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Using Standardized Patients in an Undergraduate Nursing Health Assessment Class
Clinical Simulation in Nursing (2017) 13, 309-313
www.elsevier.com/locate/ecsn
Featured Article
Using Standardized Patients in an Undergraduate Nursing Health Assessment Class Joan Andrea, RN, DNP, Peggy Kotowski, RN, MSN* School of Nursing and Health Sciences, North Park University, Chicago, IL 60625, USA KEYWORDS interviewing skills; health history; standardized patients; undergraduate nursing students; health assessment; nursing education
Abstract Background: Although standardized patients (SPs) are routinely used in graduate nursing programs and medical school, limited data are available regarding use with undergraduate baccalaureate nursing students. Method: A quantitative research design was used to investigate using SPs as an effective teaching method to increase students’ confidence, communication skills, and clinical judgment to obtain a health history from patients. Results: Working with SPs increased participant’s level of confidence in performing a health history. Conclusions: Using SPs in an undergraduate health assessment class can enhance students’ ability to communicate and interact with patients in gathering a health history thereby strengthening patient care. Cite this article: Andrea, J., & Kotowski, P. (2017, July). Using standardized patients in an undergraduate nursing health assessment class. Clinical Simulation in Nursing, 13(7), 309-313. http://dx.doi.org/10.1016/ j.ecns.2017.05.003. Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
In the 1960s, neurologist Howard Barrows (1993) trained nonmedical people to act as ‘‘patients’’ for medical students. Adopting this pedagogy of standardized patients (SPs) to teach medical students and nurse practitioners has proven benefits (Gibbons et al., 2002; HetzelCampbell, Pagano, O’Shea, Connery, & Caron, 2013; Kameg, Mitchell, Clochesy, Howard, & Suresky, 2009; Ruterford-Hemming & Jennrich, 2013; Swanson & Stillman, 1990). A randomized controlled study examining
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflicts of interest: none. * Corresponding author: [email protected] (P. Kotowski).
the use of SPs with immediate feedback and group discussion of teaching interpersonal and communication skills to advanced practice nursing students demonstrated support of SP methodology for improving communication skills (Lin, Chen, Chao, & Chen, 2013). Psychiatric nursing education found merit with this pedagogy to develop essential communication skills (Doolen, Giddings, Johnson, Guizado de Nathan, & O’Badia, 2014; Kameg et al., 2014). A pilot study with undergraduate nursing students found that working with SPs in a mental health simulation increased their confidence, encouraged professionalism, and increased their understanding of mental illness (Alexander & Dearsley, 2013). In another study, students reported themes of improved interviewing skills, more
1876-1399/$ - see front matter Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2017.05.003
SPs in an Undergraduate Health Assessment Class
310
confidence, and improved application of skills and knowledge when working with SPs who had been taught to demonstrate symptoms of bipolar disorder, anxiety, and schizophrenia (Doolen et al., 2014). Evidence of the usefulness of incorporating SPs in the undergraduate nursing program is growing (Alexander Key points & Dearsley, 2013; Luctkar Standardized patients Flude, Wilson-Keates, & (SPs) are useful to Larocque, 2012; O’Mara, first-semester nursing McDonald, Gillespie, Brown, students in developing & Miles, 2014). The National beginning skills for Council Board of Nursing health assessment. study found that incorporation The use of SPs showed of simulation into undergradimproved confidence, uate nursing education could communication skills, replace up to 50% of clinical and clinical judgment experience without changing for first-semester nurlearning outcomes (Hayden, sing students. Smiley, Alexander, Kardong Utilization of SPs Edgrens, & Jefferies, 2014). allows for a more These results suggest that authentic experience in simulation is a pedagogy that a low-stress situation. is equivalent to traditional pedagogies and can be useful in teaching communication and history taking skills in health assessment.
Filling Gaps Between Education and Practice Reaching curriculum objectives for undergraduate health assessment class to prepare students by taking a health history using interviewing skills involves practicing the art of communication. Communication is essential in meeting quality and safety standards in patient-centered care. Between 1995 and 2005, ineffective communication was responsible for 66% of health care errors (Sherwood & Zomorodi, 2014). Ineffective communication in health care can also have a financial cost (Wilner & FeinsteinWhittaker, 2013). Reimbursement is linked to patient satisfaction that can be influenced by nurseepatient interactions (Centers for Medicare and Medicaid Services, 2014). Educating student nurses on the nuances of verbal and nonverbal communication is a skill that crosses many areas and has the potential to reap tremendous benefits. Teaching empathy and appropriate bedside manner along with the skills needed to elicit a health history can be challenging. Infrequent opportunities and fear of judgment by clinical faculty or staff can hinder students (O’Mara et al., 2014). Many current undergraduate nursing students belong to the generation called millennials or generation Y and are accustomed to communicating through the use of technology. Problem solving and patience is lacking in some millennials (Bland, Melton, Welle, & Bigham, 2012). This
generation strives for teamwork and achievement (Hartmann & McBridge, 2011). Utilizing SPs is a strategy that nurse educators can use to teach effective communication skills and build confidence. Nurse educators are increasingly using simulation to create learning opportunities to assist students to refine communication skills.
SPs as Teachers Nursing researchers are giving more attention to the value of nontechnical skills such as how to greet and introduce oneself to patients, handshakes, eye contact, sitting versus standing during an interview, words to use when speaking to family members and patients versus health care terminology or jargon, or when touch is appropriate. These are all details that can empower or inhibit communication (Hetzel-Campbell et al., 2013). SPs in this study did teach the value of both verbal and nonverbal communication. Teaching excellent interpersonal and communication skills in undergraduate nursing school benefits many aspects of health care. The didactic teaching of interview techniques and how to take a health history is followed by practice in the lab. However, in the lab, students gravitate to friends to practice taking a health history. The lab experience with fellow students does not facilitate skills in talking to patients of various ages or backgrounds. Skills or knowledge of how to speak with a patient with a cognitive or sensory impairment is not experienced. Students need to be engaged and have opportunities to participate in the learning process. Enlisting SPs, real people trained to take on the acting the role of a patient in specific clinical scenarios, helps create a more realistic situation to practice, and refine communication skills. SPs give feedback to students through their response as a patient and can also call a ‘‘time-out’’ to come out of the role and discuss the various nuances of communication, phrases, and words chosen by the student that may be misinterpreted or found to be too blunt or judgmental. SPs can stop the student/patient interaction and refocus the interview if needed.
Research Question/Problem Clinical faculty may not have direct observation of students taking health histories and not be able to provide appropriate feedback to students. Students must rely on self-assessment or reaction of patients in developing communication skills. When students are observed, they are often anxious and may feel a lack of confidence. Experiential learning in nursing programs allows students to take didactic learning, along with psychosocial and communication skills and apply it to in situ situations. Anxiety and lack of confidence can be potential barriers to learning and application of knowledge. Anxiety is high in
pp 309-313 Clinical Simulation in Nursing Volume 13 Issue 7
SPs in an Undergraduate Health Assessment Class
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these situations and can be heightened if students perceive nursing faculty are impolite, unapproachable, intimidating, or display attitudes of mistrust (Hutchinson, Janiszewski, & Goodin, 2013). Using SPs, who only provide feedback and not grades, can be less threatening to students who have high-performance anxiety. The aim of this research project was to determine if the use of SPs would be useful in increasing a students’ confidence, communication skills, and clinical judgment when working with patients in the clinical setting. For the purpose of this research, communication is conceptualized as the ability to communicate effectively (establishing rapport, address the patient and family with dignity and respect, and appropriate use of terminology). Confidence is defined as the students’ ability to approach the patient and family in a calm and assured manner that would invoke a trusting relationship. Communication and confidence are integral components leading to the development of clinical judgment allowing students to make informed decisions.
Methods Trial Design In this quantitative research study, first-semester baccalaureate nursing students of health assessment class in a Midwest liberal arts university worked with SPs. The researchers received approval from the university’s institutional review board. A convenience sample (n ¼ 80) of three cohort groups was utilized over three semesters. The first cohort group consisted of 28 females and two males, the second group contained 24 females and four males, and the final group was composed of 19 females and three males. Ages of the subjects ranged from 20 to 40 years of age. The week before the scheduled use of SPs, which were a standard part of the curriculum of this course, the students were provided with complete disclosure of the study process, and volunteers for the research were solicited. The volunteers were not provided with any incentive to take part in this research study. At the same time, informed consent was obtained from the volunteer students, and they were assigned a study participant number to track their responses to the questionnaire at the three time points. Three cohorts of students completed the Lasater Clinical Judgment Rubric (LCJR) at three different points of time. The first student self-assessment was completed at baseline. Prior to baseline, students were provided with a brief explanation of the LCJR to facilitate understanding on completing the tool. Review of the scale was not undertaken at subsequent student self-evaluations. The second data collection point was done after the student had completed 12 hours of clinical experience, two- to six-hour clinical days, with actual patients. The final self-evaluation was one week later after working with the SPs in the lab. SPs enacted the same three scenarios for groups of five to six students for each of the cohort groups in week nine of the course.
Reliability in each of the three scenarios over each of the three semesters was obtained by utilizing the same script and the same actors, who are well versed and have lots of experience in the role of SP. During the scenario, the SP holds the dual role of patient and instructor, providing feedback through the patient’s reaction or by briefly halting the scene to share teaching pearls to the student doing the interview. SP feedback was not an outcome that was measured in this study. However, as part of the SP process, time-outs are incorporated into the scenario to help clarify any issues with the students.
Assessment Tool After the completion of the signed consent, recruited students completed a self-assessment using the LCJR. This rubric was designed to describe the trajectory of students’ clinical judgment over the length of their nursing program. This tool was chosen because it incorporates communication and reflection that lead to self-confidence all that lead to improved clinical judgment. Lasater states that ‘‘Although the LCJR shows a developmental process, it was designed to evaluate a single episode requiring clinical judgment. It does, however, present a bigger picture view of clinical judgment development, allowing students to grasp what clinical judgment involves, evaluate their growth, and identify goals toward its achievement’’ (Lasater, 2007, p 499). Permission from the creator of the rubric was obtained (K. Lasater, personal communication, September 24, 2013). The LCJR consists of four levels or stages of development based on Tanner’s Model of clinical judgment (Tanner, 2006)dbeginning, developing, accomplished, and exemplary for each aspectdnoticing, interpreting, responding, and reflecting. The ‘‘noticing’’ issue involves focused observation, recognizing deviations from expected patterns and information seeking. The ‘‘interpreting’’ character looked at prioritizing and making sense of data. The ‘‘responding’’ point measured confidence, clear communication and planning interventions, and flexibility. The ‘‘reflecting’’ issue involves evaluation, self-analysis, and commitment to improvement (Lasater, 2007; Miraglia & Asselin, 2015). The only modification to the tool was that the column titles, ‘‘beginning, developing, accomplished and exemplar,’’ were removed. In their place, the numbers one, two, three, and four were added so that the researchers could quantify and document the change in students’ confidence, communication skills, and clinical judgment over time. Students were asked to circle the descriptor that best defined their selfassessment of clinical performance at each point in time.
Findings Data were analyzed using SPSS. A one-way repeated measures analysis of variance was conducted to evaluate the null hypothesis that there is no change in student’s total score when measured at baseline, after the clinical
pp 309-313 Clinical Simulation in Nursing Volume 13 Issue 7
SPs in an Undergraduate Health Assessment Class Table
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Summary of Results at Baseline, After Clinical Exposure, and After SPs Lasater Clinical Judgment Rubric Results Baseline, M (p, p)
Being skillful Evaluation/self-analysis Commitment to improvement Making sense of the data Calm, confident manner Clear communication Well-planned intervention/flexibility Focused observation Recognizing deviation from expected patterns Information seeking Prioritizing data Total
2.84 2.94 3.21 2.83 2.97 2.94 2.80 2.83 2.88 3.10 2.92 32.25
(1.00, <.01) (1.00, .04) (1.00, 1.00) (.53, <.01) (1.00, <.01) (.23, <.01) (.01, <.01) (.12,.<.01) (.51, .02) (1.00, .02) (.51, <.01) (.03, <.01)
Clinical, M (p, p) 2.90 2.92 3.22 2.91 3.03 3.05 3.05 3.00 2.98 3.13 2.98 33.16
(1.00, <.01) (1.00, .05) (1.00, 1.00) (.53, .03) (1.00, <.01) (.23, .30) (.01, .20) (.12, <.01) (.51, .69) (1.00, .02) (.51, <.01) (.32, <.01)
SP, M (p, p) 3.14 3.09 3.24 3.09 3.24 3.17 3.18 3.22 3.08 3.29 3.27 35.01
(<.01, <.01) (.04, .05) (1.00, 1.00) (<.01, .03) (<.01, <.01) (<.01, .30) (<.01, .20) (<.01, <.01) (.02, .69) (.02, .02) (.01, <.01) (<.01, .01)
Note. SPs ¼ standardized patients.
experience, and after their experience with SPs in the firstyear health assessment course. The results of the analysis of variance indicated a significant time effect, Wilk’s lambda ¼ 0.67, F (2, 76) ¼ 19.15, p < .01. Thus, there is significant evidence to reject the null hypothesis. Follow-up comparisons of individual aspects, as demonstrated in Table, on the rubric indicated that there was significant increase in scores over time in the areas of being skillful, making sense of data, feeling calm and confident, clear communication, being well planned and flexible, focused observation, and prioritizing data suggesting that work with the SP was beneficial for students. These results indicate that the use of SPs increases the participants’ level of confidence, communication skills, and clinical judgment when performing a health history with patients.
Discussion Self-assessment is the perception of a behavior and readily employed in gathering data on someone’s attitude and confidence. The Lasater Clinical Judgment Rubric has been used in other settings with undergraduate students to measure student performance and found to be well constructed (Ashcraft et al., 2013). The belief that one can be successful at a task or skill is an internal motivator for learning. Barriers of low self-confidence and high anxiety negatively affect decision-making processes. Clinical decision making can be impaired without confidence. Limitations of student self-evaluation rather than direct observation of clinical judgment abilities may yield discrepancies in perceived and actual clinical judgment abilities. One study found that young, inexperienced nurses had overconfidence in their clinical judgment skills when perceived and when actual clinical judgment skills were measured (Miraglia & Asselin, 2015). Direct observation combined with self-evaluation would be most beneficial.
This study found significant self-reported evidence supporting benefits of undergraduate nursing students working with SPs. Small groups of students working with one SP allowed for the positive feedback, prompts for improvement, and cultivated the first steps in problem solving by establishing effective communication in gathering the health history from a patient. In one scenario, the patient was elderly and had trouble hearing. Students learned to be patient in listening, repeating, and speaking slowly to the patient. In another scenario, questions about sexual activity needed to be explored. Some students were visibly uncomfortable and reluctant to enter into this area of the health history. SPs offered guidance on how to transition the interview into sensitive areas and illicit the needed information. Giving them the tools and allowing them to practice in a safe, simulated environment instills confidence in their ability to transfer these skills into the clinical area. Feeling confident and equipped motivates students to engage in new experiences and opportunities that might otherwise have deferred during clinical.
Conclusion Incorporating SPs into the undergraduate curriculum is a new methodology that could reshape nursing education. SPs can assist novice students learn how to utilize interpersonal communication skills and develop critical thinking skills. Reliance on preceptor input and instructor observation can be unreliable and biased. Finding clinical preceptors and sites can be competitive and limited. SP methodology is readily available and less costly than highfidelity manikins that have limitations. A few undergraduate nursing programs are routinely incorporating SPs. The cost of recruiting, training, and managing a pool of individuals to be SPs is the greatest barrier. Compared with the cost and maintenance of high-fidelity manikins,
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SPs may save money for nursing programs and be a means to meet many curricular objectives. Limitations of this study include the subjective evaluation of the student’s self-assessment of their competency. As previously noted, students tend to overestimate their abilities. Therefore, it is suggested that in future studies that both the student’s self-assessment and the assessment of a faculty observer in assessing the student’s skill level be undertaken to allow for appropriate leveling of the student’s skill. Implications for future research include the integration of simulation to understand the subtle nuances only available with human contact. Further exploration of how to assimilate SPs into undergraduate nursing curriculums to develop interprofessional education could potentially enhance nursing education programs.
References Alexander, L., & Dearsley, A. (2013). Using standardized patients in an undergraduate mental health simulation. International Journal of Mental Health, 42(2-3), 149-164. http://dx.doi.org/10.2753/IMH0020-7411420209. Ashcraft, A. S., Opton, L., Bridges, R. A., Caballero, S., Veesart, A., & Weaver, C. (2013). Simulation evaluation using a modified Lasater Clinical Judgment Rubric. Nursing Education Perspectives, 34(2), 122-126. Barrows, H. (1993). An overview of the uses of standardized patients for teaching and evaluating clinical skills. Academic Medicine, 68(6), 443-451. Bland, H., Melton, B., Welle, P., & Bigham, L. (2012). Stress tolerance: New challenges for millennial college students. College Student Journal, 46(2), 362-375. Centers for Medicare and Medicaid Services. (2014). HCAHPS: Patients’ perspectives of care survey. Retrieved from http://www.cms.gov/Medicare/Quality-Initiatives-Patient Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html. Doolen, J., Giddings, M., Johnson, M., Guizado de Nathan, G., & O’Badia, L. (2014). An evaluation of mental health simulation with standardized patients. International Journal of Nursing Education Scholarship, 11(1), 1-8. http://dx.doi.org/10.11515/ijnes-2013-0075. Gibbons, S., Adamo, G., Padden, D., Ricciardi, R., Graziano, M., Levine, E., & Hawkins, R. (2002). Clinical evaluation in advanced practice nursing education: Using standardized patients in health assessment. Journal of Nursing Education, 41(5), 215-221. Hartman, J., & McCambridge, J. (2011). Optimizing millennials communication styles. Business Communication Quarterly, 74(1), 22-44. http: //dx.doi.org/10.1177/1080569910395564.
Hayden, J., Smiley, R., Alexander, M., Kardong-Edgrens, S., & Jefferies, P. (2014). The NCSBN study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), S2-S41. Hetzel-Campbell, S., Pagano, M. P., O’Shea, E. R., Connery, C., & Caron, C. (2013). Development of the health communication assessment tool: Enhancing relationships, empowerment, and power-sharing skills. Clinical Simulation in Nursing, 9(11), e543-e550. Hutchinson, T., Janiszewski, S., & Goodin, H. (2013). Nursing student anxiety as a context for teaching/learning. Journal of Holistic Nursing, 31(1), 19-24. Kameg, K., Mitchell, A., Clochesy, J., Howard, V., & Suresky, J. (2009). Communication and human patient simulation in psychiatric nursing. Issues in Mental Health Nursing, 30, 503-508. http://dx.doi.org/10.108 0/01612840802601366. Lasater, K. (2007). Clinical judgment development using simulation to create an assessment rubric. Journal of Nursing Education, 46(11), 496-503. Lin, E. C., Chen, S. L., Chao, S. Y., & Chen, Y. C. (2013). Using standardized patient with immediate feedback and group discussion to teach interpersonal and communication skills to advanced practice nursing students. Nurse Education Today, 33, 677-683. Luctkar-Flude, M., Wilson-Keates, B., & Larocque, M. (2012). Evaluating high-fidelity human simulators and standardized patients in an undergraduate nursing health assessment course. Nurse Education Today, 32, 448-452. Miraglia, R., & Asselin, M. (2015). The Lasater clinical judgment rubric as a framework to enhance clinical judgement in novice and experienced nurses. Journal for Nurses in Professional Development, 31(5), 284-291. O’Mara, L. O., McDonald, J., Gillespie, M., Brown, H., & Miles, L. (2014). Challenging clinical learning environments: Experiences of undergraduate nursing students. Nurse Education in Practice, 14, 208-213. Ruterford-Hemming, T., & Jennrich, J. (2013). Using standardized patients to strengthen nurse practitioner competency in the clinical setting. Nursing Education Perspectives, 34(2), 118-121. Sherwood, G., & Zomorodi, M. (2014). A new mindset for quality and safety: The QSEN competencies redefine nurses’ role in practice. Nephrology Nursing Journal, 41(1), 15-22. Swanson, D. B., & Stillman, P. L. (1990). Use of standardized patients for teaching and assessing clinical skills. Evaluation and the Health Professionals, 13, 79. http://dx.doi.org/10.1177/016327879001300105. Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. Webster, D. (2014). Using standardized patients to teach therapeutic communication in psychiatric nursing. Clinical Simulation in Nursing, 10(2), e81-e86. Wilner, L. K., & Feinstein-Whittaker, M. (2013). Improving communication skills in healthcare, In: Perspectives on communication disorders and sciences in culturally and linguistically diverse (CLD) populations. Rockville, MD: ASHA.
pp 309-313 Clinical Simulation in Nursing Volume 13 Issue 7
www.elsevier.com/locate/ecsn
Featured Article
Using Standardized Patients in an Undergraduate Nursing Health Assessment Class Joan Andrea, RN, DNP, Peggy Kotowski, RN, MSN* School of Nursing and Health Sciences, North Park University, Chicago, IL 60625, USA KEYWORDS interviewing skills; health history; standardized patients; undergraduate nursing students; health assessment; nursing education
Abstract Background: Although standardized patients (SPs) are routinely used in graduate nursing programs and medical school, limited data are available regarding use with undergraduate baccalaureate nursing students. Method: A quantitative research design was used to investigate using SPs as an effective teaching method to increase students’ confidence, communication skills, and clinical judgment to obtain a health history from patients. Results: Working with SPs increased participant’s level of confidence in performing a health history. Conclusions: Using SPs in an undergraduate health assessment class can enhance students’ ability to communicate and interact with patients in gathering a health history thereby strengthening patient care. Cite this article: Andrea, J., & Kotowski, P. (2017, July). Using standardized patients in an undergraduate nursing health assessment class. Clinical Simulation in Nursing, 13(7), 309-313. http://dx.doi.org/10.1016/ j.ecns.2017.05.003. Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
In the 1960s, neurologist Howard Barrows (1993) trained nonmedical people to act as ‘‘patients’’ for medical students. Adopting this pedagogy of standardized patients (SPs) to teach medical students and nurse practitioners has proven benefits (Gibbons et al., 2002; HetzelCampbell, Pagano, O’Shea, Connery, & Caron, 2013; Kameg, Mitchell, Clochesy, Howard, & Suresky, 2009; Ruterford-Hemming & Jennrich, 2013; Swanson & Stillman, 1990). A randomized controlled study examining
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflicts of interest: none. * Corresponding author: [email protected] (P. Kotowski).
the use of SPs with immediate feedback and group discussion of teaching interpersonal and communication skills to advanced practice nursing students demonstrated support of SP methodology for improving communication skills (Lin, Chen, Chao, & Chen, 2013). Psychiatric nursing education found merit with this pedagogy to develop essential communication skills (Doolen, Giddings, Johnson, Guizado de Nathan, & O’Badia, 2014; Kameg et al., 2014). A pilot study with undergraduate nursing students found that working with SPs in a mental health simulation increased their confidence, encouraged professionalism, and increased their understanding of mental illness (Alexander & Dearsley, 2013). In another study, students reported themes of improved interviewing skills, more
1876-1399/$ - see front matter Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2017.05.003
SPs in an Undergraduate Health Assessment Class
310
confidence, and improved application of skills and knowledge when working with SPs who had been taught to demonstrate symptoms of bipolar disorder, anxiety, and schizophrenia (Doolen et al., 2014). Evidence of the usefulness of incorporating SPs in the undergraduate nursing program is growing (Alexander Key points & Dearsley, 2013; Luctkar Standardized patients Flude, Wilson-Keates, & (SPs) are useful to Larocque, 2012; O’Mara, first-semester nursing McDonald, Gillespie, Brown, students in developing & Miles, 2014). The National beginning skills for Council Board of Nursing health assessment. study found that incorporation The use of SPs showed of simulation into undergradimproved confidence, uate nursing education could communication skills, replace up to 50% of clinical and clinical judgment experience without changing for first-semester nurlearning outcomes (Hayden, sing students. Smiley, Alexander, Kardong Utilization of SPs Edgrens, & Jefferies, 2014). allows for a more These results suggest that authentic experience in simulation is a pedagogy that a low-stress situation. is equivalent to traditional pedagogies and can be useful in teaching communication and history taking skills in health assessment.
Filling Gaps Between Education and Practice Reaching curriculum objectives for undergraduate health assessment class to prepare students by taking a health history using interviewing skills involves practicing the art of communication. Communication is essential in meeting quality and safety standards in patient-centered care. Between 1995 and 2005, ineffective communication was responsible for 66% of health care errors (Sherwood & Zomorodi, 2014). Ineffective communication in health care can also have a financial cost (Wilner & FeinsteinWhittaker, 2013). Reimbursement is linked to patient satisfaction that can be influenced by nurseepatient interactions (Centers for Medicare and Medicaid Services, 2014). Educating student nurses on the nuances of verbal and nonverbal communication is a skill that crosses many areas and has the potential to reap tremendous benefits. Teaching empathy and appropriate bedside manner along with the skills needed to elicit a health history can be challenging. Infrequent opportunities and fear of judgment by clinical faculty or staff can hinder students (O’Mara et al., 2014). Many current undergraduate nursing students belong to the generation called millennials or generation Y and are accustomed to communicating through the use of technology. Problem solving and patience is lacking in some millennials (Bland, Melton, Welle, & Bigham, 2012). This
generation strives for teamwork and achievement (Hartmann & McBridge, 2011). Utilizing SPs is a strategy that nurse educators can use to teach effective communication skills and build confidence. Nurse educators are increasingly using simulation to create learning opportunities to assist students to refine communication skills.
SPs as Teachers Nursing researchers are giving more attention to the value of nontechnical skills such as how to greet and introduce oneself to patients, handshakes, eye contact, sitting versus standing during an interview, words to use when speaking to family members and patients versus health care terminology or jargon, or when touch is appropriate. These are all details that can empower or inhibit communication (Hetzel-Campbell et al., 2013). SPs in this study did teach the value of both verbal and nonverbal communication. Teaching excellent interpersonal and communication skills in undergraduate nursing school benefits many aspects of health care. The didactic teaching of interview techniques and how to take a health history is followed by practice in the lab. However, in the lab, students gravitate to friends to practice taking a health history. The lab experience with fellow students does not facilitate skills in talking to patients of various ages or backgrounds. Skills or knowledge of how to speak with a patient with a cognitive or sensory impairment is not experienced. Students need to be engaged and have opportunities to participate in the learning process. Enlisting SPs, real people trained to take on the acting the role of a patient in specific clinical scenarios, helps create a more realistic situation to practice, and refine communication skills. SPs give feedback to students through their response as a patient and can also call a ‘‘time-out’’ to come out of the role and discuss the various nuances of communication, phrases, and words chosen by the student that may be misinterpreted or found to be too blunt or judgmental. SPs can stop the student/patient interaction and refocus the interview if needed.
Research Question/Problem Clinical faculty may not have direct observation of students taking health histories and not be able to provide appropriate feedback to students. Students must rely on self-assessment or reaction of patients in developing communication skills. When students are observed, they are often anxious and may feel a lack of confidence. Experiential learning in nursing programs allows students to take didactic learning, along with psychosocial and communication skills and apply it to in situ situations. Anxiety and lack of confidence can be potential barriers to learning and application of knowledge. Anxiety is high in
pp 309-313 Clinical Simulation in Nursing Volume 13 Issue 7
SPs in an Undergraduate Health Assessment Class
311
these situations and can be heightened if students perceive nursing faculty are impolite, unapproachable, intimidating, or display attitudes of mistrust (Hutchinson, Janiszewski, & Goodin, 2013). Using SPs, who only provide feedback and not grades, can be less threatening to students who have high-performance anxiety. The aim of this research project was to determine if the use of SPs would be useful in increasing a students’ confidence, communication skills, and clinical judgment when working with patients in the clinical setting. For the purpose of this research, communication is conceptualized as the ability to communicate effectively (establishing rapport, address the patient and family with dignity and respect, and appropriate use of terminology). Confidence is defined as the students’ ability to approach the patient and family in a calm and assured manner that would invoke a trusting relationship. Communication and confidence are integral components leading to the development of clinical judgment allowing students to make informed decisions.
Methods Trial Design In this quantitative research study, first-semester baccalaureate nursing students of health assessment class in a Midwest liberal arts university worked with SPs. The researchers received approval from the university’s institutional review board. A convenience sample (n ¼ 80) of three cohort groups was utilized over three semesters. The first cohort group consisted of 28 females and two males, the second group contained 24 females and four males, and the final group was composed of 19 females and three males. Ages of the subjects ranged from 20 to 40 years of age. The week before the scheduled use of SPs, which were a standard part of the curriculum of this course, the students were provided with complete disclosure of the study process, and volunteers for the research were solicited. The volunteers were not provided with any incentive to take part in this research study. At the same time, informed consent was obtained from the volunteer students, and they were assigned a study participant number to track their responses to the questionnaire at the three time points. Three cohorts of students completed the Lasater Clinical Judgment Rubric (LCJR) at three different points of time. The first student self-assessment was completed at baseline. Prior to baseline, students were provided with a brief explanation of the LCJR to facilitate understanding on completing the tool. Review of the scale was not undertaken at subsequent student self-evaluations. The second data collection point was done after the student had completed 12 hours of clinical experience, two- to six-hour clinical days, with actual patients. The final self-evaluation was one week later after working with the SPs in the lab. SPs enacted the same three scenarios for groups of five to six students for each of the cohort groups in week nine of the course.
Reliability in each of the three scenarios over each of the three semesters was obtained by utilizing the same script and the same actors, who are well versed and have lots of experience in the role of SP. During the scenario, the SP holds the dual role of patient and instructor, providing feedback through the patient’s reaction or by briefly halting the scene to share teaching pearls to the student doing the interview. SP feedback was not an outcome that was measured in this study. However, as part of the SP process, time-outs are incorporated into the scenario to help clarify any issues with the students.
Assessment Tool After the completion of the signed consent, recruited students completed a self-assessment using the LCJR. This rubric was designed to describe the trajectory of students’ clinical judgment over the length of their nursing program. This tool was chosen because it incorporates communication and reflection that lead to self-confidence all that lead to improved clinical judgment. Lasater states that ‘‘Although the LCJR shows a developmental process, it was designed to evaluate a single episode requiring clinical judgment. It does, however, present a bigger picture view of clinical judgment development, allowing students to grasp what clinical judgment involves, evaluate their growth, and identify goals toward its achievement’’ (Lasater, 2007, p 499). Permission from the creator of the rubric was obtained (K. Lasater, personal communication, September 24, 2013). The LCJR consists of four levels or stages of development based on Tanner’s Model of clinical judgment (Tanner, 2006)dbeginning, developing, accomplished, and exemplary for each aspectdnoticing, interpreting, responding, and reflecting. The ‘‘noticing’’ issue involves focused observation, recognizing deviations from expected patterns and information seeking. The ‘‘interpreting’’ character looked at prioritizing and making sense of data. The ‘‘responding’’ point measured confidence, clear communication and planning interventions, and flexibility. The ‘‘reflecting’’ issue involves evaluation, self-analysis, and commitment to improvement (Lasater, 2007; Miraglia & Asselin, 2015). The only modification to the tool was that the column titles, ‘‘beginning, developing, accomplished and exemplar,’’ were removed. In their place, the numbers one, two, three, and four were added so that the researchers could quantify and document the change in students’ confidence, communication skills, and clinical judgment over time. Students were asked to circle the descriptor that best defined their selfassessment of clinical performance at each point in time.
Findings Data were analyzed using SPSS. A one-way repeated measures analysis of variance was conducted to evaluate the null hypothesis that there is no change in student’s total score when measured at baseline, after the clinical
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Summary of Results at Baseline, After Clinical Exposure, and After SPs Lasater Clinical Judgment Rubric Results Baseline, M (p, p)
Being skillful Evaluation/self-analysis Commitment to improvement Making sense of the data Calm, confident manner Clear communication Well-planned intervention/flexibility Focused observation Recognizing deviation from expected patterns Information seeking Prioritizing data Total
2.84 2.94 3.21 2.83 2.97 2.94 2.80 2.83 2.88 3.10 2.92 32.25
(1.00, <.01) (1.00, .04) (1.00, 1.00) (.53, <.01) (1.00, <.01) (.23, <.01) (.01, <.01) (.12,.<.01) (.51, .02) (1.00, .02) (.51, <.01) (.03, <.01)
Clinical, M (p, p) 2.90 2.92 3.22 2.91 3.03 3.05 3.05 3.00 2.98 3.13 2.98 33.16
(1.00, <.01) (1.00, .05) (1.00, 1.00) (.53, .03) (1.00, <.01) (.23, .30) (.01, .20) (.12, <.01) (.51, .69) (1.00, .02) (.51, <.01) (.32, <.01)
SP, M (p, p) 3.14 3.09 3.24 3.09 3.24 3.17 3.18 3.22 3.08 3.29 3.27 35.01
(<.01, <.01) (.04, .05) (1.00, 1.00) (<.01, .03) (<.01, <.01) (<.01, .30) (<.01, .20) (<.01, <.01) (.02, .69) (.02, .02) (.01, <.01) (<.01, .01)
Note. SPs ¼ standardized patients.
experience, and after their experience with SPs in the firstyear health assessment course. The results of the analysis of variance indicated a significant time effect, Wilk’s lambda ¼ 0.67, F (2, 76) ¼ 19.15, p < .01. Thus, there is significant evidence to reject the null hypothesis. Follow-up comparisons of individual aspects, as demonstrated in Table, on the rubric indicated that there was significant increase in scores over time in the areas of being skillful, making sense of data, feeling calm and confident, clear communication, being well planned and flexible, focused observation, and prioritizing data suggesting that work with the SP was beneficial for students. These results indicate that the use of SPs increases the participants’ level of confidence, communication skills, and clinical judgment when performing a health history with patients.
Discussion Self-assessment is the perception of a behavior and readily employed in gathering data on someone’s attitude and confidence. The Lasater Clinical Judgment Rubric has been used in other settings with undergraduate students to measure student performance and found to be well constructed (Ashcraft et al., 2013). The belief that one can be successful at a task or skill is an internal motivator for learning. Barriers of low self-confidence and high anxiety negatively affect decision-making processes. Clinical decision making can be impaired without confidence. Limitations of student self-evaluation rather than direct observation of clinical judgment abilities may yield discrepancies in perceived and actual clinical judgment abilities. One study found that young, inexperienced nurses had overconfidence in their clinical judgment skills when perceived and when actual clinical judgment skills were measured (Miraglia & Asselin, 2015). Direct observation combined with self-evaluation would be most beneficial.
This study found significant self-reported evidence supporting benefits of undergraduate nursing students working with SPs. Small groups of students working with one SP allowed for the positive feedback, prompts for improvement, and cultivated the first steps in problem solving by establishing effective communication in gathering the health history from a patient. In one scenario, the patient was elderly and had trouble hearing. Students learned to be patient in listening, repeating, and speaking slowly to the patient. In another scenario, questions about sexual activity needed to be explored. Some students were visibly uncomfortable and reluctant to enter into this area of the health history. SPs offered guidance on how to transition the interview into sensitive areas and illicit the needed information. Giving them the tools and allowing them to practice in a safe, simulated environment instills confidence in their ability to transfer these skills into the clinical area. Feeling confident and equipped motivates students to engage in new experiences and opportunities that might otherwise have deferred during clinical.
Conclusion Incorporating SPs into the undergraduate curriculum is a new methodology that could reshape nursing education. SPs can assist novice students learn how to utilize interpersonal communication skills and develop critical thinking skills. Reliance on preceptor input and instructor observation can be unreliable and biased. Finding clinical preceptors and sites can be competitive and limited. SP methodology is readily available and less costly than highfidelity manikins that have limitations. A few undergraduate nursing programs are routinely incorporating SPs. The cost of recruiting, training, and managing a pool of individuals to be SPs is the greatest barrier. Compared with the cost and maintenance of high-fidelity manikins,
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SPs may save money for nursing programs and be a means to meet many curricular objectives. Limitations of this study include the subjective evaluation of the student’s self-assessment of their competency. As previously noted, students tend to overestimate their abilities. Therefore, it is suggested that in future studies that both the student’s self-assessment and the assessment of a faculty observer in assessing the student’s skill level be undertaken to allow for appropriate leveling of the student’s skill. Implications for future research include the integration of simulation to understand the subtle nuances only available with human contact. Further exploration of how to assimilate SPs into undergraduate nursing curriculums to develop interprofessional education could potentially enhance nursing education programs.
References Alexander, L., & Dearsley, A. (2013). Using standardized patients in an undergraduate mental health simulation. International Journal of Mental Health, 42(2-3), 149-164. http://dx.doi.org/10.2753/IMH0020-7411420209. Ashcraft, A. S., Opton, L., Bridges, R. A., Caballero, S., Veesart, A., & Weaver, C. (2013). Simulation evaluation using a modified Lasater Clinical Judgment Rubric. Nursing Education Perspectives, 34(2), 122-126. Barrows, H. (1993). An overview of the uses of standardized patients for teaching and evaluating clinical skills. Academic Medicine, 68(6), 443-451. Bland, H., Melton, B., Welle, P., & Bigham, L. (2012). Stress tolerance: New challenges for millennial college students. College Student Journal, 46(2), 362-375. Centers for Medicare and Medicaid Services. (2014). HCAHPS: Patients’ perspectives of care survey. Retrieved from http://www.cms.gov/Medicare/Quality-Initiatives-Patient Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html. Doolen, J., Giddings, M., Johnson, M., Guizado de Nathan, G., & O’Badia, L. (2014). An evaluation of mental health simulation with standardized patients. International Journal of Nursing Education Scholarship, 11(1), 1-8. http://dx.doi.org/10.11515/ijnes-2013-0075. Gibbons, S., Adamo, G., Padden, D., Ricciardi, R., Graziano, M., Levine, E., & Hawkins, R. (2002). Clinical evaluation in advanced practice nursing education: Using standardized patients in health assessment. Journal of Nursing Education, 41(5), 215-221. Hartman, J., & McCambridge, J. (2011). Optimizing millennials communication styles. Business Communication Quarterly, 74(1), 22-44. http: //dx.doi.org/10.1177/1080569910395564.
Hayden, J., Smiley, R., Alexander, M., Kardong-Edgrens, S., & Jefferies, P. (2014). The NCSBN study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), S2-S41. Hetzel-Campbell, S., Pagano, M. P., O’Shea, E. R., Connery, C., & Caron, C. (2013). Development of the health communication assessment tool: Enhancing relationships, empowerment, and power-sharing skills. Clinical Simulation in Nursing, 9(11), e543-e550. Hutchinson, T., Janiszewski, S., & Goodin, H. (2013). Nursing student anxiety as a context for teaching/learning. Journal of Holistic Nursing, 31(1), 19-24. Kameg, K., Mitchell, A., Clochesy, J., Howard, V., & Suresky, J. (2009). Communication and human patient simulation in psychiatric nursing. Issues in Mental Health Nursing, 30, 503-508. http://dx.doi.org/10.108 0/01612840802601366. Lasater, K. (2007). Clinical judgment development using simulation to create an assessment rubric. Journal of Nursing Education, 46(11), 496-503. Lin, E. C., Chen, S. L., Chao, S. Y., & Chen, Y. C. (2013). Using standardized patient with immediate feedback and group discussion to teach interpersonal and communication skills to advanced practice nursing students. Nurse Education Today, 33, 677-683. Luctkar-Flude, M., Wilson-Keates, B., & Larocque, M. (2012). Evaluating high-fidelity human simulators and standardized patients in an undergraduate nursing health assessment course. Nurse Education Today, 32, 448-452. Miraglia, R., & Asselin, M. (2015). The Lasater clinical judgment rubric as a framework to enhance clinical judgement in novice and experienced nurses. Journal for Nurses in Professional Development, 31(5), 284-291. O’Mara, L. O., McDonald, J., Gillespie, M., Brown, H., & Miles, L. (2014). Challenging clinical learning environments: Experiences of undergraduate nursing students. Nurse Education in Practice, 14, 208-213. Ruterford-Hemming, T., & Jennrich, J. (2013). Using standardized patients to strengthen nurse practitioner competency in the clinical setting. Nursing Education Perspectives, 34(2), 118-121. Sherwood, G., & Zomorodi, M. (2014). A new mindset for quality and safety: The QSEN competencies redefine nurses’ role in practice. Nephrology Nursing Journal, 41(1), 15-22. Swanson, D. B., & Stillman, P. L. (1990). Use of standardized patients for teaching and assessing clinical skills. Evaluation and the Health Professionals, 13, 79. http://dx.doi.org/10.1177/016327879001300105. Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. Webster, D. (2014). Using standardized patients to teach therapeutic communication in psychiatric nursing. Clinical Simulation in Nursing, 10(2), e81-e86. Wilner, L. K., & Feinstein-Whittaker, M. (2013). Improving communication skills in healthcare, In: Perspectives on communication disorders and sciences in culturally and linguistically diverse (CLD) populations. Rockville, MD: ASHA.
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