An Innovative Strategy for Enhancing Advanced Practice Nursing Students' Interview Skills
Challenges exist in ensuring that novice advanced practice nursing (APN) students successfully transition to the provider role. Preceptors have expressed concern for beginning students' preparedness to assume the APN role as it pertains to interacting and gathering patient information. Faculty desire to provide student opportunities for the development of critical thinking and communication skills within the distance learning environment. Simulated clinical experiences offer opportunities for APN students to learn in a nonthreatening environment and allow faculty to examine students' baseline levels of proficiency and promote successful role advancement (Keifenheim et al., 2015).
Faculty and students often use Benner's (1984) novice-to-expert model to examine role transition. Although APN students may have felt they were at the expert level in their previous nursing role, self-assessment of history-taking skill upon transitioning to the APN role is commonly noted as novice. Beginning students' comments related to their perception of personal interview skills were consistent with Barnes (2014), in that concerns of inadequacy were voiced when considering future transition from team care provider to independent prescriber of care.
An evolving case study was designed to transition students from a live encounter with a standardized patient (SP) to an online encounter with a virtual patient. The goal of the simulated clinical activity was to provide a supportive environment for students to refine their professional communication skills. The objectives of the experience were for students to be able to (a) interact professionally with an SP to obtain an appropriate health history; (b) identify the differences between history-taking responsibilities of the nurse versus the advanced practice nurse; (c) recognize personal strengths and weaknesses in communication; and (d) transition communication skills to future virtual and precepted patient encounters.
The format was discussed with students prior to the interactive simulation. Students were aware the SP encounter would be recorded for their later review and that faculty would be observing the real-time interaction. All students consented after being informed of their right to decline being recorded. Students were then divided into small groups of up to six members. Each student reported to one of six examination rooms to interact with an SP who had rehearsed a scripted dialogue. Six interactions were completed concurrently and faculty observed the interactions via a closed circuit monitor in a nearby viewing room.
The SP was scripted as a Hispanic woman, 41 years old, who presented for an annual well-woman evaluation. Pertinent components (e.g., a strong family history of breast cancer and heart disease) were included. Each student received a standard health history template and were allowed 15 minutes to gather a routine health history. At the end of the interview, the SP evaluated the student's interview technique using an abbreviated version of the master interview rating scale ([MIRS], Eastern Virginia Medical School, 2009), a widely accepted Likert scale measure of trainees' communication skills useful in any patient interview scenario (Chandawarkar et al., 2011; Wagner, Pfeiffer, & Harrington, 2011). An abbreviated version of the MIRS was used to evaluate students' initiation of the interview, acceptable use of nonverbal communication, and avoidance of medical jargon—common concepts evaluated in graduate medical education.
Although a formal debriefing tool was not used, faculty debriefed students using open discussion to provide constructive feedback to enhance learning. Students were reassured the assignment was designed to promote growth in interviewing skills and would not have an impact on course grades. Without being singled out for their performance, missed components of the health history were reviewed by faculty. The relationship of the SP's family history to health promotion counseling was examined. Students were encouraged to self-critique during the debriefing. Positive feedback was provided as appropriate, and faculty suggested activities to strengthen the students' interviewing skills (e.g., role-playing with family and friends).
Students were given the opportunity to verbalize their impression of the simulated interview experience during the debriefing. Examples of students' responses included:
- I found it difficult initiating the conversation as the provider rather than the nurse.
- I felt lost since I was having to remember which questions to ask.
- I didn't feel qualified to be the provider.
- I felt I was missing something.
- I wasn't used to having to gather the information to make a diagnosis.
Although students commented on feelings of inadequacy, they verbalized learning from the experience, discussed making mental notes to improve future history-taking, and identified strengths and weaknesses of their personal interviewing skills. All students commented positively on the nonthreatening learning opportunity.
Following the on-campus activity, students were provided a link to the MIRS evaluation completed by the SP and the student's individual video. Students completed self-assessments and submitted to the online course. Next, students were transitioned within the online course to a virtual case study using an avatar with the same health history as the SP previously interviewed. The virtual case provided an opportunity for students to further refine their interviewing skills. The avatar was used throughout the semester to expand the interview encounter to include completion of a comprehensive physical assessment, development of a differential diagnosis list, and creation of a patient teaching plan.
This activity was unique in that it used two distinct environments for learning—transition from a scripted, live SP interaction to a virtual scenario—enabling students' to function as competent providers in precepted clinical settings. The activity reflects the use of Mezirow's (1991) transformative learning theory, which supports task-oriented problem solving and experience interpretation using reflection (Cranton, 2013).
Although the lack of a formal debriefing tool may be a potential limitation of this activity, future projects will incorporate a tool based on Kolb's theory of experiential learning (1984), validating improved student performance (Garden, Le Fevre, Waddington, & Weller, 2015). Ongoing APN skill enhancement through virtual opportunities remains a faculty focus, and additional case studies are currently in development. Lessons learned through this integrated, active, multi-platform exercise should be applicable to others.