Study design and study participants
In this study, a quasi-experimental design was applied with pre- and post-test assessments in the experimental and control groups. Convenient sampling was adopted to publicly recruit nurses who were willing to participate in the study from two hospitals of the same medical system in northern Taiwan. The inclusion criteria were nurses who had more than one year of experience in medical or surgical wards. Conversely, those who did not engage in the full study, failed to complete the questionnaire, or provided invalid responses were excluded. The sample size was estimated using the G Power 3.1 software, with error (α) = 0.05, test power = 0.8, and effect size = 0.8. The estimated sample size was at least 26 participants in each group. A total of 80 participants, 40 in the experimental group and 40 in the control group, were included. The experimental group consisted of 40 nurses, selected from a total of 500 nurses from Hospital A, who received 2.5 h of flipped education on aromatherapy. The control group consisted of 40 nurses, out of 800 nurses from Hospital B, who underwent one hour of traditional aromatherapy education and training (Fig. 1).
The pre-test was completed before the two groups began the course, and it included basic information and a questionnaire on the knowledge and self-efficacy of nursing personnel in aromatherapy. The post-test was conducted after the two groups had completed their respective courses, and it included a survey on the knowledge of and self-efficacy in aromatherapy. This study was reviewed and approved by the institutional review boards of the recruiting hospitals (No. CGH-P108116) before recruiting the participants. All participants signed a written informed consent form before participating in the study. Prior to data collection, researchers first explained the process, purpose, plan, and method of the study as well as the participants’ rights and interests. In addition, during the research process, the participants’ reactions were closely monitored to ensure that they were comfortable and without stress. Nurses had the right to refuse to participate or withdraw at any point of the study without compromising their work rights.
Study instruments
Questionnaire on basic information
The questionnaire on basic information included basic demographic characteristics (age, educational level, work hospital, work experience, and clinical ranking), frequency of caring for patients with pain issues in the past, participation in aromatherapy courses, and experience in applying aromatherapy.
Knowledge and self-efficacy scale of aromatherapy for nurses
The knowledge section of the questionnaire included pain relief mechanism of action, route, dosage, and other aspects of aromatherapy for pain relief. It consisted of six true-or-false questions. Participants would score 1 for each correct answer and 0 for each incorrect answer. The self-efficacy section of the questionnaire included two items: “The level of confidence I have in providing aromatherapy information to patients when they are in pain,” and “The level of confidence I have in helping patients performing aromatherapy when a patient is in pain.” Each question is scored on a 5-point scale, with 5 indicating “extremely confident”, and 1 indicating “extremely unconfident”. The higher the score, the more confident the subject is in executing each behavior. Once the first draft was prepared, seven experts and scholars in related fields, such as health promotion and education, healthcare, and education, were invited to conduct content validity verification, utilizing the content validity index (CVI), Cronbach’s α, difficulty of questions, and degree of discrimination. They suggested that the CVI of the scale was 0.93. Internal reliability analysis during preliminary testing showed that Cronbach’s α was 0.91. The individual difficulty of each question ranged between 0.5 and 0.75 with an average of 0.64, indicating a moderate overall difficulty. Similarly, the individual discrimination degree of each question ranged between 0.45 and 0.8 with an average of 0.65, indicating an appropriate overall discrimination degree.
Introduction to the flipped teaching aromatherapy course
The flipped aromatherapy course was based on the four pillars of flipped learning (F, L, I, and P) [24], and incorporated the four elements of self-efficacy (past performance, vicarious experiences, verbal persuasion, and physiological cues) in the design. The class was delivered in two stages, namely pre-class self-learning and during-class teaching.
Each element of flipped learning was applied as follows:
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(1)
Flexible environments: Students were asked to perform self-learning before the class commencement using electronic products, which was not limited by the environment, equipment, or time. Subsequent classroom teaching was carried out in groups, during which the traditional teacher-centered approach was replaced with student-centered group discussions.
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(2)
Learning culture: The nursing staff were asked to watch a 30-min aromatherapy concept video on the e-learning teaching platform before participating in the flipped teaching course and acquaint themselves with the prerequisite knowledge of aromatherapy. Group discussions were designed in the classroom, allowing participants to achieve self-efficacy theory achievement performance and substitute experience and verbal persuasion through group discussions. The physical operation of aromatherapy essential oils was designed, partners were invited to provide feedback at the same time, and emotional stimulation of self-efficacy theory was achieved through personal experience.
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(3)
Intentional content: The course was delivered using two teaching methods. The first one involved the design of group discussion activities based on the self-efficacy theory. Through concept clarification, case discussion, and mindmapping, this method equipped participants with the ability to prepare essential oils and strengthened their self-efficacy in performing aromatherapy on patients experiencing pain. The second approach involved practical and personal experience, providing participants with multiple essential oils to become familiar with their smells.
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(4)
Professional educator: The researcher was the teacher of the pre-class self-study course, the leader of the classroom activities, and responsible for conducting group discussion and skill guidance, and the team members discussed the case together in the course. The researcher had 10 years of clinical teaching experience, received 48 h of training for the intermediate certification of aromatherapists, and practical experience in using aromatherapy in clinical practice.
Course activities
The intervention of this study was performed in February 2020. Participants in the control group received one hour of introduction to the use of aromatherapy for pain management. This class was delivered using the traditional teaching method, during which a researcher served as the lecturer and delivered the content to the 40 nurses in the group. Contents of the class included the origin of aromatherapy, evidence of the role of aromatherapy in pain relief, types of essential oils to be used for different body systems, the mechanism of action, way of use, preparation of dosage, and precautions in using essential oils. Nurses in the experimental group received a 2.5-h flipped teaching course on aromatherapy. Two weeks before the classroom activities, the nurses in the experimental group watched a 30-min aromatherapy concept video on the e-learning teaching platform. The video included the following information: (1) the origin of aromatherapy; (2) evidence of aromatherapy and pain; (3) types of essential oils that can be selected for various systems of the body; (4) the best approach for application (topical, diffusion, or concentrated inhalation); and (5) precautions while using essential oils. Then, the nurses participated in two hours of classroom teaching in groups. The course design included a brief 15-min introduction of the self-study contents by the lecturer as a pre-class review for the students, 15 min of group discussions to clarify the concepts and share experiences, 30 min of mind mapping and case discussion, 20 min of practice with essential oils, and 40 min of do-it-yourself (DIY) essential oil preparation (Fig. 2).
Statistical analysis
The Statistical Program for SPSS version 23.0 (SPSS Inc. Chicago. IU, USA) for Windows was used for the statistical analysis, and a statistical significance level (α) of 0.05 (two-tailed test) was applied. Descriptive statistics of the background variables of the study participants were calculated, and the results are presented as frequency distribution, percentage, mean, and standard deviation. Subsequently, an independent sample t-test, chi-squared test, and generalized estimating equations (GEE) test were performed to understand the difference in the knowledge of and self-efficacy in aromatherapy between the experimental and control groups.