Exploring practical nursing skills acquisition through gamified computerized learning: A phenomenological study

Abstract

Aim

This study employed a descriptive phenomenological approach to explore the experiences of undergraduate nursing students in the context of gamified computerized learning.

Background

In the post-pandemic era, the importance of developing innovative computerized approaches to nursing education has become apparent, particularly in relation to the acquisition of clinical care skills. However, only limited research is available to guide this development.

Design

The study employed a descriptive phenomenological approach to explore undergraduate nursing students’ perceptions and experiences with gamified computerized learning of care skills.

Methods

The first author conducted individual interviews with 12 participants between April and June 2024. These interviews were audio-recorded, transcribed verbatim, and analyzed using Colaizzi's seven-step method. The study's rigor was evaluated according to Guba and Lincoln's criteria of credibility, transferability, dependability, and confirmability.

Results

Four sub-themes—learning support, visualizing learning in the mind, goal-oriented learning, and learning outcomes—were synthesized into the central theme of a Synergistic Learning Approach to the development of a teaching-learning plan. The Synergistic Learning Approach highlights the importance of robust support structures to guide learners through learning and ensure access to necessary resources and feedback.

Conclusion

The findings indicated that gamified computerized learning provided an effective approach to the development of care skills, although it cannot fully replace hands-on experience. In particular, it offers a simple, accessible, and enjoyable tool for reviewing theoretical care knowledge and skills, allowing learners to engage in trial-and-error practice without risk to patient safety.

1 Introduction

Nursing education integrates theoretical knowledge with practical care skills to produce competent nurses. Clinical placement has always been crucial for extending classroom learning and enabling students to practice care techniques. Recently, however, computerized learning of care-related theoretical knowledge and techniques has emerged as a potential tool for addressing the impact of unforeseen circumstances on student learning ( ^{Gerster et al., 2022}). Although technological advances have greatly enhanced synchronous or asynchronous computerized learning of theoretical knowledge, the use of computerized learning in the development of comprehensive care skills continues to present significant challenges. These challenges include the preparation of teaching-learning plans, digital content production capabilities, and resource availability. In the post-pandemic era, countries have reviewed online teaching practices to develop strategies for future learning guided by the WHO's (2019) disaster preparedness framework. Both educators and students must adapt to these new teaching and learning techniques and revise their expectations to prevent the development of a learning gap ( ^{Şimşek et al., 2023}). Yet, only limited research has been conducted on learners’ perspectives on the effectiveness of this kind of learning. The idea for this study originated from our experience of using the Internet to deliver an online practicum to nursing students during the pandemic. It aimed to explore nursing students' experiences of developing care skills through gamified computerized learning (GCL). The results have important practical implications for the future of nursing education. Although the potential of GCL has been recognized in other fields, its application to developing nursing skills remains under-researched, particularly in relation to the integration of theory with practice. This study aimed to address this gap.

2 Literature review

A growing body of literature has addressed two key concepts of relevance to this study: online practicum and gamified computerized learning (GCL). Each of these is discussed below.

2.1 Online practicum

The online practicum played a crucial role in clinical nursing education during the pandemic, allowing students to avoid interrupting the development of their care capacities ( ^{Dewart et al., 2020}). However, a range of challenges and negative consequences have been identified. For instance, not every nursing school can afford the resources needed to support a shift in learning behavior, such as expensive equipment for high-fidelity simulation learning ( ^{Agu et al., 2021}). ^{Olum et al. (2020)} found that the quality of internet transmission and related equipment affected the effectiveness of online learning, significantly reducing its efficacy. ^{Fogg et al. (2020)} used virtual reality (VR) during the pandemic but reported numerous negative impacts on students’ learning, including internet issues, lack of learning motivation, family difficulties, and insufficient online learning experience. While VR allowed the students to complete the required practicum hours, its implementation required them to be physically present at an institution.

Other adverse learning outcomes reported from the employment of an online practicum during the pandemic include anxiety, lack of learning motivation, and inability to practice clinical techniques ( ^{Zendrato and Hiko, 2021}). ^{Gultom and Tambunan (2021)} found that students had a negative attitude toward online learning and did not understand the learning content. ^{Ulenaers et al. (2021)} reported from a survey of nursing students' experience of an online practicum that participants doubted their future clinical performance. A qualitative study conducted during the pandemic attributed these negative outcomes to a lack of concentration, low motivation, and reduced opportunities for communication and cooperation in the online environment ( ^{Lovrić et al., 2020}).

Other research supports this suggestion. For instance, isolated learning has been shown to have a negative impact on students' learning motivation ( ^{Zendrato and Hiko, 2021; Gultom and Tambunan, 2021}). Reduced peer interaction further affects mutual learning and competitive ability, while the inability to observe actual clinical cases limits the ability to compare theoretical knowledge with clinical practice. Practicing care techniques and interacting with clinical cases also become problematic. Overall, the literature suggests that good learning outcomes require that students are adequately instructed and helped to understand their learning ( ^{Lovrić et al., 2020; Slade and Downer, 2020}), and that educational resources need to be provided in an environment in which educators and learners can maintain professionalism, positivity, and confidence while using learning software ( ^{DeLeo and Geraghty, 2018}). These findings informed the development of a gamified computerized learning (GCL) approach that sought to reduce learners' burden, enhance learning effectiveness, and maintain students' interest and motivation. This approach is elaborated in the following section.

2.2 Gamified learning

Game-based learning refers to learning that is specifically designed around games. Gamified learning, on the other hand, refers to the application of game-like elements to non-game contexts. In gamified learning, game-based learning methods are used to enhance learning motivation and promote the acquisition of knowledge and skills ( ^{Garris et al., 2002}). In recent years, an increasing number of educational fields have applied game elements to professional learning ( ^{Menon and Romero, 2019}). Research has shown that gamified learning is an effective tool for cultivating professional skills ( ^{Anguas-Gracia et al., 2021}), and that it aligns with the learning characteristics of the new generation of “digital natives”, thereby enhancing their learning motivation ( ^{Borit and Stangvaltaite-Mouhat, 2020}).

Gamified learning involves motivation, creativity, and participation. According to ^{Hung et al. (2020)}, the game content can support better learning outcomes. Compared to traditional teaching-learning pedagogy, gamified learning is claimed to increase learners' motivation and engagement ( ^{Borit and Stangvaltaite-Mouhat, 2020}), to strengthen learning objectives, improve knowledge retention, and enhance learning skills ( ^{Wingo et al., 2019}). It also provides a more enjoyable and positive learning experience, thus improving learning effectiveness ( ^{Kinder and Kurz, 2018}). Research by ^{Kinder and Kurz (2018)} showed that students using gamified learning performed better academically than those in lecture-based learning modes. The gamified learning mode has also been shown to have positive knowledge retention ( ^{Molina-Torres et al., 2021}).

The gamified learning method has been applied in healthcare education ( ^{Van Gaalen et al., 2020}). In the nursing field, it has been utilized in relation to nursing theory ( ^{Martín-Rodríguez et al., 2020}), nursing research ( ^{Han et al., 2021}), clinical judgment of postpartum hemorrhage ( ^{Zehler and Musallam, 2021}), chest tube care ( ^{Ho et al., 2021}), and clinical professional decision-making ( ^{Reed, 2020}). While these studies adopted different learning strategies, they all involved the use of gamified methods for professional learning. Studies have shown that nursing students or professionals can effectively learn through these strategies ( ^{Nascimento et al., 2021}), and that gamified learning methods are positive and acceptable for learning care techniques ( ^{Aloweni et al., 2021}). However, ^{Ignacio and Chen (2020)} found no significant difference in learning outcomes between university nursing students who participated in online gamified learning and those who were taught using traditional methods. ^{Malicki et al. (2020)} suggest that research should separately test which type of gamified learning method can enhance learners' engagement and knowledge retention.

In summary, the literature suggests that university nursing education can leverage gamified computerized learning (GCL) to provide an effective teaching-learning pedagogy that offers a safe learning environment and enhances student engagement. These benefits are influenced by extrinsic motivation factors that impact the effectiveness of GCL. Today, new-generation university students frequently use electronic devices for learning and social communication. Utilizing various media platforms has become a part of their daily life and social interactions. Accordingly, GCL is expected to enhance their motivation and interest in adapting to new learning methods.

3 Materials and methods
3.1 Study design

The study employed a descriptive phenomenological approach to explore undergraduate nursing students' perceptions and experiences with GCL of care skills. This methodology helped uncover the essence of the students’ experiences and the nature of GCL’s contribution to the development of care skills. Our research was guided by intentionality and phenomenological reduction. Intentionality pertains to the student's thoughts, feelings, and actions related to learning skills through GCL. Allowing students to express themselves freely is essential for capturing their authentic experiences. Phenomenological reduction aims to reveal the essence of phenomena by setting aside presuppositions and cultural contexts, enabling researchers to understand and describe phenomena in an un-reflected form. This study treated nursing students’ experiences as phenomena to be analyzed to generate participants’ descriptions of using computers to learn care techniques. Our report adheres to the Standards for Reporting Qualitative Research (SRQR) checklist.

3.2 Learning plan development

The learning plan, Navigating Five Trials of Central Venous Pressure (CVP) Measurement, covered care technique procedures and theoretical knowledge. It was created using the Unity game engine ( https://www.unity.com) and was based on the following design principles: aligning with teaching objectives, integrating care techniques with theoretical knowledge, incorporating clinical scenarios, and utilizing a GCL approach. This approach transformed textbook care technique procedures into dynamic, interactive experiences, allowing students to practice and make judgments in various circumstances. The tasks focused on clinical decision-making, care scenarios, and procedural steps for developing care techniques. We invited five experts to assess the content validity of our learning plan. All the experts agreed that the learning plan aligned with CVP measurement techniques and that no revisions were needed to the content or procedural steps. A screenshot of the CVP Measurement is displayed in ^{Fig. 1}. The content of this learning plan is elaborated below:

1. Preparation: Students read an English-language case scenario designed to test their diagnostic decision-making skills in relation to CVP Measurement. The scenario presents a novel and challenging case that integrates real-life clinical practice through a series of steps. Participants must choose the correct technique before moving on to the next step. Students can repeat their choices until they make the correct selection.
2. First Step—Equipment Preparation. Students must select the correct equipment for the second step.
3. Second Step—Selection of Venipuncture Site and Catheter Connection. Students must select the correct CVP venipuncture site, connect the catheters, including the infusion fluid, intravenous set, and central venous line, and ensure proper air removal from the lines.
4. Third Step—Care of Central Venous Catheter (CVC). The third step involves caring for the venous puncture site, securing the catheters, and confirming placement with a chest X-ray. Students must select the correct CVC chest X-ray from a set of three to proceed to the next step.
5. Fourth Step-CVP Measurement. The patient should be in a semi-recumbent position, and the external zero point, similar to the right atrium of a human, should align with the CVP catheter zero point. Students must follow the instructions to measure CVP using the three-way stopcock correctly. After CVP has been measured, the IV fluid and lines should be connected and run as prescribed.
6. Fifth Step—Theoretical Knowledge and Considerations. This step tests students' theoretical understanding of the meaning and significance of CVP Measurement.

3.3 Participants and setting

This study was undertaken at a university campus in south Taiwan. Approximately 150 students are enrolled annually in a four-year nursing program and divided into three classes. Adult Nursing is a compulsory course with six credits for second-year students. All Adult Nursing lecturers routinely convene to ensure consistency in course content and regulations. The ability to measure CVP is an essential clinical caring skill. The CVP Measurement learning plan was introduced to the target class without disrupting the course schedule. Purposive sampling was used to recruit participants who met the following inclusion criteria: 1) aged 20 and above, 2) agree to be interviewed and recorded, and 3) agree to complete the CVP Measurement learning module. Students in the target class who did not complete the GCL module were excluded.

3.4 Data collection

The GCL was introduced to the target class during their scheduled CVP learning session, which typically lasted two hours. Those students who expressed willingness to use the GCL could freely download the CVP Measurement module to their computers. They were subsequently contacted by email to arrange an interview. The research assistant tracked and scheduled interview times and dates for these participants. Data collection took place from April to June 2024. To ensure the study's credibility, the first author conducted all interviews using a semi-structured interview guide in order to maintain focus and avoid bias related to the researcher's personal interests ( ^{Cypress, 2018}).

The interviews were audio-recorded and transcribed verbatim by an audio-typist who signed a confidentiality agreement. Each transcript was matched with its corresponding audio recording using the same filename. Interviews lasted from 40 to 60 minutes, which allowed for the collection of rich and detailed information and enhanced external validity ( ^{Sabnis and Wolgemuth, 2024}). The first author determined that sufficient data for the study had been collected after interviewing 12 participants ( ^{Johnson et al., 2020}).

3.5 Data analysis

The analysis adopted Colaizzi's seven-step method ( ^{Colaizzi, 1978; Finlayson et al., 2019}). First, all transcripts were compiled into a single file to facilitate reading and comprehension of the content. The first author and a co-investigator listened to the audio recordings while reading the transcripts line-by-line to identify and extract significant statements. These statements were then organized into themes and sub-themes and synthesized into descriptive phenomena. Both researchers independently coded all transcripts and reached an agreement on the definitions. Finally, member checking was conducted by asking participants to review their transcripts and a list of suggested codes. The study's findings were shared with all authors to finalize the results, which were presented as evidence-supported assertions.

3.6 Trustworthiness

^{Guba and Lincoln (1985)} proposed four criteria to evaluate a study's trustworthiness: credibility, transferability, dependability, and confirmability. To ensure study credibility, seven practical strategies were implemented: 1) All interviews were conducted by the first author, a qualified and experienced qualitative researcher with a doctoral degree and publications, to ensure consistency and quality of the interview data ( ^{Lavee andItzchakov, 2023}). 2) All interviews were audio-recorded and transcribed verbatim. 3) Field notes were taken throughout the study, including the interview, transcription, and data analysis processes, to create an audit trail and avoid data loss. 4) Interviewers meticulously checked the transcripts line by line to ensure accuracy. 5) Member checking was conducted to confirm the accuracy of the transcripts. 6) Two independent investigators analyzed the data, holding regular meetings to reach a consensus on the results. 7) The research objectives were clarified to interviewees before the interview.

Transferability was demonstrated by: 1) Presenting a detailed description of interview data in research categories and results. 2) Engaging a nursing education expert and participants to review the research analysis data and report results. 3) Having the data analyzed independently by the principal investigator and co-investigators, who reached a consensus on naming themes after discussing the results of the preliminary analysis. 4) Revisiting the interview transcripts frequently during data analysis to ensure consistency between the research categories and the data.

Dependability was achieved by providing a detailed account of the methods of data collection and analysis. Confirmability was established by carefully preserving all original data, including recordings, verbatim transcripts, reflective journals, and analytic records, for future verification.

3.7 Ethical considerations

This study received approval from the Institutional Review Board (insert ID later) and the University. The University’s email system disseminated the study's purpose, data collection procedures, potential risks and benefits, the required time commitment, and privacy and anonymity protection measures. Participants were informed that their participation was voluntary and retained the right to withdraw without penalty. Before the interviews began, participants were required to sign a consent form. No coercive or deceptive methods were employed to encourage participation.

4 Results

Twelve participants were recruited for interviews after completing the GCL for care technique development. All interviewees were female and aged 20–21. Each was assigned an anonymized identifier (S1, S2, etc.) for reporting the results.

Overall, participants reported that GCL for care techniques was more effective than simply listening or watching care techniques being demonstrated but did not fully replace hands-on experience. The central theme developed from the analysis of participants’ experiences of CVP Measurement was a “Synergistic Learning Approach”. Four sub-themes were identified: learning support, visualizing learning in the mind, goal-oriented learning, and learning outcomes. Each of these is elaborated below.

4.1 Learning support

Participants experienced the CVP Measurement as a learning support for care technique development, although it could not completely replace the experience of hands-on practice. For example: …. The trials have pictures and learning interactions demonstrating the procedure of performing care techniques, which can deepen our impression of learning (S3).

4.1.1 Indispensability of hands-on learning

From the perspective of participants, hands-on practice is essential for mastering caregiving skills and cannot be effectively replaced by any other learning method. Traditionally, lecturers demonstrate care techniques, which students then practice on simulated patients. Participants highlighted the limitations of computer learning in this context. Care techniques need to be honed through hands-on practice. The more you practice, the more familiar and proficient you become. The information provided by computer learning techniques helps identify the point accurately. Care technique learning through computers does not replace hands-on training but can be helpful. (S6)

4.1.2 Muscle memory

Participants equated familiarity with care techniques to the concept of muscle memory developed through regular practice. Even if some of the steps in a care technique have been forgotten, muscle memory helps to guide the execution of the procedure. …. Computer techniques learning cannot replace hands-on practice. Only through hands-on practice can you develop muscle memory, allowing you to handle the various scenarios you may encounter in a clinical environment. (S1) I had practiced many times at school but was extremely nervous when implementing it in the clinical setting. My brain went completely blank when it came time to perform the technique of catheterization. (S12)

One participant reported that learning through GCL enhanced their muscle memory. What I learned from this GCL is not just short-term memory. Although it cannot be compared to actual practice, it involves hands-on clicking selection and thinking and helps with muscle memory. Since I have played this GCL, the knowledge is more firmly embedded in my mind and less likely to be forgotten. If I just watched a technical video or a teacher’s demonstration, the memory would be weaker and might fade over time. (S10)

4.1.3 Process over actions

The “process over actions” represents participants' experiences using computers to learn caregiving techniques. GCL emphasizes the procedures involved in the performance of a technique rather than individual actions. As noted above, mastering manual care actions requires muscle memory. However, participants did not dismiss the value of using the computerized method for developing competence in caregiving techniques. When connecting IV (intravenous) lumens or performing aseptic techniques, hands must be … [describes procedure]. Only through actual practice can you get a sense of the situation and understand how to position your hands. e … However, computer operations help reinforce the impression of the operational process…. I might not know how to find the external zero point for measuring CVP when facing an actual situation. (S2)

4.2 Visualizing learning in the mind

Participants perceived the GCL approach as a way of visualizing the learning process in their minds. They regarded it as a learning support that transformed hands-on practice into a cognitive process.

4.2.1 Hands-on practice as cognitive engagement

Although participants emphasized the importance of hands-on activities for cognitive engagement and retention of learning outcomes, they found computerized learning more effective in this context than watching videos or observing a demonstration. Hands-on practice leaves a more lasting impression. Although practical hands-on technique training is more impactful than computer-based learning, it has many limitations. Computer-based learning involves hands-on activities, which engage the thinking process more than simply watching instructional videos or observing a teacher's demonstration. (S5)

4.2.2 Immediate feedback

Participants appreciated the immediate feedback provided by the computerized learning program, which they saw as a real advantage compared to the traditional approach. Compared to hands-on lab sessions or learning from videos, computerized learning offers the advantage of repeated practice until the right choice is made. Furthermore, instant feedback informs me whether my choice is right or wrong. (S4)

4.2.3 Muscle memory versus brain memory

Brain memory refers to the retention of learned knowledge through memorization alone. Participants reported that muscle memory, developed through practical, hands-on experience, was more effective than brain memory in retaining information. For technical care skills, I use a checklist when practicing and try to memorize the steps of the technique procedure. However, since I'm unfamiliar with these techniques, the memories don't last long and are easy to forget.(S7)

4.2.4 Faster comprehension

Despite the limitations participants identified in computerized learning, they valued its ability to review the material after class. This was an advantage over the traditional approach, where only limited time is provided to learn and remember the theoretical and practical elements of a technique. This computer-based learning technique has helped me review my techniques after class. The computerized learning platform effectively visualizes the techniques, eliminating the need for imagined practice. Consequently, it enables us to grasp the comprehensive theory and practical application of CVP measurement in minutes. (S7)

4.3 Goal-oriented learning

Compared to their previous experiences, participants viewed the computerized learning plan as goal-oriented, integrating care theory and techniques into a cohesive plan. Students could choose learning activities at the beginning because the objectives were clear. This empowered them to take control of their learning.

4.3.1 Integrating theory and skills

The participants reported that computerized learning created a holistic experience that linked theoretical knowledge with real-world application in practice. The computerized learning of CVP measurement provides theoretical knowledge and technical steps. Therefore, I understand why each action is necessary before proceeding to the next step. (S9)

4.3.2 Memory-enhancing and engaging

Participants said that the method allowed them to actively engage in learning, thereby increasing their confidence, motivation, and interest in the content and their ability to recall and apply the knowledge in the future. I am amazed by the use of computerized methods to learn caregiving techniques. …. Applying this type of learning makes the techniques more memorable and leaves a deeper impression. (S7)

The interactive nature of the experience was described as enjoyable and as preferable to conventional modes of study. I find learning gamified computerized care techniques very enjoyable. Its feature allows you to connect the tubing and expel the air. I find it very intriguing, and this learning experience has left a deep impression on me. (S2)

4.3.3 Clear learning objectives

The GCL approach provided clear learning objectives, allowing participants to decide on their level of involvement and contributing to goal-oriented learning. … learning through GCL requires me to interact by moving the mouse. Although, it's not the same as hands-on practice, it leaves a more profound impression than just watching videos. (S4)

4.4 Learning outcomes

As described previously, active cognitive engagement, immediate feedback during practice, and goal-oriented learning contributed to the development of muscle memory. This in turn helped to improve knowledge retention and increase participants’ motivation and confidence in learning. These outcomes are discussed further below.

4.4.1 Knowledge retention

Knowledge retention ensures that valuable insights, techniques, and expertise remain accessible for future use. Muscle memory and cognitive engagement facilitate the ability to recall and use information more effectively than reading from books. If memorizing things from books is considered short-term memory… I feel the GCL method helps me retain memory for longer. (S10)

4.4.2 Feeling secure

Participants reported that the ability to practice techniques without any risk of harm to patients led to feelings of security and helped to reduce anxiety associated with the learning process. This simple and memorable GCL method helps me review the CVP measurement. The process allows me to learn through trial and error until I make the correct choice without harming the patient due to wrong decisions. (S7)

4.4.3 Learning motivation and confidence

Motivation and confidence are closely intertwined elements that significantly influence the learning journey. When learners are motivated, they are more likely to participate actively in their learning process. Motivation and confidence together empower learners to reach their full learning potential. Several aspects of the GCL approach, notably learning support, visualization, and goal-oriented learning, helped to increase participants’ motivation and confidence, After completing each level of GCL, I feel accomplished…. This game has increased my confidence in implementing CVP measurement (3). This GCL is about the profession of care learning, which involves theory and technology. Unlike other computer games, I can be sure of what I have learned and practiced. (S5)

Four themes formed a Synergistic Learning Approach (SLA), enriching nursing students' educational experience in a gamified, computerized learning environment. SLA incorporates learning support, visualizing learning in the mind, goal-oriented learning, and learning outcomes to create an enhanced learning experience.

5 Discussion

This study addresses a gap in nursing education research. The results indicate that gamified computerized learning (GCL) deepens students’ nursing skills, allows for repeated practice without risking patient safety, and enhances motivation and confidence in learning. These findings align with the study's purpose and provide a new perspective on nursing education. This GCL plan represents a synergistic learning approach (SLA) to the development of practical nursing techniques among students. This approach aligns with students' learning characteristics and interests ( ^{Wynn et al., 2023}). In the traditional approach, which emphasizes hands-on practice following specific steps, the underlying theories that support these steps are overlooked. As a result, learning is frequently separated into theoretical knowledge and practical techniques, making it challenging for learners to integrate the two ( ^{Conte et al., 2023}). This division leads to learning gaps as students focus solely on theory or techniques, ultimately affecting their learning efficiency and effectiveness ( ^{Liu et al., 2023}). As a form of thematic learning, the GCL approach adopted in this study integrates theoretical knowledge and techniques in line with ^{Bloom et al. (1956)} taxonomy of remembering, understanding, and applying. In the present study, the GCL approach led to "knowledge retention" as a "learning outcome".

SLA, an extensive educational framework, emphasizes the achievement of learning outcomes derived from the contributions of a diverse range of learners while underscoring the integration of both theoretical and practical knowledge ( ^{Madhuvu et al., 2023; Yang, 2023}). This distinction sets SLA apart from cooperative and collaborative learning models. SLA highlights the importance of robust support structures to guide learners through their educational journeys and ensure access to necessary resources and feedback. Visualizing learning in the mind plays a central role by utilizing visual aids to enhance comprehension and retention, making abstract concepts more tangible and understandable ( ^{Xu et al., 2024}). Goal-oriented learning establishes clear, achievable, learner-aligned objectives to encourage involvement in broader learning aspirations, foster motivation, and provide a purposeful roadmap for their educational path. The approach is outcome-driven, focusing on measurable and meaningful results, with continuous assessment and reflection ensuring that educational goals are met ( ^{Liu and Huang, 2023}). This integrated model creates a cohesive and effective learning method that is dynamic and responsive to individual needs.

In the GCL plan, care techniques are selected from a set of carefully chosen options by clicking a computer keyboard. Engaging the finger muscles provides an opportunity to memorize the learning content, leading to what participants called "muscle memory" or "body memory" (see also ^{Snijders et al., 2020}). Muscle memory aligns with the concept of "hands-on" practice, which is reflected in participants’ emphasis on the importance of the learning "process over actions". In addition, participants reported that these activities were also enjoyable, although they saw them as less effective for muscle memory learning than hands-on practice. Accordingly, the GCL approach should be considered a supplementary tool for learning care skills.

The “hands-on” element of the GCL approach also involves integrating the learning process through images. Participants referred to this as "visualizing learning in the mind." In other words, this method engages cognitive processes during learning ( ^{Su et al., 2023}). Research suggests that hands-on practice with cognitive engagement leads to more muscle memory retention ( ^{Snijders et al., 2020}) than hands-on practice alone, or what participants called "brain memory." Brain memory refers to the traditional method of memorizing learning content, which is often forgotten over time and requires refreshing through frequent revisiting ( ^{Saxena, 2022}). Thus, brain memory falls under the level of remembering in Bloom's taxonomy, while the GCL approach elevates learning to the level of understanding. Additionally, the ability to "visualize learning in the mind" gives participants a sense of security, as they receive "immediate feedback" on their learning and can make corrections. Hence, the GCL plan effectively aligns with participants’ experiences of "goal-oriented learning."

“Goal-oriented learning” is further supported by the thematic presentation of content in the GCL plan. "Clear learning objectives" helped participants to increase their interest and participation in their learning, leading to enhanced "learning motivation and confidence" ( ^{Alrashidi et al., 2023}). Although the latent learning outcomes of this indirect approach are difficult to identify through quantitative measurement, other research suggests that online teaching techniques generate longer-lasting learning effects ( ^{Akansel et al., 2020; Li et al., 2024}).

5.1 Limitations and future directions

Like all research, this study had some limitations. First, the participants were self-selected, which might have influenced the overall finding of a positive learning experience. Second, because the results of a phenomenological study are based on the abstraction of individual learning experiences, they have not been verified. Although verification was not the purpose of the study, this limitation might have affected the interpretation of the effectiveness of GCL. This should be taken into account in future studies. Finally, the study is based on data derived from the implementation of only one innovative learning method in one course at one university, which impacts the generalizability of the findings. More research is required on the longitudinal effects of computer-based learning in care techniques, as well as a comparison with traditional classroom simulations.

6 Conclusions and implications

Familiarity with clinical techniques requires practice. Regular practice reinforces these techniques in memory for practical use. GCL provides an accessible tool for students to review content and assist in acquiring theoretical knowledge and care techniques. Educators might also view the GCL as an additional strategy to inspire and engage students in the classroom. The findings indicate that a learner-centered GCL system can be effectively employed in the classroom to aid learning. The goal of such a system is not to replace existing hands-on care practices but to provide a learning plan that aligns with the level of higher-order thinking in Bloom's taxonomy and engages learners.

CRediT authorship contribution statement

Huang Ya-Ling: Writing – review & editing, Visualization. Han Chin-Yen: Project administration, Methodology, Formal analysis, Data curation. Lin Chun-Chih: Writing – original draft, Funding acquisition, Formal analysis, Data curation, Conceptualization. Ku Han-Chang: Writing – review & editing, Visualization, Validation. Chen Li-Chin: Software, Resources.

Ethical Statement

Full ethics approval has been obtained from the Chang Gung Medical Foundation Institutional Review Board (202102410A3C601).

Declaration of Generative AI and AI-assisted technologies in the writing process

While preparing this work, the author(s) used Grammarly to correct grammar and make sentences readable. After using this tool, the author(s) reviewed and edited the sentences, and a native English editor helped make the writing fluent and logical. The author (s) took full responsibility for the content of the published article.

Funding resource

The National Science and Technology Council in Taiwan supported this study. (grant number NSTC 112-2410-H-255-005 -).

Declaration of Competing Interest

none.

Acknowledgments

The authors appreciate the support from the National Science and Technology Council in Taiwan and the participation of all involved.