Nurse Education Today 33 (2013) 677–683

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Using standardized patient with immediate feedback and groupdiscussion to teach interpersonal and communication skills to advancedpractice nursing students

Esther Ching-Lan Lin a,⁎, Shiah-Lian Chen b, Shu-Yuan Chao b, Yueh-Chih Chen b

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

⁎ Corresponding author at: 1 University Road, Tainan235 3535x5038; fax: +886 6 237 7550.

E-mail address: chinglan@mail.ncku.edu.tw (E.C.-L.

0260-6917/$ – see front matter © 2012 Elsevier Ltd. Alldoi:10.1016/j.nedt.2012.07.002

s u m m a r y

a r t i c l e i n f o

Article history:

Accepted 5 July 2012

Keywords:Interpersonal and communication skillsAdvanced practice nurseStandardized patient

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 ped-agogy in medical and healthcare education; however, its effectiveness for teaching IPCS to graduate nursingstudents remains unclear.Objectives:We examined the effectiveness of using SP with SP feedback and group discussion to teach IPCS ingraduate 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 andgroup discussion) or control (SP assessments only) group. There were two outcome indicators: IPCS and stu-dent 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 significant (p ≤ 0.025) improvements onIPCS total scores, interviewing, and counseling. However, there were no significant differences betweengroups. 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 signifi-cantly improved their IPCS by interviewing SPs, but future studies are needed to confirm the effectiveness ofSP feedback and group discussions.

© 2012 Elsevier Ltd. All rights reserved.

Introduction

Good interpersonal and communication skills (IPCS) are beingemphasized more than ever in healthcare delivery systems (Maviset al., 2006; Moulton et al., 2009; van Zanten et al., 2007; Wear andVarley, 2008; Weidner et al., 2010; Yudkowsky et al., 2006). It has be-come a basic competency for medical education (Laidlaw and Hart,2011; van Zanten et al., 2007; Weidner et al., 2010), and has been in-cluded as the primary criterion in the licensing and certification ex-aminations in many countries (Boulet et al., 2009; Kozu, 2006; Liuand Tseng, 2011). Accumulated evidence supports the notion thatpoor IPCS results in inadequate relationships between clients andcare providers, increased dissatisfaction and complaints, malpracticeclaims, 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

City 701, Taiwan. Tel.: +886 6

Lin).

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IPCS often yield win-win benefits for clients, families, physicians, andthe 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). TeachingIPCS traditionally in classrooms may increase students’ knowledge ofIPCS and improve their performance on objective tests, but it generallydoes not facilitate student motivation or influence their attitudesabout perfecting their IPCS (Emmanuel et al., 2010; Xie et al., inpress). The standardized patient (SP) method has been considered in-novative and promising for IPCS education (Luctkar-Flude et al., 2012;Shawler, 2011).

SPs are simulated or actual patients trained to portray a specificclinical scenario in a standardized manner, and SP-based assessmentshave been used as part of formative evaluation activities (Barrows,1993, 2000). Numerous studies support the finding that SP pedagogyprovides learners with interactive opportunities for repeated practice;increases clinical knowledge; improves communication, interviewskills, and advanced clinical performance on diagnostic reasoning;

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promotes a patient-centered approach; and produces higher teachingand 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 SPpedagogy (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 SPmethod in nursing, a growing number address the need for alterna-tive and simulating teaching strategies. Vessey and Huss (2002) ret-rospectively analyzed the videotapes of 26 APN students' one-timesimulated clinical encounter with SPs. They concluded that usingSPs in simulated clinical encounters for summative evaluationsshowed the method's lack of reliability and validity but its usefulnessfor formative learning. Gibbons et al. (2002) found that APN students(n=21) who had completed a 9-week Health Assessment courseusing SPs showed superior performance in their physical examinationskills and greater satisfaction with their learning experience than didstudents (n=35) in the previous year's class without SPs. Shawler(2008, 2011) shared her experience using SP as a teaching strategyfor psychiatric and gerontological nurse practitioner students. Shedescribe how to initiate SP scenarios, and the development of sce-narios, guidelines for standardized response statements, SP checklistworksheet, and outcome evaluation using videotaped review and dis-cussion. Rosenzweig et al. (2008) developed a patient communicationsimulation laboratory for 38 students in an acute care nurse practi-tioner program to evaluate students' perceived confidence and com-munication effectiveness before, immediately after, and 4 monthsafter the end of the study. They found significant increases in studentconfidence and perceived communication skills. Richardson et al.(2009) described an innovative strategy that used 20 undergraduatenursing student volunteers to act as SPs to assess the performanceof 22 APN students on history taking, physical examinations, andIPCS. From the qualitative data, they found positive reciprocal learn-ing in both student groups and advocated the cost-effectiveness ofundergraduate student SPs. Becker et al. (2006) conducted a random-ized controlled pilot study to compare the SP method (n=58) withthe traditional instructive method (n=89) of teaching therapeuticcommunication skills in a class of undergraduate nursing students.They reported that students who were taught using the SP methoddescribed the experience as positive, creative, and meaningful, al-though there were no significant differences between the twogroups in their IPCS or their knowledge of depression. This studycontributed a well-designed experiment using SP methods as an al-ternative pedagogy as well as a method of performance assessment.These studies indicate that the SP method has been promisinglyimplemented in APN and undergraduate education; however, rigor-ous experimental research with reliable and valid instruments isneeded to support the evidence-based use of the SP method in IPCSnursing education.

In Taiwan, the role of APN in the healthcare delivery system isincreasingly demanding and bringing several challenges in the evo-lution of a nursing education master's degree program. It is crucialto equip APN students with advanced IPCS because advanced prac-tice nurses are expected to coordinate and communicate well withall related stakeholders in a complex healthcare delivery system(Hamric et al., 2009). The SP method used to teach clinical skillshas generated much interest for nursing faculty to respond to thechallenge (Tung et al., 2009). Based on the efficacy of SP teachingmethods for learning IPCS in medical education, we designed anopportunity for our APN students to learn and improve their IPCSby interacting with SPs. This randomized-controlled study wasintended to fill the gap in the existing literature on the effectivenessof using SP with SP feedback and group discussion to teach IPCS ingraduate nursing education.

Methods

Design and Setting

A pragmatic randomized controlled study using a two-groupdesign – experimental (SP assessments with SP feedback and groupdiscussion) vs. control (SP assessments only) – was conducted inthe APN graduate program of the nursing department in a universityin the middle of Taiwan, from September through December 2009.The APN graduate program was establish since 2008, and the SP ped-agogy was initiated in 2009. The equipments for videotaping were setup in two interview rooms and 2 informatics technicians were stand-by around for the SP assessments. Six SPs were trained to interviewwith APN students in this study.

Participant Recruitment and Procedure

Participants for this study met the following criteria: (1) first-yearAPN graduate students; (2) had practiced or currently practice as aregistered nurse for at least one year; and (3) agreed with the studypurposes and procedures. One of the authors (ECL), the faculty mem-ber in charge of the advanced communication class for the APN grad-uate program, explained the purposes and procedures of the study,and recruited all eligible students. Of the 27 first-year APN graduateswho were eligible, 26 agreed to participate and provided written in-formed consents. They were randomly assigned to either the experi-mental or the control group. All students had been guaranteed thattheir performance in the study would have no influence on theircourse grade.

Randomization

Block randomization was used to ensure an equal number of par-ticipants in each group. A block size and an allocation ratio were spec-ified. Randomization procedures were conducted by an independentassistant to produce the random numbers and completely concealthe randomized allocation in a closed opaque envelope.

Intervention

All participants received a 2-hour instructional class consisting oftheoretical knowledge and clinical skills of interpersonal relation-ships and communication, andwere assessed in 15-minute interviewswith the SP before and after the class. Participants in the control groupwere only received the conventional instruction in classes and SPassessments.

Students in the experimental group additionally received SP feed-back according to the IPCS assessment tool immediately after theirfirst interview with the SP and joined a faculty-led group discussionfor an SP-interview video before the second assessment. During thegroup discussion, students were encouraged to raise their observa-tions and inquiries about specific situations they encountered withSP. Positive and negative feedback to the students’ specific IPCSwere provided by students and faculty whose goal was to make thestudents aware of their helpful and unhelpful IPCS behaviors and tofacilitate 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 introductionto SP pedagogy, scenario demonstrations and role-playing, andmethods for rating IPCS and providing feedback. The SP scenarioconsisted of an 18-year-old female patient with a history of depres-sion, who had attempted suicide the previous night and then hadbeen taken to the emergency room by her father. Participants in

679E.C.-L. Lin et al. / Nurse Education Today 33 (2013) 677–683

this study were asked to initiate the first interview with the SP as anadvanced practice nurse. In a 2-day training course, all SP repeatedlypracticed the scenario, which was videotaped, for themselves andtheir instructors. A psychiatric instructor led a group discussion ofthe videos and pointed out discrepancies. The SP practiced the sce-nario until they were all consistent.

Outcome Evaluation

There were two outcome indicators: IPCS and learning satisfac-tion. The IPCS of all participants were assessed at baseline and atthe completion of the study; learning satisfaction was measuredonly at the end of the study. To capture the individual responses forthis innovative pedagogy, all participants were encouraged to writedown their specific feedback for the interviews with SP and relatedteaching activities after completing the questionnaire at the end ofthe study. Two outcome indicators are described as follows.

(1) Interpersonal skills (IPS) assessment tool. The IPS assessmenttool was developed to measure doctor-patient relationshipskills and associated behaviors of foreign medical graduatesin the USA (van Zanten et al., 2007). The content, scoring rubricreliability, and validity of IPS were examined. It was translatedinto Chinese specifically for assessing the IPCS of APN graduatestudents in Taiwan. The tool consists of four dimensions: skillsin interviewing and collecting information (4 items), skills incounseling and delivering information (4 items), rapport (4items), and personal manner (5 items). The techniques andcriteria of four IPS dimensions were identified by van Zantenet al. The first IPS dimension, skills in interviewing and collectinginformation, is based on the techniques of patient-centeredinterviewing. This dimension includes both a nondirectivecomponent (encouraging patients to express themselves intheir own words) and a directive component (asking directedquestions aimed at better understanding personal informationand testing hypotheses). Criteria for rating the first IPS dimen-sion consisted of the effective use of open- and closed-endedquestions, clarity of questions, avoiding jargon, and using ver-ification, segment summaries, and transition phrases. The sec-ond 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 clos-ing information, and to leave a patient with an understandingof what will happen next. This dimension assesses the abilityto demonstrate informational power, to elicit a patient's feel-ings, and to subsequently make explanations and recommen-dations that are clearly linked to the patient's concerns andto allow the patient to be involved in the decision-making pro-cess. The third dimension, rapport, assesses the ability to estab-lish a caring relationship with a patient. Criteria evaluatedinclude attentiveness, attitude, body language, including eyecontact and respect for personal space, and demonstratedempathy and support for a patient's concerns. The fourth di-mension, personal manner, assesses criteria such as an appro-priate introduction, mood, and demeanor in the encounter.Three fourth-dimension items related to physical examina-tions in the original version are excluded because of the pres-ent study's IPCS focus, which did not include a physicalexamination. Each item was measured using a 4-point Likertscale with acceptable reliability (Cronbach's α=0.89). Themaximum score was 56; higher scores indicate a better IPCSperformance. The SPs rated all students' IPCS after the inter-views, and a psychiatric instructor reviewed interview videosand independently rated the students’ IPCS performanceusing the IPS rating scale. The instructor was blinded tostudents’ assigned groups.

(2) Student learning satisfaction (SLS) scale. The SLS (Mavis et al.,2006), a self-reported questionnaire, was modified from theoriginal to evaluate our first-year students’ SLS. It consists of9 dichotomous questions, including student attitudes towardthe SP pedagogy, skills performance, learning outcomes, emo-tional reactions, perceived advantages of IPCS, and overall eval-uation of the learning experience. The reliability of SLS in thepresent study was acceptable (Kuder-Richardson coefficientof reliability [KR-20=0.61]). All students evaluated theirlearning experience after the final interview with the SP.

Data Analysis

The Statistical Package for Social Sciences 17.0 for Windows wasused to analyze all data. Descriptive statistics of all variables wereexplored. Because our sample was not dependent on a parametricmodel, the effectiveness of outcome variables between the experi-mental and the control groups was analyzed using nonparametric sta-tistical methods: the χ2 test, Mann–Whitney test, Wilcoxon Signed-Rank test, and Spearman's rho correlation coefficient.

In addition, guided by the systematic classification process of quali-tative content analysis, the participants’ qualitative feedback for the SPpedagogy were read, classified, abstracted, labeled, and categorized.Several quotations are presented because of their representativenessof the significance, similarities, and differences of the descriptions oftheir individual learning experience.

Results

Twenty-seven eligible students were recruited, but one refused tojoin the study and onemember of the control group dropped out (drop-out rate of all participants=3.85%). All participants were middle-aged,experienced, currently employed female nurses (Table 1). There wereno significant differences in demographics or baseline IPCS scoresbetween the experimental and control groups.

Table 2 showed the comparison between two groups in the pre-and post-test of IPCS scores. The highest score at baseline for all par-ticipants was for personal manner (6.77/8=84.63%), which was theleast improved item on the second assessment. The lowest scorewas for counseling and delivering information (12.12/16=75.75%),which was the most improved item. All participants showed signifi-cant improvements on total IPCS scores and on the two items ofinterviewing and collecting information and counseling and deliveringinformation (p=0.025-0.005). The interviewing and collecting infor-mation item showed a significant difference between pre- andpost-test scores in the experimental group, and total IPCS scoresand all items except interviewing and collecting information in the con-trol group. A Mann–Whitney U test showed no significant differencebetween the experimental and control groups in baseline andpost-test scores for each IPCS item (Table 3). The equal IPCS improve-ments in both groups did not support the benefits of adding SP feed-back and group discussion in the experimental group.

All participants expressed extremely high SLS scores. Participantsin the control group gave slightly higher scores than did those inthe experimental group (8.50 vs. 8.29, respectively), but the differ-ence was not significant. The Spearman's rho nonparametric correla-tion coefficient between the IPCS rating scales and the SLS wascalculated. Marginally significant correlations were found betweenthe SLS and the total IPCS scores at baseline in the control group(τ=0.58, p=0.047).

Additionally, according to students' written qualitative feedback,positive and negative learning experiences of the SP pedagogy wereidentified. Although all students agreed that SP pedagogy was benefi-cial for learning IPCS, two students in control group expressed theirnegative experience about feeling frustrated during the interview.One student, with 11 years of working experience, said: “I didn't

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

Group: Alln (%)

Experimental(n=14)n (%)

Control(n=12)n (%)

M–WU/χ2

p

Age (years)Mean (SD) 36.27 (4.92) 37.36 (5.08) 35.0 (4.61) 76.50a 0.705Range 26–51 31–51 26–4125–30 2 (7.70) 0 (0) 2 (16.70) 3.60b 0.46331–35 6 (23.1) 4 (28.6) 2 (16.7)36–40 15 (57.7) 8 (57.1) 7 (58.3)41–45 2 (7.70) 1 (7.10) 1 (8.30)>45 1 (3.80) 1 (7.10) 0 (0)

Clinical experience (years)Mean (SD) 13.58 (4.30) 15.00 (4.04) 11.95 (4.16) 55.50a 0.145Range 5–25 10–25 5–17≤5 1 (3.80) 0 (0) 1 (8.30) 3.67b 0.4536–10 4 (15.40) 1 (7.10) 3 (25.00)11–15 15 (57.70) 9 (64.30) 6 (50.00)16–20 5 (19.20) 3 (21.40) 2 (16.70)>20 1 (3.80) 1 (7.10) 0 (0)

Current employment positionAdministrator 5 (19.23) 2 (14.29) 3 (25.00) 0.78b 0.676Clinician 15 (57.69) 8 (57.14) 7 (58.33)Clinical instructor 6 (23.08) 4 (28.57) 2 (16.67)

Marital statusMarried 13 (50.00) 9 (64.29) 4 (33.33) 2.89b 0.236Unmarried 13 (50.00) 5 (35.71) 8 (66.67)

IPCS total at baselineMean (SD) 44.00(7.53) 45.21(7.04) 42.58(8.13) 66.50a 0.374

Note. 1. SD, standard deviation.a M–W U, Mann–Whitney U test.b χ2; 4. ⁎p b0.05.

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understand what was wrong with my communication and why the SPdidn't answer me for both interviews. That disappointed me.”

The other negative feedback was accompanying by positive per-spectives. Three students felt some anxiety during the interviews,but they supported this is a valuable and meaningful learning experi-ence. Two students particularly mentioned their reflective andinsightful experience from immediate SP feedback and group discus-sion as they reviewed the videotaped interview. They shared reflec-tions from the group discussion: “I never understood the way I usedto talk to others. When I watched my interview with the SP in thevideo, I learned how much I pushed my patients. I found that I justfocused on my own tasks and asked the questions I wanted answered

Table 2Comparison between pre- and post-test of two groups in interpersonal and communication

Pre-tMean

IPCS total [full score: 56]All 44.00Experimental 45.21Control 42.58

Dimension 1. Interviewing and collecting information [full score: 16]All 12.42Experimental 12.29Control 12.58

Dimension 2. Counseling and delivering information [full score: 16]All 12.12Experimental 12.64Control 11.50

Dimension 3. Rapport [full score: 16]All 12.69Experimental 13.29Control 12.00

Dimension 4. Personal manner [full score: 8]All 6.77Experimental 7.00Control 6.50

Notes. 1. SD, standard deviation.⁎ pb0.05.

without being concerned about the SP's anxiety and discomfort at thatmoment.” “I should not have insisted that she look at me. She was sodepressed. That made her very anxious and maybe made her hate totalk with me.” “I found that I wasn't speaking loudly enough to get mypatient's trust. I need to show my self-confidence.” All of these personalinsights might increase their awareness of their behavioral deficien-cies, as well as increase their motivation to change.

Discussion

It is critically important to equip APNs with better IPCS in an in-creasingly complex healthcare delivery system. The SP method is

skills (N=26).

est(SD)

Post-testMean (SD)

Wilcoxon signed-rank test

Wilcoxon W p

(7.53) 49.32 (5.19) −2.81 0.005⁎

(7.04) 48.71 (4.01) −1.58 0.113(8.13) 50.09 (6.52) −2.09 0.036⁎

(2.45) 13.84 (2.01) −2.24 0.025⁎

(2.40) 13.93 (1.73) −1.98 0.048⁎

(2.61) 13.73 (2.41) −1.13 0.258

(2.39) 14.32 (1.60) −2.84 0.004⁎

(2.00) 14.07 (1.64) −1.74 0.082(2.75) 14.64 (1.57) −2.27 0.023⁎

(2.60) 13.88 (2.07) −1.78 0.075(2.34) 13.57 (1.91) −0.30 0.765(2.83) 14.27 (2.28) −2.11 0.035⁎

(1.34) 7.28 (1.02) −1.53 0.125(1.41) 7.14 (1.17) −0.09 0.932(1.24) 7.45 (0.82) −2.33 0.020⁎

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

GROUP: Experimental(n=14)Mean (SD)

Control(n=12)Mean (SD)

M-W U p

IPCS total [full score: 56]Baseline 45.21 (7.04) 42.58 (8.13) 66.50 0.374Post-test 48.71 (4.01) 50.09 (6.52) 54.00 0.222

Dimension 1. Interviewing and collecting information [full score: 16]Baseline 12.29 (2.40) 12.58 (2.61) 74.00 0.631Post-test 13.93 (1.73) 13.73 (2.41) 76.00 0.979

Dimension 2. Counseling and delivering information [full score: 16]Baseline 12.64 (1.99) 11.50 (2.75) 63.00 0.297Post-test 14.07 (1.64) 14.64 (1.57) 60.50 0.373

Dimension 3. Rapport [full score: 16]Baseline 13.29 (2.34) 12.00 (2.83) 60.50 0.231Post-test 13.57 (1.91) 14.27 (2.28) 53.00 0.202

Dimension 4. Personal manner [full score: 8]Baseline 7.00 (1.41) 6.50 (1.24) 61.00 0.252Post-test 7.14 (1.17) 7.45 (0.82) 68.00 0.647

Self-reported Students' learning satisfaction [full score: 9]Post-test 8.29 (1.68) 8.50 (1.58) 71.50 0.531

Note. 1. SD, standard deviation; 2. M–W U, Mann–Whitney U test.⁎ pb0.05.

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recognized as innovative for teaching and learning clinical skills inhealthcare education; therefore, we selected this pedagogy for theseexperienced on-the-job APN graduate students to learn and practicetheir IPCS in simulated reality. The results of our study support thenotion that the SP method for IPCS assessments produces high levelsof learning satisfaction and helps APN graduate students significantlyimprove their communication skills. To our knowledge, this is thefirst randomized controlled study to use SP method to APN graduatestudents 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 SPpedagogy in the healthcare field reported outcomes with changes inknowledge, attitudes, and satisfaction of the learner. They urged thatmore rigorous studies with the emphasis of behavioral outcomeswill lead to real changes in clinical practice and patient outcomes.The present study, with a randomized controlled design aiming toexplore this question, showed significant behavioral improvementsin the interviewing and counseling domains of all participants. Someresearchers have argued that IPCS behaviors may be outwardlydisplayed just for “positive evaluation” or according to social desirabil-ity 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 basicallyrequired to provide care, and simulations can measure the learners'minimum behaviors or surface acting. Non-significant improvementson items of rapport and personal manner between pre- and post-tests of IPCS in this study may also indicate that these two behavioralitems were influenced by participants' attitudes and not easily out-wardly displayed at skill-level. Seemingly, to learn how to build acaring rapport and professional personal manner does not dependon superficial behavior-level regulation only, but also the internaliza-tion of a caring value system.

Teherani et al. (2008) recommended that reflective practice, chal-lenging cases, and rater training to provide feedback can supplementand enrich using SP to cultivate and evaluate competence. In thisstudy, we developed a challenging SP scenario that was close to realclinical practice. This might have motivated our students to use so-phisticated communication skillswith patients in a difficult healthcaresituation. From the qualitative data, the repeated SP assessment itselfseemed to provide an opportunity for these experienced on-the-jobAPN graduate students to reflect on their first encounter with an SP,

and to modify themselves to get a better response from the SP duringthe second assessment interview.

Consistent with the current positive evidence of SP effectivenesson IPCS, our findings replicated the effects of the SP assessment to im-prove the IPCS (Baer et al., 2004; Lewy et al., 2009; Rickles et al., 2009;Rosenzweig et al., 2008), in particular in the interviewing andcounseling domains. However, non-significant differences betweenthe experimental and control groups did not support our hypothesisof the effectiveness of adding immediate SP feedback and faculty-led group discussion of the videotaped SP interviews. In addition tothe potential effect from contamination of information exchange be-tween the two groups and compensatory rivalry of the controlgroup, this finding possibly resulted from an insufficient differencebetween the experimental and control groups. With the differenceusing the SP feedbacks and group discussion for experimental grouponly, our research design did not include a comparison without SP as-sessment because both experimental and control groups receiving SPassessments. It also hints that these two adding teaching strategiesfor experimental group might need to be strengthened. More trainingfor our undergraduate student SP to provide immediate feedbacksand more emphasis on these APN students' internalization processfor learning IPCS might enlarge the effect of SP-related pedagogy. Fu-ture studies with a larger sample size and specific outcome indicatorsneed to examine the effectiveness of these adding teaching strategiesin the present study.

Limitations and Methodological Considerations

There were several limitations to our study. First, our research de-sign contained no control group without SP assessments: both groupswere interviewed by the SP. Second, there was unavoidable contam-ination between two groups: information exchanges easily tookplace and might have inflated the treatment effect for the controlgroup. Third, compensatory rivalry of the control group in our studyseemed to affect post-test performance and interfere with our effortsto detect the real effects of conventional intervention. Fourth, gener-alizing the findings must be limited specifically to female APN stu-dents with moderate work experience, and the sample size needs tobe increased in future studies, which probably means that futurestudies will have to be multisite investigations. Fifth, there was nofollow-up to determine the long-term effect of using the SP method.

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And last, because our SP were undergraduate students asked to rateand provide feedback on the IPCS performance of senior and graduatestudents, a few of them felt stressful during the process. More prac-tice might improve their confidence and encourage them to learnmutually from the process by providing their observations from theinterview, or perhaps it would be better to use undergraduates fromother departments or the lay people so that the SPs won't feelcowed by having to assess what are in our age-graded hierarchical so-ciety their seniors and superiors.

Implications

Based on our findings, we conclude that the SP assessment meth-od is innovative and promising for providing IPCS education to APNstudents, in particular in the interviewing and counseling domains.This evidence of the effectiveness of SP pedagogy with APN studentswill encourage nursing faculty not only to use this pedagogy in theirteaching practice and to assess their students’ IPCS, but also to con-duct further rigorous studies to increase the evidence that it is worth-while. For example, the effectiveness of additional teaching strategiesin the present study, including feedback from SP and faculty-ledgroup discussion, need to be examined in the future studies with alarger sample size and multiple outcome indicators. Epstein (2007)suggested there was no single assessment that has been or shouldbe used to measure different intrapersonal and interpersonal compe-tencies (knowledge, attitudes, and skills). SP assessment could be in-corporated with other aspects of skill evaluations. Furthermore, usingSP pedagogy to teach interprofessional communication may extendour positive outcomes in teaching advanced level communicationskills to APN students so that they can collaborate with other disci-plines as a team, which is crucial for APN practice.

Conclusion

This is the first randomized controlled study to examine the effectof using the SP method to teach IPCS to APN graduate students. Itprovides evidence to support the notion that SP methods producedsignificant improvements in specific communication skills as well ashigh learning satisfaction for APN students. The insignificant differ-ence between the experimental (SP assessments with SP feedbackand group discussion) and control (SP assessments only) groupswas insufficient to support the effectiveness of SP feedbacks andgroup discussion. However, our findings highlighted the need for fur-ther research on the use of SP in teaching and learning the clinicalskills of nursing education, in particular in an APN program.

Because of its positive effects on patient outcomes, good interper-sonal and communication competence has been emphasized morethan ever in healthcare delivery systems. Meanwhile, the APN role isincreasingly demanding in many countries, an advanced practicenurse who has mastered IPCS will be able to exhibit their high-levelprofessional skills and better market themselves in the world's highlycomplex and currently resource-constrained healthcare delivery sys-tems. For nursing educators today who face numerous challenges inthe evolution of nursing education, using an evidence-based pedagogyto improve advanced practice nurses’ IPCS is crucial. The SP method ismore innovative than traditional classroom and textbook-based peda-gogy, and demonstrably more satisfying to students and teachers.

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