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 experiences
teaching effectiveness; (SPEs) to teach therapeutic communication skills in undergraduate psychiatric nursing students.
psychiatric mental Method: A quasi-experimental, one-group, preepost evaluation design was used to examine the
health simulation; effectiveness of the use of SPEs to teach therapeutic communication skills in psychiatric nursing. Study
therapeutic participants included 89 senior nursing students enrolled in a psychiatric nursing clinical course in a
communication; baccalaureate nursing program.
communication skills; Results: Faculty provided formative evaluation on 14 criteria and group feedback early in the semester
nursing students; for students’ first interaction with a standardized patient (SP). During a second intervention at the end
quasi-experimental of the semester, with an SP, summative feedback was used to evaluate the student using the same
research; 14 criteria. Significant differences were noted in 12 of the 14 criteria demonstrating improvement
training 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.
Ó 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 Ó 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

In addition to providing clinical activities when there identify the type of communication technique utilized, it
may be limited clinical options, SP experiences (SPEs) may not be accurate and is subject to distortion, because
allow faculty to control the types of patient interactions the student must rely on memory to document what was
(Founds, Zewe, & Scheuer, 2011; Parsh, 2010). This is of said and to identify nonverbal behaviors (Varcarolis &
great benefit, because providing a quality psychiatric Halter, 2010). Students may also document how they
nursing experience can be should have responded instead of what they actually said,
further complicated by fac- leading to many missed teachingelearning opportunities.
Key Points tors such as patient confiden- Because faculty do not have the opportunity to directly

Simulation involving tiality, aggression, and observe an entire studentepatient interaction in the psychi-
standardized patients unpredictability (Hermanns, atric setting, students are evaluated on brief observations
may be an effective Lilly, & Crawley, 2011). and written assignments, including the interpersonal pro-
alternative method for The use of SPEs allows fac- cess recording, both of which provide just a snapshot of
teaching therapeutic ulty to align clinical and di- the student’s ability to use therapeutic communication
communication skills dactic teaching giving skills.
in psychiatric nursing. students an opportunity to Although the field of medicine has utilized SPs for many

Role play was found engage with a variety of years, nursing is in the early stages of utilizing SPs to teach
to have a positive ef- patient diagnoses, including a variety of nursing skills. It has been suggested that
fect when the commu- those with issues of aggres- simulation using SPs can be an effective method of
nication of students sion and unpredictability. teaching students therapeutic communication skills (Lang
receiving only didactic Students are therefore able & Hahn, 2013). Marken, Zimmerman, Kennedy,
education was com- to practice in a safe yet Schremmer, and Smith (2010) had interdisciplinary teams
pared with students controlled environment. consisting of pharmacy, medical, and nursing students
who engaged in role Although SPs have been engage with SPs to practice communication skills on the
play after didactic utilized to teach commu- difficult topics of child health issues, intimate partner
education. nication in the field of violence, and suicidal ideation. The authors concluded

Standardized patient medicine for many years, that students gained confidence and improved communica-
experiences can be their use in undergraduate tion skills as a result of practicing with SPs in a simulated
utilized to teach and nursing is still in its infancy. environment.
assess undergraduate With limited information re- Role play was found to have a positive effect when the
nursing students’ use garding the effectiveness of communication of students receiving only didactic educa-
of therapeutic commu- SPEs as a teaching strategy tion was compared with students who engaged in role play
nication skills. in undergraduate nursing after didactic education (Kesten, 2011). Experiential ap-
education, it is imperative proaches including case studies and SPEs designed to
that nurse educators conduct research into this teaching mimic reality offer students ‘‘real-world’’elike experiences
strategy that is quickly gaining momentum. (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-
Literature Review lot activity designed to facilitate communication with and
care for individuals with posttraumatic stress disorder
Strategies to Teach Communication (Webster et al., 2012). Students commented that they
were better prepared to care for individuals with posttrau-
The nurseepatient relationship is at the foundation of matic stress disorder as a result of participating with SPs.
providing care to individuals with mental illness. The Using carefully designed SPEs, faculty are able to control
ability to engage in therapeutic communication is crucial the type, complexity, and length of the interaction, which
to building this relationship. With scant literature to provide can also be used to decrease the randomness of patient
guidance into how to best teach therapeutic communication encounters in the clinical setting (Becker, Rose, Berg,
skills (Webster, Seldomridge, & Rockelli, 2012), faculty Park, & Shatzer, 2006). Although high-fidelity simulations
often use methods similar to how they were taught during are often used to allow students to practice technical skills,
their own nursing education. This includes the interpersonal the use of SPs adds to the authenticity of the experience
process recording in which faculty provide feedback based (Keltner, Grant, & McLeron, 2011) and may promote ther-
on student documentation of verbal communication, apeutic communication skills and empathy development.
nonverbal behavior, and environmental influences from por- In addition to self-evaluation, peer review has been used
tions of interaction with the patient (Varcarolis & Halter, to help students improve communication skills (Yoo &
2010). This may not be the best method for teaching and Chae, 2011). In this study, students in an experimental
evaluating therapeutic communication skills. Although group watched each other’s videos and provided feedback;
the interpersonal process recording allows the student to those in the control group completed only self-evaluation.

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Standardized Patients and Therapeutic Communication
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.
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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
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- Faculty Feedback

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.
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
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
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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.
Standardized Patients and Therapeutic Communication
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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