Effectiveness of flipped teaching on the knowledge and self-efficacy of nursing personnel in non-pharmacological pain management-aromatherapy: a quasi-experiment

Pain is one of the most common medical issues for patients. Lack of pain relief does not only lead to physical imbalance but also affects the daily life, sleep, mood, and quality of life of patients, which is detrimental to patient recovery [1]. Pain management is divided into two categories, drug treatment and non-drug treatment. Many studies have listed non-drug pain countermeasures as necessary and that they can reduce the dosage of painkillers and improve patients’ anxiety and depression to achieve patient-centered holistic pain care. As a non-pharmacological pain management method, aromatherapy features convenience and few side effects [2, 3]. Aromatherapy refers to the use of essential oils to prevent and treat diseases through the uptake of these oils via the olfactory organs or skin. Through massage, bathing, inhalation, spraying, and other methods, essential oils enter the human body to generate positive emotions and activate the inborn self-healing capacity of humans, thereby relieving mental stress and improving physical health [3]. Many studies have indicated that aromatherapy could be combined with traditional therapy in pain treatment. Aromatherapy is suitable for various types of pain, such as pain from obstetric, gynecological, musculoskeletal, and neurological diseases and from surgery [4‐8]. In aromatherapy, appropriate essential oils are often chosen for different causes of pain and are combined with massage for relaxation; their pleasant smell can also help relieve chronic pain [9]. Aromatherapy has been shown to be applicable in medical care. To integrate the safe application of aromatherapy into nursing practice, its knowledge and application must be incorporated into nursing education. However, aromatherapy-related courses have not been universal in nursing schools in Taiwan, with only the introduction of aromatherapy included in the section of pain care assessment and management [10]. A previous study has indicated that nursing staff generally have insufficient knowledge on aromatherapy, and this significantly correlated with the attitude toward aromatherapy. On this basis, the authors have suggested that nursing staff be provided with education and training to provide them with relevant knowledge regarding the correct use of essential oils related to aromatherapy [11]. In addition, although previous pain management training for nursing staff used to be carried out with a unidirectional teaching approach, related literature has mentioned that this should be strengthened with case discussions or simulation practices to enhance learning effectiveness. Therefore, “flipped learning” has been introduced into the in-service education of nursing staff.

The concept of flipped teaching originated in the United States [12]. In flipped teaching, students read the teaching materials provided by the instructors before a class and write down key points or questions. The classroom is changed from the traditional one-way teaching to student-centered two-way learning activities such as discussions, debates, group discussions, and case reports. The instructors motivate the students, answer questions, clarify confusions, etc. in the classroom to help students establish correct concepts, stimulate thinking, guide them in problem-solving, and encourage students in knowledge application [13]. The four pillars of flipped learning are F (Flexible learning environments), L (Learning culture), I (Intentional content), and P (Professional educator) [14]. Multiple domestic and foreign studies have utilized flipped learning in nursing education and demonstrated that it can promote positive responses in cognition, skill, attitude, self-efficacy, and learning satisfaction [15, 16]. The flipped learning is an opportunity for increased contact time between faculty and students. Learners clarify and apply previous learning, connect this learning to clinical case scenarios, and apply classroom teachings to their work in the clinical setting. In addition, a “flipped classroom” can spark interest in higher education and offer a student-centered learning approach, which satisfies the existing needs of nursing staff and improves their learning motivation. This teaching method is consistent with the requirements for clinical nurses [12, 17, 18]. Many domestic and foreign studies have applied flipped teaching in nursing education, which includes all nursing fields [15].

Self-efficacy is a core concept proposed by the American psychologist Bandura as a part of the social cognitive theory in 1982. It refers to an individual’s belief in his or her capacity to execute behaviors necessary to produce specific performance attainments, and it is an important factor in maintaining or changing one’s health behaviors. Self-efficacy emphasizes that, while relevant knowledge and skills are necessary, an individual must also have adequate self-confidence and believe that they have the capacity to carry out relevant behaviors in order to do so [19]. Self-efficacy can be affected by four factors, namely, past performance, vicarious experiences, verbal persuasion, and physiological cues [20]. Various studies on learning and self-efficacy have verified that the latter can affect an individual’s learning motivation and behavior [21]. Therefore, improving nurses’ self-efficacy can make them believe that they are motivated and skilled; thus, they will act on achieving their goals. On the contrary, individuals with low self-efficacy tend to expect negative results, which leads to declining learning motivation, passive learning, and the inability to use resources to take necessary action. Self-efficacy is the decisive factor in determining one’s behavior motivation and can be escalated by past performance, vicarious experiences, verbal persuasion, or physiological cues. Consequently, the integration of these four elements into education and training courses will inspire nursing staff to perform specific nursing behaviors and improve their self-efficacy therein.

There have been many studies on the application of aromatherapy in clinical care, especially in pain management [3]. However, few studies have investigated aromatherapy education for nursing personnel in Taiwan [22]. Only one study investigated the learning outcomes of 2–3-year college students in applying essential oil preparations in aromatherapy for primary dysmenorrhea through problem-based learning curriculum design [23]. Therefore, the purpose of this study was to apply the flipped teaching approach to design teaching and training courses in aromatherapy for nursing personnel and to explore the effectiveness of the method among nursing personnel, which may serve as a reference for nursing schools or medical institutions to plan future teaching and training courses in aromatherapy.

This study found that only 28.8% of the participating nursing staff had received education and training on aromatherapy, and only 11.3% had previous experience in personally using aromatherapy to manage their pain. This result is similar to the findings of Laio et al. [10], who mentioned that only 32.3–36.6% of nurses received related education and training from school or workplace, and only 28.1% used aromatherapy themselves. Therefore, insufficient education on aromatherapy is currently provided by nursing schools or clinical nursing education courses. Aromatherapy was introduced in Taiwan in the late 1980s. Although many studies have confirmed the effectiveness of aromatherapy in treating pain and that it is one of the adjuvant therapies available to nursing personnel clinically, aromatherapy has not yet been included in formal nursing education, and nursing personnel are not familiar with aromatherapy. Therefore, aromatherapy teaching and training should be planned and promoted in the future so that nurses can assist patients in receiving appropriate aromatherapy during clinical care [3, 22, 25].

This study integrated a systematic literature review to design the teaching plan for the flipped teaching course [26]. Along with students’ self-learning of the prerequisite knowledge of aromatherapy before class, group discussions were also included in the course design to clarify concepts and share personal experiences of aromatherapy in life or work, which may deepen the students’ understanding of aromatherapy and promote their motivation to use it. During the class, the lecturer prepared over ten kinds of essential oils commonly used for different types of pain so that students could smell the essential oils themselves, which deepened their understanding and memory of different essential oils. Case discussion using mind mapping may help to summarize the systemic problems of the case in combination with the use of essential oils. Additionally, the group discussion may help the students brainstorm to acquire the ability to treat patients using aromatherapy. As previous investigators have reported, group learning in nursing education is a commonly used teaching method in a flipped classroom, and group learning motivates students to learn. Classroom discussions were aimed to solve clinical problems students may face in the future and develop their professional skills, thereby improving their clinical care capacity and critical thinking skills [27]. Finally, each student was asked to develop DIY essential oils according to various pain conditions, to enhance their self-efficacy in aromatherapy.

The results of this study indicated that the post-test scores of the experimental group were not only higher than pre-test scores, but also higher than the post-test scores of the control group, the differences of which were statistically significant. The fact that the post-test self-efficacy of the experimental group was substantially higher than that of the control group suggests that the perceived capacity of the experimental group for performing aromatherapy was considerably escalated after flipped learning. By contrast, after they received traditional education, although the knowledge and self-efficacy scores of nurses in the control group increased, only insignificant differences were observed. It can thus be concluded that, through flipped learning for aromatherapy, nurses can master non-pharmacological pain management in a relatively short timeframe. This reveals that the flipped learning model is superior to traditional teaching approaches and is effective in improving students’ knowledge and self-efficacy [28‐31].

Aromatherapy courses have not been universally taught in nursing departments and medical institutions in colleges and universities in Taiwan, and nursing personnel have not been fully educated in aromatherapy. Nurses may only attend aromatherapy workshops based on a personal decision and at their own expense. These factors have greatly limited nurses’ ability to apply aromatherapy to pain management. It is recommended that aromatherapy be included in educational training courses in pain management. The results of this study confirmed that the use of the flipped teaching approach indeed improved the knowledge and self-efficacy of nurses. Therefore, we hope that the course design in this study may serve as a reference for the future design of aromatherapy courses in nursing schools or medical institutions. This study only discussed the learning outcomes after the educational intervention. We recommend future follow-up on the implementation of aromatherapy by nursing staff in clinical practice and on the effect of pain relief on patients in order to improve the quality of patient care.