Content area
Background
Pressure injuries (PI) are a common health problem that reduces patients' quality of life, increases morbidity and mortality and contributes to healthcare costs. Although PI assessment is an essential skill for prevention and correct management, adequate training is not provided in nursing education.
ObjectivesTo compare the effects of three parallel PI assessment training methods—self-directed learning via a smartphone application (SDL_SA), small group teaching (SGT) and the control group—on the knowledge and skills of nursing students.
DesignA three-arm, parallel group randomized controlled trial was conducted. The trial was registered on ClinicalTrials.gov (ID: NCT05354687).
MethodsThe study was conducted at a public university in Türkiye with fourth-year undergraduate nursing students (n = 93). Students were randomly assigned to one of three groups (SDL_SA group, SGT group and control group). While the control group received the existing training, the SDL_SA and SGT groups received a two-stage training program. The Pressure Injury Assessment Knowledge Test, the Education Evaluation Form and the Pressure Injury Assessment Skill Test were administered before and after training.
ResultsThe post-test scores of the SGT and SDL_SA groups for knowledge and total skills were significantly higher than the pre-test scores (p < 0.05). On the post-skill test, both the SGT and SDL_SA groups scored significantly higher than the control group on overall score (F=36.429, p < 0.001).
ConclusionsSDL_SA and SGT can provide a comprehensive learning experience in the acquisition of nursing skills. It is recommended that further research is conducted on SDL_SA and SGT in different subjects and larger populations.
Pressure injury (PI), defined as "localized damage to the skin and/or underlying tissue as a result of pressure or shear with pressure", is a common health problem worldwide ( EPUAP, NPIAP and PPPIA, 2019). According to Li et al. (2020), the global prevalence of PI was 12.8 %. In Türkiye, the national PI point prevalence was determined as 9.5 % ( Göçmen Baykara et al., 2023). They found that 65.1 % of PI developed after hospital admission. PI reduces the quality of life of patients and may increase the length of hospital stay, morbidity and mortality ( Lin et al., 2020). In addition, wound care, debridement, graft procedure and increased length of hospital stay create extra costs for the patient and the hospital. A systematic review reported that the cost of treating PI was 470.49 Euros per day ( Demarré et al., 2015). At this point, how to manage PIs gains importance.
Nurses are the leading healthcare professionals in the management of PIs. PI is included in the nursing-sensitive quality indicators of the American National Nursing Quality Indicators Database ( Montalvo, 2007). In Türkiye, PI is also included in the Health Quality Standards published by the Ministry of Health ( General Directorate of Health Services, 2020). To achieve quality standards in healthcare, nurses need to have sufficient knowledge and skills to manage PI and achieve better outcomes ( Teo et al., 2019).
Identification and assessment are critical components of managing PIs ( Yan et al., 2022). Nursing education has a responsibility to ensure that nursing students are competent in PI assessment ( Ayello et al., 2017). However, studies show that nursing students have a poor understanding of PI assessment ( Gürlek Kısacık et al., 2019; Şahbudak, 2018). Well-educated and well-equipped nursing students are a prerequisite for a qualified nursing workforce.
Traditionally, hospital settings have provided adequate opportunities for pre-degree nursing students to acquire practical nursing skills ( Currie et al., 2023). However, these opportunities have recently diminished mainly due to concerns about patient safety, increased student numbers, limited clinical placements and increased nurse workload. Thus, training should be designed to meet the needs of today's students. Consequently, there is a need for training in PI assessment using modern teaching methods. Learner-centered and active teaching methods, such as small group teaching (SGT) and self-directed learning (SDL), can facilitate the acquisition of PI knowledge and skills among nursing students ( Serdà and Alsina, 2018; Wong, 2018).
SGT is a common learning and teaching strategy that can be implemented in a variety of ways, including snowballing/brainstorming, problem-based learning, role-playing, games, simulations and clinical teaching ( Crosby, 1997). It was found that the use of SGT in virtual patient simulators is an accessible, low-risk educational strategy that can improve students' perceptions of individual learning and curricular integration ( Mestre et al., 2022). In another study, nursing students showed high motivation with a student-centered SGT strategy ( Cui et al., 2021). At the same time, SGT may provide students with the opportunity to apply the knowledge they have learned through collaborative work, helping them to connect theoretical knowledge with practical skills ( Jackson et al., 2014). However, there is not enough information in the literature about the use of SGT in PI education for nursing students.
Another active learning method is SDL, which empowers nursing students to take control of their education. An SDL environment differs significantly from a lecture-based classroom, as it allows the learner to set goals, determine assessments, structure activities and timelines, identify resources and seek feedback, unlike the traditional model where the educator controls these aspects. Moreover, Sarmasoğlu and Görgülü (2014) stated that nursing students are ready for SDL.
SDL programs mainly associated with simulations ( Peñataro-Pintado et al., 2021), blended coaching ( Noh and Kim, 2019) and clinical placements ( Park and Cho, 2022) have been described in the literature, but there is insufficient information on SDL programs associated with smartphone applications. Mobile technologies may have a positive impact on learning because they can be accessed at a time when the learner feels ready to continue learning and the learning environment can be personalized ( Darejeh et al., 2022; Sönmez et al., 2018). The audio-visual nature of smartphone applications provides material that is more conducive to learning, retention and overall understanding; examples of such material include videos, photos and podcasts, all of which can be easily accessed by students through their mobile devices ( Kopmaz and Arslanoğlu, 2022). Because of these characteristics of smartphone applications, it is offered that they can offer important opportunities when used in SDL.
2 Theoretical frameworkThe landscape of healthcare is constantly evolving, requiring healthcare professionals to adapt to dynamic challenges and advancements. Among these professionals, nurses stand as frontline contributors to patient care, requiring a unique set of skills and knowledge ( Flaubert et al., 2021). As the healthcare sector increasingly emphasizes lifelong learning and adaptability, the synergy between adult learning theory and nursing education becomes a critical focus ( Mukhalalati and Taylor, 2019). In this context, the concept of SDL emerges as a linchpin that shapes the trajectory of nursing education and promotes the professional development of nurses.
2.1 Self-directed learningCentral to the philosophy of adult learning theory is the concept of SDL ( Van der Walt, 2019). Rooted in the seminal work of Malcolm Knowles, adult learning theory argues that adults approach learning with different motivations, experiences and orientations. Adult learning theory is derived from the term 'andragogy', which comes from the root of the Greek word 'aner', meaning man (as opposed to boy) ( Knowles, 1973). Key principles include self-concept, experience, readiness to learn and orientation to learning, all of which influence the design and delivery of educational interventions. Recognizing the autonomy and self-directed nature of adult learners, this theory posits that effective education for adults should be learner-centered, recognizing their prior experiences and encouraging active participation in the learning process ( Collier, 2022). This theory guides educators to tailor teaching strategies that resonate with the diverse backgrounds and motivations of adult learners, ultimately increasing the relevance and effectiveness of nursing education ( Collier, 2022; Morris, 2019).
SDL is recognized as a natural process in adult learning and offers a valuable perspective in higher education ( Wilcox, 1996). This process embraces the fundamental principles of higher education, emphasizing personal autonomy, responsibility and development. Active teaching-learning strategies, the development of critical skills and the use of real-life examples are examples of the effective development of SDL ( Mentz et al., 2019).
Nursing education serves as the crucible where theoretical knowledge converges with practical clinical practice. The application of adult learning theory in this context highlights the importance of recognizing learners as self-directed individuals with a wealth of prior experience ( Alsufyani et al., 2020). This informs the development of teaching strategies that are aligned with adult learners' autonomy, motivation and practical application of knowledge in the healthcare setting. Given the complex and dynamic nature of healthcare, nurses need to be equipped with foundational knowledge and the ability to adapt and continuously learn throughout their careers ( Mlambo et al., 2021). Thus, the intersection of adult learning theory and self-directed learning (SDL) in nursing education is emerging as a central paradigm for the development of competent and resilient healthcare professionals.
2.2 Small group teachingSGT is a teaching and learning strategy which is typically applied in groups of five to 12 people ( Agnihotri and Ngorosha, 2018; Cui, Laugsand and Zheng, 2021). The benefits of SGT include meaningful interaction, critical thinking, decision making, discussion, encouraging reflection, developing attitudes, sharing and reflecting on experiences. Students may have the opportunity to make new friends, have cultural exchanges, share ideas, share the workload and improve their communication skills. For teachers, group work makes assessment easier and can provide a less stressful environment due to the potential for student interaction ( Agnihotri and Ngorosha, 2018; Cui et al., 2021).
SGT can be delivered using a variety of methods including discussion, seminar, snowball, free discussion groups, problem-based learning, brainstorming, role-playing, games and simulations ( Crosby, 1997). These methods encourage deep, active, collaborative learning and can increase the engagement of less motivated students ( Jackson et al., 2014). For this reason, SGT remains a valuable approach to promoting collaborative and active learning.
Although the existing literature supports the use of both methods in nursing education, there is insufficient evidence to support their use in a cognitively demanding area such as PI assessment. In addition, our study is unique in that it integrates the smartphone application with the SDL. Therefore, the primary aim of this study was to compare the effect of SGT and SDL via a smartphone application (SDL_SA) methods on nursing students' knowledge and skills related to PI assessment.
3 Methods3.1 Study design
The study was designed as a parallel group randomized control trial with three arms (experimental group 1: SDL_SA, experimental group 2: SGT and control group) to investigate the effect of individual and group learning. The trial was registered at ClinicalTrials.gov (ID: NCT05354687). The study was designed and reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) statement ( Dwan et al., 2019).
3.2 Setting and participantsThe study was conducted at the Faculty of Health Sciences Nursing Department of a public university in Türkiye during the 2021–2022 academic spring semester. The Nursing Program takes 4 years to complete and in the fourth-year students receive 1 day of theoretical training per week and 4 days of clinical practice per week. The target population consisted of 231 fourth year nursing students. The G-Power program was used for sample calculations, using an effect size of 0.40 and 90 % power in fixed effects ANOVA, omnibus, one-way test, with a type I error set at 0.05 ( Faul et al., 2007). A total sample size of 84 participants was calculated. Therefore, a total of 93 participants were required for this study after accounting for a 20 % attrition rate based on the literature ( Doğan, 2021; Sarvan, 2021).
Inclusion criteria for the study were (1) enrolment in the Application of Nursing Vocational Course, (2) possession of a smartphone and (3) availability of an internet package. Exclusion criteria were prior training in PI assessment beyond basic nursing education. Of the 231 students who were evaluated for eligibility for the study, 96 agreed to participate in the study. Of the 96 students, 3 met the exclusion criteria. The sample was equally divided into two experimental groups and one control group using the computer-generated randomization method by an independent statistician blind to participant characteristics ( Fig. 1).
One researcher was aware of the group allocation, while the students were unaware of their group allocation throughout the study. The nurse who carried out data collection were also unaware of the students' group allocation. To establish blinding criteria, the statistical analysis was conducted using neutral coding to conceal each student's group assignment. The statistician reported the results according to the predetermined coding.
3.3 Outcome measures and instruments3.3.1 Descriptive characteristics form
This form was designed by the researchers to collect demographic information about the participants. It contains five questions about the students' age, gender, academic achievement score, the high school they attended and previous experience of observing PI assessment.
3.3.2 Pressure injury assessment knowledge testThis test was developed by researchers based on the literature ( Baranoski et al., 2016; Beeckman, 2017; Benbow, 2016; Brennan, 2019; EPUAP, NPIAP, PPPIA, 2019; LeBlanc et al., 2016; WUWHS, 2016). A total of 10 learning outcomes ( Fig. 2) were identified for the assessment of PI and a total of 34 multiple-choice questions were prepared, with at least 3 questions for each outcome. To ensure the questions' validity, they were reviewed by six faculty experts and three Wound, Ostomy and Continence Nurses. Experts' opinions were analyzed using the Lawshe technique, resulting in a content validity index of 0.94 ( Lawshe, 1975). The test was administered to 102 third-year nursing students, who were not included in the main study sample, to determine item difficulty and discrimination indices. 18 items with a low discrimination index or very easy items were removed from the test. As a result of the analysis, the test consisted of 16 multiple-choice questions. Each item had only one correct answer and a score range from 0 to 16. The KR-20 value of the test was 0.709.
3.3.3 Pressure Injury Assessment Skill TestThe form was developed using the “Wound Diagnosis, Evaluation Form” from the Wound Ostomy and Incontinence Nurses’ Society ( YOİHD, 2011). The form is divided into three main sections: "Wound area and size", "Wound bed and surrounding tissue" and "Classification". “Wound area and size” includes five items: wound localization, length (cm), width (cm), area (cm 2) and depth (cm). “Wound bed and the surrounding tissue” includes eight items: the presence of tunnel, depth of tunnel, direction of tunnel, type of wound tissue (epithelial tissue, granulation tissue, yellow fibrotic tissue and necrotic tissue) and maceration. “The classification” includes the staging of five types of PI (stage I, stage II, stage III, stage IV, unstageable PI and deep tissue PI). Each correct answer was worth 1 point, resulting in a total score ranging from 0 to 17.
3.3.4 Pressure Injuries Assessment Education Evaluation FormThis form was developed by the researchers based on the study by Bayram and Caliskan (2019). It contains 19 items on a 5-point Likert scale, which were only used in the SDL_SA group. Each item is scored individually on a scale of 1–5, with higher scores for positive items indicating better results and higher scores for negative items indicating worse results.
3.4 Development of the Educational ContentThe content was developed based on the literature ( Baranoski et al., 2016; Beeckman, 2017; Benbow, 2016; Brennan, 2019; EPUAP, NPIAP, PPPIA, 2019; LeBlanc et al., 2016; WUWHS, 2016) and includes 10 identified learning outcomes ( Fig. 2). The real wound photographs to be used in the training content were taken by the leading researcher (LR) from inpatients at a hospital in Türkiye. For the prepared training content, expert opinions were obtained from 6 faculty members and 3 Wound Ostomy and Continence nurses. The experts' opinions were analyzed for content validity using the Lawshe technique. In the Lawshe technique, the content validity criterion was determined to be 0.75 for 9 experts ( Lawshe, 1975). The content validity ratios of the expert opinions given to the content were determined to be the lowest 0.78 and the highest 1.00 and the content validity index was found to be 0.96.
3.5 Development of pressure injury assessment systemThe Pressure Injury Assessment System (PIAS) was designed and developed by the lead researcher (LR) and a computer engineer ( www.pressureinjury.net). The PIAS software was developed using the PHP language in the MySQL database. Application interfaces were prepared using HTML, CSS and JavaScript technologies. The main menu of PIAS consisted of notifications, courses, tests, self-assessment, logout, contact and online expert consultation. In the Courses section, there were a total of 12 instructional videos with pop-up questions and learning documents. In the self-assessment section, users could choose to receive three random questions from a question pool each day. By answering these questions, users could assess themselves ( Fig. 3).
Real photographs of PIs in hospitalized patients for use in the training videos were taken by LR using professional camera and lighting systems. The photographs did not contain any personal information of the patients and did not have any identifying features. In addition, informed consent was obtained from the patients to take photographs. The videos were shot by LR using professional filming equipment in the nursing skills laboratory. The educational content used in the videos was determined according to the learning objectives. To establish a connection between the learners and the video content, the duration of each educational video was less than 10 minutes ( Almeida and Almeida, 2017). The titles of the educational videos were as follows: (1) Definition and Importance of Pressure Injury, (2) Etiology of Pressure Injury, (3) Risk Factors for Pressure Injury, (4) Wound Assessment in Pressure Injuries, (5) Location, (6) Staging of Pressure Injury, (7) Wound Bed, Wound Edge and Surrounding Tissue, (8) Wound Size, (9) Presence of Infection, (10) Monitoring of Healing, (11) Characteristics of Exudate, (12) Skin Assessment.
3.6 ProceduresAll fourth-year students were informed, and consent was obtained from those who wished to participate in the study on 9 May 2022. Student volunteers completed the descriptive characteristics form and the Pressure Injury Assessment Knowledge Test. A PI model was individually assessed by all students in the experimental and control groups using the Pressure Injury Assessment Skill Test. The skills assessment was carried out by a nurse observer. All the students including the control group received current training, which was clinical practice in different services.
The SGT group received PI assessment training in two phases: Classroom training (16–29 May, 2022) and laboratory training (30–5 June 2022). In addition to PowerPoint presentations, the classroom training used active learning strategies such as group discussion and question-and-answer techniques from LR. The training was conducted in two 40-minute sessions. During the lesson, each class was divided into groups of 6–10 students. The classroom training was followed by laboratory training in small groups using a moulage-modified wound model, real PI photographs and the necessary equipment. A laboratory practice that allowed for active learning methods such as group work and group discussion was conducted with small groups of 6–8 students and lasted 60 minutes.
The SDL_SA group received PI assessment training in two phases: smartphone application training (16–29 May 2022) and instructor-assisted self-laboratory practice (30 May-5 June 2022). Active and interactive teaching methods were used throughout the training for the SDL_SA group. First, the students had the PIAS smartphone application installed on their smartphones. The LR informed the students that they could use this application at their convenience for a period of two weeks. After this initial phase, students participated in self-laboratory exercises using a wound model modified with moulage techniques, real PI photographs and other necessary equipment. Students had the opportunity to interact with both the smartphone application and the educator.
Post-test measurements were taken between 6 and 10 June 2022 by a nurse observer. At this stage, the students were first given the Pressure Injury Assessment Knowledge Test. The students then individually assessed the PI model using the Pressure Injury Assessment Skill Test as part of the skills assessment. The Pressure Injury Assessment Education Evaluation Form was administered to the students between 13 and 17 June 2022.
3.7 Statistical analysisData were analyzed using IBM SPSS Statistics version 23. Descriptive statistics (mean, standard deviation) were reported for numerical variables, while categorical variables were reported using frequencies and percentages. The assumption of normal distribution was tested using the Kolmogorov-Smirnov and Shapiro-Wilk tests. One-way ANOVA was used to analyze differences between the groups. Dependent samples t-test were used to examine the differences between time points. Effect sizes were used in hypothesis testing and power analysis. The alpha level for all inferential statistics was determined at a significance level of 0.05.
3.8 Ethical considerationsThe study was conducted according to the Declaration of Helsinki. Ethical approval was obtained from the university ethics committee (ID: 2020-650) and institutional approvals were obtained prior to data collection. Informed consent was obtained from the nursing students, with assurances that participation in the research would not affect their exam grades or academic averages. The smartphone application was installed on the smartphones of the control group students after the post-test measurements.
4 Results4.1 Participant characteristics
Of the study participants, 79.76 % were female, with a mean age of 22.44 (± 1.97) and a mean academic achievement score of 3.17 (± 0.34). There were no statistically significant differences between the groups in terms of gender (χ2 = 0.936, p = 0.626), age (F = 1.388, p = 0.255), mean academic achievement score (F = 0.862, p = 0.426) and previous experience of observing PI assessment (χ2 =7.904, p = 0.095).
4.2 Effectiveness of the programs on knowledge levelThe mean post-test knowledge scores were significantly higher in the SGT group (13.65 ± 1.26) than in the control group (11.65 ± 1.99) (p < 0.05), while the SDL_SA group scored 12.78 (± 2.67). There was a significant increase in the post-test knowledge scores compared with their pre-test scores (p < 0.05). When the effect sizes between the pre-test and post-test of knowledge test were analyzed; the effect sizes of the control, SGT and SDL_SA groups were 0.473, 1.176 and 0.691, respectively. The effect size between the groups in the post-test was determined as 0.401 (p < 0.05). In the knowledge test, the groups were compared pairwise according to the post-tests and the effect sizes with Cohen's d were found to be 1.588 between control group and SGT, 0.444 between control group and SDL and 0.347 between SGT and SDL_SA (p < 0.05; Table 1).
4.3 Effectiveness of the programs on skill levelThe mean post-test overall skill scores were 9.39 ± 2.28 in the control group, 13.92 (± 2.04) in the SGT group and 12.63 (± 1.88) in the SDL_SA group. There was no statistically significant difference in the pre-test skill scores between the groups in terms of wound area and size, wound bed and surrounding tissue, classification and overall skill score (p > 0.05). The SGT and SDL_SA groups had significantly higher post-test skill scores in the wound area and size, wound bed and surrounding tissue, classification and overall score compared with the control group (p < 0.05).
Post-test scores of all groups were significantly higher than pre-test scores in terms of wound bed and surrounding tissue, classification and overall skill score (p < 0.05). Additionally, the post-test scores for wound area and size were significantly higher in the SGT and SDL_SA groups compared with their pre-test scores (p < 0.05). When analyzing the effect sizes between the pre-test and post-test scores for overall skill level, the effect sizes for the control, SGT and SDL_SA groups were 0.792, 2.731 and 2.169 respectively. In the skill test, the groups were compared pairwise according to the post-tests and the effect sizes with Cohen's d were found to be 1.19 between the control group and SGT, 1.17 between control group and SDL_SA and 0.02 between SGT and SDL_SA ( Table 2).
4.4 Students' opinion on the mobile applicationThe statements regarding the use of the smartphone application were obtained from students in the SDL_SA group (n = 23) using 19 items. The three most positive statements made by the students were “the sound quality of the videos was sufficient” (4.65 ± 0.49), “it was easy to use” (4.61 ± 0.58), “it allowed us to reinforce the information we learned” (4.52 ± 0.51; Table 3) respectively.
5 DiscussionThe primary aim of this study was to compare the effect of SDL_SA and SGT on the development of undergraduate nursing students' knowledge and skills in PI assessment. Although the post-test scores for knowledge and total skills were significantly higher than the pre-test scores in both the SGT and SDL_SA groups, no significant difference was found between these groups in total knowledge and skills scores. SGT group was more successful than the control group in terms of both knowledge and skill acquisition. Our results are consistent with the literature showing that SGT improves learning ( Cui et al., 2021; Mestre et al., 2022; Wong, 2018). Informal learning appears to be particularly effective in these small group settings, as students have the opportunity to build stronger relationships with their peers, leading to increased confidence ( Hommes et al., 2014). Group work, if properly structured, can be effective in motivating students ( Mukurunge et al., 2020). SGT provides Flexibility, interaction and engagement in students ( Mills and Alexander, 2013). Badowski et al. (2021) suggest that shifting nursing education to emphasize teamwork, communication, flexibility, critical thinking, leadership, advocacy and policy will better prepare new nurses to adapt to practice settings. The efficacy of SGT in our study may be attributed to the fact that this pedagogical approach can motivate students, has a structured design and facilitates a group dynamic that encourages interaction.
Similarly, the SDL_SA group demonstrated significantly higher total and sub-total PI assessment scores than the control group. The findings of our study are consistent with those of Beeckman et al. (2008), who reported that e-learning enhanced PI classification abilities in comparison to the control group. Additionally, Morente et al. (2014) demonstrated that a self-directed e-learning tool facilitated more effective learning outcomes in PI assessment than traditional methods. Research in the literature also shows that SDL improves the acquisition of various nursing skills, including evidence-based practice ( Zhang et al., 2012), short-stretch compression bandaging ( Bobbink et al., 2023) and basic life support and automated external defibrillator skills ( Hernández-Padilla et al., 2015) among nursing students. Our research findings are consistent with the literature on the effect of SDL_SA on nursing students' skills, including PI assessment.
Unlike the difference in skill level, the findings of our study indicate that there was no significant difference between the SDL_SA group and the control group in terms of knowledge level. In a systematic review, it was determined that SDL was moderately effective in knowledge acquisition ( Murad et al., 2010). In the study conducted by Ahmed et al. (2016), students were tasked with preparing and presenting presentations within the scope of the course. The role of the educator was to provide corrective feedback to students to enhance their learning outcomes. The measurements of this study were made at the 5th and 10th weeks and it was revealed that the SDL group demonstrated superior performance compared with the control group ( Ahmed et al., 2016). Additionally, Schroter et al. (2011) found that both the SDL and control groups improved their knowledge at the end of a 4-month training, but there was no significant difference between the two. The reason for the difference between these studies may be due to differences in the duration of training and the time between training and measurements. Further research on the influence of the characteristics of the educational process on learning is recommended. A study by Mestre et al. (2022) found that nursing students focused less on theory but had more clinical and simulation experience. Although observation in skills training provides a valuable learning experience, it is stated that students prefer practice and learning by doing ( Reime et al., 2017). Although there was no significant difference in the knowledge level of the SDL_SA group compared with the control group, the reason for a significant increase in skill level may be that nursing students place more importance on the application of psychomotor skills compared with theoretical knowledge.
A comparison of the intervention groups with the control group in our study reveals that the SGT group exhibited superior performance compared with the SDL_SA group. In addition, the wound bed and surrounding tissue skill sub-score of the SGT group was found to be significantly higher than that of the SDL_SA group. While the SDL_SA group received training independently through the mobile application and individual laboratory work, with support from the trainer when needed, the SGT group, on the other hand, received structured training at a planned place and time, guided by an educator. A comparison of teaching methods suggests that SGT may facilitate the provision of extrinsic motivation to students. In the SGT group, an extrinsic motivation, such as the desire to be approved by one's peers or the educator, may have been provided in comparison to the SDL_SA group. While intrinsic motivation encompasses factors such as interest, enjoyment and inherent satisfaction, extrinsic motivation is characterized by the presence of external factors, including rewards and punishments, as well as approval ( Ryan and Deci, 2020). Pranawengtias (2022) reached similar conclusions, indicating that extrinsic motivation plays a more significant role in students' motivation to learn than intrinsic factors. It is therefore hypothesized that the discrepancy in the performance of the experimental groups may be attributed to the motivational factors influencing the students. There is a need for further research on the motivation factor in active learning methods.
A further potential explanation for the discrepancy in the outcomes of the experimental groups is that the SGT group is already conversant with the conventional learning methodologies that students are familiar with, whereas the SDL_SA group is not. Despite the fact that a significant proportion of the SDL_SA group indicated a preference for further training via the smartphone application, a notable number of participants stated that they would prefer to receive face-to-face training. SGT is a widely recognized approach to skills training in healthcare and studies have consistently demonstrated its efficacy in enhancing both skills and confidence ( Villela et al., 2020; You et al., 2017). David et al. (2024) observed that university students express intentions to change but do not prioritize change, which aligns with the findings of our study. These findings emphasize the necessity of considering students' preferences and preparedness for change when implementing innovative training methods ( Levett-Jones, 2005). SDL assists students in identifying the significance of their learning and in assuming responsibility for the planning, implementation and evaluation of their learning ( Knowles, 1975). It is therefore essential to consider the individual differences of students when designing a lesson plan.
6 Limitations of the studyIt is important to acknowledge the limitations of this study, which may influence the interpretation of the findings. A limitation of this study is the inability to assess certain key features, including the amount of wound exudate, the presence of epibole, induration and fistula, signs of infection (pain, odour, increased heat) and stage I PI in the skills assessment. This is since the wound model simulator does not support these features. Moreover, focusing on a single educational institution may limit the broader applicability of the findings. Additionally, the students were provided with the necessary explanations to avoid interactions between groups and students. However, there may still have been uncontrollable interactions during the training period.
7 ConclusionThis study aimed to investigate the effectiveness of self-directed learning using a smartphone application (SDL_SA) and a small group teaching (SGT) approach compared with a control group in nursing education. While both groups showed improvements, no significant difference in knowledge acquisition was observed between the SDL_SA and control groups. However, the self-directed learning experience of the SDL_SA group, although promising, faced challenges related to cognitive load and lack of consistent guidance from the educator. On the other hand, the SGT group benefited from structured training that included educator guidance, interactions and a planned learning environment, which may have led to more focused learning experiences. Given the individual differences among nursing students, it is recommended that studies of SDL_SA and SGT be replicated in different subjects and with larger populations.
CRediT authorship contribution statementAydogan Sinan: Writing – review & editing, Writing – original draft, Visualization, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Caliskan Nurcan: Writing – review & editing, Visualization, Supervision, Project administration, Methodology, Funding acquisition, Data curation, Conceptualization.
Declaration of Competing InterestThe authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Nurcan Caliskan reports financial support was provided by Gazi University. The authors would like to thank the Gazi University Academic Writing Application and Research Center for proofreading the article and the participants for taking part and their contribution to the research. The authors also thank Aysenur Aydogan for her role as an observer during the data collection process. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
| Control (n = 31) | SGT (n = 26) | SDL_SA (n = 27) | Between groups | ||||||
| M | SD | M | SD | M | SD | F | p b | Effect size | |
| Pre | 10.42 | 2.68 | 10.46 | 2.79 | 10.15 | 3.11 | 0.096 | 0.908 | 0.048 |
| Post | 11.65b | 1.99 | 13.65a | 1.26 | 12.78 | 2.67 | 6.825 | | |
| t/p a | −2.621/
| −5.999/
| −3.592/
| ||||||
| Effect size | | | | ||||||
| Control (n = 31) | SGT (n = 26) | SDL_SA (n = 27) | Between groups | ||||
| M
| M±SD | M±SD | F | p a | Effect size | ||
| Wound area and size | Pre | 3.61
| 3.65±0.98 | 3.96±0.76 | 1.245 | 0.293 | 0.171 |
| Post | 4.06±1.18b | 4.77±0.43a | 4.63±0.63a | 5.785 | | | |
| p b | 0.055 | | | ||||
| Effect size | 0.358 | 1.044 | 0804 | ||||
| Wound bed and surrounding tissue | Pre | 2.61±1.26 | 2.77±1.31 | 2.67±1.47 | 0.097 | 0.907 | 0.050 |
| Post | 3.32±1.25c | 5.58±0.95a | 4.44±1.12b | 28.657 | | | |
| p b | | | | ||||
| Effect size | | | | ||||
| Classification | Pre | 1.00±1.15 | 0.92±0.84 | 1.11±0.85 | 0.252 | 0.778 | 0.079 |
| Post | 2.00±1.34b | 3.58±1.36a | 3.56±1.19a | 14.181 | | | |
| p b | | | | ||||
| Effect size | | | | ||||
| Overall
M±SD | Pre | 7.23±2.45 | 7.35±1.79 | 7.74±1.89 | 0.469 | 0.6272 | 0.105 |
| Post | 9.39±2.28b | 13.92±2.04a | 12.63±1.88a | 36.429 | | 0.682 | |
| p b | | | | ||||
| Effect size | | | | ||||
| Statements (n = 23) | M * | SD |
| 1. It was easy to use. | 4.61 | 0.58 |
| 2. I experienced technical difficulties. | 1.57 | 0.84 |
| 3. I understood what to do at each step. | 4.48 | 0.90 |
| 4. I would prefer to receive face-to-face training. | 2.91 | 1.24 |
| 5. It was fun to use. | 4.39 | 0.58 |
| 6. It provided memorability. | 4.30 | 0.70 |
| 7. The duration of the training was too long. | 1.91 | 0.73 |
| 8. It allowed us to reinforce the information we learned. | 4.52 | 0.51 |
| 9. It was boring to use. | 1.70 | 0.56 |
| 10. It was preparatory for students in the clinic. | 4.39 | 0.66 |
| 11. I would like to receive training again with the smartphone application. | 4.30 | 0.56 |
| 12. I found it too complicated. | 1.65 | 0.65 |
| 13. It encouraged interactive learning between students and trainers in the videos. | 4.30 | 0.70 |
| 14. The visual environment was realistic. | 4.35 | 0.65 |
| 15. The information on the screen was difficult to read. | 1.74 | 0.54 |
| 16. The visuals in the videos were of good quality. | 4.48 | 0.59 |
| 17. The sound quality of the videos was sufficient. | 4.65 | 0.49 |
| 18. The photos used in the videos were not relevant to the topic. | 1.48 | 0.59 |
| 19. The speed of the training videos was sufficient. | 4.35 | 0.83 |
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