Designing, using and evaluating the effects of nursing clinical skills training software on the clinical skill level and satisfaction of nursing students

Abstract

Introduction: The integration of new educational tools and technologies has the potential to enhance nursing students’ motivation and engagement. However, existing training often fails to ensure retention and timely application of clinical skills in real, high-stress hospital settings, leading to gaps between what is taught and what is performed in practice. This study proposes the design and use of educational software targeted at nursing clinical skills, aligned with the current level of clinical proficiency of nursing interns, with the aim of bridging the gap between theoretical knowledge and practical performance in clinical environments. Method: This semi experimental study focused on 60 6th-semester students and 60 8th-semester interns who were Bachelor of Nursing students at Shahrekord University of Medical Sciences in 2024. The samples were selected via a simple sampling method and divided into two control and intervention groups through the random allocation (even-odd) assignment). The designed software was then installed on the mobile phones of the students in the intervention group, and the level of clinical skill and stress of the students was measured through a questionnaire, their performance was observed, and the skill evaluation checklist was completed. Results: Of the 60 samples in the study group, the majority were 51 (85%) who said that the information provided in the software was properly categorized (51 (85%)), that the software met the individual’s information needs, that the methods were performed correctly (56 (93%)). The types of skills that were examined in this study included checking vital signs, changing dressings, preparing serum, drawing medicine, inserting IV line, injecting, suctioning, performing heart auscultation, and inserting a gastric tube. The intervention group achieved a higher average score across all skills compared with the control group after training with the software (p < 0.05). Conclusion: This study indicates that incorporating educational simulation software as a supplement to traditional lectures and to hospital-based clinical practice may enhance students’ knowledge and skill. However, limitations such as single-site sample and the potential variability in implementation across instructors and clinical settings; reliance on self-reported outcomes could have influenced responses. Future research should employ examine long-term retention and impact on patient care outcomes and explore stakeholder experiences to identify best practices for integrating educational simulation into nursing curricula.

Introduction

The rapid penetration of information technology among people has changed their way of life. The rapid developments caused by the application of technology, including productive technology and information technology, in human life have caused tremendous changes in the industrial, economic, political and civil structures of societies, and these changes have had a significant impact on the life and work of people worldwide. It has seriously confronted the traditional methods of teaching, learning and managing education [1, 2]. Healthcare students need to be prepared with capabilities for creativity to identify and figure out problems in their learning and working environments. In the teaching process, direct and indirect teaching methods and models have been proposed. Self-directed learning, as a direct teaching method, has been considered in educational models for the past four decades. Self-directed learning is a process of individual initiative that is used with or without the help of others in identifying learning needs and specifying material and human resources for learning [3]. Electronic learning, as a type of self-centered learning, is a phenomenon of the modern world that has emerged in the information age and in knowledge-based society. The main and essential feature of e-learning is its communicative and interactive feature. Currently, electronic learning offers us better methods for processing and giving meaning to information and recreating it [4, 5]. Traditional education classes are no longer effective because they are dependent on a specific time and place and cannot provide a real and appropriate context for learning. Printed texts also cause problems due to their specific limitations. Educational software provides rich resources that can be an opportunity for the growth of learners and that create a collaborative environment that allows learners and teachers to search for and investigate a variety of issues [6]. One of the greatest challenges in the education of nursing students is providing effective education to train skilled students who can effectively provide services in the hospital environment. To achieve such a goal, the relevant professors offer different solutions; one of these solutions is the use of educational videos in the form of software, which is used as an educational strategy [7]. Using educational software in learning environments is a suitable and necessary way to discover and access information resources to prepare learners for future life. The quality of education depends on the proper and continuous use of educational software in the classroom. The most practical aspect of educational software is ease and universal access to content. By using educational software programs, the learner becomes the focus of learning and interacts with his or her environment [8].

The integration of mobile-based learning in nursing education is increasingly recognized as crucial for enhancing clinical skills and promoting effective learning outcomes [9]. Nursing students benefit from mobile learning due to its flexibility, accessibility, and ability to provide real-time information, which is essential in fast-paced clinical environments [10]. Recent studies have shown that mobile learning can enhance knowledge retention, foster independent learning, and improve clinical reasoning skills. For instance, a study by Almazroi et al. (2021)[11] highlights that nursing students who engaged with mobile learning applications demonstrated significant improvements in their clinical decision-making abilities compared to their peers who relied solely on traditional learning methods [11]. Furthermore, a systematic review by Mohamad Ali et al. (2022)[12] underscores the positive impact of mobile learning on satisfaction and learning efficacy, emphasizing that nursing students found mobile platforms beneficial for reinforcing clinical skills and accessing educational resources on-the-go [12]. Additionally, mobile technology facilitates interactive learning experiences through simulations and case studies, which are vital in preparing students for real-world clinical challenges. Therefore, incorporating mobile-based learning into nursing education not only aligns with the digital transformation in healthcare but also addresses the specific learning needs of nursing students by promoting an engaging and dynamic educational environment [13].

Evidence suggesting that mobile platforms can support spaced repetition, experiential practice, and real-time feedback in clinical skill acquisition [14]. The potential for improved transfer of theory to practice through context-sensitive, mobile-enabled simulations and decision-support tools [15].

Considering that clinical education is a fundamental and important aspect of medical science education, it is within this context that students apply their theoretical knowledge through practical skills while interacting with instructors and the clinical environment. As a result, the large volume of educational materials covered during the first semester leads to a compressed course schedule, leaving insufficient time for frequent exercises and problem-solving. Therefore, in this study, we aimed to evaluate the impact of mobile educational software on the learning outcomes of nursing trainees and interns.

Method

The present study is semiexperimental. The study population included all the nursing students at Shahrekord University of Medical Sciences who were studying in the sixth to eighth semesters at the time of the research. The inclusion criteria were as follows: 1- willing to participate in the study and 2- whose student information was registered at Shahrekord University of Medical Sciences. 3- Being in the nursing field in the training course. The exclusion criteria were as follows: 1- unwillingness to continue studying. For sampling, first, targeted sampling was performed in a simple way. Participant grouping in two groups was carried out by study team members who were not involved in the intervention or evaluation. The participants were each assigned a random no duplicate number between zero and 120 using Microsoft Excel. The random numbers/participants were divided into two groups based on odd number in intervention group and even number in control group. To evaluate balance between groups, we compared baseline characteristics (e.g., age, gender, prior clinical experience, prior exposure to related training) using appropriate statistical tests (t-tests or Mann-Whitney U tests for continuous variables; chi-square or Fisher’s exact tests for categorical variables). No significant imbalances were observed across key demographic and educational variables (all p > 0.05), supporting comparability of groups at baseline. The researchers, students and data analysts were blinded to the intervention group.

Considering a confidence factor of 95% and an error percentage of 2.3, the sample size was at least 60 in each group and 120 people in the whole study. In this study, the method of data collection was through a demographic information questionnaire, an electronic learning questionnaire, a checklist for evaluating nursing clinical skills, and a satisfaction questionnaire that measured the level of stress. Specifications of information collection tools and how to collect them include the following questionnaires. The e-learning questionnaire was designed and validated by Watkins et al. (2004).[17] This questionnaire contains 25 response items based on a five-point Likert scale and a five-dimensional questionnaire of motivation, skills and continuous communication, access to technology, and learning ability [16]. The reliability of the questionnaire was obtained 84% with Cronbach’s alpha for the whole questionnaire, which indicates that the test has acceptable reliability [17]. In Iran this questionnaire was validated by Ahangar (2014). In this study, the reliability of this tool was checked by calculating Cronbach’s alpha as 0.75. Also, to determine the content validity of this questionnaire, the researchers checked the Content Validity Ratio (CVR) and the Content Validity Index (CVI) [18]. Also in different studies in Iran the validity and reliability of this questionnaire was confirmed [19, 20].

The checklist of Discussions evaluation soft App was a valid and reliable researcher-made checklist that was a self-report tool and was completed by the participants. The content validity of the checklist was examined by six software development engineers that had more than five years of experience. Each expert rated content validity using a 4-point Likert scale. The content validity of the instruments was acceptable (CVI = 0.99, CVR = 0.6–1). The reliability of checklist was confirmed with Cronbach’s alpha of 0.77 and ICC 0.88 in test–retest with two weeks’ interval in a pilot study with 30 subjects. The check list had 15 items on a3 point Likert scale (from completely agree 3 to completely disagree1) on 3 subscales entitled content and appearance (3 questions), ease and Simplicity use (10 questions), and Up-to-date and application in the practical implementation of the skills taught (2 questions). Evaluation of nursing skills was done by checklist contain 9 basic skills and was designed and validate by Haidari et al. in Iran [21].

The educational content of this software, developed for the Android operating system, includes nine nursing clinical skills. The content was prepared using library resources. Upon opening the software, users are presented with a section explaining the educational content and listing its sections. Additionally, instructional images or educational videos for each skill were included alongside the text.

The validity of the educational content was confirmed through feedback from a panel of experts before the software was designed. The prototype was developed in collaboration with a programming engineer, and the software was designed using B4A. It supports Android versions 5 and above and enables both online and offline downloading of educational videos. A user guide was provided to ensure that all users could easily navigate the software and utilize its educational content.

To access the software, users must first register on the registration page. A server and database were implemented to record information, and the texts were included as HTML files within the software. Features incorporated into the software allow for page color settings and the ability to zoom in on content. Each user is required to create a personal password for login and software installation. Additionally, the software includes functionality to track user engagement.

A general scheme for the software was first developed, followed by the creation of its various components. Each stage of the software development was evaluated by a panel of experts and ten students who were eligible to participate in the study but were not included in the main group. Interviews were conducted to assess usability and clarify ambiguities in the program, leading to necessary modifications.

After completing the software design, it was handed over to the programming engineer for testing. Its applicability and usability were reviewed, and feedback was collected and approved. The final version of the software was subsequently used in the research. The application allows students to search for titles of procedures, medications, or any information they may have forgotten or do not know, providing quick access to educational materials.

In addition to nursing procedures and medications, the application covers topics such as test interpretation and physical examinations that nurses should be familiar with. To prevent misuse of the application’s contents, a user account section requires users to enter a username and password at the beginning of the app to gain access to the content. The app also includes a gallery where students can view images and videos that demonstrate procedures, enhancing learning through observation. Informative pictures are incorporated into the educational materials for better understanding.

In the “Contact Us” section, users can submit various questions about the application, and their inquiries will be addressed promptly. The application also features a chat room-like section where users can share scientific questions and provide feedback, suggestions, or concerns about the app’s contents with its creators. Notably, the application was designed using B4A software.

After securing the necessary approvals, eligible students were selected based on the entry criteria for the study. The researcher introduced himself, explained the purpose of the study, and included those who expressed their willingness to participate by obtaining their written consent.

Before the intervention began, the educational needs of the students were identified with the help of recent articles, and their validity and reliability were confirmed by four IT professors and nursing faculty members. Using the obtained results, the application was designed and installed on students’ phones.

The core of the program includes familiarization with diseases and medications that nurses should know, guidance on physical examinations, interpretation of tests and graphs, strategies for patient education, basic science theory materials, and training in nursing procedures. This content is presented in simple language, accompanied by relevant images. The program content was reviewed by three members of the nursing faculty at Shahrekord University of Medical Sciences and one information technology expert. Notably, the designed educational software received approval from the faculty’s research council prior to implementation.

In a meeting with the test group, the benefits of using the learning program and instructions on how to navigate the application were provided, and students’ questions and concerns were addressed. To ensure that the participants used the software during the intervention, a self-reported checklist was distributed to the students to complete daily. This checklist was used to assign a score to the program for each day it was executed. They used software for one month. Questionnaires were completed by two groups using self-report before the intervention, and after the intervention they were completed again by two groups.

The data from this research were analyzed using descriptive statistics (means, standard deviations, etc.) and inferential statistics (chi-square tests, independent T-tests, and paired T-tests).

Results

Out of 120 studied students, 78 (65%) were males. The mean age of the students was 20.34 (SD = 1.51) years. There was no significant difference between two groups regarding to demographic variable(p > 0.05). According to Table No. 1, out of the 60 sample people in the intervention group, the majority, 51 (85%), stated that the information provided in the software is properly categorized (51 (85%)), the information needs software satisfied them regarding the correct methods of performing the procedures (93% (56)), the web page link that was added to some parts of the software for more information was useful (95% (57)), and the design of soft pages is clear, transparent and without confusion (96.7%), making it possible to learn better and more easily through this software (57 (95%)). Additionally, all the study samples stated that the information and explanations in the software are easy to understand, the images in the software make learning easier, and they are generally satisfied with the software and recommend its use to other nursing students.

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According to Table No. 1, 2, 57 (95%) and 54 (90%) of the studied samples reported that the use of the software has helped many people learn new material and, when caring for a traumatized person, to the extent that they used much software information in a practical way. The types of skills that were examined in this study included checking vital signs, changing dressings, preparing serum, drawing medicine, injecting, suctioning, sounding, and inserting a gastric tube. The intervention group had a higher average score for all skills than did the control group after training with the software Table No. 3.

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The types of skills that were examined in this study included checking vital signs, changing dressings, preparing serum, drawing medicine, inserting angioket, injecting, suctioning, sounding, and inserting a gastric tube.

The results of between-group and within-group comparisons of the mean scores of skills before and after the intervention are presented in Table 3. In all skills no significant differences between the intervention and control groups were before the intervention (p > 0.05). The results of t-test analysis revealed significant differences between the two groups regarding the mean scores of all skills before and after intervention. The intervention group had a higher average score for all skills than did the control group after training with the software (p < 0.05).

Discussion

The aim of study was to Designing, using and evaluating the effects of nursing clinical skills training software on the clinical skill level and satisfaction of nursing students. The findings indicate overall student satisfaction with the educational software. Students reported that the simplicity and ease of use of the educational content, the novelty of this educational method, and the comprehensive integration of visual and textual materials were significant strengths of the software.

In this study, the majority of students expressed that the software effectively met their informational needs regarding the correct procedures. A study conducted by Bin Chen et al. (2021)[14] found that, compared to conventional methods, learning through an application positively affected clinical nursing education for nursing students [22]. The software utilized clear images and appropriate, legible fonts, and all participants in the study group agreed on the effectiveness of the included visuals.

The results of present study showed that the clinical skills in the software group were higher than those of the traditional group. It seems that using the application improved the students’ skills more than the traditional method. In line with these results, it is believed that the development of mobile phone applications for nursing education, will be beneficial. Based on the results of the study conducted by Sheikhaboumasoudi et al. in 2018, nursing students obtained satisfactory results with a combination of electronic learning and traditional methods. Moreover, this study suggests that a combination of traditional methods with electronic education methods can be an effective supplement for improving nursing students’ clinical skills [23].

Study result revealed significant differences between the two groups regarding the mean scores of all skills before and after intervention. The intervention group had a higher average score for all skills than did the control group after training with the software. In contrast with current study result in an experimental educational intervention study that was conducted by Khoshbakht-Pishkhani in Rasht results showed that the cognitive skills in the application group were higher than those of the traditional group; however, the difference was not significant. It seems that using the application improved the students’ cognitive skills more than the traditional method [9].

These results align with findings from Yu Mei Chang et al., which categorized the experiences of students participating in virtual reality (VR) skill learning into five themes: “easy to practice but requires adaptation,” “rapid skill acquisition,” “stress-free learning environment,” “environmentally friendly,” and “lack of a sense of reality” [24]. Based on the results of this study, the average score for each skill significantly increased in the intervention group compared to the control group. One possible reason for this improvement is the clarity of the information and explanations provided in the software, which facilitates practical application of learned concepts.

The study by Svenningsson et al. (2022) indicated that personal attitudes toward technology significantly influence outcomes; greater reliance on technology enhances the perceived usefulness of VR programs. Positive attitudes among peers can also amplify social influences, promoting participant acceptance of such programs. This study highlighted that the motivation of trainees to learn through virtual applications is increasing, as software is often viewed as an enjoyable activity. However, the financial cost associated with implementing virtual applications in nursing education remains a significant barrier, as not all institutions possess the financial capacity to do so [25].

According to the results of this study, the mean score of total satisfaction with application in the intervention group was high, and the students considered the use of the application as very desirable. Previous studies show that mobile phone applications in nursing education increase students’ self-confidence and competence and reduce stress. In addition, students believe that using both methods (the instructor’s lecture and mobile phone applications) simultaneously is highly practical [26]. The results indicate that the nursing clinical skills training software enhances both the motivation and the actual clinical skill levels of nursing students, with high user satisfaction. For policy integration, the software could be adopted as a supplementary or foundational educational resource in clinical training programs, contingent on validation, data privacy considerations, and alignment with national/international educational standards.

This study has potential limitations, including sample size, a single-center study design, and self-reported biases. So it is recommended that further investigations in this regard evaluate the efficacy of this method across multiple universities or healthcare settings.

Also Institutions should work to make educational software widely available to nursing students, ensuring that it is accessible across a variety of devices. Consideration should be given to providing support for students who may lack the necessary technology or internet connectivity, especially in underserved communities.

Conclusion

In general, these educational software programs in the field of nursing are completely different from each other in terms of scenario, conceptual model, graphic interface design tools, content and software evaluation methods, but what is common to all of them are the evaluation results and can be said that if educational simulation software is used in addition to the traditional methods of lecturing for theoretical topics and attendance at the hospital for clinical (practical) topics, the level of students’ knowledge will be improved, and many problems that exist in the method of lecturing and attending at the hospital will be solved.

Future versions of the software could benefit from more interactive features, such as quizzes, gamified learning modules, and simulated clinical scenarios that enable students to apply their knowledge in a virtual environment.

Data availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

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