Introduction

Advances in information technology have improved access to health-related information and introduced innovative medical technologies into clinical settings, making the roles of healthcare professionals increasingly complex (Kang et al., 2018). Thus, cultivating professionals with initiative and problem-solving abilities is necessary to ensure quality of care and safety for patients in clinical settings (Sayyah et al., 2017). To achieve this goal, flexible teaching and learning methods are required in nursing school curricula and class designs (Thabet et al., 2017), and students should be exposed to a sufficient variety of clinical cases.

The School of Medicine at McMaster University in Canada first developed and implemented problem-based learning (PBL) in 1969. PBL promotes a learning environment in which medical students are presented with practical and nonstructured clinical cases and problem scenarios. Students must identify and analyze the problems based on their current knowledge and then synthesize and apply solutions via self-directed and heuristic learning (Tekkol & Demirel, 2018; Tudor Car et al., 2019). PBL has since been utilized widely in many medical and nursing schools (Gewurtz et al., 2016; Tudor Car et al., 2019). The results of previous studies (Miterianifa et al., 2019; Sayyah et al., 2017; Solomon, 2020) have confirmed that PBL encourages student-directed active learning and improves critical thinking, problem-analysis, and problem-solving abilities.

However, cases presented within a PBL framework using traditional text-assisted methods do not adequately reproduce actual clinical situations. Thus, multimedia video-assisted scenario presentations have been developed to more accurately convey patients' physical signs, symptoms, and situations to students in a more direct and dynamic manner (de Leng et al., 2007). Educational materials that are familiar and interesting to students accustomed to today's digital and technological environments must be developed (Jackman et al., 2021). Appropriate use of technology is known to promote student participation and improve educational outcomes (Li et al., 2015). Video learning is better able to provide realistic experiences, including observations of patient posture and hearing patient voices to better understand their conditions (Lajoie et al., 2014). A comparison of digital-versus-paper case scenarios (Gavgani et al., 2015) revealed that 73% of students preferred digital scenarios. Another study (de Leng et al., 2007) also reported that using a video-assisted clinical scenario offered medical students a more authentic, holistic, and comprehensive perspective; provided better learning flow; and helped them retain lesson materials for a longer period than using a text-assisted case scenario. Garcia et al. (2017) reported that providing multimedia materials led to better comprehension and cognitive abilities in students compared with text-only materials, as multimedia materials helped reduce the amount of time students are required to process external situations cognitively and strengthened their data integration abilities. A systematic review and meta-analysis (Tudor Car et al., 2019) found that digital PBL improved health professionals' knowledge, attitudes, and satisfaction. However, other studies of medical students (e.g., Woodham et al., 2015) found that, compared with text-assisted cases, PBL using video-assisted cases resulted in lower levels of deep critical thinking, and additional studies were recommended to compare the effects of the two methods. Moreover, although multimedia PBL programs for medical students and health professionals have been developed and assessed in several studies, relevant studies on nursing students are lacking. Furthermore, in light of the wide-ranging societal effects of emerging infectious diseases such as COVID-19 (Morens & Fauci, 2020), more effective methods of conducting non-face-to-face classes are required for teaching nursing students during times when standard in-classroom learning is suspended. Developing video-based PBL is more costly in terms of budget, time, and effort than developing text-based PBL (Watson & Fang, 2012). Moreover, prior studies have reported conflicting results on the effectiveness of using video-based PBL in practice (Morens & Fauci, 2020; Tudor Car et al., 2019; Woodham et al., 2015). As part of designing new learning tools, educators must explore the possibilities and pitfalls of different teaching methods (McCollum, 2020). Thus, comparing video- and text-based PBL in terms of their respective effectiveness in fostering learning in nursing students is necessary.

In their systematic review, Gewurtz et al. (2016) stated that no single theory can fully address the complex features of PBL methodology in undergraduate health education. In response, they identified eight strategies (self-directed learning, enhancing motivation, applicability to clinical practice, using cognitive thinking, active learning, interaction, applying prior knowledge and experience, and progressive elaboration and reflection), which address 11 different theories of learning. These theories include constructivism, adult learning (andragogy), transformative/emancipatory learning, experiential learning, social learning (including vicarious learning), information processing, collaborative/cooperative learning, contextual learning, cognitive load, cognitive learning, and discovery learning. These eight strategies may be applied to PBL in education provided to health professionals.

As evidence-based PBL intervention strategies are required when designing nursing courses, this study was designed to implement and assess the efficacy of a multimedia PBL method using the abovementioned eight strategies in a pediatric nursing course. The outcome variables were chosen to measure the effectiveness of the intervention in terms of learning motivation, problem-solving ability, critical thinking, academic self-efficacy, self-directed learning, and self-leadership, each of which has been reported as significantly influenced by PBL (Kang et al., 2018; Sayyah et al., 2017).

Hypotheses

The following hypotheses regarding the posttest findings were developed:

* Hypothesis 1: The experimental group, which received the online multimedia video-assisted PBL program using the eight strategies developed by Gewurtz et al. (2016), is expected to have higher learning motivation than the control group, which received a traditional text-assisted PBL program.

* Hypothesis 2: The experimental group is expected to have higher problem-solving skills than the control group.

* Hypothesis 3: The experimental group is expected to have higher critical thinking skills than the control group.

* Hypothesis 4: The experimental group is expected to have higher academic self-efficacy than the control group.

* Hypothesis 5: The experimental group is expected to have higher self-directed learning than the control group.

* Hypothesis 6: The experimental group is expected to have higher self-leadership than the control group.

Methods

Design

This quasi-experimental study used a nonequivalent control group pretest-posttest design. An online multimedia video-assisted PBL program that involved the eight strategies developed by Gewurtz et al. (2016) was applied in a pediatric nursing course. The effects of this program on learning motivation, problem-solving skills, critical thinking skills, academic self-efficacy, self-directed learning, and self-leadership in the nursing student participants were assessed (Figure 1).

Figure 1. Research Design

Sample

The target population comprised third-year nursing students enrolled in nursing colleges in South Korea. Otherwise qualified students with at least 1 year of occupational clinical experience before college admission were excluded, as prior hands-on clinical experience may influence the study outcomes.

The sample size was determined using G*Power 3.1.9 software (Faul et al., 2007). To compare the means between the two groups with a one-tailed test at a power of .80, a significance level ([alpha]) of .05, a large effect size (d) of .80, and a degree of freedom of 1, the minimum sample size per group was calculated as 21. Sixty-eight students volunteered and were randomly assigned to the control group (35) and experimental group (33). After excluding two participants in the experimental group who did not complete the postintervention survey, data from 66 participants were available and included in the final analysis, with 31 participants in the experimental group (retention rate: 93.9%) and 35 in the control group (retention rate: 100.0%).

Procedure

The online multimedia video-assisted PBL program was designed and implemented using the Analysis, Design, Development, Implementation, and Evaluation model (Dick et al., 2001).

In the analysis stage, needs analysis, learner analysis, environment analysis, and job and task analysis were performed. In the design stage, course objectives and learning performance-based goals were set to reflect the core competencies promoted by the schools and their departments of nursing. During teaching-learning activities, the participants were separated into five groups of six to seven participants, with each group engaging in the process of identifying key problems in actual clinical cases and exploring solutions to multiple problems based on PBL, which involved discussion and group activities. Instructors facilitated the discussion by providing the multimedia data and guiding students on data usage.

In the development stage, a draft scenario containing a clinical problem was created based on data obtained from a clinical situation (with the patient details modified to ensure privacy). The scenario involved ketoacidosis occurring in a child with insulin-dependent diabetes mellitus, which required prompt evaluation and emergency treatment from health professionals at a university hospital pediatric ward. The students role-played a second-year pediatric nurse in this scenario, and problems were systematically presented that required resolution in the process of evaluating the patient's state and providing appropriate care. The eight strategies proposed by Gewurtz et al. (2016) were used in the PBL program as intervention principles to increase program effectiveness.

The draft scenarios and class operation plans were reviewed in terms of the item content validity index by an expert panel comprising pediatric nursing professors, pediatric residents, pediatric nurses, education professors, and film and digital media professors. Only items with an item content validity index of .8 or higher were included in the final program. The finalized scenarios were filmed as multimedia files at a pediatric ward in one facility, and the filmed videos were reviewed by a pediatric nursing professor, education professors, and film and digital media professors before editing. The videos were edited by film and digital media professors, and the final videos were reviewed by pediatric nursing professors, a pediatrician, pediatric nurses, and an education professor.

In the implementation stage, the experimental group received video-assisted PBL with multimedia technologies and weekly online lectures (100 minutes) for a period of 4 weeks. The two final video clips (approximately 3-5 minutes each) were shown to the entire group, after which the participants were divided into smaller groups to facilitate small-group discussions via Zoom-a cloud-based platform for video conferencing/audioconferencing. Using Google Docs, learning materials were shared and learners could note the discussion content. The faculty members sequentially joined each of the group discussion rooms on Zoom to review the participants' discussions and provide feedback. The intervention content, the eight principles used to guide the intervention strategy, and the elements used in the online multimedia video-assisted PBL program are shown in Table 1.

Table 1. Timetable of the Multimedia Problem-Based Learning Education Program

The control group received traditional face-to-face text-based PBL and weekly lectures (100 minutes) on the same subject and content as the experimental group for a period of 4 weeks. After the postintervention questionnaire was completed, additional video clips and online lecture materials were provided to the experimental group.

In the evaluation stage, learning motivation, problem-solving skills, academic self-efficacy, self-directed learning, and self-leadership were evaluated to assess the comparative effectiveness and efficiency of the online multimedia video-assisted PBL program.

Ethical Considerations

We explained the purpose, method, participant rights, and the questionnaire to the deans of the nursing colleges involved and obtained ethical consent to proceed with the study. The study was approved by the institutional review board of Konyang University (KYU-2020-178-01). The participants provided written consent to participate after being informed about privacy and confidentiality policies and their right to withdraw at any time without incurring disadvantage. Furthermore, the participants were informed that all questionnaire data would be used for research purposes only.

Data Collection

Data were collected from March to October 2021. At baseline, general characteristics and dependent variables (learning motivation, problem-solving skills, critical thinking skills, academic self-efficacy, self-directed learning, and self-leadership) were obtained for the experimental and control groups. A postintervention survey that measured the same independent variables was conducted after completion of the 4-week program.

Instruments

Learning motivation

The course interest survey developed by Keller (1987) was used. The learning motivation component used to assess general classes in the original instrument was modified for this study to assess learning motivation in nursing classes to enable a more accurate identification of learning motivation within this field. This tool consists of 31 items in four domains, with eight items addressing attention, nine addressing relevance, eight addressing confidence, and six addressing satisfaction. Each item is rated on a 5-point Likert scale, with a higher score associated with higher learning motivation. The Cronbach's [alpha] for this survey was .82 in a study by Yu and Chae (2005) and .70 in this study.

Problem-solving skills

The adults' problem-solving skills instrument developed by Lee et al. (2008) was used in this study with permission from the authors. This 30-item tool consists of five domains, with six items in each domain (clarifying problems, exploring solutions, decision making, executing solutions, evaluation, and reflection). Each item is rated on a 5-point Likert scale, with higher scores associated with higher problem-solving skills. The Cronbach's [alpha] for this instrument was .93 at the time of development and .95 in this study.

Critical thinking skills

The critical thinking disposition tool developed by Yoon (2007), which was a standardized measurement of critical thinking skills obtained after assessing the reliability and validity of various tools, was used with permission from the author. This 27-item tool consists of seven domains, including five items in the intellectual passion/curiosity domain, four in the carefulness domain, four in the confidence domain, three in the organization domain, four in the intellectual fairness domain, four in the healthy pessimism domain, and three in the objectivity domain. Each item is rated on a 5-point Likert scale, with higher scores associated with higher critical thinking skills. The Cronbach's [alpha] was .84 in Yoon's (2007) study and .89 in this study.

Academic self-efficacy

The academic self-efficacy scale developed by Kim and Park (2001) based on Bandura's (1986) self-efficacy theory was used in this study with permission from the authors. Some modifications of this scale were made for this study. This 28-item scale comprises three domains, with 10 items in the task difficulty preference domain, 10 in the self-control efficacy domain, and eight in the confidence domain. Each item is rated on a 5-point Likert scale, with higher scores indicating higher academic self-efficacy. The Cronbach's [alpha] was .76-.85 at the time of development and .82 in this study.

Self-directed learning

The self-directed learning readiness scale developed by Guglielmino (1978) was used in this study. This 32-item tool consists of six domains, with eight items in the attachment to learning domain, eight in the self-conviction as a learner domain, eight in the openness to challenge domain, four in the curiosity about learning domain, two in the self-understanding domain, and two in the taking responsibility for learning domain. Each item is rated on a 5-point Likert scale, with higher scores indicating higher self-directed learning. The Cronbach's [alpha] was .88 at the time of development and .90 in this study.

Self-leadership

The revised self-leadership questionnaire developed by Houghton and Neck (2002) was used in this study with permission from the authors. This 35-item scale consists of three domains, with 18 items in the behavior-centered strategy domain, five in the natural reward strategy domain, and 12 in the constructive thinking pattern strategy domain. Each item is rated on a 5-point Likert scale, with higher scores indicating higher self-leadership. The Cronbach's [alpha] was .76 at the time of development and .92 in this study.

Data Analysis

The collected data were analyzed using the statistical package PASW 27.0 for Windows (SPSS Inc., Chicago, IL, USA). As the participants were normally distributed, parametric methods were used. The homogeneity of the general characteristics and dependent variables (learning motivation, problem-solving skills, critical thinking skills, academic self-efficacy, self-directed learning, and self-leadership) between the two groups at baseline was tested using chi-square, Fisher's exact, and independent t tests. Changes in the dependent variables after the program in the two groups were analyzed using independent t tests. The differences in the mean changes between the two groups were analyzed using an independent t test.

Results

Preintervention Characteristics

There were 31 and 35 participants in the experimental and control groups, respectively. In terms of homogeneity in general characteristics between the two groups at baseline, there were no significant differences according to gender (p = .676), grade point average ([chi]² = 1.41, p = .704), major satisfaction (p = .962), clinical practice satisfaction ([chi]² = 0.83, p = .662), or necessity of PBL education for nursing majors ([chi]² = 0.02, p = .900; Table 2).

Table 2. Homogeneity Test of Individual Characteristics (

In terms of homogeneity in the dependent variables between the two groups at baseline, there were no significant differences in learning motivation (p = .896), problem-solving ability (p = .591), critical thinking (p = .139), academic self-efficacy (p = .193), self-directed learning (p = .061), or leadership (p = .083; see Table 3).

Table 3. Homogeneity Test of Dependent Variables (

Hypothesis Tests

The results of the statistical analyses for our hypotheses are summarized in Table 4. Regarding Hypothesis 1, the experimental group reported a higher mean posttest score for learning motivation than did the control group (125.42 [SD = 8.45] vs. 117.51 [SD = 10.98]). The mean increase of 17.10 in the experimental group and 9.46 in the control group showed a significant difference between the two groups, t(64) = 2.42, p = .018, which confirmed Hypothesis 1.

Table 4. Comparison of Dependent Variables Between the Two Groups After Preintervention and Postintervention Tests (

Regarding Hypothesis 2, the experimental group reported a higher mean posttest score for problem-solving skills than did the control group (119.90 [SD = 18.26] vs. 118.83 [SD = 19.88]). The mean increase of 9.65 in the experimental group and 6.43 in the control group did not support a significant difference between the groups, t(64) = 0.23, p = .821, thus rejecting Hypothesis 2.

Regarding Hypothesis 3, the experimental group reported a higher mean posttest score for critical thinking skills than did the control group (99.06 [SD = 11.08] vs. 97.63 [SD = 10.96]). The mean increase of 2.71 in the experimental group and 1.72 in the control group did not support a significant difference between the two groups, t(64) = 0.85, p = .862, thus rejecting Hypothesis 3.

Regarding Hypothesis 4, the experimental group reported a higher mean posttest score for academic self-efficacy than did the control group (99.42 [SD = 7.91] vs. 93.17 [SD = 12.83]). The mean increase of 6.45 in the experimental group and 3.77 in the control group showed a significant difference between the two groups, t(64) = 2.46, p = .017, which confirmed Hypothesis 4.

Regarding Hypothesis 5, the experimental group reported a higher mean posttest score for self-directed learning than did the control group (123.23 [SD = 11.93] vs. 114.11 [SD = 12.09]). The mean increase of 14.39 in the experimental group and mean decrease of 1.80 decrease in the control group showed a significant difference between the two groups, t(64) = 3.62, p = .001, which confirmed Hypothesis 5.

Regarding Hypothesis 6, the experimental group reported a higher mean posttest score for self-leadership than did the control group (136.87 [SD = 16.45] vs. 135.97 [SD = 18.99]). The mean increase of 13.03 in the experimental group and 4.43 in the control group did not support a significant difference between the two groups, t(64) = 1.39, p = .169, thus rejecting Hypothesis 6 (see Table 4).

Discussion

In this study, an online multimedia video-assisted PBL program utilizing the eight strategies proposed by Gewurtz et al. (2016) was developed and provided to nursing students in an experimental group, whereas a traditional face-to-face text-assisted PBL program was provided to a control group. The respective posttest effects of the programs were subsequently compared between the two groups.

Learning motivation increased significantly more in the experimental group than in the control group. In a previous study (Woodham et al., 2015) that did not use the same instrument and measured learning motivation as an outcome of the intervention, a video-assisted PBL program was found to increase engagement and student motivation to analyze learning contents in more detail than a text-assisted PBL program. These findings align with those of this study and are attributed to the limitations faced in capturing situations and backgrounds comprehensively using text only (Woodham et al., 2015). In another study (de Leng et al., 2007), cases presented via video reportedly helped students view these cases from a more holistic perspective and, thus, to engage with them emotionally and via motivating learning. Moreover, as students become accustomed to digital media, it is easier for them to engage with video-case scenarios, which further explains these results. Therefore, subsequent studies should develop digital learning materials for nursing course content addressing both rare and frequently encountered clinical cases. Allowing the participants in this study to become familiar with the use of digital media at the beginning of the intervention helped them engage in the learning materials without technical difficulties by the second week of classes, which further motivated their learning. The individual learning motivation of individuals plays an important role in achievement and learning activities (Steinmayr et al., 2019) and is necessary to produce engaging PBL videos addressing various cases to encourage active learning.

However, the online multimedia video-assisted PBL program did not significantly improve problem-solving skills compared with traditional learning. In Winarno et al.'s (2018) study, solving real-life problems through teamwork was emphasized as a key factor in improving problem solving. In both the experimental and control groups, realistic clinical scenarios were provided and small-group work and discussions were undertaken, which may explain the comparable outcomes with regard to problem-solving skills. In a previous systematic review and meta-analysis (Gavgani et al., 2015), video-assisted cases were identified as involving different cognitive processes and, thus, requiring more time to solve problems. However, another study (de Leng et al., 2007) claimed that video-assisted cases were more helpful than text-assisted cases because students faced problems more dynamically, which facilitates active resolution. However, as no differences in problem-solving skills between the two groups were found in this study, subsequent studies should conduct in-depth reviews and assessments of the difficulties in producing problem scenarios and of methods used in instruction. In addition, future studies should examine the influence of scenario delivery on the effects of programs. Identifying the relevant key factors when designing PBL education is important, given the necessity of presenting problem scenarios in which learners can learn key new knowledge/skills or combine previously learned knowledge/principles to enhance problem-solving abilities (Ibrahim et al., 2018).

In addition, the online multimedia video-assisted PBL program did not significantly improve critical thinking compared with the traditional face-to-face text-assisted PBL program. Previous studies (Balslev et al., 2005; Gavgani et al., 2015) similarly found no significant differences in critical thinking between comparable groups. Woodham et al. (2015) observed that students who engaged in video-assisted PBL faced difficulties identifying problems from the presented data, showed a reduced ability to evaluate and resolve clinical problems, and spent more time interpreting clinical scenarios. In contrast, Conway and McMillan (2018) found that video-assisted case delivery improved critical thinking significantly more than did text-assisted case delivery. Although these studies are not directly comparable because of the heterogeneity in study design and lack of specific application guidelines, they do indicate a need for developing evidence-based guidelines for multimedia video-assisted PBL programs to enhance students' ability to recognize relevant data and strengthen critical thinking skills. One study emphasized the importance of refraining from developing videos that are either overly complex or overly simple to prevent students from giving up or becoming unmotivated, respectively (de Leng et al., 2007). Therefore, the issue of problem presentation should be addressed appropriately when designing video-assisted scenarios. In addition, the facilitator should present structured problems in a manner that promotes cognitive thinking, which requires the development and provision of cues to help students navigate toward a desired outcome/solution. As facilitators are in a strong position to encourage peer support among students and provide appropriate feedback through the e-learning method (Sanchez-Moscona & Eiroa-Orosa, 2021), timely feedback to enhance students' problem-solving abilities that takes into account their individual levels of competency is necessary.

A greater increase in academic self-efficacy was found in the online than in the traditional PBL program. de Leng et al. (2007) reported that video-assisted scenarios provide rich information and help students understand the patient evaluation and communication process as a real-world situation, engage in that situation more fully, and build relationships with the patient. Video-assisted PBL, which simulates real-world situations for learners not yet exposed to such situations in practice, helps learners overcome general fears related to clinical situations, thus increasing academic self-efficacy.

In addition, the online multimedia PBL program improved self-directed learning more than did the traditional face-to-face text-assisted PBL program. A previous systematic review and meta-analysis of the effects of digital PBL (Tudor Car et al., 2019) similarly found comparatively higher levels of knowledge acquisition in digital PBL learners than in traditional PBL learners. This may be attributable to viewing video cases directly without first being filtered through the perspective and interpretation of an instructor, thus ensuring student autonomy in perceiving and observing the presented situations (de Leng et al., 2007). However, overly structuring situations and providing too many cues may hinder self-directed learning. Thus, students' current levels should be considered. When appropriately adapted, having students identify and solve relevant problems from video scenarios on their own has been shown to improve self-directed learning.

In this study, the online multimedia video-assisted PBL program was not shown to improve self-leadership significantly above the level attained using the traditional program. In their meta-analysis of the effectiveness of innovative learning methods in a health science course, Kalaian and Kasim (2017) claimed teaching and learning on one's own to be more effective than being taught by instructors. However, their inclusion of instructor lectures in their experimental program may have influenced these outcomes. Finally, engaging comfortably in remote discussions remains a relatively unfamiliar process for most students, which may have inhibited the improvement effect of the video-assisted PBL program in this study.

Limitations and Conclusion

This study was affected by several limitations. First, the intervention was administered and data were collected at only two universities, which limits the generalizability of findings. Conducting studies across more schools in different countries using randomized controlled trials should increase the generalizability and objectivity of the findings. Second, the intervention program included both face-to-face and contactless modes of communication. However, in light of the growing need for exclusively remote classes because of the COVID-19 pandemic, subsequent studies should compare the effectiveness of online-only and face-to-face-only courses. Third, the Cronbach's alpha for learning motivation was .70, which, although acceptable, is lower than average. Therefore, interpretation of the study results for this variable should be done particularly carefully. In follow-up studies, a more valid instrument should be used to measure learning motivation.

In this study, we used the eight strategies proposed by Gewurtz et al. (2016) to develop an online multimedia video-assisted PBL program. This program generated better student learning outcomes in a pediatric nursing course compared with traditional text-based classroom teaching, with students in the experimental group achieving significantly higher scores for learning motivation, academic self-efficacy, and self-directed learning than their control group peers. Offering multimedia video-assisted scenarios that closely resemble real-world situations was shown to increase willingness to learn in students. With growing demand, especially during periods affected by pandemic restrictions, educational alternatives such as online remote-learning, multimedia video-assisted PBL methods may be developed and used to strengthen self-directed learning.

Acknowledgment

We thank the students who participated enthusiastically in all the classes.

Author Contributions

Study conception and design: SYY

Data analysis and interpretation: SYY

Data collection: YHO

Drafting of the article: SYY

Critical revision of the article: SYY

References