The Effect of Flipped Learning on Nursing Students' Knowledge and Skills in Surgical Hand Hygiene: A Randomised Controlled Trial

Detailed Description Despite the necessary precautions being taken, Healthcare-Associated Infections (HAIs) remain a significant public health problem worldwide. HCAIs contribute to increased healthcare costs, prolonged hospital stays, and higher rates of morbidity and mortality. Among infection control practices, hand hygiene stands out as one of the most effective interventions for preventing HCAIs. In particular, surgical hand antisepsis is a critical component of general aseptic technique in surgery, aimed at removing transient microorganisms and reducing the resident skin flora. Surgical hand washing with antimicrobial solutions is a low-cost, easy-to implement and effective method for removing microorganisms from the hands and forearms prior to surgery.

Nurses form a key professional group in the delivery of healthcare services; they play a critical role in the protection and maintenance of health, as well as in the prevention and treatment of diseases. Nurses' theoretical knowledge and clinical competence are directly linked to the quality of the education they receive during their training. Nursing education consists of theoretical instruction and practical training; practical training is conducted in clinical and laboratory settings to support the acquisition of skills. In this context, the surgical nursing module is one of the specialist areas where nursing students acquire critical competencies such as surgical hand hygiene and principles of asepsis. However, there are studies indicating that, despite receiving training on surgical hand hygiene as part of the curriculum, students' knowledge levels do not reach the desired standard. This finding suggests that simply increasing knowledge levels may not always be sufficient; there is a need for learning designs that support skill acquisition, accuracy of application, and retention.

In recent years, there has been an increasing use of innovative pedagogical approaches in nursing education, such as artificial intelligence-supported learning applications, simulation laboratories, gamified educational videos and case-based learning. It has been reported that simulation-based training can enhance knowledge of hand hygiene; however, knowledge alone has been found to be limited in bringing about behavioural change. In contrast, it has been reported that training delivered using a video-based self-assessment approach is effective in developing surgical handwashing skills, and the importance of innovative teaching methods in nursing education has been emphasised.

One of these innovative approaches is the Flipped Learning Model (FLM). Unlike traditional teaching, in the FLM, students prepare for the topic individually by accessing teaching materials (videos and presentations) prepared online prior to class; in class, they consolidate their learning through interactive activities that support discussion, case presentations and practical application. By promoting active and student-centred learning environments, the model enables nursing students to develop their self-directed learning skills. Indeed, a meta-analysis reported that, compared to traditional lecture-based learning, TYÖM significantly improved the theoretical exam marks of Chinese nursing students. Similarly, some studies have shown that TYÖM may be more effective than traditional education in developing fundamental skills during clinical practice periods, as well as in theoretical learning.

Whilst there are various studies utilising the TYÖM approach specifically within nursing education, it is evident that there are limited studies directly examining the impact of TYÖM on a critical practice such as surgical handwashing, which requires both knowledge and technical skill proficiency. This situation necessitates research into the extent to which the flipped classroom approach supports nursing students' knowledge levels, skill performance and the retention of learning in surgical handwashing training. Therefore, this study aims to examine the effect of the flipped classroom model on nursing students' knowledge and skills regarding surgical handwashing.