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. 2023 Jun 22. Online ahead of print. doi: 10.1016/j.teln.2023.05.015

Nursing students’ perceived level of satisfaction and self-confidence in learning using unfolding case studies

Jenny Rose Leynes-Ignacio 1,⁎
PMCID: PMC10284683  PMID: 37360269

Abstract

Coronavirus disease 2019 (COVID-19) pandemic interrupted the clinical placements of nursing students across the globe. This required teaching and learning in nursing to adapt to continue, despite the interruption. The study aims to describe the students' perceived level of satisfaction, and their level of self-confidence in learning using the unfolding case studies. An online survey of nursing students enrolled in a higher educational institution in Angeles City, Philippines was conducted. A total of 166 nursing students completed the online survey. The majority of them were female (N=136; 81.93%). Respondents reported high levels of satisfaction (M=22.02; SD=0.29 out of a possible 25), and self-confidence (M=34.60; SD=0.48 out of a possible 40). The findings bolster the utility of the unfolding case studies in improving students’ satisfaction and self-confidence in learning.

Keywords: Nursing; Nurse education; Students, Teaching and learning; Unfolding case study

With learning as the goal of education, nurse educators must be cognizant of the students' experience specifically satisfaction and self-confidence in their learning. Students' satisfaction with learning is related to their productive academic performance. Their interaction and engagement in online learning have a significant part in attaining satisfaction (Muzammil, 2020). Meanwhile, nursing students who demonstrate self-confidence in learning show improvement in their skills in critical thinking, reflection, problem-solving, and decision-making (Pike & O'Donnell, 2010).

Learning has been challenged because of the onslaught of Coronavirus disease 2019 (COVID-19) pandemic (Dhawan, 2020), especially for courses that require skills development like engineering, and allied medicine, among others. As a response, the education sector needed to adopt new learning modalities to ensure the unhampered delivery of instruction (Commission on Higher Education, 2020). In the case of higher education, the use of technology-mediated educational tools is used to facilitate the online delivery of learning (Alea et al., 2020; Baticulon et al., 2021). With these changes, educators are encouraged to look for various means of maximizing students' learning in the unfamiliar learning environment as well as determine opportunities for them to attain the necessary skills for skill-based courses (Gillett-Swan, 2017).

Over the years, the nursing education program has faced major changes to produce clinically competent nurses who can contribute to providing quality and safe nurse care. The complexity of the nursing education program which involves teaching and learning materials, human resources, curriculum, teaching and learning processes, teaching, and clinical experiences, together with the teacher's attitudes and commitment are all necessary to produce nursing students and graduates performing exceptionally (Appiah, 2020; Backes et al., 2018). To achieve this, transition from traditional to modern teaching strategies are implemented.

Nurse educators' extensive experience in both theory and practice contributes to providing quality nursing education. This facilitates the translation of the nurses’ knowledge, skills, and bedside attitude gained in the simulation laboratory into the actual delivery of safe and quality nursing care (Appiah, 2020; Lauder et al. 2004).

One innovation to achieve learner-centered outcomes is the use of online-learning simulations such as unfolding case studies. Online simulation is an online activity that uses different, simulated scenarios in a controlled environment and the scenarios pertain to challenges that a learner will face in the area of their work (Sengupta & Johnston, 2019).

As innovative learning approaches are adopted, students' satisfaction and self-confidence need to be taken into consideration. An individual's positive feelings toward one's accomplishments and learning experiences are what we call satisfaction (Ocak & Akcayir, 2013); when students are recognized for their achievements it will boost their morale and satisfaction and they will feel that they are treated fairly (Ryan & Deci, 2000). The different course materials used in the learning environment such as hands-on activities and the use of technology presented with the use of the internet and in live classroom set-ups such as multimedia, simulations, and games are factors that can affect student's satisfaction in learning (Delialioğlu, 2012). The use of structured multimedia in nursing education helped to improve self-efficacy and self-confidence in performing nursing skills among nursing students (Kim & Choi, 2020). Whereas the psychomotor domain is affected by the use of simulation-based nursing educational interventions (Kim et al., 2016).

On the other hand, self-confidence is essential for student nurses to oversee and manage every situation and provide effective and efficient nursing care (Omer, 2016). The different complex clinical situations are an essential part of learning among nursing students; thus, they must learn how to build their self-confidence in coping with and handling these intricate situations (Abdelkader et al., 2021).

The clinical hands-on training was canceled to mitigate the spread of the infection, nurse educators are apprehensive if technology-mediated instruction is sufficient in skills transfer, enabling them to search for activities that are safe to practice and at the same time will develop student nurses' clinical judgment (Rischer, 2020). One of the challenges for nurse educators is to produce learning materials that enthuse learners' clinical judgment that promotes safety and patient-centered care (Bastable, 2003). In unfolding case studies, student nurses are required to use clinical judgment to foresee what could happen next because, in this method, information is revealed incrementally, which mirrors nursing practice (Moench, 2019).

The adoption of nontraditional teaching strategies in undergraduate nursing education was fast-tracked by the limitations brought about by COVID-19 pandemic. Unfolding case studies provided nurse educators with a viable alternative to clinical placement, that offers unpredictability and variability often encountered in clinical settings. The researcher aimed to describe the students' perceived level of satisfaction, and their level of self-confidence in learning using the unfolding case study approach in place of clinical placement.

Method

Research Design

A quantitative cross-sectional descriptive research design was used to describe the nursing students' profile, perceived level of satisfaction, and self-confidence in learning using the unfolding case study approach.

Sample and Setting

Nursing students from an autonomous higher education institution (HEI) in Angeles City, Philippines were the respondents of the study. The HEI has been using unfolding case studies in place of clinical placement since A.Y. 2020-2021. There were 169 nursing students between A.Y. 2021-2022. Total enumeration was used as the sampling strategy.

Research Instrument

The instrument is divided into two parts: the sociodemographic profile, and the Scale of Student Satisfaction and Self-confidence in Learning (Jeffries & Rizzolo, 2003). The NLN instrument is composed of 13-item questions designed to measure student satisfaction with the unfolding case study activity and self-confidence in learning using a 5-point Likert scale. The instrument is deemed to have good face and content validity and acceptable reliability with the following Cronbach's alphas: satisfaction = 0.94 and self-confidence = 0.87 (Omer, 2016). A more recent study reports the instrument to be consistently reliable, with the following Cronbach's alphas: satisfaction = 0.83-0.92 and self-confidence = 0.81-0.89 (Al-Hajri, 2021; Franklin et al., 2014; Reierson et al., 2020). Previous studies demonstrated the instrument's construct validity for its two-factor model using both exploratory- and confirmatory factor analysis (Franklin et al., 2014; Reierson et al., 2020).

The scores of the items of each subscale (Satisfaction with current learning and Self-Confidence in Learning) will be added up. The higher the score means the more satisfied (highest possible score [HPS]: 25) and more self-confident (HPS: 40) the nursing students are.

Data Collection

An online survey (thru electronic mail and other web-based platforms) was done to avoid posing risk to potential participants. The researcher collected the data using Google Forms. The preliminary page of the online form was the informed consent, participants had to signal their consent to access the survey. The responses were sent to Google Drive, a password-protected cloud. The researcher then assessed the data for completeness and discarded samples that are incomplete. The data collection occurred between October to November 2022.

Data Analysis

The data collected was analyzed using JASP v 0.16. Descriptive statistics such as frequency distribution, percentage, mean, and standard deviation were used to describe the profile of the respondents, their perceived satisfaction with learning, and their self-confidence in learning.

Ethical Consideration

This study was conducted with ethical considerations to guarantee the safety of the participants. The Holy Angel University – Institutional Review Board of Clearance approved the study (Study Protocol Code: 2022-057-JLIGNACIO-NSGSTUDENTSUFCAPPROACH).

Results

Out of a total of 169 eligible participants, 166 (98.22 %) completed the survey. The mean age of the participants was 21.79 years old with the majority of the participants female (N=136; 81.93%) and coming from the class of 2024 (N=103; 62.05%).

Table 1 presents the mean scores of the items of the respondents' perceived level of satisfaction in the use of unfolding case study approach. In terms of the respondents’ perceived level of satisfaction in the use of the unfolding case study approach, the item “The unfolding case study provided me with a variety of learning materials and activities to promote my learning of the medical-surgical curriculum,” received the highest score (M=4.47; SD=0.65). The item, “The way my instructor(s) taught the unfolding case study was suitable for the way I learn,” received the lowest score (=4.36; SD=0.73). It is good to note that all items under this subscale are interpretable as strongly agree. The mean sum of the respondents’ perceived level of satisfaction was high (M=22.02; SD=0.29 out of a possible 25).

Table 1.

Mean Scores of the Items of the Respondents’ Perceived Level of Satisfaction in the Use of the Unfolding Case Study Approach

Item M SD Interpretation
The teaching methods used in unfolding case study were helpful and effective. 4.40 0.75 Strongly Agree
The unfolding case study provided me with a variety of learning materials and activities to promote my learning of the medical-surgical curriculum. 4.47 0.65 Strongly Agree
I enjoyed how my instructor taught the unfolding case study. 4.39 0.74 Strongly Agree
The teaching materials used in the unfolding case study were motivating and helped me to learn. 4.42 0.68 Strongly Agree
The way my instructor(s) taught the unfolding case study was suitable for the way I learn. 4.36 0.73 Strongly Agree
Mean Sum 22.02 0.29 -
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Note: 1:00-1.80 = Strongly Disagree, 1.81-2.60 = Disagree, 2.61-3.40 = Neutral, 3.41-4.20 = Agree, 4.21-5.00 = Strongly Agree.

Table 2 presents the mean scores of the items of the respondents' level of self-confidence in learning using the unfolding case study approach. The item “It is my responsibility as a student to learn what I need to know from the unfolding case study activity,” received the highest mean score (M=4.69; SD=0.55). Meanwhile, the item “I am confident that I am mastering the content of the unfolding case study activity that my instructors presented to me,” received the lowest mean score (M=4.08; SD=0.74). Notably, two items are interpretable as agree while the remainder is strongly agreed. The mean sum of the respondents' perceived level of satisfaction was high (M=34.60; SD=0.48 out of a possible 40).

Table 2.

Mean Scores of the Items of the Respondents’ Level of Self-Confidence in Learning Using the Unfolding Case Study Approach

Item M SD Result
I am confident that I am mastering the content of the unfolding case study activity that my instructors presented to me. 4.08 0.74 Agree
I am confident that this unfolding case study covered critical content necessary for the mastery of the medical-surgical curriculum. 4.31 0.75 Strongly Agree
I am confident that I am developing the skills and obtaining the required knowledge from this unfolding case study to perform necessary tasks in a clinical setting. 4.24 0.67 Strongly Agree
My instructors used helpful resources to teach the unfolding case study. 4.40 0.70 Strongly Agree
It is my responsibility as the student to learn what I need to know from this unfolding case study activity. 4.69 0.55 Strongly Agree
I know how to get help when I do not understand the concepts covered in the unfolding case study. 4.45 0.63 Strongly Agree
I know how to use unfolding case study activities to learn critical aspects of these skills. 4.28 0.63 Strongly Agree
It is the instructor's responsibility to tell me what I need to learn from the unfolding case study activity content during class time. 4.15 0.94 Agree
Mean Sum 34.60 0.48 -
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Note: 1:00-1.80 = Strongly Disagree, 1.81-2.60 = Disagree, 2.61-3.40 = Neutral, 3.41-4.20 = Agree, 4.21-5.00 = Strongly Agree.

Discussion

The research intended to describe the BSN students’ demographic profile, and perceived levels of satisfaction and self-confidence in learning using the UCS approach. Results revealed that the BSN student-respondents had high levels of satisfaction and self-confidence in their learning using the UCS approach.

The responses of the nursing students in the survey instrument to assess their levels of satisfaction and self-confidence in learning using the UCS approach revealed overwhelming positive feedback. The respondents strongly agreed that the unfolding case study approach provided a variety of learning materials and activities to promote their learning of the medical-surgical curriculum.

Nursing students were satisfied with the UCS approach, with all items under the subscale being strongly agreed on. The statement: “The unfolding case study provided me with a variety of learning materials and activities to promote my learning of the medical-surgical curriculum.” received the highest mean score (M=4.47). The approach could have been positively viewed as such due to the inherent limitation imposed upon the nursing educational system by the COVID-19 pandemic (Jallad & Isik, 2021). Students of this generation Z are often more receptive to diverse and active learning approaches (Mazaudier, 2022). The UCS provided students with a dynamic approach to understanding theoretical concepts in a manner that was unpredictable yet engaging (Walker & Thrasher, 2013).

The statement: “The way my instructor(s) taught the unfolding case study was suitable for the way I learn,” was still strongly agreed on despite receiving the lowest mean score (M=4.36). Since the UCS provided nontraditional means of teaching concepts in medical-surgical nursing, it may not have melded well with every individual learning style of the students (Mazaudier, 2022). It has been a longstanding challenge for nurse educators to constantly adapt core nursing concepts into various learning styles that continuously engage students (Schmeck, 2013). This though, does not decrease the value of UCS as a viable teaching-learning approach in nursing.

Nursing students were confident in their ability to learn using the UCS approach. They strongly agreed on six of the 8 items in the subscale. Meanwhile, two were “agreed” on.

The statement “It is my responsibility as the student to learn what I need to know from this unfolding case study activity,” received the highest mean score (M=4.69). When implemented appropriately, the UCS approach can lead to more self-directed learning (West et al., 2012). It does this by explicitly stating the objectives of the case and scaffolding it around the expected learning outcomes of the course (Rischer, 2020). A baccalaureate nursing program is expected to have adult learners, thus employing andragogy rather than pedagogy. The former focuses on self-directed and independent learning (Decelle, 2016). The UCS, as described by the participants allows students to have ownership of their learning.

The statement “I am confident that I am mastering the content of the unfolding case study activity that my instructors presented to me,” received the lowest mean score (M=4.08) among the items in the self-confidence scale. The result may be due to the change in teaching-learning approaches that the students were accustomed to before the pandemic hit (Jallad & Isik, 2021). The students may have experienced some difficulty getting used to their learning management system and digital literacies which may have affected their learning or proficiency in the concepts (Calaguas & Consunji, 2022). Preoccupation with the learning environment and the needed skills for online learning do present challenges to the actual learning of concepts (Dontre, 2021).

The results bolster the utility of the unfolding case study approach to improving students’ satisfaction and self-confidence in learning. Results affirm that clinical learning can occur in simulated environments, like unfolding case studies (Kim et al, 2016). Nurse educators can use the results of the study to inform their decision-making on what teaching-learning approaches can be used. Nursing educational leaders should support their nurse educator members' attempts at simulating nursing care through unfolding case studies.

Recommendations

The results of the study should be taken in consideration of its limitations. The study was limited to a single site, which is known to have utilized the unfolding case study approach during the onslaught of the COVID-19 pandemic. The nonrandomized sampling may reduce generalizability, but efforts towards total enumeration were done to improve representativeness. The study could also be affected by socially desirable response bias, which can affect the internal validity of the study. Future researchers are encouraged to replicate the study, with an increased number of locales. Future researchers can also investigate the relationship between students’ levels of satisfaction and self-confidence in learning with their actual academic performance. A longitudinal study evaluating the progress of BSN students’ satisfaction and self-confidence in learning could shed light on the dynamic effects of simulation education on nursing students’ development. An evaluation of other simulation educational approaches using the same instrument can serve as a basis for better curricular planning.

Conclusion

Undergraduate nursing students reported high levels of satisfaction and self-confidence in their learning with the use of unfolding case studies in their clinical courses. This may serve as a basis for promoting innovation in nursing education.

Presentation information

As of this submission, the paper has not been submitted for presentation at any conference.

Declaration of Competing Interest

Author declare that she has no conflict of interest to disclose.

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