Effects of Blended Learning with Antenatal Education Practice on Nursing Students’ Communication Competence: A Mediation Model of Self-Management

Effects of Blended Learning with Antenatal Education Practice on Nursing Students’ Communication Competence: A Mediation Model of Self-Management | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of Blended Learning with Antenatal Education Practice on Nursing Students’ Communication Competence: A Mediation Model of Self-Management Feifei Li, Xiaochang Yang, Bizhen Liao, Yin Zhou, Yan Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6707208/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Blended learning is widely used in nursing education, yet its effect on students’ competence in health science communication remains underexplored. This study investigated the impact of integrating antenatal education class practice—a form of community-based maternal health education— practice into blended learning and examined the mediating role of self-management ability. Methods A randomized controlled trial was conducted with 163 third-year undergraduate nursing students assigned to either an intervention group (blended learning plus antenatal education sessions practice, n = 87) or a control group (blended learning only, n = 76). Pre- and post-intervention surveys assessed health science communication competence, self-management ability, and attitudes toward communication skills. Final examination scores measured academic performance. Mediation analysis was performed using the bootstrap method with 5000 resamples. Results Post-intervention, the intervention group scored significantly higher than the control group in health science communication competence (Z = 9.875, P < 0.001), self-management ability (Z = 4.245, P < 0.001), and communication skill attitudes (Z = 5.493, P < 0.001). Their final exam scores were also significantly higher (Z = 9.875, P < 0.001). Mediation analysis confirmed a partial mediating effect of self-management ability on the relationship between the intervention and communication competence (indirect effect = 1.8233, 95% CI: 0.6352–3.2506). Conclusions Integrating antenatal education sessions practice into blended learning significantly enhances nursing students’ communication competence, academic performance, and self-management. This approach offers an innovative model for bridging theoretical instruction and real-world health education practice. Clinical trial number Not applicable. blended learning antenatal education health science communication competence self-management ability nursing education Figures Figure 1 Figure 2 Background The rapid advancement of digital technologies and the diversification of information channels have contributed to the emergence of an “infodemic”—a digital epidemic of misinformation and disinformation that poses a significant threat to global public health systems [ 1 ] . In response, the strategic dissemination of accurate medical knowledge has become imperative for improving health literacy, countering false information, and ensuring public health security [ 2 , 3 ] . Higher education institutions are expected to play a vital role in this effort by integrating science communication into their curricula, leveraging external scientific resources, and tailoring educational content to students across disciplines and academic levels [ 4 ] . They are also encouraged to promote student participation in innovative practice-based learning and volunteer science outreach activities [ 5 , 6 ] . Such integration of science education with public engagement not only enhances the quality of education but also contributes to the cultivation of high-level talent needed for sustainable social development [ 7 ] . Blended learning is an innovative instructional approach that integrates traditional face-to-face teaching with modern online learning strategies to create a more flexible and personalized educational experience [ 8 ] . The concept of blended learning has been interpreted in various ways, generally encompassing four major categories [ 9 ] : (1) technology-based blended learning; (2) the combination of multiple instructional approaches; (3) the integration of diverse teaching methods with in-person instruction; and (4) the alignment of instructional tools with teaching tasks to achieve pedagogical goals. Among these, current research has largely focused on the first type—blending online platforms with classroom teaching—which has been shown to enhance student motivation, increase engagement, and foster autonomous learning [ 10 , 11 ] . However, this technology-oriented model still presents limitations in terms of contextual diversity and the depth of practical application. To further enhance the effectiveness of blended learning, this study introduced a third instructional setting—prenatal education classes—on top of the conventional technology-supported blended model. In this design, students acquire theoretical knowledge through online and in-person coursework, and develop fundamental nursing skills through clinical practice in hospital settings. Building upon these two foundations, the antenatal education sessions functions as a dynamic, patient-centered “third classroom,” offering nursing students an authentic environment focused on pregnant women. Through active involvement in course planning and health education activities at the antenatal education sessions, students engage in direct, meaningful interactions with expectant mothers. This setting allows them to observe real maternal needs and behaviors throughout pregnancy, while also facilitating the development of trust and rapport in a relaxed, natural atmosphere. As a result, students gain a deeper understanding of the psychological, physiological, and social dimensions of maternal care, enriching their capacity to conduct effective health communication for perinatal women and newborns. By integrating multiple learning environments, this approach supports a complete learning cycle—from knowledge acquisition to application, and ultimately internalization. It helps bridge the gap between classroom instruction and real-world nursing practice, fostering greater confidence and competence in students as they prepare to serve perinatal populations in their future professional roles. Given the rising importance of public health awareness, it is increasingly essential for undergraduate nursing students to acquire strong competencies in health science communication. Although blended learning models have been widely recognized for their ability to enhance students’ self-directed learning [ 12 ] , the extent to which such models contribute to the development of health communication competence remains unclear. In particular, the potential mediating role of self-management ability in this relationship has yet to be empirically tested. To address this gap, the present study explores the effects of integrating prenatal education courses into a blended learning framework on nursing students’ health science communication competence. It further examines the interaction between this competence and self-management ability. Findings from this research are expected to offer new insights into blended instructional strategies and provide practical implications for cultivating nursing professionals equipped with both clinical expertise and effective communication skills in health promotion. Methods Participants A purposive sampling strategy was employed to recruit participants who met the following inclusion criteria: third-year undergraduate nursing students who had completed coursework in pathophysiology, medical-surgical nursing, and possessed foundational nursing knowledge and clinical skills; individuals who had completed a two-week clinical internship at a university-affiliated hospital during the academic break and demonstrated basic doctor–patient communication competence; students aged 18 years or older with the ability to critically evaluate the authenticity of health-related information. Establishment of the Health Science Communication Teaching Team The instructional team consisted of eight members, including faculty from a key medical university and professionals from a local science communication center. All team members underwent standardized training in perinatal and neonatal nursing knowledge as well as health science communication skills. Upon completion of the training, they served as mentors responsible for guiding students in the creation and delivery of health communication content. Sample Size Calculation and Group Allocation Based on the study design and statistical requirements, an independent samples t-test was planned to compare group means. Assuming a medium effect size (Cohen’s d = 0.5), a significance level of α = 0.05, and a statistical power of 0.80, the required sample size was calculated using G*Power software. The estimated minimum number of participants was 64 per group. To account for potential attrition, a 20% buffer was added, resulting in a target of at least 77 participants per group and a total sample size of 154. Initially, 180 students were recruited. Each participant was assigned a unique identification number and randomly allocated into either the intervention or control group (n = 90 per group) using a random number table. During the study, some participants withdrew, and a total of 163 students completed the intervention (intervention group: n = 87; control group: n = 76). The eight faculty members were also randomly assigned to two teams and tasked with mentoring students in the development of health communication content related to perinatal and neonatal care. Teaching Implementation The intervention group received a blended learning model integrated with practical sessions at an antenatal education sessions. All instructional content focused on the care of perinatal women and newborns. Students participated in four structured sessions at the antenatal education sessions: attending one prenatal class as observers alongside pregnant women; conducting one structured interview with a pregnant woman; designing and organizing one antenatal education sessions activity; delivering one health education session at the antenatal education sessions. These experiential activities were designed to expose students to the real needs of pregnant women in authentic settings. Faculty mentors provided regular feedback throughout the process to guide students in developing health communication materials based on their experiences. In contrast, the control group followed a conventional blended learning model (online & offline) without antenatal education sessions integration. Students in this group were also mentored by faculty to complete health communication projects. To ensure instructional equity, the control group was later given access to the same antenatal education sessions activities after the intervention phase. To minimize potential confounding effects, a delayed-start crossover design was adopted. Only data from the synchronized intervention phase between the two groups were used in comparative analyses to ensure equivalence in baseline conditions and outcome validity. Post-intervention data from the control group’s delayed antenatal education sessions experience were archived as an independent dataset for planned longitudinal follow-up to explore the delayed intervention’s potential long-term effects. Guidance on Health Communication Content Development Both the intervention and control groups received the following structured instructional support to facilitate the creation of health communication materials: Information exposure and inspiration: Educational content related to perinatal and neonatal care was regularly disseminated via WeChat groups, including official hospital WeChat posts, science communication videos from the hospital’s Douyin (TikTok) account, and community health brochures. Idea generation through discussion: Students participated in moderated group discussions via WeChat, focusing on strategies for developing science communication content relevant to maternal and newborn health. Content creation guidance: Based on discussion outcomes, students selected topics of interest and were guided in the design and development of evidence-based, audience-friendly health communication content. Product transformation with AI assistance: Students were encouraged to convert their written health education content into multimedia formats—such as videos, social media posts, or bulletin board displays—using artificial intelligence tools (e.g., AIGC technologies) to enhance dissemination and engagement. Data Collection Data were collected using an online survey administered via the Wenjuanxing platform ( www.wjx.cn ) one week prior to the start of the course unit Nursing Care for Perinatal Mothers and Infants. The survey included the following components: General information questionnaire: Collected basic demographic and background data, including gender, personality type, monthly living expenses, interest in the nursing major, and self-perceived learning difficulty. Self-Directed Learning Ability Scale for Nursing Undergraduates (Lin Yi et al., 2004) [ 13 ] : This 28-item scale assesses self-management, information processing, and cooperative learning abilities. It uses a 5-point Likert scale, with higher scores indicating stronger self-directed learning capacity. The scale has a reported Cronbach’s α coefficient of 0.8632. Communication Skills Attitude Scale (Ren Peishu et al., 2012) [ 14 ] : A 26-item scale measuring attitudes toward learning communication skills, rated on a 5-point Likert scale. Higher scores reflect more positive attitudes. The scale has a Cronbach’s α of 0.841. Health Science Communication Competence Scale for Medical Students (Zhang Qian et al., 2023) [ 15 ] : A 43-item instrument designed to evaluate students’ competence in science communication within medical contexts. It is rated on a 5-point Likert scale, with higher scores indicating greater competence. The Cronbach’s α for the scale is 0.923. Final examination scores were extracted from the academic management system and used as indicators of theoretical knowledge acquisition. A post-intervention survey was distributed via Wenjuanxing one week after course completion to re-assess self-directed learning ability, communication skills, and health science communication competence. Statistical Analysis For continuous variables with a normal distribution, independent samples t-tests were used to compare mean differences between the intervention and control groups to assess the effects of the educational intervention. For variables that did not meet the normality assumption, the nonparametric Mann–Whitney U test was applied to examine differences in distribution. Chi-square (χ²) tests were used to analyze the independence of categorical variables between groups. To examine whether self-management ability mediated the relationship between the blended learning intervention and students’ health science communication competence, mediation analysis was conducted. The bootstrap method with 5000 resamples was used to estimate the 95% confidence interval (CI) for the indirect (mediated) effect. A CI that does not include zero was interpreted as evidence of a statistically significant mediation effect. Results Baseline Comparison A total of 163 students completed the study, including 87 in the intervention group and 76 in the control group. Baseline comparisons showed no significant differences between the two groups in terms of general demographic characteristics, self-directed learning ability, attitudes toward communication skills, and health science communication competence. These results indicate that the two groups were comparable prior to the intervention(see Table 1 ). Table 1 Baseline Characteristics and Key Competencies of Intervention and Control Groups Variable Total (n = 163) Intervention Group (n = 87) Control Group (n = 76) χ² / Z P Only Child, n (%) 0.099 0.754 Yes 105 (64.42%) 57 (65.52%) 48 (63.16%) No 58 (35.58%) 30 (34.48%) 28 (36.84%) Personality Type, n (%) 0.788 0.674 Introverted 44 (26.99%) 21 (24.14%) 23 (30.26%) Extroverted 13 (7.98%) 7 (8.05%) 6 (7.89%) Mixed 106 (65.03%) 59 (67.82%) 47 (61.84%) Monthly Living Expenses, n (%) 10.906 0.053 500–1000 RMB 16 (9.82%) 9 (10.34%) 7 (9.21%) 1001–1500 RMB 78 (47.85%) 44 (50.57%) 34 (44.74%) 1501–2000 RMB 60 (36.81%) 34 (39.08%) 26 (34.21%) 2001–2500 RMB 4 (2.45%) 0 (0%) 4 (5.26%) 2501–3000 RMB 3 (1.84%) 0 (0%) 3 (3.95%) > 3000 RMB 2 (1.23%) 0 (0%) 2 (2.63%) Interest in Nursing, n (%) 4.628 0.099 Like 50 (30.67%) 33 (37.93%) 17 (22.37%) Neutral 109 (66.87%) 52 (59.77%) 57 (75.00%) Dislike 4 (2.45%) 2 (2.30%) 2 (2.63%) Perceived Learning Difficulty, n (%) 3.445 0.179 High 23 (14.11%) 9 (10.34%) 14 (18.42%) Moderate 134 (82.21%) 76 (87.36%) 58 (76.32%) Low 6 (3.69%) 2 (2.30%) 4 (5.26%) Self-Directed Learning Ability , M (P25, P75) 91 (85, 98) 90 (84, 98) 93 (87.25, 98) 1.352 0.176 Self-management 30 (28, 34) 30 (28, 34) 30 (28, 33) 0.152 0.879 Information processing 36 (33, 40) 35 (33, 40) 37 (34, 40) 1.137 0.255 Cooperative learning 25 (23, 27) 24 (22, 26) 25 (24, 27) 1.887 0.176 Communication Skills Attitudes , M (P25, P75) 165 (149, 176) 97 (93, 104) 95 (88.25, 101) 1.806 0.071 Health Science Communication Competence , M (P25, P75) 134 (111, 148) 132 (118, 146) 140 (103, 149) 0.522 0.601 M (P25, P75) = Median (25th percentile, 75th percentile); χ² = chi-square test; Z = Mann–Whitney U test; P < 0.05 was considered statistically significant. Comparison of Academic Performance, Self-Management Ability, Communication Attitudes, and Health Science Communication Competence Final course grades were retrieved from the university's academic management system. The median final score in the intervention group was 84.95 (P25 = 81.71, P75 = 88.19), significantly higher than that of the control group [79.73 (77.06, 82.00); Z = 9.875, P < 0.001] (Table 2 ). As illustrated in Fig. 1 , the proportion of students scoring below 70 was lower in the intervention group, while the proportion scoring above 80 was higher, indicating a statistically significant shift in performance distribution (χ² = 35.003, P 0.05), the intervention group demonstrated significantly higher scores in the self-management subscale [31 (29, 34) vs. 29.5 (28, 31); Z = 4.245, P < 0.001].For attitudes toward communication skills, the intervention group also outperformed the control group, with median scores of 95 (89, 102) versus 85.5 (82, 92), respectively (Z = 5.493, P < 0.001).In terms of health science communication competence, the intervention group achieved markedly higher scores [199.6 (181.1, 215.6)] compared to the control group [139.0 (115.25, 146.5)], with the difference being statistically significant (Z = 9.875, P < 0.001). These results suggest that integrating antenatal education sessions practice into a blended learning model not only improves students’ academic performance but also enhances their self-management skills, communication attitudes, and competence in health science communication. Table 2 Comparison of Post-test Scores and Final Grades Variable Total (n = 163)M (P25, P75) Intervention Group (n = 87)M (P25, P75) Control Group (n = 76)M (P25, P75) Z* P Final Course Grades 82.08 (78.59, 86.44) 84.95 (81.71, 88.19) 79.73 (77.06, 82) 6.703 0.000** Self-Directed Learning Ability 92 (88, 98) 93 (88, 100) 92 (88, 96) 1.147 0.251 Self-management 30 (28, 32) 31 (29, 34) 29.5 (28, 31) 4.245 0.000** Information Processing 37 (35, 40) 37 (34, 41) 38 (35.25, 40) 1.150 0.250 Cooperative Learning 25 (23, 27) 25 (23, 27) 25 (23, 26) 0.878 0.380 Communication Skills Attitudes 91 (83, 98) 95 (89, 102) 85.5 (82, 92) 5.493 0.000** Health Science Communication Competence 199.6 (181.1, 215.6) 164 (158, 172) 139 (115.25, 146.5) 9.875 0.000** Note: Z = Mann–Whitney U test , P < 0.001 indicates statistical significance. Mediating Role of Self-Management Ability in the Relationship Between Blended Learning with Antenatal education sessions Integration and Health Science Communication Competence This study examined the effect of a blended learning model integrated with antenatal education sessions practice (X) on students’ health science communication competence (Y), and evaluated the mediating role of self-management ability (M).The total effect of the blended learning intervention on communication competence was significant, with an estimated value of 19.0427 (SE = 1.5597, t = 12.2095, p < 0.001, 95% CI: 15.9626 to 22.1227), indicating a strong positive impact of the intervention. After controlling for the mediator (self-management ability), the direct effect of the blended learning model on health science communication competence remained statistically significant at 17.2194 (SE = 1.6116, t = 10.6843, p < 0.001, 95% CI: 14.0365 to 20.4022).In addition, the indirect effect via self-management ability was estimated at 1.8233 (SE = 0.6625, 95% CI: 0.6352 to 3.2506). Since the confidence interval did not include zero, the mediation effect was considered statistically significant (see Table 3 ). Further analysis revealed that the product of the effect of the intervention on self-management ability (a) and the effect of self-management ability on health science communication competence (b) was equal to the observed indirect effect (a × b = 1.8233), confirming the presence of partial mediation (see Fig. 2 ).Taken together, these findings suggest that the blended learning model with antenatal education sessions integration not only directly enhances students’ health communication competence, but also indirectly promotes it by strengthening their self-management ability. Table 3 Mediation Effect of Self-Management on Health Science Communication Competence Effect Type Effect SE t p LLCI ULCI Total Effect 19.0427 1.5597 12.2095 0 15.9626 22.1227 Direct Effect 17.2194 1.6116 10.6843 0 14.0365 20.4022 Indirect Effect 1.8233 0.6625 — — 0.6352 3.2506 Discussion Effects of Blended Learning with Antenatal education sessions Practice on Students’ Learning Ability This study investigated the impact of a blended learning model, integrated with antenatal education sessions practice, on nursing students’ competence in health science communication. The results demonstrated that this model not only significantly improved students’ theoretical performance but also enhanced their self-management ability, attitudes toward communication skills, and overall health communication competence. These outcomes suggest that the integration of real-world practice into instructional design can provide robust support for students’ comprehensive development. Students in the intervention group achieved higher final examination scores, further confirming the positive association between experiential learning and academic achievement [ 16 ] . A meta-analysis by Andrew L. indicated that when students are given more opportunities for self-directed learning in the classroom, their intrinsic motivation for learning increases [ 10 ] . In the blended model applied in this study, individual learning differences were taken into account. Students were encouraged to review recorded lectures and digital materials at their own pace, thereby establishing stronger connections between theoretical knowledge and clinical practice [ 17 , 18 ] , which in turn stimulated greater learning motivation. However, it is worth noting that although the intervention group showed improved self-management ability, there was no significant difference between the two groups in overall self-directed learning ability. This suggests that while blended learning as a whole benefits self-directed learning, the addition of antenatal education sessions practice may not further enhance this particular capacity. The results imply that the improvement in self-directed learning may largely stem from the blended model itself, rather than from the antenatal education sessions component alone. Antenatal education sessions-Based Practice Enhances Students’ Communication Skills The findings of this study indicate that integrating antenatal education sessions practice into a blended learning model significantly improved students’ communication skills. Saleem et al. reported that when students are involved in real-life scenarios where they assist patients in addressing health concerns, they develop a stronger sense of social responsibility and professional commitment [ 19 ] . Such emotionally resonant experiences help students move beyond the mere transmission of medical knowledge to recognizing its tangible impact on patients’ behaviors and health outcomes [ 18 ] . Effective doctor–patient communication in authentic settings also enriches students’ emotional engagement during social practice, which in turn fosters a greater sense of accountability in health science communication. This emotional connection motivates students to translate theoretical knowledge into actionable practice, thereby bridging the gap between classroom learning and real-world health promotion [ 1 , 19 ] . The Mediating Role of Self-Management Ability in Enhancing Health Science Communication Competence This study identified that self-management ability partially mediated the relationship between the blended learning model—integrated with antenatal education sessions practice—and students’ competence in health science communication. This finding aligns with the core tenet of social cognitive theory, which posits that self-regulatory capacity can be strengthened through environmental interaction and behavioral engagement, thereby contributing to professional skill development [ 20 ] . Specifically, antenatal education sessions practice provided dynamic and authentic learning contexts that prompted students to proactively plan tasks such as interviews and health promotion events. Through real-time feedback from interactions with pregnant women, students enhanced their capacity for self-monitoring and adaptive learning control [ 21 ] . This strengthened self-management may have further translated into increased initiative in science communication, enabling students to integrate knowledge more effectively and design audience-centered materials. Notably, while no significant difference was observed in the overall self-directed learning scores between the two groups, the intervention group showed a statistically significant improvement in the self-management subdimension. This seemingly contradictory result may be explained by the multidimensional nature of self-directed learning. According to Zimmerman’s model, self-directed learning comprises three key dimensions: motivation, strategy use, and self-management [ 22 ] . The antenatal education sessions component likely had a more direct impact on the behavioral aspect—self-management—while exerting limited influence on motivational or strategic dimensions. Future research should further deconstruct these subcomponents to better identify the precise targets of blended learning interventions. From a pedagogical standpoint, these findings highlight self-management ability as a critical lever for enhancing students’ capacity for effective health communication. Educators may consider the following instructional strategies: embedding task-driven activities into blended learning modules; using real-world cases from antenatal education sessions practice to encourage reflection on the link between self-regulation and communication effectiveness; and integrating AI-powered tools to deliver personalized feedback on learning behaviors [ 23 ] . These approaches not only reinforce students’ self-regulatory capabilities but also lay a solid foundation for the integration of knowledge and practice in their future clinical work. Limitations Despite the promising findings of this study, several limitations should be acknowledged. First, the sample size was relatively small, and participants were primarily drawn from a single university cohort. Future research should consider expanding the sample size and enhancing sample diversity to improve the generalizability of the findings. Second, this study focused solely on the mediating role of self-management ability and did not account for other potential mediating or confounding variables. Factors such as students' learning motivation, learning environment, and other contextual influences may also play important roles in shaping the development of health science communication skills. Further research is needed to explore these variables and their mechanisms of influence, to gain a more comprehensive understanding of how blended learning impacts students' competency development. Conclusions The findings of this study offer new theoretical insights and practical guidance for curriculum design in nursing education. In future teaching practices, efforts should be made to further optimize the implementation strategies of blended learning models. Emphasis should be placed on integrating diverse teaching methods and learning environments, while expanding opportunities for practical engagement and multidimensional skill development. Such approaches can better support the cultivation of high-quality nursing professionals who possess both clinical competence and humanistic care. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of the Frist Affiliated Hospital of Chongqing Medical University (Approval No. 2025-239-01). All participants were informed about the study and provided written informed consent prior to participation. Consent for publication Not applicable. Availability of data and materials The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported by the Maternal and Child Health Research Training Program of Chongqing Municipal Health Commission, China (Grant No. 2023FY206). Authors’ contributions Xiaochang Yang designed and supervised this study. Bizhen Liao provided guidance and methods for the implementation of teaching methods and revised key steps of teaching methods. Feifei Li, Ying Zhou, and Yan Li were responsible for collecting and interpreting data, Li Feifei with also completing data analysis, literature review, and writing manuscripts and articles. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank the undergraduate nursing students who participated in this study and the faculty members who supported the instructional activities. Special thanks are extended to the antenatal education program for providing practical training opportunities, and to the data support team for their assistance in survey implementation. 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Utilising learning analytics to support study success in higher education: a systematic review. Educ Tech Res Dev. 2020;68:1961–90. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 15 Jul, 2025 Editor invited by journal 23 Jun, 2025 Editor assigned by journal 23 May, 2025 Submission checks completed at journal 23 May, 2025 First submitted to journal 20 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6707208","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":486588965,"identity":"b73e097c-849f-4958-9f2f-c019fcc945dc","order_by":0,"name":"Feifei Li","email":"","orcid":"","institution":"First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Feifei","middleName":"","lastName":"Li","suffix":""},{"id":486588966,"identity":"58cbf13f-7096-4cf0-b489-f5325ac22237","order_by":1,"name":"Xiaochang Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYBAC+/b+7z8+/rHhYWNvIFKLAc8BA8mZDWky/DwHiNUikWAgzdtwyEZyRgKRWswlEhIMeHcc4DG4+XjjDYYam2iCWix7HhxIkDxzh8fgdlqxBcOxtNwGgnqOJzYcMGB7BtSSYybB2HCYCC0HkhkbEtgOAx12hkgtBifSmBkOth3mkZzBQ6QWyZ4zbIwNZ9J4+HmAfkkgxi/87D1szH8qbOzZ2A9vvPGhxoYIvyA7UiKBFOUQLaTqGAWjYBSMgpEBALU4QingKxSRAAAAAElFTkSuQmCC","orcid":"","institution":"First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":true,"prefix":"","firstName":"Xiaochang","middleName":"","lastName":"Yang","suffix":""},{"id":486588967,"identity":"fca315c3-5536-4e8e-86b4-e811465205ee","order_by":2,"name":"Bizhen Liao","email":"","orcid":"","institution":"First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Bizhen","middleName":"","lastName":"Liao","suffix":""},{"id":486588971,"identity":"cb37e4c7-f1fb-4890-a648-b9e156373e4d","order_by":3,"name":"Yin Zhou","email":"","orcid":"","institution":"First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yin","middleName":"","lastName":"Zhou","suffix":""},{"id":486588973,"identity":"b34017a1-9405-437c-9604-9e8cadec8385","order_by":4,"name":"Yan Li","email":"","orcid":"","institution":"First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2025-05-20 11:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6707208/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6707208/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86964008,"identity":"0ea2c589-b9fa-42c0-8c1a-f3868fe8fc31","added_by":"auto","created_at":"2025-07-17 17:01:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":31564,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of final theoretical scores in the Obstetric and Gynecological Nursing course\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6707208/v1/46a7a71c465e439fb6138f2d.png"},{"id":86963094,"identity":"c2681ba4-3dca-4742-b1db-9f0cd12421a9","added_by":"auto","created_at":"2025-07-17 16:45:16","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58108,"visible":true,"origin":"","legend":"\u003cp\u003eMediation model of self-management ability in the effect of blended learning on health science communication competence.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6707208/v1/134d307a4e6f70ed00fc0584.png"},{"id":86965330,"identity":"ec175cf7-d202-4a14-9655-3c40f2a76f64","added_by":"auto","created_at":"2025-07-17 17:09:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1289098,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6707208/v1/98aa682e-50ab-44d9-b883-1fb1303f532e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of Blended Learning with Antenatal Education Practice on Nursing Students’ Communication Competence: A Mediation Model of Self-Management","fulltext":[{"header":"Background","content":"\u003cp\u003eThe rapid advancement of digital technologies and the diversification of information channels have contributed to the emergence of an \u0026ldquo;infodemic\u0026rdquo;\u0026mdash;a digital epidemic of misinformation and disinformation that poses a significant threat to global public health systems\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. In response, the strategic dissemination of accurate medical knowledge has become imperative for improving health literacy, countering false information, and ensuring public health security \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Higher education institutions are expected to play a vital role in this effort by integrating science communication into their curricula, leveraging external scientific resources, and tailoring educational content to students across disciplines and academic levels\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. They are also encouraged to promote student participation in innovative practice-based learning and volunteer science outreach activities\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Such integration of science education with public engagement not only enhances the quality of education but also contributes to the cultivation of high-level talent needed for sustainable social development\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eBlended learning is an innovative instructional approach that integrates traditional face-to-face teaching with modern online learning strategies to create a more flexible and personalized educational experience\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. The concept of blended learning has been interpreted in various ways, generally encompassing four major categories\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e: (1) technology-based blended learning; (2) the combination of multiple instructional approaches; (3) the integration of diverse teaching methods with in-person instruction; and (4) the alignment of instructional tools with teaching tasks to achieve pedagogical goals. Among these, current research has largely focused on the first type\u0026mdash;blending online platforms with classroom teaching\u0026mdash;which has been shown to enhance student motivation, increase engagement, and foster autonomous learning\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. However, this technology-oriented model still presents limitations in terms of contextual diversity and the depth of practical application.\u003c/p\u003e\u003cp\u003eTo further enhance the effectiveness of blended learning, this study introduced a third instructional setting\u0026mdash;prenatal education classes\u0026mdash;on top of the conventional technology-supported blended model. In this design, students acquire theoretical knowledge through online and in-person coursework, and develop fundamental nursing skills through clinical practice in hospital settings. Building upon these two foundations, the antenatal education sessions functions as a dynamic, patient-centered \u0026ldquo;third classroom,\u0026rdquo; offering nursing students an authentic environment focused on pregnant women.\u003c/p\u003e\u003cp\u003eThrough active involvement in course planning and health education activities at the antenatal education sessions, students engage in direct, meaningful interactions with expectant mothers. This setting allows them to observe real maternal needs and behaviors throughout pregnancy, while also facilitating the development of trust and rapport in a relaxed, natural atmosphere. As a result, students gain a deeper understanding of the psychological, physiological, and social dimensions of maternal care, enriching their capacity to conduct effective health communication for perinatal women and newborns.\u003c/p\u003e\u003cp\u003eBy integrating multiple learning environments, this approach supports a complete learning cycle\u0026mdash;from knowledge acquisition to application, and ultimately internalization. It helps bridge the gap between classroom instruction and real-world nursing practice, fostering greater confidence and competence in students as they prepare to serve perinatal populations in their future professional roles.\u003c/p\u003e\u003cp\u003eGiven the rising importance of public health awareness, it is increasingly essential for undergraduate nursing students to acquire strong competencies in health science communication. Although blended learning models have been widely recognized for their ability to enhance students\u0026rsquo; self-directed learning\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e, the extent to which such models contribute to the development of health communication competence remains unclear. In particular, the potential mediating role of self-management ability in this relationship has yet to be empirically tested.\u003c/p\u003e\u003cp\u003eTo address this gap, the present study explores the effects of integrating prenatal education courses into a blended learning framework on nursing students\u0026rsquo; health science communication competence. It further examines the interaction between this competence and self-management ability. Findings from this research are expected to offer new insights into blended instructional strategies and provide practical implications for cultivating nursing professionals equipped with both clinical expertise and effective communication skills in health promotion.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eA purposive sampling strategy was employed to recruit participants who met the following inclusion criteria:\u003c/p\u003e\u003cp\u003e\u003col style=\"list-style-type:lower-roman;\"\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ethird-year undergraduate nursing students who had completed coursework in pathophysiology, medical-surgical nursing, and possessed foundational nursing knowledge and clinical skills;\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eindividuals who had completed a two-week clinical internship at a university-affiliated hospital during the academic break and demonstrated basic doctor\u0026ndash;patient communication competence;\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003estudents aged 18 years or older with the ability to critically evaluate the authenticity of health-related information.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEstablishment of the Health Science Communication Teaching Team\u003c/h3\u003e\n\u003cp\u003eThe instructional team consisted of eight members, including faculty from a key medical university and professionals from a local science communication center. All team members underwent standardized training in perinatal and neonatal nursing knowledge as well as health science communication skills. Upon completion of the training, they served as mentors responsible for guiding students in the creation and delivery of health communication content.\u003c/p\u003e\n\u003ch3\u003eSample Size Calculation and Group Allocation\u003c/h3\u003e\n\u003cp\u003eBased on the study design and statistical requirements, an independent samples t-test was planned to compare group means. Assuming a medium effect size (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.5), a significance level of α\u0026thinsp;=\u0026thinsp;0.05, and a statistical power of 0.80, the required sample size was calculated using G*Power software. The estimated minimum number of participants was 64 per group. To account for potential attrition, a 20% buffer was added, resulting in a target of at least 77 participants per group and a total sample size of 154.\u003c/p\u003e\u003cp\u003eInitially, 180 students were recruited. Each participant was assigned a unique identification number and randomly allocated into either the intervention or control group (n\u0026thinsp;=\u0026thinsp;90 per group) using a random number table. During the study, some participants withdrew, and a total of 163 students completed the intervention (intervention group: n\u0026thinsp;=\u0026thinsp;87; control group: n\u0026thinsp;=\u0026thinsp;76). The eight faculty members were also randomly assigned to two teams and tasked with mentoring students in the development of health communication content related to perinatal and neonatal care.\u003c/p\u003e\n\u003ch3\u003eTeaching Implementation\u003c/h3\u003e\n\u003cp\u003eThe intervention group received a blended learning model integrated with practical sessions at an antenatal education sessions. All instructional content focused on the care of perinatal women and newborns. Students participated in four structured sessions at the antenatal education sessions:\u003c/p\u003e\u003cp\u003e\u003col style=\"list-style-type:lower-roman;\"\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eattending one prenatal class as observers alongside pregnant women;\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003econducting one structured interview with a pregnant woman;\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003edesigning and organizing one antenatal education sessions activity;\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003edelivering one health education session at the antenatal education sessions.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThese experiential activities were designed to expose students to the real needs of pregnant women in authentic settings. Faculty mentors provided regular feedback throughout the process to guide students in developing health communication materials based on their experiences.\u003c/p\u003e\u003cp\u003eIn contrast, the control group followed a conventional blended learning model (online \u0026amp; offline) without antenatal education sessions integration. Students in this group were also mentored by faculty to complete health communication projects. To ensure instructional equity, the control group was later given access to the same antenatal education sessions activities after the intervention phase.\u003c/p\u003e\u003cp\u003eTo minimize potential confounding effects, a delayed-start crossover design was adopted. Only data from the synchronized intervention phase between the two groups were used in comparative analyses to ensure equivalence in baseline conditions and outcome validity. Post-intervention data from the control group\u0026rsquo;s delayed antenatal education sessions experience were archived as an independent dataset for planned longitudinal follow-up to explore the delayed intervention\u0026rsquo;s potential long-term effects.\u003c/p\u003e\n\u003ch3\u003eGuidance on Health Communication Content Development\u003c/h3\u003e\n\u003cp\u003eBoth the intervention and control groups received the following structured instructional support to facilitate the creation of health communication materials:\u003c/p\u003e\u003cp\u003e\u003col style=\"list-style-type:lower-roman;\"\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eInformation exposure and inspiration: Educational content related to perinatal and neonatal care was regularly disseminated via WeChat groups, including official hospital WeChat posts, science communication videos from the hospital\u0026rsquo;s Douyin (TikTok) account, and community health brochures.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIdea generation through discussion: Students participated in moderated group discussions via WeChat, focusing on strategies for developing science communication content relevant to maternal and newborn health.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eContent creation guidance: Based on discussion outcomes, students selected topics of interest and were guided in the design and development of evidence-based, audience-friendly health communication content.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eProduct transformation with AI assistance: Students were encouraged to convert their written health education content into multimedia formats\u0026mdash;such as videos, social media posts, or bulletin board displays\u0026mdash;using artificial intelligence tools (e.g., AIGC technologies) to enhance dissemination and engagement.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Collection\u003c/h2\u003e\u003cp\u003eData were collected using an online survey administered via the Wenjuanxing platform (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.wjx.cn\" target=\"_blank\"\u003ewww.wjx.cn\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.wjx.cn\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) one week prior to the start of the course unit Nursing Care for Perinatal Mothers and Infants. The survey included the following components:\u003c/p\u003e\u003cp\u003e\u003col style=\"list-style-type:lower-roman;\"\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eGeneral information questionnaire: Collected basic demographic and background data, including gender, personality type, monthly living expenses, interest in the nursing major, and self-perceived learning difficulty.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eSelf-Directed Learning Ability Scale for Nursing Undergraduates (Lin Yi et al., 2004) \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e: This 28-item scale assesses self-management, information processing, and cooperative learning abilities. It uses a 5-point Likert scale, with higher scores indicating stronger self-directed learning capacity. The scale has a reported Cronbach\u0026rsquo;s α coefficient of 0.8632.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCommunication Skills Attitude Scale (Ren Peishu et al., 2012) \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e: A 26-item scale measuring attitudes toward learning communication skills, rated on a 5-point Likert scale. Higher scores reflect more positive attitudes. The scale has a Cronbach\u0026rsquo;s α of 0.841.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHealth Science Communication Competence Scale for Medical Students (Zhang Qian et al., 2023) \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e: A 43-item instrument designed to evaluate students\u0026rsquo; competence in science communication within medical contexts. It is rated on a 5-point Likert scale, with higher scores indicating greater competence. The Cronbach\u0026rsquo;s α for the scale is 0.923.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eFinal examination scores were extracted from the academic management system and used as indicators of theoretical knowledge acquisition.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eA post-intervention survey was distributed via Wenjuanxing one week after course completion to re-assess self-directed learning ability, communication skills, and health science communication competence.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eFor continuous variables with a normal distribution, independent samples t-tests were used to compare mean differences between the intervention and control groups to assess the effects of the educational intervention. For variables that did not meet the normality assumption, the nonparametric Mann\u0026ndash;Whitney U test was applied to examine differences in distribution. Chi-square (χ\u0026sup2;) tests were used to analyze the independence of categorical variables between groups. To examine whether self-management ability mediated the relationship between the blended learning intervention and students\u0026rsquo; health science communication competence, mediation analysis was conducted. The bootstrap method with 5000 resamples was used to estimate the 95% confidence interval (CI) for the indirect (mediated) effect. A CI that does not include zero was interpreted as evidence of a statistically significant mediation effect.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eBaseline Comparison\u003c/h2\u003e\u003cp\u003eA total of 163 students completed the study, including 87 in the intervention group and 76 in the control group. Baseline comparisons showed no significant differences between the two groups in terms of general demographic characteristics, self-directed learning ability, attitudes toward communication skills, and health science communication competence. These results indicate that the two groups were comparable prior to the intervention(see Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline Characteristics and Key Competencies of Intervention and Control Groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;163)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIntervention Group (n\u0026thinsp;=\u0026thinsp;87)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;76)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eχ\u0026sup2; / Z\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOnly Child, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.099\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.754\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e105 (64.42%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57 (65.52%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48 (63.16%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58 (35.58%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (34.48%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28 (36.84%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePersonality Type, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.788\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.674\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntroverted\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44 (26.99%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (24.14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23 (30.26%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExtroverted\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (7.98%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (8.05%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (7.89%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMixed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e106 (65.03%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59 (67.82%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47 (61.84%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMonthly Living Expenses, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10.906\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.053\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e500\u0026ndash;1000 RMB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (9.82%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (10.34%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (9.21%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1001\u0026ndash;1500 RMB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78 (47.85%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44 (50.57%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34 (44.74%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1501\u0026ndash;2000 RMB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60 (36.81%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34 (39.08%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26 (34.21%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2001\u0026ndash;2500 RMB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (2.45%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (5.26%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2501\u0026ndash;3000 RMB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (1.84%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (3.95%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;3000 RMB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (1.23%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (2.63%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInterest in Nursing, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.628\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.099\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLike\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (30.67%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (37.93%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (22.37%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeutral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e109 (66.87%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52 (59.77%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57 (75.00%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDislike\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (2.45%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (2.63%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerceived Learning Difficulty, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.445\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.179\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23 (14.11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (10.34%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (18.42%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e134 (82.21%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 (87.36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58 (76.32%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (3.69%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (5.26%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSelf-Directed Learning Ability\u003c/b\u003e, M (P25, P75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91 (85, 98)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90 (84, 98)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e93 (87.25, 98)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.352\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.176\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (28, 34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (28, 34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30 (28, 33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.152\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.879\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInformation processing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (33, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (33, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37 (34, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.137\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.255\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCooperative learning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (23, 27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (22, 26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (24, 27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.887\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.176\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCommunication Skills Attitudes\u003c/b\u003e, M (P25, P75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e165 (149, 176)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e97 (93, 104)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95 (88.25, 101)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.806\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHealth Science Communication Competence\u003c/b\u003e, M (P25, P75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e134 (111, 148)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e132 (118, 146)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e140 (103, 149)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.522\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.601\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eM (P25, P75)\u0026thinsp;=\u0026thinsp;Median (25th percentile, 75th percentile); χ\u0026sup2; = chi-square test; Z\u0026thinsp;=\u0026thinsp;Mann\u0026ndash;Whitney U test; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eComparison of Academic Performance, Self-Management Ability, Communication Attitudes, and Health Science Communication Competence\u003c/h2\u003e\u003cp\u003eFinal course grades were retrieved from the university's academic management system. The median final score in the intervention group was 84.95 (P25\u0026thinsp;=\u0026thinsp;81.71, P75\u0026thinsp;=\u0026thinsp;88.19), significantly higher than that of the control group [79.73 (77.06, 82.00); Z\u0026thinsp;=\u0026thinsp;9.875, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001] (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). As illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the proportion of students scoring below 70 was lower in the intervention group, while the proportion scoring above 80 was higher, indicating a statistically significant shift in performance distribution (χ\u0026sup2; = 35.003, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eAlthough no significant difference was observed between the groups in overall self-directed learning ability scores (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), the intervention group demonstrated significantly higher scores in the self-management subscale [31 (29, 34) vs. 29.5 (28, 31); Z\u0026thinsp;=\u0026thinsp;4.245, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001].For attitudes toward communication skills, the intervention group also outperformed the control group, with median scores of 95 (89, 102) versus 85.5 (82, 92), respectively (Z\u0026thinsp;=\u0026thinsp;5.493, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).In terms of health science communication competence, the intervention group achieved markedly higher scores [199.6 (181.1, 215.6)] compared to the control group [139.0 (115.25, 146.5)], with the difference being statistically significant (Z\u0026thinsp;=\u0026thinsp;9.875, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These results suggest that integrating antenatal education sessions practice into a blended learning model not only improves students\u0026rsquo; academic performance but also enhances their self-management skills, communication attitudes, and competence in health science communication.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Post-test Scores and Final Grades\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;163)M (P25, P75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIntervention Group (n\u0026thinsp;=\u0026thinsp;87)M (P25, P75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;76)M (P25, P75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eZ*\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFinal Course Grades\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82.08 (78.59, 86.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84.95 (81.71, 88.19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e79.73 (77.06, 82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.703\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSelf-Directed Learning Ability\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e92 (88, 98)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93 (88, 100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e92 (88, 96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.147\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.251\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (28, 32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31 (29, 34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29.5 (28, 31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.245\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInformation Processing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37 (35, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37 (34, 41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38 (35.25, 40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.150\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.250\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCooperative Learning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (23, 27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (23, 27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (23, 26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.878\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.380\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCommunication Skills Attitudes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91 (83, 98)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95 (89, 102)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85.5 (82, 92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.493\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHealth Science Communication Competence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e199.6 (181.1, 215.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e164 (158, 172)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e139 (115.25, 146.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.875\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote:\u003cem\u003eZ\u0026thinsp;=\u0026thinsp;Mann\u0026ndash;Whitney U test\u003c/em\u003e, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001 indicates statistical significance.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMediating Role of Self-Management Ability in the Relationship Between Blended Learning with Antenatal education sessions Integration and Health Science Communication Competence\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study examined the effect of a blended learning model integrated with antenatal education sessions practice (X) on students\u0026rsquo; health science communication competence (Y), and evaluated the mediating role of self-management ability (M).The total effect of the blended learning intervention on communication competence was significant, with an estimated value of 19.0427 (SE\u0026thinsp;=\u0026thinsp;1.5597, t\u0026thinsp;=\u0026thinsp;12.2095, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, 95% CI: 15.9626 to 22.1227), indicating a strong positive impact of the intervention.\u003c/p\u003e\u003cp\u003eAfter controlling for the mediator (self-management ability), the direct effect of the blended learning model on health science communication competence remained statistically significant at 17.2194 (SE\u0026thinsp;=\u0026thinsp;1.6116, t\u0026thinsp;=\u0026thinsp;10.6843, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, 95% CI: 14.0365 to 20.4022).In addition, the indirect effect via self-management ability was estimated at 1.8233 (SE\u0026thinsp;=\u0026thinsp;0.6625, 95% CI: 0.6352 to 3.2506). Since the confidence interval did not include zero, the mediation effect was considered statistically significant (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFurther analysis revealed that the product of the effect of the intervention on self-management ability (a) and the effect of self-management ability on health science communication competence (b) was equal to the observed indirect effect (a \u0026times; b\u0026thinsp;=\u0026thinsp;1.8233), confirming the presence of partial mediation (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).Taken together, these findings suggest that the blended learning model with antenatal education sessions integration not only directly enhances students\u0026rsquo; health communication competence, but also indirectly promotes it by strengthening their self-management ability.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMediation Effect of Self-Management on Health Science Communication Competence\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffect Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEffect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003et\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLLCI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eULCI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19.0427\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.5597\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.2095\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e15.9626\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e22.1227\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDirect Effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17.2194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.6116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.6843\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e14.0365\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e20.4022\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndirect Effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.8233\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.6625\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.6352\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3.2506\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eEffects of Blended Learning with Antenatal education sessions Practice on Students\u0026rsquo; Learning Ability\u003c/h2\u003e\u003cp\u003eThis study investigated the impact of a blended learning model, integrated with antenatal education sessions practice, on nursing students\u0026rsquo; competence in health science communication. The results demonstrated that this model not only significantly improved students\u0026rsquo; theoretical performance but also enhanced their self-management ability, attitudes toward communication skills, and overall health communication competence. These outcomes suggest that the integration of real-world practice into instructional design can provide robust support for students\u0026rsquo; comprehensive development.\u003c/p\u003e\u003cp\u003eStudents in the intervention group achieved higher final examination scores, further confirming the positive association between experiential learning and academic achievement\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. A meta-analysis by Andrew L. indicated that when students are given more opportunities for self-directed learning in the classroom, their intrinsic motivation for learning increases\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. In the blended model applied in this study, individual learning differences were taken into account. Students were encouraged to review recorded lectures and digital materials at their own pace, thereby establishing stronger connections between theoretical knowledge and clinical practice\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e, which in turn stimulated greater learning motivation.\u003c/p\u003e\u003cp\u003eHowever, it is worth noting that although the intervention group showed improved self-management ability, there was no significant difference between the two groups in overall self-directed learning ability. This suggests that while blended learning as a whole benefits self-directed learning, the addition of antenatal education sessions practice may not further enhance this particular capacity. The results imply that the improvement in self-directed learning may largely stem from the blended model itself, rather than from the antenatal education sessions component alone.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eAntenatal education sessions-Based Practice Enhances Students\u0026rsquo; Communication Skills\u003c/h2\u003e\u003cp\u003eThe findings of this study indicate that integrating antenatal education sessions practice into a blended learning model significantly improved students\u0026rsquo; communication skills. Saleem et al. reported that when students are involved in real-life scenarios where they assist patients in addressing health concerns, they develop a stronger sense of social responsibility and professional commitment\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Such emotionally resonant experiences help students move beyond the mere transmission of medical knowledge to recognizing its tangible impact on patients\u0026rsquo; behaviors and health outcomes\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eEffective doctor\u0026ndash;patient communication in authentic settings also enriches students\u0026rsquo; emotional engagement during social practice, which in turn fosters a greater sense of accountability in health science communication. This emotional connection motivates students to translate theoretical knowledge into actionable practice, thereby bridging the gap between classroom learning and real-world health promotion\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eThe Mediating Role of Self-Management Ability in Enhancing Health Science Communication Competence\u003c/h2\u003e\u003cp\u003eThis study identified that self-management ability partially mediated the relationship between the blended learning model\u0026mdash;integrated with antenatal education sessions practice\u0026mdash;and students\u0026rsquo; competence in health science communication. This finding aligns with the core tenet of social cognitive theory, which posits that self-regulatory capacity can be strengthened through environmental interaction and behavioral engagement, thereby contributing to professional skill development\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSpecifically, antenatal education sessions practice provided dynamic and authentic learning contexts that prompted students to proactively plan tasks such as interviews and health promotion events. Through real-time feedback from interactions with pregnant women, students enhanced their capacity for self-monitoring and adaptive learning control \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. This strengthened self-management may have further translated into increased initiative in science communication, enabling students to integrate knowledge more effectively and design audience-centered materials.\u003c/p\u003e\u003cp\u003eNotably, while no significant difference was observed in the overall self-directed learning scores between the two groups, the intervention group showed a statistically significant improvement in the self-management subdimension. This seemingly contradictory result may be explained by the multidimensional nature of self-directed learning. According to Zimmerman\u0026rsquo;s model, self-directed learning comprises three key dimensions: motivation, strategy use, and self-management\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. The antenatal education sessions component likely had a more direct impact on the behavioral aspect\u0026mdash;self-management\u0026mdash;while exerting limited influence on motivational or strategic dimensions. Future research should further deconstruct these subcomponents to better identify the precise targets of blended learning interventions.\u003c/p\u003e\u003cp\u003eFrom a pedagogical standpoint, these findings highlight self-management ability as a critical lever for enhancing students\u0026rsquo; capacity for effective health communication. Educators may consider the following instructional strategies:\u003c/p\u003e\u003cp\u003e\u003col style=\"list-style-type:lower-roman;\"\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eembedding task-driven activities into blended learning modules;\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eusing real-world cases from antenatal education sessions practice to encourage reflection on the link between self-regulation and communication effectiveness; and\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eintegrating AI-powered tools to deliver personalized feedback on learning behaviors\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThese approaches not only reinforce students\u0026rsquo; self-regulatory capabilities but also lay a solid foundation for the integration of knowledge and practice in their future clinical work.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eDespite the promising findings of this study, several limitations should be acknowledged. First, the sample size was relatively small, and participants were primarily drawn from a single university cohort. Future research should consider expanding the sample size and enhancing sample diversity to improve the generalizability of the findings.\u003c/p\u003e\u003cp\u003eSecond, this study focused solely on the mediating role of self-management ability and did not account for other potential mediating or confounding variables. Factors such as students' learning motivation, learning environment, and other contextual influences may also play important roles in shaping the development of health science communication skills. Further research is needed to explore these variables and their mechanisms of influence, to gain a more comprehensive understanding of how blended learning impacts students' competency development.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe findings of this study offer new theoretical insights and practical guidance for curriculum design in nursing education. In future teaching practices, efforts should be made to further optimize the implementation strategies of blended learning models. Emphasis should be placed on integrating diverse teaching methods and learning environments, while expanding opportunities for practical engagement and multidimensional skill development. Such approaches can better support the cultivation of high-quality nursing professionals who possess both clinical competence and humanistic care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This study was approved by the Ethics Committee of the Frist Affiliated Hospital of Chongqing Medical University (Approval No. 2025-239-01). All participants were informed about the study and provided written informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This study was supported by the Maternal and Child Health Research Training Program of Chongqing Municipal Health Commission, China (Grant No. 2023FY206).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXiaochang Yang designed and supervised this study. Bizhen Liao provided guidance and methods for the implementation of teaching methods and revised key steps of teaching methods. Feifei Li, Ying Zhou, and Yan Li were responsible for collecting and interpreting data, Li Feifei with also completing data analysis, literature review, and writing manuscripts and articles. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors would like to thank the undergraduate nursing students who participated in this study and the faculty members who supported the instructional activities. Special thanks are extended to the antenatal education program for providing practical training opportunities, and to the data support team for their assistance in survey implementation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. 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Nursing students\u0026rsquo; perception of digital technology in clinical education among undergraduate programs: A qualitative systematic review. J Prof Nurs. 2024;53:49\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCoyne E, Rands H, Frommolt V, Kain V, Plugge M, Mitchell M. Investigation of blended learning video resources to teach health students clinical skills: An integrative review. Nurse Educ Today. 2018;63:101\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaleem SM, Jan SS. Navigating the infodemic: strategies and policies for promoting health literacy and effective communication. Front Public Health. 2023;11:1324330.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBandura A. Social cognitive theory of self-regulation. Organ Behav Hum Decis Process. 1991;50:248\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePanadero E. A Review of Self-regulated Learning: Six Models and Four Directions for Research. Front Psychol. 2017;8:422.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZimmerman BJ, Risemberg R. Becoming a Self-Regulated Writer: A Social Cognitive Perspective. Contemp Educ Psychol. 1997;22:73\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIfenthaler D, Yau JY-K. Utilising learning analytics to support study success in higher education: a systematic review. Educ Tech Res Dev. 2020;68:1961\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"blended learning, antenatal education, health science communication competence, self-management ability, nursing education","lastPublishedDoi":"10.21203/rs.3.rs-6707208/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6707208/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eBlended learning is widely used in nursing education, yet its effect on students\u0026rsquo; competence in health science communication remains underexplored. This study investigated the impact of integrating antenatal education class practice\u0026mdash;a form of community-based maternal health education\u0026mdash; practice into blended learning and examined the mediating role of self-management ability.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA randomized controlled trial was conducted with 163 third-year undergraduate nursing students assigned to either an intervention group (blended learning plus antenatal education sessions practice, n\u0026thinsp;=\u0026thinsp;87) or a control group (blended learning only, n\u0026thinsp;=\u0026thinsp;76). Pre- and post-intervention surveys assessed health science communication competence, self-management ability, and attitudes toward communication skills. Final examination scores measured academic performance. Mediation analysis was performed using the bootstrap method with 5000 resamples.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003ePost-intervention, the intervention group scored significantly higher than the control group in health science communication competence (Z\u0026thinsp;=\u0026thinsp;9.875, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), self-management ability (Z\u0026thinsp;=\u0026thinsp;4.245, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and communication skill attitudes (Z\u0026thinsp;=\u0026thinsp;5.493, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Their final exam scores were also significantly higher (Z\u0026thinsp;=\u0026thinsp;9.875, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Mediation analysis confirmed a partial mediating effect of self-management ability on the relationship between the intervention and communication competence (indirect effect\u0026thinsp;=\u0026thinsp;1.8233, 95% CI: 0.6352\u0026ndash;3.2506).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eIntegrating antenatal education sessions practice into blended learning significantly enhances nursing students\u0026rsquo; communication competence, academic performance, and self-management. This approach offers an innovative model for bridging theoretical instruction and real-world health education practice.\u003c/p\u003e\u003ch2\u003eClinical trial number\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Effects of Blended Learning with Antenatal Education Practice on Nursing Students’ Communication Competence: A Mediation Model of Self-Management","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-17 16:45:12","doi":"10.21203/rs.3.rs-6707208/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-07-15T12:37:20+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-23T11:58:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-23T06:52:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-23T06:48:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-05-20T11:10:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d7e8d980-1858-4a44-a8ac-71e82391c6c5","owner":[],"postedDate":"July 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-17T16:45:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-17 16:45:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6707208","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6707208","identity":"rs-6707208","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}