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American Journal of Critical Care. 2008;17: 364-372
Copyright © 2008 by the American Association of Critical-Care Nurses.
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Patient Communication Simulation Laboratory for Students in an Acute Care Nurse Practitioner Program

By Margaret Rosenzweig, PhD, APN-BC, AOCNP, Marilyn Hravnak, PhD, APN-BC, Kathy Magdic, MSN, APN-BC, Michael Beach, MSN, APN-BC, Maurice Clifton, MD, MSEd and Robert Arnold, MD. Margaret Rosenzweig is an assistant professor, Marilyn Hravnak is an associate professor, Kathy Magdic is an instructor and the director, and Michael Beach is an instructor in the Acute Care Nurse Practitioner Program, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania. Maurice Clifton is associate dean for admissions and student affairs with the Mercer University School of Medicine in Macon, Georgia. Robert Arnold is the Leo H. Criep Chair in Patient Care, a professor of medicine, and chief, Section of Palliative Care and Medical Ethics, at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Corresponding author: Margaret Rosenzweig, PhD, APN-BC, AOCNP, University of Pittsburgh School of Nursing, Rm 329-A, Victoria Bldg, Pittsburgh, PA 15261 (e-mail: mros{at}pitt.edu).


   Abstract
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 Abstract
Purpose
 Methods
 Results
 Discussion
 References
 
Background Effective communication skills for clinical practice are essential for all advanced practice nurses. However, competence in these skills is not necessarily intuitive. Advanced communication skills should be taught in a way that is similar to the way other psychomotor skills in advanced nursing practice programs are taught.

Objectives To develop a patient communication simulation laboratory for the acute care nurse practitioner program at a major university and to evaluate students’ perceived confidence and communication effectiveness before and immediately as well as 4 months after completion of the laboratory.

Methods The communication simulation laboratory was developed in collaboration with faculty from the schools of nursing and medicine. Students participated in a didactic session and then completed a 2-hour communication simulation in the laboratory. Content and simulation concentrated on breaking "bad news," empathetic communication, motivational interviewing, and the "angry" patient. Students’ self-reported confidence and perceived skill in communication were measured via a Likert scale before, immediately after, and 4 months after completion of the laboratory simulation. Students also evaluated the experience by responding to open-ended questions.

Results Compared with baseline findings (before the lecture and simulation), students’ confidence in initiating difficult conversations increased significantly both immediately (P<.001) and 4 months after (P=.001) the laboratory simulation. Students’ self-ratings of overall ability to communicate were also significantly greater immediately (P<.001) and 4 months (P=.001) after the simulation. Overall, students rated the laboratory simulation experience highly beneficial.

Conclusions The content and methods used for the simulation improved students’ confidence and perceived skill in communication in potentially difficult acute care situations.

Communication skills are necessary for all areas of advanced practice nursing. These skills are poorly addressed in undergraduate and graduate nursing education in general.1,2 Nurse practitioners report that components of interaction with patients such as openness, connection, and concern are essential to fostering interpersonal relationships from which personal and professional growth evolve.3 These skills are not well addressed in the education of these practitioners. Evidence has shown that training for any learned skill is best achieved by using a mix of presentation of didactic content, students’ application of the skill, and evaluative feedback.4

Although simulation technology is increasingly popular for teaching procedural skills and situational critical thinking for acute care nurse practitioners (ACNPs),5 the use of real-time communication simulation in ACNP education has not been reported. In this article, we describe the development, implementation, and evaluation of a patient communication simulation laboratory (Patient CommSimLab) for the ACNP program at the University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania.

The importance of communication skills in advanced practice nursing education is recognized within several documents that influence educational and practice competencies: The Essentials of Master’s Education (American Association of Colleges of Nursing),6 Domains and Core Competencies of Nurse Practitioner Practice (National Organization of Nurse Practitioner Faculties),7 Acute Care Nurse Practitioner Competencies (National Organization of Nurse Practitioner Faculties),8 and the Scope and Standards of Practice for the Acute Care Nurse Practitioner (American Association of Critical-Care Nurses).9 As ACNP education and practice move to programs for doctorates in nursing practice,10,11 advanced communication skills will become even more important.

Advanced practice nurses have corroborated the need for communication skills. Kleinpell and Goolsby12 conducted a 5-year longitudinal study in which ACNPs were asked to rank their most frequent daily activities as the nurses progressed from the first year of practice after certification through the fifth year after certification. Discussing care issues with patients and patients’ families was one of the top 5 daily activities.

Although communication skills have a cognitive component, communication skills for health care providers should be taught by using an experiential and not just a didactic method. Education on communication should not be provided as a 1-time lecture; rather it should be "woven" throughout the curriculum13 to allow not just an attitudinal change but also ongoing education and feedback through practical, clinical experience.14–16 A 2004 Cochrane review17 indicated that health care professionals working with cancer patients and their families showed some improved outcomes in communication skills.


Competency in communication is required in advanced practice nursing.

 

Standardized patients (SPs) are professionals trained to portray patients with various medical conditions. SPs have been used in medical school education for decades and are now being used in other areas of clinical education as well. The reliability and validity of using SPs in the evaluation of students’ clinical skills are well established.18–21 Advantages of SPs include the ability to expose each learner to equivalent situations in a time-effective classroom setting and provision of a venue for active learning in a safe environment for both patients and learners. In addition, SPs are trained to evaluate the effectiveness of learners’ communication skills and to deliver high-quality feedback directly to the learners.20–22 SPs also provide a realistic patient encounter with instant student feedback. Students have reported decreased anxiety and increased confidence when they practiced skills with SPs rather than with fellow students.20


   Purpose
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 Abstract
 Purpose
Methods
 Results
 Discussion
 References
 
In 2004, the faculty of the ACNP program reevaluated the educational content of the program that focused on communication skills. The evaluation revealed a need for a change in instruction in these skills. The desired format for the new program was a module for didactics on the necessary communication skills of an advanced practice nurse and then application of those skills in a simulation laboratory. The hypothesis guiding the workshop development was that the instructional content and the skills workshop would increase ACNP students’ comfort level and perceived ability in initiating difficult communications.


Discussing care issues with patients and their families is 1 of the 5 most common activities for acute care nurse practitioners.

 


   Methods
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 Methods
Results
 Discussion
 References
 
The local institutional review board determined that no signed consent was required from participants in the study.

Development of the Patient CommSimLab
The concept for the Patient CommSimLab was formulated over several months. First, faculty reviewed the literature and held discussions about essential communication content. A previous communication workshop for oncology students23 was used as an initial template. The common themes of empathetic communication, "breaking bad news," communicating with "angry" patients, and motivational interviewing were considered essential communication skills for nurse practitioners in the acute care setting. The faculty then met with curricular experts from the medical school who had experience in this educational method to develop common acute care scenarios. The medical school uses problem-based learning with SPs throughout its curriculum. The collaboration with the medical school continued throughout the development, implementation, and evaluation of the workshop.


Standardized patients evaluate the effectiveness of communication skills and deliver high-quality feedback to learners.

 

The Patient CommSimLab was held within the context of a course positioned midway through the curriculum plan. With this timing, students have already had 2 courses with clinical practicums before they take the course with the Patient CommSimLab and have 2 courses with clinical practicums to follow the simulation laboratory. Thus, they can bring some of their initial experiences in patient communications in their role as providers to the laboratory with them, yet have clinical practicums ahead in which they can apply and improve learned skills. Simulation education is used throughout the ACNP program at the University of Pittsburgh, so students are familiar with this educational method.

The Patient CommSimLab itself was preceded by a short didactic module presented by an ACNP faculty member. Specific content for the 4 communication target areas—breaking bad news, empathetic communication, motivational interviewing, and communicating with angry patients—were presented and discussed. All students were provided a folder of pertinent published articles detailing the exact skills presented in the lecture. PowerPoint slide handouts were available on the Web support platform Blackboard (Blackboard, Inc, Washington, DC) used for the ACNP program.

Preparation of the Patient CommSimLab included the design of patient scenarios illustrating the communication content that faculty wanted to address, the presentation of communication content in a didactic manner, the development of "take home materials," and the implementation of the simulation workshop.

SPs were trained to play the roles of patients in 4 communication scenarios, 1 scenario for each of the target areas (Table 1Go). The SPs were given detailed written descriptions of the clinical aspects of each case and instructions on how to portray the patient. Each case included content outlining the current signs and symptoms, medical history, social and family history, and the impact of the disease on the patient.


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  		Table 1 The scenarios

 
SPs were recruited from a well-experienced pool of professional actors who supplemented stage acting by posing as patients in clinical simulations. The actors reviewed and implemented the case studies according to common protocols for case portrayal, assessment, and feedback. The coordinator from the acting company provided the cases to the SPs approximately 2 weeks before the workshop. The coordinator was in touch with lead faculty for any needed clarification. The actors, coordinators, and lead faculty also met 30 to 45 minutes before the beginning of the workshop to discuss logistics, space, and additional case details that required clarification.

For each scenario, specific communication skills appropriate for the case were determined from the literature. These skills were then developed into a 4- to 6-item case-specific checklist the SPs used to provide both verbal and written feedback to the ACNP students and faculty. Each item was phrased for either a positive or a negative evaluation point and enabled the SPs to provide scripted feedback specifically designed for each case. For example, in the case involving breaking bad news (Table 2Go), the positive checklist items were prefaced with "What went well about the interview was . . ." and included items such as "You set the stage through positioning and eye contact" and "You established what I knew about the illness." The negative items were prefaced with "What would have improved the interview was if you. . . ." The items were the same as the positive items except that they were worded "If you. . . ." All the evaluative items had been stressed in the didactic lectures.


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  		Table 2 Feedback from standardized patients: example of evaluation of a student’s skills in the scenario on breaking bad news

 
Implementation of the Patient CommSimLab
The Patient CommSimLab was symbolically given during class days with other skills laboratories, emphasizing the proficiency component of communication skills. The students were divided into groups of 4 to 5 students. The simulation was scheduled for approximately 2 hours per session, to be repeated 4 times (twice in the morning and twice in the afternoon). Students not in the Patient CommSimLab were in other laboratories (eg, ShockSimLab) or had a free period. The simulation workshop was conducted in a space within the School of Nursing generally used for ambulatory patient visits for clinical nursing research. The space was ideal for the workshop because of the contiguous layout of 4 small examination rooms and the availability of a large adjacent conference room. Each SP was stationed within 1 of the examination rooms.

The Patient CommSimLab began with all students in the large conference room, allowing them the opportunity to discuss their nervousness and feelings of vulnerability in practicing their communication skills in this setting. The students were assured that their communications with the SPs were confidential and would not be viewed by other students or faculty. The students were given their schedules for the 4 scenarios and a brief overview of each case. Only one ACNP faculty member was present for coordination. Minimal faculty presence was purposeful to reduce performance anxiety.


For each scenario, communication skills appropriate for the case were identified.

 

Each student had approximately 12 minutes for each encounter; after that, the SP quickly scored the checklist and provided 2 minutes of scripted feedback. The SP feedback started with the checklist items (communication skills) that were successfully demonstrated and then provided gentle constructive feedback by using the specific items that were not demonstrated. After completion of the Patient CommSimLab, another session was held with an ACNP faculty member to provide students an opportunity for debriefing and self-reflection. The Patient CommSimLab evaluations were conducted at that time.

Sampling
ACNP students enrolled in a didactic course with a laboratory component were approached as potential participants in the study. The course in which the Patient CommSimLab is offered is in the second year of an ACNP program. Although participation in the Patient CommSimLab was mandatory, participation in the evaluations was voluntary and anonymous.

Data Collection
All students enrolled in the Patient CommSimLab were asked to participate in 3 evaluations of their perceived confidence and skill in difficult communication: before participation in the Patient CommSimLab, immediately after participation, and 4 months later. All evaluations were anonymously returned to a designated area. In the 4-month interval between the Patient CommSimLab and the last evaluation, the students participated in a 4-week (160-hour) acute care clinical practicum.

Instruments
The evaluation questionnaire consisted of 10 questions. Among the questions, 6 were scored on a Likert scale (1–7) and 4 were open ended, requesting the student’s opinion of the strengths and weaknesses of the teaching method and overall content communication. The Likert-scale questions were used to evaluate students’ perceptions of the students’ confidence and ability to communicate with patients. Students also were asked about their satisfaction with the scenarios, the SPs, and the didactic lectures as effective teaching tools.

The 2 principal questions used to evaluate the effectiveness of the communication workshop were (1) How comfortable do you feel in initiating potentially difficult communication topics to acute care patients? and (2) How would you rate your overall ability to communicate in difficult clinical situations? A score of 1 on the Likert scale indicated poor comfort or confidence in ability; a score of 7 indicated excellent comfort or confidence in ability. Likert-scale evaluation tools have established reliability and validity,36,37 but scales with these specific anchors have not been psycho-metrically tested. The instruments were developed on the basis of a literature review of traditional communication barriers among nurses.38

Data Analysis
Descriptive statistics were used to analyze means for group results on all 3 evaluations. Data were normally distributed. Data were analyzed by using nonparametric analysis (descriptive and nonparametric unrelated 2-sample test) because of the ordinal nature of the Likert scales measurement.


   Results
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 Methods
 Results
Discussion
 References
 
Combining the number of students in the 2005 and 2006 classes who participated in the Patient CommSimLab yielded a potential sample of 38 students: 17 in 2005 and 21 in 2006. Specific demographic data were not requested because we thought that securing demographic data would jeopardize the anonymity of the respondents. Table 3Go provides the mean scores for responses.


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  		Table 3 Scores on students’ self-perceived evaluations of confidence and ability before and after the patient communication simulation

 
Compared with findings before participation in the Patient CommSimLab, students’ confidence in initiating difficult conversations improved significantly immediately (P < .001) and 4 months (P = .001) after the simulation. Students’ self-ratings of overall ability to communicate were also significantly greater immediately (P < .001) and 4 months (P = .001) after the simulation. Students rated the components (lecture, cases, and SPs) of the Patient CommSimLab favorably; the SPs received the most favorable evaluations (Table 4Go). Among the students who chose a favorite scenario, the angry patient scenario was rated the best because of the SP’s "believability."


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  		Table 4 Components of the communication curriculum

 
Table 5Go presents the content analysis of the open-ended evaluative questions. Content analysis was completed by quantifying the words and phrases mentioned most often. These words and phrases were considered the most indicative of issues of utmost importance to respondents.39


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  		Table 5 Content analysis of open-ended evaluative questions about the patient communication simulation curriculum

 
The most commonly occurring comments were related to overall enthusiasm for the teaching method; specifically, that the SPs and the case studies were realistic. Respondents made positive comments about the private feedback from the SPs as a method of evaluation and commented on the timing of the individual scenarios. Specifically, in the 2005 workshop, students noted that some of the scenarios seemed "long," and some students noted that the motivational interviewing scenario required more time than the other scenarios required. Most of the students thought that the scenarios were timed appropriately. No major changes on the workshop were made on the basis of these comments. Similar comments were not made by students who participated in the workshop in 2006.

The SPs provided feedback to the students and the faculty. The SPs’ evaluations of the students were confidential and were not shared with the faculty. Students rated this confidentiality as a highly favorable aspect of the educational experience. The SPs also participated in debriefing at the end of the day, providing faculty members with feedback on students’ preparedness, abilities, willingness to engage in the exercise, and any suggested refinement to the patient scenarios. The suggestions of the SPs to the faculty in the first year were related to students’ preparedness and professionalism. This feedback was integrated into the preparatory, didactic lecture for the second year. Students were encouraged to conduct themselves in a professional manner while role-playing and to carefully prepare for the scenarios. The medical history or social histories of the case studies also were slightly amended on the basis of what the SPs thought would be more realistic scenarios. In all cases, the SPs’ suggestions were implemented into the workshop for the second year (ie, 2006).


After the simulation, students had increased confidence in initiating difficult conversations with patients.

 


   Discussion
Top
 Abstract
 Purpose
 Methods
 Results
 Discussion
References
 
The evaluations of the communication workshop corroborated the hypothesis that a communication workshop would increase ACNP students’ confidence and perceived efficacy in difficult communications. Communication skills can be successfully implemented in the ACNP curriculum with proper foresight and planning based on clear, realistic goals. This workshop was designed in response to an educational need to teach specific ACNP communication skills, particularly for difficult situations. The students had a high level of self-reported communication competence before the workshop but still were able to perceive improvement in confidence and ability immediately and 4 months after participation in the Patient CommSimLab. These skills will need to be assessed over time, both within the program and as students become practicing ACNPs, to determine the need for refresher courses.


Scenarios and content were tailored for the unique role of the acute care nurse practitioner in communicating with patients.

 

Numerous workshops in experiential communication techniques have been successful in medicine, and to a lesser extent in nursing, for improving communication skills.16,18,40,41 For nurse practitioners, workshops and specific educational strategies to strengthen professional collaboration between nurses, nurse practitioners, and physicians have been effective for improved communication.42,43 Our workshop extends this past experience and knowledge base more specifically to specialized nurse practitioner practice for patient communication. The unique factor of the Patient CommSimLab is the tailoring of the scenarios and content for the unique role of ACNPs in communicating with patients.

Our study had limitations, including the small number of students in the sample and a reliance on student self-report. We did not include objective evaluation of skills by ACNP faculty because we thought such evaluation might interfere with the students’ comfort and anonymity. Other limitations are the reliability and validity of the Likert-style instruments developed for our evaluation. Another more subtle limitation is that some of the scenarios were more complex than others.

The barriers to implementing additional communication content and improving integration of that content include lack of faculty expertise and the expense of SPs. Few nursing faculty have expertise in using SPs to teach communication skills. Training in communication skills and educational materials in palliative care are being offered to faculty through the End-of-Life Nursing Education Curriculum,44 a "train the trainer" program for nursing faculty at the graduate and undergraduate level. The dissemination of this information to nursing schools has a potentially profound impact on faculty members’ ability to educate students in communication skills in palliative care. As faculty training is enhanced, the communication expertise among faculty should continue to expand.

An additional limitation is the expense of the SPs. The cost for a 20- to 24-student workshop is approximately $2500, both for development of case scenarios and the daylong session. Ongoing cost after initial case development depends on the number of students, but is approximately $750 to $1000 for a single all-day workshop. Payment options include adding a laboratory fee to the course, absorbing the cost through specific departmental funds, or using trained individuals (staff, non-ACNP program faculty or alumni) as SPs to help alleviate this cost.

Despite these barriers, the ACNP faculty members strongly believe that communication skills should be taught to advanced practice nursing students who specialize in acute care. Future plans include continued faculty development, student workshops, and an opportunity for a clinical preceptor workshop to ensure consistent feedback for students as they embark into the clinical arena.

FINANCIAL DISCLOSURES
This research was funded by an Innovations in Teaching Award—2005 from the University of Pittsburgh.

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