An online communication skills training program for nursing students: A quasi-experimental study.

In South Korea, in 2019, approximately 45.5% of newly-graduated nurses quit their jobs within one year of employment. To better understand the adjustment to nursing practice upon graduation, we developed an online communication skills training program based on nonviolent communication and evaluated its effectiveness. A quasi-experimental design was adopted. The sample included 28 participants in the experimental group and 27 in the control group after one participant in the control group dropped out. The participants were fourth-year nursing students at the K and S University in Gyeonggi Province, South Korea, with some clinical training in a hospital setting. Data were analyzed using the χ2 test, Fisher's exact test, and independent t-test. Participants' empathy, communication skills, anger, and self-efficacy were assessed before and after the training, as well as across the two groups. The experimental group showed significantly higher levels of empathy, communication skills, and self-efficacy compared to the control group after the program completion. However, there were no significant differences in anger. This study suggests the effectiveness of the online version of the nonviolent communication training. Therefore, providing this program to nursing students scheduled for graduation may help retain newly-graduated nurses.

Introduction

As of 2019, approximately 20,000 nursing students graduated from the 203 nursing schools in South Korea [1]. After completing a minimum of 130 theoretical courses and 1,000 clinical hours to be equipped with the competency required of nurses in clinical practice, those who pass the licensure exam become registered nurses [1].

Approximately 45.5% of the newly-graduated nurses in Korea quit their jobs within one year of employment [2], many of whom leave the profession entirely. Thus, Korea has a relatively low proportion of active nurses among the Organization for Economic Co-operation and Development (OECD) countries, despite having the highest proportion of newly-graduated nurses [3]. In Korea, it is time-consuming for a newly-graduated nurse to exhibit at least 90% proficiency as compared to that of a skilled nurse; further, on an average, over 25% of the annual cost-to-company is spent on training newly-graduated nurses [4]. Hence, the resignation of nurses within one year of employment is inefficient not only for nurses themselves, but also for the organization.

Premature resignation of newly-graduated nurses has been attributed to rotating shifts, including night shifts [5], stress from inexperience in nursing-related tasks [6], workload and burnout due to understaffing [7], and inefficient communication with fellow nurses [6, 8]. Communication problems significantly contribute to interpersonal workplace conflict [9] and cause low work efficiency and job satisfaction [10, 11]. Newly-graduated nurses, when subjected to harsh criticism, become pessimistic about their competency and feel alienated from their organization [12]. This, in turn, markedly undermines their efficiency and confidence in nursing work [9], ultimately forcing them to quit their jobs [10]. Further, approximately 60–70% of nurses in Korea and abroad have reported to have experienced verbal violence in the hospital [9, 13], which highlights the gravity of such communication problems.

Newly-graduated nurses with low levels of empathy fail to engage in effective interaction and communication with their clinical supervisor, which increases their job stress and turnover intention [10]. Further, newly-graduated nurses who are not able to engage in respectful conversations with colleagues do not develop a sense of belonging, and experience elevated job stress [14]. These findings suggest that the communication difficulties experienced by newly-graduated nurses in their workplace are associated with their communication skills. Hence, fostering effective communication skills in newly-graduated nurses would help prevent premature resignation.

Studies have reported that nurses with effective communication skills show high levels of empathy and self-efficacy [9, 15]. That is, nurses adept at effective communication can engage in conversations with fellow nurses and patients using empathy. In addition, effective communication skills enhance work efficiency [16] and improve self-efficacy, thereby increasing job satisfaction [14]. In hospital settings, wherein nurses work on rotating shifts, effective communication among nurses is essential for continuity in patient care [17]. Moreover, because nursing work often involves highly stressful situations due to the urgency and gravity of dealing with human lives [18], lack of communication or minor communication errors may lead to medical malpractice [19]. Preceptors who train newly-graduated nurses often use a strict tone with them due to the risks and possibility of errors in patient care [20]; newly-graduated nurses may take such a tone personally [20] and react with feelings of anger. Considering such work situations and conditions, training in communication skills as part of undergraduate nursing education would help newly-graduated nurses improve their empathy, self-efficacy, and anger management ability [21]. Further, better communication skills could also help prevent premature turnover [22].

Communication skills can be improved through practice and training [23]. Effective communication skills involve clearly delivering one’s opinion and accepting the other person’s opinion [24], and nonviolent communication (NVC) encompasses these factors. Nonviolent communication, also referred to as compassionate communication, is a conversation model developed by Marshall Rosenberg based on Mahatma Gandhi’s values and Carl Rogers’ therapeutic principles [25]. It comprises two key factors: expressing honestly and listening empathetically [25]. It is a conversation technique based on compassion toward others, which also helps one engage in introspection and build relationships with others [25]. Therefore, by learning and practicing NVC, we reason that the nurses would be able to empathize with their fellow nurses, understand the meaning of their words and their intentions, and appropriately and honestly express their own emotions and needs in a clinical setting.

Currently available modules for communication training and education for nursing students focus on therapeutic communication when interacting with patients [26]. Such programs rarely train nursing students on self-expression during conversations with colleagues. To the best of our knowledge, there are no online NVC training courses that are specific to undergraduate nursing students or nurses; however, online NVC courses for health professionals in general and an offline course for nurses do exist [27]. Communication courses are generally lower division courses targeting first- or second-year students who have not begun their clinical training [28]. Therefore, it is helpful for fourth-grade students who are about to graduate to receive communication training once again since their skills are limited in that they may not necessarily translate their service to the context of understanding the reality of clinical nursing settings. However, due to the global pandemic (COVID-19), online education began in the first semester for the cohort starting in 2020 [29]. Thus, this study aimed to develop and evaluate the feasibility of an NVC-based online communication skills training program (NVC-CST program) to address the needs of nursing students. The NVC-CST program that we have developed focuses on fostering students’ empathy, self-efficacy, appropriate anger expression, and communication skills.

Materials and methods

Design

The present study used a quasi-experimental pretest-posttest design. Volunteer participants were randomly assigned into the experimental group or control group using the Research Randomizer computer program (https://www.randomizer.org). The effectiveness of the online NVC-CST program was also tested.

Participants

Fifty-six nursing students at the K and S University in Gyeonggi Province, South Korea, were enrolled in the study. The inclusion criteria were (a) fourth-year nursing students, and (b) having experienced clinical training at a hospital. The exclusion criteria were (a) minors under the age of 18 (as per Article 2 of the Child Welfare Act of the Republic of Korea) and (b) currently being on a leave of absence.

The sample size to achieve the study objectives was determined using the G*Power Program (version 3.1); the minimum sample size was calculated to be 42, with 21 participants in the experimental group and 21 in the control group (effect size = 0.80, significance = .05, power = .80, two-tailed test). Considering a potential 30% withdrawal rate, 56 students were enrolled. The number of groups (2) and the total number of people (56) for the groups were entered into the Research Randomizer program. Subsequently, the participants were assigned to the experimental and control groups based on the numbers assigned to them by the program. One participant from the control group dropped out (due to personal reasons, even after having attended the program twice), resulting in 28 participants in the experimental group and 27 in the control group. The effect size was established with reference to 0.87, as reported in a Korean study that analyzed NVC-based interventions [24].

Procedure and data collection

The public institutional review board (IRB No. P01-202010-12-001) approved this study, and data were collected from October 5, 2020 to November 15, 2020. Additionally, the study protocol was in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki). Students were informed about the nature of the study, following which they provided signed consent to participate, prior to enrollment. Both the experimental and control groups completed the same questionnaire both before and after the intervention. The experimental group was instructed to access an online platform to participate in the NVC-CST program twice a week. Due to the pandemic, both sets of participants had been taking online classes without physically attending school; therefore, there was no contamination between the experimental and control groups. To prevent the diffusion effect, the duration of access to each 30-minute session was restricted to 3 hours. We also monitored the number of participants on the online platform to confirm that participants in the experimental group participated regularly. No communication program was provided to the control group. However, upon completion of the NVC-CST program, the control group students were allowed access to the program upon request.

The Nonviolent Communication-based online Communication Skills Training (NVC-CST) program

The NVC-CST program aims to help students acquire the skills of expressing their emotions and situations, empathizing with others, and accepting others during conversations, by enabling the students to practice communication skills learned online.

Specifically, this program entails educating participants about the fundamental principles of NVC and helping them practice these skills by applying the principles while communicating with fellow nurses. Various communication case studies were developed with reference to qualitative studies that examined the clinical experiences of newly-graduated nurses in the Korean cultural context [12, 30]. The facilitator of the program was a nursing professor with 15 years of clinical nursing practice and experience in training various groups on NVC. The program utilized cognitive and behavioral approaches, including lectures, conversation demonstrations, assignments, and testimonies. A lecture was provided on each session’s topic. Moreover, demonstrations of both ineffective communication and NVC-based communication were provided. Students were given an assignment to apply the topic of each session to daily life, and they were instructed to write a testimony after each session, except the introductory one.

The NVC-CST program involved four stages, comprising eight sessions overall (Table 1). Session 1 comprised an introduction to the NVC-CST program and an explanation of the objectives, with a focus on building a trusting relationship between the facilitator and the participants. Session 2 covered the four principles of NVC; the focus was on distinguishing between observations and feelings and understanding needs and requests. Students were assisted in understanding these four principles of NVC using a case study of a nurse from the period of his/her graduation to the achievement of a senior position. Session 3 focused on understanding that “feelings” and “needs” are connected, as well as understanding the positive energy of “needs”. Further, an example of a conversation with a fellow nurse was provided to help students realize that others’ needs are as important as one’s own. Session 4 comprised various clinical practice cases to provide intensive training on empathetic listening and honest self-expression.

Table 1

Nonviolent communication-based online communication skills training program.

Stage	Session	Contents	Time (minutes)
1 Introduction	1	‧ Orientation	30
		‧ Therapeutic alliance
		‧ Understanding the contents and objectives of the program
2 Understanding of the NVC principles	2	‧ Understanding of the four factors of the NVC	30
		- observation, feelings, needs, request
	3	‧ Connecting feelings and desires	30
		‧ Staying in the energy of the needs
	4	‧ Listening empathically	30
		‧ Expressing honestly
3 Application of NVC in nursing practice	5	‧ Distinguishing between observation and evaluation	30
		‧ Distinguishing between feelings and thoughts
	6	‧ Awareness of own feelings and needs	30
		‧ Awareness of others’ feeling and needs
	7	‧ Complete anger expression	30
		‧ Stage of anger expression
4 Closing	8	‧ Expressing gratitude	30
		‧ Obstacle of empathy
		‧ Self-reflection

NVC: nonviolent communication.

Session 5 comprised practices in correcting ineffective communication habits with the goal of fostering the competency to distinguish “observation” from “evaluation”. In particular, examples of criticizing or disparaging conversations that commonly occur among nurses in clinical practice were used to show the difference between criticism and objective observation. Here, the focus was to distinguish between the two. Session 6 comprised practices intended to improve recognition of one’s own and others’ feelings and needs. In this session, instances of conversations in a clinical setting was presented to provide students an opportunity to indirectly experience them. Session 7 involved learning about the appropriate ways to express anger and the steps involved in anger expression. Based on the NVC principle that views anger as an alarm for bodily and mental responses, this session trained students in appropriately expressing anger, instead of ignoring or suppressing it. For example, helping them objectively describe a situation in which they experienced anger. Session 8 comprised expressing gratitude and learning about the possible barriers to empathy. Various speech patterns that hinder empathy, such as analyzing and diagnosing, correcting, stopping the flow of emotion, sympathizing, and investigating, were described using examples of conversations among clinical nurses. In the latter part of Session 8, students were given time to briefly meditate and reflect on themselves.

Measures

Empathy

The Empathy Quotient-Short Form (EQ-Short-K) [31], a Korean-adapted version of the Empathy Quotient-Short Form [32], was used to assess empathy. The EQ-Short-K has 11 items that are responded to using a 3-point Likert scale ranging from 0 (disagree) to 2 (strongly agree). Total scores can range from 0 to 22, with a higher score indicating higher levels of empathy. The reliability of this instrument, as measured by Cronbach’s α, was .88 at the time of development [31] and .82 in the present study.

Self-efficacy

The New General Self-Efficacy Scale (NGSE) [33] was employed in the present study to assess self-efficacy; it has been used in a previous Korean study [34]. This instrument has eight items that are responded to using a 7-point Likert scale. The average score is the mean item response, ranging from 1–7, where a higher score indicates higher self-efficacy. Cronbach’s α was .84 in the Korean study [34] and .91 in the current study.

Anger

The Korean State-Trait Anger Expression Inventory (STAXI-K) [35] is a Korean standardized version of Spielberger’s [36] STAXI. There are 24 items that assess anger expression across three subscales: Anger-in, Anger-out, and Anger Control. Items are responded to using a 4-point Likert scale. The anger score was calculated as follows: [(Anger-in score + Anger-out score)–Anger Control score + 16]. Total scores range from 0 to 72, with higher scores indicating higher levels of anger expression. Cronbach’s α was .74 for Anger-in, .73 for Anger-out, and .81 for Anger Control in the Chon et al. [35] STAXI-K study; in the current study, these values were .68, .76, and .78, respectively.

Communication skills

Communication competencies were measured using the Global Interpersonal Communication Competency Scale (GICC-15) [37]. The GICC has 15 items that are responded to using a 5-point Likert scale and consists of three subscales: Relationship, Language, and Interpersonal Competency. The total score is the mean item response, with a range of 1–5, where a higher score indicates higher communication skills. Hur [37] reported a Cronbach’s α = .72 at the time of development. Cronbach’s α was .86 in the current study.

Data analysis

Participant characteristics were analyzed using frequencies, percentages, means, and standard deviations. The normality of the baseline scores for both groups was tested using the Kolmogorov–Smirnov test, and baseline homogeneity was tested using the Chi-squared test, Fisher’s exact test, and t-test. The differences between the two groups with respect to empathy, self-efficacy, anger, and communication skills based on the NVC-CST program were analyzed using independent sample t-tests. SPSS version 26.0 (IBM Corp., Armonk, NY, USA) was used for the analyses, and the significance level was set at p < .05.

Results

Participants who participated in the NVC-CST were the experimental group, and those who did not participate were set as the control group. Both the experimental (Mage = 24.4 years) and control groups (Mage = 24.3 years) were fourth-year nursing students, of whom 11 (19.6%) were men and 44 (80.4%) were women. Forty-one students (75%) lived at home, six (10.7%) in a dorm, and eight (14.3%) lived alone. There were no statistically significant differences in the demographic characteristics between the two groups at baseline. Further, there were no statistically significant differences in empathy, anger, communication skills, or self-efficacy between the two groups at baseline (Table 2).

Table 2

Homogeneity of outcome variables.

Variable		Experimental group (n = 28)	Control group (n = 27)	t	p
		n (%) or Mean ± SD
Age (years)		24.6 ± .37	24.3 ± .29	.608	.546
Gender	Male	6 (10.9)	5 (9.1)	-.331	.742
	Female	22 (40)	22 (40)
Residence	Home	20 (36.4)	18 (32.7)	1.100	.276
	Dorm	2 (3.6)	4 (7.2)
	Alone	5 (9.1)	3 (5.5)
Empathy		9.27 ± 3.13	9.21 ± 2.05	.127	.899
Self-efficacy		4.82 ± 1.11	5.03 ± .73	-.862	.392
Anger		32.68 ± 4.16	33.29 ± 3.49	-.591	.625
Communication skills		3.79 ± .44	3.85 ± .35	-.491	.557

At posttest, the experimental group showed significant changes in empathy, self-efficacy, and communication skills, after the eight-session NVC-CST program, compared to the control group. However, there were no significant differences in the anger scores between the two groups (Table 3).

Table 3

Differences in the dependent variables between groups.

Variable	Time	Experimental group (n = 28)	Control group (n = 27)	t	p
		Mean ± SD
Empathy	Pre	9.27 ± 3.13	9.21 ± 2.05
	Post	12.00 ± 3.13	11.11 ± 1.96	1.28	.021
Self-efficacy	Pre	4.82 ± 1.11	5.03 ± 0.73
	Post	5.88 ± 0.76	5.27 ± 0.75	3.02	.004
Anger	Pre	32.68 ± 4.16	33.29 ± 3.49
	Post	33.57 ± 3.74	34.89 ± 3.30	-1.40	.363
Communication skills	Pre	3.79 ± 0.44	3.85 ± 0.35
	Post	4.27 ± 0.37	4.06 ± 0.34	2.18	.034

Discussion

This study examined the effectiveness of an NVC-based online communication skills training program for fourth-year nursing students who were scheduled to graduate. Given that in-person classes or direct contact was not an option due to the COVID-19 pandemic, the program was designed to be administered online. An online program was anticipated to have limitations considering that NVC-based communication training largely utilizes demonstrations resembling the actual situation, role play, and group activities [38]. However, the results of this study indicate that an online program can be effective as well. Previous studies have suggested that the effectiveness of online education is influenced by the duration of the program, the lecturer’s competence, and learners’ motives [39]. Therefore, we speculated that the duration of the NVC-CST program in this study, competence of the facilitator, and study participants were appropriate for this purpose. Specifically, eight 30-minute sessions can be considered effective for online communication training [40]. Further, various approaches were utilized, such as providing lectures and demonstrations by a skilled expert and writing testimonies of students’ experiences. These appear to have engaged the students and strengthened their learning motivation. Moreover, most participants were fourth-year students who were scheduled to become newly-graduated nurses within a year. We reason that they would have been motivated to acquire communication skills that would help them in clinical practice. Furthermore, this study’s results confirmed that besides knowledge, skills can also be acquired via an online program, consistent with previous results that showed that clinical training can be performed online [41]. Moreover, watching videos online also fosters learning [42]. This implies that providing repetitive training by periodically offering the NVC-CST program online would help students make effective communication a habit.

The significantly higher posttest scores for empathy in the experimental group compared to the control group could be attributed to the fact that NVC, which is the fundamental principle of the NVC-CST program, is based on respect and the understanding of others [38, 43].

In light of past findings indicating that empathy has a positive effect on one’s interpersonal competency [38, 44], and that empathy of newly-graduated nurses affects their interactions with their preceptors [10], nursing students who completed training through the NVC-CST program would be more likely to have improved interpersonal competency, and, therefore, have fewer difficulties when interacting with their preceptors as newly-graduated nurses. This is because the program provides for practicing conversations using the NVC principle of observation, where the other person’s words and behaviors are accepted objectively without judgment or criticism; consequently, the person can carry on a conversation based on respect and consideration [25]. Furthermore, engaging in a mutually respectful, empathetic conversation by recognizing one’s own needs in addition to others’, and by not trying to assert one’s own needs, would deepen the bond during a conversation [25].

Consistent with previous studies indicating that NVC training resulted in significantly improved communication skills [25, 27, 38], this study found that NVC training significantly improved the posttest scores on communication skills. Thus, communication skills can be improved with practice and training [24, 43], and an online NVC-CST program can be as effective as in-person training. Thus, this study’s results support expanding the platform for delivering communication training programs. Furthermore, the take-home assignments and brief testimonies utilized in the NVC-CST program also probably contributed to increasing the effectiveness of the program. Though practicing communication skills through methods such as role play is effective, having students apply the learned skills when talking with their family and friends in their daily lives contributed to developing their communication skills. Additionally, instructing participants to write a short testimony of their experiences while completing the given assignments helped them recognize the positive changes in their conversations, which further strengthened their motivation for learning. In a previous study, engaging in NVC increased one’s self-expression and understanding of others [23], which is consistent with the results of the present study.

Self-efficacy refers to confidence in resolving a difficult situation or a challenging task [23]. Our results are consistent with previous findings that hospital staff who underwent a program that integrated mindfulness and NVC showed marked improvements in self-efficacy [45]. Thus, acquiring effective communication skills through the NVC-CST program can increase a nursing student’s sense of self-efficacy in dealing with various situations.

Next, the NVC-CST program did not affect the participants’ anger expression, which is inconsistent with previous results showing that NVC positively changed the anger expression of inpatients receiving treatment for alcohol use disorder [23]. This may be attributable to differences in the study samples. Specifically, the present study utilized a student sample with no known anger expression issues, whereas the previous study employed individuals with an alcoholism problem who had issues with emotion regulation. Furthermore, the period during which this study was conducted may have affected the results. Aside from the possibility that the participants were not specifically placed in situations that could cause anger, it is also possible that the online nature of the NVC-CST program did not provide ecologically valid communication training by introducing anger-provoking situations. Anger management is not a skill like empathy or communication that can be improved with repeated training; instead, it requires an exploration of individual needs in the contexts of anger-provoking situations or people. Therefore, it would have been difficult to provide training specific to anger expression through an online program. Further, though the stages of anger expression were described in words, the details were perhaps not sufficient to vividly portray the reality, which would have undermined the effectiveness of the training. However, while levels of anger did not diminish, improvements in other skills such as empathy, communication skills, and self-efficacy may have also improved anger management. Designing a role play to practice NVC when nurses experience frustration and anger because their needs are not met in clinical settings could further enhance the effectiveness of the program.

Conclusion

In this study, an online NVC-CST program was provided to fourth-year nursing students who were scheduled for graduation, to examine its effectiveness. The program improved students’ empathy, communication skills, and self-efficacy. Administering the program to newly-graduated nurses could improve their nursing performance. Communication skills can be improved through practice, confirming the program’s effectiveness for nursing students scheduled for graduation. Repeated exposure to the NVC-CST program before graduation could help these students maintain good relations with their fellow nurses. This would be based on empathy and an understanding of needs in various communication situations, such as handovers, after being trained by their preceptors in a clinical practice. This could ultimately help newly-graduated nurses adjust to the clinical setting and prevent premature resignations. Notably, this study substantiates the effectiveness of an online education/training program; the NVC-CST program can be utilized in communication training for nursing students without time and place restrictions. However, the unidirectional format should be revised to implement measures to enhance students’ concentration and participation. We also suggest advancing this program by utilizing virtual reality or online simulations, along with communication education and training scenarios for use with nursing students.

This study demonstrates what is likely to help new nurses adapt to their clinical practice. Successful clinical adaptation also allows nurses to keep their jobs. Although there are various factors related to the turnover of hospital nurses, the strength of this study is that it focuses on areas that can be improved.

It often takes long to improve organizational, environmental and cultural factors, and structural problems that contribute to higher turnover. This implies that turnover is influenced by various factors that are involved in a complex relationship. Nevertheless, from the perspective of a new nurse, NVC can be a passive strategy for helping them continue in their jobs and preventing interpersonal problems. This is because, through NVC, the ability to express one’s needs and understand others’ points of view can be improved, which are vital for appropriate workplace engagement.

However, this study has several limitations. The participants were sampled from nursing schools in a specific region; therefore, the findings may not be generalizable to nursing students in other schools. Additionally, it was not possible to directly verify whether this program had a positive effect on the turnover rate and whether the participants experienced improved interpersonal relationships in their actual clinical practice. Future research evaluating the effectiveness of the program should include follow-up assessments after graduation and in the first year of work. For this reason, we propose a follow-up study comparing NVC training among first-year nurses and nurses not trained in NVC.

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10 Dec 2021

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Refer to the following citations

Mittal, P., & Raghuvaran, S. (2021). Entrepreneurship education and employability skills: the mediating role of e-learning courses. Entrepreneurship Education, 4(2), 153–167. https://doi.org/10.1007/s41959-021-00048-6

Mittal, P. (2020). Impact of Digital Capabilities and Technology Skills on Effectiveness of Government in Public Services. In 2020 International Conference on Data Analytics for Business and Industry: Way Towards a Sustainable Economy, ICDABI 2020 (pp. 1–5). IEEE. https://doi.org/10.1109/ICDABI51230.2020.9325647

Chakraborty, P., Mittal, P., Gupta, M. S., Yadav, S., & Arora, A. (2021). Opinion of students on online education during the COVID-19 pandemic. Human Behavior and Emerging Technologies, 3(3), 357–365. https://doi.org/10.1002/hbe2.240

Yadav, S., Chakraborty, P., Mittal, P., & Arora, U. (2018). Children aged 6–24 months like to watch YouTube videos but could not learn anything from them. Acta Paediatrica, International Journal of Paediatrics, 107(8), 1461–1466. https://doi.org/10.1111/apa.14291

Yadav, S., Chakraborty, P., & Mittal, P. (2021). User Interface of a Drawing App for Children: Design and Effectiveness. In Advances in Intelligent Systems and Computing (Vol. 1165, pp. 53–61). https://doi.org/10.1007/978-981-15-5113-0_4

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Reviewer #1: The manuscript discusses the impact of an online training program on attributes that affect interpersonal communication like empathy, self-efficacy, and anger.

I am finding it difficult to make a recommendation for this article as it does not seem to report some important pieces of information to the reader:

1. Please submit the list of questions asked as a part of the standard questionnaires used. Please submit literature showing the validity and generalizability of these psychometric/behavioral assessment tools preferably in relation to other tools, if any. This is important to gauge the relative merits of these tools. It is difficult to rely on the study results without solid literature on the validity and generalizability backing the methods section.

2. The data tables need to show distribution of each test score as we are dealing with a sample of less than 30 units per control and experiment. Inferences from small samples have a higher risk of getting swayed in one direction or the other.

3. The study does not give details of when the training was conducted and when the pre-post tests were done. This in the case of an intervention that is online and informative in nature is important as it determines the test results.

4. The authors also need to clarify how the pre-post surveys were done. Were they online too?

I am a bit worried about the ramifications that can be drawn from these results in the absence of the above listed information.

Reviewer #2: The authors highlighted an important issue in the nursing practices in South Korea. Appreciated. However I have few comments.

1. How did you select your sample size?

2. Provide few more lines about research randomizer and G power program to make it more comprehensible for the readers.

3. Who designed NVC-CST program. The authors mentioned the program facilitator but I found lack of any information about who designed the program and what is the foundation of that training program.

4. Authors mentioned some causes (including inefficient communication) of premature resignation of newly graduate nurses, however I am interested to know why authors focused only one reason.

Rest is OK from my side.

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Reviewer #1: No

Reviewer #2: No

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27 Mar 2022

Response to reviewers

[Reviewer #1]

1. Please submit the list of questions asked as a part of the standard questionnaires used. Please submit literature showing the validity and generalizability of these psychometric/behavioral assessment tools preferably in relation to other tools, if any. This is important to gauge the relative merits of these tools. It is difficult to rely on the study results without solid literature on the validity and generalizability backing the methods section.

Response

Thank you for your detailed review. The assessment tools used in the study have been modified and used according to the culture of Korean students (Please refer below). The questionnaire was of an appropriate length and showed a good sense of self-efficacy. We received content effectiveness index (CVI) advice from two experts from the School of Nursing. The CVI score was found to be 0.8.

2. The data tables need to show distribution of each test score as we are dealing with a sample of less than 30 units per control and experiment. Inferences from small samples have a higher risk of getting swayed in one direction or the other.

Response

Thank you for your detailed review. The normality of the baseline scores for both groups was tested using the Kolmogorov–Smirnov test, and baseline homogeneity was tested using the Chi-squared test, Fisher’s exact test, and t-test.

3. The study does not give details of when the training was conducted and when the pre-post tests were done. This in the case of an intervention that is online and informative in nature is important as it determines the test results.

Response

The pre-tests of the experimental and the control groups were conducted online on October 5, 2020, using Google questionnaire. The NVC program, in which only the experimental group participated, was conducted between October 5 and October 30, 2020. An online post-test using Google questionnaire was conducted for both experimental and control groups on October 30, 2020.

4. The authors also need to clarify how the pre-post surveys were done. Were they online too?

Response

Thank you for your review. The pre-post surveys were conducted online using Google forms.

[Reviewer #2]

1. How did you select your sample size?

Response

We referred to previous studies related to NVC (Yang, J., & Kim, S. (2020). Effects of a nonviolent communication-based training program for inpatient alcoholics in South Korea. Perspectives in Psychiatric Care).

The sample size to achieve the study objectives was determined using the G*Power 3.1 Program; the minimum sample size was calculated to be 42, with 21 in the experimental group and 21 in the control group (effect size 0.80, significance .05, power .80, two-tailed test). Considering a potential 30% withdrawal rate, 56 students were enrolled. One control group participant dropped out, resulting in 28 participants in the experimental group and 27 in the control group. The effect size was established to be 0.87 in a Korean study that analyzed NVC-based interventions (Han, M., & Lee, K. (2017). Effects of communication ability enhancement program for nursing students in Korea: A systematic review and meta-analysis. The Journal of Korean academic society of nursing education, 23(1), 15–26.).

2. Provide few more lines about research randomizer and G power program to make it more comprehensible for the readers.

Response

In this study, participants were assigned to experimental and control groups using the Research randomizer (https://www.randomizer.org/) program. The number of groups (two) was entered into the program, and the total number of people (56) for the group was entered. Subsequently, the participants were assigned to the experimental and control groups based on the numbers assigned to them by the program.

3. Who designed NVC-CST program. The authors mentioned the program facilitator but I found lack of any information about who designed the program and what is the foundation of that training program.

Response

NVC-CST was developed by the main researcher (Jeongwoon Yang). Also, NVC-CST is a program developed based on NVC (Nonviolent Communication), which was developed by Marshall Rosenberg. It is a specific conversational model that focuses on two components essential to building mature relationships: honest expression and empathic listening (Rosenberg, Marshall B. (1983). A Model for Nonviolent Communication. Philadelphia PA: New Society Publishers.).

4. Authors mentioned some causes (including inefficient communication) of premature resignation of newly graduate nurses, however I am interested to know why authors focused only one reason.

Response

I agree with your opinion that, there are various factors such as the working environment, wages, and communication conflicts in the turnover of new nurses. It is impossible to solve structural problems such as the working environment and wages with individual efforts. However, conflict resolution through the acquisition of communication skills is possible through individual efforts. Therefore, this study emphasized communication skill training.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

21 Apr 2022

An online communication skills training program for nursing students: A quasi-experimental study

PONE-D-21-33565R1

Dear Dr. Kim,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Sergio A. Useche, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: please add a sentence or two detailing when the pre and post test were conducted. The dates of the intervention and the pre and post test will be helpful.

Reviewer #2: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

25 Apr 2022

PONE-D-21-33565R1

An online communication skills training program for nursing students: A quasi-experimental study

Dear Dr. Kim:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

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Academic Editor

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