Comparison of lecture-based learning with presentation-assimilation-discussion method in occupational bloodborne exposure education of nursing students, a randomised trial

Abstract

Background

Occupational Bloodborne Exposures (OBEs) are incidents where healthcare workers come into contact with blood or other potentially infectious materials, leading to risks of transmitting bloodborne pathogens. Nursing students, often in direct contact with patients, face heightened risks due to their duties.

Methods

First, we conducted a cross-sectional survey using a OBEs questionnaire to explore the knowledge, attitudes, practices, and needs regarding OBEs among nursing students. Subsequently, we used a randomized controlled trial (RCT) to compare the impact of the Presentation-Assimilation-Discussion (PAD) method with the traditional lecture-based learning (LBL) method on OBEs education for nursing students. Pre-test, post-test, and retention test were used to observe the teaching effectiveness, and the students’ feedback on the teaching method was also observed.

Results

In the cross-sectional survey, we found that nursing students lacked sufficient knowledge and management skills regarding OBEs but recognized the importance of standard precautions and expressed a desire for systematic OBEs training during their education and internships. In the RCT, the total, theoretical, and practical scores of the PAD and LBL groups were comparable in the pre-test (56.70 ± 3.47 vs. 56.40 ± 3.95, 33.09 ± 3.39 vs. 33.33 ± 2.44, 23.61 ± 4.66 vs. 23.07 ± 4.84, p > 0.05). After training, the PAD model demonstrated an advantage over the LBL model in immediate total (84.25 ± 4.06 vs. 78.95 ± 4.23, p < 0.001), theoretical (54.32 ± 2.43 vs. 51.44 ± 2.58, p < 0.001), and practical scores (29.93 ± 3.90 vs. 27.51 ± 4.33, p < 0.01). It also showed superior retention of total (69.05 ± 3.87 vs. 65.77 ± 2.94, p < 0.001) and theoretical scores (39.05 ± 3.05 vs. 36.23 ± 3.18, p < 0.001). However, there was no significant difference in the retention of practical scores between the two groups (30.00 ± 4.76 vs. 29.53 ± 3.73, p > 0.05). The PAD group benefited more across various learning dimensions but reported a higher study load.

Conclusions

Our study reveals that the PAD model could be a valuable approach for teaching OBEs to nursing students.

Introduction

Occupational Bloodborne Exposures (OBEs) is defined as any percutaneous or mucocutaneous incident in which an individual working in a healthcare setting or involved in related activities comes into contact with blood or other potentially infectious materials (OPIM) [1]. This type of exposure includes a variety of situations, such as needlestick injuries, cuts from sharp medical instruments, and contact of mucous membranes or compromised skin with materials that may contain bloodborne viruses, including the Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV) [2]. According to the World Health Report, occupational exposure is estimated to account for 2.5% of HIV/AIDS cases and 40% of hepatitis B and C cases among healthcare professionals. It is also estimated that globally, occupational exposure to percutaneous injuries has resulted in 16,000 HCV, 66,000 HBV, and 1,000 HIV infections among healthcare workers [3].

A cross-sectional study revealed that within a one-month period, 1.53% of healthcare workers experienced various types of OBEs, with students during their internship exhibiting the highest incidence rate among all healthcare professionals [4]. Notably, nurses, physicians, and logistical staff who had not received relevant training demonstrated a higher incidence of OBEs compared to their trained counterparts. The study also highlights that occupational exposure can lead to impacts on healthcare workers beyond the risk of infection, including anxiety (57.7%), stress (24.2%), and insomnia (10.2%). These effects can significantly affect the mental and physical health of healthcare personnel [5]. Furthermore, another study indicates that healthcare personnel exhibit adverse emotional responses such as anxiety, anger, and guilt following OBEs. They may engage in active coping strategies, such as seeking immediate medical attention or reporting the incident to a monitoring system, or adopt passive coping methods, including avoiding reporting the event and harboring vague hopes of encountering no subsequent issues [6]. Healthcare institutions need to provide their staff with repeated education to familiarize them with guidelines for preventing OBEs and constantly stimulate their awareness of the risks associated with injuries.

Nurses, due to their clinical duties which often involve direct and frequent contact with patients, are at a heightened risk of occupational exposure to bloodborne pathogens compared to other healthcare providers, such as physicians [7]. This increased risk can be attributed to the primary role nurses play in administering injections and intravenous fluids. Nurses make up the majority of healthcare professionals who handle injections and sharp instruments. Additionally, hospitals typically have a higher proportion of nursing staff compared to other healthcare occupational groups. The majority of these exposures occur through percutaneous injuries, such as needlestick incidents, cuts from sharp instruments, and contact of non-intact skin or mucous membranes with blood or OPIM.

An online cross-sectional survey conducted across 31 provincial administrative regions in China revealed that more than half (52.1%) of the nurses experienced occupational exposure to blood or body fluids [7]. Similarly, a study in Thailand indicated that operating room nurses face a high risk of occupational exposure to bloodborne pathogens, including needlestick injuries (NSIs), sharps injuries (SIs), and blood and body fluid exposures (BBFEs), with inadequate training identified as a significant contributing factor to these exposures [8]. In clinical practice, nursing students participate in many clinical tasks similar to those of licensed nurses. However, they show significantly lower levels of skill and experience in handling needles and sharps, leading to a higher risk of OBEs [9, 10]. More importantly, the knowledge, attitudes, practices, and needs (K-A-P-N) of Chinese nursing students, especially those during their internship, regarding OBEs are not well recognized. The OBEs questionnaire based on the “K-A-P-N” model among nursing students can assist Chinese nursing students in both theoretical studies and clinical practices related to OBEs.

Given this increased risk of OBEs for nursing students, it is crucial in nursing practice to adhere strictly to standard precautions, use appropriate personal protective equipment (PPE), and follow protocols immediately after exposure. Additionally, ongoing education and training in infection control and prevention strategies are essential in reducing nurses’ risk of OBEs. Studies indicate that high-quality training is the most important factor in preventing healthcare professionals from OBEs [11]. Nurses who do not participate in training sessions focused on the prevention and management of OBEs at their workplaces face a significantly higher risk of these injuries compared to those who undergo any form of training [12]. These studies suggest that finding an effective educational and training method is key to preventing nurses’ OBEs and protecting the health of nursing students.

The Lecture-Based Learning (LBL) paradigm, entrenched as a conventional instructional strategy in nursing education, continues to dominate due to its systematic presentation of theoretical constructs. A notable advantage of LBL lies in its ability to effectively transmit extensive knowledge to large cohorts in a constrained temporal window [13]. LBL underpins the standardization of teaching methods, thereby ensuring uniform knowledge dissemination among all learners a cornerstone for maintaining educational consistency. However, the instructor-centered nature of LBL has been criticized for limiting learner engagement and the facilitation of active learning processes. These elements are crucial in developing analytical reasoning and problem-solving skills in nursing practice [14]. Moreover, this approach is marked by a lack of opportunities for practical application of theoretical knowledge, an essential aspect of nursing education, due to its primary focus on theory [15]. The absence of interactive elements in lectures may lead to reduced knowledge retention and lower student motivation. This is because passive learning environments are generally less effective in knowledge assimilation compared to more interactive methods [16].

In 2014, a Fudan University expert in Shanghai introduced the Presentation-Assimilation-Discussion (PAD) model, a two-pronged approach to classroom teaching [17]. The PAD model is an innovative teaching approach that divides classroom time equally between teacher-led lectures and student-driven knowledge assimilation and group discussions. In the first phase, the instructor delivers core content through lectures, laying the foundation for students to understand the course material. This is followed by a second phase where students individually reflect to absorb the knowledge, then engage in group and class discussions to further solidify their understanding of the information [17, 18]. This approach not only emphasizes the teacher’s role in guiding and facilitating learning but also encourages active student participation, thereby enhancing their motivation and enthusiasm for learning [17, 18]. However, some disadvantages of the PAD model have been observed in practice, as this method requires instructors to possess strong classroom management and interaction-guidance skills, which can be challenging for teachers accustomed to traditional lecture-based methods; additionally, some students may be reluctant to participate due to shyness, lack of confidence, or unfamiliarity with the discussion content, potentially impacting their learning outcomes [19]. Currently, research on the application of the PAD model in healthcare education is relatively scarce.

Therefore, through this study, we aim to answer two questions: First, what is the current state of nursing students ' knowledge, attitudes, practices, and needs regarding OBEs? Second, is the PAD model a more effective method for OBEs education compared to the LBL model, in terms of enhancing nursing students’ mastery of OBEs knowledge and skills?

Methods

Study design

This study was conducted in a training and research hospital during the academic year of 2021–2022. First, we conducted a cross-sectional study using a blood-borne infection control questionnaire survey to explore the knowledge, attitudes, practices, and needs regarding OBEs among nursing students. Subsequently, we used a randomized controlled trial to compare the impact of the PAD method with the traditional LBL method on OBEs education for nursing students. The whole study design is illustrated in Fig. 1.

Fig. 1

Flowchart of the study design

Study participants

A total of 105 nursing students in the third year of nursing college, who were about to start their internships, were initially recruited. Fifteen students were excluded from the study: eight had previously participated in courses or training related to OBEs, and seven were unwilling to participate. Ultimately, 90 nursing students were enrolled in the study. These nursing students were then randomly divided into two groups using a digital randomization method: forty-five were trained using the presentation-assimilation-discussion (PAD) method as an experimental group, while forty-five were trained using the traditional lecture-based learning (LBL) method as a control group.

Study process

Part 1. The blood-borne infection control questionnaire survey: a cross-sectional study

After grouping, all participants completed a blood-borne infection control questionnaire. A 20-question anonymous structured questionnaire was used in this study. The 20-question questionnaire was developed, based on guidelines for the prevention of bloodborne infections from the WHO (World Health Organization) and China CDC (Centers for Disease Control and Prevention), and previous studies on bloodborne infections [20, 21]. The questions focused on students’ knowledge (K1-5), attitudes (A1-5), practice (P1-5) and training needs (N1-5) regarding OBEs (Supplemental Table S1). The 5-level Likert scoring method was adopted for each question, ranging from 1 point (very unclear/strongly disagreed/strong unwillingness) to 5 points (very clear/strongly agreed/strong willingness). A pilot testing of the questionnaire was conducted on 20 nursing students and the questions were revised accordingly. SPSS was used to analyze reliability, and Cronbach’s Alpha was 0.767. The content validity was analyzed by specialists form the hospital’s infection control department, and the construct validity was evaluated by confirmatory factor analysis (CFA). The validity and reliability were good.

Part 2. Comparing the impact of PAD method and LBL method on OBE education: a randomized controlled study

Based on the findings of this survey and historical data on OBEs provided by the hospital’s infection control department, a training program was developed. The training content primarily included blood-borne pathogen, standard precautions and procedural technique training, and post-exposure management procedures. The training course included three sessions with 90 min per session and lasted for two weeks. The two groups received the same teaching syllabus and the same reference materials one week before training. And they were taught by the same faculty members, including one instructor and four teaching assistants.

PAD method

The PAD method is made up of three major sections. The specific steps of the PAD method are detailed below. To illustrate the application of the teaching approach, we have chosen post-exposure management procedures as an example in this study.

Presentation (P) The instructor briefly emphasized key fundamental concepts and theoretical frameworks using PowerPoint presentations, leaving room for students’ subsequent independent study and discussion. This approach aimed to encourage independent thinking and assist students in constructing a closed-loop learning system. In the chapter on post-exposure management, the lecture mainly covered core concepts and frameworks such as emergency response after exposure, reporting systems, post-exposure prophylaxis (including assessment of the exposure source, assessment of the exposed person, and post-exposure preventive measures), monitoring and follow-up, and psychological intervention after exposure. This stage lasted approximately 40 min, followed by a 10-minute break.

Assimilation (A) After the instructor’s presentation, each student was tasked with identifying and addressing their knowledge gaps through independent study, and creating a mind map on post-exposure management based on what they had learned. Students were also encouraged to propose questions for discussion. Through this process, the integration of learning and thinking was achieved, facilitating the internalization of knowledge. This step took about 15 min.

Discussion (D) The discussion stage was divided into group and class discussions. In the group discussion segment, students formed groups of 4 to 6 members to collectively review key points on post-exposure management and attempt to answer raised questions. In the class discussion segment, a representative from each group, randomly selected by the instructor, summarized the highlights and confusions of their group’s discussion, which were then addressed by members of other groups or the instructor. Each discussion phase lasted 10 min. Finally, in the last 5 min of the class, the instructor summarized the key points of the lesson, highlighted areas for student improvement, and praised groups with outstanding performance in the discussion segments.

LBL method

The LBL method was implemented in the control group as follows. The instructor utilized PowerPoint to deliver lectures, each lasting 90 min, including a 10-minute mid-lecture break and a 5-minute question-and-answer session in the final. Both groups were encouraged to conduct pre-class preparation and post-class review based on the teaching syllabus to improve learning outcomes.

Measures

Demographic data included age and gender. The enrolled participants were required to complete three tests: one week before the training, one week and six months after the training (namely pre-test, post-test and retention test respectively). Each test consisted of a theoretical Sect. (60 points) and a practical Sect. (40 points), with a total score of 100 points. The theoretical section included single-choice questions, multiple-choice questions, and true/false questions with a time limit of 30 min. The questions in the three tests were evaluated by two different instructors to ensure consistency in difficulty levels. The practice section, i.e. hand hygiene practice assessment, included performing the seven-step handwashing technique and answering related questions, with a time limit of 5 min. The same senior nurse with at least 10 years of clinical and teaching experience served as the scoring expert, who was unaware of the study’s purpose, design, and group assignments. Afterward, the total score, as well as the scores for the theoretical and practice sections, were calculated for each student.

To assess the students’ feedback on the teaching method, a 9-question anonymous questionnaire survey was adopted at the end of the course. These questions were aimed to evaluate the students’ attitudes and learning experiences under each teaching method. The 5-level Likert scoring method was adopted for each question, ranging from 1 point (very dissatisfied/strongly disagreed) to 5 points (very satisfied/strongly agreed). The 9-question questionnaire utilized in this research was adapted from those used in earlier studies focused on student-centered teaching approaches [22, 23]. It was modified and updated to include elements specific to the PAD model, ensuring it accurately captured students’ feedback regarding the PAD model (Supplemental Figure S1).

Ethical considerations

This study was conducted in accordance with the 2013 version of the Helsinki Declaration. This research received approval from the Ethics Committee of the Affiliated Tumor Hospital of Chengdu Medical College. Before the study began, we explained the purpose and protocol of the study to all participants, who then reviewed and signed informed consent forms. Additionally, all participants were informed that they could withdraw from the study at any time without any consequences.

Statistical analysis

The normality of continuous data was assessed using the Shapiro-Wilk test. Depending on the data distribution, the results were presented as mean ± standard deviations (SDs) or median values, along with the interquartile range (IQR). Categorical variables were compared with the Chi-square test. Continuous variables with skewed distribution and ordinal variables were analysed using the Mann-Whitney U test. The test scores of the two groups at different time points were evaluated through a general linear model for repeated measurements. All statistical analyses were conducted using SPSS 26.0 (SPSS Inc., Chicago, USA), with all tests being two-tailed, and significance set at p < 0.05.

Results

Demographic information of students

A total of 90 nursing students were enrolled in this study and were randomly divided into two groups equally. Six months later, one participant (1/45, 2.2%) from the PAD group and two (2/45, 4.4%) from the LBL group were lost to follow-up. Consequently, the final analysis included data from 44 participants in the PAD group and 43 in the LBL group. Distribution of demographic characteristics was balanced. The gender ratio and ages for the two groups were comparable (p > 0.05; Table 1).

Table 1 Demographic information of students

Bloodborne infection control survey

Nursing students’ knowledge of OBEs were unsatisfactory: with 64.4% of students unfamiliar with post-exposure prophylaxis, 63.2% unaware of bloodborne pathogen monitoring, and 67.8% lacking knowledge about medical waste disposal. Particularly, they were almost completely unaware of the correct post-exposure management, with 78.2% of students unfamiliar with reporting procedures, 70.1% unaware of sharps injury management, 85.1% unaware of mucosal exposure treatment, and 85.1% unfamiliar with post-exposure monitoring and follow-up. However, most students recognized the importance of standard precautions. For instance, 60.9% of students believed that understanding a patient’s medical history was important, 69% emphasized the need to check for skin lesions on their hands before contacting patients, 62.1% highlighted the importance of hand hygiene after contacting patient, and 100% agreed that wearing goggles or face shields is important for preventing blood or bodily fluid splashes. At the same time, 86.2% of students believed that it is necessary to offer specialized and systematic OBEs courses in nursing education, and 63.2% and 87.4% of students, respectively, thought that it is essential for schools and hospitals to provide OBEs training before and during internships. Moreover, 50.6% and 44.8% of students expressed a willingness or strong willingness to participate in such training (Supplemental Table S1 and Fig. 2). There was no difference between the two groups regarding knowledge, attitudes, practice, and training needs related to OBEs (p > 0.05; Supplemental Table S1).

Fig. 2

Bloodborne infection control survey. The questions focused on students’ knowledge (K1-5), attitudes (A1-5), practice (P1-5) and training needs (N1-5) regarding blood-borne occupational exposures. The 5-level Likert scoring method was adopted for each question. 1 very unclear/strongly disagreed/strong unwillingness; 2 unclear/disagreed/unwillingness; 3 neutral; 4 clear/agreed/willingness; 5 very clear/strongly agreed/strong willingness

Comparison of the test scores

One week before training, nursing students underwent a pre-test evaluation. In the PAD group, the mean total score was 56.70 ± 3.47, with scores for theoretical and practice being 33.09 ± 3.39 and 23.61 ± 4.66, respectively. The LBL group presented similar scores: 56.40 ± 3.95 for the total, 33.33 ± 2.44 for theoretical, and 23.07 ± 4.84 for practice. No significant differences were observed (p > 0.05), demonstrating comparable baseline characteristics for both groups.

One week after training, the PAD group demonstrated significant improvements in their mean total score, theoretical, and practice scores, increasing from 56.70 to 84.25, 33.09 to 54.32, and 23.61 to 29.93, respectively (p < 0.001). Similarly, the LBL group showed notable gains, with scores rising from 56.40 to 78.95, 33.33 to 51.44, and 23.07 to 27.51, respectively (p < 0.001). Further inter-group comparison indicated that the PAD group’s mean total score, theoretical, and practice scores were significantly superior to those of the LBL group after training (84.25 ± 4.06 vs. 78.95 ± 4.23, 54.32 ± 2.43 vs. 51.44 ± 2.58, p < 0.001, and 29.93 ± 3.90 vs. 27.51 ± 4.33, p < 0.01, respectively).

To assess the retention of theoretical and practice, a second post-test was conducted six months after training. While the mean total and theoretical scores for both groups significantly diminished (p < 0.001), the practice score for the PAD group remained unchanged (p > 0.999), and that of the LBL group exhibited a slight increase (p = 0.70). Further analysis comparing the two groups revealed that the PAD group’s mean total and theoretical scores continued to be significantly higher than those of the LBL group (69.05 ± 3.87 vs. 65.77 ± 2.94, 39.05 ± 3.05 vs. 36.23 ± 3.18, p < 0.001). However, the difference in practice scores between the two groups was not statistically significant (30.00 ± 4.76 vs. 29.53 ± 3.73, p > 0.05). The decline in theoretical scores for both groups underscores the importance of repeated training regarding OBEs, while the maintenance of the seven-step handwashing technique may benefit from repetitive practice in clinical settings.

Additionally, when compared with the pre-test, both groups exhibited a marked enhancement in the mean total scores, theoretical and practice scores in the retention test (p < 0.001). This analysis proves the enduring impact of the training program on the participants’ knowledge and skills (Fig. 3).

Fig. 3

The test scores of PAD (n = 44) and LBL (n = 43) groups at different time points. Different time points: pre-test: 1 week before training; post-test: 1 week after training; retention test: 6 months after training. A total score; B theoretical score; C practice score. Data were presented as mean ± standard deviation (SD). ** p < 0.01, *** p < 0.001

Students’ feedback on the teaching method survey

Compared with the LBL group, the PAD group exhibited significant enhancements across various dimensions, including learning enthusiasm, understanding of teaching content, student-instructor interaction, satisfaction with teaching mode, satisfaction with teaching effect, problem-solving ability, and interest in continued learning (p < 0.01 for two aspects and p < 0.001 for the remaining aspects). However, it is important to note that a majority of students in the PAD group reported an increased study load (p < 0.001) and a reduction in the systematic organization of teaching content (p < 0.05) (Fig. 4).

Fig. 4

Five-level Likert scores of students’ feedback on the teaching method in PAD (n = 44) and LBL (n = 43) groups. A learning enthusiasm; B study load; C systematization of teaching content; D understanding of teaching content; E student-teacher interaction; F satisfaction of teaching mode; G satisfaction of teaching effect; H problem-solving ability improvement; I interest in continued learning. Data were presented as median values along with the interquartile range. * p < 0.05, ** p < 0.01, *** p < 0.001

Discussion

The “K-A-P-N” OBEs questionnaire holds significant value in assessing the status of healthcare professionals regarding OBEs, and it can provide data support for developing more effective training and intervention strategies. In the first part of our study, a cross-sectional analysis was conducted using the questionnaires to examine students’ levels of knowledge, attitudes, practices, and needs concerning OBEs. Our data has found that the majority of nursing students exhibit a significant lack of knowledge regarding OBEs. This is evident in their insufficient understanding of the basic knowledge about blood-borne pathogens, the ignorance of preventive measures following OBEs, and unfamiliarity with the standard handling of contaminated items. This finding is consistent with previous research [24, 25]. The issue of inadequate OBEs knowledge is also prevalent among students in other disciplines, such as dentistry [21].

Our OBEs questionnaire revealed that the majority of students demonstrated a high level of recognition regarding fundamental occupational protection knowledge, acknowledging its crucial role in reducing occupational exposures. Most students also recognized the importance of understanding patients’ medical histories prior to performing medical procedures, indicating an awareness of the link between patient background information and occupational exposures. In terms of routine practices, students showed a clear understanding of the need to inspect their hands for injuries and placed significant emphasis on hand hygiene after patient contact. They also believed that wearing goggles or face shields was necessary when there was a risk of blood or bodily fluid splashes. These positive attitudes suggested that students had a strong risk awareness concerning OBEs and a high level of recognition for preventive measures, reflecting their concern and emphasis on occupational safety. This awareness of OBEs and recognition of preventive measures had been observed in other studies on healthcare practitioners [26]. Moreover, other research was consistent with our findings: the majority of nurses held a positive attitude towards standard precautions against OBEs [27].

In the “Practices” section of our OBEs questionnaire, we focused on students’ familiarity with procedures and handling methods related to OBEs. Our results indicated that most students reported being very unfamiliar or unfamiliar with these issues. This situation reflected a significant lack of practical ability among nursing students when dealing with OBE incidents, particularly regarding post-OBE reporting procedures, sharp injury management, mucous membrane exposure handling, and OBE monitoring and follow-up procedures. Such unfamiliarity with post-OBE handling was also common among other healthcare practitioners [28]. These results suggested that OBE training should aim to enhance students’ ability to handle OBE incidents effectively, ensuring they can protect both themselves and patients’ health in their professional environment.

The results from the “Needs” section of our OBEs questionnaire indicated that students generally recognized the importance of training on OBEs and displayed a positive attitude toward participating in such training. This reflected their emphasis on self-protection and raising awareness of occupational safety. It also suggested that they wished to acquire sufficient knowledge and skills to handle potential occupational risks before entering practical nursing work. This positive attitude provided strong support for educational and medical institutions to further refine OBEs training programs. Schools and hospitals should seize this opportunity, integrating students’ needs, and developing an effective OBEs educational model at the outset of nursing students’ internships to enhance their sense of security and professional competence throughout their careers.

The second part of our study focused on the effectiveness of the PAD model as an innovative teaching method for nursing students in the context of OBEs. Our findings indicated that, compared to the traditional LBL method, the PAD model significantly enhanced students’ immediate theoretical knowledge and practical performance regarding OBEs. Another study observed the effectiveness of the PAD model in dental education, demonstrating that, compared to traditional lecture-based teaching, PAD model ignited students’ enthusiasm for learning and enhanced their levels of theoretical testing and practical operation [18]. These findings align with our research, indicating that the PAD model might significantly improve students’ theoretical knowledge scores and practical operation levels in healthcare-related courses. The PAD model necessitates that educators distill the essence of the teaching material, moving away from traditional didactic teaching methods and enabling students to become the protagonists of the classroom. Through student discussions, teachers can quickly grasp the students’ learning status, identify common issues, and address them in a targeted manner, thereby enhancing teaching effectiveness [29].

The key to long-term knowledge retention lies in students’ active engagement with the content and taking on greater responsibility for their learning [30]. The PAD model involves students actively participating in classroom activities and redistributes various rights and responsibilities throughout the teaching process. It enables students to learn with proper guidance from teachers, thereby encouraging them to assume responsibility for their learning [29]. All these factors suggest that the PAD model can lead to better outcomes in terms of long-term knowledge retention. Investigating the longer-term effects and knowledge retention will yield evidence of the sustainable impact of new teaching methods. Therefore, we explored whether the PAD model is superior to traditional LBL method in terms of knowledge retention after six months. Our findings suggest that, following the initial implementation of the PAD model, long-term retention of knowledge exceeds that achieved through the traditional LBL method. Moreover, in terms of practical skills, the retention test scores of the LBL method group and the PAD model group were higher than those at post-test. This can be attributed to the repeated training of practical skills during the six-month internship, which enhanced the students’ practical abilities.

Our study found that the PAD model, compared to the traditional LBL method, significantly enhanced students’ enthusiasm for learning, understanding of teaching content, satisfaction with teaching, problem-solving abilities, and interest in continued learning. This suggests that the PAD model, by enhancing students’ autonomy and engagement, contributes to deeper learning outcomes. These positive effects, particularly the enhancement of students’ self-directed learning abilities and satisfaction with teaching, have also been observed in other studies applying the PAD model in nursing education [19].

However, student feedback questionnaires also highlighted an increase in study load and certain deficiencies in the systematic organization of teaching content. This phenomenon may stem from the PAD model’s emphasis on self-directed exploration and learning, which may cause students to feel overwhelmed when faced with a large amount of information and tasks. Similar findings of increased study load have been observed in other studies using non-traditional LBL methods, which share the common feature of transforming students from passive recipients of knowledge in the classroom into active participants in the learning process [22, 31]. This suggests that in the future application of the PAD model and similar new teaching methods, it may be beneficial to provide a more structured learning framework to reduce students’ cognitive load and improve their ability to grasp the systematic nature of the knowledge being taught. Additionally, it is hoped that teachers will better manage students’ study load and the systematic organization of teaching content, enhancing the logical coherence and structure of the knowledge. These improvements are expected to offer students clearer learning pathways, leading to a better learning experience and improved educational outcomes.

Conclusion

Our study suggests that the majority of nursing students exhibit a significant lack of knowledge and managing capability of OBEs. At the same time, the students also demonstrate a strong willingness and need to learn about OBEs. Our study is the first to implement the PAD model within the OBEs course for nursing students. Compared to traditional LBL method, we found that the PAD model significantly stimulated nursing students’ enthusiasm and initiative for learning about OBEs. Moreover, the PAD model demonstrated an advantage over the LBL model in both immediate theoretical and practical scores, and it also had a superior retention of theoretical knowledge. However, there was no significant difference in the retention of practical skills between the two groups. Based on our findings, we suggest that the PAD model could be a valuable approach for teaching OBEs to nursing students.

Limitation

The scope of the investigation was confined to nursing students, highlighting the necessity for subsequent studies to incorporate a broader range of participants, such as healthcare professionals, medical students, and public health students, to corroborate the efficacy of the proposed method. Additionally, the limited sample size of this study underscores the need for further research with an expanded cohort to thoroughly assess the method’s impact and reduce potential biases identified in our findings. Furthermore, the longitudinal effects of this innovative approach were not examined adequately. Future studies should, therefore, employ multi-center randomized controlled trials with extended follow-up durations to evaluate the sustained effectiveness of the method.