Abstract
Background
Reflection is a core competency in geriatric nursing, and reflective learning is an effective approach in nursing education and pracice. An internship program is a transition course that enhances the knowledge, skills, and attitudes of aspiring nursing students in real clinical work. In geriatric clinical setting, nursing internship students require a broad understanding of professional competency that integrates reflective learning with clinical practice to deal with geriatric patient problems and equip them with the knowledge, attitudes, and skills needed to provide quality of care. However, there is a lack of studies examining the effect of holistic reflective learning on professional competency development among nursing internship students in geriatric settings.
Aim
This study aimed to investigate the effect of professional holistic reflective learning on professional competency development among nursing internship students caring for hospitalized older adults in medical-surgica wards.
Design
This study employed a quasi-experimental pretest–posttest design, where 160 participants were grouped into control and intervention groups. This study was conducted at two nursing schools under the Mashhad University of Medical Sciences in Iran in 2020. Baseline information was collected from both groups, followed by a pretest and follow-up assessment. The intervention group received a Blended Professional Holistic Reflective learning program, while the control group received conventional learning(undertaking professional clinical practice as a usual treatment and submitted reflective logbooks),, which included standard lectures and group discussions.
Methods
Participants were selected based on specific inclusion and exclusion criteria. The selection process was non-randomized and unblinded. The participants were equally divided, with 80 in the control group and 80 in the intervention group. Baseline data, including demographic characteristics, were collected. Pretest data were collected for both groups using the Geriatric Nursing-Specific Mini-CEX (GN-Specific Mini-Clinical Evaluation Exercise), an instrument designed to assess nursing students' professional competency in geriatric nursing practice. The intervention was delivered through a combination of in-person and online sessions over four mounts. Posttest data and follow-up, were collected similarly to the pretest. Data were analyzed using SPSS version 22, and potential confounding variables were controlled for in the analysis.
Results
The study included a total of 160 nursing internship students, with no exclusions. At baseline, no significant differences were observed between the intervention and control groups in terms of professional competency (PC) and its dimensions, except for age, which was adjusted as a covariate in the analyses. The intervention group showed a significant improvement in PC and its various domains (communication skills, physical examination, clinical judgment, health education, professionalism, and organizational efficacy) over time. The Generalized Estimating Equation (GEE) analysis confirmed significant interaction effects between time and group for all PC dimensions (p < 0.05). Post-test comparisons revealed that the intervention group scored 2.4 points higher than the control group in overall PC (p < 0.001), with sustained improvements in the follow-up phase. Significant within-group improvements were also found across all PC dimensions for both groups from pre-test to follow-up (p < 0.05).
Conclusions
The study found that the professional holistic reflective learning program was effective in developing professional competency among nursing internship students. The blended teaching–learning approach (face-to-face and online) during workshops and geriatric clinical practice is a practical, cost-effective, and time-efficient learning program during students' clinical practice in geriatric settings. Nurse educators are recommended to implement holistic reflective learning during clinical education.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12909-024-06133-3.
Keywords: Professional competency, Holistic reflective learning, Blended learning, Nursing students, Geriatric clinical practice
Introduction
Nowadays nursing education challenges to adapting needs-based undergraduate nursing curricula to rapidly changing healthcare environments [1]. With the growing population of older patients worldwide and their increasing use of healthcare services, geriatric education and professional development are becoming important issues for the nursing profession, which must adapt to new knowledge and skills related to health and aging [2, 3]. Therefore, all nursing students must be professionally competent to provide geriatric care for older patients in any healthcare setting [1].
Geriatric nursing is professional holistic care that requires professional competence among nursing students [2]. Professional competence (PC) is defined as use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in professional practice [4]. The PC is also as a fundamental element in geriatric care associated with professional standards to ensures the safety, quality of geriatric care and behavioral characteristics in older adults [5]. Studies showed that competent nursing care was associated with a lower readmission rate and better management of geriatric syndromes in older adults [6] because older adults are more vulnerable to functional decline just being hospitalized [7].
An internship program is a transition course that enhances the knowledge, skills, and attitudes of aspiring nursing students in real clinical work.In geriatric clinical seting, nursing internship students require a broad understanding of professional competency that integrates reflective abilitty with clinical practice to deal with geriatric patient problems and equip them with the knowledge, attitudes, and skills needed to provide quality care [7, 8]. The reflection ability is an essential skill that plays an effective role in the deep learning process and the improvement of learners’ professional competencies [9].
The finding of an integrative reviewe presented a contradictory or negative attitude about the willingness of nursing students to engage in geriatric nursing work. In most studies that rank the intention to work in nursing fields, geriatric care received the lowest or a relatively low ranking. The main factors affecting work related to geriatric nursing include prior experience caring for older adults, attitudes towards geriatrics, anxiety about ageing, clinical practice environment and living experience with older family members. The review reported that the nursing curriculum must include theory and practice and integrate geriatric content into learning activities to facilitate intergenerational contact and reflection activites between nursing students and older adults when providing geriatric care in hospital and community [10].
Morover,the results of a systematic review revealed that including geriatric care content and reflective learning in undergraduate nursing curriculum could effectively enhance students' nursing competence. Geriatric nursing curriculum development should offer established content on geriatric as a foundation to implement early learning experiences in the curriculum. Both theory and clinical practice course can be developed to increase the nursing students' knowing on the elders through the clinical placement [11].
However,the review of current internship undergardute nursing education curriculum in Iran by Mohajer et al. (2022) showed that nursing internship students had inadequate professional geriatric clinical competence because this curriculum had minimal content of geriatric skills competencies and reflection approches [2]. Additional geriatric content in the undergraduate nursing education programs was an effective intervention to develop professional competency in geriatric care delivery [12]. Another study reported that there are insufficient experts working with older people and that geriatric nursing is poorly valued in society and among nurses [13]. Therfor, ther is a need to development of nurses’ reflection and professional competency on their educational preparation to work with older people.
Reflection is a core competency in geriatric nursing, and reflective learning is an effective approach in nursing education and pracice. Nurse educators must ensure that graduates are well prepared for the demands and challenges they will encounter in practice. They must use a modern and appropriate method of clinical learning in nursing education. Reflective learning is a modern teaching approach that is effective in increasing nurses’ knowledge and professional competency in clinical situations [14], but reflective learning is a mental process that is impossible to measure or it can be verbalized through speech or writing. Therefore, learners need a structured guide for reflection and constructive feedback about their reflections in practice. Reflective practice is the ability to reflect on one's actions to engage in a process of continuous learning. The current trend requires moving from a generic, technical approach to a more holistic model of clinical learning and assessment, which supports the development of competent nursing professionals [15]. There is a critical need for a holistic educational intervention to develop geriatric competencies in professional clinical practice.Therefore, the Holistic Reflection Model (HRM) developed by Bass et al. (2017) to direct a student’s reflective writing in a few ways over the educational modules can be used [16].
On the other hand, some studies suggested that reflective practice through professional portfolio can be more effective in developing and promoting professional competency and transferring academic learning to clinical practice [17, 18]. Recently, blended learning (BL) has rapidly become a new standard for delivering course content. Therefore, reflective portfolio in blended modality (face to face and online) can promote holistic reflective learning by serving as a reflective bridge between the student, the clinical practice, and the academy [17, 19]. However, there is a lack of studies examining the effect of reflective learning on professional competency development among nursing students in geriatric settings.Concerning the urgent attention to professional geriatric competency development among nursing internship students and considering the reflection is a core professional competency, this study focused on geriatric nursing training through holistic reflective learning model with a blended portfolio modality.
To the best of our knowledge, this has not been studied in the nursing education of Iran. Thus, the current study aimed to examine the effect of professional holistic reflective learning on PC development among nursing internship students’ caring for hospitalized older adults in geriatric clinical practice related to medical-surgical wards.
Research question
Does professional holistic reflective learning effectively enhance the development of professional competency among nursing internship students caring for hospitalized older adults in geriatric clinical practice related to medical-surgical wards?
Methods
Study design & participants
This study was a quasi-experimental design with two groups, pre-test and post-test, conducted at two nursing schools under the Mashhad University of Medical Sciences in Iran in 2020. This University has four nursing and midwifery schools, and in this study, we focused on two of these nursing schools. Participants were recruited using probability-sampling methods of cluster random sampling. Nursing students were in their final year of education (internship stage), during which they completed their clinical rotations. The study took place between February and May 2020, and the students were enrolled at the university in the academic year 2019/ 2020 in professional practice for two BSN in MUMS, Iran. Inclusion criteria were students who had registered for a course, had no previous experience with reflective training, had a smartphone with internet access, and could attend a geriatric internship for four months. Exclusion criteria were failing to complete the professional holistic reflective learning program or being absent from more than one session. (Fig. 1).
Fig. 1.
Flow chart of data collection process
Sample size
The sample size was calculated based on a similar study by Liu et al. (2019) [20] on nursing education interventions, considering a power of 80%, a significance level of 0.05, and a moderate effect size. Using the G*Power software for sample size estimation, the required sample size was determined to be 160 participants, with 80 students in each group.
Research instruments and data collection
The study collected data through a two-section survey. The first section gathered respondents' demographic information, such as gender, age, marital status, clinical experience, nursing interest, and GPA. The second section used the Geriatric Nursing-Specific Mini-CEX (GN-Specific Mini-Clinical Evaluation Exercise) to measure professional geriatric competency (PGC), a tool initially developed by Mohajer et al. (2022) [2]. The American Board of Internal Medicine (ABIM) first developed the Mini-CEX in 1972 [21], and Liu et al. (2019) later developed a specific nursing mini clinical evaluation exercise (Mini-CEX) for nursing students. Our study used a further adapted version specifically designed for assessing geriatric nursing competencies. The GN-Specific Mini-CEX consisted of 40 items with seven components: communication skills and history taking, physical examination skills, clinical judgment/nursing intervention, consultation/health education, nursing professionalism and organization/efficacy, and overall nursing geriatric competence. The questionnaire used a 9-point Likert scale (1–3: "unsatisfactory," 4–6: "moderately satisfactory," and 7–9: "satisfactory"), with a total score ranging from 40 to 360. Higher scores indicated higher PGC for nursing students. The validity and reliability of the tool were established in previous studies [20, 22, 23]. A pilot test using a test–retest design was conducted to assess consistency among 20 students using the Interclass Correlation Coefficient (ICC). The Cronbach's alpha for the GN-Specific Mini-CEX in this study was 0.92, indicating high internal consistency and confirming the reliability of the instrument for measuring nursing students' PGC [2].
Data collected in this study included both continuous and categorical variables. Continuous variables such as age and GPA were measured, while categorical variables included gender, marital status, and clinical experience.
Evaluation of clinical competencies
Students' professional geriatric clinical skills were evaluated through geriatric case studies, direct observation by evaluators, and constructive feedback. For example, students were assessed through case studies that involved managing the care of elderly patients with multiple comorbidities, including dementia and diabetes, requiring them to demonstrate their clinical judgment, communication skills, and nursing interventions. The rating of clinical competencies was based on the GN-Specific Mini-CEX, ensuring a standardized approach to evaluating students’ interactions with elderly patients. Evaluators rated all competencies based on observed clinical practices for selected elderly patients in medical-surgical wards, providing a 15-min snapshot of student-geriatric patient interactions. Both groups completed the questionnaires at baseline, after the intervention, and four weeks post-intervention. Data collection was conducted by both participants and evaluators. Participants filled out self-assessment questionnaires, while evaluators gathered observational data using structured forms to assess participants' clinical competencies. This dual approach ensured a comprehensive evaluation of the intervention's effectiveness.
Designing the professional holistic reflective (PHR) learning intervention
The professional holistic reflective (PHR) learning program was a blended teaching–learning approach that incorporated learning theory and model domains. In this study,designing and implementation blended learning modalities for the intervention was underpinned by the "blending with purpose" The multimodal conceptual model by Picciano.(2017), which carefully separated face-to-face and online modalities while allowing for some overlap. The model contained six pedagogical goals and approaches forming learning modules: content, social/emotional, dialectic/questioning, reflection, collaborative learning, and senthesis/evaluation/assessing learning [24]. Reflective learning was based on the Holistic Reflection Model by Bass et al. (2017), consisting of six measurable domains for reflective writing: self-awareness, description, reflection, knowing, evaluation, and synthesis [16]. The components of program included lectures, group work sessions, clinical practice, case studies, reflective writing reports, student-led simulation seminars with debriefing, and online learning and discussions moderated by the researcher. Accordingly, this blended learning program had three online components, reflecting the domains of learning theories and models: asynchronous discussion groups; a teaching–learning environment facilitating social and emotional interactions with students, peers, and researcher presence to assess and feedback, and a professional portfolio facilitating personal and professional learning goal aspects. These blended components were employed during the four months of clinical geriatric practice in medical surgical wards, allowing nursing interns to develop their professional reflective portfolios and achieve professional competency skills (Fig. 2).
Fig. 2.
Blending with purpose: the multimodal model by Picciano (2017)
Implementation of the professional holistic reflective (PHR) learning intervention
The internship program lasted for four months, during which the students participated in six clinical shift per week, either in the morning or afternoon. Additionally, outside of these shifts, students engaged in online interactions as part of the blende holestic reflective learning program. It is important to note that participation in this intervention was entirely voluntary, and the program did not count towards the students' academic evaluation or grades for the geriatric internship course. To enhance online interaction, students were divided into eight online groups based on different eight medical-surgical wards placment, where they shared and reflected on their blended learning experiences, fostering geriatric knowledge and attitudes. Both nursing students and mentors received reflective skills training to improve geriatric care. Clinical mentors attended a one-day workshop led by the researcher to familiarize themselves with reflective practice and lead students in enhancing geriatric nursing competencies. To minimize the risk of contamination between the intervention and control groups, students from each group were assigned to different clinical shifts and were guided by separate mentors throughout the study. Additionally, online interactions and group discussions for the intervention group were held in a controlled virtual environment, ensuring no overlap with the control group. The control group did not have access to the reflective learning program content during the study, which was made available to them only after the conclusion of the research.
The intervention program of blended PHR, was implemented in three stages: a)workshop, clinical practice, and follow-up, aimed to prepare students for clinical rotations in medical-surgical wards with a focus on older adult care.
Stage 1-professional holistic reflective (PHR) workshop
The F2F four-day holistic reflective learning workshop consisted of four modules: reflective portfolio learning, geriatric case study, reflective writing, and geriatric simulation seminar, and hands-on practice to orient them to professional holistic reflective learning concepts, including definition, benefits, techniques, and strategies of holistic reflection model. Then, students practiced reflective writing based on steps of HRM for samples of scenarios relevant to common geriatric issues and syndromes. At last, the researcher was given a lecture summary of about 15 min and closed the ceremony.The workshops were held twice a day for four days. The briefing notes and teaching contents remained available in the online groups for students.
Stage 2- professional holistic reflective (PHR) learning program in clinical practice
According to six pedagogical goals and approaches of the "blending with purpose" The multimodal conceptual model, modules activity of PHR intervention was implemented during the professional clinical practice for four months in geriatric setting of medical-surgical wards. Nursing internship students were required to simulate and practice the PHR modules and activities such as geriatric case study, reflective writing, and geriatric simulation seminar that would be performed during four months of internship course and developed their reflective portfolio under face-to-face supervision and guidance from their mentors. They received online teaching, activity assessment, and written feedback from the researcher. Clinical mentors were assigned to oversee the PHR learning for nursing interns during the course, in addition to fulfilling their usual student advising responsibilities. Geriatric case studies had chances to lead the student from a holistic perspective of the older patients' needs of nursing; they could see clear benefits and were satisfied with the case study analyzing [2]. Creating and maintaining a reflective portfolio can also enable nursing students to identify their strengths and learning needs, and to improve a learning plan to address these requirements [25].
Based on the four months clinical program schedule, in the first month students were responsible for the care of their assigned older patients by performing two case studies and preparing two reflective case reports (one in group and one individually) per week to practice professional competency skills. Here the meanings of “reflection "include the reflection of learning in the practice and self-assessment of work performance. Nursing internship students performed two reflective writing based on steps of the Holistic Reflective Model (HRM), including self-awareness, description, reflection, knowing, evaluation, and synthesis [17]. Then, they shared their reports in the online group to and received feedback from the researcher. On the last day of this month, each group of nursing students implemented a reflective seminar and simulated geriatric patient scenarios under supervision of their mentors and received feedback from researcher. The HRM program was continued with duration of two month and nursing internship students implemented four individual sessions of PHR. Each reflective writing report based on HRM were posted to the discussion online group and were reviewed by the researcher after the students finished each section, and relevant feedback and responses were posted for the group. Then, researcher asked students to improve their reflective portfolio constantly and they reviewed their activities regularly with a serious consideration of the researcher feedback and submitted their revised reflective portfolio to the researcher (summative assessment). At the end of the third month, students worked on the posttest assessment section.
Stage 3-follow up
At the last month,students independently continued to utilize professional activities for duration of four weeks. Then, students completed all activities of the PHR program, revised, and compiled the reflective portfolio items. Finally, students developed their professional reflective portfolios and shared them in online groups (Supplementary file 1).
The control group students conducted traditional reflective logbook, while attending routine educational and clinical activities, about their experiences of the geriatric internship course learning process. They received online access to the PHR program content after the study.
Statistical analysis
Data were analyzed using SPSS V25. Descriptive statistics, Chi-Square tests, and Independent T-tests were employed to compare participant characteristics and study results between groups. Chi-Square tests were used to analyze categorical variables, such as gender and marital status, while Independent T-tests were used for comparing continuous variables, such as age and GPA, between the intervention and control groups. This combination allowed us to comprehensively assess differences across various types of data. Generalized Estimating Equations (GEE) were then used to investigate the influence of the Professional Holistic Reflective (PHR) program over time, considering both intervention and control groups, as well as time-group interactions. Significant pre-test discrepancies in professional competence (PC), its dimensions, and age were treated as covariates. The GEE analysis assessed variations in respondents' professional skills competencies (PSC) and its dimensions, accounting for these covariates to determine group and time effects.
Results
Participants characteristics
The study included a sample of 160 nursing internship students, with no exclusions. The Chi-Square test and independent t-test results (Table 1) revealed no significant differences in the baseline scores for any of the study outcomes between the two groups, except for age, which showed a significant difference between the intervention and control groups. Consequently, age was treated as a covariate in all analyses. Moreover, the comparison of the two groups at baseline indicated no significant differences in total PC and its dimensions. Table 2 presents the descriptive statistics (mean and 95% confidence interval) of PC and its dimensions for both groups at three time points (Table 2).
Table 1.
Comparison of the participants' characteristics between the experimental and control groups at baseline for intention-to-treat (ITT) analysis
| Variable | Group | χ2 /t | P-value | |||
|---|---|---|---|---|---|---|
| Control | Intervention | |||||
| n | % | n | % | |||
| Gender | ||||||
| Male | 26 | 33.8 | 26 | 34.2 | .003 | 0. 954 |
| Female | 51 | 66.2 | 50 | 65.8 | ||
| Marital status | ||||||
| Single | 51 | 66.2 | 58 | 76.3 | 1.89 | 0.17 |
| Married | 26 | 33.8 | 18 | 23.7 | ||
| Clinical experience | ||||||
| Yes | 71 | 92.2 | 66 | 86.8 | 1.17 | 0.28 |
| No | 6 | 7.8 | 10 | 13.2 | ||
| Nursing interest | ||||||
| High | 64 | 89.5 | 68 | 83.1 | 1.3 | 0.25 |
| Low | 13 | 16.9 | 8 | 10.5 | ||
|
Age (Years) Mean ± SD |
22.32 ± 66 | 22.8312 ± 1.71 | < 0.001 | |||
|
GPA Mean ± SD |
17.2373 ± 1.1156 | 16.9725 ± .92501 | -1.597 | 0.112 | ||
χ2 = Chi-square; P-value = level of statistical significance (p < .05)
Table 2.
Professional competency and its skills domains mean scores within and between
| Domain | Group | |||
|---|---|---|---|---|
| Intervention | Control | |||
| Mean | 95% CI | Mean | 95% CI | |
| Communication &History taking (Time) | ||||
| Pre | 6.7 | 5.4, 8 | 6.6 | 5.4, 7.8 |
| Post | 8.1 | 6.9, 9.4 | 7.1 | 5.9, 8.3 |
| Follow-up | 8.4 | 7.2, 9.7 | 7.7 | 5.9, 8.4 |
| Physical Examination (Time) | ||||
| Pre | 5 | 3.36,6.7 | 4.9 | 3.3,6.7 |
| Post | 7 | 5.37,8 | 5.3 | 3.8,6.9 |
| Follow-up | 7.1 | 8.8, 5.5 | 5.5 | 3.9, 7.1 |
| Clinical Judgment &Intervention (Time) | ||||
| Pre | 5.8 | 4.2, 7.3 | 5.7 | 4.1, 7.2 |
| Post | 8.3 | 6.7., 8.9 | 6.2 | 4.7, 7.7 |
| Follow-up | 8.1 | 6.6, 9.7 | 6.3 | 4.8, 7.8 |
| Nursing Professionalism (Time) | ||||
| Pre | 5.6 | 4.4, 6.9 | 5.5 | 4.3, 6.7 |
| Post | 8.6 | 7.3, 8.8 | 5.9 | 4.8, 7.1 |
| Follow-up | 8.3 | 7.1, 8.6 | 6.1 | 4.9, 7.3 |
| Patients Education & Consulting (Time) | ||||
| Pre | 6.1 | 5.2, 7 | 6.1 | 5.3,7 |
| Post | 7.9 | 7, 8.8 | 6.2 | 5.4, 7 |
| Follow-up | 8.1 | 7.3, 9 | 6.4 | 5.6, 7.3 |
| Organization &Efficacy (Time) | ||||
| Pre | 6.3 | 5, 7.5 | 6.2 | 5, 7.4 |
| Post | 8.3 | 7.1, 8.6 | 6.3 | 5.1, 7.6 |
| Follow-up | 8.4 | 7.1, 9.7 | 6.5 | 5.3, 7.8 |
| Overall Competency (Time) | ||||
| Pre | 6.13 | 4.7, 7.5 | 6.1 | 4.7, 7.4 |
| Post | 8.5 | 7.1, 9 | 6.14 | 4.8, 7.4 |
| Follow-up | 8.7 | 7.3, 9 | 6.4 | 5.9, 7.7 |
Pre-test (1 week); Post-test (12thweeks); Follow-up (16th weeks), CI Confidence interval
Effect of professional holistic learning program on professional competency and its dimensions
The intervention group exhibited a notable enhancement in professional competency (PC). The Generalized Estimating Equation (GEE) analysis indicated a significant interaction between time and group effects on overall PC, communication skills, physical examination abilities, clinical judgment, health education, professionalism, and organizational efficacy. This suggests that PC scores and its skill domains underwent substantial changes over time (pre, post, and follow-up assessments) between the intervention and control groups.
In alignment with the study’s research questions, comparisons between groups at various time points (pre, post, and follow-up assessments) revealed significant differences at post-test and follow-up evaluations (p < 0.05), while no significant difference was observed at pre-test (p > 0.05) (Table 3). For example, the intervention group scored 2.4 points higher than the control group on overall PC at post-test (p < 0.001), demonstrating a sustained improvement in the follow-up phase. Similarly, significant improvements were found across other domains, such as communication skills and physical examination.
Table 3.
Results of Generalized Estimating Equations (GEE) in Professional competency and its skills domains
| Variable | (I) Group | (J) Group |
Mean Difference (I-J) |
SE | P-value | 95%CI for Difference LB UB |
effect size d | |
|---|---|---|---|---|---|---|---|---|
| Communication & History taking | ||||||||
| Pretest | I | C | .12 | .11 | *0.264 | -.09 | .35 |
2.4 (L) |
| Post-test | I | C | 1 | .09 | * < 0.001 | .87 | 1.2 | |
| Follow up | I | C | .97 | 0.9 | * < 0.001 | .79 | 1.1 | |
| Physical Examination | ||||||||
| Pretest | I | C | .09 | 0.11 | *0.388 | -.12 | .31 |
2.6 (L) |
| Post-test | I | C | 1.6 | 0.12 | * < 0.001 | 1.4 | 1.9 | |
| Follow up | I | C | 1.6 | 0.9 | * < 0.001 | 1.4 | 1.7 | |
| Clinical Judgment & Intervention | ||||||||
| Pretest | I | C | .09 | 0.07 | *0.198 | -.14 | 09 |
3.3 (L) |
| Post test | I | C | 2.1 | 0.77 | * < 0.001 | 1.9 | 2.2 | |
| Follow up | I | C | 1.8 | 0.08 | * < 0.001 | 1.6 | 2 | |
| Nursing Professionalism | ||||||||
| Pretest | I | C | -.02 | 0.07 | *0.101 | -.02 | .28 |
4.4 (L) |
| Post-test | I | C | 2.6 | 0.07 | * < 0.001 | 2.4 | 2.7 | |
| Follow up | I | C | 2.2 | 0.08 | * < 0.001 | 2.1 | 2.4 | |
| Patients Education & Counselling | ||||||||
| Pretest | I | C | .35 | 0.19 | *0.689 | -.02 | .73 |
3 (L) |
| Post-test | I | C | 2.05 | 0.23 | * < 0.001 | 1.5 | 2.5 | |
| Follow up | I | C | 3.6 | 0.23 | * < 0.001 | 3.2 | 4.3 | |
| Organization/Efficiency | ||||||||
| Pretest | I | C | -.08 | 0.07 | *0.258 | -.06 | .23 |
3.5 (L) |
| Post-test | I | C | 1.9 | 0.08 | * < 0.001 | 1.8 | 2.1 | |
| Follow up | I | C | 1.8 | 0.06 | * < 0.001 | 1.6 | 2 | |
| Overall Competency | ||||||||
| Pretest | I | C | .03 | 0.05 | *0.587 | -.07 | .13 |
4.77 (L) |
| Post-test | I | C | 2.4 | 0.07 | * < 0.001 | 2.2 | 2.5 | |
| Follow up | I | C | 2.3 | 0.07 | * < 0.001 | 2.1 | 2.4 | |
*The mean difference is significant at the .05 level Adjustment for multiple comparisons: Bonferroni
Moreover, the within-group comparison results for both control and intervention groups (Table 4) demonstrated significant differences in PC and all its skill domains (overall PC, communication skills and history taking, physical examination skills, clinical judgment/nursing intervention, consultation/health education, nursing professionalism, and organization/efficacy) across time from pre-test to post-test and follow-up (p < 0.05). Additionally, the differences from post-test to follow-up were also significant (p < 0.05) for both groups. The percentage increase in PC and its skill domains in the intervention group was notably higher compared to the control group.
Table 4.
Pairwise comparison of professional competency and its skills domains mean score across time
| Group |
(I) Test |
(J) Test |
Mean Difference (I-J) |
SE | P-value |
95%CI for Difference LB UB |
Effect Size d | ||
|---|---|---|---|---|---|---|---|---|---|
| Communication & History taking | I | Pre | Post | -1.42 | 0.79 | * < 0.001 | -1.5 | -1.2 |
2.5 (L) |
| Pre | Follow-up | -1.71 | 0.08 | * < 0.001 | -1.8 | -1.5 | |||
| post | Follow-up | -.28 | 0.05 | * < 0.001 | -.4 | -.17 | |||
| C | Pre | Post | -.49 | 0.06 | * < 0.001 | -.62 | -.36 |
1 (L) |
|
| Pre | Follow-up | -.57 | 0.06 | * < 0.001 | -.7 | -.43 | |||
| post | Follow-up | -.07 | 0.04 | *.052 | -.15 | 0 | |||
| Physical Examination | I | Pre | Post | -2 | 0.08 | * < 0.001 | -1.8 | -2.1 |
3 (L) |
| Pre | Follow-up | -2.1 | 0.08 | * < 0.001 | -2.2 | -1.9 | |||
| post | Follow-up | -.13 | 0.08 | *0.117 | -.29 | -.03 | |||
| C | Pre | Post | -.4 | 0.06 | * < 0.001 | -.52 | -.28 |
1 (L) |
|
| Pre | Follow-up | -.62 | 0.06 | * < 0.001 | -.75 | -.49 | |||
| post | Follow-up | -.22 | 0.05 | * < 0.001 | -.32 | -.11 | |||
| Clinical Judgment & Intervention | I | Pre | Post | -2.5 | 0.06 | * < 0.001 | -2.6 | -2.4 |
4.6 (L) |
| Pre | Follow-up | -2.3 | 0.07 | * < 0.001 | -2.5 | -2.2 | |||
| post | Follow-up | .17 | 0.06 | *0.012 | .03 | 3 | |||
| C | Pre | Post | -.51 | 0.05 | * < 0.001 | -.63 | -.4 |
1 (L) |
|
| Pre | Follow-up | -.62 | 0.07 | * < 0.001 | -.77 | -.4 | |||
| post | Follow-up | -.1 | 0.06 | *0.111 | -.23 | 0.02 | |||
| Nursing Professionalism | I | Pre | Post | -2.9 | 0.06 | * < 0.001 | -.3 | -2.7 |
5.4 (L) |
| Pre | Follow-up | -2.6 | 0.07 | * < 0.001 | -2.8 | -2.5 | |||
| post | Follow-up | .22 | 0.06 | * < 0.001 | .09 | .34 | |||
| C | Pre | Post | -.42 | 0.05 | * < 0.001 | -.54 | -.31 |
1 (L) |
|
| Pre | Follow-up | -.54 | 0.05 | * < 0.001 | -.66 | -.42 | |||
| post | Follow-up | -.11 | 0.06 | *0.004 | -.19 | -.03 | |||
| Patients Education & Counselling | I | Pre | Post | -1.8 | 0.06 | * < 0.001 | -1.9 | -1.6 |
4.2 (L) |
| Pre | Follow-up | -2 | 0.05 | * < 0.001 | -2.1 | -1.9 | |||
| post | Follow-up | -.23 | 0.06 | * < 0.001 | -.36 | -.11 | |||
| C | Pre | Post | -.07 | 0.03 | *0.029 | -.14 | 0 |
.64 (M) |
|
| Pre | Follow-up | -.31 | 0.05 | * < 0.001 | -.42 | -.2 | |||
| post | Follow-up | -.23 | 0.04 | * < 0.001 | -.32 | -.13 | |||
| Organization/Efficiency | I | Pre | Post | -2.05 | 0.05 | * < 0.001 | -2.1 | -1.9 |
4.1 (L) |
| Pre | Follow-up | -2.1 | 0.05 | * < 0.001 | -2.2 | -1 | |||
| Post | Follow-up | -.07 | 0.05 | *0.152 | -.18 | -.02 | |||
| C | Pre | Post | -.16 | 0.04 | * < 0.001 | -.25 | -.07 |
.76 (M) |
|
| Pre | Follow-up | -.36 | 0.05 | * < 0.001 | -.47 | -.25 | |||
| Post | Follow-up | -.19 | 0.05 | * < 0.001 | -.29 | -.09 | |||
| Overall Competency | I | Pre | Post | -2.4 | 0.05 | * < 0.001 | -2.5 | -2.3 |
5.6 (L) |
| Pre | Follow-up | -2.6 | 0.05 | * < 0.001 | -2.7 | -2.4 | |||
| Post | Follow-up | -.18 | 0.04 | * < 0.001 | -.27 | -.08 | |||
| C | Pre | Post | -.03 | 0.04 | * < 0.001 | -.34 | -.15 |
.71 (M) |
|
| Pre | Follow-up | -.31 | 0.05 | *0.437 | -.13 | -.05 | |||
| Post | Follow-up | -.27 | 0.05 | * < 0.001 | -.37 | .16 | |||
*The mean difference is significant at the .05 level Adjustment for multiple comparisons: Bonferroni
*I Intervention, C Control
Discussion
The current study aimed to examine the effect of professional holistic reflective learning on PC development among nursing internship students’ caring for hospitalized older adults in geriatric clinical practice related to medical-surgical wards.The study assessed the impact of a PHR program on nursing students’ PC during geriatric clinical practice. Blended PHR learning proved more effective in developing professional competence compared to conventional methods, with a greater impact on PC development. This was the first study to implement blended PHR learning in geriatric education for nursing internship students in Iran.
Effect of professional holistic learning program on professional competency
The outcomes showed significantly improved professional competence (PC) development with high effect size, implying the effectiveness of the blended PHR learning program. These findings are consistent with previous studies [26–28] and [29]. Acquiring professional competence during nursing education is crucial to ensure the safety and quality of nursing care [25, 30]. Besides, the intervention program was guided based on principles of "blending with purpose" Multimodal conceptual model and incorporated reflection guidelines with Holistic Reflection Model, which allowed the participants to communicate with one another or with the researcher and facilitators and performing professional development activities. But interaction might not be sufficient in other reflective learning studies as compared to this blended intervention. The Blending with Purpose model posits that instruction is not always just about learning content or a skill but is also about supporting students socially and emotionally. Alternatively, mentores and researchers through blended methods provided feedback for every step the student performed in the geriatric clinical setting and supporting students socially and emotionally.Hense, it acts as a guide to reflect upon their strengths and weaknesses and so these reasons may a good explanation for the professional competence (PC) development in the current study. This finding is supported by results of other studies by,[26, 31].
Effect of professional holistic learning program on professional competency skills dimensions
During the implementation of the blended PHR program, nursing students had excellent opportunities to perform all geriatric competency domains of PC through activities such as geriatric case studies, reflective writing, and geriatric simulation seminars based on HRM. They also assessed their peers' performance and provided constructive feedback to improve their skills. These results could be attributed to the students' self-reflection and written feedback from the researcher through the reflective practice activity of the blended PHR program [16]. Competence refers to one's experiences of performing work activities with skill, which aligns with peer learning review studies describing increased clinical competence and improved problem-solving, cognitive, and motor skills [32, 33].The blended PHR and conventional learning strategies allowed nursing students to independently participate in all professional competency skills dimensiones, facilitating their practice of these competencies as they were exposed to related conditions in the geriatric clinical setting. Although the effect of each learning strategy differed, students were exposed to the same conditions when assigned to geriatric patients during professional clinical practice. The key difference was how nursing students developed these professional competencies dimensions through training in the blended PHR method. The results demonstrate that the PHR intervention had a highly significant effect on the professional competency skills dimensiones of nursing internship students in caring for geriatric patients. These results are consistent with study for nrsing students to adopt reflective learning based on visual mind mapping in geriatric practice and their finding showed students' critical thinking and professional self-concept were greatly improved in intervention group, however there were no significant differences in the improvement level of students' academic self-efficacy [34].
Moreover, the nursing students in the intervention group achieved the highest scores for overall geriatric competency, with a significant increase. For the control group, history taking remained the highest competency domain, albeit with a slight increase. These outcomes are similar to the findings of studies by [35–37], and [38]. Interestingly, when each group was studied separately over time, three professional competency dimensions showed greater improvement in the intervention group. Prior to the intervention, history taking was the highest competence domain, while physical examination, clinical judgment/intervention, and nursing professionalism were the lowest. Following the educational intervention of PHR, the students achieved a superior level in these geriatric professional competencies, with significant differences in mean scores before and after the intervention. These results are consistent with other recent studies [10, 36, 39].
Both the PHR intervention and conventional learning provided students with opportunities to independently participate in the examination, treatment, and follow-up of geriatric patients' conditions.The difference in results between the two groups can be attributed to the reflections and feedback in the blended learning approach, which help modify knowledge and skills related to the acquisition of concepts, procedures, and principles. Nursing students in the blended learning group implemented geriatric case study analysis activities and had the opportunity for professional training. They performed holistic nursing care processes for geriatric patients, including comprehensive nursing assessments, physical assessments, data analysis, and formulation of nursing diagnoses. They also planned nursing care while considering professional competency under the guidance of clinical mentors [40]. Furthermore, students assessed information using comprehensive geriatric assessments regarding the functional status of elderly patients in the hospital, including physical, mental, and environmental health issues, social engagement, and common geriatric syndromes [2]. These results are consistent with recent study that emphasize the need to incorporate aging-focused education into nursing curricula and update the curriculum, providing hands-on training such geriatric case study analysis and reflective writing with early exposure to these environments. Additionally, simulation classes can enhance critical thinking by allowing students to experience aging effects first hand [39]. The use of a professional portfolio in a blended learning modality, along with formative assessment, appears to promote a link between theory and the advancement of geriatric nursing practice.
Morover, these professional activities through implemented of PHR progrom helped develop nursing professionalism, clinical judgment, intervention skills, and overall professional competency. Our results are consistent with other studies that reported the effectiveness of blended learning interventions on clinical competencies such as history taking, physical examination, and clinical judgment [41–44]. These results also are consistent with the study reported that critical reflection competency program was effective in improving the critical thinking disposition,learning efficacy, clinical nurses’ reflective practice and professionalism of nurse educators. Therefore, it is necessary to implement the developed program for nurse educators to effectively utilize critical reflection in nursing education [45].
In contrast, the control group showed no significant increase in the mean scores of total professional competency (PC) and its domains. The conventional learning strategy seemed not to stimulate Iranian nursing students to expand their professional competency during practice, resulting in learners making little effort to fulfill their educational needs. This discrepancy could be due to the different methods of delivering the learning program. Conventional learning has been criticized for providing students with a large amount of information in a short time without effective communication, leading to challenges in creating a supportive clinical environment for critical thinking and professional competency promotion. There are also limited opportunities for active engagement in group discussions, professional clinical activities, data analysis, and the application of learned knowledge and competency in geriatric practice [46]. Consequently, nursing students in the control group had no access or chance to practice and exercise professional development activities, such as geriatric case studies, reflective practice, and geriatric simulation seminars during their professional clinical practice. However, the control group did experience a slight increase in the total mean score of PC and overall competency, possibly due to changes in the work environment, communication between nursing interns, peers, and staff, or the inspiration and activity of the control group through using a reflective logbook. Both PHR learning and conventional learning strategies offered and allowed nursing students to practice PC as they were exposed to related conditions in the geriatric clinical setting. PPL intervention and conventional learning offer the students to independently participate in the examination, treatment, and follow-up on patients' conditions. The previous studies that investigated professional competency reported similar findings [20, 47, 48]. The trend of these changes may cause more differences in the long term. These findings highlight that direct observation followed by focusing feedback changes a learner’s behavior [34].
Strengths of the study include the four-month implementation of the Holistic Reflective Learning (HRL) program with reflective portfolio, which allowed nursing internship students to gradually improve their professional competency with weekly feedback. The blended teaching–learning approach, based on multiple theories and models, facilitated communication and professional development activities among participants. The study also compared professional competency levels using GN-Specific Mini-CEX, a structured evaluation tool, with self-reported measures, providing a more comprehensive perspective.
Limitations include the study's focus on fourth-year internship nursing students only, which may limit the generalizability of the findings. The participants' awareness of their involvement in the study could introduce bias. The study employed a quantitative quasi-experimental design, leaving room for future research with qualitative or mixed-method approaches to further explore the effects of HRL with blended learning. A qualitative study could help identify the most effective delivery methods for the HRL program and factors influencing nursing interns' learning during the intervention.
Conclusion
The present study demonstrated that the PHR intervention significantly contributed to the development of professional competency among nursing students. The blended teaching–learning method, which included both face-to-face and online sessions during workshops and geriatric clinical practice, proved to be an efficient, economical, and time-saving approach. This method allowed nursing interns to manage their professional development activities of PHR alongside their demanding clinical practice schedules in geriatric settings. The program was more economical than traditional methods due to the reduced need for physical infrastructure and travel. However, further research is needed to generate more reliable and robust findings.
Implication to nursing education, research and clinical practice
Our research emphasizes the need to incorporate geriatric content education and reflective learning into undergraduate nursing internship curricula and to update the curriculum by providing hands-on training with early exposure to these environments. Additionally, reflective writing, case studies, and simulation seminars can enhance critical thinking and professional competency by allowing students to experience the effects of aging firsthand. The results are encouraging and can help both teachers and students understand the potential benefits of combining these learning modalities with geriatric nursing education. Furthermore, the findings provide a valuable reference for researchers and educational decision-making, supporting the use of a blended reflective learning program based on a holistic reflective model in nursing. This approach may serve as a complementary learning method for undergraduate nursing internship education.
Supplementary Information
Acknowledgements
The current study was supported by Mashhad University of Medical Sciences, Mashhad, Iran grant no (IR.MUMS.REC.1399.395). We express our sincere gratitude to all of the nursing students and their mentors and also evaluators for their valuable collaboration.
Abbreviations
- GEE
Generalized Estimating Equation
- PC
Professional competency
- HRM
Holistic Reflection Model
- BL
Blended learning
- PGC
Professional geriatric competency
- ABIM
American Board of Internal Medicine
- Mini-CEX
Mini clinical evaluation exercise
- ICC
Interclass Correlation Coefficient
- PHR
Professional holistic reflective
Author’s contributions
SM, Methodology design, obtained funding for the manuscript, prepared the writing of the initial draft, acquisition of data, analyze and interpret the data, conceptualize the paper, and review and synthesize the literature. TLY, CMC, Methodology design, supervised, proof-read, and provided intellectual support in terms of administrative, technical, and material support and supervised in the preparation of the manuscript. MD, SRM, Methodology design, supervised, proof-read, and provided intellectual support in terms of statistical analysis and administrative, technical, and material support and supervised in the preparation of the manuscript. NB, MN, VL, MN, Methodology design, provided critical review and significant revision of the manuscript for important intellectual content, proof-read, and supervised the preparation of the manuscript. All authors read and approved the final manuscript.
Funding
The current study was supported by Mashhad University of Medical Sciences, Mashhad, Iran.
Data availability
The datasets generated in the current study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
Ethics approval and consent to participate: Ethical approval was supported by the Ethical Committee of University Malaya (UMREC), Kuala Lumpur, Malaysia, (UMREC: UM.TNC2/UMREC-786), and ethical approval from Mashhad University of Medical Science Research Ethics Committee (IR.MUMS.REC.1399.395). All students provided written informed consent to participate. All methods were carried out in accordance with relevant guidelines and regulations or the Declaration of Helsinki. Figure 1 shows the processes involved in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Samira Mohajer, Email: s_mohajer99@yahoo.com.
Mohammad Namazinia, Email: Mnamazi99@gmail.com.
References
- 1.Markey K, O’Brien B, O’Donnell C, Martin C, Murphy J. Enhancing undergraduate nursing curricula to cultivate person-centred care for culturally and linguistically diverse older people. Nurse Educ Pract. 2021;50:102936. [DOI] [PubMed] [Google Scholar]
- 2.Mohajer S, Tang LY, Chong MC, Danaee M, Mazlum SR, Bagheri N. Development of a Geriatric Nursing-Specific Mini-CEX and Evaluation of the Professional Competence of Nursing Students: A Novel Approach to Clinical Evaluation in Implementing Case Study. Iranian Red Crescent Med J. 2022;24(5):1–9.
- 3.Wong LP, Alias H, Danaee M, Ziaee M, Abedi F, Ziaee A, Mohajer S, HajiAliBeigloo R, Nia MN, Jamei F. Uncovering psychobehavioural implications of SARS‐CoV‐2 infection in Iran. Transbound Emerg Dis. 2020;67(6):2892–900. [DOI] [PubMed]
- 4.Fouad NA, Grus CL, Hatcher RL, Kaslow NJ, Hutchings PS, Madson MB, Collins FL Jr, Crossman RE. Competency benchmarks: A model for understanding and measuring competence in professional psychology across training levels. Train Educ Prof Psychol. 2009;3(4S):S5. [Google Scholar]
- 5.Karami A, Farokhzadian J, Foroughameri G. Nurses’ professional competency and organizational commitment: Is it important for human resource management? PLoS ONE. 2017;12(11):e0187863. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Azarkhavarani MG, Alavi NM. Surveying the quality of prehospital emergency services for the elderly falls 2017. J Educ Health Promot. 2018;8(12):1–7. [DOI] [PMC free article] [PubMed]
- 7.Torkshavand G, Khatiban M, Soltanian AR. Simulation-based learning to enhance students’ knowledge and skills in educating older patients. Nurse Educ Pract. 2020;42:102678. [DOI] [PubMed] [Google Scholar]
- 8.Campbell C, Blair H. Learning the active way: Creating interactive lectures to promote student learning. In: Handbook of research on pedagogical models for next-generation teaching and learning. edn. IGI Global; 2018. p. 21–37. vol. 1(1).
- 9.Keshmiri F, Fazljoo SE. Assessing the Reflection in Learning Ability of Nursing Students: Psychometric Properties of Reflection in Learning Scale. Strides Dev of Med Educ. 2020;17(1):1–5. [Google Scholar]
- 10.Dai F, Liu Y, Ju M, Yang Y. Nursing students’ willingness to work in geriatric care: An integrative review. Nurs Open. 2021;8(5):2061–77. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Hsieh P-L, Chen C-M. Nursing competence in geriatric/long term care curriculum development for baccalaureate nursing programs: A systematic review. J Prof Nurs. 2018;34(5):400–11. [DOI] [PubMed] [Google Scholar]
- 12.Krogman S. Gerontological content In undergraduate education. Doctoral dissertation, University of Lethbridge; 2018.
- 13.Dahlke S, Kalogirou MR. Swoboda NLJIJoOPN: Registered nurses’ reflections on their educational preparation to work with older people. 2021;16(2):e12363. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Ogata YJHIDKFGG. Examination of performance reflection in nursing practice: a focus on improvement of nursing judgement. Hokkaido Iryo Daigaku Kango Fukushi Gakubu Gakkaishi.2014;10:43–7.
- 15.Reljić NM, Lorber M, Vrbnjak D, Sharvin B, Strauss M. Assessment of clinical nursing competencies: Literature review. Teac Learn Nurs. 2017;1(1):49–67.
- 16.Bass J, Fenwick J, Sidebotham M. Development of a model of holistic reflection to facilitate transformative learning in student midwives. Women and Birth. 2017;30(3):227–35. [DOI] [PubMed] [Google Scholar]
- 17.Pandya H. Slemming W. Saloojee HJAJoHPE: Reflective portfolios support learning, personal growth and competency achievement in postgraduate public health education. Afr J Health Prof Educ. 2017;9(2):78–82.
- 18.Mohajer S, Li Yoong T, Chan CM, Danaee M, Mazlum SR, Bagheri N. The effect of professional portfolio learning on nursing students’ professional self-concepts in geriatric adult internship: a-quasi-experimental study. BMC Med Educ. 2023;23(1):114. [DOI] [PMC free article] [PubMed]
- 19.Birks M, Hartin P, Woods C, Emmanuel E. Hitchins MJNeip: Students’ perceptions of the use of eportfolios in nursing and midwifery education. Nurse Educ Pract. 2016;18:46–51. [DOI] [PubMed] [Google Scholar]
- 20.Liu Y-P, Jensen D. Chan C-y, Wei C-j, Chang Y, Wu C-H, Chiu C-h: Development of a nursing-specific Mini-CEX and evaluation of the core competencies of new nurses in postgraduate year training programs in Taiwan. BMC Med Educ. 2019;19(1):270. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Norcini JJ, Blank LL, Duffy FD, Fortna GS. The mini-CEX: a method for assessing clinical skills. Ann Intern Med. 2003;138(6):476–81. [DOI] [PubMed] [Google Scholar]
- 22.Djuria SA, Afandi MJIJoN, Care H. Development of measurement tool mini-CEX (mini clinical evaluation exercise) as an evaluation tool of nursing students in teaching hospital of Universitas Muhammadiyah Yogyakarta. GSTF J Nurs Health Care (JNHC). 2013;1:127–33.
- 23.Sahebalzamani M, Farahani H, Pouryani A. Assessing the reliability and validity of the mini-clinical evaluation exercise (Mini-CEX) for nursing student. J Appl Environ Biol Sci. 2013;3(9):78–82.
- 24.Picciano AGJOL. Theories and frameworks for online education: Seeking an integrated model. Online Learning. 2017;21(3):166–90.
- 25.Gardulf A, Nilsson J, Florin J, Leksell J, Lepp M, Lindholm C, Nordström G, Theander K, Wilde-Larsson B, Carlsson M. The Nurse Professional Competence (NPC) Scale: Self-reported competence among nursing students on the point of graduation. Nurse Educ Today. 2016;36:165–71. [DOI] [PubMed] [Google Scholar]
- 26.Eachempati P, Supe A, Tripathi R, KS KK, Soe HHK, Ismail ARH, Mayya A, Farias AF. Impact of a learning portfolio on reflective, clinical and communication skills in undergraduate dental students-A pilot study. MedEdPublish. 2018;7:231.
- 27.Bahreini M, Ahmadi F, Shahamat S, Behzadi S. The Impact of Professional Portfolio on Nurses’ Clinical Competence. Strides in Development of Medical Education. 2012;8(2):107–14. [Google Scholar]
- 28.Dolatshahi M, Sohrabi S, Kazemi N, Mahmoudi SJJoME. The Effect of Portfolio on Nursing Students’ Learning and Satisfaction from Clinical Evaluation. J Med Educ. 18(4):211–8.
- 29.Hoveyzian SA, Shariati A, Haghighi S. Latifi SM. Ayoubi MJAiME, Practice: The Effect of Portfolio-Based Education and Evaluation on Clinical Competence of Nursing Students: A Pretest-Posttest Quasiexperimental Crossover Study. 2021;12:175–82. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Kajander-Unkuri S, Leino-Kilpi H, Katajisto J, Meretoja R, Räisänen A, Saarikoski M, Salminen L, Suhonen R. Congruence between graduating nursing students’ self-assessments and mentors’ assessments of students’ nurse competence. Collegian. 2016;23(3):303–12. [Google Scholar]
- 31.Bass J, Sidebotham M, Creedy D, Sweet L. Midwifery students’ experiences and expectations of using a model of holistic reflection. Women and Birth. 2020;33(4):383–92. [DOI] [PubMed] [Google Scholar]
- 32.Pålsson Y, Mårtensson G, Swenne CL, Ädel E. Engström MJNet: A peer learning intervention for nursing students in clinical practice education: A quasi-experimental study. Nurs Educ Today. 2017;51:81–7. [DOI] [PubMed] [Google Scholar]
- 33.Khodadadi A, Froutan R, Salehian M, Mazlom SR. The effect of peer teaching on the quality of report writing based on the nursing process. Iran J Nurs Midwifery Res. 2022;27(1):75–80. [DOI] [PMC free article] [PubMed]
- 34.Yang K-H, Chen H, Liu C-J, Zhang F-F, Jiang X-L. Effects of reflective learning based on visual mind mapping in the fundamentals of nursing course: A quasi-experimental study. Nurse Educ Today. 2022;119:105566. [DOI] [PubMed] [Google Scholar]
- 35.Meresh E, Daniels D, Sharma A, Rao M, Mehta K, Schilling DJAime. Practice: Review of mini-clinical evaluation exercise (mini-CEX) in a psychiatry clerkship. Adv Medical Educ Pract. 2018;9:279. [DOI] [PMC free article] [PubMed]
- 36.Buch PMJIJoCP. Impact of introduction of Mini-Clinical Evaluation Exercise in formative assessment of undergraduate medical students in pediatrics. Int J Contemp Pediatr. 2019;6(6):2248.
- 37.Rogausch A, Beyeler C, Montagne S, Jucker-Kupper P, Berendonk C, Huwendiek S, Gemperli A, Himmel WJBme. The influence of students’ prior clinical skills and context characteristics on mini-CEX scores in clerkships–a multilevel analysis. BMC Med Educ. 2015;15(1):208. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Mosalanejad L. Saeedabdollahifard RR, Rezaie R. Mobile e-portfolio as a Personal Digital Assistant in Nursing Education. Pak J Med Health Sci. 2018;12(2):930–4. [Google Scholar]
- 39.Alves SB, Magalhães CP, Fernandes A, Palmero MJF, Fernandes H. Gerontology and Geriatrics in Undergraduate Nursing Education in Portugal and Spain: An Integrative and Comparative Curriculum Review. In: Healthcare: 2024:MDPI;2024:1786. [DOI] [PMC free article] [PubMed]
- 40.Hajialibeigloo R, Mazlum SR, Mohajer S, Morisky DE. Effect of self‐administration of medication programme on cardiovascular inpatients' medication adherence and nurses' satisfaction: A randomized clinical trial. Nurs Open. 2021;8(4):1947. [DOI] [PMC free article] [PubMed]
- 41.Rowe M, Frantz J, Bozalek V. The role of blended learning in the clinical education of healthcare students: a systematic review. Med Teach. 2012;34(4):e216–21. [DOI] [PubMed] [Google Scholar]
- 42.Pinilla S, Cantisani A, Klöppel S, Strik W, Nissen C, Huwendiek S. Curriculum Development with the Implementation of an Open-Source Learning Management System for Training Early Clinical Students: An Educational Design Research Study. Adv Med Educ Pract. 2021;12(1):53–61. [DOI] [PMC free article] [PubMed]
- 43.Alizadeh-Taghiabad B, Mazloum SR, Miri K, Namazinia M. Determining the frequency of burn wound dressing for clinically competent nursing students: establishing standards based on learning curves. BMC Med Educ. 2023;23(1):678. [DOI] [PMC free article] [PubMed]
- 44.Ghasemi A, Karimi Moonaghi H, Mohajer S, Mazlom SR, Shoeibi N. Effect of self-management educational program on vision-related quality of life among elderly with visual impairment. Evid Based Care. 2018;8(1):35–44.
- 45.Shin S, Lee I, Kim J, Oh E, Hong E. Effectiveness of a critical reflection competency program for clinical nurse educators: a pilot study. BMC Nurs. 2023;22(1):69. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Liu J, Zhou B, Shi J, Shi H, XI H, YU P. Investigation of metabolic syndrome in the elderly population. Chinese J Geriatr. 2017;36(9):959–62.
- 47.Wei C-J, Lu T-H, Chien S-C, Huang W-T, Liu Y-P, Chan C-Y, Chiu C-H. The development and use of a pharmacist-specific Mini-CEX for postgraduate year trainees in Taiwan. BMC Med Educ. 2019;19(1):165. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Meresh E, Daniels D, Sharma A, Rao M, Mehta K, Schilling D. Review of mini-clinical evaluation exercise (mini-CEX) in a psychiatry clerkship. Advances in medical education practice. 2018;9:279. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated in the current study are available from the corresponding author upon reasonable request.