Yan-Yuan Lei, Chang Li, Sha-Sha Jia, Xin Fan, Mei Wang, Xiang-Shu Cui*

1 School of Nursing, Yanbian University, Yanji, 133000, China.

Abstract:Background: Recently, WeChat application has been widely applied in the field of nursing education in China. Among them, WeChat as a platform combined with problem-based learning (PBL) teaching method is a commonly used method in nursing teaching, however, no unanimous consensus on the effectiveness of the application of nursing teaching. Purpose:The purpose of this meta-analysis is to systematically evaluate the effectiveness of WeChat as a platform combined with PBL teaching method in nursing teaching for Chinese nursing students from four aspects: nursing students' performance, ability, learning interest and teaching satisfaction. Methods: The following English and Chinese databases were searched for relevant articles: PubMed, Embase, Cochrane library, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang Database, VIP Database and Chinese Biomedical Literature Database (CBM). The search timeframe was set from the establishment of these database to August 2021.Two reviewers separately screened records, abstracted data, and assessed risk of bias in trials included. Review Manager Software 5.3 was used to analyze data. Results: A total of 11 randomized controlled trials (RCTs) were included. The results of this meta-analysis showed that WeChat combined with PBL teaching method can significantly improve theory examination (SMD = 2.50, 95% CI: 1.69 to 3.30, P ＜ 0.001), operation skill (SMD = 2.32, 95% CI: 1.47 to 3.18, P＜ 0.001), comprehensive ability (SMD = 3.18, 95% CI: 1.59 to 4.76, P＜ 0.001), and learning interest (SMD = 3.08, 95% CI: 1.44 to 4.72, P＜ 0.001) in Chinese nursing students, and increase nursing students on teachers' teaching satisfaction (SMD = 2.64, 95% CI: 0.39 to 4.89, P＜ 0.001). Conclusion: WeChat combined with PBL teaching method can significantly enhance Chinese nursing students' knowledge mastery and application, improve their comprehensive ability and learning interest, and improve classroom teaching effect. College nursing educators should consider adopting WeChat combined with PBL teaching method in nursing education to fully demonstrate its application value.

Keywords:WeChat, Problem-based learning, Nursing education, Chinese nursing students, Meta-analysis

Introduction

WeChat application (APP) is a new instant messaging application launched by Tencent in early 2011 [1]. As an emerging product in the development of modern information technology, WeChat has been increasingly used in various fields in China in recent years. WeChat is currently one of the most popular free communication tools at home and abroad. It is not restricted by time or location, easy to use, and can instantly send and receive text and voice, as well as transmit images and videos [2]. Therefore, WeChat APP has become a focus of attention and research for nursing scholars in China. Some studies have confirmed that the application of WeChat in nursing teaching can achieve better teaching effectiveness [3].

Problem-Based Learning (PBL) is a new interactive teaching method of problem-based learning, which emphasizes the initiative of students’ learning, the combination of problem-solving and multiple learning pathways, and the cooperation of learners to solve problems, so as to develop the ability to analyze, solve problems, and learn independently [4-5]. It has now become a more popular teaching model internationally [6]. Some scholars have found that only the application of PBL teaching method in nursing teaching, although it has good teaching effect, but due to the short classroom time, more knowledge points to be mastered, less interaction between teachers and students, poor student learning initiative, and among others, and cannot achieve the purpose of comprehensive promotion [7-8].

Therefore, in recent years, many universities and teaching hospitals in China have started to try to combine WeChat with PBL teaching method for nursing teaching, which has become a new research trend in China, and the results achieved are multifaceted and comprehensive [9]. Although a number of relevant trials were published, at present, the practical effects of this comprehensive teaching approach now still lacks consensus. In view of the importance of this problem, the present study employed the meta-analytic method to summarize and evaluate the effects of the application of WeChat combined with PBL teaching method in nursing teaching in China, in order to provide a decision basis for whether further promote the application of this new nursing teaching method in the field of nursing education.

Materials and Methods

The studies included in this meta-analysis are all published articles, therefore no ethical approve was required.

Inclusion criteria

The inclusion criteria for this meta-analysis were as follows: (1) P: Chinese nursing students were included, regardless of grades and degrees. (2) I: The intervention group applied WeChat combined with PBL teaching method teaching method for nursing students. (3) C: The control group applied the traditional teaching method. (4) O: Nursing students’ scores, ability, learning interest and teaching satisfaction. (No specific measurement tool for the identified outcomes needed to be specified). (5) Studies needed to be randomized controlled trials (RCTs) that conducted in China.

Exclusion criteria

Studies were excluded if: (1) They were duplicated; (2) The full text was unavailable; (3) The study data was incomplete or unsuitable for meta-analysis.

Literature search

The present meta-analysis was reported in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement [10]. To achieve a more comprehensive search, the authors searched published articles from the following Chinese and English databases: PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang Database, VIP Database and Chinese Biomedical Literature Database (CBM), from the establishment of these database to August 2021. The literature search was limited to articles published in English or Chinese and conducted using combinations of the keywords. English search terms included: (“nursing students” or “nursing education”) and (“WeChat”) and (“PBL” or “Problem-based learning”) and (“randomized controlled trial” or “randomized” or “randomly” or “trials”).

Literature selection

All retrieved records were imported into EndNote X9 software following the literature retrieval, then two researchers independently screened the titles and abstracts of the articles and excluded those irrelevant to this meta-analysis. Full texts of the remaining articles were carefully read by the two independent researchers until all included articles were determined. In the case of disagreement, a decision was made in consultation with a third researcher. Additionally, to ensure the comprehensiveness of the search, the authors further searched the available references for relevant reviews, meta-analyses or systematic reviews.

Assessment of risk of bias

The quality assessment of the included literature was conducted independently by two researchers according the Cochrane Handbook (5.1.0) quality evaluation criteria. “Low-risk bias”, “unclear” and “High-risk bias” were used to indicate the degree of bias risk. In case of uncertainly, a third researcher was invited to discuss it together. Quality grade A indicated that the included study's bias was low risk and all met the above criteria; Quality grade B indicated the possibility of bias in the included study and partially met the above criteria; Quality grade C indicated a high risk of bias in the study which can be eliminated [11].

Data extraction

Data extraction was conducted by two researchers independently, in accordance with a pre-designed Excel form. The following information was extracted: author, year of publication, country, study design, sample size (trial group/control group), basic information on participants, interventions, outcomes of interest. Any differences were addressed through consultation with a third researcher.

Statistical analysis

The statistical analyses were conducted under the guidance of one of the authors (Cui XS), a professor of statistics. Data was entered into RevMan 5.3 for pooling. Standardized mean difference (SMD) with corresponding 95% confidence interval (CI) was used to report the effect sizes. Statistical heterogeneity across included RCTs was analyzed by I2statistics and with a Chi-square test [12]. If I2＜ 50% andP≥ 0.10, this indicated low statistical heterogeneity between included studies, then the fix effect model was used. If I2≥ 50% andP＜ 0.10, this indicated high clinical homogeneity, then the random effect model was adopted to synthesize the results. The subgroup analysis was conducted to explore the sources of possible heterogeneity [13]. The study with large sample were removed were examined to verify the stability of the pooled results.

Result

Literature retrieval results

A total of 125 records were preliminarily retrieved, 17 of which were duplicates. Screening of the title and abstracts resulted in 24 relevant studies. After a review of full-texts, 13 studies were excluded. Therefore, 11 RCTs were included in this meta-analysis. The literature screening process is illustrated in Figure 1.

Figure 1 Flow diagram of study selection

Figure 2 Risk of bias summary

Figure 3 Forest plot of the theory examination scores

Figure 4 Forest plot of the operation skill scores

General features of included trials

Among the included eleven RCTs, they published between 2015 and 2020 were included. All the studies were from China and were published in Chinese. The sample sizes ranged from 40 to 140, a total of and 844 nursing students were recruited in all included studies, of which 423 participated in experimental groups, and 421 in control groups. The research subjects were all nursing students, including nursing interns and nursing students in school. All interventions were the WeChat combined with PBL teaching methods. Outcome indicators included nursing students’ score, ability, learning interest and teaching satisfaction. The basic characteristics of the included studies are shown in Table 1.

Table1 Basic features of the included literature

Table 2：Literature quality assessment

Risk of bias in the included literature

All included studies randomized study participants, but the specific randomization approach was only two studies, used random number table for random grouping. None of the 11 included literatures mentioned the allocation concealment of the random scheme and the blind method of the study object, intervener and result evaluator. None of the 11 included literatures was lost to follow-up, and the integrity of outcome index data was good. There was no significant difference between the baseline data of the experimental group and the control group, which was comparable. Furthermore, the quality grade of all eleven studies were B. Specific information can be seen in Table 2, and the results of risk bias assessment are presented with a risk of bias summary in Figure 2.

Theory examination scores

The author of eleven existing studies [14-24], recruited 844 nursing students (423 in the intervention group, 421 in the control group), and reported students’ theory examination scores. Scores between the WeChat combined with PBL teaching group and the control group differed significantly (P＜ 0.05), with the WeChat combined with PBL teaching significantly improve nursing students’ theory examination scores. These eleven studies exhibited high heterogeneity (I2= 95%,P＜ 0.00001), meaning the random effects model was applied to merge the results. As suggested from the combined results (SMD = 2.50, 95% CI: 1.69 to 3.30,P＜ 0.001, Figure 3), the results remained unchanged after the fixed effects model was adopted to merge the result (SMD = 1.66, 95% CI: 1.49 to 1.83,P＜ 0.001), implying that the results of this meta-analysis are robust.

Operation skill scores

Author of eleven existing studies [14-24], including 844 nursing students (423 in the intervention group, 421 in the control group), and reported students’ Operation skill scores. Scores between the WeChat combined with PBL teaching group and the control group differed significantly (P＜ 0.05), with the WeChat combined with PBL teaching significantly improve nursing students’ Operation skill scores. These eleven studies exhibited high heterogeneity (I2= 96%,P＜ 0.001), meaning the random effects model was applied to merge the results. As suggested from the combined results (SMD = 2.32, 95% CI: 1.47 to 3.18,P＜ 0.001, Figure 4), the results remained unchanged after the fixed effects model was adopted to merge the result (SMD = 1.59, 95% CI: 1.42 to 1.76,P＜ 0.001), implying that the results of this meta-analysis are robust.

Figure 5 Forest plot of the comprehensive ability scores

Figure 6 Forest plot of the learning interest scores

Figure 7 Forest plot of the teaching satisfaction scores

The influence of the comprehensive ability of nursing students

The author of four existing studies [16, 17, 20, 23], recruited 307 nursing students (154 in the intervention group, 153 in the control group), and reported students’ comprehensive ability scores. Scores between the WeChat combined with PBL teaching group and the control group differed significantly (P＜ 0.05)，with the WeChat combined with PBL teaching significantly improve nursing students’ comprehensive ability scores. These three studies exhibited high heterogeneity (I2= 83%,P= 0.02), meaning the random effects model was applied to merge the results. As suggested from the combined results (SMD = 3.18, 95% CI: 1.59 to 4.76,P＜ 0.001, Figure 5), the results remained unchanged after the fixed effects model was adopted to merge the result (SMD = 2.69, 95% CI: 2.36 to 3.03,P＜ 0.001), implying that the results of this meta-analysis are robust.

The influence of the learning interest of nursing students

The author of four existing studies [14, 19-21], recruited 288 nursing students (144 in the intervention group, 144 in the control group), and reported students’ learning interest scores. Scores between the WeChat combined with PBL teaching group and the control group differed significantly (P＜ 0.05), with the high-fidelity simulation teaching significantly improve nursing students’ learning interest scores. These four studies exhibited high heterogeneity (I2= 96%,P＜ 0.0001), meaning the random effects model was applied to merge the results. As suggested from the combined results (SMD = 3.08, 95% CI: 1.44 to 4.72,P＜ 0.001, Figure 6), the results remained unchanged after the fixed effects model was adopted to merge the result (SMD = 2.40, 95% CI: 2.07 to 2.73,P＜ 0.001), implying that the results of this meta-analysis are robust.

The influence of nursing students on teachers' teaching satisfaction

The author of four existing studies [19-21], recruited 188 nursing students (94 in the intervention group, 94 in the control group), and reported students’ teaching satisfaction scores. Scores between the WeChat combined with PBL teaching group and the control group differed significantly (P＜ 0.05), with the WeChat combined with PBL teaching significantly improve teaching satisfaction scores. These four studies exhibited high heterogeneity (I2= 97%,P＜ 0.0001), meaning the random effects model was applied to merge the results. As suggested from the combined results (SMD = 2.64, 95% CI: 0.39 to 4.89,P＜ 0.001, Figure 7), the results remained unchanged after the fixed effects model was adopted to merge the result (SMD = 2.07, 95% CI: 1.68 to 2.46,P＜ 0.001), implying that the results of this meta-analysis are robust.

Discussion

Summary of major findings

In the present meta-analysis, relevant Chinese and English studies were comprehensively retrieved by combining MESH and free terms. Eleven high-quality randomized controlled trials were obtained and included in the meta-analysis. As the teaching method of WeChat combined with PBL teaching method was widely used in nursing education in China, 844 nursing students included were all from China. To some extent, it provided reference value for innovative teaching methods in the field of nursing education at home and abroad, which is the value of this study.

This study found that the organic combination of WeChat and PBL teaching method applied to nursing teaching was more conducive to nursing students' knowledge mastery and application, improve their comprehensive ability and learning interest, as well as improve classroom teaching satisfaction. Therefore, the results of this study provided some theoretical support for WeChat combined with PBL teaching method to be applied in nursing teaching in China, and also provided a new reference mode for nursing education abroad.

As far as nursing education abroad was concerned, modern social media such as Facebook or Twitter were more used [25-26], while WeChat was not very common. As an information technology product developed in China, WeChat has many advantages. It can send text messages, videos, and pictures quickly across platforms, can communicate in real time with single and multiple people, has low memory, multi-functional as well as instantaneous, extensive, interactive, shared, and strong semi-acquainted social and weak intra-circle social characteristics [23]. Using these advantages of the convenient, informative and repeatable WeChat platform, the researcher taught the boring and abstract nursing knowledge to nursing students, thus mobilizing their learning motivation and initiative and further promoting immediate feedback and improvement of teaching activities [27]. The real-time discussion and communication among nursing students through the WeChat platform is not restricted by subjective and objective factors such as time and identity, which makes the communication more convenient and faster, thus reducing the link of centralized discussion, saving a lot of time, and allowing nursing students to have more practice and learning opportunities [28]. WeChat as a new technological aid for teaching increases students' interest in learning and improves their independent learning ability. When PBL teaching method is combined with WeChat, the new media characteristics of WeChat APP are fully utilized to avoid the shortcomings of PBL teaching teachers and teaching resources time. Learning in online environment has been regarded as an important part of education, making up for the venue and time constraints of conventional classroom teaching method [29]. However, it also reflects certain limitations. For example, in the process of carrying out the teaching mode of WeChat and PBL, WeChat is slow in pushing out content, most teachers are not specially trained and do not have a corresponding instructional syllabus to prepare typical PBL cases fully suitable for nursing students' learning; individual students with poor self-learning ability and low knowledge reserve are not active in accepting the combination of both teaching [30].

And there is currently no feedback mechanism on how to evaluate the learning effect of students using WeChat platform [31]. This also needs further study by scholars in the future. PBL teaching method has been applied in medical education in the 1960s, and was a mature method recognized by the international education community [32]. Now, Chinese scholars are trying to carry out PBL practice teaching based on the online interactive tools of WeChat platform, so as to maximize the nursing teaching effect. When WeChat combined with PBL teaching is applied in clinical nursing teaching, it can improve nursing students' understanding and cognition of knowledge, better grasp clinical nursing skills, combine theoretical knowledge and practical skills, thus improving nurse-patient communication and enhancing nursing staff, and therefore obtaining more desirable teaching quality [33]. At the same time, WeChat joint PBL teaching is an emerging teaching method for teachers, which increases the teaching interest through interaction with nursing students and mobilizes the enthusiasm of leading teachers to a certain extent. At the same time, it broadens the teaching horizons of the lead teachers through constant question and answer, which has a facilitating effect on the knowledge update of the lead teachers, which in turn promotes the lead teachers to be more active in granting updated knowledge to nursing students, thus improving their nursing knowledge [34].

This meta-analysis included eleven studies, all of which adopt the WeChat combined with PBL teaching method. All nursing students were recruited from various universities and hospitals in China. In terms of heterogeneity, the merge results showed a high level of heterogeneity, which may be related to factors such as the inclusion of school nursing students and practice nursing students, who have different educational levels, different cognitive levels, and the inability to use unified evaluation tools to measure the outcome indicators. Therefore, more high-quality studies with large sample sizes and multiple perspectives are needed to confirm these results.

Limitations of this study

Due to the limited conditions, this study has certain limitations. First of all, the eleven studies included in this meta-analysis are all from China, which is a limitation for this meta-analysis in geographical coverage to some extent. Second, only two studies included in this meta-analysis described their method of randomization in detail. Others mentioned randomization but did not clearly explain the method used, which is a limitation for this meta-analysis to some extent. Third, there is no uniform measurement tool for the same outcome, which may increase the source of heterogeneity. In addition, quality grade of eleven studies was B, which may affect the reliability of the research conclusion to some extent. Therefore, more high-quality studies with large samples are needed to verify the effects of WeChat combined with PBL teaching method on nursing teaching.

Conclusion

The introduction of WeChat combined with PBL teaching method in nursing discipline is the embodiment of advancing with the times. This meta-analysis shows that WeChat combined with PBL teaching method can significantly enhance nursing students' knowledge mastery and application, improve their comprehensive ability and learning interest, and improve classroom teaching effect. In the future, more researchers in nursing education abroad can actively adopt this teaching method and model to fully demonstrate its application value.