Introduction

Standardized patients (SPs) have been used in medical school and graduate medical education for decades.¹ Learners are taught and assessed for physical examination skills, performance of clinical treatments, and establishment of rapport with patients.^2–5 Sessions are recorded, and learners review their performance to promote ongoing improvement. The SP model is also effective for teaching and assessing learner skills in professionalism and interpersonal communication.⁶

Physician-nurse interaction plays a critical role in patient care. Misunderstandings in physician-nurse communication can lead to medication administration errors and other problems in patient management.⁷ Conflicts between nurses and physicians, particularly at the resident level, can globally impair health care team communication, increasing the risk of errors that may harm patients.⁸

Previous publications have described education sessions to address management of nurse-physician conflict, including didactic sessions and small group discussions,^8–10 but did not include assessments of resident skills. Professionalism and interpersonal and communication skills are gaining importance in view of the Accreditation Council for Graduate Medical Education Review Committees' Program Requirements, with all specialty milestones containing assessments in these competencies, including the ability to work effectively with allied health professionals.¹¹

The SP format is an opportunity to assess and teach resident professionalism and interpersonal communication skills with colleagues. Using a PubMed search with the terms standardized patient conflict, standardized patient collaboration, patient simulation conflict, and patient simulation collaboration, we did not find prior reports using SPs to model interprofessional communication. For these reasons, we created the Standardized Professional (S-Pro) Encounter.

Methods

Using a survey instrument (provided as online supplemental material), we assessed plastic surgery residents' prior experiences with physician-nurse conflict and determined how much prior education they had received in managing such conflict. Participating residents were in postgraduate year (PGY)-2 through PGY-6. We modeled an encounter simulating nurse-physician conflict in a common clinical situation: cross-covering a patient who has been in the hospital for several days after surgery and now has uncontrolled pain. Residents were informed several weeks in advance about the simulated encounter but not about its purpose (assessment of interprofessional communication skills). Residents were provided the clinical scenario 15 minutes prior to the start of the encounter. Nurse and patient roles were portrayed by trained medical actors. Role training consisted of (1) a planning meeting between the training program faculty and the simulation center director; and (2) meeting with medical portrayers for role-specific training, discussion of the rating instrument, and modeling of the postencounter feedback session. The latter step took 2 hours, including 30 minutes for discussion of the use of the Boggs instrument. Faculty observers were given 30 minutes to review the Boggs instrument. The nurse and patient portrayers were given the clinical scenario and guidelines (provided as online supplemental material), but were allowed flexibility to respond in the encounter based on resident performance.

During the encounter, the nurse's role was to disagree with the resident's plan, but remain professional at all times. The patient's role was to manifest uncontrolled pain that has prevented sleep for 24 hours but maintain emotional control at all times. Residents were assessed for their ability to resolve the conflict.

Assessments were performed using the Boggs scale for collaboration and satisfaction about care decisions, in which the observer rates the encounter on 6 collaboration and 3 satisfaction items. Each item is scored on a scale of 1 to 7 (where 7 is highest), with the average of all 9 items reported as the score. The instrument's validity evidence was studied within a setting of a medical intensive care unit, with a resident and a nurse transferring a patient to a lower level of care. The instrument showed to have construct and criterion validity, as well as 93% interobserver reliability.¹² Residents completed a self-assessment, and were assessed by the S-Pro (nurse role) and faculty who were blinded to the residents' prior experience with nurse-physician conflict. After completing the assessments, residents met individually with the standardized professional and the SP. Residents were informed whether or not they were successful in creating collaboration between themselves and the “nurse.” Faculty raters were not present at the encounter; they viewed encounter recordings shortly after the completion of all encounters.

Of 22 eligible PGY-2 to PGY-6 residents, 18 completed the pre-encounter survey and participated in the S-Pro Encounter. Residents were allowed up to 15 minutes for the encounter. Portrayers were allowed to conclude the encounter sooner if the resident had addressed all of the patient's and nurse's concerns. All encounters were completed in 1 morning over a 2½-hour period during protected resident education time. Residents were kept separated from each other to prevent discussion of the encounter until all had completed it.

The Johns Hopkins Medical Institutional Review Board deemed this study exempt from review.

Resident self-assessments were compared to those of the S-Pro and faculty using a paired t test and intraclass correlation coefficient. Relationship to prior learning sessions on physician-nurse conflict management was compared to performance using Fisher exact test. All calculations were performed using the statistical package within Microsoft Excel 2010.

Results

All residents ultimately created collaboration and “passed,” with encounters lasting from 9 to 14 minutes. Pre-encounter survey results demonstrated that all residents had previously witnessed a nurse-physician conflict in front of a patient. A majority of senior (≥ PGY-5) residents (89%, 8 of 9) felt that nurse-physician disagreements were due to nurse inexperience, compared with a minority of junior (≤ PGY-4) residents (22%, 2 of 9). However, when dichotomized by junior (< PGY-4) versus senior (> PGY-5) training level, no significant association between ability to collaborate with the nurse and training level was found (P = .58, Fisher exact test). There was a significant positive association between prior education residents had received in physician-nurse conflict management and performance by the Boggs scale (0.032). Results are summarized in the table.

TABLE Summary of Responses to Prior Education Survey and Boggs Score for Standardized Professional (S-Pro) Encounter.

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Discussion

The S-Pro Encounter was feasible and acceptable to all residents who participated. Residents rated the encounter from neutral to helpful in terms of helping them identify their skill level in professionalism and communication.

There was a high level of agreement between faculty and S-Pro assessments of resident performance in the encounter using the Boggs scale, indicating that our model has interrater reliability between rater types (faculty surgeon versus professional actor). There was a positive association between prior resident education in physician-nurse conflict management and performance, as rated by the faculty and the S-Pro using the Boggs scale. Resident self-assessment showed poor correlation between the S-Pro and the faculty ratings on the Boggs scale.

The Boggs scale was originally studied in medical intensive care unit patient transfers to lower levels of inpatient care.¹² Our study suggests the scale also can be used to assess collaboration in an inpatient surgical setting. There was a significant association between the amount of prior education in physician-nurse conflict and the performance in the S-Pro Encounter as rated by the Boggs scale.

Disagreement between resident self-assessments and the S-Pro assessments may relate to the communication style of the resident. A previous study demonstrated that plastic surgery residents have different communication styles from the lay public.⁶ Because faculty raters were uninvolved observers of the S-Pro Encounter, they may have detected residents' failure to pick up on clues from the SP or the S-Pro when communication and building of collaboration was going poorly, even when faculty may have had a similar communication style to that of the resident.

Our training program continues to include an annual S-Pro Encounter as part of its professionalism and interpersonal communication curriculum. Because the program is relatively long (7 years for residents who match directly out of medical school), with less than 20% turnover of chief residents graduating and new residents beginning the program, we will not use this exact scenario again for several years. Future S-Pro encounters assessing interprofessional communication will continue to use the Boggs scale.

This study has several limitations. Although our program is relatively large for a plastic surgery residency, our sample size may limit the power to detect differences. All residents performed relatively well; no resident was rated below 4 either by faculty or the S-Pro. The findings may not generalize to other specialties. Trained medical portrayers and/or a live simulation center may not be available to all residency training programs.

Conclusion

The S-Pro Encounter is a simple model effective in assessing plastic surgery residents' professionalism and interpersonal communication skills. Faculty and S-Pro assessments of residents demonstrated a high level of interrater consistency.