Content area
Aims
Investigate the long-term effects of a flipped education —based on adult learning theory and incorporating multimedia teaching and physical workshops—on nurses’ self-efficacy in preventing and managing pressure injuries.
BackgroundPressure injuries remain a global challenge, requiring caregivers to blend theory with practice. Flipped learning has shown promise in boosting nurses' confidence and competence in managing these injuries through higher-level processes such as interaction, reflection, application, analysis and integration.
DesignA single-blind, multicenter, quasi-experimental, two-group parallel repeated-measures design was conducted in seven medical institutions.
MethodA total of 404 participants adopted an adult self-directed learning model. The control group received PDF-based materials, while the intervention group additionally underwent a flipped education program that combined multimedia teaching with physical workshops. Self-efficacy in the four domains—assessment, planning, monitoring and decision-making—was measured at baseline, immediately post-intervention and at one- and three-months post-intervention. Data were analyzed using descriptive statistics, chi-square tests, t-tests and generalized estimating equations.
ResultsFollowing the intervention, both groups showed a significant increase in self-efficacy (p < .05). The intervention group scored higher in all domains, with improvements lasting three months and reported greater learning satisfaction.
ConclusionMultimedia teaching enhances learners’ motivation and improves the effectiveness of adult self-directed learning. Physical workshops focused on higher-level analysis, integration and hands-on teaching further strengthened care confidence and self-efficacy. These findings confirm the effectiveness of flipped education in pressure injury education, especially regarding its long-term impact and offer valuable insights for designing future nursing training programs.
The Adult Learning Theory emphasizes the importance of addressing learners' needs for autonomy, competence and relevance, particularly in the context of online learning ( Lai and Hwang, 2023). This theory highlights that adult learners are self-directed, possess rich experiential backgrounds and often engage in learning to solve specific problems ( Merriam and Bierema, 2013). Such characteristics make Adult Learning Theory a valuable framework for guiding in-service training in nursing education. In designing curricula that meet clinical demands, educators can enhance learning effectiveness by prioritizing practicality and collaboration ( Curran, 2013). These features make the theory particularly suitable for time-constrained nursing professionals who need to acquire clinical skills efficiently.
The Flipped Education Strategy offers a flexible learning approach, well-suited for busy nursing professionals working in demanding clinical environments ( Williams, Perillo, and Brown, 2015). By integrating digital platforms with classroom interactions, flipped education fosters learners' engagement, initiative and reflective abilities ( Hessler, 2016). For instance, digital teaching resources and multimedia tools allow learners to acquire foundational knowledge independently before class and engage in collaborative problem-solving and discussions during class. This approach enhances clinical reasoning and critical thinking skills ( Sadhuwong, Koraneekij, and Natakuatoong, 2016). Multiple studies have demonstrated that flipped education significantly improves nurses’ self-efficacy and bridges the gap between theoretical knowledge and clinical practice ( Barbour and Schuessler, 2019). In clinical care, pressure injuries are a significant issue. Despite nursing professionals typically possessing foundational knowledge on pressure injury management, the incidence remains a persistent challenge ( Chao, Wu, and Liao, 2022). Transitioning from traditional learning methods to a flipped education approach, which emphasizes reflection, application, analysis and integration, has been found to actively encourage experienced nurses to engage in solving clinical problems. This approach supports the development of clinical reasoning and decision-making skills, which are essential for addressing complex patient care scenarios. Furthermore, the effectiveness of the flipped classroom (FC) method has been shown to enhance self-efficacy, a key factor in improving student engagement and motivation in learning ( Sun et al., 2023). Notably, FC has been demonstrated to work particularly well for short-term interventions and technical subjects, suggesting that careful course design is essential for optimizing its effectiveness ( Sun et al., 2023).
In nursing practice, the implementation of effective prevention and treatment strategies for pressure injuries—such as risk assessment, skin evaluation and protection, accurate wound staging and appropriate dressing techniques—directly impacts patient safety and quality of care ( Forkuo-Minka, Kumah, and Asomaning, 2024). Nurses, as frontline caregivers, often face barriers to learning due to insufficient training and a lack of accessible guidelines for pressure injury management ( Tomas and Mandume, 2024). Therefore, applying flipped learning in the context of pressure injury management is essential to evaluate both learning effectiveness and learner satisfaction. In this context, nurses’ self-efficacy in managing pressure injuries is critical, as it enables accurate wound staging and the implementation of preventive measures ( Dellafiore et al., 2019). Self-efficacy, a concept derived from Bandura's Social Cognitive Theory, refers to an individual's belief in their capability to perform specific tasks ( Bandura, Freeman, and Lightsey, 1999). According to Bandura, self-efficacy is influenced by performance accomplishments, vicarious experiences, verbal persuasion and emotional arousal. These factors not only enhance nurses’ confidence but also significantly improve their clinical performance, offering valuable insights for designing effective educational strategies ( Caruso et al., 2016).
According to adult learning theory, learners typically possess self-directedness and problem-solving abilities, and they tend to actively seek and apply knowledge during the learning process. Meanwhile, flipped learning theory posits that by using self-directed learning resources in combination with interactive, reflective, application, analysis and integration activities in physical classes, learners can experience both knowledge construction and practical application before and after class. This study aims to integrate adult learning theory with the flipped education strategy to investigate their impact on enhancing nurses' self-efficacy and satisfaction in managing pressure injuries. By systematically comparing and analyzing data collected at various time points before and after the intervention, the effectiveness of the flipped education model in promoting self-efficacy within an adult learning context can be verified, thereby providing empirical evidence for future clinical education strategies.
2 Methods2.1 Design
This study employed a single-blind, multi-center, two-group parallel quasi-experimental design. A repeated-measures longitudinal approach was used to evaluate the long-term effectiveness of different educational strategies on nurses' self-efficacy in managing pressure injuries in acute medical institutions. Grounded in adult learning theory, the study compared two distinct educational strategies.
Both the control group and the intervention group used the same digital platform to support self-directed learning concurrently. However, the intervention group additionally integrated multimedia video materials into their self-directed learning and was scheduled to participate in physical workshops. Data were collected at four specific time points: baseline (pre-intervention), immediately post-intervention and one- and three-months post-intervention.
This study is part of a broader research series aimed at comprehensively examining the effectiveness of various educational strategies in improving pressure injury management among nurses. The series evaluates a range of outcomes, including perceived barriers, long-term knowledge retention, attitude shifts and self-efficacy across diverse clinical settings.
In contrast, this specific study narrows its focus to explore the integration of adult learning theory and flipped education strategies, particularly their impact on enhancing nurses' self-efficacy and satisfaction in managing pressure injuries. The primary outcomes measured in this study include overall changes in self-efficacy and the ability to assess, plan, supervise and make decisions regarding pressure injury management. The secondary outcome centers on the satisfaction of both groups with the digital platform education provided through self-study.
2.2 Setting and participantsThe study was conducted from April to August 2022, using a purposive sampling method to recruit nurses from seven regional and acute care medical institutions. Participants were recruited through each institution's in-hospital letter distribution system and registration platform. Recruitment materials included information about the course topic, structure and incentives to encourage participation and enhance nurses’ motivation to join the study.
The sample size was estimated based on medium effect sizes observed in previous studies on the impact of educational training on nurse competencies ( Taylor-Piliae, 2008). Using G Power 3.1 software and Cohen’s power analysis method ( Cohen, 1992), a two-tailed test was performed with a power (1 - β) of.8, an alpha level of.05, an effect size of.27 and an estimated attrition rate of 20 %. The calculation indicated a requirement of 165 participants. The inclusion criteria for participants were as follows: (1) full-time or part-time nurses employed at the research sites; (2) involved in frontline clinical care or nursing-related administrative responsibilities; and (3) provided informed consent to participate in the study. Exclusion criteria included: (1) nursing students; and (2) intern nursing students. Additionally, participants who were unable to complete the entire educational training program, including those who withdrew midway or terminated their participation, were excluded to ensure the integrity and validity of the training’s effectiveness evaluation.
2.3 Educational strategies and implementationAll participants in this study underwent a digital education program focused on the prevention and management of pressure injuries. The course content was derived from the International Clinical Practice Guideline for the Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide (3rd Edition, 2019), which was developed through a consensus conference conducted by the National Pressure Injury Advisory Panel (NPIAP), the European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA). The program was delivered via a digital education platform, where each participant was provided with a unique username and password to access its features. The platform enabled participants to complete informed consent, demographic surveys, a pre-intervention test (T 0) and three post-intervention tests (T 1, T 2, T 3). Since the learners were experienced nursing professionals, the educational strategy was designed to enhance their knowledge construction and clarify concepts. Furthermore, through hands-on instruction within the course materials and participation in a physical workshop, the learners’ self-efficacy in patient care was confirmed.
The platform included 14 lessons divided into three main modules: prevention, staging assessment and wound care. These modules also incorporated training in four key competencies: assessment, planning, supervision and decision-making. Based on adult learning theory, the multimedia course materials allowed participants to schedule their own learning within a one-month period. The study's learning objectives extended beyond knowledge construction in the three modules (prevention, staging assessment and wound care) to include training aimed at building confidence in care delivery.
The course design incorporated clinical case examples, real-life wound images annotated with key features, grading techniques and care strategies. Participants could rewatch lessons, post comments, engage in brainstorming sessions, review and highlight key points and monitor their individual progress. To ensure the quality and accuracy of the content, the materials were reviewed by two professionals certified in international wound and ostomy care training. The instructors had extensive experience in pressure injury care, nursing education, research and clinical practice. In line with adult learning principles, participants from both groups completed the digital education program on pressure injury prevention and management through the platform. After completing each lesson, the system recorded the course as "completed," marking the participant’s progress. The system was designed to ensure each lesson was fully viewed before it could be marked as "completed." The primary differences between the two groups were the digital materials provided and the fact that the Intervention Group (IG) received a flipped education approach, whereas the Control Group (CG) did not. This is described in further detail below ( Supplementary Information).
2.3.1 Intervention group (IG): flipped education approachThe intervention involved self-directed learning through a digital platform to build foundational knowledge. Objectives included constructing knowledge on three modules—prevention, staging assessment and wound care—as well as building nursing confidence. Compared with the control group, the educational strategy for the IG also incorporated a flipped education approach. Within this approach, two components were employed: Multimedia Video Teaching and a Physical Workshop. The objectives of the Multimedia Video Teaching were to use vivid 3D animated multimedia resources, with each video designed to conclude with a summary of key points and a short quiz that provided detailed explanations, thereby enhancing learner engagement and motivation. Subsequently, participants engaged in a physical workshop. The workshop was designed to provide opportunities for discussion, critical thinking, communication practice and confidence building. The intervention group engaged in lower-level cognitive learning by using pre-recorded multimedia videos and self-directed activities focused on memorization and comprehension via digital platforms, thereby establishing a preliminary understanding of the topic before class. The physical workshop, on the other hand, concentrated on higher-level cognitive and practical processes such as—such as understanding, application, analysis, synthesis and evaluation—aiming to facilitate effective flipped learning. It also sought to enhance participants' self-efficacy.
The digital platform offered multimedia materials, including 3D animated virtual instructors, AI-generated voiceovers, subtitles, wound care scripts and clinical scenario-based photographs. These resources aimed to enhance participant engagement and comprehension. Each video concluded with a summary of key points and a short quiz, with the system providing detailed explanations for each quiz question. The physical workshop began with the instructor delivering key insights into comprehensive management and assessment of pressure injuries. This was followed by discussion and interactive sessions, allowing participants to address questions, clarify concepts, resolve doubts, reflect on their one-month digital learning experience and provide feedback. After two 40-minute large-group activities, participants engaged in practical small-group sessions, which included: Pressure Injury Classification and Practice (20 minutes), Wound and Peri-wound Skin Cleaning and Protection (20 minutes), Pressure Injury Wound Assessment and Dressing Selection (20 minutes), Hands-On Practice with Medical Devices for Pressure Injury Care (20 minutes).
The feedback was evaluated using a self-efficacy scale to determine the extent to which learners’ confidence in self-care improved through the flipped education approach. This combination of digital self-directed learning and hands-on physical workshop activities was designed to bridge theoretical knowledge with practical application, enhancing critical skills and participant confidence.
2.3.2 Control group (CG): digital self-directed learningParticipants in the CG engaged in self-directed learning through a digital platform, using PDF handouts that included wound care scripts and clinical scenario-based learning photographs. These handouts could be downloaded directly from the platform or accessed online. Each PDF document highlighted key points at the end of the lesson to reinforce learning. Additionally, a feedback section was provided beneath each handout on the platform, serving as an interactive forum where participants and educators could ask questions, share comments and provide feedback.
2.4 Outcomes measures and InstrumentsThe instruments used in this study included a demographic information questionnaire, the Taiwanese version of the Pressure Ulcer Management Self-Efficacy Scale (PUM-SES-T) and a self-designed structured questionnaire to assess learning satisfaction.
2.4.1 Demographic information questionnaireA structured questionnaire was designed based on existing literature regarding educational strategies and knowledge assessments related to pressure injuries ( Pieper and Zulkowski, 2014). The purpose of this tool was to gather information on participants' (1) demographic details, including gender, age and academic degree; (2) professional background, including professional category, years of work experience, work unit, any certifications related to pressure injuries (PI); and (3) prior learning experiences, such as attendance at PI lectures in the past year, reading books or articles on PI, seeking information on PI via the internet and reading PI guidelines. The questionnaire consisted of 12 multiple-choice items.
2.4.2 The pressure ulcer management self-efficacy scale, Taiwanese version (PUM-SES-T)The Pressure Ulcer Management Self-Efficacy Scale was developed by Dellafiore et al. (2019) to evaluate nurses' self-efficacy in managing pressure injuries. The scale consists of 10 items across four domains: assessment, planning and supervision (each with two items) and decision-making (four items). These domains are positively correlated, reflecting a comprehensive approach to measuring self-efficacy ( Dellafiore et al., 2019).
Participants respond to the prompt: "Consider your working experience regarding to patients with pressure ulcer, how much do you feel able to face the following situation …?" Responses are rated on a 5-point Likert scale, ranging from 5 (completely capable) to 1 (completely unable). Total scores range from 10 to 50, with higher scores indicating greater self-efficacy in pressure injury prevention and management. The assessment takes approximately 3–5 minutes to complete.
The Taiwanese version of the Pressure Ulcer Management Self-Efficacy Scale demonstrated excellent content validity and reliability. The Content Validity Index (CVI), evaluated by seven experts—including a surgery chief physician, nursing professors, international wound care specialists, nursing administrators and clinical nurses—was calculated at 0.995, reflecting high levels of importance, clarity and precision in the items. Reliability testing showed outstanding results. The internal consistency of the scale achieved a Cronbach's α of 0.973 and the test-retest reliability coefficient was 0.999, indicating the scale's robustness and consistency in measuring nurses' self-efficacy in preventing and managing pressure injuries ( Chao, Wu, and Liao, 2022).
2.4.3 Learning satisfaction scaleThe Learning Satisfaction Scale is a self-designed structured questionnaire comprising 10 items. The evaluation focuses on teaching objectives, instructional content design, multimedia design and perceived learning effectiveness. Responses are rated on a 5-point Likert scale, ranging from 5 (very satisfied), 3 (neutral), to 1 (very dissatisfied). The total score ranges from 10 to 50, with higher scores indicating greater satisfaction with the educational interventions for pressure injury prevention and management.
The content validity of the scale was established using Lynn’s (1986) Content Validity Index (CVI) ( Lynn, 1986). A panel of three experts, including a teaching physician, a nursing director and a head nurse, evaluated each item based on three criteria: importance, clarity and precision. These criteria addressed the relevance of the item to the research topic, the clarity of wording and semantic descriptions and the overall accuracy of the content. Ratings were provided on a 5-point scale, where 5 indicated "very important," "very clear," or "very precise," and 1 indicated "not important," "not clear," or "not precise." For items scoring below 3, experts were asked to provide suggestions for improvement. The CVI for the Learning Satisfaction Scale was calculated at 0.855, indicating good content validity for assessing satisfaction with the educational interventions.
2.5 Data collectionDifferent educational strategies were implemented for the Intervention Group (IG) and Control Group (CG). Participants were required to complete the pre-test (T 0) before advancing to the learning phase. Following the completion of the learning phase, a post-test (T 1) was administered immediately, with additional assessments conducted at one month (T 2) and three months (T 3) post-intervention. Each stage was conducted sequentially and participants who failed to complete a stage were not permitted to proceed to the next phase, ensuring data integrity throughout the study.
Data were collected through the backend of the digital platform by the researchers and analyzed using SPSS version 22.0. Descriptive statistics were applied to present the demographic characteristics of both groups, including frequency distributions and percentages. Means and standard deviations were calculated to describe the scores for self-efficacy and learning satisfaction. Inferential statistical methods were used to explore the study outcomes. Chi-square tests were employed to compare demographic variables between the groups, while generalized estimating equations (GEE) were used to assess differences in self-efficacy scores across the pre-test and post-test phases for both groups, following the implementation of their respective educational interventions. Furthermore, an independent sample t-test was conducted to examine differences in learning satisfaction between the IG and CG, focusing on satisfaction with the micro-course flipped education strategy compared with the digital platform education approach. For all analyses, a p-value of less than.05 was considered statistically significant. This comprehensive analytical approach allowed for a detailed examination of the effects of the educational interventions on the study's primary and secondary outcomes.
2.6 Ethical considerationsThis study adhered to the ethical principles outlined in the Declaration of Helsinki and received approval from the Institutional Review Board (IRB) of the Ministry of Health and Welfare's Caotun Psychiatric Center Human Trials Ethics Review Committee (Approval Number: 111030). Prior to participation, all individuals were provided with detailed information about the study, including its objectives, procedures, potential risks and anticipated benefits. Written informed consent was obtained from each participant, ensuring that their decision to participate was fully informed and voluntary.
Participants were assured that they could withdraw from the study at any time without facing any negative repercussions. Confidentiality and anonymity were strictly maintained throughout the research process. Data were securely stored and restricted to access by the research team, with no personal identifiers recorded to protect participant privacy. All data were used exclusively for research purposes, ensuring the utmost respect for participant confidentiality and ethical standards.
3 Results3.1 Comparison of homogeneity in demographic variables between the two groups
A total of 512 participants were screened for eligibility, of which 404 nurses agreed to participate, while 108 declined. The participants were divided into two groups: the intervention group (n = 244) and the control group (n = 160). Both groups completed the pre-test (T 0), which included a sociodemographic survey and a self-efficacy assessment ( Fig. 1). Among the 404 participants, significant differences were observed in the age distribution between the two groups. In the control group, the largest proportion of participants were aged 25–34 years (43.1 %), whereas in the intervention group, the highest proportion was aged 35–50 years (49.2 %) ( p = .000). Regarding work background, there were significant differences between the groups in total years of work experience and the type of work unit ( p < .05). No statistically significant differences were found between the groups in the remaining demographic and professional background variables. However, significant differences were observed in past learning experiences over the previous year, including reading books or guidelines, attending lectures and searching for related information online ( p < .05). In contrast, no significant differences were found between the groups regarding obtaining professional certifications ( p > .05).
3.2 Comparison of the pretest and posttest results on self-efficacy between the two groupsThe PUM-SES-T assessment comprises four domains: assessment (2 items), planning (2 items), supervision (2 items) and decision-making (4 items). In the intervention group (IG), 230 participants completed the pretest (T 0) and 59.1 % completed the full sequence after the flipped education intervention; in the control group (CG), 155 participants completed the pretest, with 57.9 % completing the entire sequence, including the pretest, intervention education and all three posttests. The intervention group engaged in self-directed learning via digital platforms to establish foundational knowledge, then participated in physical workshops to integrate higher-level cognitive processes, such as understanding, application and analysis and had the opportunity to engage in hands-on practice, which resulted in a significant improvement in overall self-efficacy scores. Both groups showed improvements in self-efficacy, with average scores peaking at T 2 and slightly declining at T 3. When examining the four domains individually, posttest scores exceeded pretest scores for both groups. In the IG, scores in all four domains—assessment, planning, supervision and decision-making—peaked at T 2, with T 3 scores remaining higher than those at T 1 and T 0. In the CG, assessment and planning scores peaked at T 2, whereas supervision and decision-making scores reached their highest levels at T 1, followed by a gradual decline from T 2 onward ( Table 1). Trends across the four time points for each group are illustrated in Figures 2–6 ( supplemental material).
3.3 Differences in self-efficacy scores at different time pointsOver time, significant differences in self-efficacy scores were observed between the two groups, with the intervention group (IG) scoring 2.82 points lower than the control group (CG) ( p < 0.001). After accounting for the interaction between group and time points, both the IG and the CG demonstrated increased improvement. The magnitude of change between the groups was statistically significant, with a score increase of 4.34 points for T 1 vs. T 0 ( p < 0.001), 5.56 points for T 2 vs. T 0 ( p < 0.001) and 6.76 points for T 3 vs. T 0 ( p < 0.001). These findings indicate that the IG benefited more effectively from the flipped education approach than the CG. Further details are presented in Table 2 (Model 2).
3.4 Comparison of learning satisfaction between the two groupsParticipants in this study were required to complete the pre-test and three post-tests at designated time points. The intervention group (IG) participated in flipped education and physical workshops, while the control group (CG) engaged in digital self-directed learning. Only after fully completing these activities were participants asked to fill out the learning satisfaction scale. A total of 135 participants in the IG and 92 in the CG completed the satisfaction survey.
Of the ten items in the learning satisfaction scale, eight showed statistically significant differences between the groups, with IG reporting higher satisfaction than CG. These included the clarity of course objectives ( p < .000), the arrangement and explanations of course content with pictures and texts aiding memory ( p < .000), the course’s learning mode enhancing operational skills ( p < .000), treating patients differently post-training ( p < .000), willingness to practice professional skills related to pressure injuries ( p = .005), the multimedia design attracting attention ( p < .000) and multimedia teaching methods being helpful and engaging ( p = .048). Two items did not show statistically significant differences between the groups: the syllabus being designed in a structured way ( p = .162) and the course improving knowledge and skills in pressure injury prevention ( p = .965). The overall satisfaction score, ranging from 10 to 50 points, also showed that IG outperformed CG with a statistically significant difference ( p = .001) ( Table 3).
4 DiscussionThis study aimed to evaluate the long-term effects of combining an adult self-learning model with flipped education in physical workshops on the self-efficacy of nurses in the prevention and management of pressure injuries. Participants were divided into a control group and an intervention group, using PDF-based teaching materials and multimedia digital teaching materials, respectively, for self-directed learning. Significant improvements were observed in the four domains of self-efficacy—assessment, planning, supervision and decision-making—highlighting the effectiveness of the educational strategies designed for this study.
The intervention group participated in physical workshops through the flipped education model. These workshops included discussions and interactive sessions, allowing nurses to ask questions, clarify concepts, resolve doubts, reflect on their one-month digital learning experience and provide feedback. Practical cases were integrated into the workshops to enhance nurses’ abilities in evaluation, planning, supervision and decision-making while incorporating hands-on exercises to build confidence. Self-efficacy scores for the intervention group peaked in the post-test conducted one month after the educational intervention. Although a slight decline was observed in the three-month post-test, the scores remained higher than both the pre-test and the immediate post-intervention test, indicating that the educational intervention effectively enhanced the overall self-efficacy of nurse in preventing and managing pressure injuries. It also shows that the effects of teaching are not permanent. Learners often quickly improve their confidence and skills due to novel and focused learning modes. However, over time, if there is a lack of continuous review or reinforcement, these short-term results tend to gradually weaken, which is consistent with the theory of the forgetting curve ( Peterson and Peterson, 1959). When designing teaching intervention strategies, we should not only focus on initial improvements, but also establish a long-term, continuous learning support system to ensure that learning outcomes can be stably transferred to actual work.These findings are consistent with the results of the study by Dellafiore et al. (2019), which developed the self-efficacy scale. Currently, this study is among the few to evaluate the effectiveness of educational interventions in improving self-efficacy related to the prevention and management of pressure injuries, demonstrating significant results. Further research is needed to validate these findings.
In this study, the design of self-learning teaching materials, whether PDF-based or multimedia digital materials, was guided by the International Clinical Practice Guideline for the Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide (2019). The content focused on three key aspects: prevention, stage interpretation and wound care, emphasizing the enhancement of learners’ abilities in assessment, planning, supervision and decision-making. The goal was to foster learners’ confidence in effectively managing pressure injury care and to strengthen their belief in using their professional skills effectively ( Bandura, 1986). Self-efficacy is recognized as an essential predictor of clinical competence (Rosario Caruso, Fida, Sili, and Arrigoni, 2016; R. Caruso, Pittella, Zaghini, Fida, and Sili, 2016) and nurses' belief in their ability to optimally manage pressure injuries reflects their self-efficacy in fulfilling professional responsibilities ( Dellafiore et al., 2019).
This study integrated adult self-learning theory with flipped education in the design of teaching materials. The development process considered clinical applicability, case authenticity and the stimulation of visual and auditory engagement to enhance the learning flexibility and interest of nurse. Classroom teaching videos were recorded using specialized software and uploaded to a digital platform to facilitate the acquisition of foundational knowledge. Additionally, workshops were designed with interactive question-and-answer sessions to enable learners to deepen their understanding, broaden their knowledge and clarify ambiguous concepts. This approach aimed to improve classroom learning outcomes ( Bergmann and Sams, 2012). Although flipped learning may impose challenges, it is a teaching method that enhances communication skills, rebuilds self-confidence, fosters personal growth and ensures a deeper comprehension of learning content, ultimately improving self-efficacy ( Zheng, Johnson, and Zhou, 2020).
In this study, both short-term outcomes and long-term tracking demonstrated significant improvements and sustained effects on self-efficacy. The design and presentation of teaching materials also received high satisfaction ratings. Differences between the intervention and control groups were evident in areas such as teaching content design, multimedia features and perceived learning effectiveness. Nurses showed a preference for vivid and audible short videos, which not only captured their attention but also aided memory retention, strengthened operational skills and increased enthusiasm for practicing professional skills. According to Dale’s Learning Pyramid, different teaching methods result in varying levels of knowledge retention: lectures (5 %), reading (10 %), demonstrations (30 %), discussions (50 %) and hands-on practice (75 %) ( Dale, 1969). Based on this theory, the combination of multimedia digital audio-visual teaching materials and flipped education in this study provided an effective approach to enhancing knowledge absorption.
Long-term tracking of study results is inherently challenging. During the study period, participants who were identified by the system as having incomplete self-study participation or those in the intervention group who did not attend the workshops were excluded from the final analysis. This finding highlights that motivated adult learners are more likely to take initiative and seek opportunities to improve their skills. The study also considered cultural differences; it has been reported that nurses in hospitals under policy promotion in Taiwan exhibit high compliance ( Wu et al., 2022), which was a key factor in the successful completion of this study. Another unavoidable challenge during the study was the global COVID-19 pandemic, which caused nurses to miss physical workshops due to shift rotations, caring for infected patients, or their own COVID-19 diagnoses.
5 ConclusionThis study demonstrates that through the process of adult self-directed learning, integrated with a physical workshop that combines higher-level cognitive engagement with hands-on practice, the flipped education approach can significantly enhance nurses' self-efficacy in preventing and managing pressure injuries. The findings provide valuable insights for healthcare managers, educators and researchers in understanding nurses' self-efficacy, serving as a foundation for designing future preventive programs and strategies.
6 Study limitationsAlthough this study did not directly assess the clinical practice capabilities related to pressure injury management, participants in the flipped education approach provided positive feedback on satisfaction survey items, such as “I think the learning mode of this course can strengthen my ability to operate professional skills,” “I think the content of the course has made me treat patients differently in terms of preventing pressure injuries,” and “I think this course will make me more comfortable practicing professional skills.” Additionally, the intervention group reported significantly higher satisfaction levels than the control group. The intervention group also exhibited greater motivation and practical abilities, aligning with the self-efficacy results measured in this study. These findings underscore the effectiveness of the educational interventions in enhancing self-efficacy and practical application.
Funding sourcesThis study was supported by the Ministry of Health and Welfare, Taiwan, under Grant No. 11129.
CRediT authorship contribution statementChao Wen-Yi: Writing – original draft, Validation, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Liao Wen-Chun: Writing – review & editing, Supervision, Methodology, Investigation, Formal analysis.
Declaration of Competing InterestThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
AcknowledgmentsThe completion of this study was made possible by the participation of every member involved and the cooperation of the interviewees.
Appendix A Supporting informationSupplementary data associated with this article can be found in the online version at doi:10.1016/j.nepr.2025.104368.
Appendix A Supplementary materialSupplementary material
Supplementary material
| items | Over all | Assessment | Planning | Supervision | Decision Making | ||
| group | Test timing | score range | 10–50 | 2–10 | 2–10 | 2–10 | 4–20 |
| participants | Mean (SD) | ||||||
| CG | T
| | 29.95 (8.69) | 6.05 (1.86) | 6.02 (1.96) | 5.95 (1.80) | 11.93 (3.56) |
| T
| | 33.29 (8.97) | 6.85 (1.75) | 6.65 (1.82) | 6.76 (1.73) | 13.38 (3.54) | |
| T
| | 33.61 (8.30) | 6.94 (1.63) | 6.60 (1.81) | 6.72 (1.73) | 13.34 (3.53) | |
| T
| | 32.82 (8.23) | 6.78 (1.54) | 6.59 (1.84) | 6.66 (1.81) | 12.78 (3.52) | |
| IG | T
| | 26.29 (8.25) | 5.22 (1.74) | 5.26 (1.85) | 5.13 (1.80) | 10.68 (3.43) |
| T
| | 32.69 (8.21) | 6.43 (1.78) | 6.49 (1.80) | 6.54 (1.79) | 13.22 (3.23) | |
| T
| | 34.74 (7.50) | 6.84 (1.64) | 6.96 (1.64) | 6.96 (1.66) | 13.98 (2.95) | |
| T
| | 34.51 (7.35) | 6.77 (1.59) | 6.93 (1.62) | 6.93 (1.64) | 13.89 (2.93) | |
| Self-efficacy | Model 1 | Model 2 | ||||||||
| Estimate | SE | 95 %C.I. | | Estimate | SE | 95 %C.I. | | |||
| GROUP | −8.06 | 1.17 | −10.35 | −5.76 | < 0.001 | −2.82 | 0.917 | −0.462 | −1.026 | 0.002 |
| Test (Time) | ||||||||||
| T
| 0.01 | 0.98 | −1.90 | 1.94 | 0.984 | 2.849 | 0.615 | 1.644 | 4.055 | < 0.001 |
| T
| 0.45 | 0.84 | −1.19 | 2.09 | 0.590 | 3.224 | 0.501 | 2.241 | 4.207 | < 0.001 |
| T
| 0.11 | 0.93 | −1.71 | 1.94 | 0.905 | 2.061 | 0.568 | 0.947 | 3.175 | < 0.001 |
| GROUP x Time | ||||||||||
| GROUP x T
| 6.37 | 1.46 | 3.51 | 9.24 | < 0.001 | 4.344 | 0.741 | 2.289 | 5.796 | < 0.001 |
| GROUP x T
| 7.73 | 1.44 | 4.90 | 10.57 | < 0.001 | 5.564 | 0.720 | 4.153 | 6.974 | < 0.001 |
| GROUP x T
| 8.41 | 1.59 | 5.28 | 11.53 | < 0.001 | 6.762 | 0.774 | 5.245 | 8.278 | < 0.001 |
| items | CG (N = 135) | IG (N = 92) | | ||
| Mean | SD | Mean | SD | ||
| | 3.90 | 0.96 | 4.23 | 0.42 | < .000 |
| | 4.13 | 0.68 | 4.00 | 0.69 | .162 |
| | 3.91 | 0.82 | 4.43 | 0.85 | < .000 |
| | 3.78 | 0.87 | 4.43 | 0.85 | < .000 |
| | 4.13 | 0.68 | 4.68 | 0.46 | < .000 |
| | 4.01 | 0.76 | 4.66 | 0.48 | < .000 |
| | 4.22 | 0.74 | 4.44 | 0.84 | .048 |
| | 4.01 | 0.60 | 4.01 | 0.69 | .965 |
| | 3.94 | 0.72 | 4.22 | 0.74 | .005 |
| | 3.92 | 0.72 | 4.13 | 0.77 | .041 |
| total | 40.26 | 5.74 | 40.26 | 5.74 | .001 |
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