Ms. Zavertnik is Clinical Instructor, Ms. Huff is Clinical Assistant Professor, and Dr. Munro is Professor, Virginia Commonwealth University, School of Nursing, Richmond, Virginia.
The authors thank the Center for Biobehavioral Clinical Research, Virginia Commonwealth University, School of Nursing, and Dr. Patty Gray, Director of Adult Health and Nursing Systems, Virginia Commonwealth University. Funding for the research was provided by the Virginia Commonwealth University Center for Teaching Excellence Small Grant Program Fall 2006.
Address correspondence to Jean Ellen Zavertnik, MN, RN, ACNS-BC, Clinical Instructor, Virginia Commonwealth University, School of Nursing, 1100 East Leigh Street, Box 980567, Richmond, VA 23298-0567; e-mail: firstname.lastname@example.org.
Effective nurse-family communication is essential to quality care of the patient-family unit. The American Association of Critical Care Nurses’ Standards for Establishing and Sustaining Healthy Work Environments (2005) stated in standard one (i.e., skilled communication), “Nurses must be as proficient in communication skills as they are in clinical skills” (p. 2). The nurses’ development of effective communication in the health care setting should begin in the nursing education program. Classroom-based knowledge is not always easily transferred into clinical practice, as was demonstrated in the research by Aled (2007). The researcher explored nursing undergraduates’ interpersonal skills by reviewing and analyzing tapes and transcriptions of actual nurse-patient interactions. Aled (2007) noted in the research findings that the style of communication did not correspond to the didactic teaching presented and encouraged for nurse-patient interactions. Observing and recording actual nurse-patient communication for the purpose of evaluation is time consuming and tedious. Traditional classroom teaching of communication skills does not allow for practical application. Practicing communication skills through simulation in a clinical learning laboratory allows students to practice and test skills in a safe, nonthreatening environment and allows faculty to evaluate and provide feedback to the students. This article discusses a study evaluating one method for educating and assessing teaching communication skills to undergraduate nursing students using simulation.
This study tested an intervention designed to enhance the current classroom-based approach to teaching communication skills by providing an opportunity for students to actively engage in demonstrating communication skills and to receive constructive feedback and coaching. Students who had the additional educational communication opportunity enhanced by the interaction with a standardized family member were compared with students who had only traditional classroom teaching. Determining the effectiveness of the more interactive approach is important, as the approach is more faculty intensive and costly.
Documentation of the effectiveness of this educational approach helps in building an evidence-based curriculum and making decisions for allocation of teaching support funds. In addition, the outcome of the study provides information for use in selecting skill development strategies in simulation laboratories, a rapidly expanding resource in health education settings.
Although various methods of communication instruction are available in nursing education programs, the best method for this skill training has not been established. Yoo and Yoo (2003) compared the effects of two teaching methods on sophomore-level nursing students’ clinical competence—a traditional lecture and laboratory method and an experimental simulated standardized patient method for communication skills. Yoo and Yoo (2003) evaluated communication skills and found students in the standardized patient groups showed significantly higher scores in communication skills than did the control group. Using two teaching methods, Becker, Rose, Berg, Park, and Shatzer (2006) compared therapeutic communication skills of undergraduate nursing students. Both groups of students attended didactic lectures on therapeutic communication. The control group received the traditional method of instruction (i.e., a structured clinical conference). The intervention group interviewed a standardized patient in the clinical teaching laboratory, followed by a group debriefing and student videotaped self-analysis. Students were evaluated using two instruments developed by the authors. Although there was no significant difference between the two groups on measures of interpersonal skills and therapeutic communication skills, the students indicated that the experience was positive, creative, and meaningful. The current study built on this premise that role-playing with a standardized patient or family member would improve communication skills.
Several studies have used simulations and role-play as instructional methods for communication skills, both in nursing and medicine. Role-playing, a form of simulation, as a method for learning communication was used with first-year undergraduate medical students (Nestel & Tierney, 2007). The students evaluated the experience as valuable, with student comments including positive opportunities for observation, rehearsal, and discussion. Other studies have indicated a positive response from medical students with interactive communication training (Wagner, Lentz, & Heslop, 2002).
Several nursing studies have investigated the simulation use for learning communication skills. However, these studies varied in their approach and evaluation of communication, and thus direct comparison with this study would be difficult. Yedidia et al. (2003) studied the effects of communication training on medical student performance using student interaction with a standardized patient, individual feedback, and student self-reflection. The results indicated that the students exposed to the intervention improved significantly on combined outcome measures, compared with the control group. The study by Roter et al. (2004) to enhance communication skill training among medical students included didactic and role-playing sessions with a standardized patient. The results demonstrated changes in medical residents’ communication behaviors, including a reduction in verbal dominance, increased use of open-ended questions, increased use of empathy, and increased partnership building and problem solving for therapeutic regime adherence. Although studies have indicated simulation teaching methods to be beneficial for instructional use with students, the literature review by Lane and Rollnick (2007) concluded that there is a need for more well-designed studies that assess skill acquisition following the use of simulated patients and role-play in a number of different settings, both at the undergraduate level and with experienced clinicians.
Studies on communication skills in nursing education have lacked sound research design and have demonstrated limited evidence regarding the effectiveness of different educational interventions (Kruijver, Kerkstra, Francke, Bensing, & van de Weil, 2000). Rosenzweig, Clifton, and Arnold (2007) designed and implemented a communication skills workshop for oncology advanced practice nursing students. They implemented the use of three case studies with standardized patients, focusing on specific communication skills: asking before telling, and overall empathic communication. Although no formal student grading was performed, the responses from the students in the study were positive related to helpfulness in learning communication skills through lecture, standardized patient encounters, and feedback sessions.
We were interested in determining a method for training and evaluating nursing students in communication skills with family members. Lorin, Rho, Wisnivesky, and Nierman (2006) studied an educational initiative to teach intensive care unit communication skills to fourth-year medical students. The scenarios for both the intervention and the assessment evolved around the first meeting between the health care provider and the family. They demonstrated improvement in communication skills of medical students using a formal teaching session and a simulated practice session with a standardized family member. Standardized family members were actors playing an established role. Using the study by Lorin et al. (2006) as a foundation, we developed and tested a similar approach to teach nursing students communication skills with family members. The objective of our research was to assess the effectiveness of a learner-centered simulation intervention designed to improve the communication skills of preprofessional nursing students.
Method and Design
We examined the effectiveness of role-playing with standardized family members on learning communication skills using a quasi-experimental two-group posttest design. This project replicated the study by Lorin et al. (2006) of fourth-year medical student communications with standardized family members. In the study, medical students at the beginning of a 4-week block rotation were assigned to either a control group or an intervention group. The control group received no teaching session, whereas the intervention group, in a formal teaching session held with an actor and experienced critical care educators, received a lecture on a framework for communication and discussion on guidelines for use of the framework. Using actors as standardized family members, the students role-played for 90 minutes, focusing on the guidelines and teaching points regarding communication skills. Two case studies were developed by Lorin et al. (2006)—one for use with the intervention and one for use with the assessment. The medical students were allowed to ask questions or advice of their colleagues or instructor about how to address difficult questions during the intervention. At the end of the students’ block rotation, students from both the control group and intervention group were tested using a standardized grading tool developed by the authors (Lorin et al., 2006).
Our methods replicated those implemented by Lorin et al. (2006), with some modification. Nursing students were divided into a control group and an intervention group at the beginning of the semester. Although we modified the clinical patient description from the study by Lorin et al. (2006) to simplify the disease process, the description of the family member for each case was the same. During the intervention, the wife was passive and emotionally labile and had difficulty making decisions. During the intervention, the daughter was aggressive, distrustful, and controlling and wanted “everything done.” The role-playing session with the standardized family member was 60 minutes. A two-group comparison (control and intervention groups) was conducted after the intervention to assess communication with a standardized family member using a modification of the standardized grading tool. The standardized grading tool was developed by the original researchers based on four communication domains, the researchers’ clinical experiences, and guidelines proposed in the literature on communication for end-of-life care. The reliability of the assessment tool from Lorin et al. (2006) was excellent (k = 0.086). The tool for this research was adapted from the one used by Lorin et al. (2006), and permission for use was obtained by the author and the publisher (Table 1). Because Lorin et al. (2006) developed the tool for use with medical students, modifications were made to better reflect the nurse’s role in communication with families. For example, we altered “creating a medical plan of care” to “clarifying the physician’s plan.” The modified tool is presented in Table 1. To determine interrater reliability, five randomly selected videotapes (12%) were scored by both of the blinded faculty evaluators using the standardized grading tool. Interrater reliability (Pearson’s R) was 0.71.
Table 1: Standardized Grading Tool
The institutional review board’s expedited approval was granted for the research project. Funding of $3,000 was obtained for this study through the University’s Center for Teaching Excellence. This money supported the use of the professionally trained standardized family members and data management.
At the beginning of the semester, 41 students were recruited in their first clinical course of the nursing curriculum. Twenty-one students from the class volunteered for the control group, and a nonrandomized group of 20 students, mainly from the investigators’ two clinical groups, volunteered for the intervention group. Students in the investigators’ two clinical groups were not always available or interested in volunteering for the research project; therefore, students from other clinical groups volunteered. Students in the intervention group were advised to refrain from communicating information and instruction they learned to the students in the control group. No testing of the two sample groups was done to evaluate initial differences between the two groups. Other clinical faculty members were not aware of the intervention or which students were included in the study. Participation was voluntary, and students were assured their grades would not be influenced by a decision regarding participation, group assignment, or performance in the activity. Written consent was obtained and interventions were videotaped for later interrater reliability assessment.
The control condition consisted of the current instruction provided on communication. In the current curriculum, concepts of therapeutic communication are described in the classroom but are not demonstrated or formally evaluated in the laboratory or clinical setting. The control group received the current standard education provided to students in the beginning nursing course (two 1-hour lectures on principles of communication and communication strategies). In addition, the intervention group received a 30-minute training session in the clinical learning laboratory during which a framework for communication and guidelines on how to use this framework when communicating with family members was presented. The communication framework for this study was based on a framework created by the original researchers using their own experiences, as well as on guidelines in the literature for communication for end-of-life care. Because Lorin et al. (2006) were unable to find any published literature for a recommended framework for an initial intensive care unit communication episode with the patient’s family member, the authors devised a structure that incorporated four teaching domains: how to introduce yourself, how to gather information, how to present information, and how to set goals and expectations. Each domain listed major teaching goals with specific criteria. These criteria were the basis for the evaluation of the communication episode (i.e., the standardized grading tool).
Following the information session, the intervention group of nursing students was divided into smaller groups of 5 students. Each individual student role-played with the same trained standardized family member, practicing the communication skills presented in the training session. The students were given a scenario and asked to communicate with a family member of a patient newly admitted to the intensive care unit. The standardized family members were professional paid actors who were trained by a regional medical school in the role of family members of hospitalized patients. Students received informal feedback and coaching from the standardized family members, peers, and faculty in the 60-minute practice session. Thus, the total instructional time was 90 minutes. Students in the intervention group were asked to practice these communication skills during their clinical rotation. Students in the control and intervention groups had equivalent clinical experiences during the semester. No further instructional information was given to any of the students in the intervention or control group in the form of postconference or daily delivery of care.
Both the intervention group and the control group were evaluated at the end of the semester in a testing session with a standardized family member. Three standardized family members were used for all 41 assessments. Each member was provided with a profile that outlined his or her situation, temperament, and responses patterns. Each student was given the same patient scenario to review before the beginning of the intervention. The students were given the patient history, reason for hospitalization, physician orders, and physician progress note from the emergency department admission. The students were then placed in a simulated environment with a manikin as their patient and were asked to communicate information about this patient’s condition to the arriving standardized family member. The nurse-family interaction focused on the initial meeting between the nurse and the family member. The evaluators, nursing faculty blinded to the intervention and control groups, graded the communication skills on the standardized grading tool by observing communication skills in the area of performing introductions, gathering information, imparting information, and clarifying goals and expectations.
Assessments conducted at the end of the semester (postintervention) using the standardized grading tool evaluated students’ skills and abilities related to communication with a family member. A one-way multivariate analysis of variance was used to compare control and intervention groups on standardized grading tool scores. The mean and standard deviation for each group was determined in each of the four domains (performing introduction, gathering information, imparting information, and clarifying goals and expectations), as well as the summative score of all four domains. Demographic information was used for group descriptions and comparisons. The Center for Biobehavioral Clinical Research at Virginia Commonwealth School of Nursing provided data management support, including development of data collection instruments, development of a project database, and data support, entry, and consultation.
Sample characteristics are presented in Table 2. The sample comprised primarily women and young adults as representative of the nursing student body. In this small, volunteer sample, minorities and men were underrepresented.
Table 2: Group Characteristics
Assessment scores for control and intervention groups in the study with nursing students are presented in Table 3. Despite having higher scores in the intervention group, results in our study indicated only one area of significance: the domain of gathering information.
Table 3: Assessment Scores by Group
The relationships among domains were analyzed by correlation in the whole sample. The results are presented in Table 4. Statistically significant positive correlations (p < 0.05) existed between gathering information and imparting information, gathering information and clarifying goals and expectations, and imparting information and clarifying goals and expectations. A significant correlation did not exist between introduction and the other three domains.
Table 4: Correlation Among Assessment Domains
The relationship of age and previous experience in health care settings (years of employment or volunteering) to assessment scores was examined. No significant relationship was found between assessment scores (subsets or total) to age or years employed or volunteered in a health care setting. The effects of gender, ethnicity, and race differences were not examined due to the small sample size.
The standardized grading tool, developed by Lorin et al. (2006) and modified for this project, evaluated communication skills in four teaching domains: how to introduce yourself, how to gather information, how to impart information, and how to clarify goals and expectations. The sophomore nursing students in the intervention group scored higher than the control group in all areas, with a statistically significant difference in gathering information. The intervention group appeared to have benefited from the instructional intervention that included practicing with the standardized family member. In the original research study by Lorin et al. (2006), results from 106 fourth-year medical students revealed that total mean scores, as well as scores for gathering information, imparting information, and setting goals and expectations for the intervention group, were significantly higher than for the control group (p < 0.01).
The process of communicating with families involves an array of skills, from simple skills such as data acquisition to more complex skills such as consulting and negotiating care goals. The differences in scores between groups were greatest in the simpler skill of information gathering and imparting than in the more complex skills. These aspects of interaction may indicate that sophomore nursing students are not yet developmentally ready to learn these higher level skills. However, as the intervention group acquires better basic skills with families, one strategy is to integrate communication throughout the clinical curriculum, with simulation activities beginning with simple foundational communication skills and advancing to more complex, nurse-patient-family interactions.
The group scores differed least in the simplest skill of self-introductions and identification of their position in the patient’s care team. However, this interaction is concrete and functions more as a communication to the family instead of an interaction with the family. Introductions are a social skill that students are apparently able to transfer from previous experience, and thus there were no differences in this aspect of the assessment. In addition, the assessment tool rated performance in this area dichotomously (i.e., yes or no), which may not reflect the quality of the initial interaction.
Nursing students receive classroom information regarding interacting with family members of hospitalized patients; however, the students do not have an opportunity to practice these skills prior to real clinical encounters. By simulating communication between nurses and patients’ family members, students can practice their communication skills in a controlled, nonthreatening environment. Interaction with standardized family members provides opportunities for students to be directly involved in their own learning, build on their current skill level, demonstrate the learned behavior, benefit from structured feedback about the effectiveness of the skill, and gain confidence in communication abilities. Then, students can integrate these skills into practice in the clinical setting.
Replication of the study with a larger sample to include more male and minority students is desirable. Replication of this study with junior and senior nursing students would help in determining the optimal time for focusing on particular communication skills, such as interviewing, consulting, and giving bad news. It would be interesting to assess the effect of teaching strategies using standardized family members to improve communications skills longitudinally as students gain knowledge and experience in the clinical setting. The results would give further credence to support how and when communication skills are taught. A questionnaire eliciting students’ perspectives on the use of simulation as a teaching strategy for learning communication skills would be helpful in understanding the students’ experience.
Using standardized patients and family members to instruct and evaluate communication skill in the nursing education program may be cost prohibitive in many schools. Training faculty to play the role of patient or family may be an alternative approach.
Communication is a core competency for nursing. This study provides an innovative approach to meet the needs of assessing this core competency. Providing students with a simulated learning environment in which practice enhances communication skills, and use of a standardized family member in student evaluation enhances the objectivity and rigor of assessments by providing controlled testing conditions. More opportunities for this method of education should be evaluated and, if effective, adopted into the curriculum. This study provides initial information about a standardized family member-based teaching strategy to enhance communication skills of preprofessional nursing students. This project also provides a foundation on which future systematic investigation into learner-centered teaching methods for clinical skills can be based.
- Aled, J. (2007). Putting practice into teaching: An exploratory study of nursing undergraduates’ interpersonal skills and the effects of using empirical data as a teaching and learning resource. Journal of Clinical Nursing, 16, 2297–2307. doi:10.1111/j.1365-2702.2007.01948.x [CrossRef]
- American Association of Critical Care Nurses. (2005). AACN standards for establishing and sustaining healthy work environments: A journey to excellence. Retrieved May 15, 2009, from http://www.aacn.org/WD/HWE/Docs/ExecSum.pdf
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- Kruijver, I.P., Kerkstra, A., Francke, A.L., Bensing, J.M. & van de Weil, H.B. (2000). Evaluation of communication training programs in nursing care: A review of the literature. Patient Education and Counseling, 39, 129–145. doi:10.1016/S0738-3991(99)00096-8 [CrossRef]
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- Roter, D.L., Larson, S., Shinitzky, H., Chernoff, R., Serwint, J.R. & Adamo, G. et al. (2004). Use of an innovative video feedback technique to enhance communication skills training. Medical Education, 38, 145–157. doi:10.1111/j.1365-2923.2004.01754.x [CrossRef]
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Standardized Grading Tool
| Introduces himself or herself||YesNo|
| Identifies himself or herself and delineates his or her position of authority||YesNo|
| Begins the process with open-ended questions||YesNo|
| Listens effectively to family member’s responses||Unsatisfactory (i.e., constantly interrupts)Average (i.e., sometimes interrupts unnecessarily)Superior (i.e., inquires with detail and specifics)|
| Discusses advanced directives and inquires about appropriate forms||Unsatisfactory (i.e., does not raise the topic)Average (i.e., inquires without detail)Superior (i.e., inquires with detail and specifics)|
| Accurately identifies point of contact or power of attorney||Unsatisfactory (i.e., does not raise the topic)Average (i.e., inquires, but not accurate)Superior (i.e., accurately identified)|
| Uses terms that the family member could understand||Unsatisfactory (i.e., infrequently)Average (i.e., mostly)Superior (i.e., always)|
| Communicates the severity of illness||Unsatisfactory (i.e., does not raise the topic)Average (i.e., raises the topic but lacks clarity)Superior (i.e., conveys with clarity both the number or organs affected and the overall likelihood of death)|
| Assesses family member’s understanding of problem||Unsatisfactory (i.e., does not raise the topic)Average (i.e., at minimum just asks)Superior (i.e., asks and probes for understanding)|
|Clarifying goals and expectation|
| Clarifies the medical plan with identifiable short-term goals||Unsatisfactory (i.e., does not raise the topic)Average (i.e., raises the topic but lacks depth of understanding and agreement)Superior (i.e., obtains understanding and agreement with focus on specific terms such as blood pressure, oxygen levels, mental status, and life-supporting medications and technology including ventilation, renal replacement therapy, or cardiopulmonary resuscitation over the next 24 to 72 hours)|
| Clarifies the medical plan with identifiable long-term goals||Unsatisfactory (i.e., does not raise the topic)Average (i.e., raises the topic but lacks depth of understanding and agreement)Superior (i.e., obtains understanding and agreement with focus on the best hoped for outcome in the long term regarding overall level of function and quality of life after hospitalization)|
| Summarizes the care plan||Unsatisfactory (i.e., does not raise the topic or raises it incorrectly)Average (i.e., provides summary but still lacks some clarity)Superior (i.e., clearly stated)|
| Checks for mutual understanding||YesNo|
| Identifies additional resources (e.g., social worker, clergy)||YesNo|
| Asks whether the family member has any further questions or concerns||YesNo|
|Characteristic||Control (N= 21)||Intervention (N= 20)|
| Black or African American||1||0|
|Years in health care setting||1.0±1.3||1.3±1.3|
Assessment Scores by Group
|Domain||Control (N= 21)||Intervention (N= 20)||p|
|Clarifying goals and expectations||6.2±1.4||6.6±1.8||0.2246|
Correlation Among Assessment Domains
|Variable||Introduction||Gathering Information||Imparting Information||Clarifying Goals and Expectations|
|Introduction||0.1097 (p = 0.4946)||–0.254 (p = 0.8746)||0.1988 (p = 0.2187)|
|Gathering information||0.5256 (p = 0.0004)*||0.3636 (p = 0.0211)*|
|Imparting information||0.6071 (p ≤ 0.0001)*|