Blended learning pedagogy designed for a communication module among
undergraduate nursing students: A quasi-experimental study

Shefaly Shorey, Yanika Kowitlawakul, M. Kamala Devi, Hui-Chen Chen,

Swee Kit Alan Soong, Emily Ang

PII: S0260-6917(17)30265-4
DOI: doi:10.1016/j.nedt.2017.11.011
Reference: YNEDT 3659

To appear in: Nurse Education Today

Received date: 1 February 2017

Revised date: 5 October 2017
Accepted date: 7 November 2017

Please cite this article as: Shorey, Shefaly, Kowitlawakul, Yanika, Kamala Devi, M.,
Chen, Hui-Chen, Soong, Swee Kit Alan, Ang, Emily, Blended learning pedagogy de-
signed for a communication module among undergraduate nursing students: A quasi-
experimental study, Nurse Education Today (2017), doi:10.1016/j.nedt.2017.11.011

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TITLE: BLENDED LEARNING PEDAGOGY DESIGNED FOR

COMMUNICATION MODULE AMONG UNDERGRADUATE NURSING

STUDENTS: A QUASI-EXPERIMENTAL STUDY

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Shefaly Shorey*, Yanika Kowitlawakul, M Kamala Devi, Hui-Chen Chen, Swee Kit

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Alan Soong, Emily Ang

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Shefaly SHOREY, PhD, RN, RM

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Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of
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Medicine, National University of Singapore; National University Health System,

Singapore, 117597.
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Yanika KOWITLAWAKUL, PhD, RN

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Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of

Medicine, National University of Singapore; National University Health System

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Singapore, 117597.
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M Kamala DEVI, PhD, RN

Senior Lecturer, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of

Medicine, National University of Singapore; National University Health System

Singapore, 117597.

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Hui-Chen CHEN, MSN, RN

Senior Lecturer, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of

Medicine, National University of Singapore; National University health System,

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Singapore, 117597.

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Swee Kit Alan SOONG, MA

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Associate Director, Centre for Development of Teaching & Learning, National

University of Singapore, Singapore, 119077.

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Emily ANG, DNurs, RN

Professor and Head, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of
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Medicine, National University of Singapore, Singapore, 117597.

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*CORRESPONDING AUTHOR:

Dr. Shefaly Shorey, PhD, RN, RM

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Assistant Professor
Alice Lee Centre for Nursing Studies
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Yong Loo Lin School of Medicine

National University of Singapore
Level 2, Clinical Research Centre, Block MD11
10 Medical Drive, Singapore 117597
Tel: (65) 66011294; Fax: (65) 67767135
Email: nurssh@nus.edu.sg

ACKNOWLEDGEMENT

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The authors would like to thank the National University of Singapore for the LIFT

grant. The authors also send special thanks to the National University Health System,

Medical Publications Support Unit, for assistance in the language editing of this

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manuscript.

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CONFLICT OF INTEREST

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None.

FUNDING STATEMENT
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The study is funded by the National University of Singapore LIFT Grant, Reference

Number: C-027-000-068 (LEARNING INNOVATION FUND – TECHNOLOGY) –

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SOF 133.

WORD COUNT
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5000
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TITLE

Blended learning pedagogy designed for a communication module among

undergraduate nursing students: A quasi-experimental study

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ABSTRACT

Background

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Effective communication is important for nurse and patient outcomes. Nursing

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students often feel unprepared to communicate effectively with patients and other

healthcare workers within the clinical environment. Blended learning pedagogy-based

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communication skills training can provide an alternative to traditional methods of
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teaching to enhance students’ satisfaction and self-efficacy levels in communicating

with others.
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Objectives

To examine the effectiveness of blended learning pedagogy in a redesigned

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communication module among nursing undergraduates in enhancing their satisfaction

levels and attitudes towards learning communication module as well as self-efficacy

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in communication.
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Design

A single group pre-test and post-test quasi-experimental design was adopted.

Settings and Participants

Data were collected from August 2016 to November 2016 from 124 nursing

undergraduates from a leading nursing school.

Methods

Blended learning pedagogy was adopted to redesign a communication module that

offered a wide array of learning opportunities via face-to-face classroom and online

sessions. Validated and reliable instruments were used to measure satisfaction levels

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with blended learning pedagogy, attitudes towards learning communication, and

communication self-efficacy. Descriptive and inferential statistics were used to

analyze the data.

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Results

Participants had enhanced satisfaction levels with blended learning pedagogy, better

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attitudes in learning communication skills, and improved communication self-

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efficacies at posttest (week 13 of the semester) when compared with their pre-test

scores (week one of the semester). Participants scored higher in the Blended Learning

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Satisfaction Scale, the Communication Skills Attitude Scale, and the communication
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skills subscale of the Nursing Students Self-Efficacy Scale.

Conclusions
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Blended learning pedagogy can be effectively used in facilitating communication

modules and enhancing student outcomes among nursing undergraduates. The long-
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term effectiveness of using blended learning pedagogy in facilitating communication

modules should be evaluated from students’ and patients’ perspectives. Additionally,

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the technology should be constantly improved by incorporating more interactive

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functions and should be tested to accommodate the learners’ needs.

KEYWORDS

Blended learning pedagogy; nursing undergraduates; satisfaction; attitude; self-

efficacy; communication; authentic learning; quasi-experimental.

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INTRODUCTION

A patient’s ability to follow through with medical treatment and preventive health

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behaviors is positively related to a healthcare member’s communication skills

(Haskard Zolnierek and DiMatteo 2009, Ha and Longnecker 2010). Communication

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between nurses and patients is especially essential for successful outcomes of

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individualized nursing care (Kourkouta and Papathanasiou 2014). Previous studies

have shown that a nurse’s ability to communicate effectively with a patient has

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profound effects on the physical and emotional health outcomes of the patient
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(Dingley et al. 2008, Fakhr-Movahedi et al. 2011). However, nursing students often

feel stressed due to the lack of skills necessary to communicate effectively with
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patients/caregivers (Villagran et al. 2010). Experiences and needs of nurses, patients,

and caregivers have been explored in order to establish guidelines for effective
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communication training (Lewis et al. 2017). There is a shortage of specialized

communication training available to nurses specifically, and researchers believe that

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nurses will benefit from a more focused training module (Wittenberg-Lyles et al.
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2008). Several studies have revealed that through training and instructions, nursing

students’ self-efficacies in communicating with a patient/caregiver and other

healthcare professionals can be enhanced (Staples and Webster 2007, Kameg et al.

2010). Hence, this study aims to evaluate a redesigned communication module

entitled “Effective Communication for Health Professionals” by incorporating

blended learning pedagogy (BLP) based on Bandura’s self-efficacy theory (1997) and

the authentic learning model (Herrington et al. 2010) for first-year undergraduate

nursing students.

BACKGROUND

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Effective communication skills are an integral part of the nursing profession and the

foundation for high quality nursing care (McCabe and Timmins 2014). Poor

communication has been directly linked with high turnover rates and low morale

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among nurses (Brinkert 2010, Vessey et al. 2010). Poor communication has also been

related to poor patient outcomes such as medical error, lower adherence to treatment

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plans, and lower satisfaction levels with the care (Foronda et al. 2016). As per the

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Joint Commission’s analysis, poor communication among health professionals was

one of the top primary causes of these sentinel events (Goeckner et al. 2006, Joint

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Commission 2008). In previous literature (Joekes et al. 2007, Markova and Broome
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2007, Kourkouta and Papathanasiou 2014), effective communication among nurses

lead to decreased medical errors, an increased sense of safety and protection,

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improved levels of patient satisfaction, and greater adherence to treatment plans

among patients. Therefore, effective communication is crucial for enhancing positive

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outcomes for nurses and the patients under their care.

Previous literature (Kourkouta and Papathanasiou 2014, Weissman 2011)

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highlighted that education and experience play integral roles in enhancing effective
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communication. Nursing students and newly graduated nurses have more difficulties

in communicating with others due to their lack of experience and training in

communication skills (Hezaveh et al. 2014). This was also one of the main reasons

nursing students felt less efficacious in communicating with others (Chant et al.

2002a, Chant et al. 2002b, Tay et al. 2011). Pascoe et al. (2007) and Weissman (2011)

highlighted that communication skills during baccalaureate nursing is one of the most

important educational areas. Therefore, teaching effective communication skills to

undergraduate nursing students is integral for them to practice client-centered

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communication skills to enhance the overall disease outcome of the patients under

their care (Chan and Lai 2016).

Currently, communication skills trainings for nursing undergraduates are

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ineffective (Parry 2008, Jamshidi et al. 2016) as they are mainly delivered via

traditional lectures in classroom settings (Aspergren 1999, Fellowes et al. 2004, Wool

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2005). There is a need to incorporate new pedagogies so that communication skills

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training can be both participatory and experiential (Parry 2008). An advanced

constructivist pedagogical approach, such as BLP, is one such effective strategy

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(Baumgarthner 2005, Cole et al. 2014). BLP involves a systematic integration of both
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face-to-face and online engagement to introduce meaningful interactions between

resources, teachers, and students (O'Byrne and Pytash 2015). The use of technology
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in pedagogy can lead to flexible student-centered teaching that encourages

asynchronous communication among students and their education facilitators

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(Ellaway and Masters 2008).

Singapore’s Ministry of Education (2015) encourages technology-enhanced

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teaching and learning in schools and universities. To overcome the challenge of

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meeting the needs of different learners, BLP might be the best approach in the local

context (Ministry of Education 2015). Previous studies have emphasized that the

focus in BLP should incorporate theory-based and well-planned contextualized

innovative approaches to specific subject matters (Gray and Tobin 2010, Laurillard

1993, Rowe et al. 2012). BLP has been used successfully in nursing and midwifery

education (Ireland et al. 2009, Pereira et al. 2007) in various courses such as ethics

(Hsu 2011), clinical education (Rowe et al. 2012), nursing foundational courses (Li et

al. 2014), and research and evidence based nursing (Jang and Hong 2016). Although

BLP has its strengths, it is highly context-based, posing a challenge for the

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generalization of findings that supports its use across subjects and geographical areas

(Harris et al. 2009). Hence, the successful implementation of blended learning among

students from a particular origin may not be necessarily valuable to another

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population. To the best of our knowledge, this study is the maiden attempt in

evaluating the effectiveness of theory-based BLP for a communication module

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catered to multi-racial nursing undergraduates.

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Conceptual framework

Bandura’s self-efficacy theory (1997) and the authentic learning concept (Herrington

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et al. 2010) guided the BLP used in this study. To enhance the self-efficacy of
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effective communication among first-year nursing students (Bandura 1997), mastery

experience (learning from own experience), vicarious experience (learning from

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others such as classmates and facilitators), and verbal persuasion (receiving feedback

on their performance from peers and lecturers) were considered in planning the
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module. Additionally, nine elements of the authentic learning environment

(Herrington et al. 2010), as described in Table 1, were introduced in the module to

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provide an authentic exposure to prepare nursing students for their future professional
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lives. The aim of including the authentic learning concept was to incorporate real-life

learning for first-year nursing students who had not been previously exposed to

clinical environment. The conceptual framework of the study is presented in Figure 1.

METHODS

Aim

The aim of the study was to evaluate the effectiveness of BLP in a redesigned

communication module for first-year nursing undergraduates. The following

hypothesis was tested:

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i. Students will score significantly higher on the Blended Learning Satisfaction

Scale, the Communication Skills Attitude Scale, and the communication skills

subscale of the Nursing Students Self-Efficacy Scale from the baseline to 13

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weeks post-exposure to BLP.

Design

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A single group pre-test and post-test quasi-experimental design was used.

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Participants

The study was conducted among first-year undergraduate nursing students enrolled in

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the nursing course at the leading nursing school in Singapore. All enrolled students
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were invited to participate in the study as the redesigned communication module was

compulsory for all students regardless of their participation in the research. The
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inclusion criteria were semester one first-year undergraduate students who were

enrolled in the nursing programme and: 1) taking the core module entitled “Effective
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communication for Health professionals” and 2) able to read and write English.

Students from other levels (year 2-4) were excluded from the study.
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Sample size calculation

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Convenience sampling was adopted to recruit all enrolled first-year nursing students.

Based on the sample size calculation, a power of 80%, a correlation index of 0.8, and

a p value of less than or equal to 0.05, 80 participants were needed in this study (Hsu

and Hsieh 2011). Considering a 50% attrition rate, 120 participants were needed for

this study. Eventually, 124 participants were included in this study.

Intervention

The module was redesigned as a blended learning environment and introduced to

students for a period of 13 weeks (one semester). This module takes up four modular

credits in the university’s modular system. According to the university’s guidelines,

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each modular credit requires 2.5 hours of study and preparation time per week

(National University of Singapore, n.d.). Hence, four modular credits equates to a

total of 10 hours of study and preparation (2-3 hours for face-to-face tutorial or

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lecture and 7-8 hours for the self-directed learning) time as required for this

communication module. In this redesigned communication module, students and the

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facilitator met face-to-face each week for tutorials while receiving lecture materials

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online. Eighty percent of the original didactic face-to-face lectures were offered as e-

lectures in the form of breeze presentations, PowerPoints slides, and multi-media

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components, delivered using an integrated virtual learning environment. To enhance
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students’ engagement with the online course-material, online quizzes, discussion

forums, and reflection exercises were introduced on a weekly basis. To enhance

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meaningfulness of the theoretical content offered online, face-to-face tutorials

provided authentic clinical scenarios based on the topic covered in the lectures. Role-
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playing and problem-based learning was the main pedagogical tool used during these

tutorials. Students’ academic performances were determined by both formative (class

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and online active participation) and summative (authentic assessment) evaluations.

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Authentic assessment involved analyzing real life clinical scenarios by creating online

videos as a group project and an individual interview exercise with standardized

patients. Practice sessions with standardized patients were introduced to enacted

varied real-life situations such as being a ‘difficult patient’ or an ‘uncommunicative

patient’.

Outcome measures

i. The Blended Learning Satisfaction Scale (BLSS) (Hsu and Hsieh 2011), an

18-item 5-point Likert scale with a total score range of 18 to 90 points, was

used to examine students’ satisfaction at post-test (week 13 post-exposure to

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the blended module). Higher scores corresponded to higher satisfaction levels.

The Cronbach’s alpha values for this instrument were 0.90 in the previous

study (Hsu and Hsieh, 2011) and 0.92 in this study.

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ii. The Communication Skills Attitude Scale (CSAS) (Rees et al. 2002), a 26-

item 5-point Likert scale, was used to collect students’ attitudes towards the

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blended module at pre-test (week 1, before the start of the module) and post-

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test (week 13). The Cronbach’s alpha values were from 0.80 to 0.87 in the

previous study (Rees et al. 2002) and 0.90 in this study.

iii.
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The communication skills subscale of the Nursing Students Self-Efficacy
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Scale (C-NSSES) (Stump et al. 2012), an 8-item 5-point Likert scale, was used

to assess students’ self-efficacies in communication with others at pre-test

(Week 1) and post-test (Week 13). The Cronbach’s alpha values of this
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subscale were 0.85 in the previous study (Stump et al. 2012) and 0.87 in this
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study.

Data collection
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After obtaining ethics approval, the research assistant (RA) who was completely
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unaware of the study design engaged in the data collection procedure. In week one of

the academic year (2016/2017 cohort), before the first lecture of this redesigned

communication module, the RA briefed all enrolled nursing students about this

research study. The procedure of the data collection, the amount of involvement, and

the signing of informed consent were explained in detail. Voluntary participation was

strongly highlighted to the students and choosing to not participate in this study will

not harm their grades and learning journey. After the RA’s brief, ample time was

given to the students to seek clarifications and pose questions. Written informed

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consent from each participant was obtained. The participants were informed that they

would be contacted again at week 13 (post-test) to fill up the questionnaires.

Ethical considerations

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Ethics approval was sought from the institutional review board (IRB: Reference: B-

16-127). Written consent was obtained from each participant before the data

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collection and ethical principles of beneficence, justice, and respect for the

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participants were applied throughout the study. All participants were equally eligible

to participate in the study and decisions to not participate were respected without any

harmful effect on their learning journeys.

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Data analysis

Data were analyzed using IBM SPSS 24.0 by the RA who was unaware of the study
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design. Statistical significance was set at p < 0.05. The list wise deletion method was

used to deal with missing data. Descriptive statistics such as means, frequencies, and
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standard deviation were used to present demographic data. Mean and frequency

differences were used to present scores from the BLSS, CSAS, and C-NSSES.
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Relationships between demographics and outcome variables were tested by

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correlations and paired t-tests. Percentage was used to present satisfaction levels with

the module.

RESULTS

The data collection period was from August 2016 to November 2016. A total of 124

year one students who were newly enrolled into the undergraduate nursing course

were eligible to participate in this study. All of them (n =124) completed the pre-test

data collection (week 1 of the semester). At the end of the semester, all enrolled

participants (n=124) completed the post-test (week 13 of the semester). The details on

recruitment and follow-up data collection are provided in Figure 2. . Based on their

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classroom and online participation, all students actively participated in the classroom

and all online discussion activities. Table 2 represents the demographic profile of the

participants. The mean age of the participants was 19.54 years (SD 1.11). The average

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age was similar to other nursing faculties in other countries (Florida Faculty of

Nursing 2013) and university enrollment in general (National Center for Education

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Statistics n. d.). The majority of participants were Chinese (87.1%), and the rest were

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Malay (7.3%) or Indian (5.6%). Most of the participants were females (87.1%) with

no previous experience (82.3%) in learning communication skills. All of the

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participants were unmarried (n = 124, 100%) and had internet access (n = 124,
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100%). Each participant spent an average of 3.72 hours (SD 1.46) daily using the

internet. Most of the participants attended the online weekly activities (n = 113,
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91.1%) and face-to-face tutorials (n = 115, 94.3%). The majority of the participants

felt satisfied with the redesigned communication module (n = 114, 92.0%). (Table 2).
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There was a statistically significant increase in the BLSS scores from pre-test

(M = 59.62, SD = 12.67) to post-test (M = 129.76, SD = 304.49), t ((122) = -2.55, p =

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0.012 (two-tailed). The mean difference between the two scores was -70.14, with a
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95% confidence interval ranging from -124.56 to -15.72. Similarly, a statistically

significant increase in the CSAS scores were seen from pre-test (M = 80.57, SD =

9.43) to posttest (M = 159.59, SD = 426.36), t ((122) = -2.06, p = 0.042 (two-tailed).

The mean difference between the two scores was -79.02, with a 95% confidence

interval ranging from -154.95 to -3.09. There was also a statistically significant

increase in the C-NSSES scores from pre-test (M = 12.21, SD = 7.14) to post-test (M

= 49.08, SD = 136.83), t ((122) = -3.00, p = 0.003 (two-tailed). The mean difference

between the two scores was -36.87, with a 95% confidence interval ranging from -

61.20 to -12.54. Furthermore, the Cohen’s effect size values (0.3 to 0.2) for the three

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outcome variables suggested a small significant effect of the BLP incorporated

intervention (Cohen 1992). No statistically significant difference was seen between

the outcome variables when compared with those who had prior experiences in

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learning communication skills. The magnitude in the difference of the means (mean

difference = -4.73, 95% CI: -5.92 to -3.55) was moderate.

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DISCUSSION

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This study aimed to evaluate BLP incorporated in a communication module for

undergraduate nursing students on their satisfaction levels with BLP, attitudes in

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learning communication skills, and self-efficacies with their communication skills.
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The participants in this study showed better satisfaction levels with the newly

introduced BLP. The results in this study concurred with some of the previous
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research (Jang and Hong 2016, Zolfaghari et al. 2013) in which participants achieved

higher satisfaction levels with BLP. In contrary, other studies found no significant
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difference in satisfaction levels with BLP among nursing students (Allen et al. 2004,

Block et al. 2008, Buckley 2003, Rivera and Rice 2002, Leasure et al. 2000, Russell
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et al. 2008). The reason for these contrasting results was that nursing students in the
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previous study were more comfortable with traditional classroom teaching whereby a

teacher takes the center stage (Hsu and Hsieh 2011). The authors highlighted that

nursing students preferred online discussions conducted alongside classroom

discussions to have more meaningful learning (Curran et al. 2008, Hsu and Hsieh

2011). In this study, the online activities were strategically matched with the face-to-

face weekly activities. This could account for nursing students’ great satisfaction

levels with BLP. The student-centered teaching approaches were introduced

considering different learning styles (Fleming 2001) in this study. Additionally,

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timely feedback was provided on each student’s engagement. These were found to be

crucial components in the success of BLP (Ireland et al. 2009, Zolfaghari et al. 2013).

The participants had better attitudes towards learning communication skills

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after attending the course. This is an important finding because effective

communication is considered one of the core competencies by both international and

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national nursing regulatory bodies (Affara 2009, Singapore Nursing Board 2012). The

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communication module in this study was offered in semester one for first-year

nursing students, as recommended in literature (Chan and Lai 2016), since most of

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these nursing students would have had no prior experience in learning communication
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and no exposure to clinical placement. The face-to-face component of this redesigned

module involved role-playing and problem-based learning exercises in evaluating

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authentic scenarios. Showcasing various clinical scenarios that these nursing students

might face in the future could have enhanced their curiosity and provided them with
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the necessary exposure to what would be expected in their professional lives (Rees

and Garrud 2001). The online component of this redesigned module used discussion
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forums and social networking tools such as WhatsApp, which might have promoted
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collaboration in both individual and group articulations (Herrington et al. 2010).

Thus, varied disclosure via BLP may have influenced students’ attitudes in seeing the

importance of learning communication skills.

Similar to previous studies (Ammentorp et al. 2007, McConville and Lane

2006, Norgaard et al. 2012), the participants in this study had enhanced self-efficacies

in communication skills. They had an unlimited access to the online videos that

explained the fundamentals of communication skills with examples in authentic

situations. They also engaged in role-playing to analyze real-life scenarios and

practice communicating with standardized patients. This may have provided them

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with the contextualization of information, which aided their learning experiences

(McConville and Lane 2006, Mafinejad et al. 2017). Adding realism by including

authentic case scenarios and the use of actors have been recommended to enhance

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self-efficacy in communication skills (Pike and O'Donnell 2010). The participants’

enhanced self-efficacies can also be explained by Bandura’s self-efficacy theory

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(1997). Repeated role-plays and practice may have provided these students with the

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mastery of techniques (mastery experience) as they learnt from their own experiences.

Seeing their classmates perform communication skills (vicarious experience) might

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have provided them with the necessary exposure for these students to reflect on their
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own communication skills. Feedback (verbal persuasion) from peers and facilitators

during the online and face-to-face sessions and practicing their skills may have
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allayed their anxiety and enhanced their self-efficacies in communicating with others.

The mean age of the students in this study was similar to the national mean
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age of the students attending universities in Singapore (Ministry of Education 2015).

Similar to global trends, the majority of the participants were female in this study due
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to the fact that nursing is a female-dominated profession and though the uptake of
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males entering this profession is increasing, the percentage is still comparatively low

(Gan 2013). The majority of the participants were Chinese, and the rest were Malay

or Indian, which is similar to the demographic profile of the citizens in Singapore

(Singapore Department of Statistics 2016). All participants had internet access, which

is explainable as internet penetration in Singapore’s population is 82.5% (Internet

Live Stats 2016).

This is a small-scale study that used convenience sampling, which limits its

generalizability. The effect of the intervention was small which requires intervention

to be more rigorous by incorporating the more interactive functions. This may also

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enable to measure the dosage of the intervention by assessing the amount of time

spent by the participants in receiving the intervention (Bellg et al. 2004). Potential

researcher bias was another limitation as the researcher was also the main instructor

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of the course. To reduce bias, the RA was hired for data collection. To evaluate the

effectiveness of BLP, a randomized controlled trial would have been the best design.

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However, it was ethically inappropriate to divide the students into groups that

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received different desirable treatments. A longitudinal study design is recommended

to evaluate the stability and long-term influence of the improvements in the

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communication skills seen in this study. Specifically, observational studies are needed
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to evaluate the students’ performances in clinical areas. More interrelated components

such as self-efficacy, stress, anxiety, and social support can be evaluated in future
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studies. Patient outcomes should also be evaluated, especially how patients perceive

students’ performances in communicating with them. Qualitative studies are needed

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to understand the in-depth experiences of students with BLP when learning

communication skills. Lastly, future research should consider random samples of

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students from different years and diverse institutes to evaluate the phenomenon of
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interest.

CONCLUSIONS

The BLP used in redesigning the communication module for nursing undergraduates

was successful in enhancing their satisfaction levels and self-efficacies. The students

had positive attitudes towards learning communication skills. The students scored

significantly higher on the Blended Learning Satisfaction Scale, the Communication

Skills Attitude Scale, and the communication skills subscale of the Nursing Students

Self-Efficacy Scale. By adopting the theory-based approach in offering an authentic

learning context, and using role-play exercises and problem-based activities, nursing

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students were stimulated to believe in the importance of effective communication

skills. Future studies are needed to evaluate the long-term influence of

communication skills in nursing students from stakeholders’, patients’, and students’

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perspectives.

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Ammentorp, J., Sbaroe, S., Kofoed, P.-E. & Mainz, J. (2007) The effect of training in

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Education and Counselling, 66(3), 270-277.
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Authentic learning
Self-efficacy theory

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environment
(Herrington, Reeves, & (Bandura, 1997)
Oliver, 2010)

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• Mastery experience:
• Authentic context Learning from own
Redesigned experiences
• Authentic activity

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communication • Vicarious experience:
• Expert performances module Learning from similar
• Multiple perspectives others
• Collaboration • Verbal persuasion:
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• Reflection Receiving
• Articulation constructive feedback
• Coaching & scaffolding
• Authentic assessment
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Figure 1: Theoretical Framework to guide Blended Learning Pedagogy

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Assessed for eligibility (n=124)
Enrolment All the nursing undergraduates enrolled for year 1 Semester
1 at the leading nursing school and taking the core
communication for health professionals’ module

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Received Blended Learning Pedagogy based redesigned

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Allocation communication for health professionals module (n =124)
Pre-test Data: Demographics, CSAS*, C-NSSES** (n=124)

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Post-test Data: CSAS*, C-NSSES**, BLSS***, Students’
Follow-up & academic performance (n =123)
Analysis
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*CSAS: Communication skills Attitude Scale

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** C-NSSES: Communication skills subscale of Nursing Students Self-

efficacy scale
***BLSS: Blended Learning Satisfaction Scale
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Figure 2: Participants Flow Chart

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Table 1 Authentic learning environment and effective communication module

Characteristics Activities

1. Authentic To provide an authentic context, the tutorials were held in a

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context simulated ward (clinical lab) setting.
2. Authentic Students analyzed real clinical scenarios (which were obtained
activity from the hospitals based on patients’, family members’, and other

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professionals’ complaints and compliments) and practiced
communication skills via role-play among themselves. Some of

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the examples of such scenarios are difficult patients, conflict
management among colleagues, and interviewing a family
member.

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3. Expert Videos were created in which the alumni (those who have
performances graduated as clinical nurses) shared their communication skills
experiences with real-life patients.
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4. Multiple Various resources, including consultations with lecturers, clinical
perspectives nurses (Adjunct faculty), online materials (videos, journal articles,
case-studies), and books, were provided for students to experience
multiple perspectives of a problem provided.
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5. Collaboration Students worked in groups of 3 to 5 and collaborated via various

means, such as WhatsApp group chats and Dropbox, to produce a
short video as one of their assessments on the scenario provided.
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6. Reflection Students reflected on a weekly basis after each online and face-to-
face session on the various communication skills learned.
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7. Articulation Students were provided with the opportunity to present their

videos to the rest of their classmates to enable defense of position
and ideas. Peer feedback was encouraged throughout the weekly
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tutorials to better prepare students for constructive feedback

during the final presentation.
8. Coaching Students were provided with coaching and scaffolding by the
scaffolding faculty based on the individualized needs of the groups. Avenues
were provided to the students for consulting healthcare
professionals who were currently working in the clinical areas via
an adjunct faculty, which mainly consists of clinical staff working
in the hospitals.
9. Authentic Students were assessed on their final product, a short video that
assessment incorporated role-play for therapeutic communication based on the
given scenario, which students prepared over a period of time after
consulting various resources and with the efforts of each member
of the group. Additionally, the students were assessed on their
ability to interview standardized patients based on real-life
scenarios presented by the standardized patients.

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Table 2 Demographic characteristics of the participants (n=124)

Characteristics Number of participants (n=124)

n (%)
Age

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Mean (SD) 19.54 (1.11)
Range 18-23
Gender

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Male 16 (12.9)
Female 108 (87.1)
Ethnicity

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Chinese 108 (87.1)
Malay 8 (6.5)
Indian 7 (5.6)

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Others 1 (0.8)
Highest education level
GCE “A” Level 97 (78.2)
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GCE “O” Level 1 (0.8)
ITE/Polytechnic 25 (20.2)
University 1 (0.8)
Marital status
Not married 124 (100)
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Married 0 (0.0)
Previous working experience
Yes 93 (75.0)
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No 31 (25.0)
Previous experience with communication
course 22 (17.7)
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Yes 102 (82.3)

No
Access to the internet
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Yes 124 (100.0)

No 0 (0.0)
Number of hours spent on the internet daily
Mean (SD) 3.72 (1.46)
Range 1-6
Attendance of all online activities
Yes 113 (91.1)
No 11 (8.9)
Attendance of all face-to-face tutorials
Yes 115 (94.3)
No 9 (5.7)
Satisfaction level with blended pedagogy
Satisfied 114 (92.0)
Not satisfied 10 (8)

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Table 3 Outcome measures

Outcome Pre-test Post-test Mean 95% t Cohen

variable Mean Mean difference confidence (p- (d)
(SD) (SD) interval value) Effect
Range Range range size

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(n=124) (n=124)
Blended 59.62 129.76 -70.14 -124.56 to - -2.55 0.2

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Learning (12.67) (304.49) 15.72 (0.012)
Satisfaction
Scale

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Communication 80.57 159.59 -79.02 -154.95 to - -2.06 0.2
Skills Attitude (9.43) 3.09
(426.36) (0.042)

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Scale

Communication 12.21 49.08 -36.87 -61.20 to - -3.00 0.3

skills subscale (7.14) (136.83) 12.54 (0.003)
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of the Nursing
Students Self-
efficacy Scale
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 Highlights

o Blended learning pedagogy can be adopted to teach communication skills.

o Theory-based blended learning pedagogy should be designed and

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evaluated.

o Long-term influence of the communication skills improvement should be

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assessed.

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