Integrating Video-Based Scaffolding into Problem-Based Learning for Nursing Skills Education: Development and Evaluation of the MEDIFA Model

Introduction

Preparing nursing graduates who are able to demonstrate both clinical competency and critical thinking continues to be a major concern in contemporary healthcare education. Increasingly complex healthcare environments require nurses not only to perform technical procedures accurately, but also to make rapid clinical judgments, communicate effectively, and adapt to changing patient conditions. Within this context, nursing education institutions are under growing pressure to develop learning environments that support procedural mastery alongside higher-order reasoning skills.^1,2

The rapid expansion of digital learning technologies has significantly influenced the way clinical skills are taught in nursing education. Instructional videos, simulation-based resources, and multimedia learning environments are now widely used to support procedural demonstration and independent learning.^3,4 Video-based learning, in particular, offers several pedagogical advantages, including repeatability, visual clarity, flexible access, and opportunities for self-paced learning.⁵ Systematic review evidence also suggests that educational video can improve learning performance in higher education when integrated appropriately into instructional processes.⁶

Despite these advantages, the effectiveness of video-based learning in nursing education remains uneven. In many instructional settings, videos are still used primarily as supplementary materials rather than as integrated pedagogical components within structured learning models. As a consequence, students may become familiar with procedural sequences without fully understanding the clinical rationale underlying their actions. Several studies have reported that nursing students continue to experience difficulties in applying procedural knowledge during authentic or simulated clinical situations, particularly when tasks require simultaneous technical performance and clinical reasoning.^7,8

At the same time, problem-based learning (PBL) has been widely recognized as an important approach for promoting collaborative inquiry, reflective thinking, and self-directed learning in health professions education.^9,10 Rather than positioning students as passive recipients of information, PBL encourages learners to actively construct understanding through engagement with contextualized clinical problems. Recent developments in PBL research have also emphasized its role in supporting adaptive problem-solving and professional identity formation in higher education environments.^11,12

However, instructional video and PBL are frequently implemented as separate pedagogical strategies. In many nursing programs, procedural videos are used independently from collaborative problem-solving activities, while PBL sessions often emphasize discussion and reasoning without providing structured procedural scaffolding. This separation creates a pedagogical tension within clinical skills education. Students may repeatedly observe technical procedures through video-based instruction yet struggle to transfer procedural knowledge into meaningful clinical decision-making contexts. Conversely, students engaged in PBL discussions may lack sufficient visual and procedural support when attempting to perform complex nursing skills.

This issue becomes particularly relevant in undergraduate nursing skills training, where students are expected to integrate psychomotor performance, conceptual understanding, communication, and clinical judgment within limited instructional time. Evidence from nursing education research suggests that technology-enhanced learning environments are most effective when digital tools are embedded within coherent pedagogical structures rather than used as isolated instructional supplements.^13,14 Nevertheless, studies that systematically integrate video-based scaffolding within a problem-based learning framework in nursing education remain relatively limited.

From a theoretical perspective, the integration of video-based instruction and PBL can be understood through several complementary learning perspectives. Cognitive Load Theory proposes that well-structured multimedia instruction may reduce unnecessary cognitive burden and support procedural understanding through visual segmentation and guided repetition.¹⁵ Situated Learning Theory further suggests that meaningful learning develops through participation in authentic social and contextual activities, including collaborative clinical problem-solving.¹⁶ In addition, Self-Determination Theory emphasizes the importance of autonomy, competence, and relatedness in sustaining learner motivation and engagement.¹⁷ When combined within a coherent instructional design, these perspectives suggest that video-based scaffolding and problem-based learning may support both procedural competency and higher-order clinical reasoning.

Building on these considerations, this study develops and evaluates a Video-Supported Problem-Based Learning (VS-PBL) model, referred to as the MEDIFA model, within undergraduate nursing skills education. Unlike approaches that position instructional video merely as supplementary material, the MEDIFA model integrates video-based procedural scaffolding directly into the problem-based learning process. The model was designed to support students in understanding procedural demonstrations while simultaneously engaging in collaborative reasoning, reflection, and clinical decision-making activities.

The objectives of this study are threefold: (1) to examine the effect of the VS-PBL model on nursing students’ clinical competency in selected nursing procedures, (2) to explore students’ perceptions of critical thinking and self-directed learning during the intervention, and (3) to evaluate the feasibility and instructional effectiveness of the model through expert validation and field implementation.

This study contributes to the growing discussion on digital pedagogical innovation in nursing education by offering an empirically grounded instructional model that integrates multimedia scaffolding with collaborative clinical learning. In addition to providing practical implications for competency-based nursing instruction, the study also responds to the need for more context-sensitive and pedagogically integrated approaches to technology-enhanced learning in healthcare education.

Methods

Results

Discussion

The findings of this study suggest that the integration of video-based procedural scaffolding within a problem-based learning environment may contribute meaningfully to the development of clinical competency in undergraduate nursing education. The substantial increase in post-intervention competency scores, accompanied by a high normalized gain and large effect size, indicates that the MEDIFA model functioned not merely as a supplementary digital resource, but as a pedagogically integrated instructional approach within the observed learning context.

These findings are broadly consistent with previous research demonstrating the value of instructional video in supporting procedural learning and independent practice in nursing education.^3,5,6 Earlier studies have shown that video-based learning environments can improve procedural clarity, facilitate repeated observation, and enhance learner confidence during skills acquisition.^7,13,2728 Similarly, research on problem-based learning has consistently associated PBL environments with collaborative reasoning, reflective inquiry, and self-directed learning processes.^9–12,26 However, the present study extends this discussion by suggesting that the educational value of digital instructional media may depend less on technological availability itself and more on the extent to which such media are embedded within coherent pedagogical interaction.

Rather than functioning as isolated audiovisual demonstrations, the instructional videos in the MEDIFA model appeared to operate as procedural scaffolds that supported repeated cognitive rehearsal during clinical preparation. Students frequently described pausing, replaying, and revisiting selected procedural segments in response to areas of uncertainty. This pattern suggests that video-based instruction may reduce unnecessary cognitive burden during procedural acquisition by allowing learners to regulate the pace and sequencing of information exposure. Such findings are consistent with Cognitive Load Theory, which proposes that structured multimedia presentation can support learning when complex information is segmented and cognitively manageable.^15,20

At the same time, the findings also indicate that procedural repetition alone was insufficient to explain observed learning improvements. The problem-based learning component appeared to play an important role in transforming procedural performance into clinically meaningful understanding. Students repeatedly described how discussion of infection risks, patient conditions, and nursing rationale altered their perception of procedural activities that had previously been approached as memorized technical routines. In this respect, the study supports the view that contextualized collaborative inquiry may strengthen the relationship between psychomotor performance and clinical reasoning in nursing education.

These findings also resonate with recent studies suggesting that scaffolding within problem-based learning environments may strengthen active reasoning and independent engagement during higher education learning processes.^22,23

This interaction between procedural scaffolding and contextual problem-solving reflects important aspects of Situated Learning Theory.¹⁶ Learning did not occur solely through observation of procedural demonstrations, but through participation in socially mediated problem-analysis activities situated within realistic clinical scenarios. The collaborative discussions appeared to encourage students to negotiate meaning, justify procedural choices, and reflect on patient safety considerations rather than merely reproduce technical steps.

An additional finding emerging from the study concerns changes in instructional interaction patterns. Students perceived that instructors shifted from repetitive procedural demonstration toward facilitation of questioning, clarification, and reflective guidance. This shift is pedagogically important because it suggests that video-supported instruction may redistribute instructional attention within laboratory learning environments. When procedural demonstrations become consistently accessible through digital scaffolding, instructors may be able to devote more time to higher-order coaching processes, including clinical reasoning, feedback, and reflective inquiry.

The qualitative findings also suggest that the MEDIFA model may support aspects of self-regulated learning. Students frequently described preparing independently before laboratory sessions and revisiting learning materials outside formal instructional hours. Although the present study did not directly measure motivational constructs, these patterns appear consistent with Self-Determination Theory, particularly in relation to learner autonomy and perceived competence.¹⁷ Nevertheless, the extent to which such learning behaviors are sustained over longer periods remains uncertain and requires further investigation.

Despite these positive findings, several considerations should be acknowledged when interpreting the results. First, the study was conducted within a single institutional setting involving one cohort of undergraduate nursing students. Educational culture, instructor characteristics, and institutional learning environments may therefore have influenced implementation outcomes. Second, the quasi-experimental one-group pre-test–post-test design limits causal interpretation because improvements cannot be attributed exclusively to the intervention in the absence of a comparison group. Third, portions of the qualitative findings relied on self-reported student perceptions, which may contain subjective bias despite efforts to ensure voluntary participation and response anonymity.

In addition, adaptation to the VS-PBL approach was not uniform across all participants. Several students initially expressed discomfort with collaborative discussion and analytical participation, particularly those who were more familiar with instructor-centered demonstration models. This finding suggests that pedagogical transition toward more active learning environments may require gradual adjustment and facilitative support rather than immediate instructional replacement.

From a practical perspective, the findings highlight the importance of viewing digital instructional media as components of broader pedagogical ecosystems rather than standalone technological solutions. Within the present study, the educational contribution of video appeared strongest when integrated with collaborative reasoning activities, reflective questioning, and contextual clinical discussion. This observation may be particularly relevant for nursing education institutions seeking to strengthen competency-based learning within increasingly digital learning environments.

Future research should explore the long-term sustainability of video-supported problem-based learning models, including retention of clinical competency, transferability to authentic clinical practice, and implementation across different institutional and cultural contexts. Comparative studies involving control groups and multi-site implementation may also help clarify the extent to which observed outcomes are attributable to specific instructional components within the MEDIFA framework.

Conclusion

The present study explored the development and implementation of the MEDIFA model, a Video-Supported Problem-Based Learning (VS-PBL) approach designed for undergraduate nursing skills education. Within the context of this study, the integration of video-based procedural scaffolding and collaborative problem-based learning was associated with substantial improvement in students’ clinical competency outcomes and meaningful changes in learning engagement.

The findings suggest that instructional video may become pedagogically more valuable when embedded within reflective and context-oriented learning environments rather than used solely as supplementary demonstration material. Students not only demonstrated improvement in procedural performance, but also described increased opportunities for repeated practice, collaborative reasoning, and independent preparation during laboratory learning activities. These findings indicate that the educational contribution of digital learning tools may depend largely on how they are integrated within broader pedagogical interaction.

At the same time, the study highlights the importance of maintaining caution in interpreting intervention outcomes. The research was conducted within a single institutional context using a one-group quasi-experimental design, and portions of the qualitative findings relied on self-reported experiences. Consequently, the findings should be understood as contextually situated rather than universally generalizable.

Despite these limitations, the study contributes to ongoing discussions concerning digital pedagogical innovation in nursing education, particularly within competency-based and student-centered learning environments. The MEDIFA model offers a context-sensitive instructional framework that may support the integration of procedural learning, clinical reasoning, and reflective engagement in nursing skills education. Further research involving broader institutional settings, comparison groups, and longitudinal observation may help clarify the sustainability and transferability of the model across diverse clinical learning contexts.

Ethical considerations

Ethical approval for this study was obtained from the Research Ethics Committee of Universitas Binawan, Jakarta, Indonesia (Approval No. 203/KEPK-UBN/IV/2022). Permission to conduct the study was subsequently obtained from the Faculty of Health Sciences, Universitas Islam As-Syafi’iyah, Jakarta, Indonesia. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and relevant institutional guidelines for research involving human participants.

All participants received detailed information regarding the objectives, procedures, voluntary nature of participation, and intended use of the research data prior to enrollment. Participation was entirely voluntary and did not affect students’ academic assessment or course standing. Written informed consent was obtained from all participants before participation in the study.

To protect participant confidentiality, all questionnaire responses, interview data, and assessment results were anonymized during analysis and reporting. Participants were informed that they could withdraw from the study at any stage without academic consequences. No personally identifiable information was disclosed in any part of the research process or publication.