Abstract
Aim
To examine whether participation in a Massive Open Online Course-based flipped classroom strategy was associated with improved digital competence and self-organized learning among nursing students.
Background
Nursing students require digital competence and independent learning skills to participate effectively in technology-supported education and contemporary healthcare practice. Combining Massive Open Online Courses with flipped classroom instruction may integrate flexible digital learning with structured, active classroom participation.
Design
A non-randomized quasi-experimental study.
Methods
The study included 210 nursing students enrolled in a health education course. Students were allocated according to their pre-existing course sections to an intervention group or a control group, with 105 students in each group. The intervention group participated in a six-week Massive Open Online Course-based flipped classroom strategy comprising pre-class digital materials, online discussions, preparatory assignments, and face-to-face collaborative learning activities. The control group received conventional instructor-led teaching. Digital competence and self-organized learning were assessed before and immediately after the intervention using validated questionnaires. Pre- and post-intervention outcomes were compared between the groups.
Results
The intervention group demonstrated significantly greater improvements than the control group in overall digital competence and all its domains, including information and data literacy, communication and collaboration, digital content creation, safety, and problem-solving. Significant improvements were also observed in overall self-organized learning and its dimensions of academic motivation, self-monitoring, and adaptation strategy. All group-by-time differences were statistically significant at p < .001. Most intervention-group students reported overall satisfaction with the strategy (94.3%).
Conclusion
Participation in the Massive Open Online Course-based flipped classroom strategy was associated with improved digital competence and self-organized learning among nursing students compared with conventional instructor-led teaching. Randomized, multicentre, and longitudinal studies are required to determine the effectiveness, generalizability, and sustainability of these outcomes.
Keywords: Digital competence, Flipped classroom, Massive open online course, Nursing education, Nursing students, Self-organized learning
What is already known?
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Digital competence and independent learning skills are increasingly important in nursing education and professional practice.
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Massive Open Online Courses offer flexible access to digital learning resources but may be limited by poor engagement, accountability, and time management.
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Flipped classrooms combine pre-class preparation with active classroom learning, collaboration, problem-solving, and teacher feedback.
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What this paper adds?
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A six-week Massive Open Online Course-based flipped classroom strategy was associated with greater improvements in nursing students’ digital competence than conventional teaching.
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The strategy was also associated with improvements in academic motivation, self-monitoring, adaptation strategies, and overall self-organized learning.
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Students reported high satisfaction with the strategy, supporting its acceptability as a technology-supported nursing education approach.
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1. Introduction
Higher education is a place that is still undergoing digital transformation, and students' ways of accessing information, communicating, collaborating, and learning are being transformed in the process. The role of a university student is to become more active learner who can seek, assess, and use information independently in digital environments. In the current time of rapid advancements in technology-mediated education, especially after the COVID-19 pandemic, the necessity of flexible instructional models and enhanced digital skills of students and educators has emerged as a crucial challenge (Parveen and Imran, 2024).
Healthcare delivery and professional nursing practice are increasingly influenced by digital technologies. Consequently, nursing education should equip students not only with clinical knowledge and skills but also with the digital competence required to access information, communicate effectively, use technology-supported learning resources, and participate responsibly in digital environments (Iyi et al., 2022; Zhao et al., 2021). Nursing students also require independent learning abilities because lifelong learning is essential for adapting professional knowledge and practice to changing patient needs, emerging evidence, and technological developments in healthcare (Mlambo et al., 2021).
Passive information delivery through conventional lectures may be insufficient to develop these competencies. In nursing education, pedagogical approaches should encourage students to assume greater responsibility for their learning, participate actively in classroom activities, and use digital media purposefully. Student-centred strategies can support deeper learning by shifting the instructor’s role from primarily delivering information to facilitating application, discussion, reflection, and problem-solving (Lai et al., 2021; Baig and Yadegaridehkordi, 2023).
The one method that is gaining more traction is the blending of Massive Open Online Courses with the flipping classroom. Massive Open Online Courses offer access to digital learning resources such as recorded lectures, readings, interactive resources, assessments, and online communication tools, and can be accessed flexibly. They can be used around the time and at the speed that is appropriate for the learner, can be used to review hard content, and can be used to learn away from the classroom. These attributes can foster autonomy, lifelong learning, and digital engagement (Pérez-Sanagustín et al., 2021).
But some online learning and course materials do not guarantee sustained involvement or meaningful learning. Students can have low engagement, low interaction, low accountability, or low independent work management. A flipped classroom model can tackle these problems and bring together pre-class online preparation and structured classroom work. The flipping classroom model provides a chance for students to gain a basic understanding of the material prior to coming to class, while class time is reserved for discussion, case analysis, problem-solving, group activities, and feedback (Baig and Yadegaridehkordi, 2023).
Massive Open Online Courses combined with flipping learning may thus be a blend of the flexibility of online learning and the structure and interaction of classroom learning. Content can be read independently by students prior to class and then applied through activities during class. A redistribution of learning could be particularly suited for nursing education, where students are required to interpret information, communicate effectively, solve problems, and to apply theory to realistic contexts related to health. The studies conducted in this area have indicated that purposefully integrating the online and in-class parts of a flipped classroom can improve in-class interaction, learner autonomy, and participation (Williams et al., 2019; Yaşar and Polat, 2021).
However, the success of a Massive Open Online Course-based flipped classroom depends not only on the availability of technology but also on the quality of its instructional design. Pre-class materials should be concise, accessible, and aligned with the intended learning outcomes, while classroom activities should require students to apply the knowledge acquired before class. Instructors should also provide clear guidance, clarification, scaffolding, and timely feedback throughout the learning process (Baig and Yadegaridehkordi, 2023). Without these elements, flipped learning may increase students’ workload and become burdensome rather than providing a meaningful learning experience (Huang et al., 2023).
1.1. Self-Organized learning
Self-organized learning refers to learners’ ability to plan, monitor, evaluate, and adjust their learning processes. It involves setting goals, selecting appropriate resources, managing time, assessing progress, and adapting learning strategies when difficulties arise. These abilities are particularly important for nursing students, who must manage complex theoretical and clinical learning requirements and continue developing their professional competence after graduation (Muhanna, 2015).
A Massive Open Online Course-based flipped classroom may provide an environment that supports self-organized learning. Before class, students access digital materials, study independently, complete preparatory tasks, and check their understanding. During face-to-face sessions, they apply their preparation through discussion, collaboration, case analysis, and problem-solving activities. This sequence may help students connect independent preparation with active participation, self-monitoring, and strategy adaptation (van Alten et al., 2020; Pérez-Sanagustín et al., 2021).
Muhanna (2015) pointed out that academic motivation, self-monitoring, and adaptation of learning strategies are three key components of self-organized learning. These dimensions are related to flipped teaching as students need to keep their interest in learning, understand the pre-class materials, and adapt learning strategies when having problems.
Goal-setting processes in Massive Open Online Courses were shown to be correlated with Massive Open Online Course learners' satisfaction and achievement of learning goals (Rabin et al., 2019). Van Alten et al. (2020) found that self-regulated learning prompts led to higher students' pre-class engagement in a flipped classroom. Similarly, Pérez-Sanagustín et al. (2021) showed that self-regulated learning support in a Massive Open Online Course-based flipped experience helped students to better manage their time and engage with the course.
But it cannot be taken for granted that learner autonomy is a natural consequence. Students who are not used to independent learning, who have poor time management skills, or who have limited access to digital materials may find it challenging to adapt to flipped instruction. So, it is important to have clear expectations, work levels that are manageable, preparatory instructions, and instructor support so that flexibility does not lead to confusion or disenfranchisement.
1.2. Digital competence
Digital competence is defined as knowledge, skills, and attitudes that enable the effective, critical, safe, and responsible use of digital technologies. It is not only about technical functioning; it is also about finding and assessing information, communicating in digital environments, producing digital information, safeguarding digital information, and solving technology-related issues (Eger et al., 2018; Kwon, 2021).
Digital competence is important not only for nursing students’ academic learning but also for their future professional practice. Students need to locate and critically evaluate online information, access electronic learning systems, communicate through digital platforms, and create educational resources. These competencies can support information retrieval, professional communication, patient education, and participation in technology-supported healthcare environments (Zhao et al., 2021; Iyi et al., 2022).
A Massive Open Online Course-based flipped classroom may support the development of digital competence by embedding digital activities within meaningful learning tasks. Rather than using technology merely as a means of receiving information, students use digital tools to access course content, participate in discussions, complete assignments, collaborate with peers, and create educational materials. Repeated engagement in these activities may strengthen information and data literacy, digital communication and collaboration, digital content creation, safety awareness, and technology-related problem-solving (Iyi et al., 2022; Li, 2024).
Henseruk et al. (2021) pointed out the importance of embedding technology in relevant learning experiences to build digital competence. Similarly, Li (2024) claims that the digital fluency initiative can help to build students' technological fluency by creating connections between digital tools and active learning. It has also been found that digital competence of students is related to engagement and effective participation in technology-supported education (Bergdahl et al., 2020; Zhao et al., 2021).
1.3. Theoretical framework
The Massive Open Online Course-based flipped classroom approach used in this study was guided by the theories of self-regulated learning, constructivism, Bloom’s taxonomy, and cognitive load theory. The self-regulated learning theory is a theory in which students plan, monitor, and adjust their learning. During the pre-class phase, students must carefully allocate time, access content independently, prepare for the activity, and determine learning needs. Academic motivation, self-monitoring, and strategic adaptation (Rabin et al., 2019; van Alten et al., 2020) are theoretically linked to these processes.
Constructivist learning theory proposes that learners actively construct knowledge by integrating new information with prior knowledge through experience, interaction, and reflection. In a flipped classroom, discussions, case analyses, role-plays, presentations, collaborative activities, and peer feedback provide opportunities for students to apply knowledge and construct meaning collectively rather than receive information passively from the instructor (Gilboy et al., 2015; Baig and Yadegaridehkordi, 2023).
The taxonomy of Bloom also contributes to the redistribution of learning activities. The face-to-face lesson with the teacher's guidance can focus on higher-order thinking skills (such as application, analysis, evaluation, creation), while the pre-class digital materials can address lower-order thinking skills (such as remembering and understanding) (Morton and Colbert-Getz, 2017).
The rationale for letting students review introductory content at their own rate is also provided by cognitive load theory. Access to digital materials in the classroom might foster a student's ability to handle complex information before participating in more sophisticated classroom tasks (Clark et al., 2005; Sweller et al., 1998).
In line with this, the proposed framework suggests that structured pre-class digital engagement can facilitate learning by the learner himself, and guided use of the classroom can enhance collaboration, problem-solving, and digital competence. The present study used a non-randomized design, so this theoretical framework accounts for the hypothesized relationships in this study, although it does not allow for the establishment of definitive causal effects.
1.4. Aim of the study
This study aims to explore the influence of a Massive Open Online Course-based flipped Classroom Strategy on Digital Competence and Self-Organized Learning among Nursing Students.
1.5. Research hypotheses
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Nursing students who learn through Massive Open Online Course-based Flipped Classroom Strategy demonstrate higher digital competence than those who learn through traditional learning strategies.
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Nursing students who learn through the Massive Open Online Course-based Flipped Classroom Strategy demonstrate higher self-organized than those who learn through traditional learning strategies.
2. Research design
This quasi-experimental study was reported in accordance with the Transparent Reporting of Evaluations with Nonrandomized Designs statement for nonrandomized intervention evaluations (Des Jarlais et al., 2004). It was conducted over two months, from the beginning of December 2024 to the end of January 2025.
2.1. Settings
This study was conducted at the Nursing Education Department at the Faculty of Nursing, Alexandria University, Egypt.
2.2. Subjects
A convenient sample of 210 nursing students recruited from health education courses during the first semester of the academic year 2024–2025 represented the study sample. The required sample size was estimated using G*Power version 3.1 (Faul et al., 2009). Assuming the effect size of the impact of the Massive Open Online Course-based flipped classroom strategy on self-organized learning and digital competencies among nursing students is 0.15, using an alpha error of 0.05. With a study power of 80 %. Number of groups and number of measurements = 2; the minimum required sample size is 90 for each group. The sample will be increased to 105 for each group (Fig. 1).
Fig. 1.
Student recruitment flow diagram.
Inclusion Criteria: Nursing students enrolled in the health education course during the first semester of the academic year 2024–2025, students willing to participate in the study and provide informed consent, and students who have access to the internet and digital devices for Massive Open Online Course participation. Exclusion Criteria were students who did not give informed consent to participate in the study.
2.3. Study tools
2.3.1. Tool I: nursing students' digital competence questionnaire
It was developed by Iyi et al. (2022) to assess nursing students' digital competence. This scale was found to have a high internal consistency, with a Cronbach's alpha coefficient of α = 0.94, indicating its reliability. The tool is divided into five domains: information and data literacy, communication and collaboration, safety, digital content creation, and problem-solving. It consists of 22 statements that are evaluated using a 5-point Likert scale, where (1) represents very poor, (2) poor, (3) satisfactory, (4) good, and (5) excellent. The total score ranges from 22 to 110, with the following classifications: a score between 22 and 51 indicates low-level digital competence development, a score between 51 and 80 indicates moderate-level digital competence development, and a score between 81 and 110 indicates high-level digital competence development.
2.3.2. Tool II: self-organized learning scale
The Self-organized learning scale, developed by Muhanna (2015), was used to assess nursing students' self-organizational abilities, with a reported reliability of 0.85. The scale covered three subscales: academic motivation, self-monitoring, and strategy adaptation. This subscale consisted of 14 statements evaluated using a 4-point Likert scale, where responses ranged from Always (4), Sometimes (3), Usually (2), to Rarely (1). The total score ranged from 14 to 56, with the following classifications: a score between 14 and 28 indicated a low level of self-organization, a score between 28 and 42 showed a moderate level of self-organization, and a score between 42 and 56 showed a high level of self-organization.
In addition to the two validated tools, social and academic data, such as age, gender, and GPA, were collected.
3. Method
3.1. Ethical considerations
Ethical approval was obtained from the Research Ethics Committee of the Faculty of Nursing, Alexandria University, Egypt, prior to data collection under the reference code: IRB00013620/AU-20-9-316. This committee operates in accordance with international guidelines and applicable local and institutional regulations, ensuring that all research adheres to ethical standards. Additionally, official permission was secured from both the Dean of the Faculty of Nursing and the Head of the Nursing Education Department. These approvals were obtained after a thorough explanation of the study's objectives, ensuring transparency and institutional support. All participants provided written informed consent, affirming their voluntary participation and understanding of the study's purpose. To maintain confidentiality, participants' personal information was anonymized, and data were securely stored, accessible only to the research team. Participants were also informed of their right to withdraw from the study at any time without any negative consequences.
3.2. Instrument's validity
Both the Nursing Students' Digital Competence Questionnaire and the Self-Organized Learning Scale underwent a comprehensive validation process to ensure both linguistic accuracy and conceptual equivalence in their Arabic adaptations. Initially, the instruments were translated into Arabic by two bilingual experts, and their independent translations were synthesized into one version, which was subsequently back-translated into English by another set of bilingual translators. Any discrepancies found during this process were carefully analyzed and resolved to maintain the original meaning of each item. This was followed by a thorough expert review, where a panel of five nursing education specialists evaluated the clarity, relevance, and cultural appropriateness of the translated items. The experts confirmed that the items adequately represented the intended domains—information and data literacy, communication and collaboration, safety, digital content creation, and problem-solving in the case of the digital competence questionnaire, and academic motivation, self-monitoring, and strategy adaptation for the self-organized learning scale—earning content validity indices largely above acceptable thresholds. To further establish construct validity, the instruments were subjected to the Lwen test, which yielded robust homogeneity values of approximately 0.92 and 0.88 for the digital competence questionnaire and the self-organized learning scale, respectively.
3.3. Pilot study and reliability
A pilot study involving 25 nursing students then assessed the usability and internal consistency of the tools. Face validity was confirmed, and Cronbach's alpha coefficients of 0.91 for the digital competence questionnaire and 0.81 for the self-organized learning scale indicated excellent and good reliability, respectively. This sequential process, from translation and expert evaluation to statistical testing and pilot implementation, confirms that both instruments are valid, reliable, and well-suited for assessing digital competence and self-organizational abilities among nursing students.
3.4. Data collection and student preparation
After obtaining ethical approval and formal permission from the Dean of the Faculty of Nursing and the Head of the Nursing Education Department, eligible nursing students enrolled in the health education course were invited to participate in the study.
The researcher explained the study aim, procedures, voluntary nature of participation, confidentiality measures, and the students’ right to withdraw at any time without academic penalty. Written informed consent was obtained from all participants before data collection. The baseline questionnaires, including the Nursing Students’ Digital Competence Questionnaire, the Self-Organized Learning Scale, and the personal and academic data form, were administered to the study and control groups before implementation of the intervention. Students completed the questionnaires in the academic setting under the supervision of the researcher, with sufficient time provided to answer all items independently. The 210 participating students were assigned to the study and control groups according to their pre-existing health education course sections, with 105 students in each group. No individual random allocation was performed.
Before implementation of the Massive Open Online Course-based flipped classroom strategy, students in the study group attended introductory face-to-face orientation sessions. During these sessions, the researcher explained the objectives, structure, learning activities, and expectations of the strategy. Students were also introduced to the Microsoft Teams platform and trained to access recorded lectures, PowerPoint presentations, supplementary readings, quizzes, assignments, case studies, and discussion forums.
A dedicated Microsoft Teams channel was established to facilitate communication between the students and the researcher, provide clarification regarding learning activities, address technical or procedural difficulties, and support students throughout the six-week intervention. Students in the control group received the same health education course content through conventional instructor-led teaching without access to the structured pre-class digital materials, online discussion forums, or required preparatory assignments provided to the study group.
3.5. Intervention and control groups
The study group received the Massive Open Online Course-based flipped classroom strategy developed according to Yu et al. (2025) and Yaşar and Polat (2021). Before each classroom session, students accessed short, recorded lectures, PowerPoint presentations, supplementary readings, case studies, quizzes, discussion forums, and assignments through Microsoft Teams. Students were expected to review these materials before attending class. Face-to-face sessions were then devoted to active learning activities, including group discussion, problem-solving, case analysis, role-play, student presentations, collaborative assignments, and formative feedback.
The control group received conventional instructor-led teaching and did not receive recorded pre-class lectures, Massive Open Online Course materials, structured online discussion forums, or required pre-class digital assignments. Course content was delivered during scheduled face-to-face sessions through lectures, instructor explanations, and routine classroom discussions, followed by the standard course activities. Illustrative matched instructional units demonstrating the operational differences between the Massive Open Online Course-based flipped classroom and conventional instructor-led teaching conditions are provided in Appendices A for study group and B for control group.
Both groups studied the same health education content over the same six-week period and were assessed using the same instruments at baseline and immediately after the intervention.
3.6. Follow-Up
Following the six-week intervention period during which the study group engaged with the Massive Open Online Course-based flipped classroom model, both groups were reassessed using the same validated tools to measure any changes in digital competence and self-organized learning. The follow-up data collection was structured to mirror the baseline process, ensuring consistency in administration and timing.
3.7. Data analysis
Data were analysed using IBM SPSS Statistics, version 26.0. Categorical variables were summarized using frequencies and percentages, whereas continuous variables were summarized using means and standard deviations. The chi-square test was used to compare categorical personal and academic characteristics between the study and control groups. An independent-samples t-test was used to compare continuous baseline characteristics between the two groups.
A two-way mixed-design analysis of variance was conducted separately for each digital competence and self-organized learning outcome. Group—study versus control—was included as the between-subjects factor, and time—pre-intervention versus post-intervention—was included as the within-subjects factor. The analysis examined the main effect of group, the main effect of time, and the group-by-time interaction. The group-by-time interaction was used to determine whether changes in outcome scores over time differed significantly between the study and control groups.
Separate mixed-design analyses were conducted for the overall digital competence score and its five domains: information and data literacy, communication and collaboration, digital content creation, safety, and problem-solving. Similar analyses were conducted for the overall self-organized learning score and its three dimensions: academic motivation, self-monitoring, and adaptation strategy.
The assumptions of normality, independence of observations, homogeneity of variance, and homogeneity of covariance were assessed before interpreting the analyses. Results were reported using means and standard deviations, F statistics, p values, and partial eta-squared (ηp²) effect sizes. Students’ satisfaction with the Massive Open Online Course-based flipped classroom strategy was assessed descriptively among the study group after the intervention. Satisfaction responses were summarized using frequencies, percentages, means, and standard deviations. Statistical significance was established at p ≤ .05.
4. Results
Table 1 provides the personal and academic characteristics of the study population. Based on the table descriptions, it can be observed that most of the Study and control groups were < 30 years old (66.7 % & 71.4 %). Additionally, nearly three-quarters of them were female (72.4 % & 67.6 %, respectively. Regarding GPA, the distribution of grades (A-, B+, B, B-) shows no significant difference between the two groups, with p-values greater than .05 for all categories (p = .277 from the Chi-square test). The two groups did not exhibit significant differences in terms of personal and academic characteristics (p > .05).
Table 1.
Personal and academic characteristics.
| Control group (n = 105) |
Study group (n = 105) |
χ2 | p | |||
|---|---|---|---|---|---|---|
| No. | % | No. | % | |||
| Age (years) | ||||||
| <30 | 75 | 71.4 % | 70 | 66.7 % | ||
| 30 – < 40 | 25 | 23.8 % | 33 | 31.4 % | 2.486 | .281 |
| 40 – < 50 | 5 | 4.8 % | 2 | 1.9 % | ||
| Mean±SD | 27.90 ± 5.43 | 27.82 ± 4.82 | t = .121 | .904 | ||
| Gender | ||||||
| Male | 34 | 32.4 % | 29 | 27.6 % | ||
| Female | 71 | 67.6 % | 76 | 72.4 % | 0.567 | .451 |
| GPA | ||||||
| A- | 10 | 9.5 % | 7 | 6.7 % | ||
| B+ | 5 | 4.8 % | 12 | 11.4 % | 3.856 | .277 |
| B | 70 | 66.7 % | 70 | 66.7 % | ||
| B- | 20 | 19.0 % | 16 | 15.2 % | ||
χ2: Chi-square test t: Student t-test.
Table 2 presents changes in nursing students’ digital competence scores before and after the intervention. Significant group-by-time interaction effects were observed for all digital competence domains, including information and data literacy, communication and collaboration, digital content creation, safety, and problem-solving (all p < .001).
Table 2.
Comparison of pre- and post-intervention digital competence scores between the study and control groups.
| Nursing students’ digital competence questionnaire | Control group (n = 105) | Study group (n = 105) | Interaction of groups |
Interaction of Time |
Interaction Groups x time |
ηp² | |||
|---|---|---|---|---|---|---|---|---|---|
| F | p | F | p | F | p | ||||
| Information and data literacy | |||||||||
| Pre-Intervention (M ± SD) | 9.84 ± 1.66 | 10.24 ± 1.42 | 80.189* | < .001* | 34.995* | < .001* | 44.561* | < .001* | .972 |
| Post-Intervention (M ± SD) | 9.70 ± 1.88 | 12.45 ± 2.15 | |||||||
| Communication and collaboration | |||||||||
| Pre-Intervention (M ± SD) | 22.30 ± 5.96 | 22.91 ± 5.88 | 104.481* | < .001* | 78.218* | < .001* | 84.716* | < .001* | .943 |
| Post-Intervention (M ± SD) | 22.08 ± 8.20 | 33.90 ± 4.24 | |||||||
| Digital content creation | |||||||||
| Pre-Intervention (M ± SD) | 8.55 ± 2.82 | 8.95 ± 2.53 | 42.099* | < .001* | 45.555* | < .001* | 24.228* | < .001* | .932 |
| Post-Intervention (M ± SD) | 9.02 ± 2.37 | 11.93 ± 2.73 | |||||||
| Safety | |||||||||
| Pre-Intervention (M ± SD) | 12.05 ± 3.71 | 12.13 ± 3.26 | 28.772* | < .001* | 39.063* | < .001* | 25.798* | < .001* | .947 |
| Post-Intervention (M ± SD) | 12.40 ± 3.12 | 15.54 ± 1.98 | |||||||
| Problem solving | |||||||||
| Pre-Intervention (M ± SD) | 9.48 ± 2.55 | 9.86 ± 2.15 | 43.287* | < .001* | 29.176* | < .001* | 24.550* | < .001* | .949 |
| Post-Intervention (M ± SD) | 9.58 ± 2.70 | 12.29 ± 2.15 | |||||||
| Overall nursing students’ digital competence | |||||||||
| Pre-Intervention (M ± SD) | 62.21 ± 10.22 | 64.10 ± 6.87 | 155.309* | < .001* | 124.610* | < .001* | 112.316* | < .001* | .978 |
| Post-Intervention (M ± SD) | 62.78 ± 12.52 | 86.10 ± 11.01 | |||||||
Data are presented as mean ± standard deviation (SD). F: F-statistics for the two-way mixed-design analysis of variance. ηp²: Partial eta squared. *: Statistically significant at p ≤ 0.05.
The study group demonstrated substantial improvements across all domains following implementation of the Massive Open Online Course-based flipped classroom strategy, whereas the control group’s scores remained relatively stable. The most pronounced improvement was observed in communication and collaboration, where the study group’s mean score increased from 22.91 ± 5.88 before the intervention to 33.90 ± 4.24 after the intervention.
Overall digital competence in the study group increased from 64.10 ± 6.87 to 86.10 ± 11.01, compared with a minimal change in the control group from 62.21 ± 10.22 to 62.78 ± 12.52. The significant group-by-time interaction (F = 112.316, p < .001) indicates that the improvement over time differed significantly between the two groups. The reported effect sizes were very large across all domains (η² = .932 – .978), supporting the substantial effect of the Massive Open Online Course-based flipped classroom strategy on students’ digital competence.
Table 3 illustrates changes in self-organized learning scores among the study and control groups before and after the intervention. Significant group-by-time interaction effects were identified for academic motivation, self-monitoring, adaptation strategy, and the overall self-organized learning score (all p < .001). Following implementation of the Massive Open Online Course-based flipped classroom strategy, the study group demonstrated marked improvements in academic motivation, self-monitoring, and adaptation strategy. In contrast, the control group showed little or no meaningful change across these dimensions. The overall self-organized learning score of the study group increased from 27.76 ± 3.65 before the intervention to 34.25 ± 3.20 after the intervention. Conversely, the control group’s score remained nearly unchanged, decreasing slightly from 27.30 ± 3.53 to 27.18 ± 3.19. The significant group-by-time interaction (F = 99.055, p < .001) demonstrates that the improvement over time was significantly greater in the study group than in the control group. The reported effect sizes were very large (η² = .970 – .987), indicating a substantial effect of the Massive Open Online Course-based flipped classroom strategy on self-organized learning.
Table 3.
Comparison of pre- and post-intervention self-organized learning scores between the study and control groups.
| Self -organized learning scale | Control group (n = 105) | Study group (n = 105) | Interaction of groups |
Interaction of time |
Interaction groups x time |
ηp² | |||
|---|---|---|---|---|---|---|---|---|---|
| F | p | F | p | F | p | ||||
| Academic motivation | |||||||||
| Pre-Intervention (M ± SD) | 9.24 ± 1.83 | 9.52 ± 1.72 | 68.923* | < .001* | 33.899* | < .001* | 43.709* | < .001* | .970 |
| Post-Intervention (M ± SD) | 9.10 ± 1.88 | 11.63 ± 1.46 | |||||||
| Self-monitoring | |||||||||
| Pre-Intervention (M ± SD) | 10.50 ± 1.37 | 10.33 ± 2.02 | 40.029* | < .001* | 43.638* | < .001* | 53.751* | < .001* | .976 |
| Post-Intervention (M ± SD) | 10.38 ± 1.94 | 12.71 ± 1.57 | |||||||
| Adaptation strategy | |||||||||
| Pre-Intervention (M ± SD) | 7.56 ± 1.53 | 7.90 ± 1.42 | 103.704* | < .001* | 72.544* | < .001* | 55.606* | < .001* | .977 |
| Post-Intervention (M ± SD) | 7.70 ± 0.86 | 9.91 ± 1.24 | |||||||
| Overall Self-organized learning scale | |||||||||
| Pre-Intervention (M ± SD) | 27.30 ± 3.53 | 27.76 ± 3.65 | 128.343* | < .001* | 91.775* | < .001* | 99.055* | < .001* | .987 |
| Post-Intervention (M ± SD) | 27.18 ± 3.19 | 34.25 ± 3.20 | |||||||
Data are presented as mean ± standard deviation (SD). F: F-statistics for the two-way mixed-design analysis of variance. ηp²: Partial eta squared. *: Statistically significant at p ≤ 0.05.
Table 4 shows the study group's Satisfaction with applying the Massive Open Online Course-based Satisfaction flipped classroom strategy. The table shows that most students agree with this strategy, as they were satisfied that it contributed to their educational development, the level of interaction, and their willingness to use this strategy again (94.3 %, 92.4 %, 98.1 %, 97.1 %, and 91.4 %).
Table 4.
Satisfaction of study group about applying massive open online course-based flipped classroom strategy post intervention (n = 105).
| Satisfaction | Mean ± SD | Strongly disagree/ Disagree |
Neutral |
Agree /Strongly agree |
|||
|---|---|---|---|---|---|---|---|
| No. | % | No. | % | No. | % | ||
| 1. Overall, I am satisfied with using Massive Open Online Course based flipped classroom in this class. | 4.57 ± 0.82 | 0 | 0.0 % | 6 | 5.7 % | 99 | 94.3 % |
| 2. This class contributed to my educational development. | 4.56 ± 0.99 | 2 | 1.9 % | 6 | 5.7 % | 97 | 92.4 % |
| 3. This class contributed to my professional development | 4.88 ± 0.64 | 0 | 0.0 % | 2 | 1.9 % | 103 | 98.1 % |
| 4. I am satisfied with the level of interaction that happened in this class. | 4.69 ± 0.80 | 1 | 1.0 % | 2 | 1.9 % | 102 | 97.1 % |
| 5. In the future, I would be willing to take a full Massive Open Online Course -based flipped classroom again. | 4.55 ± 1.07 | 3 | 2.9 % | 6 | 5.7 % | 96 | 91.4% |
| Total mean score | 23.59 ± 3.83 | ||||||
| Mean percentage score | 91.25 ± 17.12 | ||||||
5. Discussion
The relationship between the flipped classroom model, which utilizes Massive Open Online Courses, and nursing students' digital competence, self-organized learning, and satisfaction was studied. Intervention students gained more than the students who were taught by their regular teachers. The results indicate that the use of pre-class digital preparation, combined with the active application of the face-to-face method, can support key nursing-education competencies.
In a Massive Open Online Course-based flipped classroom, pre-class learning and classroom learning are redistributed. This is done via recorded lecture content, readings, quizzes, and online discussion, and the classroom application of this content, problem-solving, collaboration, and feedback. The students are, therefore, prepared prior to class and use their knowledge in class under the guidance of the teacher (Baig and Yadegaridehkordi, 2023).
5.1. Self-Organized learning
Better self-organised learning could be attributed to the increased level of responsibility given to students. The participants used learning materials, managed the time during the preparation process, were able to complete the assignments, identified gaps in their knowledge, and actively engaged during class. The activities are closely linked with academic motivation, academic self-monitoring, and adaptation of learning strategies.
This interpretation aligns with Long et al. (2016), who found that the pre-class videos enhance student preparation, and the more time that was available for the students to learn in the classroom. The same was true for Van Alten et al. (2020), who found that self-regulated learning prompts led to engagement with preclass materials. While self-regulated and self-organized learning are not synonymous, both entail planning, monitoring, and adapting learning behavior.
Online may also have enhanced time management and goal setting. Self-management is key to participation in Massive Open Online Courses, as these environments allow students some choice and control over when and how they engage with content. Rabin et al. (2019) related goal setting in Massive Open Online Courses to learner satisfaction, and Pérez-Sanagustín et al. (2021) concluded that scaffolding self-regulated learning also enhanced time management and engagement.
These processes are likely to have been reinforced during the classroom phase, as there was evidence of connection to the following: discussion, case analysis, role playing, problem solving, presentation, and feedback. Students thus had good motivation to do pre-class work and put their learning into practice. Similarly, Kim et al. (2021) found that self-regulated learning was related to satisfaction and continued intentions regarding flipped learning.
The improvement in academic motivation may also be related to autonomy and active participation. This approach allowed students to work at their own speed and get assistance from the instructor, which could enhance their self-directed learning, teamwork, sense of self-efficacy, and critical thinking (He et al., 2023).
But not all students thrive in an autonomous setting. Flipped learning can lead to an overload of workload and may be challenging for students who lack digital access, have poor time management, or are not ready for self-directed learning. In cases of excessive or poorly coordinated activities, students might perceive the model as cumbersome, as mentioned by Huang et al. (2023). This means managing the workload, set clear expectations, and providing adequate support in implementing.
5.2. Digital competence
The enhancement of digital competency can be attributed to the fact that digital activities are an integral part of everyday learning. Students read online resources, interacted with one another via Microsoft Teams, engaged in electronic assignments, assessed information, and developed instructional products. Digital competence was therefore implemented by providing meaningful academic tasks instead of as a standalone subject.
Students were repeatedly finding, reading, and utilizing digital sources, and identifying an increase in information and data literacy. A similar viewpoint was presented by Lendínez Turón et al. (2024), who suggested that flipped learning can reinforce the skills necessary to locate, organize and assess digital information through Massive Open Online Courses.
Communication and collaboration may have originated from an online discussion and group activity. Students were able to engage with fellow students and teachers, ask questions, share opinions, and develop tasks together. Henseruk et al. (2021) highlighted that digital competence will be better developed if learning activities are meaningful and contain technology.
The quality of the digital content produced might have been enhanced as students created presentations, lesson plans, posters, and other educational materials. These activities involved them in creating and sharing digital information rather than just consuming information. Similarly, Moreno et al. (2020) associated digital competence with good-quality instructional materials created for flipped learning.
Exposure to real-life technological challenges (such as access, files, communications, platform-related challenges, etc.) may have helped develop safety and problem-solving skills. Li (2024) stated that the addition of technology in digital fluency initiative can enhance competence through authentic academic tasks.
There may be a benefit to a combined model since weaknesses in Massive Open Online Courses and flipped learning can be offset by one another. Massive Open Online Courses provide flexible access to learning material and can be less engaging if self-directed. Flipped classrooms bring structure, accountability, collaboration, and feedback from the teacher. According to Pérez-Sanagustín et al. (2021), the effectiveness of engagement and time management was enhanced when Massive Open Online Course-based learning was paired with self-regulated learning support.
However, it was a multi-component intervention. Students also interacted in discussions, quizzes, assignments, role-play, presentations, problem-solving, and feedback, which explains the improvement that was observed, and not solely due to the Massive Open Online Course materials. The results are thus a result of the integrated implementation of the strategy, not of the individual components.
5.3. Students' satisfaction
In terms of feedback from the students, the high level of satisfaction means that the strategy was acceptable. This could have been influenced by flexible access to content, active participation, peer communication, and feedback from the instructor. Prior research also associates engagement and interaction with satisfaction in flipped learning (Guan, 2024; He et al., 2023).
But satisfaction does not equal effectiveness. High ratings could be due to novelty, social desirability, or perceptions of the instructor. Satisfaction was only measured after the program in the intervention group and thus could not be compared to the control condition or measured over time.
5.4. Strengths and limitations
There are several strengths in this study. It showed how it presented an educational problem and explored an educational approach that includes digital learning, active participation, and learning responsibility. Having an intervention group and a comparison group allowed for the comparison of changes between two instructional conditions. The pre- and post-testing also enabled changes over time to be investigated.
Another advantage was the instruments that were translated, back-translated, piloted, and tested before use. The procedures ensured the linguistic clarity, cultural appropriateness, and reliability of the Arabic translations of the instruments within the target population. The intervention was also introduced at several points during the health education course and contained pre-, in class and after-class learning activities.
There are some restrictions that should be noted, however. The first one was convenience sampling without individual randomizing for participants. This procedure may have resulted in selection bias and restricted the ability to draw causal inferences. The groups were similar with respect to all measured demographic, academic, and baseline child characteristics, but the possibility of residual confounding by unmeasured factors is not ruled out.
Second, it was carried out in one academic environment and one health education course. Many course and institutional factors can vary between nursing programs, such as the characteristics of the institution, the digital infrastructure, course content, student characteristics, and teaching practices. So, the generalization of the results to other universities, courses, or educational settings might be restricted.
Thirdly, the intervention was given for six weeks, and the outcome was measured immediately following the intervention. The study, however, could not conclude whether the improvement of digital competence and self-organized learning was long-term. Medium- and Long-term follow-up assessments should be performed in future studies.
Fourth, self-report questionnaires were used as measures of primary outcomes. Self-reported digital competence and self-organized learning may not accurately represent students' capabilities and may be subject to recall bias and/or social desirability bias. Future studies could incorporate both self-report tools and objective tools like electronic performance tasks, learning analytics, platform engagement data, assignment quality, and academic outcomes.
Fifth, due to the nature of the educational intervention, the teacher and students were not blinded to the teaching condition. Student motivation and engagement, or their responses to the questionnaires, may have been influenced by awareness of participation in an innovative teaching strategy.
Sixth, the intervention integrated at least six elements such as recorded materials, online discussions, assignments, quizzes, group activities, presentations, role-play, problem-solving, and feedback. Thus, it was not possible to separate the different components or combinations of components responsible for the improvements that were observed in the study.
Finally, satisfaction was assessed only among students in the intervention group and only after the intervention. Since there is no parallel satisfaction evaluation conducted in the control group, it is difficult to draw conclusions on whether there was a more positive perception of the Massive Open Online Course flipped classroom than the conventional classroom.
6. Conclusion and recommendations
The results suggest that the application of the Massive Open Online Course-based flipped classroom increases the digital competence and self-organized learning for nursing students more than the traditional classroom-based teaching model. This strategy can help achieve these outcomes by having students access digital content outside of class, organize their learning, interact with others via digital technologies, and put knowledge into practice in the classroom.
The results should not be considered as conclusive evidence of the effectiveness of the intervention as the sole cause of the improvements, due to the non-randomized design. However, the outcomes justify the educational promise of using structured digital preparation combined with active, in-person learning in nursing preparation.
If a nursing faculty is considering implementing this method, it is important for the faculty to make sure student digital devices are easily accessible and a reliable network is available, as well as to orient students to the learning platform, set clear expectations for pre-class preparation, and not overload students with too much work. Teachers should also be trained to create succinct digital resources, engage students online, plan active classroom exercises, and give prompt feedback.
Randomized or cluster-randomized controlled designs should be used in future studies, if possible. To enhance the generalizability of findings across educational and institutional contexts, multicenter studies are recommended. Further research is required to assess whether improvements in digital competence and self-organized learning are maintained over time. Objective indicators of digital performance, academic outcomes, digital platform engagement, and behavioral indicators of self-organized learning should also be included in future studies.
Comparing the different parts of the intervention could help identify which of these contributes the most strongly to the effects seen and identify which parts of the intervention would benefit as a standalone support tool for students. Qualitative studies can also offer a more in-depth understanding of the students' experiences, barriers, workload, and readiness for Massive Open Online Course-based flipped learning.
7. Implications for nursing education
The findings are relevant to nursing education as we move into a digital era; independent learning, critical appraisal, communication, and adaptability are integral parts of nursing practice. Using a Massive Open Online Course-based flipped classroom in the education system may give students chances to develop these skills in the classroom prior to their practice in the workplace.
This approach moves content from the start of the classroom period and allows teachers to spend more time in class discussing cases, doing clinical reasoning exercises, problem-solving, discussing content with peers, role-playing, and giving feedback. These activities could aid in a more in-depth understanding of the course material and help to foster greater student responsibility in learning. The strategy could also help to link together digital competence with useful nursing and health education activities instead of learning technology as a standalone skill.
But this isn't enough for successful implementation. Pedagogical and technical training of nurse educators is required to create coherence between pre-class materials and class activities. Digital content should be: Concise, Accessible, Learning Outcome-oriented, and supported by clear guidance. Use of pre-class content in classroom activities should be expected to promote accountability and ensure that the use of pre-class content has a clear educational purpose.
Students' access to digital tools, technological experience, and ability to learn on their own should also be considered. Ensuring the strategy is not a disadvantage for low-resource students or those with less digital confidence may require technical support, platform orientation, accessible learning materials, and alternative access arrangements.
The flipping classroom should therefore not be considered as a simple technological tool for an already existing course, but as a pedagogical scheme. With adequate support, it can support nursing graduates in becoming better learners and more collaboration-oriented and proficient at applying digital resources in academic and professional settings.
Ethics declaration
Informed consent and patient details
Written informed consent to take part in the study and to publish the article has been obtained from all participants or their legal representatives. The privacy rights of participants have been observed.
Studies in human
This study was performed in compliance with relevant laws, regulatory frameworks and guidelines where the research took place.
Ethics approval and consent to participate
All methods employed in this study strictly adhered to the applicable rules and regulations set forth in the Declaration of Helsinki (DoH-Oct2008). Formal approval and permission to conduct the research were diligently obtained from the Research Ethics Committee of the Faculty of Nursing at Alexandria University, Egypt, under the reference code: IRB00013620-AU-20-9-316. Furthermore, prior to their participation in the study, written informed consent was obtained from nursing faculty staff who willingly agreed to take part in the research.
Consent for publication
Not applicable.
Funding
No funding
CRediT authorship contribution statement
Zeinab Bassiouny Seifelnasr Sallam: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Ayman Mohamed El-Ashry: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Amal Diab Ghanem Atalla: Writing – review & editing, Writing – original draft, Supervision, Software, Resources, Methodology, Funding acquisition, Data curation, Conceptualization. Hajer I. Motakef: Writing – review & editing, Writing – original draft, Validation, Funding acquisition, Data curation, Conceptualization. Bushra Alshammari: Writing – review & editing, Resources, Funding acquisition, Data curation, Conceptualization. Awatif Alrasheeday: Writing – original draft, Funding acquisition, Data curation, Conceptualization. Farhan Alshammari: Writing – review & editing, Funding acquisition, Formal analysis, Conceptualization. Yasmeen Mohamed Mohamed Shehata: Writing – review & editing, Writing – original draft, Visualization, Supervision, Resources, Project administration, Methodology, Investigation, Data curation, Conceptualization.
Declaration of competing interest
The authors declare that there are no conflicts of interest.
Acknowledgment
Our sincere thanks go to all participants in the study.
Footnotes
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ijnsa.2026.100647.
Contributor Information
Zeinab Bassiouny Seifelnasr Sallam, Email: zeinab-bassiouny@alexu.edu.eg.
Ayman Mohamed El-Ashry, Email: ayman.el-ashry@alexu.edu.eg.
Amal Diab Ghanem Atalla, Email: aml.diab@alexu.edu.eg.
Hajer I. Motakef, Email: Ha.matekef@uoh.edu.sa.
Bushra Alshammari, Email: bu.alshammari@uoh.edu.sa.
Awatif Alrasheeday, Email: a.alrasheeday@uoh.edu.sa.
Farhan Alshammari, Email: frh.alshammari@uoh.edu.sa.
Yasmeen Mohamed Mohamed Shehata, Email: yasmeen.shehata@alexu.edu.eg.
Appendix. Supplementary materials
Data Availability Statement
The de-identified data supporting the findings of this study are available from the corresponding author upon reasonable request, subject to approval by the relevant institutional authority and applicable ethical and confidentiality requirements.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The de-identified data supporting the findings of this study are available from the corresponding author upon reasonable request, subject to approval by the relevant institutional authority and applicable ethical and confidentiality requirements.