Effectiveness of Virtual Reality Situation-Based Flipped Learning and Gamification on Nursing Students' Learning Attitudes, Problem-solving Abilities, and Empathetic Abilities
Phase: NA
Conditions: Educational Problems, Problem;Learning
Sponsor: Alexandria University

 
 
 Effectiveness of virtual reality Situation-Based Flipped Learning and 
Gamification on nursing students' learning attitudes, problem-solving abilities, 
and empathetic abilities. 
 
 
IRB00013623 
    
 
 
Date of document: 10-1-2024 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
The integration of innovative educational approaches in nursing education has become 
increasingly crucial for enhancing learning outcomes. Among these approaches, virtual 
reality (VR), Situation-Based Flipped Learning, and Gamification have gained 
attention as promising tools to engage nursing students and promote a deeper 
understanding of complex concepts. This study aims to investigate the effectiveness of 
combining these strategies in a virtual reality Situation-Based Flipped Learning 
environment with elements of Gamification on nursing students' learning attitudes, 
problem-solving abilities, and empathetic skills. By leveraging these technologies, 
educators seek to create an immersive and interactive learning experience that not only 
aligns with the demands of modern education but also addresses the unique challenges 
faced by nursing students in developing critical competencies. This research explores 
the potential impact of this integrated approach on nursing education, contributing 
valuable insights to the ongoing efforts to optimize teaching methodologies for future 
healthcare professionals. 
Aim of the Study 
 
To explore the impact of educational program by using situation-based flipped learning 
and gamification on nursing students' learning attitudes, problem-solving abilities, and 
empathetic abilities at the Faculty of Nursing Zagazig University. 
 
Research Hypotheses 
 
1. The students’ learning attitude will be improved after participating in situation-
based FL with gamification classes. 
 
2. The students’ problem-solving abilities will show a significant change after 
situation based FL classes combined with gamification. 
 
3. There is a significant increase in students’ empathetic abilities after completing 
situation-based FL classes combined with gamification. 
 
 
 
 
Research Design:  
A quasi - experimental design was used. 
 
Study Setting:  
The study was carried out at the Faculty of Nursing, Zagazig University, Egypt, which 
includes seven scientific departments namely; Nursing Administration, Psychiatric and 
Mental Health Nursing, Pediatric Nursing, Community Health Nursing, Maternal and 
New Born Health Nursing, Medical Surgical Nursing, Community Health Nursing and 
Geriatric Nursing. 
 
Subjects:  
The subjects of the study included fourth year nursing students who enrolled in nursing 
administration course in the academic year 2022-2023. 
 
Sample Size:  

The sample was taken through a proportionate random sampling technique by using a 
simplified formula n= N/1+N (e) 2, provided by Yamane [1]. A 95% confidence level 
and P =0.05 are assumed for Equation. The ideal sample size was 70 students.  
 
Field Work:  
The study was carried out for three months from the beginning of January to the end of 
March 2023, as the following: 
 
Preparatory phase:  
It started with reviewing national and international resource of theoretical and empirical 
literature on the topic of the study using textbooks, articles, magazines, research, and 
internet search to get a clear image of all parts of the study. The instructional system 
was based on Dick and Carey’s [27] analysis, design, development, implementation, 
and evaluation model. This model is a systematic approach that analyzes educational 
needs to find solutions; designs, develops, implements, and evaluates the results. A 
needs analysis was conducted via a pre-test questionnaire sheet of students’ preferred 
teaching methods and learning activities. The estimated time each student needed to 
complete each sheet varied between 30-40 minutes. Accordingly, the educational 
program’s objectives were set out and the content was designed.  
 
The design phase: involved preparing the program, which included a weekly schedule 
and a list of learning activities divided into out-of-class and in-class activities. Students’ 
performance goals were prepared based on a weekly schedule. Various videos and 
lecture materials for each class were prepared based on previous studies and the 
literature on FL. The researchers conducted lectures on FL teaching methods to develop 
instructional and teaching materials.  
The development phase: involved developing educational materials on the selected 
nursing management skills for out- of-class activities by designing teaching objectives, 
providing prerecorded video lectures, which can be downloaded by mobile technology 
devices for preview, and design quizzes, questions, and set up scenarios for application 
exercise. For in-class activities, individual and group discussion regarding the topic  
,collecting activity data {quizzes and answer to questions}, students were given 
Individual Readiness Assurance test, collaborative Readiness Assurance test , in 
addition, based on the role-play scenarios and demonstrations, the roles of the patient, 
patient family,  head nurse, nurse leader, and the nurse were assigned to each, and 
nursing intervention was applied during the role-play. Students who participated in this 
study were provided immediate feedback on their progress, achievement or rewarded 
with a badge.  
 The developed situation-based FL combined with gamification were applied during 
twelve weeks of decision-making skills, problem solving skills, communication skills, 
motivation skills, and time management skills modules. In particular, the gamification 
elements of challenge, competition, scaffolding, achievement, and compensation were 
applied to all out-class, in-class, and deeper-class domains the students participated in.  
 
For example, in the decision-making skills module, for the out of class activity, goal of 
decision-making  was accurately presented, a prerecorded video lecture on decision 
making with quiz, questions and a situation problem with scenario as an  application 
exercise pre settled up; the students were asked to watch videos,  answer quizzes and  

analyze the presented people appeared in the presented situational case scenario as  
patients, nurses and  patient family. 
 
for  the in class activity, collecting activity data (answer of questions and quizze1), 
individual and group  discussion , students were given Individual Readiness Assurance 
test, collaborative team Readiness Assurance test , based on the role-play scenarios and 
demonstrations, the roles of the patient, patient family, and the nurse were assigned to 
each, and nursing intervention was applied during the role-play. To ensure that the 
students who participated in this study were compensated, they were provided 
immediate feedback on their progress or achievement or rewarded with a badge.  
 
Students were able to check their learning effects and progress, and the results were 
shared on the leader board to encourage users to learn voluntarily, moreover, stimulate 
student's competitive spirit, the leader board provided the ranking of each team and the 
records of the opponents.  
 
The implementation phase 
 The planned educational program was implemented across 12 class; these class lasted 
20 hours; from which 6 theory (out-of-class activity: two hours for each module;75min 
MP4 video lectures and 15 min quiz questions, and 30 min situation case were uploaded 
to mobile phones); and 6 practical class (in-class activity: four hours for each module) 
were performed. Five modules comprising 75min MP4 video lectures and 15 min five 
quiz questions, and 30 min situation case were uploaded to mobile phones for the out-
of-class activity. 
 
The modules allowed the students to understand and apply communication skills, 
decision-making skills, problem solving skills, time management skills, and motivation 
skills in each class. For the out-of-class activity, students were asked to watch skills for 
each a video lecture and participate in the class. The video presented knowledge about 
each skill through videos, images, and sound. In-class activity was operated with mini-
lectures and team-based learning. The students faced challenges, competition, self-
expression, achievements, and rewards during the course, which are gamification 
elements. It was hard to take the entire number of students at the same time, so the 
students were distributed into five groups; every group comprised approximately 14 
students. All sessions were repeated to the five main groups until the 70 students 
finished all 15 hours of instruction.  
The evaluation phase, the students took the individual readiness assurance test (iRAT) 
before each class to review the content they had learned while preparing for each class. 
This was followed by the team readiness assurance test (tRAT), in which they formed 
teams to discuss, solve, and submit answers to a quiz composed of the same questions 
as those in the iRAT. After completing the tRAT, the instructor shared the correct 
answers and gave mini-lectures to explain what the students had not understood. The 
questions in these situational cases were to be solved through team based cooperative 
learning and competition. Additionally, after each class, the students wrote in reflection 
notes as a post-class activity.  
 
 
 
 

 
 
 
 
 
 
 
Figure 1. Situation-based flipped learning and gamification as combined 
methodologies on nursing students' 
learning attitudes, problem-solving abilities, and empathetic abilities. 
Abbreviations: FL: Flipped Learning; iRAT: Individual Readiness Assurance Test.  
 
Tools of data collection: 
 
A questionnaire sheet including 4 parts:  
Part (1): Personal characteristics of nursing students developed by the researchers: 
Age, gender, previous working, and previous training about flipped learning and 
gamification. 
 (2):  Learning Attitude Scale 
Developed by Hwang [28] to evaluate students’ attitudes, habits, beliefs, and 
motivations toward class. The scale consisted of  40 items divided into four sub-
sections; the first (9 items), dealt with the nature of learning, e.g. (the clever ones learn 
more easily); the second (11 items), with expectations from learning e.g. (learning new 
things makes me successful in what I do.); the third (10 items), with openness to 
learning e.g.(I want to develop my communication with people through learning new); 
and the fourth (10 items), with anxiety about learning, e.g. (I am anxious while being 

introduced a new subject). This tool uses a five-point Likert scale (1 = not at all, 5 = 
very much), and the higher the score, the better the learning attitude. In Hwang’s study 
[28], Cronbach’s _ was 0.84. 
 
Problem-Solving Ability 
Developed by Lee et al. [29] to measure problem-solving ability. It consists of 45 items 
in five categories and six sub- categories (Clarifying problem, seeking a solution, 
decision making, applying the solution, and evaluation & reflection). The tool uses a 
five-point Likert scale (never, rarely, sometimes, often, always), and the higher the 
score, the higher the problem-solving ability. Cronbach’s _ was0.94 while developing 
this instrument [29], and Cronbach’s _ was 0.92 in this study. 
 
Empathetic Ability 
Empathetic ability was measured using a tool developed byWakabayashi et al. [30] and 
validated by Yeo [31] using the Korean version of the Empathy Quotient-Short form. 
It comprises 11 items on a two-point scale to measure empathy’s cognitive, emotional, 
and social aspects e.g.( I can tune into how someone else feels rapidly and intuitively,& 
I can easily tell if someone else is interested in or bored by what I am saying). The 
higher the total score, the higher the empathetic ability. In a study by Yeo [31], 
Cronbach’s _ was 0.88, and in this study, Cronbach’s _ was 0.81. 
 
Ethical Consideration 
 
This study was conducted after obtaining ethical approval from the Faculty of nursing 
- Zagazig University. The students voluntarily participated in this study. They had 
opportunities to ask questions and were allowed to refuse to provide information. The 
researchers explained the purpose and method of the study and obtained written 
informed consent from the participants before conducting the surveys. The students 
were treated equally, regardless of whether they participated in the study. Furthermore, 
they were guaranteed anonymity, and their data were not shared with anyone other than 
the researchers.  
 
Content Validity:  
A self-administered questionnaire was used, after the translation of instrument to 
Arabic. The content and face validity were established by a jury of experts (5 professors 
& 4 assistant professors) from academic nursing staff, Zagazig and Cairo Universities. 
In addition, the content validity of the modules were also assessed by them. 
 
Pilot Study:  
To test the questionnaire accuracy and feasibility before using, a pilot study was 
conducted on 10 percent of the research sample (n=7). Those students who were 
included in the pilot study were removed from the sample analysis. Informed consent 
has been received from the entire study group for participation in the study, and they 
have been told that participation in the research is voluntary. And that every student 
can decide to stop completing the study and withdraw without consequences at any 
point. 
 
Statistical Design:  

Entering data and using statistical evaluation (SPSS), version 21.0. And checked to 
ensure no information was lost or inadequate. ANOVA F test and t-test were used to 
identify the relationship between the variables and the analysis of the association 
between total scores. 
 
 
 
  
References 
 
27- Dick,W.; Cary, L. The Systematic Design of Instruction, 4th ed.; Harper 
Collins College Publishers: New York, NY, USA, 1996. 
 
28- Hwang, S. Problem-Based Learning on the Knowledge Achievement, Critical 
Thinking Ability, Attitude and Motivation Toward Learning of Nursing Students; 
Chonnam National University: Gwangju, Korea, 2003.am Readiness Assurance 
Test 
29- Lee, S.J.; Jang, Y.K.; Park, G.Y. Study on the Development of Life-Skills: 
Communication, Problem Solving, and Self-Directed Learning; Korea 
Educational Development Institute: Jincheon, Korea, 2003. 
30- Wakabayashi, A.; Baron-Cohen, S.; Wheelwright, S.; Tojo, Y. The Autism-
Spectrum Quotient (aq) in japan: A cross-cultural 
comparison. J. Autism. Dev. Disord. 2006, 36, 263–270. 
31- Yeo, J.Y. Validation of the Korean version of the empathy quotient-short form. 
J. Korea Acad.-Ind. Coop Soc. 2012, 13, 5356–5363.