Effect of self-directed versus traditional learning model on nurses’ airway management competencies and patients’ airway-related incidents | BMC Nursing

Trial design

The current study utilized a prospective open-label parallel 1:1 experimental research design employing a posttest-only control group structure within a two-group comparison framework. Pretest was not implemented to avoid a testing threat. The study was carried out between February 2020 and July 2021 and adhered to the guidelines outlined in the Consolidated Standards of Reporting Trials (CONSORT). In addition, the study was registered with Clinical Trials.gov (Registration # NCT04244565) on 28/01/2020, and Official IRB approval for the study’s execution was obtained at the Faculty of Nursing, Cairo University (CU), Egypt (approval # 2020-52). The study’s objectives, methods, potential risks, and benefits were thoroughly explained to the participants, allowing nurses sufficient review time. Participation was voluntary and had no impact on the participants’ performance appraisal. Moreover, participants had the right to withdraw from the study at any time without any repercussions on their professional evaluations. Withdrawn participants received equivalent treatment to those who remained in the regular study. Data was encoded to guarantee the anonymity and confidentiality of the subjects. It should be noted that the data collected were exclusively utilized for the specified research purpose and were not repurposed for any other purposes.

Participants sample and setting

The research was carried out at the Obstetrics and Gynecology Hospital affiliated with Cairo University, Egypt. The architectural construction of selected units consists of pairs of sections, with each pair comprising two sections. These two sections within each pair have comparable numbers of beds, patient flow, equipment, and working nurses. Each pair was divided into two sections, with one section assigned to the control group and the other to the intervention group. This method ensured that the groups were comparable and reduced the influence of potential confounding variables related to the setting. A total of 72 voluntary participants were recruited for study inclusion, all of whom were included in the final analysis. The sample size was determined using G* Power software V.3.1.9.4 (Psychonomic Society, Madison, Wisconsin, USA) with independent t-tests, α = 0.05, Power (1-β) = 0.80, balanced allocation ratio 1:1, and Effect size = 0.65 which is consistent with the effect sizes reported in previous studies [23, 24]. The participants were divided into 35 in the study group and 37 in the control group. All selected nurses met the following inclusion criteria: hold their current position for at least one month and have a minimum of two years of critical care experience. Nurses who had plans to resign within the next six months or have been involved in any educational programs related to AM in the past six months were excluded.

Randomization and allocation

The eligible nurses were randomly selected using a simple random sample method utilizing the computer-based program Statistical Package for Social Sciences (SPSS) V.23.0 (IBM, New York) after obtaining the sampling frame, including the pool of eligible participants. Subsequently, a sequential, random allocation was carried out for both the intervention and control groups. In order to prevent contamination between the intervention and control groups, measures were taken to ensure that each group operated in distinct sections throughout the study period. In addition, the process of randomization and allocation was carried out by an uninvolved third party.

Outcomes

The Primary endpoint: The primary outcome was a significant elevation in nurses’ airway management competency indicated by nurses’ knowledge and practices, measured by the Airway Management Structured Questionnaire (AMSQ) and Airway Management Structured Observational Checklist (AMSOC) at the endpoint-2nd post-assessment (3 months after receiving SDL).

The secondary endpoint: The secondary outcome was a significant decrease in airway-related incidents reported during the three-month duration of patient care after receiving the SDL. The incidents were measured using Patient Safety Incident Reports (PSIR).

Measurement tools

1. 1.

   The Self-directed Learning Readiness Scale (SDLRS) was developed by Guglielmino in 1977 [25]. It is a widely used self-reported tool [26] designed to measure individuals’ perceptions of their ability and readiness to participate in SDL. It consists of 58 items, divided into eight factors. Participants respond to each item using a 5-point Likert scale, with scores ranging from “1 = almost never true of me” to “5 = almost always true of me.” The overall score varies from 58 to 290, with higher values reflecting a higher perceived level of preparedness for SDL. Individuals with a score above 226 are deemed to be above average and prepared for SDL [27]. The scale demonstrates satisfactory internal consistency, as evidenced by a Cronbach’s Alpha ranging from 0.71 to 0.88 [28]. Furthermore, the scale collects demographic data, including participant sex, years of experience, staff category, and educational level. We chose the SDLRS for our study because it uses simple and straightforward language, making it easier for participants with limited English skills to understand. Additionally, we provide clear instructions in Arabic and on-demand assistance, enhancing the participants’ sense of ease and guaranteeing easy access to the tool. Finally, this tool is in the public domain, thus necessitating no permission.

2. 2.

   The Airway Management Nurses’ Knowledge Questionnaire (AMNKQ) is a tool that was developed by reviewing previous research [7, 29]. It is a self-reported tool that was used to assess nurses’ knowledge regarding AM. The questionnaire comprises 20 multiple-choice questions, with options for true and false. Each correct answer is given one point, while an incorrect answer receives zero points. Each student’s scores were summed to calculate the total score, with a maximum possible score of 20.

3. 3.

   The Airway Management Nurses’ Practices Checklist (AMNPC) is a checklist designed to monitor the nurses’ practices regarding AM-related nursing practices. A third-party evaluator collected the data, we selected a team of experienced third-party evaluators who underwent comprehensive training to familiarise themselves with the (AMNPC). The training included a detailed overview of the tool, scoring criteria, and case studies. Following the initial training, raters participated in calibration sessions, which involved practice evaluations using standardised video recordings and consensus discussions to align their scoring interpretations. Also, ongoing calibration sessions and periodic reviews were conducted to maintain consistency. The tool consists of 150 steps. Those who successfully and accurately complete a step will receive a score of 2. Those who did complete a step received a score of 1. Those who incorrectly completed a step received a score of zero. The scores of each nurse were aggregated for interpretation, with the maximum score being 300.

4. 4.

   The Patient Safety Incident Reports (PSIR): It is an adopted tool developed by the UK National Patient Safety Agency in 2019 for assessing airway-related incidents reported by nurses [30]. Specifically, it focuses on events associated with airway obstruction, injury, or aspiration. The data collected pertains to the type of incident, its causes, and the frequency of occurrence. A third-party evaluator regularly asked the participants to document any airway-related incidents encountered.

Reliability and validity

Content and scope validity for the developed second and third tools were determined utilizing the Lawshe method [31]. The tool was reviewed by a panel of five experts in medicine and nursing. After calculating each item’s content validity ratio (CVR), AMNKQ and AMNPC content validity index (CVI) were 0.94 and 0.95, respectively. Before the main study, a pre-test pilot study was conducted with 12 nurses from the same setting to assess the feasibility, acceptability, and internal consistency of the tools. Internal consistency (Cronbach’s alpha) was measured to evaluate the scale’s reliability. The Cronbach’s alpha for AMNPC and AMNKQ were 0.77 and 0.75, respectively, indicating a satisfactory internal consistency.

Self-directed learning for the intervention group

The SDL model was conducted to teach the intervention group of working nurses the concept and competencies of AM. After the assessment of nurses’ readiness to utilize the SDL approach by Tool 1, Knowles’ SDL principles (1975) [22](Fig. 1) were implemented as follows: The participants engaged in a deliberation process to formulate and establish a prearranged course of action. This plan involved defining learning objectives, organizing outlines, arranging activities in a specific order, and setting a timeline for completing the activities within one month. In addition, the participants were provided with a diverse selection of EBP resources and learning materials. These resources were reviewed by nursing experts, and each participant chose the ones that aligned with their preferred learning styles and preferences. Examples of such resources include the Egyptian Knowledge Bank and the book library. The clinical instructor serves as a facilitator, providing regular feedback to both clinical instructors and peers. In addition, participants actively engaged in self-reflection about this learning experience.

Traditional learning model for the control group

The control group of nurses learned the concept of AM and related nursing competencies using the regular clinical teaching approach familiar to the participants. A one-month plan was implemented during regular working hours. We divided the control group into two equal subgroups, each receiving pre-scheduled integrated lectures on the theoretical foundations of AM. There were a total of four lectures, each lasting two hours. The lectures were held once a week and participants received written handouts. The scientific content was adopted from different reviews of the literature [4, 6]. After each driven lecture, the researcher gave a supportive four-hour clinical application in a clinical setting utilizing the “see one-do one” clinical learning method. Furthermore, clinical supervision and guidance were given to the participants to ensure their ability to apply acquired knowledge in a real clinical setting.

Procedures of data collection

After the implementation was completed, the follow-up and evaluation process began. This involved monitoring the occurrence of airway-related incidents reported by nurses in both the control and study-selected units on a daily basis for a continuous three-month period using (tool 4). Subsequently, the proficiency and methodologies of the nurses in the control group were assessed on two occasions. The initial assessment took place immediately after the completion of the implementation, while the second assessment occurred three months later to gauge the extent to which the education and training had been retained. This evaluation was conducted using tools 2 and 3. In contrast, self-evaluation was utilized among the study group using tools (2, 3), and it was observed and rated by someone else (peer colleague). Peer evaluations were conducted anonymously, cross-verified by multiple peers, and regular feedback sessions were held to ensure consistency and objectivity in the evaluations. Also, peer raters underwent comprehensive training, practice sessions, consensus meetings, and ongoing calibration to ensure consistency and reliability. The study group was also evaluated two times, similar to the control group. Finally, the researcher conducted a comparative analysis between the SDL results in the study group and the baseline data collected from the control group that underwent traditional ongoing learning practices.

Data analysis

The study of both descriptive and inferential statistics was conducted using IBM SPSS Statistics version 23.0, IBM in New York. The data were presented using mean and standard deviation (SD). The data collected was assessed for normality using Shapiro-Wilk’s test and box plots. In order to examine the statistical differences between the control and intervention groups, an independent samples t-test was conducted with a significance level set at P < .05. Furthermore, the clinical significance was assessed using Cohen’s d effect size, where an effect size (ES) ≥ 0.4 was considered to be clinically meaningful [32]. In addition, an analysis of covariance (ANCOVA) was utilized to examine potential confounding factors that may have a statistical influence on the study’s dependent variable, with groups being considered as fixed factors.

Result

A total of 91 nurses were assessed for their eligibility to partake in the present study. Out of these, 72 nurses were successfully enrolled and remained participants until the 2nd post-assessment, which marked the last stage of analysis, as reported in Fig. 2. The female participants accounted for 93% of the total, with 36.1% falling within the age range of 30 to 40 and 44.4% having accumulated 10 to 20 years of experience. In addition. 69.5% of the participants were diploma nurses. No significant difference was found between the intervention and control groups in terms of demographic features (Table 1).

CONSORT flow chart shows subjects’ participation flow

A statistically significant difference was found between the control and intervention groups regarding their practice score during both the first and second points of assessments, with p-values of 0.01 and 0.02, respectively. The intervention group demonstrated the highest practice score (251.05 ± 12.37) during the initial assessment out of a maximum score of 300. Conversely, the control group had the lowest practice score (240.05 ± 10.36) during the subsequent assessment. In addition, the knowledge score was found to be significantly different between the control and intervention groups, either at the first or second assessment points, with p-values of 0.01 and < 0.01, respectively. The intervention group exhibited the highest scores in nurses’ knowledge during the initial assessment, with a mean score of 17.60 ± 0.94 out of a total of 20. The control group achieved the lowest knowledge score in the second assessment point, with a mean score of (13.62 ± 1.47). However, the overall nurses’ practices and knowledge scores were found to be statistically significantly different between the control and intervention groups with p < .01. Moreover, the difference found between control and intervention groups was clinically relevant, as evidenced by the effect size (ES) Cohen’s d in both practices and knowledge level (-0.56 and − 1.55, respectively) (Table 2). This result indicates significant differences between groups [31].

A significant difference was found between the immediate first post-assessment and the paired second (three months later) post-assessment concerning nurses’ knowledge and practices among control and intervention groups, as indicated by the paired t-test with p < .01 (Table 3). This difference occurs due to a significant decrease in the mean scores of nurses in the second assessment compared to the first assessment.

The intervention group reported 18 airway-related incidents over three months, whereas the control group reported 24 incidents. Nevertheless, the observed difference was not statistically significant. The most prevalent type of airway-related incidents reported by both the control and intervention groups of nurses was airway injury, accounting for a total of 20 occurrences (47.6%). Conversely, the least frequent airway-related incident was aspiration, which was reported by both groups a total of seven times (16.6%) over a three-month period (Table 4).

Covariance analysis was conducted to examine the relationship between nurses’ practice scores at the second point (dependent variable) and participants’ groups (fixed variable). The results showed that nurses’ practice scores at the first point were a significant confounding variable (f = 688.96, p < .01). After adjusting for covariates, such as nurses’ demographic characteristics, nurses’ knowledge, and airway-related incidents, there was no statistically significant impact on the nurses’ practice scores at the second point. In addition, the relationships between groups and study-dependent variables did not demonstrate a statistically significant effect, as indicated by low values of partial eta squared (< 0.02), as shown in Table 5. This finding suggests that the tested variables have a relatively minor impact on the dependent variable being examined.