Clinical Simulation in Nursing (2017) 13, 309-313

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Featured Article

Using Standardized Patients in an Undergraduate

Nursing Health Assessment Class
Joan Andrea, RN, DNP, Peggy Kotowski, RN, MSN*
School of Nursing and Health Sciences, North Park University, Chicago, IL 60625, USA

KEYWORDS Abstract
interviewing skills; Background: Although standardized patients (SPs) are routinely used in graduate nursing programs
health history; and medical school, limited data are available regarding use with undergraduate baccalaureate nursing
standardized patients; students.
undergraduate nursing Method: A quantitative research design was used to investigate using SPs as an effective teaching
students; method to increase students’ confidence, communication skills, and clinical judgment to obtain a
health assessment; health history from patients.
nursing education Results: Working with SPs increased participant’s level of confidence in performing a health history.
Conclusions: Using SPs in an undergraduate health assessment class can enhance students’ ability to
communicate and interact with patients in gathering a health history thereby strengthening patient
care.

Cite this article:

Andrea, J., & Kotowski, P. (2017, July). Using standardized patients in an undergraduate nursing
health assessment class. Clinical Simulation in Nursing, 13(7), 309-313. http://dx.doi.org/10.1016/
j.ecns.2017.05.003.
Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier
Inc. All rights reserved.

In the 1960s, neurologist Howard Barrows (1993)
trained nonmedical people to act as ‘‘patients’’ for medical
students. Adopting this pedagogy of standardized patients
(SPs) to teach medical students and nurse practitioners
has proven benefits (Gibbons et al., 2002; Hetzel-
Campbell, Pagano, O’Shea, Connery, & Caron, 2013;
Kameg, Mitchell, Clochesy, Howard, & Suresky, 2009;
Ruterford-Hemming & Jennrich, 2013; Swanson &
Stillman, 1990). A randomized controlled study examining
This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors. Conflicts of interest:
none.
* Corresponding author: mkotowski@northpark.edu (P. Kotowski).
the use of SPs with immediate feedback and group discus-
sion of teaching interpersonal and communication skills to
advanced practice nursing students demonstrated support of
SP methodology for improving communication skills (Lin,
Chen, Chao, & Chen, 2013). Psychiatric nursing education
found merit with this pedagogy to develop essential
communication skills (Doolen, Giddings, Johnson,
Guizado de Nathan, & O’Badia, 2014; Kameg et al.,
2014). A pilot study with undergraduate nursing students
found that working with SPs in a mental health simulation
increased their confidence, encouraged professionalism,
and increased their understanding of mental illness
(Alexander & Dearsley, 2013). In another study, students
reported themes of improved interviewing skills, more

1876-1399/$ - see front matter Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2017.05.003
SPs in an Undergraduate Health Assessment Class 310

confidence, and improved application of skills and knowl- generation strives for teamwork and achievement
edge when working with SPs who had been taught to (Hartmann & McBridge, 2011). Utilizing SPs is a strategy
demonstrate symptoms of bipolar disorder, anxiety, and that nurse educators can use to teach effective communica-
schizophrenia (Doolen et al., 2014). tion skills and build confidence. Nurse educators are increas-
Evidence of the usefulness of incorporating SPs in the ingly using simulation to create learning opportunities to
undergraduate nursing pro- assist students to refine communication skills.
gram is growing (Alexander
Key points & Dearsley, 2013; Luctkar-

Standardized patients Flude, Wilson-Keates, & SPs as Teachers
(SPs) are useful to Larocque, 2012; O’Mara,
first-semester nursing McDonald, Gillespie, Brown, Nursing researchers are giving more attention to the value
students in developing & Miles, 2014). The National of nontechnical skills such as how to greet and introduce
beginning skills for Council Board of Nursing oneself to patients, handshakes, eye contact, sitting versus
health assessment. study found that incorporation standing during an interview, words to use when speaking

The use of SPs showed of simulation into undergrad- to family members and patients versus health care termi-
improved confidence, uate nursing education could nology or jargon, or when touch is appropriate. These are
communication skills, replace up to 50% of clinical all details that can empower or inhibit communication
and clinical judgment experience without changing (Hetzel-Campbell et al., 2013). SPs in this study did teach
for first-semester nur- learning outcomes (Hayden, the value of both verbal and nonverbal communication.
sing students. Smiley, Alexander, Kardong- Teaching excellent interpersonal and communication

Utilization of SPs Edgrens, & Jefferies, 2014). skills in undergraduate nursing school benefits many aspects
allows for a more These results suggest that of health care. The didactic teaching of interview techniques
authentic experience in simulation is a pedagogy that and how to take a health history is followed by practice in
a low-stress situation. is equivalent to traditional the lab. However, in the lab, students gravitate to friends to
pedagogies and can be useful practice taking a health history. The lab experience with
in teaching communication fellow students does not facilitate skills in talking to patients
and history taking skills in health assessment. of various ages or backgrounds. Skills or knowledge of how
to speak with a patient with a cognitive or sensory
impairment is not experienced. Students need to be engaged
Filling Gaps Between Education and Practice and have opportunities to participate in the learning process.
Enlisting SPs, real people trained to take on the acting the
Reaching curriculum objectives for undergraduate health role of a patient in specific clinical scenarios, helps create a
assessment class to prepare students by taking a health more realistic situation to practice, and refine communica-
history using interviewing skills involves practicing the art tion skills. SPs give feedback to students through their
of communication. Communication is essential in meeting response as a patient and can also call a ‘‘time-out’’ to come
quality and safety standards in patient-centered care. out of the role and discuss the various nuances of
Between 1995 and 2005, ineffective communication was communication, phrases, and words chosen by the student
responsible for 66% of health care errors (Sherwood & that may be misinterpreted or found to be too blunt or
Zomorodi, 2014). Ineffective communication in health judgmental. SPs can stop the student/patient interaction and
care can also have a financial cost (Wilner & Feinstein- refocus the interview if needed.
Whittaker, 2013). Reimbursement is linked to patient satis-
faction that can be influenced by nurseepatient interactions
(Centers for Medicare and Medicaid Services, 2014). Research Question/Problem
Educating student nurses on the nuances of verbal and
nonverbal communication is a skill that crosses many areas Clinical faculty may not have direct observation of students
and has the potential to reap tremendous benefits. taking health histories and not be able to provide appropriate
Teaching empathy and appropriate bedside manner along feedback to students. Students must rely on self-assessment
with the skills needed to elicit a health history can be or reaction of patients in developing communication skills.
challenging. Infrequent opportunities and fear of judgment When students are observed, they are often anxious and may
by clinical faculty or staff can hinder students (O’Mara et al., feel a lack of confidence.
2014). Many current undergraduate nursing students belong Experiential learning in nursing programs allows students
to the generation called millennials or generation Y and are to take didactic learning, along with psychosocial and
accustomed to communicating through the use of technol- communication skills and apply it to in situ situations.
ogy. Problem solving and patience is lacking in some millen- Anxiety and lack of confidence can be potential barriers to
nials (Bland, Melton, Welle, & Bigham, 2012). This learning and application of knowledge. Anxiety is high in

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SPs in an Undergraduate Health Assessment Class
these situations and can be heightened if students perceive
nursing faculty are impolite, unapproachable, intimidating, or
display attitudes of mistrust (Hutchinson, Janiszewski, &
Goodin, 2013). Using SPs, who only provide feedback and
not grades, can be less threatening to students who have
high-performance anxiety. The aim of this research project
was to determine if the use of SPs would be useful in
increasing a students’ confidence, communication skills,
and clinical judgment when working with patients in the clin-
ical setting. For the purpose of this research, communication
is conceptualized as the ability to communicate effectively
(establishing rapport, address the patient and family with dig-
nity and respect, and appropriate use of terminology). Confi-
dence is defined as the students’ ability to approach the patient
and family in a calm and assured manner that would invoke a
trusting relationship. Communication and confidence are in-
tegral components leading to the development of clinical
judgment allowing students to make informed decisions.
Methods
Trial Design
In this quantitative research study, first-semester baccalau-
reate nursing students of health assessment class in a
Midwest liberal arts university worked with SPs. The
researchers received approval from the university’s institu-
tional review board. A convenience sample (n ¼ 80) of three
cohort groups was utilized over three semesters. The first
cohort group consisted of 28 females and two males, the
second group contained 24 females and four males, and the
final group was composed of 19 females and three males.
Ages of the subjects ranged from 20 to 40 years of age.
The week before the scheduled use of SPs, which were a
standard part of the curriculum of this course, the students
were provided with complete disclosure of the study
process, and volunteers for the research were solicited.
The volunteers were not provided with any incentive to take
part in this research study. At the same time, informed
consent was obtained from the volunteer students, and they
were assigned a study participant number to track their
responses to the questionnaire at the three time points.
Three cohorts of students completed the Lasater Clinical
Judgment Rubric (LCJR) at three different points of time.
The first student self-assessment was completed at baseline.
Prior to baseline, students were provided with a brief
explanation of the LCJR to facilitate understanding on
completing the tool. Review of the scale was not undertaken
at subsequent student self-evaluations. The second data
collection point was done after the student had completed
12 hours of clinical experience, two- to six-hour clinical
days, with actual patients. The final self-evaluation was one
week later after working with the SPs in the lab. SPs enacted
the same three scenarios for groups of five to six students for
each of the cohort groups in week nine of the course.
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311
Reliability in each of the three scenarios over each of the
three semesters was obtained by utilizing the same script and
the same actors, who are well versed and have lots of
experience in the role of SP. During the scenario, the SP holds
the dual role of patient and instructor, providing feedback
through the patient’s reaction or by briefly halting the scene to
share teaching pearls to the student doing the interview. SP
feedback was not an outcome that was measured in this study.
However, as part of the SP process, time-outs are incorporated
into the scenario to help clarify any issues with the students.
Assessment Tool
After the completion of the signed consent, recruited students
completed a self-assessment using the LCJR. This rubric was
designed to describe the trajectory of students’ clinical
judgment over the length of their nursing program. This
tool was chosen because it incorporates communication and
reflection that lead to self-confidence all that lead to improved
clinical judgment. Lasater states that ‘‘Although the LCJR
shows a developmental process, it was designed to evaluate a
single episode requiring clinical judgment. It does, however,
present a bigger picture view of clinical judgment develop-
ment, allowing students to grasp what clinical judgment
involves, evaluate their growth, and identify goals toward its
achievement’’ (Lasater, 2007, p 499). Permission from the
creator of the rubric was obtained (K. Lasater, personal
communication, September 24, 2013).
The LCJR consists of four levels or stages of develop-
ment based on Tanner’s Model of clinical judgment (Tanner,
2006)dbeginning, developing, accomplished, and exem-
plary for each aspectdnoticing, interpreting, responding,
and reflecting. The ‘‘noticing’’ issue involves focused obser-
vation, recognizing deviations from expected patterns and
information seeking. The ‘‘interpreting’’ character looked
at prioritizing and making sense of data. The ‘‘responding’’
point measured confidence, clear communication and plan-
ning interventions, and flexibility. The ‘‘reflecting’’ issue in-
volves evaluation, self-analysis, and commitment to
improvement (Lasater, 2007; Miraglia & Asselin, 2015).
The only modification to the tool was that the column titles,
‘‘beginning, developing, accomplished and exemplar,’’ were
removed. In their place, the numbers one, two, three, and
four were added so that the researchers could quantify and
document the change in students’ confidence, communica-
tion skills, and clinical judgment over time. Students were
asked to circle the descriptor that best defined their self-
assessment of clinical performance at each point in time.
Findings
Data were analyzed using SPSS. A one-way repeated
measures analysis of variance was conducted to evaluate
the null hypothesis that there is no change in student’s total
score when measured at baseline, after the clinical
SPs in an Undergraduate Health Assessment Class 312

Table Summary of Results at Baseline, After Clinical Exposure, and After SPs
Lasater Clinical Judgment Rubric Results
Baseline, M (p, p) Clinical, M (p, p) SP, M (p, p)
Being skillful 2.84 (1.00, <.01) 2.90 (1.00, <.01) 3.14 (<.01, <.01)
Evaluation/self-analysis 2.94 (1.00, .04) 2.92 (1.00, .05) 3.09 (.04, .05)
Commitment to improvement 3.21 (1.00, 1.00) 3.22 (1.00, 1.00) 3.24 (1.00, 1.00)
Making sense of the data 2.83 (.53, <.01) 2.91 (.53, .03) 3.09 (<.01, .03)
Calm, confident manner 2.97 (1.00, <.01) 3.03 (1.00, <.01) 3.24 (<.01, <.01)
Clear communication 2.94 (.23, <.01) 3.05 (.23, .30) 3.17 (<.01, .30)
Well-planned intervention/flexibility 2.80 (.01, <.01) 3.05 (.01, .20) 3.18 (<.01, .20)
Focused observation 2.83 (.12,.<.01) 3.00 (.12, <.01) 3.22 (<.01, <.01)
Recognizing deviation from expected patterns 2.88 (.51, .02) 2.98 (.51, .69) 3.08 (.02, .69)
Information seeking 3.10 (1.00, .02) 3.13 (1.00, .02) 3.29 (.02, .02)
Prioritizing data 2.92 (.51, <.01) 2.98 (.51, <.01) 3.27 (.01, <.01)
Total 32.25 (.03, <.01) 33.16 (.32, <.01) 35.01 (<.01, .01)
Note. SPs ¼ standardized patients.

experience, and after their experience with SPs in the first-
year health assessment course. The results of the analysis of
variance indicated a significant time effect, Wilk’s
lambda ¼ 0.67, F (2, 76) ¼ 19.15, p < .01. Thus, there
is significant evidence to reject the null hypothesis.
Follow-up comparisons of individual aspects, as demon-
strated in Table, on the rubric indicated that there was sig-
nificant increase in scores over time in the areas of being
skillful, making sense of data, feeling calm and confident,
clear communication, being well planned and flexible,
focused observation, and prioritizing data suggesting that
work with the SP was beneficial for students. These results
indicate that the use of SPs increases the participants’ level
of confidence, communication skills, and clinical judgment
when performing a health history with patients.
Discussion
Self-assessment is the perception of a behavior and readily
employed in gathering data on someone’s attitude and
confidence. The Lasater Clinical Judgment Rubric has been
used in other settings with undergraduate students to
measure student performance and found to be well
constructed (Ashcraft et al., 2013). The belief that one
can be successful at a task or skill is an internal motivator
for learning. Barriers of low self-confidence and high anx-
iety negatively affect decision-making processes. Clinical
decision making can be impaired without confidence. Lim-
itations of student self-evaluation rather than direct
observation of clinical judgment abilities may yield
discrepancies in perceived and actual clinical judgment
abilities. One study found that young, inexperienced nurses
had overconfidence in their clinical judgment skills when
perceived and when actual clinical judgment skills were
measured (Miraglia & Asselin, 2015). Direct observation
combined with self-evaluation would be most beneficial.
This study found significant self-reported evidence
supporting benefits of undergraduate nursing students
working with SPs. Small groups of students working with
one SP allowed for the positive feedback, prompts for
improvement, and cultivated the first steps in problem
solving by establishing effective communication in gath-
ering the health history from a patient. In one scenario, the
patient was elderly and had trouble hearing. Students
learned to be patient in listening, repeating, and speaking
slowly to the patient. In another scenario, questions about
sexual activity needed to be explored. Some students were
visibly uncomfortable and reluctant to enter into this area
of the health history. SPs offered guidance on how to
transition the interview into sensitive areas and illicit the
needed information. Giving them the tools and allowing
them to practice in a safe, simulated environment instills
confidence in their ability to transfer these skills into the
clinical area. Feeling confident and equipped motivates
students to engage in new experiences and opportunities
that might otherwise have deferred during clinical.
Conclusion
Incorporating SPs into the undergraduate curriculum is a
new methodology that could reshape nursing education.
SPs can assist novice students learn how to utilize
interpersonal communication skills and develop critical
thinking skills. Reliance on preceptor input and instructor
observation can be unreliable and biased. Finding clinical
preceptors and sites can be competitive and limited. SP
methodology is readily available and less costly than high-
fidelity manikins that have limitations. A few undergradu-
ate nursing programs are routinely incorporating SPs. The
cost of recruiting, training, and managing a pool of
individuals to be SPs is the greatest barrier. Compared
with the cost and maintenance of high-fidelity manikins,

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 SPs in an Undergraduate Health Assessment Class
SPs may save money for nursing programs and be a means
to meet many curricular objectives.
Limitations of this study include the subjective evalua-
tion of the student’s self-assessment of their competency.
As previously noted, students tend to overestimate their
abilities. Therefore, it is suggested that in future studies that
both the student’s self-assessment and the assessment of a
faculty observer in assessing the student’s skill level be
undertaken to allow for appropriate leveling of the student’s
skill. Implications for future research include the integra-
tion of simulation to understand the subtle nuances only
available with human contact. Further exploration of how to
assimilate SPs into undergraduate nursing curriculums to
develop interprofessional education could potentially
enhance nursing education programs.
References
Alexander, L., & Dearsley, A. (2013). Using standardized patients in an under-
graduate mental health simulation. International Journal of Mental Health,
42(2-3), 149-164. http://dx.doi.org/10.2753/IMH0020-7411420209.
Ashcraft, A. S., Opton, L., Bridges, R. A., Caballero, S., Veesart, A., &
Weaver, C. (2013). Simulation evaluation using a modified Lasater Clin-
ical Judgment Rubric. Nursing Education Perspectives, 34(2), 122-126.
Barrows, H. (1993). An overview of the uses of standardized patients for
teaching and evaluating clinical skills. Academic Medicine, 68(6), 443-451.
Bland, H., Melton, B., Welle, P., & Bigham, L. (2012). Stress tolerance:
New challenges for millennial college students. College Student Jour-
nal, 46(2), 362-375.
Centers for Medicare and Medicaid Services. (2014). HCAHPS: Patients’
perspectives of care survey. Retrieved from http://www.cms.gov/Medi-
care/Quality-Initiatives-Patient Assessment-Instruments/HospitalQuali-
tyInits/HospitalHCAHPS.html.
Doolen, J., Giddings, M., Johnson, M., Guizado de Nathan, G., &
O’Badia, L. (2014). An evaluation of mental health simulation with
standardized patients. International Journal of Nursing Education
Scholarship, 11(1), 1-8. http://dx.doi.org/10.11515/ijnes-2013-0075.
Gibbons, S., Adamo, G., Padden, D., Ricciardi, R., Graziano, M.,
Levine, E., & Hawkins, R. (2002). Clinical evaluation in advanced prac-
tice nursing education: Using standardized patients in health assessment.
Journal of Nursing Education, 41(5), 215-221.
Hartman, J., & McCambridge, J. (2011). Optimizing millennials commu-
nication styles. Business Communication Quarterly, 74(1), 22-44. http:
//dx.doi.org/10.1177/1080569910395564.
pp 309-313
Clinical Simulation in Nursing
Volume 13
Issue 7
313
Hayden, J., Smiley, R., Alexander, M., Kardong-Edgrens, S., & Jefferies, P.
(2014). The NCSBN study: A longitudinal, randomized, controlled
study replacing clinical hours with simulation in prelicensure nursing
education. Journal of Nursing Regulation, 5(2), S2-S41.
Hetzel-Campbell, S., Pagano, M. P., O’Shea, E. R., Connery, C., &
Caron, C. (2013). Development of the health communication assessment
tool: Enhancing relationships, empowerment, and power-sharing skills.
Clinical Simulation in Nursing, 9(11), e543-e550.
Hutchinson, T., Janiszewski, S., & Goodin, H. (2013). Nursing student
anxiety as a context for teaching/learning. Journal of Holistic Nursing,
31(1), 19-24.
Kameg, K., Mitchell, A., Clochesy, J., Howard, V., & Suresky, J. (2009).
Communication and human patient simulation in psychiatric nursing.
Issues in Mental Health Nursing, 30, 503-508. http://dx.doi.org/10.108
0/01612840802601366.
Lasater, K. (2007). Clinical judgment development using simulation to create
an assessment rubric. Journal of Nursing Education, 46(11), 496-503.
Lin, E. C., Chen, S. L., Chao, S. Y., & Chen, Y. C. (2013). Using standard-
ized patient with immediate feedback and group discussion to teach
interpersonal and communication skills to advanced practice nursing
students. Nurse Education Today, 33, 677-683.
Luctkar-Flude, M., Wilson-Keates, B., & Larocque, M. (2012). Evaluating
high-fidelity human simulators and standardized patients in an under-
graduate nursing health assessment course. Nurse Education Today,
32, 448-452.
Miraglia, R., & Asselin, M. (2015). The Lasater clinical judgment rubric as
a framework to enhance clinical judgement in novice and experienced
nurses. Journal for Nurses in Professional Development, 31(5), 284-291.
O’Mara, L. O., McDonald, J., Gillespie, M., Brown, H., & Miles, L.
(2014). Challenging clinical learning environments: Experiences of un-
dergraduate nursing students. Nurse Education in Practice, 14, 208-213.
Ruterford-Hemming, T., & Jennrich, J. (2013). Using standardized patients
to strengthen nurse practitioner competency in the clinical setting.
Nursing Education Perspectives, 34(2), 118-121.
Sherwood, G., & Zomorodi, M. (2014). A new mindset for quality and
safety: The QSEN competencies redefine nurses’ role in practice.
Nephrology Nursing Journal, 41(1), 15-22.
Swanson, D. B., & Stillman, P. L. (1990). Use of standardized patients for
teaching and assessing clinical skills. Evaluation and the Health Profes-
sionals, 13, 79. http://dx.doi.org/10.1177/016327879001300105.
Tanner, C. (2006). Thinking like a nurse: A research-based model of clin-
ical judgment in nursing. Journal of Nursing Education, 45(6), 204-211.
Webster, D. (2014). Using standardized patients to teach therapeutic
communication in psychiatric nursing. Clinical Simulation in Nursing,
10(2), e81-e86.
Wilner, L. K., & Feinstein-Whittaker, M. (2013). Improving communica-
tion skills in healthcare, In: Perspectives on communication disorders
and sciences in culturally and linguistically diverse (CLD) populations.
Rockville, MD: ASHA.