The study was conducted by obtaining the ethics committee document dated 22.11.2021 and numbered 1598 from Siirt University Ethics Committee.
The students participating in the study consisted of three groups. The gastric anatomy and histology course were completed in 2 hours (one hour of theoretical, one hour of practical). Group 1 and Group 2, who participated in the research, attended one hour of theoretical lecture in the classroom. Group 3 followed the theoretical lesson through the mobile application. The institution's standard curriculum or didactic content for mobile learning was similar in both education methods. Group 1 was given the anatomy and histology book [24, 25] for theoretical lesson and the anatomy and histology atlas [26, 27] for the applied lesson. In addition, classical model and light microscope applications were shown to Group 1.
Collection of Data
Before starting the education, students were given a student introduction form and a knowledge exam (pre-test) and asked to answer them. After answering, the students were divided into groups. All three groups were asked to fill out the State-Trait Anxiety Inventory (STAI). Group 3 was transferred to another class. They were told how to use the smart model and mobile application, and they were given two hours to study. Group 1 and Group 2 were given theoretical education at the same time. Group 1 was then taken to another classroom to study classical models, the light microscope, and textbooks for an hour together. After explaining the smart model and mobile application, group 2 was given one hour to work with the smart model education set. Afterward, the post-test and state anxiety scale was distributed to all groups, and they were asked to answer.
The research is a randomized controlled study and was conducted with nursing students who took anatomy and histology courses in the fall semester of 2021. Power analysis was performed using a statistical power analysis software, G*Power, version 18.104.22.168 (Heinrich Heine University, Düsseldorf, Germany) to establish the research sample and determine the required number of students . The number of students in each group was determined as 45 to carry out a study at the P≤0.1 level.
Design of Study and Randomization
The study was devised as a randomized controlled trial. During the randomization of the research, using the website , students were divided into Group 1 (classical education group, n=46), Group 2 (smart model education set and theoretical expression group, n=47), and Group 3 (smart model education set group, n=45) (Fig. 1).
Data Collection Tools
Data collecting was made using the student introduction form, knowledge exam on gastric anatomy and histology, and STAI.
Student introduction form
This form consists of data including socio-demographic characteristics of participants such as gender and age. The student introduction form consists of a total of five questions.
State-trait anxiety inventory
The State-Trait Anxiety Inventory (STAI) was improved by Spielberger et al . It has two subscales measuring different types of anxiety: state anxiety (STAI-S subscale) and trait anxiety (STAI-T subscale). The scale was translated into Turkish in 1983 . Each subscale is graded on a four-point Likert-type scale and comprise of 20 items. The response options in the four classes of the State Anxiety Inventory (STAI-S) are: (1) None, (2) A few, (3) A lot, and (4) Completely. The Trait Anxiety Inventory (STAI-T) has the following options: (1) Almost never, (2) Sometimes, (3) Often, and (4) Almost always. Scores from both subscales theoretically vary between 20 and 80 points. High scores demonstrate high anxiety levels. Low scores indicate low anxiety levels .
Knowledge exam on Gastric Anatomy and Histology
Gastric anatomy and histology questions were prepared according to the literature (25, 26) and consisted of 20 multiple-choice questions. Each question score was calculated as 0.5 points. The highest score that can be taken from the exam was identified as 10 points, and the lowest score was 0 points. Exams were given to all groups in the same format. The pre-test and post-test exams included the same questions. An equal number of questions were asked about stomach anatomy and histology.
Development of the model
The education set, which consists of smart interactive models and software programs, consists of two main parts, including hardware and software parts. The hardware part consists of touch sensors that show models of organs or tissues on a three-dimensional smart model with light and sound explanations. The software part was developed to reach detailed, up-to-date information about tissues or organs that represent the smart model. This information can be accessed by scanning the QR code on the model via any smart device.
Both the outer surface and one half of the inner surface of the smart model, which is attached to each other with a hinge and can be opened and closed in twofold, have the appearance that reflects the macroscopic (anatomical) feature of the relevant organ or tissue. The other half of the inner surface of the same model has an appearance that reflects the microscopic (histological) feature of the relevant organ or tissue. The histological surface will be placed on the model by enlarging the microscopic image of the section of the tissue or organ it belongs to. There are touch sensors on the places corresponding to each formation on the smart model, and when these are pressed, audible information about that formation is given. In addition, when the name of any of the formations is spoken, this spoken word is detected by the microphone embedded in the system, and audio information about it is given through the built-in speaker. Thus, both macroscopic and microscopic visual education is integrated with theoretical information on the same model, and interactive education is provided. Having different apparatus such as speakers, microphones and headphones offer comfort and options while studying while giving voice information through the device. In addition, since the borders of the pressed area are shown on the model with light, the student can better understand which area they are working on (Fig. 2).
Multimedia (multimedia) used in the teaching-learning process is educational designs that enable learners to become active by integrating video, animation, visual, diagram, sound, etc., types through information Technologies . The use of both verbal and visual features in instructional materials enables the two parts of memory to work together, making learning easier [34-36]. Technology and multimedia products support students' learning and individual work. In order for these products to be successful, they must be developed with certain principles. "Mayer's Multimedia Design Principles" were taken into consideration in the mobile application developed in this context [37, 38] (Table 1).
The Anatomitas mobile application was improved using a Web 2.0 tool called mobiroller . The android package kit (APK) of the developed mobile application named "anatomitas.apk" was uploaded on two experimental group phones. The algorithm of the developed mobile application is shown in Figure 3.
The developed Mobile Application consists of 8 sections. These sections are, lecture notes, lecture videos, pill information, screening test, notepad, favorites, contact, and about us (Fig. 4).
Lecture notes, videos, pill information, and screening test was divided into 11 systems (Fig. 5a). For the research, only the stomach structure of the digestive system was developed in the mobile application. Users were able to access the theoretical documents on stomach offline whenever they wanted (Fig. 5b). The videos were uploaded to the Youtube channel, and the students were able to watch the Youtube videos embedded in the mobile application (Fig. 5c). Other parts of the application consist of the note-taking section where they write the notes they want, the favorite section where they can save the pages they want, and the contact sections where they can contact the mobile application developer.
There is a QR code system on the smart model that can be integrated with devices such as smartphones and tablets. Through this integration, when the person reads the QR code with his smart device, he can easily access all documents, videos, and relevant organ or tissue simulations. This system also allows up-to-date information to be added to the system at any time, thanks to its ability to be updated. The microprocessor card in the model hardware can also be updated when necessary with Wifi and USB input, as in the software. The model can be controlled via the application and can receive simultaneous commands.
State and trait anxiety scales and the compatibility of the achievement levels before and after the education were examined with the Kolmogrov Smirnov test. It was seen that the data were in accordance with the normal distribution. Significant difference of data between groups was analyzed with one-way analysis of variance, and variation for the group was analyzed with t-test in dependent groups. Cohens' d statistics were calculated to determine the effect size. Analyzes were performed with SPSS 20.0 software at 95% confidence level.