INTRODUCTION
Nursing education incorporates both theoretical and practical components designed to foster students’ professional skills across cognitive, affective, and psychomotor domains. The curricula developed within this context seek to equip students with the necessary knowledge, skills, and attitudes required to navigate clinical challenges effectively and provide optimal patient care [1].
In contemporary clinical settings, there is a growing need for experienced care providers with sufficient knowledge and skills [2]. Nevertheless, current studies reveal that nursing graduates often exhibit gaps in their professional knowledge and practical abilities [3-5]. A study conducted by Sancar et al. [6] indicated that more than half of nursing students perceived their theoretical education as insufficient for effective patient communication and felt unable to apply theoretical knowledge directly in clinical practice. Similarly, research by Sönmez et al. [7] reported that 62.6% of students regarded the theoretical and skill training provided as inadequate. Existing literature underscores a misalignment between theoretical instruction and practical experiences in nursing education, suggesting a need for curriculum revisions to better prepare students for clinical practice challenges [8, 9].
The video modeling method, rooted in Bandura’s Social Learning Theory and adapted from Applied Behavior Analysis, seeks to enhance learning through observation. Video self-modeling is utilized to acquire new skills, increase proficiency in previously learned skills, and reduce problematic behaviors [10]. This method involves presenting individuals with video recordings of themselves correctly performing targeted behaviors or skills, thus enabling the acquisition of new competencies. Video presentations during skill instruction allow students to mentally visualize and better comprehend the skills being taught [11].
Urethral urinary catheters are commonly utilized for measuring urine output, monitoring urine production during surgery, and managing urinary elimination issues, such as incontinence or urinary retention [12, 13]. Urinary catheterization procedures carry significant patient safety risks. Nursing students frequently lack opportunities to perform these procedures in clinical settings due to the high infection risk and increased privacy sensitivities compared to other procedures [14, 15]. Consequently, it is critical that students acquire urinary catheterization skills and current procedural knowledge prior to graduation [16, 17]. Advancements in technology now enable the integration of innovative methods with traditional educational approaches [18].
This study aimed to investigate the impact of a technology-supported, video-based self-assessment method on clinical skill development among nursing students. Emphasizing the significance of integrating digital tools and self-assessment techniques into nursing education, this study expands beyond traditional teaching methods, providing evidence-based contributions to the field. The following hypotheses were tested: H1: Nursing students taught using the video-based method will have higher mean scores on the urinary catheterization knowledge test compared to students in the control group. H2: Nursing students taught using the video-based method will have higher mean scores on the urinary catheterization skill assessment compared to students in the control group.
MATERIALS AND METHODS
Study Design
This study was a randomized, single-blind, parallel-group controlled trial. It was registered with ClinicalTrials.gov under number NCT06561737 on August 15, 2024.
Sample
The study was conducted at Ordu University, Faculty of Health Sciences, Department of Nursing. The population comprised 112 first-year nursing students actively enrolled in the Nursing Department. Eligibility criteria included being a first-year nursing student, using a smartphone, attending the nursing principles course for the first time, and volunteering to participate.
Exclusion criteria were having prior knowledge of urinary catheter insertion skills and requesting withdrawal from the study at any stage.
All students who met the inclusion criteria and consented to participate were enrolled without sample size calculation. Out of 100 eligible students invited, 87 initially agreed to participate. Of these, 43 were assigned to the experimental group, and 44 to the control group. Participants were randomly allocated to the 2 groups using a randomization list generated with Research Randomizer (www.randomizer.org). At the beginning of the study, participants completed pretests. Thirteen participants in the experimental group (8 did not attend the second session and 5 missed the posttest), and 13 participants in the control group (none attended the final session or completed the posttest), were subsequently excluded (Fig. 1).
Procedure
Initially, 87 participants were assigned to experimental and control groups using a computer-generated randomization table. The research protocol followed SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) guidelines [19], and reporting adhered to CONSORT (Consolidated Standards of Reporting Trials) guidelines [20] (Fig. 1). This study was single-blind, meaning that participants were unaware of their group allocation until the end of the trial. The theoretical knowledge regarding urinary excretion was provided to all participants by a lecturer from the research team. After this theoretical instruction, consenting students completed a knowledgeassessment pretest. In both groups, urinary catheterization skills were demonstrated using models in the skills laboratory, followed by each student individually performing the procedure. While students performed the procedure, independent assessments were conducted using the Urinary Catheterization Skill Checklist developed by the researchers, and interobserver agreement was subsequently examined.
Experimental group
While students in the experimental group performed urinary catheterization, the procedure was video-recorded on each student’s own smartphone by an individual who was not part of the research team. Students were instructed to review their recorded videos, self-assessing their performance according to the skill checklist. After 15 days, students performed the procedure again. Upon completion of all students’ second performances, posttests were administered.
Control group
Data from the control group were collected in a manner similar to the experimental group. Participants completed a pretest prior to the study commencement. After theoretical instruction, students performed urinary catheterization in the laboratory. Two weeks later, students returned and repeated the same procedure. Following the second performance, posttests were administered.
Data Collection Forms
Three instruments were used: a Personal Information Form, a Urinary System Information Test, and a Urinary Catheterization Insertion Skill Checklist.
Urinary System Information Test
This test, designed by the researchers according to the literature [24, 25], included 20 multiple-choice questions about urinary system anatomy (3 questions) and urinary system procedures (17 questions). Scores ranged from 0 (lowest) to 20 (highest). Expert feedback was obtained from 5 lecturers specializing in nursing principles, and revisions were made according to their recommendations.
Urinary Catheterization Insertion Skill Checklist
The checklist was developed based on the literature to assess students’ urinary catheterization skills [24-28]. Expert feedback was sought from 5 Nursing Fundamentals lecturers and 2 clinical nurses. The final checklist included 47 items. Each item was scored as follows: 2 points were given to the response of “correctly performed,” 1 point to the response of “incorrect sequence of steps” and 0 points to the response of “skill forgotten or performed incorrectly.” The checklist used to evaluate the skill performance of the students included 3 steps related to preapplication preparation, 29 steps related to the application phase and 15 steps related to catheter removal. Students could receive a minimum score of 0 and a maximum score of 94 points.
Data Analysis
Data were analyzed using IBM SPSS Statistics ver. 26.0 (IBM Co.). Normality was assessed using the Kolmogorov-Smirnov test. Descriptive analyses (mean, standard deviation, percentiles) characterized participant demographics. Mean scores for the Urinary System Information Test and the Urinary Catheterization Insertion Skill Checklist were compared using the Student t-test. Complications were evaluated via the chi-square test. The Fisher exact test and Pearson chi-square test were used to evaluate differences between follow-ups. The Cohen kappa test was conducted to assess interobserver agreement and variability within and between groups. Results were presented with 95% confidence intervals, and statistical significance was set at P<0.05.
RESULTS
The demographic characteristics of students participating in the study are presented in Table 1. Statistical analysis indicated no significant differences between the experimental and control groups regarding individual characteristics (P>0.05).
No statistically significant difference was found between the experimental and control groups in terms of pretest mean scores on the Urinary System Information Test (P=0.183). The mean pretest score was 11.20±2.48 for the experimental group and 11.41±1.72 for the control group (Table 2).
Similarly, no statistically significant difference emerged between the groups’ mean posttest scores on the Urinary System Information Test (P=0.454). The experimental group’s mean posttest score was 12.20±2.45, while the control group’s mean posttest score was 11.93±2.20 (Table 2).
Regarding the first application of urinary catheterization placement skills, the analysis showed no statistically significant difference between the experimental and control groups (P=0.152). However, a statistically significant difference (P<0.001) was observed between the groups’ mean scores during the final application (Table 3).
When comparing each group’s first and final application scores, a statistically significant improvement was observed within the experimental group (P<0.001). Conversely, no statistically significant difference was found in the control group’s mean scores between the initial and final applications (P=0.109) (Table 3).
DISCUSSION
In this study, we aimed to evaluate the effectiveness of the video-based self-assessment method in enhancing urinary catheterization skills among nursing students. The observed improvement in knowledge levels among students in the experimental group, who recorded and self-assessed their catheterization performances via video, indicates that the designed educational method was effective. Programs aligned with technological advancements may facilitate the integration of theoretical knowledge with clinical practice, thereby more effectively enhancing students’ professional skills. Clinical skill training is crucial for nursing students’ preparation prior to graduation, and various teaching methods are implemented to optimize this training process.
With advances in technology, smartphones have become widely accessible to nursing students. Since most students spend considerable time using smartphones, it has been suggested that these devices could be effectively used to teach fundamental nursing skills [29]. In this study, allowing students to use their own smartphones aimed to create an effective, engaging educational method without incurring additional costs.
Educational programs developed with technological alignment can help students bridge theoretical knowledge and clinical practice, improving their professional skillsets more effectively. The significant improvement in skill performance observed in the experimental group’s final practice supports the effectiveness of video-based training and self-assessment as a teaching method (P<0.001). These results suggest that video-based self-assessment may be valuable in clinical skill development.
Our findings align with previous research by Chuang et al. [30], who reported positive impacts of smartphone-viewed catheterization training videos on student performance and confidence. Similarly, Hernon et al. [31] demonstrated that structured self-assessment through video-recorded performance significantly improved students’ knowledge, attitudes, confidence, and performance in peripheral intravenous catheter insertion. Another study involving physiotherapy students highlighted the advantages of engaging in self-assessment during clinical training, particularly for students in the early stages of their academic education [32]. This finding aligns well with our sample of first-year nursing students.
The video-based self-assessment approach enabled students to evaluate their performance and receive immediate feedback. Actively participating in self-assessment plays a crucial role in bridging theoretical knowledge and practical application [33]. Integrating nursing students into their own learning processes via technology facilitated their awareness of learning needs and allowed them to set personal educational goals.
In this study, students identified their own mistakes and overlooked steps by reviewing their performances. While students may recognize their errors, they might not fully understand the reasons behind those errors or how to prevent them in future practices. Video-based self-assessment gave nursing students the opportunity to directly observe and correct their mistakes. The literature often addresses nursing students’ errors in clinical settings [34], yet little emphasis is placed on correcting errors learned during educational laboratory experiences. Our findings suggest that reviewing their own errors can help students effectively correct them. Previous research has demonstrated that self-assessment during cricothyrotomy training yields results equivalent to those obtained from expert evaluations [35]. Thus, video-based self-assessment may be particularly beneficial where expert instructors are unavailable or to encourage active student participation in their training.
This study highlights the importance of standardizing catheterization training in undergraduate education, incorporating varied scenarios, and maintaining consistent skill practice in clinical environments. Video-based self-assessment methods are easily integrable into nursing education curricula and may significantly enhance skill training.
This study has several limitations. Firstly, the attrition of students (13 from the experimental group and 13 from the control group) limited the overall sample size. Secondly, participant blinding was restricted to the students themselves. Additionally, video recordings were made using students’ personal smartphones, leading to technological variability such as differences in phone quality and video resolution. Consequently, findings from this study are generalizable only to the included participants and cannot be generalized to all nursing students.
In conclusion, this study demonstrated that video-based self-assessment significantly improved urinary catheterization skills among first-year nursing students compared to conventional training methods alone. While there was no significant difference between groups in theoretical knowledge acquisition, the experimental group showed substantial improvement in skill performance after self-reviewing their recorded performances.
These findings suggest that integrating self-assessment tools, such as video recordings, into nursing education enhances practical procedural skills and fosters students’ self-awareness and critical thinking. The study underscores the potential benefits of adopting innovative, technology-based approaches in clinical skill education to improve educational outcomes in healthcare professions.
Future research should evaluate the long-term impact of video-based self-assessment on skill retention and explore its applicability in various educational and clinical contexts.
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