Clinical Simulation in Nursing (2014) 10, e81-e86

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Featured Article

Using Standardized Patients to Teach Therapeutic

Communication in Psychiatric Nursing
Debra Webster, EdD, RNBC, CNE*
Associate Professor and Associate Chair, Salisbury University, 1101 Camden Avenue, Salisbury, MD 21801 USA
KEYWORDS Abstract
standardized patients; Background: There is limited research into the effectiveness of standardized patient
teaching effectiveness; experiences (SPEs) to teach therapeutic communication skills in undergraduate psychiatric
psychiatric mental
nursing students. Method: A quasi-experimental, one-group, preepost evaluation design was
health simulation; used to examine the effectiveness of the use of SPEs to teach therapeutic communication
therapeutic skills in psychiatric nursing. Study participants included 89 senior nursing students enrolled
communication; in a psychiatric nursing clinical course in a baccalaureate nursing program.
communication skills; Results: Faculty provided formative evaluation on 14 criteria and group feedback early in the
nursing students; semester for students’ first interaction with a standardized patient (SP). During a second
quasi-experimental intervention at the end of the semester, with an SP, summative feedback was used to
research; evaluate the student using the same 14 criteria. Significant differences were noted in 12 of
training the 14 criteria demonstrating improvement in therapeutic communication skills.
Conclusion: Although further research is needed, this study suggests that the use of SPEs is
an effec-tive methodology for promoting therapeutic communication skills in undergraduate
psychiatric nursing students.

Cite this article:

Webster, D. (2014, February). Using standardized patients to teach therapeutic
communication in psy-chiatric nursing. Clinical Simulation in Nursing, 10(2), e81-e86.
http://dx.doi.org/10.1016/ j.ecns.2013.08.005.
2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier
Inc. All rights reserved.
 Effective communication skills are a core competency
for nurses. Without this essential skill, psychiatric nurses
are unable to build a therapeutic relationship and care for
individuals with mental illness. Providing students with
opportunities to practice therapeutic communication with
individuals with mental illness can often be a challenge for
nurse educators (Webster, 2010). Opportunities may be
limited due to decreased patient census, length of stay, and
* Corresponding author: dawebster@salisbury.edu (D. Webster).
an increase in the severity of the illness of hospitalized indi-
viduals. In addition, a patient may refuse, be considered too
dangerous or fragile, or refuse to work with a student. This
may result in encounters with only certain patient diagnoses
and no opportunity to interact with patients with common
psychiatric diagnoses. Nurse educators are therefore
challenged to substitute other clinical teaching strategies that
promote the use of therapeutic communication skills.
Simulation involving standardized patients (SPs) may be an
effective alternative method for teaching therapeutic
communication skills in psychiatric nursing.
1876-1399/$ - see front matter 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2013.08.005
Standardized Patients and Therapeutic Communication e82
 education. This includes the interpersonal process recording
In addition to providing clinical activities when there in which faculty provide feedback based on student
may be limited clinical options, SP experiences (SPEs) documentation of verbal communication, nonverbal behavior,
allow faculty to control the types of patient interactions and environmental influences from por-tions of interaction
(Founds, Zewe, & Scheuer, 2011; Parsh, 2010). This is of with the patient (Varcarolis & Halter, 2010). This may not be
great benefit, because providing a quality psychiatric the best method for teaching and evaluating therapeutic
nursing experience can be communication skills. Although the interpersonal process
further complicated by fac- recording allows the student to
tors such as patient confiden-
tiality, aggression, and
unpredictability (Hermanns,
Lilly, & Crawley, 2011). The
use of SPEs allows fac-ulty
to align clinical and di-dactic
teaching giving students an
opportunity to engage with a
variety of patient diagnoses,
including those with issues of
aggres-sion and
unpredictability. Students are
therefore able to practice in a
safe yet controlled
environment.

Although SPs have been

utilized to teach commu-nication in the field of medicine
for many years, their use in undergraduate nursing is still in
its infancy. With limited information re-garding the
effectiveness of SPEs as a teaching strategy in
undergraduate nursing
education, it is imperative

that nurse educators conduct research into this teaching

strategy that is quickly gaining momentum.

Literature Review

Strategies to Teach Communication

The nurseepatient relationship is at the foundation of

providing care to individuals with mental illness. The ability
to engage in therapeutic communication is crucial to building
this relationship. With scant literature to provide guidance into
how to best teach therapeutic communication skills (Webster,
Seldomridge, & Rockelli, 2012), faculty often use methods
similar to how they were taught during their own nursing

identify the type of communication technique utilized, it
may not be accurate and is subject to distortion, because the
student must rely on memory to document what was said
and to identify nonverbal behaviors (Varcarolis & Halter,
2010). Students may also document how they should have
responded instead of what they actually said, leading to
many missed teachingelearning opportunities. Because
faculty do not have the opportunity to directly observe an
entire studentepatient interaction in the psychi-atric setting,
students are evaluated on brief observations and written
assignments, including the interpersonal pro-cess
recording, both of which provide just a snapshot of the
student’s ability to use therapeutic communication skills.
Although the field of medicine has utilized SPs for many
years, nursing is in the early stages of utilizing SPs to teach
a variety of nursing skills. It has been suggested that
simulation using SPs can be an effective method of
teaching students therapeutic communication skills (Lang
& Hahn, 2013). Marken, Zimmerman, Kennedy,
Schremmer, and Smith (2010) had interdisciplinary teams
consisting of pharmacy, medical, and nursing students
engage with SPs to practice communication skills on the
difficult topics of child health issues, intimate partner
violence, and suicidal ideation. The authors concluded that
students gained confidence and improved communica-tion
skills as a result of practicing with SPs in a simulated
environment.
Role play was found to have a positive effect when the
communication of students receiving only didactic educa-
tion was compared with students who engaged in role play
after didactic education (Kesten, 2011). Experiential ap-
proaches including case studies and SPEs designed to
mimic reality offer students ‘‘real-world’’elike experiences
(Webster et al., 2012) provide other opportunities to learn
therapeutic communication skills. Using a case study com-
bined with an SP, students practiced communication in a
pi-lot activity designed to facilitate communication with
and care for individuals with posttraumatic stress disorder
(Webster et al., 2012). Students commented that they were
better prepared to care for individuals with posttrau-matic
stress disorder as a result of participating with SPs. Using
carefully designed SPEs, faculty are able to control the
type, complexity, and length of the interaction, which can
also be used to decrease the randomness of patient
encounters in the clinical setting (Becker, Rose, Berg, Park,
& Shatzer, 2006). Although high-fidelity simulations are
often used to allow students to practice technical skills, the
use of SPs adds to the authenticity of the experience
(Keltner, Grant, & McLeron, 2011) and may promote ther-
apeutic communication skills and empathy development.
In addition to self-evaluation, peer review has been used
to help students improve communication skills (Yoo &
Chae, 2011). In this study, students in an experimental
group watched each other’s videos and provided feedback;
those in the control group completed only self-evaluation.
pp e81-e86 Clinical Simulation in Nursing Volume 10 Issue 2
Standardized Patients and Therapeutic Communication e83
The researchers reported students who participated in peer
review had significantly better communication skills and
higher learning motivation than students who did not
partic-ipate in peer evaluation (Yoo & Chae, 2009).
Debriefing in groups as a form of peer review can be
utilized to facilitate discussion including strengths and
weaknesses allowing students to learn from one another.
This helps to better prepare students for interactions with
real patients and can also decrease the anxiety of working
with this challenging population. Individual and faculty-led
group debriefing can also be used to reinforce application
and provide further teaching of theory. When combined
with debriefing and reflection, the use of SPs to teach
therapeutic communication provides an active learning
environment in which knowledge and skills are translated
into practice (Marken et al., 2010).
Although there are many advantages to using SPEs,
evaluation of effectiveness as a teaching method is needed
(Keltner et al., 2011). It has been suggested that SPEs
create an active learning environment in which students are
able to make mistakes and refine skills based on feed-back
(Crider & McNiesh, 2011). Simulation has been shown to
be an effective alternative to traditional clinical
placements, allowing students to practice skills and experi-
ence situations similar to those experienced in actual
clinical practice (Schlairet & Pollock, 2010). Student self-
assessment (Becker et al., 2006) and peer review (Yoo &
Chae, 2011) help students to learn therapeutic communica-
tion and allow the refinement of student decision-making
and problem-solving skills in a controlled, safe, and
nonthreatening environment (Keltner et al., 2011). Debrief-
ing after SPEs has been noted as an essential component of
learning and should be used by faculty to provide
formative feedback to help students understand and apply
theory to practice (Billings & Halstead, 2009). Last, SPEs
can be de-signed to present a patient problem in a clinically
relevant and realistic way (Becker et al., 2006), allowing
faculty to target teaching and more accurately evaluate a
student’s communication skills. Similar interactions and
patient pre-sentation allows for standardization and greater
objectivity in the student evaluation process.
Study Purpose
The purpose of this study was to determine the effective-
ness of SPEs as a teaching modality to improve nursing
students’ use of therapeutic communication skills with
individuals with mental illness.
Method
This study used a quasi-experimental, one-group, preepost
evaluation using a 14-point checklist of criteria designed to
examine the effectiveness of the use of SPEs to teach
therapeutic communication skills in psychiatric nursing.
Sample
A convenience sample of 89 senior baccalaureate nursing
students enrolled in a psychiatric clinical course
voluntarily participated in the study. Participants ranged in
age from 20 to 60. The sample was made up of 78 (87.6%)
Caucasian, 5 (5.6%) African-American, and 6 (6.7%) other
students. There were 81 (91%) female and 8 (9%) male
participants in the group (8). Second degree students
comprised 27% and traditional students 73% of the sample.
Procedure
Students were voluntarily recruited from those enrolled in the
psychiatric nursing clinical course taught in the fall of each
academic year. Permission to conduct the research study was
granted by the university’s Human Subjects Research
Committee. A disclosure statement was provided, informing
participants of the purpose of the study and informed consent
was obtained. In addition, all participants including SPs gave
permission to be video-recorded for subsequent review and
critique by faculty and peers. Participants were able to
withdraw from the study at any time.
The Standardized Patient Experience
Ten paid SPs ranging from age 20 to 75 were recruited.
They included members of a local acting group, students
from theater and communication arts majors, and retired
nurses. Scripts were written and training conducted by two
expert psychiatric nursing faculty each with more than 20
years of clinical psychiatric nursing experience. Four
sessions each lasting 4 hours were conducted over a period
of 2 months, allowing ample time for SPs to view movies
and memorize scripts. Didactic content on mental illness,
symptoms, and presentation was taught during session one.
Detailed scripts with information about the case, common
symptoms, and questions SPs could expect from students
along with suggested responses were provided. The SPs
were given permission to improvise as long as they
maintained character and symptoms. Movies in which
professional actors accurately portrayed mental illness
were assigned for viewing and faculty-led discussions were
held in session two to discuss the movies. During sessions
two and three, faculty assumed the student role and SPs
practiced the scripts. The SPs were asked to self-reflect on
their own performance and to provide feedback to other
SPs. Faculty also provided feedback to assist SPs in
perfecting the performance. Session four was utilized to
video-record and critique SP performance.
Each student participated in two SPEs, one at the
beginning of the semester and one at the end of the
semester. During each SPE, they interacted with an SP who
had been trained to portray an individual with one of the
following diagnoses: Paranoid schizophrenia, bipolar
mania, depression with suicidal ideation, obsessive
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Standardized Patients and Therapeutic Communication e84

Table 1 Effectiveness of Standardized Patient Experiences (SPE) Evaluation Criteria (n ¼ 89)

Evaluation First SPE (mean) Second SPE (mean) t p
Approaches client using a nonthreatening body stance 1.45 1.27 1.237 .218
Introduces self 1.31 1.27 0.328 .743
*
Establishes eye contact, if appropriate 1.66 1.22 1.978 .049
*
Engages in efforts to put the patient at ease 2.06 1.42 2.978 .003
*
Maintains appropriate therapeutic boundaries 2.61 1.40 3.631 <.001
*
Assesses for safety 3.20 1.71 5.010 <.001
*
Responds appropriately, verbally and nonverbally to patient’s 2.49 1.78 2.930 .004
verbal statements
*
Responds appropriately to patient’s nonverbal behavior 2.82 1.58 4.898 <.001
*
Uses therapeutic communication techniques 2.01 1.57 2.610 .010
*
Sets limits on inappropriate behaviors 3.34 2.07 5.058 <.001
*
Validates meaning of patient’s response 2.85 1.63 3.749 <.001
*
Demonstrates anxious behaviors 3.26 4.46 1.969 .050
*
Summarizes content of interaction 2.93 1.82 4.627 <.001
*
Terminates interaction appropriately 2.26 1.63 2.491 .014
* p < .05.
compulsive disorder, borderline personality disorder, de-
mentia, or posttraumatic stress disorder. The 15- to 20-
minute sessions were video-recorded for later review by
students and faculty. The SPs randomly selected which
case to portray. Students did not receive any information
about the SPE before the event. Instead, they were only
told that they would be interacting with an SP and that they
would receive feedback from faculty on 14 expectations
that were provided before the interaction.
A multifaceted approach to student feedback and evalu-
ation was provided. The first SPE early in the semester was
utilized for formative feedback from faculty to assist the
students in developing therapeutic communication skills, and
the second SPE late in the semester was utilized for
summative feedback in which the student’s use of therapeu-tic
communication skills was graded. Students watched their
video and conducted a self-reflection of strengths and areas
for improvement. Students also identified the communica-tion
techniques utilized as well as a diagnostic evaluation of the
patient with supporting assessment data.
In addition to debriefing, review of video clips by
groups of six to eight students was conducted by faculty to
further teach communication concepts using a problem-
based learning approach. Many students identified
nonverbal behaviors that could lead to problems in
establishing a therapeutic nurseepatient relationship during
the first SPE, allowing them to make improvements during
their second SPE. Students also developed an awareness of
the SPs’ nonverbal behaviors and were more alert to safety
concerns during the second SPE. Students commented on
decreased anxiety and increased confidence during their
second SPE. Students also noted improvements, including
the use of therapeutic communication techniques,
congruency in ver-bal communication and nonverbal
behavior, providing patient teaching, and summarizing the
content of the interaction during their second SPE.
Faculty Feedback
Feedback from faculty consisted of a 14-point checklist of
criteria (Table 1). This criteria was rated on a 5-point Likert
scale of 1 (strongly agree) to 5 (strongly disagree) for each
criteria with the exception of demonstration of anxiety which
was rated on a reverse scale of 5 (strongly agree) to 1
(strongly disagree). Review of the video-recording dur-ing
small group debriefing by faculty and students also pro-vided
opportunity for peer review and further teaching of
therapeutic communication skills with a discussion of the
challenges of working with this patient population, as well as
reinforcement of theory and clinical application.
To maintain objectivity, faculty were trained on how to
properly use the evaluation tool to evaluate student perfor-
mance for each of the 14 identified areas. For example,
when students introduced themselves, it was an expectation
that they gave their name, stated that they were a nursing
student, and informed the patient how much time they
would spend with them during the session.
Results
Data were analyzed using SPSS version 20 (SPSS, Inc.,
Chicago, IL). Mean scores were computed for each
evaluation criteria and the faculty evaluation scores for the
first and second SPE were compared using a t-test for
independent samples. Significant differences were noted in
12 of the 14 evaluation criteria (Table 1).
Although students did not demonstrate significant
improvement on 2 of the 14 evaluation criteriadapproaching
client with a nonthreatening body stance and introducing
selfdthere was improvement noted for the two. Because the
means scores indicated that students performed well on these
two evaluation criteria during the initial SPE (mean, 1.45
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Standardized Patients and Therapeutic Communication e85
approaching client; mean, 1.31 introducing self), there was
little room for improvement during the second SPE (mean,
1.27 approaching client; mean, 1.27 introducing self).
Although student anxiety is expected to be high initially,
anxiety should decrease with repeated contact and
increased confidence in working with the mentally ill
population. Student anxiety was 3.26 for the initial SPE
and 4.46 on a scale of 5 (strongly agree) to 1 (strongly
disagree), indicating an overall decrease in student anxiety.
In addition to decreased anxiety, students demonstrated
significant improvement from the first to the second SPE in
all other evaluation criteria. There was improvement noted
in students’ ability to establish eye contact (mean, 1.66
initial; mean, 1.22, second SPE), suggesting increased
student comfort and confidence. There was also improve-
ment in the students’ ability to engage in efforts to put the
patient at ease (mean, 2.06 initial; mean, 1.42 second SPE),
suggesting a move away from focus on self and toward the
focus on the patient’s needs.
Patient safety is important in psychiatric nursing. As
such, safety assessments and the ability to set limits on
inappropriate behavior become paramount. Improvements
were noted for both of these competencies (safety assess-
ment: mean, 3.2 initial and 1.71 second SPE; and limit
setting: mean, 2.85 initial and 1.63 second SPE).
In building a therapeutic relationship, focus on the
patient and a genuine display of empathy must be present
(Varcarolis & Halter, 2010). The student should be able to
respond appropriately to the patient’s nonverbal behavior
and verbal statements using therapeutic communication
techniques. Improvements were also noted in all three of
these areas (using therapeutic communication techniques:
mean, 2.01 initial and 1.57 second SPE; responding appro-
priately to verbal statements: mean, 2.49 initial and 1.78
sec-ond SPE; and responding appropriately to nonverbal
behavior: mean, 2.82 initial and 1.58 second SPE).
The ability to validate the meaning of a patient’s
response is also important when working with individuals
with mental illness. This may help to further build the
relationship and establish understanding and empathy.
Improvement was also noted for this skill (mean, 2.85
initial and 1.63 second SPE).
Last, the appropriate termination of the session should
include what transpired during the interaction, a summari-
zation of patient concerns, and plans for the next course of
action, including teaching and follow-up care. Improvements
were also noted for these two areas (summarizing content of
interaction: mean 2.93 initial and 1.82 second SPE; termi-
nating appropriately: mean 2.26 initial and 1.63 second SPE).
Discussion
This study found that SPEs can be utilized to teach and assess
undergraduate nursing students’ use of therapeutic commu-
nication skills. Students reported satisfaction with the learning
experience and described an overall decrease in anxiety
during interactions with individuals with mental illness. Many
students commented they appreciated the opportunity to gain
experience communicating with a patient with a diagnosis that
they did not get the chance to interact with in the inpatient
psychiatric setting. Students also acknowledged that they
found practicing communication with a more difficult patient
in the simulated environment gave them the confidence they
needed to engage with ‘‘real patients.’’
Faculty satisfaction with the standardized presentation of
symptoms and objective method of evaluating the student was
reported. Faculty also commented on the importance of group
debriefing and found that although many students did not
want other students to see their video-recording, peer review
was a very important component of student learning and,
when carefully led by faculty, provided a means for students
to provide and receive peer feedback in a profes-sional
setting. Self-reflection was also noted to be an important
component of student learning.
Research using SPEs to teach therapeutic communica-
tion in undergraduate psychiatric nursing is very limited.
The findings from this study support the use of SPEs to
teach and evaluate therapeutic communication skills in
undergraduate nursing education. Future directions for this
project include an examination of interrater reliability of
SP and faculty feedback for high-stakes testing, providing
written feedback from SPs to students, and including the
SPs in debriefing sessions with students and faculty.
Comparison and control groups will also be utilized to
provide further insight into the effectiveness of the use of
SPs to teach and evaluate therapeutic communication. Pre-
and post-testing student knowledge of therapeutic commu-
nication skills is another option for further exploration of
the effectiveness of this teaching strategy.
Limitations
In this study, one limitation related to the small sample
size. In addition, participants were not randomly selected,
but were a convenience sample. There was no comparison
using control and comparison groups. Although all students
were provided didactic course content in the same manner,
it is possible that other confounding variables could have
been responsible for some of the noted improvements. For
example, some students may have been influenced by
personal experience or prior course work in psychology. In
addition, clinical experiences with mentally ill patients in
the outpatient and inpatient acute settings between the first
and second SPE may have led to some of the noted
improvement in therapeutic communication skills. It is also
important to take into consideration that knowledge of the
rating scale may have influenced improvements.
Additional research is therefore needed to determine all
influencing variables. Furthermore, reliability of the
evaluation tool has not yet been established.
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Standardized Patients and Therapeutic Communication e86
 In conclusion, using SPEs as a clinical teaching method
allows a unique way for students to develop communication
skills and for faculty to evaluate performance in an objective
manner. This simulation utilized SPEs to teach therapeutic
communication skills in a controlled, safe and nonthreatening
learning environment. Debriefing, self-reflection, and peer
review helped students to further enhance therapeutic
communication skills. Student and faculty response to this
learning activity was positive.
As faculty continue to develop SPEs, additional data
need to be collected to establish the effectiveness of this
growing teaching methodology, especially if high-stakes
testing is utilized. Although much research has been
conducted in the field of medicine showing that SPs are an
effective way to teach communication and assessment
skills, research on the use of SPs to teach therapeutic
communication skills in undergraduate nursing is limited.
Evaluating the effectiveness of any teaching strategy is a
necessary component in providing quality nursing educa-
tion. Continued research and valid evaluation instruments
are needed. This will help nurse educators to determine the
best strategies to teach therapeutic communication skills in
undergraduate psychiatric mental health nursing. This may
also lead to the use of alternative clinical teaching strate-
gies that are most effective in helping students to apply
theory in practice. As nurse educators seek high-quality
educational strategies to teach communication, SPEs may
be one such strategy. Additional research will also help to
provide insight into how to better facilitate the develop-
ment of a therapeutic relationship and improve care for
individuals with mental illness. The use of well-planned
SPEs by nurse educators can provide alternative clinical
learning activities to ensure that students have the assess-
ment knowledge and communication skills to provide care
that is therapeutic and safe. As such, well-prepared
psychiatric nurses will enter the profession.
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