Received: 6 December 2020 | Accepted: 9 August 2021

DOI: 10.1111/bjet.13158

ORIGINAL MANUSCRIPT

Promoting students' learning achievement and

self-­efficacy: A mobile chatbot approach for
nursing training

Ching-­Yi Chang1 | Gwo-­Jen Hwang2 | Meei-­Ling Gau3

1
School of Nursing, College of Nursing,
Taipei Medical University, Taipei, Taiwan
2
Graduate Institute of Digital Learning and
Education, National Taiwan University of
Science and Technology, Taipei, Taiwan
3
Department of Midwifery and Women
Health Care, National Taipei University
of Nursing and Health Sciences, Taipei,
Taiwan
Correspondence
Gwo-­Jen Hwang, Graduate Institute of
Digital Learning and Education, National
Taiwan University of Science and
Technology, #43, Sec.4, Keelung Rd.,
Taipei, 106, Taiwan.
Email: gjhwang.academic@gmail.com
Funding information
Ministry of Science and Technology,
Taiwan, Grant/Award Number: MOST-­109-­
2511-­H -­011-­0 02-­M Y3, MOST 109-­2635-­H -­
227-­0 01 and MOST 110-­2511-­H -­038-­0 08
Abstract
The aims of nursing training include not only master-
ing skills but also fostering the competence to make
decisions for problem solving. In prenatal educa-
tion, cultivating nurses' knowledge and competence
of vaccine administration is a crucial issue for pro-
tecting pregnant women and newborns from infec-
tion. Therefore, obstetric vaccination knowledge has
become a basic and essential training program for
nursing students. However, most of these training
programs are given via the lecture-­based teaching
approach with skills practice, providing students with
few opportunities to think deeply about the relevant
issues owing to the lack of interaction and context.
This could have a negative impact on their learning
effectiveness and clinical judgment. To address this
problem, a mobile chatbot-­based learning approach
is proposed in this study to enable students to learn
and think deeply in the contexts of handling obstetric
vaccine cases via interacting with the chatbot. In order
to verify the effectiveness of the proposed approach,
an experiment was implemented. Two classes of 36
students from a university in northern Taiwan were
recruited as participants. One class was the experi-
mental group learning with the proposed approach,
while the other class was the control group learning

© 2021 British Educational Research Association

Br J Educ Technol. 2021;00:1–18.  wileyonlinelibrary.com/journal/bjet | 1

2 |    CHANG et al.

with the conventional approach (ie, giving lectures to

explain the instructional content and training cases).
The results indicate that applying a mobile chatbot
for learning can enhance nursing students' learning
achievement and self-­efficacy. In addition, based on
the analysis of the interview results, students gener-
ally believed that learning through the mobile chatbot
was able to promote their self-­efficacy as well as their
learning engagement and performance.

KEYWORDS
chatbot, COVID-­19 pandemic, mobile learning, nursing
education, professional training, vaccine administration

Practitioner notes
What is already known about this topic
• Issues relevant to AI technology in education have been extensively discussed
and explored around the world.
• Among the various AI systems, the potential of chatbots has been highlighted by
researchers owing to the user-­friendly interface developed using the natural lan-
guage processing (NLP) technology.
• Few studies using AI chatbots in professional training have been conducted.
What this paper adds
• In this study, a mobile chatbot was used in a nursing training program to enhance
students' learning achievement and self-­efficacy for handling vaccine cases.
• The mobile chatbot significantly improved the students' learning achievement and
self-­efficacy in comparison with the conventional learning approach in the vaccine
training program.
• From the interview results, it was found that the students generally believed that
the mobile chatbot was able to promote their self-­efficacy as well as learning en-
gagement and performances in the vaccine training program.
Implications for practice and/or policy
• Mobile chatbots have great potential for professional training owing to their con-
venient and user-­friendly features.
• It would be worth applying mobile chatbots as well as other NLP-­based applica-
tions to other professional training programs in the future.

INTRODUCTION

The content of medical and nursing education is constantly changing with the evolution
of medical technology as well as the mutation of viruses that infect all types of life forms;
therefore, continuously enhancing medical staff's knowledge and capabilities is a critical
educational objective (D'Alessandro et al., 2018). With frequent international interaction
and communication and the prevalence of epidemics, it is especially crucial to improve
MOBILE CHATBOT APPROACH FOR NURSING TRAINING    | 3

medical staff's vaccination knowledge (Arghittu et al., 2020; Kyaw et al., 2019). There are
several factors which need to be taken into account when administering a vaccine, such
as the type of vaccine, and the patient's health status and medical history. For example,
if an attenuated live vaccine is made by reducing the toxicity of live viruses or bacteria, it
is not recommended for those who are allergic to protein (Keller-­Stanislawski et al., 2014;
Moro et al., 2011). Moreover, if the patient is pregnant, improper obstetric vaccination knowl-
edge may significantly affect the morbidity and mortality rate of a mother and child (Poliquin
et al., 2019). However, in many nursing courses, obstetric vaccination knowledge is mostly
taught via a didactic teaching approach. Since this teaching approach lacks interaction with
real cases and clinical contexts, it is not easy for students to think deeply about the issues
relevant to different obstetric vaccination knowledge at each stage of pregnancy (Arriola
Vasconez et al., 2018). From the perspective of constructivism, it is important to engage stu-
dents in an interactive learning mode to facilitate knowledge construction (Jong, 2016; Lim &
Habig, 2020). The provision of personalized learning supports has been emphasized by sev-
eral researchers (Holmes Anastopoulou et al., 2018; Mavrikis & Holmes, 2019). In particular,
during the COVID-­19 pandemic, people tend to seek advice online (Adnan & Anwar, 2020;
Dhawan, 2020). To this end, researchers have pointed out that providing personalized inter-
action and in-­depth discussion on issues via AI technology is an approach with great poten-
tial for improving nursing education (Chen et al., 2020; Hwang Sung et al., 2020).
Over the past few decades, issues relevant to AI technology, machine learning and nat-
ural language processing (NLP) have been extensively discussed and explored globally
(Bini, 2018; Chen et al., ; Miller & Brown, 2018). Amershi Cakmak et al. (2014) pointed out
the role of humans in interacting with systems with the NLP and machine learning mech-
anism; that is, the human input could be a reference for the machine learning mechanism
to modify the NLP knowledge base or parameters for interpreting the meaning of human
input. The modifications made by the machine learning mechanism then enable the system
to provide better support or feedback to humans based on their needs. This implies that
humans and the system both benefit from the interactions. Accordingly, several researchers
have attempted to adopt machine learning and NLP techniques to provide better support
for enhancing students' learning effectiveness (Chih-­Ming & Ying-­You, 2020; Gasparetti
et al., 2018). For example, Tseng (2017) demonstrated the use of the techniques to enable
the computer to interact with students, thus improving their English learning performance. In
recent years, the application of AI technology in education has received increasing attention
from researchers (Mehta & Devarakonda, 2018). Researchers generally believe that the
integration of AI technology has the potential to facilitate learners' learning effectiveness
(Chen et al., , 2020; Gasparetti et al., 2018; Hwang et al., 2020). Among various computer
systems, chatbots are such systems that allow users to actively explore and construct knowl-
edge. Their use increases opportunities for practice, and enhances learning effectiveness
(Lalwani et al., 2018); therefore, researchers have attempted to develop various chatbots for
health and education, especially during this COVID-­19 pandemic. For example, Chen and
Jiang (2020) discussed a mental health chatbot and showed its effectiveness by examining
users' motivations, active communicative action and engagement after mass-­shooting di-
sasters. Valtolina et al. (2020) also employed a chatbot for healthcare.
In many nursing training programs, such as the obstetric vaccination program, students
need to take into account various factors, including the features and medical history of in-
dividual patients and the features of different vaccinations as well as the complex process
of medical treatment details. This is generally a challenge for students without personalized
supports. Scholars have pointed out that, without proper supports when learning complex
knowledge and skills, students' learning performance and self-­efficacy could be signifi-
cantly affected (Zheng et al., 2018). As a consequence, the current study adopted the mo-
bile chatbot-­based learning approach for an obstetric vaccination knowledge course so as
4 |    CHANG et al.

to overcome the shortcomings of conventional didactic instruction. In order to substantiate

the effectiveness of the mobile chatbot-­based learning approach, the following research
questions were proposed:

1. Could the mobile chatbot-­based learning approach promote students' learning achieve-
ment in an obstetric vaccination knowledge course when compared to the conventional
instruction?
2. Could the mobile chatbot-­based learning approach promote students' self-­efficacy in an
obstetric vaccination knowledge course when compared to the conventional instruction?
3. What was students' learning experience when adopting the mobile chatbot-­based learning
approach in an obstetric vaccination knowledge course when compared to the conven-
tional instruction?

LITERATURE REVIEW

Chatbots refer to computer applications that interact with users with a chatting-­like inter-
face (Smutny & Schreiberova, 2020). With the advancement of AI, which is a computer
programming technology that allows computers to simulate human thinking and reasoning
behaviours (Arrieta et al., 2020; Chen et al., ; Joost, 2009; Sutton, 2020), some chatbots
can even interact with users using NLP (Mehta & Devarakonda, 2018). NLP refers to the
technology of interpreting free-­style statements, such as human language, to understand
the meanings behind the statements, so that the computer systems can interact with users
by enabling them to express their thoughts as well as raising questions without being limited
by a particular form. At one extreme, it could be as simple as counting word frequencies to
compare different writing styles. At the other extreme, NLP involves “understanding” com-
plete human utterances, at least to the extent of being able to give useful responses to them
(Bird et al., 2009).
Lalwani et al. (2018) specified that a chatbot is an AI product based on text analysis.
Chatbots can not only talk directly to people, but also provide a voice-­based query func-
tion. They can obtain information through the Internet of Things, computers, and mobile
phones, and they serve as a conversation agent and a specific user. When users ask
some questions or start up new discussion topics, they input specific topics in natural lan-
guages for interaction and discussion such as Messenger (Smutny & Schreiberova, 2020),
WeChat (Zhang et al., 2018), LINE and Kik (Balsmeier, 2018; Mehta & Devarakonda, 2018).
Researchers have indicated that the use of a free-­style interacting interface in chatbots is
generally highly accepted by users since they are able to talk to chatbots according to their
own conversational habits (Chang & Tseng, 2019; Li et al., 2018). As a consequence, several
studies have adopted such a free-­style interface when conducting training programs or con-
sulting services (López-­Úbeda et al., 2020; Shorey et al., 2019), such as science courses
(Benotti et al., 2018), language learning (Dokukina & Gumanova, 2020) and engineering
courses (Abidin, 2019). Moreover, several chatbots have been adopted in educational set-
tings to serve as a digital assistant for students or teachers, such as those reported in the
EduTech50 2020 yearbook (https://unesd​oc.unesco.org/ark:/48223/​pf000​0376709). Some
instructors have adopted chatbots in healthcare or nursing education, such as the study
conducted by Stathakarou et al. (2020).
From the literature, it was found that few studies have been conducted to apply chatbots
to nursing education (Montayre, 2018). For example, prenatal health education providers'
knowledge of vaccines and information about foetal safety has become the main reason
for vaccination, and yet there are few intervention measures for educational research to
improve vaccination during pregnancy (Poliquin et al., 2019). Although researchers believe
MOBILE CHATBOT APPROACH FOR NURSING TRAINING    | 5

that chatbots have the potential to facilitate learning interest and interactivity, the effective-
ness of their application in nursing courses still needs further investigation. As a result, the
current study integrated a chatbot into prenatal education in the hope of exploring its effects
on students' learning achievement, self-­efficacy, and learning experience.

EXPERIMENTAL DESIGN

A quasi-­experiment with pre-­and post-­testing was adopted to examine the differences in the
learning achievement, self-­efficacy and learning experience of students who learned with
the chatbot-­based learning approach and those who learned with the conventional didactic
instructional approach.

Participants

The study recruited 36 nursing students with an average age of 21 years old from two
classes of a nursing school in northern Taiwan. The students were trained in the obstetric
vaccination knowledge course, which is a required course of basic healthcare in nursing
schools and hospitals, and is an essential part of nursing training. One class was selected
as the experimental group with 18 students who adopted the chatbot-­based learning ap-
proach. The other class was the control group with 18 students who adopted the conven-
tional didactic instructional approach. All of the students were taught by the same teacher
and did not have experience of using chatbots before the training program.

Medical chatbot

This study adopted the disease manager system (@taiwancdc) (https://page.line.me/

vqv2007o) developed by a team from HTC (HTC Corporation) and Taiwan Centers for
Disease Control (Taiwan CDC). This system uses a chatbot, Disease Manager, devel-
oped using NLP technology to provide educational knowledge about infectious diseases
and vaccine administration, as well as instant information about human epidemics such as
COVID-­19 epidemic news. It also offers global epidemic trends to warn people of necessary
precautions when traveling abroad. Users can use this @taiwancdc system to chat and ask
questions in an interactive way to obtain the professional prevention knowledge they want.
That is, they can use natural language to express their questions or points or use a pop-­up
menu to search for the information they need. They can also discuss medical issues with
the chatbot, and they can download the Line application and chat with @taiwancdc through
their mobile phones, as shown in Figure 1.
Figure 2 is an example to show the chatbot interface for interacting with learners. As
presented from the left to the right snapshots of the chatbot interface, the learner interacts
with the chatbot using natural language to discuss a medical issue. More details of the inter-
actions can be found in the Appendix.

Experimental procedure

Figure 3 shows the experimental procedure, illustrating the experimental steps of this 2-­week
study. In the first week, the teacher introduced the basic knowledge of pregnant women's
vaccines, and administered the pre-­questionnaire and the pre-­test to understand students'
6 |    CHANG et al.

FIGURE 1 Screenshot of the student test activity using the mobile chatbot-­based learning approach

prior abilities and perceptions. In the second week, the students in both groups were sched-
uled to complete the learning sheets, as shown in Table 1. In this learning task, the experi-
mental group adopted the chatbot to learn and complete the learning sheet. On the other
hand, the control group adopted the conventional didactic instructional approach; that is,
they could review the teacher's lectures and search for data on the Internet to complete
the learning sheet. After the classroom activity, the two groups of students were required to
carry out the post-­learning achievement test and complete the self-­efficacy questionnaire.
Besides, the study conducted interviews with participants in the experimental and control
groups.

Measuring instruments

The pre-­and post-­tests were designed by two experienced instructors who had more than
10 years' experience teaching the nursing course. The pre-­test aimed to evaluate the stu-
dents' basic vaccine knowledge, while the post-­test was used to assess the students' knowl-
edge of infectious diseases and the decision-­making competence to administer vaccinations
to pregnant women. Both tests consisted of 10 multiple-­choice items with a perfect score of
100. The KR20 (Kuder Richardson-­20), a measure of internal consistency for measurement
scales, was 0.82 for the pre-­test and 0.79 for the post-­test. This indicates that the items in
the tests were highly correlated (Mohamad et al., 2015).
In addition, a working sheet was compiled from frequently asked questions about mater-
nal vaccinations by the clinical teacher to guide the students to interact with the chatbot, as
shown in Table 1.
MOBILE CHATBOT APPROACH FOR NURSING TRAINING    | 7

FIGURE 2 Chatbot interface

Experimental group Control group

Pre-test and pre-questionnaire 50 mins

Mobile chatbot-based
Traditional instruction 100 mins
learning approach

Vaccine knowledge training 100 mins

Post-test and post-questionnaires 50 mins

interview 320 mins

FIGURE 3 Procedure of the experiment design

The self-­efficacy measuring tool was adopted from the self-­efficacy questionnaire con-
structed by Pintrich et al. (1991). It employed a five-­point Likert scale. The Cronbach's α
value of the original questionnaire was 0.93. The items represented students' self-­efficacy,
as shown in Table 2.
8 |    CHANG et al.

TA B L E 1 The content of the learning sheet

The content of the learning sheet

A. Is it safe for a pregnant woman to be vaccinated? Please explain your answer
B. What kind of vaccines can be given during pregnancy? Please state the reasons and detailed procedure
C. What kind of vaccines cannot be given during pregnancy? Why?
D. Can a pregnant woman have a flu vaccine? Please explain your answer
E. Where can a pregnant woman get a publicly funded flu vaccine?

TA B L E 2 Items of the self-­efficacy questionnaire

Items of the self-­efficacy questionnaire

I believe I will receive an excellent grade in this assignment
I'm certain I can master the skills taught in this assignment
I'm certain I can understand the most difficult part presented in this assignment
I'm confident I can understand the most complex part taught by the instructor in this assignment
I'm confident I can understand the basic concepts taught in this assignment
I'm confident I can do an excellent job on this assignment
I expect to get a high grade in this assignment
Considering the difficulty of this assignment, the teacher, and our team's skills, I think I can do well in this
assignment

TA B L E 3 ANCOVA of learning achievement by comparing the experimental and control groups

Adjusted Std.
Variance Group N Mean SD mean error. F η2
Learning Experimental 18 88.58 11.02 87.36 3.47 22.80*** 0.409
achievement control 18 60.51 15.01 61.73 3.47
***p < 0.001.

Moreover, interviews were conducted to explore students' learning perspectives and opin-
ions based on Hwang et al. (2009). What was the difference between the mobile chatbot-­
based learning approach and the conventional instruction? Did you think it worked? Why?
Did you take it seriously? Was it helpful for you? Overall, what were the advantages and
disadvantages of the mobile chatbot-­based learning approach? Would you like to use the
mobile chatbot-­based learning approach for learning again in the future? Would you recom-
mend the mobile chatbot-­based learning approach to your family and friends?

EXPERIMENTAL RESULTS

Learning achievement

In this study, the pre-­test scores served as a covariate and those of the post-­test were used
as a dependent variable for the analysis. The Levene's test revealed that the homogeneity
assumption was confirmed with F (1, 34) = 1.30 (p > 0.05). In addition, after verifying that F
MOBILE CHATBOT APPROACH FOR NURSING TRAINING    | 9

(1, 34) = 1.30 (p > 0.05) did not violate the regression homogeneity hypothesis, the ANCOVA
was performed to analyse the post-­hoc test scores of the two groups. The ANCOVA could
be carried out; the results of the two groups (see Table 3) showed F (1, 33) = 22.80 (p
< 0.001), indicating that the mobile chatbot-­based learning approach (Mean = 88.58; SD
= 11.02) had better results than the conventional didactic instructional approach (Mean =
60.51; SD = 15.01). The adjusted means of the experimental and control groups were 87.36
and 61.73, respectively, showing that the mobile chatbot-­based learning approach could
better enhance students' learning achievement when compared to the conventional didactic
instructional approach. Furthermore, the effect size (η2 = 0.409) was greater than 0.138,
which specified that the mobile chatbot-­based learning approach had a great influence on
students' learning achievement. In other words, the mobile chatbot-­based learning approach
could effectively improve students' learning achievement.

Self-­efficacy

In the current study, the pre-­questionnaire of self-­efficacy was used as a covariate and the
post-­questionnaire of self-­efficacy was used as a dependent variable for the analysis. The
Levene's test revealed that the homogeneity assumption was confirmed with F (1, 34) =
0.82 (p > 0.05). In addition, after verifying that F (1, 34) = 7.65 (p > 0.05) did not violate the
regression homogeneity hypothesis, ANCOVA was carried out to analyse the post-­hoc test
scores of the two groups. The ANCOVA could be performed; the results of the two groups
(see Table 4) illustrated F (1, 33) = 34.75 (p < 0.001), implying that the mobile chatbot-­based
learning approach (Mean = 4.54; SD = 0.53) had better results than the conventional didac-
tic instructional approach (Mean = 3.31; SD = 0.45). The adjusted means of the experimental
and control groups were 4.45 and 3.40, respectively, indicating that the mobile chatbot-­
based learning approach could better increase students' self-­efficacy when compared to the
conventional didactic instructional approach. Besides, the correlation coefficient (η2 = 0.513)
was greater than 0.138, which denoted that the mobile chatbot-­based learning approach
had a strong influence on students' self-­efficacy. In other words, the mobile chatbot-­based
learning approach could effectively enhance students' self-­efficacy.

Interview

In order to investigate students' learning responses to the mobile chatbot-­based learning ap-
proach, we randomly chose five participants from the experimental group and five from the
control group to be interviewed. For each participant, the interview time was 15 minutes. By
referring to grounded theory (Glaser & Strauss, 1967) and the coding procedure suggested
by Creswell (2013) and Miles et al. (2013), the interview results were analysed using three
critical analysis strategies: (1) coding: we categorized the qualitative data and described
the meaning and details of each category, (2) recall: we recorded the overall thinking and
thoughts during the research process, and (3) generalize and summarize: we compiled all

TA B L E 4 ANCOVA of self-­efficacy by comparing the experimental and control groups

Adjusted Std.
Variance Group N Mean SD mean error. F η2
Self-­efficacy Experimental 18 4.54 0.53 4.45 0.12 34.75*** 0.513
control 18 3.31 0.45 3.40 0.12
***p < 0.001.
10 |    CHANG et al.

the details and verified the most critical factors to facilitate understanding. Two researchers
were asked to code the interview results. The kappa coefficient was 0.80. The two coders
were then asked to discuss any inconsistent coding results until agreement was reached.
Finally, the coding results in Table 5 were obtained.

Interview results of the experimental group

The interview results showed that the experimental group students generally believed that
the mobile chatbot-­based learning approach had three advantages, that is, a “user-­friendly
interface,” “promoting learning engagement,” and “enhancing self-­efficacy.”
In terms of the “user-­friendly interface,” most of the students conveyed that adopting the
mobile chatbot-­based learning approach to learn obstetric vaccination knowledge might in-
spire them to propose more information relevant to the learning content, and even stimulate
them to further observe and collect relevant obstetric vaccination knowledge.

“It is easy to interact with the chatbot. I am happy to learn in this mode.”
(SIS1-­20200618)

“I can easily derive up-­to-­date information via interacting with the chatbot. In
traditional instruction, I hardly have such opportunities to explore. Learning with

TA B L E 5 Coding results for the interview

Number of times
mentioned

Theme Code Experimental Control

User-­friendly interface
Enhancing learning engagement
Enhancing self-­efficacy
Other feedback
Easy to use (the chatbot) 5 0
Helpful guidelines (the chatbot) 5 0
Easy-­to-­understand content (the chatbot) 5 0
Paying more attention to the class than 5 2
before
Concentrating on the learning tasks 5 3
Interesting learning mode 5 1
Actively exploring relevant information 3 1
Engaging in practices 5 5
Up-­to- ­date information 4 2
Gaining knowledge effectively 5 1
More confidence to learn better 5 2
Clarifying midsections 4 2
Providing instant feedback 5 0
Effectiveness of practices 5 2
Clear learning objectives and tasks 5 5
Concerns of out-­of-­date content 0 3
Feeling bored 0 3
Lacking interactions 0 4
Lacking confidence 0 3
Lacking in-­depth thinking 0 3
MOBILE CHATBOT APPROACH FOR NURSING TRAINING    | 11

this mobile chatbot, I find that there are lots of things to learn, and this easy-­to-­
operate interface enables me to find what I need.” (SIS2-­20200618)

Regarding “learning engagement,” the students generally expressed that the mobile chatbot-­
based learning approach stimulated their deep motivation, strengthened their understanding of
obstetric vaccination knowledge, and allowed them to obtain more understanding and vaccina-
tion precautions of different vaccines.

“The mobile chatbot-­based learning approach not only entertains me, but also
allows me to understand the maternal infectious disease prevention knowledge
and obstetric vaccination knowledge. It also provided interesting and compre-
hensible content, which makes me more willing to use this approach for learn-
ing.” (SIS4-­20200619)

“The learning task of obstetric vaccination knowledge enables me to gain a

deeper understanding of different measures according to each pregnancy stage.
Using the chatbot interactive learning approach makes me more engaged in the
problem context.” (SIS1-­20200618)

“In order to answer the obstetric vaccination knowledge in prenatal health edu-
cation, I need to understand the accurate concept of obstetric vaccination knowl-
edge rather than ask pregnant women to ask a doctor. I have never practiced
and learned in a similar context.” (SIS2-­20200618)

“Adopting the mobile chatbot-­based learning approach in the obstetric vaccina-

tion knowledge course activity makes students happy and engaged because it
is their first time to use this approach.” (RRW-­20200619)

As for “self-­efficacy,” most of the students stated that adopting the mobile chatbot helped
them clarify misconceptions by providing instant feedback or guidance, and hence promoted
their confidence in learning the obstetric vaccination knowledge well.

“I agree with the science theory of applying machine learning in the mobile chatbot-­
based learning approach to support obstetric vaccination knowledge courses. It is
not only for entertainment but also for in-­depth understanding. I also realize that
my teacher has worked very hard to prepare the obstetric vaccination knowledge
courses when designing, teaching and planning, enabling me to know how to im-
prove my confidence in health education in the workplace.” (SIS5-­202006019)

“This is a very practical method; the abundant content in the chatbot and the
good interactive reminder function are beneficial to pregnant women and their
families in health education. It can let me learn to improve my self-­care ability; in
addition, I will not be afraid of being asked about obstetric vaccination questions
in the future clinical environment.” (SIS3-­20200618)

“This mobile chatbot-­based learning approach helps me to further explore ob-

stetric vaccination knowledge. It allows me to learn how to help women and their
families understand, and to integrate the existing knowledge to carry out in-­
depth learning. This is a good learning approach that is worth promoting. I hope
that there will be more customized educational systems adopting the mobile
chatbot-­based learning approach in clinical contexts.” (SIS4-­20200619)
12 |    CHANG et al.

“Based on my observations, the mobile chatbot-­based learning approach in-

tegrates the task for answering obstetric vaccination knowledge. It also helps
learners to clarify the wrong concepts immediately, improve the accuracy of self-­
care, and pay more attention to the training tasks by bringing us into a similar
chatbot learning environment.” (RRW-­20200618)

Interview results of the control group

The interview data showed that most of the control group students considered the traditional
instruction as a direct and simple way of delivering knowledge. In the meantime, they indi-
cated that in such a lecture-­based teaching mode, they usually did not think in depth and
did not have sufficient interactions with the teacher. Several students further stated that they
needed to relearn a large portion of the program when dealing with practical cases since they
only tried to memorize what the teacher had taught, rather than thinking how to apply the
knowledge in the traditional instruction mode; moreover, sometimes the up-­to-­date knowl-
edge related to particular diseases or medicines could be different from what the teacher
provided.

“After taking the lecture of obstetric vaccination, I was still unable to answer
some relevant questions when facing the patients. For example, I didn't know
that different pregnancy periods have different vaccination precautions.”
(SIS10-­20200620)

“The teacher gave a professional talk to deliver the obstetric vaccination knowl-
edge. I can memorize most of the learning content. However, I don't feel con-
fident when learning with the traditional instruction since the teaching mode
seems far from practical applications.” (SIS12-­20200620)

“Only when facing the real cases related to the obstetric vaccination knowl-
edge did I start to think in depth regarding the relevant knowledge I had
learned. After reviewing the learning content, I recalled that some vaccines
can affect the fetus through the placenta, so they cannot be taken orally.”
(SIS13-­20200620)

“There was a pandemic. If the classroom teaching materials are not updated
immediately, we may not know how to respond.” (SIS14-­20200620)

Above all, the majority of students agreed that the mobile chatbot-­based learning ap-
proach can help students carry out in-­depth learning and simulate the abstract problems
of health education in the workplace as preparation for entering into clinical contexts.
It is recommended that the built-­in function of the chatbot-­based approach can include
image recognition to help students or the public distinguish and identify vaccines. In the
comparison of the two groups, it can be found that the students who adopted the mo-
bile chatbot-­based learning approach not only memorized the learning content, but also
learned how to apply the obstetric vaccination knowledge or solve problems by thinking
in depth. On the other hand, those in the control group only memorized part of the learn-
ing content. It is concluded that interacting with the chatbot-­based approach can help
students connect what they are learning with practical cases or problems, helping them
to think in depth.
MOBILE CHATBOT APPROACH FOR NURSING TRAINING    | 13

DISCUSSION AND CONCLUSIONS

The present study integrated the mobile chatbot-­based learning approach in an obstetric
vaccination knowledge course. The experimental results indicated that this approach im-
proved the students' learning achievement regarding their obstetric vaccination knowledge,
self-­efficacy, and learning experience.
From the perspective of constructivism, which emphasizes the importance of support-
ing learners' interaction with the learning contexts for knowledge construction (Sabariego
Sánchez-­Martí et al., 2020), allowing students to browse and search for learning content
via the mobile chatbot-­based learning approach is not just for answering the questions pro-
posed on the learning sheet by the teacher; it also enables them to re-­examine different
aspects of the content of obstetric vaccination knowledge (ie, possible treatments for indi-
vidual cases by taking into account different factors, such as patients' age, medical history,
and symptoms), and to try to connect the new knowledge and their acquired knowledge
or past experience (Chung & Park, 2019; Lalwani et al., 2018). This specifies that the mo-
bile chatbot-­based learning approach not only facilitates students' self-­efficacy and in-­depth
thinking, but also assists them in expanding their learning scope and re-­organizing their ac-
quired knowledge. As a result, it helps students organize effective knowledge based on the
learning objective. The findings are in line with previous studies on the mobile chatbot-­based
learning approach, for example, Yadav et al. (2019) and Dyachenko et al. (2017).
The results also show that the mobile chatbot-­based learning approach enhanced stu-
dents' self-­efficacy. Students were confident about finishing the learning sheet and task
assigned by the teacher on their own, which is consistent with the self-­efficacy theory pro-
posed by Bandura (1969), who pointed out that self-­efficacy has been defined as individuals'
belief in their abilities of organizing and carrying out actions to attain specific goals they have
set up. Scholars believe this is the most crucial element determining whether and how much
effort individuals will expend on a specific task (Power et al., 2020). With the mobile chatbot-­
based learning approach, not only do students find learning to be more interactive and inter-
esting, they can also organize and re-­examine their acquired knowledge. It can be inferred
that students' self-­efficacy increased because they had the opportunity to understand the
full picture of obstetric vaccination knowledge and to perform in-­depth thinking by exploring
relevant information. This is one of the objectives of adopting the mobile chatbot-­based
learning approach, that is, providing timely knowledge to individual learners to resolve prob-
lems encountered during the training process. This echoes the findings of Hernandez (2019)
and Liu et al. (2018), showing that an effective mobile chatbot-­based learning approach can
stimulate students' potential and improve their self-­efficacy.
In general, the main contribution of the current study is to provide the supporting data on
the effectiveness of applying chatbots in nursing education. Mehta and Devarakonda (2018)
pointed out that the adoption of machine learning combined with the analysis technology of
NLP in medical systems is insufficient compared to other fields. Therefore, how to use AI
algorithms to carry out cross-­disciplinary cooperation among computer engineering, educa-
tion, and medical professionals and develop more effective learning systems in the future is
an important issue, as suggested by Mavrikis and Holmes (2019).
It should be noted however that this study has some limitations. In order to further
investigate the factors that affect students' learning effectiveness, an in-­depth coding
analysis can be conducted after exporting the conversation content when adopting the
mobile chatbot-­based learning approach in the future. Second, there have been stud-
ies developing the mobile chatbot-­based learning approach with professional academic
value over the past few years; yet, random trials in the professional field have not been
conducted, which means that the results need be interpreted in a conservative man-
ner. Third, self-­efficacy is Bandura's concept that has been widely used and applied in
14 |    CHANG et al.

a variety of studies, and refers to self-­c onfidence in academic or non-­academic learn-

ing, both as a general approach to tasks in life or in specific situations (Bandura, 1969);
however, the instrument in this study concerned only the specific course assignment.
Furthermore, the application of the current study is the obstetric vaccination knowledge
database; due to the diversity of diseases, the development of vaccines requires time.
It also requires a team to maintain the professional knowledge content in the chatbot.
Hence, the findings of the present study are only limited to nursing or medical training
programs with similar purposes and characteristics.
According to the results and discussion of this study, several suggestions for future stud-
ies are proposed. First, it is suggested that researchers in this field apply the integration of
the mobile chatbot-­based learning approach and professional knowledge to other occu-
pational training programs to develop learners' decision-­making and problem-­solving ca-
pability. As suggested by several previous studies (Zajda, 2018), from the perspective of
constructivism, it is important to enable learners to browse and search for learning content
in an interactive manner for those learning activities aiming at fostering learners' decision-­
making and problem-­solving capability, while chatbots could be a suitable learning tool in
this regard. Second, it could be valuable to investigate the influences of personal factors
on learners' achievement, self-­efficacy, and learning experience when using the mobile
chatbot-­based learning approach. These factors may be students' personal characteristics
or perspectives. By taking these factors into consideration in future studies, more accurate
suggestions could be provided via the mobile chatbot-­based learning approach. Third, it is
important to explore the effectiveness of the mobile chatbot-­based learning approach from
different aspects. In addition to the foci of the present study (ie, learning achievements, self-­
efficacy and learning experience), there are other important objectives of professional train-
ing, such as learning engagement, critical thinking, reflective thinking, and problem-­solving
competence. Furthermore, it is also important to investigate the factors affecting learners'
achievement, self-­efficacy, and experience of learning with chatbots. As suggested by Yin
and Satar (2020), knowing the factors which affect learners' performance and perceptions is
crucial for researchers and school teachers to make reflections and develop better learning
approaches in the future.

ACKNOWLEDGEMENTS
This study was supported in part by the Ministry of Science and Technology (Taiwan) under
contract numbers MOST-­106-­2511-­S - ­011- ­005- ­MY3, MOST-­108-­2511-­H - ­011- ­005- ­MY3,
MOST-­106-­2511-­S -­152-­012-­MY3, MOST 109-­2635-­H -­227-­001.

CONFLICT OF INTEREST
There is no potential conflict of interest in this study.

D ATA AVA I L A B I L I T Y S TAT E M E N T

The data can be obtained by sending a request e-mail to the corresponding author.

E T H I C S S TAT E M E N T
The study has been evaluated and approved by the research ethics committee of National
Taiwan University with the IRB number 202008ES007. The participants were protected by
hiding their personal information during the research process. They knew that their partici-
pation was voluntary and they could withdraw from the study at any time.

ORCID
Ching-­Yi Chang https://orcid.org/0000-0002-3146-2270
Gwo-­Jen Hwang https://orcid.org/0000-0001-5155-276X
MOBILE CHATBOT APPROACH FOR NURSING TRAINING    | 15

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How to cite this article: Chang, C.-­Y., Hwang, G.-­J., & Gau, M.-­L. (2021). Promoting
students' learning achievement and self-­efficacy: A mobile chatbot approach for
nursing training. British Journal of Educational Technology, 00, 1–­18. https://doi.
org/10.1111/bjet.13158
18 |    CHANG et al.

APPENDIX

I L L U S T R AT I V E E X A M P L E O F I N T E R A C T I N G W I T H T H E C H AT B O T