SOCIAL BEHAVIOR AND PERSONALITY, 2018, 46(1), 151–160

© 2018 Scientific Journal Publishers Limited. All Rights Reserved. https://doi.org/10.2224/sbp.6906

SIMULATION EDUCATION WITH PROBLEM-BASED

LEARNING: EFFECT ON NURSING STUDENTS’
COMMUNICATION APPREHENSION

YOUNG-HEE KIM
Daejeon Institute of Science and Technology
KYUNG-HYE HWANG
Suwon Science College
OK-HEE CHO
Kongju National University

We investigated the effect of simulation education with problem-based learning (SIM-PBL)

on nursing students’ communication apprehension, assertiveness, and nursing clinical self-
efficacy. Participants were 82 senior nursing students at a university in South Korea.
Through the pre–post SIM-PBL comparison, we found that communication apprehension in
group discussion decreased and nursing clinical self-efficacy increased, but no difference
was found in assertiveness. Based on these findings, we recommend the development and
application of SIM-PBL for various situations in the curriculum for nursing students prior to
clinical practice.

Keywords: simulation education, problem-based learning, communication, assertiveness,

clinical self-efficacy.

Patients want to be provided with the best care from their nurses and
increasingly refuse to be subjects of nursing students’ clinical practice
(Bremner, Aduddell, Bennett, & VanGeest, 2006). Further, hospital regulations
for patient safety have been strengthened. This means that nursing students are
increasingly

Young-Hee Kim, Department of Nursing, Daejeon Institute of Science and Technology; Kyung-Hye
Hwang, Department of Nursing, Suwon Science College; Ok-Hee Cho, Department of Nursing,
College of Nursing and Health, Kongju National University.
Correspondence concerning this article should be addressed to Ok-Hee Cho, Department of Nursing,
College of Nursing and Health, Kongju National University, 56 Gongjudeahak-ro, Gongju-si,
152 SIMULATION EDUCATION AND NURSING COMMUNICATION

Chungcheong nam-do 314-701, Republic of Korea. Email: ohcho@kongju.ac.kr

151

taking part in observation-based, passive, and nonparticipatory practice. To

supplement such a limited practice environment, nursing universities run
simulation-based practical training in which clinical situations are simulated.
Simulation education with problem-based learning (SIM-PBL) is an integrated
curriculum that links problem-based learning and simulation practices whereby
realistic practice activities are induced. In problem-based learning, through
group collaboration, students proactively solve the nursing problems of the
clinical case presented to them (Murphy, Hartigan, Walshe, Flynn, & O’Brien,
2011). In simulation practice, nursing students use a virtual clinical simulation
laboratory designed to mimic real-world acute clinical care, and use the
simulated and programmed learning activities to improve their communication,
clinical judgement, and confidence. This process includes assessment,
simulation with a high-fidelity simulator, and debriefing (Bambini, Washburn,
& Perkins, 2009; Foronda, Gattamorta, Snowden, & Bauman, 2014). SIM-PBL
is effective for improving learners’ health assessment, clinical decision making,
nursing, and communication skills. For example, M.-N. Lee, Nam, and Kim
(2017) reported the effectiveness of SIM-PBL in improving interpersonal
relationships and team efficacy through its application in a patient scenario of
increased intracranial pressure. SIM-PBL is also a teaching–learning strategy
that integrates student-led education and performance-based assessment
(Walshe, O’Brien, Murphy, & Hartigan, 2013).
The effects of the SIM-PBL can vary depending on the students’ willingness to
participate actively in clinical practice and their ability to communicate with
patients or team members. Despite communication ability being one of the core
competencies that nursing students must have as preliminary nurses (Korean
Accreditation Board of Nursing Education, 2012), the most difficult area for a
new nurse adapting to the clinical environment after graduation is reporting to
doctors and other communication-related aspects such as nursing handover
(Casey, Fink, Krugman, & Propst, 2004). Nursing students also have difficulty
during clinical practice in communication with nurses and head nurses (S.-J.
Park & Park, 2013). Foronda et al. (2014) reported improvement in
communication skills through performing the Identify, Situation, Background,
Assessment, and Recommendation (ISBAR) communication technique in the
clinical space. Therefore, in order for nursing students to meet their
communication competency requirement and to be able to use the ISBAR
technique in a clinical context, it is necessary to reduce their communication
apprehension by developing nursing students’ communication ability through
SIM-PBL experience in various simulated situations.
 SIMULATION EDUCATION AND NURSING COMMUNICATION 153

Another key skill for student nurses to develop is assertiveness. Nurses’

assertiveness is an important factor in interpersonal relationships between
patients and nurses, and it plays an important role in providing patients with
care in nursing practice (Timmins & McCabe, 2005). Assertiveness is an
expression of self-trust and self-confidence (Ibrahim, 2011), and these need to
be improved for the enhancement of communication ability. The assertiveness
of nursing students has positive correlations with psychological encouragement
(Ibrahim, 2011) and self-esteem (Ilhan, Sukut, Akhan, & Batmaz, 2016).
Further, there have been reports that the greater the assertiveness, the higher the
self-efficacy in training (Poyrazli, Arbona, Nora, McPherson, & Pisecco, 2002)
and clinical competencies, such as nursing skills, interpersonal relationships,
and professional development (K. E. Lee, Ha, & Kil, 2000).
SIM-PBL is used as an instructional method to give nursing students the ability
to report to other nurses or other medical team members the results of nursing
assessments that they perform and to express their opinions actively. As
preliminary nurses, nursing students feel pressure in regard to patient care and
interactions with other medical staff (Labrague et al., 2016). Lewis, Strachan,
and McKenzie Smith (2012) have suggested that high-fidelity simulation
education is a method to improve application of communication skills without
fear of mistakes, thinking ability in critical situations, and the efficacy of
clinical performance ability. Sohn, Ahn, Lee, Park, and Kang (2013) also
reported improvements in the practice efficacy of nursing students in areas of
assessment, prioritization, and health promotion after SIM-PBL. Therefore, the
purpose of the present study was to investigate the effect of SIM-PBL on senior
nursing students’ communication apprehension, assertiveness, and nursing
clinical self-efficacy through a quantitative approach and data analysis, by
developing and applying a SIM-PBL module as part of the curriculum for
nursing students.

Method

Participants
This study was approved by the Institutional Review Board at Kongju National
University of Korea. All information and responses were maintained
confidentially and the detail condition of data collection and usage was
explained to participants before data collection.
Participants were convenience sampled from senior nursing students of a
university in Chungcheongnam-do, South Korea. They had completed over
1,000 hours of regular clinical training course work. In this study, they were
educated through a simulation training course (two credits, four instructional
hours) in the second semester of their sophomore year. The minimum number of
participants required to test the mean difference pre- and posteducation was
154 SIMULATION EDUCATION AND NURSING COMMUNICATION

calculated using G*POWER 3.1.9.2. That is, 68 was the number of participants
needed to maintain the prediction power for the significance level of .05, power
of .90, and effect size of .4. In the present study, we collected data from 82
student nurses, making the sample size appropriate for the collection of data. All
participants were senior nursing students, and the average age was 22.4 years
(range 21–28 years). There were 72 female students (87.8%) and 10 male
students (12.2%).

Measures
Communication apprehension. We measured communication apprehension
with an instrument developed by McCroskey, Beatty, Kearney, and Plax (1985).
The instrument consists of 24 items, of which there are six items in each of four
areas (group discussion, meetings, interpersonal conversations, and public
speaking) rated on a 5-point Likert scale ranging from 1 = strongly disagree to 5
= strongly agree. The higher the score, the higher the level of communication
apprehension (total score range = 24–120). Sample items are “I dislike
participating in group discussions” (group discussion); “I usually tend to get
nervous when meeting people” (meetings); “I get very nervous when talking
with new people” (interpersonal conversations); “I’m not afraid when giving
presentations” (public speaking). The Cronbach’s  was .87 before and .90 after
the education in this study.
Assertiveness. We measured assertiveness with an instrument developed by
Rathus (1973). The instrument has 30 items (e.g., “Most people seem to be more
aggressive and assertive than I am”) rated on a 6-point Likert scale ranging from
1 = very uncharacteristic of me to 6 = very characteristic of me. A higher score
signifies more assertiveness (total score range = 30–180). The Cronbach’s 
was .78 before and .76 after the education in this study.
Nursing clinical self-efficacy. To measure nursing clinical self-efficacy, we
used an instrument Ahn (2000) modified from the Nursing Clinical Self-
Efficacy Scale (Harvey & McMurray, 1994) and a self-efficacy instrument
developed by Parker (1993). The modified instrument has 25 items (e.g., “I can
make a nursing diagnosis by assessing a patient’s health problem”) rated on a
10-point Likert scale ranging from 1 = no confidence at all to 10 = complete
confidence. Higher scores signify higher self-efficacy in clinical practice (total
score range = 25–250). The Cronbach’s  was .96 before and .95 after the
education in this study.
Satisfaction with simulation practical education. We measured satisfaction
with our simulation practical education with an instrument developed by Levett-
Jones et al. (2011). The instrument has 19 items (e.g., “The teaching methods
used in simulation were effective”) rated on a 5-point Likert scale ranging from
1 = not satisfied at all to 5 = very satisfied. A higher score signifies higher
 SIMULATION EDUCATION AND NURSING COMMUNICATION 155

satisfaction with the education (total score range = 19–95). The Cronbach’s  in
this study was .95.
Procedure
The data collection period was from September to December 2016, covering 4
weeks for each of the four classes, and a preliminary survey on the research
variables was conducted one week before the beginning of the education
program. Development of a SIM-PBL module. The subject of the SIM-PBL
module was nursing a 55-year-old female colon cancer patient (colectomy, with
colostomy) at the time of hospitalization and pre- and postoperation. A SimMan
3G simulator was used for the simulation practice. We developed four scenarios
for problem-based learning, one for each week of four weeks, as well as
simulation practice scenarios linked to them. The scenario topic was care of the
patient described above through arrival at an emergency room (primary),
admission care (secondary), preoperation care (tertiary), and postoperation care
(quaternary). Tasks were arranged to solve the health issues of the patient
according to the nursing process system for the problem-based learning process,
and after the simulation practice students were asked to organize the nursing
process according to priority in the implemented situation. We structured the
simulation practice process in such a way that the nursing students were
expected to take the initiative and perform specific nursing interventions such as
history taking, physical examination, admission care, preoperation care, and
postoperation care. Expert validity was checked by a nursing professor who had
experience in developing and managing the curriculum.
SIM-PBL application. The education program was applied once a week for
about 150 minutes each time for four weeks. Four classes (20–21 students per
class) were involved in the SIM-PBL operation. Each class was divided into
four teams, and each team consisted of five or six students. The SIM-PBL
education program was composed of problem-based learning (90 minutes),
simulation practice (15 minutes), debriefing (30 minutes), and rest (15 minutes).
To minimize the experimental effect, one instructor who was experienced in
simulation practical training conducted the whole program.

Data Analysis
The collected data were analyzed using SPSS/WIN 23.0. The participants’
general characteristics, communication apprehension, assertiveness, nursing
clinical self-efficacy, and the level of educational satisfaction were measured by
the actual numbers, as well as the percentages, means, and standard deviations.
The pre- and posteducation differences of the variables were analyzed by
paired-samples t test.
156 SIMULATION EDUCATION AND NURSING COMMUNICATION

Results

Results in Table 1 show that the communication apprehension about group

discussion significantly decreased from 17.44 before education to 16.71 after
education (t = -2.02, p = .047), whereas the communication apprehension about
meetings, interpersonal conversations, and public speaking did not decrease.
Nursing clinical self-efficacy significantly increased from 174.83 before training
to 185.91 after training (t = 3.20, p = .002). After the training, satisfaction with
SIM-PBL was on average 4.18 (± 0.45) out of 5 points.
Table 1. Differences After the Simulation Education Integrated with Problem-Based
Learning on Communication Apprehension, Assertiveness, and Nursing Clinical Self-
Efficacy
Variables Preeducation Posteducation t p
M ± SD M ± SD

Communication apprehension 69.78 ± 11.92 68.00 ± 11.57 -1.77 .080

Group discussion 17.44 ± 3.74 16.71 ± 3.84 -2.02 .047
Meetings 16.26 ± 3.87 15.83 ± 3.41 -1.33 .189
Interpersonal conversations 16.91 ± 3.70 16.46 ± 3.46 -1.37 .173
Public speaking 19.17 ± 3.31 19.00 ± 3.94 -0.42 .675
Self-assertiveness 106.76 ± 15.34 109.51 ± 11.28 1.72 .088
Nursing clinical self-efficacy 174.83 ± 33.60 185.91 ± 25.84 3.20 .002

Note. N = 82; df = 81.

Discussion

In the present study, we investigated the effect of SIM-PBL on nursing students’

communication apprehension, assertiveness, and nursing clinical self-efficacy
by developing and applying a SIM-PBL module. Our results showed that, first,
among the four subareas of communication apprehension, only the
communication apprehension area for group discussion decreased after the SIM-
PBL education compared to before the education. Communication apprehension
is a personal internal apprehension that appears when communicating with
others (McCroskey et al., 1985), and although it is difficult to improve
communication skills when communication apprehension is high (Arquero,
Hassall, Joyce, & Donoso, 2007), communication apprehension can be reduced
as communication skills improve (J. W. Park & Ha, 2014). Our finding that
group discussion among students in the problem-based learning process was
effective in reducing communication apprehension, is similar to that of
Kedrowicz (2016), who found that communication apprehension of North
American medical students decreased while communication competency
increased after group discussion training. Hendry, Ryan, and Harris (2003),
 SIMULATION EDUCATION AND NURSING COMMUNICATION 157

however, reported that in a problem-based learning class for medical students,

individual quietness and dominant behavior were observed and negative
problems in team cooperation activities occurred.
The reason for the nonsignificant reduction of the communication apprehension
score in the other subareas after the SIM-PBL in the present study appears to be
due to the simulation practice environment being monitored by the educator, and
this becoming an obstacle for reducing communication apprehension. Even
though the SIM-PBL education took place four times within four weeks (once a
week), this period appears to have been too short to reduce communication
apprehension in the subareas other than group discussion.
Second, the results in the present study showed that even though assertiveness
increased after the SIM-PBL, the increase was statistically nonsignificant. This
result is different from the results of a study that showed an improved
communication competency after applying a virtual clinical simulation of
ISBAR communication skills to U.S. nursing students (Foronda et al., 2014).
With expressive behavior being the skill used in relation to interpersonal
relationships or roles, it has been found that the higher the level of speaking,
writing, and understanding, the greater the assertiveness (Poyrazli et al., 2002;
Timmins & McCabe, 2005). The reason for nonimprovement of assertiveness in
the present study, despite the learning and discussions in the problem-based
learning process, appears to be the limited priority given to assertiveness
because students had to focus more on problem solving under the urgent clinical
situation of the simulation laboratory. As the assertiveness of nursing students
increases with more psychosocial empowerment (Ibrahim, 2011), it is necessary
in nursing training for professors to create a permissive atmosphere, encourage
students to express their own thoughts through debriefing sessions, listen to
students’ opinions carefully, and provide sufficient support.
Third, in the present study, nursing clinical self-efficacy increased after the
SIM-PBL education, compared to before the education. Such a result has been
reported in previous studies. Bambini et al. (2009) reported that communication,
nursing skills, confidence in interaction with patients, and self-efficacy in
clinical judgment were significantly increased after experiencing simulation
practice on postpartum nursing. Liaw et al. (2010) reported that the group that
received SIM-PBL education for patients with respiratory and cardiovascular
disorders had higher clinical competency in patient assessment for an acute
situation, immediate nursing intervention, and reporting to the doctor using the
ISBAR communication model than did the problem-based learning group. Sohn
et al. (2013) also reported that nursing students’ self-efficacy increased in
assessment, physical examination, prioritization, and all areas of education after
SIM-PBL education. The SIM-PBL education of the present study appears to
have helped participants to increase their nursing clinical self-efficacy because
the content of the module consisted of scenarios of hospitalization and pre- and
158 SIMULATION EDUCATION AND NURSING COMMUNICATION

postoperative nursing issues that nursing students frequently encounter in

hospital practice.
Finally, satisfaction with SIM-PBL after the education program was 4.18 points
(out of 5 points) in the present study. The score was higher than the satisfaction
scores reported of 3.51–3.99 after problem-based learning on nursing ethics
(Lin, Lu, Chung, & Yang, 2010), and the 7.64 (out of 10 points) reported after
simulation education on cardiopulmonary resuscitation (Roh, Lee, Chung, &
Park, 2013). Such results of increased educational satisfaction along with
increased nursing clinical self-efficacy may be due to the increased learning
presence of nursing students with the synergistic action of the application of
SIM-PBL education (Cho & Hwang, 2016), rather than solely due to the
application of problem-based learning or simulation education.

Limitations and conclusion

The interpretation of the results in the present study is limited because the
participants were from only one university and because we employed the single
group design, which does not require a comparison group. In group discussions,
we were not able to control external factors such as competitive-driven anxiety
among students and potential problems due to excessive assertiveness.
Future research to verify the effect longitudinally by developing
communication-based scenarios according to specific cases and intensively
providing simulation education programs is necessary. It is also necessary to
remeasure the effect with communication apprehension and self-efficacy set as
the effect variables by adding a practice scenario focused on communication
skills with patients.
The present study has its significance in the confirmation of the SIM-PBL as a
teaching–learning strategy that reduces communication apprehension and
improves the nursing clinical self-efficacy of nursing students. From the nursing
education perspective, adding sessions on therapeutic communication skills with
patients is required when planning a SIM-PBL education module in order to
provide an effective way of achieving the reduction of communication
apprehension and the improvement of self-assertiveness.

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