Knowledge, self-efficacy, satisfaction, and self-confidence of nursing students for stoma care using active learning methods: a controlled experimental study

doi:10.21203/rs.3.rs-4687725/v1

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Knowledge, self-efficacy, satisfaction, and self-confidence of nursing students for stoma care using active learning methods: a controlled experimental study

https://doi.org/10.21203/rs.3.rs-4687725/v1

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Background: An intestinal stoma is a surgery in which an artificial opening (stoma) is made in the abdomen to bypass the outflow of faeces. It is essential to provide training in stoma therapy as a core competency for nursing students to ensure optimal care for patients’ rehabilitation, occupational, social and family needs. While nursing skills are mainly taught through traditional teacher-centred lectures, the use of active learning methods can improve students’ competencies.

Objectives: To assess knowledge about stoma care in relation to the level of learning methods and to measure students' self-confidence, satisfaction and self-efficacy with the training received using different levels of fidelity, including simulation.

Design: Controlled experimental study involving three groups, with a pretest and post-test design. Settings: Faculty of Nursing of two Spanish public universities. Participants: Third-year nursing students during the academic year 2022-2023.

Methods: Group A received traditional teaching methods and low-fidelity simulation, group B received traditional teaching methods and high-fidelity simulation and group C received active learning methods and high-fidelity simulation. The instruments for data collection were the Nursing Outcomes Classification: "Knowledge: Ostomy Care [1829]” and its indicators, self-efficacy, and student satisfaction-self-confidence with learning. Results: Significant differences were found in 14 of the 15 NOC indicators measured between groups. The analysis of self-efficacy indicated notable differences in scores between the different groups after the intervention. For satisfaction and self-confidence, there were also significant differences, with group C (active learning methods and high-fidelity simulation) having the highest scores. Conclusions: Active learning methods are considered instruments that appear to improve ostomy knowledge and the degree of fidelity of the simulation impacts on student satisfaction and self-confidence in learning.

Active learning

Nursing Education

Simulation

Surgical Stomas

Virtual Reality

An intestinal stoma is a surgical opening created in the abdominal wall to allow the passage of faeces from the intestine to an external collecting device, bypassing the usual route through the rectum and anus. Many diseases lead to its creation; however, colorectal cancer, the third most diagnosed cancer worldwide (American Cancer Society, 2023), is the main cause (Capilla-Díaz et al., 2019). People with ostomies experience changes that result in impaired body image, depression, social isolation, etc. (Duque & Campino-Valderrama, 2019), often requiring educational interventions to address them. The ability to perform stoma care can provide the competence of the ostomate to feel confident in the management of the ostomy and improve their quality of life. The stoma care nurses are the main provider of care to these people, offering them strategies to address their new reality, ensure continuity of care, minimise complications, and reduce costs and hospitalisation time, among others (Capilla-Díaz et al., 2019). Therefore, it is essential to integrate stoma care training as a fundamental competency for nursing students to ensure optimal care and support their professional, social, and familial adaptation. (Monteiro et al., 2020). However, nursing techniques are mainly taught by traditional teacher-centered lectures and demonstrations, which no longer seem to meet students' needs (Kweon & Choi, 2020).

Currently, there is a significant change occurring in the clinical learning experiences of graduate nursing students. However, stoma care training still relies largely on physical manikins (Andersen & Cox, 2020; Handeland et al., 2021) more than in active learning methods (ALMs), such as flipped classroom or virtual reality (VR). Among the great challenges posed by the European Higher Education Area ALMs stand out, where the student is the protagonist of his or her learning, adopting an active, creative, and autonomous role (Mujica & Orellana, 2019). For their part, Information Technologies have replaced traditional teaching methods with new digital learning spaces, thereby helping in the integration of ALMs into teaching processes. Their use increases motivation by achieving attractive, fun, and meaningful learning that improves the quality of the teaching-learning process (Canales-García et al., 2020). These techno-methodological changes have promoted new forms of knowledge transmission with great educational potential (Cabral Melo et al., 2022). Flipped Classroom (FC), Gamification and simulation are considered innovative and improve academic results (Mendez et al., 2020; Parra-González et al., 2020). Simulation allows clinical and decision-making skills to be practiced in a safe and controlled learning environment avoiding patient safety issues and ethical concerns (Ulenaers et al., 2021). The use of ALMs in nursing is seen to improve the different competencies of students, such as Evidence-Based Practice (Ruzafa-Martínez et al., 2023) or perceived clinical and cultural competencies (Fung et al., 2023), which are essential for the profession. To date, no study has assessed knowledge, self-confidence, satisfaction, and self-efficacy with ALMs and virtual reality simulation in learning how to care for people with ostomies. Thus, the results of this study could shed light on future educational modes for developing clinical competencies in ostomy care-related content. Therefore, the aims of this study are a) to assess knowledge about stoma care regarding level of learning methods; and b) to measure students' self-efficacy, satisfaction and self-confidence with the training received from the level of fidelity, including simulation.

2.1 Study design and setting

A controlled experimental study was conducted to evaluate the knowledge about stoma care, the self-efficacy, and satisfaction-self-confidence with the use of different learning methods and different levels of simulation in nursing students. The research design can be seen in Figure. 1 (Fig. 1). Group A-GA included traditional teaching methods and low-fidelity simulation, group B-GB, included traditional teaching methods and high-fidelity simulation (HFS) and group C-GC, included active learning methods (ALMs) and HFS. The data collection period was from November to December 2022, at two different times, one week apart. The study design and procedures conform to the criteria of the "CONSORT - Simulation-Based Research Extension”.

Figure 1 Research design

2.2 Participants

The target population was all third-year nursing students enrolled in two Spanish Nursing Faculties of two public universities (academic year 2022–2023) (n = 429) taking the subject "Adult Nursing III" at the University of Granada (UGR) (GC and GA) and the subject "Clinical Nursing III" at the University of Jaén (UJA) (GB), all of them taught in the third year of the fifth semester. In these courses, the content of the training in stoma care is taught in small groups of 15–20 students each.

GA (114 participants) and GC (165 participants) (both at the University of Granada-Granada, Ceuta, and Melilla Campuses) were selected by matching the morning and afternoon groups. GB was composed of students from the University of Jaén (83 participants). The final participation rate was 84.38% (n = 362). The specific responses of the students were not known to the teachers. The data collected were used for research purposes only and were kept in the custody of the researchers.

2.3 The scenario Virtual Reality stoma site marking training (sVR-SSIMAT)

The design of the sVR-SSIMAT was created by the researchers and a stomatherapy nurse based on the literature (Ota et al., 2023) CREAME software was used in the development of the idea. The experience immerses the student, through the Oculus Quest 2 Virtual Reality goggles. The student can see a clinical room with a patient and a tablet with the steps for a stoma marking procedure. Once the student reads the first steps about location, ribs, scars, etc., the virtual patient lies down and with a pencil the student has to mark the stoma. Once the bisector point is drawn, the trainee has to mark the stoma in multiple potential sites in different abdominal quadrants (Fig. 2).

Figure 2. Screenshot showing a digital content of the sVR-SSIMAT

a. Implementation phase

For the implementation phase, three intervention groups were conducted:

The intervention for GA and GC was carried out at University of Granada with a total of 23 sessions of 120 min each. The GB intervention was carried out at the University of Jaén with a total of 10 sessions lasting 180 min each. All the monitors who participated in the experience received previous training for the type of methodology to be developed. At the UGR (Granada and Ceuta Campuses) the interventions were developed by the same researcher (in addition to the teachers of the subject) while at the Melilla Campus and at the UJA, the interventions were carried out by two researchers participating in the study, who also have the role of teacher. A planning was prepared for each group of simulation (Table 1).

Table 1. Planning of each group of simulation

Group	Planification	Min
A	Introduction of the lecturer and explanation of the content of the seminar by means of a master class	5
	Teacher's demonstration of the contents through lecture: 1) Concept of ostomy and types of pouching; 2) General complications; 3) Peristomal skin measurement scales and marking;	45
	Students will divide the class into 4-5 groups of 4-5 people and perform teacher-guided group practice on the manikin: device change, irrigation and marking.	70
B	Introduction of the lecturer and explanation of the content of the seminar by means of a master class	45
	Teacher demonstration of the procedures to be performed: 1) Placement and removal of devices + hygiene; 2) Peristomal skin assessment with DET scale; 3) Stoma marking	15
	Organisation of the group in 3 scenarios: 1) Placement and removal of devices + hygiene; 2) Evaluation of peristomal skin with DET scale through imaging; 4) Stoma marking with virtual reality. sVR-SSIMAT	60
C	Introduction of the lecturer and explanation of the seminar contents	5
	Resolution of doubts that may have arisen after consulting PRADO infographics.	15
	Individual game dynamics through 10 knowledge questions with four alternative answers that students will answer through the Socrative platform. It is a space race where, the more questions they get right, the better place they will obtain in the competition.	15
	Students will divide the class into 4-5 groups of 4-5 people and will perform group practices guided by the teacher on the manikin: changing the device, irrigation. Stoma marking with virtual reality sVR-SSIMAT (Parallel session with another teacher).	85

Table 1. Planning of each group of simulation

2.4 Data collection procedure

Data were collected through a questionnaire with demographic information, and the following evaluative tools: The Nursing Outcomes Classification (NOC) "Knowledge: Ostomy Care [1829]” (Moorhead et al., 2018) and its indicators, self-efficacy (Sanjuan-Suárez and Pérez-García, 2000) (Supplementary material 1), and student satisfaction-self-confidence with learning (Román-Cereto, 2017) (Supplementary material 2).

By completing the questionnaires, participants gave their consent to participate in the study. The students were also clearly informed that their answers would not be used to evaluate them in the course.

The pretest included:

- Questionnaire with demographic information.

It included the age of the participants, gender, class shift (morning-afternoon), university of belonging and number of times the course is taken.

-Ad hoc knowledge test on nursing stoma care.

To measure the level of knowledge about stoma care, no validated scale was found, so it was considered appropriate to use the NOC outcomes "Knowledge: Ostomy Care [1829]” (Moorhead et al., 2018). (Extent of understanding conveyed about maintenance of an ostomy for elimination) and its indicators as used in other studies (Hueso-Montoro et al., 2023). It consists of 16 indicators, observable and quantifiable measures used to evaluate the level of knowledge about ostomy care through a Likert scale from 1 to 5, where 1 = No knowledge and 5 = Extensive knowledge. The NOC outcomes are a standardised nursing language that has been translated into nine languages to explore and describe nursing practice in a variety of specialisms, patient groups, and healthcare settings (Leoni-Sheiber et al., 2019; Moorhead et al., 2018).

- Self efficacy scale

The "General Scale of Self-Efficacy" (Sanjuan-Suárez and Pérez-García, 2000), validated for the Spanish university population, was used to evaluate the student's perception of self-efficacy with respect to learning. It aims to assess the stable feeling of personal competence to effectively handle a wide variety of stressful situations. It has good internal consistency (Cronbach's alpha = 0.87) and a high validity rate. It consists of 10 items evaluated with Likert scale from 1 to 10, whose total score varies between 10 and 100 points (higher scores indicate higher levels of perceived self-efficacy).

In the post-test, on the one hand, the instruments of the pre-test (excluding the demographic variables) were measured, as well as the satisfaction and self-confidence of the students in learning with respect to the simulation. For this purpose, the satisfaction and self-confidence scale adapted and validated for implementation in the Spanish educational context was used. This tool evaluates clinical learning based on simulation in the Nursing degree. It has a high internal consistency (Cronbach's alpha α = 0.93) and consists of 13 items distributed in two dimensions (satisfaction/5 items and self-confidence in learning/8 items) that are evaluated with Likert scale from 1 to 5, where 1 = Totally disagree and 5 = Totally agree. This instrument was distributed to all students after the session.

2.5 Data analysis

The analysis of the data was conducted using SPSS (Statistical Package for the Social Sciences) version 28.0.1.0. Data from the descriptive analysis were presented as percentages for categorical variables and as the mean (M) along with the standard deviation (SD) for continuous variables.

Different non-parametric tests were employed for inferential analysis due to the non-normality and lack of homoscedasticity, as demonstrated by the Kolmogorov-Smirnov and Levene's tests, respectively. Kruskal-Wallis tests were conducted to check for differences among fidelity groups and groups based on shifts for the variables NOC outcomes, confidence, satisfaction, and self-efficacy. Additionally, Friedman tests were carried out to compare pre- and post-simulation differences in the variables NOC outcomes and self-efficacy. Significant differences were considered for p-values less than 0.05. Students with incomplete tests were excluded from the analysis.

2.6 Ethical considerations

The study was approved by the Research Ethics Committee at the University of Granada (registry number: 2110/CEIH/2021) and Research Ethics Committee at the University of Jaén (registry number: OCT.22/4. PRY). Students were asked for consent to take part in the study and were informed about the main goal of the investigation.

3.1 Participants´ characteristics

The sample consisted of a total of 362 undergraduates nursing students, of whom 65 (17.96%) were male, 295 (81.49%) were female, and 2 others (0.55%). The average age was 22.31 years (SD = 4.98). Among the participants, 98.62% were taking the adult III subject for the first time, while the remaining had repeated the course on one or more occasions (Table 1). The students belonged to the different campuses: Ceuta, Melilla, Granada, and Jaén. The total number of students was as follows: Ceuta (n = 59), Melilla (n = 80), Granada (n = 140), and Jaén (n = 83). The groups and shifts can be found in Table 2.

Table 2. Distribution of participants

3.2 Evaluative Tools

To achieve the proposed objectives the different evaluative tools were completed before (pre-test) and after (post-test) the class (Fig. 3).

Figure 3. Participants´ flow chart

The NOC indicators

Before the simulation, no significant differences among the fidelity groups were observed in 9 out of 15 indicators. However, statistically significant differences were found after the simulation (p < 0.05). Specifically, in 14 out of 15 NOC indicators measured (no significant differences for the "Indicator [182909]: Supplies required to care for ostomy") (Table 3). In addition to the Kruskal-Wallis analysis, a Mann-Whitney test was performed, revealing significant differences in all indicators between GA and GC, except for the indicator [182909]. In contrast, when comparing the GB and GC groups, only two indicators showed significant differences: [182911] and [182912]. Moreover, during the post hoc analysis between the GA and GB groups, significant differences were observed in 11 of the indicators measured, with the exceptions of [182902], [182908], [182909], and [182916].

Table 3. Comparison of NOC indicators pre and post-test mean scores, test statistics, and p-values among different learning methodologies and different levels of simulation in nursing students (GA, GB, GC)

A comprehensive analysis of repeated measures was performed to assess the intervention's effect on NOC indicators responses before and after the -simulation. The findings indicated a notable increase in NOC indicator scores post-simulation, demonstrating statistically significant differences both within each group and across all three groups. These enhancements were evident after the simulation not only in the cumulative NOC indicator scores (Table 4) but also across all individual indicators, highlighting the intervention's impact.

Table 4. Comparison of NOC indicators in post and pre-test accumulative score among groups

Self-efficacy

Prior to the intervention, baseline self-efficacy scores did not differ significantly among the groups (p > 0.5). This also happened with the post-intervention results as indicated by the Kruskal-Wallis test, although a tendency toward higher scores was noted in the GC Table 5). The analysis between fidelity groups (Mann-Whitney test) revealed no differences when comparing the groups pairwise (either in the pre- or post-simulation results). Nevertheless, when analysing the changes in self-efficacy scores after the intervention (pre- and post-simulation), a significant overall difference was identified among all the participant groups (p < 0.05).

Table 5. Comparison of self-efficacy final score in post-test and pre-test and differences between pre- and post-intervention scores

Student satisfaction and self-confidence

Regarding learning satisfaction and self-confidence, the intervention revealed significant differences across the groups. The satisfaction scores reported in GC were the highest (Table 6). Likewise, self-confidence scores exhibited significant variations among the groups. Notably, the GC reported higher self-confidence levels compared to the GB and GA. Comparing satisfaction and self-confidence scores (Mann-Whitney test) among the fidelity groups pairwise, differences were observed between GA and GB/GC, and GB and GC (p < 0.001).

Table 6. Comparison of satisfaction and self-confidence among groups

This study addresses the differences on learning methods as well as the level of fidelity simulation developed on the knowledge, self-efficacy, satisfaction, and self-confidence of nursing students in stoma care. More specifically on virtual reality in stoma care and nursing focus on the nursing degree.

The NOC outcome “Knowledge: Ostomy Care [1829]”

In this study, the simulation appeared to positively influence the cognitive ability of nursing students, indicating an improvement in the acquisition of knowledge for the care of people carrying digestive stoma. The results point to an improvement in knowledge in the GC and GB groups, compared to the GA group. These results are consistent with other studies such as Park et al., (2016) who demonstrated that simulation increases the acquisition of knowledge and critical thinking skills among nursing students while performing cardiopulmonary resuscitation. Other studies also show that the use of high-fidelity simulation in nursing education is more effective than the traditional method in terms of knowledge improvement, skill levels for cardiac auscultation, and anxiety reduction (Vural Doğru & Zengin Aydın, 2020).

On the same line, Aljohani et al., (2019) show an improvement in training in cardiac life support with simulation. For their part, So et al. (2019) find that simulation-based learning increases the retentive ability of nursing students by improving their future learning skills. Finally, other authors argue that the integration of ALMs with simulation technology increases the acquisition of knowledge (Chan et al., 2021; Gu et al., 2017; Peinado-Molina et al., 2023).

Self-efficacy

Although in this study self-efficacy did not present significant differences between the different intervention groups, other studies show that simulation learning experiences increase self-efficacy and clinical competencies (Khalaila, 2014; Kim, 2018). In this case, the result is consistent with other authors in which no improvements were found when comparing the simulation with the traditional methodology (Scherer et al., 2007). This may be because, as some papers report (Bong, 2001; Komarraju et al., 2014), self-efficacy declines significantly as students’ progress in courses or as Halstead & Lare (2018) indicate, that university self-efficacy is not high or constant.

These results suggest that simulation may not have a uniform impact on students' self-efficacy and that other factors may influence these results.

Thus, it is important to explore other variables that may affect the perception of self-efficacy of university students in relation to simulation due to the effects it may have on the development of adaptive academic goals and successful effort in nursing students (Covarrubias Apablaza et al., 2019; Wolf et al., 2018). For example, not having a scholarship to cover the expenses of the career affects the self-efficacy of the students (Bagheri et al., 2012). Since self-efficacy is a complex construct and depends on several factors, such as mastery experience, where repeated success in tasks would increase positive self-efficacy self-assessments and repeated failures would decrease them (Bandura, 1993), this could justify the result in this study, since the students only had one opportunity to experience VR.

Satisfaction and self-confidence

Finally, regarding the level of satisfaction and self-confidence of the students, the GB and GC achieved a higher scores than the GA. This suggests that HFS increases the satisfaction and self-confidence of nursing students in stoma care. So, Zapko et al., (2018) conclude that using simulations of patients with HFS and MFD, and actors as patients in different real scenarios (e..g., mental health, critical care, obstetrics, medical/surgical, and geriatric scenarios), students improved satisfaction and confidence. Another study (Demirtas et al., 2021) examines the use of simulation for cardiopulmonary resuscitation learning in nursing students, revealing high satisfaction and self-confidence scores. Some authors (Marion-Martins & Pinho, 2020) attribute the satisfaction with the simulation to the improvement that occurs in the collaboration and communication skills of the students and the perception that the simulation will better prepare them for their future clinical practice (Ha, 2018).

Meanwhile, Tawalbeh (2020) studied the effect of simulation on the learning of nursing care in critical patients with cardiac, respiratory, and neurological problems, revealing an increase in student self-confidence after the simulation. So et al., (2019) describe that the increase in student self-confidence is due to the simulation providing a safe environment where students can apply care without fear of harming patients, which positively influences satisfaction, contributing to the development of self-confidence and essential skills to provide safe care to patients (Alharbi & Alharbi, 2022).

Limitations

This research is not without limitations. First, the need to conduct the research at two different universities in order to have a considerable sample. It would be necessary to perform the same study in a single university to reduce bias in this aspect. Another limitation has been the decompensation of groups in terms of gender. Since the degree of nursing is a majority female career, no analysis of this category has been possible.

Likewise, another limitation has been the lack of studies on simulation in the area of ostomies in the degree of nursing, particularly with VR, so the data could not be compared with similar experiences. Additionally, the lack of validated scales in terms of knowledge of the ostomies in the degree of nursing causes their evaluation to have been based on the NOC outcomes and its indicators, showing the need to validate scales that measure that knowledge.

It has been found that simulation improves the level of knowledge in relation to ostomies as well as that the degree of fidelity of simulation has a positive impact on student satisfaction and self-confidence in learning.

These findings offer an opportunity to implement ALM in stoma care teaching and highlight the need to validate scales to measure the knowledge about stoma care. This will help in future studies to measure more properly active learning methods in the topic, helping teachers to evaluate the simulation, enabling them to improve it.

Author Contribution

CCD: Conceptualization, Formal analysis, Investigation, Methodology, Writing, review & editing. RRP: Data curation, Invvestigation, Software. MEPG: Supervision, Project administration, Writing – review & editing. KAA: Conceptualization; Investigation; Project administration, Resources, Writing – original draft.

Acknowledgement

The authors would like to thank Víctor Javier Costela-Ruiz, María Isabel Tovar-Gálvez, Miriam Mohatar-Barba, María Granados-Santiago, Emilio González-Jiménez, César Hueso-Montoro, Isabel María López-Medina and the nursing students who participated in this study for their time and patience.

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Table 1. Planning of each group of simulation

Group	Planification	Min
A	Introduction of the lecturer and explanation of the content of the seminar by means of a master class	5
	Teacher's demonstration of the contents through lecture: 1) Concept of ostomy and types of pouching; 2) General complications; 3) Peristomal skin measurement scales and marking;	45
	Students will divide the class into 4-5 groups of 4-5 people and perform teacher-guided group practice on the manikin: device change, irrigation and marking.	70
B	Introduction of the lecturer and explanation of the content of the seminar by means of a master class	45
	Teacher demonstration of the procedures to be performed: 1) Placement and removal of devices + hygiene; 2) Peristomal skin assessment with DET scale; 3) Stoma marking	15
	Organisation of the group in 3 scenarios: 1) Placement and removal of devices + hygiene; 2) Evaluation of peristomal skin with DET scale through imaging; 4) Stoma marking with virtual reality. sVR-SSIMAT	60
C	Introduction of the lecturer and explanation of the seminar contents	5
	Resolution of doubts that may have arisen after consulting PRADO infographics.	15
	Individual game dynamics through 10 knowledge questions with four alternative answers that students will answer through the Socrative platform. It is a space race where, the more questions they get right, the better place they will obtain in the competition.	15
	Students will divide the class into 4-5 groups of 4-5 people and will perform group practices guided by the teacher on the manikin: changing the device, irrigation. Stoma marking with virtual reality sVR-SSIMAT (Parallel session with another teacher).	85

Table 2. Distribution of participants

Groups	Total participants (n=362)	%
Group A. University of XXX	XXX=16 XXXa= 68 XXX= 30 114	31.5
Group B. University of XXX	83	22.9
Group C. University of XXX	XXX=43 XXX= 72 XXX= 50 165	45.56
Number of times the course is taken
First time	357	98.6
More than one	5	1.4
Class shift
Morning	172	47.5
Afternoon	190	52.5

Table 3. Comparison of NOC indicators pre and post-test mean scores, test statistics, and p-values among different learning methodologies and different levels of simulation in nursing students (GA, GB, GC)

NOC	GA		GB		GC		p value
NOC	M± SD		M± SD		M± SD		p value
	Pre-test	Post-test	Pre-test	Post-test	Pre-test	Post-test	Pre-test	Post-test
[182901] Function of ostomy	2.60 ± 0.88	4.43 ± 0.58	2.38 ± 0.96	4.28 ± 0.64	2.58 ± 0.93	4.45 ± 0.58	0.167	<0.001
[182902] Purpose of ostomy	3.27 ± 0.94	4.62 ± 0.53	3.11 ± 1.02	4.62 ± 0.56	3.24 ± 1.03	4.66 ± 0.54	0.447	<0.001
[182903] Skin care needs around ostomy	2.63 ± 0.96	4.42 ± 0.63	2.54 ± 1.04	4.54 ± 0.57	2.76 ± 1.04	4.50 ± 0.65	0.102	<0.001
[182904] Irrigation techniques	1.80 ± 0.86	4.05 ± 0.76	1.90 ± 1.12	3.86 ± 0.67	1.88 ± 0.99	4.18 ± 0.65	0.927	<0.001
[182905] How to measure stoma	2.03 ± 1.16	4.78 ± 0.50	1.73 ± 1.10	4.65 ± 0.57	1.96 ± 1.19	4.65 ± 0.68	0.130	<0.001
[182907] Complications related to stoma	2.34 ± 0.93	4.36 ± 0.71	2.10 ± 0.90	4.29 ± 0.56	2.31 ± 1.07	4.39 ± 0.75	0.221	<0.001
[182908] Schedule for changing ostomy bag	2.35 ± 1.14	4.55 ± 0.63	1.95 ± 1.02	4.59 ± 0.56	2.29 ± 1.19	4.64 ± 0.60	0.035	<0.001
[182909] Supplies required to care for ostomy	2.45 ± 1.09	4.57 ± 0.59	2.16 ± 1.09	4.56 ± 0.58	2.29 ± 1.10	4.55 ± 0.60	0.149	0.215
[182910] Flatus-producing foods	2.75 ± 1.13	4.18 ± 0.83	2.32 ± 1.05	3.99 ± 0.66	2.70 ± 1.17	4.47 ± 0.67	0.012	<0.001
[182911] Diet modifications	2.51 ± 1.02	4.19 ± 0.83	1.96 ± 0.82	3.95 ± 0.74	2.49 ± 1.11	4.46 ± 0.64	0.001	<0.001
[182912] Fluid intake requirements	2.41 ± 1.04	4.32 ± 0.78	2.05 ± 0.91	4,07 ± 0.73	2.45 ± 1.07	4.53 ± 0.59	0.012	<0.001
[182914] Modification of daily activities	2.39 ± 0.99	4.25 ± 0.71	1.94 ± 0.81	4.18 ± 0.66	2.49 ± 1.01	4.41 ± 0.72	0.001	<0.001
[182915] Procedure to change ostomy bag	2.30 ± 1.16	4.71 ± 0.50	2.12 ± 1.17	4.62 ± 0.57	2.40 ± 1.19	4.63 ± 0.59	0.178	<0.001
[182916] Procedure to empty ostomy bag	2.12 ± 1.07	4.59 ± 0.59	2.02 ± 1.03	4.60 ± 0.61	2.22 ± 1.11	4.49 ± 0.69	0.430	<0.001
[182917] Available support groups	1.59 ± 0.77	3.95 ± 0.94	1.60 ± 0.87	3.88 ± 0.88	1.84 ± 0.96	4.12 ± 0.86	0.024	<0.001

*H= Kruskal-Wallis test

* α= 0.05

Table 4. Comparison of NOC indicators in post-test and pre-test accumulative score among groups

	Groups			X² _F	p value
	GA	GB	GC
	M± SD	M± SD	M± SD
Pre-Intervention	35.56 ±10.83	31.88 ±10.13	36.00 ±11.34	7928	<0.001
Post-Intervention	65.96 ± 7.09	64.67 ± 6.31	67.11±7.14	7928	<0.001

*Friedman test

*α= 0.05

Table 5. Comparison of self-efficacy final score in post-test and pre-test (individually) and differences between pre and post intervention scores

	Groups			H/p	X² _F/p
	GA	GB	GC
	M± SD	M± SD	M± SD
Pre-Intervention	70.76 ±1 2.70	69.66 ± 11.62	73.85 ± 10.94	5.79/0.055	188.478/ <0.001
Post-Intervention	77.94 ± 14.07	78.06 ± 12.72	81.28 ± 10.76	3.267/ 0.195	188.478/ <0.001

*H= Kruskal-Wallis test, p= p value, α= 0.05, X² _F= Friedman test

Table 6. Comparison of satisfaction and self-confidence among groups

	Groups			H	p value
	GA	GB	GC
	M± SD	M± SD	M± SD
Satisfaction	21.69 ± 4.36	24.76 ± 2.22	22.99 ± 4.512	74.046	<0.001
Self-confidence	33.50 ± 6.38	39.92 ± 0.28	34.44 ± 7.28	115.85	<0.001
H= Kruskal-Wallis test α= 0.05

No competing interests reported.

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Knowledge, self-efficacy, satisfaction, and self-confidence of nursing students for stoma care using active learning methods: a controlled experimental study

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Abstract

Figures

INTRODUCTION

BACKGROUND

METHODS

2.1 Study design and setting

2.2 Participants

2.3 The scenario Virtual Reality stoma site marking training (sVR-SSIMAT)

a. Implementation phase

2.4 Data collection procedure

- Self efficacy scale

2.5 Data analysis

2.6 Ethical considerations

RESULTS

3.1 Participants´ characteristics

3.2 Evaluative Tools

The NOC indicators

Self-efficacy

Student satisfaction and self-confidence

DISCUSSION

The NOC outcome “Knowledge: Ostomy Care [1829]”

Self-efficacy

Satisfaction and self-confidence

Limitations

CONCLUSIONS

Declarations

Author Contribution

Acknowledgement

References

Tables

Additional Declarations

Supplementary Files

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