comparative analysis in education

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In This Article Expand or collapse the "in this article" section Comparative Education

Introduction, general overviews.

• The Early Stage
• The 19th Century
• The 20th Century to the Present
• Education and Development
• A Codified Body of Theory and Knowledge Informing the Field
• Shifts in Paradigms
• The Case Study Approach versus Large-Scale Research
• Complexity, Continua, and Transitions
• International Testing Regimes
• Higher Education Programs and Professional Societies
• Scholarly Journals and Publications
• International and Regional Education Databanks and Statistics

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Comparative Education by Robert Arnove , Stephen Franz , Patricia K. Kubow LAST REVIEWED: 29 May 2019 LAST MODIFIED: 29 May 2019 DOI: 10.1093/obo/9780199756810-0152

Comparative education is a loosely bounded field that examines the sources, workings, and outcomes of education systems, as well as leading education issues, from comprehensive, multidisciplinary, cross-national, and cross-cultural perspectives. Despite the diversity of approaches to studying relations between education and society, Arnove, et al. 1992 (cited under General Overviews ) maintains that the field is held together by a fundamental belief that education can be improved and can serve to bring about change for the better in all nations. The authors further note that comparative inquiry often has sought to discover how changes in educational provision, form, and content might contribute to the eradication of poverty or the end of gender-, class-, and ethnic-based inequities. A belief in the transformative power of education systems is aligned with three principal dimensions of the field. Arnove 2013 (cited under General Overviews ) designates these dimensions as scientific/theoretical, pragmatic/ameliorative, and global/international understanding and peace. According to Farrell 1979 (cited under General Overviews ), the scientific dimension of the field relates to theory building with comparison being absolutely essential to understanding what relationships pertain under what conditions among variables in the education system and society. Bray and Thomas 1995 (cited under General Overviews ) point out that comparison enables researchers to look at the entire world as a natural laboratory in viewing the multiple ways in which societal factors, educational policies, and practices may vary and interact in otherwise unpredictable and unimaginable ways. With regard to the pragmatic dimension, comparative educators have studied other societies to learn what works well and why. At the inception of study of comparative education as a mode of inquiry in the 19th century, pioneer Marc-Antoine Jullien de Paris (b. 1775–d. 1848) aimed at not only informing and improving educational policy, but also contributing to greater international understanding. According to Giddens 1991 , Rivzi and Lingard 2010 , and Carney 2009 (all cited under General Overviews ), international understanding has become an even more important feature of comparative education as processes of globalization increasingly require people to recognize how socioeconomic forces, emanating from what were previously considered distant and remote areas of the world, impinge upon their daily lives. The priority given to each of these dimensions varies not only across individuals but also across national and regional boundaries and epistemic communities. Yamada 2015 (cited under General Overviews ), for example, finds notable differences between the discourses and practices of North American and Japanese researchers, with the former tending to locate their research in existing theories and the latter trying to understand a particular situation before eventually finding patterns or elements applicable to a wider situation. Takayama 2011 (cited under General Overviews ) notes that one reason for differences in research traditions is the Japanese emphasis on area studies. The evolution of comparative education as a scholarly endeavor reflects changes in theories, research methodologies, and events on the world stage that have required more sophisticated responses to understanding transformations occurring within and across societies.

The references cited here include leading English-language textbooks in the field that introduce readers to the principal dimensions of comparative education, including its contributions to theory building, more informed and enlightened educational policy and practice, and international understanding and world peace. They illustrate the increasing focus of the field on how globalization impacts national education systems and, in turn, are refracted and changed by local contexts. Japan, which has one of the longest traditions of comparative studies, is included to point out differences in scholarly traditions.

Arnove, Robert F. 2013. Introduction: Reframing comparative education; The dialectic of the global and the local. In Comparative education: The dialectic of the global and the local . 4th ed. Edited by Robert F. Arnove, Carlos Alberto Torres, and Stephen Franz, 1–26. Lanham, MD: Rowman and Littlefield.

The global economy and the increasing interconnectedness of societies pose shared challenges for education worldwide. Understanding the tensions between the global and the local is necessary to reframing the field of comparative education. The global-local dialectic is explored in relation to Africa, Europe, Latin America, the Middle East, and the United States.

Arnove, Robert F., Philip G. Altbach, and Gail P. Kelly. 1992. Introduction. In Emergent issues in education . Edited by Robert F. Arnove, Philip G. Altbach, and Gail P. Kelly, 1–10. Albany: State Univ. of New York Press.

The three editors/authors discuss how the book reflects the field as it emerged in the 1990s. They review the debates over theory that have remained unresolved since they emerged in the 1960s. Issues examined include modernization without Westernization, the role of international donor agencies, the reform of educational governance, public-private relations, the changing patterns of higher education, the education of girls and women, the professionalization of teaching, and the nature of literacy campaigns.

Bray, Mark, and R. Murray Thomas. 1995. Levels of comparison in educational studies: Different insights from different literatures and the value of multilevel analysis. Harvard Educational Review 65.3: 474–491.

DOI: 10.17763/haer.65.3.g3228437224v4877

The initial conceptual framework provided by Bray and Thomas constitutes a seminal contribution to comparative education that alerts scholars to the importance of multilevel units of analysis along three dimensions: geographic/local units (ranging from world/regions/ continents to that of schools/classrooms/individuals); nonlocational demographic units (ranging from ethnic/age/religious/gender groups to entire populations); and aspects of education and society (typically subjects studied, such as curriculum, teaching methods, educational finance, and management structures).

Carney, Stephen. 2009. Negotiating policy in an age of globalization: Exploring educational “policyscapes” in Denmark, Nepal, and China. Comparative Education Review 53.1: 63–68.

DOI: 10.1086/593152

The author explores the processes of policy implementation in Denmark, Nepal, and China. Carney introduces the notion of “policyscape” (one of “hyper-neoliberalism”) as a common context for understanding change efforts at different levels of education in particular localities.

Farrell, Joseph P. 1979. The necessity of comparison in educational studies: Different insights from the salience of science and the problem of comparability. Comparative Education Review 23.1: 3–16.

DOI: 10.1086/446010

In this presidential address, Farrell affirms that all sciences are comparative. The goal of science is not only to establish that relationships exist between variables, but also to determine the range over which they exist. Farrell makes a major contribution in discussing how variables in education-society relations may not be phenomenally identical, but they can be conceptually equivalent. A body of scholarship can be gradually constructed to establish comparative education as a disciplinary field of study.

Giddens, Anthony. 1991. The consequences of modernity . Stanford, CA: Stanford Univ. Press.

Giddens discusses the nature of social institutions at the end of the 20th century. Societies are entering a stage of “high modernity”—not post-modernity—as dominant forms of social and cultural organization have not yet been radically transformed. The current stage of world development provides previously unavailable opportunities for the well-being of humanity; however, it also poses systemic dangers resulting from totalitarian governments, degrading industrial work, environmental destruction, and militarism.

Rivzi, Fazal, and Bob Lingard. 2010. Globalizing education policy . London: Routledge.

The authors critique “the rationalist approach” to policy studies that have a narrow national focus. Instead, they offer insights into how reform trends in curriculum, pedagogy, evaluation, governance, and equity policies are located within a global framework. Their conclusions call for a new imaginary of globalization that challenges the dominance of the “neoliberal construction” of the world based in economics, while strengthening social solidarity and democratic learning within and across national borders.

Takayama, Keita. 2011. Reconceptualizing the politics of Japanese education: Reimagining comparative studies of Japanese education. In Reimagining Japanese education: Borders, transfers, circulations, and the comparative . Edited by David Blake Willis and Jeremy Rappleye, 247–285. Oxford: Symposium Books.

Takayama makes a strong case for viewing a dialogic relation between Japanese and non-Japanese research traditions that enables scholars to draw upon external transformations that have occurred in Japanese society and education in what he calls the “post-post-war time.”

Yamada, Shoko. 2015. The constituent elements of comparative education in Japan: A comparison with North America. Comparative Education Review 59.2: 234–260.

DOI: 10.1086/680172

Yamada analyzes how comparative education has been discussed and practiced in Japan, based on a questionnaire completed by members of the Japan Comparative Education Society and classification of articles published in its journal between 1975 and 2011. This information is then contrasted with North American trends identified by scholars examining research by members of the Comparative and International Education Society and articles in the Comparative Education Review (cited under Scholarly Journals and Publications ).

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A comparative analysis of education costs and outcomes: The United States vs. other OECD countries

Research output : Contribution to journal › Article › peer-review

In this paper we confirm the universality of steadily rising education expenditures among OECD nations, as predicted by "Baumol and Bowen's cost disease", and show that this trajectory of costs can be expected to continue for the foreseeable future. However, we find that while the level of education costs in America is significantly higher than that of all other OECD countries, education spending per student in the United States is increasing about as quickly as it is in many other countries-perhaps even less quickly. Although these cost increases undoubtedly will contribute to each nation's fiscal problems, we conclude that effective education contributes to improvement of the economic performance of each country and can mitigate resulting financial pressures by spurring growth in overall purchasing power.

• Cost disease
• International comparison
• Productivity

ASJC Scopus subject areas

• Economics and Econometrics

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• 10.1016/j.econedurev.2013.12.002

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• Analysis of Education Business & Economics 100%
• Education costs Social Sciences 87%
• OECD Social Sciences 56%
• OECD Countries Business & Economics 54%
• Comparative Analysis Business & Economics 49%
• costs Social Sciences 33%
• education expenditures Social Sciences 29%
• purchasing power Social Sciences 25%

T1 - A comparative analysis of education costs and outcomes

T2 - The United States vs. other OECD countries

AU - Wolff, Edward N.

AU - Baumol, William J.

AU - Saini, Anne Noyes

N1 - Funding Information: We are deeply indebted to the Smith Richardson Foundation for its generous support of this work.

PY - 2014/4

Y1 - 2014/4

N2 - In this paper we confirm the universality of steadily rising education expenditures among OECD nations, as predicted by "Baumol and Bowen's cost disease", and show that this trajectory of costs can be expected to continue for the foreseeable future. However, we find that while the level of education costs in America is significantly higher than that of all other OECD countries, education spending per student in the United States is increasing about as quickly as it is in many other countries-perhaps even less quickly. Although these cost increases undoubtedly will contribute to each nation's fiscal problems, we conclude that effective education contributes to improvement of the economic performance of each country and can mitigate resulting financial pressures by spurring growth in overall purchasing power.

AB - In this paper we confirm the universality of steadily rising education expenditures among OECD nations, as predicted by "Baumol and Bowen's cost disease", and show that this trajectory of costs can be expected to continue for the foreseeable future. However, we find that while the level of education costs in America is significantly higher than that of all other OECD countries, education spending per student in the United States is increasing about as quickly as it is in many other countries-perhaps even less quickly. Although these cost increases undoubtedly will contribute to each nation's fiscal problems, we conclude that effective education contributes to improvement of the economic performance of each country and can mitigate resulting financial pressures by spurring growth in overall purchasing power.

KW - Cost disease

KW - Education

KW - International comparison

KW - Productivity

UR - http://www.scopus.com/inward/record.url?scp=84893515798&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84893515798&partnerID=8YFLogxK

U2 - 10.1016/j.econedurev.2013.12.002

DO - 10.1016/j.econedurev.2013.12.002

M3 - Article

AN - SCOPUS:84893515798

SN - 0272-7757

JO - Economics of Education Review

JF - Economics of Education Review

The Landscapes for Comparative and International Education

• First Online: 01 July 2021

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• Beverly Lindsay 2  

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This introductory chapter highlights the overall objectives and purposes of the volume, to articulate the research and significance of the field of comparative and international education and affairs experienced by Fellows of the Comparative and International Education Society (CIES). They will explicate critical components of their research and policy modalities and postulate how future directions of the field may evolve, based upon ongoing professional involvement in their specialties. Rationales for the subcategories are expounded regarding the salience of crosscutting and interdisciplinary themes. Important dimensions of the field include how the social sciences, humanities, and international affairs have affected the evolving nature of comparative and international education. Hence, the volume is centered around the following themes: (1) succinct history and selection of Fellows by professional societies; (2) conceptual, historical, and theoretical frameworks for enriching the field; (3) pedagogical epistemologies, teachers, and genders to deepen global engagement; (4) policies, practices, and paradigms emerging from applied research; and (5) movements in the new decade.

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Clinical decision making: validation of the nursing anxiety and self-confidence with clinical decision making scale (NASC-CDM ©) into Spanish and comparative cross-sectional study in nursing students

• Daniel Medel   ORCID: orcid.org/0009-0007-5883-295X 1 ,
• Tania Cemeli   ORCID: orcid.org/0000-0002-6683-3756 1 ,
• Krista White   ORCID: orcid.org/0000-0003-4179-5383 2 ,
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• Judith Roca   ORCID: orcid.org/0000-0002-0645-1668 1 , 6  

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Decision making is a pivotal component of nursing education worldwide. This study aimed to accomplish objectives: (1) Cross-cultural adaptation and psychometric validation of the Nursing Anxiety and Self-Confidence with Clinical Decision Making (NASC-CDM©) scale from English to Spanish; (2) Comparison of nursing student groups by academic years; and (3) Analysis of the impact of work experience on decision making.

Cross-sectional comparative study. A convenience sample comprising 301 nursing students was included. Cultural adaptation and validation involved a rigorous process encompassing translation, back-translation, expert consultation, pilot testing, and psychometric evaluation of reliability and statistical validity. The NASC-CDM© scale consists of two subscales: self-confidence and anxiety, and 3 dimensions: D1 (Using resources to gather information and listening fully), D2 (Using information to see the big picture), and D3 (Knowing and acting). To assess variations in self-confidence and anxiety among students, the study employed the following tests: Analysis of Variance tests, homogeneity of variance, and Levene’s correction with Tukey’s post hoc analysis.

Validation showed high internal consistency reliability for both scales: Cronbach’s α = 0.920 and Guttman’s λ2 = 0.923 (M = 111.32, SD = 17.07) for self-confidence, and α = 0.940 and λ2 = 0.942 (M = 80.44, SD = 21.67) for anxiety; and comparative fit index (CFI) of: 0.981 for self-confidence and 0.997 for anxiety. The results revealed a significant and gradual increase in students’ self-confidence ( p  =.049) as they progressed through the courses, particularly in D2 and D3. Conversely, anxiety was high in the 1st year (M = 81.71, SD = 18.90) and increased in the 3rd year (M = 86.32, SD = 26.38), and significantly decreased only in D3. Work experience positively influenced self-confidence in D2 and D3 but had no effect on anxiety.

The Spanish version (NASC-CDM-S©) was confirmed as a valid, sensitive, and reliable instrument, maintaining structural equivalence with the original English version. While the students’ self-confidence increased throughout their training, their levels of anxiety varied. Nevertheless, these findings underscored shortcomings in assessing and identifying patient problems.

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Decision making in nursing is a critical process that all nurses around the world use in their daily practice, involving the assessment of information, the identification of health issues, the establishment of care objectives, and the selection of appropriate interventions to address the patient’s health problems [ 1 , 2 ]. Nursing professionals must effectively apply their knowledge, skills, and clinical judgment to ensure the delivery of safe and high-quality care within the context of complex and ever-evolving situations [ 3 ]. For nearly 25 years, clinical decision-making has been highlighted as one of the key aspects of nursing practice [ 2 , 4 ].

Decision making in nursing does not follow a linear relationship that culminates in the decision made; instead, it has a circular nature that repeats through data collection, alternative selection, reasoning, synthesis, and testing [ 5 ]. Expert nurses, moreover, possess the ability to discern patterns and trends within clinical situations, providing them with a general overview of patient issues and facilitating decision making [ 6 ]. In this iterative and dynamic process, a solid knowledge base, clinical experience, reliable information, and a supportive environment are crucial pillars underpinning clinical decisions [ 7 ]. Therefore, nursing students, during their educational journey, require the support of others in decision making [ 4 ] and adequate training that optimizes their learning opportunities [ 8 ]. Clinical decision-making forms the cornerstone of professional nursing practice [ 9 ].

The process of decision making regarding patient care integrates theoretical knowledge with hands-on experience [ 10 ]. This practical experience has been instrumental in augmenting analytical skills, intuition, and cognitive strategies essential for determining sound judgment and decision-making in complex situations [ 11 ]. Although students’ clinical experience is limited, some of them work as nursing assistants or in support roles. This profile of nursing student is quite common [ 12 ]. Hence, prior work experience in healthcare should be considered in nursing students.

Additionally, it has been suggested that emotional factors, such as heightened levels of anxiety and low self-confidence, may influence clinical decision-making processes [ 13 ]. The Nursing Anxiety and Self-Confidence with Clinical Decision Making (NASC-CDM©) scale is used to make a self-report of how they feel about students’ self-confidence and anxiety levels during clinical decision-making [ 14 ] On one hand, nursing students frequently grapple with elevated stress and anxiety, which adversely affect their learning process [ 15 ]. Conversely, self-confidence is defined as a person’s self-recognition of their abilities and capacity to recognize and manage their emotions [ 16 ]. Self-confidence can foster well-being by strengthening positive emotions among nursing students [ 17 ]. In this regard, one of the leading authors in the study of self-confidence is Albert Bandura (1977) [ 18 ]. He employs the term self-efficacy to describe the belief that one holds in being capable of successfully performing a specific task to achieve a given outcome. Consequently, it can be considered a situationally specific self-confidence [ 19 ]; however, these terms are related to potential emotional barriers in decision making [ 20 ].

In line with the aforementioned, and as a rationale for this study, it should be noted that the NASC-CDM© scale offers significant contributions. Firstly, it highlights the ability to address self-reported levels of self-confidence and anxiety, both independently and interrelatedly, as these two are two distinct constructs with relevant effects on clinical decision making. This separation allows for a more comprehensive and precise understanding of the context [ 21 ]. Secondly, it is worth noting that the scale can be administered to both students and professionals [ 22 ]. The results obtained through this scale enable the identification of areas in which students need improvement and provide nursing educators the opportunity to develop strategies to strengthen students’ clinical decision-making skills [ 14 ].

The absence of a validated Spanish version of the Nursing Anxiety and Self-Confidence with Clinical Decision Making (NASC-CDM©) scale poses a significant challenge for researchers and educators. This limitation hinders the accurate assessment of self-confidence and anxiety levels among Spanish-speaking nursing students and professionals in both clinical decision-making both academic and healthcare settings. In heath research, the availability of reliable measurement tools is crucial to ensure accuracy and comparability across cultural and linguistic contexts [ 23 ]. Moreover, it is noteworthy that the NASC-CDM© scale is not only accessible in English [ 14 ] but also in other languages such as Turkish [ 24 ] and Korean [ 22 ], Therefore, its availability in Spanish presents numerous opportunities for cross-cultural comparisons in academic and healthcare settings, as well as between academic and clinical researchers.

Hence, this study aims to address two deficits in the Spanish context: first, to validate the NASC-CDM© scale in Spanish, and second, to employ it to assess self-confidence and anxiety levels in decision making among nursing students by academic year and the influence of prior work experience. By achieving these objectives, the study seeks to provide educators with essential insights to enhance the teaching and learning process in both academic and environments. Additionally, it aims to offer support students in enhancing their decision-making skills, ultimately fostering the development of proficient healthcare professionals capable of delivering care. Therefore, this study was designed to achieve three primary objectives: (1) To perform a cross-cultural and psychometric validation of the Nursing Anxiety and Self-Confidence scale with the Clinical Decision Making (NASC-CDM©) from English to Spanish Nursing Anxiety and Self-Confidence with Clinical Decision Making– Spanish (NASC-CDM-S©) scale.; (2) To compare groups of nursing students from their first to fourth academic year in terms of anxiety and self-confidence in their decision-making processes; and (3) To Investigate the potential impact of the participants’ work experience on their decision-making abilities. Hence, concerning objectives 2 and 3, the following hypothesis was posited: participants in higher academic years and participants with work experience have higher levels of self-confidence and lower levels of anxiety in their decision-making processes.

This study adopted a quantitative cross-sectional and analytical approach.

Setting and sampling

The study population comprised nursing students from the Faculty of Nursing and Physiotherapy, University of Lleida (Spain). The nursing degree program in Spain consists of 240 European Credit Transfer System (ECTS) credits, approximately equivalent to 6000 h, distributed across 4 academic years (60 ECTS per year, totaling 1500 h per year). One ECTS credit corresponds to 25–30 study hours (Royal Decree 1125/2003). The first year primarily focuses on theoretical training in basic sciences, with more specific nursing sciences covered in higher years. Clinical practices gradually increase, with the fourth year being predominantly practical (1st year 6 ECTS, 2nd year 12 ECTS, 3rd year 24 ECTS, and 4th year 39 ECTS).

A convenience sample of 301 participants was used, representing a non-probability sampling method [ 25 ]. The sample size aligns with the recommended person-item ratio, with a minimum of 10 subjects per item for general psychometric approaches and 300–500 for confirmatory factor analysis (CFA) or conducting propriety analysis [ 23 ]. The NASC-CDM© scale contains 27 items. Inclusion criteria were nursing students from all four academic years who were willing to participate, and no exclusion criteria were specified. Participants received no compensation, and their participation was voluntary.

Instrument and variables

The original version of the NASC-CDM© tool was developed by White [ 14 , 21 ]. The use of this tool for the study was authorized in May 2022 through email communication with the instrument’s creator.

Regarding the original instrument, it is noteworthy that it was validated through an exploratory factor analysis (EFA) with 545 pre-licensure nursing students in the United States. The analysis revealed moderate convergent validity and significant correlations between the self-confidence and anxiety variables that constitute two separate sub-scales within the same instrument. The instrument achieved a Cronbach’s α of 0.98 for self-confidence and 0.94 for anxiety [ 14 , 21 ]. This instrument comprises 27 items and uses a 6-point Likert scale for responses (1 = Not at all; 2 = Only a little; 3 = Somewhat; 4 = Mostly; 5 = Almost completely; 6 = Completely). Scores range from 27 to 162 points. The EFA results confirmed a scale with three dimensions (D1, D2, and D3):

D1 (Using resources to gather information and listening fully) includes statements about recognizing clues or issues and assessing their clinical significance. This dimension comprises 13 items, with a minimum score of 13 and a maximum of 78.

D2 (Using information to see the big picture) includes statements about determining the patient’s primary problem. This dimension contains 7 items, with a minimum score of 7 and a maximum of 42.

D3 (Knowing and acting) includes statements about performing interventions to address the patient’s problem. This dimension consists of 7 items, with a minimum score of 7 and a maximum of 42.

Based on the original tool, the questionnaire used in this study consisted of two parts. It included the following variables: (a) sociodemographic data such as age (numeric), gender (male, female, non-binary), academic year (1st, 2nd, 3rd, 4th), university entrance pathway (secondary school, training courses, other university degrees, over 25–45 years old), and participants’ work experience in healthcare (Yes or No); and (b) 27 paired statements about students’ perceptions of their level of self-confidence and anxiety (dependent variable) in decision making as per the translated NASC-CDM©. Regarding work experience, it should be noted that some nursing students work in healthcare facilities as nursing assistants or in support roles during their nursing studies.

Instrument validation

The tool presented by White [ 14 ] underwent translation and adaptation, following the guidance provided by Sousa & Rojjanasrirat [ 23 ] and Kalfoss [ 26 ]. In the forward-translation (English to Spanish) and back-translation phases, two independent bilingual translators participated, who were not part of the research team and who usually work with health-related translations. The back-translated version of the scale was reviewed and approved by the tool’s creator (Dr. White). These steps ensured content validity.

In the expert panel phase, 5 expert nurse educators from our university who were not part of the research team, with a doctoral degree and more than 5 years of teaching experience, assessed content relevancy. The scale proposed by Sousa & Rojjanasrirat [ 23 ] (1 = not relevant, 2 = unable to assess relevance, 3 = relevant but needs minor alteration, 4 = very relevant and succinct), along with the Kappa index were used to assess agreement. The educators rated the 27 items between 3 and 4. The concordance analysis yielded a score of 0.850, which, as per Landis & Koch [ 27 ], is considered nearly perfect. Only some expressions were modified for better cultural adaptation while retaining the original meaning of the statements. Finally, a pilot test was conducted during the pre-testing phase, involving 20 students, to assess comprehension and completion time. The students encountered no comprehension difficulties, and the average response time was 13 min. Therefore, it was concluded that the questionnaire was feasible in terms of time required taken and clarity of the questions/answers [ 28 ].

This validation process concludes with the psychometric testing of the prefinal version of the translated instrument. During this phase, the psychometric properties are established using a sample from the target population, in this case, nursing students [ 23 ]. The psychometric characteristics examined include: (1) the reliability of internal consistency (Cronbach’s Alpha coefficient (α) and Guttman split-half coefficients (λ2); (2) criterion validity, where the concurrent validity of the new version of the instrument was assessed against the original version via confirmatory factor analysis (CFA), and (3) for construct and structural validity, exploratory factor analysis (EFA) and CFA were conducted to demonstrate the discriminant validity of the instrument by comparing groups within the sample.

Data collection

Data collection took place between May 2022 and June 2023. The lead researcher in a classroom administered the questionnaire in a paper format. Response times ranged from 10 to 15 min.

Data analysis

A descriptive statistical analysis of the participants’ study variables was conducted. Reliability was determined using Cronbach’s Alpha coefficient (α) and Guttman split-half coefficients (λ2) for both sub-scales (self-confidence and anxiety) and their respective dimensions (D1, D2, D3). Cronbach’s provides a measure of item internal consistency, while Guttman split-half coefficient assesses the extent to which observed response patterns align with those expected from a perfect scale [ 29 ]. Item correspondence was reviewed by repeating the exploratory factor analysis (EFA) using the extraction and rotation methods outlined by the tool’s creator [ 14 , 21 ]. Factor validity was confirmed through confirmatory factor analysis (CFA), where a value ≥ 0.9 of the fit indices (comparative fit index (CFI), Tucker-Lewis Index (TLI), Bentler-Bonett Non-normed Fit Index (NNFI), and Bollen’s Incremental Fit Index (IFI) indicate reasonable fit [ 30 ]. The root mean square error of approximation (RMSEA) and the unweighted least square (ULS) estimator was used Likert ordinal data [ 31 ]. Sample adequacy was also reviewed using Kaiser-Meyer-Olkin (KMO), Bartlett’s sphericity test, and average variance extracted (AVE).

Normality tests for self-confidence and anxiety data distribution ( N  = 301) were performed using Kolmogorov-Smirnov test (K-S = 0.043 and 0.41; p  >.05) and multivariable normality (Shapiro-Wilk = 0.993 and 994; p  >.05). The results indicated that all dimensions followed a normal distribution. Consequently, parametric tests such as Pearson’s correlation coefficient (r) and group comparison tests (t-Student) were employed. To analyze differences in self-confidence and anxiety among students by academic year (1st, 2nd, 3rd, 4th), the following tests were conducted: analysis of variance (ANOVA) tests, homogeneity of variance tests, and Levene’s test applying Tukey’s post hoc correction to p -values for combined groups correction for combined groups. Effect sizes were determined using Cohen’s d for t-student tests and eta-squared (η²) for ANOVA tests.

Data were analyzed using IBM SPSS Statistics 24 and JASP 0.18.1. A significance level was set at p  <.05 for all analyses.

The results are presented in 4 sections: (1) Descriptive data of the participants, (2) Psychometric validation study of the NASC-CDM© questionnaire in Spanish (NASC-CDM-S©), (3) Comparative analysis of self-confidence and anxiety in decision making by academic year, and (4) The impact of students’ work experience on their decision-making processes.

Descriptive data of the participants

The nursing study involved 301 participants, mostly women who entered through high school. The sample comprised students from the 1st year of the degree (28.57%, with an average age of 20.43 years), 2nd year (38.54%, with an average age of 21.10 years), 3rd year (3.29%, with an average age of 23.90 years), and 4th year (19.60%, with an average age of 22.92 years). Nearly 2/3 of the participants entered the nursing program from secondary school, and just over 50% had work experience in healthcare. See Table  1 for Sample Characteristics.

Psychometric validation study of the NASC-CDM© questionnaire in Spanish

The set of items showed high internal consistency reliability in both sub-scales. In self-confidence, Cronbach’s α = 0.920, and Guttman’s λ2 = 0.923 (M = 111.32, SD = 17.07) and in anxiety the values were α = 0.940 and λ2 = 0.942 (M = 80.44, SD = 21.67). The KMO adequacy measure was 0.921 for self-confidence and 0.946 for anxiety, and Bartlett’s sphericity was highly significant, resulting in a p -value not exceeding 0.05, indicating a significantly different item correlation matrix (self-confidence χ2 = 4250.632, p  <.001; anxiety χ2 = 5612.051, p  <.001). In addition, the average variance extracted (AVE) index exceeded 0.50, confirming the suitability of the original variables in both sub-scales for structure detection.

To confirm the validity of the factors, agreement of item alignment with the dimensions of the original tool was first examined through EFA (factor loading > 0.4), followed by a confirmatory analysis of the entire scale using CFA. Repeating the EFA, as conducted by White (2011) using alpha factoring extraction and Promax rotation with 3 factors (no eigenvalue), the total variance explained in both scales was 48.30% in self-confidence and 55.30% in anxiety, with an average of 51.80%. The agreement between the items in the resulting factor structure matrix from the EFA and the original matrix were very similar for the anxiety sub-scale (89.90%) but only moderately similar for the self-confidence sub-scale (59.30%), where items did not fall within the same dimensions.

Given the low result, a CFA was conducted based on the dimensions proposed by White (2011). The goodness-of-fit indicators of the model were: (CFI, IFI = 0.981, TLI, NNFI = 0.979, and RMSEA = 0.052) for self-confidence and (CFI, TLI, NNFI, IFI = 0.997 and RMSEA = 0.024) for anxiety. This indicates that the three-factor model retains the description with the original items.

Table  2 shows the estimated factor loadings by dimension and item, illustrating the robust composition of the dimensions with no item elimination. Although items Q5, Q27 and Q11 had factor loadings below 0.60, their KMO values were ≥ 0.80, indicating adequate sampling.

Highly significant correlations were found regarding criterion validity and relevance ( p  <.001). Correlations within the dimensions within the same scale (D1, D2, D3) were positive, whereas the paired correlations between self-confidence and anxiety were inversely correlated, as increased confidence was associated with decreased anxiety: (D1 r  = −.500), (D2 r  = −.500) and (D3 r  = −.532).

Comparative analysis of self-confidence and anxiety in decision making by academic year

The overall results for self-confidence and anxiety by academic year indicated that students significantly and gradually increased their self-confidence ( p  =.049) as they progressed from the 1st year (M = 108.22, SD = 14.96) to the 4th year (M = 115.54, SD = 16.28). However, anxiety was higher in the 1st year (M = 81.71, SD = 18.90) and increased in the 3rd year (M = 86.32, SD = 26.38) (Table  3 ).

Table  4 shows statistically significant differences in dimensions D2 and D3 for self-confidence and D3 for anxiety.

Dimension D1 - using resources to collect information and listening carefully

The post hoc Tukey test results indicate no statistically significant differences between academic years in dimension D1 (Table  4 ). Students in higher academic years did not obtain significantly higher self-confidence or lower anxiety scores (Fig.  1 a). The self-confidence means were similar across all 4 groups, while the anxiety mean had varying values. The highest anxiety was observed in the 3rd year (M = 37.67; SD = 14.63), and the lowest was in the 4th year (M = 31.76; SD = 10.82), although the differences were not statistically significant ( p  =.178).

Comparison graphics of different dimensions of different Academic years ( a ) D1. Using resources to collect information and listening carefully: Post Hoc Comparisons Academic year (1st, 2nd, 3rd, 4th) ( b ) D2. Using information to see the big picture: Post Hoc Comparisons Academic year (1st, 2nd, 3rd, 4th). ( c ) D3. Knowing and acting: Post Hoc Comparisons Academic year (1st, 2nd, 3rd, 4th)

Dimension D2 - using information to see the big picture

Students in the higher academic years (3rd and 4th) obtained significantly higher self-confidence scores (M = 28.69; SD = 5.44) compared to the lowest, which is from the 1st year (M = 25.40; SD = 5.33) (Table  4 ; Fig.  1 b). There was a downward trend in anxiety in the later years, but it was not significant. Once again, the highest mean anxiety was observed in the 3rd year (M = 23.42; SD = 6.80) and the lowest in the 4th year (M = 20.44; DS = 6.39).

Dimension D3 - knowing and acting

This is the only dimension where a balance was maintained: self-confidence increased with academic years, while anxiety decreased. Significant differences in self-confidence scores were observed between the 1st year (M = 23.70; SD = 4.85) and the 4th year (M = 27.13; SD = 5.47). At the same time, anxiety significantly decreased between the 1st year (M = 25.93; SD = 5.90) and the 4th year (M = 22.85; SD = 6.36) (Table  4 ; Fig.  1 c).

Effect of students’ work experience on their decision-making processes

A comparative test was conducted between groups based on work experience to identify explanatory variables regarding the extent of self-confidence and anxiety (Table  5 ). Two significant differences were found, indicating that students with work experience, as opposed to students without experience, had higher self-confidence in D2 (M = 27.66, SD = 5.43 vs. M = 26.63, SD = 5.61) and D3 (M = 26.24, SD = 5.52 vs. M = 24.58, SD = 5.10). Meanwhile, the level of anxiety was similar in both groups.

Furthermore, when contrasting individual items, 7 specific items showed significant differences in self-confidence and 2 in anxiety based on students’ work experience (Table  6 ).

Two items belong to D2- Using information to see the big picture, where experienced students exhibited greater self-confidence in detecting important patient information patterns in I1 (M = 4.10 vs. M = 3.98) and experienced less anxiety (M = 2.96 vs. M = 3.30), and simultaneously evaluated their decisions better with patient laboratory results in I7 (M = 4.00 vs. M = 3.67).

The other five items correspond to D3- Knowing and acting, where nursing students with prior nursing experience felt more self-confidence when deciding the best priority alternative for the patient’s problem in I5 (M = 3.53 vs. M = 3.30), more confidence in implementing an intuition-based intervention in I14 (M = 3.95 vs. M = 3.59) with less anxiety (M = 3.38 vs. M = 3.69), more confidence in analyzing the risks associated with interventions I15 (M = 4.10 vs. M = 3.86) a better ability to make autonomous clinical decisions in I17 (M = 3.71 vs. M = 3.42), and to implement a specific intervention in an emergency in I20 (M = 3.79 vs. M = 3.47).

Given the objectives and results of this study, the discussion is subdivided into two sections: (1) Study of the Nursing Anxiety and Self-Confidence with Clinical Decision Making (NASC-CDM©) scale from English to Spanish, and (2) Assessment of self-confidence and anxiety in nursing students.

Study of the nursing anxiety and self-confidence with clinical decision making (NASC-CDM©) tool

The findings of this study highlight the successful adaptation and validation of the NASC-CDM© scale, originally developed by White [ 14 , 21 ], into Spanish (NASC-CDM-S©). This adaptation process demonstrated high reliability in both self-confidence and anxiety scales. The psychometric study conducted confirmed the validity of the three original dimensions. This result was achieved by examining item concordance with the dimensions of the original scale, followed by CFA of the entire scale. This resulted in a total variance exceeding 40% for both scales and across dimensions, confirming construct validity. The Spanish version effectively maintains the three- dimension groupings (D1, D2 and D3), which also preserves the item descriptions. Consequently, the obtained results align closely with White’s original study [ 14 ] and the Turkish version [ 24 ]. Regarding the loading factor, only one item, I5, “Make a decision on the ‘best’ prioritized alternative for the user’s problem,” had a loading value below 0.30 [ 32 ]. While its factor loading was 0.23 and exhibited a low correlation with the other items ( r  =.22), its KMO ratio was ≥ 0.80, suggesting potential influence by underlying factors such as age or work experience. Therefore, the decision was made to retain it. However, these findings were not replicated in the translation of the NASC-CDM into Korean (KNASC-CDM) (KNASC-CDM) [ 22 ]. The Korean version comprises 23 items grouped into 4 groupings: (i) Listening fully and using resources to gather information; (ii) Using information to see the big picture; (iii) Knowing and acting; and (iv) Seeking information from clinical instructors.

The observed correlations between the dimensions of self-confidence and anxiety provide valuable and interesting insight. The results indicate an inverse relationship between the two, suggesting that strengthening self-confidence can have a positive impact on reducing anxiety. This aspect was corroborated by the original study by White [ 21 ] and Bektas et al. [ 13 ], demonstrating that metacognitive awareness increases nursing students’ self-confidence in clinical decision-making and reduces anxiety.

Furthermore, it is worth noting that the NASC-CDM© scale has been employed in numerous research studies related to nursing education. Therefore, its potential for educational purposes in both academic and clinical settings as a scale for measuring the enhancement of clinical decision-making skills is acknowledged. Several studies [ 33 , 34 , 35 ] suggest the effectiveness of in-person or virtual simulation in enhancing skills related to self-confidence in clinical decision-making, situational awareness, and communication effectiveness among students. Comparing the outcomes of this study with others utilizing the NASC-CDM© scale to gauge self-confidence and anxiety [ 33 , 36 ], it was noted that self-confidence levels increase with diverse teaching strategies, while anxiety levels are not negatively impacted. Overall, these findings underscore the importance of the NASC-CDM© scale in assessing students’ readiness for decision-making, highlighting the necessity to address emotional factors such as anxiety and the need to bolster self-confidence to enhance the education and preparation of future nursing professionals for challenging clinical scenarios.

Assessment of self-confidence and anxiety in nursing students

The results of the comparative study among nursing students across different academic years reveal an intriguing dynamic between self-confidence and anxiety throughout their academic progression. While self-confidence increases as students advance through their courses due to the acquisition of knowledge and skills, anxiety shows variations over time. Regarding confidence perception, some authors [ 37 ] claim that confident students learn better and that this self-confidence increases with experience, leading to improved knowledge [ 13 ].

One factor that might explain the difference in anxiety levels is that in the initial academic years (first and second), clinical practices are conducted in a more guided and supervised manner. In the third, and especially in the fourth year, clinical practices increase in terms of hours and complexity, requiring students to take on more responsibility and autonomy. This factor might account for the higher levels of anxiety in the third year, when students begin to engage in more autonomous practices and specialized units [ 38 , 39 ]. This stage could induce anxiety due to the increased responsibility and potential consequences in patient care. In other words, even though students become more secure in their skills, they may also experience anxiety due to the weight of their clinical practice decisions in the knowledge that they will soon be certified professional nurses caring for patients. This duality is understandable in a context where decision-making has direct implications for patient health and the potential consequences of their actions in patient care. However, this situation is rectified in the fourth or final year, when anxiety decreases, and self-confidence increases. Clinical experience helps students develop skills and self-confidence, which, in turn, reduces anxiety [ 15 , 40 ]. Just as in the case of nurses, the benefits of experience in decision-making are evident in students [ 3 ]. However, some researchers [ 41 ] emphasize the need to reinforce training in aspects such as situational awareness and cognitive apprenticeship to develop decision-making skills in senior students. There is evidence linking emotion and cognition to clinical decision-making [ 42 ].

Results from this study allow for a more detailed analysis by dimensions (D1, D2, D3) across academic years. Dimension 1 - Using resources to gather information and listening fully (D1) is the only dimension that does not show significant differences by year in either self-confidence or anxiety. This dimension includes fundamental aspects of assessment and information gathering (verbal and non-verbal communication, the ability to review the literature, and information provided by others, among others) [ 14 ]. In Dimension 2 - Using information to see the big picture (D2), self-confidence significantly increases, and anxiety decreases, although the latter is not statistically significant. This dimension encompasses aspects related to interpreting information to identify the patient’s actual problem, filtering out irrelevant information, and applying knowledge to the detected problem [ 14 ]. Finally, Dimension 2 - Knowing and acting (D3) - is the only dimension that behaves as hypothesized, with increasing self-confidence and decreasing anxiety. This dimension includes aspects related to training in addressing the problem and detecting the repercussions of the interventions performed, as well as the student’s autonomous ability to address the detected problem [ 14 ].

The results indicate that although students demonstrate skills in applying knowledge and performing interventions (D2 and D3), there appears to be a lack of training proficiency in the comprehensive assessment of the patient as an individual with specific needs (D1). This shortcoming is likely caused by various factors, including lack of experience, inadequate training skills, and the complexity of the assessment process. Understanding the patient is a complex task, as nurses must consider not only physiological indicators. Therefore, this requires time and experience [ 3 ] This implies that students tend to focus more on pathology and standardized care rather than on the patient as a unique individual with specific needs and characteristics.

In contrast, in the case of nurses, when patients do not align with their prior experience, nurses are more motivated to assess the patient and facilitate decision making [ 3 ]. The need for a proper and personalized patient assessment emerges as a crucial point for improvement in the education of nursing students [ 43 ]. Therefore, an educational intervention focused on strengthening the skill of patient assessment throughout the nursing degree program could favor the development of nursing students as future professionals. Such an intervention could include the implementation of more effective assessment tools and the promotion of careful observation of all aspects of the patient. It should extend beyond nursing-specific procedures involving the development of cognitive skills [ 44 ]. Importantly, it should be implemented not only in the academic context but also in the clinical setting. Given that education alone is not an ideal measure [ 3 ], this clinical involvement is essential based on patient-centered health care ( [ 45 ].

Finally, in relation to students with work experience, those who work as nursing assistants during their nursing education exhibit more self-confidence and less anxiety in various items: seeing patterns in patient information (I1) and implementing interventions based on gut feeling or intuition (I14). They also demonstrate higher self-confidence when making a decision about the ‘best’ priority decision option for the patient’s problem (I5), evaluating whether their clinical decision improved the patient’s laboratory results (I7), analyzing the risks of the interventions (I15), making independent clinical decisions to solve the patient’s problem (I17), and implementing a specific intervention in case of an urgent problem (I20). It can be affirmed that experienced students show more self-confidence in having a holistic view of the patient (D2) and in their knowledge and patient-related actions (D3). Other studies [ 46 ] detail the benefits of work experience in emotional control and stress reduction among students. Moreover, students’ prior work experience contributes to decision making, as it provides them with a more realistic understanding of the role and responsibilities of the nursing profession [ 47 ].

Limitations

Due to its cross-sectional design, this study prevents the establishment of causal relationships between self-confidence and anxiety. The study sample was limited to a specific group of students from a single Spanish-speaking university. Similar to the study by Bektas [ 24 ] only voluntary students participated in this study. It is pertinent to acknowledge potential biases in interpreting differences by academic year, as the sample is disproportional in one of the strata (with 9% margin of error), attributed to the absence of third-year students engaged in mobility programs and clinical practices. Moreover, the present study did not evaluate organizational and nursing practice factors, which could explore nursing students’ perceptions regarding clinical decision-making. Finally, even though the availability of the SNASC-CDM will facilitate its use in other Spanish-speaking countries, it is advisable to conduct specific studies to ensure its validity in a cultural context different from Spain.

Implications for nursing education

Nursing degree programs should prioritize the development of students’ self-confidence and the management of their anxiety. This could involve implementing educational interventions, including clinical simulation and reflective teaching that incorporate elements of metacognition. Collaboration across different subjects is essential to foster the integration of skills and knowledge. It is also vital that nursing programs provide students with opportunities to develop their clinical and communication skills. This will help students feel more secure in their abilities and reduce anxiety in challenging clinical settings.

The findings of this study suggest that nursing students face challenges in assessing patients, which can be attributed to various factors, including lack of time, insufficient training, and limited experience. To address this issue, an educational intervention is proposed for nursing students. This intervention would focus on conducting a comprehensive and holistic patient assessment with the support of practicing nurses and involving the patients themselves in identifying problems and needs. Such an intervention should include discussing the significance of considering the patient’s physical, emotional, spiritual, and social needs. It should also emphasize the importance of building a trusting relationship with the patient.

Conclusions

The Spanish version of the NASC-CDM (NASC-CDM-S©) allows for the identification of self-confidence and anxiety in clinical decision-making in Spanish-speaking nursing students. Moreover, it retains the same structure as the original English version. The availability of the NASC-CDM-S© will facilitate its use in other Spanish-speaking countries, thus enhancing the education and preparation of future nursing professionals in clinical situations.

Self-confidence increases as students progress through their academic years due to knowledge and skills acquisition, while anxiety shows variations over time. Specifically, anxiety tends to increase in the third year, when students transition to more autonomous practices and specialized health care units. However, diverse perceptions are identified depending on the dimension. The only dimension that achieves a positive balance in self-confidence and anxiety is D3 (Knowing and acting). Nevertheless, the findings reveal deficiencies in D1 ( Using resources to gather information and listening fully) regarding assessing and detecting problems.

Students with prior work experience show improved self-confidence in D2 and D3, but the level of anxiety does not differ between students with and without work experience. Therefore, targeted interventions addressing emotional and cognitive aspects are needed to enhance clinical decision-making and provide better patient care. Considering these aspects, future lines of research could explore the impact of teaching interventions, as well as conduct further studies on the NASC-CDM-S©, validating it in different Spanish-speaking countries, and applying it in clinical settings with healthcare professionals.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The authors wish to acknowledge the students and experts who assisted us in the validation process. We also wish to acknowledge the translator of this article, Mark Lodge.

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Conceptualization: D.M and J.R.; methodology: D.M, T.C, M J-H. and J.R.; software: W. C-H. and J.R.; validation: J.R.; formal analysis: W. C-H, A T-R, J.R. and A.B; resources: J.R and D.M; data curation: W.C-H., AT-R. and J.R.; writing—original draft preparation: DM, TC, WK, AB, A T-R, J.R.; writing—review and editing: D.M., T.C., K.W., W. C-H. and J.R. and supervision: M. J-H. and J.R. All authors have read and agreed to the published version of the manuscript.

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This study received authorization from the Research Commission of the Faculty of Nursing and Physiotherapy (FIF) of the University of Lleida (UdL). It was approved by the Research and Transfer Ethics Committee (CERT) of the University of Lleida (nº CERT13_31052023) and the data protection officer of the UdL Data Protection Delegate. Data were collected anonymously. Participants were duly informed about the study, and their written consent was obtained before they completed the questionnaire. Participation was voluntary, and the lead researcher of the study securely held the data. Students were informed that their participation or non-participation would have no impact on the course grade or standing at the university. The study conformed to the standards of the Declaration of Helsinki, the Spanish Biomedical Research Act 14/2007 and data processing was covered by EU Regulation 2016/679.

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Medel, D., Cemeli, T., White, K. et al. Clinical decision making: validation of the nursing anxiety and self-confidence with clinical decision making scale (NASC-CDM ©) into Spanish and comparative cross-sectional study in nursing students. BMC Nurs 23 , 265 (2024). https://doi.org/10.1186/s12912-024-01917-w

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Training nurses in an international emergency medical team using a serious role-playing game: a retrospective comparative analysis

• Hai Hu 1 , 2 , 3   na1 ,
• Xiaoqin Lai 2 , 4 , 5   na1 &
• Longping Yan 6 , 7 , 8  

BMC Medical Education volume  24 , Article number:  432 ( 2024 ) Cite this article

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Although game-based applications have been used in disaster medicine education, no serious computer games have been designed specifically for training these nurses in an IEMT setting. To address this need, we developed a serious computer game called the IEMTtraining game. In this game, players assume the roles of IEMT nurses, assess patient injuries in a virtual environment, and provide suitable treatment options.

The design of this study is a retrospective comparative analysis. The research was conducted with 209 nurses in a hospital. The data collection process of this study was conducted at the 2019-2020 academic year. A retrospective comparative analysis was conducted on the pre-, post-, and final test scores of nurses in the IEMT. Additionally, a survey questionnaire was distributed to trainees to gather insights into teaching methods that were subsequently analyzed.

There was a significant difference in the overall test scores between the two groups, with the game group demonstrating superior performance compared to the control group (odds ratio = 1.363, p value = 0.010). The survey results indicated that the game group exhibited higher learning motivation scores and lower cognitive load compared with the lecture group.

Conclusions

The IEMT training game developed by the instructor team is a promising and effective method for training nurses in disaster rescue within IEMTs. The game equips the trainees with the necessary skills and knowledge to respond effectively to emergencies. It is easily comprehended, enhances knowledge retention and motivation to learn, and reduces cognitive load.

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Since the beginning of the twenty-first century, the deployment of international emergency medical teams in disaster-stricken regions has increased world wide [ 1 ]. To enhance the efficiency of these teams, the World Health Organization (WHO) has introduced the International Emergency Medical Team (IEMT) initiative to guarantee their competence. Adequate education and training play a vital role in achieving this objective [ 2 ].

Nurses play a vital role as IEMTs by providing essential medical care and support to populations affected by disasters and emergencies. Training newly joined nurses is an integral part of IEMT training.

Typical training methods include lectures, field-simulation exercises, and tabletop exercises [ 3 , 4 , 5 ]. However, lectures, despite requiring fewer teaching resources, are often perceived as boring and abstract. This may not be the most ideal method for training newly joined nurses in the complexities of international medical responses. However, simulation field exercises can be effective in mastering the knowledge and skills of disaster medicine responsiveness. However, they come with significant costs and requirements, such as extended instructional periods, additional teachers or instructors, and thorough preparation. These high costs make it challenging to organize simulation exercises repeatedly, making them less ideal for training newly joined nurses [ 6 ].

Moreover, classic tabletop exercises that use simple props, such as cards in a classroom setting, have limitations. The rules of these exercises are typically simple, which makes it challenging to simulate complex disaster scenarios. In addition, these exercises cannot replicate real-life situations, making them too abstract for newly joined nurses to fully grasp [ 7 , 8 ].

Recently, game-based learning has gained increasing attention as an interactive teaching method [ 9 , 10 ]. Previous studies have validated the efficacy of game-based mobile applications [ 11 , 12 ]. Serious games that align with curricular objectives have shown potential to facilitate more effective learner-centered educational experiences for trainees [ 13 , 14 ]. Although game-based applications have been used in disaster medicine education, no serious computer games have been designed specifically for training newly joined nurses in an international IEMT setting.

Our team is an internationally certified IEMT organization verified by the WHO, underscoring the importance of providing training for newly joined nurses in international medical responses. To address this need, we organized training courses for them. As part of the training, we incorporated a serious computer game called the IEMTtraining game. In this game, players assume the roles of IEMT nurses, assess patient injuries in a virtual environment, and provide suitable treatment options. This study aims to investigate the effectiveness of the IEMTtraining game. To the best of our knowledge, this is the first serious game specifically designed to train newly joined nurses in an IEMT setting.

The IEMTtraining game was subsequently applied to the training course for newly joined nurses, and this study aimed to investigate its effectiveness. To the best of our knowledge, this is the first serious game specifically designedto train newly joined nurses in an IEMT setting.

Study design

This study was conducted using data from the training records database of participants who had completed the training. The database includes comprehensive demographic information, exam scores, and detailed information from post-training questionnaires for all trainees. We reviewed the training scores and questionnaires of participants who took part in the training from Autumn 2019 to Spring 2020.

The local Institutional Review Committee approved the study and waived the requirement for informed consent due to the study design. The study complied with the international ethical guidelines for human research, such as the Declaration of Helsinki. The accessed data were anonymized.

Participants

A total of 209 newly joined nurses needed to participate in the training. Due to limitations in the size of the training venue, the trainees had to be divided into two groups for the training. All trainees were required to choose a group and register online. The training team provided the schedule and training topic for the two training sessions to all trainees before the training commenced. Each trainee had the opportunity to sign up based on their individual circumstances. Furthermore, the training team set a maximum limit of 110 trainees for each group, considering the dimensions of the training venue. Trainees were assigned on a first-come-first-served basis. In the event that a group reached its capacity, any unregistered trainees would be automatically assigned to another group.

In the fall of 2019, 103 newly joined nurses opted for the lecture training course (lecture group). In this group, instructors solely used the traditional teaching methods of lectures and demonstrations. The remaining 106 newly joined nurses underwent game-based training (game group). In addition to the traditional lectures and demonstrations, the instructor incorporated an IEMTtraining game to enhance the training experience in the game group.

The IEMTTraining game

The IEMTtraining game, a role-playing game, was implemented using the RPG Maker MV Version1.6.1 (Kadokawa Corporation, Tokyo, Tokyo Metropolis, Japan). Players assumed the roles of rescuers in a fictional setting of an earthquake (Part1 of Supplemental Digital Content ).

The storyline revolves around an earthquake scenario, with the main character being an IEMT nurse. Within the game simulation, there were 1000 patients in the scenario. The objective for each player was to treat as many patients as possible to earn higher experience points compared to other players. In addition, within the game scene, multiple nonplayer characters played the role of injured patients. The players navigate the movements of the main character using a computer mouse. Upon encountering injured persons, the player can view their injury information by clicking on them and selecting the triage tags. The player can then select the necessary medical supplies from the kit to provide treatment. Additionally, the player is required to act according to the minimum standards for IEMTs, such as registration in the IEMT coordination cell and reporting of injury information following the minimum data set (MDS) designed by the WHO [ 15 , 16 ]. This portion of the training content imposes uniform requirements for all IEMT members, hence it is necessary for IEMT nurses to learn it. All correct choices result in the accumulation of experience points. Game duration can be set by the instructor and the player with the highest experience points at the end of the game.

Measurement

We have collected the test scores of the trainees in our training database to explore their knowledge mastery. Additionally, we have collected post-training questionnaire data from the trainees to investigate their learning motivation, cognitive load, and technology acceptance.

Pre-test, post-test, and final test

All trainees were tested on three separate occasions: (1) a “pre-test”before the educational intervention, (2) a “post-test”following the intervention, and (3) a “final test”at the end of the term (sixweeks after the intervention). Each test comprised 20 multiple-choice questions (0.5 points per item) assessing the trainees’ mastery of crucial points in their knowledge and decision-making. The higher the score, the better the grade will be.

Questionnaires

The questionnaires used in this study can be found in Part 2 of the Supplemental Digital Content .

The learning motivation questionnaire used in this study was based on the measure developed by Hwang and Chang [ 17 ]. It comprises seven items rated on a six-point scale. The reliability of the questionnaire, as indicated by Cronbach’s alpha, was 0.79.

The cognitive load questionnaire was adapted from the questionnaire developed by Hwang et al [ 18 ]. It consisted of five items for assessing “mental load” and three items for evaluating “mental effort.” The items were rated using a six-point Likert scale. The Cronbach’s alpha values for the two parts of the questionnaire were 0.86 and 0.85, respectively.

The technology acceptance questionnaire, which was only administered to the game group, as it specifically focused on novel teaching techniques and lacked relevance tothe lecture group, was derived from the measurement instrument developed by Chu et al [ 19 ]. It comprised seven items for measuring “perceived ease of use” and six items for assessing “perceived usefulness.” The items were rated on a six-point Likert scale. The Cronbach’s alpha values for the two parts of the questionnaire were 0.94 and 0.95, respectively.

The lecture group received 4 hours of traditional lectures. Additionally, 1 week before the lecture, the trainees were provided with a series of references related to the topic and were required to preview the content before the class. A pre-test was conducted before the lecture to assess the trainees’ prior knowledge, followed by a post-test immediately after the lecture, and a final test 6 weeks after training.

In the game group, the delivery and requirements for references were the same as those in the lecture group. However, the training format differed. The game group received a half-hour lecture introducinggeneral principles, followed by 3 hours of gameplay. The last halfhour was dedicated to summarizing the course and addressing questions or concerns. Similar to the lecture group, the trainees in this group also completed pre-, post-, and final tests. Additionally, a brief survey ofthe teaching methods was conducted at the end of the final test (see Fig.  1 ).

General overview of the teaching procedure. Figure Legend: The diagram shows the teaching and testing processes for the two groups of trainees. Q&A: questions and answers

Data analysis

All data were analyzed using IBM SPSS Statistics (version 20.0;IBM Inc., Armonk, NY, USA). Only the trainees who participated in all three tests were included in the analysis. In total, there were 209 trainees, but 11 individuals (6 from the lecture group and 5 from the game group) were excluded due to incomplete data. Therefore, the data of 198 trainees were ultimately included in the analysis.

In addition, measurement data with a normal distribution were described as mean (standard deviation, SD). In contrast, measurement data with non-normal distributions were expressed as median [first quartile, third quartile]. Furthermore, enumeration data were constructed using composition ratios.

Moreover, a generalized estimating equation (GEE) was employed to compare the groups’ pre-, post-, and final test scores. The Mann–Whitney U test was used to compare the questionnaire scores between the two groups. The statistical significance was set at a level of 0.05.

Among the data included in the analysis, 97 (48.99%) participants were in the lecture group, and 101 (51.01%)were in the game group.

The number of male trainees in the lecture and game groups was 30 (30.93%) and 33 (32.67%), respectively. The mean age of participants in the lecture group was 27.44 ± 4.31 years, whereas that of the game group was 28.05 ± 4.29 years. There were no significant differences in sex or age (Table  1 ). Regarding the test scores, no significant differences were found between the two groups in the pre- and post-tests. However, a significant difference was observed in the final test scores conducted 6 weeks later (Table 1 ).

According to the GEE analysis, the overall scores for the post-test and final test were higher compared to the pre-test scores. Additionally, there was a significant difference in the overall test scores between the two groups, with the game group demonstrating superior performance compared to the control group (odds ratio = 1.363, p value = 0.010). Further details of the GEE results can be found in Part 3 of the supplementary materials .

Table  2 presents the results of the questionnaire ratings for the two groups. The median [first quartile, third quartile] of the learning motivation questionnaire ratings were 4 [3, 4] for the lecture group and 5 [4, 5] for the game group. There were significant differences between the questionnaire ratings of the two groups ( p  < 0.001), indicating that the game group had higher learning motivation for the learning activity.

The median [first quartile, third quartile] of the overall cognitive load ratings were 3 [3, 4] and 4 [4, 5] for the game and lecture groups, respectively. There was a significant difference between the cognitive load ratings of the two groups ( p  < 0.001).

This study further compared two aspects of cognitive load: mental load and mental effort. The median [first quartile, third quartile] for the mental effort dimension were 3 [2, 3] and 4 [4, 5] for the game and lecture groups, respectively (p < 0.001). For mental load, the median [first quartile, third quartile] were 4 [3, 4] and 4 [3, 4] for the game and lecture groups, respectively. There was no significant difference in the mental load ratings between the two groups ( p  = 0.539).

To better understand the trainees’ perceptions of the use of the serious game, this study collected the feedback of the trainees in the game group regarding “perceived usefulness” and “perceived ease of use,” as shown in Table 2 . Most trainees provided positive feedback on the two dimensions of the serious game.

To the best of our knowledge, this IEMT training game is the first serious game intended for newly joined nurses of IEMTs. Therefore, this study presents an initial investigation into the applicability of serious games.

Both lectures and serious games improved post-class test scores to the same level, consistent with previous studies. Krishnan et al. found that an educational game on hepatitis significantly improved knowledge scores [ 20 ]. Additionally, our study showed higher knowledge retention in the game group after 6 weeks, in line with previous studies on serious games. In a study on sexually transmitted diseases, game-based instruction was found to improve knowledge retention for resident physicians compared to traditional teaching methods [ 21 ]. The IEMTtraining game, designed as a role-playing game, is more likely to enhance knowledge retention in newly joined nurses in the long term. Therefore, serious games should be included in the teaching of IEMT training.

This study demonstrated improved learning motivation in the game group, consistent with previous research indicating that game-based learning enhances motivation due to the enjoyable and challenging nature of the games [ 22 , 23 ]. A systematic review by Allan et al. further supports the positive impact of game-based learning tools on the motivation, attitudes, and engagement of healthcare trainees [ 24 ].

As serious games are a novel learning experience for trainees, it is worth investigating the cognitive load they experience. Our study found that serious games effectively reduce trainees’ overall cognitive load, particularly in terms of lower mental effort. Mental effort refers to the cognitive capacity used to handle task demands, reflecting the cognitive load associated with organizing and presenting learning content, as well as guiding student learning strategies [ 25 , 26 ]. This reduction in cognitive load is a significant advantage of serious gaming, as it helps learners better understand and organize their knowledge. However, our study did not find a significant difference in mental load between the two groups. Mental load considers the interaction between task and subject characteristics, based on students’ understanding of tasks and subject characteristics [ 18 ]. This finding is intriguing as it aligns with similar observations in game-based education for elementary and secondary school students [ 27 ], but is the first mention of game-based education in academic papers related to nursing training.

In our survey of the game group participants, we found that their feedback regarding the perceived ease of use and usefulness of the game was overwhelmingly positive. This indicates that the designed game was helpful to learners during the learning process. Moreover, the game’s mechanics were easily understood by the trainees without requiring them to investsignificant time and effort to understand the game rules and controls.

This study had some limitations. First, this retrospective observational study may have been susceptible to sampling bias due to the non-random grouping of trainees. It only reviewed existing data from the training database, and future research should be conducted to validate our findings through prospective studies. Therefore, randomized controlled trials are required. Second, the serious game is currently available only in China. We are currently developing an English version to better align with the training requirements of international IEMT nurses. Third, the development of such serious gamescan be time-consuming. To address this problem, we propose a meta-model to help researchers and instructors select appropriate game development models to implement effective serious games.

An IEMT training game for newly joined nurses is a highly promising training method. Its potential lies in its ability to offer engaging and interactive learning experiences, thereby effectively enhancing the training process. Furthermore, the game improved knowledge retention, increased motivation to learn, and reduced cognitive load. In addition, the game’s mechanics are easily understood by trainees, which further enhances its effectiveness as a training instrument.

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Abbreviations

World Health Organization

International Emergency Medical Team

Minimum Data Set

Generalized estimating eq.

Standard deviation

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Acknowledgements

We would like to thank all the staffs who contribute to the database. We would like to thank Editage ( www.editage.cn ) for English language editing. We also would like to thank Dr. Yong Yang for statistics help. We would like to thank The 10th Sichuan University Higher Education Teaching Reform Research Project (No. SCU10170) and West China School of Medicine (2023-2024) Teaching Reform Research Project (No. HXBK-B2023016) for the support.

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Both Hai Hu and Xiaoqin Lai contributed equally to this work and should be regarded as co-first authors.

Authors and Affiliations

Emergency Management Office of West China Hospital, Sichuan University, The street address: No. 37. Guoxue Road, Chengdu City, Sichuan Province, China

China International Emergency Medical Team (Sichuan), Chengdu City, Sichuan Province, China

Hai Hu & Xiaoqin Lai

Emergency Medical Rescue Base, Sichuan University, Chengdu City, Sichuan Province, China

Day Surgery Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China

Xiaoqin Lai

Department of Thoracic Surgery, West China Tianfu Hospital, Sichuan University, Chengdu City, Sichuan Province, China

West China School of Nursing, Sichuan University, Chengdu City, Sichuan Province, China

Longping Yan

West China School of Public Health, Sichuan University, Chengdu, Sichuan, China

West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China

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Contributions

HH conceived the study, designed the trial, and obtained research funding. XL supervised the conduct of the data collection from the database, and managed the data, including quality control. HH and LY provided statistical advice on study design and analyzed the data. All the authors drafted the manuscript, and contributed substantially to its revision. HH takes responsibility for the paper as a whole.

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Correspondence to Hai Hu .

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Hu, H., Lai, X. & Yan, L. Training nurses in an international emergency medical team using a serious role-playing game: a retrospective comparative analysis. BMC Med Educ 24 , 432 (2024). https://doi.org/10.1186/s12909-024-05442-x

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