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. 2025 Dec 9;26:77. doi: 10.1186/s12909-025-08379-x

Analysis of the effectiveness of SPOC combined with BOPPPS teaching method in stoma care training for nurses in neonatal intensive care units

Xushu Chen 1,2,#, Yan Song 1,2,#, Xiaowen Li 1,2,✉, Xiufang Zhao 1,2,✉
PMCID: PMC12801441  PMID: 41366400

Abstract

Background

Effective training for nurses in neonatal intensive care unit (NICU) is crucial to alleviate suffering, prevent complications, and enhance the quality of life for infants with stomas. Although both Small Private Online Courses (SPOC) and the BOPPPS (Bridge-in, Objective, Pre-assessment, Participatory Learning, Post-assessment, Summary) method are established educational strategies based on strong, theoretical frameworks, their potential integration remains unexplored. This study evaluates the effectiveness of the combined SPOCs and BOPPPS approach in comparison to conventional methods for teaching stoma care to neonatal nurses.

Methods

In September 2023, a total of 44 nurses from the NICU were selected as participants in the study through convenience sampling. They were grouped by their year of joining the hospital: 16 nurses were in the control group (joined in 2019), and 28 nurses were in the experimental group (joined in 2020). The experimental group received training through a SPOC integrated with the BOPPPS teaching model, while the control group underwent traditional offline instruction. The results indicated significant differences between the two groups in terms of stoma-related theoretical knowledge, operational skills, and self-efficacy scores for stoma care management. This analysis aimed to assess the effectiveness of the training.

Results

Statistically significant differences were observed in both theoretical knowledge (F = 32.537, P < 0.001) and practical skills test (F = 17.257, P < 0.001) across the groups. Furthermore, the self-efficacy scores for stoma care management in the experimental group were significantly higher than those in the control group (F = 21.706, P < 0.001).

Conclusions

Our study demonstrates that the SPOC + BOPPPS model significantly enhances theoretical knowledge, practical skills, and self-efficacy in stoma care among NICU nurses compared to traditional methods. Although this was a single-center study with a limited sample size, the results provide preliminary evidence supporting the value of this integrated approach in training for neonatal stoma care.

Keywords: SPOC, BOPPPS, NICU, Stoma management, Nurse training

Background

Newborns with severe conditions, such as congenital digestive tract malformations and acquired intestinal diseases, often require emergency intestinal ostomy surgery to save their lives and improve their prognosis [1]. Newborns have significantly underdeveloped skin barriers, making them especially vulnerable to complications such as irritant contact dermatitis and skin breakdown around the stoma site [2, 3]. Statistical data indicate that the incidence of complications in newborns with intestinal ostomies ranges from approximately 17.28% to 59.49% [3, 4]. Stoma complications not only increase suffering in pediatric patients, prolong hospital stays, and raise medical costs, but they may also present life-threatening risks and severely impact long-term quality of life [5, 6].

In the neonatal ward, nurses undertake nearly all stoma care responsibilities [2], making them crucial to every aspect of stoma patient care [7]. Professional, standardized, and proficient stoma management is vital to ensure patient safety, reduce the risk of complications, and facilitate recovery [5]. Stoma care constitutes a fundamental nursing skill [8]. Nevertheless, some nurses possess outdated skills and lack practical experience [9], which can increase risks to patient safety and lower nursing quality. Consequently, training junior NICU nurses in stoma care is imperative for reducing complications and enhancing family satisfaction.

Despite the strong emphasis on educational reform aimed at developing new and more effective teaching method, the predominant instructional approach in nursing education remains the traditional classroom model [10]. This method, characterized by one-way knowledge transfer from instructors and minimal nurse engagement, offers the distinct advantage of efficient management of teaching content [11]. However, traditional pedagogical methods are increasingly inadequate in meeting the changing needs of nurses [12]. This mechanical training model limited nurse autonomy and lead to consistently low levels of innovation and practical skills [13]. A significant gap exists between theoretical knowledge and clinical practice [14].

The widespread adoption of internet-based online teaching during the COVID-19 pandemic has significantly advanced online education, particularly in medical training in recent years [15]. Small private online courses (SPOC), a variant of online instruction, have gained notable attention in medical education due to their blended teaching model, which integrates both online and offline components [16]. Characterized by small scale and restricted access conditions, SPOCs are widely utilized in teaching and research related to oncology [17] and surgical procedures [18]. However, in the context of neonatal stoma care, while the acquisition of theoretical knowledge is vital, the critical aspect is translating theory into practical application with clinical patients. The BOPPPS model represents a dynamic closed-loop instructional design framework that encompasses six essential elements: Bridge-in, Objective, Pre-test, Participation, Post-test, and Summary. These components are interconnected, further stimulating students’ clinical reasoning and enhancing their practical skills [19]. A meta-analysis demonstrated that this model significantly improved test scores (SMD = 1.14), student satisfaction, and classroom interaction [20].

The integration of the SPOC and BOPPPS models transcends traditional teaching approaches by establishing a student-centered framework with the instructor serving as a facilitator. The two models are synergistically aligned, enabling the full utilization of their respective strengths. This approach has been successfully implemented in dental and anesthesiology education [21, 22], yielding favorable educational outcomes. However, in the field of neonatal stoma care, the hybrid teaching model that combines SPOC and BOPPPS is still relatively unexplored. Therefore, an innovative approach to the educational framework is warranted [23]. Our study aims to investigate the effectiveness of a teaching model that amalgamates SPOC and BOPPPS for NICU nurses, with the objective of enhancing the stoma management competencies of NICU nursing professionals.

Methods

This study was a non-randomized controlled trial conducted at West China Second University Hospital, Sichuan University, China. The hospital has a total of 307 neonatal beds, including 12 surgical beds. In September 2023, nurses officially working in the NICU were conveniently selected as study participants. Participants were assigned to groups based on their year of hospital entry. This study was conducted in accordance with the Declaration of Helsinki. The study was approved by the Ethics Committee of West China Second University Hospital, Sichuan University (No.2023044), and informed consent was obtained from all participants.

Both the control group and experimental group nurses received ostomy care theory training during the same period after employment. Both participants in groups received the same course content, which covered the following four topics: (1) Overview of ostomy-related knowledge in newborns and key points for stoma observation and assessment; (2) Identification and management of common complications in neonatal stoma; (3) Identification and management of skin complications around the stoma in newborns; (4) Introduction to ostomy supplies and ostomy bag replacement. The training comprised a total of 16 academic hours, divided into four half-day sessions.

Nurses in the control group were taught using the traditional lecture-based learning approach, which is a teacher-centered, face-to-face instructional model commonly employed in medical education in China. Prior to the course began, there were no required pre-session preparation for participants. The lessons were delivered by specialized and experienced wound and ostomy care nurses. Each session began with the instructor presenting core concepts and slide-based content, supplemented by interactive question-and-answer segments throughout the class. Upon completion of the instruction, an electronic questionnaire was administered to evaluate the effectiveness of the teaching.

The experimental group adopted a blended teaching model integrating SPOC and BOPPPS to deliver instruction through both online and offline channels. The implementation consisted of the following three phases:

  1. Pre-class phase:

    Bridge-in (B): One week before the course, teachers sparked students’ interest by introducing clinical cases. Relevant teaching videos were uploaded to the UMU platform(an interactive learning platform) [24], where nurses were required to preview the contents and document any questions or unclear points. Objectives (O): Learning objectives should be align with job competency requirements (covering knowledge, skills, and competencies) and were clearly stated on the UMU platform [24]. Pre-assessment (P): Prior to the class, an online assessment was administered to participants. Based on the test results and questions raised in discussion forums, instructors evaluated the nurses’ self-directed learning progress and knowledge acquisition to optimize the teaching content.

  2. In-class phase:

    Participatory Learning (P): During class, nurses discussed and presented case studies in small groups. The instructor randomly selected a group member to present their wound and ostomy care plans,. The instructor facilitated the process, guiding the nurses to revise and refine the stoma care plan.

  3. Post-class phase:

    Post-assessment (P): At the end of each session, the instructor summarized the key teaching points and provided individualized feedback to each nurse. Summary (S): In offline sessions, the instructor promptly evaluated nurse learning outcomes and post-class feedback based on in-class performance and theoretical assessment results.

The two groups received identical instructions. The main content covered the characteristics and classification of neonatal stomas, complications associated with neonatal stomas, complications associated with the skin surrounding neonatal stomas, and standard operating procedures for stoma replacement. The course provided a foundation in basic knowledge of stomas and methods for identifying and treating abnormal stomas. Specific teaching design is detailed in Table 1.

Table 1.

SPOC in conjunction with BOPPPS blended online and offline teaching design

SPOC BOPPPS Instructional design
Before class (online platform) Bridge-in

Teacher tasks:

1. Online recording of micro-lecture videos: Overview of neonatal stomas and key points for observation and assessment, identification and management of common complications associated with neonatal stomas, identification and management of skin complications around neonatal stomas, introduction to stoma care products, and stoma bag replacement. A quiz was included at the end of each video.

2. Create instructional PowerPoint presentations.

3. Post typical or special cases in the discussion forum on the online platform.
Objective

Knowledge objectives:

1. Familiarise yourself with the characteristics of neonatal stomas and stoma classification; master the key points of observing and assessing neonatal stomas.

2. Identify common stoma complications in newborns; master the treatment measures for common stoma complications.

3. Identify common complications of the skin surrounding the stoma in newborns; master the treatment measures for common complications of the skin surrounding the stoma.

4. Be familiar with ostomy supplies and understand how they work; master the principles and steps for changing ostomy bags.

Competency objectives: Developing the analytical and problem-solving skills of neonatal nurses through participatory learning.

Competency goals: Through group learning discussions, cultivate teamwork awareness and communication skills.
Pre-test

Student tasks:

1. Complete online micro-course learning.

2. Discuss the assessment and handling of typical or special cases posted by teachers.

3. Complete the online pre-class test questions.
During class (offline teaching) Participation

Teacher tasks: Divide the learning content into four knowledge modules and use typical case study images to introduce the teaching material, allowing students to form groups and discuss the content on their own.

Knowledge Module 1: Overview of ostomy in newborns and key points for observation and assessment.

Using images of different types of stomas in newborns, this presentation explains concepts related to stomas in newborns, their characteristics, classification, and key points for observation and assessment of stomas in newborns.

Knowledge Module 2: Identification and management of common complications in neonatal stoma care.

Using images of common complications associated with neonatal stomas as an introduction, this presentation explains the causes, risk levels, and management strategies for various complications.

Knowledge Module 3: Identification and management of skin complications around the stoma in newborns.

Using images of common complications around the stoma site in newborns as an introduction, this presentation explains the characteristics of newborn skin, key points for caring for the skin around the stoma site, and measures for managing complications.

Knowledge Module 4: Introduction to ostomy supplies and ostomy bag replacement.

Import images to explain the usage and working principles of ostomy supplies, the STOMA principles and steps for ostomy bag replacement, and the selection of supplies when replacing ostomy bags; play a video of ostomy bag replacement and demonstrate how to replace ostomy bags on a model.

Student tasks: Students are divided into small groups for discussion, using task-based teaching methods. They analyse and discuss the assessment results and handling measures for different real-life case images provided by the teacher, and share their findings in class. Practical exercises are carried out on models, with the teacher providing individual feedback and corrections, ultimately completing the learning of relevant knowledge points.
After class (online platform) Post-test

Teacher tasks:

1. Post test questions online after class.

2. Arrange offline practical exams.

Student tasks: Complete the post-class test within one week and select clinical cases for the practical exam.
Summary

Teacher tasks:

1. Online release of course highlights and key points summary.

2. Evaluate whether the expected goals have been achieved.

3. Provide timely online feedback on students’ learning progress and task completion results.

Student tasks: Use a mind map to summarize the content learned in this section.
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All teachers who taught the course first underwent standardized training before teaching. During the training, teachers learned standardized method for implementing the syllabus. Subsequently, each teacher strictly followed the syllabus when explaining relevant knowledge points. This ensured that the content learned by both groups of nurses remained consistent, preventing indiviual teaching styles from influencing the overall teaching process.

Outcome measures

We first used electronic questionnaires for theoretical knowledge tests on ostomy care. Next, practical skills tests of ostomy care were conducted using neonatal ostomy models. Finally, we distributed electronic questionnaires via Questionnaire Star [25] to evaluate self-efficacy in ostomy management for both groups.

Theoretical knowledge test. Within one week after the completion of the two teaching courses, a centralized online theoretical knowledge test will be conducted through the UMU platform [24]. The examination questions were jointly developed and graded by two stoma therapists who did not participate in the teaching. The test included single-choice and multiple-choice questions, with a total score of 100 points.

Practical skill test. After the theoretical knowledge test, both groups of participates must complete a practical skill test on a neonatal stoma model within two weeks. The skill test will be jointly supervised by two senior stoma therapists who were blinded to the participants’ group to minimize assessment bias. The average score will be taken as the final score. The practical test standards align with the textbook, with a total score of 100 points.

Self-efficacy in ostomy management was evaluated using the Self-Efficacy Measuring Scale for Ostomy Care Nursing Management (SE-OCNM), developed by Federica et al. in 2019 [26]. This self-assessment questionnaire for nurses consists of 24 items rated on a 5-point Likert scale, from 1 (‘completely unable’) to 5 (‘completely able’). The scale covers three dimensions: Clinical Assessment (10–50 points), Relationships and Education (12–60 points), and Teamwork (2–10 points), with total scores ranging from 24 to 120. Higher scores indicate better self-efficacy in managing stoma care. The scale’s Cronbach’s α is 0.978, with dimension scores ranging from 0.757 to 0.973.

Data analysis

IBM SPSS Statistics version 26.0 (Armonk, NY, United States) was used for the statistical analysis. Measurement data are expressed as means ± standard deviations. Data that conform to a normal distribution and are homogeneous in variance are analyzed using the independent samples t-test. Count data are expressed as rates or proportions N. To control for potential confounding factors, we used an analysis of covariance (ANCOVA) to compare the differences between groups. A p-value < 0.05 is considered statistically significant.

Results

Participant characteristics

Those who joined in 2019 formed the control group (16 participants), while those who joined in 2020 formed the experimental group (28 participants). The control group averaged 25.00 ± 1.18 years old with 3.56 ± 0.81 years of work experience (t = 0.118, P = 0.907). The experimental group averaged 25.89 ± 1.23 years old with 3.50 ± 0.75 years of work experience (t = 0.259, P = 0.797). There were no statistically significant differences between the groups in age (t = 0.118, P = 0.907), work experience (t = 0.259, P = 0.802), or other general characteristics (P > 0.05), as shown in Table 2.

Table 2.

Comparison table of general information on NICU Nurses (n = 44)

Variable Control group Experimental group X2/t P
Gender 0.653 0.419
 Male 1 4
 Female 15 24
level of education 0.558 0.455
 undergraduate 13 25
 junior college 3 3
Have you ever changed a colostomy bag? 0.227 0.598
 Yes 9 18
 No 7 10
Have you ever cared for a child with a stoma? 0.593 0.441
 Yes 9 19
 No 7 9
Have you received training related to ostomy care? 0.476 0.49
 Yes 8 17
 No 8 11
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Comparison of theoretical and practical scores between two groups of nurses

The experimental group had significantly higher theoretical knowledge test scores (91.25 ± 5.86) than the control group (79.31 ± 7.24), as well as higher practical skill test scores (90.39 ± 3.89 vs. 83.88 ± 5.12). After controlling for variables including gender, age, years of service, educational attainment, prior experience in caring for pediatric ostomy patients, prior experience in changing ostomy pouches, and prior training in ostomy care, we found the ANCOVA indicated a statistically significant difference in theoretical knowledge between the groups, with an F value of 32.537 and a P value of less than 0.001. A significant difference was also found in practical skills, with an F value of 17.257 and a P value of less than 0.001 (see Fig. 1.).

Fig. 1.

Fig. 1

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Comparison of theoretical and practical test scores between two groups of nurses. **p < 0.001

Comparison of self-efficacy scores for stoma care management between two groups of nurses

The total score for self-efficacy in stoma care management in the experimental group was (106.64 ± 9.53), which was significantly higher than the total score for self-efficacy in care management in the control group (90.06 ± 12.70) (F = 21.706, P < 0.001). Additionally, the experimental group scored significantly higher than the control group in the clinical assessment (F = 10.848, P < 0.01), relationships and education (F = 21.422, P < 0.001), and teamwork (F = 43.468, P < 0.001) (see Table 3).

Table 3.

Comparison of self-efficacy scores for stoma care management between two groups of nurses (Inline graphic±s)

Group Stoma management self-efficacy Clinical assessment Relationships and education Teamwork
Control group(n = 16) 90.06 ± 12.70 38.5 ± 5.47 44.31 ± 7.89 7.25 ± 0.78
Experimental group(n = 28) 106.64 ± 9.53 43.86 ± 3.86 53.75 ± 5.65 9.04 ± 0.84
F 21.706 10.848 21.422 43.468
P < 0.001 0.002 < 0.001 < 0.001
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Discussion

Neonatal stoma care is a sub-section of nursing assessment and intervention in the care of digestive system diseases in neonatal nursing. This is particularly important for departments that perform neonatal surgery. The results of this study further indicate that the combination of SPOC and BOPPPS teaching methods has achieved preliminary success in stoma care for NICU nurses, proposing a promising concept for the continued professional development of this field.

The results of this study indicate that the experimental group demonstrated higher levels of theoretical knowledge and practical skills compared to the control group. This finding aligns with that of Wang et al. [22] in their study on anaesthesiologists’ continuing education. The alignment underscores the proven capacity of the SPOC་BOPPPS model to markedly boost student initiative and foster excellent performance [21]. We applied the SPOC + BOPPPS model in clinical nursing skills training. This model employed a framework of clearly defined learning objectives. Compared to the traditional flipped classroom, this structure more effectively ensures consistency in teaching quality and outcomes across diverse participates [27]. This makes it as a solution with outstanding application value and developmental potential in the field. Additionally, nurses’ self-efficacy levels in stoma care management also significantly improved. This may be attributed to the hybrid model combining SPOC with BOPPPS, which enhances participants’ confidence in overcoming obstacles encountered when caring for stoma patients [28].

In neonatal care clinical skills training, SPOC and BOPPPS teaching methods demonstrate significant advantages. The preview session can stimulate nurses’ interest in nursing knowledge [29]. Face-to-face classroom interactions can increase NICU nurses’ clinical thinking in ostomy care. Based on specific feedback, instructors can summarize and review the learning process to help NICU nurses better apply ostomy care skills [30]. Integrating SPOC and BOPPPS methods can improves teaching quality [31]. This hybrid teaching method offers personalized, flexible instruction that enhances engagement, moving beyond traditional one-way teaching. The focus shifts from teacher-led to nurse-led classrooms in NICU settings. Instructors can focus on each nurse, understand individual differences, and evaluate knowledge [32]. Consequently, instruction aligns with nurses’ competency levels, offering personalized recommendations to achieve efficient learning [33]. Therefore, nursing managers should conduct regular stoma care management training for NICU nurses to strengthen their self-directed learning ability, maximize their professional initiative, and ultimately improve their competencies in stoma care. Meanwhile, in academic settings, nursing educators are encouraged to adopt a blended approach integrating SPOC and BOPPPS for teaching stoma-related knowledge and clinical skills.

Technological requirements

The implementation of the SPOC + BOPPPS teaching model necessitates a stable and robust online learning management platform [22], which can be a commercial system, an open-source solution, or a module embedded within a hospital’s internal training infrastructure. Core platform functionalities are essential to support the structured, interactive nature of the BOPPPS instructional cycle.

This model places greater demands on educators, particularly in specialized fields like wound and ostomy care, where standardized curricula may be lacking. Instructors are required to assess learners’ foundational knowledge and identify individual needs during the pre-assessment phase [34]. Substantial initial effort is involved in producing high-quality instructional videos and developing interactive courseware [35]. However, once created, these materials become reusable digital assets that can serve multiple cohorts of learners over time.

Cost challenges

From a cost perspective, although upfront investment in content creation is required, the model proves more cost-effective than traditional in-person training in the long run [36]. It eliminates the recurring need to coordinate instructor schedules, physical venues, and teaching materials. Moreover, a mature SPOC course can be delivered simultaneously to tens, hundreds, or even thousands of participants without incurring significant additional expenses, making it highly scalable for large-scale standardized training or continuing education programs [37].

Future research

The BOPPPS model offers a robust, universal structure for designing effective teaching loops through its goal-oriented and participatory approach. Complementing this, the SPOC platform provides inherent flexibility to host a wide range of instructional content. The inherent “universal framework + flexible content” design of the SPOC + BOPPPS model underpins its strong potential for generalization. The BOPPPS component ensures pedagogical rigor, while the SPOC element allows for customization to various specialized knowledge domains [21]. Consequently, nursing educators and administrators can extend this approach to other specialized fields—such as chronic wound management, critical care, diabetes health education, emergency skills, or psychological care. The model is also adaptable across professional hierarchies: it can be used for standardizing training for new graduates, updating knowledge for practicing nurses, and even in pre-clinical courses for nursing students. To further optimize resources, regional medical alliances or nursing associations could lead the development of a shared core SPOC course library [38]. Such a collaborative effort would not only maximize resource utilization and reduce duplication of effort across institutions but also promote the establishment of consistent, high-quality nursing training standards throughout a region.

Limitations

This study has several limitations that should be considered when interpreting the findings. First, the use of convenience sampling and allocation by year of entry introduces a potential risk of selection bias. Although baseline characteristics were comparable between the two groups, the influence of unmeasured confounders, such as individual learning motivation, cannot be entirely excluded. Thus, the results should be interpreted with caution, and future randomized controlled trials are recommended to strengthen the evidence. Second, the focus on neonatal stoma care, a highly specialized clinical area, limits the immediate generalizability of the results to other nursing contexts, such as adult stoma care, wound management, or central venous catheter care. Third, our study collected data through self-report questionnaires and did not include a power analysis, which are susceptible to social desirability bias. Future research employing objective assessment tools for measurement would enhance the generalizability of findings. Furthermore, as a single-center study, the transferability of our findings to other institutions or healthcare settings may be constrained.

Conclusion

This study demonstrated that the SPOC+BOPPPS teaching model significantly enhanced NICU nurses’ theoretical knowledge, practical skills, and self-efficacy in stoma care. While these results are promising, they are considered preliminary, underscoring the need for larger, multicenter randomized controlled trials to validate their generalizability.

Acknowledgements

We thank the Second West China Hospital of Sichuan University for supporting this study.

Authors’ contributions

Chen Xushu: wrote the paper; Song Yan: distributed questionnaires, collected data, and organized data; Li Xiaowen & Zhao Xiufang: analyzed data, designed the study, and revised the paper.

Funding

Research Project of the Nursing Department, West China Second University Hospital, Sichuan University(ID: YJJG-2022-YB12).

Data availability

The datasets analyzed during the present research are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Our research complies with the relevant requirements of the Declaration of Helsinki. Our study was approved by the Scientific Ethics Committee of West China Second University Hospital, Sichuan University. We also obtained informed consent from all study participants.

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.

Xushu Chen and Yan song contributed equally to this work.

Contributor Information

Xiaowen Li, Email: xiaowenli@scu.edu.cn.

Xiufang Zhao, Email: xiufangzh@163.com.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets analyzed during the present research are available from the corresponding author on reasonable request.

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