Assessing the Effectiveness of an Ethical Communication Course for Romanian Medical Students: A Pretest-Posttest Study

INTRODUCTION

Ethical issues are a daily reality in healthcare, affecting both patient care and professionals’ well-being. Studies indicate that nurses and physicians frequently encounter dilemmas related to patient autonomy, informed consent, resource allocation, and end-of-life care [1,2,3]. Ethical conflicts often arise when professional values clash with institutional constraints, leading to moral distress and demoralization [4]. The World Medical Association (WMA) International Code of Medical Ethics (2022) and the International Council of Nurses (ICN) Code of Ethics [5] emphasize that healthcare professionals must uphold patient rights, confidentiality, and informed decision-making, yet the ability to navigate these obligations depends on effective communication skills. Nurses, in particular, report high levels of stress and burnout due to ethical conflicts, with staffing shortages and inadequate support being major contributors [3]. Younger and less experienced professionals struggle more with ethical dilemmas, highlighting the need for early training in ethical reasoning and communication during medical education [2].

Without structured guidance, healthcare professionals may feel powerless or unprepared to address ethical concerns, negatively impacting patient trust and care quality. The increasing ethical complexity of medical practice demands that future healthcare professionals receive formal training in ethical communication. Research demonstrates that ethical challenges are frequent and stressful, particularly for younger and less experienced clinicians [2,3]. Demoralization, moral distress, and institutional constraints further complicate decision-making, highlighting the need for early intervention through ethics education [4]. A structured ethical communication course for medical students would provide the necessary skills to navigate ethical dilemmas, improve patient relationships, and support professional integrity in healthcare practice.

Effective communication is a critical tool for resolving ethical dilemmas, reducing stress, and fostering patient-centered care [3,4]. The professionalization of healthcare ethics has gained momentum, emphasizing the need for structured training in ethical decision-making [6]. Ethical communication courses can serve as a preventive strategy against demoralization, equipping students with tools to navigate ethical tensions proactively. Current medical education often provides limited exposure to ethics beyond theoretical frameworks, leaving students unprepared for real-world ethical dilemmas [4]. Communication skills are considered essential in the healthcare professions, prompting the inclusion of courses aimed at developing these competencies within many medical education programs [7,8]. These courses generally aim to improve students’ attitudes towards patient communication (i.e., their perception of the importance of communication skills), to increase students’ self-efficacy regarding communication with patients (i.e., their confidence in their ability to communicate effectively), and to improve their actual communication skills [8]. Furthermore, the majority of medical education programs addressing communication skills encompass an ethical dimension related to patient communication [9]. Communication with patients is also a topic of interest for the Romanian academic medical community, with experts in the Romanian healthcare system highlighting the necessity of cultivating students’ communication skills [10]. However, the efficacy of such courses for Romanian medical students has yet to be evaluated. To cover this gap, the purpose of the current study is to investigate the effectiveness of a course on ethical considerations in communication with patients for Romanian medical students. Specifically, we examined the course’s impact on increasing students’ medical communication self-efficacy, health professionals’ communication skills, and perceived importance of medical communication.

Previous studies support the effectiveness of courses designed to enhance communication skills with patients. In one study [11], nursing students were trained in communication skills using complex care scenarios, with professional actors portraying patients. The training effectively enhanced self-efficacy and communication skills, with sustained benefits observed 6 months post-intervention. In another study [12], a communication skills training program that included experiential learning methods (e.g., role-playing) and a medical psychology course significantly improved medical students’ positive attitudes toward communication skills. A recent research [13] evaluated the acceptability and efficacy of a communication skills training program tailored for nursing students. The program focused on building empathy and discussing complex situations such as end-of-life care. Results indicated that the training significantly improved nursing students’ confidence and usage of essential communication skills in complex clinical scenarios. One study found that three experiential teaching methods (practicing patient interviews with peers, followed by debriefing and feedback; conducting interviews with trained actors simulating patients, followed by feedback sessions; watching actors playing a theatrical performance that included communication challenges between doctor and patient) are equally effective in teaching interpersonal communication skills to medical students [14].

In addition to effective communication, recent medical literature emphasizes the importance of ethical competence in protecting patients and promoting high-quality care [15]. It requires a combination of personal virtues, professional ethics, reflective practice, and a commitment to confidentiality and honesty [15,16]. Ethical competence enhances the quality of care and supports healthcare professionals in making ethical decisions [16]. In a systematic review that explored the literature on ethics education aimed at fostering ethical competence among healthcare professionals and students [17], based on the thematic analysis of 40 articles, the review highlights that ethics education is crucial for developing the ability to recognize and manage ethical issues in healthcare settings. Key themes identified include the importance of creating supportive conditions for ethical learning, designing effective educational strategies, and fostering interaction among learners. The studies reviewed indicate that ethics education can help healthcare professionals and students become more aware of ethical problems, enhance their ethical reasoning skills, and ultimately improve their ability to act in the best interests of patients. Indeed, another literature review based on 23 empirical studies [18] revealed that ethics interventions enhanced ethical knowledge, moral sensitivity, and the ability to identify ethical problems among healthcare workers and students. Interventions also improved ethical empowerment, including moral courage and the ability to cope with moral distress.

These findings underscore the importance of integrating comprehensive ethical communication skills training into medical students’ education programs. Such training can significantly enhance medical students’ confidence and skills, particularly in handling complex and emotionally charged interactions with patients and families, the ability to recognize and manage ethical issues, and ethical reasoning skills. Following this general trend of integrating communication and ethics courses in medical educational programs, the purpose of the current study is to evaluate the effectiveness of an ethical communication course for Romanian medical students in increasing students’ medical communication self-efficacy, health professionals’ communication skills, and perceived importance of medical communication.

MATERIALS AND METHODS

Participants

No a priori power analysis was conducted, as the pilot study relied on a small convenience sample of available students. As such, the findings should be interpreted with caution, as the limited sample size reduces statistical power and increases the likelihood of both Type I and Type II errors. Fifty-eight healthcare students completed the questionnaire. Five responses were excluded because the participants answered an attention check question incorrectly (“Do you think stones float on water?”, Agree/Disagree). One case was excluded due to missing values. The final sample at the pre-test consisted of 42 women (80.8%) and 10 men (19.2%). Of these, 32 (61.5%) previously participated in other communication courses, and 45 (86.5%) did medical practice or volunteering in a hospital or clinic. The pilot study participants had an average age of 20.21 years with a standard deviation of .72. The posttest questionnaire was completed by 24 students. Among them, 16 (66.7%) were women, 8 (33.3%) were men, 21 (87.5%) had previously done medical practice or volunteering in a hospital or clinic, and 11 (45.8%) had participated in a communication course in the past. The students had an average age of 20.25 years with a standard deviation of .67.

To assess potential differences between the students who completed only the pretest and those who completed both the pretest and posttest, we conducted non-parametric and categorical comparisons. A Mann–Whitney U test showed no significant difference in age between the two groups (U = 334.00, Z = –.04, p = .97). However, Chi-square tests indicated significant differences in gender distribution (χ²(1) = 5.71, p = .02), with a higher proportion of male students among those who completed both assessments. There was also a significant association between attrition and prior participation in communication courses (χ²(1) = 4.65, p = .03), suggesting that students without previous communication training were more likely to remain in the study. No significant difference was found regarding prior clinical or volunteering experience (χ²(1) = 1.01, p = .32).

Procedure

The students participated in a 3-month course called Ethical Considerations in Communication with Patients. The first session, called Ethical Communication with Patients and Relatives, included topics such as active listening, assertive communication, conflict management, non-verbal communication, and patient-centered care. The second session, Ethical Communication in Oncology and Palliative Care, included the presentation of the WHO principles of patient care, case studies, and ethical dilemmas. The third session was about ethical considerations in organ transplantation. The fourth session addressed the ethical considerations in communication within the field of psychiatry and mental health. Finally, the last session was about social media, mass media, and public health issues.

The sessions were developed based on the European Psychiatric Association guide regarding ethical aspects of communication with patients and their families [19]. The basic principles of communication that were presented were: respecting the patients’ autonomy, dignity, opinions, values, privacy, and confidentiality; sincere and clear communication; encouraging the expression of emotions; using a language adapted to the patient’s age and culture; avoiding time constraints [19]. Regarding the communication about the diagnosis, four principles were proposed: informing patients about their diagnosis after analyzing what they know and what they want to know about the disease; the step-by-step and flexible approach to presenting the diagnosis, avoiding the communication of unreliable information; prior discussion with patients to clarify what can be communicated to relatives [19]. Finally, the recommendations regarding communication about treatments were followed: presentation of all relevant information about treatments (risks and benefits, duration, possible adverse events); presenting the advantages and disadvantages of refusing treatment; helping the patient to make an informed decision; informing the relatives about the treatment [19].

Participation in the ethical communication course was optional. Since the present pilot study included only students who voluntarily attended the course, there was no inter-group comparison performed, and variability between groups was not controlled for. The course sessions were delivered by faculty members from the medical university, specifically two psychologists and one psychiatrist with clinical and teaching experience. All lecturers were course coordinators with expertise in communication skills training and medical ethics. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Research Ethics Committee of the University (Approval No. 8371, dated March 29, 2024).

Measurements

Medical communication self-efficacy was evaluated with the scale developed by Parle, Maguire, and Heaven (1997) that measures self-efficacy regarding nine components of communication with the patient (e.g., helping a patient deal with the uncertainty of his/her situation, breaking bad news to a patient) [20]. Students reported on a scale from 0 (not at all confident) to 100 (totally confident) how confident they were that they could successfully manage each situation.

Health professionals’ communication skills were measured with the Health Professionals Communication Skills Scale (HP-CSS) [21], which contains 18 items (e.g., When I give information to patients, I do so in understandable terms.) on a scale from 1 (seldom) to 6 (many times) that evaluates four communication skills dimensions (empathy, informative communication, respect, and social ability/assertiveness).

Perceived importance of medical communication was measured with a modified form of the medical communication self-efficacy scale [20], in which the students reported, on a scale from 1 (not important at all) to 5 (very important), how important they consider the behaviors in the respective scale (e.g., concluding a patient interview with an agreed problem list and a plan of action) in the physician-patient relationship.

The instruments were translated into Romanian by two psychologists with expertise in health psychology using the back-translation method. Internal consistency was evaluated using Cronbach’s alpha coefficients for each scale at both pretest and posttest, indicating good reliability (values presented in Table 1).

RESULTS

Descriptive Statistics

We performed the descriptive analysis for the study variables at the pretest and posttest for the students who completed the questionnaires at both time points. Results are presented in Table 1.

The Differences between Pretest and Posttest

We analyzed differences between the pretest and posttest using the Wilcoxon signed-rank test. Students reported significantly higher levels of medical communication self-efficacy after the course, Z = –3.29, p = .001, with a large effect size (r = .67). Similarly, the

perceived importance of medical communication significantly increased from the pretest to the posttest, Z = –2.26, p = .02, with a medium effect size (r = .46) (Table 2). No significant change was observed in health professionals’ communication skills, Z = –1.72, p = .09, although the effect size was in the medium range (r = .35).

DISCUSSION

This pilot study aimed to assess the effectiveness of an ethical communication course for Romanian medical students in enhancing students’ self-efficacy in medical communication, improving health professionals’ communication skills, and increasing the perceived importance of medical communication. The course followed the European Psychiatric Association’s guide on ethical communication [19]. Key principles included respecting patients’ autonomy, dignity, privacy, and confidentiality; clear communication; encouraging emotional expression; using appropriate language; and avoiding time constraints. For diagnosis, principles included informing patients, using a step-by-step approach, avoiding unreliable information, and clarifying what can be shared with relatives. For treatment, recommendations included presenting all relevant information, discussing treatment refusal consequences, aiding informed decisions, and informing relatives.

Ethical communication is increasingly recognized as an essential competency in healthcare, yet many medical students receive inadequate formal training in this area [1,2,3]. Research shows that healthcare professionals frequently encounter ethical dilemmas that require effective communication skills, particularly in cases of informed consent or end-of-life decision-making [4]. The ICN Code of Ethics (2021) and the WMA International Code of Medical Ethics (2022) stress the importance of ensuring clear, transparent, and compassionate communication in patient care, yet studies indicate that many healthcare professionals struggle to implement these principles effectively [3,22]. Ethical stress and moral distress are also common among nurses and physicians who feel unprepared to navigate these complex interactions, leading to demoralization and job dissatisfaction [4]. Given these challenges, structured ethical communication training is essential for enhancing professionalism, patient trust, and ethical decision-making in clinical practice [6].

Students reported higher levels of medical communication self-efficacy and perceived importance of medical communication after completing the course. These results are in line with previous studies in which different types of communication courses had a positive effect on healthcare students’ communication self-efficacy and attitudes toward communication skills [11,12,13]. Our results are also in accordance with the studies highlighting that ethical interventions enhance ethical knowledge [17,18]. Research further suggests that integrating ethics training into medical curricula can reduce moral distress and improve ethical resilience, helping future healthcare professionals navigate value conflicts and ethical dilemmas with greater confidence [2,3].

No statistically significant differences were found in terms of health professionals’ communication skills. This result is in contradiction with other studies in the field [7,13,14,17]. There are two possible explanations for this result. Firstly, without ongoing reinforcement and opportunities to practice these skills in clinical settings, the impact of the course might diminish. It is possible that the students did not have enough opportunities to interact with patients and practice the new skills. Future courses could offer students more practical contexts in which to interact with patients. Secondly, the lack of effect may be because the course did not include didactic methods used in the training that had positive results in increasing communication skills (e.g., care scenarios with professional actors playing the role of patients, practicing patient interviews with peers, watching actors perform a theatrical piece depicting communication challenges between doctor and patient) [11,14]. Future courses could include a greater variety of teaching methods.

The present pilot study has several limitations. First of all, the sample is very small. Second, the study was based on a convenience sample. Thirdly, the sample lacked diversity, as most students shared similar educational backgrounds, age ranges, and academic experiences. This limited representativeness may affect the generalizability of the results to broader and more heterogeneous student populations. Fourth, some of the students did not complete the questionnaire at both time points. Additionally, the voluntary nature of participation may have introduced self-selection bias, as more motivated or engaged students were likely overrepresented in the

post-test sample, potentially inflating the observed effects. These limitations regarding the participants make the conclusions of the study inconclusive. Future studies could be based on larger statistically representative samples. Fifthly, there was no control group of students to compare their scores with those of the students who attended the course. Therefore, it was not possible to test whether the increases in self-efficacy and the perception of the importance of communication were due to the participation in the communication course or due to other factors (e.g., the participation in other courses, and the experience with patients in hospitals). Future studies could also include a control group to test the effectiveness of the course. Another limitation of this study is the exclusive use of self-report questionnaires, which are subject to personal biases and may not accurately reflect actual improvements in communication skills. Without objective assessments, such as knowledge tests, role-playing evaluations, or clinical observations, it is difficult to determine whether students have effectively internalized and applied the skills learned. Future research should combine subjective and objective measures to better evaluate training outcomes. In addition, the statistical power of the study was limited due to the small sample size and lack of a priori power analysis. Future studies should conduct formal power calculations to ensure adequate sensitivity for detecting meaningful changes. Finally, although the students participated in the course, they did not have extensive practical experience with patients in hospitals. Therefore, the study participants could not evaluate whether they improved their communication skills in real contexts with patients. Future studies could test the effectiveness of such courses after students have more practical experience with patients. Future studies could also explore the integration of structured pedagogical frameworks (such as experiential or transformative learning models) into course design, to better support behavioral change and deepen students’ engagement with ethical communication principles.

CONCLUSION

This pilot study explored the effectiveness of an ethical communication course for Romanian medical students, focusing on its impact on communication self-efficacy, perceived importance of communication, and communication skills. The results indicate that theoretical training can improve students’ confidence in communicating with patients and raise their awareness of the ethical significance of medical communication. However, the course did not produce measurable changes in actual communication skills. These findings highlight the need to complement theoretical instruction with practical components such as role-playing, simulations, or supervised patient interactions to support skill development. Given the small, non-representative sample and lack of a control group, the results should be interpreted with caution. Future research should test similar interventions using larger, randomized samples and objective outcome measures. Additionally, future courses could consider incorporating structured pedagogical frameworks to enhance student engagement and better support the internalization and application of ethical communication principles.

Conflicts of interest and sources of funding

The authors declare no conflict of interest. No artificial intelligence automatically generated text was inserted in this manuscript, and no image was previously published in another journal or is under consideration for publication elsewhere. This research received no external funding.

Authors’ contribution

Conceptualization, M.L., C.G.I., A.C.C. and A.C.; methodology, B.O.; software, D.M.P.; validation, M.L.., B.O., and A.C.; formal analysis, D.M.P.; investigation, S.G.; resources, M.L. and A.C.C.; data curation, C.G.I.; writing—original draft preparation, B.O..; writing—review and editing, M.L. and A.C.; visualization, B.O..; supervision, M.L.; project administration, L.S.; funding acquisition, M.L. All authors have read and agreed to the published version of the manuscript

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki and was approved by the Research Ethics Committee of the University (Approval No. 8371, dated March 29, 2024).

Patient consent for publication

Informed consent was obtained from all subjects involved in the study.

References:

1. Aitamaa E, Leino-Kilpi H, Puukka P, Suhonen R. Ethical problems in nursing management: the role of codes of ethics. Nurs Ethics. 2010;17(4):46982. doi: 10.1177/0969733010364896.
2. Aitamaa, E., Suhonen, R., Puukka, P., & Leino-Kilpi, H.. Ethical problems in nursing management: The views of nurse managers. Nursing Ethics,2015, 22(6), 693–707. doi: 10.1177/0969733015579309
3. Ulrich CM, Taylor C, Soeken K, O’Donnell P, Farrar A, Danis M, Grady C. Everyday ethics: ethical issues and stress in nursing practice. J Adv Nurs. 2010;66(11):2510-9. doi: 10.1111/j.1365-2648.2010.05425.x.
4. Gabel S. Demoralization in health professional practice: development, amelioration, and implications for continuing education. J Contin Educ Health Prof. 2013;33(2):118-26. doi: 10.1002/chp.21175.
5. International Council of Nurses (ICN). ICN Code of Ethics for Nurses. 2021. Retrieved from: https://www.icn.ch/sites/default/files/202306/ICN_Code-of-Ethics_EN_Web.pdf. Accessed April 28, 2025.
6. Brown NC, McGee SJ. Conceptualizing boundaries for the professionalization of healthcare ethics practice: A call for empirical research. HEC Forum. 2014;26(4):325–341. doi:10.1007/s10730-014-9240-x.
7. Chant S, Tim, Randle J, Russell G, Webb C. Communication skills training in healthcare: a review of the literature. Nurse Educ Today. 2002;22(3):189-202. doi: 10.1054/nedt.2001.0690.
8. Ishikawa H, Eto M, Kitamura K, Kiuchi T. Resident physicians’ attitudes and confidence in communicating with patients: a pilot study at a Japanese university hospital. Patient Educ Couns. 2014;96(3):361-6. doi: 10.1016/j.pec.2014.05.012.
9. Rhodes R, Cohen DS. Understanding, being, and doing: medical ethics in medical education. Camb Q Healthc Ethics. 2003;12(1):39-53. doi: 10.1017/s0963180103121056.
10. Suciu N, Melit LE, Marginean CO. Teaching communication in medical students–a cornerstone for patient’s outcome. Rom J Med Pract. 2021;16(2):143–147. doi: 10.37897/RJMP.2021.2.6.
11. Cabañero-Martínez MJ, Escribano S, Sánchez-Marco M, Juliá-Sanchis R. Effectiveness of a standardised patient simulation programme in undergraduate nursing students 6 months after implementation: A quasi-experimental study. Nurs Open. 2023;10(7):4747-4755. doi: 10.1002/nop2.1726.
12. Givron H, Desseilles M. Longitudinal study: Impact of communication skills training and a traineeship on medical students’ attitudes toward communication skills. Patient Educ Couns. 2021;104(4):785-791. doi: 10.1016/j.pec.2020.09.010.
13. Cannity KM, Banerjee SC, Hichenberg S, Leon-Nastasi AD, Howell F, Coyle N, Zaider T, Parker PA. Acceptability and efficacy of a communication skills training for nursing students: Building empathy and discussing complex situations. Nurse Educ Pract. 2021;50:102928. doi: 10.1016/j.nepr.2020.102928..
14. Koponen J, Pyörälä E, Isotalus P. Communication skills for medical students: Results from three experiential methods. Simul Gaming. 2014;45(2):235–254. doi:10.1177/1046878114538915.
15. Grönlund CF, Brännström M. Postgraduate nursing students’ experiences of practicing ethical communication. Nurs Ethics. 2022;29(7-8):17091720. doi: 10.1177/09697330221109943.
16. Hemberg J, Hemberg H. Ethical competence in a profession: Healthcare professionals’ views. Nurs Open. 2020;7(4):1249-1259. doi: 10.1002/nop2.501.
17. Andersson H, Svensson A, Frank C, Rantala A, Holmberg M, Bremer A. Ethics education to support ethical competence learning in healthcare: an integrative systematic review. BMC Med Ethics. 2022;23(1):29. doi: 10.1186/s12910-022-00766-z.
18. Stolt M, Leino-Kilpi H, Ruokonen M, Repo H, Suhonen R. Ethics interventions for healthcare professionals and students: A systematic review. Nurs Ethics. 2017;25(2):133–152. doi:10.1177/0969733017700237.
19. Carpiniello B, Wasserman D; EPA Council of National Psychiatric Associations Working Group on Communication with Patients and Families*. European Psychiatric Association policy paper on ethical aspects in communication with patients and their families. Eur Psychiatry. 2020;63(1):e36. doi: 10.1192/j.eurpsy.2020.33.
20. Parle M, Maguire P, Heaven C. The development of a training model to improve health professionals’ skills, self-efficacy and outcome expectancies when communicating with cancer patients. Soc Sci Med. 1997;44(2):231-40. doi: 10.1016/s0277-9536(96)00148-7.
21. Leal-Costa C, Tirado-González S, Rodríguez-Marín J, Vander-Hofstadt-Román CJ. Psychometric properties of the Health Professionals Communication Skills Scale (HP-CSS). Int J Clin Health Psychol. 2016;16(1):76-86. doi: 10.1016/j.ijchp.2015.04.001.
22. World Medical Association (WMA). International Code of Medical Ethics. 2022. Retrieved from: https://www.wma.net/policies-post/wmainternational-code-of-medical-ethics/. Accessed April 28, 2025.