A Multi- country Perspectives on Social Networking Sites Utilization, Perceived Benefits & Potential for Improving Study Habits among Nursing Students

Background: The abundance of easy and accessible information and the fast developing social networking sites (SNS) have proven the world is small and within reach. The great implication of this interconnectedness can be somehow attributed to the change in the learning and sharing environment— something a classroom is lacking; and considering the potential implication of SNS in nursing education reveals that the benefit allows the students to communicate and interact with wider audience and beyond the classroom. The aim of this study is to identify the extent of social networking site utilization, the perceived benefits and the potential for improving study habits of nursing students in five countries (Israel, Iraq, Oman, Philippines & Turkey). Methods: The Study is a Quantitative –Cross-sectional study that determines the relationship between the utilization, the perceived benefits of social networking sites, and the potential for improving study habits among nursing students in the five participating countries (Israel, Iraq, Oman, Philippines, and Turkey). The basis of this paper is the careful analysis survey of students’ responses from a sample of 1,137 students from an online hosting site. The online instrument study focuses on the extent of utilization and benefits of social networking sites according to its accessibility, usability, efficiency and reliability. Results: Our findings in correlation using Pearson R- reveals a significant positive correlation between the extent of doing possible study habits and the extent of utilization of social networking sites in terms of the four domains, namely, accessibility (r=0.246), usability (r=0.377), reliability (r=0.287) and efficiency (r=0.387). Conclusion: It can be concluded that a significant positive correlation between students’ study habits and the extent of utilization means that the more students devote themselves on study habits, the higher the level of social networking site utilization. There are positive and negative implications in using social networking sites among nursing students and there is greater potential in further improving the approaches to nursing education through adaptation of curricula based around the proper utilization of social networking sites. significant of pairwise comparison the result on the significant difference. The extent of utilization of SNS in all areas was consistently higher in female nursing students except in accessibility. This suggests a possible relationship that the female students tend to have a higher extent of utilization of social networking sites but not in accessibility. Mann-Whitney U test was used and the test revealed that there was a significant difference in the extent of utilization of social networking sites only in terms of accessibility. This indicates that the extent of utilization of nursing students in terms of accessibility was significantly higher in male students than the extent of utilization of female students. Since the results indicate a non-significant p-value (p>0.05), this also means that the extent of utilization of SNS in terms of usability (p = 0.134), reliability (p = 0.264) and efficiency (p = 0.586) of the nursing students were the same regardless of their sex. On accessibility, fifth-year nursing students have the highest utilization of SNS in terms of accessibility (Mn Rank = 538.86), reliability (Mn Rank = 603.22), and efficiency (Mn rank = 631.38). Fourth-year nursing students were consistently the lowest in the extent of utilization in terms of usability (471.68), reliability (Mn rank = 448.22), efficiency (Mn rank = 419.48) but not in accessibility (Mn rank = 486.23). It was also observed that there was a fluctuating pattern as the students’ year level goes up which was consistent with the results presented.

academic advising, and for student education [5]. Nursing students identified three proposed reasons for the use of social media to learn through social networking and to socialize with other students which establishes professional social networking [6]. First, social networking sites also allow communication with students through instant messages. Second, they enable rapid response to questions asked by students and facilitate virtual discussions that make students a part of a community. Third, these SNS also allow active, interactive and reflective learning [6]. A study on the use of Facebook for online discussions among distance learners the results show that interaction via Facebook was more frequent compared to the use of the forum; and indicates that Facebook has the potential to be used in online academic discussions [7]. The use of Twitter allowed connection between students, access to external resources, improved learning, and support to access videos providing an opportunity for reflection, flexibility, collaboration, and feedback [8]. The use of a social networking tool called Ning verifies the feasibility and effectivity of integrating inter-professional education, that most students showed interest in learning more and in optimizing patient cares [9]. The use of social networking platforms is a less expensive way of interpersonal education with the possibility of implementing interprofessional education on a large scale and in the long term [9]. A study identified that most students agree that the use of SNS like Ning contributed to adding knowledge and increase in understanding of content [10]. The study on considering the potential implication of SNS in nursing education revealed that the benefit allows the students to communicate and interact with a wider audience and beyond the classroom [11]. One example is the creation of a research group called MARG (mentors and researchers group) to create mentors that use Facebook as a communication platform to promote events and serve as a network to discuss issues and concerns among nursing students [ 12]. Students realize that Facebook groups can be an innovative method to study. It is also described to be useful in promoting learning among peers and teachers [13]. SNS are very widely used among college students and are beneficial to them because they have the ability to mingle students from all over the world in one virtual world [14]. This also means that campuses can now begin to blend classes' subject areas as well as different campuses,A similar study agree that students spend on average, 1-2 hours a day on SNS for educational purposes [15]. In relation to this a study on social networks and learning stated that students listed learning as a top priority in utilizing SNS [16]. In contrast, however, other studies say that Facebook leads to lower grades [15]. The use of social media has greatly shown an unlimited influence in a student's lifestyle in general. The study is aimed at identifying the nursing students' degree of utilization, perceived benefits of social networking sites and their potential in improving student study habits. This study also seeks to determine the relationship between utilization, perceived benefits, and the potential for improving study habits among nursing students in five countries. There is a scarcity of research specifically addressing nursing education and the use of social networking sites that this study generally aims to shed light on the potential of SNS in improving the study habits of nursing students among the five countries.

Research Questions & Hypothesis
This research study seeks to answer the following questions: What is the extent of utilization of social networking sites as a means of communication in terms of educational purposes? What social media network is most helpful among nursing students? What are the perceived benefits of social networking sites in terms of Accessibility, Usability, Efficiency and Reliability? Is there a significant relationship between the extent of utilization and perceived benefits of social networking sites among nursing students? And is there a potential for improving the study habits of nursing students utilizing SNS?
The level of significance is tested at α0.05. HO 1: There is no significant relationship between the extent of utilization and benefits of social networking sites among nursing students. HO 2: Using Social Networking Sites has no potential for improving students' study habits.

Study Design
This study is a quantitative-cross-sectional design that determines the relationship between the utilization and perceived benefits of social networking sites and the potential for improving study habits among nursing students in the five participating countries (Israel, Iraq, Oman, Philippines, and Turkey)

Research Locale
The study was conducted in five countries (Iraq, Israel, Oman, the Philippines, and Turkey).
Country selection participation is through a voluntary system. The focus of the study is on the utilization and perceived benefits of social networking sites and the potential for improving study habits among regular nursing students in the selected colleges and universities of the participating countries. The study participants consisted of first-year to fifth-year Bachelor of Science in nursing students from the five participating countries.

Sample and Sampling Techniques
The sample of respondents of the study comprised 1,200 students selected study cohort in each university that meets the set of inclusion criteria, and based on the returned accomplished online form, 1400 links were forwarded. The purposive sampling technique was used considering the criteria for the population, and a post hoc sample was computed using Proportion Analysis using

Ethical Considerations
The study sought approval from Assiut University in Egypt dated IRB 08/08/2017 number 38 and ethical clearances in the respective participating countries. . The study is a non-experimental study that will not utilize human subjects. The study is done by seeking permission and approval from respective focal collaborating countries. The three-part survey tool is administered through the use of an online survey -a provided consent form to proceed and to seek their willingness to partake in the study. The return of the electronically tallied survey form indicates a willingness to participate. The participants' identities and personal information are left undisclosed. Blind tallying was used to secure privacy and to maintain participant anonymity by using codes. All respondents were informed about voluntary withdrawal from the study.

Data Gathering Procedure
Main IRB approval and a communication letter with the IRB approval was coursed through the pre-identified colleges and universities in the five (5) aforementioned participating countries. Once approval from each locale IRB has been taken, the corresponding co-researchers were in charge of the selection of the study participants based on the inclusion and exclusion criteria. Data collection transpired between the Spring of 2017 and Fall of 2018. Through a hosting site, a web-based online tool was forwarded as a link to study participants for easy access.

Research Instrument
The Instrument has been subjected to both internal validity and reliability. Likert scale. When responding to a Likert questionnaire item, respondents specify their level of agreement to a statement. Participants were asked to check the number that best corresponds to their answer regarding the extent of utilization and perceived benefits of social networking sites among nursing students. The highest range is 4 and 1 is the lowest.

Data Analysis
The results of this study were analyzed and interpreted using the Statistical Package for Social Sciences (The IBM SPSS 24.0) considering the following: Weighted Mean was used to determine the average of the extent of utilization of social networking sites among nursing students. It was also used to determine the perceived benefits of social networking sites in terms of accessibility, usability, efficiency, and reliability of social networking sites among nursing students. After gathering all the answered questionnaires, the mean is computed and gauged according to the following range and qualitative interpretation: ANOVA was also utilized to identify significant differences among the two different mean domains and a post hoc test was performed using Bonferroni α [17]. Mann Whitney U test was used to test two or more independent samples that have been drawn from the same population where the level of measurement is ordinal [18]. Pearson R is both descriptive and inferential [17], and was used to determine the magnitude and direction of a significant relationship between the extent of utilization and perceived benefits of social networking sites among nursing students, and to determine the relationship between student demographic profile, utilization & perceived benefits with the potential to improve study habits.

Results
The study recruited 1,200 participants out of which a post hoc sample using proportion analysis yielded 1,137 students that were taken as an actual sample for the study. The profile distribution of the nursing students grouped by country showed that students from Israel were mostly 26-28 years old, female and first-year students. While nursing students from Iraq were mostly 20-22 years old, female and second-year students. In Oman, most of the nursing students were also 20-22 years old, female, and do not belong to first to fifth-year levels. They were irregular students who can be placed in between levels depending on their nursing major courses, and they can be clustered on a specific year. In the Philippines and Turkey, most of them were 20-22 years old, female and third-year students. Overall, the majority of the students were 20-22 years old and female. Most of them were third-year students ( Table 1).
The percent distribution of the extent of utilization of SNS as means of communication according to educational purposes among nursing students in five countries shows that majority of the nursing students slightly utilized SNS in terms of their accessibility (61.3%), and moderately utilized them in terms of usability (60.2%). It also shows that most of them moderately utilized SNS in terms of their efficiency (45.2%) and reliability (46.8%) (  (3.12) or sometimes studying with music or while watching TV (2.41). Moreover, they often consider studying even without exam (2.70) or completing difficult assignments (2.70). They normally enjoy learning (2.81), and they were always confident that they can get good grades (3.10). They also frequently give importance to getting exceptional grades (3) and they make sure that they know which homework to accomplish (3.10)( Table 5) ( Table 7).
Furthermore, the result of repeated measures ANOVA revealed that there was a significant difference among the domains of the utilization of the SNS. Hence, a further test performed through Bonferroni posthoc test accessibility was significantly lower than usability, reliability or efficiency. However, usability was significantly higher than reliability or efficiency, and reliability was significantly higher than efficiency (Table 8). Pearson R-reveals a significant positive correlation between the extent of doing possible study habits and the extent of utilization of social networking sites in terms of the four domains, namely accessibility (r = 0.246), usability (r = 0.377), reliability (r = 0.287) and efficiency (r = 0.387). This means that there was a direct relationship between the two variables. It further means that the more study habits done by the nursing students, the higher the extent of utilization in terms of accessibility, usability, reliability, and efficiency (Table 9).

Discussion
The findings of this study identified social networking sites and the relationship between their utilization and perceived benefits, and their potential for improving study habits among nursing students in five different countries. Based on the analysis of the findings in the study, most student respondents were female, third-year students of Bachelor of Science in nursing ages 20-22 years.
Similar findings with the study conducted in Pakistan where the majority of the nursing respondents were female within the age bracket of 21 to 25 years [19]. A relevant finding explained how social media is an important aspect of today's adolescents which poses efficiency if properly utilized [20].
The study reveals that the majority of the nursing students from across five countries were more

engaged in websites and SNS such as Facebook, WhatsApp and Google. A study conducted in 2009 in
Brazil & Singapore showed wide utilization of Facebook on a regular basis [21]. These findings were also true in earlier studies where My Space and Facebook are among the most popular sites among students even though it is not created for educational purposes [22]. In the study results, it was also evident that the use of SNS was important in establishing communication for educational purposes, and 61.3 % of the respondents utilize social networking sites for the purpose of relaying information relevant to their studies.
A study suggested that SNS are platforms that can be used to improve educational impact by adapting modifications in instructional curricula in medical schools [2]. The aspect of accessibility is an important factor in today's generation of internet-savvy students, and the study findings suggested the great importance of accessibility. It was found that students were able to get access to their social networking profiles through internet cafes, malls, restaurants and within the campus. A study mentioned that access to information is just a click away and the accessibility of the information in the internet and SNS is widely used, and it was inherently identified as the main reason why most students are not visiting libraries anymore [23]. Quick and easy access to SNS makes it preferable for most students especially for the purpose of education and learning.
The usability of SNS in terms of educational purposes is yet a topic that needs to contextualize as the study findings showed that nursing students in five countries use SNS for educational gain by taking advantage of the information in acquiring knowledge on current lessons, getting updated on ongoing school activities, and for the purpose of advanced studies. This is contrary to the study done in Oman where the findings showed that SNS was mainly used for entertainment purposes and lesser for educational purposes [24]. SNS can be presented in various mediums such as photos, videos, interactive interfaces and games which make them highly engaging among students. Moreover, nursing students engage in more interactive skill-based learning sessions. In terms of reliability, nursing students from the five participating countries identified that SNS was moderately utilized for the purpose of keeping track of school activities and improving knowledge and skills. In the aspect of efficiency, students scored high in providing correct data and information, enhanced their abilities in providing nursing care, and learning was drawn from performing proper techniques relevant to their nursing skills. It was also noted that clinical instructors partly recognized students' expertise drawn from social networking sites which was supported by a study intervention using SNS that teach nursing students about the ethical and moral behavior done through Facebook by humanized mannequins in social networks [25].
Advancing teaching strategies and the availability of updated and timely learning materials can be advantageous as a learning platform among nursing students. Overall, the nursing students in all five countries were synonymous in that they moderately utilize SNS. In terms of benefits, students from the five countries said that SNS are highly beneficial according to a study where 54.92% of dental students in a university in India suggested that usage of social networking sites were beneficial in their studies and learning needs [26]. This can be supported by an online survey conducted about social networking as a learning tool, where it was found that majority of the students perceive SNS as an innovative method of study support guided by learning and by enhancing efficacy [13]. However, this is contrary to the study results on the effects of online social networking on student performance that suggest that time spent in social networking sites by medical students can negatively influence student achievement [27]. The negative and positive aspects of SNS utilization is a debatable issue that is yet to be addressed, because SNS can be addicting and their improper usage may lead to less positive outcomes. Studying is a skill, and developing study habits is vital to the progress of the students' academic performance [28]. There is available literature that highly contends the use of social networking sites as means to become academically successful like in a study that mentioned that Facebook and SNS are considered the biggest distraction among college students, and that their study habits and grades are affected [29]. Based on the nursing students' perspectives on their study habits, the study participants from the five countries unanimously identified time management as essential, and a fixed schedule is important when utilizing social networking platforms. This is evidently described in the result of the study conducted where SNS can enhance performance in a simple task environment and will make no difference in a complex performance environment [30].
Utilization was also found to be consistently high among female nursing students. It's a known fact that nursing is female-dominated [31], there are confirmed gender differences that exist with adopted technologies, and they occur among genders of ages 16 to 35 [32]. These findings are firmly contradicted by a study conducted in China where Chinese females were found to be clearly less engaged with technology as compared with Chinese males [33]. On the other hand, women who were found to have higher introversion and extraversion traits turned to the internet for social services, such as online chats and discussion groups [34].
In a geographical and cultural context, it can be viewed that in countries like Iran, Israel, Oman & Turkey, the female gender is given less opportunity for public exposure which results to higher use of SNS which is seen as a viable medium to socialize and be engaged with others instead of being physically present. Oman and the Philippines are identified highest in terms of utilization. In a study conducted by Sultan Qaboos University among health science students, the findings showed Youtube, Facebook, and Twitter as the highest used social media platforms. The findings generally suggest that usage and addiction is similar to the rest of the world [35]. On other hand, in the Philippines, the USbased Pew Research Center said that 88% of Filipinos see that increasing Internet usage is good for education, given that the Philippines is often dubbed as the "social media capital" of the world, [36].
On the contrary, Turkey ranks least in the utilization of social networking sites in the findings of Kirschner & Karpinski in Turkey, a study among undergraduate students reveals that students who report academic problems are more likely to use the Internet for social networking (e.g., Facebook) purposes [37]. The results of the hypothesis testing yielded positive relationship between study habits against the extent of utilization among nursing students in the five participating countries. The levels of engagement among nursing students in the utilization of SNS can be most beneficial and relevant to their study purpose. SNS are deemed necessary in this generation of learners wherein a significant amount of information acquisition is within grasp and readily available.

Conclusion
It can be concluded that the nursing students from five participating countries are widely female dominated and that the extent of utilization is of foremost female gender. This study also identified the level of nursing student social networking sites' utilization and benefits perceived moderately in both aspects, taking into account access, usability, efficiency and reliability. The most utilized social media platform in Israel, Iraq, Oman, Philippines, and Turkey are WhatsApp & Facebook. A triangulation of utilization, perceived benefits and study habits show a positive relationship among the three factors. Similarly, a significant positive correlation between students' study habits and the extent of utilization means that the more students devote themselves to study habits, the higher the level of SNS utilization. The utilization of SNS for educational purposes have both positive and negative implications [13,[38][39].

Recommendations
The study further suggests that similar studies in the future should focus not only on the aspects of access, usability, efficiency & reliability, but the inclusion of behavioral aspects as well as cultural differences can also be taken into consideration. The homogeneity of the sample can also be improved by tapping more diverse nursing student population in Israel and Iraq. Oman and Turkey with the exception of the Philippines are homogenous in terms of culture and geographic settings. A mixed-method approach can also be recommended to contextualize the confounding influence of culture and geographic location in future studies. Although there are several studies on SNS and academic performance, very few are done in nursing academia that focus on skills or psychomotor development through these virtual platforms that can also be used in the teaching-learning process [40]. The influences of SNS among nursing students and their great potentials in enhancing students' study habits are an area of opportunity in developing curricula that are not restricted to the four corners of the classroom. SNS by and wide is the current and most relevant platform that can further add to the learning success and academic achievement of nursing students. A tailored strategy for enhancing student participation, interaction and real-life learning are just a few of the advantages of tapping on the positive contribution of SNS as a learning-teaching tool in nursing education.     STROBE_checklist.doc