Comparing the effects of online teaching during the COVID-19 pandemic and traditional teaching in Surgical Nursing

Comparing the effects of online teaching during the COVID-19 pandemic and traditional teaching in Surgical Nursing | 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 Comparing the effects of online teaching during the COVID-19 pandemic and traditional teaching in Surgical Nursing Taoyun Zheng, Xinhong Zhu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-108407/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Background : The coronavirus disease 2019 (COVID-19) pandemic has necessitated a dramatic shift in how nursing faculty and undergraduate nursing students are educated. This study aims to examine the teaching effectiveness of Surgical Nursing using both face-to-face teaching and online teaching in undergraduate nursing education. Methods : A quantitative approach was adopted. Year-3 undergraduate nursing students were recruited. face-to-face teaching was conducted in semester 1, and online teaching was conducted in semester 2 during COVID-19 pandemic. Student evaluations were collected at the beginning of semester 1 and the end of semester 1 and semester 2. Results : 162 students were recruited in the study. 45.1% students held neutral attitude towards online course of Surgical Nursing. Students were more likely to prefer unit quizzes online and mind maps as homework, task-driven learning, recording videos and online question and answer as the means of theoretical teaching online, and watching surgical nursing skills video and case-based learning in groups as the means of practical teaching online. However, nearly 62.4% students admitted the effectiveness of online teaching was worse than face-to-face teaching. During online teaching, the mean grades of student in unit quizzes were improved, but there were no differences in student evaluations of instruction mean scores for critical thinking, self-directed learning and self-efficacy in comparison with the baseline. Additionally, differences between the face-to-face and online teaching were found in terms of self-directed learning, critical thinking and self-efficacy. Conclusion : The effectiveness of online teaching was not superior to the traditional teaching. Although online teaching has advantages of convenience, speed, anytime and anywhere, face-to-face teaching in classroom and interpersonal interaction in the real situation are insurmountable limitations in online teaching. Nursing COVID-19 undergraduate nursing students online teaching Surgical Nursing traditional teaching Figures Figure 1 Figure 2 Figure 3 Background Coronavirus disease 2019 (COVID-19) as public health emergency of international concern, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was outbreak in Wuhan, China on 31December 2019 that is now global pandemic and has infected 20, 439,814 patients from more than 200 countries by 13 August 2020 [ 1 ] . The growing number of infected people and deaths and no cure found against COVID-19 forced nearly all countries to apply restrictions, sanctions, social distancing and self-isolation to block spreading virus, which are leading the suspension of life worldwide. COVID-19 pandemic is challenging all circles of society overworld, especially for education. UNESCO estimated that the closure of educational institutions is affecting 890 million students in 114 countries [ 2 ] . Universities have either postponed or canceled classroom-based class and academic activities, and modified teaching plans to prevent students and professors from infected as a result of health crises. The impact of this lethal COVID-19 will reverberate in global higher education much longer after the pandemic has been finally controlled. Since February 2020, following the government’s requirement of “nonstop teaching and learning” education in China has experienced an unprecedented online teaching practice. In a short time period, millions of faculty members started to teach in front of a computer screen via Tencent Classroom, QQ group, Tencent Meeting, WeChat, ZOOM and Ding Talk app. Online teaching is not a new concept, web-based and technology-integrated learning has been embedded in education for many years. However, the global scale and speed of the current educational disruption are unfortunately unmatched because of COVID-19 outbreak. It is a massive, challenge and disruptive shift to move all the existing courses to online in a matter of days. Meanwhile, shifting from face-to-face to online classes has raised concern about faculty members’ capability to deal with existing technology. In general, an elaborate lesson plan, lecture content and course PowerPoint (PPT) as well as technology support teams are required for holistic online course. Nevertheless, most faculty members were lack of experience in online teaching and in the absence of well-considered, durable learning plans. In addition to the challenges to the faculty, evidence has indicated that students were lack of good learning attitudes and self-discipline, and more than 60% Chinese college students spend more time in-class study than out-class according to their study time [ 3 ] . At present, universities should hold positive and prudent attitudes towards online teaching, adhere to the educational concepts of “openness”, “sharing” and “student-centered” and provide educational technology support and various online educational resources, which promote online teaching in an orderly and effective manner. Besides, the faculty should coordinate the characteristics of online learning and the actual needs of students, and avoid copying the same methods, duration and arrangement of in-class teaching. Nowadays, COVID-19 pandemic has placed unprecedented demands on medical education, which disrupted medical students’ clinical clerkships, in-person classes, lab tests, practical and medical conferences, with most being replaced by recorded lectures or live-streams [ 4 ] . The benefits of online teaching have been well documented in terms of increased accessibility to education, efficacy, cost effectiveness, learner flexibility and interactivity [ 5 ] . Admittedly, online teaching has been widely applied in continuing education, undergraduate and graduate education, and patients’ guidance [ 6 – 9 ] . Therefore, by cancelling in-person classes, many medical students may perceive little change in their study schedule, but the loss of clinical skills training and practical in clinical has the potential to become a detriment to medical education, especially for surgical education. In addition, attending class in-person, real-time feedback and back and forth are hard to replicate in online teaching. Therefore, how to guarantee the effect of medical online teaching during the COVID-19 outbreak is worth to be explored further. Nursing is a very practical subject, which is required to assure that students have opportunities to practice what they have learned in class and in the clinical setting. Surgical Nursing, as a compulsory and core course of nursing professional course system, is the science of clinical nursing that provides optimal comprehensive care in the field of surgery, which focuses on cultivation of clinical thinking and clinical practical skill. Therefore, the transition face-to-face learning to online teaching may be particularly challenging to those in the Surgical Nursing as many conventional Surgical Nursing education pedagogies rely on “hands-on” practical experience. This study aimed at evaluating the teaching effectiveness of online teaching vs face-to-face learning in Surgical Nursing among undergraduate nursing students and sharing experiences of Surgical Nursing educators in changing their teaching practice during the COVID-19 pandemic. Method Design A single-group, three-time point repeated measures design in this study. Participants Participants were enrolled from a convenience sample comprising third-year nursing students at School of Nursing, Hubei University of Chinese Medicine. The criteria for involvement in the research was being voluntary to participate in the study. Students who had incomplete questionnaires were excluded. In total, 162 students were recruited to the study. Instruments Critical Thinking Dispositions Inventory-Chinese Version (CTDI-CV) [ 10 ] : The CTDI-CV, which was adapted by Peng et al according to Facione’s California Critical Thinking Dispositions Inventory (CCTDI) [ 11 ] , was implemented to measure critical thinking dispositions of nursing students and registered nurses in China. The CTDI-CV is a standardized, 70-item, multiple choice tests that is scored on each of seven categories: truth seeking (10 items), open-mindedness (10 items), analyticity (10 items), systematicity (10 items), critical thinking self-confidence (10 items), inquisitiveness (10 items), and cognitive maturity (10 items). Responses are recorded using a six-point Likert scale ranging from “strongly agree” to “strongly disagree”. Higher scores indicate stronger critical thinking dispositions. Self-Rating Scale of Self-Directed Learning (SRSSDL) [ 12 ] : The SRSSDL was a self-evaluation tool on self-directed learning. SRSSDL is composed of 60 items articulated in five subscales: Awareness (12 items), Learning strategies (12 items), Learning activities (12 items), Evaluation (12 items), Interpersonal skills (12 items). Responses for each item are rated by using a five-point Likert scale ranging from “always” to “never”. High scores show a high level of self-directed learning. General Self-efficacy Scale (GSE) [ 13 ] : The German version of GSE was originally developed by Jerusalem and Schwarzer in 1981, first as a 20-item version and later as a reduced 10-item version. High reliability, stability, and construct validity of the GSE scale were confirmed in earlier studies [ 13 , 14 ] . Responses for each item are rated by using a four-point Likert scale ranging from “completely incorrect” to “complete correct”. High scores indicate a high level of self-efficacy. Demographic questionnaire: A demographic information sheet was used to acquire basic information, such as gender, age, like nursing, learning resources, learning motivation and so on. 2.4 Data collection and procedures The theoretical and practical course of Surgical Nursing were taught in two semesters. The first semester (2019.09-2020.01) comprising 15 weeks was traditional offline teaching, which was carried out according to teaching plan and syllabus. Due to the COVID-19 outbreak, the second semester comprising 14 weeks (2020.02-2020.05) was online teaching. Students completed a demographic form, CTDI-CV, SRSSDL and GSE scale prior to traditional teaching, and at the end of semester 1 and semester 2. Curricular Framework for Surgical Nursing online The curricular design of Surgical Nursing was based on “Teacher-oriented, Student-centered” education concept. According to the syllabus and teaching objectives, combined with online teaching resources, course team reconstructed online teaching process and progress. Online teaching of Surgical Nursing mainly relied on online platforms such as Tencent Meeting, Tencent Classroom, QQ screen sharing, Massive Online Open Courses (MOOCs), Rain Classroom and Questionnaire Star. Online open courses built by MOOCs, electronic version textbooks of People’s Medical Publishing House, databases such as Wanfang data, CNKI, teaching courseware and unit quizzes were main curriculum resources. Implement “upload learning materials before class, self-directed learning before class, play the recorded videos in class, answer students’ questions in class and unit quizzes and feedback after class” as online teaching model of Surgical Nursing. Preparation before class 1) Teachers: Prior to online course, QQ group of Surgical Nursing was set up. Upload learning materials such as literatures, videos, teaching courseware, website links via QQ group and tasks of each lesson, and sum up students’ questions and confused knowledge points of each chapter before class. Based on the feedback from the students, lectures recorded the teaching video with 30 min as supplementary curriculum resource. Case-based learning (CBL), team-based learning (TBL) and task-driven learning were applicated in practical lessons. The teaching cases were prepared by the core teacher based on the curricular standards, teaching objectives, and students’ prior knowledge level, needs and interests. Prior to practical lessons, lectures uploaded cases, tasks and nursing skill videos via QQ group. 2) Students: This was the phase of self-directed learning. Students were required to give feedback about confused knowledge points three days before class. In practical class, students were divided into groups of 5 ~ 6 people, then discussing cases in groups with online promotive interaction, holding individually accountable to do their share of the work, and identifying nursing problems of patients in the cases. The team members divided their work according to their individual strengths and clinical cases, such as role-playing, narration, and collection of difficult knowledge. In class Play video recorded by lectures during class, or take class via screen sharing or live broadcast within 45 min. In the last 30 min of each lesson, lectures concentrated on answering students’ questions and errors in homework and tasks, and interacted with students via QQ group or Tencent Meeting. Develop students’ critical thinking by analyzing cases, formatting nursing care plan, situation simulation online, recording videos of health education and group discussion in the practical class. Enhance their understanding of surgical nursing skills by describing and decomposing nursing skills steps online, watching nursing skill videos and recording videos of practicing nursing skills. Each group showed their nursing diagnosis, measures and videos within 15 min. After the demonstration, students were asked to comment on advantages and disadvantages of nursing diagnosis and measures, and put forward their opinions about presentation of other groups. After class After class, lectures uploaded unit quizzes of each chapter via Rain Classroom and asked students to write learning notes and draw mind maps of important knowledge points. Students were encouraged to display their learning notes and mind maps in the QQ group. Evaluation of teaching effectiveness The evaluations of teaching effectiveness were adopted formative evaluation, including process evaluation and end-stage evaluation. The process evaluations utilized multiple evaluation methods, including conducting questionnaire survey before the beginning of the course, one month later and at the end of course to assess students’ the fundamental condition, self-learning, self-efficacy and critical thinking via Questionnaire Star. Additionally, the students and instructors were interviewed respectively to master their opinions and suggestions on the instructional design, process and effectiveness. The score of tests was accounted for 50% of the total score. The rest were formative evaluations, which mainly included classroom reports, scenario simulation and nursing rounds. Data analysis The data were shown as the mean ± standard deviation (SD) and analyzed using SPSS 20.0 software package with chi-square (fisher exact probability), t-test, and one-way analysis of variance (ANOVA). The statistical significance was defined as a difference between groups of P < 0.05. Results Demographic Characteristics A total of 162 students (16 [9.9%] male and 146 [90.1%] female) with a mean age of 21.06 (SD = 0.91) ranging from 19 to 24 years participated in the study (Table 1 ). Regarding career choice during the COVID-19 pandemic, the proportion of students who chose to be a nurse after graduation were increased compared with baseline. Compared with traditional teaching, learning resources in online teaching were more abundant. During COVID-19 pandemic, 60.5% students admitted that they had enough learning resources. Furthermore, students got learning resource via search engine (92.0%), social media (90.7%) and Web portals (40.7%) during online course. There was no difference in response to the question “learning motivation” between traditional teaching and online teaching. Regarding learning motivation, 54.9% students selected “sometimes” and 32.7% selected “often” during online teaching. Table 1 Demographics of students participating in the study (n = 162). Variable Baseline (%) Traditional teaching (%) Online teaching (%) Like nursing No 9 (5.5) 4 (2.5) 5 (3.1) Unclear 112 (70.0) 103 (63.5) 94 (58.0) Yes 41 (25.3) 55 (34.0) * 63 (38.9) # Engaged in nursing work after graduate No 17 (10.5) 4 (2.4) 5 (3.1) Unclear 54 (33.3) 56 (34.6) 43 (26.5) Yes 91 (56.2) 102 (63.0) * 114 (70.4) # Learning resources Never 1 (0.6) 1 (0.6) 0 Little 19 (11.7) 15 (9.3) 5 (3.1) Much 98 (60.5) 72 (44.4) 59 (36.4) Very Much 43 (26.5) 73 (45.1) 97 (59.9) Complete 1 (0.6) 1 (0.6) * 1 (0.6) #★ Learning motivation Never 0 0 0 Rarely 27 (16.6) 19 (11.7) 19 (11.7) Sometimes 94 (58.0) 87 (53.7) 89 (54.9) Often 35 (21.6) 52 (32.1) 53 (32.7) Always 6 (3.7) 4 (2.5) * 1 (0.6) # *: P < 0.05 vs Baseline, #: P < 0.05 vs Baseline, ★: P < 0.05 vs Traditional teaching. Perception and attitude towards online teaching of Surgical Nursing As shown in Table 2 , although 38.8% participants held positive attitude towards online teaching of Surgical Nursing, only 9.3% of them admitted that the effect of online teaching was better than traditional teaching. Regarding what happened to you during online teaching, 89.3% students admitted that they felt tired of eyes facing screen for a long time, 70.0% students reported network interruption and excess phone data traffic, 63.2% students acknowledged they were unable to concentrate on learning, and 53.4% of them admitted they had low efficiency of study. Furthermore, 22.7% students spent over 6 h on social media usage per day. Nearly 71.0% students suggested that each lesson of online teaching should be within 40 min. The most effective ways of online course were watching teaching videos recorded by lecturers (64.8%), group discussion (21.6%), online courses (6.8%) and reading relevant books (6.8%). Furthermore, the most effective ways of online practical teaching on surgical nursing skills were watching nursing skills videos (71.0%), CBL in groups (67.3%), and describing and decomposing surgical nursing skills step by step by themselves (56.8%). Meanwhile, 15.4% participants admitted online teaching was not suitable for practice learning. The most effective ways to finish homework were mind map (35.2%), self-directed learning (29.6%) and online quizzes via the Rain Class (29.6%). 96.3% students did not agree with taking videos as homework. 51.9% students acknowledged that the time of each homework would be limited to 30 min. The disadvantages of online teaching were poor learning effectiveness (30.9%), poor learning atmosphere (25.9%) and poor learning surroundings (22.8%). Table 2 Perception and attitudes towards online teaching of Surgical Nursing Variable n (%) Attitudes towards online teaching Strongly disagree 5 (3.1) Disagree 21 (13.0) Not agree 73 (45.1) Agree 49 (30.2) Strongly agree 14 (8.6) Compared with traditional teaching, the effect of online teaching Better than traditional teaching 14 (8.6) Same effect 47 (29.0) Worse than traditional teaching 101 (62.4) The duration of each lesson in online teaching < 10 min 0 < 20 min 4 (2.5) < 30 min 43 (26.5) < 40 min 115 (71.0) The most helpful way to learn in online teaching Group discussion 35 (21.6) Teaching videos recorded by the teachers 105 (64.8) Online courses 11 (6.8) Reading books 11 (6.8) The most helpful way to learn surgical nursing practical teaching online Watching nursing skills video 115 (71.0) Describing and decomposing surgical nursing skills steps by themselves 92 (56.8) Case-based learning in groups 109 (67.3) Recording videos in groups 26 (16.0) Not ideal online 25 (15.4) The most helpful way to finish homework Unit quizzes via Rain Classroom 48 (29.6) Mind map 57 (35.2) Concept map 3 (1.9) Recording videos in groups 6 (3.7) Self-directed learning 48 (29.6) Time spent on each homework < 20 min 28 (17.3) < 30 min 84 (51.9) < 40 min 28 (17.3) < 50 min 4 (2.5) < 60 min 18 (11.1) The disadvantages of online teaching Insufficient learning resources 7 (4.3) Poor learning surroundings 37 (22.8) Poor learning effect 50 (30.9) Limited learning approaches 26 (16.0) Poor learning atmosphere 42 (25.9) Comparison between traditional teaching and online teaching As depicted in Table 3 , compared with the baseline, there were no significant differences between the mean scores obtained of self-directed learning, critical thinking and self-efficacy after performing online teaching. Of the five subscales in SRSSDL, learning strategies and interpersonal skills were significantly improved after performing online teaching in comparison with baseline (Fig. 1 ). However, a significant decrease in awareness was observed after online teaching compared with baseline. The comparison of the mean scores obtained for the different dimensions of critical thinking after the implementation of online teaching showed a significant increase in analyticity (Fig. 2 ). Moreover, there were significant differences between the mean scores obtained for CTDI-CV, SRSSDL and GSE after performing traditional teaching compared with baseline. Differences between the face-to-face and online teaching were found in terms of self-directed learning, critical thinking and self-efficacy. 68.6% students finished all 13 units quizzes via the Rain Classroom in the semester 1, and the mean accuracy rate was 0.91% (SD = 0.05). During the online teaching, 78.9% students finished all 12 units quizzes, and the mean accuracy rate was 0.94% (SD = 0.06), which was higher than the traditional teaching (Fig. 3 ). Table 3 Outcomes of self-efficacy, self-directed learning and critical thinking between traditional teaching and online teaching. Variable Baseline Traditional teaching Online teaching M (SD) M (SD) M (SD) Self-efficacy 2.36 (0.40) 2.50 (0.45) * 2.34 (0.44) ★ Self-directed learning 207.87 (25.71) 216.09 (23.40) * 208.81 (24.91) ★ Critical thinking 216.2 (25.36) 227.18 (16.63) * 217.96 (23.49) ★ *: P < 0.05 vs Baseline, ★: P < 0.05 vs Traditional teaching. *: P < 0.05 vs Baseline, #: P < 0.05 vs Baseline. Discussion In the emerging and ever-changing COVID-19 context, universities should implement a number of measures to slow the virus spread. The safety and health of students and the faculty members should be the top priority. Postponing or cancelling classroom-based class and academic activities are an essential means to protect the health of students and the faculty members. Following the government’s requirement of “nonstop teaching and learning”, almost all existing course were moved to online in a matter of days. This is an unprepared challenge for millions of faculty members and administrators and tens of million students in colleges and universities that everyone must face. In this study, although 38.8% students held positive attitudes towards online teaching, only 8.6% students admitted the effect of online teaching on Surgical Nursing was better than traditional teaching. Evidence has suggested that online learning in undergraduate nursing education is no less effective than traditional means [ 15 , 16 ] . Although the advantages of online teaching including enhancing engagement, learning easier in groups, flexibility in time allocated to complete tasks have been reported, it is challenge for impaired communication due to poor network access [ 17 ] . 70.0% students experienced network interruption and excess phone data traffic resulting in poor teaching effect. During the COVID-19 pandemic, the majority of faulty members and students had encountered technical difficulties such as poor internet connection and the lack of computer. Therefore, ensure the smooth implementation of teaching activities through combined usage of multiple platforms to avoid problems such as stuck and interruption of teaching activities due to network and large visitor volume. In the online course of Surgical Nursing, lectures used various platforms including QQ group, WeChat, Tencent Classroom, Tencent Meeting, Rain Classroom and other apps for online teaching. In order to ensure the effectiveness of online teaching, well-considered and durable teaching plans as well as emergency prepared plans for unexpected problems were prepared. Therefore, there were various types and quantities of online teaching methods such as live broadcast and online interaction, live broadcast, recording and online interaction, self-directed learning, MOOCs, Small Private Online Courses (SPOC), PPT and online interaction and answering questions online. In this study, 64.8% students admitted that they were more likely to prefer recording videos of each chapter and answering questions online. Each lesson should be limited within 40 min. Meanwhile, if you normally teach a 3-hour class, summarize its essence in a video no longer than 30 minutes [ 18 ] . Experts have suggested that lectures should not convert their entire lecture contents to videos because students are not willing to watch slides without a teacher’ face or voice [ 18 ] . Compared with traditional in-class lectures, faculty have less control online teaching, and students are more likely to “skip the class” [ 3 ] . In order to strengthen learning effectiveness and students’ high-level active learning outside of class, faculty members could release homework and reading requirements. In the course of Surgical Nursing, unit quizzes for each chapter via Rain Classroom, mind map for important knowledge points, keep class notes, reading literatures and taking videos were the common manners of homework. The most popular ways of homework were mind map (35.2%), unit quizzes (29.6%) and self-directed learning (29.6%) in this study. However, most students complained about heavy workload leading to poor effectiveness of completion of homework at initial stage of online teaching. 89.3% students admitted that they felt tired of eyes facing screen for a long time. Hence, each task was best completed within 30 min. Practical teaching for surgical nursing skills training, as an important part of Surgical Nursing, is difficult to be implemented online. Drainage bag replacement, fracture plaster fixation and closed thoracic drainage were the main practical teaching content in the semester 2. Combined with the current actual situation, teaching plan had been appropriately revised, and training of surgical nursing skills was moved to offline after resuming classes. CBL, TBL and task-driven teaching were applicated in practical lessons online. The most effective ways implemented in practical teaching were watching videos of nursing skills (71.0%), CBL (67.3%) and describing and decomposing surgical nursing skills steps by themselves (56.8%). Evidence has shown that CBL is an effective educational method for developing critical thinking, reinforcing peers' potentials and improving diagnostic abilities [ 19 ] . Furthermore, the web-based CBL is not inferior to the traditional classroom CBL method [ 20 ] . It was worth to be noted that students were disgusted with taking videos as assignments. In order to diversity case tasks, the lecture asked students to show simple nursing skill such as shoulder joint movement, or health education by taking videos. However, only 16.0% students chose to take video clips in this study. Due to the influence of objective factors such as the network coverage of students’ area, and different family economy, students in remote villages or poor families cannot got equal education. In addition to great difference in students’ personal conditions, heavy workload was also an important factor influencing students’ willing to take video clips. In general, poor learning effectiveness and poor learning atmosphere were the disadvantages of online courses. Insufficient pre-class preparation, limited participation in class discussion, and inadequate discussion are common phenomena in online teaching [ 3 ] . In order to solve such problems in online teaching, expert recommends that faculty should consider two phases of teaching, the offline self-learning phase and the online teaching phase [ 3 ] . In the present study, the scores of self-directed and self-efficacy were not significantly different. This outcome could possibly be attributed to the fact that students studied at home, which made students more difficult to manage themselves. Especially, the scores of awareness in self-directed learning were decreased. Students were accustomed to lecture in-class and depend on faculty direction leading to low-level active in learning online. Interestingly, the scores of learning strategies and interpersonal skills in self-directed learning were increased compared with baseline. Maybe it is because that students were required to read the course-specific literature and watch various videos in the offline self-learning phase. Meanwhile, during the COVID-19 pandemic, learning resources were more abundant and open than before, and there were more opportunities for group learning. Critical thinking is an important skill for all nurses, as the ability to critically assess and interpret situations and to use the knowledge correctly will enable them to provide optimal comprehensive care and other services [ 21 ] . In this study, significant differences in the measure of critical thinking between online course and face-to-face class were observed due to various influencing factors, including learning surroundings, the instructors’ approaches to teach, students’ intrinsic motivation and learning strategies. However, it was reported that critical thinking is enhanced via online learning [ 22 , 23 ] . This inconsistent result may be due to the fact that online teaching as part of blended teaching is well-prepared and technology-support. Among the seven subscales, the scores of truth seeking, maturity, systematicity and inquisitiveness were found to be lower than traditional teaching, suggesting that the students were week in intellectual curiosity and desire for learning, courageous about asking questions, decision-making and using organized and focused methods of reasoning. Nevertheless, the accuracy rate and the proportion of completing all unit quizzes were higher than traditional teaching. Although students actively participated in discussion online and unit quizzes, high-frequency interaction did not achieve the desired outcome and curiosity and desire for learning were still low. The best online instructors set up their courses so that students can pursue self-paced enquiry under their own initiative [ 18 ] . The progress of online teaching largely depends on students’ high-level active learning, which adheres to the educational concept of “Student-centered”. Strengthen the learning requirements, enhance the enthusiasm and initiative of self-directed learning are key factors in online teaching. Studying at home was challenge for students’ self-management due to lack of learning atmosphere. It was worth to be noted that the mean score of analyticity was higher than traditional learning, indicating that students prized the application of reasoning and the use of evidence to resolve problem. Conclusion The sudden outbreak of COVID-19 accelerates the acceptance of online teaching by all the staff in colleges and universities in China. In this study, most students held neutral attitude towards online teaching in Surgical Nursing. Task-driven learning, recording videos and answering questions online were more suitable for theoretical teaching online. Watching nursing skills video and CBL in groups were more suitable for practical teaching online. Students were more likely to prefer unit quizzes online and mind maps as homework. Individual students’ grades in unit quizzes improved, but there were no differences in student evaluations of instruction mean scores for critical thinking, self-directed learning and self-efficacy. Nearly 3/5 students admitted the effect of online teaching was worse than traditional teaching. In conclusion, face-to-face teaching in classroom and interpersonal interaction in the real situation are insurmountable limitations in online teaching, leading to failure to achieve the expected teaching effectiveness. Abbreviations CBL: Case-based learning; COVID-19: Coronavirus disease 2019; CTDI-CV: Critical Thinking Dispositions Inventory-Chinese Version; GSE: General Self-efficacy Scale; MOOCs: Massive Online Open Courses; PPT: PowerPoint; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; SPOC: Small Private Online Courses; SRSSDL: Self-Rating Scale of Self-Directed Learning; TBL: Team-based learning Declarations Acknowledgments We thank Hubei University of Chinese Medicine for providing us to conduct this study and its ethical approval. Authors’ contributions We thank XZ and TZ designed research; XZ and TZ conducted research; XZ analyzed data; XZ wrote the manuscript; TZ provided language help, and TZ had primary responsibility for the final content. All authors revised it critically for important intellectual content. Funding This work was supported by the National Natural Science Found of China (No. 82003448). Availability of data and materials All the data supporting the study findings are within the manuscript. Additional detailed information and raw data are available from the corresponding author on reasonable request. Ethical Approval and consent to participate Prior to data collection, the protocol was reviewed and ethical permission for the study was received from the Hubei university of Chinese Medicine human ethics committee. All students were informed for All nurses were informed for their voluntary participation and they have the right to refuse, withdraw or stop at any time during their participation. Their identities and potential risks were strictly kept and maintained confidential throughout the study. Consent for publication Not applicable. Declaration The authors declare that they have no competing interests. Author details School of Nursing, Hubei University of Chinese Medicine, Wuhan, China. *Corresponding to: Dr. Zheng Taoyun, Nursing Educator, School of Nursing, Hubei University of Chinese Medicine, Wuhan, China, phone: +86027-688890395. E-mail: [email protected] References World Health Organization. (2020). Coronavirus disease 2019 (‎‎COVID-19)‎‎: situation report, 206. Retrieved from Geneva: https://apps.who.int/iris/handle/10665/333839. Araújo, F.J.O., de Lima, L. S. A., Cidade, P. I. M., et al. Impact Of Sars-Cov-2 And Its Reverberation In Global Higher Education And Mental Health. Psychiatry Res, 2020. 288: p. 112977. Bao, W. COVID-19 and online teaching in higher education: A case study of Peking University. Hum Behav Emerg Technol, 2020. 2(2): p. 113-115. Ferrel, M. N. and Ryan, J. J. The Impact of COVID-19 on Medical Education. Cureus, 2020. 12(3): p. e7492. Sinclair, P., Kable, A., and Levett-Jones, T. 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Peng, M.C., Wang, G.C., Chen, J.L., et al. (2004). Validity and reliability of the Chinese critical thinking disposition inventory. J Nurs in China (Zhong Hua Hu Li Za Zhi), 39, 644-647.11. Facione, N.C., Facione, P. A and Sanchez, C.A.G. Critical Thinking Disposition as a Measure of Competent Clinical Judgment: The Development of the California Critical Thinking Disposition Inventory. J Nurs Educ, 1994. 33(8): p. 345-350. Williamson, S.N., Development of a self-rating scale of self-directed learning. Nurse Res, 2007. 14(2): 66-83. Cheung, S. K. and Sun, S.Y. Assessment of optimistic self-beliefs: further validation of the Chinese version of the General Self-Efficacy Scale. Psychol Repo, 1999. 85(3_suppl): p. 1221-1224. Luszczynska, A., Scholz, U., Schwarzer, R. The general self-efficacy scale: multicultural validation studies. J Psychol, 2005. 139(5): p. 439-457. McCutcheon, K., Lohan, M., Traynor, M., et al. A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education. J Adv Nurs, 2015. 71(2): p. 255-70. Pei, L. Wu, H. Does online learning work better than offline learning in undergraduate medical education? A systematic review and meta-analysis. Med Educ Online, 2019. 24(1): p. 1666538. Willemse, J.J., Jooste, K., Bozalek, V. Experiences of undergraduate nursing students on an authentic mobile learning enactment at a higher education institution in South Africa. Nurse Educ Today, 2019. 74: p. 69-75. Gewin, V. Five tips for moving teaching online as COVID-19 takes hold. Nature, 2020. 580(7802): p. 295-296. Gholami, M., Saki, M., Toulabi, T., et al. Iranian Nursing Students' Experiences of Case-Based Learning: A Qualitative Study. J Prof Nurs, 2017. 33(3): p. 241-249. Chan, A.W., Chair, S. Y., Sit, J. W. Case-Based Web Learning Versus Face-to-Face Learning: A Mixed-Method Study on University Nursing Students. J Nurs Res, 2016. 24(1): p. 31-40. Yu, D., Zhang, Y., Xu, Y., et al. Improvement in Critical Thinking Dispositions of Undergraduate Nursing Students Through Problem-Based Learning: A Crossover-Experimental Study. J Nurs Educ, 2013. 52(10): p. 574-581. Brahler, C.J., Quitadamo, I.J., Johnson, E.C. Student critical thinking is enhanced by developing exercise prescriptions using online learning modules. Adv Physiol Educ, 2002. 26(1-4): p. 210-21. Novotny, N.L., Stapleton, S.J. and Hardy, E.C. Enhancing Critical Thinking in Graduate Nursing Online Asynchronous Discussions. J Nurs Educ, 2016. 55(9): p. 514-21. Supplementary Files questionnaire.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Major revision 28 Dec, 2020 Review # 3 received at journal 14 Dec, 2020 Review # 2 received at journal 14 Dec, 2020 Review # 1 received at journal 07 Dec, 2020 Reviewer # 3 agreed at journal 20 Nov, 2020 Reviewer # 2 agreed at journal 17 Nov, 2020 Reviewers invited by journal 17 Nov, 2020 Reviewer # 1 agreed at journal 17 Nov, 2020 Editor assigned by journal 12 Nov, 2020 Submission checks completed at journal 12 Nov, 2020 Editor invited by journal 12 Nov, 2020 First submitted to journal 24 Oct, 2020 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-108407","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":4773754,"identity":"df653ff2-120c-43f8-9dbb-1fe62ff29233","order_by":0,"name":"Taoyun Zheng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwElEQVRIiWNgGAWjYBAC+/bGxsc/eGx4+InWYsBzuNmYQSZNTrKBaC0S6W3CDDaHjA0OEKvFnCGxjbkg50Di5uPJGxh+VGwjrMWy4WDb4xln7iRuO/OsgLHnzG0irDnY2G7A2/MscduNHANmxjZitBxmbJPg/Xc4cfMMYrUYHGNsk+bhOWxsIEGsFskexmbDGTxpchJAvxwkyi/88s8fPvgAisr25I0PflQQ4xcESCA+ahBaSNUxCkbBKBgFIwQAAJyuQnJn2y/uAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-0371-3914","institution":"Hubei University of Chinese Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Taoyun","middleName":"","lastName":"Zheng","suffix":""},{"id":4773755,"identity":"57a27097-561c-4af4-9f3d-2530a98f79b4","order_by":1,"name":"Xinhong Zhu","email":"","orcid":"","institution":"Hubei University of Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xinhong","middleName":"","lastName":"Zhu","suffix":""}],"badges":[],"createdAt":"2020-11-14 13:24:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-108407/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-108407/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":3645683,"identity":"0a958e0f-2330-4178-88fd-7775eb36f49a","added_by":"auto","created_at":"2020-11-17 20:27:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":14401,"visible":true,"origin":"","legend":" Outcomes of subscales in self-directed learning between traditional teaching and online teaching. *: P\u003c0.05 vs Baseline, #: P\u003c0.05 vs Baseline. ","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-108407/v1/468649e4a87c57a5b00f3885.png"},{"id":3645684,"identity":"bad19f13-3176-4af9-8307-ba8787152aaf","added_by":"auto","created_at":"2020-11-17 20:27:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":23378,"visible":true,"origin":"","legend":"Outcomes of subscales in critical thinking between traditional teaching and online teaching. *: P\u003c0.05 vs Baseline, #: P\u003c0.05 vs Baseline. ","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-108407/v1/a28cd566e4d9dc64a5a1be24.png"},{"id":3645685,"identity":"3b2fbec3-5fcd-4b75-86a4-1be5d7f8d129","added_by":"auto","created_at":"2020-11-17 20:27:20","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":120221,"visible":true,"origin":"","legend":"Outcomes of regular unit quizzes between traditional teaching and online teaching.","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-108407/v1/5a2201aeee5d54ea7004f70b.jpeg"},{"id":13616275,"identity":"b522820f-b2dd-49af-b617-3ac36783c3b7","added_by":"auto","created_at":"2021-09-17 06:48:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":485638,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-108407/v1/6a5af3d3-6124-406c-933d-675dfe723b3c.pdf"},{"id":3645686,"identity":"5b808187-9240-4d76-89f1-b1fdbdae9625","added_by":"auto","created_at":"2020-11-17 20:27:20","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":40539,"visible":true,"origin":"","legend":"","description":"","filename":"questionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-108407/v1/92457afafba38858b53ff0eb.docx"}],"financialInterests":"","formattedTitle":"Comparing the effects of online teaching during the COVID-19 pandemic and traditional teaching in Surgical Nursing","fulltext":[{"header":"Background","content":"\u003cp\u003eCoronavirus disease 2019 (COVID-19) as public health emergency of international concern, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was outbreak in Wuhan, China on 31December 2019 that is now global pandemic and has infected 20, 439,814 patients from more than 200 countries by 13 August 2020 \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. The growing number of infected people and deaths and no cure found against COVID-19 forced nearly all countries to apply restrictions, sanctions, social distancing and self-isolation to block spreading virus, which are leading the suspension of life worldwide. COVID-19 pandemic is challenging all circles of society overworld, especially for education. UNESCO estimated that the closure of educational institutions is affecting 890\u0026nbsp;million students in 114 countries \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Universities have either postponed or canceled classroom-based class and academic activities, and modified teaching plans to prevent students and professors from infected as a result of health crises. The impact of this lethal COVID-19 will reverberate in global higher education much longer after the pandemic has been finally controlled.\u003c/p\u003e\n\u003cp\u003eSince February 2020, following the government\u0026rsquo;s requirement of \u0026ldquo;nonstop teaching and learning\u0026rdquo; education in China has experienced an unprecedented online teaching practice. In a short time period, millions of faculty members started to teach in front of a computer screen via Tencent Classroom, QQ group, Tencent Meeting, WeChat, ZOOM and Ding Talk app. Online teaching is not a new concept, web-based and technology-integrated learning has been embedded in education for many years. However, the global scale and speed of the current educational disruption are unfortunately unmatched because of COVID-19 outbreak. It is a massive, challenge and disruptive shift to move all the existing courses to online in a matter of days. Meanwhile, shifting from face-to-face to online classes has raised concern about faculty members\u0026rsquo; capability to deal with existing technology. In general, an elaborate lesson plan, lecture content and course PowerPoint (PPT) as well as technology support teams are required for holistic online course. Nevertheless, most faculty members were lack of experience in online teaching and in the absence of well-considered, durable learning plans. In addition to the challenges to the faculty, evidence has indicated that students were lack of good learning attitudes and self-discipline, and more than 60% Chinese college students spend more time in-class study than out-class according to their study time \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. At present, universities should hold positive and prudent attitudes towards online teaching, adhere to the educational concepts of \u0026ldquo;openness\u0026rdquo;, \u0026ldquo;sharing\u0026rdquo; and \u0026ldquo;student-centered\u0026rdquo; and provide educational technology support and various online educational resources, which promote online teaching in an orderly and effective manner. Besides, the faculty should coordinate the characteristics of online learning and the actual needs of students, and avoid copying the same methods, duration and arrangement of in-class teaching.\u003c/p\u003e\n\u003cp\u003eNowadays, COVID-19 pandemic has placed unprecedented demands on medical education, which disrupted medical students\u0026rsquo; clinical clerkships, in-person classes, lab tests, practical and medical conferences, with most being replaced by recorded lectures or live-streams \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. The benefits of online teaching have been well documented in terms of increased accessibility to education, efficacy, cost effectiveness, learner flexibility and interactivity \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Admittedly, online teaching has been widely applied in continuing education, undergraduate and graduate education, and patients\u0026rsquo; guidance \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Therefore, by cancelling in-person classes, many medical students may perceive little change in their study schedule, but the loss of clinical skills training and practical in clinical has the potential to become a detriment to medical education, especially for surgical education. In addition, attending class in-person, real-time feedback and back and forth are hard to replicate in online teaching. Therefore, how to guarantee the effect of medical online teaching during the COVID-19 outbreak is worth to be explored further.\u003c/p\u003e\n\u003cp\u003eNursing is a very practical subject, which is required to assure that students have opportunities to practice what they have learned in class and in the clinical setting. Surgical Nursing, as a compulsory and core course of nursing professional course system, is the science of clinical nursing that provides optimal comprehensive care in the field of surgery, which focuses on cultivation of clinical thinking and clinical practical skill. Therefore, the transition face-to-face learning to online teaching may be particularly challenging to those in the Surgical Nursing as many conventional Surgical Nursing education pedagogies rely on \u0026ldquo;hands-on\u0026rdquo; practical experience. This study aimed at evaluating the teaching effectiveness of online teaching vs face-to-face learning in Surgical Nursing among undergraduate nursing students and sharing experiences of Surgical Nursing educators in changing their teaching practice during the COVID-19 pandemic.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA single-group, three-time point repeated measures design in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003cp\u003eParticipants were enrolled from a convenience sample comprising third-year nursing students at School of Nursing, Hubei University of Chinese Medicine. The criteria for involvement in the research was being voluntary to participate in the study. Students who had incomplete questionnaires were excluded. In total, 162 students were recruited to the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstruments\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003cp\u003eCritical Thinking Dispositions Inventory-Chinese Version (CTDI-CV) \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e: The CTDI-CV, which was adapted by Peng et al according to Facione\u0026rsquo;s California Critical Thinking Dispositions Inventory (CCTDI) \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, was implemented to measure critical thinking dispositions of nursing students and registered nurses in China. The CTDI-CV is a standardized, 70-item, multiple choice tests that is scored on each of seven categories: truth seeking (10 items), open-mindedness (10 items), analyticity (10 items), systematicity (10 items), critical thinking self-confidence (10 items), inquisitiveness (10 items), and cognitive maturity (10 items). Responses are recorded using a six-point Likert scale ranging from \u0026ldquo;strongly agree\u0026rdquo; to \u0026ldquo;strongly disagree\u0026rdquo;. Higher scores indicate stronger critical thinking dispositions.\u003c/p\u003e\n\u003cp\u003eSelf-Rating Scale of Self-Directed Learning (SRSSDL) \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e: The SRSSDL was a self-evaluation tool on self-directed learning. SRSSDL is composed of 60 items articulated in five subscales: Awareness (12 items), Learning strategies (12 items), Learning activities (12 items), Evaluation (12 items), Interpersonal skills (12 items). Responses for each item are rated by using a five-point Likert scale ranging from \u0026ldquo;always\u0026rdquo; to \u0026ldquo;never\u0026rdquo;. High scores show a high level of self-directed learning.\u003c/p\u003e\n\u003cp\u003eGeneral Self-efficacy Scale (GSE) \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e: The German version of GSE was originally developed by Jerusalem and Schwarzer in 1981, first as a 20-item version and later as a reduced 10-item version. High reliability, stability, and construct validity of the GSE scale were confirmed in earlier studies \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Responses for each item are rated by using a four-point Likert scale ranging from \u0026ldquo;completely incorrect\u0026rdquo; to \u0026ldquo;complete correct\u0026rdquo;. High scores indicate a high level of self-efficacy.\u003c/p\u003e\n\u003cp\u003eDemographic questionnaire: A demographic information sheet was used to acquire basic information, such as gender, age, like nursing, learning resources, learning motivation and so on.\u003c/p\u003e\n\u003cp\u003e2.4 \u003cem\u003eData collection and procedures\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe theoretical and practical course of Surgical Nursing were taught in two semesters. The first semester (2019.09-2020.01) comprising 15 weeks was traditional offline teaching, which was carried out according to teaching plan and syllabus. Due to the COVID-19 outbreak, the second semester comprising 14 weeks (2020.02-2020.05) was online teaching. Students completed a demographic form, CTDI-CV, SRSSDL and GSE scale prior to traditional teaching, and at the end of semester 1 and semester 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCurricular Framework for Surgical Nursing online\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\n\u003cp\u003eThe curricular design of Surgical Nursing was based on \u0026ldquo;Teacher-oriented, Student-centered\u0026rdquo; education concept. According to the syllabus and teaching objectives, combined with online teaching resources, course team reconstructed online teaching process and progress. Online teaching of Surgical Nursing mainly relied on online platforms such as Tencent Meeting, Tencent Classroom, QQ screen sharing, Massive Online Open Courses (MOOCs), Rain Classroom and Questionnaire Star. Online open courses built by MOOCs, electronic version textbooks of People\u0026rsquo;s Medical Publishing House, databases such as Wanfang data, CNKI, teaching courseware and unit quizzes were main curriculum resources. Implement \u0026ldquo;upload learning materials before class, self-directed learning before class, play the recorded videos in class, answer students\u0026rsquo; questions in class and unit quizzes and feedback after class\u0026rdquo; as online teaching model of Surgical Nursing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cspan class=\"BoldItalic\"\u003ePreparation before class\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1) Teachers: Prior to online course, QQ group of Surgical Nursing was set up. Upload learning materials such as literatures, videos, teaching courseware, website links via QQ group and tasks of each lesson, and sum up students\u0026rsquo; questions and confused knowledge points of each chapter before class. Based on the feedback from the students, lectures recorded the teaching video with 30\u0026nbsp;min as supplementary curriculum resource. Case-based learning (CBL), team-based learning (TBL) and task-driven learning were applicated in practical lessons. The teaching cases were prepared by the core teacher based on the curricular standards, teaching objectives, and students\u0026rsquo; prior knowledge level, needs and interests. Prior to practical lessons, lectures uploaded cases, tasks and nursing skill videos via QQ group.\u003c/p\u003e\n\u003cp\u003e2) Students: This was the phase of self-directed learning. Students were required to give feedback about confused knowledge points three days before class. In practical class, students were divided into groups of 5\u0026thinsp;~\u0026thinsp;6 people, then discussing cases in groups with online promotive interaction, holding individually accountable to do their share of the work, and identifying nursing problems of patients in the cases. The team members divided their work according to their individual strengths and clinical cases, such as role-playing, narration, and collection of difficult knowledge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIn class\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\n\u003cp\u003ePlay video recorded by lectures during class, or take class via screen sharing or live broadcast within 45\u0026nbsp;min. In the last 30\u0026nbsp;min of each lesson, lectures concentrated on answering students\u0026rsquo; questions and errors in homework and tasks, and interacted with students via QQ group or Tencent Meeting. Develop students\u0026rsquo; critical thinking by analyzing cases, formatting nursing care plan, situation simulation online, recording videos of health education and group discussion in the practical class. Enhance their understanding of surgical nursing skills by describing and decomposing nursing skills steps online, watching nursing skill videos and recording videos of practicing nursing skills. Each group showed their nursing diagnosis, measures and videos within 15\u0026nbsp;min. After the demonstration, students were asked to comment on advantages and disadvantages of nursing diagnosis and measures, and put forward their opinions about presentation of other groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAfter class\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\n\u003cp\u003eAfter class, lectures uploaded unit quizzes of each chapter via Rain Classroom and asked students to write learning notes and draw mind maps of important knowledge points. Students were encouraged to display their learning notes and mind maps in the QQ group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluation of teaching effectiveness\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\n\u003cp\u003eThe evaluations of teaching effectiveness were adopted formative evaluation, including process evaluation and end-stage evaluation. The process evaluations utilized multiple evaluation methods, including conducting questionnaire survey before the beginning of the course, one month later and at the end of course to assess students\u0026rsquo; the fundamental condition, self-learning, self-efficacy and critical thinking via Questionnaire Star. Additionally, the students and instructors were interviewed respectively to master their opinions and suggestions on the instructional design, process and effectiveness. The score of tests was accounted for 50% of the total score. The rest were formative evaluations, which mainly included classroom reports, scenario simulation and nursing rounds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003cp\u003eThe data were shown as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) and analyzed using SPSS 20.0 software package with chi-square (fisher exact probability), t-test, and one-way analysis of variance (ANOVA). The statistical significance was defined as a difference between groups of \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 162 students (16 [9.9%] male and 146 [90.1%] female) with a mean age of 21.06 (SD\u0026thinsp;=\u0026thinsp;0.91) ranging from 19 to 24\u0026nbsp;years participated in the study (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Regarding career choice during the COVID-19 pandemic, the proportion of students who chose to be a nurse after graduation were increased compared with baseline. Compared with traditional teaching, learning resources in online teaching were more abundant. During COVID-19 pandemic, 60.5% students admitted that they had enough learning resources. Furthermore, students got learning resource via search engine (92.0%), social media (90.7%) and Web portals (40.7%) during online course. There was no difference in response to the question \u0026ldquo;learning motivation\u0026rdquo; between traditional teaching and online teaching. Regarding learning motivation, 54.9% students selected \u0026ldquo;sometimes\u0026rdquo; and 32.7% selected \u0026ldquo;often\u0026rdquo; during online teaching.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDemographics of students participating in the study (n\u0026thinsp;=\u0026thinsp;162).\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eBaseline (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTraditional teaching (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOnline teaching (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLike nursing\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (5.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (2.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnclear\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e112 (70.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e103 (63.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94 (58.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41 (25.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e55 (34.0) *\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e63 (38.9) \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eEngaged in nursing work after graduate\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17 (10.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (2.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnclear\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e56 (34.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43 (26.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e91 (56.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e102 (63.0) *\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e114 (70.4) \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLearning resources\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNever\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (0.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (0.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLittle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19 (11.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15 (9.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMuch\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e98 (60.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e72 (44.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e59 (36.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVery Much\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43 (26.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e73 (45.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e97 (59.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eComplete\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (0.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (0.6) *\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (0.6) \u003csup\u003e#★\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLearning motivation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNever\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRarely\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27 (16.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19 (11.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19 (11.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSometimes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94 (58.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87 (53.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e89 (54.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOften\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35 (21.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52 (32.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53 (32.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAlways\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (3.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (2.5) *\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (0.6) \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003e*: \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs Baseline, #: \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs Baseline, ★: \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs Traditional teaching.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerception and attitude towards online teaching of Surgical Nursing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, although 38.8% participants held positive attitude towards online teaching of Surgical Nursing, only 9.3% of them admitted that the effect of online teaching was better than traditional teaching. Regarding what happened to you during online teaching, 89.3% students admitted that they felt tired of eyes facing screen for a long time, 70.0% students reported network interruption and excess phone data traffic, 63.2% students acknowledged they were unable to concentrate on learning, and 53.4% of them admitted they had low efficiency of study. Furthermore, 22.7% students spent over 6\u0026nbsp;h on social media usage per day. Nearly 71.0% students suggested that each lesson of online teaching should be within 40\u0026nbsp;min. The most effective ways of online course were watching teaching videos recorded by lecturers (64.8%), group discussion (21.6%), online courses (6.8%) and reading relevant books (6.8%). Furthermore, the most effective ways of online practical teaching on surgical nursing skills were watching nursing skills videos (71.0%), CBL in groups (67.3%), and describing and decomposing surgical nursing skills step by step by themselves (56.8%). Meanwhile, 15.4% participants admitted online teaching was not suitable for practice learning. The most effective ways to finish homework were mind map (35.2%), self-directed learning (29.6%) and online quizzes via the Rain Class (29.6%). 96.3% students did not agree with taking videos as homework. 51.9% students acknowledged that the time of each homework would be limited to 30\u0026nbsp;min. The disadvantages of online teaching were poor learning effectiveness (30.9%), poor learning atmosphere (25.9%) and poor learning surroundings (22.8%).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePerception and attitudes towards online teaching of Surgical Nursing\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAttitudes towards online teaching\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStrongly disagree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDisagree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21 (13.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot agree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e73 (45.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAgree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49 (30.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStrongly agree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (8.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCompared with traditional teaching, the effect of online teaching\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBetter than traditional teaching\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (8.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSame effect\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e47 (29.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWorse than traditional teaching\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e101 (62.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe duration of each lesson in online teaching\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;10\u0026nbsp;min\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;20\u0026nbsp;min\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (2.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;30\u0026nbsp;min\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43 (26.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;40\u0026nbsp;min\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e115 (71.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eThe most helpful way to learn in online teaching\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGroup discussion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35 (21.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTeaching videos recorded by the teachers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e105 (64.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOnline courses\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (6.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReading books\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (6.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eThe most helpful way to learn surgical nursing practical teaching online\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWatching nursing skills video\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e115 (71.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDescribing and decomposing surgical nursing skills steps by themselves\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e92 (56.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCase-based learning in groups\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e109 (67.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRecording videos in groups\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26 (16.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot ideal online\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25 (15.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe most helpful way to finish homework\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnit quizzes via Rain Classroom\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e48 (29.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMind map\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e57 (35.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eConcept map\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (1.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRecording videos in groups\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (3.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSelf-directed learning\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e48 (29.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTime spent on each homework\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;20\u0026nbsp;min\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28 (17.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;30\u0026nbsp;min\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e84 (51.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;40\u0026nbsp;min\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28 (17.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;50\u0026nbsp;min\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (2.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;60\u0026nbsp;min\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe disadvantages of online teaching\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInsufficient learning resources\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (4.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePoor learning surroundings\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37 (22.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePoor learning effect\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50 (30.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLimited learning approaches\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26 (16.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePoor learning atmosphere\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e42 (25.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison between traditional teaching and online teaching\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs depicted in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, compared with the baseline, there were no significant differences between the mean scores obtained of self-directed learning, critical thinking and self-efficacy after performing online teaching. Of the five subscales in SRSSDL, learning strategies and interpersonal skills were significantly improved after performing online teaching in comparison with baseline (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). However, a significant decrease in awareness was observed after online teaching compared with baseline. The comparison of the mean scores obtained for the different dimensions of critical thinking after the implementation of online teaching showed a significant increase in analyticity (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Moreover, there were significant differences between the mean scores obtained for CTDI-CV, SRSSDL and GSE after performing traditional teaching compared with baseline. Differences between the face-to-face and online teaching were found in terms of self-directed learning, critical thinking and self-efficacy. 68.6% students finished all 13 units quizzes via the Rain Classroom in the semester 1, and the mean accuracy rate was 0.91% (SD\u0026thinsp;=\u0026thinsp;0.05). During the online teaching, 78.9% students finished all 12 units quizzes, and the mean accuracy rate was 0.94% (SD\u0026thinsp;=\u0026thinsp;0.06), which was higher than the traditional teaching (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eOutcomes of self-efficacy, self-directed learning and critical thinking between traditional teaching and online teaching.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eBaseline\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTraditional teaching\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOnline teaching\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eM (SD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eM (SD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eM (SD)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSelf-efficacy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.36 (0.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.50 (0.45) *\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.34 (0.44)\u003csup\u003e★\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSelf-directed learning\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e207.87 (25.71)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e216.09 (23.40) *\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e208.81 (24.91)\u003csup\u003e★\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCritical thinking\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e216.2 (25.36)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e227.18 (16.63) *\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e217.96 (23.49)\u003csup\u003e★\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003e*: \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs Baseline, ★: \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs Traditional teaching.\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003e*:\u0026nbsp;\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs Baseline, #:\u0026nbsp;\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs Baseline.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the emerging and ever-changing COVID-19 context, universities should implement a number of measures to slow the virus spread. The safety and health of students and the faculty members should be the top priority. Postponing or cancelling classroom-based class and academic activities are an essential means to protect the health of students and the faculty members. Following the government\u0026rsquo;s requirement of \u0026ldquo;nonstop teaching and learning\u0026rdquo;, almost all existing course were moved to online in a matter of days. This is an unprepared challenge for millions of faculty members and administrators and tens of million students in colleges and universities that everyone must face. In this study, although 38.8% students held positive attitudes towards online teaching, only 8.6% students admitted the effect of online teaching on Surgical Nursing was better than traditional teaching. Evidence has suggested that online learning in undergraduate nursing education is no less effective than traditional means \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Although the advantages of online teaching including enhancing engagement, learning easier in groups, flexibility in time allocated to complete tasks have been reported, it is challenge for impaired communication due to poor network access \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. 70.0% students experienced network interruption and excess phone data traffic resulting in poor teaching effect. During the COVID-19 pandemic, the majority of faulty members and students had encountered technical difficulties such as poor internet connection and the lack of computer. Therefore, ensure the smooth implementation of teaching activities through combined usage of multiple platforms to avoid problems such as stuck and interruption of teaching activities due to network and large visitor volume. In the online course of Surgical Nursing, lectures used various platforms including QQ group, WeChat, Tencent Classroom, Tencent Meeting, Rain Classroom and other apps for online teaching.\u003c/p\u003e\n\u003cp\u003eIn order to ensure the effectiveness of online teaching, well-considered and durable teaching plans as well as emergency prepared plans for unexpected problems were prepared. Therefore, there were various types and quantities of online teaching methods such as live broadcast and online interaction, live broadcast, recording and online interaction, self-directed learning, MOOCs, Small Private Online Courses (SPOC), PPT and online interaction and answering questions online. In this study, 64.8% students admitted that they were more likely to prefer recording videos of each chapter and answering questions online. Each lesson should be limited within 40\u0026nbsp;min. Meanwhile, if you normally teach a 3-hour class, summarize its essence in a video no longer than 30 minutes \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Experts have suggested that lectures should not convert their entire lecture contents to videos because students are not willing to watch slides without a teacher\u0026rsquo; face or voice \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Compared with traditional in-class lectures, faculty have less control online teaching, and students are more likely to \u0026ldquo;skip the class\u0026rdquo; \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. In order to strengthen learning effectiveness and students\u0026rsquo; high-level active learning outside of class, faculty members could release homework and reading requirements. In the course of Surgical Nursing, unit quizzes for each chapter via Rain Classroom, mind map for important knowledge points, keep class notes, reading literatures and taking videos were the common manners of homework. The most popular ways of homework were mind map (35.2%), unit quizzes (29.6%) and self-directed learning (29.6%) in this study. However, most students complained about heavy workload leading to poor effectiveness of completion of homework at initial stage of online teaching. 89.3% students admitted that they felt tired of eyes facing screen for a long time. Hence, each task was best completed within 30\u0026nbsp;min.\u003c/p\u003e\n\u003cp\u003ePractical teaching for surgical nursing skills training, as an important part of Surgical Nursing, is difficult to be implemented online. Drainage bag replacement, fracture plaster fixation and closed thoracic drainage were the main practical teaching content in the semester 2. Combined with the current actual situation, teaching plan had been appropriately revised, and training of surgical nursing skills was moved to offline after resuming classes. CBL, TBL and task-driven teaching were applicated in practical lessons online. The most effective ways implemented in practical teaching were watching videos of nursing skills (71.0%), CBL (67.3%) and describing and decomposing surgical nursing skills steps by themselves (56.8%). Evidence has shown that CBL is an effective educational method for developing critical thinking, reinforcing peers' potentials and improving diagnostic abilities \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Furthermore, the web-based CBL is not inferior to the traditional classroom CBL method \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. It was worth to be noted that students were disgusted with taking videos as assignments. In order to diversity case tasks, the lecture asked students to show simple nursing skill such as shoulder joint movement, or health education by taking videos. However, only 16.0% students chose to take video clips in this study. Due to the influence of objective factors such as the network coverage of students\u0026rsquo; area, and different family economy, students in remote villages or poor families cannot got equal education. In addition to great difference in students\u0026rsquo; personal conditions, heavy workload was also an important factor influencing students\u0026rsquo; willing to take video clips. In general, poor learning effectiveness and poor learning atmosphere were the disadvantages of online courses.\u003c/p\u003e\n\u003cp\u003eInsufficient pre-class preparation, limited participation in class discussion, and inadequate discussion are common phenomena in online teaching \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. In order to solve such problems in online teaching, expert recommends that faculty should consider two phases of teaching, the offline self-learning phase and the online teaching phase \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. In the present study, the scores of self-directed and self-efficacy were not significantly different. This outcome could possibly be attributed to the fact that students studied at home, which made students more difficult to manage themselves. Especially, the scores of awareness in self-directed learning were decreased. Students were accustomed to lecture in-class and depend on faculty direction leading to low-level active in learning online. Interestingly, the scores of learning strategies and interpersonal skills in self-directed learning were increased compared with baseline. Maybe it is because that students were required to read the course-specific literature and watch various videos in the offline self-learning phase. Meanwhile, during the COVID-19 pandemic, learning resources were more abundant and open than before, and there were more opportunities for group learning.\u003c/p\u003e\n\u003cp\u003eCritical thinking is an important skill for all nurses, as the ability to critically assess and interpret situations and to use the knowledge correctly will enable them to provide optimal comprehensive care and other services \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. In this study, significant differences in the measure of critical thinking between online course and face-to-face class were observed due to various influencing factors, including learning surroundings, the instructors\u0026rsquo; approaches to teach, students\u0026rsquo; intrinsic motivation and learning strategies. However, it was reported that critical thinking is enhanced via online learning \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. This inconsistent result may be due to the fact that online teaching as part of blended teaching is well-prepared and technology-support. Among the seven subscales, the scores of truth seeking, maturity, systematicity and inquisitiveness were found to be lower than traditional teaching, suggesting that the students were week in intellectual curiosity and desire for learning, courageous about asking questions, decision-making and using organized and focused methods of reasoning. Nevertheless, the accuracy rate and the proportion of completing all unit quizzes were higher than traditional teaching. Although students actively participated in discussion online and unit quizzes, high-frequency interaction did not achieve the desired outcome and curiosity and desire for learning were still low. The best online instructors set up their courses so that students can pursue self-paced enquiry under their own initiative \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. The progress of online teaching largely depends on students\u0026rsquo; high-level active learning, which adheres to the educational concept of \u0026ldquo;Student-centered\u0026rdquo;. Strengthen the learning requirements, enhance the enthusiasm and initiative of self-directed learning are key factors in online teaching. Studying at home was challenge for students\u0026rsquo; self-management due to lack of learning atmosphere. It was worth to be noted that the mean score of analyticity was higher than traditional learning, indicating that students prized the application of reasoning and the use of evidence to resolve problem.\u003c/p\u003e"},{"header":"Conclusion","content":" \u003cp\u003eThe sudden outbreak of COVID-19 accelerates the acceptance of online teaching by all the staff in colleges and universities in China. In this study, most students held neutral attitude towards online teaching in Surgical Nursing. Task-driven learning, recording videos and answering questions online were more suitable for theoretical teaching online. Watching nursing skills video and CBL in groups were more suitable for practical teaching online. Students were more likely to prefer unit quizzes online and mind maps as homework. Individual students\u0026rsquo; grades in unit quizzes improved, but there were no differences in student evaluations of instruction mean scores for critical thinking, self-directed learning and self-efficacy. Nearly 3/5 students admitted the effect of online teaching was worse than traditional teaching. In conclusion, face-to-face teaching in classroom and interpersonal interaction in the real situation are insurmountable limitations in online teaching, leading to failure to achieve the expected teaching effectiveness.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eCBL: Case-based learning; COVID-19: Coronavirus disease 2019; CTDI-CV: Critical Thinking Dispositions Inventory-Chinese Version; GSE: General Self-efficacy Scale; MOOCs: Massive Online Open Courses; PPT: PowerPoint; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; SPOC: Small Private Online Courses; SRSSDL: Self-Rating Scale of Self-Directed Learning; TBL: Team-based learning\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Hubei University of Chinese Medicine for providing us to conduct this study and its ethical approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank XZ and TZ designed research; XZ and TZ conducted research; XZ analyzed data; XZ wrote the manuscript; TZ provided language help, and TZ had primary responsibility for the final content. All authors revised it critically for important intellectual content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Natural Science Found of China (No. 82003448).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the data supporting the study findings are within the manuscript. Additional detailed information and raw data are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior to data collection, the protocol was reviewed and ethical permission for the study was received from the Hubei university of Chinese Medicine human ethics committee. All students were informed for All nurses were informed for their voluntary participation and they have the right to refuse, withdraw or stop at any time during their participation. Their identities and potential risks were strictly kept and maintained confidential throughout the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSchool of Nursing, Hubei University of Chinese Medicine, Wuhan, China.\u003c/p\u003e\n\u003cp\u003e*Corresponding to: Dr. Zheng Taoyun, Nursing Educator, School of Nursing, Hubei University of Chinese Medicine, Wuhan, China, phone: +86027-688890395. E-mail: [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. (2020). Coronavirus disease 2019 (\u0026lrm;\u0026lrm;COVID-19)\u0026lrm;\u0026lrm;: situation report, 206. Retrieved from Geneva: https://apps.who.int/iris/handle/10665/333839.\u003c/li\u003e\n\u003cli\u003eAra\u0026uacute;jo, F.J.O., de Lima, L. S. A., Cidade, P. I. M., et al. Impact Of Sars-Cov-2 And Its Reverberation In Global Higher Education And Mental Health. Psychiatry Res, 2020. 288: p. 112977.\u003c/li\u003e\n\u003cli\u003eBao, W. COVID-19 and online teaching in higher education: A case study of Peking University. Hum Behav Emerg Technol, 2020. 2(2): p. 113-115.\u003c/li\u003e\n\u003cli\u003eFerrel, M. N. and Ryan, J. J. The Impact of COVID-19 on Medical Education. Cureus, 2020. 12(3): p. e7492.\u003c/li\u003e\n\u003cli\u003eSinclair, P., Kable, A., and Levett-Jones, T. The effectiveness of internet-based e-learning on clinician behavior and patient outcomes: a systematic review protocol. JBI Database System Rev Implement Rep, 2015. 13(1): p. 52-64.\u003c/li\u003e\n\u003cli\u003eBrusamento, S., Kyaw, B. M., Whiting, P., Li, L., et al. Digital Health Professions Education in the Field of Pediatrics: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. J Med Internet Res, 2019. 21(9): p. e14231.\u003c/li\u003e\n\u003cli\u003eMilic, N.M., Trajkovic, G. Z., Bukumiric, Z. M., et al. Improving Education in Medical Statistics: Implementing a Blended Learning Model in the Existing Curriculum. PLoS One, 2016. 11(2): p. e0148882.\u003c/li\u003e\n\u003cli\u003eMunro, V., Morello, A., Oster, C., et al. E-learning for self-management support: introducing blended learning for graduate students - a cohort study. BMC Med Educ, 2018. 18(1): p. 219.\u003c/li\u003e\n\u003cli\u003eOzturk, E., van Iersel, M., van Loon, K., et al. Interactive online learning on perioperative management of elderly patients. Am J Surg, 2018. 216(3): p. 624-629.\u003c/li\u003e\n\u003cli\u003ePeng, M.C., Wang, G.C., Chen, J.L., et al. (2004). Validity and reliability of the Chinese critical thinking disposition inventory. J Nurs in China (Zhong Hua Hu Li Za Zhi), 39, 644-647.11.\u003c/li\u003e\n\u003cli\u003eFacione, N.C., Facione, P. A and Sanchez, C.A.G. Critical Thinking Disposition as a Measure of Competent Clinical Judgment: The Development of the California Critical Thinking Disposition Inventory. J Nurs Educ, 1994. 33(8): p. 345-350.\u003c/li\u003e\n\u003cli\u003eWilliamson, S.N., Development of a self-rating scale of self-directed learning. Nurse Res, 2007. 14(2): 66-83.\u003c/li\u003e\n\u003cli\u003eCheung, S. K. and Sun, S.Y. Assessment of optimistic self-beliefs: further validation of the Chinese version of the General Self-Efficacy Scale. Psychol Repo, 1999. 85(3_suppl): p. 1221-1224.\u003c/li\u003e\n\u003cli\u003eLuszczynska, A., Scholz, U., Schwarzer, R. The general self-efficacy scale: multicultural validation studies. J Psychol, 2005. 139(5): p. 439-457.\u003c/li\u003e\n\u003cli\u003eMcCutcheon, K., Lohan, M., Traynor, M., et al. A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education. J Adv Nurs, 2015. 71(2): p. 255-70.\u003c/li\u003e\n\u003cli\u003ePei, L. Wu, H. Does online learning work better than offline learning in undergraduate medical education? A systematic review and meta-analysis. Med Educ Online, 2019. 24(1): p. 1666538.\u003c/li\u003e\n\u003cli\u003eWillemse, J.J., Jooste, K., Bozalek, V. Experiences of undergraduate nursing students on an authentic mobile learning enactment at a higher education institution in South Africa. Nurse Educ Today, 2019. 74: p. 69-75.\u003c/li\u003e\n\u003cli\u003eGewin, V. Five tips for moving teaching online as COVID-19 takes hold. Nature, 2020. 580(7802): p. 295-296.\u003c/li\u003e\n\u003cli\u003eGholami, M., Saki, M., Toulabi, T., et al. Iranian Nursing Students' Experiences of Case-Based Learning: A Qualitative Study. J Prof Nurs, 2017. 33(3): p. 241-249.\u003c/li\u003e\n\u003cli\u003eChan, A.W., Chair, S. Y., Sit, J. W. Case-Based Web Learning Versus Face-to-Face Learning: A Mixed-Method Study on University Nursing Students. J Nurs Res, 2016. 24(1): p. 31-40.\u003c/li\u003e\n\u003cli\u003eYu, D., Zhang, Y., Xu, Y., et al. Improvement in Critical Thinking Dispositions of Undergraduate Nursing Students Through Problem-Based Learning: A Crossover-Experimental Study. J Nurs Educ, 2013. 52(10): p. 574-581.\u003c/li\u003e\n\u003cli\u003eBrahler, C.J., Quitadamo, I.J., Johnson, E.C. Student critical thinking is enhanced by developing exercise prescriptions using online learning modules. Adv Physiol Educ, 2002. 26(1-4): p. 210-21.\u003c/li\u003e\n\u003cli\u003eNovotny, N.L., Stapleton, S.J. and Hardy, E.C. Enhancing Critical Thinking in Graduate Nursing Online Asynchronous Discussions. J Nurs Educ, 2016. 55(9): p. 514-21.\u003c/li\u003e\n\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":"COVID-19, undergraduate nursing students, online teaching, Surgical Nursing, traditional teaching","lastPublishedDoi":"10.21203/rs.3.rs-108407/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-108407/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: The coronavirus disease 2019 (COVID-19) pandemic has necessitated a dramatic shift in how nursing faculty and undergraduate nursing students are educated. This study aims to examine the teaching effectiveness of Surgical Nursing using both face-to-face teaching and online teaching in undergraduate nursing education. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A quantitative approach was adopted. Year-3 undergraduate nursing students were recruited. face-to-face teaching was conducted in semester 1, and online teaching was conducted in semester 2 during COVID-19 pandemic. Student evaluations were collected at the beginning of semester 1 and the end of semester 1 and semester 2. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: 162 students were recruited in the study. 45.1% students held neutral attitude towards online course of Surgical Nursing. Students were more likely to prefer unit quizzes online and mind maps as homework, task-driven learning, recording videos and online question and answer as the means of theoretical teaching online, and watching surgical nursing skills video and case-based learning in groups as the means of practical teaching online. However, nearly 62.4% students admitted the effectiveness of online teaching was worse than face-to-face teaching. During online teaching, the mean grades of student in unit quizzes were improved, but there were no differences in student evaluations of instruction mean scores for critical thinking, self-directed learning and self-efficacy in comparison with the baseline. Additionally, differences between the face-to-face and online teaching were found in terms of self-directed learning, critical thinking and self-efficacy. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The effectiveness of online teaching was not superior to the traditional teaching. Although online teaching has advantages of convenience, speed, anytime and anywhere, face-to-face teaching in classroom and interpersonal interaction in the real situation are insurmountable limitations in online teaching.\u003c/p\u003e","manuscriptTitle":"Comparing the effects of online teaching during the COVID-19 pandemic and traditional teaching in Surgical Nursing","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-11-17 20:27:18","doi":"10.21203/rs.3.rs-108407/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-12-29T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-12-15T00:00:00+00:00","index":3,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"editorInvitedReview","content":"","date":"2020-12-15T00:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nIn the following, you can find some comments for the paper entitled on \"Comparing the effects of online teaching during the COVID-19 pandemic and traditional teaching in Surgical Nursing\":\n\nTitle\n* The word \"effect\" in the title is not clear. According to the goal of the study \"teaching effectiveness 'is more suitable.\nAbstract\n* In method section page 1, line 21, it must be determined that which kind of quantitative design applied in this study.\n* In method section page 1, data collection tools must be mentioned.\n* The sample size (162 students) should be mentioned in method section (not in results).\nMethods\n* How sample size was calculated? How many students were in the statistical population of the study?\n* Please explain the validity and reliability of all data collection instruments. Also minimum and maximum scores of each tool must be determined.\n* In page8, line 26, it is mentioned that \"the students and instructors were interviewed…\". Please clarify had these interviews be done using a questionnaire or in a qualitative manner?\n* Regarding the study design, repeated measure ANOVA test is recommended.\n* The contents of table 2 are repeated in the text. Please delete table 2 or summarize explanations in the text.\n\nDiscussion\n* The limitations of the study must be mentioned.\n\n* There are some spelling and grammar errors within the manuscript.\n\nBest Regards\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2020-12-08T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reject\nForm responses:\n---\n\nComments to Author:\n---\nThank you to the author for submitting this manuscript on an interesting topic related to nurse education. There is merit in this study. However, regretfully the major errors in grammar, at this time, means the manuscript is not publishable.\n\nParticipants\nMore detail regarding the participants is needed. How were the participants recruited? How many students were recruited in total and how many did not complete the survey? Information about ethics approval needs to be moved to this section not at the end of the paper. How were the students given the survey i.e. on line?\n\nInstrument\nHow many questions in total were developed for the survey?\nThis sentence \"was implemented to measure critical thinking dispositions of nursing students and registered nurses in China\" reads as if registered nurses were also surveyed in this project.\n\nCurricular Framework for Surgical Nursing online - this whole section needs re-writing, it is very difficult to understand.\n\nPreparation before class\nHow can there be a \"sum up students' questions and confused knowledge points of each chapter before class\" before the class was started?\n\nEvaluation of teaching effectiveness\n\"Additionally, the students and instructors were interviewed respectively to master their opinions and suggestions on the instructional design, process and effectiveness\" This is the first mention of an interview. How was this undertaken and why?\n\nThis is unclear what score tests? The score of tests was accounted for 50% of the total score. The rest were formative evaluations, which mainly included classroom reports, scenario simulation and nursing rounds.\n\nResults\nThe tables are difficult to read. Consider putting the likert categories in a row above and the responses in columns underneath.\nIt is unusual to say participants \"admitted\" - it is more usual to say they \"reported\"\nIt would be good to know how each of the components of the survey were scored. It makes a difference to the tables. For example, table 3 is very difficult ot understand without knowing how the categories were scored.\n\nDemographic Characteristics. Why are learning resources and learning motivation included in the demographics section?\n\nAre these mean scores accurate? and the mean accuracy rate was 0.91% (SD = 0.05). During the online teaching, 78.9% students finished all 12 units quizzes, and the mean accuracy rate was 0.94% (SD = 0.06)\n\nDiscussion\nBecause the results in the tables were difficult to interpret, the discussion at times appeared unsubstantiated by the results. Further, some of the discussion looked more like a presentation of results and was not embedded in the literature. At times the discussion seemed repetitive.\n\nThere is a lot of material in the introduction that is unreferenced. There is a lot written about on-line versus face-to-face learning. This work needs to be more closely referenced.\n\nThe paper needs a lot of careful editing; there are a large number of grammatical issues throughout the paper that impede meaning. Indeed, there are too many errors to provide all the examples. I would strongly suggest getting support with English grammar.\n* Publons Reviewer Recognition. 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