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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, problem-
solving 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 learning methods, is an interactive, student-centered explora-

tion strategy that draws on real-life situations to initiate and
Communication skills are considered a core competency for
promote authentic learning (Williams, 2005). Case-based
nursing professionals working with patients, care providers,
learning is a constructive learning paradigm, in which learn-
and health-team members (Nørgaard et al., 2012). Nurses
ers select and transform information, construct ideas, and
must be effective communicators to deliver appropriate
make decisions based on their current or past knowledge
nursing care, empower patients, and improve patient satis-
(Brandon & All, 2010). In CBL, classroom instructors help
faction; furthermore, having good communication skills
students to solve diverse case-based problems that occur in
improves nurses’ confidence in caring for patients (Roter
real-world situations, moving from abstract knowledge to
et al., 2012; Lau & Wang, 2013). However, studies on commu-
practical applications (Srisawasdi, 2012). Since CBL focuses
nication skills in nursing education have indicated that
on real-life case problems, it is a potentially powerful method
nursing students often experience fear, anxiety, and negative
for training nursing students to communicate sensitively with
attitudes when communicating with patients (Kameg et al.,
patients in challenging clinical situations. The real-life cases
2010) and are poorly prepared to communicate with patients
presented using CBL enable students to integrate and apply
in practical situations (Baghcheghi et al., 2011). To address
their developing clinical communication knowledge, as well
this gap in core skills, training for communication skills
as to reflect on complex situations, as opposed to performing
should be grounded in lectures, but must also be supple-
clearly defined, predetermined tasks (Smith & Christie, 2004;
mented with hands-on student participation in practical
Bosse et al., 2012; Tayem, 2013).
learning (Parry, 2008; van Dalen, 2013).
In addition, CBL encourages students to actively create
Communication-skills training is more effective when
their own knowledge and independently develop solutions,
using learner-centered (Lau & Wang, 2013), practice-based
rather than refer to the knowledge imparted to them by
strategies (Berkhof et al., 2011; Aebersold et al., 2013). Case-
educators or textbooks for problem-solving (Jonassen &
based learning (CBL), which is one of such teaching and
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)
Correspondence address: Hyung-Ran Park, Ajou University College of Nursing,
and learning motivation (Kühne-Eversmann et al., 2008).
Woncheon-dong, Yeongtong-gu, Suwon, 443-721, South Korea. Email: hyungran@
ajou.ac.kr However, there are limited empirical results on the impact
Received 29 January 2014; revision received 18 April 2014; accepted 22 April 2014 of CBL on clinical performance or skill improvement

© 2014 Wiley Publishing Asia Pty Ltd. doi: 10.1111/nhs.12151

Case-based learning on nursing education 167

(Williams, 2005; Jamkar et al., 2006). Previous studies on CBL purpose and process, as well as their right to withdraw par-
have focused on students’ attitudes or knowledge levels ticipation at any time without any adverse effect on their
(Dupuis & Persky, 2008; Ciraj et al., 2010; Malau-Aduli et al., course grade.
2013). Therefore this study investigates the impact of CBL on
communication skills, problem-solving ability, and learning
Case-based learning development
motivation among undergraduate nursing students enrolled
in a health communication course through lecture and
Case contents
practice.
The cases of CBL were developed in July 2011. Communica-
tion conflicts from miscommunication between patients and
Purpose nurses can result in inappropriate nursing care, which nega-
tively influences patient’s health promotion (Morgan, 2013;
The purpose of this study was to evaluate the effectiveness of Tsai et al., 2013). Therefore, for the selection of the authentic
CBL on undergraduate nursing students in the health com- cases used in the CBL course, two research assistants
munication course. Students in the intervention group, who observed situations causing communication conflict prob-
were receiving CBL, were expected to show improved com- lems between a nurse and patients, which was a core content
munication skills, problem-solving ability, and learning moti- in communication education, at the researcher’s university
vation when compared to the control group receiving hospital during a period of one week. The education and
traditional lecture-based learning. clinical expert panel, including a course professor, two clini-
cal instructors, and three clinical nurse specialists, considered
whether an observed communication conflict situation was
METHODS suitable for use by the students to analyze and subsequently
solve the applicable communication problem. For use as
Design and sample learning cases, the expert panel selected the most frequently
In this prospective, quasi-experimental study, we compared observed communication conflict situations. These five situa-
pretest and post-test scores obtained by the experimental tions were delayed laboratory tests, bedside-rail management
group and the nonequivalent, nonsynchronized control to prevent patients from falling out of bed, reintravenous
group. Participants from both groups were selected using catheterization due to delayed fluid change, delayed dis-
convenience sampling from a population of sophomore charge time, and unsatisfactory pain control. The selected five
undergraduate students enrolled in a mandatory health com- communication conflict situations were developed as cases
munication course in the fall semesters of 2011 (control during December 2011. Cases were designed in a manner
group) and 2012 (experimental group) at a nursing college in requiring students to improve in problem-solving ability. This
Suwon, Korea. Initially, 77 students in the experimental group ability related to considering the most appropriate commu-
and 74 in the control group agreed to participate. However, nication skills, as well as identifying the cause of the conflict
five post-test questionnaires in the experimental group and in the miscommunication process. Two clinical nurse special-
three in the control group were incomplete and were there- ists from the clinical expert panel, each with clinical and
fore excluded. As a result, a total of 143 students became educational experience spanning more than ten years,
participants, 72 in the experimental group and 71 in the reviewed the learning objectives and clinical realism of the
control group. While the same material was covered in both cases.
courses, in 2011, a traditional lecture-based learning course
was delivered, and was replaced with a CBL course covering Case presentation
the required material through five authentic cases of patient–
nurse communication in 2012. Following the development of the cases, scenarios were
A post-hoc power analysis using the independent t-test drawn up, and standardized patients (SPs) and standardized
(Faul et al., 2007) for sample sizes of 72 (experimental group) nurses (SNs) were prepared for the re-enactment of the cases
and 71 (control group) yielded a power of 99.9% with an during January 2012. Five SPs and five SNs were appointed;
effect size (0.90) and an alpha value of 0.05. they received training in appropriate behavior and speech
patterns, and were also provided with costumes and appro-
priate make-up so as to lend authenticity to their roles. The
training was provided by a SP trainer over a three-week
Ethical considerations
period, 3 h per week. Two clinical nurse specialists reviewed
Before the study, approval was obtained from the Institu- the constructed scenario and behaviors of the SPs and SNs.
tional Review Board at Ajou University (AJIRB-MED-
SUR-11–195). All participants were enrolled in a
Procedure and data collection
mandatory health communication course, which was deliv-
ered through traditional lectures in 2011 and CBL in 2012.
Pretest and intervention
However, participants who completed the questionnaire
survey also filled out an informed consent form agreeing to All participants were enrolled in a health communication
participate in the study. Students were briefed on the study course worth two credits and lasting 28 h in total. Participants

© 2014 Wiley Publishing Asia Pty Ltd.

168 M-S. Yoo and H-R. Park

Figure 1. Research process.

completed a demographic survey, an assessment of commu- nication problem situation, and then presented solutions in
nication skills using SPs, and tests on problem-solving ability the form of appropriate communication strategies during the
and learning motivation before the start of the course lecture.
(Fig. 1).
The lesson in the CBL health communication course had
Post-test
four stages. First, five cases of communication conflict result-
ing from miscommunication between a nurse and a patient After the final lesson, problem-solving ability and learning
were presented to the students, enacted by SPs and SNs for motivation among the intervention and control groups were
10–15 min per case. In this stage, the students were asked to assessed via self-administered questionnaires. The students’
decipher the nature of the communication problem. In the communication skills were assessed using observational
second stage, the students individually formulated detailed grading by a course professor and two clinical instructors
plans on how to solve the communication conflicts. They during their communication enactment involving SPs.
could also analyze the situation that brought about the mis- Version 19.0 of the SPSS (Statistical Package for the Social
communication and obtain first-hand experience of the Sciences; SPSS Inc, Chicago, IL) was used for data analysis.
problem-solving process. In the third stage, the course pro-
fessor randomly assigned the students to small groups. Each
Measurements
of 15 groups was made up of five to six students. The students
solved the communication problems through group discus-
Communication skills
sions that were based on the individually formulated
problem-solving plans. They shared their alternative commu- The Communication Assessment Tool (CAT) developed by
nication strategy with the group members and drew Makoul et al. (2007), and translated and revised into Korean
comparisons. The group then analyzed the cause of the com- by Yoo and Chae (2011), was used to measure students’
munication conflict situations, and considered anticipated interpersonal and communication skills.The CAT contains 15
results of the suggested solutions. The course professor items scored on a five-point Likert-type scale (1 = poor,
facilitated the discussion process and ensured alignment 2 = fair, 3 = good, 4 = very good, 5 = excellent). The possible
with the learning objectives, and encouraged coopera- range of total scores is 15–75, with higher scores denoting
tive interactions. In the fourth stage, a solution to the prob- better communication skills. In a previous study, the reliabil-
lems was suggested. Based on the group discussion outcomes, ity of the CAT had been established with a Cronbach’s alpha
the students proposed an appropriate communication solu- of 0.83 for nursing students (Yoo & Chae, 2011). A
tion. Finally, the students participated in the enactment with Cronbach’s alpha of 0.83 was also obtained in this study.
SPs as the role of nurses using an improved communication In order to measure students’ communication skills using
style. the CAT, two nursing experts developed a pilot test using a
In the traditional learning environment that the control history-taking case in July 2011. A history-taking interview is
group had been exposed to, the course was delivered through a common communication process between a nurse and a
didactic lectures. The five cases in which communication con- patient during a hospital visit. Two nursing experts, one a
flict situations involving nurses and patients occurred were course professor and the other a clinical nurse specialist at
included in the learning material. The course professor a hospital, constructed the history-taking scenario according
described the cause and the process relating to the commu- to the process found in the CAT, namely, introduction,

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Case-based learning on nursing education 169

problem identification, offering information, understanding Cronbach’s alpha of 0.75 was previously obtained during
the patient, and closing. The course professor and two clinical use of the scale on nursing students (Yoo & Chae, 2011),
instructors tested the CAT three times and adjusted the test while in this study a Cronbach’s alpha of 0.87 was
guidelines accordingly. obtained.

Problem-solving ability
Data analysis
The Problem-Solving Inventory (PSI), developed by
Descriptive statistics including means, standard deviation
Heppner and Petersen (1982) and translated into Korean by
(SD), frequencies, and percentages were used to describe
Jun (1994), was used to assess students’ self-reported
sociodemographics with SPSS Version 19.0 programs. A t-test
problem-solving styles. The PSI contains 35 items (including
was used to compare differences in means of communication
three filler items) scored on a six-point Likert-type scale
skills, problem-solving ability, and learning motivation scores.
ranging from 1 (strongly agree) to 6 (strongly disagree). The
All analyses were two-tailed, and the significance level was
PSI contains three subscales: problem-solving confidence (11
set at 0.05.
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 indicat-
ing poorer self-reported problem-solving skills.A Cronbach’s RESULTS
alpha of 0.82 was obtained during use of the scale on gradu-
ate nurses (Yoo & Park, 2014), whereas a Cronbach’s alpha General characteristics and homogeneity test
of 0.92 was obtained in the present study. The demographic characteristics of the intervention and
control groups are shown in Table 1 and are briefly summa-
rized here. The majority of participants were female (93.0%).
Learning motivation
Most (62.9%) had obtained an average grade of 3.0–3.9 in the
The Instructional Materials Motivation Scale (IMMS) previous semester. Moreover, 68.5% of the participants
developed by Keller (1987) and translated into Korean by regarded their personality as neutral during interpersonal
Jang (1996), was used to evaluate students’ learning moti- relations. The pretest scores denoted test homogeneity for
vation in four domains: attention, relevance, confidence, and the two groups (Table 2). No significant differences were
satisfaction. The IMMS comprises 35 items scored on a five- detected between the intervention and control groups in the
point Likert-type scale ranging from 1 (not true) to 5 (very pretest scores obtained for communication skills (t = 1.88,
true). The possible range of scores is 35–175, with higher P = 0.061), problem-solving ability (t = −0.68, P = 0.501), and
scores denoting more self-directed motivation to learn. A learning motivation (t = −1.88, P = 0.061).

Table 1. General characteristics of the participants

Intervention group (n = 72) Control group (n = 71)

Variables Categories N (%) N (%) χ2 P

Gender Male 7 (9.7) 3 (4.2) 1.661 0.198

Female 65 (90.3) 68 (95.8)
Average grade previous semester > 4.0 7 (9.7) 9 (12.7) 4.132 0.248
3.0–3.9 50 (69.4) 40 (56.3)
2.0–2.9 14 (19.4) 22 (31.0)
< 1.9 1 (1.4) –
Interpersonal personality Active 21 (29.2) 24 (33.8) 0.356 0.551
Neutral 51 (70.8) 47 (66.2)
Negative – –

Table 2. Homogeneity comparison of communication skills, problem-solving ability, and learning motivation

Intervention group (n = 72) Control group (n = 71)

Variables Mean (SD) Mean (SD) t (P)

Communication skills 40.69 (6.56) 42.70 (6.16) 1.88 (0.061)

Problem-solving ability 112.32 (5.27) 111.75 (4.87) −0.68 (0.501)
Learning motivation 102.63 (8.75) 99.53 (10.85) −1.88 (0.061)

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170 M-S. Yoo and H-R. Park

Table 3. Differences in learning motivation, problem-solving ability, and communication skills

Intervention group (n = 72) Control group (n = 71)

Variables Mean (SD) Mean (SD) t (P)

Communication skills Pretest 40.69 (6.56) 42.70 (6.16)

Post-test 58.42 (6.75) 46.64 (9.79) −8.36 (< 0.001)
Difference 17.73 (8.21) 3.94 (9.59)
t (P) 18.33 (< 0.001) 3.46 (0.001)
Problem-solving ability Pretest 112.32 (5.27) 111.75 (4.87)
Post-test 97.73 (16.08) 123.49 (14.16) 10.16 (< 0.001)
Difference −14.59 (16.41) 11.75 (16.33)
t (P) −7.55 (< 0.001) 6.06 (< 0.001)
Learning motivation Pretest 102.63 (8.75) 99.53 (10.85)
Post-test 110.05 (11.87) 98.29 (12.97) −5.65 (< 0.001)
Difference 7.41 (11.46) −1.23 (12.95)
t (P) 5.49 (< 0.001) −0.80 (0.425)

Effectiveness of the CBL interaction with SPs, may have been effective strategies for
communication skills training, thus contributing to the
After completing the course, the intervention group
current findings (Chan et al., 2008; Berkhof et al., 2011).
improved more than the control group with regard to com-
Moreover, five communication cases were developed on the
munication skills, problem-solving ability, and learning moti-
basis of real clinical settings. These improved students’ inter-
vation (Table 3). A significant increase in the communication
action patterns and enabled them to respond sensitively in
skills score of the intervention group was observed (t = 18.33,
communication situations involving patients. A previous
P < 0.001), while a slight increase was observed for the
study evaluating the impact of communication intervention
control group (t = 3.46, P < 0.001). There was a significant
on healthcare professionals concluded that Case-based learn-
difference in the communication skills of the two groups
ing cases reflecting reality are essential for improving com-
(t = −8.36, P < 0.001). A significant decrease in the problem-
munication (Nørgaard et al., 2012).
solving ability score of the intervention group was observed
Problem-solving ability showed significant improvement in
(t = −7.55, P < 0.001), whereas an increase was observed in
the CBL group, and deteriorated in the group that received
the control group (t = 6.06, P < 0.001). A significant improve-
traditional lectures. This is consistent with two previous
ment was observed for the problem-solving ability of the
studies on the effectiveness of CBL on graduate nurses who
intervention group, as compared to the control group
had taken a preclinical course aimed at bridging basic scien-
(t = 10.16, P < 0.001). Finally, scores for learning motivation
tific and clinical literacy (Schoeman et al., 2009) and a prac-
showed a significant increase of + 7.41 (t = 5.49, P < 0.001)
tical course comprising immersion in a clinical setting (Yoo &
for the intervention group, whereas a decrease of −1.23
Park, 2014). Case-based learning exposes students to appro-
(t = −0.80, P > 0.05) was observed for the control group.
priate responses in the first and second phases of the learning
Moreover, a significant difference was found in the learning
and teaching approach, thus enabling them to successfully
motivation scores of the two groups (t = −5.65, P < 0.001).
recognize, analyze, and solve communication problems
(Jonassen & Hernandez-Serrano, 2002; Allchin, 2013). This is
especially true for CBL exposing students to multifaceted
DISCUSSION
problems that reflect a real clinical situation, as these present
The present study evaluated the effects of CBL on nursing opportunities for students to discuss and integrate clinical
students’ communication skills, problem-solving ability, and knowledge in order to recognize problems and solve them
learning motivation. The results of this study showed that accordingly (Bosse et al., 2012). Exposure to communication
CBL effectively facilitated the development of communica- conflict in this study could have enhanced cognitive abilities
tion skills and increased problem-solving ability and learning that are necessary for problem-solving. Miscommunication is
motivation. an extremely complex phenomenon that could occur at any
Improvement in the communication skills of the group that stage in the communication process (Morgan, 2013).
was exposed to CBL in this study is compatible with findings In-depth analysis of cases involving miscommunication
of previous studies. The significant increase in the communi- enhances problem-solving ability due to the transition from
cation skills of nursing students in this study, following the individually formulated solutions to systematic problem-
CBL intervention, is similar to previous studies on CBL solving that occurs during group discussions.
intervention conducted on medical (Chan et al., 2008) and In this study, a significant increase was observed in the
pharmacological students (Tayem, 2013). Active and student- learning motivation score of the group that received CBL.
centered practice, involving the sharing of opinions in the Although there are only a few studies with which
form of group discussions, as well as verbal and nonverbal the current findings on the effect of CBL on learning

© 2014 Wiley Publishing Asia Pty Ltd.

Case-based learning on nursing education 171

motivation can be compared, this finding is similar to a CBL CONTRIBUTIONS

study in which video footage was shown to have a positive
Study Design: MSY.
effect on learning motivation (Yoo et al., 2010). Self-
Data Collection and Analysis: MSY, HRP.
directed, individual problem-solving prior to group discus-
Manuscript Writing and Revision: MSY, HRP.
sion stimulates individuals’ interest, curiosity, and intrinsic
attention, thus encouraging active participation and improv-
ing self-efficacy (Keller, 1987; Jonassen & Hernandez-
Serrano, 2002; Williams, 2005; Yoo et al., 2010) and,
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