Digital Flashcards for Fluid and Electrolyte Education in Surgical Nursing: A Solomon Four-Group Study

In nursing education, the topic of fluid-electrolyte balance is one of the challenging subjects for students due to its physicochemical complexity, the multidimensionality of its clinical reflections, and the requirement to simultaneously comprehend processes such as preoperative fasting, intraoperative fluid-blood losses, and postoperative drainage management. Since traditional lecturing is based on passive learning, it alone may remain limited in supporting the long-term retention of knowledge in memory. To overcome this limitation, the digital flashcard method, which is based on the principles of active recall and spaced repetition, offers effective learning support. Moreover, pre-testing posing a potential artificial increase (sensitization) effect on post-test performance constitutes a methodological issue in nursing education. The lack of studies in the literature investigating the effect of the digital flashcard method on fluid-electrolyte balance using a Solomon four-group experimental design (controlling for the pre-test effect) renders this study necessary and original in terms of both knowledge level and self-efficacy perception based on Bandura's social cognitive theory. This research is a prospective study with a Solomon four-group experimental design to be conducted with second-year students. The study will include a total of four groups: two experimental (D1, D2) and two control (K1, K2) groups.Standard Practice: Students in all groups will receive the fluid-electrolyte content through traditional lecturing, writing boards, and written materials within the scope of the standard curriculum.

Group Applications: While a pre-test will be administered to the D1 and K1 groups prior to the education/application, no pre-test will be administered to the D2 and K2 groups. In addition to standard education, the experimental groups (D1 and D2) will receive digital flashcard training specific to the fluid-electrolyte topic via the Brainscape platform, which operates with a spaced-repetition algorithm. These cards will not be provided to the control groups during the intervention period; instead, access will be provided after the study in accordance with the ethical balance principle.Data: Data will be collected through the Introductory Information Form prepared by the researchers, the Fluid-Electrolyte Knowledge Test, and the Student Self-Efficacy Scale (SSES) developed by Rowbotham and Schmitz (2013).

• Digital Flashcard Training & Pre-test/Post-test (Other): A pre-test will be administered to students in Group-D1. Students will receive standard lectures and will be trained using digital flashcards on the fluid-electrolyte topic via the Brainscape platform, with an interval of spaced repetition. Post-tests (Fluid-Electrolyte Knowledge Test, and the Student Self-Efficacy Scale) will be administered at the end of the process.
• Digital Flashcard Training & Post-test Only (Other): Students in Group-D2 will receive standard lectures and will be trained using digital flashcards on the fluid-electrolyte topic via the Brainscape platform without taking a pre-test. Post-tests (Fluid-Electrolyte Knowledge Test, and the Student Self-Efficacy Scale) will be administered at the end of the process.
• Standard Lecture Only & Pre-test/Post-test (Other): A pre-test will be administered to students in Group-K1. Students will receive only standard lectures and traditional learning materials without any digital flashcard intervention. Post-tests (Fluid-Electrolyte Knowledge Test, and the Student Self-Efficacy Scale) will be administered at the end of the process.
• Standard Lecture Only & Post-test Only (Other): Students in Group-K2 will receive only standard lectures and traditional learning materials without taking a pre-test and without any digital flashcard intervention. Post-tests (Fluid-Electrolyte Knowledge Test, and the Student Self-Efficacy Scale) will be administered at the end of the process.

Primary outcomes

• Knowledge Level [Three days after the time of inclusion in the study.]: The students' level of knowledge regarding fluid-electrolyte balance, tonicity, electrolyte imbalances, acid-base balance, and the associated surgical nursing care will be assessed using the Fluid-Electrolyte Knowledge Test developed by the researchers. This test is an assessment tool consisting of 10 questions, each worth 10 points, for a total of 100 points. A high score will indicate a high level of knowledge on the part of the student.
• Self-Efficacy Level [Three days after the time of inclusion in the study.]: Students' self-efficacy levels and beliefs regarding the educational process will be evaluated using The Student Self-Efficacy Scale, developed by Rowbotham and Schmitz (2013) and adapted into Turkish by Yurtçiçek Eren and Başgöl (2023). The scale, developed to assess students' self-efficacy levels, is unidimensional and consists of 10 items. The scale is designed using a 4-point Likert-type format. Higher scores indicate a high level of self-efficacy.

Sex: All, ages: 18 Years to any, accepts healthy volunteers

Inclusion Criteria:

* Being enrolled in the Surgical Nursing Course
* Agreeing to participate voluntarily in the research
* Not having previously received fluid-electrolyte education through any digital flashcard application

Exclusion Criteria:

* Having previously taken the Surgical Nursing Course
* Failing to attend any of the measurement sessions

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• Cansu YESİLFİDAN, Study director, Saglik Bilimleri Universitesi