The Effect of Teaching Clinical Skills Through Social Networks on Nursing Students’ Clinical Skills in Crisis Handling: A Quasi- Experimental Study

Background: When a crisis occurs, nurses are at the forefront of providing care to patients in emergency rooms. The need for skilled nurses is increasing due to the crises and disasters that are occurring around the world. The aim of the study was to determine whether teaching clinical skills through social networks can affect nursing students’ clinical skills in crisis handling. Methods: This study was done in Iran in 2021. One hundred nursing students were selected by simple random sampling and divided into control and intervention groups. Nursing clinical skills in crisis questionnaires were used before and after intervention in two groups. Distance learning through social networks was done for a month. SPSS version 15 was used for data analysis. The signicance level was 0.05. Results: There was no signicant difference between the control and intervention groups before the intervention (P >0.05). The mean score of clinical skills in the control group increased from 60.82 before the study to 62.75 after the study, which was not statistically signicant (P >0.05). The mean clinical skills of the intervention group increased from 58.02 before the intervention to 82.52 after the intervention, which was statistically signicant (P < 0.001). Conclusions: This study showed nurses’ clinical skills are low during crises. Education through social networks can improve them and should be part of nursing education. The application of this low-cost and inexpensive method is recommended for improving clinical skills in nursing.


Background
Caring is one of the main duties of nurses. Care has long been one of the duties of nurses and will continue in the future. The purpose of nursing care is to create well-being in patients [1]. Nurses need both knowledge and skills to perform good care. In fact, science and practice are the two wings of nursing care [2].
The need for skilled nurses is increasing due to the crises and disasters that are occurring around the world. Nurses should have the essential knowledge and abilities to work in a crisis. World Health Organization (WHO) recommends that all countries should organize healthcare workers for disasters and crises, but most nurses are not ready for them because of lack of experience [3,4].
Usher believed that education of disasters and crises was neglected in the undergraduate nursing curriculum in Australia and there was inadequate attention in addressing this issue in the nursing curriculum. [5]. Iran is exposed to many natural disasters due to its geographical location. Iran is located in the Middle East with a population of about 83 million people and an area of about 1648 million square kilometers.
Crises affect the health system, for example, in Bam (2003) and Zarand (2005) earthquakes, most hospitals in Kerman province were lled with patients [6]. Therefore, nurses and other members of the health team must be fully prepared to care for patients. Preparing nurses to care for patients is one of the tasks of nursing schools, but unfortunately, there are not many units in the nursing curriculum to prepare nurses for crises.
The world's population is growing and the number of people using the Internet and social networks is constantly increasing [7]. Social media is one of the educational methods that is held online and it is an interactive method between teachers and students. Media can be played through a blog, website or network [8]. On the other hand, during Covid-19, there are concerns for student safety and nursing schools have postponedclassroom-based education, and face-to-face training gave way to virtual training [9], so the social network is a good way to educate a nursing student. The different studies have shown the role of social networks in disaster management [10][11][12].
The purpose of this study is to determine whether teaching clinical skills through social networks can effect on nursing students' clinical skills in crisis handling.

Method
This quasi-experimental study was done in Kerman, Iran from September 2020 to January 2021. In the study, 100 nursing students were selected by simple random sampling. There were almost 500 nursing students in the School of Nursing a liated to Kerman University of Medical Sciences. The sample size was determined based on previous studies [13] by using the formula for comparison of two averages and considering the following: d = 0.15 β = 0. 80 α = 0.05 There were 50 nursing students in each of the intervention and control groups. The study could detect at least a 15 percent difference in clinical skills between the two groups, with a power of 80 percent.
To run simple random sampling, the researchers rst listed the study population, gave numbers to the units, found random numbers on the table and selected their samples from the random number table.
Finally, 50 nursing students were selected for each group. Passing at least two semesters in nursing was an inclusion criterion. Students, who participated in courses related to crisis skillswere excluded from the study. Therefore, second and third-year students were included in the study (Third to fth-semester students) Fig. 1. The students were divided into two groups. initially, the purpose of the study was explained to the students. The two groups completed the questionnaires related to demographic information and nursing clinical skills during crises before and after the intervention. Participants of the intervention group became members of a social network (whats App). The researcher taught rst aid and crisis management with instructional videos, text les, recorded audio, and pre-prepared scenarios during a month. Each part of the training les was sent once every two days. A reminder text message was sent once a day. The researchers didn't send any les to the control group. The content of the training le included the following: In this study, the researchers used two questionnaires: 1) demographic questionnaire, including students' age, sex, semester, and grade point average, 2) Nurses' clinical skills in the face of crisis.

Intervention and Data collection
Nurses' clinical skills in crisis questionnaire designed by Shahabinejad et al. is an instrument for evaluating nurses' clinical skills in a crisis. The Questionnaire contains 30 items, each of which is graded from 1 to 4 based on the Likert scale. Score one represents "I have no skills" and score four represents "I am fully skilled". The range of scores is between 30 and 120 points. Scores less than 80 are considered poor skills, 80-100 show moderate skills, and 100-120 show good skills. Shahabinejad reported reliability of 0.95 for this questionnaire [13]. This study was single-blinded, soonly the statistician did not know the sample allocation tothe intervention and control groups.
SPSS15 was used for data analysis. T-test and chi-square tests were used to evaluate the difference between the intervention and control group in terms of demographic characteristics before the study. A paired t-test was used to compare the mean pre-test and posttest scores of the nursing skills in each group. T-test was used to compare the mean score of the nursing skills between the two groups. The signi cance level was 0.05.

Results
One hundred students participated in the study, with 50 individuals in each of the control and intervention groups. Table 1 shows the demographic information of the students in both the intervention and control groups . There were no statistically signi cant differences between the interventional and control groups in the demographic characteristics (p.0.05). Table 1 Demographic characteristics of the students According to table 2, there was no signi cant difference between the control and intervention group in nurses' clinical skills during crises before the intervention (P >0.05). Table 2 shows that the mean score for clinical skills in the control group increased from 60.82 before the study to 62.75 after the study, which was not statistically signi cant (P >0.05). The mean clinical skills of the intervention group increased from 58.02 before the intervention to 82.52 after the intervention, which were statistically signi cant (P < 0.001).  Table 3 comparedresponses of thetwo groups regarding nursing clinical skills. Items "methods of protection of self and patients against NBC ( Nuclear, Biological, Chemical) agents" and "provision of nursing care to the injured with NBC" obtainedthe lowest scores before and after the intervention, respectively. The intervention group obtained the highest score in the item "Evaluating your clinical knowledge to provide care during a crisis" after the intervention .

Discussion
The present study aimed to determine the effect of teaching clinical skills through social networks on nursing students' clinical skills in crisis handling in Iran. The result showed that participants who received clinical skills training in crisis had higher clinical skills scores. The clinical skills of the nursing students were low before the intervention. Since then nurses have been playing a key role in managing crises and caring for patients during crises, and patient's mortality will increase if nurses fail to function properly during crises. Shahab et al. showed that the clinical skill of nurses was moderate during crises [13]. Yin (2011) considered intravenous insertion and patient observation and monitoring as vital skills for nurses [14], but the present study showed that both groups obtained low scores in methods of protection of self and patients against NBC agents. These ndings were consistent with previous studies in other countries.
Azeemi (2019) showed that health care providers in Pakistan were not prepared for the NBC incidents [15], and O'Sullivan showed that nurses in Canada were not prepared to respond to NBC disasters [16].
The difference between the present study and Yin's study can be use of different questionnaires.
In the present study, virtual education was used to educate nursing students. The present study also showed that education through networks improved clinical skills. Triola et al. showed no difference between virtual and live education in performance and diagnosis [17]. The teaching method has changed in countries during the COVID-19 pandemic,, and face to face education gave way to virtual education [18]. Cunningham et al. in a review study demonstrated that professional networks increased the transfer of information in the health system and interpersonal interactions [19], which is in line with the present study. Furthermore, Mesquita et al. showed several bene ts of social networks such as what's app and Twitter for nurses [7]. Sigalit demonstrated that social networking improved personal and group resilience among nursing students [20]. Naja Ghezeljeh (2019) observed that learning through social networks increased the nurses' knowledge of disaster [21]. Kaplan et al. showed that simulation education and scenarios increased nurses' abilities in handling an emergency situation and clinical skills [22]. Chan et al. studied nursing students' competencies in disasters and showed an increase in their competencies after learning [23] Conclusion Nurses in Iran play a critical role in crises, disasters, and emergency situations. the mean score for clinical skills in the nurses is low. training and education through social networks increases the mean score for clinical skills. Education through social networks improves nurses' clinical skills and prepare them for the crises. Clinical skills during crises and disasters should be part of undergraduate nursing curricula. The present study had some limitations. This study was conducted on the nursing students, and the researchers were not sure whether the students in the intervention group provided the training to the control group or not.

Implications for Practice
It is predicted that this method can improve the clinical skills of nurses in crises if the virtual education infrastructure in the country is well provided. The application of this low-cost and inexpensive method is recommended for improving clinical skills in nursing.  Standard owchart for entry of participants