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Nurse Education Today 33 (2013) 677–683

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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 significant (p ≤ 0.025) improvements on
IPCS total scores, interviewing, and counseling. However, there were no significant 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 significantly improved their IPCS by interviewing SPs, but future studies are needed to confirm 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 certification 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 benefits 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 influence 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 specific
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 finding 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;

2009. 2008. Students in the experimental group additionally received SP feedback according to the IPCS assessment tool immediately after their first interview with the SP and joined a faculty-led group discussion for an SP-interview video before the second assessment. rigorous experimental research with reliable and valid instruments is needed to support the evidence-based use of the SP method in IPCS nursing education. Participants in . and the development of scenarios. students were encouraged to raise their observations and inquiries about specific situations they encountered with SP. and meaningful. Rickles et al. who had attempted suicide the previous night and then had been taken to the emergency room by her father. 2011) shared her experience using SP as a teaching strategy for psychiatric and gerontological nurse practitioner students. Shawler (2008. from September through December 2009. Richardson et al... 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. Intervention All participants received a 2-hour instructional class consisting of theoretical knowledge and clinical skills of interpersonal relationships and communication. Positive and negative feedback to the students’ specific 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. Participants in the control group were only received the conventional instruction in classes and SP assessments. Lee et al. they found positive reciprocal learning in both student groups and advocated the cost-effectiveness of undergraduate student SPs. The APN graduate program was establish since 2008. 2009. 2006). These studies indicate that the SP method has been promisingly implemented in APN and undergraduate 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 fill 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. 2009. and outcome evaluation using videotaped review and discussion. The SP method used to teach clinical skills has generated much interest for nursing faculty to respond to the challenge (Tung 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. Six SPs were trained to interview with APN students in this study. and recruited all eligible students. were given a 2-day SP training course. This study contributed a well-designed experiment using SP methods as an alternative pedagogy as well as a method of performance assessment. 2011. Moulton et al. Based on the efficacy of SP teaching methods for learning IPCS in medical education. 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. Richardson et al. a growing number address the need for alternative and simulating teaching strategies. (2) had practiced or currently practice as a registered nurse for at least one year. They found significant increases in student confidence and perceived communication skills. however. During the group discussion. although there were no significant differences between the two groups in their IPCS or their knowledge of depression. From the qualitative data.. Participant Recruitment and Procedure Participants for this study met the following criteria: (1) first-year APN graduate students. immediately after. Lin 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. A block size and an allocation ratio were specified. / Nurse Education Today 33 (2013) 677–683 promotes a patient-centered approach. Manning and Kripalani. scenario demonstrations and role-playing. guidelines for standardized response statements. and 4 months after the end of the study. control (SP assessments only) – was conducted in the APN graduate program of the nursing department in a university in the middle of Taiwan. Yudkowsky et al. (2008) developed a patient communication simulation laboratory for 38 students in an acute care nurse practitioner program to evaluate students' perceived confidence and communication effectiveness before. In Taiwan. 2006. and were assessed in 15-minute interviews with the SP before and after the class. SP checklist worksheet.678 E.-L. Methods Design and Setting A pragmatic randomized controlled study using a two-group design – experimental (SP assessments with SP feedback and group discussion) vs. creative. However. Gibbons et al. It consisted of an introduction to SP pedagogy. a review of the literature on SP pedagogy (N = 69) found that only 4. 2009). Shawler... Of the 27 first-year APN graduates who were eligible. 26 agreed to participate and provided written informed consents. Rosenzweig et al. 2011. recruited from volunteer undergraduate nursing students. The SP scenario consisted of an 18-year-old female patient with a history of depression. and (3) agreed with the study purposes and procedures.3% were randomized studies (n = 3) and 15% were nursing-related (n = 10) compared with 73% physician-related (n = 51) (May et al. and the SP pedagogy was initiated in 2009. and methods for rating IPCS and providing feedback..C. 2009). and IPCS.. They were randomly assigned to either the experimental or the control group. She describe how to initiate SP scenarios. One of the authors (ECL). Becker et al. Although there are only few published articles on using the SP method in nursing. Randomization procedures were conducted by an independent assistant to produce the random numbers and completely conceal the randomized allocation in a closed opaque envelope. They reported that students who were taught using the SP method described the experience as positive. All students had been guaranteed that their performance in the study would have no influence on their course grade. and produces higher teaching and learning satisfaction for faculty and students (Becker et al. physical examinations. 2009). (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. 2007. Vessey and Huss (2002) retrospectively analyzed the videotapes of 26 APN students' one-time simulated clinical encounter with SPs. explained the purposes and procedures of the study. SP Training Six SP. The equipments for videotaping were set up in two interview rooms and 2 informatics technicians were standby around for the SP assessments. Randomization Block randomization was used to ensure an equal number of participants in each group. the faculty member in charge of the advanced communication class for the APN graduate 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.

all SP repeatedly practiced the scenario. body language. which was the least improved item on the second assessment. skills in counseling and delivering information (4 items). a self-reported questionnaire. the participants’ qualitative feedback for the SP pedagogy were read. Several quotations are presented because of their representativeness of the significance.. / Nurse Education Today 33 (2013) 677–683 this study were asked to initiate the first interview with the SP as an advanced practice nurse. Outcome Evaluation There were two outcome indicators: IPCS and learning satisfaction. One student. learning outcomes. There were no significant differences in demographics or baseline IPCS scores between the experimental and control groups. The equal IPCS improvements in both groups did not support the benefits of adding SP feedback and group discussion in the experimental group. and Spearman's rho correlation coefficient. It was translated into Chinese specifically for assessing the IPCS of APN graduate students in Taiwan. emotional reactions. 2006). Criteria evaluated include attentiveness. Mann–Whitney test. and a psychiatric instructor reviewed interview videos and independently rated the students’ IPCS performance using the IPS rating scale.85%). classified. Participants in the control group gave slightly higher scores than did those in the experimental group (8. and transition phrases. This dimension assesses the ability to demonstrate informational power. Three fourth-dimension items related to physical examinations in the original version are excluded because of the present study's IPCS focus. In a 2-day training course. The second dimension. abstracted. scoring rubric reliability. the effectiveness of outcome variables between the experimental and the control groups was analyzed using nonparametric statistical methods: the χ 2 test. Additionally. and to leave a patient with an understanding of what will happen next. 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. Marginally significant correlations were found between the SLS and the total IPCS scores at baseline in the control group (τ = 0. Because our sample was not dependent on a parametric model. Although all students agreed that SP pedagogy was beneficial for learning IPCS. The first IPS dimension. Results Twenty-seven eligible students were recruited.005). 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). Descriptive statistics of all variables were explored. A Mann–Whitney U test showed no significant difference between the experimental and control groups in baseline and post-test scores for each IPCS item (Table 3). said: “I didn't . The Spearman's rho nonparametric correlation coefficient between the IPCS rating scales and the SLS was calculated. 679 (2) Student learning satisfaction (SLS) scale. Lin et al.E. Each item was measured using a 4-point Likert scale with acceptable reliability (Cronbach's α = 0. Two outcome indicators are described as follows. assesses criteria such as an appropriate introduction. 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. The techniques and criteria of four IPS dimensions were identified by van Zanten et al. and demeanor in the encounter.63%). The content. Criteria for rating the first IPS dimension consisted of the effective use of open. and differences of the descriptions of their individual learning experience. The SLS (Mavis et al.and post-test scores in the experimental group. and categorized. All participants showed significant improvements on total IPCS scores and on the two items of interviewing and collecting information and counseling and delivering information (p = 0. which was videotaped.29. guided by the systematic classification process of qualitative content analysis. and demonstrated empathy and support for a patient's concerns. In addition.-L. learning satisfaction was measured only at the end of the study. experienced. but one refused to join the study and one member of the control group dropped out (dropout rate of all participants = 3. rapport. currently employed female nurses (Table 1).. with 11 years of working experience.77/8 = 84. focuses on the skills needed to check a patient's understanding. A psychiatric instructor led a group discussion of the videos and pointed out discrepancies. The reliability of SLS in the present study was acceptable (Kuder-Richardson coefficient of reliability [KR-20 = 0.and closed-ended questions. to link a patient's symptoms or concerns to closing information.047). and using verification. assesses the ability to establish a caring relationship with a patient. mood. 8. avoiding jargon. two students in control group expressed their negative experience about feeling frustrated during the interview. To capture the individual responses for this innovative pedagogy. p = 0. (1) Interpersonal skills (IPS) assessment tool. The fourth dimension. skills in counseling and delivering information.75%). rapport (4 items). segment summaries.025-0.61]). positive and negative learning experiences of the SP pedagogy were identified. All participants were middle-aged. according to students' written qualitative feedback. higher scores indicate a better IPCS performance. attitude. including eye contact and respect for personal space. 2007). which did not include a physical examination.58. The lowest score was for counseling and delivering information (12. all participants were encouraged to write down their specific feedback for the interviews with SP and related teaching activities after completing the questionnaire at the end of the study. The IPCS of all participants were assessed at baseline and at the completion of the study. is based on the techniques of patient-centered interviewing.12/16 = 75. and total IPCS scores and all items except interviewing and collecting information in the control group. The SPs rated all students' IPCS after the interviews. labeled. to be tactful. which was the most improved item. The maximum score was 56. It consists of 9 dichotomous questions. The SP practiced the scenario until they were all consistent. The highest score at baseline for all participants was for personal manner (6. skills in interviewing and collecting information. Table 2 showed the comparison between two groups in the preand post-test of IPCS scores. and personal manner (5 items). All students evaluated their learning experience after the final interview with the SP. skills performance.0 for Windows was used to analyze all data. The tool consists of four dimensions: skills in interviewing and collecting information (4 items). The interviewing and collecting information item showed a significant difference between pre. including student attitudes toward the SP pedagogy.C. The third dimension. perceived advantages of IPCS. personal manner.89). and validity of IPS were examined. but the difference was not significant. was modified from the original to evaluate our first-year students’ SLS. The instructor was blinded to students’ assigned groups. clarity of questions. All participants expressed extremely high SLS scores. and overall evaluation of the learning experience. similarities. Wilcoxon SignedRank test. to elicit a patient's feelings. for themselves and their instructors. Data Analysis The Statistical Package for Social Sciences 17. respectively).50 vs.

1. / Nurse Education Today 33 (2013) 677–683 Table 1 Characteristics of all participants (N = 26).07 (1.765 0. ⁎ p b 0. I learned how much I pushed my patients.374 3.80) 4 (15. IPCS total [full score: 56] All Experimental Control Dimension 1.80) 37.53) 45.17) 7.50a 0. Lin et al.70) 1 (3.30 −2.71 (4.33) 2 (16.453 5 (19.58 (4. Rapport [full score: 16] All Experimental Control Dimension 4.30) 0 (0) 76.082 0. Two students particularly mentioned their reflective and insightful experience from immediate SP feedback and group discussion as they reviewed the videotaped interview.29) 8 (57.70) 6 (23.10) 11.32 (1.00) 7 (58.83) 13.27 0.113 0. Group: Age (years) Mean (SD) Range 25–30 31–35 36–40 41–45 >45 Clinical experience (years) Mean (SD) Range ≤5 6–10 11–15 16–20 >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 (%) M–W U/χ2 p 36.16) 5–17 1 (8.025⁎ 0.04) 42.08) 31–51 0 (0) 4 (28.24 −1.32 (5.21(7.463 13.10) 1 (7.05.20) 1 (3.09 0. She was so depressed.13) 66.74 −2.23) 15 (57.75) 14.00(7.77 (1.30) 5–25 1 (3.41) 6.30) 3 (21.60) 14.1) 15 (57.6) 8 (57.91) 14.and post-test of two groups in interpersonal and communication skills (N = 26).42 (2.57) 3 (25.09 (6.035⁎ 6.58 (2.00 (1.67 Note.00) 9 (64.00 (2.13 0. SD.69) 6 (23.64 (1.00 (4.14 (1.11 0.023⁎ 12. Personal manner [full score: 8] All Experimental Control Notes.67) 2.40) 12.01) 50.04) 10–25 0 (0) 1 (7.048⁎ 0.30) 3 (25.64 (2.036⁎ 12.00) 11.78 −0.88 (2.12 (2.07) 13.00) 13 (50. The SP method is Table 2 Comparison between pre.00 (7.28) −1. Pre-test Mean (SD) Post-test Mean (SD) Wilcoxon signed-rank test Wilcoxon W p 44.57 (1.004⁎ 0.005⁎ 0.58 (8.24) 7.45 (0.34) 12. Mann–Whitney U test.29) 5 (35.70) 5 (19.09 −2. That made her very anxious and maybe made her hate to talk with me.680 E.50a 0.05.7) 2 (7.” “I should not have insisted that she look at me.81 −1. understand what was wrong with my communication and why the SP didn't answer me for both interviews.95 (4.92) 26–51 2 (7.00) 6 (50.50 (2.” All of these personal insights might increase their awareness of their behavioral deficiencies. standard deviation.19) 48.67) 0. 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.932 0.64) 14.53 −0. b χ2.0 (4.70) 2 (16.60 3.93 (1. 4. as well as increase their motivation to change.236 44.27 (2.84 −1.27 (4.02) 7.39) 12.10) 35. but they supported this is a valuable and meaningful learning experience. Counseling and delivering information [full score: 16] All Experimental Control Dimension 3.58(8.3) 1 (8.29 (2.34) 7.40) 15 (57.50 (1.08) 2 (14.53) 45.29 (2.36 (5.89b 0.73) 13.82) −1. standard deviation. That disappointed me.73 (2.020⁎ .705 b 0. They shared reflections from the group discussion: “I never understood the way I used to talk to others.41) −2.57) −2.45) 12.40) 1 (7.98 −1.145 b 0.50a 0.10) 9 (64.78b 0.52) −2.075 0.01) 13.61) 13.258 12.80) 15.125 0. a M–W U.C. SD. Three students felt some anxiety during the interviews.13) 49.00) 2 (16.84 (2.33 0.1) 1 (7.21 (7. 1.33) 8 (66. I need to show my self-confidence.” “I found that I wasn't speaking loudly enough to get my patient's trust.58 −2.60) 13.28 (1. When I watched my interview with the SP in the video.70) 0 (0) 55.04) 42.61) 26–41 2 (16.69 (2.-L.71) 4 (33.” The other negative feedback was accompanying by positive perspectives. Interviewing and collecting information [full score: 16] All Experimental Control Dimension 2.14) 4 (28. ⁎p b0. Discussion It is critically important to equip APNs with better IPCS in an increasingly complex healthcare delivery system.7) 7 (58.676 13 (50.

Seemingly.and posttests of IPCS in this study may also indicate that these two behavioral items were influenced by participants' attitudes and not easily outwardly displayed at skill-level. Interviewing and collecting information [full score: 16] Baseline Post-test Dimension 2. 2009. non-significant 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.41) 7. 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. the majority of studies on using SP pedagogy in the healthcare field reported outcomes with changes in knowledge. From the qualitative data.631 0. 2011). They urged that more rigorous studies with the emphasis of behavioral outcomes will lead to real changes in clinical practice and patient outcomes. there was no follow-up to determine the long-term effect of using the SP method. GROUP: IPCS total [full score: 56] Baseline Post-test Dimension 1.222 12.71 (4. 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.13) 50. this is the first randomized controlled study to use SP method to APN graduate students in learning IPCS (Gibbons et al. / Nurse Education Today 33 (2013) 677–683 681 Table 3 Comparison between two groups in interpersonal and communication skills and learning satisfaction (N = 26). Rosenzweig et al. With the difference using the SP feedbacks and group discussion for experimental group only.. 2. 2004.00 (2.64 (1. 2009.91) 12.07 (1. SD. (2008) recommended that reflective practice.99) 14.00 0. Teherani et al. Non-significant improvements on items of rapport and personal manner between pre. our findings replicated the effects of the SP assessment to improve the IPCS (Baer et al.01) 42.50 54.14 (1. This might have motivated our students to use sophisticated communication skills with patients in a difficult healthcare situation. which probably means that future studies will have to be multisite investigations.50 (2. Shawler.29 (1. in particular in the interviewing and counseling domains.00 0. showed significant behavioral improvements in the interviewing and counseling domains of all participants. Counseling and delivering information [full score: 16] Baseline Post-test Dimension 3.57) 63. but also the internalization of a caring value system.50 53.231 0. we developed a challenging SP scenario that was close to real clinical practice. But Teherani et al. the repeated SP assessment itself seemed to provide an opportunity for these experienced on-the-job APN graduate students to reflect on their first encounter with an SP. Fifth. However. our research design contained no control group without SP assessments: both groups were interviewed by the SP.64) 11.297 0.50 0.58 (8. there was unavoidable contamination between two groups: information exchanges easily took place and might have inflated the treatment effect for the control group.73 (2. and simulations can measure the learners' minimum behaviors or surface acting. to learn how to build a caring rapport and professional personal manner does not depend on superficial behavior-level regulation only. Lewy et al.04) 48. 2009.-L. 1. ⁎ p b 0. In addition to the potential effect from contamination of information exchange between the two groups and compensatory rivalry of the control group. Second.93 (1.50 (1.64 (1.29 (2. Fourth. 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 p 45.09 (6.34) 13. challenging cases.21 (7.. (2009). May et al. Consistent with the current positive evidence of SP effectiveness on IPCS.45 (0. we selected this pedagogy for these experienced on-the-job APN graduate students to learn and practice their IPCS in simulated reality. Rapport [full score: 16] Baseline Post-test Dimension 4. Limitations and Methodological Considerations There were several limitations to our study. 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 significantly improve their communication skills.82) 61.83) 14.00 0.374 0. 2009.. Wear and Varley. First. and the sample size needs to be increased in future studies. attitudes. 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. and to modify themselves to get a better response from the SP during the second assessment interview. . Third. Future studies with a larger sample size and specific outcome indicators need to examine the effectiveness of these adding teaching strategies in the present study.68) 8. 2002.647 8.979 12.373 13.29 (2.531 Note.58 (2. with a randomized controlled design aiming to explore this question.24) 7..50 (1. In this study. 2008). Lin et al. Richardson et al. Rickles et al. therefore. Mann–Whitney U test. this finding possibly resulted from an insufficient difference between the experimental and control groups.73) 12.58) 71.E.00 76.00 68..61) 13. standard deviation.57 (1.27 (2. According to May et al. 2006. recognized as innovative for teaching and learning clinical skills in healthcare education. our research design did not include a comparison without SP assessment because both experimental and control groups receiving SP assessments. To our knowledge.05.17) 6. and satisfaction of the learner..28) 60. (2008) said that these overt behaviors are basically required to provide care.00 60.00 0.41) 74. M–W U. 2008).75) 14.00 (1.50 0. generalizing the findings must be limited specifically to female APN students with moderate work experience. The present study.40) 13. It also hints that these two adding teaching strategies for experimental group might need to be strengthened.C.202 7.252 0..52) 66. and rater training to provide feedback can supplement and enrich using SP to cultivate and evaluate competence.

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