Abstract
Background
Delivering bad news is a fundamental communication skill in clinical practice, with direct implications for patient satisfaction, adherence, and clinical outcomes. While lecture-based teaching builds essential theoretical knowledge, simulation-based training is increasingly valued for its potential to enhance practical communication skills, including empathy, confidence, and responsiveness to patient emotions. This study explores differences in self-reported outcomes following two instructional approaches delivered at different stages of undergraduate medical training.
Methods
A quasi-experimental pre-test/post-test study was conducted at the University of Jordan with 267 medical students. Participants included 129 fifth-year students who received a lecture-based session and 138 sixth-year students who participated in simulation-based role-play. Academic year was inherently linked to instructional approach. All students completed structured self-administered questionnaires before and after the sessions assessing perceived knowledge, self-rated competence, comfort, and emotional communication domains. Paired-sample and independent-sample t-tests were used to examine within-group changes and exploratory between-group differences.
Results
Both groups demonstrated statistically significant improvements in self-reported knowledge, competence, and comfort with BBN delivery (p < 0.001). The simulation group reported greater perceived gains in empathy (p = 0.042), recognition of emotional reactions (p = 0.005), and confidence in responding to emotional cues during difficult conversations (p < 0.001). Simulation participants also reported higher satisfaction and were more likely to recommend the training to peers.
Conclusions
Both lecture-based and simulation-based approaches were associated with improvements in students’ self-reported knowledge and comfort in delivering bad news. Simulation-based training was associated with higher perceived gains in emotional and interpersonal communication domains. These findings suggest that experiential approaches such as role-play may enhance perceived readiness in emotionally complex clinical communication.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12909-026-09034-9.
Keywords: Experiential learning, communication skills, simulation, empathy, medical education, breaking bad news
Introduction
Effective communication is one of the cornerstones of medical education, vital for delivering bad news, managing challenging patient interactions, and fostering strong patient–physician trust [1, 2]. Effective communication and appropriate conveyance of information are associated with patients’ quality of life, adherence, and overall clinical outcomes [3].
Several educational modalities have been utilized to train medical students, and traditional methods such as live role-playing have been widely used and associated with positive educational outcomes. This may relate to the immersive, experience-based nature, which allows learners to practice and refine their social skills in a realistic yet simulated environment [4–6].
In recent years, teaching innovations have introduced methods such as computerized simulations and internet-based role-play scenarios. These approaches provide repeatable, flexible, and scalable learning opportunities and were particularly valuable during crises such as the COVID-19 pandemic, when face-to-face interaction was limited [7–9]. However, online methods may differ from in-person interactions in terms of emotional richness and contextual depth, prompting ongoing discussion about their role in preparing learners for complex clinical communication [10–12].
While face-to-face interactions may provide a different experiential context, they are also resource-intensive and difficult to scale compared with internet-based methods [11, 13, 14].
Despite significant advancements in educational technology and the growing integration of eLearning in medical training, comparative evidence examining different instructional approaches remains limited. Previous studies have examined individual teaching modalities without fully addressing how they influence skill maintenance, learner flexibility, long-term readiness for clinical practice, or the integration of these approaches into curricula [6, 15].
This study is grounded in experiential learning principles, which emphasize active engagement, reflection, and real-world application as mechanisms for skill acquisition. Within communication training, such frameworks bridge the gap between cognitive understanding and emotional competence—skills that are essential when delivering bad news in clinical practice.
Despite the recognized importance of communication training, few studies have directly compared didactic and experiential methods using validated pre- and post-training measures. This study addresses that gap by evaluating both knowledge-based and affective learning outcomes among undergraduate medical students.
To address this question, two instructional approaches were implemented: an online seminar and a face-to-face session with guided role-play. We chose role-playing for the in-person training based on David Kolb’s experiential learning theory, which emphasizes that hands-on, interactive experiences facilitate deeper understanding and skill acquisition [16]. Research suggests that immersive and reflective learning environments are associated with increased student engagement, satisfaction, and perceived skill development [17]. These characteristics may be particularly relevant when teaching emotionally challenging skills, such as breaking bad news (BBN), where practice and structured reflection are central to learning.
To systematically assess self-reported changes in knowledge and communication-related domains following both instructional approaches, pre- and post-intervention assessments were administered following established best practices in medical education research design. These assessments aimed to capture changes in cognitive understanding and perceived competence, consistent with established approaches to evaluating instructional interventions in health professions education [18].
This study explores differences in self-reported outcomes associated with two instructional approaches implemented at different stages of undergraduate medical training. Fifth-year students attended an online BBN lecture, while sixth-year students participated in a moderated role-play session. We assessed outcomes such as comfort, empathy, understanding of patients’ emotional responses, and confidence in delivering difficult information. These skills were measured before and after the training using pre- and post-tests, providing insights into changes in perceived readiness across instructional approaches.
Methodology
Study design and setting
This quasi-experimental pre-test/post-test study was conducted at the University of Jordan School of Medicine to examine differences in self-reported outcomes associated with two instructional approaches in teaching medical students breaking bad news (BBN). Academic year was inherently linked to instructional approach, as fifth-year students received lecture-based instruction while sixth-year students participated in simulation-based role-play. Medical education at the University of Jordan spans six years: the first three years are pre-clinical, while the final three focus on clinical training. By the fifth year, students are fully engaged in hospital-based rotations.
Fifth-year cohort (didactic instruction)
The fifth-year cohort consisted of medical students enrolled in a four-week Family Medicine clinical rotation during the 2024–2025 academic year. Each rotation included approximately 60–70 students. During this period, students attended structured online seminars covering consultation skills, communication strategies, diagnostic reasoning, management planning, difficult patient encounters, and breaking bad news.
The BBN session consisted of a structured didactic lecture addressing:
Communication frameworks (including the SPIKES protocol).
Ethical principles in delivering difficult information.
Structuring clinical conversations.
Recognizing and responding to patient emotions.
The lecture emphasized cognitive understanding and structured communication models.
Sixth-year cohort (experiential role-play training)
The sixth-year cohort consisted of students enrolled in a Job Readiness rotation at the beginning of their final year. This rotation was designed to support transition to clinical practice and included interactive workshops, including a face-to-face BBN workshop led by the Family Medicine Department.
Students in this cohort were assumed to have previously attended the didactic BBN lecture during their fifth year as part of the standard curriculum.
Sixth-year students participated in a structured role-play workshop facilitated by a senior family medicine specialist experienced in communication skills training. The session included a brief theoretical review followed by scenario-based role-play exercises simulating common clinical situations involving breaking bad news. Structured debriefing and feedback were provided after each exercise to encourage reflection on communication strategies and emotional responsiveness.
A detailed description of the role-play workshop structure, scenarios, and feedback process is provided in Supplementary Material 1.
Cohort selection and participation
Two cohorts—129 fifth-year and 138 sixth-year students—were included in the study. Students were recruited from their respective rotations. A random selection of rotation groups was used to identify participating cohorts; however, students were not randomized to instructional approach, and academic year remained fully confounded with modality.
Participation was voluntary, and informed consent was obtained prior to data collection.
Design considerations
Given the use of naturally occurring academic cohorts and the absence of randomization or a parallel control group, the study was designed to explore associations between instructional approach and self-reported outcomes rather than to establish causal effects. Differences observed between cohorts may reflect variation in stage of training, clinical exposure, or baseline characteristics in addition to instructional approach.
This quasi-experimental design was used to explore associations between instructional approaches and students’ self-reported outcomes in breaking bad news training. Such designs are commonly used in medical education when interventions are delivered within existing curricula and randomization is not feasible [10]. In addition, questionnaire-based educational evaluations require attention to measurement reliability when interpreting self-reported constructs [19]. Findings should therefore be interpreted within the context of this educational setting.
Data collection tools
Data were collected using a structured, self-administered questionnaire developed specifically for this study. The instrument was informed by a review of the literature on breaking bad news (BBN) training and was reviewed by three faculty members with expertise in family medicine and communication skills to assess the relevance and clarity of the items. A pilot test was conducted with 20 students, who were excluded from the final analysis, to ensure comprehensibility and feasibility of the questionnaire. The full questionnaire is provided in Supplementary Material 2.
Internal consistency reliability of the multi-item domain was assessed using Cronbach’s alpha. The scale demonstrated acceptable reliability in the pre-training assessment (α = 0.785) and excellent reliability in the post-training assessment (α = 0.908).
The questionnaire collected information on demographic characteristics, previous exposure to BBN training, and students’ self-reported perceptions of their communication-related abilities and learning experience. The instrument was organized into five sections:
Demographics and Prior Exposure: Recorded sex, year of study, prior BBN training, and real-life experience delivering bad news.
Pre-Training Self-Assessment: Completed immediately before the instructional session to assess students’ perceived comfort with delivering bad news, beliefs about whether BBN is a learnable skill, willingness to receive training, and self-rated abilities in empathy, understanding emotional responses, responding to emotional cues, and confidence when communicating difficult information. Responses were recorded using a 5-point Likert scale (1 = very poor, 5 = excellent). Students also estimated their perceived knowledge of BBN as a percentage.
Training Feedback: Completed immediately after the session to capture students’ perceptions of the usefulness of the training and its perceived contribution to their understanding of BBN communication.
Post-Training Self-Assessment: The same items as the pre-training section were administered after the session to allow comparison of changes in students’ self-reported perceptions of knowledge, comfort, and communication-related abilities.
Final Reflections (Qualitative Feedback): Included open-ended questions exploring students’ perceptions of the training experience, perceived areas of improvement, suggestions for enhancement, and their likelihood of recommending the session to peers.
Statistical analysis
Data were analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA), with statistical significance set at p < 0.05.
Descriptive statistics were used to summarize participant characteristics and survey responses. Continuous variables were reported as means ± standard deviations, while categorical variables were summarized using frequencies and percentages.
Changes in outcomes before and after the intervention were assessed using paired-sample t-tests, while independent-sample t-tests were used to compare post-intervention outcomes between fifth- and sixth-year students.
Normality of the pre–post difference scores was assessed using the Shapiro–Wilk test. Although some variables showed statistically significant deviations from normality, skewness values remained within acceptable limits. Given the relatively large sample size, parametric tests were considered appropriate for the analysis.
To facilitate interpretation of the magnitude of change, effect sizes (Cohen’s d) with 95% confidence intervals were calculated for the paired comparisons.
Because baseline differences were observed between fifth- and sixth-year students, analysis of covariance (ANCOVA) was conducted to adjust for baseline scores. For each outcome scale, post-intervention scores were used as dependent variables, year of study (fifth vs. sixth year) as the fixed factor, and baseline scores as covariates.
Results
Participant characteristics
A total of 267 medical students participated in the study, including 129 fifth-year (48.3%) and 138 sixth-year students (51.7%). The majority were female (58.8%), with no significant difference between the two cohorts (p = 0.088). Most students had limited prior exposure to breaking bad news (BBN); 80.1% had not previously attended formal BBN-related training, and 78.7% had not delivered bad news to a patient. These rates were similar between academic years (p > 0.05) (Table 1).
Table 1.
Participant Characteristics and Prior BBN Experience (N = 269)
| Variable | Fifth Year (n = 129) | Sixth Year (n = 138) | Total (N = 267) | p-value |
|---|---|---|---|---|
| Gender (Female) | 72 (55.8%) | 86 (62.3%) | 158 (58.8%) | 0.088 |
| Attended BBN Lecture (Yes) | 27 (20.9%) | 26 (18.8%) | 53 (19.7%) | 0.674 |
| Delivered Bad News to a Patient (Yes) | 29 (22.5%) | 28 (20.3%) | 57 (21.3%) | 0.651 |
Pre- and post-training outcomes
After the training, students across both groups reported increases in self-perceived knowledge, self-rated competence, and comfort related to delivering BBN (Table 2). Paired-sample t-tests indicated statistically significant pre–post changes across all measured domains.
Table 2.
Pre- and Post-Training Outcomes (All Participants)
| Outcome | Pre Mean (SD) | Post Mean (SD) | Mean Difference | p-value |
|---|---|---|---|---|
| Perceived Knowledge (/100) | 49.25 (19.28) | 73.97 (18.02) | + 24.72 | < 0.001 |
| Self-Rated Competence (/20) | 13.93 (3.27) | 16.15 (3.39) | + 2.21 | < 0.001 |
| Comfort Level (/5) | 2.67 (1.00) | 3.50 (1.35) | + 0.84 | < 0.001 |
When outcomes were stratified by academic year, sixth-year students reported higher post-training scores across the measured domains than fifth-year students (Table 3). However, baseline differences between cohorts were observed and should be considered when interpreting these comparisons.
Table 3.
Post-Training Outcomes by Year of Study
| Outcome | Fifth-Year Post Mean (SD) | Sixth-Year Post Mean (SD) | p-value |
|---|---|---|---|
| Perceived Knowledge (/100) | 68.81 (20.17) | 78.79 (14.21) | < 0.001 |
| Self-Rated Competence (/20) | 15.47 (3.63) | 16.78 (3.02) | 0.001 |
| Comfort Level (/5) | 3.17 (1.42) | 3.82 (1.19) | < 0.001 |
Domain-Specific Outcomes
Both groups reported increases across the assessed communication-related domains. Sixth-year students reported larger changes in several domains, particularly in responding to emotional cues and communicating difficult information (Table 4). These findings represent differences in students’ self-reported perceptions of communication-related abilities following training.
Table 4.
Domain-Specific Gains by Year of Study
| Domain | Fifth Year Pre (M ± SD) | Fifth Year Post (M ± SD) | Sixth Year Pre (M ± SD) | Sixth Year Post (M ± SD) | p-value (Year × Time) |
|---|---|---|---|---|---|
| Empathy with Patients | 3.70 ± 1.14 | 3.98 ± 1.03 | 3.88 ± 1.00 | 4.18 ± 0.82 | 0.042 |
| Understanding Emotional Responses | 3.74 ± 1.10 | 4.12 ± 0.92 | 3.90 ± 1.07 | 4.34 ± 0.81 | 0.005 |
| Responding to Emotional Cues | 3.48 ± 1.14 | 3.91 ± 1.09 | 3.62 ± 1.04 | 4.44 ± 0.84 | < 0.001 |
| Delivering Difficult Information | 2.85 ± 1.08 | 3.47 ± 1.26 | 2.69 ± 0.99 | 3.81 ± 1.13 | < 0.001 |
Students’ Perceptions of the Training
Students’ perceptions of the training experience differed between cohorts. Sixth-year students were more likely to rate the training as “very helpful” (70.9% vs. 29.1%) and to recommend it to peers (64.2% vs. 35.8%; p < 0.001) (see Supplementary Figures S1 and S2).
Summary of key findings
Both fifth- and sixth-year students reported increases in self-perceived knowledge, competence, and comfort related to BBN following the training sessions.
Sixth-year students reported higher perceived knowledge both before and after the intervention.
Post-training, sixth-year students reported higher levels of comfort and self-rated competence.
Sixth-year students were more likely to rate the training as helpful and report willingness to recommend it to their peers.
Discussion
Our study compared two instructional approaches—lecture-based and simulation-based role-play—to explore differences in perceived learning outcomes related to delivering bad news (BBN) among medical students. Both methods yielded significant improvements in students’ self-reported knowledge, competence, and comfort levels. However, simulation-based role-play was associated with higher perceived gains in confidence, empathy, and recognition of emotional cues. These findings align with experiential learning principles and prior studies emphasizing the relevance of active learning in emotionally demanding clinical communication [7, 16].
These results reinforce the importance of integrating experiential learning into medical curricula. In the present study, students who participated in role-play sessions reported greater perceived improvements, consistent with educational models that emphasize learning through experience, reflection, and feedback. This approach complements the cognitive learning achieved through lectures and supports the broader movement toward competency-based medical education that prioritizes authentic, learner-centered experiences.
Role-playing has also been shown to improve emotional intelligence, interpersonal communication, and the ability to navigate challenging clinical conversations [5]. These qualities are essential when delivering bad news and may contribute to the greater perceived gains reported by students in the simulation group. In contrast, while online seminars provide a consistent and structured means of delivering theoretical content—and have been shown to be effective in previous studies on e-learning in medical education [20]—they may lack the emotional depth and immediacy that face-to-face role-play provides. These differences in learning context may help explain the variation in perceived outcomes observed between the two instructional approaches.
Role-play simulations allow students to experience the patient’s perspective, navigate emotional responses, and develop empathy, thereby enhancing their perceived confidence and preparedness for real-life clinical scenarios [21, 22]. These findings highlight the importance of integrating structured, experiential communication training into curricula to build competence in challenging, emotionally charged situations.
Our findings are consistent with broader evidence on the SPIKES framework for teaching communication skills. A systematic review of 37 studies using SPIKES-based interventions—including lectures, role-play with standardized patients, videos, debriefing sessions, and computer simulations—reported improvements in learner satisfaction, knowledge, and performance, although few examined patient or system-level outcomes [23–26]. Importantly, these studies echo our observation that hands-on, experiential methods—such as role-play—enable learners to develop practical communication strategies beyond theoretical instruction [27, 28].
These findings align with prior research demonstrating that role-play enhances emotional intelligence, self-efficacy, and responsiveness in high-stakes communication [4, 5]. While fifth-year students who received lecture-based instruction using structured models such as SPIKES [3] demonstrated meaningful improvement, their gains were less pronounced in domains related to emotional responsiveness, which is consistent with earlier evidence suggesting that didactic instruction alone may be less effective in addressing affective communication competencies [4, 20].
Additionally, active learning strategies such as group discussion, video analysis, and structured reflection have been shown to improve communication-focused assessments such as OSCEs [29]. Structured milestone-based assessments further provide a practical means to track skill development when aligned with frameworks such as SPIKES [3]. Similar improvements in self-perceived clinical skills following simulation-based and flipped classroom training have been reported in recent studies, although these authors also emphasize that perceived competence should not be interpreted as equivalent to objectively measured performance [30].
This distinction between self-perceived competence and objectively demonstrated performance is increasingly recognized in simulation-based medical education. While improvements in confidence and perceived preparedness represent meaningful educational outcomes, they do not necessarily reflect objectively assessed clinical competence. For example, simulation-based ultrasound training studies have emphasized the importance of incorporating objective performance measures when evaluating educational interventions, highlighting the need to complement self-reported outcomes with validated assessments of clinical skills [31].
Interestingly, although sixth-year students began with slightly higher baseline scores, likely reflecting prior clinical exposure, they still demonstrated substantial post-training gains. However, because academic year was inherently linked to instructional approach in the study design, these differences should be interpreted cautiously. Given that only a minority (20%) had previously attended a BBN lecture, their higher post-training scores may reflect the influence of experiential training as well as differences related to academic seniority and prior clinical exposure. These findings are consistent with prior evidence suggesting that in-person, active learning approaches may be associated with greater perceived improvements than lecture-based instruction alone [8, 11].
The enhanced outcomes observed among sixth-year students echo findings reported by Bhatri and Skye, who reported that senior learners with greater clinical exposure derive more benefit from experiential training [4, 5]. Importantly, our sixth-year cohort undertook the course at the beginning of their academic year, prior to accumulating further clinical experience. Nevertheless, the study design does not allow clear separation of the effects of instructional modality from differences related to academic seniority. Furthermore, although these students were assumed to have prior exposure to BBN content from their fifth-year curriculum, only 20% reported having attended such a lecture. This limited prior exposure suggests that their higher post-training scores may not be explained solely by prior theoretical instruction and may also reflect the influence of the experiential training component.
However, contrasting evidence exists in the literature. For instance, the randomized MyDispense® study [32] found no significant difference between online simulation and classroom learning in knowledge, satisfaction, or self-confidence, suggesting that well-designed online simulations may offer equivalent benefits in certain contexts. Taken together, these findings suggest that the relative effectiveness of different instructional approaches may depend on contextual factors such as learning objectives, instructional design, and available resources. Further research is needed to explore long-term skill retention, optimal timing within the curriculum, and comparisons of different simulation models, all of which would inform the design of more structured undergraduate communication training programs [33].
Although simulation-based training is widely considered beneficial, its resource-intensive nature presents logistical challenges. Structured debriefing, emotional safety, and skilled facilitation are essential but not always feasible on a large scale. Consequently, blended learning—combining lectures, digital modules, and limited in-person simulation—has been proposed as a scalable, sustainable compromise [34, 35].
Educational implications
The results of this study support the incorporation of structured role-play and simulation exercises within medical communication curricula. Such experiential approaches may enhance students’ perceived empathy and emotional responsiveness, while also helping learners internalize theoretical communication frameworks. These findings may be particularly relevant to educators seeking to align communication training with the objectives of competency-based education and professional identity formation.
Theoretical and practical contributions
This study contributes to existing educational literature by examining differences in perceived learning outcomes associated with two instructional approaches implemented at different stages of undergraduate medical training. The findings highlight how experiential engagement may help translate conceptual knowledge into applied communication strategies during emotionally challenging clinical encounters. Practically, the results provide educators with insights into how simulation and role-play can complement traditional didactic teaching within undergraduate curricula.
Limitations
This study has several limitations that should be considered when interpreting the findings. First, the study was conducted at a single institution, which may limit the generalizability of the results. Second, the outcomes were based entirely on self-reported measures, which reflect perceived competence rather than objectively assessed communication performance. Third, the quasi-experimental design compared two different academic cohorts, meaning that academic year was inherently confounded with the instructional approach, and therefore differences between groups cannot be attributed solely to the teaching modality. Finally, although baseline differences were statistically adjusted in the analysis, residual confounding related to clinical exposure or prior training cannot be excluded.
Conclusion
Both lecture-based and simulation-based approaches were associated with improvements in students’ self-reported knowledge, confidence, and comfort in delivering bad news. Simulation-based role-play was associated with greater perceived gains in emotional communication domains, including empathy and responsiveness to patients’ emotional cues. These findings suggest that experiential approaches such as role-play may enhance learners’ perceived readiness for emotionally challenging clinical conversations. However, given the quasi-experimental design and reliance on self-reported outcomes, these findings should be interpreted cautiously and viewed as complementary to, rather than replacing, studies using objective performance measures.
Supplementary Information
Acknowledgements
The authors would like to express their sincere gratitude to the Department of Family Medicine at the University of Jordan for their support in conducting this study. Special thanks are extended to all participating medical students for their time, engagement, and valuable feedback. The authors also acknowledge the contributions of faculty members and colleagues who assisted in facilitating the simulation workshops and data collection.
Authors’ contributions
All authors contributed substantially to the conception and design of the study, data collection, analysis, and interpretation. All authors read and approved the final version of the manuscript.
Funding
This study was conducted without financial support from any public, commercial, or not-for-profit funding agencies.
Data availability
The datasets generated and/or analyzed during this study are available from the corresponding author on reasonable request. The questionnaire used in the study has been uploaded as a supplementary file.
Declarations
Ethics approval and consent to participate
Informed consent was obtained at the start of the survey, with participants confirming voluntary participation. Confidentiality was maintained, and all data were anonymized. The study received approval from the University of Jordan’s Institutional Review Board (IRB reference: 19/2024/999). This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated and/or analyzed during this study are available from the corresponding author on reasonable request. The questionnaire used in the study has been uploaded as a supplementary file.