Introduction

Background

Korea has already become a super-aged society with the proportion of the elderly population aged 65 or older reaching 20.3% of the total population in 2025, and the proportion of the elderly population is projected to exceed 30.9% in 2036 and 40% in 2050 [1]. Meanwhile, as of the end of 2024, the total number of registered people with disabilities was 2,631,356, accounting for approximately 5.1% of the total population, and elderly people aged 65 or older took up 55.3% of the total registered people with disabilities, indicating that the population living with disabilities is also undergoing rapid population aging [2]. This increase in the elderly population and the aging of the disabled population mean an overall increase of the population with limited mobility, and as a result, the social demand for care services is expected to continue to increase.

Among all the caregivers’ tasks, excretion care is performed approximately 6 times per day on average [3], and takes up a significant proportion of the overall caregiving activities. This is due to the fact that if excretion management is not appropriately performed, it can lead to serious complications, such as urinary tract infections and bedsores, so it has been repeatedly pointed out that there is a need to perform excretion relatively frequently [4]. In addition, movements with a high physical load, such as changing the positions of patients or care recipients, impose additional physical burden on caregivers, and thus, excretion care is classified as a high-risk care activity with a high possibility of developing musculoskeletal disorders [3]. This care environment can increase caregivers’ fatigue and ultimately negatively affect the physical well-being and quality of life of care recipients.

Under the above circumstances, technology-based devices such as excretion care robots are receiving attention as an alternative that can reduce the burden of caregivers [5]. An excretion care robot is a device that performs the functions that partially or fully support handling and disposal of bodily waste (urine and feces) [5]. Excretion care using this device can be applied as a nursing intervention method since the use of excretion care robots has been shown to have various positive effects on care recipients in previous studies, including reducing the risk of incontinence-associated dermatitis and pressure ulcers, reducing lymphocyte production, and improving serum albumin levels [6].

However, most products currently under development still have technological limitations, and their functions are still limited to assisting caregiving activities [7]. To effectively utilize and safely operate new technology-based care devices that are still unfamiliar to most people, it is necessary to have the ability to understand the principles of standardized procedures and perform caregiving activities with adequate skills. Cultivating this competency requires a systematic education process [8], but most current educational materials related to care robots focus on the method to operate the devices as presented in the user manuals provided by manufacturers, and there is a lack of a comprehensive and systematic educational approach that comprehensively considers the needs, attitudes, and preferences of both caregivers and care recipients, the ethics of care, and educational needs. In addition, education on the use of care robots should not be limited to the simple acquisition of skills for operating the devices, but should focus on strengthening integrated competency, including professional knowledge and skills required in clinical settings and appropriate attitudes toward care [9].

In particular, one-time training has limitations in ensuring that learners accurately learn the procedures for using excretion care robots, and a flipped learning-based integrated education program that combines repetitive learning using videos with theoretical and practical training is believed to be an effective approach in improving the user’s familiarity and proficiency with an unfamiliar device. Flipped learning is a teaching and learning method that helps learners recognize their weaknesses in advance by watching pre-produced video materials before in-person education so that they can more efficiently participate in practical training and perform interaction-centered learning during the subsequent in-person education sessions [10]. A previous study reported that a combination of pre-learning using supplemental video materials and practical training including repeated demonstrations, self-directed practice, and feedback was effective in improving learners’ positive attitudes and enhancing their technical skills [11]. Another previous study also reported that pre-learning using video educational materials was evaluated as an effective learning method for acquiring relevant knowledge, since the method allowed learners to individually watch video materials repeatedly without location or time constraints [12]. Meanwhile, it has been found that learners who participated in in-person, hands-on practical training showed high satisfaction with the fact that they could directly experience the tactile feel of the device [9].

Although there are diverse types of caregivers, in particular, nurses are expected to perform a wider range of roles beyond their traditional roles centered around medical institutions as a result of advances in technology [13]. Therefore, a prior study emphasized that a sufficient review of the perceived usefulness of care robots among nurses rather than patients or their guardians as well as systematic support such as providing various educational programs for nurses is required to ensure that nurses will appropriately adapt to the changing work environment and acquire the required capabilities [14].

Therefore, this study aimed to evaluate the effectiveness of a flipped learning-based education program that combines video educational materials and theoretical and practical in-person education for nurses, the actual users of excretion care robots in preparation for the adoption of this technology-based device in clinical practice in the near future.

Aims and objectives

The purpose of this study was to develop an education program for the utilization of excretion care robots and apply it to nurses in order to verify its effects on nurses’ knowledge, skills, and attitudes about excretion care and excretion care robots through a comparison with a conventional education method. The specific objectives of this study were as follows:

1) To develop an education program on excretion care robots based on integrated education combining theory and practice;

2) To verify the effects of the developed education program on excretion care robots on the knowledge, attitudes, and skills of nurses.

Research hypotheses

The following ten hypotheses were postulated in this study.

1) H1: The experimental group that participated in the educational program on the excretion care robot will show a higher level of knowledge on excretion care and excretion care robots than the control group.

2) H2: The experimental group that participated in the educational program on the excretion care robot will show a higher level of self-efficacy in excretion care than the control group.

3) H3: The experimental group that participated in the educational program on the excretion care robot will show a higher level of self-efficacy in using the excretion care robot than the control group.

4) H4: The experimental group that participated in the educational program on the excretion care robot will show a higher level of perceived usefulness of excretion care robots than the control group.

5) H5: The experimental group that participated in the educational program on the excretion care robot will show a higher level of perceived ease of use of the excretion care robot than the control group.

6) H6: The experimental group that participated in the educational program on the excretion care robot will show a lower level of anxiety about excretion care robots than the control group.

7) H7: The experimental group that participated in the educational program on excretion care robots will show a higher level of behavioral intention to use the excretion care robot than the control group.

8) H8: The experimental group that participated in the educational program on the excretion care robot will show a higher level of proficiency in using the excretion care robot than the control group.

9) H9: The experimental group that participated in the educational program on the excretion care robot will show a higher level of accuracy in the execution procedure of the excretion care robot than the control group

10) H10: The experimental group that participated in the educational program on the excretion care robot will show a higher level of accuracy in the performance outcome of the excretion care robot than the control group.

Methods

Study design

This study was a randomized controlled trial to apply an educational program on the excretion care robot to nurses and verify its effectiveness.

Participants

1. Selection of participants

The participants of this study were selected among the nurses who voluntarily agreed to participate in the study after they were fully informed of and understood the purpose and procedures of the study. In addition, nurse unit managers and supervisors who did not directly perform caregiving activities were excluded from the study.

2. Sample size determination

The sample size for this study was calculated using G*power 3.1.9.7. The minimum sample size for a two-sided independent samples t-test was calculated to be 44 people, using an effect size of 0.87 [15], a significance level of 0.05, and a power of 0.80, based on previous studies. Thus, considering the research period of approximately one week and the need to visit the location of education, the dropout rate was set at 20% and the target sample size was planned as 55 people. Although a total of 55 nurses were initially recruited, two persons in the experimental group and three persons in the control group withdrew halfway through the study because of personal reasons that prevented them from attending in-person education. As a result, the final attrition rate was 9.1%, and data from a total of 50 participants with 25 participants in each of the experimental and control groups were included in the final analysis (Figure 1).

3. Participant allocation

Participants were randomly allocated to the two groups using the block randomization method with a block size of 4. The presence of experience in receiving education on care robots was applied as a stratification variable. With a block size of 4, there were a total of six possible permuted combinations of allocation within each block, and the random number generation function ‘=RANDBETWEEN (1,6)’ in Excel (Microsoft 365) was used to divide the participants in each block into the experimental and control groups at a 1:1 ratio. The participants were assigned to each group according to the random allocation table in the order of recruitment. The two tasks of participant registration and the randomized allocation of participants were each performed by different researchers, and their access to the order of allocation was prevented by strictly separating the researchers in charge of each task.

Measures

1. General characteristics

The general characteristics of the participants were examined using five questions on age, gender, clinical experience, care robot usage experience, and care robot education experience by a self-administered survey method.

2. Knowledge

① Knowledge of excretion care and excretion care robots

In this study, the level of knowledge of excretion care and excretion care robots was assessed using a knowledge assessment tool based on related professional books, a literature review of previous studies, and consultation with experts. The questionnaire items were finalized after the review of their content validity by three nursing professors. This scale consisted of 8 questions in total, and each question was scored by giving 1 point for each correct answer and 0 points for each incorrect answer. Total scores range from 0 to 8 points, and higher scores indicate higher levels of knowledge of excretion care and excretion care robots. Regarding the reliability of the scale, the value of KR-20 was calculated as .322 in this study.

3. Attitudes

① Self-efficacy in excretion care

The level of self-efficacy in excretion care was measured using the items about excretory and perineal care from the caregiving self-efficacy scale developed by EJ Kim [16] with the permission from the author of the scale. The scale used consists of a total of 5 questions, and each item is rated on a 5-point Likert scale ranging from 1 point (= ‘Not at all’) to 5 points (= ‘Very much’). Total scores range from 5 to 25 points, and higher scores indicate higher levels of self-efficacy in excretion care. The Cronbach’s α value was reported as .96 by the developer of the scale [16], and it was calculated as .96 in this study.

② Self-efficacy in using the excretion care robot

The level of self-efficacy in using the excretion care robot was assessed using the items on gerontechnology self-efficacy, a sub-factor of a senior technology acceptance model developed by Chen & Chan [17] after receiving permission from the authors. The scale used consists of two items in total, and each item is rated on a 5-point Likert scale. Scores range from 2 to 10 points, and higher scores indicate higher levels of self-efficacy in using the excretion care robot. In the study by Chen & Chan [17], the construct reliability of this tool was reported as 0.671, and the Cronbach’s α value was calculated as .841 in this study.

③ Perceived usefulness of the excretion care robot

The level of perceived usefulness of the excretion care robot was measured using a modified and supplemented version of the scale developed by Davis et al. [18]. The modified version of the scale used in this study was created by Chen & Chan [17], and it was used with the permission from the authors of the scale. This tool consists of 3 items in total, and each item is rated on a 5-point Likert scale. Total scores range from 3 to 15 points, and higher scores indicate higher levels of perceived usefulness of the excretion care robot. The construct reliability of this tool was reported as 0.952 in the study by Chen & Chan [17], and the Cronbach’s α value in this study was .897.

④ Perceived ease of use of the excretion care robot

The perceived ease of use of the excretion care robot was assessed using a modified version of the scale developed by Davis et al. [18]. More specifically, this study used the modified and supplemented version of the scale presented by Chen & Chan [17] with the permission from the authors of the scale. This tool consists of two items and each item is rated on a 5-point Likert scale. Total scores range from 2 to 10 points, and higher scores indicate higher levels of perceived ease of use of the excretion care robot. The construct reliability of this tool was reported as 0.784 in the study by Chen & Chan [17], and the Cronbach’s α value in this study was .767.

⑤ Anxiety about the excretion care robot

Anxiety about the excretion care robot was assessed using a modified and supplemented version of the scale developed by Venkatesh et al. [19]. The modified version of the original scale used in this study was created by Chen & Chan [17], and it was used after receiving permission from the authors. This tool consists of two items, and each item is rated on a 5-point Likert scale. Total scores range from 2 to 10 points, and higher scores indicate higher levels of anxiety about the excretion care robot. The construct reliability of this tool was reported as 0.849 in the study by Chen & Chan [17], and the Cronbach’s α value in this study was .844.

⑥ Behavioral intention to use the excretion care robot

The intention to use the excretion care robot was assessed using the scale developed by Venkatesh et al. [19] with the permission from the authors of the scale. This scale contains three items in total, and each item is rated on a 5-point Likert scale. Total scores range from 3 to 15 points, and higher scores indicate higher levels of behavioral intention to use the excretion care robot. Regarding the reliability of the scale, the Cronbach’s α value was reported as .92 in the study by Venkatesh et al. [19], and the Cronbach’s α value was calculated as .915 in this study.

4. Skills

① Proficiency

A 10-point numeric rating scale (NRS) was used to assess overall proficiency in using the excretion care robot. Higher scores indicate greater proficiency.

② Accuracy in the execution procedure of the excretion care robot

To assess accuracy in the execution procedure of the excretion care robot, an eight-item checklist of the key steps during the wearing process was used. The items were finalized through a review of previous studies, consultation with field experts, and evaluation of the content validity of the tool by three nursing professors with experience in care robots. The execution procedure of each participant was videotaped and evaluated by two evaluators who were not directly involved in the intervention, with the assigned group of each participant concealed from the evaluators. The evaluators received prior training in the evaluation method, and evaluation was carried out after consistent criteria were established through sufficient discussion. Prior to conducting a reliability analysis of the entire data, preliminary estimation of inter-rater reliability was conducted using the data of three participants. As a result, the Cohen’s Kappa coefficient was calculated as .821. The inter-rater reliability value for the entire data set was .851. Each item is scored by giving 2 points for ‘Completely performed’, 1 point for ‘Partially performed’, and 0 points for ‘Not performed’, and total scores range from 0 to 16 points. Higher scores indicate higher levels of accuracy in the execution procedure of the excretion care robot. The value of Cronbach’s α was .821 in this study.

③ Accuracy in the performance outcome of the excretion care robot

Accuracy in the performance outcome of the excretion care robot was assessed using a 5-item checklist regarding the results of wearing the device. The items were finalized through the review of the user manual of the device, consultation with field experts on clinical application of the device, and the evaluation of the content validity of the tool by three nursing professors with experience with care robots. The evaluation was conducted by two evaluators who were not directly involved in the intervention, with the assigned group of each participant concealed from the evaluators. The level of accuracy of each item of the checklist was evaluated according to the checklist based on the last scene in which all procedures were completed in the video footage showing the process in which each participant was performing the procedures. The evaluators received training on the evaluation method in advance, and consistent criteria for evaluation were determined through sufficient discussion before performing evaluation. Before performing the reliability analysis of the entire data, a preliminary reliability analysis was conducted by computing inter-rater reliability using data from three participants, and the Cohen’s Kappa coefficient was calculated to be .806. Afterward, as a result of calculating the inter-rater reliability for the entire data, the Cohen’s Kappa coefficient was calculated to be .811. Each item for assessing accuracy in the performance outcome of the excretion care robot was scored by giving 2 points for ‘Completely performed,’ 1 point for ‘Partially performed,’ and 0 points for ‘Not performed,’ and total scores range from 0 to 10 points. Higher scores indicate higher levels of accuracy in the performance outcome.

5. Satisfaction

To measure the level of satisfaction with the educational program, the satisfaction scale developed by Shin & Lee [20] was used after modifying and supplementing it to suit the purpose of this study after receiving permission from the authors of the scale. This scale consists of 10 items, and each item is rated on a 5-point Likert scale ranging from 1 point (= ‘Not at all’) to 5 points (= ‘Very much’). Total scores range from 10 to 50 points, and higher scores indicate higher levels of satisfaction with the educational program. The value of Cronbach’s α was .913 in this study.

Study design

The educational programs provided to the experimental and control groups were developed by analyzing educational needs through a review of domestic and foreign literature, and were reviewed by an expert panel composed of three nursing professors to confirm the appropriateness and validity of the content. The excretion care robot used in the study is a product called Carebidet (Curaco Inc.), a device developed to provide excretion care to elderly people with limited mobility and bedridden patients. This device detects the urine and feces of the patient using its built-in sensors, and removes the excrement via suction. Afterwards, it cleans the area around the genitals using a rotating nozzle and air-dries the area with warm air [6].

1. Experimental group

① Non-face-to-face pre-learning

Before the intervention, the participants responded to an online pre-survey, and watched seven 3-minute videos on the functions, usage procedures, and management of the excretion care robot for one week. These videos were used as pre-learning materials. The participants were required to watch each video at least once, and allowed to watch the videos repeatedly for repetitive learning (Table 1). How many times each participant watched the videos was examined by a self-report method.

② In-person theoretical education

The participants received one-hour theoretical education, and its content included the methods of excretion care, devices related to excretion care, and the application of excretion care robots.

③ In-person practical training

Immediately following the theoretical education session, a practical training session was held for approximately two hours. After the researcher demonstrated how to apply the excretion care robot, the participants were given an opportunity to experience the operation process of the device. Additionally, immediate feedback was provided through a Q&A session during the education. A post-training survey was conducted after completion of the education.

2. Control group

After they were assigned to the control group, the participants in the control group participated in an online pre-survey, and no separate intervention was provided to them during the one-week period when the experimental group participated in non-face-to-face pre-learning using video materials (Figure 2). Afterwards, on the day when education was conducted, the participants in the control group visited the designated education location and received lecture-style education for about an hour, which was focused on basic information about the use of the excretion care robot, including the operating principles, main functions, and usage procedures of the robot. Additionally, to ensure the fairness of the study in terms of providing the intervention, the same educational program that was given to the experimental group was also provided to the participants in the control group who wished to receive it after completing the education for the control group.

Data collection

This study was conducted from April 14 to July 17, 2025, and the participants were recruited by posting a research participant recruitment notice on an online community for nurses. Only the nurses who voluntarily agreed to participate in the study were included in the study. The education of the participants was conducted in a nursing lab at the Nursing Simulation Center of the College of Nursing at Hanyang University, and the questionnaire data were collected by a self-administered survey method before and after the implementation of the educational program.

Data analysis

The collected data was analyzed using SPSS WIN 29.0, and the specific analysis methods used are as follows:

1) The general characteristics of the participants were analyzed using descriptive statistics by calculating frequencies and percentages;

2) The prior homogeneity test for the general characteristics of the experimental and control groups and main dependent variables was performed using χ2-test, Fisher’s exact test, and the independent t-test.

3) After the completion of the education program, differences in nurses’ knowledge, attitude, and skills between the two groups were analyzed using the independent t-test.

Ethical considerations

This study was conducted after obtaining approval from the Institutional Review Board of Hanyang University (IRB No. HYUIRB-202504-005). The research participants were informed in advance that they had the right to withdraw from the study at any time without any disadvantages if they wished to, and written informed consent was obtained from them before conducting research. The participants were also informed that the collected data would not be used for any purpose other than research, and all information was anonymized to ensure confidentiality. They were also informed that the education program on excretion care robots provided to the experimental group would be provided to the participants in the control group who wished to receive it after the completion of the intervention, and a small amount of compensation was paid to all the participants as a token of appreciation.

Results

Homogeneity test for general characteristics of the participants and dependent variables

To examine the general characteristics of 50 participants in total, frequency analysis was conducted. The average age of the participants was 32.62±6.80 years, and among the total age groups, the 30-39 age group accounted for the highest proportion (23 people, 46.0%). The majority of the participants were female (49 people, 98.0%), and there was 1 male participant (2.0%). As for the length of clinical experience, the average length of clinical experience was 8.50±5.97 years, and the group with 7-12 years of clinical experience (19 people, 38.0%) accounted for the largest proportion of the participants, followed by the group with 3-7 years of clinical experience (14 people, 28.0%). Regarding care robot usage experience, 46 people (92.0%) had no experience. Similarly, in care robot education experience, the majority of the participants (47 people, 94.0%) reported not having previously received education on care robots, and only 3 people (6.0%) had the experience of receiving education on care robots. The homogeneity test for general characteristics between the experimental and control groups was performed before the intervention, and the results showed no statistically significant differences in any items. In addition, the homogeneity test for dependent variables also showed no significant differences between the two groups in any dependent variables, indicating that homogeneity of the two groups was established (Table 2).

Effects of the educational program on the excretion care robot

1. Knowledge

After an interventional educational program on the excretion care robot, there was a statistically significant difference in the level of knowledge of excretion care and the excretion care robot between the two groups (t=-7.89, p<.001). Thus, Hypothesis 2, ‘The experimental group that participated in the educational program on the excretion care robot will show a higher level of knowledge of excretion care and the excretion care robot than the control group,’ was supported (Table 3).

2. Attitudes

After the intervention, there was a statistically significant difference in the level of self-efficacy in excretion care between the two groups (t=-3.34, p=.002). Thus, Hypothesis 1, ‘The experimental group that participated in the educational program on the excretion care robot will show a higher level of self-efficacy in excretion care than the control group,’ was supported. In addition, after the intervention, there was a statistically significant difference in the level of self-efficacy in using the excretion care robot between the two groups (t=-2.29, p=.027). Thus, Hypothesis 3, ‘The experimental group that participated in the educational program on the excretion care robot will show a higher level of self-efficacy in using the excretion care robot than the control group,’ was also supported. Additionally, after the intervention, there was a statistically significant difference in perceived usefulness of the excretion care robot between the two groups (t=-2.51, p=.016), indicating that Hypothesis 4, ‘The experimental group that participated in the educational program on the excretion care robot will show a higher level of perceived usefulness of the excretion care robot than the control group’ was supported. Furthermore, after the intervention, there was a statistically significant difference in perceived ease of use of the excretion care robot between the two groups (t=-4.06, p<.001), indicating that Hypothesis 5, ‘The experimental group that participated in the educational program on the excretion care robot will show a higher level of perceived ease of use of the excretion care robot than the control group,’ was supported. In addition, after the intervention, there was a statistically significant difference in the level of anxiety about the excretion care robot between the two groups (t=4.23, p<.001), showing that Hypothesis 6, ‘The experimental group that participated in the educational program on the excretion care robot will show a lower level of anxiety about the excretion care robot than the control group,’ was also supported. Furthermore, after the intervention, there was a statistically significant difference in behavioral intention to use the excretion care robot between the two groups (t=-3.07, p=.004). Thus, Hypothesis 7, ‘The experimental group that participated in the educational program on the excretion care robot will show a higher level of behavioral intention to use the excretion care robot than the control group,’ was also supported by the research data (Table 3).

3. Skills

After the intervention, there was a statistically significant difference in the score for proficiency in using the excretion care robot between the two groups (t=-7.47, p<.001), indicating that Hypothesis 8, ‘The experimental group that participated in the educational program on the excretion care robot will show a higher level of proficiency in using the excretion care robot than the control group,’ was supported. In addition, after the intervention, there was a statistically significant difference in the level of accuracy in the execution procedure of the excretion care robot between the two groups (t=-10.33, p<.001), showing that Hypothesis 9, ‘The experimental group that participated in the educational program on the excretion care robot will show a higher level of accuracy in the execution procedure of the excretion care robot than the control group,’ was also supported. Lastly, after the intervention, there was a statistically significant difference in the level of accuracy in the performance outcome of the excretion care robot between the two groups (t=-10.67, p<.001). Thus, Hypothesis 10, ‘The experimental group that participated in the educational program on the excretion care robot will show a higher level of accuracy in the performance outcome of the excretion care robot than the control group,’ was also supported.

4. Satisfaction

The experimental group showed a high level of satisfaction with the overall aspects of education, and, in particular, showed the highest level of satisfaction with the content of the practical training (Table 3).

Discussion

This study was conducted to analyze the effects of a flipped learning-based integrated theory-practice educational program on nurses’ knowledge, attitudes, and skills regarding excretion care and the use of excretion care robots. To investigate differences in the effects of education according to the educational method, the experimental group was provided with an educational program on excretion care robots that included non-face-to-face video educational materials, in-person theoretical education, and hands-on practical training, while the control group was provided with conventional lecture-style education. In the field of nursing education, several studies have reported that flipped learning can increase the acquisition of procedural skills and improve clinical performance, critical thinking, self-directedness, and learning satisfaction in nursing students [21]. The significance of this study lies in the fact that it applied flipped learning to the area of education on care robots, and found that a flipped learning-based educational program resulted in improvements in the attitudinal determinants corresponding to the main variables of the Technology Acceptance Model, such as perceived usefulness, perceived ease of use, self-efficacy, and intention to use, as well as proficiency and accuracy in execution and performance among nurses. In particular, among the research results, the reduction of the user’s anxiety, which is a frequently raised issue in the introduction of new technologies, and the improvement of behavioral intention to use provide empirical evidence that a flipped learning-based integrated educational program can be used as a method to overcome the initial barrier to technology diffusion [22]. In this study, a total of 10 hypotheses were posited to evaluate the effectiveness of the educational program applied in this study, and all the hypotheses were statistically significantly supported by the research data.

The experimental group that participated in an educational program on excretion care robots showed significant improvements in knowledge, attitude, and skill levels regarding excretion care and the use of excretion care robots. These results were consistent with previous studies that confirmed that flipped learning is effective in improving learning outcomes in nursing education [23,24]. It has been shown that video-based pre-learning can improve learners’ interest and knowledge level [12], and combining theoretical education and practical training helps to improve self-directed and positive learning attitudes and clinical performance ability [11]. In particular, video education on the usage procedures of excrement care robots applied in this study has been reported to be effective in enhancing learning persistence and self-directed learning ability because they allow learners to control their own learning speed by pausing, rewinding, and repeatedly viewing videos [25]. In addition, hands-on practical training on the use of the care robot was found to allow participants to directly experience the operating process of care robots, thereby increasing their understanding of the device. Additionally, it was shown that systematic stepwise education and on-site practical training allowed learners to effectively learn detailed procedures that are frequently overlooked in general user manuals for devices, leading to improved performance capabilities for using the device.

The educational program applied in this study was found to be effective not only in acquiring knowledge and skills, but also in helping nurses to trust their own ability and build self-confidence in their ability to solve problems on their own. In particular, according to a previous research, in the case of technology-based devices such as care robots, the user’s self-efficacy in using the device is closely associated with the acceptance of the device as well as the long-term sustainability of using the device [26]. In this respect, the results of this study are consistent with previous research that showed that when designing an educational program, it is important to consider not only the content related to functions but also factors that can increase self-efficacy [27].

In addition, from the perspective of the Technology Acceptance Model [28], the improvement in the levels of perceived usefulness and perceived ease of use of excretion care robots among nurses after education suggests that flipped learning-based training can promote the acceptance and continued use of excretion care robots by positively improving the perceptions of the new technology. According to a previous study, higher levels of perceived usefulness and perceived ease of use are associated with a higher level of behavioral intention to use care robots [26], and perceived usefulness and perceived ease of use are considered important variables affecting technology acceptance as they act as mediating factors in the acceptance of flipped learning [29].

In this study, anxiety about the excretion care robot, which is perceived as an unfamiliar and strange object, was significantly decreased after education, and the level of behavioral intention to use the robot was statistically significantly increased after education. From the perspective of the Uncertainty Reduction Theory, these results can be interpreted as showing that as a result of directly observing and operating an unfamiliar excretion care robot and experiencing the operating principles and safety of the new technology, the participants’ anxiety and perceived threat of the unfamiliar device were reduced, and they could gain a sense of predictability as well as a sense of control, which led to positive changes in attitudes [30]. These results support the findings of a previous study reporting that nurses’ intention to apply excretion care robots in actual clinical practice may vary depending on whether sufficient education on the device is provided [31], and suggest that experiential exposure through flipped learning-based education can be used as an effective interventional strategy to reduce anxiety about new technology and enhance the technology acceptance attitude.

In the present study, the participants showed the highest level of satisfaction with practical training among the items for which the degree of satisfaction was measured. This finding is consistent with the results of a previous study that applied flipped learning-based in-school practice education to nursing students, and found a high level of learning satisfaction among the participants [32]. The result of this study is also similar to the results of a previous study reporting that the participants showed high preference for in-person practice education as an educational method [33]. In view of previous findings about high satisfaction with and preference for practice education, when field-oriented practical training reflecting actual clinical situations as well as the user manual for the device was provided to ensure nurses’ effective use of excretion care robots in this study, this hands-on practical training increased motivation for learning and the level of learning flow among the participants, and ultimately served as a key factor in improving their overall educational satisfaction.

In short, this study empirically showed that as the introduction of care robots in healthcare settings is increasingly likely to become a reality, simply providing manuals or basic theoretical education has limitations as a method to enable nurses to effectively use excretion care robots, so an integrated educational process that combines pre-learning using video materials, theoretical education, and mannequin-based practical training is required to ensure that nurses will have an increased understanding of the functions and operating principles of excretion care robots, and acquire the actual procedures of excretion care. These results can be used as basic data for the development of a standardized educational program for the use of excretion care robots in the future.

Conclusions

This study developed a multifaceted educational program designed to improve nurses’ knowledge, attitudes, and skills regarding the use of excretion care robots, as distinct from simple education on the use of the device, and empirically confirmed that an integrated educational program can play an important role in promoting the acceptance and effective use of new technology. In particular, for the safe and efficient utilization of excretion care robots in various healthcare settings such as long-term care facilities, home care facilities, and hospitals, it is essential to establish a systematic education system, and it is believed that the education program developed and applied in this study can be used as a model for such an educational system.

Figure 1.

Consort flow.

Figure 2.

Process of the experiment.

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