Nursing and Health Sciences (2015), 17, 166Ð172

Research Article

Effects of case-based learning on communication skills,

problem-solving ability, and learning motivation in nursing
students
Moon-Sook Yoo, PhD, RN and Hyung-Ran Park, PhD, RN
Ajou University College of Nursing, Suwon, South Korea

Abstract The purpose of this study was to explore the effects of case-based learning on communication skills, problem-
solving ability, and learning motivation in sophomore nursing students. In this prospective, quasi-experimental
study, we compared the pretest and post-test scores of an experimental group and a nonequivalent,
nonsynchronized control group. Both groups were selected using convenience sampling, and consisted of
students enrolled in a health communication course in the fall semesters of 2011 (control group) and 2012
(experimental group) at a nursing college in Suwon, South Korea. The two courses covered the same material,
but in 2011 the course was lecture-based, while in 2012, lectures were replaced by case-based learning
comprising Þve authentic cases of patientÐnurse communication. At post-test, the case-based learning group
showed signiÞcantly greater communication skills, problem-solving ability, and learning motivation than the
lecture-based learning group. This Þnding suggests that case-based learning is an effective learning and
teaching method.

Key words case-based learning, communication skills, Korea, learning motivation, nursing education, problem-solving.

INTRODUCTION
Communication skills are considered a core competency for nursing professionals working with patients, care providers, and health-team
members (N¿rgaard et al., 2012). Nurses must be effective communicators to deliver appropriate nursing care, empower patients, and
improve patient satis-faction; furthermore, having good communication skills improves nursesÕ conÞdence in caring for patients (Roter
et al., 2012; Lau & Wang, 2013). However, studies on commu-nication skills in nursing education have indicated that nursing students
often experience fear, anxiety, and negative attitudes when communicating with patients (Kameg et al., 2010) and are poorly prepared to
communicate with patients in practical situations (Baghcheghi et al., 2011). To address this gap in core skills, training for communication
skills should be grounded in lectures, but must also be supple-mented with hands-on student participation in practical learning (Parry,
2008; van Dalen, 2013).
Communication-skills training is more effective when using learner-centered (Lau & Wang, 2013), practice-based strategies (Berkhof
et al., 2011; Aebersold et al., 2013). Case-based learning (CBL), which is one of such teaching and

Correspondence address: Hyung-Ran Park, Ajou University College of Nursing, Woncheon-dong, Yeongtong-gu, Suwon, 443-721, South Korea. Email: hyungran@ ajou.ac.kr
Received 29 January 2014; revision received 18 April 2014; accepted 22 April 2014
learning methods, is an interactive, student-centered explora-tion strategy that draws on real-life situations to initiate and promote
authentic learning (Williams, 2005). Case-based learning is a constructive learning paradigm, in which learn-ers select and transform
information, construct ideas, and make decisions based on their current or past knowledge (Brandon & All, 2010). In CBL, classroom
instructors help students to solve diverse case-based problems that occur in real-world situations, moving from abstract knowledge to
practical applications (Srisawasdi, 2012). Since CBL focuses on real-life case problems, it is a potentially powerful method for training
nursing students to communicate sensitively with patients in challenging clinical situations. The real-life cases presented using CBL
enable students to integrate and apply their developing clinical communication knowledge, as well as to reßect on complex situations, as
opposed to performing clearly deÞned, predetermined tasks (Smith & Christie, 2004; Bosse et al., 2012; Tayem, 2013).

In addition, CBL encourages students to actively create their own knowledge and independently develop solutions, rather than refer to
the knowledge imparted to them by educators or textbooks for problem-solving (Jonassen & Hernandez-Serrano, 2002; Brandon & All,
2010). This would promote the development of their problem-solving abilities (Schoeman et al., 2009; Ciraj et al., 2010; Yoo & Park,
2014) and learning motivation (KŸhne-Eversmann et al., 2008).
However, there are limited empirical results on the impact of CBL on clinical performance or skill improvement

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Case-based learning on nursing education 167

(Williams, 2005; Jamkar et al., 2006). Previous studies on CBL have focused on studentsÕ attitudes or knowledge levels (Dupuis &
Persky, 2008; Ciraj et al., 2010; Malau-Aduli et al., 2013). Therefore this study investigates the impact of CBL on communication skills,
problem-solving ability, and learning motivation among undergraduate nursing students enrolled in a health communication course
through lecture and practice.

Purpose
The purpose of this study was to evaluate the effectiveness of CBL on undergraduate nursing students in the health com-munication
course. Students in the intervention group, who were receiving CBL, were expected to show improved com-munication skills, problem-
solving ability, and learning moti-vation when compared to the control group receiving traditional lecture-based learning.

METHODS

Design and sample

In this prospective, quasi-experimental study, we compared pretest and post-test scores obtained by the experimental group and the
nonequivalent, nonsynchronized control group. Participants from both groups were selected using convenience sampling from a
population of sophomore undergraduate students enrolled in a mandatory health com-munication course in the fall semesters of 2011
(control group) and 2012 (experimental group) at a nursing college in Suwon, Korea. Initially, 77 students in the experimental group and
74 in the control group agreed to participate. However, Þve post-test questionnaires in the experimental group and three in the control
group were incomplete and were there-fore excluded. As a result, a total of 143 students became participants, 72 in the experimental
group and 71 in the control group. While the same material was covered in both courses, in 2011, a traditional lecture-based learning
course was delivered, and was replaced with a CBL course covering the required material through Þve authentic cases of patientÐ nurse
communication in 2012.

A post-hoc power analysis using the independent t-test (Faul et al., 2007) for sample sizes of 72 (experimental group) and 71 (control
group) yielded a power of 99.9% with an effect size (0.90) and an alpha value of 0.05.

Ethical considerations
Before the study, approval was obtained from the Institu-tional Review Board at Ajou University (AJIRB-MED-SUR-11Ð195). All
participants were enrolled in a mandatory health communication course, which was deliv-ered through traditional lectures in 2011 and
CBL in 2012. However, participants who completed the questionnaire survey also Þlled out an informed consent form agreeing to
participate in the study. Students were briefed on the study purpose and process, as well as their right to withdraw par-ticipation at any
time without any adverse effect on their course grade.

Case-based learning development

Case contents
The cases of CBL were developed in July 2011. Communica-tion conßicts from miscommunication between patients and nurses can
result in inappropriate nursing care, which nega-tively inßuences patientÕs health promotion (Morgan, 2013; Tsai et al., 2013).
Therefore, for the selection of the authentic cases used in the CBL course, two research assistants observed situations causing
communication conßict prob-lems between a nurse and patients, which was a core content in communication education, at the
researcherÕs university hospital during a period of one week. The education and clinical expert panel, including a course professor, two
clini-cal instructors, and three clinical nurse specialists, considered whether an observed communication conßict situation was suitable
for use by the students to analyze and subsequently solve the applicable communication problem. For use as learning cases, the expert
panel selected the most frequently observed communication conßict situations. These Þve situa-tions were delayed laboratory tests,
bedside-rail management to prevent patients from falling out of bed, reintravenous catheterization due to delayed ßuid change, delayed
dis-charge time, and unsatisfactory pain control. The selected Þve communication conßict situations were developed as cases during
December 2011. Cases were designed in a manner requiring students to improve in problem-solving ability. This ability related to
considering the most appropriate commu-nication skills, as well as identifying the cause of the conßict in the miscommunication process.
Two clinical nurse special-ists from the clinical expert panel, each with clinical and educational experience spanning more than ten years,
reviewed the learning objectives and clinical realism of the cases.

Case presentation
Following the development of the cases, scenarios were drawn up, and standardized patients (SPs) and standardized nurses (SNs) were
prepared for the re-enactment of the cases during January 2012. Five SPs and Þve SNs were appointed; they received training in
appropriate behavior and speech patterns, and were also provided with costumes and appro-priate make-up so as to lend authenticity to
their roles. The training was provided by a SP trainer over a three-week period, 3 h per week. Two clinical nurse specialists reviewed the
constructed scenario and behaviors of the SPs and SNs.

Procedure and data collection

Pretest and intervention

All participants were enrolled in a health communication course worth two credits and lasting 28 h in total. Participants completed a
demographic survey, an assessment of commu-nication skills using SPs, and tests on problem-solving ability and learning motivation
before the start of the course (Fig. 1).

168 M-S. Yoo and H-R. Park

The lesson in the CBL health communication course had four stages. First, Þve cases of communication conßict result-ing from
miscommunication between a nurse and a patient were presented to the students, enacted by SPs and SNs for 10Ð15 min per case. In this
stage, the students were asked to decipher the nature of the communication problem. In the second stage, the students individually
formulated detailed plans on how to solve the communication conßicts. They could also analyze the situation that brought about the mis-
communication and obtain Þrst-hand experience of the problem-solving process. In the third stage, the course pro-fessor randomly
assigned the students to small groups. Each of 15 groups was made up of Þve to six students. The students solved the communication
problems through group discus-sions that were based on the individually formulated problem-solving plans. They shared their alternative
commu-nication strategy with the group members and drew comparisons. The group then analyzed the cause of the com-munication
conßict situations, and considered anticipated results of the suggested solutions. The course professor facilitated the discussion process
and ensured alignment with the learning objectives, and encouraged coopera-tive interactions. In the fourth stage, a solution to the prob-
lems was suggested. Based on the group discussion outcomes, the students proposed an appropriate communication solu-tion. Finally,
the students participated in the enactment with SPs as the role of nurses using an improved communication style.

In the traditional learning environment that the control group had been exposed to, the course was delivered through didactic lectures.
The Þve cases in which communication con-ßict situations involving nurses and patients occurred were included in the learning material.
The course professor described the cause and the process relating to the communication problem situation, and then presented solutions
in the form of appropriate communication strategies during the lecture.

Post-test
After the Þnal lesson, problem-solving ability and learning motivation among the intervention and control groups were assessed via self-
administered questionnaires. The studentsÕ communication skills were assessed using observational grading by a course professor and
two clinical instructors during their communication enactment involving SPs. Version 19.0 of the SPSS (Statistical Package for the
Social Sciences; SPSS Inc, Chicago, IL) was used for data analysis.
Measurements

Communication skills
The Communication Assessment Tool (CAT) developed by Makoul et al. (2007), and translated and revised into Korean by Yoo and
Chae (2011), was used to measure studentsÕ interpersonal and communication skills.The CAT contains 15 items scored on a Þve-point
Likert-type scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). The possible range of total scores is 15Ð75, with higher
scores denoting better communication skills. In a previous study, the reliabil-ity of the CAT had been established with a CronbachÕs
alpha of 0.83 for nursing students (Yoo & Chae, 2011). A CronbachÕs alpha of 0.83 was also obtained in this study.
In order to measure studentsÕ communication skills using the CAT, two nursing experts developed a pilot test using a history-taking
case in July 2011. A history-taking interview is a common communication process between a nurse and a patient during a hospital visit.
Two nursing experts, one a course professor and the other a clinical nurse specialist at a hospital, constructed the history-taking scenario
according to the process found in the CAT, namely, introduction,
problem identiÞcation, offering information, understanding the patient, and closing. The course professor and two clinical instructors
tested the CAT three times and adjusted the test guidelines accordingly.

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Case-based learning on nursing education 169

CronbachÕs alpha of 0.75 was previously obtained during use of the scale on nursing students (Yoo & Chae, 2011), while in this study a
CronbachÕs alpha of 0.87 was obtained.

Problem-solving ability
The Problem-Solving Inventory (PSI), developed by Heppner and Petersen (1982) and translated into Korean by Jun (1994), was used to
assess studentsÕ self-reported problem-solving styles. The PSI contains 35 items (including three Þller items) scored on a six-point
Likert-type scale ranging from 1 (strongly agree) to 6 (strongly disagree). The PSI contains three subscales: problem-solving conÞdence
(11 items), approach-avoidance style (16 items), and personal control (5 items). The total score (the sum of the three subscales) ranges
from 32 to 192, with higher scores indicat-ing poorer self-reported problem-solving skills.A CronbachÕs alpha of 0.82 was obtained
during use of the scale on gradu-ate nurses (Yoo & Park, 2014), whereas a CronbachÕs alpha of 0.92 was obtained in the present study.

Learning motivation
The Instructional Materials Motivation Scale (IMMS) developed by Keller (1987) and translated into Korean by Jang (1996), was used
to evaluate studentsÕ learning moti-vation in four domains: attention, relevance, conÞdence, and satisfaction. The IMMS comprises 35
items scored on a Þve-point Likert-type scale ranging from 1 (not true) to 5 (very true). The possible range of scores is 35Ð175, with
higher scores denoting more self-directed motivation to learn. A
Data analysis
Descriptive statistics including means, standard deviation (SD), frequencies, and percentages were used to describe sociodemographics
with SPSS Version 19.0 programs. A t-test was used to compare differences in means of communication skills, problem-solving ability,
and learning motivation scores. All analyses were two-tailed, and the signiÞcance level was set at 0.05.

RESULTS

General characteristics and homogeneity test

The demographic characteristics of the intervention and control groups are shown in Table 1 and are brießy summa-rized here. The
majority of participants were female (93.0%). Most (62.9%) had obtained an average grade of 3.0Ð3.9 in the previous semester.
Moreover, 68.5% of the participants regarded their personality as neutral during interpersonal relations. The pretest scores denoted test
homogeneity for the two groups (Table 2). No signiÞcant differences were detected between the intervention and control groups in the
pretest scores obtained for communication skills (t = 1.88, P = 0.061), problem-solving ability (t = −0.68, P = 0.501), and learning
motivation (t = −1.88, P = 0.061).

Table 1. General characteristics of the participants

Intervention group (n = 72) Control group (n = 71)

Variables Categories N (%) N (%) χ2 P

Gender Male 7 (9.7) 3 (4.2) 1.661 0.198

Female 65 (90.3) 68 (95.8)
Average grade previous semester > 4.0 7 (9.7) 9 (12.7) 4.132 0.248
3.0Ð3.9 50 (69.4) 40 (56.3)
2.0Ð2.9 14 (19.4) 22 (31.0)
< 1.9 1 (1.4) Ð
Interpersonal personality Active 21 (29.2) 24 (33.8) 0.356 0.551
Neutral 51 (70.8) 47 (66.2)
Negative Ð Ð

Table 2. Homogeneity comparison of communication skills, problem-solving ability, and learning motivation

Intervention group (n = 72) Control group (n = 71)

Variables Mean (SD) Mean (SD) t (P)

Communication skills 40.69 (6.56) 42.70 (6.16) 1.88 (0.061)

Problem-solving ability 112.32 (5.27) 111.75 (4.87) −0.68 (0.501)
Learning motivation 102.63 (8.75) 99.53 (10.85) −1.88 (0.061)

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170 M-S. Yoo and H-R. Park

Table 3. Differences in learning motivation, problem-solving ability, and communication skills

Intervention group (n = 72) Control group (n = 71)

Variables Mean (SD) Mean (SD) t (P)

Communication skills Pretest 40.69 (6.56) 42.70 (6.16)

Post-test 58.42 (6.75) 46.64 (9.79) −8.36 (< 0.001)
Difference 17.73 (8.21) 3.94 (9.59)
t (P) 18.33 (< 0.001) 3.46 (0.001)
Problem-solving ability Pretest 112.32 (5.27) 111.75 (4.87)
Post-test 97.73 (16.08) 123.49 (14.16) 10.16 (< 0.001)
Difference −14.59 (16.41) 11.75 (16.33)
t (P) −7.55 (< 0.001) 6.06 (< 0.001)
Learning motivation Pretest 102.63 (8.75) 99.53 (10.85)
Post-test 110.05 (11.87) 98.29 (12.97) −5.65 (< 0.001)
Difference 7.41 (11.46) −1.23 (12.95)
t (P) 5.49 (< 0.001) −0.80 (0.425)
Effectiveness of the CBL
After completing the course, the intervention group improved more than the control group with regard to com-munication skills,
problem-solving ability, and learning moti-vation (Table 3). A signiÞcant increase in the communication skills score of the intervention
group was observed (t = 18.33, P < 0.001), while a slight increase was observed for the control group (t = 3.46, P < 0.001). There was a
signiÞcant difference in the communication skills of the two groups (t = −8.36, P < 0.001). A signiÞcant decrease in the problem-solving
ability score of the intervention group was observed (t = −7.55, P < 0.001), whereas an increase was observed in the control group (t =
6.06, P < 0.001). A signiÞcant improve-ment was observed for the problem-solving ability of the intervention group, as compared to the
control group (t = 10.16, P < 0.001). Finally, scores for learning motivation showed a signiÞcant increase of + 7.41 (t = 5.49, P < 0.001)
for the intervention group, whereas a decrease of −1.23 (t = −0.80, P > 0.05) was observed for the control group. Moreover, a signiÞcant
difference was found in the learning motivation scores of the two groups (t = −5.65, P < 0.001).

DISCUSSION
The present study evaluated the effects of CBL on nursing studentsÕ communication skills, problem-solving ability, and learning
motivation. The results of this study showed that CBL effectively facilitated the development of communica-tion skills and increased
problem-solving ability and learning motivation.

Improvement in the communication skills of the group that was exposed to CBL in this study is compatible with Þndings of previous
studies. The signiÞcant increase in the communi-cation skills of nursing students in this study, following the CBL intervention, is similar
to previous studies on CBL intervention conducted on medical (Chan et al., 2008) and pharmacological students (Tayem, 2013). Active
and student-centered practice, involving the sharing of opinions in the form of group discussions, as well as verbal and nonverbal
interaction with SPs, may have been effective strategies for communication skills training, thus contributing to the current Þndings (Chan
et al., 2008; Berkhof et al., 2011). Moreover, Þve communication cases were developed on the basis of real clinical settings. These
improved studentsÕ inter-action patterns and enabled them to respond sensitively in communication situations involving patients. A
previous study evaluating the impact of communication intervention on healthcare professionals concluded that Case-based learn-ing
cases reßecting reality are essential for improving com-munication (N¿rgaard et al., 2012).

Problem-solving ability showed signiÞcant improvement in the CBL group, and deteriorated in the group that received traditional
lectures. This is consistent with two previous studies on the effectiveness of CBL on graduate nurses who had taken a preclinical course
aimed at bridging basic scien-tiÞc and clinical literacy (Schoeman et al., 2009) and a prac-tical course comprising immersion in a clinical
setting (Yoo & Park, 2014). Case-based learning exposes students to appro-priate responses in the Þrst and second phases of the learning
and teaching approach, thus enabling them to successfully recognize, analyze, and solve communication problems (Jonassen &
Hernandez-Serrano, 2002; Allchin, 2013). This is especially true for CBL exposing students to multifaceted problems that reßect a real
clinical situation, as these present opportunities for students to discuss and integrate clinical knowledge in order to recognize problems
and solve them accordingly (Bosse et al., 2012). Exposure to communication conßict in this study could have enhanced cognitive
abilities that are necessary for problem-solving. Miscommunication is an extremely complex phenomenon that could occur at any stage
in the communication process (Morgan, 2013). In-depth analysis of cases involving miscommunication enhances problem-solving ability
due to the transition from individually formulated solutions to systematic problem-solving that occurs during group discussions.

In this study, a signiÞcant increase was observed in the learning motivation score of the group that received CBL. Although there are
only a few studies with which the current Þndings on the effect of CBL on learning motivation can be compared, this Þnding is similar to
a CBL study in which video footage was shown to have a positive effect on learning motivation (Yoo et al., 2010). Self-directed,
individual problem-solving prior to group discus-sion stimulates individualsÕ interest, curiosity, and intrinsic attention, thus encouraging
active participation and improv-ing self-efÞcacy (Keller, 1987; Jonassen & Hernandez-Serrano, 2002; Williams, 2005; Yoo et al., 2010)
and, consequently, learning motivation. Furthermore, tangible and realistic cases that were used in this study were relevant to the clinical
environment, thereby improving participantsÕ motivation to learn.

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Case-based learning on nursing education 171
Limitation of the study
Several limitations pertaining to this study must be consid-ered when interpreting the Þndings. First, convenience sam-pling limits the
generalizability of the Þnding in this study. Therefore, a study using a random sample of students across Korean nursing schools should
be considered in order to provide empirical evidence of the effects of CBL.
Second, outcomes of CBL were evaluated through a quan-titative instrument, which does not facilitate in-depth under-standing of
studentsÕ experiences, such as their experiences of the CBL process. Third, although the same professor taught the course to both
groups, we could not control the effect of professorÕs individual endeavor and passion for the new teaching method on the results in this
study. The Þnal limita-tion was that we did not consider the studentÕs learning styles such as interactive or passive. Despite these
limitations, this research is meaningful in that it evaluates the effect of CBL on communication skills, along with problem-solving ability
and learning motivation among undergraduate nursing students.

CONCLUSIONS
This study suggests that CBL is a more effective technique than traditional didactic lectures for improving communica-tion skills,
problem-solving ability, and learning motivation in undergraduate nursing students; during the course of a CBL lecture, nursing students
appeared to learn how to solve problems and communicate effectively in diverse clinical situations through exploring and participating in
authentic case-based practice. The results indicate that CBL could be incorporated into nursing education curricula as a teaching method.
It is also important to develop authentic, reality-based cases, as these are necessary for the effectiveness of CBL. Wide application of
CBL would enhance the quality of education imparted to undergraduate nursing students, par-ticularly education related to patient care.

ACKNOWLEDGMENTS
This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by
the Ministry of Education (No. 2011-0009593).

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