The effect of blended role-playing and reflective training on nursing students' communication skills with depressed patients

Copy igh © 2025 Zanjan Uni e si y o Medical Sciences. Published by Zanjan Uni e si y o Medical Sciences. This wo k is licensed unde a C ea i e Commons A ibu ion-NonComme cial 4.0 In e na ional license (h ps://c ea i ecommons.o g/licenses/by- nc/4.0/). Noncomme cial uses o he wo k a e pe mi ed, p o ided he o iginal wo k is p ope ly ci ed. The e ec o blended ole-playing and e lec i e aining on nu sing s uden s’ communica ion skills wi h dep essed pa ien s Fa eme Fa ahi1, Zah a Amouzeshi1, Hamid Naza i1, Da ood Oudi1* 1Depa men o Nu sing, School o Nu sing and Midwi e y, Bi jand Uni e si y o Medical Sciences, Bi jand, I an A icle in o Abs ac In oduc ion E ec i e communica ion is a i al elemen and an in eg al pa o quali y ca e in he nu sing p o ession [1]. Communica ion is he p ocess o ansmi ing messages in a planned and pu pose ul way o collec da a, suppo he pa ien , c ea e a collabo a i e space o de elop a ca e plan and each basic ips o imp o e he heal h le el [2]. Gi en he unique na u e o men al illnesses and he psychological symp oms expe ienced by hese pa ien s, es ablishing e ec i e communica ion in he nu sing ca e o indi iduals wi h men al heal h issues becomes pa icula ly impo an [3]. Conside ing men al illnesses, using e ec i e communica ion skills is a c ucial ool o heal hca e wo ke s om diagnosis o ea men . In mos cases, he signs and symp oms o men al illnesses can only be assessed h ough e ec i e communica ion and he applica ion o app op ia e communica ion echniques and skills [4]. Communica ing wi h a pa ien wi h men al diso de s can be associa ed wi h challenges ha a e ba ely isible in o he pa ien s and needs enough skills [5]. The psychological aspec s o hese illnesses, along wi h he social s igma ela ed o men al heal h diagnoses, necessi a e he use o speci ic communica ion skills when in o ming indi iduals and hei amilies abou men al illnesses—pa icula ly when hey may lack su icien unde s anding o li e acy [6]. In o he wo ds, one o he mos impo an dimensions o quali y ca e in A icle his o y: Recei ed 16 Sep. 2024 Accep ed 21 May. 2025 Published 13 Jul. 2025 Fa ahi e al. J Med Edu De . 2025; 18(2): 36-45 Jou nal o Medical Educa ion De elopmen Backg ound & Objec i e: Communica ing wi h dep essed pa ien s is a c ucial p o essional skill o nu sing s uden s, which hey mus lea n du ing hei s udies. This s udy aimed o assess he e ec i eness o blended aining—inco po a ing bo h ole-playing and e lec i e p ac ice— on nu sing s uden s' communica ion skills in hei in e ac ions wi h dep essed pa ien s. Ma e ials & Me hods: The p esen semi-expe imen al s udy was conduc ed in 2023 wi h a be o e and a e wo-g oup design. All six h-semes e nu sing s uden s a To ba Jam Facul y o Medical Sciences we e andomly selec ed and di ided in o wo g oups: an expe imen al g oup and a con ol g oup. The in e en ion included he apeu ic communica ion skill aining sessions wi h he ole-playing and e lec ion blended me hod. The con ol g oup ecei ed he s anda d aining me hod. The apeu ic communica ion skills in dealing wi h dep essed pa ien s be o e and a e he in e en ion we e e alua ed by a communica ion skills ques ionnai e. Da a we e analyzed using he s a is ical so wa e SPSS e sion 20, desc ip i e s a is ical es s and in e en ial es s ( - es , analysis o a iance, and pai ed- ) a a signi icance le el 0.05. Resul s: The a e age communica ion skills sco es be o e he in e en ion showed no s a is ically signi ican di e ence be ween he in e en ion and con ol g oups (p > 0.05). Howe e , he mean sco e o communica ion skills a e he in e en ion was signi ican ly di e en in he wo g oups (p < 0.05). The esul s also indica ed ha he mean communica ion skill sco e a e he in e en ion signi ican ly imp o ed in he expe imen al g oup compa ed o be o e he in e en ion (p < 0.05). Howe e , he e was no s a is ically signi ican change in he mean communica ion skill sco e in he con ol g oup be o e and a e he in e en ion (p > 0.05). Conclusion: Educa ional sys em manage s and planne s a e sugges ed o use a blend o hese wo me hods o ain nu sing s uden s' communica ion skills, especially in he psychia ic depa men and when dealing wi h dep essed pa ien s. Keywo ds: ole-playing, e lec ion, communica ion skill, s uden , nu sing, dep essed pa ien *Co esponding au ho : Da ood Oudi, Depa men o Nu sing, School o Nu sing and Midwi e y, Bi jand Uni e si y o Medical Sciences, Bi jand, I an. Email: da [email protected] O iginal A icle How o ci e his a icle: Fa ahi F, Amouzeshi Z, Naza i H, Oudi D. The e ec o blended ole- playing and e lec i e aining on nu sing s uden s’ communica ion skills wi h dep essed pa ien s. J Med Edu De . 2025; 18(2): 36-45. [ DOI: 10.61882/edcj.18.2.36 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 1 / 10 Fa ahi e al . : E ec o Blended T aining o Role-Playing and Re lec ion on he Communica ion Skills Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 37 nu sing is he abili y o es ablish a p ope ela ionship wi h he pa ien . This issue is pa icula ly impo an and necessa y in dealing wi h people wi h a men al heal h condi ion, such as dep essed pa ien s, who ha e a weake abili y o communica e han o he pa ien s [4]. Dep ession has se ious consequences o people's heal h, and he ea men eam aces many challenges when communica ing wi h a dep essed pa ien . These pa ien s p o ide less eedback du ing communica ion and pa icipa e less han o he pa ien s. Following he educ ion o he pa icipa ion o hese pa ien s du ing communica ion, hei adhe ence o he ea men egimen may also be a ec ed, which h ea ens hei heal h [7]. Thus, in dealing wi h hese pa ien s, using e ec i e communica ion echniques o he ea men eam membe s is especially impo an [8]. Also, e ec i e communica ion be ween nu ses and nu sing s uden s wi h dep essed pa ien s plays an impo an ole in educing s ess and c ea ing elaxa ion o hem. The p o essional pa ien -s uden ela ionship as a sou ce o suppo can a ec he p og ess and de elopmen o an o iginal and pa ien -cen ed he apeu ic app oach o be e ca e o people wi h a men al heal h condi ion among s uden s [9]. Recognizing ha e ec i e e bal and non- e bal communica ion skills a e i al o enhancing ea men ou comes, os e ing ela ionships wi h colleagues, pa ien s, and hei amilies, and na iga ing complex ea men si ua ions o nu ses and nu sing s uden s as a po en ial wo k o ce o he u u e [10], eaching communica ion skills has become a key componen o nu sing educa ion in ecen yea s. Nu sing s uden s should be able o p o ide app op ia e communica ion in he pa ien -ca ing p ocess [11, 12]. S udies indica ed ha nu sing s uden s a e unable o communica e e ec i ely wi h pa ien s, and many s uden s a e a aid o encoun e ing pa ien s and ela i es wi h di e en backg ounds and pe sonali ies in men al heal h [13]. Addi ionally, communica ion skills a e a i al ye o en o e looked educa ional need o s uden s in nu sing p og ams. The esea ch esul s emphasize ha ine icien aining leads o a de ici in communica ion skills in heal hca e p o ide s [13, 15] and holding app op ia e aining cou ses o de elop he communica ion skills o heal hca e p o ide s is an impo an s ep owa d imp o ing hese skills [14, 13]. Role-playing is one o he e ec i e me hods o eaching communica ion and social skills [16]. Role-playing is a o m o simula ion in which pa icipan s in e ac wi h a pa ien wi hou he app ehension o po en ial isks associa ed wi h hei ca e me hods. In his me hod, a pu pose ul show is pe o med, and by discussing i , people can discuss hei eelings, a i udes, and p oblem- sol ing s a egies ega ding he si ua ion [17]. The educ ion o ime and cos equi ed o aining, imp o emen o decision-making and c i ical hinking skills, and inc ease o comp ehensi e sel -con idence a e among he ad an ages o his aining me hod [16]. Despi e he bene i s o his me hod, in ou coun y, ole- playing is a ely used in medical science educa ion, and in o ma ion on he e ec i eness o his me hod in eaching nu sing s uden s in I an is limi ed [18, 19]. Ano he way o imp o e lea ning is e lec i e hinking. Re lec i e hinking is a ho ough, ongoing, and ac i e examina ion o one's belie s and knowledge, u ilizing pe sonal jus i ica ions and in e ences ha help ein o ce and solidi y hose opinions o belie s [20]. The p ocess o e lec i e hinking allows people o ecall and e iew he expe ience and encou ages hem o sea ch o and e alua e solu ions in complex si ua ions [16]. Re lec ion can lead o imp o ing clinical easoning skills and deep lea ning; hus, i is conside ed an impo an educa ional ool in he nu sing p o ession [21]. In addi ion o imp o ing knowledge and skills, e lec ion eaches lea ne s he habi o c i ical hinking and lea ning, and he e o e, i is conside ed an e ec i e educa ion me hod [22]. Re lec i e hinking helps s uden s o imp o e hei lea ning expe iences du ing and a e pe o ming clinical skills and o ealize hei lea ning de iciencies h ough sel -c i icism [24, 23]. The nume ous bene icial e ec s o ole-playing and e lec i e hinking educa ional me hods ha e been demons a ed indi idually. Some esea ch has conside ed hese wo educa ional me hods complemen a y and concluded ha combining hem in eaching skills esul s in syne gis ic lea ning in he indi idual [24-26]. Despi e nume ous s udies on each o hese educa ional models and hei e ec s, e y li le esea ch has been conduc ed on he e ec o blended aining wi h ole-playing and e lec ion me hods on he communica ion skills o nu sing s uden s in dealing wi h dep essed pa ien s. Ma e ials & Me hods Design and se ing(s) This semi-expe imen al esea ch uses a wo-g oup design (in e en ion and con ol) wi h p e- es and pos - es assessmen s. I began on July 16, 2023, and concluded on Sep embe 20, 2024. [ DOI: 10.61882/edcj.18.2.36 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 2 / 10 Fa ahi e al . : E ec o Blended T aining o Role-Playing and Re lec ion on he Communica ion Skills 38 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 Pa icipan s and sampling The esea ch popula ion consis ed o all six h-semes e nu sing s uden s a To ba Jam Facul y o Medical Sciences, who we e included in he s udy h ough a con enience non- andom sampling me hod based on speci ic inclusion and exclusion c i e ia. The inclusion c i e ia included being a six h-semes e nu sing s uden , passing he ele an heo e ical and p ac ical uni s so a , and no passing he in e nship uni in psychology. The exclusion c i e ia included being ans e s uden s o he acul y and pa icipa ing in communica ion skills aining wo kshops. A o al o 44 s uden s pa icipa ed in he s udy (Figu e 1). Figu e 1. Flow cha o he s udy Tools/Ins umen s Da a we e collec ed using a demog aphic in o ma ion ques ionnai e (age, gende , do mi o y s a us, ma i al s a us, and na i eness) and a s anda d In e pe sonal Communica ion Skills Scale (ASMA). This ques ionnai e was de eloped by Vakili e al. The ini ial ques ionnai e con ains 43 i ems ha all in o se en dimensions, including public communica ion skills, speaking skills, lis ening skills, in e p e a ion and cla i ica ion skills, ques ioning skills, encou agemen skills, and eedback skills. The op ions o his ques ionnai e a e g aded acco ding o a 5-poin Like scale o 1 ( e y weak), 2 (weak), 3 (mode a e), 4 (good) and 5 ( e y good). Vakili and his colleagues psychome ically e alua ed his ques ionnai e in a s udy on he popula ion o heal h wo ke s in Zanjan. Based on he esul s o explo a o y ac o analysis, 30 i ems om his ques ionnai e we e con i med and placed in 7 a eas o gene al communica ion skills (6 i ems), speaking skills (4), lis ening skills (4), in e p e a ion and cla i ica ion skills (4), and ques ioning skills (4), encou agemen and p aise skill (4) and eedback skill (4). The eliabili y o he en i e ques ionnai e in his s udy was epo ed using C onbach's alpha 0.91 [27]. [ DOI: 10.61882/edcj.18.2.36 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 3 / 10 Fa ahi e al . : E ec o Blended T aining o Role-Playing and Re lec ion on he Communica ion Skills Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 39 Da a collec ion me hods Six h-semes e nu sing s uden s wi h bachelo 's deg ees we e assigned in o wo expe imen al and con ol g oups using a simple andom me hod o conduc he s udy. Communica ion skills we e e alua ed in bo h expe imen al and con ol g oups be o e he in e en ion by comple ing a ques ionnai e. The con ol g oup ecei ed he usual heo e ical and p ac ical me hod o aining communica ion skills wi h dep essed pa ien s. Fo he in e en ion g oup, he aining was implemen ed in combina ion wi h ole-playing and e lec i e hinking skills o communica ion skills wi h dep essed pa ien s. A e he in e en ion, he communica ion skills o bo h he expe imen al and con ol g oups we e e-e alua ed using he same measu emen ins umen . The in e en ion included aining in he blended me hod o ole-playing and e lec i e hinking. The ole-playing aining me hod was done in he o m o a heo e ical explana ion o he p oblem, and hen he oles and pe o ming he ole we e de e mined by he s uden s and eedback was p o ided o hem. The me hod consis ed o se en s eps: he i s s ep in ol ed wa ming up he g oup by in oducing he p oblem, explaining he si ua ion, discussing he con ex ual s o y, highligh ing key issues, and ou lining he ole-playing ac i i ies. The second s ep is selec ing he pa icipan s by analyzing he oles and selec ing he ole playe s. The hi d s ep is p ocessing he scene by adjus ing he p inciples o beha iou in he ole, es a ing he oles and acing he p oblem si ua ion. The ou h s age p epa es he obse e s by de e mining he subjec o he sea ch and explaining he obse a ion asks. The i h s age is discussion and e alua ion, which in ol es e iewing ole-playing beha iou (inciden s, issues, ealism), discussing cases, and c ea ing he nex s age. six h s age, e-playing by playing he modi ied oles and sugges ing he ollowing s ages wi h mo e app op ia e beha iou s) [28]. A e eaching communica ion skills o he s uden s using he ole- playing me hod, hey we e asked o e lec on hei expe iences based on he 6-s ep e lec ion model de eloped by Mezi ow and Taylo (2009). The s eps included: 1) emo ional eac ion, 2) explana ion and desc ip ion, 3) in e nal e iew, 4) c i ical analysis, 5) e alua ion, and 6) new ac ion planning. S uden s e lec ed on how o communica e wi h pa ien s, he ele an in o ma ion ega ding pa ien in e ac ions, hei communica ion skills, and he ou comes o using hese skills. They documen ed hei e lec ions on a shee o ganized acco ding o Mezi ow and Taylo 's e lec ion model [29]. The esea che s udied he s uden s' w i ings, and app op ia e eedback was p o ided o imp o e hei lea ning (Table 1). All e hical conside a ions we e conside ed when conduc ing he s udy. Ob aining pe mission om he Uni e si y o Medical Sciences and he Ins i u e o Medical Educa ion o pa icipa e in he s udy, ob aining w i en in o med consen om he esea ch uni s o pa icipa e in he s udy, eedom o en e and exi he s udy, he anonymi y o he ques ionnai es, and he emphasis on he con iden iali y o in o ma ion we e aken in o conside a ion. Table 1. Mezi ow and Taylo ole play s eps Implemen a ion plan S eps o conduc ing educa ional sessions Wa ming up he g oup by in oducing he p oblem, explaining he p oblem, explaining he s o y o he p oblem, showing he impo an issues and explaining he ole-playing Fi s s ep Role-playing me hod selec ing he pa icipan s by analyzing he oles, and selec ing he ole playe s Second s ep p ocessing he scene by adjus ing he p inciples o beha io in he ole, es a ing he oles and acing he p oblem si ua ion Thi d s ep p epa ing he obse e s by de e mining he subjec o he sea ch and explaining he obse a ion asks Fou h s age discussion and e alua ion by e iewing ole-playing beha io (inciden s, issues, ealism Fi h s age Replaying he modi ied oles and sugges ing imp o ed beha io al esponses o u u e si ua ions Six h s age A e eaching communica ion skills o he s uden s using he ole- playing me hod, he s uden s we e asked o e lec based on he 6-s ep e lec ion model o Mezi ow and Taylo (1, emo ional eac ion, 2, explana ion and desc ip ion, 3, in e nal e iew, 4, c i ical analysis, 5, e alua ion, 6, new ac ion planning) [29]. Re lec ion [ DOI: 10.61882/edcj.18.2.36 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 4 / 10 Fa ahi e al . : E ec o Blended T aining o Role-Playing and Re lec ion on he Communica ion Skills 40 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 Da a analysis The da a we e analyzed using SPSS e sion 20 wi h desc ip i e s a is ics ( equency, pe cen age, mean, and s anda d de ia ion) and in e en ial es s (pai ed - es , - es , chi-squa e, and ANOVA). Resul s All s uden s pa icipa ed in he s udy, and he e was no sample a i ion. The Kolmogo o –Smi no es esul s indica ed ha he s udy a iables ha e a no mal dis ibu ion (p > 0.05). Fo y-eigh pe cen o he pa icipan s in his s udy we e male. The ages o he esea ch subjec s anged om 23 o 51 yea s. The dis ibu ion o pa icipan s based on demog aphic a iables is p esen ed in Table 2. Addi ionally, he ANOVA and chi-squa e indica ed no signi ican di e ences in demog aphic a iables be ween he wo g oups (p > 0.05). The mean dis ibu ion o communica ion skills abou demog aphic cha ac e is ics among he s uden s also showed no signi icance (p > 0.05), as de ailed in Table 3. Fu he mo e, he e was no signi ican di e ence in he mean communica ion skills o s uden s be ween he expe imen al and con ol g oups be o e he in e en ion (p = 0.16). The e was a signi ican di e ence be ween he cases and con ols in he mean communica ion skills a e he in e en ion (p = 0.04). The e was a signi ican di e ence in he mean communica ion skills o s uden s in he expe imen al g oup be o e and a e he in e en ion (p = 0.04). In con as , no signi ican di e ence was obse ed in he mean communica ion skills o he con ol g oup be o e and a e he in e en ion (p = 0.065) (Table 4). Table 2. F equency, mean, and s anda d de ia ion o demog aphic cha ac e is ics o pa icipan s in he in e en ion and con ol g oups Indi idual speci ica ions In e en ion n (%) Con ol n (%) Sig. Indi idual speci ica ions Age 19-21 5 (22.72) 4 (18.19) F = 1.056 p = 0.631 22-24 14 (63.64) 16 (72.72) 25-27 3 (13.64) 2 (9.09) Gende Male 4 (18.18) 7 (31.82) X2 = 1.011 p = 0.262 Female 18 (81.82) 15 (68.18) Do mi o y s a us Do mi o y 17 (77.27) 19 (86.36) X2 = 1.112 p = 0.090 Non-do mi o y 5 (22.73) 3 (13.64) Ma i al s a us Ma ied 2 (9.1) 1 (4.55) X2 = 0.198 p = 0.124 Single 20 (90.9) 21 (95.45) Na i eness Na i e 7 (31.81) 3 (13.63) X2 = 0.054 p = 0.263 Non-na i e 15 (68.19) 19 (13.63) No e: ANOVA was used o compa e quan i a i e demog aphic a iables be ween g oups, while he Chi-squa e es was used o compa e quali a i e a iables. Abb e ia ions: n, numbe o pa icipan s; SD, s anda d de ia ion; X2, Chi-squa e es ; Sig., s a is ical signi icance; p, p obabili y- alue. Table 3. Mean and s anda d de ia ion o s uden s’ communica ion skills by demog aphic a iables eibai aV N e Vb PVbaVnei V lcee naaieacn umaaa Mean ± SD eibai aV GVndVb Male 11 25 119.13 ± 27.16 Female 33 75 109.7 ± 18.06 = 1.03 , p = 0.066 Mibaeia ueie u Mdii a 3 6.82 121.13 ± 23.66 S lgn 41 93.18 118.16 ± 13.27 = 1.91, p = 0.0712 A V (sVibu) 19-21 9 20.45 111.9 ± 24.12 22-24 30 83.63 102.10 ± 13.12 25-27 5 63.18 112.11 ± 23.11 F = 2.54, p = 0.191 scbeaecbs ueie u Dmio imio 36 81.81 123.11±28.22 Nml-amio imio 8 18.19 119.16±18.82 = 1.51, p = 0.301 Niea Vness Ndi 10 22.72 98.16 ± 15.12 Nml-ldi 34 77.28 102.11 ± 24.22 = 1.03, p = 0.621 No e: ANOVA es was used o compa e pa icipan s based on quan i a i e demog aphic a iables o g oups. es was employed o compa e pa icipan s based on quali a i e a iables Abb e ia ions: n, numbe o pa icipan s; SD, s anda d de ia ion; F, analysis o a iance es ; Sig, s a is ical signi icance; p, p obabili y- alue [ DOI: 10.61882/edcj.18.2.36 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 5 / 10 Fa ahi e al . : E ec o Blended T aining o Role-Playing and Re lec ion on he Communica ion Skills Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 41 Table 4. Compa ison o mean communica ion skills be ween in e en ion and con ol g oups be o e and a e he in e en ion lcee naaieacn umaaas In e en ion g oup Mean ± SD Con ol g oup Mean ± SD Sa . nVicbV aneVb Vneacn 69.25 ± 8.14 68.65 ± 11.48 = 1.06 p = 0.166 nieVb e V aneVb Vneacn 112.35 ± 12.21 73.15 ± 6.51 = 1.02 p = 0.043 ua . = 1.001 p = 0.043 = 1.006 p = 0.065 - No e: Independen - es was used o compa e communica ion skills be ween g oups, and pai ed - es was used o wi hin-g oup compa isons. Abb e ia ions: SD, s anda d de ia ion; p, p obabili y- alue. Discussion The p esen s udy's esul s indica ed ha eaching nu sing s uden s communica ion skills by blending ole- playing and e lec ion, compa ed o he usual me hod, imp o ed hei communica ion skills in dealing wi h dep essed pa ien s. Huang e al. conduc ed a s udy o de e mine he e ec o eco ded ideo ole-playing and guided e lec ion on empa hy, ca ing beha io and compe ence o 72 i s -yea nu sing s uden s o medical acul ies in Taiwan. The con ol g oup ecei ed he adi ional me hod o educa ion. The esul s indica ed ha aining based on eco ded ideo ole-playing and guided e lec ion imp o ed s uden s' empa hy, ca ing beha io and compe ence [30]. The indings o his s udy a e consis en wi h he esul s o he p esen s udy. Al hough he dependen a iables, as well as he s udied g oups, a e di e en in he cu en s udy and ou s udy, in bo h s udies, he blend o wo me hods o ole-playing and e lec ion was able o c ea e posi i e e ec s on he s uden s' desi ed a iables. In a s udy, Sho ey e al. in es iga ed he e ec i eness o blended lea ning based on a communica ion module designed based on lea ning sa is ac ion, a i ude owa d communica ion skills, and sel -e icacy o Bachelo nu sing s uden s in es ablishing communica ion. In designing he educa ional p og am o his s udy, in addi ion o using mul imedia ools and i ual eali y o inc ease s uden s' pa icipa ion in lea ning, ole-playing and e lec ion exe cises we e used. The s udy's esul s indica ed ha all h ee a iables o sa is ac ion wi h lea ning, a i ude owa ds communica ion skills, and sel -e icacy in communica ing signi ican ly di e ed a e he s udy han be o e [31]. The esul s o his s udy we e also consis en wi h ou esul s. In bo h s udies, ole-playing and e lec ion in e en ions signi ican ly inc eased s uden s' communica ion skills. In hei s udy, Chung e al. in es iga ed he e ec i eness o a blended aining p og am consis ing o an online module and a s uc u ed eedback sys em on senio nu sing s uden s' communica ion skills and sel -e icacy in a local college in Hong Kong. The aining p og am in he in e en ion g oup was in-pe son and as an online module. In he con ol g oup, only in-pe son aining was done. The esul s o his s udy indica ed he e ec i eness o he blended lea ning app oach in imp o ing he compe ency o communica ion skills and sel -e icacy o senio nu sing s uden s in clinical deli e y [32]. The esul s o his s udy we e also consis en wi h ou s udy. Al hough he ype o in e en ion in ou s udy and his s udy was di e en , in bo h s udies, he me hod o blending wo educa ional me hods was used, signi ican ly imp o ing nu sing s uden s' communica ion skills. In hei s udy, Sadhuwong e al. explo ed he impac o a blended aining model ha combined mul imedia ools wi h cogni i e lea ning me hods on he clinical easoning skills o 56 junio nu sing s uden s a he Royal Thai Na al Academy. The pa icipan s engaged in his blended mul imedia and cogni i e app oach o e 10 days. In he con ols, hese wo me hods we e p esen ed wi hou blending. The esul s indica ed ha a hyb id lea ning model by blending si ua ional mul imedia lessons and cogni i e in e nship me hods could enhance he clinical easoning skills o nu sing s uden s. Howe e , implemen ing he model should in ol e p epa ing lea ne s in e ms o hei lea ning skills and sel -di ec ed hinking, as hese a e ounda ional o de eloping clinical easoning skills [33]. The s udy's esul s, simila o ou s, indica ed ha he blended app oach can e ec i ely enhance he skills o nu sing s uden s. In analyzing he esul s o his s udy wi h ou s udy, bo h he ype o blended aining and he dependen a iable we e di e en in bo h s udies. Howe e , in he men ioned s udy, p epa ing s uden s o communica ion skills was emphasized be o e s a ing he s udy. In hei s udy, Hojja i e al. in es iga ed he e ec i eness o a blended clinical educa ion model on nu sing s uden s' a i udes owa d pa ien s in he psychia ic depa men o Za e Hospi al in Sa i. Eigh y- i e s uden s we e included in he s udy, and he educa ional con en o he in e en ion g oup and he men ioned i ems included ilm sc eening, g oup [ DOI: 10.61882/edcj.18.2.36 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 6 / 10 Fa ahi e al . : E ec o Blended T aining o Role-Playing and Re lec ion on he Communica ion Skills 42 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 discussion, and pa ien educa ion. Among cases, blended aining was also gi en in addi ion o ou ine aining. Fo con ols, he usual clinical aining such as d ug he apy skills, pa icipa ion in daily psychia ic isi s and pa icipa ion in daily ounds o he psychia ic depa men we e implemen ed. The s udy's esul s indica ed ha blended aining signi ican ly imp o ed s uden s' a i udes owa d homewo k in he men al depa men [34]. The esul s o his s udy a e consis en wi h ou s udy in e ms o he e ec o he blended me hod on nu sing s uden s in he psychological lea ning en i onmen . Howe e , he blended me hod used, as well as he dependen a iable in he wo s udies, we e di e en . In any case, ega dless o he ype o me hod, blended aining can posi i ely a ec he a i ude o nu sing s uden s in he psychia ic depa men and on homewo k in he psychia ic depa men . In a s udy, Shahsa a i Es ahani in es iga ed he e ec i eness o he blended aining me hod wi h he p oblem-sol ing me hod and ole-playing on he sa is ac ion o lea ning he p ac ical skill o pa ien educa ion among i s -yea nu sing s uden s a Jah om Uni e si y. The indings indica ed ha s uden s' sa is ac ion wi h he blended me hod inc eased signi ican ly a e he in e en ion. Also, he ole-playing me hod inc eased s uden s' emo ional exci emen by 85%, making hem eel close o he s age and use all hei senses o obse e (87%). In addi ion, he p oblem-based lea ning me hod leads o he imp o emen o s uden s' skills (90%) and mo i a ion managemen (92%), and he blended aining me hod leads o high sel -es eem (95%). Thei p ac ical lea ning inc eased by 89% [35]. The esul s o his s udy we e consis en wi h ha o ou s udy in e ms o he posi i e e ec s o he blended me hod. Al hough he dependen a iables in his s udy di e ed om ou s, he common poin be ween hese s udies can be exp essed as a signi ican inc ease in hei p ac ical lea ning. Also, he blended aining me hod in his s udy was ole-playing, which is he same as ou s. In a s udy, Ilic e al. in es iga ed he e ec i eness o eaching he basics o e idence-based medicine in a blended me hod compa ed o lec u e me hod educa ion on compe ence, sel - e icacy, a i ude and beha io owa d e idence-based medicine in medical s uden s in hei i s yea o clinical educa ion. The con en o he aining wi h a blended app oach, in addi ion o using he lec u e me hod, included online and mobile phone-based lea ning, showing an educa ional ideo, communica ing wi h he pa ien and p o iding him wi h he necessa y aining by he s uden . The indings showed no signi ican di e ence in he knowledge and skills o s uden s be ween he wo g oups. Howe e , he s uden s' a i ude in he blended aining g oup was signi ican ly highe [36]. Pe haps he lack o e ec i eness o his me hod in s uden s' knowledge and skills can be a ibu ed o a ious easons, including he i s expe ience o s uden s who a e mo e ocused on heo e ical basis and me hods such as lec u es. Howe e , his blended me hod signi ican ly a ec ed he s uden s' a i udes. In a s udy, Pa anda a e al. in es iga ed he e ec o designing a blended aining p og am on he pe o mance and clinical easoning o midwi e y s uden s o Azad Uni e si y, Jah om B anch. The educa ional p og am implemen ed o he in e en ion g oup included ilm showing, g oup discussion abou eal scena ios, use o a simula ion model and clinical decision-making exe cise, and he con ol g oup ecei ed lec u e-s yle aining. Acco ding o he indings o he s udy, al hough in he in e en ion g oup, he a e age sco e o pe o mance and clinical easoning a e he in e en ion was signi ican ly highe han be o e, he e was no s a is ically signi ican di e ence in he mean sco e o pe o mance and clinical easoning a e he implemen a ion o he in e en ion be ween he wo g oups [37]. The e o e, he esul s o his s udy con as wi h hose o he p esen s udy. The e is a need o wide in e en ions o clinical easoning. In his s udy, su icien ime was no alloca ed o p o ide blended aining. The e o e, no signi ican di e ence was obse ed be ween he sco es o he wo g oups a e implemen ing he in e en ion. In a s udy, Choi e al. in es iga ed he e ec i eness o lea ning based on he p oblem-sol ing model compa ed o lec u e-based eaching on c i ical hinking, p oblem-sol ing, and sel - di ec ed lea ning in i s -yea nu sing s uden s in Ko ea. Based on he s udy's indings, he wo g oups had no signi ican di e ence in c i ical hinking, p oblem- sol ing and sel -di ec ed lea ning [38]. The esul s o his s udy a e inconsis en wi h he indings o he p esen esea ch. The small size o he sample and he lack o use o he blended app oach in aining based on he p oblem- sol ing model led o he absence o a signi ican di e ence be ween he wo g oups in his s udy. One limi a ion o ou s udy was he use o a non- andom sampling me hod, which es ic s he gene alizabili y o he indings o he b oade popula ion. The e o e, i is ecommended ha a s udy be conduc ed using a andom sample. Ano he o he limi a ions o he p esen s udy is he indi idual cha ac e is ics and pe sonali y di e ences among s uden s ega ding hei willingness o lea n [ DOI: 10.61882/edcj.18.2.36 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ] 7 / 10 Fa ahi e al . : E ec o Blended T aining o Role-Playing and Re lec ion on he Communica ion Skills Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 43 p o essional skills, which ha e in luenced he esea ch and a e beyond he esea che 's con ol. Conclusion Based on he esul s o he p esen s udy, i seems ha blended aining o ole-playing and e lec ion is e ec i e in imp o ing he communica ion skills o nu sing s uden s in dealing wi h dep essed pa ien s. In ligh o he indings om he p esen s udy and he posi i e impac o he blended me hod compa ed o adi ional app oaches, i is ecommended ha educa ional sys em manage s conside inco po a ing his me hod in o bo h heo e ical and p ac ical aining cou ses o s uden s. Addi ionally, p o esso s in he psychia ic nu sing depa men should adop his app oach o enhance s uden s' communica ion skills wi h a ious pa ien s in he psychia ic uni and solici eedback on i s e ec i eness om he s uden s. Nu sing s uden s a e encou aged o sha e hei expe iences wi h new eaching me hods, such as his blended app oach, wi h educa ional adminis a o s and acul y membe s. Sha ing hese expe iences can help iden i y po en ial obs acles and weaknesses in implemen ing hese me hods. Fu he mo e, u u e s udies should explo e his skill ac oss di e en academic p og ams o unco e he long- e m e ec s o his me hod on s uden s' communica ion skills. E hical conside a ions The esea ch p oposal was app o ed by he Resea ch Depa men o Bi jand Uni e si y o Medical Sciences unde he iden i ie IR.BUMS.REC.1402.478. The s udy objec i es we e explained o pa icipan s, and in o med consen was ob ained. Pa icipan s we e also assu ed ha he da a was con iden ial and ha hey could wi hd aw om he s udy a any ime. A i icial in elligence u iliza ion o a icle w i ing The au ho s con i m ha gene a i e a i icial in elligence (AI) and AI-assis ed echnologies we e no u ilized in he w i ing p ocess o his pape . Acknowledgmen The au ho s hank he Vice Chancello o To ba Jam Facul y o Nu sing and Midwi e y and nu sing s uden s o hei coope a ion in his esea ch. Con lic o in e es s a emen The au ho s decla e no con lic o in e es . Au ho con ibu ions DO designed he s udy, collec ed da a, pe o med he s a is ical analysis, and d a ed he manusc ip . ZA concei ed he ini ial idea o he s udy, assis ed wi h he s udy design, and con ibu ed o he inal edi ing o he a icle. FF also collec ed da a and conduc ed he s a is ical analysis while d a ing he manusc ip . HN con ibu ed o he in e en ion design and helped d a he manusc ip . All au ho s e iewed and app o ed he inal e sion o he manusc ip . Funding This esea ch ecei ed no speci ic unding om public, comme cial, o non-p o i agencies. Da a a ailabili y s a emen The da ase s used and/o analyzed du ing he cu en s udy a e a ailable om he co esponding au ho upon easonable eques . Re e ences 1. Suikkala A, Koskinen S, Ka ajis o J, Leino-Kilpi H. Cong uence be ween nu sing s uden s’ and pa ien s’ iews o s uden –pa ien ela ionships. Ad ances in Heal h Sciences Educa ion. 2021;26:79-115. [h ps://doi: 10.1007/s10459-020-09972-z] 2. Gu ié ez-Pue as L, Má quez-He nández VV, Gu ié ez-Pue as V, G anados-Gámez G, Aguile a- Man ique G. Educa ional in e en ions o nu sing s uden s o de elop communica ion skills wi h pa ien s: a sys ema ic e iew. In e na ional Jou nal o En i onmen al Resea ch and Public Heal h. 2020;17(7):2241. [h ps://doi: 10.3390/ije ph17072241] 3. Fu nes M, K aal KS, Høye S. Communica ion in men al heal h nu sing-bachelo s uden s' app aisal o a blended lea ning aining p og amme-an explo a o y s udy. 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