Nurse Education Today 33 (2013) 677683

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

Using standardized patient with immediate feedback and group

discussion to teach interpersonal and communication skills to advanced
practice nursing students
Esther Ching-Lan Lin a,, Shiah-Lian Chen b, Shu-Yuan Chao b, Yueh-Chih Chen b
a
b

Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
Department of Nursing, HungKuang University, Taichung, Taiwan

a r t i c l e

i n f o

Article history:
Accepted 5 July 2012
Keywords:
Interpersonal and communication skills
Advanced practice nurse
Standardized patient

s u m m a r y
Background: Interpersonal and communication skills (IPCS) are essential for advanced practice nursing (APN)
in our increasingly complex healthcare system. The Standardized Patient (SP) is a promising innovative pedagogy in medical and healthcare education; however, its effectiveness for teaching IPCS to graduate nursing
students remains unclear.
Objectives: We examined the effectiveness of using SP with SP feedback and group discussion to teach IPCS in
graduate nursing education.
Design: Randomized-controlled study.
Participants: First-year APN students in Taiwan.
Methods: Participants were randomly assigned to the experimental (SP assessments with SP feedback and
group discussion) or control (SP assessments only) group. There were two outcome indicators: IPCS and student learning satisfaction (SLS). The IPCS were assessed before and after the study in interviews with the SPs.
SLS was measured when the study ended.
Results: All participants expressed high SLS (94.44%) and showed signicant (p 0.025) improvements on
IPCS total scores, interviewing, and counseling. However, there were no signicant differences between
groups. Qualitative feedback from encounters with SPs is described.
Conclusions: Using SPs to teach IPCS to APN students produced a high SLS. The students learned and signicantly improved their IPCS by interviewing SPs, but future studies are needed to conrm the effectiveness of
SP feedback and group discussions.
2012 Elsevier Ltd. All rights reserved.

Introduction
Good interpersonal and communication skills (IPCS) are being
emphasized more than ever in healthcare delivery systems (Mavis
et al., 2006; Moulton et al., 2009; van Zanten et al., 2007; Wear and
Varley, 2008; Weidner et al., 2010; Yudkowsky et al., 2006). It has become a basic competency for medical education (Laidlaw and Hart,
2011; van Zanten et al., 2007; Weidner et al., 2010), and has been included as the primary criterion in the licensing and certication examinations in many countries (Boulet et al., 2009; Kozu, 2006; Liu
and Tseng, 2011). Accumulated evidence supports the notion that
poor IPCS results in inadequate relationships between clients and
care providers, increased dissatisfaction and complaints, malpractice
claims, poor treatment adherence, and negative health outcomes
(Falvo and Tippy, 1988; Levinson et al., 1997; Hamasaki and Hagihara,
2011; Tallman et al., 2007; Wofford et al., 2004). In contrast, positive

Corresponding author at: 1 University Road, Tainan City 701, Taiwan. Tel.: +886 6
235 3535x5038; fax: +886 6 237 7550.
E-mail address: chinglan@mail.ncku.edu.tw (E.C.-L. Lin).
0260-6917/$ see front matter 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2012.07.002

IPCS often yield win-win benets for clients, families, physicians, and
the healthcare system (Arora, 2003; Flocke et al., 2002; Stewart et al.,
2000).
While IPCS have been extensively studied in medical education,
other healthcare programs, including advanced practice nursing
(APN) programs, also emphasize IPCS elements in the curriculum
(Baer et al., 2004; Rickles et al., 2009; Shawler, 2008, 2011). Teaching
IPCS traditionally in classrooms may increase students knowledge of
IPCS and improve their performance on objective tests, but it generally
does not facilitate student motivation or inuence their attitudes
about perfecting their IPCS (Emmanuel et al., 2010; Xie et al., in
press). The standardized patient (SP) method has been considered innovative and promising for IPCS education (Luctkar-Flude et al., 2012;
Shawler, 2011).
SPs are simulated or actual patients trained to portray a specic
clinical scenario in a standardized manner, and SP-based assessments
have been used as part of formative evaluation activities (Barrows,
1993, 2000). Numerous studies support the nding that SP pedagogy
provides learners with interactive opportunities for repeated practice;
increases clinical knowledge; improves communication, interview
skills, and advanced clinical performance on diagnostic reasoning;

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E.C.-L. Lin et al. / Nurse Education Today 33 (2013) 677683

promotes a patient-centered approach; and produces higher teaching

and learning satisfaction for faculty and students (Becker et al., 2006;
Lee et al., 2011; Manning and Kripalani, 2007; Moulton et al., 2009;
Richardson et al., 2009; Rickles et al., 2009; Shawler, 2008, 2011;
Yudkowsky et al., 2006). However, a review of the literature on SP
pedagogy (N = 69) found that only 4.3% were randomized studies
(n = 3) and 15% were nursing-related (n = 10) compared with 73%
physician-related (n = 51) (May et al., 2009).
Although there are only few published articles on using the SP
method in nursing, a growing number address the need for alternative and simulating teaching strategies. Vessey and Huss (2002) retrospectively analyzed the videotapes of 26 APN students' one-time
simulated clinical encounter with SPs. They concluded that using
SPs in simulated clinical encounters for summative evaluations
showed the method's lack of reliability and validity but its usefulness
for formative learning. Gibbons et al. (2002) found that APN students
(n = 21) who had completed a 9-week Health Assessment course
using SPs showed superior performance in their physical examination
skills and greater satisfaction with their learning experience than did
students (n = 35) in the previous year's class without SPs. Shawler
(2008, 2011) shared her experience using SP as a teaching strategy
for psychiatric and gerontological nurse practitioner students. She
describe how to initiate SP scenarios, and the development of scenarios, guidelines for standardized response statements, SP checklist
worksheet, and outcome evaluation using videotaped review and discussion. Rosenzweig et al. (2008) developed a patient communication
simulation laboratory for 38 students in an acute care nurse practitioner program to evaluate students' perceived condence and communication effectiveness before, immediately after, and 4 months
after the end of the study. They found signicant increases in student
condence and perceived communication skills. Richardson et al.
(2009) described an innovative strategy that used 20 undergraduate
nursing student volunteers to act as SPs to assess the performance
of 22 APN students on history taking, physical examinations, and
IPCS. From the qualitative data, they found positive reciprocal learning in both student groups and advocated the cost-effectiveness of
undergraduate student SPs. Becker et al. (2006) conducted a randomized controlled pilot study to compare the SP method (n = 58) with
the traditional instructive method (n = 89) of teaching therapeutic
communication skills in a class of undergraduate nursing students.
They reported that students who were taught using the SP method
described the experience as positive, creative, and meaningful, although there were no signicant differences between the two
groups in their IPCS or their knowledge of depression. This study
contributed a well-designed experiment using SP methods as an alternative pedagogy as well as a method of performance assessment.
These studies indicate that the SP method has been promisingly
implemented in APN and undergraduate education; however, rigorous experimental research with reliable and valid instruments is
needed to support the evidence-based use of the SP method in IPCS
nursing education.
In Taiwan, the role of APN in the healthcare delivery system is
increasingly demanding and bringing several challenges in the evolution of a nursing education master's degree program. It is crucial
to equip APN students with advanced IPCS because advanced practice nurses are expected to coordinate and communicate well with
all related stakeholders in a complex healthcare delivery system
(Hamric et al., 2009). The SP method used to teach clinical skills
has generated much interest for nursing faculty to respond to the
challenge (Tung et al., 2009). Based on the efcacy of SP teaching
methods for learning IPCS in medical education, we designed an
opportunity for our APN students to learn and improve their IPCS
by interacting with SPs. This randomized-controlled study was
intended to ll the gap in the existing literature on the effectiveness
of using SP with SP feedback and group discussion to teach IPCS in
graduate nursing education.

Methods
Design and Setting
A pragmatic randomized controlled study using a two-group
design experimental (SP assessments with SP feedback and group
discussion) vs. control (SP assessments only) was conducted in
the APN graduate program of the nursing department in a university
in the middle of Taiwan, from September through December 2009.
The APN graduate program was establish since 2008, and the SP pedagogy was initiated in 2009. The equipments for videotaping were set
up in two interview rooms and 2 informatics technicians were standby around for the SP assessments. Six SPs were trained to interview
with APN students in this study.
Participant Recruitment and Procedure
Participants for this study met the following criteria: (1) rst-year
APN graduate students; (2) had practiced or currently practice as a
registered nurse for at least one year; and (3) agreed with the study
purposes and procedures. One of the authors (ECL), the faculty member in charge of the advanced communication class for the APN graduate program, explained the purposes and procedures of the study,
and recruited all eligible students. Of the 27 rst-year APN graduates
who were eligible, 26 agreed to participate and provided written informed consents. They were randomly assigned to either the experimental or the control group. All students had been guaranteed that
their performance in the study would have no inuence on their
course grade.
Randomization
Block randomization was used to ensure an equal number of participants in each group. A block size and an allocation ratio were specied. Randomization procedures were conducted by an independent
assistant to produce the random numbers and completely conceal
the randomized allocation in a closed opaque envelope.
Intervention
All participants received a 2-hour instructional class consisting of
theoretical knowledge and clinical skills of interpersonal relationships and communication, and were assessed in 15-minute interviews
with the SP before and after the class. Participants in the control group
were only received the conventional instruction in classes and SP
assessments.
Students in the experimental group additionally received SP feedback according to the IPCS assessment tool immediately after their
rst interview with the SP and joined a faculty-led group discussion
for an SP-interview video before the second assessment. During the
group discussion, students were encouraged to raise their observations and inquiries about specic situations they encountered with
SP. Positive and negative feedback to the students specic IPCS
were provided by students and faculty whose goal was to make the
students aware of their helpful and unhelpful IPCS behaviors and to
facilitate their introspective insight.
SP Training
Six SP, recruited from volunteer undergraduate nursing students,
were given a 2-day SP training course. It consisted of an introduction
to SP pedagogy, scenario demonstrations and role-playing, and
methods for rating IPCS and providing feedback. The SP scenario
consisted of an 18-year-old female patient with a history of depression, who had attempted suicide the previous night and then had
been taken to the emergency room by her father. Participants in

E.C.-L. Lin et al. / Nurse Education Today 33 (2013) 677683

this study were asked to initiate the rst interview with the SP as an
advanced practice nurse. In a 2-day training course, all SP repeatedly
practiced the scenario, which was videotaped, for themselves and
their instructors. A psychiatric instructor led a group discussion of
the videos and pointed out discrepancies. The SP practiced the scenario until they were all consistent.
Outcome Evaluation
There were two outcome indicators: IPCS and learning satisfaction. The IPCS of all participants were assessed at baseline and at
the completion of the study; learning satisfaction was measured
only at the end of the study. To capture the individual responses for
this innovative pedagogy, all participants were encouraged to write
down their specic feedback for the interviews with SP and related
teaching activities after completing the questionnaire at the end of
the study. Two outcome indicators are described as follows.
(1) Interpersonal skills (IPS) assessment tool. The IPS assessment
tool was developed to measure doctor-patient relationship
skills and associated behaviors of foreign medical graduates
in the USA (van Zanten et al., 2007). The content, scoring rubric
reliability, and validity of IPS were examined. It was translated
into Chinese specically for assessing the IPCS of APN graduate
students in Taiwan. The tool consists of four dimensions: skills
in interviewing and collecting information (4 items), skills in
counseling and delivering information (4 items), rapport (4
items), and personal manner (5 items). The techniques and
criteria of four IPS dimensions were identied by van Zanten
et al. The rst IPS dimension, skills in interviewing and collecting
information, is based on the techniques of patient-centered
interviewing. This dimension includes both a nondirective
component (encouraging patients to express themselves in
their own words) and a directive component (asking directed
questions aimed at better understanding personal information
and testing hypotheses). Criteria for rating the rst IPS dimension consisted of the effective use of open- and closed-ended
questions, clarity of questions, avoiding jargon, and using verication, segment summaries, and transition phrases. The second dimension, skills in counseling and delivering information,
focuses on the skills needed to check a patient's understanding,
to be tactful, to link a patient's symptoms or concerns to closing information, and to leave a patient with an understanding
of what will happen next. This dimension assesses the ability
to demonstrate informational power, to elicit a patient's feelings, and to subsequently make explanations and recommendations that are clearly linked to the patient's concerns and
to allow the patient to be involved in the decision-making process. The third dimension, rapport, assesses the ability to establish a caring relationship with a patient. Criteria evaluated
include attentiveness, attitude, body language, including eye
contact and respect for personal space, and demonstrated
empathy and support for a patient's concerns. The fourth dimension, personal manner, assesses criteria such as an appropriate introduction, mood, and demeanor in the encounter.
Three fourth-dimension items related to physical examinations in the original version are excluded because of the present study's IPCS focus, which did not include a physical
examination. Each item was measured using a 4-point Likert
scale with acceptable reliability (Cronbach's = 0.89). The
maximum score was 56; higher scores indicate a better IPCS
performance. The SPs rated all students' IPCS after the interviews, and a psychiatric instructor reviewed interview videos
and independently rated the students IPCS performance
using the IPS rating scale. The instructor was blinded to
students assigned groups.

679

(2) Student learning satisfaction (SLS) scale. The SLS (Mavis et al.,
2006), a self-reported questionnaire, was modied from the
original to evaluate our rst-year students SLS. It consists of
9 dichotomous questions, including student attitudes toward
the SP pedagogy, skills performance, learning outcomes, emotional reactions, perceived advantages of IPCS, and overall evaluation of the learning experience. The reliability of SLS in the
present study was acceptable (Kuder-Richardson coefcient
of reliability [KR-20 = 0.61]). All students evaluated their
learning experience after the nal interview with the SP.
Data Analysis
The Statistical Package for Social Sciences 17.0 for Windows was
used to analyze all data. Descriptive statistics of all variables were
explored. Because our sample was not dependent on a parametric
model, the effectiveness of outcome variables between the experimental and the control groups was analyzed using nonparametric statistical methods: the 2 test, MannWhitney test, Wilcoxon SignedRank test, and Spearman's rho correlation coefcient.
In addition, guided by the systematic classication process of qualitative content analysis, the participants qualitative feedback for the SP
pedagogy were read, classied, abstracted, labeled, and categorized.
Several quotations are presented because of their representativeness
of the signicance, similarities, and differences of the descriptions of
their individual learning experience.
Results
Twenty-seven eligible students were recruited, but one refused to
join the study and one member of the control group dropped out (dropout rate of all participants = 3.85%). All participants were middle-aged,
experienced, currently employed female nurses (Table 1). There were
no signicant differences in demographics or baseline IPCS scores
between the experimental and control groups.
Table 2 showed the comparison between two groups in the preand post-test of IPCS scores. The highest score at baseline for all participants was for personal manner (6.77/8 = 84.63%), which was the
least improved item on the second assessment. The lowest score
was for counseling and delivering information (12.12/16 = 75.75%),
which was the most improved item. All participants showed signicant improvements on total IPCS scores and on the two items of
interviewing and collecting information and counseling and delivering
information (p = 0.025-0.005). The interviewing and collecting information item showed a signicant difference between pre- and
post-test scores in the experimental group, and total IPCS scores
and all items except interviewing and collecting information in the control group. A MannWhitney U test showed no signicant difference
between the experimental and control groups in baseline and
post-test scores for each IPCS item (Table 3). The equal IPCS improvements in both groups did not support the benets of adding SP feedback and group discussion in the experimental group.
All participants expressed extremely high SLS scores. Participants
in the control group gave slightly higher scores than did those in
the experimental group (8.50 vs. 8.29, respectively), but the difference was not signicant. The Spearman's rho nonparametric correlation coefcient between the IPCS rating scales and the SLS was
calculated. Marginally signicant correlations were found between
the SLS and the total IPCS scores at baseline in the control group
( = 0.58, p = 0.047).
Additionally, according to students' written qualitative feedback,
positive and negative learning experiences of the SP pedagogy were
identied. Although all students agreed that SP pedagogy was benecial for learning IPCS, two students in control group expressed their
negative experience about feeling frustrated during the interview.
One student, with 11 years of working experience, said: I didn't

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Table 1
Characteristics of all participants (N = 26).
Group:

Age (years)
Mean (SD)
Range
2530
3135
3640
4145
>45
Clinical experience (years)
Mean (SD)
Range
5
610
1115
1620
>20
Current employment position
Administrator
Clinician
Clinical instructor
Marital status
Married
Unmarried
IPCS total at baseline
Mean (SD)

All
n (%)

Experimental
(n = 14)
n (%)

Control
(n = 12)
n (%)

MW
U/2

36.27 (4.92)
2651
2 (7.70)
6 (23.1)
15 (57.7)
2 (7.70)
1 (3.80)

37.36 (5.08)
3151
0 (0)
4 (28.6)
8 (57.1)
1 (7.10)
1 (7.10)

35.0 (4.61)
2641
2 (16.70)
2 (16.7)
7 (58.3)
1 (8.30)
0 (0)

76.50a

0.705

0.463

13.58 (4.30)
525
1 (3.80)
4 (15.40)
15 (57.70)
5 (19.20)
1 (3.80)

15.00 (4.04)
1025
0 (0)
1 (7.10)
9 (64.30)
3 (21.40)
1 (7.10)

11.95 (4.16)
517
1 (8.30)
3 (25.00)
6 (50.00)
2 (16.70)
0 (0)

55.50a

0.145

0.453

5 (19.23)
15 (57.69)
6 (23.08)

2 (14.29)
8 (57.14)
4 (28.57)

3 (25.00)
7 (58.33)
2 (16.67)

0.78b

0.676

13 (50.00)
13 (50.00)

9 (64.29)
5 (35.71)

4 (33.33)
8 (66.67)

2.89b

0.236

44.00(7.53)

45.21(7.04)

42.58(8.13)

66.50a

0.374

3.60

3.67

Note. 1. SD, standard deviation.

a
MW U, MannWhitney U test.
b
2; 4. p b0.05.

understand what was wrong with my communication and why the SP

didn't answer me for both interviews. That disappointed me.
The other negative feedback was accompanying by positive perspectives. Three students felt some anxiety during the interviews,
but they supported this is a valuable and meaningful learning experience. Two students particularly mentioned their reective and
insightful experience from immediate SP feedback and group discussion as they reviewed the videotaped interview. They shared reections from the group discussion: I never understood the way I used
to talk to others. When I watched my interview with the SP in the
video, I learned how much I pushed my patients. I found that I just
focused on my own tasks and asked the questions I wanted answered

without being concerned about the SP's anxiety and discomfort at that
moment. I should not have insisted that she look at me. She was so
depressed. That made her very anxious and maybe made her hate to
talk with me. I found that I wasn't speaking loudly enough to get my
patient's trust. I need to show my self-condence. All of these personal
insights might increase their awareness of their behavioral deciencies, as well as increase their motivation to change.
Discussion
It is critically important to equip APNs with better IPCS in an increasingly complex healthcare delivery system. The SP method is

Table 2
Comparison between pre- and post-test of two groups in interpersonal and communication skills (N = 26).

IPCS total [full score: 56]

All
Experimental
Control
Dimension 1. Interviewing and collecting information [full score: 16]
All
Experimental
Control
Dimension 2. Counseling and delivering information [full score: 16]
All
Experimental
Control
Dimension 3. Rapport [full score: 16]
All
Experimental
Control
Dimension 4. Personal manner [full score: 8]
All
Experimental
Control
Notes. 1. SD, standard deviation.

p b 0.05.

Pre-test
Mean (SD)

Post-test
Mean (SD)

Wilcoxon signed-rank test

Wilcoxon W

44.00 (7.53)
45.21 (7.04)
42.58 (8.13)

49.32 (5.19)
48.71 (4.01)
50.09 (6.52)

2.81
1.58
2.09

0.005
0.113
0.036

12.42 (2.45)
12.29 (2.40)
12.58 (2.61)

13.84 (2.01)
13.93 (1.73)
13.73 (2.41)

2.24
1.98
1.13

0.025
0.048
0.258

12.12 (2.39)
12.64 (2.00)
11.50 (2.75)

14.32 (1.60)
14.07 (1.64)
14.64 (1.57)

2.84
1.74
2.27

0.004
0.082
0.023

12.69 (2.60)
13.29 (2.34)
12.00 (2.83)

13.88 (2.07)
13.57 (1.91)
14.27 (2.28)

1.78
0.30
2.11

0.075
0.765
0.035

6.77 (1.34)
7.00 (1.41)
6.50 (1.24)

7.28 (1.02)
7.14 (1.17)
7.45 (0.82)

1.53
0.09
2.33

0.125
0.932
0.020

E.C.-L. Lin et al. / Nurse Education Today 33 (2013) 677683

681

Table 3
Comparison between two groups in interpersonal and communication skills and learning satisfaction (N = 26).
GROUP:

IPCS total [full score: 56]

Baseline
Post-test
Dimension 1. Interviewing and collecting information [full score: 16]
Baseline
Post-test
Dimension 2. Counseling and delivering information [full score: 16]
Baseline
Post-test
Dimension 3. Rapport [full score: 16]
Baseline
Post-test
Dimension 4. Personal manner [full score: 8]
Baseline
Post-test
Self-reported Students' learning satisfaction [full score: 9]
Post-test

Experimental
(n = 14)
Mean (SD)

Control
(n = 12)
Mean (SD)

M-W U

45.21 (7.04)
48.71 (4.01)

42.58 (8.13)
50.09 (6.52)

66.50
54.00

0.374
0.222

12.29 (2.40)
13.93 (1.73)

12.58 (2.61)
13.73 (2.41)

74.00
76.00

0.631
0.979

12.64 (1.99)
14.07 (1.64)

11.50 (2.75)
14.64 (1.57)

63.00
60.50

0.297
0.373

13.29 (2.34)
13.57 (1.91)

12.00 (2.83)
14.27 (2.28)

60.50
53.00

0.231
0.202

7.00 (1.41)
7.14 (1.17)

6.50 (1.24)
7.45 (0.82)

61.00
68.00

0.252
0.647

8.29 (1.68)

8.50 (1.58)

71.50

0.531

Note. 1. SD, standard deviation; 2. MW U, MannWhitney U test.

p b 0.05.

recognized as innovative for teaching and learning clinical skills in

healthcare education; therefore, we selected this pedagogy for these
experienced on-the-job APN graduate students to learn and practice
their IPCS in simulated reality. The results of our study support the
notion that the SP method for IPCS assessments produces high levels
of learning satisfaction and helps APN graduate students signicantly
improve their communication skills. To our knowledge, this is the
rst randomized controlled study to use SP method to APN graduate
students in learning IPCS (Gibbons et al., 2002; May et al., 2009;
Richardson et al., 2009; Shawler, 2011).
According to May et al. (2009), the majority of studies on using SP
pedagogy in the healthcare eld reported outcomes with changes in
knowledge, attitudes, and satisfaction of the learner. They urged that
more rigorous studies with the emphasis of behavioral outcomes
will lead to real changes in clinical practice and patient outcomes.
The present study, with a randomized controlled design aiming to
explore this question, showed signicant behavioral improvements
in the interviewing and counseling domains of all participants. Some
researchers have argued that IPCS behaviors may be outwardly
displayed just for positive evaluation or according to social desirability associated with good communication in the point-counterpoint
simulation format (Hanna and Fins, 2006; Wear and Varley, 2008).
But Teherani et al. (2008) said that these overt behaviors are basically
required to provide care, and simulations can measure the learners'
minimum behaviors or surface acting. Non-signicant improvements
on items of rapport and personal manner between pre- and posttests of IPCS in this study may also indicate that these two behavioral
items were inuenced by participants' attitudes and not easily outwardly displayed at skill-level. Seemingly, to learn how to build a
caring rapport and professional personal manner does not depend
on supercial behavior-level regulation only, but also the internalization of a caring value system.
Teherani et al. (2008) recommended that reective practice, challenging cases, and rater training to provide feedback can supplement
and enrich using SP to cultivate and evaluate competence. In this
study, we developed a challenging SP scenario that was close to real
clinical practice. This might have motivated our students to use sophisticated communication skills with patients in a difcult healthcare
situation. From the qualitative data, the repeated SP assessment itself
seemed to provide an opportunity for these experienced on-the-job
APN graduate students to reect on their rst encounter with an SP,

and to modify themselves to get a better response from the SP during

the second assessment interview.
Consistent with the current positive evidence of SP effectiveness
on IPCS, our ndings replicated the effects of the SP assessment to improve the IPCS (Baer et al., 2004; Lewy et al., 2009; Rickles et al., 2009;
Rosenzweig et al., 2008), in particular in the interviewing and
counseling domains. However, non-signicant differences between
the experimental and control groups did not support our hypothesis
of the effectiveness of adding immediate SP feedback and facultyled group discussion of the videotaped SP interviews. In addition to
the potential effect from contamination of information exchange between the two groups and compensatory rivalry of the control
group, this nding possibly resulted from an insufcient difference
between the experimental and control groups. With the difference
using the SP feedbacks and group discussion for experimental group
only, our research design did not include a comparison without SP assessment because both experimental and control groups receiving SP
assessments. It also hints that these two adding teaching strategies
for experimental group might need to be strengthened. More training
for our undergraduate student SP to provide immediate feedbacks
and more emphasis on these APN students' internalization process
for learning IPCS might enlarge the effect of SP-related pedagogy. Future studies with a larger sample size and specic outcome indicators
need to examine the effectiveness of these adding teaching strategies
in the present study.
Limitations and Methodological Considerations
There were several limitations to our study. First, our research design contained no control group without SP assessments: both groups
were interviewed by the SP. Second, there was unavoidable contamination between two groups: information exchanges easily took
place and might have inated the treatment effect for the control
group. Third, compensatory rivalry of the control group in our study
seemed to affect post-test performance and interfere with our efforts
to detect the real effects of conventional intervention. Fourth, generalizing the ndings must be limited specically to female APN students with moderate work experience, and the sample size needs to
be increased in future studies, which probably means that future
studies will have to be multisite investigations. Fifth, there was no
follow-up to determine the long-term effect of using the SP method.

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E.C.-L. Lin et al. / Nurse Education Today 33 (2013) 677683

And last, because our SP were undergraduate students asked to rate

and provide feedback on the IPCS performance of senior and graduate
students, a few of them felt stressful during the process. More practice might improve their condence and encourage them to learn
mutually from the process by providing their observations from the
interview, or perhaps it would be better to use undergraduates from
other departments or the lay people so that the SPs won't feel
cowed by having to assess what are in our age-graded hierarchical society their seniors and superiors.
Implications
Based on our ndings, we conclude that the SP assessment method is innovative and promising for providing IPCS education to APN
students, in particular in the interviewing and counseling domains.
This evidence of the effectiveness of SP pedagogy with APN students
will encourage nursing faculty not only to use this pedagogy in their
teaching practice and to assess their students IPCS, but also to conduct further rigorous studies to increase the evidence that it is worthwhile. For example, the effectiveness of additional teaching strategies
in the present study, including feedback from SP and faculty-led
group discussion, need to be examined in the future studies with a
larger sample size and multiple outcome indicators. Epstein (2007)
suggested there was no single assessment that has been or should
be used to measure different intrapersonal and interpersonal competencies (knowledge, attitudes, and skills). SP assessment could be incorporated with other aspects of skill evaluations. Furthermore, using
SP pedagogy to teach interprofessional communication may extend
our positive outcomes in teaching advanced level communication
skills to APN students so that they can collaborate with other disciplines as a team, which is crucial for APN practice.
Conclusion
This is the rst randomized controlled study to examine the effect
of using the SP method to teach IPCS to APN graduate students. It
provides evidence to support the notion that SP methods produced
signicant improvements in specic communication skills as well as
high learning satisfaction for APN students. The insignicant difference between the experimental (SP assessments with SP feedback
and group discussion) and control (SP assessments only) groups
was insufcient to support the effectiveness of SP feedbacks and
group discussion. However, our ndings highlighted the need for further research on the use of SP in teaching and learning the clinical
skills of nursing education, in particular in an APN program.
Because of its positive effects on patient outcomes, good interpersonal and communication competence has been emphasized more
than ever in healthcare delivery systems. Meanwhile, the APN role is
increasingly demanding in many countries, an advanced practice
nurse who has mastered IPCS will be able to exhibit their high-level
professional skills and better market themselves in the world's highly
complex and currently resource-constrained healthcare delivery systems. For nursing educators today who face numerous challenges in
the evolution of nursing education, using an evidence-based pedagogy
to improve advanced practice nurses IPCS is crucial. The SP method is
more innovative than traditional classroom and textbook-based pedagogy, and demonstrably more satisfying to students and teachers.
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