Teaching and Learning Forum 96 [ Contents ]

Communication skill development in health professional education: The use of standardised patients in combination with a peer assessment strategy

Rick Ladyshewsky and Evangeline Gotjamanos
School of Physiotherapy
Curtin University of Technology


The development of communication skills in health professional students is central for success as a clinician and requires considerable breadth and understanding of key principles. The development of interpersonal communication skills in health professionals is well described in the literature (Dickson et al, 1989; Dockrell, 1988; Gartland, 1984b; Alroy et al, 1984; Quirk & Letendre,1986 Scheidt et al, 1986; Schultz et al, 1988). Dockrell (1988), for example found that physiotherapy students had sufficient knowledge concerning interpersonal communication. She found, however, that these students lacked the necessary skills in practice. Alroy et al (1984) described their evaluation of the short term effects of an interpersonal skills course on internal medicine clerks. They were able to measure improvements in supporting behaviour, confidence and caring behaviours with patients.

In terms of teaching communication skills, the strategies that one can use range from purely didactic approaches to ones which are more experiential in nature. Quirk & Letendre (1986) describe a communication skills course for first year medical students. The use of videotape and simulated patients were used to develop verbal and non-verbal communication skills. Students rated role playing and the observation and analysis of the recorded interviews as significantly more valuable than readings or lectures. The students also rated the actors as more valuable than fellow students as simulated actors.

Standardised Patients

A standardised patient (SP) is a person who has been trained to portray a uniform case presentation and who is able to repeat this presentation for a number of students (Gold et al, 1995; Nayer, 1993). The use of standardised patients has been proven to be quite an accurate means of reproducing clinical scenarios in health professional education (Barrows, 1993; Gold et al, 1995). Because of this presentation consistency, the use of SPs have been used in a wide variety of situations to teach and evaluate health professionals. (Colliver & Williams, 1993; Gold et al, 1995; Hasle et al, 1994; Heaton et al, 1994; Kaiser & Bauer, 1995; Nayer, 1993; Colliver et al, 1991; Schultz et al, 1988).

With respect to communication skill training, the use of SPs has been used quite effectively in health professional education (Barrows, 1993; Gold et al, 1995; Hasle et al, 1994; Heaton et al, 1994; Sanson-Fisher & Poole, 1980; Schultz et al, 1988). Barrows (1993) utilised SPs in conjunction with videotape recordings of the interaction. He found the videotape playbacks to be a very powerful tool for stimulating students' recall and reflection.

Student comments about the use of SPs in their training is also very positive (Gold et al, 1995; Hasle et al, 1994; Kaiser & Bauer, 1995; Schultz et al, 1988) although stress associated with this type of learning activity is not uncommon. In spite of this anxiety, Hasle (1994) demonstrated that participation in the SP program leads to a reduction in anxiety when students are then required to perform tasks on real patients.

Barrows (1993) describes the educational advantages of SPs. Specific problems can be chosen in advance to highlight parts of the curriculum and they can be manipulated in several different ways depending upon the desired educational outcome. Often, students may not encounter these types of problems in the clinical setting so the use of SPs ensures that all students have access to important clinical scenarios. Barrows (1993) goes on to state that students are able to get unique forms of objective and subjective feedback from videotape reviews and SP comments. Difficult and emotionally charged interpersonal situations can also be modelled using SPs.

Peer Evaluation/Assessment

The use of peer evaluation as a source of feedback for students has received considerable attention in the literature. This evaluative component may be purely for feedback purposes or for the actual assignment of marks. Traditional marking schemes are often criticised by students for their unreliability, inaccuracy and for their low learning value (Falchikov, 1986; Fry, 1990; Orpen, 1982; Rushton et al, 1993). An underlying assumption that occurs during the evaluation process is that lecturers, because of their greater experience and expertise in the subject matter, are more capable of marking and ranking students (Orpen, 1982).

The advantages and disadvantages of peer assessment have been summarised by several authors (Fry, 1990; Orpen,1982; Rushton et al, 1993; Boud, 1986; Williams, 1992; Falchikov, 1986). Advantages centre around reductions in the teacher's marking workload, students think more deeply about the exercise and get to view how others tackled the same problem, students learn how to constructively criticise the work of others and the gap between teacher and student narrows with the instructor viewed more positively as a facilitator. Disadvantages are that students may not have the same level of understanding as the teacher, may not provide useful feedback, need clearer guidance in terms of what they should look for, may show bias towards their friends and be reluctant to award low marks for poor work because of fear of offending peers.

Teaching Communication Skills in Physiotherapy

The unit which provided the framework for this teaching dilemma analysis is entitled "Health and Social Behaviour in Physiotherapy (HSBIP)" The unit is for year 3 students in a 4 year BSc degree program at the School of Physiotherapy, Curtin University of Technology A total of 73 students were enrolled in this particular unit. The unit is comprised of a lecture and tutorial stream. In the lecture stream, students explore issues related to health and physiotherapy from a psycho-social perspective. The tutorial stream focuses on interpersonal skills necessary for effective performance as a health professional. Both components of the unit are closely interrelated. Skills such as verbal and non-verbal communication, patient interviewing, counselling, assertiveness, conflict resolution and cross cultural interaction are covered in the unit. Teaching approaches utilise a combination of group discussion, group exercises, student presentations, role plays, videotape, standardised patient simulations and interactive improvisation with actors. The experiential focus of the tutorial stream is intentional given the highly practical and situational context of communication skill training.

Four actors were trained by one of the unit coordinators using scripts that had been developed by the academic staff in the School of Physiotherapy. These 4 SP scenarios were further developed by one of the Unit Coordinators to stimulate a variety of communication behaviours in the students. An emphasis was placed on the psychosocial elements of each clients' history as this was the prime focus of the unit.

Four tutorial sessions on communication principles, interviewing and counselling skills were presented by the students following Dickson & Maxwell's (1985) model of sensitisation and feedback. Following these tutorials, students undertook their interview with the simulated patient under videotape. When all students had completed their interview, the videotapes were exchanged amongst the student peers. Each student was required to review one videotape of a peer and to make comments on a marking sheet that had been developed by the unit coordinators.

Peer Evaluation Results

The students' mean average mark (mean = 80.26, sd 7.16) was significantly higher than the mean mark of the unit coordinators (mean = 68.37, sd 9.83) (Z = -3.2059, N = 19, p0.01). There was also less variation or spread in the students' marking distribution when compared to the mark distribution of the unit coordinators.

Learning Experience Evaluation

One of the questions on the unit evaluation asked them, "In general, was the complete simulated patient interview exercise (interview, videotape, peer review) a useful learning experience?" Students overwhelmingly commented in favour of the exercise (mean response = 4.38 out of 5). Students suggested that there was room for improvement in the overall exercise, but found the entire process a useful learning experience both from their own self-evaluation perspective but also from the perspective of learning from and observing the performance of others.

Review of the Learning Experience

The concepts raised by Dockrell (1988), which pointed out that students do possess sufficient knowledge about communication skills but lack adequate practice and self-awareness, were central to the design of the unit. Making the assumption that students do not have much to contribute to the program ignores one of the cornerstones of adult education theory. That is, that all individuals have a rich personal experiential history which should be valued and incorporated into the learning strategy.

The experiential nature of the unit and the focus on issues of immediate relevance to the students - another tenet of adult learning theory - was central to eliciting the student's interest and support for the program. The SPs were very effective in drawing out the desired behaviour in students which added depth to the concepts covered in the course. Greater self awareness about one's own communication skills was also a direct product of the exercise. Many students became aware of behaviours or mannerisms in their communication style which they did not expect or necessarily like. This 'awareness' is consistent with the findings cited by Barrows (1993) and Dockrell (1988) and further reinforces the positive effects of SPs in communication skill training.

The peer assessment process produced some interesting information. The students themselves were an excellent source of information about how the process could have been improved. Some of the strategies that will be included in future programming include: more specific marking guidelines, appointment of the unit controllers as dispute mediators, review of a couple of student-SP interactions on videotape to prepare students for the experience and the marking exercise that follows and the incorporation of the SP's mark into the overall grading strategy.

In terms of disadvantages, some students did not provide useful written feedback to their peers. The group was also very generous in their allocation of marks. Marks were significantly higher in the student group sample as compared to the grades awarded by the unit coordinators for this same sample. There was also less variation in the students' marks - clustering around a high average grade. This tendency to award peers high marks was consistent with findings cited by Williams, 1992; Falchikov, 1986 and Orpen, 1982.

The suggestion from some of the students that the peer assessment be a group (n=4) process may prove to be effective in minimising the mark discrepancy that occurred in this particular instance. The presence of other colleagues during the videotape review process will hopefully produce more objectivity in marking as well as pressure to provide responsible and useful feedback.


The experience of using SPs and peer assessment to develop greater communication skill self-awareness was quite successful. An interactive, experiential course of study which valued the students previous life experience and which focussed on issues of direct and immediate relevance to students was effective in raising their commitment to the unit. To this end, any course of study which focuses on communication skill development should consider the role of actors and the use of drama. It is hoped that our experience will assist others who are responsible for the teaching and development of professional interpersonal communication skills.

Question for Teaching Dilemma Discussion


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Barrows, H. (1993). An overview of the uses of standardized patients for teaching and evaluating clinical skills. Academic Medicine, 68, 443-451.

Boud, D. J. (1986). Implementing Student Self-Assessment. (Sydney, HERDSA)

Colliver, J. A., Mast, T. A., Vu, N. V., Barrows, H. S. (1991). Sequential testing with a performance - based examination using standardised patients. Academic Medicine, 66,S64-S66.

Colliver, J. & Williams, R. (1993). Technical Issues: Test Application. Academic Medicine, 68, 454-460.

Dickson, D.A., Hargie, O. Morrow, N. C. (1989). Communication Skills Training for Health Professionals - An Instructor Handbook. Chapman and Hall.

Dickson, D.A. & Maxwell, M. (1985) The interpersonal dimension of physiotherapy: Implications for training. Physiotherapy, 71,306-310.

Dockrell, S. (1988). An investigation of the use of verbal and non-verbal communication skills by final year physiotherapy students. Physiotherapy, 74, 52-56.

Falchikov, N. (1986). Product comparisons and process benefits of collaborative peer group and self assessments. Assessment and Evaluation in Higher Education, 11, 146-166.

Fry, S. (1990). Implementation and evaluation of peer marking in higher education. Assessment and Evaluation in Higher Education, 15, 177-189.

Gartland, G. J. (1984b). Communication skills instruction in Canadian physical therapy schools: A report. Physiotherapy Canada, 36, 29-31.

Gold, G., Hadda, C., Taylor, B., Tideiksaar, R. & Mulvihill, M. (1995). A standardized patient program in a mandatory geriatrics clerkshop for medical students. The Gerontologist, 35, 61-66.

Hasle, J., Anderson, D. & Szerlip, H. (1994). Analysis of the costs and benefits of using standardized patients to help teach physical diagnosis. Academic Medicine, 69, 567-570.

Heaton, C., Watson, S. & Alger, E. (1994). Using a standardized patient to teach health appraisal in a problem-based format. Academic Medicine, 69, 415-416.

Kaiser, S. & Bauer, J. (1995). Checklist self-evaluation in a standardised patient exercise. The American Journal of Surgery, 169, 418-420.

Nayer, M. (1993). An overview of the objective structured clinical examination. Physiotherapy Canada, 45, 171-178.

Orpen, C. (1982). Student versus lecturer assessment of learning: A research note. Higher Education, 11, 567-572.

Quirk, M. & Letendre, A. (1986). Teaching communication skills to first-year medical students. Journal of Medical Education, 61, 603-605.

Rushton, C., Ramsey, P. & Rada, R. (1993). Peer assessment in a collaborative hypermedia environment: A case study. Journal of Computer-Based Instruction, 20, 75-80.

Sanson-Fisher, R. & Poole, A. (1980). Simulated patients and the assessment of medical students' interpersonal skills. Medical Education, 14, 249-253.

Scheidt, P. C., Lazoritz, S., Ebbeling, W. et. al. (1986). Evaluation of system providing feedback to students on videotaped patient encounters. Journal of Medical Education, 61, 585-589.

Schultz, C., Wellard, R., Swerissen, H. (1988). Communication and interpersonal helping skills: An essential component in physiotherapy education? The Australian Journal of Physiotherapy, 34; 75-80.

Somervell, H. (1993). Issues in Assessment, Enterprise and Higher Education: The case for self-, peer and collaborative assessment. Assessment and Evaluation in Higher Education, 18, 221 - 233.

Tamblyn, R., Klass, D., Schanbl, G. & Kopelow, M. (1990). Factors associated with the accuracy of standardized patient presentation. Academic Medicine, 65, S55-56.

Please cite as: Ladyshewsky, R. and Gotjamanos, E. (1996). Communication skill development in health professional education: The use of standardised patients in combination with a peer assessment strategy. In Abbott, J. and Willcoxson, L. (Eds), Teaching and Learning Within and Across Disciplines, p93-97. Proceedings of the 5th Annual Teaching Learning Forum, Murdoch University, February 1996. Perth: Murdoch University. http://lsn.curtin.edu.au/tlf/tlf1996/ladyshewsky1.html

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