The effect of competency-based educational application on the knowledge and skill of working with a ventilator in nursing students: A randomized controlled trial

Abstract

BACKGROUND:

Mechanical ventilation is crucial for reducing mortality, hospital stay duration, and treatment costs in intensive care units. However, nursing students often receive insufficient training in ventilator management. This study aimed to evaluate the effect of a competency-based educational application on nursing students’ knowledge and practical skills in ventilator operation.

MATERIALS AND METHODS:

This randomized controlled trial was conducted in 2023 on 72 fourth-semester undergraduate nursing students in Yazd, Iran. Participants were selected through purposive sampling and randomly assigned into intervention (n = 36, app-based training) and control (n = 36, lecture-based training) groups. The intervention group used a competency-based Android application over 30 days, progressing through structured modules and a final exam. The primary outcomes were knowledge and practical skills related to ventilator use, assessed using a validated 20-item multiple-choice questionnaire and an OSCE checklist. Secondary outcomes included ventilator setup time and students’ satisfaction with the app. Data analysis was performed using SPSS v22, employing independent and paired t-tests, and Chi-square tests at a significance level of P < 0.05.

RESULTS:

Post-test knowledge scores (App: 13.91 ± 2.62; Lecture: 12.77 ± 2.71; P = 0.001), OSCE scores (App: 16.13 ± 1.85; Lecture: 14.54 ± 1.94; P = 0.001), and ventilator setup time (App: 189.43 ± 26.90 s; Lecture: 208.57 ± 30.04 s; P = 0.001) all significantly favored the app group. The mean satisfaction score with the application was 7.10 ± 1.20 out of 9.

CONCLUSION:

The competency-based educational application significantly enhanced nursing students’ knowledge and skills in ventilator use compared to traditional methods. This approach offers a practical and effective training strategy for improving ventilator competency in nursing education.

Introduction

Mechanical ventilation is a widely used, life-saving intervention for patients with acute respiratory failure, commonly administered in intensive care units (ICUs).[1] Mechanical ventilation is a technique that supports or replaces spontaneous breathing using a machine. Invasive ventilation involves inserting an endotracheal tube to deliver air directly into the trachea, ensuring adequate oxygenation in critically ill patients or those with respiratory failure.[2] Mechanical ventilation is indicated when patients are unable to maintain a patent airway, achieve adequate ventilation, or sustain sufficient oxygenation on their own. This can result from airway obstruction (e.g., trauma and swelling), impaired respiratory drive or muscle weakness leading to inadequate breathing, lung conditions causing poor oxygen exchange, or situations where the body’s oxygen demands exceed respiratory capacity, such as severe infection or metabolic disturbances. Proper identification of these conditions is essential to initiate timely and effective mechanical support.[3] Invasive mechanical ventilation is widely utilized in critically ill patients who require support for respiratory function or airway protection. It ensures adequate gas exchange while other therapeutic measures are implemented to stabilize the patient’s condition.[4] Although mechanical ventilation is a life-saving intervention, it may lead to several complications, including alveolar damage, airway injury, pneumothorax, oxygen toxicity, and reduced cardiac output.[2]

Critical care nurses are required to demonstrate advanced clinical knowledge and emotional resilience in managing high-pressure, life-threatening situations. One of their core competencies involves delivering effective care to patients on mechanical ventilation, which demands both technical expertise and sound clinical judgment.[5] Effective management of mechanically ventilated patients and reduction of healthcare costs require nurses to possess adequate knowledge and skills. A comprehensive educational strategy involving students, educators, and practitioners is vital to developing this competence. Proper training in ventilator care across the healthcare team significantly improves patient outcomes.[6]

A 2018 study reported that senior nursing students often lack adequate ventilator skills, and even ICU nurses may struggle to interpret ventilator data. This competency gap can jeopardize patient safety, as delays in identifying or correcting improper ventilation settings may result in life-threatening consequences.[7] Nurses frequently act as frontline providers in managing both patient care and ventilator support, necessitating a thorough understanding of ventilator modes, settings, and alarms. Their prompt recognition and response to ventilation issues are crucial for preventing complications such as respiratory distress and minimizing patients’ work of breathing, thereby ensuring timely and effective care.[8] Nurses responsible for ventilated patients must demonstrate clinical competence to ensure high-quality care. Implementing structured educational programs that directly address the challenges of ventilator management can substantially improve the safety and quality of nursing practice.[5]

Printed materials such as books and pamphlets are still used in ventilator training,[7] but they are often bulky and quickly become outdated. To deliver optimal care, nursing students need access to current clinical guidelines, which static references may not provide.[9] Although hospitals have prioritized short-term retraining programs, face-to-face instruction is often hindered by nurse workload, rotating shifts, and limited material accessibility. Traditional educational approaches frequently fail to meet evolving learning needs. In contrast, asynchronous learning—which allows flexible, self-directed engagement—has gained popularity. Given these gaps, incorporating mobile learning tools into ventilator education may offer a practical solution. Research shows that diverse strategies, including asynchronous and technology-based methods, can effectively enhance ventilator training for nurses.[7]

Mobile technology has emerged as an innovative tool for assessment, offering new opportunities for nursing educators to improve evaluation processes.[10] Moreover, the use of mobile applications represents a growing instructional model in contemporary nursing education.[11] Mobile learning provides flexibility, accessibility, and greater engagement for nursing students. Mobile educational applications allow learners to progress at their own pace, support self-directed learning, and promote self-efficacy and clinical competence. Evidence shows that m-learning tools enhance knowledge retention, reduce learning-related anxiety, and improve satisfaction and confidence in clinical performance.[12]

A study in Korea found that using an interactive mobile application for nursing skills training significantly enhanced students’ knowledge, self-efficacy, and clinical performance. These results underscore the effectiveness of learner-centered mobile technologies in practical nursing education and highlight the need for developing comprehensive apps to strengthen clinical competence across various domains of nursing practice.[13]

Similarly, a 2021 study by Radmard et al.[7] assessed the impact of a smartphone-based ventilator training application (VT App) on ICU nurses, reporting significant improvements in both knowledge and practical skills. These findings further confirm the value of mobile-based training interventions in strengthening clinical competence in critical care environments.

Furthermore, a four-phase intervention conducted in Iran demonstrated that employing a mobile application to evaluate clinical performance in critical care nursing increased student satisfaction, strengthened stakeholder collaboration, and offered a more effective alternative to traditional paper-based logbooks.[10]

Recent research emphasizes the advantages of smartphone-based applications in nursing education, particularly for training related to mechanical ventilation. Although several apps are currently available, many suffer from being outdated and lacking comprehensive content, thus failing to fully address the educational requirements of nurses. Moreover, there is a scarcity of studies focusing on the effectiveness of app-based training programs for mechanical ventilation, highlighting the necessity to develop and rigorously evaluate more advanced and impactful mobile learning tools in this field.[7] Therefore, this study was designed to assess the impact of a competency-based educational application on enhancing nursing students’ knowledge and practical skills in ventilator management. Based on the objectives of the study and relevant literature, a conceptual framework was developed to illustrate the anticipated mechanism of action of the competency-based educational application [Figure 1].

Figure 1.

Conceptual framework of the competency-based educational application intervention

The framework illustrates how the mobile learning application, based on competency-based education principles, enhances nursing students’ knowledge, skill performance, task efficiency, and satisfaction through mechanisms such as self-efficacy and learner engagement. This structure is grounded in Bandura’s self-efficacy theory and emphasizes the role of structured content, self-paced progression, and feedback in facilitating learning outcomes.

Materials and Methods

Study design and setting

This randomized controlled trial (RCT) (IRCT registration code: IRCT20230819059187N1) was conducted in 2023 among 72 fourth-semester undergraduate nursing students in Yazd, Iran. After receiving approval from the educational vice-chancellor and obtaining the student list, participants were selected using purposive sampling and randomly allocated to intervention and control groups through a lottery method.

To prevent information contamination, students had already been divided by the faculty into two separate classes based on residence: native students (intervention group, receiving application-based training) and non-native students (control group, receiving lecture-based training), with minimal interaction due to housing arrangements. Each class initially included 45 students. Based on the inclusion and exclusion criteria, 36 eligible and willing students were selected from each class.

The sample size was calculated using data from Keegan et al.,[14] assuming a 95% confidence level (Z = 1.96), 90% power (Z = 1.31), and a 10% anticipated dropout rate, resulting in 36 students per group (72 in total).

Study participants and sampling

Initially, 90 fourth-semester undergraduate nursing students were available, divided into two classes of 45 students each. After applying the inclusion and exclusion criteria, 36 eligible students were selected from each class, resulting in a total of 72 participants. Among them, 36 students from each class voluntarily consented to participate in the study after completing informed consent forms.

The sample size was calculated based on a study by Keegan et al.,[14] which used a screen-based simulation to teach mechanical ventilation. Assuming a 95% confidence level (Z = 1.96) and 90% power (Z = 1.31), the minimum required sample size was 32 per group. Considering a 10% expected dropout rate, the final sample size was increased to 36 participants per group.

Inclusion criteria included being a second-year, fourth-semester Bachelor of Nursing student; willingness to participate; availability to attend all stages of the intervention; participation in the practical ventilator training session; and possession of an Android smartphone. Exclusion criteria included prior participation in similar educational programs, prior experience with ventilator use, or being on academic or medical leave.

Two students in the intervention group did not complete the application-based training and were excluded, resulting in a final sample of 70 participants for statistical analysis.

Ventilator-related knowledge was assessed before and after the intervention, while ventilator-related skills were evaluated post-intervention. This clinical trial adhered to the CONSORT guidelines for standardized reporting of the study’s design, implementation, and outcomes [Figure X].

Figure X.

CONSORT flow diagram of participant progression through the study

This CONSORT diagram illustrates the flow of participants through each stage of the RCT.

The study was conducted between September 23 and November 8, 2023, among fourth-semester Bachelor of Nursing students.

Data collection tools and technique

Data collection instruments included a demographic questionnaire, a ventilator knowledge assessment questionnaire, an OSCE-based skills evaluation, and a checklist to record the accuracy and timing of ventilator settings. The primary outcome of the study was the improvement of nursing students’ knowledge and practical skills in ventilator management, assessed using a validated knowledge questionnaire and a structured OSCE checklist. Secondary outcomes included the time required to set the ventilator and students’ satisfaction with the educational application.

Data were collected using self-reported questionnaires administered at designated intervals. Participants were instructed to complete the forms carefully and accurately. The study was implemented in sequential steps. Following random allocation via a lottery method, fourth-semester nursing students were assigned to the intervention group (Group 2) or the control group (Group 1). Subsequently, all participants completed a demographic questionnaire—including items on age, gender, and previous semester GPA—and the ventilator knowledge pre-test.

Knowledge assessment questionnaire

The knowledge assessment questionnaire was developed by the researchers and consisted of 20 multiple-choice questions covering selected topics on ventilator use, based on authoritative textbooks and credible sources. Each correct response was awarded one point, yielding a total score range of 0–20. The questions addressed ventilator modes, parameter locations, and adjustment procedures, and were designed according to standard multiple-choice construction principles, including Meilman’s design rules.

To ensure face and content validity, the questionnaire was reviewed by five nursing faculty members and five master’s-level nurses specialized in critical care. Their feedback was incorporated into the final version. For reliability assessment, the questionnaire was administered electronically to 44 eighth-semester nursing students in two rounds, 2 weeks apart. Cronbach’s alpha was calculated at 0.872, indicating good internal consistency.

Following the pre-test, students in the intervention group participated in a 1-hour session during which the educational application was installed on their Android smartphones and instructions on its use were provided. They had access to the app for 30 days. On day 30, the training period concluded. The researcher accessed the application’s user panel to verify which students had completed all educational steps and passed the in-app final exam.

Meanwhile, the control group received conventional lecture-based training on the same content, delivered by an instructor using slides at the nursing faculty. Ten days after the lecture, the knowledge post-test was administered to both groups.

On day 40, students who had completed all training phases in both groups participated in a 2-hour practical session using a real ventilator (with no patient present). During this session, they were allowed to ask questions and practice under instructor supervision.

Seven days after the practical session, all students underwent an Objective Structured Clinical Examination (OSCE) to assess their ventilator-related practical skills. The OSCE checklist evaluated the accuracy and timing of ventilator settings. Higher scores and shorter setup times reflected greater clinical proficiency.

OSCE test

The OSCE test consisted of five stations designed to evaluate ventilator-related clinical skills.

• Station 1 involved turning on the ventilator and performing basic settings based on a hypothetical patient’s gender, height, and weight (5 items).

• Station 2 assessed ventilator settings in volume-controlled CMV mode (6 items).

• Station 3 evaluated SIMV mode (9 items).

• Station 4 focused on SPONT mode (5 items).

• Station 5 tested pressure support ventilation settings (5 items).

In total, the OSCE included 30 items.

A researcher-developed checklist was used to evaluate both performance and timing for each parameter. The content of the checklist was derived from commonly used ventilator modes in critical care units. All scenarios and their related items were reviewed and approved by 10 clinical and academic experts. Evaluators received standardized training on how to score each item by using the checklist. The time required to complete each scenario was measured using a stopwatch. Higher scores and shorter completion times reflected greater proficiency in ventilator use.

To establish face and content validity, the OSCE scenarios and checklist were reviewed by five nursing faculty members and five ICU nurses. Revisions were made based on their feedback. For reliability assessment, 10 eighth-semester nursing students were asked to complete the ventilator OSCE based on a defined scenario. Their performance was video-recorded. Each video was independently scored by the same evaluator at two different time points, 10 days apart. The intrarater reliability coefficient, calculated using the test-retest method, was 0.930, indicating excellent reliability.

Intervention description

The intervention consisted of a competency-based educational application specifically designed for Android devices. The app contained eight sequential training modules and a final exam, each incorporating written content, images, and instructional videos related to ventilator management. To proceed through the modules, learners were required to pass a five-question multiple-choice quiz with a minimum score of 60%. If unsuccessful, learners had to review the content and repeat the quiz after a 72-hour interval.

The application also featured a simulated ventilator interface modeled after the Hamilton C2 system. The minimum time required to complete the full course was 21 days. Upon passing the final exam, students gained access to the simulator and received a certificate after submitting their completion data. All educational content was reviewed and approved by critical care experts. To ensure academic integrity, user access was individually restricted to prevent information sharing.

Competency-based educational application features

To develop the educational software, web programmers and graphic designers collaborated in designing the interface and icons. The application was developed for Android smartphones and structured into eight sequential educational stages focused on ventilator training, followed by a final test stage. Each stage included written content and instructional videos, presented in short segments to enhance student engagement and closely simulate real ventilator settings.

The application required learners to pass a five-question multiple-choice test at the end of each stage, achieving at least 60% accuracy to proceed. If they did not meet the required score, the related content remained accessible, and they were instructed to review the material and retake the test after 72 hours. If a learner failed to pass the same stage every 72 hours over a 14-day period, they were returned to the previous level (except for the first stage). This structure was designed to promote deeper learning and focused study through repetition and progression limits. After completing all training stages, students took the final exam. Upon passing, they advanced to a simulator section within the application.

The simulator, developed by the app team, was modeled after the Hamilton C2 ventilator to closely resemble real device functions. In this final section, students entered their email address, which was sent to the researcher to receive a certificate issued by the nursing school. To ensure ethical considerations, access to the competency-based application was also granted to students in the lecture-based group.

The software was created in collaboration with two IT specialists and was developed on the Android platform by using the B4A programming language, later converted to Java. A MySQL database was used for data management, while the user panel was developed using PHP and Materialize CSS. The application supported online access to educational videos and included a user panel where participants could submit their information to the research team.

The application consisted of eight stages (excluding the first stage), and students had to wait at least 72 hours before progressing to the next stage. Therefore, the minimum time to complete the course was 21 days. The app provided educational content in the form of video, text, and images, with fast access to materials. It also included features such as exam schedules, course timelines, integration with the device’s internal calendar, and real-time notifications on course completion or failure. If a student failed a stage, the app prompted them to review the material and retake the test after 72 hours. Successful completion was clearly indicated within the app.

To prevent sharing of content between groups, access was restricted to approved students. Each user was required to register with their full name, contact number, and password. Users were instructed not to share personal or educational content with others. All educational videos were created and edited by the research team, and the distribution of materials outside the app was strictly prohibited.

To ensure that the educational content was appropriate for undergraduate nursing students, feedback was obtained from eight experts, including three clinical supervisors, three nursing graduates with ICU experience, and two faculty members. Educational content covered the following categories:

1. Principles and types of mechanical ventilation

2. Ventilator parameters and settings

3. Ventilator modes

4. Ventilator alarms

5. Adjusting ventilator settings for various diseases

6. Ventilator calibration

Reference books on intensive care and medical-surgical nursing were used in content development. The compiled material was reviewed by the experts to ensure alignment with the Hamilton C2 ventilator model, and necessary revisions were made. Finalized content was added to the app in the form of written materials and instructional videos recorded from the simulator environment, providing accessible and practical training.

A user guide was included so that any approved user could navigate the application and access its educational resources. The application supported Android version 5 and above. It is important to note that the educational content, instructors, practical training materials, and assessment tools were identical for both the app-based and lecture-based groups; the only difference was the method of instruction.

QUIS-questionnaire of user interface satisfaction

At the end of the study, student satisfaction with the competency-based educational application for ventilator training was assessed as a secondary outcome. A standardized questionnaire designed to evaluate usability and user satisfaction was used for this purpose. Based on the questionnaire, students’ satisfaction was evaluated in five specific areas: user satisfaction from the screen, technology and system information, learning, system capabilities, and general impressions of the software. Each section contained questions scored on a scale from 1 to 9. A score of 1–2 was categorized as poor, 3–5 as average, 6–8 as good, and 9 as excellent. This instrument has been previously used in related research studies. The validity of the questionnaire has been confirmed, and its reliability has been reported with a Cronbach’s alpha coefficient of 0.76.[15]

Ethical consideration

Participants were fully informed about the study’s purpose, objectives, and their right to voluntarily participate or withdraw at any time. Written informed consent was obtained from all participants, and data confidentiality was maintained throughout the study. The research was conducted in accordance with the Declaration of Helsinki and approved by the Committee of Ethics in Human Research at Shahid Sadoughi University of Medical Sciences (Ethical Code: IR.SSU.REC.1401.091). In addition, the study was registered in the Iranian Registry of Clinical Trials (IRCT) under the registration number IRCT20230819059187N1, with full details available at www.irct.ir.

Data analysis

The Kolmogorov-Smirnov test was first used to assess the normality of data distribution. Statistical analyses were then conducted using SPSS version 22. Descriptive statistics, including mean and standard deviation, were applied, along with inferential tests such as the independent t-test, paired t-test, and Chi-square test. A P value of less than 0.05 was considered statistically significant.

Results

A total of 70 eligible students participated in the study. Among them, 27 participants (38.57%) were male and 43 (61.43%) were female. The mean age of the students was 20.29 ± 1.28 years (range: 19–28 years), and the mean GPA across both groups was 16.37 ± 1.03.

Independent t-test analysis showed no statistically significant differences between the two groups in terms of age (t = 0.391, P = 0.697) and GPA (t = 0.442, P = 0.660). Additionally, the Chi-square test indicated no significant difference between groups regarding gender distribution (χ² = 0.31, P = 0.575).

Paired t-tests revealed a significant improvement in knowledge scores within each group after the intervention (Lecture group: from 11.44 ± 3.45 to 12.77 ± 2.71, P = 0.001; App group: from 11.33 ± 3.31 to 13.91 ± 2.62, P = 0.001).

Before the intervention, there was no significant difference in knowledge scores between groups (t = 0.34, P = 0.731); however, post-intervention scores were significantly higher in the application group (mean difference = 1.14, 95% CI: −0.11 to 2.39, t = 3.354, P = 0.001, Cohen’s d = 0.43).

In terms of practical skills, the mean OSCE score in the application group was 16.13 ± 1.85, which was significantly higher than the lecture group’s score of 14.54 ± 1.94 (mean difference = 1.59, 95% CI: 0.70–2.48, t = 3.502, P = 0.001, Cohen’s d = 0.84).

The average time required to set up the ventilator was significantly lower in the app group (189.43 ± 26.90 seconds) compared to the lecture group (208.57 ± 30.04 seconds), with a mean difference of −19.14 seconds (95% CI: −32.48 to −5.80, t = −2.841, P = 0.001, Cohen’s d = −0.67). The comparison of outcomes between the intervention and control groups is presented in Table 1.

Table 1.

Comparison of outcomes between the intervention and control groups

Variable		App group (mean±SD)		Lecture group (mean±SD)		t-value		P-value		95% CI		Effect size (Cohen’s d)
Knowledge (post-test)		13.91±2.62		12.77±2.71		3.354		0.001		0.47–1.81		0.43
OSCE score		16.13±1.85		14.54±1.94		3.502		0.001		0.70–2.48		0.84
Ventilator setup time (sec)		189.43±26.90		208.57±30.04		−2.841		0.001		−32.48 to−5.80		0.67

Notes: Data are presented as mean±standard deviation. Independent t-test was used to compare groups. P-values, t-values, 95% confidence intervals (21), and Cohen’s d effect sizes are reported. A P-value<0.05 was considered statistically significant

Finally, the average satisfaction score with the educational application was 7.10 ± 1.12 out of 10, indicating a high level of student satisfaction. Students’ satisfaction with the competency-based educational application are shown in Table 2.

Table 2.

Students’ satisfaction dimensions with the competency-based educational application

Satisfaction dimension		Mean±SD
Screen features		7.07±1.87
Technology and system info		7.19±1.72
Learning		7.16±1.83
System capabilities		7.20±1.89
General impressions		6.92±2.15
Total satisfaction		7.10±1.89

Discussion

The results of this study showed that the competency-based educational application significantly enhanced nursing students’ knowledge and practical skills, which were defined as primary outcomes in ventilator management (knowledge P = 0.001; OSCE P = 0.001) compared to traditional lecture-based methods. These findings directly support the study’s primary aim, which was to evaluate whether a competency-based educational application enhances nursing students’ knowledge and practical skills in ventilator management compared to traditional lecture-based methods. The findings support the conceptual framework [Figure 1], suggesting that competency-based mobile learning enhances students’ theoretical and practical competencies through structured content delivery and self-paced progression. This approach not only improved theoretical understanding and clinical performance but also led to a high level of student satisfaction, indicating its effectiveness as an engaging and learner-centered educational strategy. These results confirm the primary hypothesis of the study, indicating that the competency-based mobile application significantly improved both knowledge and practical skills in ventilator management among nursing students.

The competence of critical care nurses in managing mechanically ventilated patients is crucial. Ongoing development of their knowledge, skills, and clinical judgment in ventilator care is essential to ensure optimal patient outcomes.[16] An Iranian study reported that senior nursing students showed significant deficiencies in ventilator-related skills and expressed low confidence in managing ventilators, underscoring the urgent need to address this educational gap.[17] Deficiencies in ventilator management are not unique to Iran and have been reported among ICU nurses globally, indicating a widespread competency gap that calls for targeted educational interventions.[7] An Australian study found that around 63% of ICU nurses had no prior training in ventilator use, with many lacking familiarity with invasive ventilation, highlighting a global gap in ventilation-related competencies, especially among early-career nurses.[18,19] A recent study by Ramírez et al.[20] demonstrated that specific training significantly improved healthcare professionals’ ability to detect and manage patient–ventilator asynchrony, highlighting the critical role of structured education in enhancing ventilator management competencies and improving clinical outcomes. The significant improvement in post-test knowledge scores in the intervention group (mean: 13.91 ± 2.62 vs. 12.77 ± 2.71; P = 0.001) suggests that the app’s structured modules and repeated quizzes effectively facilitated theoretical learning. This aligns with the principles of competency-based education and supports its use in critical care topics. This confirms the hypothesis that mobile-based, self-paced modules can improve theoretical understanding. The finding also aligns with Bandura’s self-efficacy theory, in which structured content and repeated assessment promote deeper cognitive learning. A study indicated that nursing students readily adopt smartphones for clinical training, highlighting their potential as effective educational tools in practice settings.[17] Smartphones are widely used by nursing students in clinical settings due to their portability, accessibility, and multifunctionality. By facilitating instant feedback, real-time information access, and efficient data sharing, they have become valuable tools for enhancing clinical learning and performance.[21] Smartphones have become integral to the daily lives of nursing students, serving not only as tools for communication but also as valuable resources for academic learning and clinical education. With widespread ownership among undergraduate students, smartphones are increasingly utilized for accessing information and supporting research activities, reflecting a broader trend of digital reliance among younger generations.[22] Smartphones offer valuable advantages for nursing students in clinical settings by enabling quick access to drug dosage calculators, clinical guidelines, and health-related information, thereby enhancing decision-making and the quality of patient care. They also facilitate communication with healthcare professionals, fostering knowledge exchange and experiential learning—key elements of clinical education. This engagement helps improve students’ self-efficacy, clinical competence, and efficiency, while also reducing anxiety during practice. Nevertheless, concerns persist regarding the reliability and quality of some smartphone-based resources.[21] Although numerous healthcare apps are available worldwide, specialized nursing applications—especially in Persian—are still limited in Iran. Most focus on basic tasks such as drug dosage, with few addressing advanced clinical needs such as ventilator management. This underscores the need for localized, critical care-focused educational tools for nurses.[7] The findings of this study showed a significant improvement in nurses’ knowledge and skills following the intervention. Similar positive outcomes have been reported in other studies on the use of mobile phones in nursing education.

A 2021 study conducted in Iran, titled “The Effect of the Smartphone Ventilator Training Application on the Knowledge and Skills of Nurses in Intensive Care Units,” reported that smartphone-based training significantly enhanced ICU nurses’ knowledge and skills in ventilator management. These findings are in line with the present study, reinforcing the effectiveness of mobile educational tools in improving clinical competence.[7]

A scoping review by Gagnon et al.[23] showed that self-supporting mobile applications for wound care enhanced clinical decision-making, facilitated care delivery, and improved access to evidence-based information for nurses. These findings align with our study, supporting the positive impact of technology-based education on improving nurses’ clinical competencies.

Similarly, a RCT in China demonstrated that a game-based mobile application significantly enhanced nursing students’ practical skills in flushing and locking venous catheters, supporting the effectiveness of mobile learning tools alongside conventional training methods.[24]

In line with previous findings, a 2021 study in Iran demonstrated that a smartphone-based educational application significantly enhanced ICU nurses’ understanding of arterial blood gas interpretation, highlighting the effectiveness of mobile learning for teaching complex and specialized nursing topics.[25]

A quasi-experimental study at Damanhour University showed that a mobile-based learning program significantly improved postgraduate nursing students’ satisfaction and attitudes toward learning, supporting the effectiveness of mobile education in nursing—similar to the results of our study.[26]

In contrast to the present findings, a study by Kim et al.[27] on a mobile application for teaching infant airway obstruction care found no statistically significant difference in knowledge gains between intervention and control groups. This discrepancy may stem from differences in educational design; while the current study employed a competency-based approach with unrestricted content access, Kim et al.’s[27] intervention was more general, potentially limiting its impact.

Although Kim et al.[27] found significantly higher self-confidence and skill scores in the intervention group, the difference in satisfaction was not statistically significant. This may be due to the repetitive nature of the tasks and potential anxiety associated with simulation use. In contrast, the interactive and learner-centered design of the application in the present study likely contributed to higher satisfaction levels.

A study examining the impact of an educational application during nursing internship clinical training found improvements in students’ cognitive and functional skills, as well as satisfaction. However, the differences were not statistically significant compared to traditional methods.[28] The authors suggested that factors such as limited interactivity and the brief duration of the intervention might have contributed to these modest effects. In contrast, our study employed a competency-based, interactive application with unrestricted access, which likely enhanced engagement and mastery, resulting in significant improvements in knowledge and skills.

A RCT investigating mobile-based video learning for clinical nursing skills found improvements in students’ cognitive knowledge but no significant enhancement in practical skills or satisfaction.[29] The difference from our study may stem from the passive nature of video content compared to our interactive, competency-based application, which likely fostered deeper engagement and skill mastery, leading to greater practical improvement and satisfaction.

A study published in Healthcare evaluated a tablet-based mobile learning program for nursing education and found significant improvements in clinical competency and problem-solving. However, it reported no significant difference in learning satisfaction or self-directed learning between groups.[30] This contrast with our findings may stem from differences in instructional design; our competency-based app emphasized interactive, learner-centered content, which likely contributed to higher satisfaction and engagement.

These findings, along with evidence from similar studies, underscore the potential of mobile-based educational tools in nursing education—particularly when grounded in structured, competency-based frameworks. However, the effectiveness of such interventions varies depending on factors such as content design, interactivity, and integration into the curriculum. Some studies have reported limited improvements, often due to less targeted or less engaging instructional approaches.

In the present study, the competency-based educational application significantly improved nursing students’ knowledge, skill, and performance in ventilator management. The observed improvement in OSCE scores further validates the hypothesis that interactive mobile tools can enhance clinical competence. The app allowed students to review ventilator procedures at their own pace, which likely contributed to better procedural recall and performance, while also achieving good levels of user satisfaction. These results support the use of such digital tools as effective supplements to traditional instruction, especially in complex clinical areas such as mechanical ventilation. The high satisfaction levels reported by students support the usability, engagement, and acceptability of the application, reinforcing its potential for broader integration into nursing education. It also highlights the intervention’s potential scalability and alignment with modern educational policy goals, such as learner-centered design and technology integration into formal curricula. Additionally, the significant reduction in ventilator setup time observed in the intervention group, which was one of the secondary outcomes (189.43 ± 26.90 vs. 208.57 ± 30.04 seconds; P = 0.001), suggests improved task efficiency, which is critical in high-pressure clinical environments. This outcome was one of the study’s secondary hypotheses and reflects the real-world applicability of competency-based mobile tools in preparing students for critical care procedures.

Nonetheless, this study has limitations, including its single-center design and the potential for information exchange between groups. Future multicenter trials with more diverse populations are recommended to strengthen generalizability and minimize bias.

In conclusion, the use of a competency-based mobile application provided clear educational benefits, including enhanced theoretical understanding, clinical skills, and timely performance. These outcomes suggest that integrating such applications into nursing curricula may be a valuable strategy to address existing gaps in critical care education and improve the preparedness of future nurses.

Conclusion

This study showed that a competency-based educational application effectively improved nursing students’ knowledge and skills in ventilator management (primary outcomes) and also reduced ventilator setup time and improved satisfaction (secondary outcomes) (knowledge: P = 0.001; OSCE: P = 0.001; setup time: P = 0.001). Integrating such tools into nursing education aligns with health policy priorities that emphasize competency-based training, digital learning integration, and the development of practice-ready healthcare professionals. This approach supports scalable, standardized, and cost-effective methods for clinical education, particularly in resource-limited settings. Policymakers and academic institutions should consider incorporating such digital tools into national nursing curricula to enhance critical care preparedness and optimize patient outcomes. Further multicenter studies are recommended to confirm the long-term policy-level impact of this intervention.

Declaration of authors’ contributions and approvals

All authors have read and approved the final version of the manuscript and agree with its submission to the Journal of Education and Health Promotion. The study has received all necessary approvals from the affiliated institution and the funding body. The corresponding author accepts full responsibility for communicating with the journal on behalf of all co-authors and will ensure that all authors are informed of any updates, revisions, or changes made during the review and proofreading process.

We also authorize the Editor and the publisher to make necessary editorial modifications, including minor corrections and formatting adjustments, to the accepted manuscript. Furthermore, we confirm that the manuscript includes clear information regarding the source of funding, potential conflicts of interest for all authors, adherence to ethical standards, informed consent procedures, and ethical approval (IRB).

Clinical trial registration number and link to registration site (name of the registry and its URL)

Iranian Registry of Clinical number (IRCT20230819059187N1)/www.irct.ir.

Institutional review board/ethical approval information

IR.SSU.REC.1401.091.

Author’s contributions

All authors meet the criteria for authorship based on the recommendations of the International Committee of Medical Journal Editors (ICMJE). The contributions of each author are as follows: HG: Conceptualization, data collection, statistical analysis, manuscript drafting, and correspondence. MJ: Supervision, methodology, and critical revision of the manuscript. KN: Project administration, validation of findings, and final approval of the manuscript. All authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.

Conflict of interest

No conflict of interest has been declared by the authors.

Funding Statement

This study was supported by a grant from Shahid Sadoughi University of Medical Sciences and health services, Yazd, Iran. The grant supported data collection process. The funders had no role in the design of the study and collection, and analysis, interpretation of data. The authors send the report of the study’s findings to funder at the end of the study.