Nonviolent communication training among undergraduate medical students in emergency medicine teaching: a randomized controlled educational trial

ERCT Criteria Breakdown

• Level 1 Criteria

  • C

    Class-level RCT

    • Randomization was performed at the individual student level within a single cohort, not at the class or school level, and the intervention is group-based teaching rather than one-to-one tutoring.
    • "Participants were randomized in a 1:1 ratio using a computer-generated random sequence."
    • Relevant Quotes: 1) "Participants were randomized in a 1:1 ratio using a computer-generated random sequence. The sequence was generated by an independent staff member who was not involved in teaching or outcome assessment. Allocation concealment was maintained using sequentially numbered, opaque, sealed envelopes prepared by an independent staff member; envelopes were opened only after baseline assessment was completed." (Methods) 2) "100 were allocated to the NVC training group and 98 were allocated to the control group (Figure 1)." (Methods) 3) "Foundational content introduced the NVC model and core principles, followed by small-group practice (approximately 20 students per group)." (Methods) 4) "contamination between groups cannot be fully excluded because participants were drawn from the same undergraduate cohort, although sessions were delivered separately and teaching materials were distributed only within the assigned study arm." (Discussion, limitations) Detailed Analysis: The C criterion requires randomisation at the class level or stronger (school level), unless the intervention is one-to-one/personal tutoring in which case student-level randomisation is acceptable. Here, the unit of randomisation was the individual student (1:1 allocation of 198 students drawn from the same fourth-year cohort). The intervention was delivered to groups of students (approximately 20 per small group), so it is classroom-style group teaching, not personal tutoring, and the tutoring exception does not apply. The authors themselves acknowledge contamination risk because both arms came from the same cohort, which is exactly the problem the class-level requirement is designed to prevent. Criterion C is not met because randomisation was at the individual student level within a single shared cohort rather than at the class or school level, and no tutoring exception applies.
  • E

    Exam-based Assessment

    • Outcomes were measured with a self-report empathy questionnaire (JSPE) and a study-specific custom checklist (SCCG), neither of which is a standardized exam-based achievement assessment.
    • "The secondary outcome was the change in observed communication performance assessed using a study-specific, simplified Calgary-Cambridge-Guided communication checklist (SCCG)."
    • Relevant Quotes: 1) "The primary outcome was change in empathy measured using the Jefferson Scale of Physician Empathy (JSPE), a 20-item self-report instrument rated on a 7-point Likert scale, with total scores ranging from 20 to 140." (Methods) 2) "The secondary outcome was the change in observed communication performance assessed using a study-specific, simplified Calgary-Cambridge-Guided communication checklist (SCCG). ... We developed this shortened checklist pragmatically from the Calgary-Cambridge Guides." (Methods) 3) "This process was intended to support content relevance rather than to establish full psychometric validity. The instrument was intended to support structured observation of communication performance in this study context rather than to serve as a fully established, standalone psychometric scale." (Methods) Detailed Analysis: The E criterion requires a standardised, widely recognised exam-based assessment that was not created specifically for the study. The primary outcome, JSPE, is a validated self-report attitudinal questionnaire about empathy, not an exam-based assessment of academic achievement. The secondary outcome, SCCG, is explicitly a study-specific instrument developed pragmatically by the authors for this study, and they state it was not intended to establish full psychometric validity or to serve as a standalone validated scale. Neither instrument constitutes a standardised exam-based assessment in the sense required by the standard. Criterion E is not met because the outcomes were a self-report empathy questionnaire and a custom study-specific checklist rather than a standardised exam-based assessment.
  • T

    Term Duration

    • The intervention ran about one month and outcomes were measured in the final week of the course, so the interval from intervention start to measurement was far shorter than one academic term.
    • "The intervention consisted of five sessions delivered over approximately 1 month (approximately 2 hours per session)."
    • Relevant Quotes: 1) "The intervention consisted of five sessions delivered over approximately 1 month (approximately 2 hours per session)." (Methods) 2) "Outcomes were assessed at baseline (immediately before the first session) and at post-course assessment during the final week of the course, after completion of the training period." (Methods) 3) "the interpretation of these findings should remain cautious given the single-center design, the short follow-up period, and the use of a simulated assessment context." (Discussion) Detailed Analysis: The T criterion requires that outcomes be measured at least one full academic term (about 3-4 months) after the intervention begins, and the standard permits short interventions only if term-long follow-up tracking is provided. Here the intervention spanned roughly one month, and the post-course measurement occurred in the final week of the course, immediately after training. The interval from intervention start to outcome measurement is therefore about one month, well short of a full term, and there is no longer-term follow-up. The authors repeatedly describe the results as short-term. Criterion T is not met because the interval from intervention start to outcome measurement was about one month, far shorter than one academic term.
  • D

    Documented Control Group

    • The control group is well documented, with baseline demographics and baseline outcome scores tabulated and the control curriculum described in detail.
    • "Baseline demographic characteristics and outcome measures were well balanced between groups (Table 1)."
    • Relevant Quotes: 1) "Participants were randomized to an NVC-based training program (n = 100) or a time- and dose-matched standard curriculum control (active control, n = 98)." (Abstract) 2) "The control group received time- and dose-matched standard communication teaching based on emergency medicine textbook content. ... each control session also incorporated instructor-led case discussion and structured summary around communication-relevant textbook themes. However, the control curriculum did not include explicit NVC concepts or the NVC-based deliberate-practice framework." (Methods) 3) "Mean age was 23.1 +/- 0.9 years in the NVC group and 23.1 +/- 0.8 years in the control group (P = 0.73). Female students accounted for 57.0% of the NVC group and 55.1% of the control group (P = 0.79). Baseline JSPE scores were 92.42 +/- 3.87 in the NVC group and 92.43 +/- 3.86 in the control group (P = 0.99). Baseline SCCG scores were 17.55 +/- 2.69 and 17.92 +/- 2.25, respectively (P = 0.30)." (Results) 4) "Table 1. Baseline characteristics of participating students ... Control group (n = 98) ... Age ... Female ... JSPE ... SCCG." (Table 1) Detailed Analysis: The D criterion requires clear documentation of the control group's size, characteristics, and conditions. The paper provides a dedicated control-group column in Table 1 with age, sex, and baseline JSPE and SCCG scores, states the control arm's size (n = 98), and describes the control curriculum content (textbook-based standard communication teaching, matched for time and dose, without NVC concepts). This gives readers sufficient information about who the control group was, their baseline performance, and what they received. Criterion D is met because the control group's size, baseline demographics, baseline outcome scores, and instructional conditions are clearly documented.

• Level 2 Criteria

  • S

    School-level RCT

    • This was a single-center study with randomisation at the individual student level, so no school-level randomisation occurred.
    • "We conducted a single-center, parallel-group, randomized controlled educational intervention during the 2024-2025 academic year at the School of Medicine, Nantong University."
    • Relevant Quotes: 1) "We conducted a single-center, parallel-group, randomized controlled educational intervention during the 2024-2025 academic year at the School of Medicine, Nantong University." (Methods) 2) "Participants were randomized in a 1:1 ratio using a computer-generated random sequence." (Methods) Detailed Analysis: The S criterion requires randomisation among schools (or the equivalent institutional/site unit implementing the intervention). This study was conducted at a single institution and randomised individual students, so there was no randomisation of schools or comparable units. Criterion S is not met because the study was single-center and randomised individual students rather than schools.
  • I

    Independent Conduct

    • The authors designed the study and intervention and also conducted and analysed it, with no independent external evaluation of the trial as a whole.
    • "DJ designed the study. ... DJ and TB performed the statistical analyses and interpreted the results with XY."
    • Relevant Quotes: 1) "DJ designed the study. MW and HQ coordinated the study and the data acquisition. DJ and TB performed the statistical analyses and interpreted the results with XY. DJ and XY drafted the manuscript." (Authors' contributions) 2) "An emergency medicine specialist with more than 10 years of clinical and teaching experience led the NVC curriculum." (Methods) 3) "The sequence was generated by an independent staff member who was not involved in teaching or outcome assessment. ... Communication performance encounters were scored in real time by two trained faculty raters who were blinded to group allocation." (Methods) Detailed Analysis: The I criterion requires that the study be conducted independently from those who designed the intervention, to reduce bias in implementation, measurement, and analysis. In this study the same author team designed the study, delivered the intervention, coordinated data acquisition, and performed the analysis. There are partial safeguards (an independent staff member generated the randomisation sequence, and faculty raters were blinded to group allocation), but these are local procedural measures rather than an independent third-party evaluation of the trial. No external evaluation team independent of the intervention designers conducted the study. Criterion I is not met because the intervention was designed, delivered, and evaluated by the same author team, with no independent external conduct of the trial.
  • Y

    Year Duration

    • Follow-up was about one month and criterion T is not met, so the year-duration requirement cannot be satisfied.
    • "The intervention consisted of five sessions delivered over approximately 1 month (approximately 2 hours per session)."
    • Relevant Quotes: 1) "The intervention consisted of five sessions delivered over approximately 1 month (approximately 2 hours per session)." (Methods) 2) "Outcomes were assessed at baseline (immediately before the first session) and at post-course assessment during the final week of the course, after completion of the training period." (Methods) 3) "Multicenter trials with longer follow-up are needed to assess durability and generalizability." (Abstract, Conclusions) Detailed Analysis: The Y criterion requires outcomes to be measured at least 75% of a full academic year (about 9-10 months) after the intervention begins, and per the standard, if T is not met then Y is automatically not met. Here the interval from intervention start to measurement was about one month, and the authors explicitly call for longer follow-up in future work. Criterion Y is not met because follow-up was only about one month, and criterion T was not met.
  • B

    Balanced Control Group

    • The control was an active, time- and dose-matched curriculum receiving equivalent contact time and instructional resources, so the groups were balanced.
    • "The NVC and control curricula were embedded within this course component and were matched for contact time and assessment schedule."
    • Relevant Quotes: 1) "Participants were randomized to an NVC-based training program (n = 100) or a time- and dose-matched standard curriculum control (active control, n = 98)." (Abstract) 2) "The NVC and control curricula were embedded within this course component and were matched for contact time and assessment schedule." (Methods) 3) "The control group received time- and dose-matched standard communication teaching based on emergency medicine textbook content. ... each control session also incorporated instructor-led case discussion and structured summary around communication-relevant textbook themes." (Methods) 4) "In contrast, the control curriculum emphasized textbook-based principles, real-case discussion, and structured consolidation without explicit NVC concepts or the NVC-based deliberate-practice framework." (Methods) Detailed Analysis: The B criterion asks whether the control condition received comparable time, budget, and instructional resources to isolate the specific intervention. Applying the decision tree: the intervention did not add extra contact time or budget relative to the control, because the two arms were explicitly matched for contact time, dose (five sessions of about two hours), and assessment schedule. The control arm was an active curriculum delivering equivalent standard communication teaching rather than a no-treatment baseline. The only intended difference between arms was the content (NVC framework and deliberate-practice structure versus textbook-based teaching), which is the treatment variable itself. Because time and resources were equalised across arms, the balance requirement is satisfied. Criterion B is met because the control was a time- and dose-matched active control receiving equivalent contact time and instructional resources, with only the content differing.

• Level 3 Criteria

  • R

    Reproduced

    • This is a single new trial with no independent replication of it reported or identified.
    • "to our knowledge the NVC framework has not been evaluated as a structured curriculum for undergraduate medical students in emergency medicine education."
    • Relevant Quotes: 1) "to our knowledge the NVC framework has not been evaluated as a structured curriculum for undergraduate medical students in emergency medicine education." (Introduction) 2) "Multicenter trials with longer follow-up are needed to assess durability and generalizability." (Abstract, Conclusions) 3) "Epinat-Duclos J, Foncelle A, Quesque F, et al. Does nonviolent communication education improve empathy in French medical students? International Journal of Medical Education. 2021." (Reference 14) Detailed Analysis: The R criterion requires that this specific study be independently replicated by a different team in a different context, published in a peer-reviewed journal. This is a newly published single-center trial (2026), and the authors state that NVC has not previously been evaluated in this specific emergency medicine undergraduate context. While related NVC-in-medical- education studies exist (e.g., Epinat-Duclos et al., 2021, in French medical students), these are separate studies rather than independent replications of this particular Nantong University trial. An external check (limited, as web-search access was unavailable during verification) does not identify any independent replication of this specific 2026 study, which would in any case be implausible given its recency. Criterion R is not met because no independent replication of this specific trial exists.
  • A

    All-subject Exams

    • Only empathy and communication were assessed, not all core subjects, and criterion E is not met, so this criterion cannot be met.
    • "Empathy was measured using the Jefferson Scale of Physician Empathy (JSPE; primary outcome), and observed communication performance was assessed using the simplified Calgary-Cambridge-Guided communication checklist (SCCG; secondary outcome)."
    • Relevant Quotes: 1) "Empathy was measured using the Jefferson Scale of Physician Empathy (JSPE; primary outcome), and observed communication performance was assessed using the simplified Calgary-Cambridge-Guided communication checklist (SCCG; secondary outcome) in OSCE-style role-play encounters." (Abstract) 2) "The primary outcome was change in empathy measured using the Jefferson Scale of Physician Empathy (JSPE)." (Methods) Detailed Analysis: The A criterion requires that impact be measured across all main subjects using standardised exam-based assessments, and it explicitly depends on criterion E: if E is not met, A cannot be met. Here the outcomes were confined to empathy and communication performance, measured with a self-report questionnaire and a custom checklist rather than standardised exams across the curriculum. Both the single-domain focus and the failure of criterion E preclude meeting this criterion. Criterion A is not met because only empathy and communication were measured (not all core subjects) and criterion E was not satisfied.
  • G

    Graduation Tracking

    • Students were assessed only up to the end of the course with no tracking to graduation, and criterion Y is not met.
    • "Outcomes were assessed at baseline (immediately before the first session) and at post-course assessment during the final week of the course, after completion of the training period."
    • Relevant Quotes: 1) "Outcomes were assessed at baseline (immediately before the first session) and at post-course assessment during the final week of the course, after completion of the training period." (Methods) 2) "longer follow-up across subsequent clerkships is needed to determine durability and transfer." (Discussion) Detailed Analysis: The G criterion requires tracking participants through to graduation from their educational stage, and per the standard it depends on criterion Y: if Y is not met, G is not met. Here outcomes were collected only at the end of the course, about one month after the intervention began, with no follow-up toward graduation. The authors explicitly note that longer follow-up across subsequent clerkships would be needed. No subsequent graduation-tracking publication by the same authors was identified (web-search access was unavailable during verification, but this is a newly published 2026 study so a follow-up cohort paper would not yet be expected). Criterion G is not met because there was no tracking to graduation and criterion Y was not met.
  • P

    Pre-Registered

    • The authors explicitly state the study was not prospectively registered.
    • "Trial registration: Not prospectively registered."
    • Relevant Quotes: 1) "Trial registration: Not prospectively registered." (Abstract) 2) "This study was not prospectively registered. At the time of implementation, it was conducted as a teaching-focused educational intervention embedded in an undergraduate course. ... no public trial record was available to externally verify a prespecified hierarchy of primary and secondary outcomes. ... We acknowledge the absence of prospective registration as an important limitation." (Methods) Detailed Analysis: The P criterion requires a full study protocol pre-registered on a public registry before data collection began. The authors state plainly that the study was not prospectively registered and that no public trial record exists. Although they note some elements were specified before data analysis, there is no pre-registration reference or date, and they acknowledge this as a limitation. With no registry ID to check, there is nothing to verify against a public database. Criterion P is not met because the study was explicitly not prospectively registered.