implementing EBP

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Nurse Education Today

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Implementation of an SBAR communication program based on experiential
learning theory in a pediatric nursing practicum: A quasi-experimental study
Ju-Yeon Uhma, YoungJi Koa,⁎, Suhee Kimb
a Department of , Daegu Haany University, 1 Haanydaero, Gyeongsan-si, Gyeongsangbuk-Do, 38610, Republic of Korea
b School of and Research Institute of Science, Hallym University, 1 Hallimdaehak-gil, Chuncheon-si, Gangwon-do 24252, Republic of Korea

A R T I C L E I N F O

Keywords:
Pediatric nursing practicum
Role play
SBAR
students

A B S T R A C T

Background: Effective communication by nurses is crucial to ensure patient safety. A structured communication
program increases communication clarity, education satisfaction, and positivity during interprofessional colla-
boration among students. In an effort to facilitate effective communication between nurses and physicians, the
well-known structured communication tool SBAR (Situation, Background, Assessment, and Recommendation)
has been extensively used in clinical and educational settings.
Objectives: The purpose of the study is to investigate the impact of an SBAR communication program on com-
munication performance, perception, and practicum-related outcomes in senior-year nursing students.
Method: The study employed a non-equivalent control group quasi-experimental design and implemented the
tool in the pediatric nursing practicum of a nursing school. The experimental group participated in a SBAR
program, where role playing using SBAR techniques for different scenarios was used to improve practical
communication among nursing students. The SBAR program was developed based on Kolb’s Experiential
Learning Theory. Communication performance was assessed via the SBAR communication tool and the com-
munication clarity scale. Communication perception was measured by handover confidence level. Practicum-
related outcomes of clinical practice self-efficacy, perceived nurse–physician collaboration, and practicum sa-
tisfaction, were also evaluated.
Results: The experimental group demonstrated significantly higher SBAR communication (p < .001), commu- nication clarity (p < .001), and handover confidence (p < .001) than the control group. Clinical practice self- efficacy, perceived nurse–physician collaboration, and practicum satisfaction did not differ. Conclusions: The SBAR program in a pediatric nursing practicum improves SBAR communication, commu- nication clarity, and perceived handover confidence in senior-year nursing students. 1. Introduction Collaborative practice in clinical settings is essential for achieving optimal patient outcomes (World Health Organization, 2010). Effective communication between nurses and physicians leads to the provision of comprehensive services for patients (Lancaster et al., 2015). Commu- nication performance has been considered by several organizations to be one of the crucial outcomes of nursing education (Australian and Midwifery Federation, 2014; Society of Pediatric , 2017). However, unclear and imprecise communication is common among healthcare personnel (Tang et al., 2013). A lack of professional com- munication and collaboration may be one of the main causes of medi- cation errors (Farzi et al., 2017). Simulations are increasingly used to improve the practical capacity of students in various nursing education programs. Until now, simula- tion-based education regarding communication has focused mainly on communication between clinicians and patients (Kaplonyi et al., 2017; MacLean et al., 2017). Notably, it has been found that nursing students experienced difficulties in notifying doctors of patients' health problems in the pediatric nursing practicum (Bowling, 2015). Moreover, nursing reported moderate to severe stress from simulation education, which may be related to critiques by faculty and peers (Cantrell et al., 2017). These reports indicate the limitations of excessive pedagogical de- pendency on simulation-based approaches to communication educa- tion. Furthermore, the Korean Accreditation Board of Education (2017) only accepts simulation classes for 12% of the 1000 required practical hours; the greater part of the clinical nursing course is practica https://doi.org/10.1016/j.nedt.2019.05.034 Received 12 February 2019; Received in revised form 8 April 2019; Accepted 20 May 2019 ⁎ Corresponding author at: Department of , Daegu Haany University, Republic of Korea. E-mail addresses: [email protected] (Y. Ko), [email protected] (S. Kim). Nurse Education Today 80 (2019) 78–84 0260-6917/ © 2019 Elsevier Ltd. All rights reserved. T http://www.sciencedirect.com/science/journal/02606917 https://www.elsevier.com/locate/nedt https://doi.org/10.1016/j.nedt.2019.05.034 https://doi.org/10.1016/j.nedt.2019.05.034 mailto:[email protected] mailto:[email protected] https://doi.org/10.1016/j.nedt.2019.05.034 http://crossmark.crossref.org/dialog/?doi=10.1016/j.nedt.2019.05.034&domain=pdf in hospitals, which largely focus on case reports reflecting the nursing process, and have been criticized for their limited approach to real practice in South Korea (Shin et al., 2017). Therefore, strengthening interdisciplinary communication programs linked to hospital clinical practica is needed in order to improve the practical capacity of nursing schools. 1.1. review 1.1.1. Standardized communication tool In an effort to facilitate effective communication between nurses and physicians, SBAR (Situation, Background, Assessment, and Recommendation), a well-known structured communication tool, has been extensively used in clinical and educational settings (Buckley et al., 2016; Compton et al., 2012). SBAR communication should in- clude the patients' current problems (Situation), medical history (Background), current symptoms and vital signs (Assessment), and nurses' recommendations (Recommendation). The SBAR educational program improves communication performance among nurses (Chaharsoughi et al., 2014); in addition, it increases communication knowledge (Wang et al., 2015), communication clarity (Yu and Kang, 2017), and attitude of interprofessional collaboration (Kostoff et al., 2016) among nursing students. 1.1.2. Application of experiential learning theory and role play in communication programs Lisko and O'Dell (2010) developed a medical-surgical course in- cluding clinical experience in the nursing laboratory, skill demonstra- tion, scenario-based presentation, and reflection, based on Kolb's ex- periential learning theory. The experiential learning theory emphasizes the experiential aspect of the learning process; hence, it seeks to con- tinuously change the experiences of the student. This ongoing educa- tional process of alternating the student's experiences help build their knowledge and influence schema (Kolb, 1984). An educational com- munication program based on experiential learning theory should be considered by nursing educators. Virtual environments and role play using scenarios could allow students to train themselves according to real nurses' roles. Scenario-based learning has been shown to enhance the attitude of nursing students (Richardson et al., 2017). Role play is also an experiential learning technique for introducing learners to be- have appropriately in various situations, as it provides them with tar- geted practice and feedback to acquire and improve skills and integrate new information (Joyner and Yound, 2006). Role play has been shown to be one of the most effective strategies in education for helping stu- dents learn how to communicate with each other (Chan, 2012; Yu and Kang, 2017). Therefore, this study aimed to evaluate whether an SBAR commu- nication program based on experiential learning increased nursing students' communication performance, communication perception, and practicum-related outcomes. 2. Methods 2.1. Research design A quasi-experimental non-equivalent control group pretest and posttest design was implemented in a pediatric nursing practicum. The experimental group participated in the SBAR communication program, composed of instruction in the SBAR technique, scenarios, and role playing, while the control group received the usual practicum education. The four-phase program was conducted within 2 weeks from pre-practicum orientation, before the one-week practicum, to the con- ference after the finish of the practicum. The impact of the program on communication performance, communication perception, and prac- ticum-related outcomes was evaluated using instruments to measure communication, communication clarity, handover confidence, practicum satisfaction, clinical practice self-efficacy, and nurse–physi- cian collaboration through comparison of pretest and posttest in both groups. 2.2. Settings and participants The programs were delivered through a pediatric nursing practicum for a bachelor of nursing course at a university in South Korea. In a previous study, the effect size was 0.7 (Noh et al., 2016). An α of 0.05 and power of 0.9 meant that an adequate sample size was 36 per group using G*Power. The study involved a total 81 participants, with 41 students in the control group and 40 students in the experimental group. The achieved actual power was 0.928. 2.3. The SBAR communication program 2.3.1. Development of the SBAR program The SBAR communication program was developed based on ex- periential learning theory (Kolb, 1984). New knowledge transformed from experience into a cognitive framework can induce ideas in stu- dents to solve problems and perform new skills. The learning process has four phases: concrete experience, reflection, abstract con- ceptualization, and active experimentation (Kolb, 1984). We viewed pre-practicum orientation based on scenario-based learning as the concrete experience stage, which relies on open-mindedness. This was followed by giving the students reflective experiences of communica- tion between nurses and physicians in the real world through articu- lating SBAR components of communication situations in clinical set- tings and analyzing their relevance. Subsequently, the abstract conceptualization stage comprised presenting students with situations in clinical settings and asking them to identify gaps between theory and practice regarding SBAR. In the final stage, an active experiment was implemented for virtual patients, using scenarios and real patients in clinical settings. The SBAR communication program development process consisted of three phases, including a literature review, development of scenarios, and evaluation of scenarios (Table 1). The program was composed of a pediatric nursing practicum with an additional four-hour course based on existing literature (Bowling, 2015; McCaffrey et al., 2012; Yu and Kang, 2017). Five scenarios involving common pediatric health pro- blems were developed by a faculty with 15-years' experience in pe- diatric clinical practice. Three were modified from previously devel- oped scenarios for students in a pediatric nursing practicum (Kim et al., 2017). Two scenarios were newly developed. Two pediatric nursing professionals reviewed the contents of the scenarios. The experimental group students participated in the SBAR communication program in a pediatric nursing practicum. The program was conducted according to the experiential learning theory's stages and provided students with guidelines regarding the program process. 2.4. Procedures The SBAR program was delivered to each practicum team for a one- week pediatric nursing practicum and an additional four-hour course. A class of senior nursing students was divided into A class and B class. A class was set as the experimental group and B class was set as the control group. Six teams per class were composed of 6 or 7 nursing students. The program was facilitated in the conference room of the school and at the hospital. One practicum instructor facilitated the program, introducing the SBAR technique, providing scenarios to stu- dents, checking students' SBAR cases, and guiding students' role plays. The program was delivered in four phases, starting one week after the orientation of the hospital practicum and pretest. The first phase developed concrete experience in a clinical setting using scenarios. The instructor lectured on the SBAR technique; the lecture included the importance of interprofessional communication, what SBAR is, how we J.-Y. Uhm, et al. Nurse Education Today 80 (2019) 78–84 79 can communicate using the SBAR tool, and the first scenario. Students practiced by role playing SBAR communication using the second sce- nario, about patients with constipation. The instructor informed stu- dents of an assignment about nurses' SBAR cases in which they should engage in observations in the hospital unit for the practicum of the next week. In the second phase, on practicum days 1 and 2, was carried out to allow the reflective observation element of experiential learning. Students were observing the use of SBAR in the clinical setting on their own. They were taught to recognize how SBAR is used in the clinical setting, experience professional medical communication in the real world, and reflect on components omitted in the SBAR case in this practical setting. In addition, they were given the task of listening to and organizing nurses' communication content using the SBAR tool. The third phase, on practicum day 3, was delivered during an in- structor's visit to the clinical setting. Two to four students engaged in role play regarding each SBAR case and shared other students' cases. Students role played being a clinical nurse notifying the doctor about the patient's status. The instructor gave students feedback regarding the adequacy and significance of the SBAR case in each situation. Students were trained in the third scenario, about patients with febrile convul- sion. Finally, the instructor helped students to understand gaps between theory and practice using both case presentations and scenarios to support their abstract conceptualization, because some SBAR compo- nents were frequently omitted. The instructor informed students of second assignment, on other SBAR cases. In the fourth phase, on practicum days 3 and 4, students again observed the use of SBAR on their own in the clinical setting. They actively experienced SBAR cases in the real clinical world and prepared second SBAR cases in their hospitals during the remaining hospital practicum days. Then, during the practicum conference after the hos- pital practicum ended, all team members participated in role plays regarding their cases and received feedback from the instructor. Students applied SBAR using the fourth scenario, about a patient with congestive heart failure, as an active experimentation phase. In con- trast, the control group students learned regular nursing processes and therapeutic communication with patients and family, in only 30 min. 2.5. Data collection The data were collected from February through June 2018. For a pretest, participants filled out questionnaires. Then, audio recordings using the bronchiolitis scenario were conducted after the end of general orientation to the practicum. The posttest was conducted using the same questionnaires, and audio recordings were made using the sce- nario of patients with acute gastroenteritis following the end of the program. 2.6. Study variables and instruments 2.6.1. Communication performance SBAR communication was measured using an instrument to assess the accuracy with which nursing students reported patient information to physicians that employed the SBAR tool regarding patients' problem (Yu and Kang, 2017). This scale contained 12 items in four categories: Situation, Background, Assessment, and Recommendation. Each item in the tool was rated on a three-point Likert-type scale, with higher scores indicating greater reporting accuracy. Two raters completed the eva- luation tool regarding SBAR communication. The Cohen's kappa with linear weighting (a measure of inter-rater reliability for ordinal cate- gories) (Parker et al., 2013) was 0.736 (95% confidence interval [CI] 0.621–0.851). Kappa values of 0.61–0.80 indicate good agreement (Landis and Koch, 1977). Communication clarity was measured using the interprofessional Table 1 SBAR communication program. Learning processa Practicum day Contents Methods Duration Pretest Scenario I Pretest [1] Concrete experience Orientation SBAR orientation Scenario I Scenario II Small group teaching Discussion Role-plays 1.5 h [2] Reflective observation Day 1-2 SBAR experience Observing SBAR in clinical settings 2 days [3] Abstract conceptualization Day 3 Clinical SBAR case I Scenario III Role-plays Providing feedback Small group teaching Discussion 1 h [4] Active experimentation Day 4-5 SBAR experience Observing SBAR in clinical settings 3 days Conference Clinical SBAR case II Scenario IV Role-plays Providing feedback Small group teaching Discussion 1.5 h Posttest Scenario V Posttest a The learning process was based on experiential learning theory (Kolb, 1984). Scenarios included the following health problems: bronchiolitis with desaturation, febrile convulsion, constipation, ventricular septal defect with heart failure, and acute gastroenteritis with severe dehydration. J.-Y. Uhm, et al. Nurse Education Today 80 (2019) 78–84 80 clinical communication tool (Marshall et al., 2009). The scale consisted of eight questions with a five-point Likert scale. The Cohen's kappa with quadratic weighting (a measure of inter-rater reliability for five ordinal categories) between the two raters was 0.724 (95% CI 0.483–0.964). 2.6.2. Communication perception Handover confidence was assessed using a visual analog scale (VAS), with a higher score indicating stronger confidence (Yu and Kang, 2017). 2.6.3. Practicum-related outcomes Practicum satisfaction was also evaluated using a VAS, between 0 (dissatisfied) and 10 (fully satisfied). Perceived nurse–physician colla- boration level was evaluated using a Korean version of the nurse–- physician collaboration scale, including 27 questions measured on a five-point Likert scale (Mun, 2015). Cronbach's α value was 0.91. Clinical practice self-efficacy through the practicum was measured using a Korean version of the learning self-efficacy scale to assess the individuals' perception related to trying new things, including 10 items with a seven-point Likert scale (Park and Kweon, 2012). Cronbach's α value was 0.93. 2.7. Data analysis Descriptive statistics, such as mean and percentage, were used to assess participants' characteristics. We conducted chi-squared tests and independent t-tests to examine the homogeneity of the groups and used an independent t-test for comparison of outcomes between the control and experimental groups using SPSS 24.0. 2.8. Ethical considerations This study was performed after receiving approval from the in- stitutional review board of D Hospital. The students were informed of the need, purpose, and methods of this study by the researcher and voluntarily participated in this research. 3. Results The students in the experimental group were similar in demo- graphics to those in the control group (Table 2). The results indicated that students in the experimental group re- ported significantly higher SBAR communication, communication clarity, and handover confidence compared to students in the control group. Clinical practice self-efficacy, perceived nurse–physician colla- boration, and practicum satisfaction did not differ between the groups. There was a significant increase in SBAR communication, with scores of 17.65 ± 3.16 for the experimental group and 9.02 ± 2.52 for the control group at posttest (p < .001). Moreover, there was a significant difference in all domains' scores between two groups. In the control group, the mean differences between posttest and pretest scores of subscales were 1.02–0.56. In the experimental group, differences between posttest and pretest scores of subscales were 1.55–2.87 (Table 3). Students showed a significant increase in communication clarity at posttest, with scores of 29.90 ± 3.32 for the experimental group and 22.41 ± 2.24 for the control group (p < .001) (Table 3). There were significant differences in handover confidence at posttest, with reporting scores of 6.05 ± 1.63 in the experimental group and 5.14 ± 1.81 in the control group (p < .001) (Table 4). There were no significant differences in the practicum satisfaction between the two groups: 7.92 ± 1.54 in the experimental group and 7.46 ± 1.50 in the control group (p = .876). There were no significant differences in the clinical practice self-efficacy: 59.52 ± 6.64 score in the experimental group and 56.87 ± 6.87 score in the control group (p = .109). The nurse–physician collaboration was 101.47 ± 10.73 in the experimental group and 98.00 ± 12.47 in the control group (p = .904) (Table 4). 4. Discussion The SBAR communication program included effective components, such as scenario and role play on nursing education, as well as SBAR Table 2 Participants’ demographics. Variables Categories Total (n=81) N(%) or M ± SD Exp (n=40) N(%) or M ± SD Cont (n=41) N(%) or M ± SD t or Chi- square p Age 22.32 ± 2.43 22.65 ± 21.97 22.65 ± 2.93 1.26 0.209 Gender Female 73 (90.1) 38 (95.0) 35 (85.4) 2.11 0.264 Male 8 (9.9) 2 (5.0) 6 (14.6) Religion Yes 32 (39.5) 14 (35.0) 18 (43.9) 1.77 0.621 No 49 (60.5) 26 (65.0) 23 (56.1) Attendance of communication class Yes 46 (56.8) 25 (62.5) 21 (51.2) 1.05 0.372 No 35 (43.2) 15 (37.5) 20 (48.8) Activity of club or student council Yes 51 (63.0) 27 (67.5) 24 (58.5) 0.69 0.492 No 30 (37.0) 13 (32.5) 17 (41.5) Satisfaction of theory subjects Not satisfied at all 0 0 0 −0.90 0.367 Not satisfied 1 (1.2) 0 1 (2.4) Neutral 21 (25.9) 9 (22.5) 12 (29.3) Satisfied 53 (65.4) 28 (70.0) 25 (61.0) Very satisfied 6 (7.4) 3 (7.5) 3 (7.3) Satisfaction of clinical practice Not satisfied at all 0 0 0 −0.86 0.392 Not Satisfied 2 (2.5) 0 2 (4.9) Neutral 25 (30.9) 12 (30.0) 13 (31.7) Satisfied 50 (61.7) 26 (65.0) 24 (58.5) Very satisfied 7 (8.6) 2 (5.0) 5 (4.9) Average academic grade < 2.5 5 (6.2) 1 (2.5) 4 (9.8) 3.98 0.408 2.5−3.0 27 (33.3) 7 (17.5) 20 (48.8) 3.0−3.5 30 (37.0) 14 (35.0) 16 (39.0) > 3.5 19 (23.5) 18 (45.0) 1 (2.4)

Experience of hospital visiting
program

Yes 3 (3.7) 1 (2.5) 2 (4.9) 0.32 > 0.999
No 78 (96.3) 39 (97.5) 39 (95.1)

Experience of hospital internship Yes 6 (7.4) 1 (2.5) 5 (12.2) 2.77 0.096
No 75 (92.6) 39 (97.5) 36 (87.8)

J.-Y. Uhm, et al. Nurse Education Today 80 (2019) 78–84

81

tools. Both scenarios and role play are extensively used in various
nursing curricula and these strategies have various advantages in stu-
dents’ learning (Richardson et al., 2017; Thomas et al., 2009; Yu and
Kang, 2017). Chaharsoughi et al. (2014) carried out the SBAR program
with role plays for nurses. We included common childhood health
problems, such as respiratory and febrile disease. Scenarios pertaining
to major health problems could help nursing students improve their
clinical capacity because they cannot experience all clinical situations
in the hospital practicum. In addition, the introduction of SBAR before
the practicum could enhance students’ interests in nurse–physician
communication. Clarity and precision of message are important for
effective interprofessional communication (Robinson et al., 2010).

The SBAR communication program was implemented in a pediatric
nursing practicum. The use of scenarios and observation of SBAR
communication in clinical settings provided concrete experience to the
students, helping them to understand communication problems be-
tween nurses and physicians. Understanding gaps between theory and
practice is necessary for students’ abstract conceptualization regarding
the use of SBAR because parts of information conveyed during com-
munication between nurses and physician tend to be omitted (Joffe
et al., 2013). Accordingly, the instructor provided participants feedback
about real cases observed in the clinical setting. Although simulation-
based educational programs are effective in educational contexts, par-
ticularly as it pertains to communication, there has been limited re-
search testing whether this communication improvement in the simu-
lation room reflects real performances in hospitals (Kaplonyi et al.,
2017).

First, the implementation of SBAR communication effects an in-
crease of SBAR communication. In a previous study, the SBAR program
with role play for nurses positively influenced SBAR communication
(Chaharsoughi et al., 2014). All four categories’ scores significantly
increased following participation in the program, with particularly
higher improvements occurring in the Background domain. This is
noteworthy because nurses often omit information or report wrong
information regarding the background cue (Joffe et al., 2013). There
was a small change in the Situation domain, suggesting that nursing
students did recognize the aggravating situation of the patients

(Bogossian et al., 2014). The total score of 17.65 at posttest following
the implementation of the program was higher than that of 17.29 in a
previous study with SBAR role play using simulation, and there were
significant changes in scores for the Situation, Background, and Re-
commendation domains, but not the Assessment domain (Yu and Kang,
2017). In particular, the improvement of the Recommendation domain
following the program is noteworthy, because Recommendation accu-
racy is low among nurses (Spooner et al., 2016).

Second, the program increased students’ perception on commu-
nication clarity. This result is similar with that of a study that conducted
an SBAR education program involving role play and simulator-en-
hanced communication clarity (Yu and Kang, 2017). The program was
not effective in terms of the “Emphasis on an emergency patients’
problem” item, a result that resembles the finding of a previous study
(Yu and Kang, 2017). Therefore, nursing faculties should educate stu-
dents to recognize and respond to clinical deterioration (Bucknall et al.,
2016).

Third, the program enhanced nursing students’ handover con-
fidence. Findings of previous studies were mixed. Thomas et al. (2009)
reported that simulation-based education had a positive impact on
handover confidence, while Yu and Kang (2017) reported that there
was no significant improvement. This is possibly because our program
provided various scenarios and repeated feedback to nursing students
who have been adequately exposed to SBAR cases.

Fourth, the program was not effective in increasing practicum sa-
tisfaction. The posttest means of 7.92 in the experimental group and
7.46 in the control group were higher than those of 7.42 in the ex-
perimental group and 5.35 in the control group in a previous study (Yu
and Kang, 2017), but there was no significant difference between the
two groups in this study. Practicum satisfaction has relationships with
various factors, such as stress and depression (Jeong and Park, 2013),
curriculum, grades, and satisfaction on nursing major (Kim et al.,
2013). To enhance students’ practicum satisfaction, efforts to decrease
psychological distress related to the practicum, as well as improvements
of educational factors by school faculty members, may be necessary.

Fifth, this program was not effective in increasing clinical practice
self-efficacy. Simulation education’s effects on self-efficacy depend on

Table 3
Comparisons of SBAR communication and communication clarity between the two groups.

Variables Categories Range Groups Pre-test (M ± SD) Post-test (M ± SD) t or F p

SBAR communication S 0–6 Exp (n = 40) 3.47 ± 1.35 5.02 ± 1.04 −5.25 < 0.001 Cont (n = 41) 3.68 ± 1.57 3.60 ± 1.44 B 0–6 Exp (n = 40) 0.95 ± 1.01 3.82 ± 1.81 −6.25 < 0.001 Cont (n = 41) 0.74 ± 0.97 1.29 ± 1.28 A 0–10 Exp (n = 40) 5.00 ± 1.66 6.97 ± 1.74 −6.04 < 0.001 Cont (n = 41) 5.02 ± 1.75 4.00 ± 1.58 R 0–2 Exp (n = 40) 0.05 ± 0.22 1.82 ± 0.44 −16.98 < 0.001 Cont (n = 41) 0.14 ± 0.52 0.12 ± 0.33 Total 0–24 Exp (n = 40) 9.47 ± 2.43 17.65 ± 3.16 −11.18 < 0.001 Cont (n = 41) 9.58 ± 2.67 9.02 ± 2.52 Communication clarity Total 0–40 Exp (n = 40) 22.40 ± 2.20 29.90 ± 3.22 −12.11 < 0.001 Cont (n = 41) 22.98 ± 3.00 22.41 ± 2.24 S, Situation; B, Background; A, Assessment; R, recommendation. Table 4 Comparisons of handover confidence, practicum satisfaction, clinical practice self-efficacy, and perceived nurse-physician collaboration between the two groups. Variables Groups Pre-test (M ± SD) Post-test (M ± SD) M (df) ± SD t p Handover confidence Exp (n = 40) 4.27 ± 1.73 6.05 ± 1.63 1.77 ± 1.84 −4.40 < 0.001 Cont (n = 41) 5.02 ± 1.73 5.14 ± 1.81 0.12 ± 1.51 Practicum satisfaction Exp (n = 40) 7.25 ± 1.72 7.92 ± 1.54 0.67 ± 2.20 −0.15 0.876 Cont (n = 41) 6.85 ± 1.31 7.46 ± 1.50 0.60 ± …