Running head: ROLE-PLAY AND STANDARDIZED PATIENTS

Comparing the Use of Peer Role-Play and Standardized Patients in Undergraduate Mental-Health
Nurse Communication Training: A Literature Review
Michelle A. Stimson
Ferris State University

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Abstract
Approximately 18% of adults living in the United States have been diagnosed with a form of mental
illness (National Institute of Mental Health [NIMH], n.d.). Providing adequate care to mental-health
patients rests on many factors. One important factor is the ability for student nurses to obtain
effective therapeutic communication skills upon graduation. Academic nurse educators face many
barriers in providing adequate experiences in which students can practice communication skills
(Doolen et al., 2014; Rossetti et al., 2014). Therefore, many schools of nursing are turning to
simulation-based learning to bridge the gap between skill mastery and hands-on practice (Doolen et
al., 2014; Rossetti et al., 2014). If done correctly, simulation-based learning can properly mimic the
clinical environment and promote knowledge and improved skill performance (Oh, Jeon, & Koh,
2015). Both peer role-play and standardized patients are mentioned extensively in the literature as
viable methods for teaching communication skills. However, benefits to each technique exist and
few studies have compared the two methods against each other. In this paper, current research
comparing the two techniques is explored.

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Comparing the Use of Peer Role-Play and Standardized Patients in Undergraduate Mental-Health
Nurse Communication Training: A Literature Review
Approximately 18% of adults living in the United States have some form of mental illness
(National Institute of Mental Health [NIMH], n.d.). Providing high-quality, safe care to mentalhealth patients requires effective therapeutic communication skills (Schlegel et al., 2012).
Communication skill training (CST) is an integral component of mental-health nursing curricula
(Schlegel et al., 2012). However, in order to make connections between the didactic and clinical
setting, students need hands-on practice (Hart & Chilcote, 2016). Due to a lack of funding and shifts
in mental-health care delivery models, high-quality clinical sites are dwindling and several have
become observational in nature (Rossetti et al., 2014). This new reality requires academic nurse
educators to adopt innovative teaching strategies such as simulation-based learning (SBL). Both
peer role-play (RP) and standardized patients (SPs) are supported in the literature as effective
techniques for teaching communication skills. However, enormous differences between the two
methods exist. In this paper, current research comparing the two techniques is explored.
Peer Role-Play and Standardized Patients
Simulation-based learning is an interactive, well supported, and validated method for
teaching and learning therapeutic communication skills (American Association of Colleges of
Nursing [AACN], 2008; Oh, Jeon, & Koh, 2015). However, several ways to employ SBL exist
including the use of SPs, computerized manikins, and RP (Kameg et al., 2009). Effective
therapeutic communication requires active listening, responding to body language, rapport building,
and the demonstration of empathy (Ryan et al., 2010). Computerized manikins are less ideal due to
their lack of facial expressions and ability to adjust body language (Doolen et al., 2014).
Peer role-play is widely used in SBL (Schlegel et al., 2012). Several advantages of using RP
include minimal resource utilization, portability, and the opportunity to experience both the clinician
and patient's perspective (Schlegel et al., 2012). However, in order to ensure success, carefully

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crafted scenarios, realistic roles, and structured feedback are needed (Bosse et al., 2015). In
contrast, an SP is an ...individual trained to portray a patient with a specific condition in a realistic,
standardized and repeatable way (Association of Standardized Patient Educators, 2011, para. 1).
The benefits of SPs include realism, a safe environment for learning, and the ability to provide
professional feedback (Bosse et al., 2015). However, SPs can be costly to utilize, present scheduling
barriers, and vary in quality (Hart & Chilcote, 2016).
PICO Question
Variations in each technique in terms of resource utilization, style, and quality create
different challenges for educators providing SBL communication training for undergraduate mentalhealth nursing students. While both are well established in the literature, little is known about the
efficacy of the two techniques when measured against each other. Therefore the following PICO
question was asked: In undergraduate mental-health nursing students learning therapeutic
communication skills (P), can SBL using SPs (I) compared to RP (C) promote the attainment of
effective therapeutic communication skills (O) (examples: establish eye contact, show empathy,
build relationships, understand the patient's perspective, and improved self-efficacy)?
Methodology
The evidence comparing the use of RP and SPs for teaching communication skills to
undergraduate mental-health nursing students was explored using CINAHL and PubMed databases.
The search terms used individually and in combination include: simulation, standardized patient,
role-play, communication skills, nursing, psychiatric, and mental-health. The number of studies
found comparing RP and SPs was sparse. Since communication is a relatively universal skill, the
search was expanded beyond mental-health nursing and studies using medical students were
included. Studies that did not directly compare RP and SPs for communication training and were
greater than five years old were excluded. The final selection included four studies.
Results

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Most studies hypothesized using SPs would yield superior knowledge acquisition and
performance results. Alfes (2015) studied knowledge acquisition using a pre and post test crossover
design in 77 mental-health nursing students at one university. Students were first assigned to an SP
scenario, then an RP scenario, or the reverse. No statistical difference in knowledge was found
between the sequencing of the scenarios, however, both groups improved over time. Schlegel et al.
(2012) evaluated the performance of 55 student nurses conducting a pain assessment. Students were
randomly assigned to either CST with RP or an SP. Student performance was evaluated by a clinical
supervisor (SP group) or a written test (RP group). Performance levels were superior in the SP
group. In a randomized control trial, Bosse et al. (2012) evaluated the performance of 69 medical
students counseling the parent of a sick child. Students received CST through either an SP or RP
scenario. Using a post-intervention objective evaluation, students trained through the RP scenario
demonstrated greater overall performance especially in the areas of empathy and understanding the
parent's perspective. Peer RP allows the learner to experience both the client and clinician
perspective possibly yielding greater results. The results of these studies are mixed with two
yielding opposite results and one showing no difference between the two methods.
Self-efficacy is the belief in one's ability to accomplish a given task and plays an important
role in learning therapeutic communication skills (Schlegel et al., 2012). Alfes (2015) showed no
statistical difference in self-efficacy ratings based on scenario sequencing but ratings did improve
over time. Bosse et al. (2012) discovered improved self-efficacy in both SP and RP groups,
however, high levels of self-efficacy did not necessarily correlate with student performance levels.
Schlegel et al. (2012) also measured self-efficacy and found no significant difference between the
RP and the SP group. However, both groups showed improved self-efficacy post intervention. The
results of these studies do not justify one method over the other for improving self-efficacy.

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Academia has finite resources and the use of cost-effective SBL methods is warranted
(Bosse et al., 2015). Compared to SPs, RP is hypothesized to be less costly. Bosse et al. (2015) used
retrospective data from their 2012 study to compare the cost of utilizing RP and SPs against student
performance. Utilizing SPs cost 53% more than RP and yielded less desirable results. The authors
recommend using SPs for high-stakes testing or situations in which RP is not suitable. According to
Bosse et al. (2015) and the results of the literature search, no other comparable studies exist.
Conclusion
Academic nurse educators face many barriers in providing undergraduate mental-health
nursing students with adequate clinical experiences and learning opportunities. Competition for
clinical sites continues to grow and several experiences have become observational in
nature. Simulation-based learning is a viable method for teaching therapeutic communication skills;
an integral component of mental-health nursing practice. The results of the studies comparing the
efficacy of RP and SPs in CST are mixed. Two studies support RP over SPs in terms of cost
effectiveness, ease of use, and insight to both the clinician and patient's perspective. One study
showed superior student performance conducting CST with an SP. Another study showed no
difference between the two methods. Self-efficacy ratings did not vary by method. Only one study
evaluated mental-health nursing students and each study had a small sample size making the overall
findings inconclusive. More studies are needed to compare the two methods especially as they relate
to the learning needs of the undergraduate mental-health nursing student.

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