Since the COVID-19 epidemic, the country has begun to pay more attention to the clinical teaching function of university hospitals. Strengthening the integration of medicine and education and improving the quality and effectiveness of clinical teaching are major challenges facing medical education. The difficulty of teaching orthopedics lies in the wide variety of diseases, high professionalism and relatively abstract characteristics, which influence the initiative, enthusiasm and effectiveness of teaching of medical students. This study developed a flipped classroom teaching plan based on the CDIO (Concept-Design-Implement-Operate) concept and implemented it in an orthopedic nursing student training course to improve the practical learning effect and help teachers realize flipping the future of nursing education and even medical education. Classroom learning will be more effective and focused.
Fifty medical students who completed an internship in the orthopedic department of a tertiary hospital in June 2017 were included in the control group, and 50 nursing students who completed an internship in the department in June 2018 were included in the intervention group. The intervention group adopted the CDIO concept of the flipped classroom teaching model, while the control group adopted the traditional teaching model. After completing the practical tasks of the department, two groups of students were assessed on theory, operational skills, independent learning ability and critical thinking ability. Two groups of teachers completed eight measures assessing clinical practice capabilities, including four nursing processes, humanistic nursing capabilities, and an assessment of the quality of clinical teaching.
After training, clinical practice ability, critical thinking ability, independent learning ability, theoretical and operational performance, and clinical teaching quality scores of the intervention group were significantly higher than those of the control group (all P < 0.05).
The teaching model based on CDIO can stimulate nursing interns’ independent learning and critical thinking ability, promote the organic combination of theory and practice, improve their ability to comprehensively use theoretical knowledge to analyze and solve practical problems, and improve the learning effect.
Clinical education is the most important stage of nursing education and involves the transition from theoretical knowledge to practice. Effective clinical learning can help nursing students master professional skills, strengthen professional knowledge, and improve their ability to practice nursing. It is also the final stage of career role transition for medical students [1]. In recent years, many clinical teaching researchers have conducted research on teaching methods such as problem-based learning (PBL), case-based learning (CBL), team-based learning (TBL), and situational learning and situational simulation learning in clinical teaching. . However, different teaching methods have their advantages and disadvantages in terms of the learning effect of practical connections, but they do not achieve the integration of theory and practice [2].
The “flipped classroom” refers to a new learning model in which students use a specific information platform to independently study a variety of educational materials before class and complete homework in a form of “collaborative learning” in the classroom while teachers guide students. Answer questions and provide personalized assistance[3]. The American New Media Alliance noted that the flipped classroom adjusts time inside and outside the classroom and transfers student learning decisions from teachers to students [4]. The valuable time spent in the classroom in this learning model allows students to focus more on active, problem-based learning. Deshpande [5] conducted a study on flipped classroom in paramedic education and teaching and concluded that flipped classroom can improve students’ learning enthusiasm and academic performance and reduce class time. Khe Fung HEW and Chung Kwan L.O. [6] examined the research results of comparative articles on the flipped classroom and summarized the overall effect of the flipped classroom teaching method through meta-analysis, indicating that compared with traditional teaching methods, the flipped classroom teaching method in professional health education is significantly better and improves student learning. Zhong Jie [7] compared the effects of flipped virtual classroom and flipped physical classroom hybrid learning on students’ knowledge acquisition, and found that in the process of hybrid learning in flipped histology classroom, improving the quality of online teaching can improve students’ satisfaction and knowledge. hold. Based on the above research results, in the field of nursing education, most scholars study the effect of flipped classroom on classroom teaching effectiveness and believe that flipped classroom teaching can improve nursing students’ academic performance, independent learning ability, and classroom satisfaction.
Therefore, there is an urgent need to explore and develop a new teaching method that will help nursing students absorb and implement systematic professional knowledge and improve their clinical practice ability and comprehensive quality. CDIO (Concept-Design-Implement-Operate) is an engineering education model developed in 2000 by four universities, including the Massachusetts Institute of Technology and the Royal Institute of Technology in Sweden. It is an advanced model of engineering education that allows nursing students to learn and acquire abilities in an active, hands-on, and organic manner [8, 9]. In terms of core learning, this model emphasizes “student-centeredness,” allowing students to participate in the conception, design, implementation, and operation of projects, and to transform acquired theoretical knowledge into problem-solving tools. Numerous studies have shown that the CDIO teaching model contributes to improving clinical practice skills and comprehensive quality of medical students, improving teacher-student interaction, improving teaching efficiency, and plays a role in promoting informatization reform and optimizing teaching methods. It is widely used in applied talent training [10].
With the transformation of the global medical model, people’s demands for health are increasing, which has also led to an increase in the responsibility of medical personnel. The ability and quality of nurses is directly related to the quality of clinical care and patient safety. In recent years, the development and assessment of clinical abilities of nursing staff has become a hot topic in the field of nursing [11]. Therefore, an objective, comprehensive, reliable, and valid assessment method is critical for medical education research. The mini-clinical evaluation exercise (mini-CEX) is a method for assessing the comprehensive clinical abilities of medical students and is widely used in the field of multidisciplinary medical education at home and abroad. It gradually appeared in the field of nursing [12, 13].
Many studies have been conducted on the application of the CDIO model, flipped classroom, and mini-CEX in nursing education. Wang Bei [14] discussed the impact of the CDIO model on improving nurse-specific training for the needs of COVID-19 nurses. The results suggest that using the CDIO training model to provide specialized nursing training on COVID-19 will help nursing staff better acquire specialized nursing training skills and related knowledge, and comprehensively improve their comprehensive nursing skills. Scholars such as Liu Mei [15] discussed the application of team teaching method combined with flipped classroom in training orthopedic nurses. The results showed that this teaching model can effectively improve the basic abilities of orthopedic nurses such as comprehension. and application of theoretical knowledge, teamwork, critical thinking, and scientific research. Li Ruyue et al. [16] studied the effect of using the improved Nursing Mini-CEX in the standardized training of new surgical nurses and found that teachers could use the Nursing Mini-CEX to evaluate the entire assessment and performance process in clinical teaching or work.weak links in her. nurses and provide real-time feedback. Through the process of self-monitoring and self-reflection, the basic points of nursing performance evaluation are learned, the curriculum is adjusted, the quality of clinical teaching is further improved, the comprehensive surgical clinical nursing ability of students is improved, and the flipped classroom combination based on the CDIO concept is tested, but there is currently no research report. Application of the mini-CEX assessment model to nursing education for orthopedic students. The author applied the CDIO model to the development of training courses for orthopedic nursing students, built a flipped classroom based on the CDIO concept, and combined with the mini-CEX assessment model to implement a three-in-one learning and quality model. knowledge and abilities, and also contributed to improving the quality of teaching. Continuous improvement provides the basis for practice-based learning in teaching hospitals.
To facilitate the implementation of the course, a convenience sampling method was used as study subjects to select nursing students from 2017 and 2018 who were practicing in the orthopedic department of a tertiary hospital. Since there are 52 trainees at each level, the sample size will be 104. Four students did not participate in full clinical practice. The control group included 50 nursing students who completed an internship in the orthopedic department of a tertiary hospital in June 2017, of which 6 men and 44 women aged 20 to 22 (21.30 ± 0.60) years, who completed an internship at that the same department in June 2018. The intervention group included 50 medical students, including 8 men and 42 women aged 21 to 22 (21.45±0.37) years. All subjects gave informed consent. Inclusion Criteria: (1) Orthopedic medical internship students with a bachelor’s degree. (2) Informed consent and voluntary participation in this study. Exclusion criteria: Individuals who are unable to fully participate in clinical practice. There is no statistically significant difference in the general information of the two groups of medical student trainees (p>0.05) and they are comparable.
Both groups completed a 4-week clinical internship, with all courses completed in the Department of Orthopedics. During the observation period, there were a total of 10 groups of medical students, 5 students in each group. Training is carried out in accordance with the internship program for nursing students, including theoretical and technical parts. The teachers in both groups have the same qualifications, and the nurse teacher is responsible for monitoring the quality of teaching.
The control group used traditional teaching methods. During the first week of school, classes begin on Monday. Teachers teach theory on Tuesdays and Wednesdays, and focus on operational training on Thursdays and Fridays. From the second to the fourth week, each faculty member is responsible for a medical student giving occasional lectures in the department. In the fourth week, assessments will be completed three days before the end of the course.
As mentioned earlier, the author adopts a flipped classroom teaching method based on the CDIO concept, as detailed below.
The first week of training is the same as in the control group; Weeks two through four of orthopedic perioperative training utilize a flipped classroom teaching plan based on the CDIO concept for a total of 36 hours. The ideation and design part is completed in the second week and the implementation part is completed in the third week. Surgery was completed in the fourth week, and assessment and evaluation were completed three days before discharge. See Table 1 for specific class time distributions.
A teaching team consisting of 1 senior nurse, 8 orthopedic faculty and 1 non-orthopedic CDIO nursing expert was established. The Chief Nurse provides teaching team members with the study and mastery of the CDIO curriculum and standards, the CDIO workshop manual and other related theories and specific implementation methods (at least 20 hours), and consults with experts at all times on complex theoretical teaching issues. Faculty set learning objectives, manage the curriculum, and prepare lessons in a consistent manner consistent with adult nursing requirements and the residency program.
According to the internship program, with reference to the CDIO talent training program and standards [17] and in combination with the teaching characteristics of the orthopedic nurse, the learning objectives of nursing interns are set in three dimensions, namely: knowledge objectives (mastering basic knowledge), professional knowledge and related system processes, etc.), competency goals (improving basic professional skills, critical thinking skills and independent learning abilities, etc.) and quality goals (building sound professional values and a spirit of humanistic caring and etc.). .). Knowledge goals correspond to the technical knowledge and reasoning of the CDIO curriculum, personal abilities, professional abilities and relationships of the CDIO curriculum, and quality goals correspond to the soft skills of the CDIO curriculum: teamwork and communication.
After two rounds of meetings, the teaching team discussed a plan for teaching nursing practice in a flipped classroom based on the CDIO concept, divided the training into four stages, and determined the goals and design, as shown in Table 1.
After analyzing nursing work on orthopedic diseases, the teacher identified cases of common and common orthopedic diseases. Let’s take the treatment plan for patients with lumbar disc herniation as an example: Patient Zhang Moumou (male, 73 years old, height 177 cm, weight 80 kg) complained of “lower back pain accompanied by numbness and pain in the left lower limb for 2 months” and was hospitalized in an outpatient clinic. As a patient Responsible nurse: (1) Please systematically ask the patient’s history based on the knowledge you have acquired and determine what is happening to the patient; (2) Select systematic survey and professional assessment methods based on the situation and suggest survey questions that require further evaluation; (3) Perform nursing diagnosis. In this case, it is necessary to combine the case search database; record targeted nursing interventions related to the patient; (4) Discuss existing problems in patient self-management, as well as current methods and content of patient follow-up upon discharge. Post student stories and task lists two days before class. The task list for this case is as follows: (1) Review and reinforce theoretical knowledge about the etiology and clinical manifestations of lumbar intervertebral disc herniation; (2) Develop a targeted care plan; (3) Develop this case based on clinical work and implement preoperative and postoperative care are the two main scenarios of teaching project simulation. Nursing students independently review course content with practice questions, consult relevant literature and databases, and complete self-study tasks by logging into the WeChat group.
Students freely form groups, and the group selects a group leader who is responsible for dividing labor and coordinating the project. The pre-team leader is responsible for disseminating four contents: case introduction, nursing process implementation, health education, and disease-related knowledge to each team member. During the internship, students use their free time to research theoretical background or materials to solve case problems, conduct team discussions, and improve specific project plans. In project development, the teacher assists the team leader in assigning team members to organize relevant knowledge, develop and produce projects, demonstrate and modify designs, and assist nursing students in integrating career-related knowledge into design and production. Gain knowledge of each module. The challenges and key points of this research group were analyzed and developed, and the implementation plan for the scenario modeling of this research group was implemented. During this phase, teachers also organized nursing round demonstrations.
Students work in small groups to present projects. Following the report, other group members and faculty members discussed and commented on the reporting group to further improve the nursing care plan. The team leader encourages team members to simulate the entire care process, and the teacher helps students explore the dynamic changes of disease through simulated practice, deepen their understanding and construction of theoretical knowledge, and develop critical thinking skills. All content that must be completed in the development of specialized diseases is completed under the guidance of teachers. Teachers comment and guide nursing students to perform bedside practice to achieve a combination of knowledge and clinical practice.
After evaluating each group, the instructor made comments and noted each group member’s strengths and weaknesses in the content organization and skill process to continually improve the nursing students’ understanding of the learning content. Teachers analyze teaching quality and optimize courses based on nursing student evaluations and teaching evaluations.
Nursing students take theoretical and practical exams after practical training. The theoretical questions for the intervention are asked by the teacher. The intervention papers are divided into two groups (A and B), and one group is randomly selected for the intervention. The intervention questions are divided into two parts: professional theoretical knowledge and case analysis, each worth 50 points for a total score of 100 points. Students, when assessing nursing skills, will randomly select one of the following, including the axial inversion technique, good limb positioning technique for patients with spinal cord injury, use of pneumatic therapy technique, technique of using the CPM joint rehabilitation machine, etc. Full score is 100 points.
In week four, the Independent Learning Assessment Scale will be assessed three days before the end of the course. The independent assessment scale for learning ability developed by Zhang Xiyan [18] was used, including learning motivation (8 items), self-control (11 items), ability to collaborate in learning (5 items), and information literacy (6 items). Each item is rated on a 5-point Likert scale from “not at all consistent” to “completely consistent,” with scores ranging from 1 to 5. The total score is 150. The higher the score, the stronger the ability to learn independently. The Cronbach’s alpha coefficient of the scale is 0.822.
In the fourth week, a critical thinking ability rating scale was assessed three days before discharge. The Chinese version of the Critical Thinking Ability Assessment Scale translated by Mercy Corps [19] was used. It has seven dimensions: truth discovery, open thinking, analytical ability and organizing ability, with 10 items in each dimension. A 6-point scale is used ranging from “strongly disagree” to “strongly agree” from 1 to 6, respectively. Negative statements are reverse scored, with a total score ranging from 70 to 420. A total score of ≤210 indicates negative performance, 211–279 indicates neutral performance, 280–349 indicates positive performance, and ≥350 indicates strong critical thinking ability. The Cronbach’s alpha coefficient of the scale is 0.90.
In the fourth week, a clinical competency assessment will take place three days before discharge. The mini-CEX scale used in this study was adapted from the Medical Classic [20] based on the mini-CEX, and failure was scored from 1 to 3 points. Meets requirements, 4-6 points for meeting requirements, 7-9 points for good. Medical students complete their training after completing a specialized internship. The Cronbach’s alpha coefficient of this scale is 0.780 and the split-half reliability coefficient is 0.842, indicating good reliability.
In the fourth week, the day before leaving the department, a symposium of teachers and students and an assessment of the quality of teaching were held. The teaching quality evaluation form was developed by Zhou Tong [21] and includes five aspects: teaching attitude, teaching content, and teaching. Methods, effects of training and characteristics of training. A 5-point Likert scale was used. The higher the score, the better the quality of teaching. Completed after completing a specialized internship. The questionnaire has good reliability, with Cronbach’s alpha of the scale being 0.85.
Data were analyzed using SPSS 21.0 statistical software. Measurement data are expressed as mean ± standard deviation (\(\strike X \pm S\)) and intervention group t is used for comparison between groups. Count data were expressed as number of cases (%) and compared using chi-square or Fisher’s exact intervention. A p value <0.05 indicates a statistically significant difference.
A comparison of the theoretical and operational intervention scores of the two groups of nurse interns is shown in Table 2 .
A comparison of the independent learning and critical thinking abilities of the two groups of nurse interns is shown in Table 3.
A comparison of clinical practice ability assessments between two groups of nurse interns. The clinical nursing practice ability of students in the intervention group was significantly better than that in the control group, and the difference was statistically significant (p < 0.05) as shown in Table 4.
The results of assessing the teaching quality of the two groups showed that the total teaching quality score of the control group was 90.08 ± 2.34 points, and the total teaching quality score of the intervention group was 96.34 ± 2.16 points. The difference was statistically significant. (t = – 13.900, p < 0.001).
The development and progress of medicine requires sufficient practical accumulation of medical talent. Although many simulation and simulation training methods exist, they cannot replace clinical practice, which is directly related to the ability of future medical talent to treat diseases and save lives. Since the COVID-19 epidemic, the country has paid more attention to the clinical teaching function of university hospitals [22]. Strengthening the integration of medicine and education and improving the quality and effectiveness of clinical teaching are major challenges facing medical education. The difficulty of teaching orthopedics lies in the wide variety of diseases, high professionalism and relatively abstract characteristics, which affects the initiative, enthusiasm and learning ability of medical students [23].
The flipped classroom teaching method within the CDIO teaching concept integrates learning content with the process of teaching, learning and practice. This changes the structure of classrooms and places nursing students at the core of teaching. During the educational process, teachers help nursing students independently access relevant information on complex nursing issues in typical cases [24]. Research shows that CDIO includes task development and clinical teaching activities. The project provides detailed guidance, closely combines the consolidation of professional knowledge with the development of practical work skills, and identifies problems during simulation, which is useful for nursing students in improving their independent learning and critical thinking abilities, as well as for guidance during independent learning. -study. The results of this study show that after 4 weeks of training, the independent learning and critical thinking abilities scores of nursing students in the intervention group were significantly higher than those in the control group (both p < 0.001). This is consistent with the results of Fan Xiaoying’s study on the effect of CDIO combined with CBL teaching method in nursing education [25]. This training method can significantly improve trainees’ critical thinking and independent learning abilities. During the ideation phase, the teacher first shares difficult points with the nursing students in the classroom. Nursing students then independently studied relevant information through micro-lecture videos and actively sought out relevant materials to further enrich their understanding of the orthopedic nursing profession. During the design process, nursing students practiced teamwork and critical thinking skills through group discussions, guided by faculty and using case studies. During the implementation phase, educators view perioperative care of real-life illnesses as an opportunity and use case simulation teaching methods to teach nursing students to conduct case exercises in group collaboration to familiarize themselves with and discover problems in nursing work. At the same time, by teaching real cases, nursing students can learn the key points of preoperative and postoperative care so that they clearly understand that all aspects of perioperative care are important factors in the patient’s postoperative recovery. At the operational level, teachers help medical students master theories and skills in practice. In doing so, they learn to observe changes in conditions in real cases, to think about possible complications, and not to memorize various nursing procedures to assist medical students. The process of construction and implementation organically combines the content of training. In this collaborative, interactive and experiential learning process, nursing students’ self-directed learning ability and enthusiasm for learning are well mobilized and their critical thinking skills are improved. Researchers used Design Thinking (DT)-Conceive-Design-Implement-Operate (CDIO)) to introduce an engineering design framework into offered web programming courses to improve students’ academic performance and computational thinking (CT) abilities, and the results show, that students’ academic performance and computational thinking abilities are significantly improved [26].
This study helps nursing students to participate in the entire process according to the Questioning-Concept-Design-Implementation-Operation-Debriefing process. Clinical situations have been developed. The focus then is on group collaboration and independent thinking, supplemented by a teacher answering questions, students suggesting solutions to problems, data collection, scenario exercises, and finally bedside exercises. The results of the study showed that the scores of medical students in the intervention group on the assessment of theoretical knowledge and operational skills were better than those of students in the control group, and the difference was statistically significant (p < 0.001). This is consistent with the fact that medical students in the intervention group had better results on the assessment of theoretical knowledge and operational skills. Compared with the control group, the difference was statistically significant (p<0.001). Combined with relevant research results [27, 28]. The reason for the analysis is that the CDIO model first selects disease knowledge points with higher incidence rates, and secondly, the complexity of the project settings matches the baseline. In this model, after students complete the practical content, they complete the project task book as needed, revise the relevant content, and discuss the assignments with group members to digest and internalize the learning content and synthesize new knowledge and learning. Old knowledge in a new way. Knowledge assimilation improves.
This study shows that through the application of the CDIO clinical learning model, nursing students in the intervention group were better than nursing students in the control group at performing nursing consultations, physical examinations, determining nursing diagnoses, implementing nursing interventions, and nursing care. consequences. and humanistic care. In addition, there were statistically significant differences in each parameter between the two groups (p < 0.05), which was similar to the results of Hongyun [29]. Zhou Tong [21] studied the effect of applying the Concept-Design-Implement-Operate (CDIO) teaching model in the clinical practice of cardiovascular nursing teaching, and found that students in the experimental group used CDIO clinical practice . Teaching method in nursing process, humanities Eight parameters, such as nursing ability and conscientiousness, are significantly better than those of nursing students using traditional teaching methods. This may be because in the learning process, nursing students no longer passively accept knowledge , but use their own abilities. acquire knowledge in various ways. Team members fully unleash their team spirit, integrate learning resources, and repeatedly report, practice, analyze, and discuss current clinical nursing issues. Their knowledge develops from superficial to deep, paying more attention to the specific content of cause analysis. health problems, formulation of nursing goals and feasibility of nursing interventions. Faculty provide guidance and demonstration during discussions to form a cyclic stimulation of perception-practice-response, help nursing students complete a meaningful learning process, improve nursing students’ clinical practice abilities, enhance learning interest and effectiveness, and continually improve student clinical practice – nurses. . ability. The ability to learn from theory to practice, completing the assimilation of knowledge.
The implementation of CDIO-based clinical education programs improves the quality of clinical education. The research results of Ding Jinxia [30] and others show that there is a correlation between various aspects such as learning motivation, independent learning ability, and effective teaching behavior of clinical teachers. In this study, with the development of CDIO clinical teaching, clinical teachers received enhanced professional training, updated teaching concepts, and improved teaching abilities. Secondly, it enriches clinical teaching examples and cardiovascular nursing education content, reflects the orderliness and performance of the teaching model from a macro perspective, and promotes students’ understanding and retention of course content. Feedback after each lecture can promote self-awareness of clinical teachers, encourage clinical teachers to reflect on their own skills, professional level and humanistic qualities, truly realize peer learning, and improve the quality of clinical teaching. The results showed that the teaching quality of clinical teachers in the intervention group was better than that in the control group, which was similar to the results of the study by Xiong Haiyang [31].
Although the results of this study are valuable for clinical teaching, our study still has several limitations. First, the use of convenience sampling may limit the generalizability of these findings, and our sample was limited to one tertiary care hospital. Secondly, the training time is only 4 weeks, and nurse interns need more time to develop critical thinking skills. Third, in this study, the patients used in the Mini-CEX were real patients without training, and the quality of the trainee nurses’ course performance may vary from patient to patient. These are the main issues that limit the results of this study. Future research should expand sample size, increase training of clinical educators, and unify standards for developing case studies. A longitudinal study is also needed to investigate whether the flipped classroom based on the CDIO concept can develop comprehensive abilities of medical students in the long term.
This study developed the CDIO model in course design for orthopedic nursing students, constructed a flipped classroom based on the CDIO concept, and combined it with the mini-CEX assessment model. The results show that the flipped classroom based on the CDIO concept not only improves the quality of clinical teaching, but also improves students’ independent learning ability, critical thinking, and clinical practice ability. This teaching method is more reliable and effective than traditional lectures. It can be concluded that the results may have implications for medical education. The flipped classroom, based on the CDIO concept, focuses on teaching, learning and practical activities and closely combines the consolidation of professional knowledge with the development of practical skills to prepare students for clinical work. Given the importance of providing students with the opportunity to actively participate in learning and practice, and considering all aspects, it is proposed that a clinical learning model based on CDIO be used in medical education. This approach can also be recommended as an innovative, student-centered approach to clinical teaching. In addition, the findings will be very useful to policymakers and scientists when developing strategies to improve medical education.
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
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Post time: Feb-24-2024