The research, conducted by Esra Özkan of Giresun University in Türkiye and Katarina Vojvodic of the Institute of Public Health of Belgrade in Serbia, employed a phenomenological design, a qualitative approach that seeks to capture lived experience in depth rather than to measure knowledge with checklists. The team carried out semi-structured, in-depth interviews with 26 nurses working in primary healthcare services across the two countries. Participants were recruited through purposive criterion sampling, meaning the researchers deliberately selected nurses whose daily work positioned them to encounter screening questions and patient concerns about colorectal cancer. Interviews continued until data saturation was achieved, the point at which additional conversations stop yielding new themes, and each session was audio-recorded with the participant’s consent, transcribed verbatim, and analyzed using Colaizzi’s seven-step phenomenological method, a rigorous framework that moves from reading raw transcripts to extracting significant statements, formulating meanings, clustering themes, and validating the resulting description against the original data.

Methodological transparency was a priority. The study was conducted and reported in accordance with the Consolidated Criteria for Reporting Qualitative Research, known as COREQ, a 32-item checklist designed to ensure that qualitative studies disclose enough detail about the research team, the interview process, and the analytic choices for readers to judge their trustworthiness. Ethical approval was granted by the Giresun University Scientific Research and Publication Ethics Committee and by the Ethics Committee of the Institute of Public Health of Belgrade, and informed consent was obtained from every participant before interviews began. The work was supported by a Short-Term Scientific Mission grant through COST Action CA23151, a European networking framework that funds cross-border research collaboration, which is precisely the kind of mechanism that made this two-country comparison possible.

From the transcripts, six major themes emerged: colorectal cancer early symptoms and awareness; nurses’ roles in screening and patient education; education, guidance, and the screening process; risk stratification in colorectal cancer; nurses’ educational experiences, knowledge competence, and development needs; and challenges and limitations in the screening process. The thematic architecture itself tells a story. It moves from what nurses know about the disease, through what they actually do in clinics, to what they feel they lack and what stands in their way. This structure mirrors the journey a patient takes through a screening program, and it suggests that the researchers see nursing knowledge not as an abstract asset but as a functional component of the early-detection pipeline.

The most encouraging finding is the shared foundation. Nurses in both countries demonstrated solid awareness of common colorectal cancer symptoms and clearly recognized that their profession has a legitimate role in patient education, guiding people toward screening, and following up on results. This matters because primary care nurses are frequently the first, and sometimes the only, health professionals a hesitant patient speaks with at length. When a nurse understands that persistent changes in bowel habits, unexplained weight loss, or blood in the stool warrant urgent investigation, that understanding can translate directly into a timely referral. The study suggests that this basic clinical literacy is present in both health systems, providing a platform on which stronger screening programs could be built.

Yet beneath the similarities, the comparative analysis exposed meaningful divergences in how nurses in the two countries conceptualize risk. Turkish nurses more frequently emphasized lifestyle-related risk factors, such as diet and physical activity, and placed greater weight on patient education as their contribution to prevention. Serbian nurses, by contrast, placed greater emphasis on family history and age-based screening, focusing on systematically identifying individuals eligible for screening programs. These are not trivial differences. A nurse who instinctively thinks in terms of lifestyle counseling will approach a patient differently from one who instinctively thinks in terms of pedigree and age thresholds. Effective risk stratification for colorectal cancer requires both perspectives: lifestyle factors modulate baseline risk, while family history and age determine who should be prioritized for colonoscopy or fecal occult blood testing. The study implies that each country’s nurses may be operating with half of the risk-assessment picture more salient than the other half, a finding with direct implications for continuing education curricula.

The barriers the nurses described were equally revealing, and here the two national contexts produced distinct portraits of friction. Nurses in both countries reported a pressing need for continuous education and identified heavy workloads, staffing limitations, time constraints, and difficulties reaching the target population as major obstacles to effective screening work. These are systemic constraints that no amount of individual knowledge can overcome; a nurse who understands screening guidelines perfectly cannot act on that knowledge if the appointment schedule leaves no room for counseling. Serbian nurses additionally emphasized referral delays and particular difficulty reaching working-age populations, people who are employed, mobile, and often absent from routine primary care contact. Turkish nurses, meanwhile, highlighted fear and avoidance among patients, the psychological resistance that keeps people from attending screening even when they are eligible and invited. The contrast is instructive: one system struggles with plumbing, the pipes of referral and outreach, while the other struggles with psychology, the emotional barriers that screening programs must address through communication and trust-building.

The authors argue that strengthening continuous, structured, and practice-based education for nurses is the central lever for improvement. The distinction between continuous and practice-based is important. Periodic lectures that update guidelines may refresh factual knowledge, but they do little to build the conversational skills needed to talk a frightened patient past their avoidance of a colonoscopy, or the organizational instincts needed to flag an eligible individual in a crowded clinic. Practice-based education embeds learning in the actual workflow of primary care, where the real decisions about who gets educated, who gets referred, and who gets followed up are made. Combined with improved organizational support, adequate staffing, and effective referral and follow-up systems, the study’s implications section suggests, this educational investment could enable nurses to participate far more actively in colorectal cancer screening and early detection rather than serving as passive adjuncts to physician-led programs.

The broader significance of the study lies in its comparative design. Most studies of nursing knowledge in cancer screening examine a single country, leaving open the question of whether observed gaps reflect universal features of the profession or local conditions. By running identical methods in parallel in Türkiye and Serbia, Özkan and Vojvodic have shown that the core competencies and the core frustrations of frontline screening nurses travel across borders, while the specific emphases and barriers are shaped by each health system’s structure and culture. For policymakers in both countries, the message is twofold: invest in the shared foundation of symptom awareness and role recognition that already exists, and tailor interventions to the distinct weak points each system exhibits, whether that is referral infrastructure in Serbia or patient fear in Türkiye. For the rest of the world, the study is a reminder that the cheapest, most scalable improvements in cancer early detection may not come from new technology at all, but from better equipping the nurses who already occupy the decisive first conversation with every patient who walks through a clinic door.

Subject of Research: Nurses’ knowledge on early diagnosis and screening of colorectal cancer: a comparative qualitative study of the cases of Türkiye and Serbia

Article Title: Nurses’ knowledge on early diagnosis and screening of colorectal cancer: a comparative qualitative study of the cases of Türkiye and Serbia

Article References: Özkan, E., & Vojvodic, K. (2026). Nurses’ knowledge on early diagnosis and screening of colorectal cancer: a comparative qualitative study of the cases of Türkiye and Serbia. BMC Cancer. https://doi.org/10.1186/s12885-026-16885-4

Image Credits: AI Generated

DOI: 10.1186/s12885-026-16885-4

Keywords: Nurses, knowledge, early, diagnosis, screening, colorectal, cancer, comparative, qualitative, cases, rkiye, Serbia

Knowledge tracing is a family of computational methods designed to estimate a learner’s evolving mastery over time. In a typical system, each exercise is linked to one or more knowledge components, such as solving a linear equation, applying a grammatical rule or identifying a chemical property. The model receives a stream of responses and updates an internal estimate of the learner’s knowledge after each interaction. Traditional Bayesian knowledge tracing represents learning as transitions between states, often balancing the probability that a student has learned a skill against the possibility of guessing, making a careless mistake or forgetting. More recent approaches use neural networks and other machine-learning architectures to capture complex patterns in long sequences of student activity. These systems have generally emphasized temporal information: what happened previously, how much time has passed and how a learner’s performance changes across attempts. The study’s authors note that this focus leaves another source of information comparatively underused—the spatial organization of the knowledge itself. Here, spatial does not mean physical distance. It describes the relational arrangement of concepts in a knowledge graph, where edges indicate dependencies, influence or causal connections among components.

The distinction matters because educational knowledge is often hierarchical. Understanding how to solve a two-step equation may depend on addition, subtraction, multiplication, division and the ability to preserve equality across operations. In a science course, interpreting a graph may require knowledge of axes, variables and proportional relationships before a student can reason about a more advanced model. If an assessment system examines only the label attached to the current exercise, it may overlook the chain of concepts that supports performance. A network-based system can represent these dependencies explicitly. In such a representation, a knowledge component is a node, while a directed connection can indicate that changes in one component are related to another. Immediate neighbors form a first-order structure. A second-order structure includes connections reached through those neighbors, allowing the model to consider a wider local context. The researchers studied whether these multilevel relationships could improve knowledge tracing models across both deep-learning and traditional machine-learning settings. Their analysis treats the structure as informative evidence rather than as a decorative visualization added after prediction.

To construct the relevant relationships, the researchers used causal structure learning, a group of statistical methods that attempts to infer directional connections from observed variables and their patterns of association. In educational data, the variables can represent knowledge components and the response information associated with them. Causal discovery does not automatically prove that one concept directly causes another in the psychological sense, but it can provide a principled way to estimate a network of dependencies from data. The resulting structure was then incorporated into knowledge-tracing models. This step is technically important because it changes the information available during prediction. Instead of relying solely on a student’s past response sequence, a model can also aggregate signals from related concepts and from concepts linked through an additional level of the network. A learner’s performance on one skill can therefore be interpreted alongside evidence about prerequisite or neighboring skills. The approach gives the model a way to distinguish a narrowly isolated weakness from a broader pattern that may arise when several connected components remain uncertain.

The reported experiments found that second-order spatial information consistently improved model performance. The source article does not present the result as a replacement for temporal modeling; rather, it shows that spatial structure can complement the time-based information already central to knowledge tracing. That combination is significant because learning is both sequential and relational. A student’s latest answer depends on prior practice, but it can also reflect the status of concepts connected to the current task. A model that captures only one of these dimensions may miss part of the explanation. The researchers tested the structural information in deep-learning models as well as traditional machine-learning models, indicating that the benefit was not confined to a single algorithmic family. The finding suggests that educational prediction systems may gain from improved representations of knowledge even when their core predictive machinery differs. It also reframes model development: progress may depend not only on building larger or more complicated networks, but on supplying models with a more meaningful description of the domain they are trying to understand.

Performance, however, is only one part of the study’s contribution. The researchers also examined interpretable features to clarify how spatial information shaped diagnostic predictions. Interpretability methods are intended to show which inputs most strongly influence a model’s output, helping researchers and educators investigate why a system reaches a particular conclusion. In this context, a spatial feature might represent information propagated from a related knowledge component or from a concept several links away in the inferred structure. If such a feature contributes strongly to a prediction of difficulty, it may indicate that the current error is connected to a weakness elsewhere in the knowledge network. This is different from simply reporting that a student answered an item incorrectly. It offers a possible explanation for the prediction and can make automated recommendations easier to scrutinize. The article identifies interpretable analysis as a route toward understanding the factors underlying students’ learning challenges, while the associated keywords identify explainable artificial intelligence and SHAP, a method commonly used to examine feature contributions. The practical value lies in connecting prediction with a diagnostic account.

That account could support more targeted instruction, although the study does not claim to have demonstrated outcomes in classrooms. A tutoring system informed by hierarchical dependencies might recommend reviewing a prerequisite rather than assigning more exercises that repeat the same surface-level task. It could also avoid treating every wrong answer as an independent event. Suppose a student repeatedly fails problems involving a particular advanced operation while also showing uncertainty on its prerequisites. A spatially aware model could flag the connected pattern and help an instructor decide whether to revisit foundational material, change the explanation or provide practice that bridges the concepts. The system might likewise identify cases in which a student has mastered supporting skills but is struggling with a specific application. Those distinctions matter for adaptive learning because effective feedback depends on the source of an error, not merely its existence. The researchers describe the spatial perspective as having potential to inform more effective instructional strategies, but the appropriate use of such predictions would still require validation with teachers, learners and real educational interventions.

The work also leaves important questions for future research. Inferred relationships can reflect the quality and scope of the data used to learn them, and knowledge dependencies may differ across curricula, age groups, subjects and populations. A hierarchy that describes one mathematics course may not transfer directly to another, while relationships in language learning or programming may be less strictly hierarchical. Student behavior can also be influenced by factors that a knowledge graph does not capture, including motivation, fatigue, unfamiliar wording and access to prior instruction. Better structural information should therefore be treated as one component of a broader assessment system, not as a complete representation of learning. The study provides evidence that second-order relationships can improve knowledge-tracing performance and make predictions more interpretable. Its larger message is that educational AI should model the architecture of knowledge as carefully as it models the passage of time. By combining learner histories with causal and hierarchical maps of concepts, future systems may move closer to diagnosing how understanding develops—and where the next useful lesson should begin.

The result is especially relevant to the distinction between prediction and diagnosis in educational data mining. A model can become better at forecasting a response without revealing whether its estimate reflects durable learning, temporary performance, or an unresolved dependency elsewhere in the curriculum. By examining contributions from spatial features, the study provides a way to investigate whether a prediction is being driven by the assessed component itself or by information carried through connected components. This makes the inferred structure potentially useful not only as an input to a predictor, but also as an object for examining the model’s reasoning.

At the same time, the study’s causal terminology requires careful interpretation. Causal structure learning produces an inferred pattern of directional dependencies from data; it does not by itself establish that mastering one knowledge component will produce mastery of another. For instructional use, those inferred links would therefore be most defensible as hypotheses about relationships to test through assessment and intervention. The strongest near-term application is likely to be prioritizing which connected skills deserve further examination, rather than automatically prescribing a specific remedy. This distinction can help prevent a system from converting a statistical association into an unwarranted claim about the source of a learner’s difficulty. It also creates a foundation for future studies comparing structurally informed predictions with teachers’ diagnoses and students’ subsequent learning outcomes.

Subject of Research: Hierarchical knowledge structures in knowledge tracing

Article Title: Unveiling the Impact of Hierarchical Knowledge Dependencies on Knowledge Tracing: A Spatial Structure Perspective

Article References: Wei, Y., Jia, R., Ding, Y., & Jiang, B. (2026). Unveiling the Impact of Hierarchical Knowledge Dependencies on Knowledge Tracing: A Spatial Structure Perspective. Frontiers of Digital Education, 3(3), Article 23. https://doi.org/10.1007/s44366-026-0097-8

Image Credits: AI Generated

DOI: 10.1007/s44366-026-0097-8

Keywords: knowledge tracing, educational AI, learning analytics, knowledge graphs, causal structure learning, explainable AI, adaptive learning, student modeling, Unveiling, Impact, Hierarchical, Knowledge