Nurse Education Today 91 (2020) 104467

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Nurse Education Today

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Efficacy of the computer simulation-based, interactive communication T

education program for nursing students
Heeseung Choia,b, , Ujin Leea, Ye Seul Jeona, Chanhee Kimc
⁎

a
College of Nursing, Seoul National University, Seoul, Republic of Korea
b
College of Nursing & The Research Institute of Nursing Science, Seoul National University, Seoul, Republic of Korea
c
College of Nursing, Dong-A University, Busan, Republic of Korea

ARTICLE INFO ABSTRACT

Keywords: Background: Simulation-based education using standardized patients or high fidelity patient simulators is re-
Communication source-intensive and can be limited in its consistency and repeatability. Standardized, interactive, and effective
Psychiatric nursing computer simulation-based education programs that improve communication skills among nursing students are
Nursing education greatly needed.
Simulation
Objectives: This study aimed to (1) compare the efficacy of a computer simulation-based, interactive commu-
Computer
Nursing students
nication education (ComEd) program and an attention control (AC) program on communication knowledge,
learning self-efficacy, and communication efficacy at baseline and twice after the intervention (immediately
after and two weeks after); and (2) assess the acceptability and satisfaction of the ComEd reported by the
participants.
Design: This study employed a mixed-method, randomized controlled design with repeated measures.
Methods: Students were recruited from four nursing schools and randomly assigned to either the intervention or
AC group. They received either the ComEd or AC program installed on a tablet PC or a desktop computer in the
classrooms and completed a 15-item communication knowledge scale, 10-item learning self-efficacy scale, 22-
item communication efficacy scale, and 14-item satisfaction scale. In addition, six open-ended questions were
used to help participants reflect on their learning experiences and explore their satisfaction with the programs.
The Generalized Estimating Equation (GEE) model was the main model employed to examine the effects of the
ComEd program over time in comparison with the AC program, and the content analysis method was used for
qualitative data.
Results: In total, 131 nursing students (66 in ComEd and 65 in AC) completed the programs and 127 participated
through the two-week follow-up test. Compared to the AC group, the ComEd group significantly improved
communication knowledge, learning self-efficacy, and communication efficacy; these effects were maintained at
two weeks. The ComEd program was well accepted by the participants.
Conclusions: The ComEd is a promising approach because it is highly accessible, consistent, and repeatable, and
has positive learning effects.

1. Introduction
As opportunities for involvement in direct patient care are limited to
students due to the protection of patient rights and confidentiality, si-
mulation-based education has become an essential part of clinical
education in nursing. It is an effective teaching method by which real-
life clinical experiences and instant feedback are provided to students in
a simulated setting (Jeffries, 2012) and it has been found to improve
nursing knowledge, nursing skills, communication skills, empathy,
critical thinking abilities, leadership, and situation management among
nursing students (Cant and Cooper, 2010; Guise et al., 2012; La Cerra
et al., 2019; Sherwood and Francis, 2018). In particular, larger effect
sizes were reported for knowledge and skills performance than for other
outcomes (La Cerra et al., 2019).
Therapeutic communication skill is an essential competency that
nurses need to acquire to understand the needs of patients, foster
therapeutic nurse-patient relationships, and thereby work to help re-
duce a patient's anxiety, fear, and aggression (Riley, 2017). Simulation-
based education designed to foster communication skills using stan-
dardized patients (SPs) or high fidelity patient simulators has helped

⁎
Corresponding author at: College of Nursing, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea.
E-mail address: hchoi20@snu.ac.kr (H. Choi).

https://doi.org/10.1016/j.nedt.2020.104467
Received 1 October 2019; Received in revised form 16 February 2020; Accepted 4 May 2020
0260-6917/ © 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
H. Choi, et al.
nursing students to foster empathy and simulation-related efficacy and
diminish prejudice toward mental illness and anxiety related to clinical
practicum (Choi, 2012; Choi et al., 2016; Lehr and Kaplan, 2013; Park
and Kweon, 2012). However, simulation-based education using SPs or
high fidelity patient simulators is resource-intensive and can be limited
in its consistency and repeatability (Kameg et al., 2010; Wallace, 2007).
Due to these limitations, in Korea, simulation-based education using
SPs or high fidelity patient simulators is offered only at nursing schools
located in the metropolitan area with sufficient resources. In addition,
because debriefing—a facilitated, interactive process for reflective
learning in simulation education (Wallace, 2007)—has been offered
solely in a group format, students have not had access to individual
feedback.
Web- or computer-based learning is a useful approach to reach a
large number of learners while maintaining the consistency and quality
of education with relatively low costs (Cant et al., 2015). Until now,
web- or computer-based education has been applied only to knowledge
and skill-building courses, and computer-based simulation to enhance
communication skills is very limited. Bogossian et al. (2015) demon-
strated that e-simulation of sudden patient deterioration was an effec-
tive learning method in improving nursing students' knowledge, effi-
cacy, and performance. However, the study was limited by its design
(i.e., one-group, pre-post study design) and one-way, uniform content
for all students (e.g., generic debriefing for all students). This is not
surprising, since studies testing the effects of simulation-based educa-
tion still tend to be limited in their fidelity and robustness of experi-
mental design. According to a systematic review and meta-analysis of
simulation studies (La Cerra et al., 2019; Sherwood and Francis, 2018),
about 75% of reviewed studies showed a high risk of bias; significant
heterogeneity among the studies was also noted.
A study that examined the effects of a computer simulation on
teaching communication skills for second-year medical students (Kron
et al., 2017) demonstrated that computer simulations were effective in
imparting clinical knowledge and communication skills among second-
year medical students. In addition, the students who received the
computer simulation showed high levels of satisfaction and positive
attitudes toward the new learning method.
To our knowledge, currently, no computer simulation-based, inter-
active communication education program for nursing students exists.
Considering the potential benefits, standardized, interactive, and ef-
fective computer simulation-based education programs that focus on
building communication skills among nursing students are greatly
needed. Based on the Social Cognitive Theory (Bandura, 1994), we
developed a computer simulation-based, interactive communication
education (ComEd) program for nursing students (Choi et al., 2019a,
2019b).
The present study was designed to test the efficacy of the newly
developed ComEd program on communication knowledge, learning
self-efficacy, and communication efficacy among nursing students. The
specific aims of this study were (1) to compare the efficacy of a ComEd
program and an attention control (AC) program on communication
knowledge, learning self-efficacy, and communication efficacy at
baseline and twice after the intervention (immediate after and two
weeks after); and (2) to assess the acceptability and satisfaction of the
ComEd program reported by the participants.
2. Methods
2.1. Study design and sample
The present study used a mixed-method, randomized controlled
study design with repeated measures. The inclusion criteria were nur-
sing students who: (1) completed communication courses but had not
yet undergone psychiatric nursing practicum courses; (2) were able to
use a tablet PC; and (3) were willing to participate in the study.
Students who had been exposed to similar education programs were
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Nurse Education Today 91 (2020) 104467
excluded from the study. We recruited prospective participants from
four different Korean nursing schools from their respective cities.
Controlling for possible bias that may arise from curriculum differences
or previous educational experiences, we randomly assigned the stu-
dents from each nursing school to either the intervention or AC group.
2.2. Description of the ComEd and AC programs
We developed the ComEd program for nursing students based on
interviews with nine nursing students, 10 experts in nursing education
and practice, and a pilot study with 30 nursing students (Choi et al.,
2019a, 2019b). The ComEd program consisted of a brief patient med-
ical history video, an interactive clinical performance with virtual pa-
tients, and a debriefing session including model videos demonstrating
therapeutic communication skills, reviews of one's own virtual clinical
performance, and individualized and tailored feedback on each per-
formance. The simulation scenarios cover various clinical situations,
including interacting with patients with hallucinations, depressive
symptoms, or suicidal ideation; responding to an angry patient; and
communicating with a doctor. Students who were assigned to the AC
group watched an educational video about mental health issues and a
lecture video on the relevant communication skills.
2.3. Study procedure
After the study was reviewed and approved by the institutional
review board of S. University, study participants were recruited from
four nursing schools located in four Korean cities. Research team
members announced the study in the classroom and asked students who
were willing to participate to share their names and contact informa-
tion. Students who agreed to participate were then randomly assigned
to either the intervention or AC group. On the intervention day, we
assembled students in the classroom, explained the detailed study
procedure, and obtained informed consent from each student.
Students who were assigned to the intervention group received the
ComEd program installed on a tablet PC, and students in the AC group
received the control program using either a tablet PC or a desktop
computer. Due to the recording activities and interactive nature of the
ComEd program, each student in the ComEd group completed the
program in a private and quiet place. Students in the AC group com-
pleted the program in a classroom as a group.
All students were asked to complete the questionnaire thrice (i.e.
before the program, immediately after the program, and two weeks
after the program). Due to the nature of the interactive and tailored
intervention, the duration within which the ComEd program was
completed varied from student to student (about 40–50 min). It took
about 40 min for students in the AC group to complete the study. All
participants completed their two-week follow-up test at places of their
convenience using any computer. Upon completion of the program, we
offered participants $20 for their time and effort. Data were collected
from March through May 2019. A total of 135 students out of 186
prospective participants from four nursing schools responded to the
study announcement (response rate = 72.6%).
2.4. Measures
General characteristics revealed participants' age, gender, grade,
and previous experience with simulation education. Questionnaires
consisted of scales on communication knowledge, learning self-efficacy,
communication efficacy, and satisfaction with 15, 10, 22, and 14 items,
respectively. In addition, we used six open-ended questions to explore
participants' learning experiences with the education programs.
The communication knowledge scale was used to assess the
knowledge of therapeutic communication skills. This 15-item scale
consists of a variety of communication situations with psychiatric pa-
tients (e.g., schizophrenia, depression), and study participants were
H. Choi, et al.
Fig. 1. CONSORT chart.
asked to choose the most appropriate answer in a given clinical situa-
tion. Choi et al. (2019a, 2019b) developed this scale based on a review
of literature and various clinical cases. First, simulation scenarios for
psychiatric nursing and the communication knowledge scale assessing
pertinent knowledge were developed. Then, the content validity of the
developed scenarios and the communication knowledge scale were re-
viewed by two experts in psychiatric nursing and the level of difficulty
of the scale was tested on 10 nursing students. Scale items were fina-
lized after conducting a pilot test on 30 nursing students. The detailed
instrument development process is reported elsewhere (Choi et al.,
2019a, 2019b). Higher scores on the scale indicate a higher level of
communication knowledge. The Cronbach's α for Communication
knowledge was 0.68 in this study.
Learning self-efficacy was assessed using the Post-Training Self-
Efficacy Scale which was developed by Ayres (2005) and translated and
validated by Park and Kweon (2012). Learning self-efficacy is defined
as one's belief in the ability to apply new knowledge after professional
education. This scale consists of 10 items rated on a 7-point Likert scale,
with total scores ranging from 10 to 70. Higher scores indicate greater
learning self-efficacy. The Cronbach's α for the scale was 0.90 in this
study.
We used the 22-item communication efficacy scale to evaluate the
efficacy of communication skills. Communication efficacy refers to how
confident a person is in using communication skills in clinical settings.
This scale includes 15 items related to the efficacy of therapeutic
communication skill developed by Lee (2015) and 7 items regarding the
efficacy of communication skill related to psychiatric symptoms, which
were specifically added for this study. The items are rated on a 7-point
Likert scale from 1 (“strongly disagree”) to 7 (“strongly agree”). Higher
scores indicate a higher level of the communication efficacy. The
Cronbach's α for communication efficacy was 0.93 in this study.
To assess participants' reactions and feedback about the programs,
we used the 14-item attitudinal survey developed for Modeling
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Nurse Education Today 91 (2020) 104467
Professionalism and Teaching Humanistic Communication in Virtual
Reality (MPathic-VR) study (Kron et al., 2017). This scale comprises
items assessing the program's purpose, clarity, utility, and contents, as
well as the likelihood of participants recommending it to other students.
Participants were asked to respond on a scale of 1 to 7 (“Strongly dis-
agree” to “Strongly agree”). Higher scores indicate higher satisfaction.
We also included six open-ended questions to help participants re-
flect on their learning experiences and to explore their satisfaction with
the education programs. In addition to the four questions used in Kron
et al.'s study (2017), we added two more questions assessing partici-
pants' perceptions about nurse-patient relationships and communica-
tion with psychiatric patients.
2.5. Analysis
Quantitative data were analyzed using SPSS 21 (IBM, Armonk, NY
2013). Descriptive analyses were used to analyze the general char-
acteristics of study participants, which, along with their pre-test scores
of outcome measures, were compared between the intervention and AC
groups to examine group differences at pre-test using a t-test and chi-
square test. A generalized estimating equation (GEE) model was em-
ployed to examine the effects of the ComEd program over time in
comparison with the AC program after adjusting for age, gender, grade,
school, and experience of simulations. For the purpose of exploration,
growth mixture modeling (GMM) was employed to capture changes of
communication efficacy score as the primary outcome variable in the
intervention group at pre-, post-, and follow-up tests and to determine
whether these changes are heterogeneous. GMM was developed to
identify homogeneous subgroups with similar growth trajectories
within repeated measures (Muthén and Shedden, 1999; Nagin, 1999;
Nagin and Nagin, 2005). The final number of subgroups was identified
based on the following criteria: (1) smallest Bayesian information cri-
terion (BIC) (Nylund et al., 2007) and (2) each subgroup comprising at
H. Choi, et al. Nurse Education Today 91 (2020) 104467

least 5% of participants for the practical applicability of findings. Table 2

Conventional content analysis was used to analyze the qualitative Mean scores of outcome variables (n = 131).
data collected using open-ended questions (Ryan and Bernard, 2000; Variables Categories Mean ± SD t (p)*
Patton, 2002). Two independent researchers coded the participants'
responses to the open-ended questions independently and any dis- Communication Pre test Intervention 8.70 ± 2.07 −.238
knowledge AC 8.78 ± 2.15 (.871)
crepancies and issues related to the coding were discussed in the re-
Post test Intervention 12.88 ± 1.54
search team meetings. The coded data were arranged and the de- AC 10.00 ± 1.98
scriptive summary of the patterns and main themes emerging from the Follow up Intervention 11.97 ± 2.38
data were identified. test AC 8.85 ± 2.92
Learning self- Pre test Intervention 51.71 ± 6.23 .147 (.270)
efficacy AC 51.55 ± 6.09
Post test Intervention 54.91 ± 6.20
3. Results AC 54.28 ± 5.51
Follow up Intervention 53.88 ± 7.46
3.1. Characteristics of study participants test AC 50.66 ± 6.99
Communication Pre test Intervention 115.82 ± 14.05 −1.048
efficacy AC 118.23 ± 12.22 (.252)
Among the 135 students who agreed to participate in the study Post test Intervention 128.73 ± 13.63
(who signed the consent form), 131 completed either the intervention AC 127.57 ± 12.25
(n = 66) or the AC (n = 65) program, and 127 students completed the Follow up Intervention 126.65 ± 14.99
two-week follow-up test (retention rate = 95.5%). The total number of test AC 121.69 ± 13.40

participants enrolled in the study and the detailed recruitment and

p-Value refers to t-tests of significant differences between the two groups at pre-
retention process are depicted in the CONSORT chart (see Fig. 1).
test.
The general characteristics of the 131 study participants are shown
in Table 1. The participants had a mean age of 22.91 years. Most par-
3.3. Acceptability and satisfaction
ticipants (90.1%) were female and more than half (53.4%) did not have
any previous simulation experiences. The intervention group did not
Overall, participants were highly engaged and satisfied with the
statistically differ from the AC group in terms of age, gender, grade,
ComEd program. The item mean score for the satisfaction scale was
experience of simulations, and outcome variables.
6.36 out of 7 and participants in the ComEd program group reported
significantly higher satisfaction scores than did participants in the AC
group (p < .001). In particular, the following items received high
3.2. Efficacy of the ComEd program
ratings: “The education program was interesting (mean score of 6.62)”;
“The education program was effective in learning verbal communica-
Table 2 shows the mean values for communication knowledge,
tion (mean score of 6.59)”; “Video media was effective in learning
learning self-efficacy, and communication efficacy from the pretest,
(mean score of 6.58).” On the other hand, participants rated the item,
posttest, and two-week follow-up test. GEE results showed that there
“The education program was effective in learning non-verbal commu-
were significant group × time interaction effects on communication
nication skills (mean score of 5.86)” lowest. Participants described the
knowledge (p = .001), learning self-efficacy (p = .016), and commu-
ComEd program as “interesting,” “engaging,” and “helpful.”
nication efficacy (p = .001) compared with the AC group over time
Three themes, “Experienced cognitive, emotional, and behavioral
after adjusting for age, gender, grade, school, and experience of simu-
changes,” “Acquired communication skills specific to psychiatric nur-
lations, as shown in Table 3.
sing care,” and “Being satisfied with new learning method” emerged
GMM was adopted to explore communication efficacy changes in
from the data analysis of ComEd program participants. Participants also
the intervention group at pre-, post-, and follow-up tests and to de-
reported that practicing various clinical cases gave them confidence
termine whether these changes are heterogeneous. Based on the BIC
and motivated them to practice more diverse cases.
values, three subgroups within the intervention group were identi-
fied:“high-level improved, maintained” (24.4%), “medium-level im-
3.3.1. Experienced cognitive, emotional, and behavioral changes
proved, maintained” (55.2%), and “lower-level improved, mildly de-
Participants reported that they were able to differentiate ther-
clined” (20.4%) (see Fig. 2). The majority of participants (79.6%) in
apeutic communication skills from non-therapeutic skills and clearly
intervention groups—the first and second subgroups—showed that the
understand abstract concepts, such as “reflection” or “clarification,”
effects of communication efficacy were maintained at follow-up. In
and apply them in clinical situations. They felt more comfortable and
addition, 20.4% of the intervention group with relatively lower level of
less anxious about patients who displayed psychiatric symptoms after
communication efficacy at pre-test, showed improvement at post-test
completing the education.
but mildly declined at the follow-up test.
“I felt uncomfortable and scared about interacting with psychiatric

Table 1
General characteristics of the participants (n = 131).
Overall Intervention (n = 66) AC (n = 65) χ2 or t p

n(%) or Mean ± SD

Age (years) 22.91 ± 1.41 22.97 ± 1.58% 22.84 ± 1.22%

Gender Male 13 (9.9%) 6 (9.1%) 7 (10.8%) 0.10 0.748
Female 118 (90.1%) 60 (90.9%) 58 (89.2%)
Grade Junior 65 (49.5%) 33 (50%) 32 (49.2) 0.01 0.930
Senior 66 (50.4%) 33 (50%) 33 (41.5)
Previous Simulation Experiences Yes 2 (46.6%) 34 (51.5%) 27 (41.5%) 1.31 0.252
No 70 (53.4%) 32 (48.5%) 38 (58.5%)

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H. Choi, et al. Nurse Education Today 91 (2020) 104467

Table 3
Results of the generalized estimating equation model.
Variables Categories Pre test Post test Follow up test p for group × time

Mean (SD) Mean (SD) Mean (SD)

Communication Knowledge Intervention 8.70 (2.07) 12.88 (1.54) 11.97 (2.38) .001
AC 8.78 (2.15) 10.00 (1.98) 8.85 (2.92)
Learning self-efficacy Intervention 51.71 (6.23) 54.91 (6.20) 53.88 (7.46) .016
Ac 51.55 (6.09) 54.28 (5.51) 50.66 (6.99)
Communication Efficacy Intervention 115.82 (14.05) 128.73 (13.63) 126.65 (14.99) .001
AC 118.23 (12.22) 127.57 (12.25) 121.69 (13.40)

Data were adjusted for age, gender, grade, school, and experience of simulations.
p-Values are for the test of the interaction of group and time by repeated measures.

nurse having a more empathetic attitude and better communication

skills”.
(ID ig14)

3.3.3. Being satisfied with new learning method

Fig. 2. Intervention groups based on changes in communication efficacy scores
at pre-, post-, and follow-up tests.
patients. But (after the education), I realized that they are all human
beings like me, and I have become more comfortable now”.
(ID ij09)
“Actually interacting with virtual patients and applying the concepts that
I had learned purely from texts and lectures to actual cases was inter-
esting and made it easier to understand”.
(ID ig16)
“Initially, when imagining interacting with psychiatric patients, I was
anxious about whether I would be able to do a good job. However, after
practicing the theory-based therapeutic communication skills on cases, I
feel confident that I can do well with real patients”.
(ID is08)
3.3.2. Acquired communication skills specific to psychiatric nursing care
Participants reported that they realized the importance of expres-
sing empathy and learned communication skills and intervention stra-
tegies specific to various psychiatric symptoms, such as auditory hal-
lucinations, delusions, severe depression, anxiety, and suicidal ideation.
“I was able to learn how to initiate a conversation with a patient, what
aspects to assess, and how to offer alternatives to the patients”.
(ID is02)
“I learned how to notify a doctor about changes in the patients' condition
and how to manage the complaints of patients with an empathetic re-
sponse”.
(ID ig02)
“I thought that patients with schizophrenia tend to be violent and do not
listen to other people. However, after participating in this education
program, I learned that a patient's behavior can improve in response to a
Participants reported that the ComEd program was effective in
learning because they were able to record the conversations and review
not only their tone, volume, and speed of voice but also the content of
the conversation. They particularly enjoyed the interactive simulation
experiences, the instant and tailored feedback on their virtual clinical
performance, and the debriefing session using model videos.
“The program explained why my answers were non-therapeutic and
compared my responses with those shown in the model videos. The
teaching method helped me understand the rationale and reasons for
using proper communication skills”.
(ID is04)
“I've been told that my voice is too soft and my pronunciation is not clear.
When re-listening to my recording, I had to try hard to figure out what I
told the patient. I believe that I will be able to improve my communication
skills by realizing my own weaknesses in that area”.
(ID ij08)
“When I learned the communication skills in the class before, I just tried
to memorize the content; thus, I often got confused. (During the ComEd
program,) I felt a bit awkward talking to virtual patients in the beginning,
but I retained what I learned from this program longer since I actually
practiced the skills and recorded them. It was definitely (a) different
(experience)”.
(ID ij12)
“It was effective in learning because re-listening to and reviewing the
recording of my own voice and conversation helped me to check my tone
and pace of speaking”.
(ID is14)
In addition to the main themes, participants reported various opi-
nions on the content and format of the ComEd program. Most men-
tioned that it was “new,” “real,” and “interesting,” and thus they were
able to “engage in the learning process.” Regarding the areas for im-
provement, participants reported that they wished that they could also
practice non-verbal communication skills, such as their facial expres-
sions or gestures.
4. Discussion
The present study demonstrated that the ComEd program, com-
pared to the AC program, significantly improved communication
knowledge, learning self-efficacy, and communication efficacy among
nursing students, and the effects of the program were maintained at two
weeks. Both quantitative and qualitative findings of the study con-
firmed that the participants experienced cognitive, emotional, and

5
H. Choi, et al.
behavioral changes along with improved self-efficacy. The findings of
this study also showed that participants were highly engaged and sa-
tisfied with this new mode of learning.
These findings are consistent with those of a previous meta-analysis
of 18 controlled trials involving 1326 nursing students (Oh et al., 2015).
Oh and her colleagues (2015) concluded that simulation-based learning
using SPs have a positive impact on the cognitive, affective, and psy-
chomotor domains of learning, including acquisition of communication
knowledge and skills. The present study confirmed that computer si-
mulation-based education, through an interactive and engaging
learning process, could also produce similar effects on cognitive, af-
fective, and behavioral domains of learning as can simulation-based
learning using SPs. Namely, participants of the ComEd program had
similar learning experiences as those participating in a simulation
education program using SPs. It is believed that the ComEd program
could bring about comparable learning experiences since it was real,
engaging, and interactive.
The significant learning effect of the ComEd program is possibly due
to the various teaching strategies it applies. Researchers (Goldenberg
et al., 2005; McConville and Lane, 2006; Madorin and Iwasiw, 1999)
have revealed that computer-assisted instruction, on-line video clips,
role playing, and case studies contribute to a positive effect on self-
efficacy among nursing students. Various media tools used in the
ComEd program might also contribute to significant learning outcomes.
The ComEd program was found to be particularly useful for im-
proving confidence in managing psychiatric symptoms and reducing
anxiety and fear associated with the symptoms among nursing students.
Previous studies (Kim and Kim, 2014; Choi et al., 2016), have also
demonstrated the significant effects of simulation education with SPs
on improving nursing students' confidence and skills in managing
psychiatric symptoms. Furthermore, the ComEd program helped in-
crease students' confidence in communicating with a doctor. Effective
communication with treatment team members is another crucial com-
ponent in psychiatric nursing to promote outcomes and quality of care
(Suter et al., 2009; Fay-Hillier et al., 2012; Nørgaard et al., 2012). Kron
et al. (2017) also have demonstrated that computer simulation is ef-
fective in training second-year medical students about inter-profes-
sional communication. The findings of these studies confirmed that
computer-based simulation education is effective in improving self-ef-
ficacy not only for relationships with psychiatric patients but also for
inter-professional communication.
Furthermore, participants of the ComEd program reported a high
level of satisfaction with the program, while Oh et al. (2015) could not
prove any significant benefit on learning satisfaction from simulation-
based learning using SPs. The ComEd program revealed the significant
benefits on satisfaction because it was well-accepted by participants
and is a suitable learning modality for the “Net Generation” who are
comfortable using technology and digitally literate (Oblinger and
Oblinger, 2005). Net Generation learners are more likely learn better by
doing than by learning from lectures (Oblinger and Oblinger, 2005). A
high level of satisfaction among nursing students with the e-simulation
program for deteriorating patient cases has been previously reported
(Cant and Cooper, 2014).
In the subgroup analysis of the trajectory of communication effi-
cacy, 20.4% of the participants who had relatively lower scores at pre-
test showed a slight decrease in communication efficacy scores at the
two-week follow up. In a previous study with various health care pro-
fessionals, including nurses, the level of communication efficacy was
maintained for up to six months after the training except for doctors
(Nørgaard et al., 2012). They were able to maintain the training effect
by having the participants continue to videotape communication si-
tuations and review their recordings with their colleagues (Nørgaard
et al., 2012). Therefore, in the future, it would be beneficial to offer
booster sessions and chances to practice communication skills for stu-
dents with relatively low level of communication efficacy so that they
can maintain a better level. Moreover, it is important to incorporate a
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Nurse Education Today 91 (2020) 104467
computer simulation-based, interactive communication education pro-
gram into the nursing curriculum and to develop education programs
for new graduate nurses in the future. To promote communication skills
with patients and colleagues, structured scenarios and diverse cases
covering both verbal and non-verbal communication skills also need to
be developed.
The present study is limited in that the actual behaviors and com-
munication with actual patients were not measured. However, this
randomized controlled study made an important contribution in the
development of nursing education and practice by demonstrating the
significant and sustained effects of computer simulation-based educa-
tion. This research represents a significant contribution to the literature
since there have only been limited studies thus far evaluating the in-
termediate (1–3 weeks) and long-term (1–6 months) effects of simula-
tion-based education (Sherwood and Francis, 2018).
5. Conclusions
This mixed-method, randomized controlled study with repeated
measures demonstrated that computer simulation-based, interactive
ComEd could produce desirable outcomes in improving communication
knowledge and self-efficacy among nursing students and is well ac-
cepted by the students. The findings of the study can inform future
trainings for nursing students to improve their communication skills.
Moreover, computer simulation-based, interactive ComEd is a pro-
mising approach since it is highly accessible, consistent, repeatable, and
cost-effective compared to conventional simulations using SPs or high
fidelity simulators.
Acknowledgements
This research was supported by Basic Science Research Program
through the National Research Foundation of Korea (NRF) by the
Ministry of Education [grant numbers 2017R1D1A1B03033861] and
the Research Institute of Nursing Science, Seoul National University.
Author statement
Heeseung Choi: Conceptualization, Methodology, Validation,
Investigation, Writing - original draft preparation, Writing - reviewing
and editing, Supervision, Project administration, Funding acquisition.
Ujin Lee: Investigation, Formal analysis, Validation, Writing - original
draft preparation, Visualization. Ye Seul Jeon: Investigation, Formal
analysis, Validation, Writing - original draft preparation, Visualization.
Chanhee Kim: Formal analysis, Validation, Writing - original draft
preparation, Visualization.
Declaration of competing interest
None.
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