Compare Efficiency of ComEd to that of AC Program Presentation. Nurse Education Today 91 (2020) 104467 Contents lists available at ScienceDirect Nurse Education Today journal homepage: www.elsevier.com/locate/nedt Efficacy of the computer simulation-based, interactive communication education program for nursing students T Heeseung Choia,b, , Ujin Leea, Ye Seul Jeona, Chanhee Kimc ⁎ a College of Nursing, Seoul National University, Seoul, Republic of Korea 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 b ARTICLE INFO ABSTRACT Keywords: Communication Psychiatric nursing Nursing education Simulation Computer Nursing students Background: Simulation-based education using standardized patients or high fidelity patient simulators is resource-intensive and can be limited in its consistency and repeatability. Standardized, interactive, and effective computer simulation-based education programs that improve communication skills among nursing students are greatly needed. Objectives: This study aimed to (1) compare the efficacy of a computer simulation-based, interactive communication 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, 22item 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, simulation-based education has become an essential part of clinical education in nursing. It is an effective teaching method by which reallife 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). FIU Compare Efficiency of ComEd to that of AC Program Presentation

Compare Efficiency of ComEd to that of AC Program Presentation. 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 reduce a patient’s anxiety, fear, and aggression (Riley, 2017). Simulationbased education designed to foster communication skills using standardized 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/). Nurse Education Today 91 (2020) 104467 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) demonstrated that e-simulation of sudden patient deterioration was an effective learning method in improving nursing students’ knowledge, efficacy, 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 education still tend to be limited in their fidelity and robustness of experimental 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 secondyear 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, interactive communication education program for nursing students exists. Considering the potential benefits, standardized, interactive, and effective 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).FIU Compare Efficiency of ComEd to that of AC Program Presentation

Compare Efficiency of ComEd to that of AC Program Presentation. 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. 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 students from each nursing school to either the intervention or AC group. 2. Methods 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 patients (e.g., schizophrenia, depression), and study participants were 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 medical history video, an interactive clinical performance with virtual patients, 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 performance. 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 information. 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.FIU Compare Efficiency of ComEd to that of AC Program Presentation

Compare Efficiency of ComEd to that of AC Program Presentation. 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 completed 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 2.1. Study design and sample The present study used a mixed-method, randomized controlled study design with repeated measures. The inclusion criteria were nursing 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 2 Nurse Education Today 91 (2020) 104467 H. Choi, et al. Fig. 1. CONSORT chart. 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 disagree” to “Strongly agree”). Higher scores indicate higher satisfaction. We also included six open-ended questions to help participants reflect 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 participants’ perceptions about nurse-patient relationships and communication with psychiatric patients. asked to choose the most appropriate answer in a given clinical situation. 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 reviewed by two experts in psychiatric nursing and the level of difficulty of the scale was tested on 10 nursing students. Scale items were finalized 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 SelfEfficacy 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. FIU Compare Efficiency of ComEd to that of AC Program Presentation

Compare Efficiency of ComEd to that of AC Program Presentation. 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 2.5. Analysis Quantitative data were analyzed using SPSS 21 (IBM, Armonk, NY 2013). Descriptive analyses were used to analyze the general characteristics 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 chisquare test. A generalized estimating equation (GEE) model was employed 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 criterion (BIC) (Nylund et al., 2007) and (2) each subgroup comprising at 3 Nurse Education Today 91 (2020) 104467 H. Choi, et al. least 5% of participants for the practical applicability of findings. Conventional content analysis was used to analyze the qualitative data collected using open-ended questions (Ryan and Bernard, 2000; Patton, 2002). Two independent researchers coded the participants’ responses to the open-ended questions independently and any discrepancies and issues related to the coding were discussed in the research team meetings. The coded data were arranged and the descriptive summary of the patterns and main themes emerging from the data were identified. Table 2 Mean scores of outcome variables (n = 131). Variables Categories Communication knowledge Pre test Learning selfefficacy 3. Results 3.1. Characteristics of study participants Communication efficacy Among the 135 students who agreed to participate in the study (who signed the consent form), 131 completed either the intervention (n = 66) or the AC (n = 65) program, and 127 students completed the two-week follow-up test (retention rate = 95.5%). The total number of participants enrolled in the study and the detailed recruitment and retention process are depicted in the CONSORT chart (see Fig. 1). The general characteristics of the 131 study participants are shown in Table 1. The participants had a mean age of 22.91 years. Most participants (90.1%) were female and more than half (53.4%) did not have any previous simulation experiences. The intervention group did not statistically differ from the AC group in terms of age, gender, grade, experience of simulations, and outcome variables. Post test Follow up test Pre test Post test Follow up test Pre test Post test Follow up test Intervention AC Intervention AC Intervention AC Intervention AC Intervention AC Intervention AC Intervention AC Intervention AC Intervention AC Mean ± SD t (p)* 8.70 ± 2.07 8.78 ± 2.15 12.88 ± 1.54 10.00 ± 1.98 11.97 ± 2.38 8.85 ± 2.92 51.71 ± 6.23 51.55 ± 6.09 54.91 ± 6.20 54.28 ± 5.51 53.88 ± 7.46 50.66 ± 6.99 115.82 ± 14.05 118.23 ± 12.22 128.73 ± 13.63 127.57 ± 12.25 126.65 ± 14.99 121.69 ± 13.40 −.238 (.871) .147 (.270) −1.048 (.252) p-Value refers to t-tests of significant differences between the two groups at pretest. 3.3. Acceptability and satisfaction Overall, participants were highly engaged and satisfied with the ComEd program. The item mean score for the satisfaction scale was 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 ratings: “The education program was interesting (mean score of 6.62)”; “The education program was effective in learning verbal communication (mean score of 6.59)”; “Video media was effective in learning (mean score of 6.58).” On the other hand, participants rated the item, “The education program was effective in learning non-verbal communication skills (mean score of 5.86)” lowest. Participants described …