in psychiatric nursing. students an opportunity to Although the field of medicine has utilized SPs for many
Role play was found engage with a variety of years, nursing is in the early stages of utilizing SPs to teach
to have a positive ef- patient diagnoses, including a variety of nursing skills. It has been suggested that
fect when the commu- those with issues of aggres- simulation using SPs can be an effective method of
nication of students sion and unpredictability. teaching students therapeutic communication skills (Lang
receiving only didactic Students are therefore able & Hahn, 2013). Marken, Zimmerman, Kennedy,
education was com- to practice in a safe yet Schremmer, and Smith (2010) had interdisciplinary teams
pared with students controlled environment. consisting of pharmacy, medical, and nursing students
who engaged in role Although SPs have been engage with SPs to practice communication skills on the
play after didactic utilized to teach commu- difficult topics of child health issues, intimate partner
education. nication in the field of violence, and suicidal ideation. The authors concluded
Standardized patient medicine for many years, that students gained confidence and improved communica-
experiences can be their use in undergraduate tion skills as a result of practicing with SPs in a simulated
utilized to teach and nursing is still in its infancy. environment.
assess undergraduate With limited information re- Role play was found to have a positive effect when the
nursing students’ use garding the effectiveness of communication of students receiving only didactic educa-
of therapeutic commu- SPEs as a teaching strategy tion was compared with students who engaged in role play
nication skills. in undergraduate nursing after didactic education (Kesten, 2011). Experiential ap-
education, it is imperative proaches including case studies and SPEs designed to
that nurse educators conduct research into this teaching mimic reality offer students ‘‘real-world’’elike experiences
strategy that is quickly gaining momentum. (Webster et al., 2012) provide other opportunities to learn
therapeutic communication skills. Using a case study com-
bined with an SP, students practiced communication in a pi-
Literature Review lot activity designed to facilitate communication with and
care for individuals with posttraumatic stress disorder
Strategies to Teach Communication (Webster et al., 2012). Students commented that they
were better prepared to care for individuals with posttrau-
The nurseepatient relationship is at the foundation of matic stress disorder as a result of participating with SPs.
providing care to individuals with mental illness. The Using carefully designed SPEs, faculty are able to control
ability to engage in therapeutic communication is crucial the type, complexity, and length of the interaction, which
to building this relationship. With scant literature to provide can also be used to decrease the randomness of patient
guidance into how to best teach therapeutic communication encounters in the clinical setting (Becker, Rose, Berg,
skills (Webster, Seldomridge, & Rockelli, 2012), faculty Park, & Shatzer, 2006). Although high-fidelity simulations
often use methods similar to how they were taught during are often used to allow students to practice technical skills,
their own nursing education. This includes the interpersonal the use of SPs adds to the authenticity of the experience
process recording in which faculty provide feedback based (Keltner, Grant, & McLeron, 2011) and may promote ther-
on student documentation of verbal communication, apeutic communication skills and empathy development.
nonverbal behavior, and environmental influences from por- In addition to self-evaluation, peer review has been used
tions of interaction with the patient (Varcarolis & Halter, to help students improve communication skills (Yoo &
2010). This may not be the best method for teaching and Chae, 2011). In this study, students in an experimental
evaluating therapeutic communication skills. Although group watched each other’s videos and provided feedback;
the interpersonal process recording allows the student to those in the control group completed only self-evaluation.
approaching client; mean, 1.31 introducing self), there was experience and described an overall decrease in anxiety
little room for improvement during the second SPE during interactions with individuals with mental illness.
(mean, 1.27 approaching client; mean, 1.27 introducing self). Many students commented they appreciated the opportunity
Although student anxiety is expected to be high initially, to gain experience communicating with a patient with a
anxiety should decrease with repeated contact and diagnosis that they did not get the chance to interact with in
increased confidence in working with the mentally ill the inpatient psychiatric setting. Students also acknowledged
population. Student anxiety was 3.26 for the initial SPE that they found practicing communication with a more
and 4.46 on a scale of 5 (strongly agree) to 1 (strongly difficult patient in the simulated environment gave them the
disagree), indicating an overall decrease in student anxiety. confidence they needed to engage with ‘‘real patients.’’
In addition to decreased anxiety, students demonstrated Faculty satisfaction with the standardized presentation of
significant improvement from the first to the second SPE in symptoms and objective method of evaluating the student
all other evaluation criteria. There was improvement noted was reported. Faculty also commented on the importance of
in students’ ability to establish eye contact (mean, 1.66 group debriefing and found that although many students did
initial; mean, 1.22, second SPE), suggesting increased not want other students to see their video-recording, peer
student comfort and confidence. There was also improve- review was a very important component of student learning
ment in the students’ ability to engage in efforts to put the and, when carefully led by faculty, provided a means for
patient at ease (mean, 2.06 initial; mean, 1.42 second SPE), students to provide and receive peer feedback in a profes-
suggesting a move away from focus on self and toward the sional setting. Self-reflection was also noted to be an
focus on the patient’s needs. important component of student learning.
Patient safety is important in psychiatric nursing. As Research using SPEs to teach therapeutic communica-
such, safety assessments and the ability to set limits on tion in undergraduate psychiatric nursing is very limited.
inappropriate behavior become paramount. Improvements The findings from this study support the use of SPEs to
were noted for both of these competencies (safety assess- teach and evaluate therapeutic communication skills in
ment: mean, 3.2 initial and 1.71 second SPE; and limit undergraduate nursing education. Future directions for this
setting: mean, 2.85 initial and 1.63 second SPE). project include an examination of interrater reliability of SP
In building a therapeutic relationship, focus on the patient and faculty feedback for high-stakes testing, providing
and a genuine display of empathy must be present written feedback from SPs to students, and including the
(Varcarolis & Halter, 2010). The student should be able to SPs in debriefing sessions with students and faculty.
respond appropriately to the patient’s nonverbal behavior Comparison and control groups will also be utilized to
and verbal statements using therapeutic communication provide further insight into the effectiveness of the use of
techniques. Improvements were also noted in all three of SPs to teach and evaluate therapeutic communication. Pre-
these areas (using therapeutic communication techniques: and post-testing student knowledge of therapeutic commu-
mean, 2.01 initial and 1.57 second SPE; responding appro- nication skills is another option for further exploration of
priately to verbal statements: mean, 2.49 initial and 1.78 sec- the effectiveness of this teaching strategy.
ond SPE; and responding appropriately to nonverbal
behavior: mean, 2.82 initial and 1.58 second SPE).
The ability to validate the meaning of a patient’s Limitations
response is also important when working with individuals
with mental illness. This may help to further build the In this study, one limitation related to the small sample size.
relationship and establish understanding and empathy. In addition, participants were not randomly selected, but
Improvement was also noted for this skill (mean, 2.85 were a convenience sample. There was no comparison
initial and 1.63 second SPE). using control and comparison groups. Although all students
Last, the appropriate termination of the session should were provided didactic course content in the same manner,
include what transpired during the interaction, a summari- it is possible that other confounding variables could have
zation of patient concerns, and plans for the next course of been responsible for some of the noted improvements. For
action, including teaching and follow-up care. Improvements example, some students may have been influenced by
were also noted for these two areas (summarizing content of personal experience or prior course work in psychology.
interaction: mean 2.93 initial and 1.82 second SPE; termi- In addition, clinical experiences with mentally ill patients
nating appropriately: mean 2.26 initial and 1.63 second SPE). in the outpatient and inpatient acute settings between the
first and second SPE may have led to some of the noted
improvement in therapeutic communication skills. It is also
Discussion important to take into consideration that knowledge of the
rating scale may have influenced improvements. Additional
This study found that SPEs can be utilized to teach and assess research is therefore needed to determine all influencing
undergraduate nursing students’ use of therapeutic commu- variables. Furthermore, reliability of the evaluation tool has
nication skills. Students reported satisfaction with the learning not yet been established.
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