Development of Communication Skills through virtual reality on Nursing school students: Clinical Trial Desarrollo de las competencias de comunicación a través de la realidad virtual en estudiantes de Enfermería: Ensayo Clínico Running Head – Virtual Reality for Communication Skills Abstract word count: Word count: Number of tables: 3 Number of figures: 2 Abstract Introduction: Virtual simulation is a recreation of reality where it gets represented through virtual reality goggles and involves real people that operate simulated systems. There are multiple studies that demonstrate its benefits in the development of instrumental skills, but there are few randomized studies that prove its efficacy in the development of communication and interpersonal relationships skills. Objective: To develop a virtual reality simulator to develop the communication skill and compare its results with a traditional workshop based on cases and theoretical content explained through video. Method: A randomized and controlled clinical trial was made, with a pretest and a posttest. Participants were first year students from the Faculty of Nursing, Complutense University of Madrid, Spain (n=100). The sample was divided in two groups: The Intervention Group (n=50) was provided a virtual reality simulation teaching process as a novel resource, whilst the Control Group was provided with a case-based traditional workshop. For data analysis, SPSS v24 software was used. Since data followed a normal distribution, it was analyzed with Student’s t-test for independent samples, for group samples comparison, and ANOVA, to find the difference amongst age subgroups. Results: Significant changes were observed at the time of evaluating the skills for the Intervention Group (p <0.01) in comparison with the Control group. Conclusion: Both interventions are effective after the first evaluation, however, virtual reality-based intervention stands above the usual method and showed better results in older students. Keywords: Clinical simulation, scenario, teaching, nursing, health sciences, debriefing. Introduction Simulation is conceived as a mean that reproduces the behavior of a given system in certain conditions of clinical practice in a controlled space1. In this sense, simulators constitute a procedure for both the shaping of concepts and building knowledge in general, as well as the application of these to new settings on which, for various reasons, the students cannot access from the methodological setting where their learning develops1,2. That is how virtual reality (VR) could help, by generating that practice and learning environment. The VR was applied initially to help Nursing school students with the acquisition of basic nursing skills3,4. It has also been applied on complex nursing settings, such as emergency and disaster management5,6; accute situations7, chronic situations8, and home care visits9. The VR stands as an ideal learning method to create new educational environment, enriches the learning media and allows instructors to understand the needs of each student without overlooking the group dynamics10,11. One classification method of simulation-through-virtual-reality divides them in three categories, according to the immersion degree each of them produces in the participant12: The immersive methods would be those based on scenario simulation (2D or 3D), on which the users perceive said scenes with a first person on-site feel to it, as if they were really immersing within it. The user has a first person perspective using 360° goggles and headphones, in which case, the experience is a greatly immersive. The semi-immersive methods would be those based on watching virtual scenes in third person, with 360° goggles and headphones that allow the observations of the entire setting. Non immersive methods give the feeling to the user of being watching said virtual scenes “from a window”, like a computer or mobile screen, as with Second Life, which can be a barrier for immersion13. On 35% of studies, researchers used Second Life platform to develop the virtual simulation, followed by Unity 3D and vSim. An essential component of this learning method is debriefing, defined as the conversation among several people to review a real or simulated event, on which participants analyze their actions and reflect on the role of thought processes, psychomotor skills and emotional states, to improve or uphold their performance in the future14. Background Among the transversal skills that nursing students must develop and demonstrate worldwide, apparently, are those related to communication skills and interpersonal relationship, for this, there are different documentary references that endorse that justify this need. Based mainly on the framework of competence of the CIE15 the framework of competences of the EFN16, and the European Directive17, as well as Ministerial Order CIN / 213418 for the nursing degree in Spain. Nursing professionals must possess communication and interpersonal skills. Regardless of the context, they must demonstrate these skills, therefore, using VR as a means to understand them is an excellent way for them to be evaluated. Above all, if there are tools that can assess communication skills in any context. Concerning Bachelor of Science in Nursing, the undergraduate study plan of the Faculty of Nursing of the Complutense University of Madrid, Spain, is developed in 4 academic years with 240 ECTS, which are made up of 5 modules. These modules include basic training and nursing science, where knowledge is collected with a nursing approach from a holistic point of view, as well as the elements of therapeutic action that is taught between the first courses. The use of clinic simulation as a training tool for health care provider has increased exponentially in the last decade. This is due to its higher efficacy for learning how to make clinical decisions, for the acquisition of technical skills and for enhanced teamwork, compared to the traditional teaching methods19,20. Also, the acquired skills transfer to the work environment, which translates into an improvement on clinical results. All of it, without risking patients or health care provider21. Many are the studies that describe the benefits of VR in teaching, such as: enhancement in understanding, time saving, longer lasting acquired knowledge, more attentive and cooperative students, teaching customization and an increase in students’ motivation and interest10,11. Regarding Nursing profession, VR is becoming one of the most powerful technologies to innovate and to research in the improvement of nursing care and learning, through this simulated environment. Rourke S.22 shows that VR leads to educational results similar or superior to traditional simulated practice. Nevertheless, when the term “virtual reality” is used, it must be considered as quasi experimental methods most of them, and that the result measurement uses different methods but some not as rigorous, since many VR devices are employed. The results related to psychomotor skills performance support the use of VR, proving that it is a method that allows for a swifter acquirement and learning, but that performance precision may decrease. For that, Shin et al23, share the positive aspects of VR use, but recommends simulators to follow the 2016 design norms by the International Nursing Association for Clinical Simulation and Learning. Taking into account this previous research context on VR simulation, the current work is made with the objective of developing a VR simulator to evaluate the communication skill and to see if it achieves better results than a traditional workshop based on cases and theoretical content explained through video. Method A randomized and controlled clinical trial was made, with pretest and posttest, with first year students (N=366) from the Faculty of Nursing, Physiotherapy and Podiatry, at Complutense University of Madrid, Spain; between September and December 2019. Selection of volunteers and allocation process Participant were first year volunteer students. This study was made through the 2018-2019 school year. All enrolled students (N=366) were invited via email to participate voluntarily in the study. Those who volunteered (n=105) were convened to an informative meeting through a virtual simulation workshop at the virtual campus, on which each student could read a document describing the project and requesting their consent. This meeting took place in a Faculty’s computer room and dates for the meeting on which intervention was requested were provided (see flow diagram 1). This study was approved by the Faculty of Nursing, Physiotherapy and Podiatry Ethics Committee at the Complutense University of Madrid, registration number 06/18_CI_FEFP; and the Ethics and Clinic Investigation Committee at Madrid’s Hospital Clínico San Carlos, Spain, registration number C.I. 18/005-E. Both ruled it as favorable since including voluntary students and doesn’t entail any risk for participants. The sample size of the study was determined by a one-tailed unpaired t-test, Type-1 error of 0.05, a statistical power of 0.80 and an effect size of d=0.50. This study required a total of 100 students, 50 per group. For the analysis, G*Power software was used. On a second meeting, group randomization was made. Students were allocated through a simple random allocation using IBM SPSS Statistics version 24. (IBM Corp. Armonk, N.Y., USA). Volunteers completed an anonymous questionnaire with each student’s socio-demographic data, through the assignment of a 6-digit number of the student’s choice, without possibility for researchers to identify them. Afterwards they completed the communication and interpersonal relationships skills self-evaluation. On a third meeting, students allocated in the intervention group were sent to a specially conditioned hall within the Faculty library, provided with five computers, VR goggles and headphones. Control group students were sent to the Faculty’s computer room. The experimental (simulation) group, adhered to the following execution sequence: 1. Entrance into the conditioned hall in groups of five. 2. At the hall, a technical expert was present for contingencies prevention and management. 3. Students were given the instruction to enter into the online campus and to follow the proposed sequence. They were also instructed in the use of VR goggles. 4. The virtual campus had an explanatory presentation for the session to be performed. 5. Each student performed each case, allowing five minutes for personal reflection. 6. Discussion of the students’ performance, each supporting their own answers, via Google Meets video-call. 7. Elaboration of a plan of action for each student to improve their performance in similar situations, which were uploaded to the virtual campus. The control group (traditional workshop), performed the following contents: 1. Viewing of theoretical contents about communication skills in health care provider, for a ten-minute length. 2. Completion of a written case with similar content to that of the virtual simulator. 3. Sharing and solving doubts in an interactive Q&A forum. 4. Instructor’s feedback on the correct answers. Two months after the third meeting and intervention, students were evaluated on communication and interpersonal relationships skills once again. It is determined to carry out the follow-up two months later in relation to the recommendations by Furr M. (2018)24 as a maximum time of 8 weeks after the first test. Evaluation Method As evaluation method, the Nursing Skills Assessment Scale (ECOEnf)25,26, was used, an evaluation tool for Nursing professionals. The design of the scale is based on the competencies established for the degree in Nursing in Order CIN / 2134/2008, of July 318, According to the objectives that this study persues, Skill Unit UC6 was used: Communication and Interpersonal Relationships. This tool is valid and reliable, it has a Content validation index (CVI) above 0.85, which indicates that the total UCs utilized to measure Nursing skills have a high content validity. For the Kappa index, it has a total score of 0.83, which indicates a high consistency of concensus from experts for all UC. The current study was made based on UC6: Communication and Interpersonal Relationships, which specifically has a 0.93 CVI Content Validation Index and 0.92 Kappa index. The questionnaire was self-administered and consisted of 19 items, evaluating the situation prior to intervention, and the intervention itself, both at traditional workshop as well as at Virtual simulator. Statistical Analysis A first analysis was made, describing the evaluation’s means, ranges, minima and maxima. Afterwards, a Kolmogorov-Smirnov test for normality was made as well as an adjustment through Lilliefors test to verify the assumption of normality. Given that the dependent variable fitted the normal curve model, a Student’s t-test inferential analysis for related samples was made when comparing the mean, after intervention for both groups. For the means’ difference between the control and the intervention groups, a Student t-test for independent samples was used. For the homogeneity of variance assumption, Levene’s equality of variances test was used. Lastly, ANOVA was performed to find the differences by age and gender subgroups. The main variable in the study is the development of the communication and interpersonal relationships skill level, for that, the differences were obtained between the evaluations completed before and after the interventions. The positive values reveal an improvement between both evaluations. The results were considered statistically significant with a P value <0.05. Regarding the measures of effect size, it was according by Cohen's criteria27, classified as follows: Cohen’s d: 0.2-0.3 = small; in the vicinity of 0.5 = medium, and 0.8 = large. Results. A total of 100 first year students from Nursing school (50 allocated in the control group, 50 in the intervention group) volunteered. Three control group students didn’t continue with the study, two students from intervention group did not continue the follow-up due to loss of classes. (See Figure 1). Table 1 shows the socio-demographic variables and the global evaluations. An age average of 18.34 ± 0.11 SD can be observed at control group, 19.46 ± 1.44 SD at intervention group. For both groups there is a prevalence of female students of 84%. Regarding the student’s pretest measurement, it shows an average of 63.50 ± 1.05 standard deviation in control group and 7.01 ± 0.79 SD for the intervention group, with a remarkable increase in both groups, mainly for the intervention group (8.78 ± 0.63). (See Table 1). Table 2 shows the Kolmogorov-Smirnov statistic test performed to find the data distribution. The existent difference after the intervention has a normal distribution (p > 0.05), reason why a parametric statistical test was made. Regarding the communication skills evaluation with the ECOEnf20,21 tool, there was an improvement on all items, finding a statistical significance; nevertheless, it was observed a lower score at control group on “To ensure that the patient and/or family member has understood the information” (0.046), “To encourage the individual, family or social group to share all information that might be relevant to solve a contingency or to avoid risks” (0.042) and “To demonstrate the ability of active listening with patients as well as team members, and to provide consistent answers” (0.044). For the intervention group the lower score was found on “To encourage the individual, family or social group to share all information that might be relevant to solve a contingency or to avoid risks” (0.049). (See Table 3). The volunteer students’ t-test results showed differences statistically relevant, with higher scores compared to the first test utilizing the usual method on the control group (t 49 = −9.429; P = <.001; d = 1.18). For the intervention group on which VR was used, there were also statistically significant changes, after the first measurement two months later (t 49 = -18.273; P = <.001; d = 2.58). For the homogeneity of variance assumption, it is assumed that variances on both groups are equal (p = 0.134). When comparing means from intervention group versus control group, a statistically significant difference was found; with higher scores for the VR method (t 98 = -7.520; P = <.001; d = 4.30). That is to say that intervention group students (VR group) better developed the communication skill than the control group students. Cohen’s d values reinforce the intervention’s effect size. In regards to the age subgroup evaluation for the control group, there was no statistical significance found, that is to say, scores were similar (F=.680; p=.869). Nevertheless, for the intervention group significant differences were obtained, with higher scores for the 21-22 years old age subgroup (F=7.99; p=<0.015) (See Figure 2). Discussion Parting from the objective of developing communication skills through the use of a VR simulator, the results seem to indicate that the use of this tool favors the development of such skills. This work converges with Cuesta and Mañas, LaFond, et al., and Levett-Jones et al.7,9,10, on which the development of professional skills is favored. The contribution of this current work consists on skills being evaluated specifically for communication and interpersonal relationships. In this sense, skills may be trained through different ways other than experience from hospital practice or live-simulation rehearsal. This may help to open a new work field in the training of professionals, particularly in case of pandemics that prevent many a student to access clinical practice, as it has been observed during the COVID-19 world landscape. In addition, data show that virtual clinical simulation allows for an improvement in learning compared to the traditional method, as pointed by Contreras et al.1, Levett-Jones et al.9, Liaw et al4, Shin et al23; and Rourke22. This indicates that despite the cost of building a virtual simulator, it can be more efficient for skills development, in contrast with the usual method of case discussion. This may be due to the reinforcing of adherence to these practices, especially when they are made as a self-learning process that the student must make from a computer. Likewise, a greater sensibility to develop this type of skills is observed in older students than in younger ones. Apparently, this goes against common sense, since younger students are the main users of this sort of technologies. However, the degree of improvement in students over 20 years of age against 18-year-old students is high enough to see that this is a recommended practice starting at second year, and not for students recently admitted. With the current work’s data, it is proved that clinical simulation is a strategic learning method for an environment marked by confinement and quarantines, which makes for off-site learning and for a virtual new normality. In this sense, bets must be made for a new formative strategy, even in subjects as intrinsic as communication and human relationships. Study limitations As limitations for this study was identified the fact of counting only with first curse Nursing school students. However, the fact of carrying out this experience with students from different grades, and even with experience in clinical practice, helped us to have them really value the contribution of this system against hospital practice. On the other hand, the follow up period was too short to fully evaluate the acquisition of communication skills. It would have been interesting to have made a student follow up over several months to see which results uphold for longer, if traditional method or clinical simulation, for which the replication of this study is proposed, but now from a multicenter perspective and for different formative curses. For future research, the level of digital skills should be assessed prior to the intervention to avoid possible biases in achievement that students with higher digital skills may have compared to those with less. Conclusion It may be concluded from these data that clinical simulation favors the development of communication skills and may be used as an aid instrument for professors in the health field because of its pedagogical usefulness. In addition, VR simulation is presented as an alternative, which is efficiently adapted to the circumstantial and contingent requirements that make it a necessity to have non–face-to-face methods because of the COVID-19 pandemic. While it’s true it has a higher cost and its creation implies more time, it has demonstrated to be more efficient in relationship regarding the time it involves to perform this practice against the relationship of the traditional method of cases and discussions given that it obtains equal or even better results in fewer hours. Perhaps this line may open new job perspectives to create simulators for aspects that could only be worked before while practicing with patients, such as humanization of care, empathy, emotional aspects, etc., which may open a new learning paradigm in a so ever changing environment. References 1. Contreras G, Garcia R, Ramirez M. Uso de simuladores como recurso digital para la transferencia de conocimiento. Apertura, Rev Innovación Educ. 2010;2(1):86-100. http://www.udgvirtual.udg.mx/apertura/index.php/apertura/article/view/22. Accesed June 1, 2021 2. Stuart J, Aul K, Bumbach MD, Stephen A, Lok B. Building a Handoff Communication Virtual Experience for Nursing Students Using Virtual Humans. Comput Informatics Nurs. 2021, 24 May. Doi: 10.1097/CIN.0000000000000760 3. Soy-Andrade MT, Cuevas-Budhart MÁ, Hernández-Iglesias S, Crespo-Cañizares A, Renghea A, Gómez del Pulgar García-Madrid M. Effectiveness of the educational strategy for the prevention of violence and child abuse in the Nursing Degree curriculum. Educ Medica. 2021;22(5):370-374.. Doi:10.1016/j.edumed.2019.12.005 4. Liaw SY, Chan SWC, Chen FG, Hooi SC, Siau C. Comparison of virtual patient simulation with Mannequin-based simulation for improving clinical performances in assessing and managing clinical deterioration: Randomized controlled trial. J Med Internet Res. 2014;16(9). doi:10.2196/jmir.3322 5. Freina L, Ott M. A Literature Review on Immersive Virtual Reality in Education: State Of The Art and Perspectives. 11th eLearning and Software for Education Conference 2015. 6. Farra SL, Smith SJ, Ulrich DL. The Student Experience With Varying Immersion Levels of Virtual Reality Simulation. Nurs Educ Perspect. 2018;39(2):99-101. Doi:10.1097/01.NEP.0000000000000258 7. LaFond CM, Van Hulle Vincent C, Lee S, et al. Development and validation of a virtual human vignette to compare nurses’ assessment and intervention choices for pain in critically ill children. Simul Healthc. 2015;10(1):14-20. Doi:10.1097/SIH.0000000000000061 8. Tschannen D, Aebersold M, … CS-TJ of, 2013 U. Improving nurses’ perceptions of competency in diabetes self-management education through the use of simulation and problem-based learning.. J Contin Educ Nurs. 2013;44(6):257-63. Doi:10.3928/00220124-20130402-16 9. Levett-Jones T, Bowen L, Morris A. Enhancing nursing students’ understanding of threshold concepts through the use of digital stories and a virtual community called “Wiimali.” Nurse Educ Pract. 2015;15(2):91-96. Doi:10.1016/j.nepr.2014.11.014 10. Cuesta U, Mañas L. Integración de la realidad virtual inmersiva en los Grados de Comunicación Integration of immersive virtual reality in Communication Degrees. Icono14 2016;14(2):1-21. Doi:10.7195/ri14.v14i2.953 11. Vera G, Ortega, JA, Burgos MA. La Realidad Virtual y Sus Posibilidades Didácticas.Etic@Net; 2003;2. https://www.ugr.es/~sevimeco/revistaeticanet/Numero2/Articulos/Realidadvirtual.pdf. Accessed June 1, 2021. 12. Radianti J, Majchrzak TA, Fromm J, Wohlgenannt I. A systematic review of immersive virtual reality applications for higher education: Design elements, lessons learned, and research agenda. Comput Educ. 2020;147:103778. Doi:10.1016/J.COMPEDU.2019.103778 13. Galvan H, Bovet S, Salomon R, Blanke O, Herbelin B, Boulic R. Characterizing first and third person viewpoints and their alternation for embodied interaction in virtual reality.. PLoS One. 2017;12(12):e0190109. doi:10.1371/journal.pone.0190109 14. Maestre JM, Rudolph JW. Theories and styles of debriefing: The good judgment method as a tool for formative assessment in healthcare. Rev Esp Cardiol. 2015;68(4):282-285. Doi:10.1016/j.recesp.2014.05.018 15. Alexander MF, Runciman PJ. Marco de competencias del CIE para la enfermera generalista: Informe del proceso de elaboración y de las consultas. Geneve: Consejo Internacional de enfermeras; 2003 16. European Federation of Nurses Associations (2015). EFN Competency Framework. EFN Guideline to implement Article 31 into national nurses’ education programmes. . Available at: http://www.efnweb.be/?page_id=6897  Accessed May 22, 2021 17. Directiva 2013/55/UE del Parlamento Europeo y del Consejo, de 20 de noviembre de 2013, por la que se modifica la Directiva 2005/36/CE relativa al reconocimiento de cualificaciones profesionales y el Reglamento (UE) no 1024/2012 relativo a la cooperación administrativa a través del Sistema de Información del Mercado Interior (Reglamento IMI). Diario Oficial de la UE. 2013; 354:132-170.-. 18. Orden CIN 2134/2008 de 3 de Julio por la que se establecen los requisitos para la verificación de los títulos oficiales que habiliten para el ejercicio de la profesión de Enfermero.Boletín Oficial del Estado. 2008;174:31680-31683. http://www.boe.es/boe/dias/2008/07/19/pdfs/A31680-31683.pdf 19. Gordon JA. As accessible as a book on a library shelf: The imperative of routine simulation in modern health care. Chest. 2012;141(1):12-16. Doi:10.1378/chest.11-0571 20. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003-2009. Med Educ. 2010;44(1):50-63. Doi:10.1111/j.1365-2923.2009.03547.x 21. Moral I del, Maestre JM. A view on the practical application of simulation in professional education. Trends Anaesth Crit Care. 2013;3(3):146-151. Doi:10.1016/j.tacc.2013.03.007 22. Rourke S. How does virtual reality simulation compare to simulated practice in the acquisition of clinical psychomotor skills for pre-registration student nurses? A systematic review. Int J Nurs Stud. 2020;102:103466. Doi:10.1016/j.ijnurstu.2019.103466 23. Shin H, Rim D, Kim H, Park S. Educational Characteristics of Virtual Simulation in Nursing: An Integrative Review. Clin Simul Nurs. 2019;37:18-28. Doi: 10.1016/j.ecns.2019.08.002 24. Furr RM. Psychometrics : an introduction LK. Los Ángeles, LA: SAGE, 2018 25. Gómez del Pulgar García Madrid M, Hernández-Iglesias S, Crespo Cañizares A, Pérez Martín AM, González Jurado MA, Beneit Montesinos JV. Reliability of a scale for the evaluation of nurses competence: Concordance study. Educ Medica. 2019;20(4):221-230. Doi:10.1016/j.edumed.2018.12.002 26. Gómez del Pulgar M, Pacheco del Cerro E, González MA, Fernández PM, Fernández PM BJ. Diseño y validación de contenido de la escala “ECOEnf” para la evaluación de competencias enfermeras. Index Enferm. 2017;26(4): 265-269. http://www.index-f.com/index-enfermeria/v26n4/11186r.php. Accessed February 7, 2021. . 27. Cohen J. The Concepts of Power Analysis BT - Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, N.J. : L. Erlbaum Associates; 1988. Doi:10.4324/9780203771587 Table 1: Socio-demographic variables and study variables. Control Group (n=50) Intervention Group (n=50) Variable Num. % X SD Num. % X SD Age 18,34 0,11 19,46 1,44 Gender Male Female 8 42 16,0 84,0 8 42 16,0 84,0 Marital Status Single Married Divorced 50 0 0 100 0 0 47 2 1 94,0 4,0 2,0 Evaluation Skills prior intervention Skills after intervention 6,50 7,45 1,05 1,35 7,01 8,78 0,79 0,63 Table 2. Kolmogorov-Smirnov normality test. PreTest CG Post CG Pre EG Post EG Mean Standard Variance Z (K-S) 6,50 1,05 1,19 ,113 7,45 1,35 8,30 ,068 7,01 0,79 7,05 ,045 8,78 0,63 0,41 0,105 P. Value .130 .200 200* 200* KS: Kolmogorov-Smirnov. * p value > 0,05 by which a normal distribution can be observed. Table 3. Skills evaluation prior and after intervention Control group Experimental group Skills Evaluation. Basal Evaluation Post usual method P value Basal Evaluation Post usual method P value X (SD) X (SD) X (SD) X (SD) To ensure a clear and precise communication. 6.40 (1.68) 7.50 (1.36) < .001 7.06 (1.08) 8.80 (0.90) .001 To express with clarity and precision towards the individuals, family members and social groups adapting the code to the recipients’ comprehension level. 6.66 (1.57) 7.32 (1.53) < .001 7.38 (1.21) 9.04 (0.81) < .001 To express with clarity and precision towards the other health team members to make explicit the difficulties posed in the development of the activities. 7.00 (1.62) 7.29 (1.41) .001 6.82 (1.24) 8.68 (1.04) < .001 To perform the welcoming of the patient and family upon admission following the established protocols. 6.14 (2.09) 7.22 (1.66) .004 6.54 (1.73) 8.68 (1.11) < .001 To provide emotional and spiritual support to the individual, family or social group. 7.08 (1.66) 7.96 (1.48) < .001 7.44 (1.55) 8.94 (0.84) < .001 To accompany the patient’s family during the disease process. 6.62 (1.94) 7.73 (1.58) .002 7.06 (1.56) 8.74 (0.92) < .001 To ensure the patient and/or family has understood the information. 6.58 (1.86) 7.70 (1.34) .046 6.98 (1.35) 8.96 (0.99) < .001 To relate with the patient applying the verbal and non-verbal communication and interpersonal relationship techniques correctly, adapting to each situation. 7.06 (1.82) 7.45 (1.47) .003 6.68 (1.39) 8.92 (0.99) .001 To encourage the individual, family or social group to share information that might be relevant to solve the situation or to avoid risks. 6.58 (1.54) 7.54 (1.09) .042 7.26 (1.18) 8.90 (0.89) .049 To guide patients towards the most adequate decision making. 6.18 (1.72) 7.48 (1.40) .007 6.70 (1.57) 8.68 (0.77) < .001 To demonstrate the ability of active listening towards patients as well as team members, and provide consistent answers. 6.86 (1.67) 7.80 (1.58) .044 7.66 (1.22) 8.88 (0.82) < .001 To utilize in a correct manner the health sciences specific language on situations that require it. 6.94 (2.12) 7.32 (1.65) < .001 6.26 (1.55) 8.46 (1.27) .001 To establish actions directed towards overcoming the factors that interfere in communication whenever they suppose a limitation. 6.32 (1.54) 7.42 (1.42) < .001 6.56 (1.23) 8.56 (1.07) .035 To ensure a clear and precise communication. 6.58 (1.68) 7.88 (1.15) < .001 7.36 (1.08) 8.94 (0.87) .005 To express with clarity and precision towards the group, adapting the code to the recipients’ comprehension level. 6.80 (1.62) 7.88 (1.24) < .001 7.18 (1.06) 8.72 (1.03) < .001 To ensure the group has understood the information. 7.22 (1.17) 8.10 (1.22) 004 7.30 (1.11) 9.00 (1.01) < .006 To relate with the group applying the verbal and non-verbal communication and interpersonal relationship techniques correctly, adapting to each situation. 7.60 (1.44) 7.90 (1.29) .001 7.12 (1.24) 8.92 (0.97) < .001 To demonstrate the ability of active listening towards team members, and provide consistent answers. 7.24 (1.35) 8.20 (1.08) .002 7.58 (1.18) 9.08 (0.76) .006 To utilize in a correct manner the health sciences specific language on situations that require it. 6.02 (1.86) 7.43 (1.41) < .001 6.34 (1.52) 8.62 (1.12) < .001 pág. 14