Micro-learning and Mindtools in Mobile-Learning (M-Learning): effects on knowledge and self-efficacy in laparoscopy education for surgical nursing students
In this study, an online Mobile-Learning (M-learning) application was developed based on the principles of mindtools and micro-learning strategy to educate surgical nursing students in laparoscopic surgical units. This study aimed to assess the effect of education using M-learning in laparoscopic surgical units on nursing students’ knowledge and self-efficacy.
Method
This experimental study was conducted at Shahid Sadoughi University of Medical Sciences from 2022 to 2023. Surgical nursing students were included in the study (n = 57) and were classified into intervention and control groups using random sampling. This educational program aimed to develop learners’ ability to recognize laparoscopic surgical tools and diagnose appropriate tools in laparoscopic surgery steps using scrub and circular techniques. The students in the intervention group used M-Learning during workplace-based learning in the surgical laparoscopy unit. Students’ training in the control group included routine clinical education, including observation and practice. The students in both groups participated in a knowledge examination (n = 13 questions) and self-efficacy assessment before and one week after. The data were summarized using descriptive statistics and analyzed using Pearson’s test and Student t-test. The effect size of the educational intervention on the variables was reported using Partial Eta Square.
Results
The results revealed significant differences in knowledge scores between the intervention and control groups after the training (P-value = 0.004, partial η² = 0.11). However, the difference in self-efficacy between the two groups after the intervention was not statistically significant (P-value = 0.148, partial η² = 0.03).
Conclusion
The present study used M-learning with a Mindtools strategy as a complementary tool in clinical education. The findings indicated that the intervention’s educational effect on learners’ knowledge was favorable, while the educational effect on students’ self-efficacy was moderate. In conclusion, this M-learning application tool in clinical training planning is proposed as a support tool to improve students’ capabilities in clinical training programs.
Trial registration number (TRN)
In our context, clinical studies in the patient community have criteria for receiving a TRN code. Educational interventions in the student community have not been assessed because they are not eligible for the trial code. The study has been reviewed and approved by the ethics committee. We have added a certificate in the supplementary section.
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Introduction
Technology in advancing medical education has grown significantly [1‐3]. The development of digital education in surgical departments is crucial due to patient safety risks and limitations of the surgical field, such as restrictions on the opportunity to manipulate and participate in operations [4]. Integrating digital learning tools in blended and interactive clinical learning is recommended for developing students’ technical and non-technical surgical skills [3]. Laparoscopy is an advancing surgical technique within the realm of minimally invasive procedures, necessitating the use of specialized, varied, and costly instrumentation. Their users are expected to be proficient in the comprehensive recognition of these instruments, their utilization, and the discernment of the appropriate tool requisite for distinct surgical steps. The improper utilization of these tools and equipment leads to premature deterioration of the instruments and causes substantial costs for the healthcare system [5]. With the advancements in laparoscopic surgeries that have mitigated risks associated with open surgeries, the need for comprehensive knowledge imparts a significant cognitive load on the surgical team members. Nurses within a surgical team play a crucial role in preparing and assisting to perform surgery activities accurately and on time. In the surgical field, surgical nurses were expected to discern the instruments and equipment within the operating room for various and diverse surgical procedures. They should also assist the surgical team members in the preoperative, intraoperative, and postoperative stages of surgical interventions. Given the intricate nature of the tasks requiring meticulous attention during these stages, it is imperative to create supportive learning opportunities for surgical nurses through M-learning [2].
Digital training methods and tools such as M-Learning have recommended laparoscopy education for students, including medicine, nursing, and allied medicine engaged in healthcare teams [1, 3, 6, 7]. M-learning has enabled students to use all available opportunities to learn by using a wide range of prepared content, recorded videos, or offline or online applications [8]. Students believe that M-learning is an effective tool for education in various situations within traditional, formal, and informal learning processes, whether in clinical or classroom settings, according to Qureshi et al. [8]. This method increases the opportunity to use clinical experiences as an effective learning situation. Furthermore, M-Learning allows students to review keynotes and learn during clinical activities or clinical cases and compare them with real-world findings. Then, they can complement or amend their learning accordingly [9]. This feature led to the expansion of the use of M-learning in the educational systems of medical sciences [1, 9].
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Mobile applications, as credible and effective methods of M-learning, are suggested for formal and informal learning and personal development in medical science systems [8]. These tools provide a suitable opportunity for learning and sharing information within the healthcare team [8, 10, 11]. In the BEME Guide (Best Evidence Medical Education Guid), Maudsley recommends using M-learning to support student learning in clinical education. Just-in-time access to new learning resources and reviewing information provides the perfect opportunity for effective learning and evidence-based practice. The M-learning model facilitates clinical activity classification, workplace-based assessment, and learners’ monitoring [12]. A meta-analysis study conducted by Kim et al. indicated that in clinical education, where complex healthcare services are required, nursing students face significant challenges applying the knowledge and skills acquired in the clinical setting. Thus, it is recommended that a suitable strategy be used in designing M-learning applications to increase the opportunity to review the content taught and facilitate the application of knowledge in the clinical setting [2].
The use of the micro-learning strategy in the M-learning teaching method is advised to facilitate the acquisition of knowledge or skills in small units [12, 13]. “Micro-learning has the potential to meet the learner’s personalized learning needs through a variety of small educational resources and flexible learning opportunities [14]”. Micro-learning is a relatively small, focused learning unit that includes condensed learning activities and is available on multiple devices [12]. De Gagne et al., in a review study, showed that micro-learning had a positive impact on the knowledge and confidence of health profession students in performing procedures, retaining knowledge, and participating in collaborative learning [13].
A main issue in micro-learning is that patchy knowledge points may limit the learner’s understanding and the construction of knowledge. Ma and colleagues suggested a ‘knowledge map-based online micro-learning system’ to solve this problem [14]. In addition, Kuwabara and colleague used concept maps in their Micro-learning [15].
Lai and colleagues introduced ten strategies for M-learning, including guided learning, peer assessment, video sharing, synchronous sharing, issue-based discussion, mindtools (using a concept map), project-based learning, digital storytelling, inquiry-based learning, and contextual mobile learning [16]. The mindtool-based learning strategy helps students connect information meaningfully, compare what they observe in their surgical workplace with prior knowledge, and create the necessary knowledge directly. This strategy facilitates students in organizing learning content and stimulates students to evaluate their learning and reflect on it. Moreover, this strategy creates a flexible framework for establishing meaningful connections between prior knowledge and new knowledge [16]. So, a concept map was introduced as a tool for the implementation of the mindtool strategy.
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The findings of a meta-analysis study confirmed the positive effect of M-learning application on the development of nursing students’ knowledge, attitude towards learning, self-confidence, and skills. However, most studies used a quasi-experimental design that restricted the generalizability of their findings. Therefore, further research is suggested to assess the effect of M-learning in clinical education [2] and to evaluate the outcomes of M-learning by mindtools on learners’ capability in clinical settings [13, 15, 17].
Overall, this study used an online M-Learning application, using the principles of Micro-learning and Mindtools strategy, to educate surgical nursing students in surgical units. It aimed to assess the effect of education using the M-learning application in laparoscopic surgical units on nursing students’ knowledge and self-efficacy.
Method
This experimental study was conducted at Shahid Sadoughi University of Medical Sciences from 2022 to 2023.
Participants
Learners
The undergraduate surgical nursing students were included in the study. The inclusion criteria were having passed the courses on operating room devices and equipment, anatomy, gastrointestinal surgery technology, signing consent forms to participate in the study, and having a smartphone. The exclusion criteria were having previous experience in laparoscopic surgical procedures. Students were classified into intervention and control groups by random sampling. The sample size was determined using a Type I error rate of 5%, a statistical power of 80%, and an effect size of 0.08 on students’ knowledge, as derived from the pilot study. This calculation determined that 26 students per group were required. To accommodate a potential 10% dropout rate, the final sample size was increased to 28 students per group.
Experts
The educational program was developed through a team of laparoscopic surgeons (n = 2), qualified surgical nurses in laparoscopy (n = 2), and an expert in health professions education (n = 1).
Faculty members, including ten surgical nursing specialists and five laparoscopic surgeons, participated in the psychometric steps of instruments in this study. The mean age was 48 years (SD = 9.50), and their work experience was 18 years (SD = 13.50).
Educational intervention
The objectives of this educational program were to develop learners’ ability to recognize and use laparoscopic surgical tools and to diagnose appropriate tools in laparoscopic surgery steps by the role of scrub and circular.
Development of M-learning application
The M-learning application was developed based on the principles of Mindtools and micro-learning. Common and important laparoscopic surgeries of the abdominal area, including cholecystectomy, appendectomy, sleeve gastrectomy, and inguinal herniorrhaphy, were concentrated on in the M-learning.
In this step, the concept maps and M-learning application were designed and developed according to the principles of Micro-learning, conceptual learning, and mindtool in M-learning units [12, 13, 15]. According to Micro-learning, each map is relatively small and focused on surgery as a learning unit. Besides, the concept maps assist the students in organizing learning content, connecting information meaningfully, and comparing what they observe in their field of work with prior knowledge. The maps restricted the patchy knowledge points by meaningful organization of the surgical steps, the applied instruments, and the expected roles of surgical nurses (Fig. 1).
Fig. 1
The concept map in M-learning
×
The content and organization of the maps were conducted based on the appropriate evidence and experts’ opinions. Concept maps demonstrated surgeries and their steps, features of laparoscopic tools, and the application of each tool in each stage of the surgery. Furthermore, static and animated images of surgical instruments were used to learn how to use the instruments. The expected tasks, according to the role of scrub and circular, were considered when designing the maps. The prepared materials were compiled as a spider concept map by the Mindomo platform. Finally, concept maps were designed in the M-learning application.
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The M-Learning application consisted of a concept map panel and a self-assessment panel, which assessed individuals’ learning regarding instrumentation through multiple-choice questions (n = 40). Surgical technology nurses (n = 10) and laparoscopic surgeons (n = 5) confirmed the validity of M-learning, including the content and face validity of concept maps, applications, and questions.
Education in the intervention group
The educational intervention included briefing sessions, lectures, small group training sessions (n = 3), and workplace-based learning. In the briefing session, the students were introduced to the M-learning application and panels, and the students were asked to work with the application in small groups. During the clinical education, students learned in the surgical units for three weeks as practitioners in different scrub and circulator roles. Students in the intervention group used the M-learning application during their internship in the surgical laparoscopy unit. The progression through designed stages and assessments affirmed students’ engagement in learning from the application. Through the application’s management panel, the facilitator monitored and provided feedback to students. An interaction between students and the facilitator was planned in the forum.
Education in the control group
The control group’s students were trained in surgical procedures, instrumentation, and their application through three lecture sessions and routine clinical training. The lecture sessions included explanations of instruments and surgery processes. During clinical education, students routinely experienced the activities of practitioners in the laparoscopy units as scrubs or circulators.
Study measures
Participants in both groups took part in a knowledge examination and self-efficacy assessment before and one week after the treatment.
Knowledge assessment
The multiple-choice questions (MCQ) were developed by two surgical nursing instructors. The validity of the questions (n = 20) was assessed by quantitative indexes of content validity (Content Validity Ratio (CVR) and Content Validity Index (CVI)). Fifteen faculty members of the surgical nursing and laparoscopic surgeons participated in this step. Seven questions that obtained CVR less than 0.49 and CVI less than 0.79 were excluded from the examination. The validity of 13 questions was confirmed. The lowest score was zero, and the highest score was 15 (Appendix 1).
Self-efficacy assessment
A Self-Efficacy Scale questionnaire was used, designed, and validated by Sedigh et al. (Cronbach 0.84). This questionnaire contains 17 items. The 5-point Likert Scale is as follows: strongly agree [5], agree [4], no opinion [3], disagree [2] and strongly disagree [1]. The minimum and maximum scores for this questionnaire are 17 and 85. Obtaining a high score on this scale indicates higher self-efficacy [18] (Appendix 2).
Data analysis
The data were summarized using descriptive statistics, including mean, standard deviation, and percentage. Subsequently, Pearson’s test, an independent samples t-test, a paired samples t-test, and ANCOVA (Analysis of covariance) were used. These analyses were conducted using SPSS version 25 software. The effect size of the educational intervention on the variables was reported using partial eta square. Cohen’s d index was used across three categories to assess the extent of educational impact: small (0.01), medium (0.06), and large (0.14) [19]. A significance threshold of 0.05 throughout the analysis was considered.
Ethical consideration
To minimize the risk of contamination, several precautions were implemented. First, separate training sessions were scheduled for the M-learning and traditional method groups, ensuring no overlap in time or location. The control group received training before the intervention group to reduce the likelihood of knowledge transfer from the M-learning group to the control group. Participants were instructed to refrain from discussing the study or sharing information with individuals outside their respective groups. During training sessions, a researcher was present to monitor and supervise the participants. For the M-learning group, online platforms were utilized, with access restricted to their assigned group to prevent interaction with participants from the traditional method group. Data collection was conducted using paper-based tests, which were completed individually by each participant. These measures were designed to minimize the risk of contamination and ensure the integrity of the study. The present study was approved by the Research Ethics Committee at Shahid Sadoughi University of Medical Sciences, Yazd, Iran (ID: IR.SSU.SPH.REC.1400.117).
Results
Fifty-seven surgical nursing students participated in the current study, including 29 students (52%) in the intervention group and 28 (48%) in the control group. The mean (SD) age of students was 26.63 (1.38). Demographic information of the participants is shown in Table 1.
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Table 1
Demographic information of the participants
Demographic information
Categories
Group
P-value
Intervention N = 29
Control N = 28
N
%
N
%
Gender
Male
23
73.9
17
60.7
0.125
Female
6
20.7
11
39.3
Academic years
2
11
37.9
8
28.6
0.702
3
11
37.9
11
39.3
4
7
24.1
9
32.1
GPA scores
< 16
3
10.3
4
14.3
0.845
16–18
23
79.3
22
78.6
> 18
3
10.3
2
7.1
A comparison of the students’ knowledge scores before training revealed no significant difference between the intervention and control groups (P-value = 0.720). However, a significant difference was found in knowledge scores between the two groups after training, with the intervention group demonstrating superior knowledge acquisition (P-value = 0.004) (Table 2). The educational effect of the intervention on the students’ knowledge was reported as partial eta squared = 0.11. According to Cohen’s d values, the educational effect in the intervention group is at a higher level than that of the control group. The results of the Analysis of Covariance (ANCOVA) revealed that even after adjusting for the variables of academic years, GPA, age, and gender as covariance, the students’ knowledge score was significant (F (1.51) = 0.13.11, P-value = 0.001).
Table 2
The knowledge and self-efficacy scores of learners in the intervention and control groups
Group
Pre-test
Post-test
P-Value
Partial eta squared
Mean
SD
Mean
SD
Knowledge
Intervention
5.21
2.27
9.74
2.42
0.004
0.11
Control
4.12
1.76
8.32
2.98
Self-Efficacy
Intervention
57.21
11.72
67.68
7.97
0.148
0.03
Control
58.79
8.04
64.14
10.16
The difference in students’ self-efficacy between the two groups after the intervention was insignificant (P-value = 0.148). The effect size of the educational intervention on self-efficacy was reported at a medium-level educational effect (Partial eta-squared = 0.03). (Table 2). The results of the Analysis of Covariance (ANCOVA) revealed that even after adjusting for the academic years, age, GAP, and gender of the students as a covariance, the students’ self-efficacy scores before and after the training were insignificant (F (1.51) = 0.1.53, P = 0.222). The results revealed no significant differences between self-efficacy scores concerning gender (P-value = 0.817) and GPA (P-value = 0.723) of the students.
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Discussion
The findings revealed that the educational effects of the intervention on students’ knowledge and self-efficacy were reported at a favorable and a moderate level, respectively. The students’ knowledge scores in the intervention group were significantly higher than in the control group. The self-efficacy scores of the intervention and control groups did not differ significantly.
Digital learning tools used for developing knowledge at the cognitive, emotional, and functional levels have been considered [2, 20]. The Mindtools strategy was used in M-learning to develop cognitive skills and apply the student’s learning in clinical practice. Concept maps were designed according to the principles of micro-learning. They presented a meaningful and small process of laparoscopic surgeries. Moreover, static and animated images of surgical instruments were used to understand the application of instruments better, which effectively improved students’ learning along with concept maps. The results showed that the M-learning application increased the knowledge scores significantly compared to the scores of control group students who had solely experienced lectures. Besides, the implementation of the mindtool strategy for organizing information in a meaningful way had a positive impact on the participants’ knowledge scores.
Furthermore, the use of visual aids, such as figures and animated illustrations of surgical instruments, significantly enhanced the scores of students in the intervention group. In line with our results, Alt and colleagues (2021) [21] investigated the impact of digital concept maps in an online learning environment. Their results revealed that the digital concept maps led to an enhancement in the level of learning, problem-solving skills, and the overall advancement of self-directed learning among the students. Likewise, Major and colleagues stated that micro-learning supports learning by accessing bites of information designed in M-learning. This method resulted in improving knowledge retention [22].
Ma and colleagues [14] showed that micro-learning coupled with maps improved the participants’ learning. In this study, the principles of microlearning were applied [23], encompassing the use of short and comprehensible topics in each part, interactive activities, self-assessment tasks, a wide range of media formats, and immediate feedback. These principles positively influenced the students’ cognitive skills and led to improved scores in the intervention group. Similarly, the results of Pape-Koehler and colleagues examined the impact of multimedia-based training on internet platforms on laparoscopic cholecystectomy surgery. Their results indicated that multimedia-based training significantly enhanced the level of learning and clinical skills either on its own or as part of a blended learning method [24]. The up-to-date and fast access to internet networks, delivering content in small segments, engaging multiple senses in learners, and employing animated images and instructional videos within the training have contributed to the growth of student’s knowledge.
One of the key features of M-learning is the unrestricted access to educational resources. In the current study, these resources were organized and categorized using the Mindtool strategy. This organization allows students to use M-learning to significantly facilitate the rapid recall of educational content during the clinical education process, particularly in critical fields such as surgery. Accessibility and unrestricted access in terms of time and location provide the opportunity to review the topics taught and focus on the connections between fundamental and subordinate concepts in concept maps, which effectively improves the learners’ knowledge enhancement [25]. In a review study, O’Connor showed that M-learning enhanced students’ knowledge in clinical education. This improvement was attributed to the convenient access to key information through M-learning platforms [26]. Salmani et al. investigated the effect of the mobile application designed based on concept maps on nursing students’ learning in two levels of knowledge and meaningful learning. In the intervention group, students received concept maps on their mobile after each teaching session; their scores for meaningful learning increased, unlike those who only encountered concept maps during the teacher’s instruction [25].
M-learning is a support tool in nursing clinical education [2]. In the present study, surgical nursing students used M-learning in clinical education in surgery. M-learning facilitated the remembering and reviewing of previously learned knowledge, enabling them to be prepared for each surgery. Given that scrub or circulator nurses were tasked with numerous activities, it was assumed that accessing the concept maps within M-learning would offer a chance to comprehensively review and execute essential tasks with precision, reinforcing their self-efficacy. The present results indicated that the educational intervention had a moderate effect on students’ self-efficacy in the intervention group compared to the control group.
Moreover, the results indicated that the self-efficacy scores of the intervention and control groups did not differ significantly. The limited sample size and restricted time frame for using M-learning in clinical education could potentially impact this finding. Goldsworthy’s study revealed that using personal digital assistants (PDAs) as a supplementary tool in clinical education significantly impacted the self-efficacy of nursing students compared to the control group, which did not utilize PDAs [27]. O’Connor showed that using M-Learning in the clinical training of nursing students improves their self-confidence, which can be caused by quick access to the information they need [26]. Kim showed that students who utilized a smartphone-based application with video content exhibited notably greater knowledge and self-confidence than those who attended traditional lectures [28].
Likewise, Kim stated that participants’ satisfaction and familiarity with M-learning significantly affect their learning outcomes within this method. Lack of familiarity with educational technologies leads to lower user satisfaction and lower learning outcomes [2]. The results of the studies differ from those of the current study. This study used M-learning as a supplementary tool in clinical education. It seems that factors related to the clinical education program have had a more significant impact on student self-efficacy rather than using M-Learning as a supplementary tool. This difference can be caused by the educational program experienced in digital education, the student’s capability, and the previous experience of students in using M-leaning. Krishnasamy stated that the effectiveness of M-Learning in improving knowledge and attitudes was argued in previous studies and was influenced by various factors.
It is worth mentioning that perceived characteristics of the intervention, such as satisfaction and attitudes towards this method, impact the success of this approach and the results [29]. Additionally, a structured training program and guided opportunities to use M-leaning in the clinical training process can foster a feeling of self-efficacy [26, 29].
Consequently, using the M-learning application in clinical education planning is suggested as a supporting tool to enhance students’ learning. In addition, students’ familiarity with M-learning improved their positive attitude toward using the application in clinical education programs. It is also recommended that students’ cognitive performance at higher levels be evaluated using higher-ordering thinking tests and that the retention of learning over time be investigated in future studies.
Implications for nursing education
The M-learning strategy, combined with concept mapping, facilitates a deeper understanding of the fundamental concepts and principles underlying the correct use of laparoscopic tools and equipment among surgical nursing students. Through repetition and convenient access to educational resources, students can retrieve their knowledge and improve their self-efficacy in acquiring clinical skills. The M-learning strategy enables learners to capitalize on opportunistic learning moments, which is particularly valuable in clinical education. Specifically, students can use M-learning to review and retrieve their knowledge at various points, such as before the commencement of their internship, before surgery, or during inter-surgical intervals. By reviewing concept maps and accessing educational resources, learners can engage in self-directed learning without instructors, thereby actively participating in the learning process with enhanced self-efficacy in mobile or surgical roles.
The development and integration of M-learning strategy in various fields of surgical technology, such as laparoscopy, orthopedics, cardiology, and neurology, can be particularly beneficial. These fields often involve complex and sensitive conditions, requiring students to memorize an extensive amount of information during surgical procedures.
Limitations of the study
The study’s small sample size is a notable limitation, which may impact the generalizability of the findings. Furthermore, the limited training duration of three weeks may have affected the results. Knowledge and self-efficacy were not longitudinally assessed, which may limit the investigation of the sustained impact of M-learning on these outcomes. Future research with larger sample sizes and longer training periods is suggested to explore the relationship between M-learning and students’ self-efficacy and learning over time.
Conclusion
The present study used M-learning as a complementary tool in clinical education. The results indicated that the M-learning application in the clinical education of surgical nurses has improved the nursing students’ learning. The knowledge of students who used M-learning in laparoscopy training during their clinical education was reported to be higher than the scores of the control group. However, the self-efficacy scores of the intervention and control groups did not differ significantly. The findings indicated that the intervention’s educational effect on learners’ knowledge was at a favorable level, while this effect was at a moderate level on self-efficacy. In conclusion, this M-learning application tool in clinical training planning is proposed as a support tool to improve students’ learning in clinical training programs.
Acknowledgements
We would like to thank all of the participants who have been involved in the study.
Declarations
Ethics approval and consent to participate
The present study was approved by the Research Ethics Committee at Shahid Sadoughi University of Medical Sciences, Yazd, Iran (ID: IR.SSU.SPH.REC.1400.117). Written informed consent was obtained from all participants. The work was conducted following the Declaration of Helsinki.
Consent for publication
Not Applicable.
Competing interests
The authors declare no competing interests.
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Micro-learning and Mindtools in Mobile-Learning (M-Learning): effects on knowledge and self-efficacy in laparoscopy education for surgical nursing students