A Systematic Review of the Use of Standardized Patients as a Simulation Modality in Nursing Education
Tonya Rutherford-Hemming, Celeste M. Alfes, and Tonya L. Breymier
Nursing Education Perspectives
Aim: The objective of the study was to search, extract, appraise, and synthesize studies using standardized patients (SPs) in nursing academia to determine how this modality of simulation is being used.
Background: SPs are a common simulation modality used in nursing education.
Method: This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Five databases were searched as well as keywords to retrieve nonindexed citations for the period January 2011 to September 2016. The inclusion criteria included nurses, a simulated experience with SPs, and original research published in English.
Results: Sixty-five studies were identified and analyzed.
Conclusion: More randomized controlled trials and studies with power analyses and validated measurement instruments are needed. Studies that compare SPs to high-fidelity simulators are also desired to determine optimal student learning outcomes and standardize best practices in simulation.
Simulation-based education has rapidly expanded in health care in the past two decades due to decreased training opportunities, infrequent clinical events, increased attention to patient safety, and limited clinical placement opportunities. Utilizing standardized patients (SPs) is an example of a simulation approach used for teaching and learning in health care education. Introduced in 1963 by Barrows and Abrahamson, the term SP is “the umbrella term for both a simulated patient (a well person trained to simulate a patient’s illness in a standardized way) and an actual patient (who is trained to present his or her own illness in a standardized way)” (Barrows, 1993, p. 443). Barrows saw the SP as being able to provide students with additional training outside a textbook by putting them face-to-face with “patients” who could provide the physical, psychological, and emotional aspects of clinical practice.
Two meta-analyses have been completed in nursing. One provided a meta-analysis on the effectiveness of simulation-based nursing education depending on fidelity (Kim, Park, & Sulin, 2016). The other described the effects of simulation-based learning outcomes using SPs (Oh, Jeon, & Koh, 2015). No review to date has investigated the overall use of SPs in nursing academia.
The purpose of this systematic review was to search, extract, appraise, and synthesize studies using SPs in nursing academia to gain a better understanding of how this modality of simulation is being utilized. The research question that guided this study was: What research studies utilizing SPs within nursing academia emerged in the literature between January 2011 and September 2016? The specific aim was to synthesize research completed in the last five years to report the current state of the science on the use of SPs within nursing academia.
Design and Search Methods
This systematic review was conducted consistent with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (Liberati et al., 2009). The inclusion criteria were broad in order to disseminate information on future research needed; however, to be included in this review, several criteria had to be met. The sample had to include nurses, prelicensure or postlicensure, in academia. The intervention had to include a simulated experience with SPs, describe original research, and be published in English between January 2011 and September 2016.
A thorough and comprehensive literature search was done at the start of the systematic review. Five databases (CINAHL, PubMed, Cochrane Library, Web of Science, and Psych/INFO) were searched using a combination of medical subject headings or Mesh terms, as well as key words to retrieve nonindexed citations.
Search Outcome and Quality Appraisal
The database search strategy yielded 194 citations. These results were narrowed down to 65 studies through an in-depth analysis of each article using identified inclusion criteria. An illustration of the study selection is presented in a figure available as Supplemental Digital Content 1 at http://links.lww.com/NEP/A99.
A data extraction form was created for the 65 identified research studies. The authors divided the studies and initially extracted the following data: design, purpose, sample, intervention, control, measurements, outcomes, limitations, and notes. The data extraction form was revised and refined to capture data in a succinct and concise manner (see Supplementary Digital Content 3 at http://links.lww.com/NEP/A101). As a meta-analysis could not be performed because of the lack of similarities in study characteristics, a narrative summary was conducted.
In a span of five years, 65 research studies were published that incorporated SPs to educate nurses within the academic setting. The largest gaps discovered included a lack of randomized controlled trials, lack of power analyses, and comparative studies to elicit outcomes on best practices.
Forty-five percent (29 studies) were quantitative in design. Of the other studies in this review, 15 were qualitative, 14 used mixed methods, 5 were literature or systematic reviews, and 2 were meta-analyses. Table 1 outlines the studies by design. A power analysis was completed on only three studies (Alfes, 2015; Shin & Kim, 2014; Shin, Park, & Shim, 2015c), and only one qualitative study stated saturation was met (Defenbaugh & Chikotas, 2016
SPs participated in simulation as a patient or as a patient and evaluator. Information on the role of the SP as well as who portrayed the SP is available as Supplemental Content 5 at http://links.lww.com/NEP/A103.
There were a variety of clinical foci, or topics, and purposes for incorporating SPs into simulations, including skill assessment/competency, communication, objective structured clinical examination, interprofessional education, psychiatric mental health, and student satistaction and self-efficacy. See Supplemental Content 6 at http://links.lww.com/NEP/A104 for the most common topics in the research study.
There is lack of rigorous research studies producing empirical evidence in simulations that have used SPs as a modality. Only seven randomized controlled trials were published in the last five years. More studies employed a one-group design versus a two-group design, decreasing findings from comparison studies and further highlighting an abundance of weak study designs. Without a power analysis, it is unclear if the findings of quantitative studies are meaningful. The same is true for qualitative studies completed. Only one group of authors (Defenbaugh & Chikotas, 2016) stated saturation was met, leaving the reader unclear as to whether saturation was met even in studies with sample sizes greater than 75 participants.
In studies in this review, SPs were used twice as often in simulations with undergraduate nursing students compared to graduate nursing students. It is difficult to determine where in the undergraduate nursing curriculum SPs are being used because nursing programs do not have a standardized entry point into the nursing curriculum. Some schools allow students to begin taking nursing courses in their very first semester of college; others allow students to only take nursing courses during the final four semesters.
Graduate nursing programs may use SPs less than undergraduate nursing programs because simulation is not fully embraced by the National Task Force on Quality Nurse Practitioner Education (2012). When SPs were used in the graduate curriculum, the sample often consisted of nonacute nurse practitioner students. Because a hallmark of nurse practitioner practice is the ability to diagnose and treat patients, it would seem that placing students in simulations with live individuals who can provide a more realistic face-to-face interaction would be preferred. It is plausible that SPs are used more than high-fidelity manikins in academia, and this was not seen in the research studies included in this review.
It was surprising that only 12 studies were interprofessional, including disciplines outside of nursing in the sample. The Institute of Medicine (2011)called for a transformation in the nursing profession to include greater emphasis on interprofessional education. However, this is not evident in the number of studies that included various health care disciplines. It may be that the research is only now being conducted and more studies will be published in the future.
SPs were compared to a variety of interventions. High-fidelity simulators were most often compared to SPs, but the number of studies that compared the two types of simulation was small, leaving unanswered questions as to whether one type of simulation is better than the other, and if so, SPs are better suited than manikins to implement certain topics. It is often assumed that SPs are a better teaching methodology for communication skills, but no studies have completed head-to-head comparisons to determine if this is true.
It is evident that a variety of individuals from various backgrounds and training experiences are used as SPs. Again, it is unclear if one group is better than another. For example, do individuals who have had a diagnosis or currently have a diagnosis provide a more realistic and thorough history than individuals who have been trained to portray the illness but have no personal experience with the diagnosis? It would seem likely that having the diagnosis would aid in the simulation, but no comparative studies have been done to investigate if and how this might be beneficial.
Another unanswered question in the literature is how individuals are chosen to be SPs. At times, it is clear why certain individuals are selected. For example, in some studies individuals from culturally diverse backgrounds were selected to more accurately portray a patient from a particular culture. However, in other instances, the decision of who to use as an SP is less clear. Not all schools of nursing have access to SP consortiums associated with a medical school and therefore must seek alternate individuals to serve as patients. Are drama students used because of their ability to enact performance art? Are nurses used because they possess a medical background related to the patient presentation? Are volunteers used because of financial constraints associated with the school’s budget? What is the rationale for using particular groups of individuals as SPs? Perhaps there are no underlying assumptions that one group will perform better than another and merely a decision based on feasibility.
When nursing students portray the SP, it leaves more unanswered questions and an area rich for further inquiry. As the patient, the student would be taught the patient perspective while also having a bird’s eye view of the actions of the student provider. Are the learning outcomes the same for both students at the end of the encounter? If the student (as the patient) participates in debriefing, he or she is exposed to reflective inquiry in the same manner as the student provider. Are there differences in knowledge, skills, and attitudes between the two students at the end of the debriefing? These are some of the unanswered questions that exist.
Regardless of who portrays the SP, training is necessary to ensure standardization. Yet, only 26 studies mentioned training the SP. The time involved in training varied from hours to weeks, and objectively determining if the SP was ready to accurately portray the patient in the scenario was stated in only a few studies. It would seem that when the simulation is part of a research study, verification of an accurate portrayal by the SP would be essential in order to ensure valid findings. The same would be true if the SP is an evaluator of student performance, yet absent from most studies in this review was objective documentation evaluating the SP prior to the simulation and/or a standardized process for providing feedback to SPs. This is consistent with previous literature documenting a deficiency in standards with regard to effective feedback training for SPs (Bokken, Linssen, Scherpbier, van der Vleuten, & Rethans, 2009).
The lack of standardization and rigor in the training process exposes gaps in the literature related to the use of SPs in research studies and in some instances may affect the validity of the findings of the study. The Association of Standardized Patient Educators (2016) Core Curriculum provides modules on training SPs that are rooted in best practices and standards of practice. It is unclear if the training that takes place in practice reflects the best practices in the literature.
At times, SPs are part of the debriefing process. It is unknown if and how this affects student learning. It would be interesting to assess student outcomes with and without the SP present to determine if any differences exist between groups.
Validated measurement instruments were used in less than half the studies reviewed. Validation of the tool helps ensure that the findings in a study are meaningful. Therefore, conclusions from studies that did not utilize a validated measurement instrument should be interpreted cautiously.
SPs are used in simulations involving a variety of topics, which demonstrates the versatility of SPs and their ability to provide diverse learning opportunities. Communication training appears to be the most common topic when utilizing SPs in the academic setting. However, more research is needed to determine if SPs are a better teaching method for effective communication training than other types of simulation experiences. What is inherently missing in the literature is research focused on the SP. Except for two studies (Schlegel et al., 2016; Smeltzer et al., 2015), which examined perspectives of the SP, research studies utilized SPs, but SPs were not the focus of the research questions. Rather, they were the vehicle of the intervention.
Positive and negative outcomes were reported in the studies included in this review. Because the topics and research questions of studies are so diverse, it is difficult to ascertain definite conclusions from the findings. It is clear SPs are used to portray a variety of health care topics, and students report increased confidence and satisfaction in simulations with SPs.
Another unanticipated finding in this review was having 40 percent of studies completed outside the United States. With 12 countries represented in this systematic review, it is apparent that the use of SPs has become a global trend. At the same time, it is evident there are areas that are either not using SPs or are not publishing research studies that include SPs.
The purpose of this systematic review was to search, extract, appraise, and synthesize research related to the use of SPs to train nurses within the academic setting to gain a better understanding of how SPs are being used to facilitate student learning. This systematic review synthesized the research completed in the last five and a half years and reported on the current state of the science on the use of SPs within nursing academia.
Our review found that SPs are used in a variety of health care curricula to portray diverse patient diagnoses and have become an integral part of simulation methodology. However, gaps remain in the literature regarding their impact on student learning outcomes. More randomized controlled trials and studies with power analyses and validated measurement instruments are needed. Studies that compare SPs to high-fidelity simulators are also desired to determine optimal student learning outcomes and standardize best practices in simulation.
Alexander, L., & Dearsley, A. (2013). Using standardized patients in an undergraduate mental health simulation. International Journal of Mental Health, 42(2/3), 149-164. doi:10.2753/IMH0020-7411420209 Alfes, C. M. (2015). Standardized patient versus role-play strategies: A comparative study measuring patient-centered care and safety in psychiatric mental health nursing. Nursing Education Perspectives, 36(6), 403-405. Association of Standardized Patient Educators. (2016). Core curriculum. Retrieved from www.aspeducators.org/core-curriculum Bagnasco, A., Tolotti, A., Pagnucci, N., Torre, G., Timmins, F., Aleo, G., & Sasso, L. (2016). How to maintain equity and objectivity in assessing the communication skills in a large group of student nurses during a long examination session, using the objective structured clinical examination (OSCE). Nurse Education Today, 38, 54-60. doi:10.1016/j.nedt.2015.11.034 Barrows, H. S. (1993). An overview of the uses of standardized patients for teaching and evaluating clinical skills. Academic Medicine, 68(6), 443-451. Bays, A. M., Engelberg, R. A., Back, A. L., Ford, D. W., Downey, L., Shannon, S. E., … Curtis, J. R. (2014). Interprofessional communication skills training for serious illness: Evaluation of a small-group, simulated patient intervention. Journal of Palliative Medicine, 17(2), 159-166. doi:10.1089/jpm.2013.0318 Bokken, L., Linssen, T., Scherpbier, A., van der Vleuten, C., & Rethans, J. (2009). Feedback by simulated patients in undergraduate medical education: A systematic review of the literature. Medical Education, 43, 202-210. Bornais, J. A., Raiger, J. E., Krahn, R. E., & El-Masri, M. M. (2012). Evaluating undergraduate nursing students’ learning using standardized patients. Journal of Professional Nursing: Official Journal of the American Association of Colleges of Nursing, 28(5), 291-296. doi:10.1016/j.profnurs.2012.02.001 Ching-Lan Lin, E., Chen, S., Chao, S., & Chen, Y. (2013). Using standardized patient with immediate feedback and group discussion to teach interpersonal and communication skills to advanced practice nursing students. Nurse Education Today, 33, 677-683.
Choi, Y. J. (2012). Exploring experiences of psychiatric nursing simulations using standardized patients for undergraduate students. Asian Nursing Research, 6(3), 91-95. doi:10.1016/j.anr.2012.07.001 Corcoran, A. M., Lysaght, S., Lamarra, D., & Ersek, M. (2013). Pilot test of a three-station palliative care observed structured clinical examination for multidisciplinary trainees. The Journal of Nursing Education, 52(5), 294-8. doi:10.3928/01484834-20130328-02 Cowperthwait, A. L., Campagnola, N., Doll, E. J., Downs, R. G., Hott, N. E., Kelly, S. C., … Buckley, J. M. (2015). Tracheostomy overlay system: An effective learning device using standardized patients. Clinical Simulation in Nursing, 11(5), 253-258. doi:10.1016/j.ecns.2015.03.001 Dearmon, V., Graves, R. J., Hayden, S., Mulekar, M. S., Lawrence, S. M., Jones, L., … Farmer, J. E. (2013). Effectiveness of simulation-based orientation of baccalaureate nursing students preparing for their first clinical experience. Journal of Nursing Education, 52(1), 29-38. doi:10.3928/01484834-20121212-02 Defenbaugh, N., & Chikotas, N. E. (2016). The outcome of interprofessional education: Integrating communication studies into a standardized patient experience for advanced practice nursing students. Nurse Education in Practice, 16(1), 176-181. doi:10.1016/j.nepr.2015.06.003 Doolen, J., Giddings, M., Johnson, M., Guizado de Nathan, G., & O Badia, L. (2014). An evaluation of mental health simulation with standardized patients. International Journal of Nursing Education Scholarship, 11(1). doi:10.1515/ijnes-2013-0075 Eid, A., Petty, M., Hutchins, L., & Thompson, R. (2009). “Breaking bad news”: Standardized patient intervention improves communication skills for hematologyoncology fellows and advanced practice nurses. Journal of Cancer Education, 24(2), 154-159. doi:10.1080/08858190902854848 Fink, M., Linnard-Palmer, L., Ganley, B., Catolico, O., & Phillips, W. (2014). Evaluating the use of standardized patients in teaching spiritual care at the end of life. Clinical Simulation in Nursing, 10(11), 559-566. doi:10.1016/j.ecns.2014.09.003 Goh, Y. S., Selvarajan, S., Chng, M. L., Tan, C. S., & Yobas, P. (2016). Using standardized patients in enhancing undergraduate students’ learning experience in mental health nursing. Nurse Education Today, 45, 167-172. doi:10.1016/j. nedt.2016.08.005 Guvenc, G., Unver, V., Basak, T., Yuksel, C., Ayhan, H., Kok, G., … Iyigun, E. (2016). Turkish senior nursing students’ communication experience with Englishspeaking patients. The Journal of Nursing Education, 55(2), 73-81. doi:10. 3928/01484834-20160114-03 Ignacio, J., Dolmans, D., Scherpbier, A., Rethans, J. J., Chan, S., & Liaw, S. Y. (2015). Comparison of standardized patients with high-fidelity simulators for managing stress and improving performance in clinical deterioration: A mixed methods study. Nurse Education Today, 35(12), 1161-1168. doi:10.1016/j. nedt.2015.05.009 Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Jacobs, A. C., & van Jaarsveldt, D. E. (2016).“The character rests heavily within me”: Drama students as standardized patients in mental health nursing education. Journal of Psychiatric and Mental Health Nursing, 23(3–4), 198-206. doi:10. 1111/jpm.12302 Jo, K. H., & An, G. J. (2014). Qualitative content analysis experiences with objective structured clinical examination among Korean nursing students. Japan Journal of Nursing Science, 11(2), 79-86. doi:10.1111/jjns.12006 Johns Hopkins Hospital. (2017). JHNEBP research evidence appraisal. Retrieved from http://umms.org/shoremagnet/Attachments/pdf_folder/NK6bb.pdf Kameg, K. M., Szpak, J. L., Cline, T. W., & Mcdermott, D. S. (2014). Utilization of standardized patients to decrease nursing student anxiety. Clinical Simulation in Nursing, 10(11), 567-573. doi:10.1016/j.ecns.2014.09.006 Karadag, M., Caliskan, N., & Iseri, O. (2016). Effects of case studies and simulated patients on students’ nursing care plan. International Journal of Nursing Knowledge, 27, 87-94. Kenny, G., Cargil, J., Hamilton, C., & Sales, R. (2016). Improving and validating children’s nurses communication skills with standardized patients in end of life care. Journal of Child Health Care, 20(2), 145-152. doi:10.1177/ 1367493514555588 Kiersma, M. E., Plake, K. S., & Darbishire, P. L. (2011). Patient safety instruction in US health professions education. American Journal of Pharmaceutical Education, 75(8), 1-11. Kim, J., Park, J., & Sujin, S. (2016). Effectiveness of simulation-based nursing education depending on fidelity: A meta-analysis. BMC Medical Education, 16(152), 1-8. doi:10.1186/s12909-016-0672-7 Kim-Godwin, Y. S., Livsey, K. R., Ezzell, D., & Highsmith, C. (2013). Home visit simulation using a standardized patient. Clinical Simulation in Nursing, 9, e55-e61. Kirkpatrick, D. L. (1998). Evaluating training programs: The four levels. San Francisco, CA: Berrett-Koehler Publishers. Koo, L., Layson-Wolf, C., Brandt, N., Hammersla, M., Idzik, S., Rocafort, P. T., … Windemuth, B. (2014). Qualitative evaluation of a standardized patient clinical simulation for nurse practitioner and pharmacy students. Nurse Education in Practice, 14, 740-746. Kowitlawakul, Y., Chow, Y. L., Salam, Z. H., & Ignacio, J. (2015). Exploring the use of standardized patients for simulation-based learning in preparing advanced practice nurses. Nurse Education Today, 35, 894-899. Liberati, A., Altmann, D. G., Tetzlaff, J., Mulrow, C., Gottzsche, P.C., Ioannidis, J.P. A., …Moher, D. (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. Journal of Clinical Epidemiology, 62, e1-e34. Lu, C., Hsu, S., & Shu, I. (2016). Elements of scenario-based learning on suicidal patient care using real-time video. Nursing Informatics, 225, 257-261. doi:10. 3233/978-1-61499-658-3-257 Luctkar-Flude, M., Wilson-Keates, B., & Larocque, M. (2012). Evaluating high-fidelity human simulators and standardized patients in an undergraduate nursing health assessment course. Nurse Education Today, 32, 448-452. Luebbert, R., & Popkess, A. (2015). The influence of teaching method on performance of suicide assessment in baccalaureate nursing students. Journal of American Psychiatric Nurses Association, 21(2), 126-133. doi:10.1177/ 1078390315580096 MacDonnell, C. P., George, P., Nimmagadda, J., Brown, S., & Gremel, K. (2016). A team-based practicum bringing together students across educational institutions and health professions. American Journal of Pharmaceutical Education, 80(3), article 49. MacDonnell, C. P., Rege, S. V., Misto, K., Dollase, R., & George, P. (2012). An introductory inter-professional exercise for healthcare students. American Journal of Pharmaceutical Education, 76(8), 1-6. McNett, S. (2012). Teaching nursing psychomotor skills in a fundamentals laboratory: A literature review. Nursing Education Perspectives, 33(5), 328-333. McWilliam, P. L., & Botwinski, C. A. (2012). Identifying strengths and weaknesses in the utilization of objective structured clinical examination (OSCE) in a nursing program. Nursing Education Perspectives, 33(1), 35-39. Miles, L. W., Mabey, L., Leggett, S., & Stansfield, K. (2014). Teaching communication and therapeutic relationship skills to baccalaureate nursing students. Journal of Psychosocial Nursing, 52(10), 34-41. Murdoch, N. L., Bottorff, J. L., & McCullough, D. (2013). Simulation education approaches to enhance collaborative healthcare: A best practices review. International Journal of Nursing Education Scholarship, 10(1), 307-321. Murray, D. J. (2014). Progress in simulation education: Developing an anesthesia curriculum. Current Opinions in Anesthesiology, 27, 610-615. National Heart, Lung, and Blood Institute. (2014). Quality appraisal of systematic reviews and meta-analyses. Retrieved from https://www.nhlbi.nih.gov/healthpro/guidelines/in-develop/cardiovascular-risk-reduction/tools/sr_ma National Task Force on Quality Nurse Practitioner Education. (2012).Criteria for evaluation of nurse practitioner programs. Washington, DC: National Organization of Nurse Practitioner Faculties. Ndiwane, A., Koul, O., & Theroux, R. (2014). Implementing standardized patients to teach cultural competency to graduate nursing students. Clinical Simulation in Nursing, 10, e87-e94. Nikendel, C., Huhn, D., Pittius, G., Trost, Y., Bugaj, T. J., Koechel, A., & Schultz, J.-H. (2016). Students’ perceptions on an interprofessional ward round training: A qualitative pilot study. GMS Journal for Medical Education, 33(2), 1-15. Oh, P., Jeon, K. D., Koh, M. S. (2015). The effects of simulation-based learning using standardized patients in nursing students: A meta-analysis. Nurse Education Today, 35, e6-e15. doi:10.1016/j.nedt.2015.01.019 Palumbo, M. V., Sandoval, M., Hart, V., & Drill, C. (June, 2016). Teaching electronic health record communication skills. CIN: Computers, Informatics, Nursing, 34(6),254-258. Phillips, S. J., Lie, D., Encinas, J., Ahearn, C. S., & Tiso, S. (2011). Effective use of interpreters by family nurse practitioner students: Is didactic curriculum enough? Journal of the American Academy of Nurse Practitioners, 23, 233-238. doi:10. 1111/j.1745-7599.2011.00612.x Pilkenton, D., Collins, M. R., & Holley, S. (2015). Teaching labor support: An interprofessional simulation. Journal of Midwifery & Women’s Health, 60(6), 699-705. Pritchard, S. A., Blackstock, F. C., Nestel, D., & Keating, J. L. (2016). Simulated patients in physical therapy education: Systematic review and meta-analysis. Physical Therapy, 96, 1342-1353. doi:10.2522/ptj.20150500 Rutherford-Hemming, T. (2012). Learning in simulated environments: Effect on learning transfer and clinical skill acquisition in nurse practitioner students. Journal of Nursing Education, 51(7), 403-406. doi:10.3928/01484834-20120427-04 Ryall, T., Judd, B. K., & Gordon, C. J. (2016). Simulation-based assessments in health professional education: A systematic review. Journal of Multidisciplinary Healthcare, 9, 69-82. Sarmasoglu, S., Dinc, L., & Elcin, M. (2016). Using standardized patients in nursing education: Effects on students’ psychomotor skill development. Nurse Educator, 41(2), E1-E15. doi:10.1097/NNE.000000000000188
Schlegel, C., Bonvin, R., Rethans, J., & van der Vleuten, C. (2016). Standardized patients’ perspectives on workplace satisfaction and work-related relationships: A multicenter study. Simulation in Healthcare, 11(4), 278-285. Schlegel, C., Woermann, U., Shaha, M., Rethans, J. J., & van der Vleuten, C. (2011). Effects of communication training on real practice performance: A role-play module versus a standardized patient module. Journal of Nursing Education, 51(1), 16-22. Schram, A. P., & Mudd, S. (2015). Implementing standardized patients within simulation in a nurse practitioner program. Clinical Simulation in Nursing, 11(4), 208-213. doi:10.1016/j.ecns.2015.02.002 Schwindt, R., & McNelis, A. (2015). Integrating simulation into a reflection-centered graduate psychiatric/mental health nursing curriculum. Nursing Education Perspectives, 36(5), 326-328. doi:10.5480/15-1614 Shin, H., & Kim, M. J. (2014). Evaluation of an integrated simulation courseware in a pediatric nursing practicum. Journal of Nursing Education, 53(10), 589-594. Shin, H., Ma, H., Park, J., Ji, E. S., & Kim, D. H. (2015). The effect of simulation courseware on critical thinking in undergraduate nursing students: Multi-site pre–post study. Nurse Education Today, 35, 537-542. Shin, H., Park, C. G., & Shim, K. (2015). The Korean version of the Lasater Clinical Judgment Rubric: A validation study. Nurse Education Today, 35, 68-72. Shin, H., Sok, S., Hyun, K. S., & Kim, M. J. (2015). Competency and an active learning program in undergraduate nursing education. Journal of Advanced Nursing, 71(3), 591-598. doi:101111/jan.12564 Slater, L. Z., Bryant, K. D., & Ng, V. (2016). Nursing student perceptions of standardized patient use in health assessment. Clinical Simulation in Nursing, 12(9), 368-376. Smeltzer, S. C., Mariani, B., Ross, J. G., de Mange, E. P., Meakim, C. H., Bruderie, E., & Nthenge, S. (2015). Persons with disability: Their experiences as standardized patients in an undergraduate nursing program. Nursing Education Perspectives, 36(6), 398-400. doi:10.5480/15-1592 Smithson, J., Bellingan, M., Glass, B., & Mills, J. (2015). Standardized patients in pharmacy education: An integrative literature review. Currents in Pharmacy Teaching and Learning, 7(6), 851-863. doi:10.1016/j.cptl.2015.08.002 Solomon, P., & Salfi, J. (2011). Evaluation of an interprofessional education communication skills initiative. Education Health (Abingdon), 24(2), 616. Terzioglu, F., Yucel, C., Koc, G., Simsek, S., Yasar, B. N., Sahan, F. U., … Yildirim, S. (2016). A new strategy in nursing education: From hybrid simulation to clinical practice. Nurse Education Today, 39, 104-108. Turrentine, F. E., Rose, K. M., Hanks, J. B., Lorntz, B., Owen, J. A., Brashers, V. L., & Ramsdale, E. E. (2016). Interprofessional training enhances collaboration between nursing and medical students: A pilot study. Nurse Education Today, 40, 33-38. doi:10.1016/j.nedt.2016.01.024 Tuzer, H., Leyla, D., & Elcin, M. (2016). The effects of using high-fidelity simulators and standardized patients on the thorax, lung, and cardiac examination skills of undergraduate nursing students. Nurse Education Today, 45, 120-125. doi:10.1016/j.nedt.2016.07.002 Unver, V., Basak, T., Iyigun, E., Tastan, S., Demiralp, M., Yildiz, D., … Hatipoglu, S. (2013). An evaluation of a course on the rational use of medication in nursing from the perspective of the students. Nurse Education Today, 33, 1362-1368. Wamsley, M., Staves, J., Kroon, L., Topp, K., Hossaini, M., Newlin, B., … O’Brien, B. (2012). The impact of an interprofessional standardized patient exercise on attitudes toward working in interprofessional teams. Journal of Interprofessional Care, 26, 18-35. doi:10.3109/13561820.2011.628425 Webster, D. (2014). Using standardized patients to teach therapeutic communication in psychiatric nursing. Clinical Simulation in Nursing, 10(2), e81-e86. doi: 10.1016/j.ecns.2013.08.005 Zheng, J., Jing, Y., Wang, S., Jin, R., & Gao, Y. (2014). Constructing the training curriculum of standardized patients for OSCE examination for undergraduate nursing students in Shanxi Medical University. Open Journal of Nursing, 4, 132-133. doi:10.4236/ojn.2014.43017 Zhu, Z., Yang, L., Lin, P., Lu, G., Xiao, N., Yang, S., & Sui, S. (2016). Assessing nursing students’ clinical competencies using a problem-focused objective structured clinical examination. Western Journal of Nursing Research, 1-12. doi:10. 1177/0193945916667727