{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T05:18:38Z","timestamp":1787721518977,"version":"build-2784847793"},"reference-count":30,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T00:00:00Z","timestamp":1787529600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100010814","name":"Anhui Provincial Department of Education","doi-asserted-by":"publisher","award":["No. 2024jyxm0599."],"award-info":[{"award-number":["No. 2024jyxm0599."]}],"id":[{"id":"10.13039\/501100010814","id-type":"DOI","asserted-by":"publisher"}]},{"award":["No. 2024jyxm0599."],"award-info":[{"award-number":["No. 2024jyxm0599."]}],"id":[{"id":"https:\/\/ror.org\/012m7k033","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nurs. Rep.","Nursing Reports"],"abstract":"<jats:p>Background\/Objectives: Communication training in undergraduate nursing skills courses is often overshadowed by procedural skill acquisition, leaving limited opportunities for students to develop patient-centered communication skills and engage in reflective learning. This study evaluated a reflection-integrated CICARE communication program embedded in a Fundamentals of Nursing skills course and explored students\u2019 learning experiences. Methods: A quasi-experimental study with an embedded qualitative component was conducted among second-year undergraduate nursing students in China. The quantitative component used a non-equivalent control group design, while reflective journals from the Intervention Group provided qualitative data on students\u2019 learning experiences. Two intact classes were assigned to the Intervention Group (n = 65), and two intact classes were assigned to the Control Group (n = 66). The Intervention Group received an 18-week CICARE-based communication program integrated into skills training, including scenario-based role-play, emotional cue recognition, demonstration videos, feedback, and reflective journals. The Control Group received conventional skills training. Outcomes included communication competence, empathy, professional identity, clinical judgment, and course performance. Analysis of covariance was used to compare post-intervention outcomes after adjustment for baseline scores. Reflective journals from the Intervention Group were analyzed thematically. Results: After adjustment for baseline scores, the Intervention Group showed significantly higher communication competence than the Control Group (adjusted mean difference = 2.699, 95% CI: 0.108\u20135.291, p = 0.041). Empathy was also higher in the Intervention Group (adjusted mean difference = 3.796, 95% CI: 0.538\u20137.053, p = 0.023). The between-group difference in professional identity was not statistically significant (p = 0.073). The Intervention Group achieved higher total clinical judgment scores than the Control Group (31.52 \u00b1 5.50 vs. 27.20 \u00b1 6.45, p &lt; 0.001), with significant differences in noticing, interpreting, and reflecting. Course performance was also higher in the Intervention Group. In their reflective journals, students described greater patient-centered awareness, attention to patients\u2019 emotional needs, professional reflection, and motivation for self-directed learning. Conclusions: Integrating CICARE-based communication training with reflective learning may strengthen communication competence, empathy, clinical judgment, and course performance in undergraduate nursing skills education. Further studies with longer follow-up are needed to determine whether the observed differences persist over time and whether professional identity and action-oriented clinical responses improve with longer educational exposure. Registration: This study was not registered.<\/jats:p>","DOI":"10.3390\/nursrep16090296","type":"journal-article","created":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T14:49:34Z","timestamp":1787582974000},"page":"296","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Effects of a Reflection-Integrated CICARE Program on Empathy and Clinical Judgment in Nursing Students: A Quasi-Experimental Study"],"prefix":"10.3390","volume":"16","author":[{"given":"Qingqing","family":"Feng","sequence":"first","affiliation":[{"name":"Department of Nursing, Clinical College of Anhui Medical University, Hefei 230031, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Min","family":"Liu","sequence":"additional","affiliation":[{"name":"Department of Nursing, Clinical College of Anhui Medical University, Hefei 230031, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tang","family":"Tang","sequence":"additional","affiliation":[{"name":"Department of Nursing, Clinical College of Anhui Medical University, Hefei 230031, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lulu","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Nursing, Clinical College of Anhui Medical University, Hefei 230031, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,24]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1486","DOI":"10.1111\/jonm.13324","article-title":"Nurse manager communication and outcomes for nursing: An integrative review","volume":"29","author":"Fowler","year":"2021","journal-title":"J. Nurs. Manag."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"103826","DOI":"10.1016\/j.nepr.2023.103826","article-title":"Factors affecting the development of clinical nurses\u2019 competency: A systematic review","volume":"73","author":"Almarwani","year":"2023","journal-title":"Nurse Educ. Pract."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"28","DOI":"10.2202\/1548-923X.2043","article-title":"Strengthening communication education in an undergraduate nursing curriculum","volume":"7","author":"Boschma","year":"2010","journal-title":"Int. J. Nurs. Educ. Scholarsh."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Isangula, K.G., Pallangyo, E.S., and Ndirangu-Mugo, E. (2023). Improving nursing education curriculum as a tool for strengthening the nurse-client relationships in maternal and child healthcare: Insights from a human-centered design study in rural Tanzania. Front. Public Health, 11.","DOI":"10.3389\/fpubh.2023.1072721"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1111\/j.1365-2648.2009.05240.x","article-title":"Simulation-based learning in nurse education: Systematic review","volume":"66","author":"Cant","year":"2010","journal-title":"J. Adv. Nurs."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"53","DOI":"10.7748\/ns.29.14.53.e9355","article-title":"Effective communication skills in nursing practice","volume":"29","author":"Bramhall","year":"2014","journal-title":"Nurs. Stand."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"323","DOI":"10.5539\/gjhs.v7n4p323","article-title":"Evaluation of nursing students\u2019 communication abilities in clinical courses in hospitals","volume":"7","author":"Shafakhah","year":"2015","journal-title":"Glob. J. Health Sci."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"104738","DOI":"10.1016\/j.nedt.2020.104738","article-title":"Major educational factors associated with nursing adverse events by nursing students undergoing clinical practice: A descriptive study","volume":"98","author":"Li","year":"2021","journal-title":"Nurse Educ. Today"},{"key":"ref_9","first-page":"e20220005","article-title":"Patient Safety Incidents and the second victim phenomenon among nursing students","volume":"56","author":"Tavares","year":"2022","journal-title":"Rev. Esc. Enferm. USP"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1136\/bmjqs-2011-000332","article-title":"Promoting patient-centred care through trainee feedback: Assessing residents\u2019 C-I-CARE (ARC) program","volume":"21","author":"Wen","year":"2012","journal-title":"BMJ Qual. Saf."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e022202","DOI":"10.1136\/bmjopen-2018-022202","article-title":"Impact of the communication and patient hand-off tool SBAR on patient safety: A systematic review","volume":"8","author":"Klingberg","year":"2018","journal-title":"BMJ Open"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"6947","DOI":"10.12998\/wjcc.v12.i36.6947","article-title":"CICARE based communication technique: A passage to faster and smoother visual rehabilitation in post cataract surgery patients","volume":"12","author":"Morya","year":"2024","journal-title":"World J. Clin. Cases"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"707","DOI":"10.5498\/wjp.v13.i9.707","article-title":"Effect of CICARE communication nursing model combined with motivational psychological intervention in patients with post-intensive care unit syndrome","volume":"13","author":"She","year":"2023","journal-title":"World J. Psychiatry"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"e39293","DOI":"10.1097\/MD.0000000000039293","article-title":"CICARE communication model and hierarchical responsibility nursing coordination in the application research of elderly patients with chronic heart failure","volume":"103","author":"Zhao","year":"2024","journal-title":"Medicine"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Zhu, X., Rask, M., and Xu, H. (2023). First year nursing students\u2019 reflections about developing their verbal nursing skills during their nursing education in China: A qualitative study. Front. Public Health, 11.","DOI":"10.3389\/fpubh.2023.1149512"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"104364","DOI":"10.1016\/j.nepr.2025.104364","article-title":"The impact of an empathy education programme on empathy, communication skills and emotional competency in nursing students: A quasi-experimental study","volume":"85","author":"Ko","year":"2025","journal-title":"Nurse Educ. Pract."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Sanchis-Gim\u00e9nez, L., Lacomba-Trejo, L., Prado-Gasc\u00f3, V., and Gim\u00e9nez-Espert, M.d.C. (2023). Attitudes towards Communication in Nursing Students and Nurses: Are Social Skills and Emotional Intelligence Important?. Healthcare, 11.","DOI":"10.3390\/healthcare11081119"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Gim\u00e9nez-Espert, M.D.C., Maldonado, S., and Prado-Gasc\u00f3, V. (2023). Influence of Emotional Skills on Attitudes towards Communication: Nursing Students vs. Nurses. Int. J. Environ. Res. Public Health, 20.","DOI":"10.3390\/ijerph20064798"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Ahmadpour, N., Shariati, A., and Moghadam, M.P. (2025). Effect of narrative writing based on Gibbs\u2019 reflective model on the empathy and communication skills of nursing students. BMC Med. Educ., 25.","DOI":"10.1186\/s12909-024-06593-7"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1016\/j.profnurs.2024.05.002","article-title":"Technology-based interactive communication simulation addressing challenging communication situations for nursing students","volume":"53","author":"Jeon","year":"2024","journal-title":"J. Prof. Nurs."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Yang, J., Zhou, W.J., Zhou, S.C., Luo, D., Liu, Q., Wang, A.-L., Yu, S.-H., Zhu, X.-P., He, X.Y., and Hu, F. (2024). Integrated virtual simulation and face-to-face simulation for clinical judgment training among undergraduate nursing students: A mixed-methods study. BMC Med. Educ., 24.","DOI":"10.1186\/s12909-023-04988-6"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"106564","DOI":"10.1016\/j.nedt.2024.106564","article-title":"A mixed method approach to substantiate quantitative data with qualitative data: Improving clinical judgment in prelicensure nursing students using simulation","volume":"147","author":"Reents","year":"2025","journal-title":"Nurse Educ. Today"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"104847","DOI":"10.1016\/j.nedt.2021.104847","article-title":"Situation, Background, Assessment, and Recommendation Stepwise Education Program: A quasi-experimental study","volume":"100","author":"Lee","year":"2021","journal-title":"Nurse Educ. Today"},{"key":"ref_24","first-page":"3721","article-title":"Preliminary development of the Clinical Communication Competence Scale for nursing students","volume":"16","author":"Yang","year":"2010","journal-title":"Chin. J. Mod. Nurs."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1177\/00131640121971158","article-title":"The Jefferson Scale of Physician Empathy: Development and Preliminary Psychometric Data","volume":"61","author":"Hojat","year":"2001","journal-title":"Educ. Psychol. Meas."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"866","DOI":"10.1111\/jpm.12024","article-title":"Psychometric properties of a Chinese version of the Jefferson Scale of Empathy-Health Profession Students","volume":"20","author":"Hsiao","year":"2013","journal-title":"J. Psychiatr. Ment. Health Nurs."},{"key":"ref_27","first-page":"137","article-title":"Measurement of professional identity in Chinese nursing students","volume":"1","author":"Hao","year":"2014","journal-title":"Int. J. Nurs. Sci."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"67","DOI":"10.3928\/01484834-20210120-03","article-title":"The Lasater Clinical Judgment Rubric: Implications for Evaluating Teaching Effectiveness","volume":"60","author":"Lee","year":"2021","journal-title":"J. Nurs. Educ."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Yang, F., Wang, Y., Yang, C., Zhou, M.H., Shu, J., Fu, B., and Hu, H. (2019). Improving clinical judgment by simulation: A randomized trial and validation of the Lasater clinical judgment rubric in Chinese. BMC Med. Educ., 19.","DOI":"10.1186\/s12909-019-1454-9"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"104260","DOI":"10.1016\/j.nedt.2019.104260","article-title":"Effectiveness of empathy clinical education for children\u2019s nursing students: A quasi-experimental study","volume":"85","author":"Ding","year":"2020","journal-title":"Nurse Educ. Today"}],"container-title":["Nursing Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2039-4403\/16\/9\/296\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T04:22:13Z","timestamp":1787718133000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2039-4403\/16\/9\/296"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,24]]},"references-count":30,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["nursrep16090296"],"URL":"https:\/\/doi.org\/10.3390\/nursrep16090296","relation":{},"ISSN":["2039-4403"],"issn-type":[{"value":"2039-4403","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,24]]}}}