The effect of web‐based education on the self‐confidence and anxiety levels of paediatric nursing interns in the clinical decision‐making process
Abstract
This study was conducted to investigate the effect of web‐based teaching on paediatric nursing internship students' self‐confidence and anxiety levels in the clinical decision‐making process. The study sample consisted of 61 students who received internship training in the Pediatric Nursing department. There were 30 students in the control group and 31 students in the experimental group. Data were collected using a sociodemographic form, and nursing anxiety and self‐confidence levels were measured using a clinical decision‐making scale. The data were analysed using a t test, a Mann‐Whitney U test, a correlation analysis, and a regression analysis, along with power and effect size. The self‐confidence scores of the experimental group were higher than the scores of the control group (p < 0.05), and the anxiety scores of the experimental group were lower than the scores of the control group (p < 0.05). The web‐based training program accounted for 17.8% of the change in self‐confidence and 12.8% of the change in anxiety level. Therefore, the web‐based training program was effective in increasing nursing students' self‐confidence levels and decreasing their anxiety levels in the clinical decision‐making process.
Lay Description
Problem
- There is a general lack of an identified theoretical framework of “Effect of Web‐Based Education on Self‐Confidence and Anxiety Levels of Pediatric Nursing Interns in Clinical Decision‐Making Process.”
- Web‐based education are effective educational methods to improve the learning outcome through nursing intern student knowledge and practice. But there is not enough information about the effect of web‐based education on self‐confidence and anxiety levels of paediatric nursing interns in clinical decision‐making process.
- This study provides evidence for web‐based education effect the self‐confidence and anxiety levels of paediatric nursing interns in clinical decision‐making process.
1 INTRODUCTION
Clinical decision making is the ability of nurses to select the most appropriate solution for patients by identifying appropriate solutions to the problems that patients face (Azak & Taşçı, 2009). Nurses should evaluate all factors associated with patient care before making the right decision and reaching the most effective conclusion. The decision‐making process for nurses involves steps to identify appropriate interventions for a problem and evaluate the results of these interventions (Sucu, Dicle, & Saka, 2012). Thus, clinical decision making in nursing is an important part of the health care system, consisting of a complex structure that provides a systematic problem‐solving approach by utilizing the knowledge, skills, and experience of nurses, thereby making them autonomous health care professionals (Azak & Taşçı, 2009; Baykara & Şahinoğlu, 2013).
Clinical decision‐making skills begin to develop and gradually increase during nursing education. These skills are most strongly developed during the final undergraduate year of study through an internship program (Atasoy & Sütütemiz, 2014; Bulut, Ertem, & Sevil, 2009). During their education, nursing students are in an educator‐dependent working environment; however, during their internship, they learn to work as a team and develop critical thinking and clinical decision‐making skills. A previous study has shown that nursing students used the clinical decision‐making skills developed during internships while taking care of many different groups of patients (Sabancıoğulları, Doğan, Kelleci, & Avcı, 2012). However, lack of sufficient experience, fear of making mistakes, and worry about child discomfort and painful procedures have been shown to increase the anxiety of nursing students in paediatric clinics (Oermann & Lukomski, 2001). In addition, the importance and priority of trust in child care, the presence of parents during the care, and the inadequacies of nursing students in this regard are among the factors that lead to anxiety among students (Oermann & Lukomski, 2001). Furthermore, nursing students are taught skills pertaining to adult care, but these skills are expected to be used in child care as well. Paediatric nursing interns experience more anxiety because of the developmental differences in children, the children's need to be with parents during medical care, and the difficulty in communicating with children (McNee & Clarke, 2005). Therefore, supportive training programs are required for paediatric nursing interns to increase their confidence and decrease their anxiety in the decision‐making process.
Previous studies have shown that computer programs, which have been used intensively in nursing education in recent years, enable continuity of education and provide quick and easy access to information (Adams & Timmins, 2006; Bahar, 2015; Durmaz, Dicle, Cakan, & Cakir, 2012; Novotny & Wyatt, 2006). Web support is necessary in nursing education to obtain and share information without time or location constraints. Although students have reported that web‐based education had a positive impact on their training process, they also stated the importance of building a face‐to‐face information sharing system with instructors and benefiting from their experiences (Şenyuva & Kaya, 2014). However, studies evaluating both web‐based and face‐to‐face training activities for paediatric intern nurses have not been performed thus far.
This study examines the effects of web‐based education on the self‐confidence and anxiety levels of paediatric nursing interns during the clinical decision‐making process.
2 METHOD
2.1 Study design
This study had a semiexperimental design. We used an unpaired t test to compare the prescores and postscores to examine the effects of web‐based education on the self‐confidence and anxiety levels of paediatric nursing interns during the clinical decision‐making process.
2.2 Participants
This study was conducted between February 2016 and January 2017 with senior students in the Nursing Faculty of an advanced university located in the western region of Turkey. The study's sample consisted of 63 nursing students interning at the Pediatric Nursing Department of the Faculty of Nursing at Dokuz Eylul University during the 2015–2016 academic year and the 2016–2017 fall semester. Considering a Type I error of 0.05 and a Type II error of 0.20 (80% power), the total sample size required for these two groups at medium effect size was set at 61, according to the GPower statistical program. Sampling was not performed in this study; instead, 30 students who were trained in the spring semester and 31 students who were interning in the fall semester were assigned as the control and experimental groups, respectively, to prevent information sharing between them.
2.3 Data collection procedure
In this study, the data were collected using the Sociodemographic Data Collection Form and the Nursing Anxiety and Self‐confidence with Clinical Decision‐making Scale (NASC‐CDM). The pretest data of the control group were obtained by applying the scale in a classroom environment on February 22, 2016, before they began their internship. The posttest data from the control group were obtained by applying the scale in a classroom environment on May 21, 2016, after they finished their internship. A pseudonym‐named system was prepared with special instructions to ensure anonymity and match the pretests and posttests. Training content was created between October 15, 2015, and September 1, 2016, and expert opinions on the content were subsequently obtained. Pretest data from the experimental group were collected in a classroom environment on September 19, 2016, before the internship training started. The posttest data from the experimental group were obtained by applying the scale in a classroom environment on December 31, 2016, after they finished their internship. The website was introduced to the students in the experimental group after the pretest data were obtained, and the students' e‐mails were received and registered into our system.
The website was developed by the Dokuz Eylul University Distance Education Center. It includes a special software that sets a framework for different programs to enable them to run together, therefore, ensuring that programs in different contexts and different formats work properly on the same system. Courses are introduced, and course registration is performed. In the opened courses, homework can be given via the homework module, and students can upload their homework to the system. Students can take their exams through the test and quiz modules, and all forms can be completed. PowerPoint presentations, videos, and course notes can be uploaded through the resource module. Students are directed to the presentations and videos prepared by the educators as well as contents on other websites. The virtual classroom application program allows educators to come together with their students live at any time; courses and presentations can be given, and questions can be answered. Announcements are made to students over the announcement system module. The system can also send reminder messages to the mobile phones of students registered on the system, if requested. Students can arrange the weekly programs through the system and see academic programs. They can also contact other students registered on the page through the chat room. The system displays how many times each student has entered the system; when they have entered; and which modules, videos, or scenarios they have reviewed. The educator can check whether the students have read the module and watched the videos, and they can send monitoring notices via e‐mail or SMS, if necessary. The students can quickly access the system's contents on a desktop or mobile device without page or program opening issues because the server is hosted by Dokuz Eylul University Distance Education Center.
The information on the website gradually progresses from basic paediatric issues to complex paediatric cases. The website consists of five modules, including communication with children, physical examination of children, fluid and electrolyte monitoring and catheter care of children, paediatric drug applications for children, and care of paediatric patients dependent on technology. Modules were uploaded to the website in accordance with a timetable that was planned in line with the students' clinical practice objectives. Additionally, these uploads occurred at 2‐week intervals to provide adequate time for the students to read the modules. The main contents of each module are as follows:
- Module 1:
Introduction to paediatric nursing and communication with children. This module included the philosophy of paediatric nursing, techniques for communicating with children, preparing children for age‐specific medical interventions, and using therapeutic games. One PowerPoint presentation was used, along with video and question and answer sessions.
- Module 2:
History and physical examination of paediatric patients. This module included the importance of taking a paediatric patient's history, along with points to be considered while obtaining the patient history. The module also included measures to obtain details about the medical history from the family as well as the child, applying the principles of physical examination, evaluating the child's health status, and assessing the growth and development process. Further content included assessing the child's general appearance and system findings and documenting results and vital signs. PowerPoint presentations, along with video, scenario, and question and answer sessions were used in this module. The scenarios illustrated how to obtain information about the medical history of a child with a fever, as well as how to perform a physical examination, take anthropometric measurements of a child with an eating disorder, and assess their growth and development.
- Module 3:
Fluid and electrolyte monitoring and catheter care in paediatric patients. This training module included the differences between children and adults, the distribution of fluid and electrolytes in babies and children, and the types of fluid intake and output. The mechanisms regulating fluid and electrolyte balance, measuring daily fluid requirements in abnormal cases, and the types of fluids used in children were presented. Additional content included fluid and electrolyte imbalances, accurately providing nursing care, and fluid and medication administration. PowerPoint presentations, along with video, scenario, and question and answer sessions were used in this module. A scenario on the clinical findings of a child with vomiting and diarrhoea was presented, which included assessing the fluid–electrolyte balance, determining dehydration, and developing a nursing care plan.
- Module 4:
Paediatric medication administration. This module included educational content related to medication administration, explaining child‐specific differences in medication administration, and the ability to calculate drug dosages. Further content included using the concept of dry powder volume in practice and explaining medication administration in children and its practical applications. PowerPoint presentations, videos, and question and answer sessions were used in this module.
- Module 5:
The care of paediatric patients relying on technology. This module focused on bedridden and technology‐dependent children, the problems that may arise in these children, and the processes of providing care to these patients. PowerPoint presentations, videos, and question and answer sessions were used in this module.
2.4 Data collection
In this study, data were collected using the Sociodemographic Data Collection Form and the NASC‐CDM.
2.4.1 Sociodemographic Data Collection Form for nursing students
This form consists of eight questions about the students' age, gender, economic situation, whether they worked as a nurse, academic success levels, perceived success levels, Internet access status (at home or mobile phone), and order of preference for internship program.
2.4.2 Nursing Anxiety and Self‐confidence with Clinical Decision‐making Scale
The NASC‐CDM was developed by Krista A. White in 2011. This scale assesses the anxiety and self‐confidence levels of nursing students in making clinical decisions. It is designed as a 6‐point, Likert‐type tool with two subscales, namely, self‐confidence and anxiety. Individual scores for self‐confidence and anxiety are obtained from the scale. Each subscale includes three subdimensions: using resources and listening strictly to get information, using available information to determine the problem, and knowing and acting. A high score on the self‐confidence subscale and its subdimensions indicated high self‐confidence levels, and a low score on the anxiety subscale and its subdimensions indicates low anxiety levels. The lowest and highest scores that can be obtained from the self‐confidence and anxiety subscales are 27 and 162, respectively. The self‐confidence and anxiety scales were 69.51% and 63.39% of the total variance, respectively. The factor loadings were above 0.40 in all the scale and subdimensions. In addition, Cronbach's alpha coefficient was 0.97 for the self‐confidence subscales and 0.96 for the anxiety subscales (White, 2011).
The Turkish validity and reliability of the scale was developed by Bektaş, Yardımcı, Bektaş, and White (2017) with the participation of 334 nursing students. Cronbach's alpha coefficient was above 0.85 for the entire scale and all subscales, and factorial loads were above 0.40 in all subscales (Bektaş et al., 2017). Factor analysis indicated that the total variances explained by the self‐confidence and anxiety subscales were 69.35% and 66.88%, respectively. The confirmatory factor analysis determined that all fit indices were above 0.90 and that Root Mean Square Error of Approximation (RMSEA) was below 0.080 (Bektaş et al., 2017).
2.5 Data analysis
Data were analysed using a t test, a Mann–Whitney U test, a correlation analysis, and a regression analysis, along with power and effect size. A p value of less than 0.05 was considered statistically significant.
2.6 Ethics
Written permissions to conduct this study were obtained from the Ethics Committee (IRB: 27344949/131) and the Dean of the Nursing Faculty (24403912/52). Written consent forms were received from the participating students after the research purpose, implementation method, and planned outcomes were explained to them.
3 RESULTS
The mean age of the students in the experimental group was 22.44 ± 1.72 years, whereas the mean age of students in the control group was 23.16 ± 1.36 years. No statistically significant difference was observed between the mean ages of students in both groups (p > 0.05). The experimental group had 78.8% female students and 21.2% male students; the control group had 96.7% female students and 3.3% male students. No significant difference was observed in the gender of both groups (p > 0.05). No significant difference was observed between the incomes of both groups (p > 0.05); 93.9% students of the experimental group and 96.7% students of the control group had a moderate income. No students were working as a nurse in either group. Self‐evaluation indicated that 60.6% students in the experimental group and 36.7% students in the control group were moderately successful. No significant difference in their perceived success (p > 0.05) was found between the groups (Table 1).
| Experimental group | Control group | X2/t | p | |||
|---|---|---|---|---|---|---|
| Age | 22.44 ± 1.72 | 23.16 ± 1.36 | 1.851 | 0.069 | ||
| Gender | n | % | n | % | ||
| Female | 26 | 78.8 | 29 | 96.7 | 0.056a | |
| Male | 7 | 21.2 | 1 | 3.3 | ||
| Income | n | % | n | % | ||
| Low | 2 | 6.1 | — | — | 2.930 | 0.231 |
| Medium | 31 | 93.9 | 29 | 96.7 | ||
| High | — | — | 1 | 3.3 | ||
| Working as a nurse | n | % | n | % | ||
| Work | — | — | — | — | — | — |
| Not working | 33 | 100 | 31 | 100 | ||
| Perceived academic success level | n | % | n | % | ||
| Good | 12 | 36.4 | 17 | 56.7 | 3.674 | 0.159 |
| Moderate | 20 | 60.6 | 11 | 36.7 | ||
| Bad | 1 | 3.0 | 2 | 6.6 | ||
- a Fisher's X2.
The comparison of pretest and posttest total scores of the experimental and control groups in the self‐confidence subscale is shown in Table 2. No statistically significant difference was observed in total pretest scores of the self‐confidence subscale of both groups; the experimental group received 111.90 ± 20.53 and the control group received 118.10 ± 18.69 (p > 0.05). A statistically significant difference was observed in the total posttest scores of the self‐confidence subscale of the experimental and control groups, which were 137.30 ± 14.08 and 126.63 ± 16.13, respectively (p < 0.05). Comparison of the group scores and the score differences yielded meaningful results. Whereas the difference between the pretest and posttest scores of the experimental group was 25.39 ± 17.19, the difference between the pretest and posttest scores of the control group was 8.53 ± 11.86, which is statistically significant (p < 0.05).
| Group | Pretest total score | Posttest total score | Difference | t | p |
|---|---|---|---|---|---|
| Experimental group | 111.90 ± 20.53 | 137.30 ± 14.08 | 25.39 ± 17.19 | 8.492 | 0.000 |
| Control group | 118.10 ± 18.69 | 126.63 ± 16.13 | 8.53 ± 11.86 | 3.939 | 0.000 |
| t/U | 1.247 | 2.802 | 238.500 | ||
| p | 0.217 | 0.007 | 0.000 |
We observed a statistically significant difference in the pretest and posttest total scores of the self‐confidence subscale in the experimental group, which were 111.90 ± 20.53 and 137.30 ± 14.08, respectively, (p < 0.05). The self‐confidence pretest and posttest total scores of the control group were significantly different, 118.10 ± 18.69 and 126.63 ± 16.13, respectively (p < 0.05).
The comparison of pretest and posttest total scores of the experimental and control groups in the anxiety subscale is shown in Table 3. No statistically significant difference was observed in the pretest total scores on the anxiety subscale in the experimental and control groups, which were 72.69 ± 22.52 and 63.13 ± 17.60, respectively (p > 0.05). The difference in the anxiety posttest total scores of the experimental and control groups was not statistically significant, 59.81 ± 18.36 and 58.36 ± 13.84, respectively (p > 0.05). We observed a statistically significant difference between the pretest and posttest scores in the experimental and control groups, which were 12.87 ± 11.89 and 4.76 ± 9.35, respectively (p < 0.05).
| Group | Pretest total score | Posttest total score | Difference | t | p |
|---|---|---|---|---|---|
| Experimental group | 72.69 ± 22.52 | 59.81 ± 18.36 | 12.87 ± 11.89 | 4.411 | 0.000 |
| Control group | 63.13 ± 17.60 | 58.36 ± 13.84 | 4.76 ± 9.35 | 2.507 | 0.012 |
| t/U | 1.864 | 0.352 | 270.000 | ||
| p | 0.067 | 0.726 | 0.002 |
A significant difference was observed in the anxiety pretest and posttest total scores of the experimental group, which were 72.69 ± 22.52 and 59.81 ± 18.36, respectively (p < 0.05). The anxiety pretest and posttest total scores of the control group were also significantly different, 63.13 ± 17.60 and 58.36 ± 13.84, respectively (p < 0.05).
The relationship between the education program and self‐confidence and anxiety is shown in Table 4. We observed a moderately significant relationship between the education program and self‐confidence (p < 0.01) and a low negative and advanced relationship between the education program and anxiety (p < 0.01).
| Variable | 1 | 2 | 3 |
|---|---|---|---|
| 1. Education program (distance education) | 1.000 | ||
| 2. Self‐confidence | 0.448* | 1.000 | |
| 3. Anxiety | −0.394* | −0.557* | 1.000 |
- * p < 0.01.
The predictive power of the education program for the change in self‐confidence and anxiety levels is shown in Table 5. The education program explains 17.8% (R2 = 0.178) of the increase in the level of self‐confidence, and education increases self‐confidence by 0.422 times (β = 0.422). The education program explains 12.8% (R2 = 0.128) of the increase in the level of anxiety, and education decreases anxiety by 0.357 times (β = −0.357).
| Variable | Self‐confidence | Anxiety | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| B | SH | β | t | p | B | SH | β | t | p | |
| Constant | 2.352 | 0.022 | 2.427 | 0.018 | ||||||
| Education programa | 17.179 | 4.720 | 0.422 | 3.639 | 0.001 | 8.112 | 2.714 | −0.357 | 2.989 | 0.004 |
| R | 0.422 | 0.357 | ||||||||
| R2 | 0.178 | 0.128 | ||||||||
| F | 13.246 | 8.934 | ||||||||
| p | 0.001 | 0.004 | ||||||||
| DW (1.5–2.5) | 2.005 | 1.594 | ||||||||
- Note: SH, Standart Error (SE); DW, Durbin Watson.
- a When the education program was coded, the experimental and control groups were coded as “1” and “0,” respectively.
The power and effect size of the education program were evaluated according to the regression analysis. The power and effect size of the education program for self‐confidence were 0.94 and 0.21, respectively (f2). The power and effect size of the education program for anxiety were 0.83 and 0.15, respectively (f2).
4 DISCUSSION
The results of this study are discussed in light of the existing literature. The students in the experimental and control groups had similar sociodemographic characteristics, and no statistically significant difference was found between the groups in this regard (p > 0.05).
We observed no statistically significant difference between the self‐confidence pretest total scores of the experimental and control groups (p > 0.05), but the posttest total score of the experimental group and the difference between the pretest and posttest scores of the experimental group were statistically higher than those of the control group (p < 0.05, Table 2). To date, no study has examined the effects of web‐based education on the self‐confidence levels of paediatric nursing students in the clinical decision‐making process. However, previous studies have shown the effects of computer‐aided and other education models on the self‐confidence levels of nursing students in the clinical decision‐making process (Bean, 2015; Canova, Brogiato, Roveron, & Zanotti, 2016; Cobbett & Snelgrove‐Clarke, 2016; Coram, 2016; Durmaz et al., 2012; Forbes, Bucknall, & Hutchinson, 2016; Ross & Carney, 2017; Thompson & Stapley, 2011; Warren, 2015). A study performed by Durmaz et al. (2012) in Turkey as a part of his doctoral dissertation showed that a computer‐assisted training program moderately affected the self‐confidence of second‐grade nursing students in making clinical decisions, but no significant difference was observed in the self‐confidence posttest mean scores between the experimental and control groups in the clinical decision‐making process (Durmaz et al., 2012). Forbes, Bucknall, and Hutchinson (2016) showed that video‐assisted training programs were effective in improving the self‐confidence, knowledge, and skills of nursing students. Warren (2015) determined that simulation‐based learning significantly increased self‐confidence in clinical decision making, and the self‐confidence posttest mean score of the experimental group was significantly higher than that of the control group. Bean (2015) found that clinical improvement courses increased the self‐confidence posttest scores of nursing students and provided the desired improvement in their self‐confidence levels. Ross and Carney (2017) found that structured scenarios significantly improved the clinical self‐confidence level of students. Cobbett and Snelgrove‐Clarke (2016) compared face‐to‐face scenario training with virtual scenario training, finding that both training models had similar effects on increasing the self‐confidence of students, and their results showed no significant difference between the self‐confidence posttest scores of the groups. Thompson and Stapley (2011) showed that different types of studies yielded different results, and the effect of training methods on improving the clinical self‐confidence of students was not clearly demonstrated.
This study is different from previous studies; for instance, this study planned modules according to students' clinical requirements; made modules accessible anytime from computers, tablets, and mobile phones; and allowed students to create discussion topics in chat rooms with other students registered on the system. Additionally, students were able to share information and comments about the modules, receive reminders, and contact the educators and researchers live within the virtual classroom to ask questions and discuss the modules. Furthermore, the educators could contact the students via SMS and upload scenarios. For these scenarios, the students could send their assessment and comments via the system, and the scenario homework was discussed with the students in a live classroom environment. Overall, students' learning processes were supported by the educators guiding them through the system and directing them to internet links and educational videos on other websites.
In this study, information was directly available to the students from the web, students' questions and problems were discussed in the classroom, the students could access the information as convenient, various scenarios were discussed, and students had the opportunity to discuss issues or problems among themselves online; the factors were responsible for the differences observed between the control and experimental groups and increasing the self‐confidence levels of students in making clinical decisions.
There was a significant difference between the pretest and posttest mean self‐confidence scores in both the experimental and control groups (p < 0.05, Table 2). Various factors affect the self‐confidence levels of students in making clinical decisions (Bean, 2015; Canova et al., 2016; Cobbett & Snelgrove‐Clarke, 2016; Coram, 2016; Durmaz et al., 2012; Forbes et al., 2016; Ross & Carney, 2017; Thompson & Stapley, 2011; Warren, 2015). This study suggests that a significant increase in the self‐confidence scores of the control group may be because of their nursing intern program, the common compulsory and elective courses taken by them, and the guidance given by the instructors during their clinical practice. Moreover, the self‐confidence mean score of the experimental group was three times higher than that of the control group, which indicates the effectiveness of the web‐based education program in improving the self‐confidence level of the students.
There was no significant difference between the anxiety scale pretest and posttest total scores of the experimental and control groups (p > 0.05, Table 3). However, a statistically significant difference was found between pretest and posttest scores within each group (p < 0.05, Table 3). In addition, the difference between the pretest and posttest mean scores of the groups was found to be statistically significant (p < 0.05, Table 3), and the score of the experimental group was three times higher than the control group. These results show the effectiveness of education.
To date, no study has examined the direct effect of a web‐based education program on the anxiety level of nursing students in making clinical decisions, but a number of studies have examined the effects of computer‐assisted training, face‐to‐face training, simulation training, and risk reduction training on the anxiety level of nursing students in making clinical decisions (Bean, 2015; Cobbett & Snelgrove‐Clarke, 2016; Lee & Noh, 2016; Megel et al., 2012; Ross & Carney, 2017; Turner & McCarthy, 2016; Warren, 2015). Training programs focused on reducing or coping with anxiety alone are not effective in decreasing the anxiety levels of students (Bean, 2015; Cobbett & Snelgrove‐Clarke, 2016; Lee & Noh, 2016; Megel et al., 2012; Ross & Carney, 2017; Turner & McCarthy, 2016; Warren, 2015).
There was no statistically significant difference between the mean posttest anxiety scores of the students. Computer‐assisted programs cause anxiety due to factors, such as high‐end technology, difficulties in usage, and Internet access problems (Turner & McCarthy, 2016; Warren, 2015). However, such programs may be able to reduce anxiety because they are easily accessible, divert from educational and evaluation stress, and can be accessed as required (Bean, 2015; Cobbett & Snelgrove‐Clarke, 2016; Lee & Noh, 2016; Megel et al., 2012; Ross & Carney, 2017; Turner & McCarthy, 2016; Warren, 2015).
Although there was no difference between the posttest scores in both groups, this study's results were consistent with those reported in previous studies in that the anxiety levels of the students in the experimental group were three times lower than those of the control group. We observed no statistically significant difference between the posttest mean scores of the groups, and the pretest mean score of the control group was lower than that of the experimental group. The reasons for this include the fact that the intern training program reduced anxiety for both groups because of the confidence boost given to the graduated students, along with the fact that the students had similar experiences. Although the groups were statistically similar, differences may also arise from the characteristics of the groups because they cannot match each other exactly. Previous studies have shown that student anxiety level increases because of lack of knowledge, lack of information about the working environment and equipment, fear of making a mistake in the case of children, discomfort about being clinically evaluated by trainers, and stress about making case presentations (Elcigil & Sarı, 2008; Han & Lee, 2016; Moscaritolo, 2009). The anxiety levels in both groups decreased significantly because of the increase in their knowledge levels during internship training, the familiarity of the clinical environment, the development of their communication skills with children and families, educational support, observation of each other's case presentations, and understanding and fulfilling the expectations of their instructors.
However, the significant decrease in anxiety scores in the experimental group was similar to that observed in the web‐based education program of the experimental group and the care plans integrated into the clinic, the communication skills with the paediatric patient and the family, the patient‐centred care skills, psychomotor skills lists and videos, the virtual classrooms and chat rooms, and the trainer's convenience. Although there was a significant reduction in anxiety scores in both groups, the fact that the anxiety levels of the students in the experimental group were three times lower than those of the control group may have arisen from the care plans integrated into the topics in the web‐based education program and clinics, along with training on communication skills with paediatric patients and their families, patient‐centred care skills, guidance scenarios for clinical decision making, psychomotor skill lists and videos, and use of virtual classrooms and chat rooms and trainer transportation facilities.
There was a moderate positive correlation between using the web‐based education program and self‐confidence and a moderate negative correlation between using the web‐based education program and anxiety (Table 4). Web‐based education accounts for 17.8% of the change in student self‐confidence levels and 12.8% of the change in student anxiety levels (Table 5). The effect of education programs on self‐confidence and anxiety has not been determined thus far. However, previous studies have shown that many factors affect self‐confidence and anxiety (Bean, 2015; Canova et al., 2016; Cobbett & Snelgrove‐Clarke, 2016; Coram, 2016; Durmaz et al., 2012; Elcigil & Sarı, 2008; Forbes et al., 2016; Han & Lee, 2016; Karabulut & Aktas, 2016; Lee & Noh, 2016; Megel et al., 2012; Noohi, Karimi‐Noghondar, & Haghdoost, 2012; Park & Kim, 2000; Ross & Carney, 2017; Thompson & Stapley, 2011; Turner & McCarthy, 2016; Warren, 2015; White, 2009). Thus, an 18% increase in self‐confidence and a 13% decrease in anxiety due to web‐based education indicate a good result, demonstrating the effectiveness of the study. This result was obtained because of student‐oriented web‐based education, reality‐based scenarios, live‐virtual classroom applications, group discussions, information sharing in chat rooms, academic content, easily accessible web page information, and content compatible with student needs.
The power and effect size of the education program for self‐confidence were 0.94 and 0.21, respectively (f2). The power and effect size of the education program for anxiety were 0.83 and 0.15, respectively (f2; Table 6). Whereas the power indicates the statistical significance of the study, the effect size gives information about practice and clinical significance (Cohen, 1988; Cohen, 1992). The power and effect size were calculated according to the regression analysis, and both self‐confidence and anxiety dimension were determined to be strong. Cohen (1988) categorized effect sizes as follows: (f2) 0.02 ≥ f2 < 0.15 as low effect size, 0.15 ≥ f2 < 0.35 as moderate effect size, and ≥0.35 as large effect size. Considering these values, both self‐confidence and anxiety subscales have moderate effect size in this study. Previous studies using web‐based or computer‐aided programs do not include the power and effect sizes of the education programs on self‐confidence and anxiety in students (Bean, 2015; Canova et al., 2016; Cobbett & Snelgrove‐Clarke, 2016; Coram, 2016; Durmaz et al., 2012; Elcigil & Sarı, 2008; Forbes et al., 2016; Han & Lee, 2016; Karabulut & Aktas, 2016; Lee & Noh, 2016; Megel et al., 2012; Noohi et al., 2012; Park & Kim, 2000; Ross & Carney, 2017; Thompson & Stapley, 2011; Turner & McCarthy, 2016; Warren, 2015; White, 2009). For this reason, this study's results have not been compared with the literature.
| Power | Effect size (f2)a | |
|---|---|---|
| Self‐confidence | 0.94 | 0.21 |
| Anxiety | 0.83 | 0.15 |
- a Cohen f2.
Although there are many strong points of the study, there are a few limitations. First, the small sample size and the lack of random assignment of sample are the most important limitation. Second, experiment and control groups were taken different semester to prevent interaction between groups. The control group was taken in the spring semester and the experimental group in the fall semester. Because the control group has a longer internship education, it is thought that the results may be influenced in favour of the control group. Third, students' use of the web page has been checked from web page statistics. However, the student's entry into the page does not show that they have reached all the content in the modules. The last, the reliability of the study is based on the researchers' ability to analyse the content and describe the results.
5 CONCLUSION
This study has been shown to be a feasible and effective study, which indicates that web‐based education increased the self‐confidence levels and decreased the anxiety levels of paediatric intern nursing students in the clinical decision‐making process. This study's results show that web‐based education is an effective method for training nursing students and thus should be using during nursing student internships. In addition, education programs should include customized modules for self‐confidence and anxiety, and clinical evaluations, especially the evaluation of cognitive and psychomotor skills, should be added to studies to obtain precise results. Further studies should be performed for quantitative and qualitative evaluations, and the web‐based program should be used in nursing education courses. To increase the efficiency of the web‐based education is suggested to authors take students' opinion in the preparation of the web page content, and use the students as peer educators in the web‐based education. Web‐based education should be used in combination with other forms of teaching such as traditional classroom methods to increase the self‐confidence levels and decrease the anxiety levels of the students in the clinical decision‐making process. To reduce the effects of maturation, it is recommended that the sample should be randomly assignment to groups, the intervention should be administered in the same semester, and web‐based education be extended to all classes.
ACKNOWLEDGEMENT
Thank you very much to all participants. We would like to thank DEUZEM for their technological support.
CONFLICT OF INTEREST
No conflict of interest has been declared by the authors.
