Digital Microlearning for Patient-Safety Readiness in Nursing Students

The transition from classroom-based nursing education to surgical clinical practice is a critical period for patient safety. Students entering clinical practice must recognize safety risks and clinical errors, prioritize an appropriate response, and communicate or escalate concerns within a supervised clinical environment. Short, scenario-based digital learning may support this transition by linking recognizable clinical cues with specific safety actions and by providing repeated retrieval and corrective feedback close to the start of clinical practice.

This study was a single-center, two-arm, parallel randomized controlled trial embedded within an explanatory sequential mixed-methods design (QUAN to qual). It was conducted among second-year undergraduate nursing students enrolled in surgical nursing at the Faculty of Health Sciences, Department of Nursing, Agri Ibrahim Cecen University. Of 111 students assessed for eligibility, 21 were excluded before randomization and 90 were randomized in a 1:1 ratio. All randomized students were analyzed according to their assigned group.

The intervention group received standard education plus seven consecutive days of mobile-optimized digital microlearning before surgical clinical placement. One module was delivered each day and lasted approximately 3-5 minutes. Each module followed a consistent structure: a surgical patient-safety scenario, a pause to identify the risk, a forced-choice retrieval question, corrective feedback, and a cue-action takeaway. Content addressed patient identification, medication safety, documentation omissions, deterioration cues, falls and other safety risks, prioritization, escalation, and decision-making under stress. Platform analytics captured module completion, time on task, retrieval-question accuracy, feedback viewing, and technical delivery.

The control group received the standard undergraduate curriculum without additional digital microlearning. Standard education consisted of two two-hour surgical patient-safety lectures and a written guideline. Both groups subsequently completed seven weeks of routine surgical clinical practice, one day per week, under the same usual supervision. The comparator was not attention matched.

Outcomes were assessed at baseline before the program (T0), immediately after the seven-day intervention (T1), at the end of the first week of surgical clinical practice (T2), and at the end of the seventh week of surgical clinical practice (T3). The primary outcome was clinical error recognition performance, with the principal endpoint at T3. Secondary outcomes included patient-safety awareness, clinical decision-making under stress, clinical practice readiness, clinical self-confidence, blinded objective transfer, weekly safety-oriented behavioral transfer, and intervention acceptability.

At T3, objective transfer was assessed using a blinded Objective Structured Clinical Examination safety station, an independently scored transfer vignette, and a standardized escalation task. During each of the seven clinical weeks, students completed an ecological momentary assessment prompt at the end of their scheduled clinical practice day. The prompt recorded whether a safety risk was noticed, whether an appropriate response occurred, and whether the concern was escalated or discussed with a supervisor. Confidence, stress, reflective depth, and a brief contemporaneous note were collected as separate contextual EMA items.

After completion of the quantitative follow-up, 15 intervention participants were selected using maximum-variation sampling across response profile, engagement, sex, age, digital readiness, and placement type. Semi-structured interviews explored clinical cue recognition, application under pressure, escalation and speaking up, delivery conditions, and negative or disconfirming experiences. Quantitative estimates, weekly EMA patterns, objective-transfer findings, and qualitative themes were integrated in a joint display to explain how and under what conditions transfer occurred.

The study involved an educational intervention only and did not include invasive procedures, drugs, or medical devices. Written informed consent was obtained from all participants. Unintended effects and access burdens were solicited through weekly EMA prompts and at T3.

Inclusion criteria

• Second-year undergraduate nursing students enrolled in the Faculty of Health Sciences, Department of Nursing
• Registered for the relevant surgical nursing course
• Preparing to begin their first surgical clinical placement
• Aged 18 years or older
• Willing and able to provide written informed consent

Exclusion criteria

• Previous failure or repetition of the relevant surgical nursing course
• Absenteeism meeting the course exclusion threshold before randomization
• Previous surgical clinical practice experience
• Previous professional nursing or healthcare work experience
• Concurrent participation in another patient-safety education study
• Inability to complete the baseline assessment before randomization