Investigating the effectiveness of Case-Based Technology-Enhanced workshops (e-Flipped vs. Online) among health worker nurses during the COVID-19 pandemic

Abstract

Aim

This study aimed to compare the efficacy of e-flipped and online case-based workshops on the nurses' knowledge, attitude and behaviour regarding thalassemia during the COVID-19 pandemic.

Design

A pre-test–posttest interventional study was conducted with two intervention groups and a control group.

Methods

One hundred and fifty nurses were recruited from comprehensive urban health centres in June–December 2020. The nurses were randomly allocated to one of the three groups: case-based e-flipped workshop (n = 50), case-based online workshop (n = 50) and control (n = 50). A researcher-made questionnaire was completed by eligible subjects at baseline, after the end of the training sessions and 4 weeks after interventions to assess their knowledge, attitude and behaviour. Data were analysed in IBM SPSS v16.0. ANOVA and Tukey's post hoc tests were used to compare the three groups.

Results

The mean knowledge, attitude and behaviour scores in the intervention groups increased significantly more than that in the control group (p < .001). One week and 4 weeks following the intervention, the mean score of knowledge, attitude and behaviour in the e-flipped group was greater than that in the online group (p < .001). According to the results, e-flipped and online case-based workshops can improve nurses' knowledge, attitude and behaviour regarding thalassemia.

INTRODUCTION

Thalassemia, which is very common in Iran, is considered one of the most common inherited diseases globally (Ansari-Moghaddam et al., 2018). In recent years, one of the major concerns of the healthcare system is providing effective educational programs for preventing and controlling thalassemia in people.

Training nurses can increase their knowledge, attitude and skills more efficiently in developing educational interventions for people referring to health centres (Sarayloo et al., 2019).

The COVID-19 pandemic from the last months of 2019 profoundly influenced the world's teaching strategies (Guraya, 2020). After the pandemic commenced, all in-person education was transformed into technology-enhanced learning strategies (Zayapragassarazan, 2020). Although the technologies have provided many benefits and opportunities, developing appropriate training strategies is a significant challenge (Samadbeik et al., 2020). In recent decades, learning approaches have evolved by utilizing and integrating active and interactive learning approaches such as workshop and case-based methods. The workshop efficiently enables group discussion and interactions between teachers and learners and enhances learning (Spicer et al., 2021). Research has shown that developing workshops based on a case-based approach multiplies their quality. This method confronts learners with their actual job situation, provides analysis and decision-making opportunities (Berta et al., 2020) and enhances nurses’ in-depth group learning, intrinsic motivation and mastery learning, attitudes and skills (Ignacio & Chen, 2020).

In this approach, the teacher, as a facilitator, initiates the learning process by providing a scenario and encouraging learners to participate in the learning process actively. After the discussion, participants spend enough time identifying the problem, discovering the related topics and strengthening high-level learning and skills (Ansari-Moghaddam et al., 2018).

Nowadays, nursing education utilizes new technologies to flexibly train students and workers in terms of time, place and speed of learning (Schuler et al., 2021). Research has shown that integrating case-based workshops with proper technologies increases the effectiveness of these methods (Kan et al., 2020). One of the most effective technology-enhanced learning strategies is flipped classroom combining individual and group learning. The educational content is provided outside the school using different technologies to promote self-directed learning (Strelan et al., 2020). Furthermore, the time inside the classroom is spent on group learning activities. Thus, besides flexibility of time, place and learning speed, integrating case-based workshops with flipped classrooms promotes higher learning and interaction levels between learners and teachers (Biewald et al., 2021).

Some experts believe that a case-based blended workshop is a practical approach for fostering critical thinking and problem-solving skills (Yu et al., 2021) and interpersonal communication, as well as applying the learned theoretical knowledge in real situations (Weng et al., 2019; Zayapragassarazan, 2020). However, unlike the results in some other studies, no significant difference was reported between online and flipped classrooms (Garcia-Vedrenne et al., 2020; Ohtake et al., 2018; Shiau et al., 2018). On the other hand, the case-based flipped workshop has been less emphasized and considered in the education of health worker nurses (Pilcher, 2019).

Traditionally, flipped learning has been used to describe the combination of online and face-to-face education. Given the sudden shift from traditional to online education during the coronavirus pandemic, flipped learning integrated with online teaching developed a new learning paradigm known as the “e-flipped model” that improves the effectiveness of the online approach (Guraya, 2020).

Given that most health professionals provide primary care and community services, practical training based on technology can lead to increased quality of services to prevent and control certain diseases such as thalassemia during the COVID-19 pandemic. In addition, no research has been done on educating healthcare nurses in thalassemia education at the Shiraz University of Medical Sciences (SUMS), and an information gap is felt in this field. As a result, the present study was conducted to compare the effect of the case-based workshop with e-flipped-classrooms and online approaches in healthcare nurses.

METHODS Study design

The present pre-test–posttest interventional study was conducted on two intervention groups (case-based workshops through e-flipped and online methods) and a control group (no intervention).

Participants

Nurses working as healthcare professionals at comprehensive urban health service facilities affiliated with 0000 during the period June–December 2020, with a bachelor's degree in nursing, willing to participate and completion of an informed consent form met the inclusion criteria. Data from those who dropped out and those who went on a willingness of absence during the research were deleted.

Teaching interventions in two interventions and a control group

This intervention included developing educational content, selecting a strategy and implementing two intervention and control groups. Both intervention groups were trained in case-based workshops (e- flipped and online methods), and the control group did not receive any training. A professor of haematology and a nurse specializing in medical education with 15 years of work experience in this field were responsible for training nurses about beta-thalassemia, prevention, and treatment in the intervention groups.

Intervention group 1: Case-based e-flipped workshop

All nurses in this group undertook the case-based e-flipped workshop based on theories of constructivism, self-directed, active learning and multimedia learning, which believe that the learner actively builds knowledge by interacting with others and with content (Fary et al., 2015; Tuma, 2021).

The overall purpose of teaching this topic was to increase the knowledge, attitude and behaviour required by nurses about thalassemia. The educational content was taken from the educational booklet, videos and animations about preventing thalassemia prepared by Iran's Ministry of Health and Medical Education.

The multimedia content was delivered through the participants' WhatsApp, providing asynchronous and self-directed learning. The average duration of the educational content was 30 minutes, and participants had 2 weeks to study the content. Subsequently, two 25 groups were designed in WhatsApp for better management of group discussions. Within the next 4 weeks, eight scenarios of clinical conditions were presented to the group, following the learning objectives. The role of the instructor was as a facilitator, providing the necessary guidance to nurses and trying to encourage all of them to participate in the discussion. The instructor summarized the training material on the fourth day, expressed the solution to the problems raised, and answered the participants' questions. In addition, the supplementary training content was sent to the group in the form of audio podcasts, videos, and short animations. In the next stage, the group underwent two 1-hr online workshops in the following weeks. In these sessions, the training materials were summarized, and the participants' questions were answered. Immediately after the end of the training sessions, the participants completed the questionnaire, and 4 weeks later the same questionnaire was sent to the participants again.

Intervention group 2: Case-based online workshop

The workshops using scenarios of clinical conditions were created to provide teachers and nurses with an opportunity to clarify thalassemia. Pedagogical approaches included the theories of constructivism and active learning. For 8 weeks, eight 2-hr online workshops were held in two groups of 25 nurses through the Adobe Connect platform. Following the learning objectives, a scenario involving clinical situations and strategic questions was given in each workshop. After setting up five Adobe Connect Breakout rooms, nurses held small groups to discuss the scenario and answer the questions. At this point, the professors served as facilitators, providing participants with essential guidance and encouraging them to join in the discussion. The instructor supplemented the supplied cases with extra material via PowerPoint and instructional films and summarized the contents in the subsequent stage. The topics covered in intervention group 1 were educational in nature, and both groups were taught by the same instructor.

The Wait-list control group

In the control group, no intervention was carried out. It is worth mentioning that at the end of the study, the instructional information in the form of a booklet was made accessible to the control group.

There was no unexpected change in this educational intervention, and the intervention was carried out according to the plan. Moreover, the initial content, case study educational strategy, and teaching professors were the same in the intervention and control groups.

Data collection tools

The nurses' knowledge, attitude, and behaviour regarding thalassemia were evaluated at baseline, after the training sessions (the end of the eighth week), and 4 weeks later in the intervention and control groups. Initially, online questionnaires were provided through WhatsApp to eligible nurses 24 hr after completing the informed consent form. Participants who did not return the questionnaires were contacted and encouraged to do so. Notably, only one follow-up effort per participant was undertaken.

The data collection tool consisted of two sections, the first of which dealt with demographic details (age, marital status, education level, employment status, and work experience). The second section included a 34-researcher-made questionnaire for assessing nurses' knowledge, attitude, and behaviour to prevent thalassemia as follows. It should be noted that because all nurses were women, the gender option was not raised.

Knowledge

In this dimension, healthcare nurses' knowledge of thalassemia was measured, including ten four-option questions. Each correct answer scored one point, an incorrect answer zero, and a total score between 0 and 10 points.

Attitude

In this dimension, nurses' attitudes toward the importance of family awareness in preventing thalassemia, the role of nurses in preventing thalassemia, the importance of thalassemia training time, and attitude toward different educational methods were measured. It included nine questions based on a five-point Likert scale, from totally agree (five points) to totally disagree (one point), with a total score between nine and 45.

Behaviour

The behaviour of caregivers in training target groups, practical training, and effective communication with carrier couples and couples covered by prevention programs were assessed in this dimension. It consisted of 15 questions on a 5-point Likert scale, ranging from always (five points) to never (one point), with a possible total score of 15–75 points. Also noteworthy is that individuals took approximately 15 min to complete the questionnaire.

Validity and reliability

For the face and content validity of the questionnaire, we enlisted the help of 20 medical educators, and nursing and haematological specialists. Face validity was established by looking at the syntax and relevant words used. The “simplicity,” “relevance” and “clarity” of the knowledge section's questions were evaluated. Experts were tasked with evaluating the relevance of each attitude and behaviour item on a 6-point Likert scale, and the “Impact score” was calculated using the technique outlined below.

Impact score = Frequency (%) × importance.

The Content Validity Index (CVI) and the Content Validity Ratio (CVR) were approved, with the CVI being 0.84 and the CVR being 0.75, respectively. Confirmatory factor analysis was used to determine the construct validity in SMART-PLS version 3.2.4. Goodness-of-fit criteria were evaluated in terms of reliability, Convergent validity and discriminant validity. Using the test–retest method, the reliability of items linked to the knowledge part was ICC = 0.73 among 60 nurses with 2-week intervals which were not included in the study. Cronbach's alpha was used to validate the attitude and behaviour sections, yielding 0.81 and 0.79 for attitude and behaviour, respectively. The composite reliabilities of all constructs were greater than 0.70. The average Variance Extracted was found 0.51 in attitude, and 0.50 in behaviour dimensions, demonstrating appropriate convergent validity. Finally, the Fornell-Larcker test proved Divergent validity.

Randomization

The study population consisted of all nurses who worked in 21 comprehensive urban health service centres of SUMS (n = 550). The sample size considering a type I error rate of 0.05, power of 0.80, and the probability of dropout using the following formula was 150 nurses. Randomization of health centres was performed to minimize the risk of contamination between intervention and controls and controls and recruitment bias. The risk of contamination was decreased because the nurses in the intervention and control groups worked in different health centres and were not in contact with each other. Therefore, the samples were not aware of which groups they were in, both in the intervention and the control groups.

Twenty-one comprehensive urban health service centres were divided into three groups by the cluster randomization method so that the names of the centres were written on paper. Then seven first centres were randomly selected as the control group, seven-second centres as the first intervention group and seven-third centres as the second intervention group. Then, by the systematic method in the control group (144 people), number 2 was selected as the first sample, and then one out of every four people was chosen to increase the number of pieces to 50.

In intervention group 1, we divided the number of groups (n = 240) into 50, and one out of every four people was selected to increase the number of samples to 50. The population of the second intervention group was 166 people; after being divided into 50, one out of every three people was selected, and the samples reached 50.

An uninvolved assistant researcher performed the randomization.

Statistical methods

The data were examined using descriptive and analytical statistical tests in IBM SPSS v16.0.

To compare the three groups, one-way analysis of variance and Tukey's post hoc test were employed, and repeated measures ANOVA was utilized to examine the temporal trend in the groups. The significance threshold was set at a p-value < .05.

Ethical consideration

The study began once it was authorized by the SUMS local ethics committee (decree code: IR.SUMS.REC.1399.354). In the first meeting, the study objectives were presented to the participants, and signed informed permission was acquired. To ensure anonymity, no names were put on the surveys, and completed questionnaires were decoded by a research assistant to avoid any mistakes. To adhere to ethical norms, participants were guaranteed their voluntary involvement and the right to withdraw at any moment.

FINDINGS

The study lasted between June and December 2020. All the randomized participants completed the baseline and the follow-up assessment (Figure 1). Participants' demographic characteristics are shown in Table 1.

FIGURE 1. The participants’ recruitment flow diagram

TABLE 1 Demographic characteristics of nurses among different workshop groups.

[Table omitted. See PDF]

Participants' demographic characteristics are shown in Table 1.

The chi-square test results did not show a significant difference between the three groups regarding demographic characteristics such as age (p = .08), marital status (p = .97), job status (p = .76), education (p = .99) and work experience (p = .64). The participants (n = 150) in the intervention and control groups were matched.

Knowledge score

The scores were compared between the three groups using a one-way analysis of variance and Tukey's post hoc test, while within-group comparisons were done using repeated measures analysis of variance (Table 2).

TABLE 2 Between and within-group comparison of the case-based workshop (e-flipped and online) and control groups.

Variables	Groups	Pre-testa	Posttesta	Follow-upa	p-Valueb
Knowledge	Control	4.4 ± 1.14	4.48 ± 1.14	4.28 ± 1.57	.389
	Online workshop	4.34 ± .1.93	7.7 ± 1.93	8.28 ± 1.93	<.001
	e-Flipped workshop	4.10 ± 01.57	8.71 ± 1.19	8.95 ± 0.92	<.001
	F	0.49	168	3.97	–
	Between-group comparison P-value	0.608	<0.001	0.021	–
Attitude	Control	28.16 ± 2.11	27.76 ± 2.23	27.90 ± 2.38	.126
	Online workshop	28.60 ± 3.43	29.64 ± 4.70	30.16 ± 5.20	<.001
	e-Flipped workshop	27.56 ± 2.94	38.78 ± 1.88	37.42 ± 2.42	<.001
	F	1.64	155.19	91.77	–
	Between-group comparison p-value	0.20	<0.001	<0.001	–
Behaviour	Control	49.59 ± 2.7	47.61 ± 3.06	46.02 ± 2.5	˂.001
	Online workshop	49.94 ± .3.12	53.88 ± 3.11	59.96 ± 3.47	<.001
	e-Flipped workshop	49.02 ± 02.60	54.73 ± 3.13	64.37 ± 4.17	<.001
	F	1.339	75.5	84.2	–
	Between-group comparison p-value	0.265	<0.001	<0.001	–

a

Based on ANOVA test.

b

Based on repeated measurement tests.

The knowledge score in the online and e-flipped workshops was significantly higher than that in the control group (no intervention) a week later (p < .001) and 4 weeks later (p = .02). Based on the repeated measure analysis, both instructional approaches influenced the nurses' knowledge, although the e-flipped workshop had a slightly greater increase in mean score than the online group (Table 2).

Attitude score

As can be seen in Table 2, there was no significant difference between the groups' attitude scores before the intervention (p = .20). However, the attitude score in the intervention groups was significantly higher than that in the control group (no intervention) a week later and 4 weeks after the intervention (p < .001). At the same time, the attitude level in the e-flipped workshop was considerably higher than in the online workshop group (p < .001).

Behaviour score

Based on one-way analysis of variance test and in-group analysis, it was observed that the trend of changes in the control group was significantly decreasing, while in both intervention groups, the trend of changes in behaviour score was considerably increasing, among which the e-flipped workshop scores showed the most increase. Therefore, both e-flipped and online workshop methods significantly affected the nurses' behaviour, but the e-flipped ones had a more significant effect (p < .001) (Table 2).

It should be noted that the researchers investigated the relationship between demographic characteristics, such as age, education, marital status, employment status and work experience, with their posttest knowledge, attitude and behaviour, but no significant relationship was observed.

DISCUSSION

The purpose of this study was to assess the efficacy of e-flipped and online case-based workshops on nurses' knowledge, attitude and behaviour regarding thalassemia to determine which was more effective. According to the findings, case-based workshop (both e-flipped and online) methods increased nurses' knowledge, attitude and behaviour towards thalassemia. The e-flipped approach, on the other hand, had a more significant impact on improving learning, attitude, and behaviour. The findings also indicate that the retention rate after 4 weeks was significant in both groups and somewhat higher in the e-flipped group.

The result of the present study is consistent with similar results regarding the effects of the blended case-based approach on clinical decision-making, on knowledge and skills (McPherson & MacDonald, 2017), on learning and self-efficacy (Shinnick & Woo, 2013) and health skills training (Hussain et al., 2019) in health students. The results revealed that this approach could enhance students' clinical knowledge and skills by improving flexible, collaborative learning and providing effective feedback.

On the other hand, some studies showed the same effectiveness for flipped and online methods in patients' quality of life (Sajjad et al., 2016) and physiotherapy students learning (Shead et al., 2020). According to some experts, effectiveness is very closely related to the appropriate educational strategies. Therefore, the online or blended delivery methods alone do not make a difference in the audience's learning (Zayapragassarazan, 2020).

In the present study, the educational strategy was based on case-based workshops in both intervention groups, one of the active and interactive learning methods (Nielsen, 2016). In addition, the purpose of holding online workshops was to improve group discussion about the case presentation. In this regard, the relevant cases were first introduced, and then the nurses discussed them. Therefore, there was a very high level of cooperation and interaction between the participants. One of the strengths of online workshops that cannot be ignored is the close relationship between students and the teacher, filling knowledge gaps.

On the other hand, learners in the e-flipped group were able to learn in a flexible manner, both in terms of time, place and speed, utilizing multimedia content. Multimedia with the right combination of media such as text, shape, image, video and audio is very attractive for learners with different learning styles, draws their attention to educational content, and enhances interaction with the content and the learner in the educational process (Sebelas & Rejekiningsih, 2020; Vu et al., 2022). In addition, by creating a case-based group discussion on one social network, interaction with other participants was strengthened. Finally, by holding online workshops, the learners' questions were answered and summarized. This method supports learners' interaction with the content, colleagues and teacher. Using various teaching methods meets learners' expectations with different learning preferences and increases their attitude towards educational content (Zhu et al., 2020). It also allows learners to learn at their own time, place and learning speed (Shiau et al., 2018). Learners can gain mastery of a piece of information or skill via practice and repetition in this manner.

Perhaps for this reason, despite the effectiveness of both methods, the scores in the e- flipped group were somewhat higher. In this regard, case-based e-flipped workshops can improve learners' level of knowledge, attitude and behaviour.

In light of the study's limitations, it is recommended that future research compare case-based e-flipped workshops to case-based online workshops over a more extended period and with a larger sample size in order to obtain a more accurate measurement of the level of knowledge, attitude and behaviour among health worker nurses.

CONCLUSION

Given that nurses have an essential role in thalassemia prevention, practical training of nurses in this field can lead them to greater efficiency. The findings of the present study showed that the thalassemia prevention program in a case-based workshop through online and e-flipped methods could increase healthcare nurses' knowledge, attitudes and behaviours.

Overall, the level of learning and retention in this study was higher in the e- flipped group than in the online workshop; therefore, a case-based e- flipped workshop is recommended for better learning and retention of materials.

AUTHOR CONTRIBUTIONS

NZ, RS and ZK devised the study concept, designed the study, supervised the intervention, data collection and analysis, coordinated the research and critically revised the manuscript. NZ, RS and LK collected data, ran the study intervention, participated in the study concept, performed the analyses and revised the manuscript. HR participated in developing the questionnaires and statistical analysis of the data. All authors have read and approved the content of the manuscript.

All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/)]:

• Substantial contributions to conception and design, acquisition of data or analysis and interpretation of data;
• Drafting the article or revising it critically for important intellectual content.

ACKNOWLEDGEMENTS

This article was the result of a master's thesis research project at Shiraz University of Medical Sciences. We are grateful to the Shiraz University of Medical Sciences (SUMS) research counsellor for supporting this study and the Clinical Research Development Centre of SUMS for the statistical analysis. We also wish to thank Dr. Mohsen Rastegar for his honest cooperation and guidance in training nurses and for help in conducting the present study.

FUNDING INFORMATION

The authors would like to thank the Vice-chancellor of Research at Shiraz University of Medical Sciences, Shiraz, Iran for their financial support (grant no. 354).

CONFLICT OF INTEREST

None declared.

ETHICAL APPROVAL

The present study was approved by the ethics committee of Shiraz University of Medical Sciences (decree code: IR.SUMS.REC.1399.354). The basis and necessary information about the study objectives and method were given to all participants before the commencement of the study, and the written informed consent were obtained from them. Participants were assured of the confidentiality of data and that only general statistics would be presented.