Digital Microlearning for Patient-Safety Readiness in Nursing Students (DigiM-2026)

Digital Microlearning for Patient-Safety Readiness Before Surgical Clinical Practice: A Randomized Controlled Trial With Ecological Momentary Assessment and Mixed-Methods Integration

This randomized controlled trial evaluated whether a seven-day, patient-safety-focused digital microlearning program improved sustained clinical error recognition and the transfer of safety learning among second-year nursing students entering surgical clinical practice. Ninety students were randomly assigned in a 1:1 ratio to digital microlearning plus standard education or standard education alone. Outcomes were assessed at baseline, immediately after the intervention, at the end of the first week of surgical clinical practice, and at the end of the seventh week of surgical clinical practice. Weekly ecological momentary assessment prompts examined safety-oriented behavior during clinical practice. Blinded performance tasks assessed objective clinical transfer, and an explanatory qualitative component explored how and under what conditions students applied the learning in practice.

Study Overview

• Status: Completed
• Conditions: Medical Education; Nursing Education; Patient Safety
• Intervention / Treatment: Behavioral: Digital Microlearning Program on Patient Safety

Detailed Description

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 a priori sample-size calculation was based on clinical error recognition measured across T0-T3, with T3 designated as the principal endpoint. Assuming f=0.20, two groups, four measurements, alpha=0.05, 80% power, a within-participant correlation of 0.50 and epsilon=1.0, the minimum sample size was approximately 76; 90 students were randomized to allow for attrition.

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 T3 designated as the principal endpoint. Alternate 10-scenario assessment forms were drawn from an expert-reviewed bank of 15 retained surgical patient-safety scenarios. Each response was scored 1 for correct identification of the safety error and 0 for an incorrect or absent identification. Form scores were converted to a 0-100 scale as (number correct/10) × 100, yielding 10-point score units. 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 one 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 items. Free-text notes were not used to calculate the behavioral index or quantitative group-effect estimates and did not contribute to the interview-derived qualitative themes. Potentially identifying patient information was removed during data cleaning and was not retained in the analytical dataset.

After completion of the quantitative follow-up, 15 intervention participants were interviewed. The purposive sampling frame sought variation across response profile, engagement, sex, age, digital readiness, and placement type. The achieved sample varied in sex, age, digital readiness, and completion exposure but was homogeneous on the derived response and engagement classifications. The interviews produced 30 coded records; these were coding units, not additional participants. Repeated identical wording in the coded records was deduplicated for reporting and was not counted as additional evidence of thematic breadth. Quantitative estimates, weekly ecological momentary assessment 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. Research participation was operationally separated from academic assessment. Written informed consent was obtained by a researcher without responsibility for course or clinical grades before any study procedure. Students were informed that refusal or withdrawal would not affect grades, attendance, placement allocation, or usual education. Interview participation and audio recording were explained and consented to separately. Unintended effects and access burdens were solicited through the weekly research prompts and again at T3; intervention-related experiences were distinguished from burdens associated with the study's ecological momentary assessment and reminder procedures.

• Study Type: Interventional
• Enrollment (Actual): 90
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Merkez
    • AĞRI, Merkez, Turkey (Türkiye), 04100
      • Agri Ibrahim Cecen University Faculty of Health Sciences

Participation Criteria

Eligibility Criteria

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

Description

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

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Digital Microlearning Intervention Group; Participants received a seven-day patient-safety-focused digital microlearning program in addition to standard education before surgical clinical practice.	Behavioral: Digital Microlearning Program on Patient Safety; A structured, mobile-optimized digital microlearning program delivered asynchronously over seven consecutive days. Participants completed one scenario-based module per day, lasting approximately 3-5 minutes. Each module included a surgical patient-safety scenario, a pause to identify the risk, a forced-choice retrieval question, corrective feedback, and a cue-action takeaway. Content covered patient identification, medication safety, documentation omissions, deterioration cues, falls and other safety risks, prioritization, escalation, and clinical decision-making under stress.
No Intervention: Control Group Standard Education; Participants received the existing undergraduate curriculum without additional digital microlearning. Standard education consisted of two two-hour surgical patient-safety lectures and a written guideline. Participants then completed seven weeks of routine surgical clinical practice, one day per week, with the same usual supervision as the intervention group. The control condition was not attention matched.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Clinical Error Recognition Performance at Clinical Week 7 (T3)	Clinical error recognition was assessed using alternate scenario-based forms drawn from an expert-reviewed bank of 15 retained surgical patient-safety scenarios. Each assessment form contained 10 scored scenarios covering patient identification, medication safety, documentation, deterioration, falls, and escalation. Each response was scored 1 for correct identification of the safety error and 0 for an incorrect or absent identification. The form score was converted to a 0-100 scale as (number correct/10) × 100, yielding scores in 10-point units; higher scores indicate better clinical error recognition. Alternate forms used patients, clinical cues, and action sequences distinct from the intervention scenarios. T3 was the principal endpoint; T0, T1, and T2 measurements described the outcome trajectory.	Baseline before the program (T0), immediately after completion of the seven-day intervention (T1), end of the first week of surgical clinical practice (T2), and end of the seventh week of surgical clinical practice (T3; principal endpoint).

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Clinical Decision-Making Under Stress	Clinical decision-making under stress was assessed using scenario-based evaluations that required participants to recognize, prioritize, and respond to patient-safety problems in stressful surgical clinical situations. Scores were converted to a 0-100 scale, with higher scores indicating better decision-making performance under stress.	Baseline before the program (T0), immediately after completion of the seven-day intervention (T1), end of the first week of surgical clinical practice (T2), and end of the seventh week of surgical clinical practice (T3).
Patient Safety Awareness	Patient-safety awareness was assessed using the Patient Safety Awareness Questionnaire, which evaluates understanding of patient-safety principles, recognition of safety risks, and safe practices relevant to surgical care. Scores were converted to a 0-100 scale, with higher scores indicating greater patient-safety awareness.	Baseline before the program (T0), immediately after completion of the seven-day intervention (T1), end of the first week of surgical clinical practice (T2), and end of the seventh week of surgical clinical practice (T3).
Clinical Practice Readiness	Perceived readiness for surgical clinical practice was assessed using the 12-item Clinical Placement Readiness Scale. Item responses were transformed to a 0-100 score for analysis, with higher scores indicating greater perceived readiness for clinical practice.	Baseline before the program (T0), immediately after completion of the seven-day intervention (T1), end of the first week of surgical clinical practice (T2), and end of the seventh week of surgical clinical practice (T3).
Clinical Self-Confidence	Clinical self-confidence was assessed using a structured self-confidence measure addressing preparedness and the performance of patient-safety actions within supervised surgical clinical practice. Scores were converted to a 0-100 scale, with higher scores indicating greater clinical self-confidence.	Baseline before the program (T0), immediately after completion of the seven-day intervention (T1), end of the first week of surgical clinical practice (T2), and end of the seventh week of surgical clinical practice (T3).
Acceptability of the Digital Microlearning Program	Acceptability was assessed in the intervention group using a post-intervention questionnaire covering satisfaction, perceived usefulness, usability, and relevance to surgical clinical practice. The total score ranged from 1 to 5, with higher scores indicating greater acceptability and perceived usefulness.	Immediately after completion of the seven-day intervention (T1).
Blinded Objective Transfer Composite	Objective transfer at T3 was assessed using three independently administered performance tasks: an Objective Structured Clinical Examination safety station, a transfer vignette containing scenarios not used in the intervention, and a standardized escalation task. Each component was z-standardized across the full randomized sample and assigned equal weight. The mean of the three standardized components was transformed as 50 + 10 x mean(z). Higher scores indicate better objective transfer of patient-safety learning. Supervisor ratings were not included in this composite.	End of the seventh week of surgical clinical practice (T3).
EMA Behavioral Transfer Index	Safety-oriented behavioral transfer during surgical clinical practice was assessed using one ecological momentary assessment prompt at the end of each scheduled clinical practice day. The index comprised three binary actions: noticing a patient-safety risk, making an appropriate response, and escalating or discussing the concern with a supervisor. The index was calculated as the mean of the three binary actions multiplied by 100, producing a score from 0 to 100. Higher scores indicate stronger safety-oriented behavioral transfer. EMA confidence, stress, reflective depth, and the contemporaneous note were separate contextual items and were not included in the index. Free-text notes were not used in quantitative group-effect estimates or interview-derived qualitative themes. Potentially identifying patient information was removed during data cleaning and was not retained in the analytical dataset.	Weekly during surgical clinical practice, weeks 1 through 7.

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Intervention Fidelity	Intervention fidelity was assessed from platform-recorded module completion (0-7 modules), completion percentage (0-100%), total time on task in minutes, retrieval-question accuracy (0-100%), proportion of corrective feedback viewed (0-100%), reminder-opening percentage (0-100%), and platform uptime (0-100%). These measures described exposure and delivery fidelity and were not interpreted as clinical outcomes.	Throughout the seven-day intervention and summarized immediately after intervention completion (T1).
Unintended Effects and Access Burdens	Unintended effects and access burdens were prospectively elicited through weekly study prompts and a T3 assessment. Each report was coded by event category (notification fatigue, temporary pre-placement anxiety, technical access frustration, minor extra stress, or data/connectivity barrier), severity, relatedness, action taken, resolution, and whether it led to discontinuation. The outcome was summarized for each arm as the number of event reports by category and the number and percentage of participants reporting at least one event. This was a count-based outcome, not a scale; no composite score or score range was used, and lower counts indicated fewer reported burdens. Reports included both intervention-related experiences and burdens arising from the study's ecological momentary assessment and reminder procedures. Notification or access reports in the control arm were not attributed to digital microlearning exposure.	Weekly during surgical clinical practice, weeks 1 through 7, and at the end of the seventh clinical week (T3).

Collaborators and Investigators

• Sponsor: Agri Ibrahim Cecen University

Publications and helpful links

General Publications

• World Health Organization. Patient safety curriculum guide: Multi-professional edition. Geneva: WHO; 2011.
• Lee SE, Morse BL, Kim NW. Patient safety educational interventions: A systematic review with recommendations for nurse educators. Nurs Open. 2022 Jul;9(4):1967-1979. doi: 10.1002/nop2.955. Epub 2021 May 28.
• De Gagne JC, Park HK, Hall K, Woodward A, Yamane S, Kim SS. Microlearning in Health Professions Education: Scoping Review. JMIR Med Educ. 2019 Jul 23;5(2):e13997. doi: 10.2196/13997.
• Hopewell S, Chan AW, Collins GS, Hrobjartsson A, Moher D, Schulz KF, Tunn R, Aggarwal R, Berkwits M, Berlin JA, Bhandari N, Butcher NJ, Campbell MK, Chidebe RCW, Elbourne D, Farmer A, Fergusson DA, Golub RM, Goodman SN, Hoffmann TC, Ioannidis JPA, Kahan BC, Knowles RL, Lamb SE, Lewis S, Loder E, Offringa M, Ravaud P, Richards DP, Rockhold FW, Schriger DL, Siegfried NL, Staniszewska S, Taylor RS, Thabane L, Torgerson D, Vohra S, White IR, Boutron I. CONSORT 2025 explanation and elaboration: updated guideline for reporting randomised trials. BMJ. 2025 Apr 14;389:e081124. doi: 10.1136/bmj-2024-081124.

Helpful Links

• World Health Organization resources providing background information on patient safety principles relevant to the study protocol.

Study record dates

Study Major Dates

• Study Start (Actual): February 10, 2026
• Primary Completion (Actual): April 30, 2026
• Study Completion (Actual): April 30, 2026

Study Registration Dates

• First Submitted: January 13, 2026
• First Submitted That Met QC Criteria: January 20, 2026
• First Posted (Actual): January 26, 2026

Study Record Updates

• Last Update Posted (Actual): September 9, 2026
• Last Update Submitted That Met QC Criteria: September 3, 2026
• Last Verified: September 1, 2026

More Information

Terms related to this study

• Keywords: Randomized controlled trial; Nursing students; Educational intervention; Mixed methods; Clinical decision-making; Digital microlearning; Patient safety awareness; Clinical error recognition; Surgical clinical practice
• Other Study ID Numbers: Digital Microlearning-2026

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Individual participant data will not be shared publicly because the study involved undergraduate students at a single institution and combined repeated performance measures, questionnaire responses, ecological momentary assessment records, and qualitative interview material. This combination could permit re-identification even after removal of direct identifiers. Findings will be reported in aggregate form. Aggregated statistical outputs and a de-linked qualitative theme-coverage matrix support the reported findings. Further de-identified supporting materials and analytic code may be considered by the corresponding author on reasonable request, subject to institutional, ethical, and confidentiality requirements. No separate public statistical analysis plan was prepared.

Drug and device information, study documents

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