Flipped Learning in PPH Education: Impact on Midwifery Students' Knowledge, Skills, Self-Efficacy, and Satisfaction

Effect of Postpartum Hemorrhage Education Structured With Flipped Learning Model on Knowledge, Skills, Clinical Self-Efficacy and Satisfaction of Midwifery Students

Maternal death refers to a woman's death due to direct or indirect causes during pregnancy, childbirth, or within 42 days postpartum. Postpartum hemorrhage (PPH) is the leading cause of maternal mortality globally and in our country. Rapid and effective management of PPH is crucial in reducing maternal deaths. WHO, UNFPA, and UNICEF emphasize the critical role of midwives in PPH management, highlighting the importance of enhancing their knowledge and skills during pre-graduate education.

Traditional education models are often insufficient for fostering permanent learning, especially in acquiring psychomotor skills like PPH management. In traditional learning, classroom instruction follows a teacher-centered approach, covering only the first two levels of Bloom's taxonomy-knowledge and comprehension-while higher-order cognitive skills such as application, analysis, synthesis, and evaluation are left to individual effort. However, effective and lasting learning requires an active learning environment where students engage more deeply with the material.

The flipped learning model addresses these challenges by allowing students to access foundational knowledge outside the classroom and dedicate class time to higher-order skills like discussion, application, and problem-solving. This model enhances learning through technology and interactive face-to-face activities, fostering professional competence in health education. While the flipped learning model is widely used in health education, most studies focus on theoretical knowledge, with limited research on psychomotor skill acquisition.

To our knowledge, this study is the first to evaluate the effectiveness of flipped learning in midwifery education for both theoretical and psychomotor skill development. The findings are expected to contribute to advancements in midwifery education and healthcare services.

Study Overview

• Status: Active, not recruiting
• Conditions: Postpartum Hemorrhage; Flipped Classroom Model in Teaching; Midwifery Students Education; Teaching Innovation
• Intervention / Treatment: Behavioral: Intervention Group

Detailed Description

Material and Methods Type of Research: This study was planned to evaluate the effect of the flipped learning model on the knowledge, skills and clinical self-efficacy of midwifery students in postpartum hemorrhage education. The research will be conducted in a randomized experimental design with a pre-test, post-test control group and a clinical trials number will be obtained.

Population and Sample of the Research: The population of the research will consist of 310 midwifery students studying at the Health Sciences University, Gülhane Faculty of Health Sciences. Power analysis was conducted to determine the number of people to be included in the study. The power of the test was calculated with the G*Power 3.1 program. In a similar study in the relevant literature, the effect size (Effect size) regarding the self-efficacy difference was calculated as 0.771. In order to exceed the 90% value in determining the power of the study; 60 people need to be reached, 30 in groups, at a significance level of 5% and an effect size of 0.771 (df=58; t=1.672). Considering the high power of the test and the losses, it was aimed to reach a total of 72 people, 36 in groups. Inclusion Criteria for the Study:

• Being a 3rd year student in the Midwifery Department of Gülhane Health Sciences Faculty
• Having successfully completed the normal birth course
• Not having problems accessing a computer and the internet
• Being an active registered student
• Agreeing to participate in the study

Exclusion Criteria for the Study:

• Students who were on sick leave or on leave during the study period
• Those who did not take the normal birth course or failed
• Those who had previously received training on postpartum hemorrhage

Exclusion Criteria for the Study:

• Students who were absent from at least one of the sessions of the training program
• Students who took a course, seminar, etc. on postpartum hemorrhage from another place during the study period Independent Variables of the Study: Postpartum hemorrhage training based on the flipped learning model Dependent Variables of the Study: Postpartum hemorrhage knowledge level, clinical skills self-efficacy level, postpartum hemorrhage management skill level, training satisfaction level Hypotheses of the Study: In the training of postpartum hemorrhage management, flipped- midwifery students who received face learning based education and midwifery students who received traditional education in the post-test;
• H01: There is no significant difference in postpartum hemorrhage knowledge level
• H02: There is no significant difference in postpartum hemorrhage skill level.
• H03: There is no significant difference in clinical self-efficacy.
• H04: There is no significant effect on education satisfaction. Data Collection Tools: Data will be collected using the "Student Information Form", ''Postpartum Hemorrhage Management Information Form'', ''Postpartum Hemorrhage Management Skill Checklist'' and ''Self-efficacy Scale for Clinical Skills'' developed by the researcher, and the ''Visual Analog Scale (VAS)'' to evaluate education satisfaction.

Data Collection:

The data of the study will be collected by the researchers themselves after receiving ethics committee approval and institutional permission. Researcher Lecturer Sümeyra DAMSARSAN is working as a lecturer in the department where the study will be conducted and has completed the 134-hour ''Certification in Flipped Learning- Level I'' training on Flipped Learning Education.

Preparation of training content and implementation plan: Training on postpartum hemorrhage management consists of two parts: theoretical and practical. The topics and content regarding the theoretical part of the training will be prepared in a way that will be standard for both groups in line with the literature. The topics are planned to be; definition, importance, frequency of occurrence, etiology, symptoms, management and prevention, midwifery interventions of postpartum hemorrhage. Lecture notes regarding the training content will be shared with the students. The theoretical part of the training will be completed in 2 weeks and two sessions are planned as a total of four sessions, 30 minutes of lecture and 15 minutes of break, held once a week on the same day. One week after the completion of theoretical training, students will practice with a simulated postpartum hemorrhage model in the department laboratory. First, the steps of postpartum hemorrhage management will be demonstrated on the model by the trainer in accordance with the skill checklist, then each student will practice the skill at least once and experience the skill. Preparation of Educational Content as Flipped Learning Materials: The educational content will be organized in accordance with the flipped learning model. For this purpose, short lesson videos will be uploaded to the ''Edpuzzle'' platform (maximum 15 minutes each), games and discussion cases will be prepared, in-class activities will be planned, and different types of assessment questions and quizzes suitable for measurement and evaluation will be prepared using current technology (Kahoot, BigBlueBotton, etc.). The features of the educational platform and tools are suitable for the flipped learning model. The videos prepared by the students provide the opportunity to monitor and evaluate their class participation status, individual and collective success percentages obtained from question and answer and quizzes. The researcher will create a class on these platforms and ensure that students are registered in these classes with their e-mail addresses and identification information. The main tools to be used in the educational process; Edpuzzle platform; It is a platform based on the flipped learning model, where audio, open-ended or multiple-choice questions can be added to videos, provides the educator with video viewing reports and supports interactive learning. BigBlueButton is a distance education tool that supports the interactive lesson process with study rooms and whiteboard. The Microsoft Office 2019 program to be used in the creation of educational videos has features such as preparing educational presentations and educational videos that include the educator's image. Movavi Video Editor to be used in editing educational videos is a video editing program that provides ease of use. It is planned to use programs such as Kahoot in the education process and the aim is for students to actively participate in the lessons. Kahoot will be preferred because it is a learning tool with games and exercises and supports student-centered learning. Mentimeter is a platform that supports fun learning with features such as warm-up chats, creating word clouds and taking quizzes.

The researchers have registered with all relevant systems. All educational materials such as videos, games and quizzes will be prepared in advance but will be uploaded to the system in accordance with the planned education calendar.

Implementation of the Study

• After explaining the purpose and importance of the study to the 3rd year students of the Midwifery Department of the Faculty of Health Sciences, students who meet the criteria for inclusion in the study will be invited to participate.
• First, all students in the intervention and control groups will be given the "Student Information Form" and the "Postpartum Hemorrhage Management Knowledge Test".
• The study will begin with the training of the students in the control group.
• The control group will complete the theoretical part of the training in a classroom environment, in the form of presentation and Q&A in 2 weeks. Q&A, discussion and brainstorming techniques will be used predominantly in the last session of the training.
• The training of the intervention group will begin after the control group's training is completed and all data is collected. At the same time, all students will sign a commitment that they will not share all forms and materials shared with them with anyone. In this way, it is aimed to prevent students in different groups from being influenced by each other and to prevent the sharing of forms and materials used with each other.

• Study Type: Interventional
• Enrollment (Estimated): 72
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey
  • Çankaya
    • Ankara, Çankaya, Turkey, 06660
      • University of Health Sciences

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Being a 3rd year student in the Midwifery Department of Gülhane Health Sciences Faculty
• Having successfully completed the normal birth course
• Agreeing to participate in the study

Exclusion Criteria:

• Students who were on sick leave or on sick leave during the study period
• Those who did not take the normal birth course or failed
• Students who were absent from at least one session of the training program

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Basic Science
• Allocation: Non-Randomized
• Interventional Model: Sequential Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Control Group (Traditional Education Model Based Education Group); This group will be trained with the traditional education model regarding the management of postpartum hemorrhage. Theoretical training in this group is planned as face to face in the classroom with the traditional lecture model; practical training is planned as face to face in the laboratory.
Experimental: Intervention Group (Flipped Learning Model Based Training Group); This group will receive training on postpartum hemorrhage management using the reverse learning model. Theoretical and practical lessons will be given primarily through out-of-class activities. Students will learn simple basic information outside of class whenever they want with the instructor's videos. Thus, advanced methods (gamification, concept analysis, group discussions) can be applied to ensure active and permanent learning in in-class activities.	Behavioral: Intervention Group; (Flipped Learning Model Based Training Group)-Arm Description: This group will receive training on postpartum hemorrhage management using the reverse learning

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Clinical Skills Self-Efficacy	Description: The self-efficacy levels of students regarding clinical skills will be evaluated. Assessment Tool: Clinical Skills Self-Efficacy Scale. The minimum score is 14, and the maximum score is 70. Higher scores indicate greater self-efficacy. Unit of Measure: Scale score (range: 14-70).	At the beginning (immediately before the practical training) and 3 weeks after the completion of the practical training.
Postpartum Hemorrhage Knowledge and Skills	Description: Knowledge and skills related to postpartum hemorrhage will be assessed. Assessment Tool: A test developed by researchers, with scoring determined based on expert opinions. Unit of Measure: Test score (numerical). (Scoring for this test will be determined after the tests are developed by the researcher and expert opinions are received.)	Baseline (just before training) and 3 weeks after the completion of training.
Educational Satisfaction	Description: Students' satisfaction with postpartum hemorrhage training will be measured, comparing traditional education with the flipped learning model. Assessment Tool: A satisfaction scale rang. The minimum score is 10 and the maximum score is 0. Higher scores indicate greater educational satisfaction.	After the theoretical and practical training has been fully completed for both groups (approximately 10-14 weeks after the start of the training)

Collaborators and Investigators

• Sponsor: Saglik Bilimleri Universitesi

Study record dates

Study Major Dates

• Study Start (Actual): January 7, 2025
• Primary Completion (Estimated): June 30, 2025
• Study Completion (Estimated): September 1, 2025

Study Registration Dates

• First Submitted: January 28, 2025
• First Submitted That Met QC Criteria: February 28, 2025
• First Posted (Actual): March 25, 2025

Study Record Updates

• Last Update Posted (Actual): March 25, 2025
• Last Update Submitted That Met QC Criteria: March 6, 2025
• Last Verified: March 1, 2025

More Information

Terms related to this study

• Keywords: Postpartum Hemorrhage; Flipped Learning; Midwifery Education; Clinical Self-Efficacy
• Additional Relevant MeSH Terms: Urogenital Diseases; Pathologic Processes; Female Urogenital Diseases and Pregnancy Complications; Obstetric Labor Complications; Pregnancy Complications; Puerperal Disorders; Uterine Hemorrhage; Postpartum Hemorrhage; Hemorrhage
• Other Study ID Numbers: 913715751 2025/09

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: The results of this study will be published in the form of a thesis, articles, and conference presentations. De-identified individual participant data (IPD) may be shared upon request, in accordance with appropriate ethical principles.
• IPD Sharing Time Frame: After completion of the study (approximately 1 year later)
• IPD Sharing Access Criteria: Researchers who wish to access the data should submit a formal request, providing details of their research purpose. Data sharing will be considered in compliance with ethical guidelines and institutional policies.
• IPD Sharing Supporting Information Type: CSR

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No