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Nursing and Health Sciences (2015), 17, 166–172
Research Article
Effects of case-based learning on communication skills, problem-solving ability, and learning motivation in nursing students Moon-Sook Yoo, PhD, RN and Hyung-Ran Park, PhD, RN Ajou University College of Nursing, Suwon, South Korea
Abstract
The purpose of this study was to explore the effects of case-based learning on communication skills, problemsolving ability, and learning motivation in sophomore nursing students. In this prospective, quasi-experimental study, we compared the pretest and post-test scores of an experimental group and a nonequivalent, nonsynchronized control group. Both groups were selected using convenience sampling, and consisted of students enrolled in a health communication course in the fall semesters of 2011 (control group) and 2012 (experimental group) at a nursing college in Suwon, South Korea. The two courses covered the same material, but in 2011 the course was lecture-based, while in 2012, lectures were replaced by case-based learning comprising five authentic cases of patient–nurse communication. At post-test, the case-based learning group showed significantly greater communication skills, problem-solving ability, and learning motivation than the lecture-based learning group. This finding suggests that case-based learning is an effective learning and teaching method.
Key words
case-based learning, communication skills, Korea, learning motivation, nursing education, problem-solving.
INTRODUCTION Communication skills are considered a core competency for nursing professionals working with patients, care providers, and health-team members (Nørgaard et al., 2012). Nurses must be effective communicators to deliver appropriate nursing care, empower patients, and improve patient satisfaction; furthermore, having good communication skills improves nurses’ confidence in caring for patients (Roter et al., 2012; Lau & Wang, 2013). However, studies on communication skills in nursing education have indicated that nursing students often experience fear, anxiety, and negative attitudes when communicating with patients (Kameg et al., 2010) and are poorly prepared to communicate with patients in practical situations (Baghcheghi et al., 2011). To address this gap in core skills, training for communication skills should be grounded in lectures, but must also be supplemented with hands-on student participation in practical learning (Parry, 2008; van Dalen, 2013). Communication-skills training is more effective when using learner-centered (Lau & Wang, 2013), practice-based strategies (Berkhof et al., 2011; Aebersold et al., 2013). Casebased learning (CBL), which is one of such teaching and
Correspondence address: Hyung-Ran Park, Ajou University College of Nursing, Woncheon-dong, Yeongtong-gu, Suwon, 443-721, South Korea. Email: hyungran@ ajou.ac.kr Received 29 January 2014; revision received 18 April 2014; accepted 22 April 2014
© 2014 Wiley Publishing Asia Pty Ltd.
learning methods, is an interactive, student-centered exploration strategy that draws on real-life situations to initiate and promote authentic learning (Williams, 2005). Case-based learning is a constructive learning paradigm, in which learners select and transform information, construct ideas, and make decisions based on their current or past knowledge (Brandon & All, 2010). In CBL, classroom instructors help students to solve diverse case-based problems that occur in real-world situations, moving from abstract knowledge to practical applications (Srisawasdi, 2012). Since CBL focuses on real-life case problems, it is a potentially powerful method for training nursing students to communicate sensitively with patients in challenging clinical situations. The real-life cases presented using CBL enable students to integrate and apply their developing clinical communication knowledge, as well as to reflect on complex situations, as opposed to performing clearly defined, predetermined tasks (Smith & Christie, 2004; Bosse et al., 2012; Tayem, 2013). In addition, CBL encourages students to actively create their own knowledge and independently develop solutions, rather than refer to the knowledge imparted to them by educators or textbooks for problem-solving (Jonassen & Hernandez-Serrano, 2002; Brandon & All, 2010). This would promote the development of their problem-solving abilities (Schoeman et al., 2009; Ciraj et al., 2010; Yoo & Park, 2014) and learning motivation (Kühne-Eversmann et al., 2008). However, there are limited empirical results on the impact of CBL on clinical performance or skill improvement doi: 10.1111/nhs.12151
Case-based learning on nursing education
(Williams, 2005; Jamkar et al., 2006). Previous studies on CBL have focused on students’ attitudes or knowledge levels (Dupuis & Persky, 2008; Ciraj et al., 2010; Malau-Aduli et al., 2013). Therefore this study investigates the impact of CBL on communication skills, problem-solving ability, and learning motivation among undergraduate nursing students enrolled in a health communication course through lecture and practice.
Purpose The purpose of this study was to evaluate the effectiveness of CBL on undergraduate nursing students in the health communication course. Students in the intervention group, who were receiving CBL, were expected to show improved communication skills, problem-solving ability, and learning motivation when compared to the control group receiving traditional lecture-based learning.
METHODS Design and sample In this prospective, quasi-experimental study, we compared pretest and post-test scores obtained by the experimental group and the nonequivalent, nonsynchronized control group. Participants from both groups were selected using convenience sampling from a population of sophomore undergraduate students enrolled in a mandatory health communication course in the fall semesters of 2011 (control group) and 2012 (experimental group) at a nursing college in Suwon, Korea. Initially, 77 students in the experimental group and 74 in the control group agreed to participate. However, five post-test questionnaires in the experimental group and three in the control group were incomplete and were therefore excluded. As a result, a total of 143 students became participants, 72 in the experimental group and 71 in the control group. While the same material was covered in both courses, in 2011, a traditional lecture-based learning course was delivered, and was replaced with a CBL course covering the required material through five authentic cases of patient– nurse communication in 2012. A post-hoc power analysis using the independent t-test (Faul et al., 2007) for sample sizes of 72 (experimental group) and 71 (control group) yielded a power of 99.9% with an effect size (0.90) and an alpha value of 0.05.
Ethical considerations Before the study, approval was obtained from the Institutional Review Board at Ajou University (AJIRB-MEDSUR-11–195). All participants were enrolled in a mandatory health communication course, which was delivered through traditional lectures in 2011 and CBL in 2012. However, participants who completed the questionnaire survey also filled out an informed consent form agreeing to participate in the study. Students were briefed on the study
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purpose and process, as well as their right to withdraw participation at any time without any adverse effect on their course grade.
Case-based learning development Case contents The cases of CBL were developed in July 2011. Communication conflicts from miscommunication between patients and nurses can result in inappropriate nursing care, which negatively influences patient’s health promotion (Morgan, 2013; Tsai et al., 2013). Therefore, for the selection of the authentic cases used in the CBL course, two research assistants observed situations causing communication conflict problems between a nurse and patients, which was a core content in communication education, at the researcher’s university hospital during a period of one week. The education and clinical expert panel, including a course professor, two clinical instructors, and three clinical nurse specialists, considered whether an observed communication conflict situation was suitable for use by the students to analyze and subsequently solve the applicable communication problem. For use as learning cases, the expert panel selected the most frequently observed communication conflict situations. These five situations were delayed laboratory tests, bedside-rail management to prevent patients from falling out of bed, reintravenous catheterization due to delayed fluid change, delayed discharge time, and unsatisfactory pain control. The selected five communication conflict situations were developed as cases during December 2011. Cases were designed in a manner requiring students to improve in problem-solving ability. This ability related to considering the most appropriate communication skills, as well as identifying the cause of the conflict in the miscommunication process. Two clinical nurse specialists from the clinical expert panel, each with clinical and educational experience spanning more than ten years, reviewed the learning objectives and clinical realism of the cases.
Case presentation Following the development of the cases, scenarios were drawn up, and standardized patients (SPs) and standardized nurses (SNs) were prepared for the re-enactment of the cases during January 2012. Five SPs and five SNs were appointed; they received training in appropriate behavior and speech patterns, and were also provided with costumes and appropriate make-up so as to lend authenticity to their roles. The training was provided by a SP trainer over a three-week period, 3 h per week. Two clinical nurse specialists reviewed the constructed scenario and behaviors of the SPs and SNs.
Procedure and data collection Pretest and intervention All participants were enrolled in a health communication course worth two credits and lasting 28 h in total. Participants © 2014 Wiley Publishing Asia Pty Ltd.
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M-S. Yoo and H-R. Park
Figure 1.
completed a demographic survey, an assessment of communication skills using SPs, and tests on problem-solving ability and learning motivation before the start of the course (Fig. 1). The lesson in the CBL health communication course had four stages. First, five cases of communication conflict resulting from miscommunication between a nurse and a patient were presented to the students, enacted by SPs and SNs for 10–15 min per case. In this stage, the students were asked to decipher the nature of the communication problem. In the second stage, the students individually formulated detailed plans on how to solve the communication conflicts. They could also analyze the situation that brought about the miscommunication and obtain first-hand experience of the problem-solving process. In the third stage, the course professor randomly assigned the students to small groups. Each of 15 groups was made up of five to six students. The students solved the communication problems through group discussions that were based on the individually formulated problem-solving plans. They shared their alternative communication strategy with the group members and drew comparisons. The group then analyzed the cause of the communication conflict situations, and considered anticipated results of the suggested solutions. The course professor facilitated the discussion process and ensured alignment with the learning objectives, and encouraged cooperative interactions. In the fourth stage, a solution to the problems was suggested. Based on the group discussion outcomes, the students proposed an appropriate communication solution. Finally, the students participated in the enactment with SPs as the role of nurses using an improved communication style. In the traditional learning environment that the control group had been exposed to, the course was delivered through didactic lectures. The five cases in which communication conflict situations involving nurses and patients occurred were included in the learning material. The course professor described the cause and the process relating to the commu© 2014 Wiley Publishing Asia Pty Ltd.
Research process.
nication problem situation, and then presented solutions in the form of appropriate communication strategies during the lecture.
Post-test After the final lesson, problem-solving ability and learning motivation among the intervention and control groups were assessed via self-administered questionnaires. The students’ communication skills were assessed using observational grading by a course professor and two clinical instructors during their communication enactment involving SPs. Version 19.0 of the SPSS (Statistical Package for the Social Sciences; SPSS Inc, Chicago, IL) was used for data analysis.
Measurements Communication skills The Communication Assessment Tool (CAT) developed by Makoul et al. (2007), and translated and revised into Korean by Yoo and Chae (2011), was used to measure students’ interpersonal and communication skills.The CAT contains 15 items scored on a five-point Likert-type scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). The possible range of total scores is 15–75, with higher scores denoting better communication skills. In a previous study, the reliability of the CAT had been established with a Cronbach’s alpha of 0.83 for nursing students (Yoo & Chae, 2011). A Cronbach’s alpha of 0.83 was also obtained in this study. In order to measure students’ communication skills using the CAT, two nursing experts developed a pilot test using a history-taking case in July 2011. A history-taking interview is a common communication process between a nurse and a patient during a hospital visit. Two nursing experts, one a course professor and the other a clinical nurse specialist at a hospital, constructed the history-taking scenario according to the process found in the CAT, namely, introduction,
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Cronbach’s alpha of 0.75 was previously obtained during use of the scale on nursing students (Yoo & Chae, 2011), while in this study a Cronbach’s alpha of 0.87 was obtained.
problem identification, offering information, understanding the patient, and closing. The course professor and two clinical instructors tested the CAT three times and adjusted the test guidelines accordingly.
Problem-solving ability
Data analysis
The Problem-Solving Inventory (PSI), developed by Heppner and Petersen (1982) and translated into Korean by Jun (1994), was used to assess students’ self-reported problem-solving styles. The PSI contains 35 items (including three filler items) scored on a six-point Likert-type scale ranging from 1 (strongly agree) to 6 (strongly disagree). The PSI contains three subscales: problem-solving confidence (11 items), approach-avoidance style (16 items), and personal control (5 items). The total score (the sum of the three subscales) ranges from 32 to 192, with higher scores indicating poorer self-reported problem-solving skills.A Cronbach’s alpha of 0.82 was obtained during use of the scale on graduate nurses (Yoo & Park, 2014), whereas a Cronbach’s alpha of 0.92 was obtained in the present study.
Descriptive statistics including means, standard deviation (SD), frequencies, and percentages were used to describe sociodemographics with SPSS Version 19.0 programs. A t-test was used to compare differences in means of communication skills, problem-solving ability, and learning motivation scores. All analyses were two-tailed, and the significance level was set at 0.05.
RESULTS General characteristics and homogeneity test The demographic characteristics of the intervention and control groups are shown in Table 1 and are briefly summarized here. The majority of participants were female (93.0%). Most (62.9%) had obtained an average grade of 3.0–3.9 in the previous semester. Moreover, 68.5% of the participants regarded their personality as neutral during interpersonal relations. The pretest scores denoted test homogeneity for the two groups (Table 2). No significant differences were detected between the intervention and control groups in the pretest scores obtained for communication skills (t = 1.88, P = 0.061), problem-solving ability (t = −0.68, P = 0.501), and learning motivation (t = −1.88, P = 0.061).
Learning motivation The Instructional Materials Motivation Scale (IMMS) developed by Keller (1987) and translated into Korean by Jang (1996), was used to evaluate students’ learning motivation in four domains: attention, relevance, confidence, and satisfaction. The IMMS comprises 35 items scored on a fivepoint Likert-type scale ranging from 1 (not true) to 5 (very true). The possible range of scores is 35–175, with higher scores denoting more self-directed motivation to learn. A
Table 1. General characteristics of the participants
Variables
Categories
Gender
Male Female > 4.0 3.0–3.9 2.0–2.9 < 1.9 Active Neutral Negative
Average grade previous semester
Interpersonal personality
Intervention group (n = 72) N (%)
Control group (n = 71) N (%)
7 (9.7) 65 (90.3) 7 (9.7) 50 (69.4) 14 (19.4) 1 (1.4) 21 (29.2) 51 (70.8) –
3 (4.2) 68 (95.8) 9 (12.7) 40 (56.3) 22 (31.0) – 24 (33.8) 47 (66.2) –
χ2
P
1.661
0.198
4.132
0.248
0.356
0.551
Table 2. Homogeneity comparison of communication skills, problem-solving ability, and learning motivation
Variables Communication skills Problem-solving ability Learning motivation
Intervention group (n = 72) Mean (SD)
Control group (n = 71) Mean (SD)
t (P)
40.69 (6.56) 112.32 (5.27) 102.63 (8.75)
42.70 (6.16) 111.75 (4.87) 99.53 (10.85)
1.88 (0.061) −0.68 (0.501) −1.88 (0.061)
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Table 3.
M-S. Yoo and H-R. Park
Differences in learning motivation, problem-solving ability, and communication skills
Variables Communication skills
Problem-solving ability
Learning motivation
Pretest Post-test Difference t (P) Pretest Post-test Difference t (P) Pretest Post-test Difference t (P)
Intervention group (n = 72) Mean (SD)
Control group (n = 71) Mean (SD)
40.69 (6.56) 58.42 (6.75) 17.73 (8.21) 18.33 (< 0.001) 112.32 (5.27) 97.73 (16.08) −14.59 (16.41) −7.55 (< 0.001) 102.63 (8.75) 110.05 (11.87) 7.41 (11.46) 5.49 (< 0.001)
42.70 (6.16) 46.64 (9.79) 3.94 (9.59) 3.46 (0.001) 111.75 (4.87) 123.49 (14.16) 11.75 (16.33) 6.06 (< 0.001) 99.53 (10.85) 98.29 (12.97) −1.23 (12.95) −0.80 (0.425)
Effectiveness of the CBL After completing the course, the intervention group improved more than the control group with regard to communication skills, problem-solving ability, and learning motivation (Table 3). A significant increase in the communication skills score of the intervention group was observed (t = 18.33, P < 0.001), while a slight increase was observed for the control group (t = 3.46, P < 0.001). There was a significant difference in the communication skills of the two groups (t = −8.36, P < 0.001). A significant decrease in the problemsolving ability score of the intervention group was observed (t = −7.55, P < 0.001), whereas an increase was observed in the control group (t = 6.06, P < 0.001). A significant improvement was observed for the problem-solving ability of the intervention group, as compared to the control group (t = 10.16, P < 0.001). Finally, scores for learning motivation showed a significant increase of + 7.41 (t = 5.49, P < 0.001) for the intervention group, whereas a decrease of −1.23 (t = −0.80, P > 0.05) was observed for the control group. Moreover, a significant difference was found in the learning motivation scores of the two groups (t = −5.65, P < 0.001).
DISCUSSION The present study evaluated the effects of CBL on nursing students’ communication skills, problem-solving ability, and learning motivation. The results of this study showed that CBL effectively facilitated the development of communication skills and increased problem-solving ability and learning motivation. Improvement in the communication skills of the group that was exposed to CBL in this study is compatible with findings of previous studies. The significant increase in the communication skills of nursing students in this study, following the CBL intervention, is similar to previous studies on CBL intervention conducted on medical (Chan et al., 2008) and pharmacological students (Tayem, 2013). Active and studentcentered practice, involving the sharing of opinions in the form of group discussions, as well as verbal and nonverbal © 2014 Wiley Publishing Asia Pty Ltd.
t (P)
−8.36 (< 0.001)
10.16 (< 0.001)
−5.65 (< 0.001)
interaction with SPs, may have been effective strategies for communication skills training, thus contributing to the current findings (Chan et al., 2008; Berkhof et al., 2011). Moreover, five communication cases were developed on the basis of real clinical settings. These improved students’ interaction patterns and enabled them to respond sensitively in communication situations involving patients. A previous study evaluating the impact of communication intervention on healthcare professionals concluded that Case-based learning cases reflecting reality are essential for improving communication (Nørgaard et al., 2012). Problem-solving ability showed significant improvement in the CBL group, and deteriorated in the group that received traditional lectures. This is consistent with two previous studies on the effectiveness of CBL on graduate nurses who had taken a preclinical course aimed at bridging basic scientific and clinical literacy (Schoeman et al., 2009) and a practical course comprising immersion in a clinical setting (Yoo & Park, 2014). Case-based learning exposes students to appropriate responses in the first and second phases of the learning and teaching approach, thus enabling them to successfully recognize, analyze, and solve communication problems (Jonassen & Hernandez-Serrano, 2002; Allchin, 2013). This is especially true for CBL exposing students to multifaceted problems that reflect a real clinical situation, as these present opportunities for students to discuss and integrate clinical knowledge in order to recognize problems and solve them accordingly (Bosse et al., 2012). Exposure to communication conflict in this study could have enhanced cognitive abilities that are necessary for problem-solving. Miscommunication is an extremely complex phenomenon that could occur at any stage in the communication process (Morgan, 2013). In-depth analysis of cases involving miscommunication enhances problem-solving ability due to the transition from individually formulated solutions to systematic problemsolving that occurs during group discussions. In this study, a significant increase was observed in the learning motivation score of the group that received CBL. Although there are only a few studies with which the current findings on the effect of CBL on learning
Case-based learning on nursing education
motivation can be compared, this finding is similar to a CBL study in which video footage was shown to have a positive effect on learning motivation (Yoo et al., 2010). Selfdirected, individual problem-solving prior to group discussion stimulates individuals’ interest, curiosity, and intrinsic attention, thus encouraging active participation and improving self-efficacy (Keller, 1987; Jonassen & HernandezSerrano, 2002; Williams, 2005; Yoo et al., 2010) and, consequently, learning motivation. Furthermore, tangible and realistic cases that were used in this study were relevant to the clinical environment, thereby improving participants’ motivation to learn.
Limitation of the study Several limitations pertaining to this study must be considered when interpreting the findings. First, convenience sampling limits the generalizability of the finding in this study. Therefore, a study using a random sample of students across Korean nursing schools should be considered in order to provide empirical evidence of the effects of CBL. Second, outcomes of CBL were evaluated through a quantitative instrument, which does not facilitate in-depth understanding of students’ experiences, such as their experiences of the CBL process. Third, although the same professor taught the course to both groups, we could not control the effect of professor’s individual endeavor and passion for the new teaching method on the results in this study. The final limitation was that we did not consider the student’s learning styles such as interactive or passive. Despite these limitations, this research is meaningful in that it evaluates the effect of CBL on communication skills, along with problem-solving ability and learning motivation among undergraduate nursing students.
CONCLUSIONS This study suggests that CBL is a more effective technique than traditional didactic lectures for improving communication skills, problem-solving ability, and learning motivation in undergraduate nursing students; during the course of a CBL lecture, nursing students appeared to learn how to solve problems and communicate effectively in diverse clinical situations through exploring and participating in authentic case-based practice. The results indicate that CBL could be incorporated into nursing education curricula as a teaching method. It is also important to develop authentic, realitybased cases, as these are necessary for the effectiveness of CBL. Wide application of CBL would enhance the quality of education imparted to undergraduate nursing students, particularly education related to patient care.
ACKNOWLEDGMENTS This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (No. 20110009593).
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CONTRIBUTIONS Study Design: MSY. Data Collection and Analysis: MSY, HRP. Manuscript Writing and Revision: MSY, HRP.
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Nursing and Health Sciences (2015), 17, 166–172
Research Article
Effects of case-based learning on communication skills, problem-solving ability, and learning motivation in nursing students Moon-Sook Yoo, PhD, RN and Hyung-Ran Park, PhD, RN Ajou University College of Nursing, Suwon, South Korea
Abstract
The purpose of this study was to explore the effects of case-based learning on communication skills, problemsolving ability, and learning motivation in sophomore nursing students. In this prospective, quasi-experimental study, we compared the pretest and post-test scores of an experimental group and a nonequivalent, nonsynchronized control group. Both groups were selected using convenience sampling, and consisted of students enrolled in a health communication course in the fall semesters of 2011 (control group) and 2012 (experimental group) at a nursing college in Suwon, South Korea. The two courses covered the same material, but in 2011 the course was lecture-based, while in 2012, lectures were replaced by case-based learning comprising five authentic cases of patient–nurse communication. At post-test, the case-based learning group showed significantly greater communication skills, problem-solving ability, and learning motivation than the lecture-based learning group. This finding suggests that case-based learning is an effective learning and teaching method.
Key words
case-based learning, communication skills, Korea, learning motivation, nursing education, problem-solving.
INTRODUCTION Communication skills are considered a core competency for nursing professionals working with patients, care providers, and health-team members (Nørgaard et al., 2012). Nurses must be effective communicators to deliver appropriate nursing care, empower patients, and improve patient satisfaction; furthermore, having good communication skills improves nurses’ confidence in caring for patients (Roter et al., 2012; Lau & Wang, 2013). However, studies on communication skills in nursing education have indicated that nursing students often experience fear, anxiety, and negative attitudes when communicating with patients (Kameg et al., 2010) and are poorly prepared to communicate with patients in practical situations (Baghcheghi et al., 2011). To address this gap in core skills, training for communication skills should be grounded in lectures, but must also be supplemented with hands-on student participation in practical learning (Parry, 2008; van Dalen, 2013). Communication-skills training is more effective when using learner-centered (Lau & Wang, 2013), practice-based strategies (Berkhof et al., 2011; Aebersold et al., 2013). Casebased learning (CBL), which is one of such teaching and
Correspondence address: Hyung-Ran Park, Ajou University College of Nursing, Woncheon-dong, Yeongtong-gu, Suwon, 443-721, South Korea. Email: hyungran@ ajou.ac.kr Received 29 January 2014; revision received 18 April 2014; accepted 22 April 2014
© 2014 Wiley Publishing Asia Pty Ltd.
learning methods, is an interactive, student-centered exploration strategy that draws on real-life situations to initiate and promote authentic learning (Williams, 2005). Case-based learning is a constructive learning paradigm, in which learners select and transform information, construct ideas, and make decisions based on their current or past knowledge (Brandon & All, 2010). In CBL, classroom instructors help students to solve diverse case-based problems that occur in real-world situations, moving from abstract knowledge to practical applications (Srisawasdi, 2012). Since CBL focuses on real-life case problems, it is a potentially powerful method for training nursing students to communicate sensitively with patients in challenging clinical situations. The real-life cases presented using CBL enable students to integrate and apply their developing clinical communication knowledge, as well as to reflect on complex situations, as opposed to performing clearly defined, predetermined tasks (Smith & Christie, 2004; Bosse et al., 2012; Tayem, 2013). In addition, CBL encourages students to actively create their own knowledge and independently develop solutions, rather than refer to the knowledge imparted to them by educators or textbooks for problem-solving (Jonassen & Hernandez-Serrano, 2002; Brandon & All, 2010). This would promote the development of their problem-solving abilities (Schoeman et al., 2009; Ciraj et al., 2010; Yoo & Park, 2014) and learning motivation (Kühne-Eversmann et al., 2008). However, there are limited empirical results on the impact of CBL on clinical performance or skill improvement doi: 10.1111/nhs.12151
Case-based learning on nursing education
(Williams, 2005; Jamkar et al., 2006). Previous studies on CBL have focused on students’ attitudes or knowledge levels (Dupuis & Persky, 2008; Ciraj et al., 2010; Malau-Aduli et al., 2013). Therefore this study investigates the impact of CBL on communication skills, problem-solving ability, and learning motivation among undergraduate nursing students enrolled in a health communication course through lecture and practice.
Purpose The purpose of this study was to evaluate the effectiveness of CBL on undergraduate nursing students in the health communication course. Students in the intervention group, who were receiving CBL, were expected to show improved communication skills, problem-solving ability, and learning motivation when compared to the control group receiving traditional lecture-based learning.
METHODS Design and sample In this prospective, quasi-experimental study, we compared pretest and post-test scores obtained by the experimental group and the nonequivalent, nonsynchronized control group. Participants from both groups were selected using convenience sampling from a population of sophomore undergraduate students enrolled in a mandatory health communication course in the fall semesters of 2011 (control group) and 2012 (experimental group) at a nursing college in Suwon, Korea. Initially, 77 students in the experimental group and 74 in the control group agreed to participate. However, five post-test questionnaires in the experimental group and three in the control group were incomplete and were therefore excluded. As a result, a total of 143 students became participants, 72 in the experimental group and 71 in the control group. While the same material was covered in both courses, in 2011, a traditional lecture-based learning course was delivered, and was replaced with a CBL course covering the required material through five authentic cases of patient– nurse communication in 2012. A post-hoc power analysis using the independent t-test (Faul et al., 2007) for sample sizes of 72 (experimental group) and 71 (control group) yielded a power of 99.9% with an effect size (0.90) and an alpha value of 0.05.
Ethical considerations Before the study, approval was obtained from the Institutional Review Board at Ajou University (AJIRB-MEDSUR-11–195). All participants were enrolled in a mandatory health communication course, which was delivered through traditional lectures in 2011 and CBL in 2012. However, participants who completed the questionnaire survey also filled out an informed consent form agreeing to participate in the study. Students were briefed on the study
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purpose and process, as well as their right to withdraw participation at any time without any adverse effect on their course grade.
Case-based learning development Case contents The cases of CBL were developed in July 2011. Communication conflicts from miscommunication between patients and nurses can result in inappropriate nursing care, which negatively influences patient’s health promotion (Morgan, 2013; Tsai et al., 2013). Therefore, for the selection of the authentic cases used in the CBL course, two research assistants observed situations causing communication conflict problems between a nurse and patients, which was a core content in communication education, at the researcher’s university hospital during a period of one week. The education and clinical expert panel, including a course professor, two clinical instructors, and three clinical nurse specialists, considered whether an observed communication conflict situation was suitable for use by the students to analyze and subsequently solve the applicable communication problem. For use as learning cases, the expert panel selected the most frequently observed communication conflict situations. These five situations were delayed laboratory tests, bedside-rail management to prevent patients from falling out of bed, reintravenous catheterization due to delayed fluid change, delayed discharge time, and unsatisfactory pain control. The selected five communication conflict situations were developed as cases during December 2011. Cases were designed in a manner requiring students to improve in problem-solving ability. This ability related to considering the most appropriate communication skills, as well as identifying the cause of the conflict in the miscommunication process. Two clinical nurse specialists from the clinical expert panel, each with clinical and educational experience spanning more than ten years, reviewed the learning objectives and clinical realism of the cases.
Case presentation Following the development of the cases, scenarios were drawn up, and standardized patients (SPs) and standardized nurses (SNs) were prepared for the re-enactment of the cases during January 2012. Five SPs and five SNs were appointed; they received training in appropriate behavior and speech patterns, and were also provided with costumes and appropriate make-up so as to lend authenticity to their roles. The training was provided by a SP trainer over a three-week period, 3 h per week. Two clinical nurse specialists reviewed the constructed scenario and behaviors of the SPs and SNs.
Procedure and data collection Pretest and intervention All participants were enrolled in a health communication course worth two credits and lasting 28 h in total. Participants © 2014 Wiley Publishing Asia Pty Ltd.
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M-S. Yoo and H-R. Park
Figure 1.
completed a demographic survey, an assessment of communication skills using SPs, and tests on problem-solving ability and learning motivation before the start of the course (Fig. 1). The lesson in the CBL health communication course had four stages. First, five cases of communication conflict resulting from miscommunication between a nurse and a patient were presented to the students, enacted by SPs and SNs for 10–15 min per case. In this stage, the students were asked to decipher the nature of the communication problem. In the second stage, the students individually formulated detailed plans on how to solve the communication conflicts. They could also analyze the situation that brought about the miscommunication and obtain first-hand experience of the problem-solving process. In the third stage, the course professor randomly assigned the students to small groups. Each of 15 groups was made up of five to six students. The students solved the communication problems through group discussions that were based on the individually formulated problem-solving plans. They shared their alternative communication strategy with the group members and drew comparisons. The group then analyzed the cause of the communication conflict situations, and considered anticipated results of the suggested solutions. The course professor facilitated the discussion process and ensured alignment with the learning objectives, and encouraged cooperative interactions. In the fourth stage, a solution to the problems was suggested. Based on the group discussion outcomes, the students proposed an appropriate communication solution. Finally, the students participated in the enactment with SPs as the role of nurses using an improved communication style. In the traditional learning environment that the control group had been exposed to, the course was delivered through didactic lectures. The five cases in which communication conflict situations involving nurses and patients occurred were included in the learning material. The course professor described the cause and the process relating to the commu© 2014 Wiley Publishing Asia Pty Ltd.
Research process.
nication problem situation, and then presented solutions in the form of appropriate communication strategies during the lecture.
Post-test After the final lesson, problem-solving ability and learning motivation among the intervention and control groups were assessed via self-administered questionnaires. The students’ communication skills were assessed using observational grading by a course professor and two clinical instructors during their communication enactment involving SPs. Version 19.0 of the SPSS (Statistical Package for the Social Sciences; SPSS Inc, Chicago, IL) was used for data analysis.
Measurements Communication skills The Communication Assessment Tool (CAT) developed by Makoul et al. (2007), and translated and revised into Korean by Yoo and Chae (2011), was used to measure students’ interpersonal and communication skills.The CAT contains 15 items scored on a five-point Likert-type scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). The possible range of total scores is 15–75, with higher scores denoting better communication skills. In a previous study, the reliability of the CAT had been established with a Cronbach’s alpha of 0.83 for nursing students (Yoo & Chae, 2011). A Cronbach’s alpha of 0.83 was also obtained in this study. In order to measure students’ communication skills using the CAT, two nursing experts developed a pilot test using a history-taking case in July 2011. A history-taking interview is a common communication process between a nurse and a patient during a hospital visit. Two nursing experts, one a course professor and the other a clinical nurse specialist at a hospital, constructed the history-taking scenario according to the process found in the CAT, namely, introduction,
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Cronbach’s alpha of 0.75 was previously obtained during use of the scale on nursing students (Yoo & Chae, 2011), while in this study a Cronbach’s alpha of 0.87 was obtained.
problem identification, offering information, understanding the patient, and closing. The course professor and two clinical instructors tested the CAT three times and adjusted the test guidelines accordingly.
Problem-solving ability
Data analysis
The Problem-Solving Inventory (PSI), developed by Heppner and Petersen (1982) and translated into Korean by Jun (1994), was used to assess students’ self-reported problem-solving styles. The PSI contains 35 items (including three filler items) scored on a six-point Likert-type scale ranging from 1 (strongly agree) to 6 (strongly disagree). The PSI contains three subscales: problem-solving confidence (11 items), approach-avoidance style (16 items), and personal control (5 items). The total score (the sum of the three subscales) ranges from 32 to 192, with higher scores indicating poorer self-reported problem-solving skills.A Cronbach’s alpha of 0.82 was obtained during use of the scale on graduate nurses (Yoo & Park, 2014), whereas a Cronbach’s alpha of 0.92 was obtained in the present study.
Descriptive statistics including means, standard deviation (SD), frequencies, and percentages were used to describe sociodemographics with SPSS Version 19.0 programs. A t-test was used to compare differences in means of communication skills, problem-solving ability, and learning motivation scores. All analyses were two-tailed, and the significance level was set at 0.05.
RESULTS General characteristics and homogeneity test The demographic characteristics of the intervention and control groups are shown in Table 1 and are briefly summarized here. The majority of participants were female (93.0%). Most (62.9%) had obtained an average grade of 3.0–3.9 in the previous semester. Moreover, 68.5% of the participants regarded their personality as neutral during interpersonal relations. The pretest scores denoted test homogeneity for the two groups (Table 2). No significant differences were detected between the intervention and control groups in the pretest scores obtained for communication skills (t = 1.88, P = 0.061), problem-solving ability (t = −0.68, P = 0.501), and learning motivation (t = −1.88, P = 0.061).
Learning motivation The Instructional Materials Motivation Scale (IMMS) developed by Keller (1987) and translated into Korean by Jang (1996), was used to evaluate students’ learning motivation in four domains: attention, relevance, confidence, and satisfaction. The IMMS comprises 35 items scored on a fivepoint Likert-type scale ranging from 1 (not true) to 5 (very true). The possible range of scores is 35–175, with higher scores denoting more self-directed motivation to learn. A
Table 1. General characteristics of the participants
Variables
Categories
Gender
Male Female > 4.0 3.0–3.9 2.0–2.9 < 1.9 Active Neutral Negative
Average grade previous semester
Interpersonal personality
Intervention group (n = 72) N (%)
Control group (n = 71) N (%)
7 (9.7) 65 (90.3) 7 (9.7) 50 (69.4) 14 (19.4) 1 (1.4) 21 (29.2) 51 (70.8) –
3 (4.2) 68 (95.8) 9 (12.7) 40 (56.3) 22 (31.0) – 24 (33.8) 47 (66.2) –
χ2
P
1.661
0.198
4.132
0.248
0.356
0.551
Table 2. Homogeneity comparison of communication skills, problem-solving ability, and learning motivation
Variables Communication skills Problem-solving ability Learning motivation
Intervention group (n = 72) Mean (SD)
Control group (n = 71) Mean (SD)
t (P)
40.69 (6.56) 112.32 (5.27) 102.63 (8.75)
42.70 (6.16) 111.75 (4.87) 99.53 (10.85)
1.88 (0.061) −0.68 (0.501) −1.88 (0.061)
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Table 3.
M-S. Yoo and H-R. Park
Differences in learning motivation, problem-solving ability, and communication skills
Variables Communication skills
Problem-solving ability
Learning motivation
Pretest Post-test Difference t (P) Pretest Post-test Difference t (P) Pretest Post-test Difference t (P)
Intervention group (n = 72) Mean (SD)
Control group (n = 71) Mean (SD)
40.69 (6.56) 58.42 (6.75) 17.73 (8.21) 18.33 (< 0.001) 112.32 (5.27) 97.73 (16.08) −14.59 (16.41) −7.55 (< 0.001) 102.63 (8.75) 110.05 (11.87) 7.41 (11.46) 5.49 (< 0.001)
42.70 (6.16) 46.64 (9.79) 3.94 (9.59) 3.46 (0.001) 111.75 (4.87) 123.49 (14.16) 11.75 (16.33) 6.06 (< 0.001) 99.53 (10.85) 98.29 (12.97) −1.23 (12.95) −0.80 (0.425)
Effectiveness of the CBL After completing the course, the intervention group improved more than the control group with regard to communication skills, problem-solving ability, and learning motivation (Table 3). A significant increase in the communication skills score of the intervention group was observed (t = 18.33, P < 0.001), while a slight increase was observed for the control group (t = 3.46, P < 0.001). There was a significant difference in the communication skills of the two groups (t = −8.36, P < 0.001). A significant decrease in the problemsolving ability score of the intervention group was observed (t = −7.55, P < 0.001), whereas an increase was observed in the control group (t = 6.06, P < 0.001). A significant improvement was observed for the problem-solving ability of the intervention group, as compared to the control group (t = 10.16, P < 0.001). Finally, scores for learning motivation showed a significant increase of + 7.41 (t = 5.49, P < 0.001) for the intervention group, whereas a decrease of −1.23 (t = −0.80, P > 0.05) was observed for the control group. Moreover, a significant difference was found in the learning motivation scores of the two groups (t = −5.65, P < 0.001).
DISCUSSION The present study evaluated the effects of CBL on nursing students’ communication skills, problem-solving ability, and learning motivation. The results of this study showed that CBL effectively facilitated the development of communication skills and increased problem-solving ability and learning motivation. Improvement in the communication skills of the group that was exposed to CBL in this study is compatible with findings of previous studies. The significant increase in the communication skills of nursing students in this study, following the CBL intervention, is similar to previous studies on CBL intervention conducted on medical (Chan et al., 2008) and pharmacological students (Tayem, 2013). Active and studentcentered practice, involving the sharing of opinions in the form of group discussions, as well as verbal and nonverbal © 2014 Wiley Publishing Asia Pty Ltd.
t (P)
−8.36 (< 0.001)
10.16 (< 0.001)
−5.65 (< 0.001)
interaction with SPs, may have been effective strategies for communication skills training, thus contributing to the current findings (Chan et al., 2008; Berkhof et al., 2011). Moreover, five communication cases were developed on the basis of real clinical settings. These improved students’ interaction patterns and enabled them to respond sensitively in communication situations involving patients. A previous study evaluating the impact of communication intervention on healthcare professionals concluded that Case-based learning cases reflecting reality are essential for improving communication (Nørgaard et al., 2012). Problem-solving ability showed significant improvement in the CBL group, and deteriorated in the group that received traditional lectures. This is consistent with two previous studies on the effectiveness of CBL on graduate nurses who had taken a preclinical course aimed at bridging basic scientific and clinical literacy (Schoeman et al., 2009) and a practical course comprising immersion in a clinical setting (Yoo & Park, 2014). Case-based learning exposes students to appropriate responses in the first and second phases of the learning and teaching approach, thus enabling them to successfully recognize, analyze, and solve communication problems (Jonassen & Hernandez-Serrano, 2002; Allchin, 2013). This is especially true for CBL exposing students to multifaceted problems that reflect a real clinical situation, as these present opportunities for students to discuss and integrate clinical knowledge in order to recognize problems and solve them accordingly (Bosse et al., 2012). Exposure to communication conflict in this study could have enhanced cognitive abilities that are necessary for problem-solving. Miscommunication is an extremely complex phenomenon that could occur at any stage in the communication process (Morgan, 2013). In-depth analysis of cases involving miscommunication enhances problem-solving ability due to the transition from individually formulated solutions to systematic problemsolving that occurs during group discussions. In this study, a significant increase was observed in the learning motivation score of the group that received CBL. Although there are only a few studies with which the current findings on the effect of CBL on learning
Case-based learning on nursing education
motivation can be compared, this finding is similar to a CBL study in which video footage was shown to have a positive effect on learning motivation (Yoo et al., 2010). Selfdirected, individual problem-solving prior to group discussion stimulates individuals’ interest, curiosity, and intrinsic attention, thus encouraging active participation and improving self-efficacy (Keller, 1987; Jonassen & HernandezSerrano, 2002; Williams, 2005; Yoo et al., 2010) and, consequently, learning motivation. Furthermore, tangible and realistic cases that were used in this study were relevant to the clinical environment, thereby improving participants’ motivation to learn.
Limitation of the study Several limitations pertaining to this study must be considered when interpreting the findings. First, convenience sampling limits the generalizability of the finding in this study. Therefore, a study using a random sample of students across Korean nursing schools should be considered in order to provide empirical evidence of the effects of CBL. Second, outcomes of CBL were evaluated through a quantitative instrument, which does not facilitate in-depth understanding of students’ experiences, such as their experiences of the CBL process. Third, although the same professor taught the course to both groups, we could not control the effect of professor’s individual endeavor and passion for the new teaching method on the results in this study. The final limitation was that we did not consider the student’s learning styles such as interactive or passive. Despite these limitations, this research is meaningful in that it evaluates the effect of CBL on communication skills, along with problem-solving ability and learning motivation among undergraduate nursing students.
CONCLUSIONS This study suggests that CBL is a more effective technique than traditional didactic lectures for improving communication skills, problem-solving ability, and learning motivation in undergraduate nursing students; during the course of a CBL lecture, nursing students appeared to learn how to solve problems and communicate effectively in diverse clinical situations through exploring and participating in authentic case-based practice. The results indicate that CBL could be incorporated into nursing education curricula as a teaching method. It is also important to develop authentic, realitybased cases, as these are necessary for the effectiveness of CBL. Wide application of CBL would enhance the quality of education imparted to undergraduate nursing students, particularly education related to patient care.
ACKNOWLEDGMENTS This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (No. 20110009593).
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CONTRIBUTIONS Study Design: MSY. Data Collection and Analysis: MSY, HRP. Manuscript Writing and Revision: MSY, HRP.
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