The effects of the forgetting curve in the training of knee arthroplasty surgical instrument nurses: a pilot randomized controlled trial - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. 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Learn more: PMC Disclaimer | PMC Copyright Notice BMC Nurs . 2026 Mar 9;25:362. doi: 10.1186/s12912-026-04521-2 Search in PMC Search in PubMed View in NLM Catalog Add to search The effects of the forgetting curve in the training of knee arthroplasty surgical instrument nurses: a pilot randomized controlled trial Lin Zhang Lin Zhang 1 Operating Room, The First Affiliated Hospital, Guangzhou Medical University, No 151, Yanjiangxi Rd., Guangzhou, 510120 China Find articles by Lin Zhang 1, # , Siwei Chen Siwei Chen 1 Operating Room, The First Affiliated Hospital, Guangzhou Medical University, No 151, Yanjiangxi Rd., Guangzhou, 510120 China Find articles by Siwei Chen 1, # , Qimei Liang Qimei Liang 1 Operating Room, The First Affiliated Hospital, Guangzhou Medical University, No 151, Yanjiangxi Rd., Guangzhou, 510120 China Find articles by Qimei Liang 1, # , Shuchen Wang Shuchen Wang 1 Operating Room, The First Affiliated Hospital, Guangzhou Medical University, No 151, Yanjiangxi Rd., Guangzhou, 510120 China Find articles by Shuchen Wang 1 , Zhanhua Han Zhanhua Han 1 Operating Room, The First Affiliated Hospital, Guangzhou Medical University, No 151, Yanjiangxi Rd., Guangzhou, 510120 China Find articles by Zhanhua Han 1 , Jingjuan Huang Jingjuan Huang 1 Operating Room, The First Affiliated Hospital, Guangzhou Medical University, No 151, Yanjiangxi Rd., Guangzhou, 510120 China Find articles by Jingjuan Huang 1, ✉ , Zeyong Zhang Zeyong Zhang 1 Operating Room, The First Affiliated Hospital, Guangzhou Medical University, No 151, Yanjiangxi Rd., Guangzhou, 510120 China Find articles by Zeyong Zhang 1, ✉ Author information Article notes Copyright and License information 1 Operating Room, The First Affiliated Hospital, Guangzhou Medical University, No 151, Yanjiangxi Rd., Guangzhou, 510120 China ✉ Corresponding author. # Contributed equally. Received 2025 Jul 18; Accepted 2026 Mar 2; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13085420 PMID: 41803836 Abstract Objective This study aimed to compare the conventional review teaching method with the forgetting curve-based teaching method in the training of novice knee replacement surgical instrument nurses. Method From April 2021 to April 2024, 30 new surgical instrument nurses were enrolled and randomly divided into 2 groups ( n = 15). The control group received the conventional review teaching method, while the intervention group received the forgetting curve-based teaching method, which included three reviews of knowledge and skills at 24 h, 7 days, and 30 days. The performance of the two groups was compared in terms of clinical training assessments, the satisfaction of surgeons with the cooperation of new operating room nurses, and the satisfaction of new operating room nurses with teaching. Result Compared to before training, the clinical training assessment scores of both groups increased 1 day (from 64.33 ± 7.17 to 90.33 ± 7.18 in the intervention group and from 64.60 ± 7.31 to 85.40 ± 8.37 in the control group) and 1 month (from 64.33 ± 7.17 to 89.86 ± 7.19 in the intervention group and from 64.60 ± 7.31 to 75.33 ± 7.91 in the control group) after training ( P < 0.05). In the experimental group, there was no significant difference in the clinical training assessment scores 1 day and 1 month (90.33 ± 7.18 vs. 89.86 ± 7.19, respectively) after training ( P > 0.05), while the control group showed a decrease in the clinical training assessment score 1 month after training compared to 1 day after training (85.40 ± 8.37 vs. 75.33 ± 7.91) ( P < 0.05). At 1 month after training, clinical training assessment scores were higher in the experimental group than in the control group (89.86 ± 7.19 vs. 75.33 ± 7.91). Compared to the control group, the experimental group exhibited a higher surgeon satisfaction score (91.44 ± 7.68 vs. 85.10 ± 8.54) ( P < 0.05) and surgical instrument nurse satisfaction scores after applying the forgetting learning curve-based teaching method ( P < 0.05). Conclusion In this study, the incorporation of the forgetting curve into educational programs improved the clinical training assessment score and satisfaction score of surgical instrument nurses and increased the satisfaction score of surgeons for knee transplantation surgery. Trial registration This clinical trial has been retrospectively registered in the Chinese Clinical Trial Registry on February 14, 2026 (registration number ChiCTR2600119024, retrospectively registered). ( https://www.chictr.org.cn/historyversionpubEN.html?regno=ChiCTR2600119024 ). Clinical trial number ChiCTR2600119024. Supplementary Information The online version contains supplementary material available at 10.1186/s12912-026-04521-2. Keywords: Forgetting curve, Novice nurses, Knee replacement surgery, Medical equipment nurse, Operation training Introduction Knee arthroplasty is a surgical procedure widely employed for the treatment of severe knee joint degeneration, characterized by unbearable pain and functional limitation [ 1 ]. The joint function can be restored by removing the damaged joint surface and replacing the damaged cartilage and other tissues with artificial biological materials [ 1 ]. A retrospective review of the NIS registry, which comprises the largest publicly available all-payer inpatient care database in the United States, showed that from 2006 to 2015, 5,901,057 patients underwent primary total knee arthroplasty and 465,968 patients underwent revision total knee arthroplasty in a single country [ 2 ]. The proficiency of operating room nurses in surgical techniques and instrumentation is necessary for successful knee arthroplasty [ 3 ]. Nevertheless, the skills and knowledge gained through training are merely transiently retained in the brain, making them susceptible to forgetting without consistent practice [ 4 ]. The forgetting curve law delineates the phenomenon of gradually losing information over time following learning [ 5 ]. Recent studies have increasingly focused on the importance of the forgetting curve in the maintenance of acquired medical knowledge [ 6 , 7 ]. By understanding this principle, a systematic review strategy can be developed to help trainees retain long-term memory of the acquired knowledge, thereby mitigating physiological forgetting [ 8 , 9 ]. Qian et al. reported that compared to the traditional teaching method, Roy’s adaptation model combined with the forgetting curve can significantly improve the learning abilities and adaptability of operating room nursing interns and enhance the relationship between physicians and nurses [ 10 ]. Similarly, Boutis et al. reported that repeated training and testing can help overcome learning decay in radiograph interpretation skills [ 6 ]. Among dental students, repeated reinforcement contributed to long-term knowledge retention and increased the confidence of students [ 11 ]. Although several studies have assessed the effects of the forgetting curve-based method on the performance of surgical nurses and physicians [ 10 , 11 ], the effects of the forgetting curve-based method on the performance and satisfaction of novice surgical instrument nurses involved in knee replacement surgery have rarely been assessed in clinical trials. Thus, this study aimed to compare the effects of the conventional review teaching method and the forgetting curve-based teaching method on clinical training assessment score, the satisfaction of surgeons with the cooperation of new operating room nurses, and the satisfaction of novice operating room nurses with teaching among novice surgical instrument nurses involved in knee replacement surgery. Method Ethics approval This study strictly followed the ethics standards defined by the Declaration of Helsinki, and informed consent was obtained from all participants before their participation. The study was reviewed by the Ethics Committee of The First Affiliated Hospital of Guangzhou Medical University (IRB name: Scientific Research Project Review Ethics Committee). Based on the “Ethical Review Measures for Biomedical Research Involving Humans” and in accordance with the Declaration of Helsinki and CIOMS ethical guidelines, the committee determined that this project met the exemption criteria and issued an official exemption decision (Approval No: KYLL-MS-011-01-FJ02). Design This study adopted a randomized controlled trial design, utilizing a pre-test and post-test framework with two parallel groups assigned in a 1:1 ratio. This clinical trial adhered to CONSORT guidelines for reporting. In addition, the study was retrospectively registered in the Chinese Clinical Trial Registry on February 14, 2026 (registration number: ChiCTR2600119024). Participants and recruitment The participants were newly appointed orthopedic instrument nurses who had been enrolled since June 2025. Upon completion of the course, an announcement was disseminated through the learning management system to remind students to complete the satisfaction survey, enabling nurses to provide feedback on the course. The inclusion criteria were as follows: (1) surgical instrument nurses with less than three years of experience; (2) those who have completed training for other subspecialties and were preparing to undergo orthopedic subspecialty training; (3) individuals willing and able to provide informed consent; and (4) participants agreeing to complete all stages of learning. The exclusion criteria were as follows: (1) surgical instrument nurses who have not completed training for any other subspecialties; and (2) those who did not agree to complete all stages of learning. In total, 30 operating room nurses participated in this study (Fig. 1 ). Fig. 1. Open in a new tab Flowchart depicting the participant screening process and trial implementation Randomization The participants were randomly allocated to the experimental or control group, and were subjected to the forgetting curve teaching method or received traditional instruction, respectively. The allocation process was conducted using a computerized random number generator developed by independent statisticians who were not involved in participant recruitment. The researchers remained unaware of group assignments, and participants were also blinded to their group allocations to minimize bias. Furthermore, individuals responsible for data collection and analysis were blinded to participant grouping. Intervention In both the control and experimental groups, the operating room nurses underwent centralized training on the theoretical aspects of knee arthroplasty surgery, including an introduction to surgical instruments. Both groups were taught and trained by the same instructors. The initial section encompassed anatomy, surgical procedures, intraoperative precautions, instrument explanations, and positioning requirements. The second part addressed the content of practical skills. In the experimental group, a teaching plan was developed based on the principles of the forgetting curve, while traditional one-time operational practice was employed in the control group. Explanation exercises were conducted to stimulate nurses’ curiosity and maintain their attention. Following the demonstration by the training instructor, the experimental group was divided into three subgroups to elucidate all operational steps. In practice sessions, peer assessments were conducted among group members, allowing the training instructor to provide immediate guidance and correction of errors. The training instructor also designed relevant simulation scenarios to encourage the critical thinking of nurses regarding typical nursing challenges in the field of knee arthroplasty surgery. Guided discussions facilitated by the training instructor focused on the identification of causes and solutions for these issues, finally leading to optimal resolutions. The training instructor summarized key findings at the end of each discussion. Nurses in the experimental group underwent three reviews of knowledge and skills. The first review (within 24 h) was conducted to reinforce memory retention of initial concepts through simple question-and-answer sessions, simulated operations, or review notes. The second review (7 days later) focused on enhancing understanding through more practical exercises, simulated surgical scenarios, and teamwork, particularly addressing common issues and improving coping abilities to assess the nurses’ grasp of theoretical knowledge about knee arthroplasty surgery. The third review (30 days later) involved a subsequent assessment where the nurses’ operational competencies were evaluated and enhanced through complex case analyses, performance assessments, and actual clinical procedures. In contrast, a traditional approach involving single repeated practice was employed for nurses in the control group to acquire knowledge and practical skills (Table 1 ). Table 1. The development and application of teaching methods based on the principles of the forgetting curve Membership composition The authors conducted a thorough literature review and participant interviews to identify their needs and challenges. In total, six members from the expert group, including one head nurse from the operating room, one head nurse from the training center, one deputy chief physician in the orthopedics department, and three senior orthopedic nurses, were responsible for proposing, guiding, implementing, and coordinating the training program. Design The authors established two distinct teaching programs, in which the principles of the forgetting curve were integrated into the experimental group’s curriculum. The teaching plan grounded in the principles of the forgetting curve encompassed the acquisition and review of knowledge and skills. Implementation Nurses in both the control and experimental groups utilized multimedia resources to participate in centralized lectures covering anatomical knowledge, surgical procedures, the installation and use of instruments, and intraoperative precautions. The experimental group employed case studies, simulated scenarios, and three review sessions to reinforce their knowledge, whereas the control group adopted a traditional one-time teaching method. After one month, both groups successfully completed clinical training in nursing for knee arthroplasty surgery. Assessment Online questionnaires were dispatched to assess students’ mastery of knowledge and satisfaction with teaching methods and evaluate clinicians’ satisfaction with the collaboration of surgical instrument nurses. Open in a new tab Measurement Clinical training assessment [ 12 ] The clinical training assessment was conducted before training, one day after training, and one month after training. The invigilator randomly assigned cases of knee replacement surgery and designated operating room nurses to participate in surgical collaboration. Invigilators closely monitored the nurses’ performance during preoperative evaluations, preparation of necessary surgical items, adherence to aseptic techniques, management and use of instruments (including installation, use, and disassembly), and transfer of instruments intraoperatively. The invigilator posed questions to the nurses regarding knee arthroplasty surgery in the operating room to assess their ability to handle emergency situations. The total score for the assessment was 100 points. Surgeons’ satisfaction with the collaboration of instrument nurses After conducting a literature review, the researchers developed this self-administered questionnaire to evaluate surgeons’ satisfaction with the collaboration of instrument nurses. The total score of the questionnaire was 100 points, and the score of each evaluation item ranged from 0 to 10 points. A higher score suggested a greater level of surgeon satisfaction with the collaboration of the operating room nurses. Satisfaction of instrument nurses with the educational program This self-administered questionnaire was developed based on a previous study conducted by Kuo et al. to measure nurses’ satisfaction with teaching methods [ 13 ]. The questionnaire comprised 10 items: stimulating learning interest, enhancing the ability to analyze and solve problems, improving clinical thinking and teamwork skills, refining data collection and literature retrieval abilities, augmenting practical operation skills, fostering learning initiative and enthusiasm, strengthening the integration of theory and practice, enhancing classroom engagement and appeal, promoting interaction between teachers and students, and satisfaction with the teaching modality. Each item was scored on a scale from 0 to 10 points, with a total score of 100 points. ‘Very able to improve’ corresponded to 10 points and ‘unable to improve’ received 0 to 5 points. A higher score indicated greater satisfaction with the teaching method, consistent with the principles of the forgetting curve in knee arthroplasty. Statistical analysis Quantitative data are expressed as mean ± standard deviation, while qualitative data are expressed as median (range) or frequency (percentage). The Kolmogorov-Smirnov test was utilized to assess the distribution of quantitative variables. Chi-square tests and t-tests were used to compare qualitative and quantitative data between the two groups, respectively. All analyses were conducted using IBM SPSS version 25 and R version 4.3.2 for Windows, with an alpha level set at 0.05 (two-tailed). Results Participants In total, 36 nurses were invited to participate in this study (Fig. 1 ). Among them, 6 individuals did not meet the inclusion criteria; therefore, 30 nurses were randomly assigned to the intervention group or the control group ( n = 15 nurses per group). All the allocated participants successfully completed the trial, and their data were used for analysis. There were no significant differences between the groups in terms of age, gender, working years, and level of education. The average age of participants was 25.1 years, 73.3% of participants were female, and their average working length was 2.9 years. Among participants, 93.3% had a bachelor’s degree, while 6.7% had a master’s degree. Table 2 summarizes the characteristics of participants. Table 2. The descriptive statistics of the samples Variable All participants ( n = 30) Control group Experimental group P value Age 25.1 (3.32) 25.13 (3.4) 25.0 (3.5) 0.545 Sex 0.682 Male 8 (26.7%) 3 (20.0%) 5 (33.3%) Female 22 (73.3%) 12 (80.0%) 10 (66.6%) Education level 0.927 Bachelor’s degree 28(93.3%) 14 (93.3%) 14 (93.3%) Master’s degree 2(6.7%) 1 (6.7%) 1 (6.7%) Working years 2.9 (0.31) 2.8 (0.28) 2.8 (0.32) 0.724 Open in a new tab Data are presented as mean (SD) or N (%) Clinical practice assessment scores and physicians’ satisfaction with instrument nurses’ collaboration were compared between the two groups before and after training Compared to before training, the clinical training assessment scores in both groups significantly increased after 1 day (from 64.33 ± 7.17 to 90.33 ± 7.18 in the intervention group and from 64.60 ± 7.31 to 85.40 ± 8.37 in the control group) and 1 month (from 64.33 ± 7.17 to 89.86 ± 7.19 in the intervention group and from 64.60 ± 7.31 to 75.33 ± 7.91 in the control group) after training ( P < 0.05). One month after training, the scores in the control group (85.40 ± 8.37 vs. 75.33 ± 7.91, Cohen’s D: 1.23), but not in the experimental group (90.33 ± 7.18 vs. 89.86 ± 7.19, Cohen’s D: 0.06), were significantly lower than those 1 day after training ( P < 0.05). Furthermore, at 1 month after training, clinical training assessment scores were higher in the experimental group than in the control group (89.86 ± 7.19 vs. 75.33 ± 7.91, Cohen’s D: 1.92). Additionally, 1 month after training, the satisfaction scores of physicians were significantly higher in the experimental group than in the control group (91.44 ± 7.68 vs. 85.10 ± 8.54, Cohen’s D: 0.78) ( P < 0.05) (Table 3 ). Table 3. Comparison of clinical practice assessment scores and physicians' satisfaction with instrument nurses' collaboration in the two groups before and after training Variable Time Participant number Group Score Mean (SD) P value Physicians’ satisfaction scores Before training 15 Experimental 79.32 (8.44) 15 Control 79.28 (8.50) 0.983 1 month after training 15 Experimental 91.44 (7.68)* 15 Control 85.10 (8.54)* 0.026 Clinical training assessment scores Before training 15 Experimental 64.33 (7.17) 15 Control 64.60 (7.31) 0.920 1 day after training 15 Experimental 90.33 (7.18) 15 Control 85.40 (8.37) 0.094 1 month after training 15 Experimental 89.86 (7.19) 15 Control 75.33 (7.91) 0.001 Open in a new tab *: p value of < 0.05 considered significant Comparison of the surgical instrument nurses’ satisfaction between the two groups after training Next, the effects of the educational program were assessed on surgical instrument nurses in a subjective manner. Compared to the control group, surgical instrument nurses in the experimental group exhibited a significant improvement in terms of stimulation of learning interest (9.32 ± 0.72 vs. 7.03 ± 0.78, Cohen’s D: 3.05), problem-solving ability (9.29 ± 0.60 vs. 8.19 ± 0.88, Cohen’s D: 1.46), clinical thinking and teamwork ability (9.13 ± 0.61 vs. 7.64 ± 0.83, Cohen’s D: 2.45), collecting materials and searching for literatures (9.22 ± 0.71 vs. 8.75 ± 0.91, Cohen’s D: 0.57), practical skills (9.60 ± 0.21 vs. 7.74 ± 0.79, Cohen’s D: 3.21), initiative and enthusiasm for learning (9.08 ± 0.74 vs. 8.20 ± 0.93, Cohen’s D: 1.04), theory with practice ability (9.37 ± 0.39 vs. 8.91 ± 0.91, Cohen’s D: 0.66), engagement and attraction (9.27 ± 0.31 vs. 7.50 ± 0.80, Cohen’s D: 2.91), teacher-student interaction (9.11 ± 0.80 vs. 7.80 ± 0.83, Cohen’s D: 1.60), satisfaction with the teaching mode (9.11 ± 0.82 vs. 7.31 ± 0.83, Cohen’s D: 2.18) (all p < 0.05) (Table 4 ). Table 4. Comparison of the surgical instrument nurses’ satisfaction between the two groups after training Items Experimental Mean (SD) Control Mean (SD) P value Stimulation of learning interest 9.32 (0.72) 7.03 (0.78) <0.001 Improvement of problem-solving ability 9.29 (0.60) 8.19 (0.88) 0.001 Improvement of clinical thinking and teamwork ability 9.13 (0.61) 7.64 (0.83) <0.001 Improvement in collecting materials and searching for literature 9.22 (0.71) 8.75 (0.91) 0.015 Improvement of practical skills 9.60 (0.21) 7.74 (0.79) <0.001 Improvement of the initiative and enthusiasm for learning 9.08 (0.74) 8.20 (0.93) 0.005 Improvement of theory with practice ability 9.37 (0.39) 8.91 (0.91) 0.009 Improvement of engagement and attraction 9.27 (0.31) 7.50 (0.80) <0.001 Improvement of teacher-student interaction 9.11 (0.80) 7.80 (0.83) <0.001 Improvement of satisfaction with the teaching mode 9.11 (0.82) 7.31 (0.83) <0.001 Open in a new tab Discussion This study introduced a learning method based on the forgetting curve, which was found to be effective for instrument nurses when learning knee arthroplasty surgery in their first three working years. Additionally, its feasibility was assessed through the improved academic performance of instrument nurses in the course and the positive feedback from both instrument nurses and surgeons; however, this pilot and single-center randomized controlled trial had a small sample size and other limitations, which necessitate further validation in future large-scale clinical trials. With the growing problem of population aging in China, the number of patients with knee diseases continues to increase [ 13 ]. As the primary clinical method for treating severe knee osteoarthritis, the number of knee arthroplasty surgeries is increasing [ 14 ]. Knee arthroplasty can effectively improve knee function and enhance the quality of life of patients; however, as a major surgical procedure, intraoperative cooperation among team members significantly affects the surgical outcome [ 15 ]. Knee arthroplasty surgery typically needs numerous externally provided instruments. Due to their high cost, wide variety, rapid updates, and lack of readily available alternatives, hospitals generally do not configure these instruments as standard equipment [ 16 ]. Studies have found that all companies permit multiple hospitals to share these instruments, typically with short usage cycles. So far, most general hospitals have not fully achieved the goal of entering the operating room without the need to follow the platform to assist the operation. There is a wide variety of surgical instruments, and a high level of professionalism is needed to use these instruments. Instrument nurses often have limited time to communicate and learn with the surgical staff, which makes it challenging for them to master the use of all supporting instruments and affects the overall quality of instrument nurse cooperation. Therefore, selecting an appropriate training method for instrument nurses is particularly critical [ 17 ]. The forgetting curve, a theory of memory research proposed by Hermann Ebbinghaus, facilitates the development of more effective learning and training strategies by appropriately applying its principles, thereby efficiently enhancing knowledge retention and application [ 18 , 19 ]. Based on the principles of the forgetting curve, instructors can scientifically plan the timing of reviews and construct an interval review teaching program to promote students’ in-depth understanding and memory of knowledge, thereby achieving optimal learning outcomes [ 20 ]. In this study, there was no significant difference in the clinical practical assessment scores of the experimental group between 1 day after training and 1 month after training, whereas the clinical practical assessment scores of the control group 1 month after training were significantly lower than those 1 day after training. The reason for this finding is that the experimental group applied the principles of the forgetting curve in teaching, which promoted the transformation from short-term memory to long-term memory through multiple reviews. This helps nurses better retain, consolidate, and internalize the learned knowledge and skills, thereby more proficiently using surgical instruments for knee arthroplasty and effectively reducing the errors caused by memory lapses or unskilled operations in practical work. In this study, compared to the control group, the clinical practical assessment scores and the satisfaction scores of physicians with the cooperation of instrument nurses after training were higher in the experimental group, suggesting that the teaching mode based on the principles of the forgetting curve can enable newly recruited instrument nurses to better master clinical practical operations, which can help acquire related theoretical knowledge and improve clinical practice in knee arthroplasty surgery. The results of this study showed that the satisfaction scores of surgeons with the cooperation of operating room nurses were higher in the experimental group than in the control group. After implementing the teaching method based on the principles of the forgetting curve, the operating room nurses have significantly improved in terms of operation and professional knowledge and could remember the instruments and steps required in the operation more effectively. In addition, their skills in coordinating knee arthroplasty surgery were improved. By enhancing the proficiency of instrument nurses in operating knee arthroplasty surgery, nurses may better master the usage methods of externally provided instruments needed during the surgery and achieve better intraoperative coordination ability. Such progress may improve the satisfaction of surgeons with the cooperation of instrument nurses. While our results are promising, the use of a non-validated assessment tool and the lack of assessor blinding mean that the observed effects should be interpreted with caution. In a border context, the findings of this study also illuminate the importance of effective nursing care in the management of patients. For instance, effective nursing performance achieved via sufficient training, reassessment, and retraining can advance the management of common medical problems, identification and treatment of surgical complications, control of drug adverse events, and management of hospital-associated infections [ 21 ]. In addition, a higher level of nurse education was shown to be associated with a significantly lower risk of failure to rescue and mortality in acute care settings [ 22 ]. Similar to this study, previous studies have reported that the forgetting curve-based teaching method can help improve the performance and confidence of dentistry students and operating room nurses [ 6 , 10 , 11 ]. Given the importance of effective nursing training in care quality, the forgetting curve-based teaching method may help markedly improve the quality of healthcare services. With recent advances in medical and nursing education, new modes of teaching or their combination have emerged as effective modalities of training [ 23 , 24 ]. For instance, simulation-based learning was discovered to improve self-efficacy, learning satisfaction scores, and nursing competence among senior nursing students in the emergency and critical care course [ 23 ]. Likewise, compared to the conventional method, spaced learning was found to improve the knowledge and retention of nurse anesthesia students and enhance their learning outcomes [ 24 ]. The combination of these novel methods of education is expected to provide more favorable outcomes in clinical practice. This study, which targeted a particular population of novice surgical instrument nurses involved in knee arthroplasty surgery, showed that compared to the traditional training method, the forgetting curve-based learning method can improve performance and satisfaction, enhancing the efficiency of novice surgical instrument nurses in knee replacement surgery. Limitations This study has two main limitations. Firstly, since this was a pilot randomized controlled trial, the sample size was relatively small, and data were collected only from newly graduated nurses within their first three working years. Therefore, further large-scale studies are needed to determine the benefits of the forgetting curve in surgical cooperation. Secondly, this pilot study included only instrument nurses. For large-scale implementation, the forgetting curve principles in learning surgical cooperation and surgical operations should be studied among other staff members, such as circulation nurses, physicians, and nursing students. Third, the surgeons’ satisfaction questionnaire used in this study was self-developed, with limited psychometric validation, which may introduce potential measurement bias and threaten the internal validity of the findings. Fourth, self-reported satisfaction scores were reported subjectively, which may be of less significance compared to objective measures. Fifth, the length of follow-up was only 1 month in this randomized controlled trial. Sixth, the assessors were not blinded to the group allocation during clinical assessment, as they observed the nurses who were practicing their specific interventions. Seventh, the intervention group received more total training time. The observed effects could be due to the additional practice time rather than the spacing of the practice per session. Eighth, if the nurses from different groups interacted during the study period, the control group could learn about the intervention strategies. Due to these limitations, future multi-center large-scale clinical trials with prolonged follow-ups are needed to validate the findings of this single-center study. Conclusion This study initially established a set of training methods based on the forgetting curve for instrument nurses with less than three years of work experience. The results showed that training based on the forgetting curve may represent a practical and effective learning method for instrument nurses to engage in complex surgical cooperation; however, these findings should be interpreted cautiously due to the limitations of this pilot randomized controlled trial, such as its small sample size and short follow-up duration. Teaching methods based on the forgetting curve should be continuously refined in the future, incorporating more detailed anatomical images, annotations, and theoretical descriptions to improve the surgical learning experience of healthcare professionals. Future large-scale studies with longer follow-up lengths are needed to validate these findings and conduct an economic analysis of the intervention’s efficiency, thereby facilitating the clinical application of the forgetting curve-based teaching method among novice surgical instrument nurses. Supplementary Information Below is the link to the electronic supplementary material. Supplementary Material 1 (19.7KB, docx) Acknowledgements None. Author contributions Lin Zhang and Qimei Liang contributed to the conception and design of this study. Lin Zhang and Zhanhua Han conducted material preparation and data collection and entry. Siwei Chen and Shuchen Wang analyzed data under the supervision of Zeyong Zhang and Jingjuan Huang. The manuscript was drafted by Lin Zhang and then revised by Siwei Chen. All authors commented on the primary version of the manuscript. All authors read and approved the final manuscript. Funding None. Data availability Data will be available by the corresponding author upon a reasonable request. Declarations Ethics approval and consent to participate This study strictly followed the ethics standards defined by the Declaration of Helsinki, and informed consent was obtained from all participants before their participation. The study was reviewed by the Ethics Committee of The First Affiliated Hospital of Guangzhou Medical University (IRB name: Scientific Research Project Review Ethics Committee). Based on the “Ethical Review Measures for Biomedical Research Involving Humans” and in accordance with the Declaration of Helsinki and CIOMS ethical guidelines, the committee determined that this project met the exemption criteria and issued an official exemption decision (Approval No: KYLL-MS-011-01-FJ02). Consent for publication Consent for participation was obtained from all participants. Competing interests The authors declare no competing interests. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Lin Zhang, Siwei Chen, and Qimei Liang equally contributed to this work and are co-first authors. Contributor Information Jingjuan Huang, Email: [email protected]. Zeyong Zhang, Email: [email protected]. References 1. Sharma L. Osteoarthritis of the Knee. N Engl J Med. 2021;384(1):51–9. [ DOI ] [ PubMed ] [ Google Scholar ] 2. Nham FH, Patel I, Zalikha AK, El-Othmani MM. Epidemiology of primary and revision total knee arthroplasty: analysis of demographics, comorbidities and outcomes from the national inpatient sample. Arthroplasty (London England). 2023;5(1):18. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 3. Zhang M, Gong SG, Xie R. Application of enhanced recovery after surgery in perioperative nursing care of elderly patients with hip and knee arthroplasty: A systematic review and meta-analysis. Medicine. 2024;103(9):e37240. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 4. Su Y, Hua RF, Pei FF, et al. The role of informational nurses in the handling of emergency surgical instruments in the central sterile supply department[J]. Chin J Disinfection. 2023;40(11):840–842846. [ Google Scholar ] 5. Cousins HC, Cahan EM, Steere JT, Maloney WJ, Goodman SB, Miller MD, et al. Assessment of Team Dynamics and Operative Efficiency in Hip and Knee Arthroplasty. JAMA Surg. 2023;158(6):603–8. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 6. Boutis K, Pecaric M, Carrière B, Stimec J, Willan A, Chan J, et al. The effect of testing and feedback on the forgetting curves for radiograph interpretation skills. Med Teach. 2019;41(7):756–64. [ DOI ] [ PubMed ] [ Google Scholar ] 7. Cortés RC, Jiménez FJG, Moreno GG, París MAH, Ruiz FMP, Cruz AC. Impact of the forgetting curve on cognitive skills in basic life support. JETT. 2024;15(3):99–111. [ Google Scholar ] 8. Chun BA, Heo HJ, editors. The effect of flipped learning on academic performance as an innovative method for overcoming ebbinghaus’ forgetting curve. Proceedings of the 6th international conference on information and education technology; 2018. 9. Liu H, Yu X, Yin C, Xu. Minjun.Application of the forgetting curve combined with blended learning in extracorporeal membrane oxygenation nursing training for ICU nurses[J]. Chin J Practical Nurs. 2024;40(15):1142–8. [ Google Scholar ] 10. Qian W, Qian L, Xu Q, Lu L. The effects of Roy’s adaptation model and the forgetting curve in the clinical instruction of operating room nursing interns. Am J translational Res. 2021;13(7):8214–20. [ PMC free article ] [ PubMed ] [ Google Scholar ] 11. Wang N, Griggs JA, Caskey CJ, Bain JL. Navigating the Forgetting Curve: A Longitudinal Study of Knowledge Retention and Confidence Dynamics in Dental Education. Educ Sci. 2025;15(9):1161. [ Google Scholar ] 12. Montgomery A, Chang HR, Ho MH, Smerdely P, Traynor V. The use and effect of OSCES in post-registration nurses: An integrative review. Nurse Educ Today. 2021;100:104845. [ DOI ] [ PubMed ] [ Google Scholar ] 13. Kuo Y-C, Walker AE, Schroder KE, Belland BR, Interaction. Internet self-efficacy, and self-regulated learning as predictors of student satisfaction in online education courses. internet High Educ. 2014;20:35–50. [ Google Scholar ] 14. Chen Q, Cao L, Li YC, Wulamu W, Zhang XG. [Outcomes of total knee arthroplasty combined with the modified overlap technique in the treatment of knee osteoarthritis with permanent patellar dislocation]. Zhonghua wai ke za zhi. [Chinese J surgery]. 2024;62(9):856–63. [ DOI ] [ PubMed ] [ Google Scholar ] 15. ahan EM, Cousins HC, Steere JT, Segovia NA, Miller MD, Amanatullah DF. Influence of team composition on turnover and efficiency of total hip and knee arthroplasty. Bone Joint J. 2021;103-B(2):347–52. [ DOI ] [ PMC free article ] [ PubMed ] 16. Jethi T, Jain D, Garg R, Selhi HS. Readmission rate and early complications in patients undergoing total knee arthroplasty: A retrospective study. World J Orthop. 2024;15(8):713–21. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 17. Zheng Y, Li Y, Yuan Z, Geng X, Tian H. Comparison of the accuracy and efficacy of different assistive techniques in primary total knee arthroplasty: A network meta-analysis. J experimental Orthop. 2024;11(4):e70098. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 18. Ebbinghaus H. Memory: a contribution to experimental psychology. Annals neurosciences. 2013;20(4):155–6. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 19. Fang W, Zhang Q, Chen Y, Qin W. Knowledge, attitude, and practice of clinical nurses towards medical device-related pressure injury prevention: A systematic review. J tissue viability. 2025;34(1):100838. [ DOI ] [ PubMed ] [ Google Scholar ] 20. Wu J, Lu AD, Zhang LP, Zuo YX, Jia YP. [Study of clinical outcome and prognosis in pediatric core binding factor-acute myeloid leukemia]. Zhonghua xue ye xue za zhi = Zhonghua. xueyexue zazhi. 2019;40(1):52–7. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 21. Chiaramonte R, D’Amico S, Marletta C, Grasso G, Pirrone S, Bonfiglio M. Impact of Clostridium difficile infection on stroke patients in rehabilitation wards. Infect Dis now. 2023;53(5):104685. [ DOI ] [ PubMed ] [ Google Scholar ] 22. Audet LA, Bourgault P, Rochefort CM. Associations between nurse education and experience and the risk of mortality and adverse events in acute care hospitals: A systematic review of observational studies. Int J Nurs Stud. 2018;80:128–46. [ DOI ] [ PubMed ] [ Google Scholar ] 23. Hung CC, Kao HS, Liu HC, Liang HF, Chu TP, Lee BO. Effects of simulation-based learning on nursing students’ perceived competence, self-efficacy, and learning satisfaction: A repeat measurement method. Nurse Educ Today. 2021;97:104725. [ DOI ] [ PubMed ] [ Google Scholar ] 24. Khalafi A, Fallah Z, Sharif-Nia H. The effect of spaced learning on the learning outcome and retention of nurse anesthesia students: a randomized-controlled study. BMC Med Educ. 2024;24(1):322. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. 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