Ms. Schlegel is Head of Skillslab, Berner Bildungszentrum Pflege, Dr. Woermann is Head of Medical Media Production, University of Bern, Institute of Medical Education, Education and Media Unit, and Dr. Shaha is Researcher in Nursing, Research, and Professional Development, University Hospital Berne, Berne, Switzerland; Dr. Rethans is Associate Professor, Skillslab, Faculty of Health, Medicine & Life Sciences, and Dr. van der Vleuten is Head of Department of Educational Development and Research, Maastricht University, Maastricht, Netherlands.
The authors have no financial or proprietary interest in the materials presented herein.
The authors thank Rachel Yudkowsky for her valuable contributions.
Address correspondence to Claudia Schlegel, MME, RN, Head of Skillslab, Berner Bildungszentrum Pflege, Reichenbachstrasse 118, 3004 Berne, Switzerland; e-mail:firstname.lastname@example.org.
Communication skills are of paramount importance for health care professionals working with patients. Kurtz, Silverman, and Draper (2005) stated that without appropriate communication skills, the better part of the clinical efforts in medical care may be wasted. It has been demonstrated that patient-centered communication improves diagnostic efficiency (Epstein et al., 2005), physicians’ and patients’ satisfaction (May, Park, & Lee, 2009), and treatment outcomes (Stewart, 2001). As a result, communication skills training (CST) has become an essential component of many curricula in the education of health care professionals (Snadden & Ker, 2005).
Ample evidence exists that CST indeed improves health care professionals’ communicative competence (Bokken, Linssen, Scherpbier, van der Vleuten, & Rethans, 2009; Browning, Meyer, Truog, & Solomon, 2007), but training methods vary. Communication skills training with peer role-playing is a widely used method with proven effectiveness (Dent & Harden, 2005; Nestel & Tierney, 2007). This method has the important advantage that it can be implemented with few resources beyond those available for regular training. Communication skills training with standardized patients (SPs) has also been shown to be effective (Dent & Harden, 2005; Kurtz et al., 2005; May et al., 2009), but it is more complex and more expensive.
Several studies have compared two teaching methods using SPs and peer role-playing (traditional method) and examined their effects on nursing students and medical students (Becker, Rose, Berg, Park, & Shatzer, 2006; Bosse et al., 2010; Yoo & Yoo, 2003). Nevertheless, Lane and Rollnick (2005) concluded, after a review of the literature on the use of SPs and role-play in CST, that more studies are needed to compare the two methods. In general, the published studies relied on the SPs’ assessment of the quality of students’ communication skills in vitro (i.e., within the training setting). The students’ communication skills were not evaluated by real patients, the students themselves, or clinical supervisors in vivo (i.e., in the real world—a health care setting). The assessment of the effectiveness of communication training modules may gain new dimensions by incorporating the perspective of real patients, students, and supervisors (trained nurses, who work together with the students during their practical rotation in hospital). Therefore, it was essential to compare and evaluate the effects of CST modules with and without the use of SPs in real clinical practice.
Our study compared the effectiveness of CST with a peer role-play module followed by a summative written test versus CST with an SP module including a performance-based test (Objective Structured Clinical Examination [OSCE]). We assessed the two modules with two different assessment formats because the introduction of SPs in our new curriculum involved not only training with SPs but also assessment with SPs. The results of these assessments were not planned to be a part of our study because our interest was the outcome of the training method, not the output. The respective effectiveness of the two training methods was evaluated by (1) students, in terms of perceived self-efficacy; (2) patients, in terms of their perception of the students’ communication skills; and (3) clinical supervisors, in terms of a judgment of the students’ communication skills. We hypothesized that a combined training (CST with SP) including an assessment (OSCE with SPs) would lead to better results on all three points of measurement in clinical practice. In addition, evidence of the superiority of the use of SPs in a CST module is required to justify the higher implementation effort.
Participants and Setting
The participants were first-year students of a nursing program in Berne, Switzerland. The students were between 18 and 20 years old and had no previous experience as nurses in a hospital. To be accepted into the program, all students had undergone the same admission procedure, which involved a structured interview with two faculty members. The four subcategories of this 14-item standardized interview addressed self-competence, social competence, professional competence, and motivation to become a nurse. The two faculty members scored each student on a response scale from 0 to 3. To pass the interview, a minimum total score of 28 points (averaged between the two raters) and no item rated zero were necessary.
After acceptance into the program, the students were assigned to one of two different school sites using random numbers generated by Microsoft® Excel. The nursing program is offered at two different sites within the city of Berne, Switzerland, which offer an identical curriculum taught by the same teachers, with the exception, for research purposes, of the CST module. The students on one campus comprised the intervention group; the students in the other comprised the control group. To determine whether the students in the intervention group differed from those in the control group, a t test of the admission test scores was conducted, and control and intervention groups did not differ (p = 0.993).
For the purpose of the study, we used a randomized posttest-only control group design (Figure).
Figure. Study design. CST = communication skills training; SP = standardized patient; OSCE = Objective Structured Clinical Examination; LEQ = Long Essay Questions.
All students had attended the same 6-month introductory program before participating in the study. One of the 10 modules in the introductory program was Basics of Communication, which was scheduled 2 months before the start of clinical practices at both school sites. As a part of this module, students of both groups (intervention and control) attended 5 hours of lectures and training on feedback and feedback rules.
SP Module for CST
On one day during the module, each student of the intervention group participated in a simulated clinical encounter (SCE) with an SP. On the day before the SCE, they received a 15-minute briefing from a faculty member about the program. The task was to conduct pain assessment with a patient with arthritis. The students had to assess (1) the location of the pain, (2) its quality, (3) its intensity, (4) whether the pain interfered with the patient’s normal everyday activities, and (5) to what extent the pain treatment had relieved the pain. Students used the template of the Swiss Cancer Society pain assessment. The day of the intervention, each student was given 15 minutes to read the case and prepare for the encounter with the SP. The one-to-one training with the SP lasted 20 minutes and was followed by oral feedback by the SP directly after the encounter. Six SPs, all women between 40 and 50 years old, took part in four to five clinical encounters with different students of the intervention group. Training for the SP role and feedback (1 hour for the role, 1 hour for the feedback) occurred according to the standards set by Wallace (2007). SPs had done one SCE previously, but the role of the pain patient was new for them.
Role-Play Module for CST
Simultaneously at the other school site, the control group took part in a traditional CST session involving peer role-playing and mutual feedback. Here, too, the students received a 15-minute briefing the day before the SCE. The task and patient case were the same as in the intervention group. On the day of the role-play, faculty trained students in role-play and feedback for 2 hours. The students were also asked to use their knowledge from the lectures and training on feedback and feedback rules, which they had attended a few weeks earlier in the module. Before the actual peer role-play, the students were also given 15 minutes to read the case and prepare their role-play and feedback.
Subsequently, groups of three students had 1 hour (20 minutes per student) to take turns playing patient, nurse, and observer. A round of mutual feedback along the lines of standardized feedback criteria followed each round of role-play.
The feedback criteria for the SPs in the intervention group and for the students in the control group were identical. These criteria included items on basics of communication skills, such as “Student has eye contact with the patient,” “Student talks in direction of patient,” “Student formulates sentences which are easy to understand,” “Student explains technical terms to the patient,” “Student invites patients to ask questions,” “Student answers the patient’s questions politely,” and “Student uses words that are easy to understand for the patient.”
Assessment of the Two Groups
A summative assessment of the CST was conducted after each module. For the CST module with SPs, a 10-station OSCE was used to assess the intervention group. During the OSCE, the students received no feedback from SPs or faculty. The control group (role-play module) took a written examination in the form of Long Essay Questions—an assessment method for complex learning situations. The questions contain phrases such as “Describe the management of a patient with postoperative pain” (Amin, Chong, & Eng, 2006). Both assessments lasted 90 minutes.
We measured self-efficacy in a posttest and a follow-up test, as suggested by (Blok et al., 2004). Blok’s Self-Efficacy Questionnaire of the European Donor Hospital Education Programme (EDHEP) was adapted by replacing the donor-related terminology by adequate phrases for nursing situations. In the posttest, all 55 participating students of both groups completed the questionnaire directly before the start of their first 6-month rotation as nursing students. The same questionnaire was used for the follow-up test, which was conducted 6 weeks into the rotation when the students returned to the school for 1 day. The follow-up test was given to explore differences between the intervention and control groups regarding an expected increase in self-efficacy. Because anonymity was required for ethical reasons, the students were instructed to choose a nickname to sign the posttest. The students were asked to use the same nickname consistently to allow for questionnaire matching.
For the clinical rotation, the nursing students were randomly assigned to different hospitals and wards in the Berne area. The clinical internship started with a 2-week introductory course with no patient contact. In the third week, students started working with patients. At this point (i.e., the third week into the rotation), various patients and supervising nurses repeatedly assessed the students’ communication skills. These supervising nurses were fully qualified and had at least 2 years of practice experience on the respective ward. Each supervising nurse was responsible to enhance the student learning experience and generally worked alongside when students worked with patients. Time and place of the assessments by the various patients and supervising nurses were not announced in advance; the students knew only that the assessments would take place during the third week. After each patient encounter, patient and observing supervising nurses completed their assessment forms. It was not disclosed to the supervising nurses and the patients whether the student belonged to the intervention group or the control group. In fact, the students had been instructed not to disclose their group identity to the supervising nurses or the patients to reduce the potential for distortion. All ratings were returned anonymously.
After completion of the 6-month introductory program, students were assigned to different clinics in different hospitals. These included acute surgery and internal medicine, as well as pediatrics and geriatrics. For students in pediatrics and geriatrics, the ethics committee did not grant approval for the evaluation by real patients. Patients in these clinics were considered too vulnerable. Due to this reason, students doing their first practice rotation in pediatrics or geriatrics were excluded from the assessment in the real clinical practice. Of the remaining 26 students (24 women and 2 men), 12 were included in the intervention group and 14 in the control group.
Self-efficacy. Self-efficacy is the belief that one is able to successfully accomplish a given task, or, according to Bandura, Cioffi, Barr Taylor, and Brouillard (1988), people’s beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives. The European Donor Hospital Education Programme Self-Efficacy Questionnaire consists of 12 statements: 6 statements concerning the students’ self-perceived knowledge about the required communication skills and 6 statements relating to the students’ degree of certainty that they were able to do what was required of them. In a previous study, the reliability of this questionnaire had been established with a Cronbach’s alpha of 0.93 for the Netherlands and 0.92 for the United Kingdom (Blok et al., 2004). In our study, the two items relating to the question of organ donation were excluded because they did not apply to our scenarios (Table 1). Because the questionnaire existed in English only, it was translated into German using the forward–backward method (Monti et al., 2008).
Table 1: Student Rating: Items of the Modified Self-Efficacy Instrument (Blok et al., 2004)
Patients’ Perspective on the Quality of Communication. The Art of Medicine Survey scale (AMS) (Webster, Swanson, & Ware, 1989) is an eight-item rating form for patients to rate the students’ communication skills (Table 2). The AMS uses a response scale ranging from not good at all (1) to very good (6). It has been used in similar studies. Brown, Boles, Mullooly, and Levinson (1999) reported a Cronbach’s alpha of 0.97 for the reliability of internal consistency for the eight-item questionnaire. This English-language questionnaire was also translated into German using the forward–backward method mentioned above.
Supervisors’ Perspective on the Quality of Communication. The supervisors evaluated students’ communication skills using the 10-item Work Samples and Situation-Related Questions to Measure Workplace-Related Competences scale (original title: Arbeitsproben und situative fragen zur messung arbeitsplatzbezogener kompetenzen), developed by Schaper (2003) (Table 3). In this scale, student performance is rated on a six-point rating scale (1 = standard not met; 6 = standard well met). For interrater reliability and internal consistency, a Cohen’s kappa of 0.86 and a Cronbach’s alpha of 0.66, respectively, have been reported for the German version.
Table 3: Supervisor Rating: Items of ‘Work Samples and Situation-Related Questions to Measure Workplace-Related Competences’ scale (Schaper, 2003)
Statistical significance tests were conducted and statistical graphs were produced using SYSTAT® version 12 software. Because the distributions of the supervisor and patient ratings were highly skewed, the nonparametric Kolmogorov–Smirnow test was used to test for differences between the intervention and control groups, with one exception: A t test was used for the mean over all 10 items of the supervisors’ ratings because it had a normal distribution. Some of the supervisors did not rate all of the items because they thought that some items of the Work Samples and Situation-Related Questions to Measure Workplace-Related Competencies scale did not apply in certain situations. In these cases, only the mean of the rated items was calculated.
The distributions of students’ self-efficacy ratings were approximately normal. Therefore, we performed an analysis of variance with control versus intervention as a between-subjects factor, and before versus after, as well as knowledge versus practical ability as within-subjects factors. To estimate the effect size of the intervention compared with the controls, Cohen’s d was computed as the difference of the two means divided by the pooled within-group standard deviation.
Ethical approval was sought from the ethics committee. Approval was granted to include students practicing in internal medicine and surgery. The hospital boards and administrators of the clinics where the student rotations in internal medicine and surgery occurred required that data collection was completely anonymous. Informed written consent was obtained from all participating students and supervising nurses. Patients were given an information leaflet. Participation in the study was completely voluntary. All participants could leave the study at any time without any repercussions. There was no financial compensation.
Students’ Perceived Self-Efficacy
No significant differences were found between control and intervention groups regarding students’ perception of self-efficacy before the practice rotation and 6 weeks into the clinical rotation (p = 0.316 for knowledge; p = 0.88 for practical ability) (Table 4). On the other hand, the analysis of variance showed a highly significant (p ≤ 0.001) increase in self-efficacy in both groups from before the practice rotation to the measurement 6 weeks into the practice rotation. Correlations between perceived knowledge about the required skills and the perceived practical ability for the required skills were high, as well before the practice rotation (r = 0.75) as 6 weeks into the practice rotation (r = 0.88). In contrast, individual students varied in the trajectory of their self-efficacy over time, resulting in low correlations for perceived knowledge (r = 0.12) and perceived practical ability (r = 0.07).
Table 4: Self-Efficacy Questionnaire of the European Donor Hospital Education Programme (EDHEP) to Measure Students’ Perception of Self-Efficacy
Ratings by Patients
A total of 107 patients completed the questionnaire, 55 for the control group and 52 for the intervention group. On average, approximately 4 patients provided a rating for each individual student. The ratings were overwhelmingly positive, with a mean of 5.60 for the control group and 5.67 for the intervention group on the six-point rating scale. The Kolmogorov-Smirnow test yielded a p value of 0.70, which means that there was no statistically significant difference between the student groups.
Ratings by Supervising Nurses
The supervising nurses returned 94 rating forms, 48 for control students and 46 for students from the intervention group. On average, 3.5 assessments were completed per student. The Kolmogorov-Smirnow test showed that compared with the control group, the item-level ratings of the students in the intervention group were significantly higher (5.21 [SD = 0.52] and 4.41 [SD = 0.82], respectively) (Table 5). The t test resulted in t = 5.71, p < 0.0001. The ratings of the control group were more spread out, whereas the ratings of the intervention group were clustered.
Table 5: Mean of Communication Skills Repeatedly Assessed by Various Supervising Nurses and Patients
The effect size of the difference between the nurse supervisor’s individual item ratings of the two groups was calculated at Cohen’s d ranging between 0.36 and 1.21. The effect sizes for the patients’ assessments and the students’ self-reported ratings were small (Cohen’s d between −0.02 and 0.46 and between −0.58 and 0.27, respectively).
The aim of our study was to test the hypothesis that a communication skills module with SPs has superior effects, compared with a module with peer role-playing. We expected that this effect would show in students’ perceived self-efficacy, as well as in patients’ perceptions and clinical supervisors’ observations of students’ communication skills.
We found no significant differences between the intervention group and the control group regarding students’ perceived self-efficacy and ratings by the patients. However, the nurse supervisor ratings were significantly higher for the intervention group. Therefore, we conclude that our hypothesis is supported only by the supervisor ratings.
Students’ self-efficacy ratings prior to clinical practice were high and did not differ between the intervention and the control groups. We conclude that students felt equally well prepared by the module with peer role-playing and by the module with SPs. This contrasts with findings reported by Barrows (1993), Dent and Harden (2005), and Kurtz et al. (2005), as well as with our own anecdotal experience that peer role-playing is often not taken seriously by students.
The low correlations between the first and second measurement within individuals is consistent with the observation of Eva and Regehr (2005) that factors such as success and failure can alter self-efficacy.
When self-efficacy was reassessed 6 weeks later, both groups showed a significant increase in self-efficacy compared with the first measurement, which suggests that both groups had similarly stimulating and positive learning experiences.
The consistently positive ratings by real patients may reflect an uncritical attitude of patients toward students. This assumption is supported by Feletti and Carney (1984), who examined patient satisfaction with medical students’ communication skills and found that patients were strongly inclined to give highly favorable ratings on report forms. However, informal conversations between patients and nurses revealed that patients were reluctant to criticize students even though they were quite capable of differentiating between ideal and nonideal bedside roles. Yudkowsky, Loy, and York (2005) also found that patients were poor discriminators in evaluating medical students, because of their feeling of dependence on the students’ goodwill during their stay in the hospital. Another reason could be altruism and empathy toward students, as suggested by Batson (1997), who reported that altruistic behavior is especially prevalent when the evaluator has empathy with the person to be evaluated.
In contrast to the ratings of self-efficacy by the students and the patient ratings, the ratings by supervisors revealed significant superiority of communication skills among students in the intervention group. The supervisors observed the interaction between students and patients from an outside perspective, as professionals. McLaughlin, Gregor, Jones, and Coderre (2006) contended that supervisors are stricter than patients and SPs in rating student performance; this fact can be explained by their training. Supervisors differ from SPs and patients in background knowledge and capability to distinguish between students with surface knowledge and those who have in-depth understanding. In addition, they have a different role and a different relationship with students than do patients in that they are responsible for the students’ professional development; this may evoke the use of higher and more specific quality standards.
Our study has several limitations. The intervention group had an OSCE, whereas the control group as administered a written examination. Hence, the intervention group had additional practice in communication, compared with the control group. This difference may have influenced the results. In addition, the intervention group was exposed to more observation than the control group due to the OSCE. Therefore, the additional observation time may also have influenced the intervention group results.
Because the students did not have prior experience as nurses, the rotation in clinical practice (i.e., the clerkship experience during the first weeks) may have influenced the students’ perception of their self-efficacy. The amount of this influence cannot be determined in this study. Further exploration of the potential confounding effect of the transition from theoretical and skills laboratory training into practice needs to be explored.
Furthermore, our samples were small and, despite randomization, preexisting differences between the two groups cannot be ruled out given that we conducted no pretest. In addition, the study was conducted in one nursing school with two sites.
To obtain evaluations of student communication skills in real practice, three different instruments, one for each participant group (patients, students, and nurse supervisors), were used. There may be inherent differences in the topics measured by each instrument. Hence, comparison of the findings is limited and needs to be further explored in terms of triangulation of instruments. The different methods used for each participant group may have skewed the actual training effect.
Two of the instruments used in this study to evaluate students’ communication skills in real practice needed to be translated from English into German. In addition, two items relating to the question of organ donation were excluded because they did not apply to our scenarios. All of these changes may have influenced the reliability of the instrument. Further exploration of the difference between CST involving standardized patients as opposed to peer role-play needs to be conducted.
Our study is one of the few to investigate the influence of SPs in a CST, in combination with OSCE in training, and assessment of communication skills modules in the clinical practice of nursing education. Despite the limitations of our study, the results suggest that training and assessment with SPs in CST modules involving OSCEs leads to greater improvement of communication skills when assessed by professional supervisors. This finding is an important argument to justify investments (financial and in terms of human resources) in communication training modules with SPs. The results also indicate that the instruments we used may be problematic for patient and student assessments of the effect of CST.
To verify our conclusions, studies with larger samples must be conducted. Such studies should use the same assessment formats for all groups to prevent an influence of the format on the results. We recommend that the effects of communication skills modules be assessed in the clinical setting by supervisors, rather than by students or patients. The potential superiority of communication training with SPs could be confirmed in a study using incognito SPs to assess students’ communication skills, a method described by Gorter et al. (2002), who suggested that the incognito SP method should be applied in studies aimed at obtaining specific information on students’ clinical performance.
The results of our study provide evidence that in communication training, using SPs is superior to peer role-playing. In addition, in contrast to clinical supervisors, patients do not seem to discriminate students’ communication skills adequately, and the measurement of students’ perceived self-efficacy does not contribute to the detection of differences between the two methods of CST.
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Student Rating: Items of the Modified Self-Efficacy Instrument (Blok et al., 2004)
|1a||I know how to explain to the patient, clearly and comprehensibly, the nursing interventions I will perform.|
|1b||I can explain to the patient, clearly and comprehensibly, the nursing interventions I will perform.|
|2a||I know how to deal with the patient’s reactions to my informing him of the nursing intervention I will perform.|
|2b||I can deal with a patient’s reactions to my informing him of the nursing intervention I will perform.|
|3a||I know how to ask the patient for permission to perform a nursing intervention.|
|3b||I can ask the patient for permission to perform a nursing intervention.|
|4a||I know how to explain the nursing intervention to the patient in a clear and comprehensible way.|
|4b||I can explain the nursing intervention in a clear and comprehensible way.|
|5a||I know how to deal with a patient’s reaction to unpleasant information (e.g., “it will hurt”).|
|5b||I can deal with a patient’s reaction to unpleasant information (e.g., “it will hurt”).|
Patient Rating: Items of the Art of Medicine Survey (Brown et al., 1999)
|1||How courteous and respectful was the nurse student?|
|2||How well did the nurse student understand your problem?|
|3||How well did the nurse student explain to you what she or he was doing and why?|
|4||Did the nurse student use words that were easy for you to understand?|
|5||How well did the nurse student listen to your concerns and questions?|
|6||Did the nurse student spend enough time with you?|
|7||How much confidence do you have in the nurse student’s ability or competence?|
|8||Overall how satisfied are you with the service you received from the nurse student?|
Supervisor Rating: Items of ‘Work Samples and Situation-Related Questions to Measure Workplace-Related Competences’ scale (Schaper, 2003)
|1||Student has eye contact to the patient|
|2||Student talks in direction of the patient|
|3||At the beginning of the dialogue, the student explains to the patient what she is doing and why|
|4||Student formulates sentences which are easy to understand|
|5||Student explains technical terms to the patient|
|6||Student invites patient to ask questions|
|7||Student explains to the patient that the action could be painful|
|8||Student politely answers the patient’s question|
|9||Student uses words that are easy to understand for the patient|
|10||Student executes the action correctly|
Self-Efficacy Questionnaire of the European Donor Hospital Education Programme (EDHEP) to Measure Students’ Perception of Self-Efficacy
|Students||Mean Knowledge Just Before Clinical Rotation||Mean Knowledge 6 Weeks into Clinical Rotation||pValue|
|Control (n = 29)||37.3||43.3||0.316|
|Intervention (n = 26)||39.9||42.4|
|Students||Mean Practical Ability Just Before Clinical Rotation||Mean Practical Ability 6 Weeks into Clinical Rotation||pValue|
|Control (n = 29)||35.1||42.1||0.88|
|Intervention (n = 26)||35.8||41.1|
Mean of Communication Skills Repeatedly Assessed by Various Supervising Nurses and Patients
|48 questionnaires||Control||4.41||< 0.0001|