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

The transition from classroom-based nursing education to surgical clinical practice is a critical period for patient safety. Students entering clinical practice must recognize safety risks and clinical errors, prioritize an appropriate response, and communicate or escalate concerns within a supervised clinical environment. Short, scenario-based digital learning may support this transition by linking recognizable clinical cues with specific safety actions and by providing repeated retrieval and corrective feedback close to the start of clinical practice.

This study was a single-center, two-arm, parallel randomized controlled trial embedded within an explanatory sequential mixed-methods design (QUAN to qual). It was conducted among second-year undergraduate nursing students enrolled in surgical nursing at the Faculty of Health Sciences, Department of Nursing, Agri Ibrahim Cecen University. Of 111 students assessed for eligibility, 21 were excluded before randomization and 90 were randomized in a 1:1 ratio. All randomized students were analyzed according to their assigned group. The a priori sample-size calculation was based on clinical error recognition measured across T0-T3, with T3 designated as the principal endpoint. Assuming f=0.20, two groups, four measurements, alpha=0.05, 80% power, a within-participant correlation of 0.50 and epsilon=1.0, the minimum sample size was approximately 76; 90 students were randomized to allow for attrition.

The intervention group received standard education plus seven consecutive days of mobile-optimized digital microlearning before surgical clinical placement. One module was delivered each day and lasted approximately 3-5 minutes. Each module followed a consistent structure: a surgical patient-safety scenario, a pause to identify the risk, a forced-choice retrieval question, corrective feedback, and a cue-action takeaway. Content addressed patient identification, medication safety, documentation omissions, deterioration cues, falls and other safety risks, prioritization, escalation, and decision-making under stress. Platform analytics captured module completion, time on task, retrieval-question accuracy, feedback viewing, and technical delivery.

The control group received the standard undergraduate curriculum without additional digital microlearning. Standard education consisted of two two-hour surgical patient-safety lectures and a written guideline. Both groups subsequently completed seven weeks of routine surgical clinical practice, one day per week, under the same usual supervision. The comparator was not attention matched.

Outcomes were assessed at baseline before the program (T0), immediately after the seven-day intervention (T1), at the end of the first week of surgical clinical practice (T2), and at the end of the seventh week of surgical clinical practice (T3). The primary outcome was clinical error recognition performance, with T3 designated as the principal endpoint. Alternate 10-scenario assessment forms were drawn from an expert-reviewed bank of 15 retained surgical patient-safety scenarios. Each response was scored 1 for correct identification of the safety error and 0 for an incorrect or absent identification. Form scores were converted to a 0-100 scale as (number correct/10) × 100, yielding 10-point score units. Secondary outcomes included patient-safety awareness, clinical decision-making under stress, clinical practice readiness, clinical self-confidence, blinded objective transfer, weekly safety-oriented behavioral transfer, and intervention acceptability.