
==== Front
Heliyon
Heliyon
Heliyon
2405-8440
Elsevier

S2405-8440(24)12729-6
10.1016/j.heliyon.2024.e36698
e36698
Research Article
Effectiveness of the small private online course‐based flipped teaching program for enhancing nursing students’ self-directed learning ability in the Surgical Nursing course: A practical study
Xu Juling xjl0125@zjhu.edu.cn
a
Huang Sanxiong sxsxhuang@126.com
b⁎
Wu Chengliang wcl2664799647@qq.com
a
Ren Yujie rrryj0110@163.com
a
Li Qiannan 499561530@qq.com
a
Cai Jiali xcduochicai@163.com
a
Wang Chunsheng 00894@zjhu.edu.cn
a
Jiang Peiyu jpy@zjhu.edu.cn
a
a School of Medicine, Huzhou University, Huzhou, 313000, China
b Department of Surgery, First People's Hospital Affiliated with Huzhou University, Huzhou, 313000, China
⁎ Corresponding author. sxsxhuang@126.com
22 8 2024
15 9 2024
22 8 2024
10 17 e366987 10 2023
9 8 2024
20 8 2024
© 2024 The Authors. Published by Elsevier Ltd.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Small private online course-based flipped teaching is an innovative hybrid instructional approach that merges online and offline activities, fostering autonomous learning among students prior to class and facilitating the assimilation of knowledge within the confines of the classroom. To determine the effectiveness of the small private online course‐based flipped teaching model on undergraduate nursing students' self-directed learning abilities, we performed a practice version of the small private online course‐based flipped teaching program as a quasi-experiment, specifically designed for the Surgical Nursing course and assessed its effectiveness in students' self-directed learning abilities. To this end, a total of 264 students from the 2019 nursing major cohort were selected. Three classes comprising 131 students were randomly selected as the experimental group, and three other classes, comprising 133 students, were set as the control group. The results revealed no significant differences in the scores of self-directed learning abilities between the experimental and control groups before the experiment. After the experiment, the average scores on each dimension of the self-directed learning abilities improved significantly, and the final score of the experimental group was higher than that of the control group. The small private online course‐based flipped teaching model can promote undergraduate nursing students’ self-directed learning abilities, owing to its practicality and feasibility for the selected course.

Keywords

Small private online course‐based flipped teaching
Nursing students
Surgical nursing
Self-directed learning
==== Body
pmc1 Introduction

With the increasing demands for public health services and the complexity of surgical healthcare systems, nursing students are expected to possess the abilities and skills necessary to make informed decisions and deal with unexpected situations, especially during the COVID-19 pandemic [[1], [2], [3]]. Nursing students have witnessed the chaos of the healthcare system as they developed their professional identities and roles. Nursing students themselves realize the importance and necessity of acquiring good professional knowledge during their undergraduate years [4,5]. To meet these new challenges and demands, it is crucial to introduce and develop appropriate teaching methods in surgical nursing education in the post-COVID-19 period. In 2013, Armando Fox, a professor of computer science from the University of California, Berkeley, first proposed the concept of small private online courses (SPOCs) [6]. The SPOC-based flipped teaching is a hybrid teaching model that organically combines online and offline activities and features independent learning by students before class and the internalization of knowledge within the classroom [7,8].

In the SPOC-based flipped teaching model, students engage in online learning through instructional videos and resources before class, after which they consolidate their knowledge through group discussions, teacher-student interaction, and question-and-answer sessions in the classroom. This approach combines the advantages of massive open online courses (MOOCs) and classroom teaching and is especially suitable for teaching tasks in nursing education in colleges and universities [2,9]. This model breaks away from the closed, fixed, and one-way traditional teacher-centered approach and truly realizes student-centered, individualized learning advocated by MOOCs [7,9,10]. Students' self-directed learning abilities (SDLAs) are considered fundamental and crucial for further learning and learning outcomes at a later stage [[11], [12], [13], [14]]. During the COVID-19 pandemic, nursing students were forced into unexpected emergent situations to complete their clinical hours and courses via online learning [4,[15], [16], [17]]. Thus, it is crucial to promote students’ awareness of holistically completing their learning tasks.

SDLA refers to a learner's ability to consciously identify and use objective resources to effectively integrate and acquire the knowledge and skills necessary for learning [[18], [19], [20]]. Previous studies have emphasized that independent learners should be motivated to learn, have clear goals, and be able to learn independently and continuously [[21], [22], [23]]. Currently, many domestic and international nursing schools have incorporated SDLAs as one of the teaching objectives for nursing majors [11,[24], [25], [26], [27], [28], [29]]. Therefore, strengthening the study of independent learning and fostering students' SDLAs have considerable theoretical and practical value within the nursing education domain. In the past few years, several reformations in teaching and learning innovations in nursing majors at Huzhou University have been practiced, and each has achieved good results [[30], [31], [32]]. However, the reformation of SPOC‐based flipped teaching innovation in nursing majors at Huzhou University has not been reported until now. In this study, we established a SPOC‐based flipped teaching model and performed a teaching reform practice on a Surgical Nursing course to examine the program's effectiveness on the development of SDLAs and self-efficacy among nursing undergraduates at Huzhou University.

2 Materials and methods

2.1 Study participants

In this study, a random sampling method was employed [33,34]. A total of 264 junior undergraduate students (40 males and 224 females) across six classes of the 2019 nursing major cohort at Huzhou University were chosen to participate. Of these, three classes consisting of 131 students (18 males and 113 females) were then randomly selected as the experimental group, and the other three classes, comprising 133 students (22 males and 111 females), were set as the control group. There was no statistical difference between the two groups in terms of entrance examination results, gender, age, elective course and examination scores, teachers, and lecture contents. These factors are frequently considered to have a direct or indirect impact on the SDLAs of nursing students [[35], [36], [37]]. Before the official start of the SPOC-based flipped course, participants were given specific skills training to improve their performance in the SPOC-based flipped classroom. Ethical approval was obtained from the Medical Ethics Committee of Huzhou University (approval number 2019‒12‒11). All participants were informed about the aims of the study and provided written informed consent.

2.2 Study design

This study aimed to investigate the changes in learning engagement and professional skills performance in the application of the SPOC‐based flipped teaching model in the Surgical Nursing course and what it brought to nursing students. This course spanned two semesters, totaling 128 class hours (102 h of theory teaching and 26 h of laboratory training), along with one week of clinical practice during the fifth and sixth semesters. The control and experimental groups received the same lectures at the same teaching week in different ways.

2.2.1 Implementation of theory teaching

The control group followed the traditional lecture mode, wherein the teacher issued the lecture plan and schedule before the course, communicated the expectation for students to engage in pre-class study, conducted the class using Microsoft PowerPoint (PPT) courseware based on the syllabus, assigned exercises after the class to highlight important and difficult aspects and directed students to review the notes after course completion. In contrast, the experimental group followed the SPOC-based flipped teaching model to organize the teaching, which involved the following steps (Fig. 1).Phase 1 Pre-class stage

Fig. 1 Schematic diagram of the teaching design of the Surgical Nursing course under the SPOC-based flipped teaching program.

Fig. 1

In the first section of the course, the teachers introduced the SPOC-based flipped teaching model to students and instructed them on how to log in and use the SPOC platform. Before the implementation of SPOC-based flipped teaching, teachers constructed the SPOC platform to facilitate comprehensive learning support and teaching control. These teaching resources, which included teaching videos, PPT courseware, and online exercises, were uploaded to the SPOC online platform, opened regularly according to the lecture schedule, and clarified the tasks they needed to complete. The students were required to access the SPOC platform, study the teaching materials and related videos, and complete the online exercises independently. They were encouraged to use the internet or consult relevant books to collect information, solve any problems encountered during the learning process, and discuss the issues in the SPOC platform discussion forum.Phase 2 Mid-class stage

During this phase, the teachers started the class with a number of questions on the chapter to be learned and some necessary guidance. Five to six students were combined into a subgroup and received inquiry-based cooperative learning in the classroom. Each subgroup was assigned a subgroup leader, whose main responsibilities were to facilitate cooperative learning, subgroup presentations, and classroom discussions. Based on the subgroup cooperative learning, the teachers reviewed and refined the subgroup presentations and classroom discussions, emphasizing key knowledge points, acknowledging positive aspects, promptly identifying problems, and suggesting potential solutions.Phase 3 Post-class stage

After the class, teachers designed post-class exercises, uploaded them to the SPOC platform, and instructed students to complete them online to consolidate their knowledge.

2.2.2 Implementation of laboratory training and clinical practice

After the theoretical class, students in the control and experimental groups moved to the virtual simulation laboratory and received the same laboratory training. For the laboratory training, they needed to log into the virtual simulation training system with their student numbers and practice the training items corresponding to the content of the theoretical course. The laboratory training covered special topics such as training and proficiency in operating procedures and precautions. At the end of the laboratory training, the teacher conducted a summative evaluation for each student in the control and experimental groups with a total score of 100.

Subsequently, the students from the control and experimental groups went to the First People's Hospital Affiliated with Huzhou University, for a one-week clinical practice. During clinical practice, they needed to follow the teacher to complete bedside practices corresponding to the content of the theoretical and laboratory courses in the Department of Surgery. At the end of the clinical practice, the teacher conducted a summative evaluation for each student in the control and experimental groups with a total score of 100.

2.3 Evaluation index

2.3.1 SDLA scale

The study employed the SDLA scale, originally developed by Fisher et al. [38] and Zhang et al. [39], with some modifications. The questionnaire (see more detailed information in Supplementary Table S1) was administered to both groups before and after the experiment. The SDLA scale comprises 30 items across four dimensions: learning motivation (LM; 10 items), self-management skills (SMS; 9 items), cooperative learning skills (CLS; 5 items), and information literacy (IL; 6 items). All items are rated on a 5-point Likert scale from 1 (“not at all”) to 5 (“exactly”) [11,24]. The internal consistency reliability of the total SDLA scale was evaluated as 0.822, which has been widely used in previous research [40,41].

2.3.2 Comprehensive scores at the end of the two semesters

The experimental group adopted a formative evaluation system, wherein the total comprehensive theoretical course scores were calculated as follows: 30 % in the pre-class stage, 30 % in the mid-class stage, 20 % in the post-class stage, and 20 % in the final examination of each semester (Fig. 1). For the control group, a summative evaluation method was adopted, wherein the total comprehensive theoretical course scores were calculated as follows: 10 % in the regular test, 30 % in the mid-term examination, and 60 % in the final examination of each semester. For both the control and experimental groups, the final comprehensive scores of the participants were calculated as follows: 70 % in the theoretical course, 20 % in the laboratory training, and 10 % in the clinical practice of each semester.

2.4 Statistical analysis

The original survey data were downloaded from the “Questionnaire Star” platform and combined with the data of students' academic performance in the theoretical course, laboratory training, and clinical practice to generate the final database. Data from the final database were statistically analyzed using the SPSS 27.0 software as described previously [42,43]. The demographic and categorical data were expressed as mean ± standard deviation (SD), and differences between groups were compared using Chi-square tests or Student's t-tests, with p < 0.05 considered a statistically significant difference. The data from the control group were used as the qualitative and quantitative controls, respectively.

3 Results

3.1 Demographic characteristics and learning basis of the participants

A total of 264 junior nursing students participated in the study, with 131 (18 males and 113 females) assigned to the experimental group and 133 (22 males and 111 females) assigned to the control group. The average age of the participants was 20.55 ± 1.12 years. There were no significant differences in terms of sex and age between the two groups (p = 0.526; p = 0.794) (Table 1). Furthermore, the analysis of the learning basis, based on participants’ mean scores on five professional foundation courses (physiology, anatomy, pharmacology, health assessment, and basic nursing), revealed no significant differences in pre-professional quality between the two groups (Table 1).Table 1 Demographic characteristics and learning basis of the pre-professional quality between the experimental and control groups.

Table 1Characteristic	Control group (n = 133, 22 males and 111 females)	Experimental group (n = 131, 18 males and 113 females)	χ2-test	
Mean ± SDa	Mean ± SDa	t	p value	
Age	20.57 ± 1.13	20.53 ± 1.12	1.029	0.794	
Physiology	83.20 ± 7.58	82.69 ± 8.22	0.530	0.596b	
Anatomy	81.76 ± 6.94	81.87 ± 7.84	−0.122	0.903b	
Pharmacology	82.32 ± 7.53	82.99 ± 7.62	−0.725	0.469b	
Health assessment	87.89 ± 4.65	87.63 ± 4.86	0.433	0.665b	
Basic nursing	79.74 ± 8.95	80.05 ± 8.63	−0.286	0.775b	
a SD, standard deviation.

b p < 0.05 was considered significant (χ2-test).

3.2 Effectiveness of the SPOC‐based flipped teaching program

Table 2 shows the comparisons of the pre- and post-test SDLA scores of the participants in the control and experimental groups. The mean post-test scores for LM, SMS, CLS, IL, and final score (FS) in the experimental group were 34.17 ± 5.52, 32.05 ± 3.59, 15.23 ± 3.70, 15.30 ± 3.28, and 96.79 ± 9.7, respectively, which were significantly higher than those in the control group (29.12 ± 6.25, 23.48 ± 4.64, 11.69 ± 2.47, 14.88 ± 3.52, and 79.17 ± 9.02, respectively) (Table 2 and Fig. 2). These data indicate that the SPOC‐based flipped teaching program can significantly increase the SDLA of nursing students (t = 54.981, p = 0.006).Table 2 Comparison of self-directed learning ability (SDLA) scores between the control and experimental groups before and after the SPOC‐based flipped teaching program.

Table 2SDLA scale	Control group (n = 133)	Experimental group (n = 131)	t-test of pre-testb	t-test of post-testc	
Pre-test	Post-test	Increment	Pre-test	Post-test	Increment	t	p value	t	p value	
Mean ± SDa	Mean ± SDa	Mean ± SDa	Mean ± SDa	Mean ± SDa	Mean ± SDa	
Learning motivation	27.88 ± 4.14	29.12 ± 6.25	1.24 ± 0.38	27.44 ± 6.89	34.17 ± 5.52	6.77 ± 1.32	0.358	0.721d	26.185	0.012d	
Self-management skills	23.74 ± 5.10	23.48 ± 4.64	−0.26 ± 0.07	25.12 ± 4.68	32.05 ± 3.59	6.93 ± 1.12	1.299	0.198d	42.012	0.008d	
Cooperative learning skills	12.14 ± 3.20	11.69 ± 2.47	−0.45 ± 0.10	12.30 ± 3.96	15.23 ± 3.70	2.97 ± 0.43	0.631	0.838d	50.768	0.019d	
Information literacy	14.02 ± 3.58	14.88 ± 3.52	0.86 ± 0.19	14.26 ± 4.26	15.30 ± 3.28	1.04 ± 0.18	0.281	0.779d	5.851	0.041d	
Final scores	77.78 ± 8.93	79.17 ± 9.02	1.39 ± 0.21	79.12 ± 9.4	96.79 ± 9.7	17.67 ± 1.93	0.674	0.502d	54.981	0.006d	
a SD, standard deviation.

b t-test of pre-test, t-test of the SDLA scores between the control and experimental groups before the SPOC‐based flipped teaching program.

c t-test of post-test, t-test of the SDLA scores between the control and experimental groups after the SPOC‐based flipped teaching program.

d p < 0.05 was considered significant (t-test).

Fig. 2 Basic image analysis of self-directed learning ability (SDLA) scores between the control and experimental groups before and after the SPOC‐based flipped teaching program. LM: learning motivation; SMS: self-management skills; CLS: cooperative learning skills; IL: information literacy; FS: final scores. Statistically significant differences are indicated with asterisks: *p < 0.05 or **p < 0.01; ns, not significant; t-test.

Fig. 2

3.3 Comprehensive score assessment

Table 3 shows the comparisons of the final comprehensive scores of the participants in the control and experimental groups in their fifth and sixth semesters. Following a semester of the SPOC‐based flipped teaching program, a significant difference was detected between the control and experimental groups (t = 2.162, p = 0.034). At the end of the second semester of the SPOC‐based flipped teaching program, the difference between the two groups remained significant at a p = 0.007 and t = 3.348 (Table 3). These results indicate that the SPOC‐based flipped teaching program can significantly improve the final comprehensive scores of nursing students. These findings suggest that the SPOC‐based flipped teaching model is beneficial in improving the SDLAs of nursing students.Table 3 Comparison of the final comprehensive scores between the control and experimental groups after the SPOC‐based flipped teaching program.

Table 3Semester	Control group (n = 133)	Experimental group (n = 131)	t-test	
Mean ± SDa	Mean ± SDa	t	p value	
Fifth semester	70.64 ± 7.83	74.17 ± 7.16	2.162	0.034b	
Sixth semester	72.95 ± 8.02	78.58 ± 7.42	3.348	0.007b	
a SD, standard deviation.

b p < 0.05 was considered significant (t-test).

4 Discussion

In this study, the SDLAs of nursing students markedly improved after undergoing the SPOC‐based flipped teaching program. Through the independent study of course resources, access to relevant materials, completion of knowledge system construction, and knowledge reprocessing through in-class group discussions and teacher guidance, the experimental group's LM, SMS, CLS, and IL levels improved (Table 2). Furthermore, compared to the control group, the experimental group gained higher final comprehensive scores through the SPOC‐based flipped teaching program (Table 3). These results suggest that the SPOC‐based flipped teaching model is effective for cultivating the SDLAs of nursing students. These findings corroborate previous reports which demonstrated that the SPOC‐based flipped teaching model is beneficial for enhancing the learning ability and nursing skills of nursing students [2,9,44,45].

Studies have shown that the motivation for learning encompasses beliefs, self-efficacy, and interests, which refer to the internal motivation directly driving students' engagement and understanding of course materials [46,47]. The SPOC‐based flipped teaching model promotes inquiry-based learning and creates an excellent interactive environment through group discussions, classroom presentations, and teacher guidance. These approaches improve students’ participation, motivation, and interest in learning, leading to increased engagement in the learning process [48,49]. Furthermore, this model created a favorable classroom atmosphere, where teachers and students felt more connected, and students no longer felt controlled in the classroom, which led to students actively engaging in learning and expressing themselves. As a result, they gradually established connections between knowledge acquisition, reflection, and review, resulting in enhanced long-term knowledge retention and overall improvement in learning outcomes.

Previous studies have noted the importance of self-management ability in learners to effectively mobilize their motivation and regulate learning to achieve learning goals [50,51]. This ability includes determining learning needs, time management, and monitoring skills, which are at the core of SDLA. The level of self-management ability is an important factor that influences social adaptation, activity performance, and psychological health of individuals, and the lack of self-management ability often results in an inability to make reasonable use of time after school [51,52]. Compared with the teacher-centered traditional teaching method, the SPOC‐based flipped teaching model interlinks all stages of implementation, with students playing the central role at each stage [2,9,44,45]. In the pre-class step, students are able to determine the learning time, adjust their learning progress, and control the learning duration based on their individual circumstances. In addition, the SPOC platform automatically records the learning materials, which encourages students to not only take the initiative to build their own knowledge system but also monitor and evaluate their learning process and outcome, thereby effectively improving their SDLAs.

Cooperative learning refers to the ability of learners to overcome learning difficulties by utilizing relevant learning materials and social resources, which is crucial for fostering autonomous learning [53,54]. The difference between SPOC‐based flipped teaching and traditional teaching lies beyond the teaching method and encompasses educational philosophy and teaching approaches. The SPOC‐based flipped teaching model emphasizes the cultivation of students' comprehensive abilities. This is achieved by designing discussion areas on the SPOC platform and facilitating small group discussions during the lesson, which allow students to collaborate naturally in an environment where they can help each other and make effective use of objective prompts and various resources for thinking and reflection. This approach has benefits such as improving students’ thinking ability, mutual learning, and teamwork skills [2,9,55,56].

In the context of the SPOC‐based flipped teaching model, IL refers to learners' ability to clearly recognize their information needs, determine, evaluate, and utilize information effectively, and communicate information in different ways [14,57,58]. The American Curriculum Management Association regards IL as an integral part of student education and encourages schools to integrate IL content into their teaching curriculum. In China, where education has undergone rapid development and the government has made a substantial investment in education resources, public schools are well-equipped with resources, such as books and networks. These schools also offer resource retrieval courses to enhance students’ IL, enabling them to excel in both traditional learning and self-directed learning processes.

5 Conclusions

SDLAs play a crucial role in the success of the SPOC‐based flipped teaching model, and conversely, this program promotes the improvement of SDLAs. Undergraduate nursing students are the backbone of clinical nursing work, and cultivating their SDLAs is important for both individual and social development. As a new and highly integrated learning model, the SPOC‐based flipped teaching program emphasizes students' learning instead of teachers' teaching and fully leverages students' learning autonomy, which in turn enhances students' interest in learning and their professional identities and roles. In this study, the application of this program in the Surgical Nursing course improved undergraduate nursing students' SDLAs, and we recommended its introduction and promotion to other courses for nursing majors. A limitation of this study is that the relatively short duration of the implementation of this program may have resulted in some indicators not reaching the expected effects. Future research should extend the implementation time and explore whether its impact on students’ SDLAs remains consistent or changes.

Ethical approval statement

This study was reviewed and approved by the Medical Ethics Committee of Huzhou University, with the approval number: 2019‒12‒11.

Data availability statement

Data included in article/supplementary material/referenced in article.

Funding

This work was supported by the first batch of teaching reform research projects in the 13th Five-Year Plan of Higher Education in Zhejiang Province (jg20180513).

CRediT authorship contribution statement

Juling Xu: Writing – original draft, Project administration, Methodology, Funding acquisition, Data curation. Sanxiong Huang: Writing – review & editing, Supervision, Conceptualization. Chengliang Wu: Resources, Formal analysis, Data curation. Yujie Ren: Methodology, Investigation, Data curation. Qiannan Li: Software, Investigation, Data curation. Jiali Cai: Visualization, Investigation, Data curation. Chunsheng Wang: Writing – original draft, Software. Peiyu Jiang: Writing – original draft, Validation.

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.

Appendix A Supplementary data

The following is the supplementary data to this article:Multimedia component 1

Multimedia component 1

Acknowledgements

The authors thank all students who voluntarily agreed to participate in this study.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.heliyon.2024.e36698.
==== Refs
References

1 Arreciado Marañón A. Isla Pera M.P. Theory and practice in the construction of professional identity in nursing students: a qualitative study Nurse Educ. Today 35 2015 859 863 10.1016/j.nedt.2015.03.014 25863650
2 Chi M. Wang N. Wu Q. Cheng M. Zhu C. Wang X. Implementation of the flipped classroom combined with problem-based learning in a medical nursing course: a quasi-experimental design Healthcare 10 2022 2572 10.3390/healthcare10122572 36554095
3 Mojarad F.A. Hesamzadeh A. Yaghoubi T. Exploring challenges and facilitators to E-learning based education of nursing students during COVID-19 pandemic: a qualitative study BMC Nurs. 22 2023 278 10.1186/s12912-023-01430-6 37608368
4 Liesveld J. Rohr J. Petrovic K. Grohman S. Bourgeois C.L. Nursing student challenges during the COVID-19 pandemic from 2020 to 2021: a thematic analysis Teach. Learn. Nurs. 18 2023 50 55 10.1016/j.teln.2022.10.006 36349287
5 Noviani W. Chong M.C. Tang L.Y. Socialization in professional reality integration for nursing student transition (SPRINT) to improve professional competence: a quasi-experimental study Heliyon 9 2023 e13433 10.1016/j.heliyon.2023.e13433
6 Fox A. From MOOCs to SPOCs Commun. ACM 56 2013 38 40 https://dl.acm.org/doi/10.1145/2535918
7 Zheng M. Chu C.C. Wu Y.J. Gou W. The mapping of on-line learning to flipped classroom: small private online course Sustainability 10 2018 748 10.3390/su10030748
8 Förster M. Maur A. Weiser C. Winkel K. Pre-class video watching fosters achievement and knowledge retention in a flipped classroom Comput. Educ. 179 2022 104399 10.1016/j.compedu.2021.104399
9 Li H. Zhao W. Li B. Li Y. Effects of the small private online course combined with simulation-based training in a patient safety education program among nursing students: a quasi-experimental study Int. J. Nurs. Sci. 10 2023 555 561 10.1016/j.ijnss.2023.09.014 38020829
10 Xu Z. Shi Y. Application of constructivist theory in flipped classroom — take college English teaching as a case study Theor. Pract. Lang. Stud. 8 2018 880 887 10.17507/tpls.0807.21
11 Avdal E.Ü. The effect of self-directed learning abilities of student nurses on success in Turkey Nurse Educ. Today 33 2013 838 841 10.1016/j.nedt.2012.02.006 22405343
12 Park S. Cho S. Lee J.Y. The effects of social concern goals on the value of learning and on the intentions of medical students to change their majors Med. Educ. Online 22 2017 1330631 10.1080/10872981.2017.1330631
13 Yang Y. Yu D. Research and practice of outcome directed SPOC teaching model Proceedings of the 2019 3rd International Conference on Education and E-Learning 2019 Association for Computing Machinery New York, NY, USA 46 51 10.1145/3371647.3371672
14 Hadad S. Shamir-Inbal T. Blau I. Leykin E. Professional development of code and robotics teachers through small private online course (SPOC): teacher centrality and pedagogical strategies for developing computational thinking of students J. Educ. Comput. Res. 59 2021 763 791 10.1177/0735633120973432
15 Haslam M.B. What might COVID-19 have taught us about the delivery of Nurse Education, in a post-COVID-19 world? Nurse Educ. Today 97 2021 104707 10.1016/j.nedt.2020.104707
16 Park H.J. Kim S. Relationship between super-leadership and self-directed learning ability in online nursing education: the mediating effects of self-leadership and self-efficacy perceptions Heliyon 9 2023 e17416 10.1016/j.heliyon.2023.e17416
17 Park J.M. Seo H.J. Kim S.M. Kang H. Lee S.J. Association between COVID-19-related stress and self-directed learning ability among Korean nursing students Nurse Educ. Pract. 69 2023 103613 10.1016/j.nepr.2023.103613
18 Brewer R. Movahedazarhouligh S. Successful stories and conflicts: a literature review on the effectiveness of flipped learning in higher education J. Comput. Assist. Learn. 34 2018 409 416 10.1111/jcal.12250
19 Szymkowiak A. Melović B. Dabić M. Jeganathan K. Kundi G.S. Information technology and gen Z: the role of teachers, the internet, and technology in the education of young people Technol. Soc. 65 2021 101565 10.1016/j.techsoc.2021.101565
20 Marra R.M. Hacker D.J. Plumb C. Metacognition and the development of self‐directed learning in a problem‐based engineering curriculum J. Eng. Technol. 111 2022 137 161 10.1002/jee.20437
21 Tekkol İ.A. Demirel M. An investigation of self-directed learning skills of undergraduate students Front. Psychol. 9 2018 2324 10.3389/fpsyg.2018.02324 30532727
22 Hill M. Peters M. Salvaggio M. Vinnedge J. Darden A. Implementation and evaluation of a self-directed learning activity for first-year medical students Med. Educ. Online 25 2020 1717780 10.1080/10872981.2020.1717780
23 Pan X. Technology acceptance, technological self-efficacy, and attitude toward technology-based self-directed learning: learning motivation as a mediator Front. Psychol. 11 2020 564294 10.3389/fpsyg.2020.564294
24 Cheng S.F. Kuo C.L. Lin K.C. Lee-Hsieh J. Development and preliminary testing of a self-rating instrument to measure self-directed learning ability of nursing students Int. J. Nurs. Stud. 47 2010 1152 1158 10.1016/j.ijnurstu.2010.02.002 20223455
25 Ghiyasvandian S. Malekian M. Cheraghi M.A. Iranian clinical nurses' activities for self-directed learning: a qualitative study Global J. Health Sci. 8 2015 48 58 10.5539/gjhs.v8n5p48
26 Gatewood E. Use of simulation to increase self-directed learning for nurse practitioner students J. Nurs. Educ. 58 2019 102 106 10.3928/01484834-20190122-07 30721310
27 Lee S. Kim D.H. Chae S.M. Self-directed learning and professional values of nursing students, Nurse Educ In Pract. 42 2020 102647 10.1016/j.nepr.2019.102647
28 Jin M. Ji C. The correlation of metacognitive ability, self-directed learning ability and critical thinking in nursing students: a cross-sectional study Nurs. Open 8 2021 936 945 10.1002/nop2.702 33570293
29 Gao Z. Zhang L. Ma J. Sun H. Hu M. Wang M. Reliability and validity of the Chinese version of the self-directed learning instrument in Chinese nursing students BMC Nurs. 22 2023 51 10.1186/s12912-023-01201-3 36823629
30 Li S. Ye X. Chen W. Practice and effectiveness of “nursing case-based learning” course on nursing student's critical thinking ability: a comparative study, Nurse Educ In Pract. 36 2019 91 96 10.1016/j.nepr.2019.03.007
31 Li S. de Ala M. Mao D. Wang A. Wu C. Effect of a nursing comprehensive skill training course (NCST-C) on nursing students' metacognitive awareness: a quasi-experimental study Asian Nurs. Res. 16 2022 275 281 10.1016/j.anr.2022.10.003
32 Wang Z. Liang Y. Zhao H. Zhu Y. Liu M. Zhang Y. Spiritual care perceptions and empathy of Chinese nursing students: the mediating roles of spiritual well-being, Palliat Support. Care 20 2022 701 710 10.1017/S1478951522001134
33 Etikan I. Bala K. Sampling and sampling methods, Biom. Biostat Int. J. 5 2017 215 217 10.15406/bbij.2017.05.00149
34 Abadiga M. Nemera G. Hailu E. Mosisa G. Relationship between nurses' perception of ethical climates and job satisfaction in Jimma University Specialized Hospital, Oromia region, southwest Ethiopia BMC Nurs. 18 2019 39 10.1186/s12912-019-0365-8 31485197
35 Tao Y. Li L. Xu Q. Jiang A. Development of a nursing education program for improving Chinese undergraduates' self-directed learning: a mixed-method study Nurse Educ. Today 35 2015 1119 1124 10.1016/j.nedt.2015.05.016 26070480
36 Luo R.Z. Zhang X.H. Zhang C.M. Liu Y.H. Impact of self-directed learning readiness and learning attitude on problem-solving ability among Chinese undergraduate nursing students Front. Nurs. 6 2019 143 150 10.2478/FON-2019-0021
37 Zhou T. Yin Y. Zhang H. Zhang J. Xu X. Zhang J. Subgroups of self-directed learning ability and their differences in professional identity among nursing undergraduates during the COVID-19 pandemic: a latent profile analysis BMC Nurs. 22 2023 122 10.1186/s12912-023-01295-9 37059992
38 Fisher M. King J. Tague G. Development of a self-directed learning readiness scale for nursing education Nurse Educ. Today 21 2001 516 525 10.1054/nedt.2001.0589 11559005
39 Zhang X. Li X. Manufacture of evaluation tool for self-learning ability of nursing specialty students Chin. Nurs. Res. 23 2009 639 640 10.3969/j.issn.1009-6493.2009.07.033
40 Cai X. Peng M. Qin J. Zhou K. Li Z. Yang S. Sandwich teaching improved students' critical thinking, self-learning ability, and course experience in the Community Nursing Course: a quasi-experimental study Front. Psychol. 13 2022 957652 10.3389/fpsyg.2022.957652
41 Meng Y. Song J. Yu X. Xu X. Zhang H. Design and evaluation of blended teaching in the smart classroom combined with virtual simulation training in basic nursing courses BMC Med. Educ. 23 2023 752 10.1186/s12909-023-04721-3 37821849
42 Chang C.Y. Hwang G.J. Gau M.L. Promoting students' learning achievement and self‐efficacy: a mobile chatbot approach for nursing training Br. J. Educ. Technol. 53 2022 171 188 10.1111/bjet.13158
43 Kesgin M.T. Tok H.H. The impact of drama education and in-class education on nursing students' attitudes toward violence against women: a randomized controlled study Nurse Educ. Today 125 2023 105779 10.1016/j.nedt.2023.105779
44 Wang S. Xu X. Li F. Fan H. Zhao E. Bai J. Effects of modified BOPPPS-based SPOC and Flipped class on 5th-year undergraduate oral histopathology learning in China during COVID-19 BMC Med. Educ. 21 2021 540 10.1186/s12909-021-02980-6 34702232
45 Tseng L.P. Hou T.H. Huang L.P. Ou Y.K. Effectiveness of applying clinical simulation scenarios and integrating information technology in medical-surgical nursing and critical nursing courses BMC Nurs. 20 2021 229 10.1186/s12912-021-00744-7 34781931
46 Yu M. Tong H. Li S. Wu X.V. Hong J. Wang W. Clinical competence and its association with self-efficacy and clinical learning environments among Chinese undergraduate nursing students, Nurse Educ In Pract. 53 2021 103055 10.1016/j.nepr.2021.103055
47 Chang C.W. Lin C.W. Huang C.Y. Hsu C.W. Sung H.Y. Cheng S.F. Effectiveness of the virtual reality chemical disaster training program in emergency nurses: a quasi experimental study Nurse Educ. Today 119 2022 105613 10.1016/j.nedt.2022.105613
48 Park H.R. Park E. Nursing students' perception of class immersion facilitators in psychiatric nursing: Team-based learning combined with flipped learning Nurse Educ. Today 98 2021 104653 10.1016/j.nedt.2020.104653
49 Xue E. Li J. Xu L. Online education action for defeating COVID-19 in China: an analysis of the system, mechanism and mode Educ. Philos. Theor. 54 2022 799 811 10.1080/00131857.2020.1821188
50 Liu J.Y. Liu Y.H. Yang J.P. Impact of learning adaptability and time management disposition on study engagement among Chinese baccalaureate nursing students J. Prof. Nurs. 30 2014 502 510 10.1016/j.profnurs.2014.05.002 25455332
51 Liu Y. Li Y. Cui X. Zhou H. Wang J. Zhang Y. Clinical study on flipped classroom and mind map in newly recruited nurses' pre-job training BMC Nurs. 21 2022 72 10.1186/s12912-022-00843-z 35351110
52 Tharani A. Van Hecke A. Ali T.S. Duprez V. Factors influencing nurses' provision of self-management support for patients with chronic illnesses: a systematic mixed studies review Int. J. Nurs. Stud. 120 2021 103983 10.1016/j.ijnurstu.2021.103983
53 Zhang J. Cui Q. Collaborative learning in higher nursing education: a systematic review J. Prof. Nurs. 34 2018 378 388 10.1016/j.profnurs.2018.07.007 30243695
54 Dong Y. Yin H. Du S. Wang A. The effects of flipped classroom characterized by situational and collaborative learning in a community nursing course: a quasi-experimental design Nurse Educ. Today 105 2021 105037 10.1016/j.nedt.2021.105037
55 Zhang L. Xuan Y. Zhang H. Construction and application of spoc‐based flipped classroom teaching mode in installation engineering cost curriculum based on obe concept Comput. Appl. Eng. Educ. 28 2020 1503 1519 10.1002/cae.22320
56 Hu K. Ma R.J. Ma C. Zheng Q.K. Sun Z.G. Comparison of the BOPPPS model and traditional instructional approaches in thoracic surgery education BMC Med. Educ. 22 2022 447 10.1186/s12909-022-03526-0 35681190
57 Robinson L. Bawden D. Identifying good practices in information literacy education: Creating a multi-lingual, multi-cultural MOOC Kurbanoğlu S. Boustany J. Špiranec S. Grassian E. Mizrachi D. Roy L. Information Literacy in the Workplace. ECIL 2017. Communications in Computer and Information Science 2018 Springer 715 727 10.1007/978-3-319-74334-9_73 2018
58 Ali K.A.G. Khalil H.E.M. El-Sharkawy F.M. Impact of online remote education on the learning process among nursing students Open J. Nurs. 10 2020 810 830 https://www.scirp.org/journal/paperinformation.aspx?paperid=102859
