Content area
Aim
This study aimed to examine the effects of flipped learning and mobile learning methods on nursing students' knowledge, psychomotor skills and self-efficacy in urinary catheterization.
Background
Flipped learning and mobile learning are increasingly used in nursing education to enhance student engagement and skill acquisition. These methods are expected to contribute to nursing education, helping students work more successfully and safely in clinical settings and providing insight into innovative and effective teaching methods that can be used.
Design
This study was conducted as a randomized controlled trial model.
Methods
It was conducted between June 2023 and June 2025 at X University Faculty of Nursing. The study population consisted of all first-year students in the nursing department. The sample consisted of 92 students (FL=30; ML=32; Control=30) determined by power analysis. Students were stratified by GPA and randomly assigned to the groups using sealed envelopes. “Individual Introduction Form”, “Knowledge Test for Urinary System Practices”, “Skill Assessment Form” and “Student Self-Efficacy Scale” were used to collect data. During the research process, students in the experimental groups were taught using flipped learning and mobile learning methods for two weeks.
Results
Both the flipped and mobile learning groups showed significantly greater improvements in knowledge (ɳ 2=0.88), skills (ω 2=0.57, ω 2=0.41, ω 2=0.77) and self-efficacy (ω 2=0.60) scores than the control group (p < 0.001). Student satisfaction with the learning methods was also significantly higher in the intervention groups (p < 0.001, ɳ 2: 0.55).
Conclusions
Flipped and mobile learning approaches effectively enhance nursing students’ cognitive and psychomotor competencies, as well as their self-confidence.
1 Introduction
Nursing education has an interdisciplinary structure that combines theory and practice and covers cognitive, affective and psychomotor learning areas ( Aygin and Çelik Yılmaz, 2022; Bektaş, 2004; Cant and Cooper, 2010). Nurses need to have 21st century skills, such as critical thinking, problem solving, collaboration and effective communication, to provide quality care and ensure patient safety at the highest level. To acquire these skills, it is important to restructure the nursing curriculum based on innovative learning approaches ( Erden, 2022). One of these innovative approaches is Flipped Learning (FL), where students acquire theoretical knowledge through online individual learning and put it into practice through problem solving and discussion in the classroom environment. The concept we refer to as the FL learning model is generally referred to as “flipped learning, flipped classroom, inverted learning, inverted classroom, flip teaching, backwards classroom, reversed instraction” in the international literature. Although the use of different terms causes confusion, “flipped learning” is the most frequently used term ( Roehl et al., 2013; FLN, 2016; Ekici, 2021). This method combines online (prior knowledge acquisition) and face-to-face (learning practices) techniques and offers a learning environment where the educator assumes a guiding role and students have active learning experiences ( Şahin and Fell-Kurban, 2016; Towle and Breda, 2014).
Technological developments have deeply affected nursing education and increased the need for the use of information technologies in the education process. Today, nursing education is updated by considering the learner profile of the digital age to adapt to changing student needs and innovations in the field of health ( Freitas and Campos, 2008). The development of mobile technologies and the internet accelerated global access to information and a relationship between mobile technologies and learning inevitably emerged. Mobile learning (ML), which emerged as an extension of computer-assisted learning, has been on the rise since the early 2000s. During this period, mobile learning was defined, but rapidly developing technology caused the definitions to be constantly updated. ML is defined as an accessible learning method that is independent of the device, place and time ( Gause et al., 2022; Hockly, 2013; Nes et al., 2021). The rapid adoption of Android and iOS-based smartphones and tablets by users and their integration into daily life have accelerated the spread of ML. The portability of smart devices, their ability to facilitate social interaction, collect instant data according to location and time, interact with other smart devices and wireless networks and be individualized, allows them to be used in educational activities. ML meets students' expectations for education that is “just in time, just enough and just for me” ( Ryan et al., 2024). It has been stated that mobile learning can increase nursing students' knowledge and cognitive load and that it has various advantages such as quick access to information, flexible learning and positive attitudes among students ( Chuang et al., 2018).
Students who doubt their skill abilities are more likely to avoid challenging practices, have low expectations for practice and show minimal commitment to their practice goals. However, students with strong self-efficacy expectations for practice approach practice as a challenge rather than a threat, persist in improving low skill scores, control stressors and maintain commitment to goals. Moreover, a high sense of self-efficacy strengthens social relationships, whereas low self-efficacy can lead to socially alienating behaviors ( Chang and Levin, 2014). Self-efficacy, a fundamental construct for understanding and changing human behavior, is defined as the belief in one’s ability to perform a task ( Bandura, 1986). Self-efficacy is a central mechanism in the implementation of an action. The learner's belief in his/her capacity to perform a skill or withstand difficulties will largely determine how he/she will perform the practice in real life ( Wang et al., 2021). Self-efficacy depends on the gradual development and accumulation of various learning environments or activities and is a source of motivation that increases students' self-learning ( Klassen and Klassen, 2018; Mohamadirizi et al., 2015). Self-efficacy is a vital component for independent performance in nursing. In recent years, self-efficacy has been associated with academic achievement and clinical skill performance ( Honicke and Broadbent, 2016; Goldshmidt, 2018). Self-efficacy plays an important role in providing quality nursing care by supporting nurses in developing their professional identity, practice performance and competence ( Yao et al., 2021; Yu et al., 2021).
Urinary catheterization skill is one of the important psychomotor skills that should be acquired in nursing education and it is a skill that is difficult to learn in a simulator with low validity, contains confusing and abstract structures and has limited application area on patients and practitioners. In addition, urinary catheterization is an invasive intervention that is usually performed inadequately and inappropriately and may lead to increased morbidity ( Wüller et al., 2019). Therefore, nursing students should improve their urinary catheterization skills before beginning clinical practice. Teaching urinary catheterization practice is usually done in professional skills laboratories by demonstration method on simulation equipment with low validity. It has been observed that this method is often insufficient to improve students' psychomotor skills. In this study, the effects of teaching urinary system applications using active learning methods were comprehensively evaluated. The FL and ML methods are important in terms of providing ease of access to educational materials for students who use modern technology frequently, saving time, actively involving the student in the learning process and being cost-effective.
These methods are thought to contribute to nursing education, help students work more successfully and safely in clinical practice and shed light on innovative and effective teaching methods that can be used.
This study aimed to investigate the effectiveness of FL and ML methods in improving students' urinary catheterization knowledge, skills and self-efficacy.
The research hypotheses are as follows:
Urinary catheterization practice education given with the FL method has an effect on the knowledge levels of nursing students.
Urinary catheterization practice education given with the FL method has an effect on the psychomotor skill performances of nursing students.
Urinary catheterization practice education given with the FL method has an effect on the self-efficacy levels of nursing students.
Urinary catheterization practice education given with ML has an effect on the knowledge levels of nursing students.
Urinary catheterization practice education given with ML has an effect on psychomotor skill performances of nursing students.
Urinary catheterization practice education given with ML has an effect on nursing students' self-efficacy levels.
2 Methods
2.1 Design
This study was conducted as a randomized controlled experimental research model. This study was registered in ClinicalTrials.gov with the protocol registration number NCT06928831. The research was conducted between June 2023 and June 2025 with first-year students of the Department of Nursing, Faculty of Nursing, Inonu University, within the scope of the Fundamentals of Nursing course. In this study, the subject of “Urinary System Practices” which is one of the difficult units to teach in the system applications in the Fundamentals of Nursing course, was selected.
2.2 Sample
A total of 297 first-year nursing students enrolled in the 2023–2024 academic year constituted the study population. The sample size was determined to be 30 in each group, with an effect size of 0.50, significance level of 0.05, confidence interval of 0.95 and power of 0.85, as calculated using the
t-test for dependent groups in the G*Power 3.1 program. Considering the potential losses in each group, an additional five students were included in each group (FL group = 35, ML group = 35 and control group = 35). However, three students who did not actively participate in the teaching methods process in mobile learning group, five students wanted to leave the study in flipped lealning group and five students had health problems and did not participate in the post-test measurements in control group were excluded in the research process. The study was finally completed with 92 students, including 30 in the FL group, 32 in the ML group and 30 in the control group. The CONSORT flow diagram for the research process is shown in
2.2.1 Inclusion criteria
Students enrolled in the first-year of nursing who received training on urinary system practices for the first time; did not have physical disabilities related to vision, hearing, or motor skills; had a smartphone with an Android or iOS operating system; and volunteered to participate in the study were included.
2.2.2 The exclusion criteria were as follows
Students who repeated the first year, received training on urinary system practices for the second time and those who did not volunteer.
3 Randomization
Students who met the inclusion criteria and volunteered to participate in the study were divided into two groups by an independent statistician not involved in the research process based on their Grade Point Average (GPA). The different researcher ensured that students with grade point averages below and above 3.00 were assigned to three groups in equal numbers. The 48 students with a GPA above 3.00 were randomized into three sets of 16 students each. The 57 students with a GPA of 3.00 or below were randomized among themselves to form three sets of 19 numbers each. To randomly assign students to the experimental and control groups in a unbiased, sets determined by the independent statistician were written on pieces of paper, placed in sealed envelopes prepared by the statistician and drawn by lottery to determine who would be where group. As a result of the draw, Envelope 1 was designated as the Control group, Envelope 2 as the ML group and Envelope 3 as the FL group. Thus, the number of students in each group was equalized and every student included in the study had an equal chance of being assigned to either the intervention or control group.
4 Blinding
Double blinding could not be done because the first researcher was involved in the data collection process. However, randomization lists were created by an independent expert statistician who was not involved in data collection. In addition, The study data were analyzed by an expert statistician to prevent reporting bias and single blinding was possible.
5 Instruments
5.1 Individual introduction form
This form was created by the researchers to determine the socio-demographic characteristics of the participants. This form included 10 questions evaluating the students’sociodemographic characteristics and their use of technological devices.
5.2 Urinary system practices skill assessment form (USPSAF)
Checklists for urinary catheter application were developed based on literature review and expert opinions ( Dikmen and Akın Korhan, 2020; Erdem and Öztürk, 2024; Kavak, 2024; Konateke, 2024) to evaluate students' performance. The USPSAF consists of three sections: (1) “Urinary catheter application for female/male patients (35 steps; 35–105 points)”, (2) “Sterile urine sampling (16 steps; 16–48 points)” and (3) “Urinary catheter removal (15 steps; 15–45 points)”. Each step is rated on a three-point scale: 1 = not performed, 2 = performed incorrectly/incompletely, 3 = performed correctly. Content validity was assessed by eight Fundamentals of Nursing experts using the Davis technique, with a minimum CVI of 0.75 accepted. The CVI values for the three checklists were 0.92, 0.87 and 0.90, respectively.
5.3 Knowledge test for urinary system practices (KTUSP)
A 25-item test was developed by the researcher based on the literature on evidence-based urinary catheterization practices, key psychomotor skill considerations and possible complications. Content validity was assessed by eight Fundamentals of Nursing experts using the Davis technique ( Davis, 1992), with a minimum CVI criterion of 0.75. The overall CVI for the KTUSP was 0.90.
5.4 Student self-efficacy scale (SSES)
The validity and reliability analysis of the scale developed by Rowbotham and Schmitz to determine the self-efficacy levels of nursing students was conducted by Eren and Başgöl in 2023 ( Eren and Başgöl, 2023). The scale is a four-point Likert-type with a single subdimension, scored from 1 (Strongly Disagree) to 4 (Strongly Agree), with total scores ranging from 10 to 40. Higher scores indicate greater self-efficacy. The Cronbach’s alpha was 0.81 in the original study and 0.85 in this study.
5.5 Teaching methods assessment form
This form was used to gather students’ opinions about the ML with the FL method for the evaluation of urinary catheterization application training. In the section related to the evaluation of teaching methods, a satisfaction scale from 1 to 10 was used. A score closer to 10 indicates an increase in satisfaction.
6 Data collection
Data were collected at X University Faculty of Nursing between 06.05.2024-03.06.2024 in the same time period for all groups.
The researcher informed students about the study and obtained consent using the “Informed Voluntary Consent Form.” Students in the FL and ML groups also signed a contract to prevent sharing of course content, ensuring data confidentiality. Data were collected at different times to prevent information exchange between groups. Urinary system applications were taught in the 12th week of the Fundamentals of Nursing curriculum. The theoretical course (6 h) was delivered face-to-face with PowerPoint presentations, followed by question-answer and review of unclear topics. During the same week, students practiced skills using the demonstration method under faculty supervision in the skills laboratory (4 h). Except for the FL group, all students attended the theoretical and laboratory sessions in person. The FL group received course content in the 11th week and was asked to come prepared for the 12th week, when the researcher conducted active learning sessions. For the pre-test, students completed the “Individual Introduction Form, KTUSP and SESS”. Psychomotor skills were assessed using the “USPSAF” by the researcher and an independent observer, each session lasting 10–15 min. The observer, a doctoral-level nursing faculty member, evaluated skills through unattended observation alongside the researcher. For the post-test, students completed the same forms and the Teaching Method Assessment Form. Skills were re-evaluated using the USPSAF by both assessors. The data collection process for all groups is summarized in
7 Nursing intervention
7.1 Preparation
At this stage, course materials and content related to urinary system applications were prepared. A virtual classroom was created via Google Classroom for the FL method and theoretical and skill practice videos were recorded. With support from a software developer, a mobile application (Hemşirelik Okulum) was developed for the ML group. Expert opinions were obtained to evaluate the course content, brochure, skill checklists, knowledge test and mobile application. After incorporating expert feedback, all materials were uploaded to the mobile application and virtual classroom.
7.2 Preparation of course materials
A unit plan was developed for the urinary system applications course, with separate plans for each group. The plan included five topics, six hours of theoretical lectures and four hours of laboratory practice. The FL unit plan covered the following elements: subject, aim, objectives, content, skills to be learned, skill levels, achievements, teaching methods (lecture, question-answer, discussion, concept mapping, quizzes, small-group teaching, video evaluation, demonstration), teaching materials (textbooks, presentations, computers, blackboards, printed materials), activities (in-class and out-of-class) and evaluation methods. Eight experts in Fundamentals of Nursing evaluated the course and mobile application content. The mean DISCERN score was 70.50 (SD 0.76) (Min: 69, Max: 71), indicating high content quality.
7.3 Preparation stages of the FL group
In this study, Google Classroom platform was used for students to access the course materials. The internet link and QR code were shared with the students to access the classroom. Students registered and logged into the system with their student e-mails by clicking on the link or scanning the QR code. All course materials were uploaded to this classroom. Students downloaded and read the theoretical course content in PDF format and watched the theoretical and practical course videos. They answered quiz questions and used the classroom to upload their assignments to the system.
7.4 Preparation of lecture presentations and recording of videos for the FL group
PowerPoint presentations were prepared for the five modules in the urinary system practices unit and used to explain the theoretical content to all groups. These presentations were converted to PDF format and uploaded to the classroom along with lecture videos explaining the presentations. Practice videos were recorded in the skills laboratory and uploaded to the system. Brochures on evidence-based practices for preventing catheter-associated urinary tract infections were also prepared, converted to PDF format and uploaded (
7.5 Mobile application preparation
The content of the mobile application developed as “Hemşirelik Okulum” was created to include five modules of theoretical content prepared on urinary system applications, skill videos, quiz questions and brochures prepared in line with evidence-based information.
7.6 Design of the “Hemşirelik Okulum” application
The “Hemşirelik Okulum” mobile application was developed with support from web software engineers and is compatible with Android and iOS devices. It can be downloaded from both the App Store and Google Play. The backend was implemented using Python and the Django framework, with API connections enabling direct interaction between the database and the mobile application. The web-based admin panel was designed with HTML5, CSS3, JavaScript and Django, providing researchers access to content management and user oversight. The mobile application was developed using Flutter and WebView technologies, with Dart as the programming language. The app interface was designed for two levels of users: students and researchers. Students in the mobile learning group registered via a “Sign-Up” screen, logged in with their student number and password and accessed the main page featuring a quick-access sidebar for learning materials and researcher contact information. The main page also included material buttons labeled with relevant names and images (
8 Implementation
8.1 FL group
The researcher met with the group in the classroom, introduced Google Classroom and explained how to access the content. A WhatsApp group was created for communication and the Google Classroom QR code and link were shared. Students were granted access to the virtual classroom one week before the theoretical class and were reminded via WhatsApp to review the content. The researcher monitored access and sent reminders to inactive students. One week later, a 30–45-minute face-to-face session was held to review unclear topics, answer questions and summarize the subject. Students were then divided into three groups (Question -Answer, Video Preparation and Concept Map; 10 students each), with one week to prepare. The researcher met twice with each group to monitor their progress. The Question-Answer group prepared 20 short questions each and completed incorrect or missing answers during class. The Concept Map group created a “Urinary System” map using Canva and presented it to the class. The Video Preparation group produced three skill videos: “Urinary Catheter Application,” “Taking a Sterile Sample,” and “Catheter Removal.” After small-group activities, all students gathered in the skills laboratory for collaborative practice, knowledge sharing and peer teaching. The researcher met the full group twice, supervised skill practice, answered questions and corrected errors (
8.2 ML group
This group received the theoretical course in the classroom according to the curriculum. Students were informed about ML and asked to install the “Hemşirelik Okulum” mobile application, which they accessed using a username and password. To protect the content, students signed a contract prohibiting sharing materials with third parties. They were informed that access would be available for two weeks and monitored by the researcher. Reminder messages were sent to students with low engagement or who did not watch the videos.
8.3 Control group
This group received the theoretical course in the classroom according to the curriculum. Skill teaching was demonstrated by the instructors in the laboratory with the demonstration method. The skills were performed by the students. Meanwhile, students' questions were answered, faulty practices were corrected and feedback was given.
9 Data analysis
The study data were analyzed using the Statistical Package for Social Sciences (SPSS) v25.0 program. Data belonging to continuous variables were reported using mean (x̄) and standard deviation (SD) values. Number (n) and percentage (%) were used for categorical variables. Chi-square test (Pearson Chi-squared test value) was used for the homogeneity test of independent variables between groups. Paired samples t test was used for dependent measurements with two groups. Statistical significance level was accepted as p < 0.05 in all tests. To examine differences between groups, ANOVA analysis was first applied, followed by Bonferroni testing when variance homogeneity was ensured for post-hoc comparisons and Games-Howell testing when it was not. These tests incorporate adjustments designed to control the Type I error rate in multiple comparisons. This method incorporates the necessary adjustments for multiple comparisons. Therefore, the methods used include appropriate adjustments for multiple comparisons. Intention-to-treat (ITT) analysis (n = 35, each group) was performed to prevent attrition bias. The results showed no difference between the ITT) and per-protocol (PP) analyses. Intraclass Correlation Coefficient (ICC) analysis was applied to evaluate the reliability of the measurements made by two independent observers. Two-Way Random Effects Model was used for the analysis and absolute agreement was calculated. ICC interpretation was based on Koo and Li (2016) classification “0.00–0.50: Poor; 0.50–0.75: Moderate; 0.75–0.90: Good; 0.90–1.00: Excellent” ( Koo and Li, 2016).
10 Ethical aspects
Ethics committee permission was obtained from Inonu University Health Sciences Non-Interventional Clinical Research Ethics Committee with the decision numbered 2023/5326 dated 26–12-2023. Institutional permission (Document Date and Number: 28/07/2023–325755) was obtained from the Dean of the Faculty of Nursing of Inonu University. Permission for data collection forms was obtained from the scale owners through e-mail. The students were informed about the confidentiality of the data and their written consent was obtained by signing the “Informed Voluntary Consent Form” where their rights and study procedures were determined. The principles of the Declaration of Helsinki were followed throughout the study.
11 Results
Intraclass Correlation Coefficient (ICC) analysis was applied to evaluate the reliability of measurements made by two independent observers. The Two-Way Random Effects Model was used for the analysis and calculations were based on absolute agreement. The ICC values for application of urinary catheter, sterile urine sampling and urinary catheter removal skills were very high across all groups in both pre- and post-tests, ranging from 0.988 to 1.000 (95 % CI: 0.965, 1.000; p < 0.001, indicating excellent reliability).
According to the results of the study, the socio-demographic characteristics of the students are given in
Intra- and inter-group comparisons of students’ knowledge levels regarding urinary system applications are presented in
In intragroup comparisons, there was a significant decrease in the post-test in the control group compared with the pre-test (-2.67 points; p = 0.038, d = 0.42 [95 % CI: 0.022, 0.766], moderate effect). The mean knowledge score of the ML (+31.06 points; p < 0.001; d = −2.82 [95 % CI: −3.591, −2.033], very large effect) and FL groups (+38.54 points; p < 0.001; d = −3.51 [95 % CI: −4.467, −2.535], very large effect) increased significantly (
Table 3,
The difference between the groups in the psychomotor skill levels of the students is given in
In the intragroup comparisons, no significant change was observed in the control group between the pre-test and post-test (+0.87 points; p = 0.543, d = 0.11 [95 % CI: −0.471, 0.247], very small effect). In the ML group, a significant increase was observed (+23.78 points; p < 0.001, d = −1.92 [95 % CI: −2.495, −1.321], large effect). In the FL group, the increase was even greater (+35.97 points; p < 0.001, d = −3.21 [95 % CI: −4.097, −2.306], very large effect).
Significant differences were also found between the groups in terms of pre-test and post-test measurements of nursing students' sterile urine sampling skills (post-test: p < 0.001, ω²=0.41, large effect). In the intergroup comparisons, the mean post-test score of the ML group was significantly higher than that of the control group (p < 0.001). The FL group scored significantly higher than both the control group (p < 0.001) and the ML group (p = 0.024).
In the intragroup comparisons, there was no significant change in the control group between the pre-test and post-test (+0.03 points; p = 0.961, d = 0.01 [95 % CI: −0.367, 0.349], negligible effect). A significant increase was observed in the ML group (+6.94 points; p < 0.001, d = −1.56 [95 % CI: −2.072, −1.034] large effect) and in the FL group (+9.70 points; p < 0.001, d = −2.05 [95 % CI: −2.685, −1.412], very large effect).
Similarly, significant differences were identified between the groups in terms of pre-test and post-test measurements of urinary catheter removal skills (post-test: p < 0.001, ω²=0.77, large effect). In the intergroup comparisons, the ML group had a significantly higher mean post-test score than the control group (p < 0.001), while the FL group scored significantly higher than both the control (p < 0.001) and ML groups (p < 0.001).
In the intragroup comparisons, a significant decrease was observed in the control group between the pre-test and post-test (-2.17 points; p = 0.001, d = 0.69 [95 % CI: −0.284, 1.081], moderate effect). In contrast, the ML group demonstrated a significant increase (+13.22 points; p < 0.001, d = −2.14 [95 % CI: −2.769, −1.502], large effect) and the FL group showed an even greater increase (+18.90 points; p < 0.001, d = −2.53 [95 % CI: −3.266, −1.785], very large effect) (
Table 4,
The change in students' self-efficacy levels between groups is given in
There were significant differences in the satisfaction levels of nursing students according to different learning methods (F = 53.765, p < 0.001, ɳ2 = 0.55, large effect). The mean satisfaction score of the control group was 4.87 (SD 1.48), 7.75 (SD 1.14) for the ML group and 8.43 (SD 1.61) for the FL group. Comparisons between groups were evaluated with Bonferroni test. The satisfaction level of the ML group and the FL group was significantly higher than that of the control group (p < 0.001). The difference between the ML group and the FL group was not statistically significant (p = 0.183) (
12 Discussion
In this study, the effects of FL and ML methods on students' knowledge, skills and self-efficacy level of urinary catheterization practice were examined. The results of the study were discussed with the related literature.
In this study, it was determined that the FL method increased the urinary catheterization knowledge level of nursing students statistically significantly compared with the control group. In a study examining the effect of the FL learning method on the motivation, learning strategies, urinary system knowledge and urinary catheterization skills of first-year nursing students, it was reported that the FL learning method was effective in increasing the theoretical knowledge level of the student ( Aksoy and Paslı, 2022). In another study, similar results were obtained with our study findings ( Aguilera-Manrique et al., 2022). In the literature, many studies comparing the effect of the FL method on different nursing skills with the traditional method have similar results ( Acun, 2024; Binoy, 2024; Chang and Hsu, 2024; Hwang and Chang, 2020; Kaliyaperumal et al., 2024; Lu et al., 2025; Öz and Abaan, 2021). Contrary to the results of this study, some studies also concluded that there was no significant difference in the academic achievement of students between FL and traditional methods ( El-Banna et al., 2017; Harrington et al., 2015; Holman and Hanson, 2016). The study conducted by El-Banna et al. (2017) to ensure the teaching of pharmacology involved students in an accelerated nursing licensure program. In the study, which compared FL with the traditional method, no significant difference was found between the groups' knowledge levels. It was noted that the accelerated nursing degree program, which was the sample for the study, included students who had previously completed a bachelor's or master's degree in a field other than nursing, that nursing education generally lasted 11–18 months and that at the end of this period, students graduated as registered nurses. These factors are thought to have influenced the research results. Harrington et al. (2015) found no significant difference between the knowledge level of the groups in the study where FL and traditional method were used for adult care learning in surgical nursing course ( Harrington et al., 2015). In the study, it is thought that the fact that students were divided into small groups and given additional tasks and that they came to the laboratory and increased interaction in the laboratory while doing FL was effective. The study found that the control group's knowledge scores decreased in the post-test. This result is consistent with the forgetting curve theory, which suggests that learned knowledge may be forgotten if it is not reinforced over time ( Murre and Dros, 2015). Similarly, studies in the field of health education report a decline in knowledge levels over time in control groups ( Shrestha and Shrestha, 2022). In topics such as urinary catheterization, which require both theoretical knowledge and clinical skills, the lack of reinforcement training and failure to transfer knowledge into practice may explain this decline observed in the control group. Both FL and ML were effective in increasing knowledge retention and level. Although there are different research results in the literature, according to some related literature and the results of this study, it can be said that FL is an effective method to increase the knowledge level of nursing students compared with the traditional method. Accordingly, the hypothesis “ H1a: Urinary catheterization practice education given with the FL method has an effect on the knowledge levels of nursing students.” was confirmed.
In this study, it was determined that the FL method statistically significantly increased the level of “Application of urinary catheter, Sterile urine sampling and Urinary catheter removal” among the urinary catheterization application skills of nursing students compared with the control group. In a study evaluating the self-efficacy level and skill practice of nursing students in the urinary catheterization procedure using the FL method and the traditional method, it was reported that the FL method significantly increased the skill practice level of the students compared with the traditional method ( Aguilera-Manrique et al., 2022). In another study on urinary system knowledge and urinary catheterization skills of first-year nursing students, it was reported that the learning and skill application performance and self-efficacy mean scores of the FL group were higher than the traditional method group ( Aksoy and Paslı, 2022). In studies comparing the effectiveness of FL and traditional methods on different nursing practice skill levels, the FL method was found to be statistically significantly more effective than the traditional method ( Gu and Sok, 2020; Lu et al., 2025; Wang et al., 2022). According to the related literature and the results of this study, it can be said that FL is an effective method to increase the psychomotor skill level of nursing students compared with the traditional method. Accordingly, the hypothesis "H1b: The urinary catheterization practice education given with the FL method has an effect on the psychomotor skill performances of nursing students." hypothesis was confirmed.
In this study, it was determined that the FL method statistically significantly increased the self-efficacy level of nursing students compared with the control group. In a study where FL and traditional method were used to evaluate nursing students' urinary catheterization skill practice and self-efficacy level, it was reported that FL significantly increased students' self-efficacy level compared with traditional method ( Aguilera-Manrique et al., 2022). Aksoy and Paslı also determined that the FL method statistically significantly increased the self-efficacy level of students compared with the traditional method ( Aksoy and Paslı, 2022). In studies comparing the effects of FL and traditional method on the self-efficacy level of different nursing students in the literature, it was stated that FL was more effective ( Al-Mugheed and Bayraktar, 2021; Demir Avcı et al., 2024; Dushyanthen et al., 2025; Gu et al., 2024; Schlegel et al., 2022; Yang, 2024; Yun-Su, 2024). However, in some studies, it was reported that there was no statistically significant difference between the effect of FL and traditional method on students' self-efficacy level ( Alsancak Sırakaya and Özdemir, 2018; Chiu and Liu, 2022). The fact that the studies were conducted with graduate nurses may have influenced the results, as these individuals possess different levels of clinical experience and professional knowledge compared with nursing students, which could lead to variations in outcomes. Furthermore, the lack of randomization in these studies may have prevented the control of pre-existing differences between groups, thereby reducing the internal validity of the results and potentially compromising the reliability of the findings. According to the relevant literature and the results of this study, it can be said that FL is an effective method to increase the self-efficacy level of nursing students compared with the traditional method. Accordingly, the hypothesis " H1c: The urinary catheterization practice education given with the FL method has an effect on the self-efficacy levels of nursing students." hypothesis was confirmed.
In this study, it was determined that the FL method statistically significantly increased the satisfaction level of nursing students compared with the control group. When the literature is examined, it is found that the FL method increases the satisfaction level of students ( Ashouri et al., 2018; Joseph et al., 2021; Kaliyaperumal et al., 2024).
It has been reported that the use of ML in nursing education facilitates the increase in knowledge, skills, self-efficacy and motivation as well as providing safe, evidence-based care to patients ( Achampong et al., 2018). In this study, it was determined that the ML method statistically significantly increased the urinary catheterization knowledge level of nursing students compared with the control group. It was reported that the ML method given with the mobile application developed to improve the knowledge and skills of nurses about urinary catheterization, care and management increased the urinary catheterization knowledge level of nurses ( Alex et al., 2025). In studies evaluating the effectiveness of the mobile application developed to increase the knowledge and skills of nurses about urinary catheterization, care and management, it was reported that ML statistically increased the level of knowledge ( Chuang et al., 2022; Lee et al., 2019). In the literature, in studies comparing the effect of ML and traditional method on the knowledge level of different nursing students, it was reported that ML was more effective ( Vicdan, 2019; Lee et al., 2019). According to the literature and the results of this study, it can be said that ML is an effective method to increase the knowledge level of nursing students compared with the traditional method. Accordingly, the hypothesis “ H1d: Urinary catheterization application education given with ML has an effect on the knowledge level of nursing students.” was confirmed.
In this study, it was determined that the ML method statistically significantly increased the urinary catheterization application skill level of nursing students compared with the control group. It was reported that the "Qstream" application, which was developed to improve the knowledge and skills of nurses on urinary catheterization care and management, statistically significantly increased the skill level of nurses ( Alex et al., 2025). In a study comparing the effectiveness of ML and traditional method, it was reported that there was a statistically significant difference in terms of students' urinary catheterization knowledge and skills ( Kim et al., 2017). In different studies evaluating the effectiveness of ML, it was reported that ML was effective in the acquisition of nursing skills ( Kim and Suh, 2018; O'Connor and Andrews, 2016; Thukral et al., 2014; Lee et al., 2016). However, in a study conducted to develop mobile applications to assist nursing students in their clinical education, it was reported that there was no statistically significant difference between the effect of ML and traditional method on students' skill score ( Ton et al., 2024). In the study, it is considered effective for the educator to manage the user panel within the mobile application, send notifications to students and provide reminder or warning messages to encourage them to watch the relevant course topics and videos, as well as to follow up on their progress. This active involvement by the educator may enhance students’ engagement with the application, promote consistent participation and ensure that learners fully benefit from the educational content, ultimately contributing to improved learning outcomes. According to the literature and the results of this study, it can be said that ML is an effective method to increase the psychomotor skill level of nursing students compared with the traditional method. Accordingly, " H1e: Urinary catheterization application education given with ML has an effect on psychomotor skill performances of nursing students." hypothesis was confirmed.
In this study, it was determined that the ML method statistically significantly increased the self-efficacy level of nursing students compared with the control group. Supporting the result of the study, it was determined that the mobile application developed for respiratory system applications and care increased the self-efficacy level of the students ( Yun-Su, 2024). In different studies, it was reported that ML increased the self-efficacy level of nursing students ( Kang, 2018; Kim et al., 2017; Lee and Shin, 2016). According to the literature and the results of this study, it can be said that ML is an effective method to increase the self-efficacy level of nursing students compared with the traditional method. Accordingly, " H1f: Urinary catheterization practice education given with ML has an effect on nursing students' self-efficacy levels." hypothesis was confirmed.
In this study, it was determined that ML method statistically significantly increased the satisfaction level of nursing students compared with the control group. When the literature is examined, it is seen that ML increases the satisfaction level of students ( İsmailoğlu et al., 2021; Kang, 2018; Lee and Shin, 2016; Lee et al., 2016). In a study conducted to determine the attitudes of nursing students towards ML, the satisfaction level of students with ML method was found to be moderate ( Ghafouri et al., 2024).
This study demonstrated that FL and ML methods positively influence nursing students’ knowledge, skills and self-efficacy. To strengthen these findings, further experimental studies are recommended in different areas of nursing care. In this study, it was determined that the FL method statistically significantly increased the knowledge, skills, self-efficacy and satisfaction levels of nursing students compared with the ML method. In a study comparing FL, ML, mobile flipped learning and traditional method, it was reported that FL method was more effective in increasing the knowledge level of students ( Ghafouri et al., 2024). In the same study, it was reported that FL and ML methods increased the satisfaction level of students ( Ghafouri et al., 2024). In the study, it was stated that FL and ML methods increased students' self-efficacy level ( Ghafouri et al., 2024). In another study evaluating the effectiveness of FL and ML methods, it was reported that FL increased the level of self-efficacy ( Baharum et al., 2020). As a result of this study, it was seen that the level of satisfaction with FL and ML methods was higher than the traditional method and supported the literature.
13 Limitations
One of the major challenges encountered during the research process was the simultaneous implementation of two active teaching methods. This required careful planning and additional effort on the part of the researcher, as balancing and integrating the methods without disrupting the flow of instruction proved to be demanding. Moreover, ensuring that students actively engaged with both methods added another layer of complexity. The coordination of instructional activities, alongside the need to conduct valid and reliable assessments, further increased the difficulty of the process. Another limitation of the study was the inability to employ a double-blind testing design, as the researcher was directly involved in the data collection process. The researcher’s presence in both instruction and data gathering may have introduced bias, since students were aware of the researcher’s dual role. This awareness could have influenced students’ behaviors and attitudes, thereby affecting the objectivity of the findings. ICC analysis was performed during the collection of study data to prevent bias in the data collection phase. The intervention was short-term and there was no long-term follow-up, which were another limitation of the study. Other limitation of this study is that the sample consisted exclusively of first-year undergraduate nursing students. Given the variability in curricular exposure, clinical experience and professional maturity across year levels, the findings may not be generalizable to more advanced students or to other nursing cohorts. Future research should replicate this work with participants from multiple academic years and diverse educational settings to strengthen the external validity of the findings. The results obtained are limited to the institution where the research was conducted. To ensure generalizability to different cultures and educational programs, it is recommended that broader studies be conducted. The study may involve potential risks such as students experiencing anxiety and minor injuries during the practices. To prevent any potential harm or adverse events during the study, all procedures were performed on simulators under supervision, strictly adhering to aseptic techniques and using personal protective equipment. Security measures, including data encryption and anonymization for the mobile application, were implemented and all content was reviewed and approved by experts before being presented to students.
14 Conclusion
This study was conducted to evaluate the effects of FL and ML methods on nursing students' knowledge, skills and self-efficacy levels in urinary catheterization practices. Both learning methods were effective in increasing nursing students' knowledge level of the urinary system, improving their psychomotor skills and enhancing their self-efficacy. There was a positive and significant relationship between the FL method and students' self-efficacy. Students were most satisfied with the FL model among the learning methods.
In line with these results;
• The use of the FL model in nursing education should be widespread.
• New mobile applications should be developed for the improvement of knowledge and skills in different nursing practices.
• The developed mobile application should be shared with other nursing department managers and its sustainability should be ensured to increase its use and spread.
• School administrators should be informed about the effects of FL and ML methods and should start working on integrating them into their educational programs.
• School administrators should be informed about the effects of FL and ML methods and initiate efforts to integrate them into their educational programs.
Authorship contribution statement
As the Corresponding Author, I confirm Ozan Konateke, and Hakime Aslan gathered all research data, and involved in data analysis and manuscript preparation.
CRediT authorship contribution statement
Aslan Hakime: Writing – review & editing, Writing – original draft, Visualization, Supervision, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Konateke Ozan: Writing – review & editing, Writing – original draft, Visualization, Validation, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Data curation, Conceptualization.
Funding statement
This research was supported by the Inonu University Scientific Research Projects Unit (Project number: TDK-2024–3539). We would like to thank Inonu University Scientific Research Project Unit (BAP).
This work was supported by the
Declaration of Competing Interest
The 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.
Table 1
| Flipped Learning Group Data Collection Stages | Week 12 | Week 13 | Week 14 |
| Individual Introduction Form | + | + | |
| Knowledge Test for Urinary System Practices | + | + | |
| Student Self-Efficacy Scale | + | + | |
| Urinary System Practices Skill Assessment Form | + | + | |
| In-classroom activities (Theoretical lessons) | + | + | |
| In-classroom activities (Laboratory application) | + | + | |
| Teaching Methods Assessment Form | + | ||
| Mobile Learning Group Data Collection Stages | |||
| Individual Introduction Form | + | + | |
| Knowledge Test for Urinary System Practices | + | + | |
| Student Self-Efficacy Scale | + | + | |
| Urinary System Practices Skill Assessment Form | + | + | |
| Teaching with mobile applications | + | + | + |
| Teaching Methods Assessment Form | + | ||
| Control Group Data Collection Stage | |||
| Individual Introduction Form | + | + | |
| Knowledge Test for Urinary System Practices | + | + | |
| Student Self-Efficacy Scale | + | + | |
| Urinary System Practices Skill Assessment Form | + | + | |
| Teaching with mobile applications | + | ||
| Teaching Methods Assessment Form | + |
Table 2
| Groups | Test
Significance | |||
|
Control
group (n = 30) |
ML
group (n = 32) |
FL
group (n = 30) | ||
| Quantitative Features | ±SD | ±SD | ±SD | |
| (Min.-Max.) | (Min.-Max.) | (Min.-Max.) | ||
| Age | 19.87 ± 1.22 | 19.69 ± 0.93 | 19.47 ± 0.82 | F= 1.194 |
| 18–22 | 18–22 | 18–21 | p = 0.308 | |
| GPA | 3.47 ± 0.57 | 3.56 ± 0.50 | 3.50 ± 0.63 | F= 0.228 |
| 2–4 | 3–4 | 2–5 | p = 0.797 | |
| Qualitative Features | n (%) | n (%) | n (%) | |
| Gender | ||||
| Female | 19 (63.3) | 18 (56.3) | 20 (66.7) | ꭓ 2= 1.502 |
| Male | 11 (36.7) | 14 (43.8) | 10 (33.3) | p = 0.064 |
| School of graduation | ꭓ
2= 1.844
p = 0.241 | |||
| Anatolian high school | 21 (70.0) | 22 (68.8) | 20 (66.6) | |
| Science high school | 5 (16.7) | 6 (18.7) | 5 (16.7) | |
| Different undergraduate program | 3 (10.0) | 4 (12.5) | 5 (16.7) | |
| Daily phone usage duration | ||||
| 1–3 h | 13 (43.3) | 10 (31.3) | 6 (20.0) | ꭓ 2= 5.701 |
| 4–5 h | 13 (43.3) | 16 (50.0) | 14 (46.7) | p = 0.223 |
| 6 h and above | 4 (13.3) | 6 (18.8) | 10 (33.3) | |
| Is active learning used during your education? | ||||
| Yes | 24 (80.0) | 29 (90.6) | 27 (90.0) | ꭓ 2= 1.905 |
| No | 6 (20.0) | 3 (9.4) | 3 (10.0) | p = 0.386 |
| How satisfied are you with the active teaching methods? | ||||
| Satisfied | 24 (80.0) | 17 (53.1) | 21 (70.0) | ꭓ 2= 5.227 |
| Partially satisfied | 6 (20.0) | 15 (46.9) | 9 (30.0) | p = 0.073 |
| Do you use mobile applications for your education? | ||||
| Yes | 9 (30.0) | 5 (15.6) | 4 (13.3) | ꭓ 2= 2.516 |
| No | 11 (36.7) | 15 (46.9) | 16 (53.3) | p = 0.414 |
| Sometimes | 10 (33.3) | 12 (37.5) | 10 (33.3) |
Table 3
| Measurements | |||||||
| Pre-test | Post-test | Intra-group comparison | |||||
| Groups | n | ±SD | ±SD | t | p | d | 95 % CI
(L/U) |
| Test score | |||||||
| Control group 1 | 30 | 41.27 ± 9.26 | 38.60 ± 6.61 | 2.176 | 0.038 | 0.42 | 0.022/0.766 |
| ML group 2 | 32 | 36.38 ± 9.72 | 63.44 ± 5.58 | −15.934 | < 0.001 | −2.82 | −3.591/−2.033 |
| FL group 3 | 30 | 37.33 ± 11.90 | 75.87 ± 5.89 | −19.202 | < 0.001 | −3.51 | −4.467/−2.535 |
| Test | F= 1.082 | F= 314.705 | |||||
| Significance | p = 0.441 | p < 0.001 | |||||
| Effect size | ɳ 2= 0.00 | ɳ 2 = 0.88 | |||||
| Difference | 2 > 1; p < 0.001 | ||||||
| 3 > 1; p < 0.001 | |||||||
| 3 > 2; p < 0.001 |
Table 4
| Psychomotor | Measurements | ||||||
| Skills | Pre-test | Post-test | Intra-group comparison | ||||
| Groups | n | ±SD | ±SD | t | p | d | 95 % CI (L/U) |
| Application of urinary catheter | |||||||
| Control group 1 | 30 | 53.10 ± 9.03 | 53.97 ± 8.77 | −0.616 | 0.543 | 0.11 | −0.471/0.247 |
| ML group 2 | 32 | 51.63 ± 12.85 | 75.41 ± 17.19 | −10.825 | < 0.001 | −1.92 | −2.495/−1.321 |
| FL group 3 | 30 | 51.30 ± 10.67 | 87.27 ± 6.19 | −17.562 | < 0.001 | −3.21 | −4.097/−2.306 |
| Test | F= 0.229 | W= 142.671 | |||||
| Significance | p = 0.796 | p < 0.001 | |||||
| Effect size | ɳ 2= 0.01 | ω 2 = 0.57 | |||||
| Difference | - | 2 > 1; p < 0.001 | |||||
| 3 > 1; p < 0.001 | |||||||
| 3 > 2; p = 0.002 | |||||||
| Sterile urine sampling | |||||||
| Control group 1 | 30 | 23.00 ± 4.76 | 23.03 ± 5.81 | −0.050 | 0.961 | 0.01 | −0.367/0.349 |
| ML group 2 | 32 | 23.22 ± 4.36 | 30.16 ± 5.95 | −8.819 | < 0.001 | −1.56 | −2.072/−1.034 |
| FL group 3 | 30 | 24.00 ± 4.79 | 33.70 ± 3.08 | −11.254 | < 0.001 | −2.05 | −2.685/−1.412 |
| Test | F= 0.388 | W= 39.545 | |||||
| Significance | p = 0.680 | p < 0.001 | |||||
| Effect size | ɳ 2= 0.01 | ω 2 = 0.41 | |||||
| Difference | - | 2 > 1; p < 0.001 | |||||
| 3 > 1; p < 0.001 | |||||||
| 3 > 2; p = 0.024 | |||||||
| Urinary catheter removal | |||||||
| Control 1 | 30 | 26.57 ± 4.83 | 24.40 ± 4.60 | 3.765 | 0.001 | 0.69 | 0.284/1.081 |
| ML 2 | 32 | 27.47 ± 5.06 | 40.69 ± 7.45 | −12.113 | < 0.001 | −2.14 | −2.769/−1.502 |
| FL 3 | 30 | 29.03 ± 7.55 | 47.93 ± 2.79 | −13.865 | < 0.001 | −2.53 | −3.266/−1.785 |
| Test | W= 1.137 | W= 283.785 | |||||
| Significance | p = 0.328 | p < 0.001 | |||||
| Effect size | ω 2= 0.01 | ω 2 = 0.77 | |||||
| Difference | - | 2 > 1; p < 0.001 | |||||
| 3 > 1; p < 0.001 | |||||||
| 3 > 2; p < 0.001 |
Table 5
| Measurements | |||||||
| Pre-test | Post-test | Intra-group comparison | |||||
| Groups | n | ±SD | ±SD | t | p | d | 95 % CI (L/U) |
| Self-efficacy scale | |||||||
| Control group 1 | 30 | 27.47 ± 3.69 | 27.80 ± 2.28 | −0.448 | 0.658 | 0.08 | −0.439/0.277 |
| ML group 2 | 32 | 27.09 ± 3.54 | 34.72 ± 3.39 | −14.908 | < 0.001 | −2.64 | −3.369/−1.891 |
| FL group 3 | 30 | 27.00 ± 2.89 | 35.97 ± 2.85 | −17.254 | < 0.001 | −3.15 | −4.027/−2.263 |
| Test | F= 0.159 | W= 89.121 | |||||
| Significance | p = 0.853 | p < 0.001 | |||||
| Effect size | ɳ 2= 0.00 | ω 2 = 0.60 | |||||
| Difference | - | 2 > 1; p < 0.001 | |||||
| 3 > 1; p < 0.001 |
Table 6
| Test | ||||
| Groups | Measurements | Significance | Self-efficacy | 95 % CI (L/U) |
| Control group | Test score | r | −0.234 | −0.548/0.138 |
| p | 0.213 | |||
| ML group | Test score | r | −0.126 | −.0455/0.233 |
| p | 0.491 | |||
| FL group | Test score | r | 0.559* | 0.249/0.765 |
| p | 0.001 |
Table 7
| Groups | n | F | p | ɳ 2 | Difference | |
| Control group 1 | 30 | 4.87 ± 1.48 | 53.765 | p < .001 | 0.55 | 2 > 1; p < 0.001 |
| ML group 2 | 32 | 7.75 ± 1.14 | 3 > 1; p < 0.001 | |||
| FL group 3 | 30 | 8.43 ± 1.61 |
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