Use of creative teaching strategies by nurse educators is essential to ensure competency and quality in nursing education. Standardized patients are employed individuals trained to accurately portray patients in specific clinical scenarios (Barrows, 1993; Ebbert & Connors, 2004). Oral and written examinations, as well as presentations, do not always reveal the clinical skills of advanced practice nurses. Therefore, incorporation of standardized patient scenarios into the graduate nursing curriculum is a creative and pragmatic method for faculty to evaluate the ability of students to assess, diagnose, and develop treatment plans in a variety of clinical situations. A creative strategy to prepare psychiatric-mental health nurse practitioner (NP) students to apply knowledge in a series of simulated clinical scenarios involving standardized patients is described in this article.
Standardized patients have been incorporated into medical (Ferrell, 1995; Norcini & Boulet, 2003) and nursing programs (Ebbert & Connors, 2004). Errichetti, Gimpel, and Boulet (2002) and Norcini and Boulet (2003) described standardized patient programs and how to integrate this method into the curriculum. Students and instructors reported that standardized patient encounters were productive and valuable, especially in the context of teaching communication and assessment skills (Ebbert & Connors, 2004; O’Connor, Albert, & Thomas, 1999). Medical educators have shown that standardized patients can be used to enhance skills in health promotion counseling, empathetic communication, spiritual assessment, health screening, and adherence to practice guidelines (Fortin & Barnett, 2004; Gimpel, Boulet, & Errichetti, 2003; Humair & Cornuz, 2003; Teutsch, 2003; Ziv, Wolpe, Small, & Glick, 2003).
The literature review related to the use of standardized patients in nursing education revealed that nurse educators used this strategy in undergraduate and graduate education. For example, Yoo and Yoo (2003) taught fundamentals and assessed clinical competency with the use of standardized patients. Videotaping standardized patient encounters helped undergraduate students develop an understanding of their strengths and weaknesses with therapeutic interaction skills and reduce anxiety in therapeutic encounters with patients in the clinical setting (Festa, Baliko, Mangiafico, & Jarosinski, 2000).
Nurse educators use standardized patients in the graduate NP programs for formative and summative evaluation (Bramble, 1994; Miller, Wilbur, Montgomery, & Talashek, 1998; O’Connor et al., 1999; Stroud, Smith, Edlund, & Erkel, 1999). In addition, graduate nursing faculty have reported that standardized patient scenarios are valuable in NP programs for assessment, communication, and knowledge development (Ebbert & Connors, 2004; Gibbons et al., 2002; O’Connor et al., 1999; Seibert, Guthrie, & Adamo, 2004; Vessey & Huss, 2002). Use of standardized patients has been successful in increasing cultural competency with NP students (Rutledge, Garzon, Scott, & Karlowicz, 2004).
Research documenting the efficacy of the use of standardized patient scenarios is in the beginning stages. Use of standardized patients with graduate NP students in a structured clinical assessment did not significantly improve their cognitive or clinical performance (Bramble, 1994). However, students reported that the experience was valuable. Carney and Ward (1998) used standardized patient scenarios to assess HIV preventive practices in physicians and NPs. Quality of care in outpatient settings was assessed using undercover standardized patients (Glassman, Luck, O’Gara, & Peabody, 2000). Both studies indicated the value of standardized patients in assessing current nursing practice. Foley, Nespoli, and Conde (1997) conducted evaluation research with practicing nurses. The scenarios involved standardized patients and physicians with practicing nurses, so the nurses could enhance their communication and collaboration skills. Although there were no statistically significant differences between the intervention and control groups, clinically significant and positive changes were noted in the nurse-patient interactions in the intervention group.
Other research findings indicated that feedback from standardized patient encounters can help develop models for education based on the most effective methods (Dube & Fuller, 2003; Gates, Fitzwater, & Telintelo, 2001). Many descriptions of the use of standardized patient scenarios in education and research involved only one or two encounters (Gates et al., 2001; O’Connor et al., 1999; Vessey & Huss, 2002). Therefore, the use of multiple standardized patient encounters will be described.
Standardized Patient Experience
A standardized patient laboratory is located on the health science campus of an urban research university. This laboratory is used primarily by faculty and students in the schools of medicine and nursing.
The standardized patient scenarios are incorporated into a preclinical course for the psychiatric-mental healthNPstudents. Thecoursedescription includes a review of the causes, manifestations, assessment, and diagnoses of psychopathology across the lifespan, with particular emphasis on the relevance of the research literature to the analysis of clinical cases. A main focus of the course was to enable students to build diagnostic reasoning skills so they could conceptualize case formulation and examination of differential diagnoses related to mental disorders. A main component of the course involved interaction of students with standardized patients who simulated complex mental disorders.
To develop the teaching method, faculty members first decided on six scenarios that would be used for the semester and would represent some of the specific mental disorders covered in the course. Faculty used nursing research findings related to the role of the advanced practice psychiatric nurse and the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000) to develop the scenarios. Faculty members then wrote the scenarios, reviewed them for content validity and accuracy, and developed the student guidelines and an evaluation process for the experience.
Initiating Use of Standardized Patient Scenarios
For this course, the standardized patient scenarios focused on patients with anxiety, depression, alcohol dependence, schizophrenia, and eating disorders. The scenarios were given a title, and the primary purpose of the case was described. For example, the purpose of the anxiety case was to teach, demonstrate, and practice appropriate assessment techniques, communication skills, and diagnostic ability with an anxious patient. The next part of the scenario involved the development of the case-specific essential student skills and behaviors to be evaluated by the faculty. Examples of these skills included:
- Demonstrate effective interviewing strategies to calm, focus, and reassure the anxious patient.
- Elicit a history from the patient.
- Determine any concurrent physical, mental, social, or interpersonal challenges or difficulties.
- Identify any diagnostic procedures that may be necessitated for the patient.
- Obtain any underlying or background information that would be helpful in diagnosis and treatment.
Faculty members designed the case scenario so that specific data were available for students to make an initial working diagnosis. However, students had to be able to question the standardized patient correctly to obtain these data.
Standardized Patient Scenario
Faculty members developed a detailed scenario for the standardized patient. The scenario included basic information for the standardized patient, including:
- Props needed.
- Patient’s age.
- Patient’s gender.
- Patient’s race.
- Patient’s chief complaint related to the case.
Additional information provided for the standardized patient situation included:
- Vital signs and other appropriate laboratory work.
- Standardized patient occupation.
- Standardized patient relevant history.
- A brief overview of the case for the simulation clinic chart.
Specific role-playing instructions for the standardized patient existed, including:
- Physical description (i.e., what the standardized patient should look like or wear).
- Social history.
- Past medical history.
- Relevant family medical and mental health history.
Instructions for the standardized patient included guidelines for:
- The kind of affect and behaviors.
- Body language and positioning.
- Cognitive and mental processes the standardized patient should demonstrate.
Guidelines for standard response statements to the students were also available. The standardized patients were given explicit response statements for specific student questions, teaching strategies, comfort measures, or suggestions for treatment based on the actual scenario. A list of spontaneous responses for the standardized patient was also developed. All content for the case was written so that it was congruent with a specific mental disorder. In all cases, extraneous data were inserted so the student would have to select multiple working diagnoses before the final diagnosis could be determined.
At the end of the 30-minute encounter, the standardized patient came out of the role and, using a checklist (Table) developed by the faculty member, reviewed the experience with the student for approximately 15 minutes. This review involved feedback about how the student performed on the 11 items. In addition, the standardized patients provided detailed feedback and debriefing to the students about how they behaved related to the indicators on the checklist.
Table: Example of Standardized Patient Checklist Worksheet
Students received didactic content about the specific mental disorder before they interacted with the standardized patient in the simulated laboratory. Faculty members prepared students by reviewing assessment, diagnostic, and screening tools for specific mental disorders. Students were given the case-specific essential skills and behaviors to be evaluated, as described above. Students went to the laboratory, designed like a primary care clinic, and interviewed the standardized patient. All student-standardized patient encounters were videotaped for review with peers and faculty immediately following the encounter. The interview with the standardized patient lasted 30 minutes.
Immediately after the students completed the standardized patient interviews, the standardized patients reviewed the checklist with the students. Then, faculty members and students spent several hours reviewing the videotapes. Discussions focused on the following objectives: First, the students evaluated their own interview skills and ability to gather patient data using various assessment, screening, and diagnostic tools. Second, the videotapes were reviewed to explore specific moments when the patient gave information that was critical to the diagnosis. Third, students and faculty discussed an appropriate working diagnosis for each standardized patient situation. Finally, discussion focused on additional data needed to make a correct diagnosis.
The course culminated with a final 45-minute interview during which each student was assigned a more complex standardized patient scenario. The faculty member added more psychosocial and neurobiological data, multiple laboratory results, and critical points to the original six cases. For example, several of the scenarios involving the standardized patient required immediate action by the student, including hospitalization of the standardized patient. From this interview, the students completed the final paper for the course. This comprehensive paper involved identification and categorization of data according to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000), identification of any extemporaneous data needed to provide further clarification and discussion of how these data were useful, analysis of relationship of data to the current diagnosis, formulation of a care plan, and discussion of developmental issues relevant to the case.
The evaluation of the experience was multifaceted. First, the students received prompt feedback from the standardized patient for approximately 15 minutes. In this discussion, the standardized patient completed the assigned checklist and described effective and ineffective communication strategies from the standardized patient’s perspective. Second, the videotaped interviews were immediately reviewed by the students and faculty in a 2-hour session. Discussion focused on interviewing skills; skills in eliciting a history from the standardized patient; determining concurrent physical, mental, social, or interpersonal challenges or difficulties; identification of any diagnostic procedures for the standardized patient; and obtaining any information that would be helpful in diagnosis and treatment. Third, the final standardized patient interview and final paper was the culmination of the course experience. This analysis reflected the student’s ability to apply comprehensive knowledge from the course to a patient scenario. Finally, in course and faculty evaluations, the students reported having more knowledge and skills and being more prepared for their next course. The next course in the curriculum is a clinical course involving experiences with patients in which students are supervised by a preceptor and a faculty member. Students also reported that practicing in the simulation clinic with standardized patients improved their confidence as they mastered skills of an advanced practice nurse.
We have offered this course for 2 semesters in the manner described in this article. Using the teaching strategies described, plans for a more detailed and systematic formative and summative evaluation of the project are underway as the third semester begins. Faculty members recommend comparison of student clinical competencies with a standardized patient experience with students who do not have the experience with the scenarios. In addition, we recommend an interrater reliability procedure in which several faculty evaluate the videotape of the student-standardized patient encounters to validate the students’ ability to accurately assess and diagnose the standardized patients.
The standardized patient scenarios have been refined with feedback from the actors and actresses as they played the roles, from students, and from faculty. Research analyzing the students’ progress from their videotaped interviews is planned, as well as future publication of all of the standardized patient cases.
Our experience with use of student and standardized patient encounters was positive. A high level of functioning was required from students as they learned to elicit information from patients with mental disorders. In a controlled environment, faculty members created complex scenarios for students that enhanced students’ clinical reasoning and diagnostic abilities.
- American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders DSM-IV-TR® (4th ed., text revision). Arlington, VA: Author.
- Barrows, HS1993. An overview of the uses of standardized patients for teaching and evaluating clinical skills. Academic Medicine, 68, 443–451. doi:10.1097/00001888-199306000-00002 [CrossRef]
- Bramble, K1994. Nurse practitioner education: Enhancing performance through the use of the objective structured clinical assessment. Journal of Nursing Education, 33, 59–65.
- Carney, PA & Ward, DH1998. Using unannounced standardized patients to assess the HIV prevention practices of family nurse practitioners and family physicians. Nurse Practitioner, 23(2), 56–58, 63, 67–68. doi:10.1097/00006205-199802000-00006 [CrossRef]
- Dube, CE & Fuller, BK2003. A qualitative study of communication skills for male cancer screening discussions. Journal of Cancer Education, 18, 182–187. doi:10.1207/s15430154jce1804_4 [CrossRef]
- Ebbert, DW & Connors, H2004. Standardized patient experiences: Evaluation of clinical performance and nurse practitioner satisfaction. Nursing Education Perspectives, 25, 12–15.
- Errichetti, AM, Gimpel, JR & Boulet, JR2002. State of the art in standardized patient programs: A survey of osteopathic medical schools. Journal of American Osteopathic Association, 102, 627–631.
- Ferrell, BG1995. Clinical performance assessment using standardized patients: A primer. Family Medicine, 27, 14–19.
- Festa, LM, Baliko, B, Mangiafico, T & Jarosinski, J2000. Maximizing learning outcomes by videotaping nursing students’ interactions with a standardized patient. Journal of Psychosocial Nursing and Mental Health Services, 385, 37–44.
- Foley, ME, Nespoli, G & Conde, E1997. Using standardized patients and standardized physicians to improve patient-care quality: Results of a pilot study. Journal of Continuing Education in Nursing, 28, 198–204.
- Fortin, AH IV. & Barnett, KG2004. Medical school curricula in spirituality and medicine. Journal of the American Medical Association, 291, 2883. doi:10.1001/jama.291.23.2883 [CrossRef]
- Gates, DM, Fitzwater, E & Telintelo, S2001. Using simulations and standardized patients in intervention research. Clinical Nursing Research, 10, 387–400. doi:10.1177/10547730122159012 [CrossRef]
- Gibbons, SW, Adamo, G, Padden, D, Ricciardi, R, Graziano, M & Levine, E et al. . 2002. Clinical evaluation in advanced practice nursing education: Using standardized patients in health assessment. Journal of Nursing Education, 41, 215–221.
- Gimpel, JR, Boulet, JR & Errichetti, AM2003. Evaluating the clinical skills of osteopathic medical students. Journal of the American Osteopathic Association, 103, 267–279.
- Glassman, PA, Luck, J, O’Gara, EM & Peabody, JW2000. Using standardized patients to measure quality: Evidence from the literature and a prospective study. Joint Commission Journal on Quality Improvement, 26, 644–653.
- Humair, JP & Cornuz, J2003. A new curriculum using active learning methods and standardized patients to train residents in smoking cessation. Journal of General Internal Medicine, 18, 1023–1027. doi:10.1111/j.1525-1497.2003.20732.x [CrossRef]
- Miller, AM, Wilbur, J, Montgomery, AC & Talashek, ML1998. Standardizing faculty evaluation of nurse practitioner students by using simulated patients. Clinical Excellence for Nurse Practitioners, 2, 102–109.
- Norcini, J & Boulet, J2003. Methodological issues in the use of standardized patients for assessment. Teaching and Learning in Medicine, 15, 293–297. doi:10.1207/S15328015TLM1504_12 [CrossRef]
- O’Connor, FW, Albert, ML & Thomas, MD1999. Incorporating standardized patients into a psychosocial nurse practitioner program. Archives of Psychiatric Nursing, 13, 240–247. doi:10.1016/S0883-9417(99)80034-X [CrossRef]
- Rutledge, CM, Garzon, L, Scott, M & Karlowicz, K. 2004. Using standardized patients to teach and evaluate nurse practitioner students on cultural competency. International Journal of Nursing Education Scholarship, 1, Article 17. doi:10.2202/1548-923x.1048 [CrossRef]
- Seibert, DC, Guthrie, JT & Adamo, G2004. Improving learning outcomes: Integration of standardized patients and telemedicine technology. Nursing Education Perspectives, 25, 232–237.
- Stroud, SD, Smith, CA, Edlund, BJ & Erkel, EA1999. Evaluating clinical decision-making skills of nurse practitioner students. Clinical Excellence for Nurse Practitioners, 3, 230–237.
- Teutsch, C2003. Patient-doctor communication. The Medical Clinics of North America, 87, 1115–1145. doi:10.1016/S0025-7125(03)00066-X [CrossRef]
- Vessey, JA & Huss, K2002. Using standardized patients in advanced practice nursing education. Journal of Professional Nursing, 18, 29–35. doi:10.1053/jpnu.2002.30898 [CrossRef]
- Yoo, MS & Yoo, IY2003. The effectiveness of standardized patients as a teaching method for nursing fundamentals. Journal of Nursing Education, 42, 444–448.
- Ziv, A, Wolpe, PR, Small, SD & Glick, S2003. Simulation-based medical education: An ethical imperative. Academic Medicine, 78, 783–788. doi:10.1097/00001888-200308000-00006 [CrossRef]
Example of Standardized Patient Checklist Worksheet
|Started with a self-introduction||Y —||N —|
|Told me what to anticipate for this visit||Y —||N —|
|Demonstrated effective interview strategies to obtain information, focus, and reassure the client||Y —||N —|
|Determined any concurrent physical, mental, social, or interpersonal challenges or difficulties regarding the client||Y —||N —|
|Identified any diagnostic procedures that may be necessitated for me, as the client||Y —||N —|
|Obtained any underlying or background information that would be helpful in diagnosis and treatment||Y —||N —|
|Ascertained the level of seriousness of my medical and mental state, as the client||Y —||N —|
|Ascertained my goals, as the client||Y —||N —|
|Balanced history taking and teaching, as appropriate in this initial interview||Y —||N —|
|Began initial treatment protocol on the basis of the working diagnosis||Y —||N —|
|Engaged me in coming again to the mental health clinic||Y —||N —|