Abstract
Background
Gamification has emerged as an innovative educational approach to enhance learner engagement and motivation in health professions education. In nursing education, accurate interpretation of cardiac rhythms is a critical competency that requires repeated practice and timely feedback. This study aimed to design, develop, and evaluate a gamified mobile application (RhythmPath) to support nursing students’ learning of cardiac rhythm interpretation.
Methods
A quasi-experimental pretest–posttest study without a control group was conducted during the fall semester of 2024 among 13 seventh-semester nursing students at Kerman University of Medical Sciences, Iran. The RhythmPath application was developed using Unity 2021 and incorporated gamification elements such as points, badges, leaderboards, and timed assessments. Students used the application for two weeks. Knowledge of cardiac rhythm interpretation was assessed before and after the intervention using equivalent validated multiple-choice tests. Software quality and usability were evaluated using a validated questionnaire. Paired t-tests were used to compare pretest and posttest scores.
Results
Mean knowledge scores increased significantly from 39.48 ± 19.52 at pretest to 51.79 ± 25.98 at posttest (t (12) = 2.45, p = 0.03). Participants spent an average of 7.2 ± 1.8 h using the application during the intervention period. Overall user satisfaction with the application was high (mean score = 4.45 ± 0.67 on a 5-point Likert scale), with ease of use and information quality receiving the highest ratings.
Conclusions
The RhythmPath gamified mobile application demonstrated potential for improving nursing students’ knowledge of cardiac rhythm interpretation and achieving high user satisfaction. As a small-sample pilot study, these findings provide preliminary evidence supporting the use of gamified mobile learning tools in nursing education. Further studies with larger samples, control groups, and longer follow-up periods are recommended to confirm effectiveness and assess long-term learning outcomes.
Keywords: Gamification, Nursing Education, Electrocardiography, Mobile Applications, Computer-Assisted Instruction
Background
Gamification uses game elements in non-game contexts [1], and its most significant application is in education [2]. The primary purpose of gamification is to increase learners’ motivation, experience, and participation [3]. Gamification in nursing education has emerged as an innovative approach to enhance student engagement and learning outcomes. Studies have shown that gamification can increase nursing students’ motivation, self-efficacy, and knowledge acquisition [4–6]. Gamification elements, such as badges, feedback, and playing cards, have been incorporated into nursing courses, increasing student satisfaction and recommendations for broader implementation [4, 5]. Furthermore, gamification has contributed to developing competencies in nursing informatics, promoting critical thinking skills [7] and decision-making patterns [8]. Given the effectiveness of gamification in supporting active learning and skill development, its application is particularly valuable for teaching complex clinical competencies that demand accurate interpretation and timely decision-making, such as cardiac rhythm interpretation.
According to the World Health Organization, cardiovascular diseases (CVDs) remain the leading cause of death globally, accounting for approximately 19.8 million deaths in 2022, which represents nearly one-third of all deaths worldwide. Over four-fifths of CVD deaths are due to heart attacks and strokes, reflecting the substantial global burden of these conditions [9, 10]. Among the various manifestations of CVDs, cardiac dysrhythmias contribute significantly to morbidity by causing life-threatening arrhythmias that can lead to sudden cardiac death if not recognized and managed promptly [11, 12]. Nurses, due to their frontline role in patient care, must possess sufficient knowledge and skills in interpreting and diagnosing electrocardiograms (ECG) to prevent fatal complications associated with these disorders [13]. This critical competency should be developed through proper and sufficient education, particularly during the foundational period of nursing education when students are first introduced to cardiac functions [14]. Information and communication technology advances have impacted teaching and learning sciences, creating opportunities to design well-structured, learner-centered, interactive, flexible, meaningful, and facilitated learning environments [15–17]. Technology-enhanced learning could complement medical science education [18] to enrich the learning experience [17]. Therefore, these environments enhance learning and promote practical application, bridging theoretical knowledge to clinical practice [19–21].
Gamification has been successfully applied to various nursing topics, including electrocardiogram interpretation, where it has demonstrated positive results in improving students’ understanding and confidence [4, 6]. Fijačko et al. declared gamification positively impacts nursing student motivation and engagement in nursing education [5]. Antit et al. showed that gamification learning using playing cards can stimulate intrinsic motivation, self-efficacy, and satisfaction in medical students learning ECG interpretation [4]. Castro et al.‘s findings demonstrated that gamification can contribute to competency development and meaningful learning in nursing education [7]. According to evidence, gamification can contribute to competency development and meaningful learning [7] and knowledge acquisition [6] in nursing education. Malicki et al., in their review, found that gamification in nursing education positively affects learner engagement and satisfaction [22]. Day-Black et al.‘s findings showed that serious games effectively improve student learning outcomes in nursing education [23]. Gamification is a powerful instructional method that can be applied in healthcare education [24]. Holthaus et al. 3D app improved nursing students’ ECG rhythm interpretation knowledge [25]. Mobile learning is more effective than learning from a booklet for training critical care nurses in interpreting cardiac arrhythmias [26]. According to Bazrafkan and Hemmati, using cardiac arrhythmias simulation software effectively improved nurses’ knowledge of cardiac arrhythmias [27]. Serious gaming and gamification in health professions education have been reported to be at least as effective as traditional instructional methods in improving knowledge, skills, and learner satisfaction; however, the overall quality of evidence remains limited [28]. Some systematic reviews indicate that evidence quality is often low or very low, with several studies showing equivalent or non-significant differences between gamification and control conditions for certain outcomes. Moreover, many interventions lacked well-defined control groups and theoretical underpinnings, making robust conclusions challenging and highlighting inconsistencies in the current literature [28, 29]. This study aimed to design, develop, and evaluate the effectiveness of RhythmPath, a gamified mobile application designed to enhance nursing students’ knowledge and engagement in electrocardiogram (ECG) interpretation.
Methods
Study design
This study adopted a quasi-experimental pretest–posttest design without a control group to evaluate the effectiveness of a gamified mobile application for teaching cardiac rhythm interpretation. As an exploratory pre–post evaluation of educational effectiveness and usability, the intervention sought to examine the application’s impact on nursing students’ knowledge by comparing their pre- and post-intervention learning outcomes. In addition, a qualitative component was integrated during the app development phase to gather feedback from nursing educators and students, ensuring that the design aligned with educational needs and user expectations.
Participants and sampling
The study population comprised seventh-semester nursing students from the Razi Nursing Faculty at Kerman University of Medical Sciences, Iran. Participants were selected through convenience sampling from all students enrolled in the semester. Inclusion criteria required participants to be in the seventh semester, provide informed consent, have successfully completed the theoretical cardiology course, not be simultaneously enrolled in other cardiovascular-related courses, and own an Android smartphone compatible with the application. Students were excluded if they withdrew from the study, encountered technical difficulties preventing app installation, used the application insufficiently (as verified through server usage logs), or began clinical practice in the Coronary Care Unit (CCU) during the intervention period, as confirmed through official faculty clinical rotation schedules and student self-report.
Of the 70 students initially screened for eligibility, 13 met all inclusion criteria and completed the study. This final sample comprised students who satisfied both the academic prerequisites and the technical requirements necessary for full participation in the intervention. Although the exclusion criteria were not conceptually restrictive, several practical and contextual factors substantially limited the number of eligible participants. These factors included incompatibility with iOS devices, hardware-related installation difficulties, concurrent enrollment in Coronary Care Unit (CCU) clinical rotations, and insufficient application usage as verified through server-based logs. Consequently, the final sample size reflects real-world implementation constraints rather than selective exclusion by the research team.
Seventh-semester nursing students were intentionally selected because they had completed the theoretical cardiovascular and cardiology-related courses but had not yet commenced their clinical training in the Coronary Care Unit (CCU). This timing allowed the evaluation of the intervention’s educational effect without the confounding influence of formal clinical ECG training or extensive real-world exposure. Students from earlier semesters were not included because they had not yet completed the core theoretical coursework required for meaningful engagement with advanced ECG interpretation content.
Intervention
The gamified educational application (RhythmPath) was designed using Unity 2021 and programmed in C#. The application consisted of three main sections: (a) Learning Module: This section provided foundational knowledge about electrocardiograms (ECGs), normal sinus rhythms, arrhythmias, and myocardial infarction patterns. Students earned experience points for engaging with the content, (b) Practice Module: This section featured interactive exercises with immediate feedback on correct and incorrect answers. Incorrect responses directed users to relevant educational content for review, and (c) Assessment Module: This section included timed multiple-choice questions to evaluate knowledge retention. Access to this module was restricted until users accumulated a minimum number of experience points and scores.
Gamification elements such as scoring, experience points, leaderboards, badges, feedback, and time limitation as challenge were integrated into the RhythmPath to enhance user motivation and engagement.
Data collection instruments
The study utilized two instruments for data collection, described as follows.
Knowledge assessment
A multiple-choice knowledge test was developed to evaluate students’ understanding of cardiac rhythm interpretation. The pretest and posttest were designed to be equivalent in content coverage, difficulty, and psychometric properties to ensure comparability of results. Item analysis indicated acceptable psychometric indices (mean difficulty = 0.58 ± 0.12; discrimination = 0.34 ± 0.08). Equivalence between the two test forms was confirmed through expert review and statistical analysis of item characteristics.
Content validity was established by a panel of ten subject matter experts, including six assistant professors and four associate professors specializing in cardiology, medical education, and emergency nursing. The content validity index (CVI) was 0.98 for simplicity and 1.00 for both clarity and relevance, indicating excellent content validity. Reliability was assessed using the test–retest method with a two-week interval, yielding a Pearson correlation coefficient of 0.87 (p < 0.001), which demonstrated strong temporal stability. Moreover, a significant positive correlation between pretest and posttest scores (r = 0.729, p < 0.001) supported the consistency and equivalence of the two assessments.
Software quality evaluation
A validated instrument with established content validity and reliability [30] was employed to evaluate the RhythmPath application from students’ perspectives in terms of usability, functionality, and overall satisfaction. The questionnaire assessed six key dimensions: Ease of Use, Information Quality (Scientific Accuracy), Reliability, Interactivity, Response (Reaction) Time, and Visual Design. To ensure contextual relevance, the instrument was adapted to reflect educational and usability dimensions specific to mobile learning applications.
Application design and development
The RhythmPath application was specifically designed and developed to support nursing students in learning cardiac rhythm interpretation. The development process was structured into several distinct phases to ensure technical accuracy, usability, and alignment with educational objectives.
Conceptual design
The conceptual framework for the application was established based on the principles of gamification and active learning. The educational content was structured into three main modules: learning, practice, and assessment. Gamification elements, including points, experience levels, badges, leaderboards, and time constraints, were incorporated to enhance user engagement and motivation.
Content development
The educational content was developed in collaboration with subject matter experts, including specialists in cardiology and emergency nursing. Topics covered included: (a) Basics of electrocardiograms (ECGs), (b) Normal sinus rhythms, (c) Arrhythmias, (d) Myocardial infarction patterns, and (e) Other factors affecting ECG readings. The content was derived from the latest nursing curricula, guidelines, and reference materials. All materials underwent multiple rounds of review and revision to ensure accuracy and clarity.
Technical development
The application was developed using Unity 2021, with programming in C#. The platform’s development incorporated several key technical components to ensure functionality, usability, and localization. A user-friendly front-end interface was designed using Photoshop, focusing on intuitive navigation and visual appeal. The back-end system was developed using the Django framework with PostgreSQL for robust data management. For mobile data storage, SQLite was integrated to provide efficient and secure handling of user information. Additionally, RTL Text Mesh Pro was implemented to support the Persian language, enabling a seamless right-to-left user experience.
Gamification features
The application integrated several gamification elements to enhance user engagement and motivation. Users earned points and experience levels by completing tasks, interacting with content, and answering questions correctly. Badges and achievements were awarded for reaching significant milestones, such as completing modules or achieving high scores. A leaderboard system displayed user rankings to encourage healthy competition among peers. Additionally, the assessment module featured timed multiple-choice challenges to simulate real-life decision-making under pressure.
Testing and quality assurance
The application underwent rigorous testing to ensure optimal functionality and user experience. During the alpha testing phase, the development team conducted internal evaluations to identify and resolve technical issues. This was followed by beta testing, where nursing students, educators, and healthcare professionals tested the refined version and provided feedback on technical performance, educational content, and overall usability, leading to further improvements. Additionally, unit testing was performed on individual modules and features to verify their independent and seamless operation.
Deployment
The final version of the application was deployed on the Android platform (Fig. 1). To ensure secure access, users were required to log in using unique credentials. Most features of the application were available offline, with internet connectivity required only for accessing the leaderboard and syncing user data with the server.
Fig. 1.
User Interface of the RhythmPath Application (Screenshots illustrate the learning, practice, and assessment modules. For publication purposes, interface labels and on-screen text have been translated into English.)
This structured and iterative development process ensured that the application met both educational and technical standards, resulting in an effective tool for teaching cardiac rhythm interpretation.
Procedure
During the two-week intervention period (October–November 2024), all participants initially completed a pretest to assess their baseline knowledge of cardiac rhythms. They were subsequently provided with access to the RhythmPath application for a two-week intervention. Upon completion of this period, a posttest was administered to evaluate knowledge acquisition. Participants were instructed to use the application for at least 30 min daily, with usage automatically tracked to ensure adherence. Comprehensive usage data, including duration and frequency of access, were recorded via a secure cloud-based server.
Data analysis
Data were analyzed using SPSS version 26. Paired t-tests were conducted to compare pretest and posttest scores within the participant group, assessing the significance of knowledge acquisition. Descriptive statistics summarized participant demographics and application feedback. Statistical significance was set at p < 0.05.
Results
Participant characteristics
Of the total seventh-semester nursing students screened for eligibility, 14 were excluded due to commencing clinical rotations in the Coronary Care Unit (CCU) at the start of the semester, 12 because they were using iOS devices or had phones incompatible with the application, one due to transferring to another university, 15 due to technical problems in installing the application, and 13 due to not using the application after installation. Consequently, 13 seventh-semester nursing students who had completed the theoretical cardiology course in the previous semester, had not yet started CCU clinical training, met all other inclusion criteria, and provided informed consent were included in the study.
A comparison of academic performance between students who participated in the study (n = 13) and the remaining seventh-semester nursing students who did not participate revealed no statistically significant differences in overall grade point average (GPA), theoretical CCU course scores, and internship scores (Table 1).The comparison presented in Table 1 was conducted for descriptive purposes only to contextualize the academic characteristics of the study participants and does not represent a control or comparison group for outcome analysis.
Table 1.
Baseline academic characteristics of study participants compared with other eligible seventh-semester nursing students
| Variable | Participants (n = 13) | Non‑participants (n = 55) | p-value |
|---|---|---|---|
| GPA | 16.02 ± 0.35 | 16.02 ± 0.40 | > 0.05 |
| Theoretical course score | 15.87 ± 0.62 | 14.39 ± 1.05 | > 0.05 |
| Internship score | 18.06 ± 0.48 | 18.06 ± 0.43 | > 0.05 |
Knowledge improvement
Pre- and posttest results indicated a significant improvement in cardiac rhythm interpretation knowledge among participating students. The mean pretest score was 39.48 (SD = 19.52), which increased to 51.79 (SD = 25.98) following the two-week use of the RhythmPath application (Table 2).
Table 2.
Pretest and posttest knowledge scores in students using the RhythmPath app
| knowledge scores of participants (n = 13) | Mean ± SD | p-value |
|---|---|---|
| Pretest | 39.48 ± 19.52 | < 0.05 |
| Posttest | 51.79 ± 25.98 |
SD Standard Deviation; a paired t-test was employed to analyze within-group differences: Paired t-test, t (12) = 2.45
A Pearson correlation analysis demonstrated a significant positive correlation between pre- and posttest scores among participants (r = 0.874, p < 0.05), indicating stability in relative student performance across the two measurement points; students with higher baseline scores also tended to achieve higher posttest scores.
Application usage and engagement
Application usage data indicated active engagement with the RhythmPath application during the intervention period. Participants logged into the application an average of 32 times, with a mean total usage duration of 7.2 ± 1.8 h per user. The practice module was the most frequently accessed component. Detailed usage analytics are presented in Fig. 2.
Fig. 2.
RhythmPath User Engagement Analytics (Aggregated data illustrating user interaction with the application, including logins, time spent, accessed modules, and performance scores.)
Software quality evaluation and feedback
Thirteen participants completed the software quality evaluation questionnaire, which assessed the RhythmPath application across six key dimensions: visual design, ease of use, information quality, reliability, response time, and interactivity. The overall results indicated a high level of user satisfaction (Table 3).
Table 3.
Student Evaluation of Software Quality (n = 13)
| Dimension | Mean ± SD | Strongly Agree/Agree (%) |
|---|---|---|
| Visual Design | 4.17 ± 0.80 | 85% |
| Ease of Use | 4.56 ± 0.48 | 100% |
| Information Quality (Scientific Accuracy) | 4.53 ± 0.56 | 100% |
| Reliability | 4.48 ± 0.59 | 93% |
| Response (Reaction) Time | 4.42 ± 1.10 | 93% |
| Interactivity | 4.51 ± 0.50 | 93% |
All scores are based on a 5-point Likert scale
SD Standard Deviation
Among the six evaluated dimensions, Ease of Use scored highest (4.56 ± 0.48) and Visual Design lowest (4.17 ± 0.80). Participants valued the clarity and accuracy of content, intuitive menu structure, and overall usability. Gamification features, including badges, points, and leaderboards, were reported as motivating and engaging. Minor issues included small font sizes and limited time for app use due to clinical duties. Overall, students expressed high satisfaction with RhythmPath, recommending its continued integration into nursing education, with a mean total score of 4.45 ± 0.67.
Formative qualitative feedback during application development
Qualitative data were collected during the application design and development phase through semi-structured interviews and a focus-group discussion. These data were not subjected to formal qualitative analytical methods (e.g., thematic or content analysis); rather, they were analyzed descriptively to inform instructional design decisions and to ensure alignment with learners’ educational needs. Key points were identified through iterative review and consensus among the research team. The focus-group discussion and interviews were conducted in person during the application design phase. The focus group was facilitated by a member of the research team with expertise in medical education and lasted approximately 60 min. It followed a semi-structured format guided by open-ended questions addressing learning challenges in electrocardiogram (ECG) interpretation, preferred instructional features, and usability considerations for mobile learning applications.
Semi-structured individual interviews were conducted with faculty members and the medical informatics specialist and lasted between 30 and 45 min. An interview guide was used to ensure consistency across sessions while allowing participants to elaborate on their experiences and perspectives. Notes were taken during all sessions, and key points were summarized immediately afterward by the research team to support iterative review and consensus building.
Participants highlighted several recurrent challenges in learning electrocardiogram (ECG) interpretation, particularly difficulties in recognizing arrhythmia patterns and interpreting ECG tracings with confidence in clinical settings. Both faculty members and students emphasized the importance of clear visual representations, concise explanations, and opportunities for repeated practice. Based on this feedback, the educational content was refined to prioritize core ECG concepts, including normal and abnormal rhythms and common dysrhythmias. Faculty experts confirmed the clarity and curricular relevance of the revised content, while students underscored the value of interactive practice and immediate feedback.
Discussion
This study was conducted as an exploratory pilot investigation to assess the feasibility, usability, and preliminary educational effectiveness of a gamified mobile learning intervention, rather than to perform hypothesis testing with population-level inference. Accordingly, the study aimed to design, develop, and evaluate RhythmPath, a gamified mobile application for teaching cardiac rhythm interpretation to nursing students. The findings revealed a statistically significant improvement in students’ ECG interpretation knowledge following the two-week intervention, accompanied by high levels of user satisfaction with the application’s usability and content quality. Collectively, these results suggest that integrating gamification into mobile learning environments may facilitate knowledge acquisition and enhance learner engagement in nursing education, particularly for complex clinical competencies such as ECG interpretation.
Gamification has increasingly gained attention as an innovative strategy to enhance engagement and learning outcomes in nursing education. The present study supports prior evidence demonstrating that gamified learning can effectively promote motivation, self-efficacy, and knowledge acquisition among nursing students. The findings revealed that the RhythmPath application was associated with a statistically significant improvement in students’ ECG interpretation performance.
As noted in the introduction, cardiovascular diseases and cardiac dysrhythmias remain leading causes of mortality worldwide, emphasizing the importance of equipping nurses with robust ECG interpretation skills early in their education. The results of this study are consistent with previous investigations, including those by Fijačko et al., Antit et al., and Castro et al. [4, 5, 7], who found that gamification enhances nursing students’ motivation, engagement, and clinical competence. In the current study, the integration of interactive features such as points, experience levels, leaderboards, and timed assessments contributed to a more engaging learning experience and encouraged repeated practice—an essential factor in skill mastery.
The qualitative findings further complement these results by providing insight into learners’ and educators’ perspectives on content design. Students’ feedback emphasized the need for clear visuals, concise explanations, and opportunities for active practice, while faculty members confirmed the educational relevance and comprehensiveness of the final content. This alignment between user feedback and design implementation underscores the importance of participatory approaches in educational technology development.
The observed increase in post-test scores aligns with the findings of Chang et al. [31], who demonstrated that game-based learning improved nursing students’ ECG learning performance, attitudes, and critical thinking skills compared to traditional instruction. Similarly, Najafi et al. [32] found that the WebQuest approach was superior to lectures for teaching ECG interpretation. Additionally, Lak et al. [14] and Yoon et al. [33] reported significant improvements in learners’ knowledge and satisfaction after using software-based ECG learning tools. These studies, together with the present findings, reinforce the notion that technology-enhanced and gamified learning environments can effectively bridge the gap between theoretical knowledge and clinical application.
In evaluating the quality of the RhythmPath application, students expressed particularly high satisfaction with ease of use and information quality, suggesting that the app’s interface and content were well aligned with user expectations. Although the visual design received slightly lower ratings, participants still reported overall positive experiences and highlighted the motivational impact of gamified features such as badges and leaderboards.
These results align with existing evidence indicating that gamification can enhance learner satisfaction and promote active engagement in medical and health professions education. Earlier work by Malicki et al. [22] and Day‑Black et al. [23] similarly identified gamification as an effective strategy for increasing student motivation and participation. However, the broader literature suggests that the pedagogical impact of gamification is not universally consistent across all learning outcomes. Recent reviews in medical education have mapped diverse gamification approaches and documented their potential to improve engagement, motivation, and clinical reasoning, while also highlighting variability in measured effects across contexts and study designs. For example, some studies report that although gamified interventions often foster engagement and motivational support, their effects on complex cognitive outcomes, knowledge retention, and performance can vary depending on instructional design, assessment methods, and integration with theory‑driven frameworks [34]. Furthermore, recent primary research in medical education indicates that gamification can enhance specific learning outcomes such as topic mastery and perceived usability, but these benefits are influenced by context and pedagogical alignment with curricular objectives[35–38].
Limitations and future research
This study has several limitations that should be considered when interpreting the findings. First, the study was conducted at a single institution with a relatively small sample size, which limits statistical power as well as the generalizability of the results. Accordingly, the findings should be interpreted as preliminary. Nevertheless, the observed effect size and the consistent improvement across participants provide a reasonable justification for conducting larger, controlled studies. Second, the short two-week intervention period did not allow for assessment of long-term knowledge retention or evaluation of the transfer of learning to clinical practice. Third, because the RhythmPath application was compatible only with Android devices, students using iOS platforms were excluded, which may have introduced selection bias. In addition, individual differences in digital literacy and prior exposure to mobile learning technologies were not controlled and may have influenced participant engagement and learning outcomes. Finally, the absence of a control group limits the ability to attribute the observed improvements exclusively to the intervention.
Although extending the recruitment or intervention period and including additional eligible participants might have increased the sample size, these options were constrained by the fixed academic calendar, scheduled clinical rotations, and the exploratory pilot nature of the study. Consequently, the study was intentionally designed to generate preliminary evidence to inform future, larger-scale investigations.
Future research should aim to replicate these findings in larger and more diverse student populations across multiple institutions. Longitudinal studies are recommended to evaluate the sustainability of learning gains and their impact on clinical performance. Expanding the application’s compatibility to iOS and web-based platforms would enhance accessibility and reduce potential selection bias. Moreover, comparative studies could investigate how different gamification strategies—such as adaptive difficulty levels, team-based competition, or social collaboration—affect learner motivation, cognitive load, and skill acquisition in health professions education.
Conclusions
The findings of this study highlight the educational value of integrating gamification into mobile learning for nursing students. The RhythmPath application effectively enhanced students’ ECG interpretation skills, promoted engagement, and achieved high levels of user satisfaction. Incorporating qualitative feedback during the design phase ensured that the application’s content was aligned with curricular objectives and learners’ real-world needs. Overall, these findings provide preliminary empirical evidence from a small-sample pilot study supporting the potential of gamified, learner-centered tools as scalable and effective strategies to enhance clinical education in nursing and other health professions. Although the results are promising, further studies with larger samples, control groups, and longitudinal designs are recommended to confirm the educational effectiveness and long-term impact of the application.
Acknowledgments
We thank our colleagues and study participants for their invaluable contributions to this research.
Authors’ contributions
S.A. and H.M. contributed to the conceptualization and design of the study. F.A. and R.MR were responsible for data collection. S.A. designed the study methodology, conducted the statistical analyses, and wrote the methods, results, and interpretation of findings sections. S.A., A.E., and H.M. critically appraised the manuscript and provided detailed comments and guidance to improve its clarity and academic quality. S.A., F.A., and H.M. jointly drafted and revised the manuscript. All authors read and approved the final version of the manuscript.
Funding
The Mashhad University of Medical Sciences, Iran (Grant No. 4001058) funded this project.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding authors upon reasonable request.
Declarations
Ethics approval and consent to participate
Participation in the study was voluntary, and written informed consent was obtained from all participants. All procedures were conducted in accordance with the ethical standards of the School of Medicine at Mashhad University of Medical Sciences (https://ethics.research.ac.ir; Approval ID: IR.MUMS.MEDICAL.REC.1401.467; Approval Date: 2022-09-25). Furthermore, all methods adhered to the principles outlined in the Declaration of Helsinki.
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.
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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 used and/or analyzed during the current study are available from the corresponding authors upon reasonable request.