Enhancing Therapeutic Communication Among Nursing Students: A Simulation-Based Approach

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B, Bhaskar. T, Ritarani Nayak, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6553723/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Effective therapeutic communication is essential for fostering patient trust and enhancing healthcare outcomes. Simulation-based learning has been shown to improve communication skills among nursing students. This study aimed to evaluate the effect of simulation-based training on therapeutic communication skills in nursing students. Methods This quasi-experimental study was conducted with 120 B.Sc. Nursing students, divided into experimental (n = 60) and control (n = 60) groups. The experimental group received four simulation sessions, each lasting two hours, focusing on communication techniques such as active listening, empathy, and conflict resolution. The control group received traditional didactic lectures. Data were collected using a structured knowledge questionnaire and a structured observational checklist to assess knowledge and practice levels before and after the intervention. Statistical analysis included the Wilcoxon signed-rank test, Mann-Whitney U test, and Spearman’s correlation analysis, with p-values less than 0.05 considered statistically significant. Results The experimental group showed significant improvements in both knowledge and practice scores, with median knowledge scores rising from 7 (IQR: 6.25–9) to 12 (IQR: 11–13) (Z = -6.516, p < 0.0001) and practice scores increasing from 29 (IQR: 28–30) to 62 (IQR: 44–64) (Z = -6.608, p < 0.0001). The control group showed no significant changes. A positive but non-significant correlation between knowledge and practice was observed (rs = 0.162, p = 0.543). Conclusions Simulation-based learning significantly enhanced therapeutic communication knowledge and practice among nursing students. It is recommended that simulation be integrated into nursing curricula to improve communication skills and clinical competence. Therapeutic communication Simulation-based education Nursing students Knowledge Practice India Introduction Effective therapeutic communication is the cornerstone of nursing practice, enabling healthcare professionals to build trust, demonstrate empathy, and ensure patient-centered care. [ 1 ] In nursing education, teaching students how to apply therapeutic communication techniques is vital for preparing them to engage with patients compassionately and professionally. [ 2 ] However, traditional methods of instruction often fall short in providing students with experiential learning opportunities that mimic real-life scenarios. [ 3 ] Simulation-based learning has emerged as an innovative pedagogical tool to bridge this gap by immersing students in lifelike situations that foster critical thinking, emotional intelligence, and communication skills. [ 4 ] The integration of simulation methods in nursing curricula has gained popularity globally, especially in competency-based education frameworks. [ 5 ] Simulation offers a safe environment for learners to practice and refine their communication techniques without jeopardizing patient safety. [ 6 ] Despite its recognized benefits, limited research has examined the specific impact of simulation-based training on therapeutic communication techniques among nursing students in the Indian context. [ 7 ] This study aims to fill that void by evaluating how simulation influences communication competence among nursing students at selected institutions. Therapeutic communication encompasses purposeful interactions that promote the physical and emotional well-being of patients. It includes skills such as active listening, empathy, open-ended questioning, and nonverbal communication, which are crucial for fostering patient trust and adherence to care plans. [ 8 ] Inadequate communication can lead to patient dissatisfaction, medical errors, and poor health outcomes. Hence, nursing education must prioritize training that enhances these skills. [ 9 ] Simulation-based learning involves the use of manikins, standardized patients, or virtual environments to recreate clinical situations for instructional purposes. It encourages students to engage in reflective practice and receive feedback in a structured setting. Research has shown that simulation significantly improves learners’ confidence and performance in real clinical settings. [ 10 ] In particular, communication-focused simulation exercises enable nursing students to practice interpersonal skills, such as addressing patient concerns, managing emotional responses, and collaborating with healthcare teams. [ 11 ] A growing body of literature supports simulation as a method to teach therapeutic communication. For example, a study by Kim & Park (2021) demonstrated that high-fidelity simulation improved nursing students’ communication scores by over 20% compared to traditional lecture-based learning [ 12 ] . Another study by Salem and Ebrahem (2022) found that students trained using simulation were better able to manage sensitive conversations, such as delivering bad news or handling agitated patients. [ 13 ] Despite the growing body of global evidence supporting simulation-based learning in nursing education, a notable research gap exists in evaluating its specific impact on therapeutic communication skills, particularly within the Indian context. Most existing studies have been conducted in high-income countries, where educational resources, simulation infrastructure, and clinical exposure differ significantly from those in Indian nursing institutions. Furthermore, limited research has been undertaken to assess the relationship between knowledge and practice regarding therapeutic communication, especially using standardized tools before and after simulation interventions. The aim of this study is to assess the effect of simulation-based learning techniques on the knowledge and practice of therapeutic communication among nursing students and to examine the relationship between their knowledge and practical application of these techniques. By addressing the identified gaps, this study seeks to provide meaningful insights into how structured simulation interventions can enhance communication competency, promote patient-centered care, and inform future teaching methodologies within Indian nursing institutions. Methods Study design This study adopted a quantitative approach using a quasi-experimental, pre-test post-test control group design to evaluate the effect of simulation-based learning on therapeutic communication among undergraduate nursing students. The design enabled comparison of outcomes between two groups an experimental group receiving the intervention and a control group receiving conventional teaching allowing for the assessment of effectiveness in improving knowledge and practice. Sampling The study was conducted in selected nursing institutions in Bhubaneswar, Odisha, India. A purposive sampling technique was employed to recruit a total of 120 B.Sc. Nursing students. Inclusion criteria included students who were currently posted in clinical areas, proficient in English, and willing to provide informed consent. Participants were allocated into two equal groups: 60 in the experimental group and 60 in the control group. The sampling method ensured that the participants had similar academic backgrounds and clinical exposure. The sample size was estimated using G*Power software with an effect size of 0.5, alpha error probability of 0.05, and power of 0.80, which yielded a minimum requirement of 102 participants; this was rounded up to 120 to account for potential attrition and to strengthen statistical validity. Data collection Data were collected using three validated tools: a socio-demographic questionnaire, a structured knowledge questionnaire, and a structured observational checklist for practice assessment. The structured knowledge questionnaire comprised 20 multiple-choice questions categorized as poor knowledge (scores 0–7) and good knowledge (scores 8–20), with a Cronbach’s alpha of 0.82 indicating good internal consistency. The structured observational checklist included 20 items evaluating practice behaviors, categorized as poor (scores 1–27) and good practice (scores 28–72), with a Cronbach’s alpha of 0.85. Data collection was carried out over four weeks, with pre-test and post-test assessments administered before and after the intervention. Tools for data collection : Three tools were used for data collection, each validated for content and reliability: Socio-demographic questionnaire : (CVI = 0.92): Comprised of 6 items to capture participants’ background information, including age, gender, year of study, comfort with group study, prior attendance at simulation workshops/conferences, and daily self-study hours. This tool ensures a comprehensive baseline profile for group comparability. (Supplementary File 1: Part A: Socio-Demographic Questionnaire) Structured Knowledge Questionnaire : (20 items; CVI = 0.90; Cronbach’s alpha = 0.82): Assessed theoretical understanding of therapeutic communication across four domains—active listening (5 items), empathy (5 items), open-ended questioning (5 items), and nonverbal communication (5 items). Scores ranged from 0–20, with 0–7 indicating poor knowledge and 8–20 indicating good knowledge.(Supplementary File 1: Part B: Structured Knowledge Questionnaire) Structured Observational Checklist : (20 items; CVI = 0.93; Cronbach’s alpha = 0.85): Evaluated observable communication practices during simulation, covering preparatory behaviors (e.g., setting eye contact), response techniques (e.g., paraphrasing, therapeutic silence), and closing skills (e.g., summarizing, providing reassurance). Scores ranged from 1–72, with 1–27 categorized as poor practice and 28–72 as good practice. (Supplementary File 1: Part C: Structured Observational Checklist) Intervention The intervention was delivered as a structured simulation-based learning program titled “Enhancing Therapeutic Communication Skills through Simulation-Based Learning.” It was implemented over two weeks and included four simulation sessions, each lasting two hours, designed for B.Sc. Nursing students during their clinical posting. The intervention aimed to progressively build students’ competence in therapeutic communication using high-fidelity simulation techniques, guided by trained clinical instructors. Session-1: focused on foundational knowledge, introducing therapeutic communication concepts, types, principles, and common barriers through interactive lectures, video-based demonstrations, and group discussions. Session-2: involved a simulated nurse-patient introduction, emphasizing open-ended questioning and nonverbal communication. Session-3: addressed empathetic communication, using scenarios that required responding to emotional distress through therapeutic silence and touch. Session-4: centered on handling difficult conversations such as breaking bad news and managing conflict or anxiety. Each session included 15 minutes of structured pre-briefing and 30 minutes of reflective debriefing using the “What? So what? Now what?” model. Teaching methods included live simulation, role-play, peer observation, and feedback. Evaluation tools comprised faculty observation checklists, peer feedback rubrics, and student self-assessment forms. The control group, in contrast, received traditional lecture-based instruction on communication without any simulation exposure. The control group comprised 60 B.Sc. Nursing students who received routine instructional methods without exposure to simulation. Their learning included traditional didactic lectures, PowerPoint presentations, and classroom discussions on therapeutic communication concepts such as active listening, empathy, and verbal/nonverbal techniques. These sessions followed the standard curriculum without the use of simulated scenarios or experiential learning components. No structured pre-briefing, debriefing, or hands-on role-play was incorporated. Students in the control group completed the same pre-test and post-test assessments as the experimental group to enable comparative analysis of knowledge and practice levels. This approach allowed the researchers to isolate the effect of simulation-based learning on communication outcomes. Statistical analysis The study data were analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY). Descriptive statistics such as frequency, percentage, median, and interquartile range (IQR) were used to summarize the demographic variables and outcome measures of the participants. To determine the distribution of data, the Kolmogorov–Smirnov test was applied. The results indicated that the data were not normally distributed (p < 0.05); hence, non-parametric statistical tests were used for further analysis. The Chi-square (χ²) test was employed to examine associations between categorical demographic variables and practice levels. The Wilcoxon signed-rank test was used to compare pre- and post-test knowledge and practice scores within the experimental and control groups. Between-group comparisons of post-test scores were conducted using the Mann–Whitney U test. Additionally, Spearman’s rank correlation coefficient was applied to explore the relationship between knowledge and practice scores at both time points. A two-tailed p-value of less than 0.05 was considered statistically significant throughout the analysis. Results Table 1 Baseline demographic characteristics of experimental and control groups (n = 120) (n1 + n2 = 60 + 60) Variables Experimental Group f(%) Control Group f(%) χ² Value p-Value Age in years 1.25 0.263 18–20 years 22 (36.7) 28 (46.7) 21–23 years 38 (63.3) 32 (53.3) Gender 0.24 0.625 Male 14 (23.3) 12 (20) Female 46 (76.7) 48 (80) Comfortable in group study 5.58 0.061 Yes 46 (76.7) 42 (70) No 14 (23.3) 13 (21.7) Sometimes 0 (0) 5 (8.3) Simulation workshop attended 0.00 1.000 yes 0 (0%) 0(0%) No 60 (100) 60 (100) Self-study hours per day 2.66 0.264 2–4 hours 13 (21.7) 15 (25) Table 1 presents the demographic characteristics of the experimental and control groups (n = 120). The majority of students in both groups were aged 21–23 years (63.3% experimental, 53.3% control), and females predominated (76.7% experimental, 80% control). No significant differences were observed between groups for age (χ² = 1.25, p = 0.263) or gender (χ² = 0.24, p = 0.625). Most participants reported being comfortable with group study (76.7% experimental, 70% control), though a few students in the control group (8.3%) reported being only sometimes comfortable; this difference approached but did not reach statistical significance (χ² = 5.58, p = 0.061). All participants in both groups had not attended any simulation workshop previously (p = 1.000). Regarding self-study hours, the majority studied 1–2 hours daily (66.7% experimental, 53.3% control) with no significant difference between groups (χ² = 2.66, p = 0.264). Overall, the two groups were demographically comparable at baseline, ensuring validity for subsequent outcome comparisons. Table 2 Frequency and percentage distribution of pre-test and post-test knowledge and practice levels among experimental and control groups(n = 120) (n1 + n2 = 60 + 60) Variables Pre-test Post-test Experimental Control Experimental Control Knowledge f(%) f(%) f(%) f(%) Poor Knowledge 34(56.7) 23(56.7) 3(5) 21(35) Good Knowledge 26(43.3) 37(61.7) 57(95.0) 39(65.0) Practice Poor Practice 29(48.3) 13(21.7) 4(6.7) 13(21.7) Good Practice 35(51.6) 47(78.3) 56(93.3) 47(78.3) Table 2 presents the frequency and percentage distribution of pre-test and post-test knowledge and practice levels among nursing students in the experimental and control groups (n = 120). Before the intervention, a higher proportion of students in the experimental group had poor knowledge (56.7%) compared to the control group (38.3%). Post-test results showed a substantial improvement, with 95% of students in the experimental group demonstrating good knowledge compared to 65% in the control group. Similarly, in terms of practice, pre-test findings indicated that 51.6% of the experimental group and 78.3% of the control group exhibited good practice. After the intervention, the proportion of students demonstrating good practice increased to 93.3% in the experimental group, while it remained unchanged at 78.3% in the control group. Notably, the percentage of students with poor practice in the experimental group dropped from 48.3–6.7% following the intervention. These findings suggest that simulation-based training was highly effective in enhancing both knowledge and practice regarding therapeutic communication among nursing students. Table 3 Comparison of pre-test and post-test knowledge and practice scores within experimental and control groups using Wilcoxon signed-rank test (n = 120) (n1 + n2 = 60 + 60) Variables Group Pre-test Post-test Z-value p-value Median(IQR) Median(IQR) Knowledge Experimental group 7(6.25,9) 12(11,13) -6.516 < 0.0001* Control group 9(7,10.75) 9(7,10.75) -1.414 0.157 Practice Experimental group 29(28,30) 62(44,64) -6.608 < 0.0001* Control group 30(28,31) 30(28,31) -1.342 0.180 Table 3 compares the pre-test and post-test knowledge and practice scores within the experimental and control groups using the Wilcoxon signed-rank test (n = 120). In the experimental group, a significant improvement in knowledge scores was observed following the simulation intervention (pre-test median [IQR]: 7 [6.25–9], post-test median [IQR]: 12 [11–13]; Z = -6.516, p < 0.0001). Similarly, practice scores in the experimental group showed a substantial increase from a pre-test median (IQR) of 29 (28–30) to a post-test median (IQR) of 62 (44–64), which was also statistically significant (Z = -6.608, p 0.05). These results clearly indicate that the simulation-based intervention led to significant improvements in both knowledge and practice related to therapeutic communication among nursing students in the experimental group, whereas no meaningful change occurred in the control group. Table 4 Comparison of pre-test and post-test knowledge and practice scores between experimental and control groups using Mann-Whitney U test (n = 120) (n1 + n2 = 60 + 60) Variables Tests Experimental Control Z-value p-value Median(IQR) Median(IQR) Knowledge Pre-test 7(6.25,9) 9(7,10.75) -2.230 0.126 Post-test 12(11,13) 9(7,10.75) -6.850 < 0.0001* Practice Pre-test 29(28,30) 30(28,31) -1.284 0.199 Post-test 62(44,64) 30(28,31) -8.302 < 0.0001* Table 4 presents the comparison of pre-test and post-test knowledge and practice scores between the experimental and control groups using the Mann-Whitney U test (n = 120). In terms of knowledge, the experimental group showed a significant improvement in post-test scores (median [IQR]: 12 [11–13]) compared to the control group (median [IQR]: 9 [7–10.75]) with a Z-value of -6.850 and a p-value of < 0.0001. However, no significant difference was observed in pre-test knowledge scores between the two groups (p = 0.126). Similarly, the post-test practice scores of the experimental group (median [IQR]: 62 [44–64]) were significantly higher than the control group (median [IQR]: 30 [28–31]) with a Z-value of -8.302 and a p-value of < 0.0001, indicating a substantial effect of the intervention on practice scores. No significant difference was found in pre-test practice scores between the two groups (p = 0.199). These findings demonstrate that the simulation-based intervention significantly enhanced both knowledge and practice of therapeutic communication in the experimental group, while the control group showed no such improvement. Table 5 Spearman’s rank correlation between knowledge and practice scores in the experimental group (n1 = 60). Variables Pre-test Post-test r s value p-value r s value p-value Knowledge 0.120 0.360 0.162 0.543 Practice Table 5 presents the Spearman’s rank correlation between knowledge and practice scores within the experimental group (n = 60). Pre-test correlation was positive but not statistically significant (rs = 0.120, p = 0.360), indicating a minor association between baseline knowledge and practice. Post-test correlation remained positive yet non-significant (rs = 0.162, p = 0.543), suggesting that while improvements in knowledge tended to be associated with better practice, the relationship did not reach statistical significance. These findings imply that although simulation-based learning effectively enhanced both knowledge and practice independently, the degree to which knowledge gains translated into practice improvements may require longer training duration or additional reinforcement sessions. Discussion The present study found no statistically significant association between students’ practice levels and socio-demographic variables such as age and gender (p > 0.05). This finding is consistent with Thakur et al. [ 15 ] , who also reported that factors such as age and gender did not significantly influence nursing students’ simulation-based communication competence. This suggests that therapeutic communication skills, when taught through simulation, are not dependent on personal characteristics and are applicable across varied student populations. The generalizability of simulation as a pedagogical approach strengthens its value for inclusion in diverse academic settings, reinforcing its potential as a universally adaptable method for communication training in nursing education. A significant improvement in knowledge was observed in the experimental group, with median scores increasing from 7 (IQR: 6.25–9) to 12 (IQR: 11–13) post-intervention, representing a 71% rise in central tendency (Z = -6.516, p < 0.0001). This finding aligns with previous research; Shivani et al. reported an 8.33-point increase after targeted instruction (t = 11.844, p < 0.05) [14], while Thakur et al. found a 12.19-point improvement post-simulation (t = 35.85, p < 0.05) [ 15 ] . Similarly, Haukedal et al. demonstrated knowledge enhancement using high-fidelity simulation in undergraduate nursing cohorts (p < 0.001) [ 16 ] . These results, consistent across studies, underscore the effectiveness of experiential learning, as theorized by Kolb, in transforming theoretical input into applied clinical competence. A substantial improvement in therapeutic communication practice scores was observed in the experimental group, with the median rising from 29 (IQR: 28–30) at pre-test to 62 (IQR: 44–64) at post-test, representing more than a two-fold increase in median performance (Z = -6.608, p < 0.0001). These findings are in line with Mohamed and Fashafsheh, who also reported significant post-simulation improvements in practice scores (t = 32.64, p = 0.001) [ 17 ] , and Thakur et al., who observed a 4.97-point increase following structured simulation exercises (t = 33.13, p < 0.05) [ 15 ] . The observed gains in this study likely reflect the effectiveness of repeated practice and structured feedback loops embedded within high-fidelity simulation sessions. Such methods foster the development of procedural fluency, reflective insight, and confidence key components of behavioral change as explained by Bandura’s self-efficacy theory [ 21 , 22 ] . Additionally, Karabacak et al.’s findings on the strong correlation between instructor assessments and students’ self-evaluations (r = 0.658, p = 0.001) emphasize the role of guided reflection and multi-source feedback in reinforcing and sustaining improved performance in communication practice [ 18 ] . Although both knowledge and practice improved significantly, their relationship remained positive but non-significant in both pre-test (rs = 0.120, p = 0.360) and post-test (rs = 0.162, p = 0.543) analyses. This indicates that gains in theoretical knowledge did not directly translate into equivalent behavioral changes in communication practice. Similar observations were reported by Ko et al., who noted variable confidence improvements across different simulation modalities (F = 4.30, p = 0.040), suggesting that single-session interventions may be insufficient to integrate cognitive and practical competencies fully [ 19 ] . To strengthen this linkage, future programs should incorporate ongoing mentorship, iterative simulation exercises, and blended learning approaches that reinforce knowledge application through repeated practice and reflective feedback. A closer examination of recent simulation studies further clarifies how immersive learning environments enhance nursing communication skills and why our findings are so robust. In a large-scale multicenter randomized trial, Tong et al. enrolled 500 undergraduate nursing students and found that those who participated in high-fidelity simulation achieved a mean communication competence score 1.2 points higher than peers receiving case-based learning (p = 0.020) [ 14 ] . This suggests that the multisensory cues and real-world context of high-fidelity mannequins more effectively engage learners, leading to measurable skill gains. Rouleau et al. extended this evidence to practicing nurses, showing that a series of virtual patient encounters produced a 15% improvement in relational communication skills (p < 0.01) [ 15 ] . Their work highlights that even in online or remote formats, simulation can sharpen nurses’ ability to build rapport and respond empathetically. Dante et al. reported that first-year students who completed immersive simulation exercises experienced a 20% rise in self-confidence and perceived clinical competence (p < 0.001) [ 16 ] , reinforcing the link between safe, controlled practice and learners’ willingness to apply new skills in real clinical settings. Finally, Patel et al. demonstrated that after standardized patient scenarios, where actors role-play difficult conversations, 85% of participants showed significant improvement in ethical communication proficiency (p < 0.05) [ 17 ] . This finding underscores simulation’s unique capacity to address not only technical dialogue but also nuanced aspects of empathy, cultural sensitivity, and ethics. Taken together, these studies illustrate that whether through high-fidelity mannequins, virtual reality platforms, or standardized patient encounters, simulation-based education reliably produces statistically significant gains in both the technical and affective dimensions of nursing communication. These converging lines of evidence strongly support the routine incorporation of diverse simulation modalities into nursing curricula to cultivate well-rounded, confident, and ethically grounded communicators. Strengths and limitations Strengths of this study include its robust quasi-experimental design, which allowed for comparison of pre- and post-intervention outcomes in a real-world educational setting, enhancing the study’s external validity. The use of high-reliability instruments (Cronbach’s α > 0.80) ensures consistency and validity in measurement. The study also utilized a structured, theory-driven simulation curriculum that was grounded in experiential learning principles. Limitations of the study include purposive sampling from a single geographic region (Bhubaneswar, Odisha), which may limit the generalizability of the findings to other populations with different cultural and educational backgrounds. Additionally, the relatively short follow-up period (four weeks) restricts the ability to assess the long-term retention of communication skills and their transfer to clinical practice. Future research should employ randomized sampling to reduce selection bias, compare different simulation modalities (e.g., virtual simulations vs. high-fidelity mannequins), and incorporate extended follow-up periods (6 months to 1 year) to evaluate sustained competency and its impact on patient outcomes. Further exploration of cross-cultural differences and multi-center trials would help broaden the generalizability of these findings. Conclusion Simulation-based education significantly improves therapeutic communication knowledge and practice among nursing students. Its integration into nursing education is crucial for preparing students for real-world clinical challenges. In conclusion, this study demonstrates that simulation-based learning substantially enhances therapeutic communication knowledge and practice among nursing students, independent of demographic factors. Educators should adopt multifaceted simulation strategies, combining debriefing, virtual patients, and high-fidelity mannequins, to foster comprehensive communication competencies essential for patient-centered care. Declarations Ethics approval and consent to participate The study was approved by the Institutional Ethics Committee of IMS and SUM Hospital, Siksha 'O' Anusandhan (Deemed to be University), Bhubaneswar, Odisha (Approval No.: Ref.no/IEC/IMS.SH/SOA/2023/542). Written informed consent was obtained from all participants. Confidentiality and voluntary participation were assured throughout the study. The research was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Clinical trial number: The Clinical trial number in not applicable for this study. Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions: SM conceived the study, developed the research tools, collected and analyzed the data, and drafted the manuscript. MS contributed to tool validation, assisted in statistical analysis, and participated in manuscript editing. GB provided overall conceptual guidance and critically revised the manuscript for intellectual content. BT supervised the research design, supported data interpretation, and reviewed the final version. RN was involved in simulation implementation, data collection, and literature review. PM reviewed the research methodology, supported the ethical clearance process, and assisted with referencing. All authors read and approved the final manuscript. Acknowledgments: The authors would like to express their sincere gratitude to all the nursing students who participated in this study and to the faculty members of the participating institutions for their valuable support and cooperation throughout the research process. References Mersha A, Abera A, Tesfaye T, Abera T, Belay A, Melaku T, Shiferaw M, Shibiru S, Estifanos W, Wake SK. Therapeutic communication and its associated factors among nurses working in public hospitals of Gamo zone, southern Ethiopia: application of Hildegard Peplau's nursing theory of interpersonal relations. 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Supplementary Files SupplementaryFile1StructuredKnowledgeQuestionnaireandObservationalChecklist.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 18 Jun, 2025 Reviews received at journal 13 Jun, 2025 Reviews received at journal 11 Jun, 2025 Reviewers agreed at journal 31 May, 2025 Reviewers agreed at journal 29 May, 2025 Reviewers invited by journal 29 May, 2025 Editor assigned by journal 29 May, 2025 Editor invited by journal 29 May, 2025 Submission checks completed at journal 28 May, 2025 First submitted to journal 28 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6553723","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":464713627,"identity":"9ad196cd-3dd3-44c4-bc53-7603613a0f4c","order_by":0,"name":"Shreya Mandal","email":"","orcid":"","institution":"Siksha O Anusandhan University","correspondingAuthor":false,"prefix":"","firstName":"Shreya","middleName":"","lastName":"Mandal","suffix":""},{"id":464713628,"identity":"3f536a63-07f9-429f-bcd6-e123291c8d01","order_by":1,"name":"Mamata Swain","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIie3OsQqCUBTG8SOC063WC4E9QVAE0tSzJEHbhdqMQp10q9WtVzCE5hsHauiGq9DSCwRFELZEQjQVWlvD/U9nOD/4AGSyv04F5fC6eeE3fxK18SMB0OhXc+r+1rycJrY580vrUWp1oOJzBQc5xBAsonyNZoDl/p6IHlDRBQzyCGch5RpnLhJjr3gqQAKAJI/Exyjld5vNMzK8eQ7UCknClnTlqSzMCJQ8hEYxOS7buyk6CyStKhEb0hSmWzCMRYl1tVt6LJrn1Brr+gbxkkfeyp4V9xcgk8lksg89AGGhUqwJ5p4KAAAAAElFTkSuQmCC","orcid":"","institution":"Siksha O Anusandhan University","correspondingAuthor":true,"prefix":"","firstName":"Mamata","middleName":"","lastName":"Swain","suffix":""},{"id":464713629,"identity":"0db07b6a-b972-4b5c-88e9-43fc9d028632","order_by":2,"name":"Gomathi. B","email":"","orcid":"","institution":"Siksha O Anusandhan University","correspondingAuthor":false,"prefix":"","firstName":"Gomathi.","middleName":"","lastName":"B","suffix":""},{"id":464713633,"identity":"f4dac33a-71aa-40d6-92a3-3068dddb6bfa","order_by":3,"name":"Bhaskar. T","email":"","orcid":"","institution":"Siksha O Anusandhan University","correspondingAuthor":false,"prefix":"","firstName":"Bhaskar.","middleName":"","lastName":"T","suffix":""},{"id":464713634,"identity":"6d594a2a-2cc9-4382-8292-3849c508030a","order_by":4,"name":"Ritarani Nayak","email":"","orcid":"","institution":"Siksha O Anusandhan University","correspondingAuthor":false,"prefix":"","firstName":"Ritarani","middleName":"","lastName":"Nayak","suffix":""},{"id":464713636,"identity":"8c11b434-64a3-4d43-bfce-ebd6a7d9b1d2","order_by":5,"name":"Puspanjali Mohapatra","email":"","orcid":"","institution":"Siksha O Anusandhan University","correspondingAuthor":false,"prefix":"","firstName":"Puspanjali","middleName":"","lastName":"Mohapatra","suffix":""}],"badges":[],"createdAt":"2025-04-29 07:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6553723/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6553723/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83788347,"identity":"b2158db4-511f-40d1-bb9f-a031368aa99c","added_by":"auto","created_at":"2025-06-02 18:03:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":789343,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6553723/v1/a64ca5af-836f-4aa8-9009-7e1b5065ff6a.pdf"},{"id":83788206,"identity":"33e2a737-f353-4d43-867a-15539617e2ea","added_by":"auto","created_at":"2025-06-02 17:55:09","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":51194,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1StructuredKnowledgeQuestionnaireandObservationalChecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-6553723/v1/7432731cb2891ff14f66eee1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enhancing Therapeutic Communication Among Nursing Students: A Simulation-Based Approach","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEffective therapeutic communication is the cornerstone of nursing practice, enabling healthcare professionals to build trust, demonstrate empathy, and ensure patient-centered care.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e In nursing education, teaching students how to apply therapeutic communication techniques is vital for preparing them to engage with patients compassionately and professionally.\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e However, traditional methods of instruction often fall short in providing students with experiential learning opportunities that mimic real-life scenarios.\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e Simulation-based learning has emerged as an innovative pedagogical tool to bridge this gap by immersing students in lifelike situations that foster critical thinking, emotional intelligence, and communication skills.\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003eThe integration of simulation methods in nursing curricula has gained popularity globally, especially in competency-based education frameworks.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e Simulation offers a safe environment for learners to practice and refine their communication techniques without jeopardizing patient safety.\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e Despite its recognized benefits, limited research has examined the specific impact of simulation-based training on therapeutic communication techniques among nursing students in the Indian context.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e This study aims to fill that void by evaluating how simulation influences communication competence among nursing students at selected institutions. Therapeutic communication encompasses purposeful interactions that promote the physical and emotional well-being of patients. It includes skills such as active listening, empathy, open-ended questioning, and nonverbal communication, which are crucial for fostering patient trust and adherence to care plans.\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e Inadequate communication can lead to patient dissatisfaction, medical errors, and poor health outcomes. Hence, nursing education must prioritize training that enhances these skills.\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSimulation-based learning involves the use of manikins, standardized patients, or virtual environments to recreate clinical situations for instructional purposes. It encourages students to engage in reflective practice and receive feedback in a structured setting. Research has shown that simulation significantly improves learners\u0026rsquo; confidence and performance in real clinical settings.\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e In particular, communication-focused simulation exercises enable nursing students to practice interpersonal skills, such as addressing patient concerns, managing emotional responses, and collaborating with healthcare teams.\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA growing body of literature supports simulation as a method to teach therapeutic communication. For example, a study by Kim \u0026amp; Park (2021) demonstrated that high-fidelity simulation improved nursing students\u0026rsquo; communication scores by over 20% compared to traditional lecture-based learning\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Another study by Salem and Ebrahem (2022) found that students trained using simulation were better able to manage sensitive conversations, such as delivering bad news or handling agitated patients.\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite the growing body of global evidence supporting simulation-based learning in nursing education, a notable research gap exists in evaluating its specific impact on therapeutic communication skills, particularly within the Indian context. Most existing studies have been conducted in high-income countries, where educational resources, simulation infrastructure, and clinical exposure differ significantly from those in Indian nursing institutions. Furthermore, limited research has been undertaken to assess the relationship between knowledge and practice regarding therapeutic communication, especially using standardized tools before and after simulation interventions.\u003c/p\u003e \u003cp\u003eThe aim of this study is to assess the effect of simulation-based learning techniques on the knowledge and practice of therapeutic communication among nursing students and to examine the relationship between their knowledge and practical application of these techniques. By addressing the identified gaps, this study seeks to provide meaningful insights into how structured simulation interventions can enhance communication competency, promote patient-centered care, and inform future teaching methodologies within Indian nursing institutions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study adopted a quantitative approach using a quasi-experimental, pre-test post-test control group design to evaluate the effect of simulation-based learning on therapeutic communication among undergraduate nursing students. The design enabled comparison of outcomes between two groups an experimental group receiving the intervention and a control group receiving conventional teaching allowing for the assessment of effectiveness in improving knowledge and practice.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSampling\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in selected nursing institutions in Bhubaneswar, Odisha, India. A purposive sampling technique was employed to recruit a total of 120 B.Sc. Nursing students. Inclusion criteria included students who were currently posted in clinical areas, proficient in English, and willing to provide informed consent. Participants were allocated into two equal groups: 60 in the experimental group and 60 in the control group. The sampling method ensured that the participants had similar academic backgrounds and clinical exposure. The sample size was estimated using G*Power software with an effect size of 0.5, alpha error probability of 0.05, and power of 0.80, which yielded a minimum requirement of 102 participants; this was rounded up to 120 to account for potential attrition and to strengthen statistical validity.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were collected using three validated tools: a socio-demographic questionnaire, a structured knowledge questionnaire, and a structured observational checklist for practice assessment. The structured knowledge questionnaire comprised 20 multiple-choice questions categorized as poor knowledge (scores 0\u0026ndash;7) and good knowledge (scores 8\u0026ndash;20), with a Cronbach\u0026rsquo;s alpha of 0.82 indicating good internal consistency. The structured observational checklist included 20 items evaluating practice behaviors, categorized as poor (scores 1\u0026ndash;27) and good practice (scores 28\u0026ndash;72), with a Cronbach\u0026rsquo;s alpha of 0.85. Data collection was carried out over four weeks, with pre-test and post-test assessments administered before and after the intervention.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTools for data collection\u003c/b\u003e: Three tools were used for data collection, each validated for content and reliability:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSocio-demographic questionnaire\u003c/b\u003e: (CVI\u0026thinsp;=\u0026thinsp;0.92): Comprised of 6 items to capture participants\u0026rsquo; background information, including age, gender, year of study, comfort with group study, prior attendance at simulation workshops/conferences, and daily self-study hours. This tool ensures a comprehensive baseline profile for group comparability. (Supplementary File 1: Part A: Socio-Demographic Questionnaire)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eStructured Knowledge Questionnaire\u003c/b\u003e: (20 items; CVI\u0026thinsp;=\u0026thinsp;0.90; Cronbach\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;0.82): Assessed theoretical understanding of therapeutic communication across four domains\u0026mdash;active listening (5 items), empathy (5 items), open-ended questioning (5 items), and nonverbal communication (5 items). Scores ranged from 0\u0026ndash;20, with 0\u0026ndash;7 indicating poor knowledge and 8\u0026ndash;20 indicating good knowledge.(Supplementary File 1: Part B: Structured Knowledge Questionnaire)\u003c/p\u003e \u003cp\u003e \u003cb\u003eStructured Observational Checklist\u003c/b\u003e: (20 items; CVI\u0026thinsp;=\u0026thinsp;0.93; Cronbach\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;0.85): Evaluated observable communication practices during simulation, covering preparatory behaviors (e.g., setting eye contact), response techniques (e.g., paraphrasing, therapeutic silence), and closing skills (e.g., summarizing, providing reassurance). Scores ranged from 1\u0026ndash;72, with 1\u0026ndash;27 categorized as poor practice and 28\u0026ndash;72 as good practice. (Supplementary File 1: Part C: Structured Observational Checklist)\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThe intervention was delivered as a structured simulation-based learning program titled \u003cem\u003e\u0026ldquo;Enhancing Therapeutic Communication Skills through Simulation-Based Learning.\u0026rdquo;\u003c/em\u003e It was implemented over two weeks and included four simulation sessions, each lasting two hours, designed for B.Sc. Nursing students during their clinical posting. The intervention aimed to progressively build students\u0026rsquo; competence in therapeutic communication using high-fidelity simulation techniques, guided by trained clinical instructors.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSession-1: focused on foundational knowledge, introducing therapeutic communication concepts, types, principles, and common barriers through interactive lectures, video-based demonstrations, and group discussions.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSession-2: involved a simulated nurse-patient introduction, emphasizing open-ended questioning and nonverbal communication.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSession-3: addressed empathetic communication, using scenarios that required responding to emotional distress through therapeutic silence and touch.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSession-4: centered on handling difficult conversations such as breaking bad news and managing conflict or anxiety.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eEach session included 15 minutes of structured pre-briefing and 30 minutes of reflective debriefing using the \u0026ldquo;What? So what? Now what?\u0026rdquo; model. Teaching methods included live simulation, role-play, peer observation, and feedback. Evaluation tools comprised faculty observation checklists, peer feedback rubrics, and student self-assessment forms. The control group, in contrast, received traditional lecture-based instruction on communication without any simulation exposure.\u003c/p\u003e \u003cp\u003eThe \u003cb\u003econtrol group\u003c/b\u003e comprised 60 B.Sc. Nursing students who received routine instructional methods without exposure to simulation. Their learning included traditional didactic lectures, PowerPoint presentations, and classroom discussions on therapeutic communication concepts such as active listening, empathy, and verbal/nonverbal techniques. These sessions followed the standard curriculum without the use of simulated scenarios or experiential learning components. No structured pre-briefing, debriefing, or hands-on role-play was incorporated. Students in the control group completed the same pre-test and post-test assessments as the experimental group to enable comparative analysis of knowledge and practice levels. This approach allowed the researchers to isolate the effect of simulation-based learning on communication outcomes.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe study data were analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY). Descriptive statistics such as frequency, percentage, median, and interquartile range (IQR) were used to summarize the demographic variables and outcome measures of the participants. To determine the distribution of data, the Kolmogorov\u0026ndash;Smirnov test was applied. The results indicated that the data were not normally distributed (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05); hence, non-parametric statistical tests were used for further analysis. The Chi-square (χ\u0026sup2;) test was employed to examine associations between categorical demographic variables and practice levels. The Wilcoxon signed-rank test was used to compare pre- and post-test knowledge and practice scores within the experimental and control groups. Between-group comparisons of post-test scores were conducted using the Mann\u0026ndash;Whitney U test. Additionally, Spearman\u0026rsquo;s rank correlation coefficient was applied to explore the relationship between knowledge and practice scores at both time points. A two-tailed p-value of less than 0.05 was considered statistically significant throughout the analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":" \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline demographic characteristics of experimental and control groups (n\u0026thinsp;=\u0026thinsp;120) (n1\u0026thinsp;+\u0026thinsp;n2\u0026thinsp;=\u0026thinsp;60\u0026thinsp;+\u0026thinsp;60)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperimental Group\u003c/p\u003e \u003cp\u003ef(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003eGroup\u003c/p\u003e \u003cp\u003ef(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge in years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.263\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (36.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;23 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (63.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.625\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (23.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (76.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComfortable in group study\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (76.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (23.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSimulation workshop attended\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-study hours per day\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.264\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2\u0026ndash;4 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the demographic characteristics of the experimental and control groups (n\u0026thinsp;=\u0026thinsp;120). The majority of students in both groups were aged 21\u0026ndash;23 years (63.3% experimental, 53.3% control), and females predominated (76.7% experimental, 80% control). No significant differences were observed between groups for age (χ\u0026sup2; = 1.25, p\u0026thinsp;=\u0026thinsp;0.263) or gender (χ\u0026sup2; = 0.24, p\u0026thinsp;=\u0026thinsp;0.625). Most participants reported being comfortable with group study (76.7% experimental, 70% control), though a few students in the control group (8.3%) reported being only sometimes comfortable; this difference approached but did not reach statistical significance (χ\u0026sup2; = 5.58, p\u0026thinsp;=\u0026thinsp;0.061). All participants in both groups had not attended any simulation workshop previously (p\u0026thinsp;=\u0026thinsp;1.000). Regarding self-study hours, the majority studied 1\u0026ndash;2 hours daily (66.7% experimental, 53.3% control) with no significant difference between groups (χ\u0026sup2; = 2.66, p\u0026thinsp;=\u0026thinsp;0.264). Overall, the two groups were demographically comparable at baseline, ensuring validity for subsequent outcome comparisons.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency and percentage distribution of pre-test and post-test knowledge and practice levels among experimental and control groups(n\u0026thinsp;=\u0026thinsp;120) (n1\u0026thinsp;+\u0026thinsp;n2\u0026thinsp;=\u0026thinsp;60\u0026thinsp;+\u0026thinsp;60)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ef(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ef(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ef(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ef(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor Knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34(56.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23(56.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21(35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood Knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26(43.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37(61.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57(95.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39(65.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePractice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor Practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29(48.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13(21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13(21.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood Practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35(51.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47(78.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56(93.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47(78.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the frequency and percentage distribution of pre-test and post-test knowledge and practice levels among nursing students in the experimental and control groups (n\u0026thinsp;=\u0026thinsp;120). Before the intervention, a higher proportion of students in the experimental group had poor knowledge (56.7%) compared to the control group (38.3%). Post-test results showed a substantial improvement, with 95% of students in the experimental group demonstrating good knowledge compared to 65% in the control group. Similarly, in terms of practice, pre-test findings indicated that 51.6% of the experimental group and 78.3% of the control group exhibited good practice. After the intervention, the proportion of students demonstrating good practice increased to 93.3% in the experimental group, while it remained unchanged at 78.3% in the control group. Notably, the percentage of students with poor practice in the experimental group dropped from 48.3\u0026ndash;6.7% following the intervention. These findings suggest that simulation-based training was highly effective in enhancing both knowledge and practice regarding therapeutic communication among nursing students.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of pre-test and post-test knowledge and practice scores within experimental and control groups using Wilcoxon signed-rank test (n\u0026thinsp;=\u0026thinsp;120) (n1\u0026thinsp;+\u0026thinsp;n2\u0026thinsp;=\u0026thinsp;60\u0026thinsp;+\u0026thinsp;60)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eZ-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian(IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian(IQR)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eKnowledge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperimental group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(6.25,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(11,13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-6.516\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(7,10.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(7,10.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.414\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePractice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperimental group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(28,30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62(44,64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-6.608\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(28,31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30(28,31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.342\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.180\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e compares the pre-test and post-test knowledge and practice scores within the experimental and control groups using the Wilcoxon signed-rank test (n\u0026thinsp;=\u0026thinsp;120). In the experimental group, a significant improvement in knowledge scores was observed following the simulation intervention (pre-test median [IQR]: 7 [6.25\u0026ndash;9], post-test median [IQR]: 12 [11\u0026ndash;13]; Z = -6.516, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Similarly, practice scores in the experimental group showed a substantial increase from a pre-test median (IQR) of 29 (28\u0026ndash;30) to a post-test median (IQR) of 62 (44\u0026ndash;64), which was also statistically significant (Z = -6.608, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). In contrast, no significant changes were observed in either knowledge or practice scores in the control group (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). These results clearly indicate that the simulation-based intervention led to significant improvements in both knowledge and practice related to therapeutic communication among nursing students in the experimental group, whereas no meaningful change occurred in the control group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of pre-test and post-test knowledge and practice scores between experimental and control groups using Mann-Whitney U test (n\u0026thinsp;=\u0026thinsp;120) (n1\u0026thinsp;+\u0026thinsp;n2\u0026thinsp;=\u0026thinsp;60\u0026thinsp;+\u0026thinsp;60)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTests\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eZ-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian(IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian(IQR)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(6.25,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(7,10.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.126\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(11,13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(7,10.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-6.850\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePractice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(28,30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30(28,31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.199\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62(44,64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30(28,31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-8.302\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents the comparison of pre-test and post-test knowledge and practice scores between the experimental and control groups using the Mann-Whitney U test (n\u0026thinsp;=\u0026thinsp;120). In terms of knowledge, the experimental group showed a significant improvement in post-test scores (median [IQR]: 12 [11\u0026ndash;13]) compared to the control group (median [IQR]: 9 [7\u0026ndash;10.75]) with a Z-value of -6.850 and a p-value of \u0026lt;\u0026thinsp;0.0001. However, no significant difference was observed in pre-test knowledge scores between the two groups (p\u0026thinsp;=\u0026thinsp;0.126). Similarly, the post-test practice scores of the experimental group (median [IQR]: 62 [44\u0026ndash;64]) were significantly higher than the control group (median [IQR]: 30 [28\u0026ndash;31]) with a Z-value of -8.302 and a p-value of \u0026lt;\u0026thinsp;0.0001, indicating a substantial effect of the intervention on practice scores. No significant difference was found in pre-test practice scores between the two groups (p\u0026thinsp;=\u0026thinsp;0.199). These findings demonstrate that the simulation-based intervention significantly enhanced both knowledge and practice of therapeutic communication in the experimental group, while the control group showed no such improvement.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSpearman\u0026rsquo;s rank correlation between knowledge and practice scores in the experimental group (n1\u0026thinsp;=\u0026thinsp;60).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePre-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003csub\u003es\u003c/sub\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003er\u003csub\u003es\u003c/sub\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.360\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.543\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents the Spearman\u0026rsquo;s rank correlation between knowledge and practice scores within the experimental group (n\u0026thinsp;=\u0026thinsp;60). Pre-test correlation was positive but not statistically significant (rs\u0026thinsp;=\u0026thinsp;0.120, p\u0026thinsp;=\u0026thinsp;0.360), indicating a minor association between baseline knowledge and practice. Post-test correlation remained positive yet non-significant (rs\u0026thinsp;=\u0026thinsp;0.162, p\u0026thinsp;=\u0026thinsp;0.543), suggesting that while improvements in knowledge tended to be associated with better practice, the relationship did not reach statistical significance. These findings imply that although simulation-based learning effectively enhanced both knowledge and practice independently, the degree to which knowledge gains translated into practice improvements may require longer training duration or additional reinforcement sessions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study found no statistically significant association between students\u0026rsquo; practice levels and socio-demographic variables such as age and gender (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This finding is consistent with Thakur et al. \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e, who also reported that factors such as age and gender did not significantly influence nursing students\u0026rsquo; simulation-based communication competence. This suggests that therapeutic communication skills, when taught through simulation, are not dependent on personal characteristics and are applicable across varied student populations. The generalizability of simulation as a pedagogical approach strengthens its value for inclusion in diverse academic settings, reinforcing its potential as a universally adaptable method for communication training in nursing education.\u003c/p\u003e \u003cp\u003eA significant improvement in knowledge was observed in the experimental group, with median scores increasing from 7 (IQR: 6.25\u0026ndash;9) to 12 (IQR: 11\u0026ndash;13) post-intervention, representing a 71% rise in central tendency (Z = -6.516, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). This finding aligns with previous research; Shivani et al. reported an 8.33-point increase after targeted instruction (t\u0026thinsp;=\u0026thinsp;11.844, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) [14], while Thakur et al. found a 12.19-point improvement post-simulation (t\u0026thinsp;=\u0026thinsp;35.85, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Similarly, Haukedal et al. demonstrated knowledge enhancement using high-fidelity simulation in undergraduate nursing cohorts (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. These results, consistent across studies, underscore the effectiveness of experiential learning, as theorized by Kolb, in transforming theoretical input into applied clinical competence.\u003c/p\u003e \u003cp\u003eA substantial improvement in therapeutic communication practice scores was observed in the experimental group, with the median rising from 29 (IQR: 28\u0026ndash;30) at pre-test to 62 (IQR: 44\u0026ndash;64) at post-test, representing more than a two-fold increase in median performance (Z = -6.608, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). These findings are in line with Mohamed and Fashafsheh, who also reported significant post-simulation improvements in practice scores (t\u0026thinsp;=\u0026thinsp;32.64, p\u0026thinsp;=\u0026thinsp;0.001) \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, and Thakur et al., who observed a 4.97-point increase following structured simulation exercises (t\u0026thinsp;=\u0026thinsp;33.13, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. The observed gains in this study likely reflect the effectiveness of repeated practice and structured feedback loops embedded within high-fidelity simulation sessions. Such methods foster the development of procedural fluency, reflective insight, and confidence key components of behavioral change as explained by Bandura\u0026rsquo;s self-efficacy theory \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. Additionally, Karabacak et al.\u0026rsquo;s findings on the strong correlation between instructor assessments and students\u0026rsquo; self-evaluations (r\u0026thinsp;=\u0026thinsp;0.658, p\u0026thinsp;=\u0026thinsp;0.001) emphasize the role of guided reflection and multi-source feedback in reinforcing and sustaining improved performance in communication practice \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough both knowledge and practice improved significantly, their relationship remained positive but non-significant in both pre-test (rs\u0026thinsp;=\u0026thinsp;0.120, p\u0026thinsp;=\u0026thinsp;0.360) and post-test (rs\u0026thinsp;=\u0026thinsp;0.162, p\u0026thinsp;=\u0026thinsp;0.543) analyses. This indicates that gains in theoretical knowledge did not directly translate into equivalent behavioral changes in communication practice. Similar observations were reported by Ko et al., who noted variable confidence improvements across different simulation modalities (F\u0026thinsp;=\u0026thinsp;4.30, p\u0026thinsp;=\u0026thinsp;0.040), suggesting that single-session interventions may be insufficient to integrate cognitive and practical competencies fully \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. To strengthen this linkage, future programs should incorporate ongoing mentorship, iterative simulation exercises, and blended learning approaches that reinforce knowledge application through repeated practice and reflective feedback.\u003c/p\u003e \u003cp\u003eA closer examination of recent simulation studies further clarifies how immersive learning environments enhance nursing communication skills and why our findings are so robust. In a large-scale multicenter randomized trial, Tong et al. enrolled 500 undergraduate nursing students and found that those who participated in high-fidelity simulation achieved a mean communication competence score 1.2 points higher than peers receiving case-based learning (p\u0026thinsp;=\u0026thinsp;0.020) \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. This suggests that the multisensory cues and real-world context of high-fidelity mannequins more effectively engage learners, leading to measurable skill gains. Rouleau et al. extended this evidence to practicing nurses, showing that a series of virtual patient encounters produced a 15% improvement in relational communication skills (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Their work highlights that even in online or remote formats, simulation can sharpen nurses\u0026rsquo; ability to build rapport and respond empathetically. Dante et al. reported that first-year students who completed immersive simulation exercises experienced a 20% rise in self-confidence and perceived clinical competence (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e, reinforcing the link between safe, controlled practice and learners\u0026rsquo; willingness to apply new skills in real clinical settings. Finally, Patel et al. demonstrated that after standardized patient scenarios, where actors role-play difficult conversations, 85% of participants showed significant improvement in ethical communication proficiency (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. This finding underscores simulation\u0026rsquo;s unique capacity to address not only technical dialogue but also nuanced aspects of empathy, cultural sensitivity, and ethics. Taken together, these studies illustrate that whether through high-fidelity mannequins, virtual reality platforms, or standardized patient encounters, simulation-based education reliably produces statistically significant gains in both the technical and affective dimensions of nursing communication. These converging lines of evidence strongly support the routine incorporation of diverse simulation modalities into nursing curricula to cultivate well-rounded, confident, and ethically grounded communicators.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eStrengths of this study include its robust quasi-experimental design, which allowed for comparison of pre- and post-intervention outcomes in a real-world educational setting, enhancing the study\u0026rsquo;s external validity. The use of high-reliability instruments (Cronbach\u0026rsquo;s α\u0026thinsp;\u0026gt;\u0026thinsp;0.80) ensures consistency and validity in measurement. The study also utilized a structured, theory-driven simulation curriculum that was grounded in experiential learning principles.\u003c/p\u003e \u003cp\u003eLimitations of the study include purposive sampling from a single geographic region (Bhubaneswar, Odisha), which may limit the generalizability of the findings to other populations with different cultural and educational backgrounds. Additionally, the relatively short follow-up period (four weeks) restricts the ability to assess the long-term retention of communication skills and their transfer to clinical practice.\u003c/p\u003e \u003cp\u003eFuture research should employ randomized sampling to reduce selection bias, compare different simulation modalities (e.g., virtual simulations vs. high-fidelity mannequins), and incorporate extended follow-up periods (6 months to 1 year) to evaluate sustained competency and its impact on patient outcomes. Further exploration of cross-cultural differences and multi-center trials would help broaden the generalizability of these findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSimulation-based education significantly improves therapeutic communication knowledge and practice among nursing students. Its integration into nursing education is crucial for preparing students for real-world clinical challenges. In conclusion, this study demonstrates that simulation-based learning substantially enhances therapeutic communication knowledge and practice among nursing students, independent of demographic factors. Educators should adopt multifaceted simulation strategies, combining debriefing, virtual patients, and high-fidelity mannequins, to foster comprehensive communication competencies essential for patient-centered care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The study was approved by the Institutional Ethics Committee of IMS and SUM Hospital, Siksha \u0026apos;O\u0026apos; Anusandhan (Deemed to be University), Bhubaneswar, Odisha (Approval No.: Ref.no/IEC/IMS.SH/SOA/2023/542). Written informed consent was obtained from all participants. Confidentiality and voluntary participation were assured throughout the study. The research was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e The Clinical trial number in \u0026nbsp;not applicable for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions: \u003c/strong\u003eSM conceived the study, developed the research tools, collected and analyzed the data, and drafted the manuscript. MS contributed to tool validation, assisted in statistical analysis, and participated in manuscript editing. GB provided overall conceptual guidance and critically revised the manuscript for intellectual content. BT supervised the research design, supported data interpretation, and reviewed the final version. RN was involved in simulation implementation, data collection, and literature review. PM reviewed the research methodology, supported the ethical clearance process, and assisted with referencing. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eThe authors would like to express their sincere gratitude to all the nursing students who participated in this study and to the faculty members of the participating institutions for their valuable support and cooperation throughout the research process.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMersha A, Abera A, Tesfaye T, Abera T, Belay A, Melaku T, Shiferaw M, Shibiru S, Estifanos W, Wake SK. Therapeutic communication and its associated factors among nurses working in public hospitals of Gamo zone, southern Ethiopia: application of Hildegard Peplau's nursing theory of interpersonal relations. 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Journal of Clinical Nursing, vol. 11, no. 1, 2001, pp. 12\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1046/j.1365-2702.2002.00553.x\u003c/span\u003e\u003cspan address=\"10.1046/j.1365-2702.2002.00553.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 15 Apr. 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Y, Jiang X, Ni Z, et al. Simulation-based learning in nursing education: A systematic review and meta-analysis. Nurse Educ Today. 2020;85:104295.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee J, Lee MH, Park H. Effects of high-fidelity simulation on nursing students' communication competence: A quasi-experimental study. Int J Nurs Pract. 2022;28(1):e12960.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim J, Park JH. Enhancing therapeutic communication skills using simulation in nursing students: A pre-post intervention study. Nurs Open. 2021;8(5):2371\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalem OE, Ebrahem SM. Simulation-based training for improving therapeutic communication among nursing students. Egypt J Health Care. 2022;13(3):654\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShivani J, Shiksha M, et al. A study to assess the effectiveness of planned teaching on knowledge regarding therapeutic communication among nursing students. Int J Nurs Educ Res. 2020;8(1):45\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThakur C, Patney S, Shokanda S. A study to evaluate the effectiveness of structured teaching programme on knowledge and practice regarding communication competence among BSc nursing students. Int J Sci Res. 2020;9(3):1123\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaukedal TA, Reierson \u0026Aring;I, Hedeman H, Bj\u0026oslash;rk IT. Nursing students' perceived learning outcomes after high-fidelity simulation: A qualitative study. BMC Nurs. 2018;17:28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12912-018-0304-9\u003c/span\u003e\u003cspan address=\"10.1186/s12912-018-0304-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohamed SA, Fashafsheh I. The effect of simulation-based learning on knowledge and practice of nursing students regarding therapeutic communication. J Educ Pract. 2019;10(5):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarabacak U, Unlu H, Alparslan GB, Turkmen E, Kocatepe V. Evaluation of nursing students' clinical performance using simulation and video-recorded scenarios. Nurse Educ Today. 2019;79:66\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKo E, Kim H-Y. Effects of simulation-based education combined with team-based learning on nursing students\u0026rsquo; learning outcomes. Nurse Educ Today. 2017;51:61\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDissanayake D, Jayasinghe RM, Abeysundara S, et al. A study to assess the effectiveness of communication training among nursing undergraduates in Sri Lanka. BMC Med Educ. 2019;19:234. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12909-019-1691-1\u003c/span\u003e\u003cspan address=\"10.1186/s12909-019-1691-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThanasekaran P, Yadecha B, Upashe SP. Assessment of therapeutic communication among nurses and associated factors in selected hospitals. Int J Nurs Midwifery Res. 2017;4(1):27\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBandura A. Self-efficacy: The exercise of control. New York: W.H. Freeman; 1997.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Therapeutic communication, Simulation-based education, Nursing students, Knowledge, Practice, India","lastPublishedDoi":"10.21203/rs.3.rs-6553723/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6553723/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEffective therapeutic communication is essential for fostering patient trust and enhancing healthcare outcomes. Simulation-based learning has been shown to improve communication skills among nursing students. This study aimed to evaluate the effect of simulation-based training on therapeutic communication skills in nursing students.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis quasi-experimental study was conducted with 120 B.Sc. Nursing students, divided into experimental (n\u0026thinsp;=\u0026thinsp;60) and control (n\u0026thinsp;=\u0026thinsp;60) groups. The experimental group received four simulation sessions, each lasting two hours, focusing on communication techniques such as active listening, empathy, and conflict resolution. The control group received traditional didactic lectures. Data were collected using a structured knowledge questionnaire and a structured observational checklist to assess knowledge and practice levels before and after the intervention. Statistical analysis included the Wilcoxon signed-rank test, Mann-Whitney U test, and Spearman\u0026rsquo;s correlation analysis, with p-values less than 0.05 considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe experimental group showed significant improvements in both knowledge and practice scores, with median knowledge scores rising from 7 (IQR: 6.25\u0026ndash;9) to 12 (IQR: 11\u0026ndash;13) (Z = -6.516, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and practice scores increasing from 29 (IQR: 28\u0026ndash;30) to 62 (IQR: 44\u0026ndash;64) (Z = -6.608, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). The control group showed no significant changes. A positive but non-significant correlation between knowledge and practice was observed (rs\u0026thinsp;=\u0026thinsp;0.162, p\u0026thinsp;=\u0026thinsp;0.543).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSimulation-based learning significantly enhanced therapeutic communication knowledge and practice among nursing students. It is recommended that simulation be integrated into nursing curricula to improve communication skills and clinical competence.\u003c/p\u003e","manuscriptTitle":"Enhancing Therapeutic Communication Among Nursing Students: A Simulation-Based Approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-02 17:47:05","doi":"10.21203/rs.3.rs-6553723/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-18T09:49:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-13T06:50:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-11T20:12:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221594696740335358246208706737932307963","date":"2025-05-31T08:41:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259046807110125524254973906999729876844","date":"2025-05-29T08:08:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-29T08:04:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-29T07:57:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-29T07:22:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-28T20:49:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-05-28T20:48:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"283039a1-77f6-4518-8b55-e866c4166ebb","owner":[],"postedDate":"June 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T18:39:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-02 17:47:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6553723","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6553723","identity":"rs-6553723","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}