The development of a tablet PC-based m-learning program was used as a nursing practice education strategy to improve the clinical practice skills of nursing students, and its effectiveness was confirmed in this study. We will divide this discussion into two parts: the process of development m-learning program and its effectiveness.
4.1. Development of Nursing Education Using M-Learning
In this study, the tablet PC was selected as the medium of education, considering that it improves accessibility by combining the portability of a cell phone with the functions and advantages of a laptop [
31]. Clinical practice involves students departing from school and classrooms to learn in hospitals. To effectively manage students and provide them with feedback and visual educational materials, m-learning education methods are needed [
32]. Therefore, the strength of this study was believed to be the use of a tablet PC that can be accessed anytime, anywhere, and has mobility and visual effects as a tool to compensate for the limitations of the clinical practice education environment.
The use of new media in student education requires a change in the students’ roles, which emphasizes understanding and experience [
33]. During conferences and on-site guidance, the instructor used m-learning to link theoretical learning content with practice and presented various examples and usage plans to emphasize practical aspects. In addition, instant feedback was provided using m-learning, enabling the learned content to be reobserved in the field. Concurrently, learning through “empirical knowledge” was stimulated by having learners select and observe cases on their own and analyze nursing activities based on theoretical learning contents. Consequently, it was possible to link theoretical learning and practice pursued in clinical practice education. In addition, the instructor was faithful to the role of a facilitator, and the learner was the subject of learning and achieved self-directed learning, which is believed to reflect constructivist learning theory.
Each step of the experiential learning model required to complete the learning was included in the nursing practice education strategy developed in this study. Various situations have been encountered to directly experience health problems in the clinical field during specific stages. The ADDIE model was employed to develop and apply an m-learning program to help students reflect on systematic analysis and design during the reflective observation stage. In addition, it underwent an abstract conceptualization step that led to generalization and transfer by introducing a teaching design that applied Gagné’s nine instructional events to link nursing knowledge and practical experiences. Finally, in the active experimental phase, Kirkpatirick’s four levels of evaluation were applied to test the effectiveness of the strategy. The elements applied at each stage were judged to be methods that can be applied evenly to most nursing students by ensuring the feasibility of strategy development based on scientific evidence.
The content of the m-learning program reflects the needs of field leaders, clinical nurses, and students with experience in the clinical field. The m-learning program developed in this study was judged to reflect the nursing work in the field of clinical practice as realistically as possible. Furthermore, the design of the program organization, composition, and teaching methods so that the composition of the m-learning program can be organically linked to existing clinical practice education programs, seems to be an approach that considers various contextual aspects when introducing new teaching and learning methods.
This study applied Gagné’s nine instructional events. In a previous study that applied Gagné’s class situation, it was said that a wide range of learning activities could be achieved by understanding the concept of learning content for application [
34,
35]. Moreover, through this process, learners can utilize the learned content at a higher level, leading to an increase in transfer [
34,
35,
36]. This study also helped organize practical training by describing specific questions, related materials, expected learner responses, and time required based on Gagné’s nine instructional events. Therefore, it was beneficial to develop and apply Gagné’s instructional events in teaching and learning guidance to the nursing practice education attempted in this study.
By applying the Kirkpatrick evaluation model, which emphasizes a methodical evaluation centered on performance and results, the learning effects at each stage were identified and analyzed. This analysis serves as a foundation for enhancing the development of nursing practice education strategies. The Kirkpatrick evaluation model delineates the evaluation of learning effects across four stages: reaction, learning, behavior, and result. The initial stage involves evaluating the learner’s response, primarily to verify satisfaction or personal opinions. Learning satisfaction in this study was used to confirm Kirkpatrick’s first-stage evaluation as a subject response evaluation.
To evaluate whether the learner has achieved the intended learning, the second step assesses their knowledge, skills, and attitudes. Accordingly, this study confirmed the clinical competency of nursing knowledge, problem-solving abilities pursued through teaching and learning methods and design, and self-directed learning abilities. The third step is to determine whether learners are applying their trained knowledge, skills, and attitudes in the field and to evaluate their performance in the field. The fourth step is to evaluate the long-term effectiveness of learning, involving assessments related to organizational performance and contribution. However, this study provides fundamental data to suggest the direction of clinical practice guidance in nursing through the short-term effects of nursing practice education strategies. We propose a study that measures long-term effects to test the effectiveness of Kirkpatrick’s steps 3 and 4.
4.2. Effectiveness of the Nursing Practice Education Using M-Learning
Learning satisfaction, as confirmed by the first-stage response evaluation, was higher in the experimental group than in the control group; however, the difference was not significant. These results are similar to those of a practical training study [
37] that applied smartphone videos to basic nursing skills. Meanwhile, it differed from a study in which nursing students who participated in a mobile-based nursing competency evaluation system [
38] and smartphone application infant airway obstruction practice education [
39] had high satisfaction with the practice.
Students’ learning satisfaction with clinical practice is influenced by the clinical environment [
40]. The ward manager’s leadership, the pedagogical environment of the ward, and the role of field leaders are considered crucial [
40]. According to students, the frequency of meetings with field instructors significantly enhances their satisfaction with the clinical practice environment [
40,
41]. It is unfortunate that neither the experimental nor control groups received any intervention related to changes in the clinical practice environment in this study.
The difference in results for learning satisfaction could be attributed to the absence of changes in direct nursing performance opportunities and the direct education of clinical field educators. Essentially, there was a change only in the role of the professor in clinical practice education and in the learner role of students, with no significant change in the role of the leader in the clinical field. Practical training can enhance learning satisfaction in clinical training by providing active guidance for clinical practitioners.
Examining studies related to learners’ learning satisfaction according to teaching and learning methods, it was found that innovative teaching methods do not affect learning satisfaction, independent of learning achievement [
42]. What needs to be considered when applying a new teaching method is the interaction between the instructor and the learner [
43]. In this study, effective interactions between students and instructors were considered; however, interactions with clinical instructors were not considered. Clinical field instructors are educators that nursing students most frequently encounter during clinical practice, making their role a significant factor. Future nursing practice education strategies need to include a clear presentation of the role of field instructors in clinical practice education and an agreement on the contents of education.
Clinical competency in the second stage of the learning evaluation was significantly higher in the experimental group than in the control group. Looking at the results of detailed subfactors, there was the biggest difference in the field of “nursing skill”. It is believed that the process of analyzing specific learning through examples or observations in the clinical field in the m-learning program and linking them with theoretical learning content served as reinforcement of learning. In addition, the lack of cognitive presence, which has been pointed out as a disadvantage of Internet-based but online-mediated learning, is believed to have been compensated for in this study’s strategy.
The researcher’s scenario was used to evaluate students’ skills and scores for clinical performance evaluation in this study. Self-reporting by learners has been the most common method for evaluating clinical performance in previous studies [
44]. In the future, methods that objectively measure students’ technical skills should be developed. In addition, it is necessary to select skills and nursing activities that could strengthen field practice abilities during clinical practice so that learning can be conducted through the stages of theoretical learning, field observation, and actual performance.
Problem-solving ability, which was the second learning evaluation, was significantly higher in the experimental group. The problem-solving process involves problem discovery, problem definition, problem-solving design, problem-solving implementation, and problem-solving review [
45]. It is believed that the experimental group experienced the problem-solving process, as several questions were raised based on their experience in the process of collecting information, analyzing applied cases, and linking them to observed nursing activities. Considering various nursing education intervention studies that improved problem-solving skills, one thing they had in common was that students took the lead in learning by actively using the examples and cases provided [
46]. Improving problem-solving abilities is not the only factor. It requires experience in actively analyzing the process by applying it to examples or cases; therefore, it is necessary to actively reflect this in the nursing practice curriculum.
Finally, there was no significant difference in self-directed learning abilities between the two groups. Looking at previous studies that applied various curricula to nursing education, the effects on self-directed learning abilities were inconsistent [
47]. The factors that influence these conflicting results are that self-directed learning requires a sense of ownership, autonomy, activity, and responsibility for learning [
48]. In the experimental group, the time they had to learn on their own increased as they added m-learning training, compared to the actual control group. Consequently, m-learning education comes across as a burden to students and is considered mandatory, which may dilute their learning motivation and independence. This result is similar to that of a previous study [
49], which found that most nursing students had positive attitudes toward m-learning, although there were some technical difficulties and burdens. Therefore, to expect changes in self-directed learning abilities, it is necessary to provide time for immersion in learning and situational considerations to stimulate and maintain learning motivation.
Another reason why different studies have produced conflicting results is that self-directed learning ability is a habit formed in the long term. A study on web-based surgical nursing learning contents [
50] also showed nonsignificant results regarding self-directed learning ability and explained that the related factor was that it took a long time for self-directed learning ability to improve. Therefore, although the nursing practice education strategy may have an improvement effect on the direct knowledge of related subjects or clinical performance ability, even in a short period, it would be helpful to evaluate self-directed learning ability, which acts as an individual’s study habit, after a long period of education and training. Therefore, we recommend further research to improve self-directed learning abilities through long-term education.
Nursing students receive clinical practice instruction at medical sites from field instructors, but real-time guidance is not consistently provided by instructors at these locations. Therefore, continuous development of teaching and learning methods and media is necessary to achieve learning goals. Online learning is one such method, allowing for convenient learning without time and space constraints. It can be regarded as a technique that facilitates self-directed learning by permitting repeated learning based on the learner’s proficiency level [
51]. Although this study was conducted prior to COVID-19, online learning remains active post-COVID-19, with increasing demand owing to limitations in the clinical environment [
51,
52]. To address the limitations of online learning, this study recommends blended learning, which combines online learning with in-person learning, rather than relying solely on online learning [
53]. This study proposes m-learning clinical content using a tablet PC as a strategy to enhance the effectiveness of clinical practice education for nursing students. This is believed to provide foundational data for future utilization of teaching and learning methods and media in nursing education.