Investigating the Effect of Evaluation by Direct Observation of Procedural Skills Method on the Level of Anxiety and Clinical Performance of Nursing Students during Drug Injections

Investigating the Effect of Evaluation by Direct Observation of Procedural Skills Method on the Level of Anxiety and Clinical Performance of Nursing Students during Drug Injections | 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 Investigating the Effect of Evaluation by Direct Observation of Procedural Skills Method on the Level of Anxiety and Clinical Performance of Nursing Students during Drug Injections Mahla Mosayebi, Mahbobeh Abdolrahimi, Soolmaz Moosavi, Malihe Nasiri This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7091396/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Introduction Junior nursing students frequently experience performance anxiety during clinical skills training, particularly with invasive procedures like injections, affecting the quality of their work. Direct Observation of Practical Skills (DOPS) constitutes a contemporary pedagogical and evaluative approach, affording constructive feedback and facilitating enhanced clinical proficiency. This study’s aim was to determine the effect of DOPS on the anxiety and performance of nursing students during injection procedures. Method This quasi-experimental study employed census to recruit 74 first-semester nursing students from Shahid Beheshti Nursing School. These students were randomly assigned to either a control group (n = 36) or an intervention group (n = 38). Both groups received equivalent training in injection techniques (intramuscular, intravenous, subcutaneous, and intradermal). Student anxiety levels and performance were assessed using the Spielberger’s State-Trait Anxiety Inventory and standardized checklists respectively on two occasions: once during the first week and again in the third week following injection training. Evaluations in the intervention group employed the DOPS method, while the control group underwent standard evaluation procedures. SPSS version 16 was utilized for data analysis, employing descriptive and analytical statistical methods with a significance level of 0.05. Results Pre-intervention, no significant differences in anxiety or performance were observed between groups (p < 0.05). Post-intervention, DOPS implementation resulted in a significant reduction in state and trait anxiety within the intervention group, as determined by the chi-square test and Wilcoxon tests(p < 0.001). Also, the results showed that, based on the independent and paired t-tests, their performance after the evaluation was better in the intervention group compared to the control group and to before the intervention. (p < 0.001). Conclusion Findings indicate that the DOPS method mitigates anxiety and enhances the injection skills of nursing students, suggesting its efficacy as a pedagogical tool in clinical training. Nursing Assessment Anxiety Injections Nursing Evaluation Research Introduction Nursing education integrates theoretical and practical components to cultivate students’ knowledge, skills, and professional attitude, ensuring their preparedness for safe and high-quality patient care upon entering healthcare settings ( 1 , 2 ). Within this context, practical training assumes paramount importance as the cornerstone of clinical education; thus, enhancing the quality of practical skills instruction has been a primary concern for educators ( 3 ). Nevertheless, numerous studies indicate that novice nursing students encounter considerable anxiety during their initial clinical placements, attributable to extensive course material, unfamiliarity with healthcare settings, and apprehension regarding patient care errors ( 4 – 6 ). Anxiety, a natural reaction to perceived threats, can manifest psychologically, cognitively, and physically—including diaphoresis, palpitations, and dyspnea—and negatively impact performance and quality of life ( 7 , 8 ). Studies across various countries indicate that anxiety rates among nursing students, particularly during their initial clinical experiences, range from 14–32% ( 8 , 9 , 10 ). Qualitative research conducted in Iran revealed that, amongst practical skills taught, the highest student anxiety levels were associated with drug injection techniques. This anxiety may negatively impact academic performance and increase the risk of medication errors ( 9 , 11 , 12 ). A Washington University of Medical Sciences Institute of Health report indicates that the United States experiences over one million annual medical errors, resulting in hundreds of thousands of fatalities, including 77,000 medication error-related deaths. Annual expenditures on medication errors in Iran, as reported by the Ministry of Health, reach into the billions of Tomans; a significant portion (approximately 54.4%) goes unreported ( 13 , 14 ). Iranian students reported the highest rate (39.68%) of medication errors, primarily during drug administration, specifically concerning incorrectly dosed or concentrated injections ( 15 ). A further qualitative study identified difficulties with injection site identification and administration technique as a significant challenge for nursing students ( 16 ). Therefore, it is imperative to rectify students’ shortcomings prior to their clinical placements to mitigate potential errors ( 17 , 18 ). Student evaluations presently use traditional methods, grounded in the principles of Ralph Tyler ( 19 , 20 , 21 ), to assess the programs and curriculum’s efficacy in achieving their objectives. Researches show that conventional assessment strategies may negatively affect student satisfaction and motivation, thus causing the implementation of contemporary evaluation techniques ( 22 , 23 ). One such method is direct observation of practical skills (DOPS) assessment, initially developed in England in 2005. This approach facilitates direct observation of student performance by the instructor, with focused feedback to improve essential clinical skills ( 24 , 25 , 26 ). An Iranian research indicates that this methodology proved superior to conventional approaches in enhancing performance in techniques including intravenous injection and wound care ( 27 ). Researchers’ clinical experience shows that nursing students exhibit heightened anxiety and inadequate skills when initially administering drug injections in a clinical setting. While prior research has investigated nursing students’ anxiety and performance ( 28 , 29 ), a comprehensive literature review revealed no studies focusing on the impact of DOPS assessment on students’ anxiety and performance during injections. Considering the significant anxiety experienced by nursing students during injections, and the potential of DOPS assessment to enhance clinical education, this study investigated the impact of DOPS assessment on the anxiety levels and injection performance of first-semester nursing students. Method Participants and setting : Following faculty approval, a quasi-experimental before-and-after study, employing a census of 76 first-semester undergraduate nursing students at Shahid Beheshti University of Medical Sciences, was conducted in 2024. A control group was included in the design. Student eligibility required enrollment in the first semester, willingness to take part in the research, absence of anti-anxiety medication use or history of anxiety disorders, no prior participation in injection or anxiety management training, and lack of a health professional background. Participants who withdrew from the study because of travel, illness, or unwillingness to cooperate were excluded from the analysis. To avoid contamination, samples were randomly assigned from students in Group A and Group B, respectively, creating two groups of 38 participants each. Because of the use of anti-anxiety medications by two students, the number of members in one group was reduced to 36. A random assignment procedure, utilizing coin tosses, resulted in the formation of intervention and control groups of 38 and 36 individuals, respectively. Data Collection Tools : The instruments employed for data gathering included a demographic questionnaire, a student performance assessment checklist, and the revised Spielberger’s State-Trait Anxiety Inventory (STAI) (1983)( 30 ). The demographic questionnaire solicited data on age, gender, field-related interests, grade point average, and history of anti-anxiety medication use or anxiety disorders. A checklist was used to assess student proficiency in two general categories—reviewing physician orders and observing sterile conditions—alongside specialized categories covering different types of injection techniques: intradermal (27 skills), subcutaneous (29 skills), intramuscular (29 skills), and intravenous (26 skills). Checklists were evaluated on a three-point likert scale (1 = fully completed, 0.5 = not fully completed, 0 = not completed) for the general domain and a four-point likert scale (2 = fully completed, 1.5 = complete with help, 1 = not fully completed, 0 = not completed) for the specialized domain. The researchers planned these checklists based on the most recent scholarly publications. Ten Shahid Beheshti School of Nursing and Midwifery professors confirmed the qualitative content validity of the checklists. Inter-rater reliability, assessed via intra-class correlation coefficient (ICC) across 15 samples, yielded a coefficient of 0.98, confirming high reliability between the two first researchers. Furthermore, the STAI was employed to assess student anxiety levels. This forty-item questionnaire, developed in the United States, measures state anxiety (the respondent’s current emotional and overt anxiety) and trait anxiety (underlying anxiety) using the subsequent twenty items. Scores are determined using a four-point Likert scale (1-very low, 4-very high), with each resulting score between 20 and 80. The STAI’s validity and reliability are supported by the findings of several studies ( 25 , 30 ). Spielberger et al. (1983) documented Cronbach’s alpha reliability coefficients of 0.92 and 0.90 for the state and trait anxiety subscales, respectively. State and trait anxiety subscales yielded test retest reliability coefficients of 0.62 and 0.68, respectively ( 31 ). Cronbach’s alpha reliability estimates for the state anxiety (α = 0.91), trait anxiety (α = 0.90), and total anxiety subscales (α = 0.94) were derived from a study of 600 individuals in Iran ( 25 , 30 ). This study established the qualitative content validity of the questionnaire through confirmation by ten Shahid Beheshti School of Nursing professors. Reliability, assessed via Cronbach’s alpha coefficient using data from fifteen students, yielded 0.77 for state anxiety and 0.79 for trait anxiety. Data Collection Method : Initially, the primary investigator delivered contemporary, hands-on injection technique training to all students. Following a week in which all students were assigned unique codes, the STAI was administered to both groups prior to evaluation. A subsequent assessment of students’ skills in four injection types was conducted by two researchers using validated checklists, taking 10 to 15 minutes. Following the evaluation, each student in the intervention group received approximately five minutes of individualized verbal feedback. In contrast, the control group only underwent observation and evaluation, with no feedback provided. Two weeks later, the students’ anxiety was reassessed via a replicated questionnaire and clinical evaluation, maintaining consistency in methods, tools, and personnel. The research followed the Consolidated Standards of Reporting Trials (CONSORT) checklist. Ethical considerations : The study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of Shahid Beheshti University of Medical Sciences (Ethics Code: IR.SBMU.PHARMACY.REC.1403.066). The code of ethics and a letter of introduction were obtained from the Vice Chancellor for Education and Research of the Faculty of Nursing, Shahid Beheshti University of Medical Sciences. Written informed consent was secured from students following a comprehensive explanation of the research methodology, including the voluntary nature of participation, the inconsequential nature of the results on academic evaluations, and the strict confidentiality measures implemented for the protection of personal data. Statistical Analysis Post-collection data analysis was conducted using SPSS version 16. An initial descriptive statistical analysis was conducted, including frequency and percentage distributions of individuals, along with mean and standard deviation calculations for questionnaire and checklist scores. Subsequently, inferential statistical analyses were performed using independent and paired t-tests, Wilcoxon tests, and chi-square tests. A significance level of p ≤ 0.05 was adopted for the variables. Results In this study, the mean age of participants was estimated at 19.38 ± 1.37 years in the control group and 19.31 ± 1.56 years in the intervention group. In the control group, 58.30% of participants were female, compared to 47.40% in the intervention group. Additionally, 66.70% of participants in the control group and 68.40% in the intervention group expressed an interest in the field of nursing. The mean grade point average (GPA) was 18.88 ± 0.85 in the control group and 18.89 ± 0.90 in the intervention group. The use of anxiolytic medication or a history of anxiety disorders was reported in two participants from the control group, and they were excluded from the study. Overall, there were no statistically significant differences in demographic characteristics between the two groups (p > 0.05) (Table 1 ). Table 1 Comparison of demographic characteristics between the two groups Demographic variable Intervention Control p value Age mean ± sd a 19.31 ± 1.56 19.38 ± 1.37 0.832 b Gender n (%) 0.345 c Female 18(47.40) 21(58.30) Male 20(52.60) 15(41.70) Interest n (%) 0.872 c Yes 26(68.40) 24(66.70) No 12(31.60) 12(33.30) GPA score ± sd 18.89 ± 0.90 18.88 ± 0.85 0.956 b a Standard deviation b Independent Samples T Test c Chi-square test The results of the Chi-square test indicated that the majority of participants’ state anxiety scores in the intervention group (47.40%) and the control group (50.00%) were in the range of 31–42 prior to the intervention, with no statistically significant difference between the groups (p > 0.05) (Table 2 ). Table 2 Comparison of the frequency distribution of state and trait anxiety scores between the two groups before and after the evaluation Variable Score Intervention Control P-value State Anxiety First evaluation n (%) n (%) 0.224 a 20–30 9(23.70) 3(8.30) 31–42 18(47.40) 18(50.0) 43–53 9(23.70) 14(38.90) 54 and higher 2(5.30) 1(2.80) Second evaluation 20–30 24(63.20) 3(8.30) < 0.001 a 31–42 11(28.90) 19(52.80) 43–53 3(7.90) 14(38.90) 54 and higher 0 0 P-value p < 0.001 b P = 0.53 b Trait Anxiety First evaluation 20–34 12(31.60) 4(11.10) 0.187 a 35–45 15(39.50) 19(52.80) 46–56 10(26.30) 11(30.60) 56 and higher 1(2.60) 2(5.60) Second evaluation 20–34 17(44.70) 4(11.10) < 0.008 a 35–45 16(42.10) 20(55.60) 46–56 4(10.50) 11(30.60) 56 and higher 1(2.60) 1(2.80) P-value p < 0.001 b P = 0.16 b a Chi-squared test b Wilcoxon signed-rank test Additionally, the Chi-square test revealed that most participants’ trait anxiety scores in the intervention group (39.50%) and the control group (52.80%) fell within the range of 35–45, and again, no statistically significant difference was observed before the intervention (p > 0.05) (Table 2 ). However, following the intervention, a statistically significant difference was observed between the two groups in state anxiety scores, as determined by the chi-square test. The majority of participants in the intervention group (63.20%) scored within the 20–30 range, whereas most participants in the control group (52.80%) remained within the 31–42 range (p < 0.001). Similarly, trait anxiety scores after the intervention showed a significant difference between the groups: 44.70% of participants in the intervention group scored in the 20–34 range, compared to 55.60% in the control group who scored in the 35–45 range (p < 0.008) (Table 2 ). The Wilcoxon test further demonstrated that in the intervention group, state anxiety scores decreased significantly from 31–42 to 20–30, representing an 83% reduction (p < 0.001), while no significant change was observed in the control group (p = 0.53). Among those in the intervention group with initial state anxiety scores of 43–53, a reduction of 89% was observed, and those with scores above 54 experienced a 100% reduction. In terms of trait anxiety, the Wilcoxon test showed a 33% reduction in the majority of participants in the intervention group, with scores shifting from the 35–45 range to 20–34 (p < 0.001), while no significant change occurred in the control group (p = 0.16). Among those in the intervention group with 35–45 trait anxiety scores before the intervention, a 33% decrease was noted, placing them in the 20–34 category post-intervention. The results of the independent t-test indicated that there were no statistically significant differences in performance scores across all four areas—intramuscular, intravenous, intradermal, and subcutaneous injections—between the two groups prior to the intervention (p > 0.05). However, following the intervention, the mean scores in all four areas in the intervention group were approximately one point higher than those in the control group, and the differences were statistically significant (p < 0.001). Furthermore, the results of the paired t-test demonstrated that the differences in mean scores before and after the evaluation were significant in both the intervention and control groups across all four areas; however, the magnitude of improvement was greater in the intervention group (p < 0.05). Specifically, the difference in intramuscular injection scores was 0.75 in the intervention group and 0.11 in the control group; for intravenous injections, 0.77 and 0.10, respectively; for intradermal injections, 0.86 and 0.18; and for subcutaneous injections, 0.94 and 0.11. All of these differences were statistically significant (p < 0.05) (Table 3 ). Table 3 Mean performance scores before and after the evaluation in the two groups Performance Evaluation Intervention Control p-value Mean + SD Mean + SD Intramuscular Pretest 18.53 + 0.53 18.60 + 0.59 0.606 a Posttest 19.28 + 0.55 18.71 + 0.65 < 0.001 a P value 0.00 b 0.001 b Intravascular Pretest 18.54 + 0.42 18.64 + 0.53 0.343 a Posttest 19.32 + 0.44 18.75 + 0.63 < 0.001 a P value 0.00 b 0.38 b Intradermal Pretest 18.59 + 0.50 18.73 + 0.52 0.228 a Posttest 19.45 + 0.47 18.92 + 0.59 < 0.001 a P value 0.00 b 0.00 b Subcutaneous Pretest 18.62 + 0.50 18.71 + 0.53 0.475 a Posttest 19.57 + 0.49 18.83 + 0.56 < 0.001 a P value 0.00 b 0.003 b a Independent Samples T Test b Paired samples t test Discussion This study explored the correlation between the DOPS assessment and anxiety and skill levels in first-semester nursing students administering intramuscular, intravenous, intradermal, and subcutaneous injections. Analysis revealed a significant reduction in state and trait anxiety among students assessed using the DOPS method compared to those assessed solely through observation. It is plausible that the lessened anxiety stems from the receipt of private feedback, promoting introspection regarding individual strengths and weaknesses. Conversely, the theoretical framework of anxiety illustrates its capacity to negatively influence academic achievement and self-assurance among students in clinical settings. Anxiety’s impact on cognitive and mental processes may result in heightened fear of errors, reduced task performance efficiency, and compromised patient safety ( 32 ). DOPS assessments foster a supportive learning environment and provide constructive feedback, mitigating student anxiety and enhancing self-confidence. Furthermore, the provision of opportunities for practice and empowerment can foster the development of coping mechanisms and enhance emotional resilience in students. Consequently, future nurses will be better equipped to deliver high-quality care, minimizing errors and contributing positively to community health. Sonmez et al. (2023) conducted a four-year longitudinal study in Turkey, which showed that traditional teaching methods may elevate stress levels among nursing students, indicating adoption of contemporary pedagogical and assessment techniques is essential to enhance their psychological well-being ( 33 ). This study revealed a statistically significant improvement in mean performance scores across all four injection types (intramuscular, intravenous, intradermal, and subcutaneous) for the intervention group compared to the control group. However, the control group also showed a non-significant performance increase in the second evaluation. Furthermore, the most significant improvement in scores was observed in the subcutaneous injection technique. This may be attributed to the fact that lower-semester students are primarily responsible for administering insulin and heparin injections, leading to increased learning motivation in this specific area. The DOPS method mandates that professors provide feedback encompassing not only accurate expectation articulation but also a comprehensive assessment of student deficiencies and salient areas for improvement to enhance subsequent performance. Consequently, the DOPS student-centered approach facilitates skill enhancement through constructive feedback within a supportive and interactive learning environment, fostering reflection consistent with constructivist pedagogy ( 34 ). In DOPS method, instead of the traditional time-based approach and interpersonal comparison, student’s performance is increased through practice on simulation mannequins, and intrapersonal comparisons so that the student reaches a high level of competence with his/her pace that is consistent with the theory of competency-based education. The researchers in the present study emphasized the importance of providing feedback on anatomical and pharmacological aspects of injections based on current reference materials. They noted that enhancement of cognitive domains, such as knowledge of anatomy and pharmacology, can contribute to achieving an acceptable level of performance in the psychomotor domain. This aligns with the concept of Integrative Science Teaching, which is grounded in Gestalt theory ( 35 ). These findings are consistent with those of other studies. For instance, the study by Parizad et al. (2021) demonstrated that the mean evaluation scores for intravenous injections among students assessed using the DOPS method were significantly higher than those of students evaluated using a logbook approach ( 36 ). Similarly, in the study by Khaghanizadeh et al. (2013), the intervention group showed a significant increase in scores for venipuncture procedures following DOPS assessment compared to the control group, which was evaluated through routine methods ( 27 ). The findings of Yalew et al. (2023) in Ethiopia also revealed a notable improvement in intravenous injection scores after DOPS-based assessment ( 37 ). Interestingly, while the aforementioned studies reported the most significant impact of the DOPS method on intravenous injections, the present study found that the greatest improvement occurred in subcutaneous injection performance. This discrepancy may be attributed to the fact that, in the current study, different injection methods were compared directly with one another, whereas the other studies compared intravenous injection training using DOPS with instruction in other procedures, such as dressing changes, evaluated using alternative methods like logbooks. Moreover, in the previous studies, score improvements in the intervention groups were not always statistically significant, whereas in the current study, even the control group showed non-significant improved scores which can be as a result of students’ self-reflection and self-study after the first evaluation. The DOPS assessment method has been applied not only to nursing students but also to students in other medical science disciplines, yielding positive outcomes. For example, the study by Profanter et al. (2015), which examined the impact of DOPS on the performance of medical students in a university skills lab in Australia, reported significant improvements in surgical abdominal examination, urinary catheterization, digital rectal examination, and central venous catheter care ( 38 ). Likewise, the study by Touhidian et al. (2017) investigated the effect of DOPS on enhancing chest radiography skills among radiology students, and the findings of both studies are consistent with the results of the present study ( 39 ). One of the strengths of this study was the assurance of confidentiality, which encouraged students to complete all questionnaires and checklists using coded identifiers. However, key limitations included the restriction of the sample to students from a single nursing faculty, the short interval between assessments due to limited time, and the implementation of the study in a skills lab rather than a real clinical environment. Therefore, it is recommended that future studies involve a larger sample size, be conducted over a longer duration, and take place in actual clinical settings. Furthermore, future research should investigate the effect of DOPS assessment on clinical outcomes such as patient satisfaction and the reduction of medical errors. Conclusion Based on the findings of this study, the implementation of the DOPS assessment method led to a significant improvement in performance and a reduction in anxiety levels among nursing students when performing injection skills, including intramuscular, intravenous, subcutaneous, and intradermal injections. These results suggest that DOPS can be utilized as an effective approach for enhancing practical learning and promoting psychological empowerment among nursing students. The feedback-oriented and student-centered nature of this method likely played a key role in achieving these outcomes. Further research with larger sample sizes and extended timeframes is recommended to confirm and expand upon these findings. Declarations Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (Ethics Code: IR.SBMU.PHARMACY.REC.1403.066). The code of ethics and a letter of introduction were obtained from the Vice Chancellor for Education and Research of the Faculty of Nursing, Shahid Beheshti University of Medical Sciences. Written informed consent was obtained from the students following a comprehensive explanation of the research methodology, including the voluntary nature of participation, the inconsequential nature of the results on academic evaluations, and the strict confidentiality measures implemented for the protection of personal data. Consent for publication: Not applicable. Data availability statement The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request. Conflict interests: The authors declare that they have no competing interests. Clinical trial number : Not applicable Funding: Not applicable Authors' Contributions : Mahla Mosayebi : Conceptualization, Investigation, Methodology, Project administration, writing – original draft, Writing – review & editing. Mahbobeh Abdolrahimi : Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing. Soolmaz Moosavi : Investigation, Formal analysis, Methodology, Writing – review & editing. Malihe Nasiri : Data curation, Formal analysis, Investigation, Writing – review & editing. Acknowledgements : This study was derived from the Master’s Thesis in Nursing, fulfilled at Shahid Beheshti University of Medical Sciences in 2024, Tehran, Iran. The authors hereby extend their sincere gratitude to the Vice Chancellor’s Office for Research at Shahid Beheshti University of Medical Sciences for their cooperation. References Park S. Effects of an intensive clinical skills course on senior nursing students' self-confidence and clinical competence: A quasi-experimental post-test study. Nurse Educ Today. 2018;61:182–6. Heshmati Nabavi F, Shariat Safa F, Rajabpour M. The Effect of Mentoring Novice Clinical Educators on the Perception of Nursing Students from the Clinical Learning Environment. J Adv Med Educ Prof. 2023;11(4):252–61. Sajadi Hezaveh M, Khosravi S. Determining novice nurses’ experiences in professional preparation: A content analysis. J Nurs Educ. 2014;3(2):1–11. Ahmari Tehran H, Gaeeni M, Rezaei M, Khoramirad A, Parizad A. The challenges of clinical education in nursing: Aqualitative analysis of nursing students and clinical instructors’ perspectives. J Nurs Midwifery Sci. 2021;8:260–7. Resch K, Schrittesser I. Using the Service-Learning approach to bridge the gap between theory and practice in teacher education. Int J Incl Educ. 2021;27(10):1118–32. Perry RN. Role Modeling Excellence in Clinical Nursing Practice. Nurse Educ Pract. 2009;9(1):36–44. Hedrick J, Bennett V, Carpenter J, Dercher L, Grandstaff D, Gosch K, et al. A descriptive study of adverse childhood experiences and depression, anxiety, and stress among undergraduate nursing students. J Prof Nurs. 2021;37(2):291–7. Li X, Song W, Zhang JY, Lu C, Wang YX, Zheng YX, Hao WN. Factors associated with mental health of graduate nursing students in China. Med (Baltim). 2021;100(3):e24247. Mashayekhi N. Stressors and Coping Styles from the Perspective of Nursing Students in Alborz University of Medical Sciences. J Nurs Educ. 2022;10(6):33–43. Yıldırım N, Karaca A, Ankaralı H, Açıkgöz F, Akkuş D. Stress experienced by Turkish nursing students and related factors. Clin Experimental Health Sci. 2016;6(3):121–8. Parveen A, Inayat S. Evaluation of factors of stress among Nursing Students. Adv Pract Nurs. 2017;2(2):136. 10.4172/2573-0347.1000136 . Rajeswaran L. Clinical experiences of nursing students at a selected institute of health sciences in Botswana. Health Sci J. 2017;10(6):471. Alrabadi N, Shawagfeh S, Haddad R, Mukattash T, Abuhammad S, Al-rabadi D, et al. Medication errors: a focus on nursing practice. J Pharm Health Serv Res. 2021;12(1):78–86. Melnyk BM, Tan A, Pavan Hsieh A, Gawlik K, Arslanian-Engoren C, Braun LT, et al. Critical care nurses’ physical and mental health, worksite wellness support, and medical errors. Am J Crit Care. 2021;30(3):176–84. Dehvan F, Dehkordi AH, Gheshlagh RG, Kurdi A. The Prevalence of Medication Errors Among Nursing Students: A Systematic and Meta-analysis Study. Int J Prev Med. 2021;12:21. 10.4103/ijpvm.IJPVM_418_19 . eCollection 2021. Valizadeh S, Abedi H, Zamanzadeh V, Fathiazar E. Challenges of Nursing Students during Their Study: A Qualitative Study. Iran J Med Educ. 2008;7(2):397–406. Nayyeri S, Bozorgvar A, Barzanouni S, Masoumiyan T. Effect of Clinical Skills Evaluation by Direct Observation of Procedural Skills (DOPS) Method on Clinical Performance of Operating Room Students. J Med Educ Future Demands. 2021;20(3):e119342. Holmboe ES, Durning SJ, Hawkins RE. Practical guide to the evaluation of clinical competence. 2nd ed. PA: Elsevier; 2018. Tyler RW. Education Evaluation: new Roles and Means. Chicago: University of Chicago Press; 1969. Asirifi M, Ogilvie L, Barton S, Aniteye P, Stobart K, Bilash O, et al. Assessing challenges of clinical education in a baccalaureate nursing program in Ghana. J Nurs Educ Pract. 2017;7(10):109–18. Cahapay MK, Model. Its Limitations as Used in Higher Education Evaluation. Int J Assess Tools Educ. 2021;8(1):135–44. Sadeghi T, Seyed Bagheri SH. Challenges of teacher-based clinical evaluation from nursing students' point of view: Qualitative content analysis. J Educ Health Promot. 2017;6:72. 10.4103/jehp.jehp_109_16 . eCollection 2017. Mehranfard S, Pelarak F, Mashalchi H, Kalani L, Masoudiyekta L. Efficacy of logbook as a clinical assessment: Using DOPS evaluation method. J Multidiscip Healthc. 2022;11(4):184–9. Motefakker S, Shirinabadi Farahani A, Nourian M, Nasiri M, Heydari F. The impact of the evaluations made by Mini-CEX on the clinical competency of nursing students. BMC Med Educ. 2022;22:634. 10.1186/s12909-022-03667-2 . Khanghahi ME, Ebadi Fard Azar F. Direct observation of procedural skills (DOPS) evaluation method: Systematic review of evidence. Med J Islam Repub Iran. 2018;32:45. 10.14196/mjiri.32.45 . eCollection 2018. Jafarpoor H, Hosseini M, Sohrabi M, Mehmannavazan M. The effect of direct observation of procedural skills/mini-clinical evaluation exercise on the satisfaction and clinical skills of nursing students in dialysis. J Educ Health Promot. 2021;10:74. 10.4103/jehp.jehp_618_20 . Habibi H, Khaghanizade M, Mahmoudi H, Ebadi A, Seyedmazhari M. Comparison of the Effects of Modern Assessment Methods (DOPS and Mini-CEX) with traditional method on Nursing Students' Clinical Skills: A Randomized Trial. Iran J Med Educ. 2013;13(5):364–72. Sharifi K, Adib-Hajbaghery M, Hosieni F. Which peer-based approach reduces the clinical anxiety of nursing students? A review study. Nurs Midwifery J. 2019;16(11):822–31. Bahrami Z, Norouzi S, Ramezanibadr F, Norouzi A. Design, implementation and evaluation of an Operational Program to Improve the Quality of Basic Clinical Skills in Nursing Students in Zanjan University of Medical Sciences in 2017. J Med Educ Dev. 2019;12(34):34–40. Speilberger CD, Gorsuch R, Lushene R, Vagg PR, Jacobs GA. Manual for the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists; 1983. Nakayama N, Ejiri H, Arakawa N, Makino T. Stress and anxiety in nursing students between individual and peer simulations. Nurs Open. 2021;8(2):776–83. World Health Organization. Scaling up care for mental, neurological, and substance use disorders. Mental Health Gap Action Program; 2008. Sonmez Y, Akdemir M, Meydanlioglu A, Aktekin MR. Psychological Distress, Depression, and Anxiety in Nursing Students: A Longitudinal Study. Healthcare. 2023;11(5):636. https://doi.org/10.3390/healthcare11050636 . Zhang WY, Peng Y, Zhuang HR, Yu HP, Liu Q, Gu Y, et al. Application of direct observation of operational skills in nursing skill evaluation of pressure injury: A randomized clinical trial. Int Wound J. 2024;21(3):e14498. 10.1111/iwj.14498 . Siau K, Crossley J, Dunckley P, Johnson G, Feeney M, Hawkes ND, Beales ILP, Joint Advisory Group on Gastrointestinal Endoscopy (JAG). Direct observation of procedural skills (DOPS) assessment in diagnostic gastroscopy: nationwide evidence of validity and competency development during training. Surg Endosc. 2020;34(1):105–14. Parizad N, Alizadeh Z, Jasemi M, Ahmadzadeh J. The Effect of Direct Observation of Procedural Skills (DOPS) Method on the Clinikal Performance and Satisfaction of Nursing Students in Intensive Care Units. Nurs Midwifery J. 2022;19(10):783–92. Hasen Y, Mequanint A, Teshome T, Belete A, Bekele D. An action research to introduce direct observation of procedural skills (DOPS) as clinical skill performance assessment tool during medical internship in the department of surgery, Debre Tabor University, Debre Tabor, Ethiopia, 2023. Afr Res J Med Sci. 2024;1(1):42–50. Profanter C, Perathoner A. DOPS (Direct Observation of Procedural Skills) in undergraduate skills-lab: Does it work? Analysis of skills-performance and curricular side effects. GMS Z Med Ausbild. 2015;32(4):Doc45. 10.3205/zma000987 . Tohidnia MR, Weisi S, Eskandari S. The effect of direct observation of procedural skills assessment method on clinical performance of radiology students. Educ Res Med Sci. 2018;7(1):e80301. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 29 Sep, 2025 Reviews received at journal 18 Sep, 2025 Reviewers agreed at journal 06 Sep, 2025 Reviewers invited by journal 13 Aug, 2025 Editor assigned by journal 25 Jul, 2025 Editor invited by journal 17 Jul, 2025 Submission checks completed at journal 17 Jul, 2025 First submitted to journal 17 Jul, 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. 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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-7091396","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":502919879,"identity":"3f29968c-32d3-4a97-89b5-3c131d4e1b19","order_by":0,"name":"Mahla Mosayebi","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mahla","middleName":"","lastName":"Mosayebi","suffix":""},{"id":502919880,"identity":"1b94758e-d3c2-4a33-a0ee-735a886adf03","order_by":1,"name":"Mahbobeh Abdolrahimi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYHACNgYeBgsGBgnGBoaECoYEqKgEIS0SUC1nSNMCZDK2wbXgBroNzM8evKmQyOef3dy64eG8ujzdGQmMH34wWOTj0mJ2gM3ccM4ZCcsZdw623UjcdrjY7EYCs2QPg4RlAy4t9x+YSfO2SRgw3EgEaTmQuO1GAoM00J0GuG1h/wbWIg/WMqcOpIX5N34tPBBbDMBaGphBWtgI2MJTDvKLgSFIS8IxoF/OPGyz7DHA67BtwBCzMZC7kf7s5o+aujyz48mHb/yoqMOpBRsAxikDSRpGwSgYBaNgFKADAPZWV9nPlNNxAAAAAElFTkSuQmCC","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Mahbobeh","middleName":"","lastName":"Abdolrahimi","suffix":""},{"id":502919882,"identity":"d61df4fb-d9f5-48ec-a5ee-f4da8ad4d70e","order_by":2,"name":"Soolmaz Moosavi","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Soolmaz","middleName":"","lastName":"Moosavi","suffix":""},{"id":502919883,"identity":"b05623d7-a8a8-41e8-a660-9049e7dd776a","order_by":3,"name":"Malihe Nasiri","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Malihe","middleName":"","lastName":"Nasiri","suffix":""}],"badges":[],"createdAt":"2025-07-10 09:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7091396/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7091396/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89596898,"identity":"7087cfac-3f9a-4d73-8d18-cb0b9fbbd167","added_by":"auto","created_at":"2025-08-21 17:05:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":690584,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7091396/v1/26ba2e91-791e-4217-b07d-642677f5dbd4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Investigating the Effect of Evaluation by Direct Observation of Procedural Skills Method on the Level of Anxiety and Clinical Performance of Nursing Students during Drug Injections","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNursing education integrates theoretical and practical components to cultivate students\u0026rsquo; knowledge, skills, and professional attitude, ensuring their preparedness for safe and high-quality patient care upon entering healthcare settings (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Within this context, practical training assumes paramount importance as the cornerstone of clinical education; thus, enhancing the quality of practical skills instruction has been a primary concern for educators (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Nevertheless, numerous studies indicate that novice nursing students encounter considerable anxiety during their initial clinical placements, attributable to extensive course material, unfamiliarity with healthcare settings, and apprehension regarding patient care errors (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnxiety, a natural reaction to perceived threats, can manifest psychologically, cognitively, and physically\u0026mdash;including diaphoresis, palpitations, and dyspnea\u0026mdash;and negatively impact performance and quality of life (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Studies across various countries indicate that anxiety rates among nursing students, particularly during their initial clinical experiences, range from 14\u0026ndash;32% (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Qualitative research conducted in Iran revealed that, amongst practical skills taught, the highest student anxiety levels were associated with drug injection techniques. This anxiety may negatively impact academic performance and increase the risk of medication errors (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA Washington University of Medical Sciences Institute of Health report indicates that the United States experiences over one million annual medical errors, resulting in hundreds of thousands of fatalities, including 77,000 medication error-related deaths. Annual expenditures on medication errors in Iran, as reported by the Ministry of Health, reach into the billions of Tomans; a significant portion (approximately 54.4%) goes unreported (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Iranian students reported the highest rate (39.68%) of medication errors, primarily during drug administration, specifically concerning incorrectly dosed or concentrated injections (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). A further qualitative study identified difficulties with injection site identification and administration technique as a significant challenge for nursing students (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTherefore, it is imperative to rectify students\u0026rsquo; shortcomings prior to their clinical placements to mitigate potential errors (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Student evaluations presently use traditional methods, grounded in the principles of Ralph Tyler (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), to assess the programs and curriculum\u0026rsquo;s efficacy in achieving their objectives. Researches show that conventional assessment strategies may negatively affect student satisfaction and motivation, thus causing the implementation of contemporary evaluation techniques (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOne such method is direct observation of practical skills (DOPS) assessment, initially developed in England in 2005. This approach facilitates direct observation of student performance by the instructor, with focused feedback to improve essential clinical skills (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). An Iranian research indicates that this methodology proved superior to conventional approaches in enhancing performance in techniques including intravenous injection and wound care (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eResearchers\u0026rsquo; clinical experience shows that nursing students exhibit heightened anxiety and inadequate skills when initially administering drug injections in a clinical setting. While prior research has investigated nursing students\u0026rsquo; anxiety and performance (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), a comprehensive literature review revealed no studies focusing on the impact of DOPS assessment on students\u0026rsquo; anxiety and performance during injections. Considering the significant anxiety experienced by nursing students during injections, and the potential of DOPS assessment to enhance clinical education, this study investigated the impact of DOPS assessment on the anxiety levels and injection performance of first-semester nursing students.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cb\u003eParticipants and setting\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e Following faculty approval, a quasi-experimental before-and-after study, employing a census of 76 first-semester undergraduate nursing students at Shahid Beheshti University of Medical Sciences, was conducted in 2024. A control group was included in the design. Student eligibility required enrollment in the first semester, willingness to take part in the research, absence of anti-anxiety medication use or history of anxiety disorders, no prior participation in injection or anxiety management training, and lack of a health professional background. Participants who withdrew from the study because of travel, illness, or unwillingness to cooperate were excluded from the analysis. To avoid contamination, samples were randomly assigned from students in Group A and Group B, respectively, creating two groups of 38 participants each. Because of the use of anti-anxiety medications by two students, the number of members in one group was reduced to 36. A random assignment procedure, utilizing coin tosses, resulted in the formation of intervention and control groups of 38 and 36 individuals, respectively.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection Tools\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe instruments employed for data gathering included a demographic questionnaire, a student performance assessment checklist, and the revised Spielberger\u0026rsquo;s State-Trait Anxiety Inventory (STAI) (1983)(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The demographic questionnaire solicited data on age, gender, field-related interests, grade point average, and history of anti-anxiety medication use or anxiety disorders. A checklist was used to assess student proficiency in two general categories\u0026mdash;reviewing physician orders and observing sterile conditions\u0026mdash;alongside specialized categories covering different types of injection techniques: intradermal (27 skills), subcutaneous (29 skills), intramuscular (29 skills), and intravenous (26 skills). Checklists were evaluated on a three-point likert scale (1\u0026thinsp;=\u0026thinsp;fully completed, 0.5\u0026thinsp;=\u0026thinsp;not fully completed, 0\u0026thinsp;=\u0026thinsp;not completed) for the general domain and a four-point likert scale (2\u0026thinsp;=\u0026thinsp;fully completed, 1.5\u0026thinsp;=\u0026thinsp;complete with help, 1\u0026thinsp;=\u0026thinsp;not fully completed, 0\u0026thinsp;=\u0026thinsp;not completed) for the specialized domain. The researchers planned these checklists based on the most recent scholarly publications. Ten Shahid Beheshti School of Nursing and Midwifery professors confirmed the qualitative content validity of the checklists. Inter-rater reliability, assessed via intra-class correlation coefficient (ICC) across 15 samples, yielded a coefficient of 0.98, confirming high reliability between the two first researchers.\u003c/p\u003e\u003cp\u003eFurthermore, the STAI was employed to assess student anxiety levels. This forty-item questionnaire, developed in the United States, measures state anxiety (the respondent\u0026rsquo;s current emotional and overt anxiety) and trait anxiety (underlying anxiety) using the subsequent twenty items. Scores are determined using a four-point Likert scale (1-very low, 4-very high), with each resulting score between 20 and 80. The STAI\u0026rsquo;s validity and reliability are supported by the findings of several studies (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Spielberger et al. (1983) documented Cronbach\u0026rsquo;s alpha reliability coefficients of 0.92 and 0.90 for the state and trait anxiety subscales, respectively. State and trait anxiety subscales yielded test retest reliability coefficients of 0.62 and 0.68, respectively (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Cronbach\u0026rsquo;s alpha reliability estimates for the state anxiety (α\u0026thinsp;=\u0026thinsp;0.91), trait anxiety (α\u0026thinsp;=\u0026thinsp;0.90), and total anxiety subscales (α\u0026thinsp;=\u0026thinsp;0.94) were derived from a study of 600 individuals in Iran (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). This study established the qualitative content validity of the questionnaire through confirmation by ten Shahid Beheshti School of Nursing professors. Reliability, assessed via Cronbach\u0026rsquo;s alpha coefficient using data from fifteen students, yielded 0.77 for state anxiety and 0.79 for trait anxiety.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection Method\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eInitially, the primary investigator delivered contemporary, hands-on injection technique training to all students. Following a week in which all students were assigned unique codes, the STAI was administered to both groups prior to evaluation. A subsequent assessment of students\u0026rsquo; skills in four injection types was conducted by two researchers using validated checklists, taking 10 to 15 minutes. Following the evaluation, each student in the intervention group received approximately five minutes of individualized verbal feedback. In contrast, the control group only underwent observation and evaluation, with no feedback provided. Two weeks later, the students\u0026rsquo; anxiety was reassessed via a replicated questionnaire and clinical evaluation, maintaining consistency in methods, tools, and personnel. The research followed the Consolidated Standards of Reporting Trials (CONSORT) checklist.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical considerations\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e The study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of Shahid Beheshti University of Medical Sciences (Ethics Code: IR.SBMU.PHARMACY.REC.1403.066). The code of ethics and a letter of introduction were obtained from the Vice Chancellor for Education and Research of the Faculty of Nursing, Shahid Beheshti University of Medical Sciences. Written informed consent was secured from students following a comprehensive explanation of the research methodology, including the voluntary nature of participation, the inconsequential nature of the results on academic evaluations, and the strict confidentiality measures implemented for the protection of personal data.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003ePost-collection data analysis was conducted using SPSS version 16. An initial descriptive statistical analysis was conducted, including frequency and percentage distributions of individuals, along with mean and standard deviation calculations for questionnaire and checklist scores. Subsequently, inferential statistical analyses were performed using independent and paired t-tests, Wilcoxon tests, and chi-square tests. A significance level of p\u0026thinsp;\u0026le;\u0026thinsp;0.05 was adopted for the variables.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn this study, the mean age of participants was estimated at 19.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37 years in the control group and 19.31\u0026thinsp;\u0026plusmn;\u0026thinsp;1.56 years in the intervention group. In the control group, 58.30% of participants were female, compared to 47.40% in the intervention group. Additionally, 66.70% of participants in the control group and 68.40% in the intervention group expressed an interest in the field of nursing. The mean grade point average (GPA) was 18.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85 in the control group and 18.89\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90 in the intervention group. The use of anxiolytic medication or a history of anxiety disorders was reported in two participants from the control group, and they were excluded from the study. Overall, there were no statistically significant differences in demographic characteristics between the two groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\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\u003eComparison of demographic characteristics between the two groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDemographic variable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge mean\u0026thinsp;\u0026plusmn;\u0026thinsp;sd \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.31\u0026thinsp;\u0026plusmn;\u0026thinsp;1.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.832 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender n (%)\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\u003cp\u003e0.345\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18(47.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21(58.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20(52.60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15(41.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterest n (%)\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\u003cp\u003e0.872 \u003csup\u003ec\u003c/sup\u003e\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\u003e26(68.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24(66.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\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\u003e12(31.60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12(33.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGPA score\u0026thinsp;\u0026plusmn;\u0026thinsp;sd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18.89\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.956 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e Standard deviation\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e Independent Samples T Test\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ec\u003c/sup\u003e Chi-square test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe results of the Chi-square test indicated that the majority of participants\u0026rsquo; state anxiety scores in the intervention group (47.40%) and the control group (50.00%) were in the range of 31\u0026ndash;42 prior to the intervention, with no statistically significant difference between the groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\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 the frequency distribution of state and trait anxiety scores between the two groups before and after the evaluation\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=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" 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\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eScore\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003eState Anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eFirst\u003c/p\u003e\u003cp\u003eevaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e0.224\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9(23.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3(8.30)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31\u0026ndash;42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18(47.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18(50.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43\u0026ndash;53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9(23.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14(38.90)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54 and higher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2(5.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1(2.80)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eSecond evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24(63.20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3(8.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31\u0026ndash;42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11(28.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19(52.80)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43\u0026ndash;53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3(7.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14(38.90)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54 and higher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.53\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003eTrait Anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eFirst\u003c/p\u003e\u003cp\u003eevaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u0026ndash;34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12(31.60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4(11.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.187\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35\u0026ndash;45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15(39.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19(52.80)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46\u0026ndash;56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10(26.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11(30.60)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56 and higher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1(2.60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2(5.60)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eSecond evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u0026ndash;34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17(44.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4(11.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.008\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35\u0026ndash;45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16(42.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20(55.60)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46\u0026ndash;56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4(10.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11(30.60)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56 and higher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1(2.60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1(2.80)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.16\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e Chi-squared test\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003eb\u003c/sup\u003e Wilcoxon signed-rank test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, the Chi-square test revealed that most participants\u0026rsquo; trait anxiety scores in the intervention group (39.50%) and the control group (52.80%) fell within the range of 35\u0026ndash;45, and again, no statistically significant difference was observed before the intervention (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, following the intervention, a statistically significant difference was observed between the two groups in state anxiety scores, as determined by the chi-square test. The majority of participants in the intervention group (63.20%) scored within the 20\u0026ndash;30 range, whereas most participants in the control group (52.80%) remained within the 31\u0026ndash;42 range (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, trait anxiety scores after the intervention showed a significant difference between the groups: 44.70% of participants in the intervention group scored in the 20\u0026ndash;34 range, compared to 55.60% in the control group who scored in the 35\u0026ndash;45 range (p\u0026thinsp;\u0026lt;\u0026thinsp;0.008) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The Wilcoxon test further demonstrated that in the intervention group, state anxiety scores decreased significantly from 31\u0026ndash;42 to 20\u0026ndash;30, representing an 83% reduction (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while no significant change was observed in the control group (p\u0026thinsp;=\u0026thinsp;0.53). Among those in the intervention group with initial state anxiety scores of 43\u0026ndash;53, a reduction of 89% was observed, and those with scores above 54 experienced a 100% reduction. In terms of trait anxiety, the Wilcoxon test showed a 33% reduction in the majority of participants in the intervention group, with scores shifting from the 35\u0026ndash;45 range to 20\u0026ndash;34 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while no significant change occurred in the control group (p\u0026thinsp;=\u0026thinsp;0.16). Among those in the intervention group with 35\u0026ndash;45 trait anxiety scores before the intervention, a 33% decrease was noted, placing them in the 20\u0026ndash;34 category post-intervention.\u003c/p\u003e\u003cp\u003eThe results of the independent t-test indicated that there were no statistically significant differences in performance scores across all four areas\u0026mdash;intramuscular, intravenous, intradermal, and subcutaneous injections\u0026mdash;between the two groups prior to the intervention (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, following the intervention, the mean scores in all four areas in the intervention group were approximately one point higher than those in the control group, and the differences were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, the results of the paired t-test demonstrated that the differences in mean scores before and after the evaluation were significant in both the intervention and control groups across all four areas; however, the magnitude of improvement was greater in the intervention group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Specifically, the difference in intramuscular injection scores was 0.75 in the intervention group and 0.11 in the control group; for intravenous injections, 0.77 and 0.10, respectively; for intradermal injections, 0.86 and 0.18; and for subcutaneous injections, 0.94 and 0.11. All of these differences were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\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\u003eMean performance scores before and after the evaluation in the two groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\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=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePerformance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEvaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003eMean\u0026thinsp;+\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eMean\u0026thinsp;+\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eIntramuscular\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e18.53\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e18.60\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.606\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePosttest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e19.28\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e18.71\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e0.00\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eIntravascular\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e18.54\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e18.64\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.343\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePosttest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e19.32\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e18.75\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e0.00\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e0.38\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eIntradermal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e18.59\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e18.73\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.228\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePosttest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e19.45\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e18.92\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e0.00\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e0.00\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eSubcutaneous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePretest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e18.62\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e18.71\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.475\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePosttest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e19.57\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e18.83\u0026thinsp;\u003cb\u003e+\u003c/b\u003e\u0026thinsp;0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003e0.00\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e0.003\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003csup\u003ea\u003c/sup\u003e Independent Samples T Test\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003csup\u003eb\u003c/sup\u003e Paired samples t test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the correlation between the DOPS assessment and anxiety and skill levels in first-semester nursing students administering intramuscular, intravenous, intradermal, and subcutaneous injections. Analysis revealed a significant reduction in state and trait anxiety among students assessed using the DOPS method compared to those assessed solely through observation. It is plausible that the lessened anxiety stems from the receipt of private feedback, promoting introspection regarding individual strengths and weaknesses. Conversely, the theoretical framework of anxiety illustrates its capacity to negatively influence academic achievement and self-assurance among students in clinical settings. Anxiety\u0026rsquo;s impact on cognitive and mental processes may result in heightened fear of errors, reduced task performance efficiency, and compromised patient safety (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDOPS assessments foster a supportive learning environment and provide constructive feedback, mitigating student anxiety and enhancing self-confidence. Furthermore, the provision of opportunities for practice and empowerment can foster the development of coping mechanisms and enhance emotional resilience in students. Consequently, future nurses will be better equipped to deliver high-quality care, minimizing errors and contributing positively to community health.\u003c/p\u003e\u003cp\u003eSonmez et al. (2023) conducted a four-year longitudinal study in Turkey, which showed that traditional teaching methods may elevate stress levels among nursing students, indicating adoption of contemporary pedagogical and assessment techniques is essential to enhance their psychological well-being (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study revealed a statistically significant improvement in mean performance scores across all four injection types (intramuscular, intravenous, intradermal, and subcutaneous) for the intervention group compared to the control group. However, the control group also showed a non-significant performance increase in the second evaluation. Furthermore, the most significant improvement in scores was observed in the subcutaneous injection technique. This may be attributed to the fact that lower-semester students are primarily responsible for administering insulin and heparin injections, leading to increased learning motivation in this specific area. The DOPS method mandates that professors provide feedback encompassing not only accurate expectation articulation but also a comprehensive assessment of student deficiencies and salient areas for improvement to enhance subsequent performance. Consequently, the DOPS student-centered approach facilitates skill enhancement through constructive feedback within a supportive and interactive learning environment, fostering reflection consistent with constructivist pedagogy (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn DOPS method, instead of the traditional time-based approach and interpersonal comparison, student\u0026rsquo;s performance is increased through practice on simulation mannequins, and intrapersonal comparisons so that the student reaches a high level of competence with his/her pace that is consistent with the theory of competency-based education. The researchers in the present study emphasized the importance of providing feedback on anatomical and pharmacological aspects of injections based on current reference materials. They noted that enhancement of cognitive domains, such as knowledge of anatomy and pharmacology, can contribute to achieving an acceptable level of performance in the psychomotor domain. This aligns with the concept of Integrative Science Teaching, which is grounded in Gestalt theory (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese findings are consistent with those of other studies. For instance, the study by Parizad et al. (2021) demonstrated that the mean evaluation scores for intravenous injections among students assessed using the DOPS method were significantly higher than those of students evaluated using a logbook approach (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Similarly, in the study by Khaghanizadeh et al. (2013), the intervention group showed a significant increase in scores for venipuncture procedures following DOPS assessment compared to the control group, which was evaluated through routine methods (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The findings of Yalew et al. (2023) in Ethiopia also revealed a notable improvement in intravenous injection scores after DOPS-based assessment (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eInterestingly, while the aforementioned studies reported the most significant impact of the DOPS method on intravenous injections, the present study found that the greatest improvement occurred in subcutaneous injection performance. This discrepancy may be attributed to the fact that, in the current study, different injection methods were compared directly with one another, whereas the other studies compared intravenous injection training using DOPS with instruction in other procedures, such as dressing changes, evaluated using alternative methods like logbooks. Moreover, in the previous studies, score improvements in the intervention groups were not always statistically significant, whereas in the current study, even the control group showed non-significant improved scores which can be as a result of students\u0026rsquo; self-reflection and self-study after the first evaluation.\u003c/p\u003e\u003cp\u003eThe DOPS assessment method has been applied not only to nursing students but also to students in other medical science disciplines, yielding positive outcomes. For example, the study by Profanter et al. (2015), which examined the impact of DOPS on the performance of medical students in a university skills lab in Australia, reported significant improvements in surgical abdominal examination, urinary catheterization, digital rectal examination, and central venous catheter care (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Likewise, the study by Touhidian et al. (2017) investigated the effect of DOPS on enhancing chest radiography skills among radiology students, and the findings of both studies are consistent with the results of the present study (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOne of the strengths of this study was the assurance of confidentiality, which encouraged students to complete all questionnaires and checklists using coded identifiers. However, key limitations included the restriction of the sample to students from a single nursing faculty, the short interval between assessments due to limited time, and the implementation of the study in a skills lab rather than a real clinical environment. Therefore, it is recommended that future studies involve a larger sample size, be conducted over a longer duration, and take place in actual clinical settings. Furthermore, future research should investigate the effect of DOPS assessment on clinical outcomes such as patient satisfaction and the reduction of medical errors.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBased on the findings of this study, the implementation of the DOPS assessment method led to a significant improvement in performance and a reduction in anxiety levels among nursing students when performing injection skills, including intramuscular, intravenous, subcutaneous, and intradermal injections. These results suggest that DOPS can be utilized as an effective approach for enhancing practical learning and promoting psychological empowerment among nursing students. The feedback-oriented and student-centered nature of this method likely played a key role in achieving these outcomes. Further research with larger sample sizes and extended timeframes is recommended to confirm and expand upon these findings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (Ethics Code: IR.SBMU.PHARMACY.REC.1403.066). The code of ethics and a letter of introduction were obtained from the Vice Chancellor for Education and Research of the Faculty of Nursing, Shahid Beheshti University of Medical Sciences. Written informed consent was obtained from the students following a comprehensive explanation of the research methodology, including the voluntary nature of participation, the inconsequential nature of the results on academic evaluations, and the strict confidentiality measures implemented for the protection of personal data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMahla Mosayebi\u003c/strong\u003e: Conceptualization, Investigation, Methodology, Project administration, writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eMahbobeh Abdolrahimi\u003c/strong\u003e: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eSoolmaz Moosavi\u003c/strong\u003e: Investigation, Formal analysis, Methodology, Writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eMalihe Nasiri\u003c/strong\u003e: Data curation, Formal analysis, Investigation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements :\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was derived from the Master\u0026rsquo;s Thesis in Nursing, fulfilled at Shahid Beheshti University of Medical Sciences in 2024, Tehran, Iran. The authors hereby extend their sincere gratitude to the Vice Chancellor\u0026rsquo;s Office for Research at Shahid Beheshti University of Medical Sciences for their cooperation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePark S. Effects of an intensive clinical skills course on senior nursing students' self-confidence and clinical competence: A quasi-experimental post-test study. Nurse Educ Today. 2018;61:182\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHeshmati Nabavi F, Shariat Safa F, Rajabpour M. The Effect of Mentoring Novice Clinical Educators on the Perception of Nursing Students from the Clinical Learning Environment. J Adv Med Educ Prof. 2023;11(4):252\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSajadi Hezaveh M, Khosravi S. Determining novice nurses\u0026rsquo; experiences in professional preparation: A content analysis. J Nurs Educ. 2014;3(2):1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhmari Tehran H, Gaeeni M, Rezaei M, Khoramirad A, Parizad A. The challenges of clinical education in nursing: Aqualitative analysis of nursing students and clinical instructors\u0026rsquo; perspectives. J Nurs Midwifery Sci. 2021;8:260\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eResch K, Schrittesser I. Using the Service-Learning approach to bridge the gap between theory and practice in teacher education. Int J Incl Educ. 2021;27(10):1118\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePerry RN. Role Modeling Excellence in Clinical Nursing Practice. Nurse Educ Pract. 2009;9(1):36\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHedrick J, Bennett V, Carpenter J, Dercher L, Grandstaff D, Gosch K, et al. A descriptive study of adverse childhood experiences and depression, anxiety, and stress among undergraduate nursing students. J Prof Nurs. 2021;37(2):291\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi X, Song W, Zhang JY, Lu C, Wang YX, Zheng YX, Hao WN. Factors associated with mental health of graduate nursing students in China. Med (Baltim). 2021;100(3):e24247.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMashayekhi N. Stressors and Coping Styles from the Perspective of Nursing Students in Alborz University of Medical Sciences. J Nurs Educ. 2022;10(6):33\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYıldırım N, Karaca A, Ankaralı H, A\u0026ccedil;ıkg\u0026ouml;z F, Akkuş D. Stress experienced by Turkish nursing students and related factors. Clin Experimental Health Sci. 2016;6(3):121\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eParveen A, Inayat S. Evaluation of factors of stress among Nursing Students. Adv Pract Nurs. 2017;2(2):136. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4172/2573-0347.1000136\u003c/span\u003e\u003cspan address=\"10.4172/2573-0347.1000136\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRajeswaran L. Clinical experiences of nursing students at a selected institute of health sciences in Botswana. Health Sci J. 2017;10(6):471.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlrabadi N, Shawagfeh S, Haddad R, Mukattash T, Abuhammad S, Al-rabadi D, et al. Medication errors: a focus on nursing practice. J Pharm Health Serv Res. 2021;12(1):78\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMelnyk BM, Tan A, Pavan Hsieh A, Gawlik K, Arslanian-Engoren C, Braun LT, et al. Critical care nurses\u0026rsquo; physical and mental health, worksite wellness support, and medical errors. Am J Crit Care. 2021;30(3):176\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDehvan F, Dehkordi AH, Gheshlagh RG, Kurdi A. The Prevalence of Medication Errors Among Nursing Students: A Systematic and Meta-analysis Study. Int J Prev Med. 2021;12:21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/ijpvm.IJPVM_418_19\u003c/span\u003e\u003cspan address=\"10.4103/ijpvm.IJPVM_418_19\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. eCollection 2021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eValizadeh S, Abedi H, Zamanzadeh V, Fathiazar E. Challenges of Nursing Students during Their Study: A Qualitative Study. Iran J Med Educ. 2008;7(2):397\u0026ndash;406.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNayyeri S, Bozorgvar A, Barzanouni S, Masoumiyan T. Effect of Clinical Skills Evaluation by Direct Observation of Procedural Skills (DOPS) Method on Clinical Performance of Operating Room Students. J Med Educ Future Demands. 2021;20(3):e119342.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHolmboe ES, Durning SJ, Hawkins RE. Practical guide to the evaluation of clinical competence. 2nd ed. PA: Elsevier; 2018.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTyler RW. Education Evaluation: new Roles and Means. Chicago: University of Chicago Press; 1969.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAsirifi M, Ogilvie L, Barton S, Aniteye P, Stobart K, Bilash O, et al. Assessing challenges of clinical education in a baccalaureate nursing program in Ghana. J Nurs Educ Pract. 2017;7(10):109\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCahapay MK, Model. Its Limitations as Used in Higher Education Evaluation. Int J Assess Tools Educ. 2021;8(1):135\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSadeghi T, Seyed Bagheri SH. Challenges of teacher-based clinical evaluation from nursing students' point of view: Qualitative content analysis. J Educ Health Promot. 2017;6:72.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/jehp.jehp_109_16\u003c/span\u003e\u003cspan address=\"10.4103/jehp.jehp_109_16\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. eCollection 2017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMehranfard S, Pelarak F, Mashalchi H, Kalani L, Masoudiyekta L. Efficacy of logbook as a clinical assessment: Using DOPS evaluation method. J Multidiscip Healthc. 2022;11(4):184\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMotefakker S, Shirinabadi Farahani A, Nourian M, Nasiri M, Heydari F. The impact of the evaluations made by Mini-CEX on the clinical competency of nursing students. BMC Med Educ. 2022;22:634. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12909-022-03667-2\u003c/span\u003e\u003cspan address=\"10.1186/s12909-022-03667-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhanghahi ME, Ebadi Fard Azar F. Direct observation of procedural skills (DOPS) evaluation method: Systematic review of evidence. Med J Islam Repub Iran. 2018;32:45.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.14196/mjiri.32.45\u003c/span\u003e\u003cspan address=\"10.14196/mjiri.32.45\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. eCollection 2018.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJafarpoor H, Hosseini M, Sohrabi M, Mehmannavazan M. The effect of direct observation of procedural skills/mini-clinical evaluation exercise on the satisfaction and clinical skills of nursing students in dialysis. J Educ Health Promot. 2021;10:74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/jehp.jehp_618_20\u003c/span\u003e\u003cspan address=\"10.4103/jehp.jehp_618_20\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHabibi H, Khaghanizade M, Mahmoudi H, Ebadi A, Seyedmazhari M. Comparison of the Effects of Modern Assessment Methods (DOPS and Mini-CEX) with traditional method on Nursing Students' Clinical Skills: A Randomized Trial. Iran J Med Educ. 2013;13(5):364\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSharifi K, Adib-Hajbaghery M, Hosieni F. Which peer-based approach reduces the clinical anxiety of nursing students? A review study. Nurs Midwifery J. 2019;16(11):822\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBahrami Z, Norouzi S, Ramezanibadr F, Norouzi A. Design, implementation and evaluation of an Operational Program to Improve the Quality of Basic Clinical Skills in Nursing Students in Zanjan University of Medical Sciences in 2017. J Med Educ Dev. 2019;12(34):34\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpeilberger CD, Gorsuch R, Lushene R, Vagg PR, Jacobs GA. Manual for the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists; 1983.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNakayama N, Ejiri H, Arakawa N, Makino T. Stress and anxiety in nursing students between individual and peer simulations. Nurs Open. 2021;8(2):776\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Scaling up care for mental, neurological, and substance use disorders. Mental Health Gap Action Program; 2008.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSonmez Y, Akdemir M, Meydanlioglu A, Aktekin MR. Psychological Distress, Depression, and Anxiety in Nursing Students: A Longitudinal Study. Healthcare. 2023;11(5):636. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/healthcare11050636\u003c/span\u003e\u003cspan address=\"10.3390/healthcare11050636\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang WY, Peng Y, Zhuang HR, Yu HP, Liu Q, Gu Y, et al. Application of direct observation of operational skills in nursing skill evaluation of pressure injury: A randomized clinical trial. Int Wound J. 2024;21(3):e14498. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/iwj.14498\u003c/span\u003e\u003cspan address=\"10.1111/iwj.14498\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSiau K, Crossley J, Dunckley P, Johnson G, Feeney M, Hawkes ND, Beales ILP, Joint Advisory Group on Gastrointestinal Endoscopy (JAG). Direct observation of procedural skills (DOPS) assessment in diagnostic gastroscopy: nationwide evidence of validity and competency development during training. Surg Endosc. 2020;34(1):105\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eParizad N, Alizadeh Z, Jasemi M, Ahmadzadeh J. The Effect of Direct Observation of Procedural Skills (DOPS) Method on the Clinikal Performance and Satisfaction of Nursing Students in Intensive Care Units. Nurs Midwifery J. 2022;19(10):783\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHasen Y, Mequanint A, Teshome T, Belete A, Bekele D. An action research to introduce direct observation of procedural skills (DOPS) as clinical skill performance assessment tool during medical internship in the department of surgery, Debre Tabor University, Debre Tabor, Ethiopia, 2023. Afr Res J Med Sci. 2024;1(1):42\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eProfanter C, Perathoner A. DOPS (Direct Observation of Procedural Skills) in undergraduate skills-lab: Does it work? Analysis of skills-performance and curricular side effects. GMS Z Med Ausbild. 2015;32(4):Doc45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3205/zma000987\u003c/span\u003e\u003cspan address=\"10.3205/zma000987\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTohidnia MR, Weisi S, Eskandari S. The effect of direct observation of procedural skills assessment method on clinical performance of radiology students. Educ Res Med Sci. 2018;7(1):e80301.\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-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Nursing Assessment, Anxiety, Injections, Nursing Evaluation Research","lastPublishedDoi":"10.21203/rs.3.rs-7091396/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7091396/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJunior nursing students frequently experience performance anxiety during clinical skills training, particularly with invasive procedures like injections, affecting the quality of their work. Direct Observation of Practical Skills (DOPS) constitutes a contemporary pedagogical and evaluative approach, affording constructive feedback and facilitating enhanced clinical proficiency. This study’s aim was to determine the effect of DOPS on the anxiety and performance of nursing students during injection procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis quasi-experimental study employed census to recruit 74 first-semester nursing students from Shahid Beheshti Nursing School. These students were randomly assigned to either a control group (n = 36) or an intervention group (n = 38). Both groups received equivalent training in injection techniques (intramuscular, intravenous, subcutaneous, and intradermal). Student anxiety levels and performance were assessed using the Spielberger’s State-Trait Anxiety Inventory and standardized checklists respectively on two occasions: once during the first week and again in the third week following injection training. Evaluations in the intervention group employed the DOPS method, while the control group underwent standard evaluation procedures. SPSS version 16 was utilized for data analysis, employing descriptive and analytical statistical methods with a significance level of 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePre-intervention, no significant differences in anxiety or performance were observed between groups (p \u0026lt; 0.05). Post-intervention, DOPS implementation resulted in a significant reduction in state and trait anxiety within the intervention group, as determined by the chi-square test and Wilcoxon tests(p \u0026lt; 0.001). Also, the results showed that, based on the independent and paired t-tests, their performance after the evaluation was better in the intervention group compared to the control group and to before the intervention. (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFindings indicate that the DOPS method mitigates anxiety and enhances the injection skills of nursing students, suggesting its efficacy as a pedagogical tool in clinical training.\u003c/p\u003e","manuscriptTitle":"Investigating the Effect of Evaluation by Direct Observation of Procedural Skills Method on the Level of Anxiety and Clinical Performance of Nursing Students during Drug Injections","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-21 16:41:29","doi":"10.21203/rs.3.rs-7091396/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"57916126809466413034857728307363251266","date":"2025-09-29T10:37:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-18T20:45:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"247146470672425976578315011078237199136","date":"2025-09-06T10:02:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-13T21:37:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-25T21:46:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-17T19:02:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-17T13:52:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-07-17T09:13:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"880b0517-943e-4dcd-9381-f56d2af54f35","owner":[],"postedDate":"August 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-21T16:41:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-21 16:41:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7091396","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7091396","identity":"rs-7091396","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}