Collaboration in education is essential in developing strong communication skills, knowledge sharing, facilitation of critical thinking, and self-confidence. Collaboration educational activities assist in the management of students in a team-building environment and aid in developing knowledge related to other professional roles, how to decrease professional barriers, and demonstrating open communication for improved patient outcomes (Mulvale, Embrett, & Razavi, 2016). A collaboration activity in education provides the foundations for promoting interprofessional collaboration. Peer collaboration paired with interprofessionalism has been linked to increases in patient safety, provider communication, and patient-centered care (Sullivan, Kiovsky, Mason, Hill, & Dukes, 2015). New graduates today will find themselves in a fast-paced and complex clinical setting that has a high demand for a competent and compassionate health care team that is focused on patient safety (Kavanagh & Szweda, 2017). It is essential that undergraduate nursing students participate in collaborative educational activities to prepare them for real-life work experiences.
The role of the nurse educator is not only to prepare the undergraduate to pass the NCLEX®, but to be able to make a smooth transition into practice. A study of new graduate nurses demonstrated that there was a major gap between passing the NCLEX and information on how to practice competently and safely (Kavanagh & Szweda, 2017). In today's health care reform climate, it is pivotal that nurse educators provide collaboration activities in student learning to foster the necessary communication and interpersonal skills to practice in all clinical settings (Alexander, Canclini, & Krauser, 2014). Nurse educators need to use creative ways to promote student learning in the cognitive, affective, and psychomotor domains, as well as help students to understand the needed skills to fulfill their future roles. The National League for Nursing's (2019) core competencies of nurse educators include competencies that facilitate learning, as well as facilitate learning development and socialization of the student. Nurse educators must help students develop cognitive and affective skills that will be necessary for future practice. One effective way to promote collaborative education is the use of undergraduate students as standardized patients (SPs). The purpose of this article is to describe an efficient way to use undergraduate nursing students as SPs while enhancing the learning of undergraduate nursing students. This educational innovation used undergraduate baccalaureate nursing students to perform as SPs for advanced practice nursing (APN) students in an advanced health assessment class.
Standardized Patient Overview
SPs are people who have been trained to portray a patient with a specific medical problem as described by a scenario (Smithson, Bellingan, Glass, & Mills, 2015). Standardized patients can be used to provide the learner with a real-life scenario that is in a safe practice environment, while assisting in learning by providing instant feedback to the learners on their performance. SPs can be community volunteers (usually paid), faculty, other teaching or administrative staff, or student peers (Smithson et al., 2015). A meta-analysis of standardized patients demonstrated that simulation using SPs had beneficial effects on the cognitive, affective, and psychomotor domains of learning (Oh, Jeon, & Koh, 2015). In general, SPs have a beneficial effect on self-efficacy, skill, and knowledge acquisition (Oh et al., 2015). SPs are an effective way to provide students with real-life scenarios in a stress-free environment that has been used in both medical and nursing education. SPs also allow faculty to create specific health problem scenarios to meet specific objectives or goals necessary for learning. However, the cost of using SPs may be prohibitive in many nursing programs. SPs from the community are usually paid $15 to $35 per hour and require from 4 to 10 hours of training per scenario (Glassdoor, 2019).
To defray the cost of SPs, peer role-playing activities have been shown to have comparable outcomes without decreasing the training session's effectiveness (Bosse, Nickel, Huwendiek, Schultz, & Nickendei, 2015). Peer role-playing can also provide insight into a patient's perspective and can help undergraduate nursing students foster an empathic approach to patients, which meets the criteria of affective domain learning (Bosse et al., 2015). There is little information available regarding the use of students as SPs or if the students find the experiences useful or beneficial.
Undergraduate and graduate faculty discussed possibilities for using undergraduate students to play SPs for APN students to foster collaboration. Faculty identified that using senior undergraduate nursing students as SPs in an advanced health assessment course for graduate nurse practitioner students would be the best avenue to assess the use and collaboration of the two groups. Faculty created a list of common primary care illness or diseases that may present to APNs in a primary care setting. The list of illnesses and diseases were agreed on as content that the undergraduate student could easily investigate and role-play. Undergraduate students were asked whether they would like to volunteer outside of class for a learning activity with graduate students. The undergraduate nursing students were then assigned an illness or disease from the list. The undergraduate students had a one-page assignment to research their chosen illness or disease, review the signs and symptoms, presentation, and the pathophysiology of the illness or disease. The written assignment was then reviewed for accuracy by faculty. The undergraduate nursing students were advised and coached to describe the symptoms and answer questions asked by the APN student related to their illness. Undergraduate students could use their own age and personal history if applicable to the illness or disease. Illnesses or diseases that required further prompts or extra information were provided to the ANP students on an index card. For example, a student who had strep throat as a diagnosis had an index card that stated the patient's throat was erythemic with plaques in the pharynx. Undergraduate students were then placed in a university laboratory bed or examination area or placed at a table with chairs. Students were separated enough to provide privacy and to promote a quiet environment for interviewing. Each undergraduate student had a station number assigned to them. The undergraduate nursing students were then interviewed by APN students. The APN students were instructed to interview their SPs and attempt to identify the illness or disease, as well as identify potential differential diagnosis. The APN students were given 15 minutes to interview the undergraduate students. The students were then rotated to another station to repeat the process. Faculty (including adjunct faculty) were available to answer questions and assist with any issues, as well as maintaining the flow of student movement to each station. Undergraduate nursing students were given extra credit for participation.
At the end of the learning session a combined group debriefing was conducted to identify issues or concerns with the process, as well as have open communication to elicit feedback from peers and faculty regarding learning and the learning process. Undergraduate students were then asked to complete a one- to two-page reflection about the learning experience. Guidelines for the reflection included:
- Evaluation of the learning experience.
- Providing positives and negatives about the experience and any other reflective feedback.
The APN students were also given the opportunity to answer survey questions regarding their learning experience, which included open-ended questions. All data were submitted in written form and given to the instructors.
It was identified after the first collaboration that students had a positive reaction to the learning experience. The collaborative event was then repeated using junior students as SPs, followed by using sophomore students as SPs.
Using an inductive approach, undergraduate reflections of the senior and junior students were reviewed and analyzed and then verified by a second reader. Analysis identified five general themes. The themes identified were: A Positive Learning Method, “Aha” Moments, Improvement in Critical Thinking and Communication, Suggestions to Improve the Assignment, and A Future in Nursing.
Theme One: A Positive Learning Method. It was identified that the learning experience was positive, and that students thoroughly enjoyed the experience. Comments included:
- A great learning experience, I think that this was a great way to help both classes.
- As an undergraduate student, this experience was educational and inspirational.
- The activity was an awesome review for a wide variety of disease processes, plus it was fun to act out the symptoms.
- This project was an opportunity for me to improve my research and my communication and for the APN student to do interview skills; it is a learning opportunity for both students.
The undergraduate nursing students were able to learn more about a specific disease in a positive nontraditional format. These responses demonstrated that using undergraduate nursing students as SPs not only assisted APNs to develop interview skills but also promoted a positive learning experience using a collaborative educational activity.
Theme Two: Aha Moments. Aha moments were significant when the student understood the process and the importance of the learning process. Undergraduate aha moments were evident with comments such as:
- It was interesting to learn about how the medical interview is performed and the usefulness of a focused nursing assessment
- It was interesting to see the thinking process of the APN students and how they started with questions that were broad in their assessment, to questions that were more specific.
- Observing their individual differences was educational…. They each had a unique personal style for assessing and diagnosing their patients.
- Some focused on efficiency…others were more interested in getting to know me briefly…. It provided the opportunity to see different styles of nursing practice and observe benefits of each.
- This taught me to focus on the area of chief complaint but also not disregard more generalized questions.
These comments indicate that undergraduate nursing students were able to assimilate critical thinking and clinical reasoning patterns that were used by the APN students when assessing the key components in a patient's history to arrive at a clinical diagnosis.
Theme Three: Improvement in Critical Thinking. Students self-identified that their critical thinking and communication skills improved in the reflective survey responses. Undergraduate students' reflections demonstrated the importance of debriefing and reflective learning:
- Going through all of the diagnoses…better prepared me as a future nurse.
- It helped me think about all the skills you need to apply… including mental health interviewing skills.
Undergraduate students had a better understanding of the need to reflect on their learning and practice. The undergraduate students also commented on the critical thinking of the APN student in that this allowed them (APRN students) to use more critical thinking and ask questions:
I believe this to be a valuable tool in the future because it allows for practice in patient communication, as well as competency in diagnosing diseases rather than the use of tests alone.
Theme Four: Improvement of the Learning Experience. Students were also willing to provide feedback to improve this educational innovation. Feedback comments included:
- For future years I think it would be more fun, interesting, and a better learning experience if there was more interaction— we could include a physical assessment as an added dimension.
- I think undergraduates should make up laboratory values and basically a patient chart for their diagnosis.
- I think it would be cool to have senior nursing students do assessments with the younger nursing students (sophomores and juniors)—I believe it would bring us all closer together and help all levels of nursing.
- I know it was “make believe.…” They should have asked the basic questions to help get a more rounded picture of the patient. Some of the APN students assumed that the common person would know certain medical diagnosis, it is important that we use simpler language and explain everything to the patient to prevent miscommunication.
This demonstrated that the undergraduate nursing students understood the need to communicate with patients in plain language.
Theme Five: A Future in Nursing. The undergraduate students were able to see the role of the APN, which provided insight into potential lifelong learning:
- It is nice to see the options we will have in the future.
- It was interesting to see what the students [APN] were actually learning and that although being able to diagnose a disease process is important, it is also important to have differential diagnoses to rule out any other possible causes.
- The graduate students are able to share their experiences with nursing students and acted as role models for furthering education after completing an undergraduate program.
- It showed us nursing students the higher level education of nursing and taking your nursing skills and knowledge to a different level.
- It really demonstrated…how focused the profession of nursing is on continuous learning.
Many of the undergraduate students reflected on the possibility of returning to school to obtain a master's degree after completing their undergraduate education:
I enjoyed learning about [future] opportunities and the APN aspirations and goals.
The collaboration between the APN students and undergraduate students enhanced the undergraduate students' levels of knowledge—the required research process for the presentation of the illness or disease was also beneficial to undergraduate learning. The need for a specific knowledge base regarding a disease process and the presentation of symptoms aided the undergraduates in discerning the importance of observation and listening to patients displaying such symptoms. Undergraduate nursing students also increased their knowledge of the signs and symptoms of a disease process and the pathophysiology as a result of their research. Finally, undergraduate nursing students felt better prepared to assess and care for patients with these specific presenting illnesses and identified the importance of patient interviewing and communication. Undergraduate nursing students were excited to be part of advance practice learning and displayed increased interest in the advance practice role. Undergraduate students also felt better about collaboration with students who are at a different level or role other than their own peers.
The only limitation identified was the use of the sophomore students as SPs. These students lacked the basic foundations to adequately portray a patient with illness or diseases with which they were unfamiliar. A recommendation for this would be using sophomores as SPs with simple diseases or illnesses that a student may have had in real life, where they would draw on personal knowledge to role-play as an SP (using diagnosis such as upper respiratory infection or gastritis).
Today's nurse educators need to facilitate learning, communication, and critical thinking with the use of teaching strategies that are engaging for students (National League for Nursing, 2019). This action-based learning strategy with the use of undergraduate nursing students as SPs helped create real-life scenarios for the undergraduate nursing and graduate APN students. It also strengthened the undergraduate nursing students' knowledge of disease processes, fostered research, and developed role-playing skills. Finally, this educational intervention demonstrated that undergraduate nursing students were not only excited to be a part of the APN's learning but displayed an increased interest in the advance practice role, which lends itself to fulfilling the Institute of Medicine's (2010) The Future of Nursing Report, which called for nurses to practice to the full extent of their education and achieve higher levels of education through training. As this intervention demonstrated that schools of nursing can use undergraduate nursing students as SPs, recommendations for nurse educators include the use of this educational activity for students to practice and demonstrate the cognitive and affective skills necessary for collaborative activities.
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