Date of Award


Degree Type

Evidence-Based Project Report

Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

Kristen L. Mauk


The National Institute of Health Stroke Scale (NIHSS) is the most common stroke assessment used by nurses. Nurses certified on the NIHSS do not consistently demonstrate inter-rater reliability nor are they confident when assessing stroke patients using the tool (Josephson, Hills, Johnston, 2006). This EBP project evaluated a standardized patient simulation for maintaining inter-rater reliability and confidence in NIHSS certified nurses. A literature review showed that a decrease in inter-rater reliability occurs within four weeks to three months of NIHSS certification. A single cohort of intensive care nurses and emergency department nurses used the NIHSS tool in a standardized patient (SP) simulation during three scenarios. The first scenario was followed by a debriefing session in which the participants were instructed on the correct way to perform each of the 15 items on the NIHSS tool. Immediately following the debriefing session the participants scored another standardized patient simulation scenario. Four weeks following the first session, the participants were asked to perform a NIHSS assessment in a virtual simulation scenario. Then three months from the debriefing session, the participants scored the last standardized stroke patient scenario. In addition, all participants filled out a pre-intervention and post-intervention survey that measured how confident they felt about performing the NIHSS. The two primary outcomes measured (a) nurses’ confidence when performing the NIHSS on stroke patients, and (b) accuracy of scoring stroke patients correctly as compared to expert scores. The data were analyzed using Descriptive Statistics, Repeated-Measures ANOVA with protected dependent t tests, Paired-Sample t-Tests and Pearson Correlation Coefficient with SPSS 22. Nurses showed a significantly higher confidence level in performing the NIHSS post-simulation versus pre-simulation. Plus, there was a higher inter-rater reliability among total correct NIHSS scores and among gaze, visual fields, ataxia, language and extinction/neglect in this project at 3 months. These findings support that standardized patient simulation with debriefing may provide an educational strategy to help maintain inter-rater reliability and confidence especially in harder to score items of the NIHSS such as visual fields, ataxia, language and extinction/neglect.