Nurse Education in Practice xxx (2015) 1e6
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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 b
Department of Family Medicine, Lehigh Valley Health Network, USF Morsani College of Medicine e SELECT Program, Allentown, 18105, PA, USA 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: Accepted 10 June 2015
The purpose of this qualitative study was to examine the impact of standardized patient experiences (SPE) in the education of the Advanced Practice Nurse (APN). The education of the APN requires educators to make every attempt to promote competency in the areas of communication and clinicaldecision making. SPE programs have been found to improve the interpersonal, problem solving, and critical thinking skills of nursing students. For this research twenty-nine APN students participated in SPEs over the course of two semesters. Fifteen student volunteers of those 29 participants were then interviewed three months after the experience. Results revealed that having an expert in the field of communication studies increased awareness of communication skills and how to improve nurse-patient 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.
Keywords: Standardized patients Interprofessional education Advanced practice nursing Communication Clinical decision making Qualitative research
Introduction For nearly fifty years standardized patient experiences (SPEs) have been utilized as a teaching tool in healthcare education. Students in various programs such as psychology (O'Connor et al., 1999; Shawler, 2008), geriatrics (Nagoshi et al., 2004), speechlanguage pathology (Hill et al., 2010), genetics (McGovern et al., 2006), trauma (Ali et al., 2009) and hematology-oncology (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 (SmithStoner, 2009; Shawler, 2011), cultural competency (Rutledge et al., 2004), individuals with disabilities (Long-Bellil, 2007), and ethics (Haddad, 2010). More recently, SPE programs are being used to educate students for clinical examinations (May, 2008; Sadeghi et al., 2007; Hauer et al., 2009; McWilliam and Botwinski, 2010). One aspect of utilizing SPEs in the education of healthcare providers is the evaluation of communication skills. Although many programs utilize the instructional strategy of SPE, no programs have * Corresponding author. Tel.: þ1 570 389 4609; fax: þ1 570 389 5008. E-mail addresses: [email protected] (N. Defenbaugh), nchikota@ bloomu.edu (N.E. Chikotas). 1 Tel.: þ1 610 969 4948.
been found to integrate a communication expert. This research article discusses the use of SPEs in an Advanced Health Assessment course for advanced practice nursing students (nurse practitioner and nurse anesthesia) and how communication skills at the advanced level are learned and later applied to current and future clinical advanced practice. The article examines how those communication skills are further developed with a skilled Communication Studies scholar as one of the faculty developers and assessors in the SPE.
Background In nursing the use of standardized patients has received extensive examination and continued attention because of its usefulness as an instructional strategy for improving learning outcomes (Seibert et al., 2004). Specific to the realm of nursing, standardized patients have been used in a variety of contexts: gerontology (Shawler, 2011), distance learning (Seibert et al., 2004), 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 (O'Connor et al., 1999) and culture (Rutledge et al., 2004). Standardized patient experiences enable nursing faculty to assess specific competencies in an evaluative format.
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Please cite this article in press as: Defenbaugh, N., Chikotas, N.E., The outcome of interprofessional education: Integrating communication studies into a standardized patient experience for advanced practice nursing students, Nurse Education in Practice (2015), http://dx.doi.org/ 10.1016/j.nepr.2015.06.003
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One competency in particular that has received notable attention in the last decade is communication. The popularity of SPEs and recognition of its measured benefits in the area of communication continues to rise. As a creative strategy employed by nearly 30% of faculty who teach Advanced Health Assessment (Kelley et al., 2007), the use of SPEs in teaching competencies to nursing students has numerous benefits, especially in improving communication skills. And although communication skills are taught at the undergraduate level, graduate nursing students entering into the realm of advanced practice (nurse practitioner, clinical nurse specialist, etc) need to have excellent communication skills to assist in the process of diagnostic reasoning. Specific communication skills or subcategories have been identified as interpersonal, listening, critical thinking, and empathy. These communicative skills are of particular interest to evaluators in SPEs because of the need for nurses to effectively interact with their patients creating a positive, engaging, and supportive encounter. Rutledge et al. (2004) state the importance of using SPEs in nurse practitioner (NP) education is because the safe learning environment helps them “be prepared to be better communicators, and ultimately, better NPs” (2004, p. 3). Yet the following questions remain: What does it mean to be an effective communicator? What does it mean to possess “good” communication skills? And how are communication skills assessed without the use of a trained communication educator? One way to assure that communication skills are being addressed within the instructional strategy of SPEs is to have a communication expert (scholar) involved, someone educated in the health communication field to assist in developing, implementing and evaluating the SPE process. This can be accomplished through interprofessional education of disciplines. Over twenty years ago the World Health Organization (WHO) called for a need for collaboration across medical professions and wrote Learning Together to Work Together for Health Report in 1988 (Lapkin et al., 2013). Interprofessional education (IPE) was listed by WHO “as a way to enhance collaboration and interprofessional teamwork” (Lapkin et al., 2013, p. 91). It is defined as “different professions working together as a team toward a common goal of providing optimal patient care using the skills/expertise of other professions” (Wu et al., 2012, p. 4). Interprofessional education seeks to join individuals from various professionsdwithin the field of healthcaredto share their unique skills, knowledge, and talents with the unified vision of improving patient care. In so doing, collaborative work has the potential to revolutionize patient care. Complementary medicine (Steel and Adams, 2012), nursing, respiratory therapy (King et al., 2013), and mental health (Kinnair et al., 2012), are just a few of the many health professional programs that have incorporated IPE in their curriculum. With an increase in preventable medical errors (King et al., 2013) and growing need for improved communication skills and teamwork (Lapkin et al., 2013), collaborative efforts in healthcare have become more important than ever. Through IPE, learners have the potential to increase their collaboration, teamwork, and communication skills. A study evaluating the importance of interprofessional simulation, for example, reported 44% of the students' answers related to the importance or need to improve communication (King et al., 2013). Incorporating collaboration in IPE has shown to positively effect teamwork, patient-centered care, and communication. Research design Sample The course in which the SPE was performed was an Advanced Health Assessment (AHA) course. All students in the advanced practice clinical specialties (nurse practitioner, clinical nurse
specialist, and nurse anesthesia options) of the Master of Science program at the university where the study was conducted are required to take the AHA. This course is designed to teach advanced history taking and physical assessment to the student who will be making medical diagnostic decisions as an Advanced Practice Nurse (APN). There were a total of 29 APN students (20 nurse practitioners and 9 nurse anesthetist students) in the AHA course, which was offered in both the fall and spring semesters. All APN students were Registered Nurses licensed in the state of which they reside and had various years of experience (2e25 years) in the acute care setting. Of the 29 students (27 female and 2 males) who participated in the SPE sessions, 15 students (all female) volunteered to participate in the study. Of those 15 female participants 11 of the participants were nurse practitioner students and four were nurse anesthetist students. Fourteen respondents were Caucasian and one respondent was African American, with the mean age of the participants being 30 years (range 24e43) and a mean of six years in practice as a registered nurse. None of the participants had been exposed to a standardized patient experience before. Procedure The SPE sessions took place in the health assessment laboratory of a northeastern university. The cases and sessions were developed and proctored by the authors of this study, a senior graduate nursing professor and a senior health communication professor/ communication studies scholar at the university where the SPE took place. The two primary roles of the Communication Studies (CS) scholar were to examine the nursing students' use of nonverbal and verbal communication skills and provide feedback regarding the application of these skills in the patient encounter. The CS scholar had experience in assessing SP sessions at a local health care network. The CS scholar worked alongside the Nursing faculty as an observer and facilitator of the SPE sessions. The scenarios were evenly divided so that both the CS and Nursing faculty were able to observe and watch each student at least once to provide a dual perspective. The use of a CS scholar allowed for a richer, more indepth discussion about effective communication practices in obtaining a detailed history for the purpose of diagnostic reasoning. All of the standardized patient (SPs) actors were recruited through a local theater company and had prior experience as trained professional actors in the health care industry. Since the hired SPs had significant prior professional training as health care actors, minimal training was required. For this experience SPs were contacted by the author and given the script/scenario one month prior to the session. Actors were then asked to solicit any questions or concerns about the script. Questions of clarification about the script (e.g., patient background) were the primary focus. On the day of the session, actors were asked to meet in advance to have any further questions answered, review the format/structure of the sessions (e.g., length of time for each nurse encounter and group debrief), be introduced to the physical space of the scenarios (e.g., patient beds, curtains/dividers) and assist as co-facilitators of the sessions. Utilizing four SPs actors, four different cases were utilized. These cases included breaking bad news, cessation of smoking, request for assistance with weight loss, and chronic headaches (domestic abuse issue). Over a two-week time frame each student had the opportunity to rotate through all four cases. The students were provided with information on the patient they would be interviewing and examining prior to the experience. The student was then given 20 min to complete the history and physical examination related to the patient's concern, and develop a plan with the patient for treatment and management. During this time the
Please cite this article in press as: Defenbaugh, N., Chikotas, N.E., The outcome of interprofessional education: Integrating communication studies into a standardized patient experience for advanced practice nursing students, Nurse Education in Practice (2015), http://dx.doi.org/ 10.1016/j.nepr.2015.06.003
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researchers evaluated the student through observation and note taking. Upon completion of the 20-min session the student was then debriefed on their overall presentation, communication skills, and physical exam techniques by the researchers and the actors. The debriefing process included two parts: individual and group. The first part of the debriefing occurred immediately after the scenario. Actors began by offering one-on-one feedback to the nursing students and faculty provided comments to the sessions they observed. During the second part of the debriefing, all participants sat in a circle to discuss the session. The group debrief began with feedback from the students. The CS scholar asked the students to articulate 1) what they did well and 2) what they will take away from the session. Although many students struggled listing positive behaviorsdmany began with what they did not do welldevery student was able to articulate at least one. The CS scholar reminded students that recognizing one's strengths allows increased awareness of those behaviors and an increased likelihood of repeating those behaviors. After the students spoke, faculty offered general comments about the session. These comments varied depending on what themes emerged during the session (e.g., talking less and listening more to a patient after a cancer diagnosis). This process was not meant to be summative in nature and the students were not graded on the process. Rather, the sessions were formative in nature to help students improve in the area of communication while obtaining a history and physical examination. Data collection The four main questions guiding the research were: How does the APN student make meaning of her/his standardized patient experience? What impact has the experience with the standardized patients had on his/her current clinical nursing practice? What impact does the inclusion of a Communication Studies scholar have on the assessment of communication skills in the standardized patient experience? What effect does the standardized patient experience have on teaching the competency of communication? The research questions called for a qualitative investigation of the lived experiences, personal meaning, and outcomes in the competency of communication. Three months after the standardized patient experience, individual face-to-face interviews were conducted in the university offices of the researchers. An interview guide was utilized using semi-structured, open-ended questions to assist in focusing on key 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, interviews were recorded and transcribed. Prior to the initial interviews, a pilot study of the questions was conducted with five participants to provide information on how well the questions could elicit the information requested. From the pilot study no restructuring occurred to the interview questions. Ethical considerations Ethical approval was sought at the authors' home institution through the University Wide IRB Committee. Since students are considered a vulnerable population, a full committee approval was required and obtained prior to the start of the research. Participation was voluntary and participants were provided information on the full nature of the research project including informed consent, 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 reporting.
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Data analysis Thematic coding was utilized in analyzing the data for patterns and themes. Defined by Boyatzis (1998) as “a process for encoding qualitative information [that] requires an explicit ‘code’” (1998, p. 4), thematic analysis involves seeing patterns, interpreting information, and developing themes into meaningful knowledge. Given the diverse background of the two researchers, this particular method of analysis was appropriate since it “can be a beneficial bridge between researchers of varying orientations and fields” (Boyatzis, p. 6). Each author coded and compared patterns individually and then together to refine and integrate as many themes as possible. This process, known as check coding, “not only aids definitional clarity but also is a good reliability check” (Miles and Huberman, 1994, p. 64). These patterns and themes were then further compared and analyzed into categories by the two authors with further additions, deletions, and refining as information was clarified and follow-up interviews occurred. Findings From the face to face interviews with the 15 APN students three categories were extracted from the data and illustrate the phenomenon of the lived experience of having been exposed to SPEs as APN students as well as how that experience impacted their communication skills in both their clinical practicum as APN students and their current practice as registered nurses. These categories included increased awareness, communication skills, and clinical practice. And although practicing registered nurses, such as our students in this study, are often well versed in therapeutic communication skills, they are being educated to utilize those skills to perform diagnostic reasoning, something they were not taught as an undergraduate nursing student. So within the findings listed here the responses relate to the process of arriving at a diagnosis for a patient, for which a higher level of communication is needed. In the first category, increased awareness, the increase in awareness of self and other became evident and was believed to have occurred as a result of the interactive and dialogic nature of SPE sessions. One student commented, “There were some things that they [actors and facilitators] told me that I did that I didn't realize that I did”. Another student remarked, “…they [actor] kind of show you things that you didn't even realize that you were even doing”. Students not only increased their awareness of their own thoughts and behaviors, they also learned new skills. For example, one student learned the importance of using the patient's own words and not her own words when summarizing what the patient said. Another student learned to be aware of differing agendas (nurse vs. patient), specifically that the patient's agenda may not be the same as the nurse's. The student also stated the importance of “making] sure that we [nurse and patient] are on the same page”. Other comments pointed to an awareness of the nurse-patient encounter and issues of control. In relation to end-of-life care, one student realized, “I think it is really key in end of life because they [patients] have lost control of most other things. The one thing they should have control over is what they want from me and not what I want to give them”. There also was an awareness of the limitations in the nursepatient encounter. For example, students commented on an
Please cite this article in press as: Defenbaugh, N., Chikotas, N.E., The outcome of interprofessional education: Integrating communication studies into a standardized patient experience for advanced practice nursing students, Nurse Education in Practice (2015), http://dx.doi.org/ 10.1016/j.nepr.2015.06.003
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increased awareness of “noncompliant” patients and the nurse's desire to fix the patient's health issue. As one student noted, “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”. In the second category, communication skills, the students frequently commented on the various communication skills they learned during the SPE sessions and how many of them had incorporated these skills into their practice. This was believed to occur as a result of having a Communication Studies scholar cofacilitating the SPE sessions. Twelve of the students mentioned an increased awareness of their communication skills listing specific aspects of communicative acts (e.g., allowing patients to talk, awareness of posture, volume level of voice) in their responses. When asked what evidence of professional development (SP experience) the nursing student observed in his/her clinical practice since participating in the program, eleven of the students mentioned “communication” directly or as a specific communication skill (e.g., listening). When initially asked to comment on the overall standardized patient experience one student stated, “It was good because it pointed out what I did verbally and nonverbally. Kind of gave me an outside view of how I could improve from my communication skills and the way I looked at patients and things like that”.
Two themes emerged in the communication skills category: nonverbal communication and listening. Students experienced increased consciousness of their own body language and the nonverbal traits of others. Examples of their own body language included, “I think it [SPE session] pointed out a lot of body language. I learned how important and aware patients are of your body language and different gestures you make or what you are doing with your hands if you're nervous or moving papers around”.
“It is something I have to practice because I wasn't a natural at really listening...You shouldn't rush to the advice because people need to feel and express their feelings.” Finally, students recognized the impact listening had on their own clinical practice and how this impacted their overall nursepatient encounters. “I deal with that every day trying to make sure that I am really listening and not putting my own agenda into the whole situation and my own personal needs as well, which is sometimes hard”. In the third category of clinical practice, two themes were presented: real life experience and safe environment. When asked to describe the experience, students believed it would be “phony” in nature but were surprised at how real it felt. “I thought oh this really won't be real, but I really felt like I was very present and all the actors were very good in making me feel that I was in a real situation”. “I wasn't sure if it would be realistic, but I found it to be very realistic!” The students were also able to correlate the SPE to the recent clinical practicum in a primary health care setting, which they were currently doing at the time of the interviews. “I started clinical this semester and I was not so nervous entering the exam room, since I felt like I had been there done that, and it helped!” Eight of the fifteen students interviewed commented on how the experience provided them with a safe environment to practice communication skills, make mistakes, reflect on those mistakes, and begin the process of becoming an APN. As described by two respondents: “It was a good experience; it took you out of your comfort zone and somewhat made you uncomfortable, but in a safe environment”.
“It makes me more consciously aware of how I am sitting, how I am communicating with the patient, and trying to make the patient more comfortable”.
“Definitely being able to practice giving someone bad news when it is really not bad news. It was really hard and it wasn't even real. But being able to practice that for the first time was a great experience”.
Additionally, students had an increased awareness of their patients' body language.
And within that safe environment the student was comfortable in transitioning into the role of an APN.
“I could tell just by their [patient and patient's daughter] responses to me and their posture that they were a little resistant with sharing information with me.”
“I feel better prepared now. It's such a profound role change to be able to sit there and actually discuss the problem with the patient. It prepared me to do that in the clinical setting I am in now”
Listening, the second theme of communication skills was the most cited communication tool listed by students. Responses included an increase in the amount of listening, ways in which students listened, and accounting for patient silence (knowing when not to talk). One student when asked how the SPE session helped him/her in clinical, commented on the importance of listening in relation to time.
The structure of the SPEs allowed for practicing clinical and communication skills in a safe environment. Through the respondents answers to questions on the experience it was found that the informal non-summative evaluation of the sessions then enabled students to make mistakes, practice feedback given, and test different communication strategies in a supportive environment 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” Students also gained an increased awareness of the skill involved in listening and its importance to the patient.
Discussion In the study we discovered that APN students make meaning of their SPE through an increased awareness of their own thoughts and behaviors in relation to the nurse (provider) e patient
Please cite this article in press as: Defenbaugh, N., Chikotas, N.E., The outcome of interprofessional education: Integrating communication studies into a standardized patient experience for advanced practice nursing students, Nurse Education in Practice (2015), http://dx.doi.org/ 10.1016/j.nepr.2015.06.003
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encounter. This included an understanding of the importance of using the patient's own words, the existence of differing agendas, issues of control, and other nuances of the nurse (provider) e patient encounter including noncompliance. Additionally, the SPE provided a safe environment for the student to practice her/his clinical skills in a more realistic format. As Rutledge et al. (2004) previously stated, allowing the student to learn in a safe environment ultimately helps her/him to be a better NP. In regards to communication skills, the SPE resulted in an increase in the incorporation of and assessment of these skills. During the debrief, students repeated the feedback they received and offered their own assessments of how well they did/did not address specific communication skills, particularly nonverbal cues and effective listening. The APN student demonstrated specific communication skills they learned to apply in their clinical encounter to better perform diagnostic reasoning. Being able to read a patient's non-verbal cues (e.g., avoidance of eye-contact), for example, will enable the APN to more effectively relate to the patient, draw important conclusions about psychosocial factors, and increase the likelihood for follow-up questions based on the perceived inferences. Similar to the study on the importance of interprofessional simulation (King et al., 2013), students' responses during the debrief highlighted the importance and need to improve communication. In summation, students were able to reflect upon and address what it means to be an effective communicator and what it means to possess “good” communication skills. Finally, the inclusion of a Communication Studies scholar resulted in an increased awareness of communication skills by the APNs and assessment of these skills by the facilitators. And although the success of the SPE can be attributed to many factors the authors believe the educational “success” of the session is attributed to the interprofessional educational nature of the SPE session that encouraged both communication and advanced practice nursing skills to be taught given the background and expertise of the two faculty members. As a result of including an “outside” faculty member (not from nursing), students learned communication skills applicable to their clinical practicum experiences. Overall, the findings indicate that the quantity and quality of feedback given by the actors and facilitators focused on communication skills, since one-third of the findings specifically addressed this area. Furthermore, the students explicitly stated their increased awareness as communicators in the clinical encounter. Limitations Although there were many benefits to the study, it was not without limitations. In this collaborative project, the authors found time to be challenging, but the desire to work interprofessionally for the purpose of educating nursing students outweighed these difficulties. The sample size was small and there was no control group utilized for comparison since the instructional strategy was part of the current curriculum. Though we were able to evaluate the experience of SPE, it was not possible to assess clinical effectiveness once the students entered clinical practicum. This study offers a single view of how the competency of communication can be attained through the use of SPEs. Further studies are needed to effectively evaluate the worth of the instructional strategy of SPEs in the education of the advanced practice nurse. Conclusions The use of SPEs in the education of the APN has existed for decades. The benefits of this instructional strategy of learning are
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many, not only for students but also for the facilitators and actors involved in the process. Standardized patient experiences allow for engaged, practical, embodied learning in a safe and supportive environment. Feedback from facilitators and actors can be useful to students in future patient encounters. Through collaboration, however, additional skills such as effective communication can be learned. Inviting a Communication Studies educator to co-facilitate the SPE resulted in valuable insight, knowledge, and skills about the process and application of communication skills in the clinical setting. By inviting other professionals from both within and outside nursing to participate in the SPE, students have the opportunity to learn about other aspects of clinical care (e.g. psychological, community/social, religion/spirituality, familial) and how to treat and effectively care for the ‘whole person’. References Ahmed, E., Petty, M., Hutchins, L., Thompson, R., 2009. “Breaking bad news”: standardized patient intervention improves communication skills for hematology-oncology fellows and advanced practice nurses. J. Cancer Educ. 24, 154e159. Ali, J., Ahmadi, K.A., Williams, J.I., Cherry, R.A., 2009. The standardized live patient and mechanical patient modelsdtheir roles in trauma teaching. J. Trauma Inj. Infect. Crit. Care 66, 98e102. Boyatzis, R.A., 1998. Thematic Analysis and Code Development: Transforming Qualitative Information. Sage, Thousand Oaks, CA. Carney, P.A., Ward, D.H., 1998. Using unannounced standardized patients to assess the HIV preventive practices of family nurse practitioners and family physicians. Nurse Pract. 23 (2), 56e58, 63, 67e68 passim. Haddad, A., 2010. What health science students learn from playing a standardized patient in an ethics course. Camb. Q. Healthc. Ethics 19, 481e487. Hauer, K.E., Chou, C.L., Souza, K.H., Henry, D., Loeser, H., Burke, C., Mayfield, C., O'Sullivan, P.S., 2009. Impact of an in-person versus web-based practice standardized patient examination on student performance on a subsequent highstakes standardized patient examination. Teach. Learn. Med. 21, 284e290. Hill, A., Davidson, B., Theodoros, D., 2010. A review of standardized patients in clinical education: implications for speech-language pathology programs. Int. J. Speech-Lang. Pathol. 12, 259e270. Kelley, F.J., Kopac, C.A., Rosselli, J., 2007. Advanced health assessment in nurse practitioner programs: follow-up study. J. Prof. Nurs. 23, 137e143. Kinnair, D.J., Anderson, E.S., Thorpe, L.N., 2012. Development of interprofessional education in mental health practice: adapting the Leicester Model. J. Interprofessional Care 26, 189e197. King, A.E.A., Conrad, M., Ahmed, R.A., 2013. Improving collaboration among medical, nursing and respiratory therapy students through interprofessional simulation. J. Interprofessional Care 27, 269e271. Lambdon, J., 2008. Integrating simulation into a pediatric nursing curriculum: a 25% solution? Simul. Healthc. 3 (1), 53e57. Lapkin, S., Levett-Jones, T., Gilligan, C., 2013. A systematic review of the effectiveness of interprofessional education in health professional programs. Nurse Educ. Today 22 (2), 90e102. Long-Bellil, L.M., 2007. Preparing Future Clinicians to Provide Medical Services to Persons with Disabilities (Doctoral dissertation). Retrieved from ProQuest Dissertations and Theses (Accession Order No. AAI3278097). May, W., 2008. Training standardized patients for a high-stakes clinical performance examination in California Consortium for the assessment of clinical competence. Kaohsiung J. Med. Sci. 24, 640e645. McGovern, M.M., Johnston, M., Brown, K., Zinberg, R., Cohen, D., 2006. Use of standardized patients in undergraduate medical genetics education. Teach. Learn. Med. 18, 203e207. McWilliam, P., Botwinski, C., 2010. Developing a successful nursing objective structured clinical examination. J. Nurs. Educ. 49, 36e41. Miles, M.B., Huberman, A.M., 1994. Qualitative Data Analysis, second ed. Sage, Thousand Oaks, CA. Nagoshi, M., Williams, S., Kasuya, R., Sakai, D., Masaki, K., Blanchette, P.L., 2004. Using standardized patients to assess the geriatrics medicine skills of medical students, internal medicine residents, and geriatrics medicine fellows. Acad. Med. 79, 698e702. O'Connor, F.W., Albert, M.L., Thomas, M.D., 1999. Incorporating Standardized Patients into a Psychosocial Nurse Practitioner Program. Rutledge, C., Garzon, L., Scott, M., Karlowicz, K., 2004. Using Standardized Patients to Teach and Evaluate Nurse Practitioner Students on Cultural Competency. Sadeghi, M., Taghva, A., Mirsepassi, G., Hassanzadeh, M., 2007. How do examiners and examinees think about role-playing of standardized patients in an OSCE setting? Acad. Psychiatry 31, 358e362. Seibert, D.C., Guthrie, J.T., Adamo, G., 2004. Improving learning outcomes: integration of standardized patients & telemedicine technology. Nurs. Educ. Perspect. 25, 232e237.
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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 b
Department of Family Medicine, Lehigh Valley Health Network, USF Morsani College of Medicine e SELECT Program, Allentown, 18105, PA, USA 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: Accepted 10 June 2015
The purpose of this qualitative study was to examine the impact of standardized patient experiences (SPE) in the education of the Advanced Practice Nurse (APN). The education of the APN requires educators to make every attempt to promote competency in the areas of communication and clinicaldecision making. SPE programs have been found to improve the interpersonal, problem solving, and critical thinking skills of nursing students. For this research twenty-nine APN students participated in SPEs over the course of two semesters. Fifteen student volunteers of those 29 participants were then interviewed three months after the experience. Results revealed that having an expert in the field of communication studies increased awareness of communication skills and how to improve nurse-patient 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.
Keywords: Standardized patients Interprofessional education Advanced practice nursing Communication Clinical decision making Qualitative research
Introduction For nearly fifty years standardized patient experiences (SPEs) have been utilized as a teaching tool in healthcare education. Students in various programs such as psychology (O'Connor et al., 1999; Shawler, 2008), geriatrics (Nagoshi et al., 2004), speechlanguage pathology (Hill et al., 2010), genetics (McGovern et al., 2006), trauma (Ali et al., 2009) and hematology-oncology (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 (SmithStoner, 2009; Shawler, 2011), cultural competency (Rutledge et al., 2004), individuals with disabilities (Long-Bellil, 2007), and ethics (Haddad, 2010). More recently, SPE programs are being used to educate students for clinical examinations (May, 2008; Sadeghi et al., 2007; Hauer et al., 2009; McWilliam and Botwinski, 2010). One aspect of utilizing SPEs in the education of healthcare providers is the evaluation of communication skills. Although many programs utilize the instructional strategy of SPE, no programs have * Corresponding author. Tel.: þ1 570 389 4609; fax: þ1 570 389 5008. E-mail addresses: [email protected] (N. Defenbaugh), nchikota@ bloomu.edu (N.E. Chikotas). 1 Tel.: þ1 610 969 4948.
been found to integrate a communication expert. This research article discusses the use of SPEs in an Advanced Health Assessment course for advanced practice nursing students (nurse practitioner and nurse anesthesia) and how communication skills at the advanced level are learned and later applied to current and future clinical advanced practice. The article examines how those communication skills are further developed with a skilled Communication Studies scholar as one of the faculty developers and assessors in the SPE.
Background In nursing the use of standardized patients has received extensive examination and continued attention because of its usefulness as an instructional strategy for improving learning outcomes (Seibert et al., 2004). Specific to the realm of nursing, standardized patients have been used in a variety of contexts: gerontology (Shawler, 2011), distance learning (Seibert et al., 2004), 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 (O'Connor et al., 1999) and culture (Rutledge et al., 2004). Standardized patient experiences enable nursing faculty to assess specific competencies in an evaluative format.
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One competency in particular that has received notable attention in the last decade is communication. The popularity of SPEs and recognition of its measured benefits in the area of communication continues to rise. As a creative strategy employed by nearly 30% of faculty who teach Advanced Health Assessment (Kelley et al., 2007), the use of SPEs in teaching competencies to nursing students has numerous benefits, especially in improving communication skills. And although communication skills are taught at the undergraduate level, graduate nursing students entering into the realm of advanced practice (nurse practitioner, clinical nurse specialist, etc) need to have excellent communication skills to assist in the process of diagnostic reasoning. Specific communication skills or subcategories have been identified as interpersonal, listening, critical thinking, and empathy. These communicative skills are of particular interest to evaluators in SPEs because of the need for nurses to effectively interact with their patients creating a positive, engaging, and supportive encounter. Rutledge et al. (2004) state the importance of using SPEs in nurse practitioner (NP) education is because the safe learning environment helps them “be prepared to be better communicators, and ultimately, better NPs” (2004, p. 3). Yet the following questions remain: What does it mean to be an effective communicator? What does it mean to possess “good” communication skills? And how are communication skills assessed without the use of a trained communication educator? One way to assure that communication skills are being addressed within the instructional strategy of SPEs is to have a communication expert (scholar) involved, someone educated in the health communication field to assist in developing, implementing and evaluating the SPE process. This can be accomplished through interprofessional education of disciplines. Over twenty years ago the World Health Organization (WHO) called for a need for collaboration across medical professions and wrote Learning Together to Work Together for Health Report in 1988 (Lapkin et al., 2013). Interprofessional education (IPE) was listed by WHO “as a way to enhance collaboration and interprofessional teamwork” (Lapkin et al., 2013, p. 91). It is defined as “different professions working together as a team toward a common goal of providing optimal patient care using the skills/expertise of other professions” (Wu et al., 2012, p. 4). Interprofessional education seeks to join individuals from various professionsdwithin the field of healthcaredto share their unique skills, knowledge, and talents with the unified vision of improving patient care. In so doing, collaborative work has the potential to revolutionize patient care. Complementary medicine (Steel and Adams, 2012), nursing, respiratory therapy (King et al., 2013), and mental health (Kinnair et al., 2012), are just a few of the many health professional programs that have incorporated IPE in their curriculum. With an increase in preventable medical errors (King et al., 2013) and growing need for improved communication skills and teamwork (Lapkin et al., 2013), collaborative efforts in healthcare have become more important than ever. Through IPE, learners have the potential to increase their collaboration, teamwork, and communication skills. A study evaluating the importance of interprofessional simulation, for example, reported 44% of the students' answers related to the importance or need to improve communication (King et al., 2013). Incorporating collaboration in IPE has shown to positively effect teamwork, patient-centered care, and communication. Research design Sample The course in which the SPE was performed was an Advanced Health Assessment (AHA) course. All students in the advanced practice clinical specialties (nurse practitioner, clinical nurse
specialist, and nurse anesthesia options) of the Master of Science program at the university where the study was conducted are required to take the AHA. This course is designed to teach advanced history taking and physical assessment to the student who will be making medical diagnostic decisions as an Advanced Practice Nurse (APN). There were a total of 29 APN students (20 nurse practitioners and 9 nurse anesthetist students) in the AHA course, which was offered in both the fall and spring semesters. All APN students were Registered Nurses licensed in the state of which they reside and had various years of experience (2e25 years) in the acute care setting. Of the 29 students (27 female and 2 males) who participated in the SPE sessions, 15 students (all female) volunteered to participate in the study. Of those 15 female participants 11 of the participants were nurse practitioner students and four were nurse anesthetist students. Fourteen respondents were Caucasian and one respondent was African American, with the mean age of the participants being 30 years (range 24e43) and a mean of six years in practice as a registered nurse. None of the participants had been exposed to a standardized patient experience before. Procedure The SPE sessions took place in the health assessment laboratory of a northeastern university. The cases and sessions were developed and proctored by the authors of this study, a senior graduate nursing professor and a senior health communication professor/ communication studies scholar at the university where the SPE took place. The two primary roles of the Communication Studies (CS) scholar were to examine the nursing students' use of nonverbal and verbal communication skills and provide feedback regarding the application of these skills in the patient encounter. The CS scholar had experience in assessing SP sessions at a local health care network. The CS scholar worked alongside the Nursing faculty as an observer and facilitator of the SPE sessions. The scenarios were evenly divided so that both the CS and Nursing faculty were able to observe and watch each student at least once to provide a dual perspective. The use of a CS scholar allowed for a richer, more indepth discussion about effective communication practices in obtaining a detailed history for the purpose of diagnostic reasoning. All of the standardized patient (SPs) actors were recruited through a local theater company and had prior experience as trained professional actors in the health care industry. Since the hired SPs had significant prior professional training as health care actors, minimal training was required. For this experience SPs were contacted by the author and given the script/scenario one month prior to the session. Actors were then asked to solicit any questions or concerns about the script. Questions of clarification about the script (e.g., patient background) were the primary focus. On the day of the session, actors were asked to meet in advance to have any further questions answered, review the format/structure of the sessions (e.g., length of time for each nurse encounter and group debrief), be introduced to the physical space of the scenarios (e.g., patient beds, curtains/dividers) and assist as co-facilitators of the sessions. Utilizing four SPs actors, four different cases were utilized. These cases included breaking bad news, cessation of smoking, request for assistance with weight loss, and chronic headaches (domestic abuse issue). Over a two-week time frame each student had the opportunity to rotate through all four cases. The students were provided with information on the patient they would be interviewing and examining prior to the experience. The student was then given 20 min to complete the history and physical examination related to the patient's concern, and develop a plan with the patient for treatment and management. During this time the
Please cite this article in press as: Defenbaugh, N., Chikotas, N.E., The outcome of interprofessional education: Integrating communication studies into a standardized patient experience for advanced practice nursing students, Nurse Education in Practice (2015), http://dx.doi.org/ 10.1016/j.nepr.2015.06.003
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researchers evaluated the student through observation and note taking. Upon completion of the 20-min session the student was then debriefed on their overall presentation, communication skills, and physical exam techniques by the researchers and the actors. The debriefing process included two parts: individual and group. The first part of the debriefing occurred immediately after the scenario. Actors began by offering one-on-one feedback to the nursing students and faculty provided comments to the sessions they observed. During the second part of the debriefing, all participants sat in a circle to discuss the session. The group debrief began with feedback from the students. The CS scholar asked the students to articulate 1) what they did well and 2) what they will take away from the session. Although many students struggled listing positive behaviorsdmany began with what they did not do welldevery student was able to articulate at least one. The CS scholar reminded students that recognizing one's strengths allows increased awareness of those behaviors and an increased likelihood of repeating those behaviors. After the students spoke, faculty offered general comments about the session. These comments varied depending on what themes emerged during the session (e.g., talking less and listening more to a patient after a cancer diagnosis). This process was not meant to be summative in nature and the students were not graded on the process. Rather, the sessions were formative in nature to help students improve in the area of communication while obtaining a history and physical examination. Data collection The four main questions guiding the research were: How does the APN student make meaning of her/his standardized patient experience? What impact has the experience with the standardized patients had on his/her current clinical nursing practice? What impact does the inclusion of a Communication Studies scholar have on the assessment of communication skills in the standardized patient experience? What effect does the standardized patient experience have on teaching the competency of communication? The research questions called for a qualitative investigation of the lived experiences, personal meaning, and outcomes in the competency of communication. Three months after the standardized patient experience, individual face-to-face interviews were conducted in the university offices of the researchers. An interview guide was utilized using semi-structured, open-ended questions to assist in focusing on key 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, interviews were recorded and transcribed. Prior to the initial interviews, a pilot study of the questions was conducted with five participants to provide information on how well the questions could elicit the information requested. From the pilot study no restructuring occurred to the interview questions. Ethical considerations Ethical approval was sought at the authors' home institution through the University Wide IRB Committee. Since students are considered a vulnerable population, a full committee approval was required and obtained prior to the start of the research. Participation was voluntary and participants were provided information on the full nature of the research project including informed consent, 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 reporting.
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Data analysis Thematic coding was utilized in analyzing the data for patterns and themes. Defined by Boyatzis (1998) as “a process for encoding qualitative information [that] requires an explicit ‘code’” (1998, p. 4), thematic analysis involves seeing patterns, interpreting information, and developing themes into meaningful knowledge. Given the diverse background of the two researchers, this particular method of analysis was appropriate since it “can be a beneficial bridge between researchers of varying orientations and fields” (Boyatzis, p. 6). Each author coded and compared patterns individually and then together to refine and integrate as many themes as possible. This process, known as check coding, “not only aids definitional clarity but also is a good reliability check” (Miles and Huberman, 1994, p. 64). These patterns and themes were then further compared and analyzed into categories by the two authors with further additions, deletions, and refining as information was clarified and follow-up interviews occurred. Findings From the face to face interviews with the 15 APN students three categories were extracted from the data and illustrate the phenomenon of the lived experience of having been exposed to SPEs as APN students as well as how that experience impacted their communication skills in both their clinical practicum as APN students and their current practice as registered nurses. These categories included increased awareness, communication skills, and clinical practice. And although practicing registered nurses, such as our students in this study, are often well versed in therapeutic communication skills, they are being educated to utilize those skills to perform diagnostic reasoning, something they were not taught as an undergraduate nursing student. So within the findings listed here the responses relate to the process of arriving at a diagnosis for a patient, for which a higher level of communication is needed. In the first category, increased awareness, the increase in awareness of self and other became evident and was believed to have occurred as a result of the interactive and dialogic nature of SPE sessions. One student commented, “There were some things that they [actors and facilitators] told me that I did that I didn't realize that I did”. Another student remarked, “…they [actor] kind of show you things that you didn't even realize that you were even doing”. Students not only increased their awareness of their own thoughts and behaviors, they also learned new skills. For example, one student learned the importance of using the patient's own words and not her own words when summarizing what the patient said. Another student learned to be aware of differing agendas (nurse vs. patient), specifically that the patient's agenda may not be the same as the nurse's. The student also stated the importance of “making] sure that we [nurse and patient] are on the same page”. Other comments pointed to an awareness of the nurse-patient encounter and issues of control. In relation to end-of-life care, one student realized, “I think it is really key in end of life because they [patients] have lost control of most other things. The one thing they should have control over is what they want from me and not what I want to give them”. There also was an awareness of the limitations in the nursepatient encounter. For example, students commented on an
Please cite this article in press as: Defenbaugh, N., Chikotas, N.E., The outcome of interprofessional education: Integrating communication studies into a standardized patient experience for advanced practice nursing students, Nurse Education in Practice (2015), http://dx.doi.org/ 10.1016/j.nepr.2015.06.003
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increased awareness of “noncompliant” patients and the nurse's desire to fix the patient's health issue. As one student noted, “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”. In the second category, communication skills, the students frequently commented on the various communication skills they learned during the SPE sessions and how many of them had incorporated these skills into their practice. This was believed to occur as a result of having a Communication Studies scholar cofacilitating the SPE sessions. Twelve of the students mentioned an increased awareness of their communication skills listing specific aspects of communicative acts (e.g., allowing patients to talk, awareness of posture, volume level of voice) in their responses. When asked what evidence of professional development (SP experience) the nursing student observed in his/her clinical practice since participating in the program, eleven of the students mentioned “communication” directly or as a specific communication skill (e.g., listening). When initially asked to comment on the overall standardized patient experience one student stated, “It was good because it pointed out what I did verbally and nonverbally. Kind of gave me an outside view of how I could improve from my communication skills and the way I looked at patients and things like that”.
Two themes emerged in the communication skills category: nonverbal communication and listening. Students experienced increased consciousness of their own body language and the nonverbal traits of others. Examples of their own body language included, “I think it [SPE session] pointed out a lot of body language. I learned how important and aware patients are of your body language and different gestures you make or what you are doing with your hands if you're nervous or moving papers around”.
“It is something I have to practice because I wasn't a natural at really listening...You shouldn't rush to the advice because people need to feel and express their feelings.” Finally, students recognized the impact listening had on their own clinical practice and how this impacted their overall nursepatient encounters. “I deal with that every day trying to make sure that I am really listening and not putting my own agenda into the whole situation and my own personal needs as well, which is sometimes hard”. In the third category of clinical practice, two themes were presented: real life experience and safe environment. When asked to describe the experience, students believed it would be “phony” in nature but were surprised at how real it felt. “I thought oh this really won't be real, but I really felt like I was very present and all the actors were very good in making me feel that I was in a real situation”. “I wasn't sure if it would be realistic, but I found it to be very realistic!” The students were also able to correlate the SPE to the recent clinical practicum in a primary health care setting, which they were currently doing at the time of the interviews. “I started clinical this semester and I was not so nervous entering the exam room, since I felt like I had been there done that, and it helped!” Eight of the fifteen students interviewed commented on how the experience provided them with a safe environment to practice communication skills, make mistakes, reflect on those mistakes, and begin the process of becoming an APN. As described by two respondents: “It was a good experience; it took you out of your comfort zone and somewhat made you uncomfortable, but in a safe environment”.
“It makes me more consciously aware of how I am sitting, how I am communicating with the patient, and trying to make the patient more comfortable”.
“Definitely being able to practice giving someone bad news when it is really not bad news. It was really hard and it wasn't even real. But being able to practice that for the first time was a great experience”.
Additionally, students had an increased awareness of their patients' body language.
And within that safe environment the student was comfortable in transitioning into the role of an APN.
“I could tell just by their [patient and patient's daughter] responses to me and their posture that they were a little resistant with sharing information with me.”
“I feel better prepared now. It's such a profound role change to be able to sit there and actually discuss the problem with the patient. It prepared me to do that in the clinical setting I am in now”
Listening, the second theme of communication skills was the most cited communication tool listed by students. Responses included an increase in the amount of listening, ways in which students listened, and accounting for patient silence (knowing when not to talk). One student when asked how the SPE session helped him/her in clinical, commented on the importance of listening in relation to time.
The structure of the SPEs allowed for practicing clinical and communication skills in a safe environment. Through the respondents answers to questions on the experience it was found that the informal non-summative evaluation of the sessions then enabled students to make mistakes, practice feedback given, and test different communication strategies in a supportive environment 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” Students also gained an increased awareness of the skill involved in listening and its importance to the patient.
Discussion In the study we discovered that APN students make meaning of their SPE through an increased awareness of their own thoughts and behaviors in relation to the nurse (provider) e patient
Please cite this article in press as: Defenbaugh, N., Chikotas, N.E., The outcome of interprofessional education: Integrating communication studies into a standardized patient experience for advanced practice nursing students, Nurse Education in Practice (2015), http://dx.doi.org/ 10.1016/j.nepr.2015.06.003
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encounter. This included an understanding of the importance of using the patient's own words, the existence of differing agendas, issues of control, and other nuances of the nurse (provider) e patient encounter including noncompliance. Additionally, the SPE provided a safe environment for the student to practice her/his clinical skills in a more realistic format. As Rutledge et al. (2004) previously stated, allowing the student to learn in a safe environment ultimately helps her/him to be a better NP. In regards to communication skills, the SPE resulted in an increase in the incorporation of and assessment of these skills. During the debrief, students repeated the feedback they received and offered their own assessments of how well they did/did not address specific communication skills, particularly nonverbal cues and effective listening. The APN student demonstrated specific communication skills they learned to apply in their clinical encounter to better perform diagnostic reasoning. Being able to read a patient's non-verbal cues (e.g., avoidance of eye-contact), for example, will enable the APN to more effectively relate to the patient, draw important conclusions about psychosocial factors, and increase the likelihood for follow-up questions based on the perceived inferences. Similar to the study on the importance of interprofessional simulation (King et al., 2013), students' responses during the debrief highlighted the importance and need to improve communication. In summation, students were able to reflect upon and address what it means to be an effective communicator and what it means to possess “good” communication skills. Finally, the inclusion of a Communication Studies scholar resulted in an increased awareness of communication skills by the APNs and assessment of these skills by the facilitators. And although the success of the SPE can be attributed to many factors the authors believe the educational “success” of the session is attributed to the interprofessional educational nature of the SPE session that encouraged both communication and advanced practice nursing skills to be taught given the background and expertise of the two faculty members. As a result of including an “outside” faculty member (not from nursing), students learned communication skills applicable to their clinical practicum experiences. Overall, the findings indicate that the quantity and quality of feedback given by the actors and facilitators focused on communication skills, since one-third of the findings specifically addressed this area. Furthermore, the students explicitly stated their increased awareness as communicators in the clinical encounter. Limitations Although there were many benefits to the study, it was not without limitations. In this collaborative project, the authors found time to be challenging, but the desire to work interprofessionally for the purpose of educating nursing students outweighed these difficulties. The sample size was small and there was no control group utilized for comparison since the instructional strategy was part of the current curriculum. Though we were able to evaluate the experience of SPE, it was not possible to assess clinical effectiveness once the students entered clinical practicum. This study offers a single view of how the competency of communication can be attained through the use of SPEs. Further studies are needed to effectively evaluate the worth of the instructional strategy of SPEs in the education of the advanced practice nurse. Conclusions The use of SPEs in the education of the APN has existed for decades. The benefits of this instructional strategy of learning are
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many, not only for students but also for the facilitators and actors involved in the process. Standardized patient experiences allow for engaged, practical, embodied learning in a safe and supportive environment. Feedback from facilitators and actors can be useful to students in future patient encounters. Through collaboration, however, additional skills such as effective communication can be learned. Inviting a Communication Studies educator to co-facilitate the SPE resulted in valuable insight, knowledge, and skills about the process and application of communication skills in the clinical setting. By inviting other professionals from both within and outside nursing to participate in the SPE, students have the opportunity to learn about other aspects of clinical care (e.g. psychological, community/social, religion/spirituality, familial) and how to treat and effectively care for the ‘whole person’. References Ahmed, E., Petty, M., Hutchins, L., Thompson, R., 2009. “Breaking bad news”: standardized patient intervention improves communication skills for hematology-oncology fellows and advanced practice nurses. J. Cancer Educ. 24, 154e159. Ali, J., Ahmadi, K.A., Williams, J.I., Cherry, R.A., 2009. The standardized live patient and mechanical patient modelsdtheir roles in trauma teaching. J. Trauma Inj. Infect. Crit. Care 66, 98e102. Boyatzis, R.A., 1998. Thematic Analysis and Code Development: Transforming Qualitative Information. Sage, Thousand Oaks, CA. Carney, P.A., Ward, D.H., 1998. Using unannounced standardized patients to assess the HIV preventive practices of family nurse practitioners and family physicians. Nurse Pract. 23 (2), 56e58, 63, 67e68 passim. Haddad, A., 2010. What health science students learn from playing a standardized patient in an ethics course. Camb. Q. Healthc. Ethics 19, 481e487. Hauer, K.E., Chou, C.L., Souza, K.H., Henry, D., Loeser, H., Burke, C., Mayfield, C., O'Sullivan, P.S., 2009. Impact of an in-person versus web-based practice standardized patient examination on student performance on a subsequent highstakes standardized patient examination. Teach. Learn. Med. 21, 284e290. Hill, A., Davidson, B., Theodoros, D., 2010. A review of standardized patients in clinical education: implications for speech-language pathology programs. Int. J. Speech-Lang. Pathol. 12, 259e270. Kelley, F.J., Kopac, C.A., Rosselli, J., 2007. Advanced health assessment in nurse practitioner programs: follow-up study. J. Prof. Nurs. 23, 137e143. Kinnair, D.J., Anderson, E.S., Thorpe, L.N., 2012. Development of interprofessional education in mental health practice: adapting the Leicester Model. J. Interprofessional Care 26, 189e197. King, A.E.A., Conrad, M., Ahmed, R.A., 2013. Improving collaboration among medical, nursing and respiratory therapy students through interprofessional simulation. J. Interprofessional Care 27, 269e271. Lambdon, J., 2008. Integrating simulation into a pediatric nursing curriculum: a 25% solution? Simul. Healthc. 3 (1), 53e57. Lapkin, S., Levett-Jones, T., Gilligan, C., 2013. A systematic review of the effectiveness of interprofessional education in health professional programs. Nurse Educ. Today 22 (2), 90e102. Long-Bellil, L.M., 2007. Preparing Future Clinicians to Provide Medical Services to Persons with Disabilities (Doctoral dissertation). Retrieved from ProQuest Dissertations and Theses (Accession Order No. AAI3278097). May, W., 2008. Training standardized patients for a high-stakes clinical performance examination in California Consortium for the assessment of clinical competence. Kaohsiung J. Med. Sci. 24, 640e645. McGovern, M.M., Johnston, M., Brown, K., Zinberg, R., Cohen, D., 2006. Use of standardized patients in undergraduate medical genetics education. Teach. Learn. Med. 18, 203e207. McWilliam, P., Botwinski, C., 2010. Developing a successful nursing objective structured clinical examination. J. Nurs. Educ. 49, 36e41. Miles, M.B., Huberman, A.M., 1994. Qualitative Data Analysis, second ed. Sage, Thousand Oaks, CA. Nagoshi, M., Williams, S., Kasuya, R., Sakai, D., Masaki, K., Blanchette, P.L., 2004. Using standardized patients to assess the geriatrics medicine skills of medical students, internal medicine residents, and geriatrics medicine fellows. Acad. Med. 79, 698e702. O'Connor, F.W., Albert, M.L., Thomas, M.D., 1999. Incorporating Standardized Patients into a Psychosocial Nurse Practitioner Program. Rutledge, C., Garzon, L., Scott, M., Karlowicz, K., 2004. Using Standardized Patients to Teach and Evaluate Nurse Practitioner Students on Cultural Competency. Sadeghi, M., Taghva, A., Mirsepassi, G., Hassanzadeh, M., 2007. How do examiners and examinees think about role-playing of standardized patients in an OSCE setting? Acad. Psychiatry 31, 358e362. Seibert, D.C., Guthrie, J.T., Adamo, G., 2004. Improving learning outcomes: integration of standardized patients & telemedicine technology. Nurs. Educ. Perspect. 25, 232e237.
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