The quantitative phase Method

Design. A quasi-experimental study with the Solomon four-group design was conducted in the first and the second semesters of the 2020 academic year and the first semester of the 2021 academic year in Shiraz University of Medical Sciences, Shiraz, Iran. The Solomon design¹⁷⁾ is one of the most powerful quantitative research designs which eliminates the confounding effects of the pretest on the results (Table 1). This phase aimed to evaluate the effects of MBE on NSC among nursing students.

Study setting and participants. This study was conducted in Hazrat-e Fatimah Faculty of Nursing and Midwifery of Shiraz University of Medical Sciences, Shiraz, Iran. This university is the largest university in the south of Iran and one of the leading universities in this country. The faculty admits BSN students in both the first and the second semesters of each academic year. Study participants were second-year BSN nursing students in the 2020 (n=74) and 2021(n=43) academic years. Only second-year students were included because they may have low NSC.¹⁸ Also, due to the fact that some time has passed since the second-year nursing students attended the nursing faculty, they are familiar with nursing courses and they have one semester of experience in the clinical environment, the researchers have chosen them to conduct the intervention. All enrolled second-year BSN students were recruited for participation. Participation was voluntary; thus, students who were reluctant to participate and those who did not complete the instrument in its entirety were excluded.

Instrument. Cowin’s Nurse Self-Concept Questionnaire (NSCQ) was used for NSC assessment. This questionnaire has 36 items in six six-item dimensions, namely general self-concept, knowledge, care, communication, staff relations, and leadership. All items are positively worded and are scored on a 1-8 Likert scale, resulting in a total score of 36-288 with higher scores representing greater NSC. Previous studies reported the acceptable validity and reliability of the Turkish,¹⁹ Chinese,²⁰ and Persian²¹ versions of this questionnaire. Participants completed the Persian version of this questionnaire through the self-report method. According to the Persian study, Cronbach's alpha of the total questionnaire was 0.95, and in the dimensions of general self-concept (0.96), care (0.91), knowledge (0.91), communication (0.94), staff relations (0.92), and leadership (0.94) were estimated.²² The reliability of the questionnaire was also investigated in a pilot study on nursing students; after completing the questionnaire by 30 nursing students except for students in the study groups, Cronbach's alpha of total questionnaire (0.96) and different dimensions of general self-concept (0.96), care (0.88), knowledge (0.88), communication (0.92), staff relations (0.91), and leadership (0.94) were confirmed.

Intervention. Students in the first and the second semesters of the 2020 academic year (n=39 and 35, respectively) were considered as the control 1 (C1) and the control 2 (C2) groups, respectively. Participants in these groups received no MBE or NSC-related intervention. Students in the C1 group were assessed for NSC both at the pretest and the posttest while their counterparts in the C2 group were assessed for NSC only at posttest. Second-year nursing students in the first semester of the 2021 academic year were randomly allocated to two experimental groups, namely the E1 (n=22) and the E2 (n=21) groups. MBE was provided to all students in these two experimental groups in a similar way. Students in the E1 group were assessed for NSC both at the pretest and the posttest while students in the E2 group were assessed for NSC only at the posttest. Posttest in both experimental groups was performed one month after providing them with the educational program.

The intervention of the study was a multimedia MBE program which was provided through an Android application. Educational materials were provided in the three main categories of professional values (namely professional ethics and autonomy), life skills (namely self-esteem, stress and adaptation, critical thinking, and communication skills), and managerial skills (namely teamwork, self-regulation, and leadership). These three categories were developed based on a qualitative study into the factors affecting nursing students’ NSC.²³ The content of the program was developed using relevant articles and textbooks and was approved by five nursing instructors from Shiraz University of Medical Sciences, Shiraz, Iran. Educational audio and video clips of the program were produced using the Camtasia program. With an appointment, the first author of the study held a twenty-minute session with participants in the experimental groups and provided them with the Android application of the study intervention through the SHAREit application. Participants installed the application on their tablets or mobile phones and then, the first author provided them with explanations about how to use the application and its different parts. The first author supervised and supported them through the WhatsApp application and telephone contacts. Accordingly, all participants in the experimental groups were added to a WhatsApp group managed by the first author, where they could text and interact with each other and the group manager about the use of technology and discussion of teaching topics. There was no time limit on student interaction and text on WhatsApp group. The final discussion and conclusion were done at the end of the study of each main category of MBE. The students completed MBE in eight weeks.

Data analysis. Data were analyzed through the SPSS software (v. 21.0). The Kolmogorov-Smirnov test showed that all variables of the study had normal distribution (p<0.05). Therefore, the independent-sample t, paired-sample t, and Chi-square tests as well as the one-way analysis of variance were used for data analysis. The data were presented using the measures of descriptive statistics, including frequency, mean, and standard deviation.

The qualitative phase method

Design. A descriptive qualitative study was conducted in the first semester of the 2021academic year through the conventional content analysis approach to explore participants’ experiences of the study intervention.

Participants and data collection. Participants were six students purposively recruited from the E1 (n=3) and E2 (n=3) groups. They were selected from those students who had the smallest and the biggest pretest-posttest changes in the mean score of NSC. Personal semi-structured interviews were held with these six students. Besides, two focus group discussions were held with a group of six students and another group of five students. At this stage, no new data was extracted and we reached data saturation. The participants of the focus groups were different from the personal interviews. Interviews and focus groups were started using these open-ended questions, “What were the effects of the educational program on your attitude towards the nursing profession?” “What was your perception of yourself as a nurse after the program?” and “May you please provide examples of your behaviors which can show the effects of the program?”. Pointed questions were also used to collect more detailed data. Interviews were held in a room in the first author’s workplace and focus group discussions were held in a conference room in the study setting. Face to face interviews and focus group discussions lasted 30-60 minutes, were digitally recorded, and transcribed verbatim. The transcripts were imported to the MAXQDA 2007 software for data management and analysis.

Data analysis. Data were analyzed through Graneheim and Lundman five-step conventional content analysis approach. The first researcher independently analyzed the data. Accordingly, each transcript of the data was read several times by the first researcher in order to grasp its main ideas. Then, meaning units were determined and coded. Generated codes were categorized according to similarities and finally, the latent content of the data was identified and presented in the form of main categories and themes.²⁴

Trustworthiness. Lincoln and Guba’s criteria were used to establish trustworthiness.²⁵ Credibility was ensured through prolonged engagement with the study subject matter, member checking, peer checking, and sampling with maximum variation in terms of participants’ gender and change in the mean score of NSC. Bracketing, peer checking, and constant comparison of the data helped establish dependability. Confirmability was ensured through keeping all documents related to the study and performing external peer checking. Moreover, clear explanations were provided about participants’ characteristics, study setting, sampling, data collection, and findings in order to ensure transferability.

Ethical considerations. The Ethics Committee of Shiraz University of Medical Sciences approved the study (IR.SUMS.REC.1397.215). An opening session was held with participants in order to inform them about the study, the voluntariness of participation, freedom to withdraw from the study, and confidentiality of the study data. Students who participate in the study were not the researchers' students, they have no coercion for participation and ensure that refusal to participate or remain in the study would never affect their final evaluation scores. Participants signed the written informed consent form of the study. At the end of the study, the Android application of the study intervention was provided to all participants in the control groups.

The findings of the quantitative phase

Two students in C1, two students in C2, two students in E1, and one student in E2 were excluded due to unwillingness to participate or continue in the study. Finally, the data of 37 students in C1, 33 students in C2, 20 students in E1, and 20 students in E2 were analyzed. The means of participants’ age and grade point average were 21.38±2.92 years and 15.27±1.99, respectively. The Iranian grades point average ranges from 0 to 20. The passing grade is 10. Grades 17 or more are considered excellent, grades 14 to 16.99 are considered good and grades 10 to 13.99 are considered acceptable. Students having 9.99 or less fail.

50.9% of participants were female. Most participants were single (88.2%) and had no clinical work experience (90.0%). Groups did not differ significantly with respect to participants' age, grade point average, gender, marital status, and clinical work experience (p<0.05; Table 2).

Table 3 showed no significant difference between the E1 and the C1 groups respecting the pretest mean scores of NSC and all its dimensions (p>0.05). Table 3 indicated that in the E1 group, the post-test means scores of NSC and all its dimensions except for the care dimension were significantly greater than their corresponding pretest values (p<0.05). However, the mean scores of NSC and its dimensions did not significantly change in the C1 group (p>0.05). It revealed that except for the mean score of the care dimension, the differences between the E1 and the C1 groups and between the E2 and the C2 groups respecting the posttest mean scores of the dimensions of NSC were statistically significant (p<0.05). Table 3 also showed that the differences between the E1 and the E2 groups and between the C1 and the C2 groups respecting the posttest mean scores of NSC and its dimensions were not statistically significant (p>0.05). These findings confirmed that the pretest mean scores had no significant effects on the corresponding posttest mean scores.

The results of the qualitative phase

The participants ranged in age from 19-25 years (9 women and 8 men).

Participants’ main perception of the effects of NSC-related MBE was Multidimensional Growth and Development that refers to the development of personal and professional knowledge and abilities which improve students’ NSC and pave their way for professional development. The three main categories of this theme were development of coping strategies, knowing professionalization strategies, and development of managerial potentials.

Development of coping strategies. Coping strategies are a set of cognitive and behavioral efforts for managing and controlling stressful situations. According to the participants, many different stressors affect nursing students. The ineffective management of these stressors can cause problems such as poor NSC and college dropout. Participants noted that the study intervention improved their ability to cope with and manage their stress: In the previous term, we had the clinical course of the Fundamentals of Nursing. Sometimes, I experienced stress and decided to drop out. But, now I know how to manage my stress and feel lower stress. I see that the educational program has had positive effects (P. 8). Participants also noted that they had problems in finding appropriate information for managing their problems and confirmed that the study intervention improved their abilities to find appropriate information and to manage their problems: I learned that we should not be routine-oriented persons; rather, we should think about the possible solutions to problems, study or ask experienced persons about them, and use the internet or any other resources in order to find the best solutions which can prevent many other problems (P. 4). Participants’ experiences also showed the positive effects of the study intervention on their NSC and their image of nursing. They noted that improvement in NSC and professional image is a type of internal strengthening. Positive changes in students’ professional image helped them value themselves and their profession and more effectively cope with problems. Participants noted that the provision of such NSC-related educations to students at university can significantly improve their NSC as nurses: Participation in this program caused me enjoy to be a nurse. I tell myself that I can be one of the best nurses in a near future (P. 13).

Recognition of professionalization strategies. Participants also noted that participation in the NSC-related MBE program helped them recognize professionalization strategies, including development of communication skills, promotion of teamwork, dynamic learning, and NSC improvement. They considered effective communication as a key requirement of professional role performance in nursing and noted that they needed to learn communication skills in order to establish effective interpersonal communications: Previously, I knew almost about 30% of communication skills; but now I know that communication skills have many different aspects, know many things about them, and will definitely use them (P. 11). Participants believed that besides professional knowledge, nursing staff should learn communication and teamwork skills. They noted that the study intervention gave them a positive attitude towards teamwork and helped them appropriately learn many things about teamwork: The program appropriately taught us the principles of teamwork and showed us how to do teamwork and establish interpersonal communication in different clinical situations (P. 7). Participants also referred to the positive effects of the study intervention on their motivation for developing their professional knowledge and clinical skills. They noted that after the intervention, they not only did not escape from the lessons, but also attempted to learn modern teaching methods. Their comments also showed that they were interested in the process of MBE and considered it beneficial and applicable: Now, I know that I need to study more. When I’m idle, I use internet or study the terminology book. I attempt to know more about illnesses in order to develop my knowledge before attending our clinical courses (P. 5); MBE is very good. It is always accessible and easy to use (P. 13).

Development of managerial potentials. The third main category of the multidimensional growth and development main theme was the development of students’ managerial skills. Participants noted that despite the importance of management and leadership, they had received little education, if any, in these areas during the first years of their university education and hence, did not have a good understanding about nurses’ managerial roles. They highlighted that the study intervention had positive effects on their understanding of the principles of nursing management: Now, I understand the tasks of a manager and know that he/she organizes the affairs, fairly assigns tasks to different staff, supervises their task performance, and knows the responsibilities of each staff (P. 5). Participants also highlighted the necessity of providing students with education about professional management and leadership in order to improve their managerial and leadership skills. They also acknowledged that performing any professional task or role of nursing necessitates the use of different managerial and leadership skills: The management part of the program was very good because each nurse needs to have managerial power. Even a simple nurse who is not a head nurse should know these things because this knowledge enables him/her to plan for patient care or promote collaboration among healthcare providers, from service workforces to physicians (P. 6).

Integration of the results of the quantitative and the qualitative phases

The results of both quantitative and qualitative phases indicated the effectiveness of the NSC-related MBE program on nursing students’ NSC and its dimensions, except for its care dimension.