Content area
Aim
To map the use of active methodologies in nursing education for teaching the nursing process.
BackgroundThe nursing process is a systematic approach essential for clinical reasoning, guiding nursing diagnoses and care planning, execution and evaluation. Its teaching requires strategies that engage students in active learning to foster evidence-based practice.
DesignScoping review performed according to the Joanna Briggs Institute Manual for Evidence Synthesis.
MethodsThe review involved seven steps: defining review questions, establishing eligibility criteria, designing search strategies, screening and selecting evidence, extracting data, analyzing results and presenting findings. Searches were conducted in July 2023 and updated in February 2024 on the databases Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Literature on Health Sciences, Excerpta Medica dataBASE, Medical Literature Analysis and Retrieval System Online, Scopus, Web of Science and Google Scholar. The review targeted graduate and undergraduate nursing students (Population), the nursing process (Concept) and active teaching methodologies (Context), guided by the PCC framework.
ResultsThe 101 included studies present key active strategies such as clinical simulation, case-based learning, web-based learning, problem-based learning, concept mapping, virtual simulation, electronic record systems, clinical practice and laboratory activities. Nursing assessment was the most frequently taught step, followed by diagnosis, interventions, evaluation and outcomes.
ConclusionActive methodologies consistently demonstrated positive impacts on critical competencies, fostering critical thinking, clinical reasoning and judgment. Integrating these strategies with traditional approaches in undergraduate nursing curricula enhances the application of theoretical knowledge in clinical practice.
The provision of nursing care demands planned actions based on technical-scientific knowledge. This involves the application of appropriate clinical judgments to identify the real or potential health needs that require nursing intervention ( de la Cuesta, 1983; Klenke-Borgmann et al., 2020). The approach to teaching should be grounded in theoretical frameworks, with nursing models or theories. An important aspect for operationalization of the nursing process is employing Evidence-Based Practice (EBP) combined with clinical experience and patient preferences to achieve better results ( Brandão et al., 2019; Kerr and Rainey, 2021).
To articulate clinical judgment in treatment and goal-oriented tasks, nurses use the nursing process – a systematic approach that integrates EBP principles, critical thinking and patient-centered approaches – to promote holistic and scientifically appropriate care in an integrated way, which in turn promotes safe and high-quality care ( Riegel et al., 2018).
The nursing process is a guiding framework for nursing care by providing a systematic structure that facilitates clinical reasoning. Through the identification of nursing diagnoses, it directs the provider to the planning, execution and evaluation of care actions. Implementing the nursing process potentially enhances safety, contributing to favorable outcomes for both patients and community. Moreover, it plays a crucial role in documenting the nursing actions ( Barros et al., 2020; Pereira et al., 2017).
Furthermore, the various Nursing Classification Systems categorize nursing diagnoses, interventions and outcomes, providing a standardized language that facilitates the systematic organization of care. This process aids in delineating the scope of nursing knowledge, fostering interdisciplinary collaboration between nursing management and care. Such standardization contributes to the EBP by complying with extensive scientific documentation ( Barros et al., 2020; de Carvalho et al., 2013).
As nursing struggled for recognition, the nursing process provided credibility in establishing nursing science and the discipline of nursing. Despite this, the nursing process remains underused in various clinical scenarios, often attributed to professionals' lack of understanding of the process and other factors such as insufficient staffing size of the nursing team ( Agyeman-Yeboah et al., 2017).
Furthermore, challenges associated with implementing the nursing process in clinical practice and the ongoing efforts to enhance clinical reasoning and nursing practice through education ( Carvalho et al., 2017; Klenke-Borgmann et al., 2020), demands effective teaching strategies. These challenges go beyond the barrier of teaching the nursing process, as they are compounded by the continuous evolution of technologies and variations in learning styles influenced by generational differences. This dynamic landscape establishes a new paradigm for nursing education, demanding an education approach centered on the nursing student ( Kavanagh and Sharpnack, 2021).
Additionally, new strategies for teaching clinical reasoning within the nursing process are required to meet the contemporary demands of public health policies ( Lisa, 2018). A pivotal objective is to allow nurses to develop competencies and skills required to navigate diverse settings and individuals’ needs ( Fernandes and Rebouças, 2013; Ximenes et al., 2019).
In the context of the present study, active learning is defined as a type of learning that empowers students to be critical, reflective and transformative, actively engaging as protagonists in their own learning. This involves a deep understanding of the stages in the teaching-learning process and the assessment of outcomes achieved in terms of knowledge, skills and attitudes ( Moran, 2018).
Active methodologies can support the development of core competencies integrating theory and practice, thus promoting active learning. When systematically developed, active teaching strategies can contribute to achieve learning objectives effectively and provide to students capability to develop critical thinking ( Palheta et al., 2020). Although challenging, this process yields significant results, particularly in the development of necessary competencies for clinical decision-making ( Oliveira Silva et al., 2022).
Incorporating active teaching strategies into the nursing curriculum helps overcome fragmented education and potentially contributes to the transfer of knowledge to clinical practice, bridging the gap between theoretical understanding and real-world application ( Alves et al., 2021; Crisol-Moya et al., 2020).
Furthermore, previous studies have emphasized the impact of incorporating instructional design strategies into the teaching process ( Oliveira Silva et al., 2023), a systematic procedure to develop and implement teaching strategies focused on increasing students’ learning outcomes achievement ( Seel et al., 2017). Consequently, the results of this scoping review have the potential to highlight innovative strategies in teaching the nursing process that bring effective outcomes to the development of core competencies required in clinical practice ( Klenke-Borgmann et al., 2020), in addition to support faculty with new teaching strategies.
In searches conducted in the International Prospective Register of Systematic Reviews (PROSPERO), Open Science Framework, Cochrane Library and Medical Literature Analysis and Retrieval System Online (MEDLINE), no records/protocols of scoping/systematic reviews or published complete reviews were identified investigating the use of active methodologies focused on teaching the nursing process. Recognizing as imperative to comprehensively understand how active methodologies are applied in teaching the nursing process and the outcomes achieved, this review seeks to fill this gap in existing literature. Therefore, the aim of this study is to map the use of active methodologies in nursing education for teaching the nursing process.
2 Methods2.1 Study design
This study employs the scoping review methodology to obtain broad and comprehensive results in studies available in the literature while maintaining a systematic and replicable research approach ( Arksey and O’Malley, 2005). Characterized by the possibility of mapping the main concepts of a specific knowledge area, the scoping review allows the integration of results of different study designs, to summarize findings and identify relevant gaps in the literature ( O’Brien et al., 2016). In the context of this study, the scoping review method was used to map the main active methodologies used to teach the nursing process.
The recommendations of the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis ( Peters et al., 2020a) were adopted in this review, being developed in seven stages: 1) identification of the review questions; 2) eligibility criteria; 3) search strategies; 4) screening and selection of evidence; 5) data extraction; 6) data analysis; and 7) presentation of the results. Furthermore, this study followed reporting guidelines based on PRISMA Extension for Scoping Reviews (PRISMA-ScR) ( Tricco et al., 2018) and was registered in the Open Science Framework database ( https://osf.io/q2tjg/).
2.2 Inclusion criteriaTo determine the research question, the acronym PCC was used ( Peters et al., 2020b), where P (Population) is equivalent to undergraduate and graduate nursing students, C (Concept) is equivalent to the nursing process and its steps and C (Context) is equivalent to the active methodologies used in the teaching process.
Studies that address the teaching of the nursing process were considered, using its five steps (data collection, nursing diagnoses, nursing planning, implementation and evaluation) either individually or together. Additional studies that evaluated learning outcomes associated with the nursing process, such as knowledge, skills and attitudes, were included. Furthermore, studies exploring nursing core competencies, including critical thinking, clinical reasoning and/or clinical judgment among nursing students, were considered in the analysis.
As a learning context, active teaching methodologies were established for this review. Initial searches using the keyword "active method* " revealed a limited number of studies that explicitly delineate titles and abstracts employing active teaching methodologies. In this sense, for this study, search strategies encompass descriptors associated with teaching strategies widely recognized as active and used in nursing education. These include, but are not limited to, clinical cases, serious games, problem-based learning (PBL), team-based learning (TBL), clinical simulation, virtual reality, virtual games, board games, laboratory training, concept maps and text readings.
2.3 Review questions- • What active teaching strategies have been used to teach the nursing process?
- • What are the outcomes associated with the use of active methodologies to teach the nursing process?
This review included primary studies of both quantitative and qualitative nature, encompassing observational and experimental studies. It also considered systematic reviews, meta-analyses, integrative and narrative reviews, opinion studies, guidelines and norms that discuss elements of nursing process teaching. Publications in English, Spanish and Portuguese, without time limitation, were included in this review. Books, event proceedings and clinical trial records or systematic/scoping review protocols without published results were not considered.
2.5 Search strategiesThe searches were conducted in July 2023 and updated in February 2024 through the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Latin American and Caribbean Literature on Health Sciences (LILACS), Excerpta Medica dataBASE (Embase), Medical Literature Analysis and Retrieval System Online (MEDLINE), SCOPUS (Elsevier) and Web of Science. Additionally, free searches and searches in the gray literature were carried out using Google Scholar, with a focus on identifying the 200 most relevant references ( Bramer et al., 2017).
The search strategies included standardized descriptors identified in the MeSH (Medical Subject Headings), DeCS (Health Descriptors) and Entree Terms: "nursing education", "nursing students", "graduate nursing education", "baccalaureate nursing education", "nursing process", "nursing assessment", "nursing diagnosis", "gamification", "problem-based simulation learning", "simulation training", "computer simulation". In addition, non-standard descriptors were used: "clinical simulation", "simulation", "simulation-based learning", "simulation-based environment", "virtual simulation", "virtual patient", "virtual reality", "augmented reality", "video games", "serious game", "game", "game-based learning", "board game", "educational technology", "learning technology", "video", "instructional films and video", "multimedia", "innovations", "role-play", "clinical case", "case stud* ", "case-based learning", "problem-based learning", "team-based learning", "skill laboratory", "laboratory training", "laboratory demonstration", "lecture", "class", "flipped classroom", "web-based learning", "active learning classroom", "conceptual map", "mental map", "read* ", "reading texts". Search strategies were developed for each database (Appendix 1).
The adequacy of the search strategy for each database was evaluated following the PRESS (Peer Review of Electronic Search Strategies) Guideline Statement ( McGowan et al., 2016). Two researchers, with previous experience in systematic and scoping reviews, conducted the assessment. The evaluation analyzed various aspects of the search, including the translation of the search question into the search, the use of Boolean and proximity operators, the incorporation of subject headings, word searches in the text (free terms), the absence of typing, syntax and line errors, as well as the application of limits and filters. After the evaluation, the search strategies were revised based on the feedback and suggestions received.
2.6 Selection of sources of evidenceThe selection of the sources of evidence was carried out in four stages: (1) a database was created with all records using the EndNote X9 software; (2) the database was then transferred to Covidence, a systematic and scoping review management software, which, identified and excluded duplicate references; (3) the screening process began with the evaluation of titles and abstracts in the initial stage; followed by (4) the confirmation stage, thorough examination and reading the full texts. This phase involved a detailed identification of relevant studies and the exclusion of those not meeting the eligibility criteria. Two reviewers (first and second authors) independently performed the screening and confirmation steps. A third reviewer resolved any disagreements that arose (last author).
2.7 Data extractionBased on the JBI model ( Peters et al., 2020a), a data extraction form was developed to analyze the scope and record the characteristics of each study. The extraction form was tested by the authors and transferred to Covidence software ( Veritas Health Innovation, 2022), where the data were extracted and imported into a Microsoft Office Excel spreadsheet.
The extracted information included details such as authors, title, sample (if applicable), methodological design, study groups, teaching strategy used, the step of the nursing process taught and outcomes. Data extraction responsibilities were divided, with one reviewer (first author) performing the initial extraction and another reviewer (last author) confirming the accuracy and completeness of the extracted data.
2.8 Quality appraisalQuality assessment was performed using Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals appraisal guidelines, an instrument used to determine the level of evidence and quality rate of included studies ( Dang et al., 2021). Through a decision tree algorithm, the instrument provides a classification in five levels of evidence and three quality rating levels, where levels I to III incorporate research studies, while levels IV and V incorporate non-research studies.
The levels of evidence are divided into: Level I – experimental studies (randomized controlled studies) and systematic reviews of randomized controlled studies; Level II – quasi-experimental studies and systematic reviews including experimental and quasi-experimental studies; Level III – non-experimental and qualitative studies; Level IV – clinical practice guidelines, consensus panels, or position statements; and Level V – experiential and non-research evidence such as integrative reviews, case reports and literature reviews. Each level is classified in high quality (Rating A), good quality (Rating B), or low quality/major flaws (Rating C) based on the study design. The appraisal was made by one reviewer (first author) and confirmed by another reviewer (last author).
2.9 Analysis of evidence and data presentationThe identified results were synthesized by mapping the approaches and strategies employed in teaching the nursing process. As a scoping review does not typically aim to synthesize the results/outcomes of the included studies in a traditional manner, the results were descriptively mapped and analyzed, focusing on divergences and similarities among the included studies. Additionally, a thematic analysis was applied to categorize the available evidence. The results were synthesized according to (1) the active teaching strategies used to teach the nursing process, and the steps of the nursing process taught; (2) evaluated outcomes from teaching the nursing process; and (3) obtained results.
The studies selection path was presented through the flowchart recommended by the PRISMA-ScR checklist ( Tricco et al., 2018). The extracted data was presented in accordance with the guidelines outlined in the Methodology for JBI Scoping Reviews ( Peters et al., 2020a). The information was displayed in tables and figures, considering the approaches and strategies used to teach the nursing process and the evaluated outcomes. To designate each study included in this review, we selected the term “Study”, described by the letter “S” followed by Arabic numerals corresponding to the order of presentation in the results.
3 ResultsThe total number of records identified in the databases, registers and additional searches was 1243. Following the removal of 375 duplicates records, 865 studies were evaluated in the screening stage, with 195 eligible for reading the full texts. At this stage, 94 records were excluded, resulting in a final sample of 101 studies ( Fig. 1).
3.1 Characteristics of included studiesThe studies included in this scoping review comprised a global sample of 6828 undergraduate nursing students in different periods of the program and 17 graduate nursing students, with studies conducted in the regions of North America (33.7 %; n = 34), Asia (19.8 %; n = 20), South America (17.8 %; n = 18), Middle East (15.8 %; n = 16), Europe (8.9 %; n = 9), Africa (2.0 %; n = 2) and Oceania (2.0 %; n = 2). Twenty-nine studies (28.7 %) were non-randomized experimental studies, 24 (23.8 %) randomized controlled trials, 13 (12.9 %) cross sectional studies, 12 (11.9 %) case reports, 10 (9.9 %) qualitative studies, six (6.0 %) descriptive studies, three (3.0 %) systematic, scoping, or integrative reviews, two (2.0 %) cohort/longitudinal studies, one (1.0 %) methodological study and one (1.0 %) text and opinion study ( Table 1).
Regarding the level and quality of evidence, 25 studies (24.7 %) are Level I of evidence, of which 14 (13.9 %) presented high quality (Rating A), 10 (9.9 %) presented good quality (Rating B) and 1 (1.0 %) presented low quality (Rating C); 29 studies (28.7 %) are Level II of evidence, of which 15 (14.9 %) were of high quality (Rating A), 11 (10.9 %) were of good quality (Rating B) and 3 (3.0 %) were of low quality; 31 studies (30.7 %) are Level III of evidence, of which 10 (9.9 %) presented high quality (Rating A), 19 (18.8 %) presented good quality (Rating B) and two (2.0 %) presented low quality (Rating C); and 16 (15.8 %) studies were Level V of evidence, of which 11 (10.9 %) presented high quality (Rating A), 4 (4.0 %) presented good quality (Rating B) and one (1.0 %) presented low quality (Rating C).
Active teaching strategies were varied, with 32 (31.7 %) studies using clinical simulation, 22 (21.8 %) case-based learning, 14 (13.9 %) web-based learning, 10 (9.9 %) PBL and virtual reality (VR) or virtual simulation respectively, 8 (7.9 %) concept map, seven (6.9 %) electronic record systems, five (5.0 %) clinical practice and skill laboratory respectively, three (3.0 %) debate, guidance about a structured form to use during clinical practice, problematization and videos followed by discussion and tutoring respectively, two (2.0 %) game-based learning, art-based learning, dramatization, flipped classroom and TBL respectively. In 26 (25.7 %) studies, it is reported the use of combining different active strategies, but only 2 studies blended learning to describe this approach, as shown in Fig. 2. Among these studies, some included comparisons of the association of active strategies with traditional teaching strategies (control group), such as theoretical classes (13.8 %; n = 13) and lectures (10.6 %; n = 10). The characteristics of the included studies are presented in detail in Appendix 2.
3.2 Steps of the nursing process taught and evaluated outcomesThe most reported element of the nursing process taught was nursing assessment, followed by establishment of nursing diagnosis, nursing interventions, evaluation and nursing outcomes ( Fig. 3).
Although nursing outcomes are present in 63 studies, few highlight how teaching strategies can be used to teach students to establish achievable goals for patients or describe the use of Nursing Outcomes Classification (NOC) in this step. Additionally, in 15 studies, the authors approach the use of tools, especially electronic documentation systems, to teach nursing documentation and the use of standardized language, focused explicitly on nursing diagnosis.
The included studies evaluated various outcomes related to general and core competencies, nursing process related abilities and self-perception of learning ( Table 2). Knowledge was the most evaluated outcome within the general competencies, followed by skills and attitudes. On the other hand, within the core competencies, critical thinking was the most evaluated outcome, followed by problem-solving, clinical competence, communication, decision-making, clinical judgment, clinical reasoning and teamwork. Among the outcomes related to specific steps of the nursing process are measures such as diagnostic accuracy, ability or reasoning, nursing process planning, nursing assessment ability and correct identification of nursing interventions. Additionally, some studies evaluated self-perception outcomes, with the most frequently assessed aspect being self-efficacy/self-confidence related to the acquired learning through the teaching strategy, followed by assessments of satisfaction, stress/anxiety and self-leadership.
Among the studies that addressed all stages of the nursing process (40.4 %; n = 38), the predominant teaching strategy was clinical simulation (19.1 %; n = 18), followed by case-based learning (9.6 %; n = 9) and Problem Based Learning (PBL) (7.4 %; n = 7). Other strategies, such as virtual simulation (n = 8), concept map (n = 7), web-based learning (n = 7), clinical practice (n = 6), skill laboratory (n = 5), game-based learning (n = 3) and guided discussions (n = 1), were less frequently used. Some studies employed strategies that covered all stages and evaluated students' care plans, comparing those created with or without electronic documentation systems (n = 2). Notably, only one study highlighted the use of a system that is linked with the three main nursing taxonomies: NANDA International Nursing Diagnoses (NANDA-I), Nursing International Classification (NIC) and NOC.
3.2.1 Nursing assessmentThe nursing assessment step is reported in most studies included in this review. It is viewed as a foundational element for students to progress through the established strategy toward subsequent steps of the nursing process. The evaluated outcomes related to this step are associated with the identification of the patient's objective and subjective data, which can be demonstrated in the assessment of knowledge and assessment skills, present in strategies such as clinical simulation, case-based learning, PBL, virtual simulations and other strategies that require students to actively seek clues and information to solve cases.
3.2.2 Nursing diagnosisStudies addressing nursing diagnoses used different strategies, as well as nursing assessment. However, studies stand out where authors use web-based tools or electronic systems to document the nursing process using the Nursing Classification Systems, with a predominance of NANDA-I. The outcomes assessed by these studies focus on the ability to establish nursing diagnoses, such as the assessing reasoning skills and diagnostic accuracy. Some studies explored the accuracy of defining characteristics and factors related to the identified nursing diagnosis.
3.2.3 Nursing outcomesDespite being present in 50 studies, nursing outcomes, an essential step of the nursing planning, are generally addressed in the evaluation of nursing care plans prepared by students. In only one study, the authors highlighted using NOC through an electronic documentation system to establish goals with quantifiable indicators. The main outcomes evaluated in studies that addressed nursing outcomes were critical thinking, clinical competence and knowledge.
3.2.4 Nursing interventionsStudies focusing on nursing interventions used clinical simulation, case-based learning, PBL, virtual simulations, web-based learning, concept maps and other strategies requiring critical decision-making thinking. The outcomes evaluated in these studies were clinical reasoning, problem-solving and performance, focusing on identifying whether the student could critically analyze the proposed scenario and establish appropriate interventions.
3.2.5 EvaluationThe nursing evaluation stage was addressed in studies that evaluated all stages of the nursing process together. However, only five studies explicitly incorporated specific dimensions for evaluating this stage. Outcomes in these studies focused on assessing knowledge, critical thinking, problem solving and skills. These measures were related to the assessment of the patient after implementing the intervention, aiming to identify the achievement of goals.
3.3 Results obtained with the implementation of teaching strategiesThe studies included in this review demonstrate that the use of active strategies for teaching the nursing process is effective in developing competencies required in clinical practice. In general, single-group studies with pre- and post-test assessments demonstrate an increase in the outcomes assessed and comparison studies consistently supported the superiority of active strategies, especially compared with traditional teaching strategies, in developing both general and core competencies necessary for nurses.
Qualitative and case report studies that address the perception of professors and students further reinforce these findings, highlighting the ability of these strategies to empower students to translate acquired competencies into patient care in clinical practice settings. However, there was no study evaluating the effect of active teaching strategies on the translation of knowledge into clinical practice.
Regarding the type of teaching strategy, there was a predominance of studies applying strategies that require students to employ competencies such as critical thinking, clinical reasoning and clinical judgment to make appropriate decisions and resolve the proposed clinical case. This is especially evident in the strategies that enable students to progress through all stages of the nursing process, such as clinical and virtual simulations, case-based simulation and PBL. Moreover, these strategies facilitate the development of skills related to the documentation of the nursing process, based on the development of care plans for the proposed cases. Additionally, these strategies also provide opportunities for students to enhance communication skills, collaborate in teamwork with peers and engage in collaborative learning.
4 DiscussionThe findings of this scoping review highlight the fundamental role of active methodologies in nursing education, emphasizing their effectiveness in developing competencies required in clinical practice. Grounded in the principles of historical-critical pedagogy—which emphasizes education as a means to understand and transform society by valuing historically and collectively constructed knowledge—and humanist pedagogy, which focuses on the holistic development of learners and their active participation in the teaching-learning process, these findings reinforce the importance of transformative approach in nursing education. By aligning with these pedagogical frameworks, active methodologies advocate for empowering students to critically engage with the nursing process, addressing both societal needs and individual growth ( Tsimane and Downing, 2020). By incorporating active teaching strategies in undergraduate curricula, associating them with conventional teaching strategies, educators harness opportunities for students to apply theoretical knowledge to real-world scenarios, fostering the development of core competencies such as critical thinking, clinical reasoning and clinical judgment ( Ghezzi et al., 2021).
Even from a different pedagogical perspective, Kolb's experiential learning theory, which emphasizes learning as a cyclical process involving concrete experience, reflective observation, abstract conceptualization and active experimentation, highlights the distinct advantage of active methodologies over conventional didactic teaching approaches. By immersing students in environments that promote hands-on experiences and critical reflection, these methodologies align with Kolb's framework, fostering deeper understanding and skill development through active participation ( Morris, 2020). The studies included in this review highlight that active teaching strategies, based on real clinical cases, expose students to complex patient scenarios, compelling them to navigate clinical decision-making processes independently ( Ienopoli et al., 2022; LuPone, 2017; Munn et al., 2021).
The findings suggest that teaching strategies can be tailored to teach each step of nursing process to enhance theoretical understanding and practical application. In the assessment phase, strategies such as concept mapping, case-based learning and virtual simulations can be used to help students gather and analyze patient data systematically, often evaluated through performance tests. For diagnosis, strategies such as online courses, case-based learning and web-based learning promote critical thinking and diagnostic reasoning, assessed through skill tests and rubrics. For implementing interventions simulations, laboratory activities and blended learning can be used to practice implementing care plans. For outcomes phase, concept mapping and simulations link interventions to measurable results, evaluated through surveys and self-assessment tools. Finally, the evaluation phase focuses on reflective practice that can be taught using strategies that allows students to reflect-on-action, such as PBL and simulations with rubrics and debriefing sessions fostering critical analysis of patient outcomes. When combined, these strategies ensure students develop comprehensive competencies across all steps of the nursing process.
The hands-on approach, facilitated by strategies like simulation, not only reinforces theoretical concepts but also helps students developing the ability to synthesize information, prioritize patient needs and develop effective nursing interventions ( Alshehri et al., 2023). These immersive experiences bridge the gap between theory and practice, supporting students with the confidence and skills necessary for nursing practice ( Oliveira Silva et al., 2022).
Moreover, active methodologies go beyond academic learning and promote the development of essential interpersonal skills. They create collaborative learning environments, mirroring the interdisciplinary nature of modern healthcare settings ( Grace, 2021). Through engaging in group discussions, debriefings and collaborative problem-solving activities, students not only learn the subject matter but also develop skills in effective communication, negotiation of differing perspectives and functioning as integral members of healthcare teams ( Sezgin and Bektas, 2023).
These interpersonal skills can be developed in teaching strategies such as TBL, PBL, problematization, clinical simulations and case-based learning, followed by group discussions and are fundamental in nursing practice, where effective communication and teamwork are essential for delivering high-quality patient care and promoting positive patient outcomes ( Beardsmore and McSherry, 2017; Dietl et al., 2023).
Additionally, strategies for consolidating learning, such as concept maps, especially when associated with other strategies ( Gao et al., 2022; Samawi et al., 2014), allows the students to connect new information with existing knowledge. This involves using critical thinking to build relations between objective and subjective patient data to establish the steps of the nursing process in clinical cases ( Yue et al., 2017). When associated with web-based learning, this strategy can improve students’ motivation for the use of critical thinking skills and diagnostic reasoning, both of which are essential competencies in the implementation of the nursing process ( Bilik et al., 2020; Ordu and Caliskan, 2023).
Importantly, using technology-enhanced learning tools, such as web-based learning and virtual simulations, not only aligns with contemporary educational trends but also prepares students to navigate increasingly digitized healthcare environments ( Nicoll et al., 2018). These strategies and tools are an alternative to expose students to challenges in a safe environment that can be tested and repeated by demand. Even less complex and widely used technology, such as electronic documentation systems and nursing taxonomies, educators provide students with the technical proficiency necessary for advanced nursing practice ( Zaman et al., 2021). Additionally, these tools facilitate the standardization of nursing documentation practices, promoting clarity, accuracy and interoperability in patient records ( De Groot et al., 2020).
However, while most studies include nursing outcomes in their activities, few strategies were used to teach outcome indicators, an essential component of the advanced nursing process that contributes to patient evaluation. Furthermore, the emphasis on evaluating learning outcomes related to the nursing process in the included studies – ranging from diagnostic accuracy to clinical competence – reflects a concern with assessing competencies necessary for clinical practice. By assessing both cognitive, psychomotor and affective domains, educators gain insights into students' proficiency in applying theoretical knowledge to clinical contexts, as well as their confidence levels, satisfaction and stress management skills ( Efendi et al., 2023; Enoch et al., 2022; Mauriz et al., 2021).
These assessment approaches are necessary, especially in the post-Covid-19 pandemic context, with the greater implementation of technologies such as e-learning, tele simulation and massive open online courses (MOOCs) ( Singh et al., 2021). This multifaceted evaluation approach enables educators to tailor teaching strategies to meet the diverse learning needs of students, fostering individual growth and development.
Thus, by prioritizing experiential learning, collaborative engagement and technology integration, educators can effectively cultivate the competencies necessary for nursing practice. Furthermore, the combination of different teaching strategies allows educators to enhance students' learning experiences ( Du et al., 2022), which in the context of this review allowed students to have a greater understanding of the nursing process and its steps.
Future studies can help elucidate the effect of active teaching strategies on translating competencies into clinical practice and how they can have an impact on patient outcomes.
4.1 Implications to Nursing EducationThe findings of this scoping review highlight the significant role of active methodologies in nursing education for developing essential competencies in clinical practice. By integrating active teaching strategies into undergraduate curricula alongside traditional approaches, educators facilitate opportunities for students to apply theoretical knowledge to real-world scenarios, fostering the cultivation of core competencies such as critical thinking, clinical reasoning and clinical judgment. These strategies, particularly evident in immersive experiences like simulation-based learning, enable students to bridge the theory-practice gap, supporting them with the confidence and skills necessary for appropriate clinical decision-making in healthcare. Moreover, active methodologies can promote collaborative learning environments, mirroring the nature of healthcare teamwork settings and fostering essential skills crucial for delivering high-quality patient care and positive outcomes.
These findings are aligned with the recommendations of “The WHO Global Strategic Directions for Nursing and Midwifery (2021–2025)” for implementing competency-based education, focused on EBP, preparation for interprofessional work, transformative education, use of digital technologies and implementing simulation-based learning in undergraduate curricula, reinforcing the importance of immersive teaching strategies that prepare students in a controlled environment ( World Health Organization, 2021).
4.2 LimitationsThe limitations of this study are primarily related to the generalizability of the data. This is due to the heterogeneity of the studies included, which varied in terms of study design and evaluation of different outcomes. Additionally, most studies were conducted in North America and Asia, potentially limiting the global applicability of the findings. However, despite these limitations, the study provides a comprehensive overview of active strategies for teaching the nursing process and the main outcomes achieved through their implementation. It’s also important to note that most of the included studies were of high or good quality.
5 ConclusionThis comprehensive literature review reveals a substantial body of research focused on active teaching strategies in nursing education, yielding valuable insights into their efficacy and the associated outcomes. Clinical and virtual simulations, case-based learning and problem-based learning are particularly effective in enabling students to translate knowledge into meaningful clinical interventions.
The findings consistently demonstrate positive outcomes from implementing active teaching strategies, especially in developing critical competencies, which are essential for effective clinical practice. However, the review also identifies research gaps, particularly the need for more studies evaluating the translation of knowledge into clinical practice. Despite these gaps, the findings highlight the transformative potential of active teaching strategies in preparing nursing students for modern healthcare's complexities and enhancing patient care quality. These insights support the integration of active methodologies into nursing curricula, thereby improving the teaching of the nursing process.
CRediT authorship contribution statementOliveira Silva George: Writing – review & editing, Writing – original draft, Project administration, Methodology, Formal analysis, Data curation, Conceptualization. Aredes Natália Del' Angelo: Writing – review & editing, Writing – original draft, Project administration, Methodology, Formal analysis, Data curation, Conceptualization. Cecílio Jessica Oliveira: Writing – review & editing, Writing – original draft, Methodology, Conceptualization. Oliveira Flavia Silva e: Writing – review & editing, Writing – original draft, Data curation. Cavalcante Agueda Maria Ruiz Zimmer: Writing – review & editing, Writing – original draft, Conceptualization. Campbell Suzanne Hetzel: Writing – review & editing, Writing – original draft.
Declaration of Competing InterestThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
AcknowledgementsNone.
Conflict of interestNone.
Appendix A Supporting informationSupplementary data associated with this article can be found in the online version at doi:10.1016/j.nepr.2025.104274.
Appendix A Supplementary materialSupplementary material
Supplementary material
| | | | | | | | | | |
| S01 | Abel and Freeze (2006) | USA | Cohort/Longitudinal study | 1st-year associate degree nursing students | 28 participants | Concept map | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Concept map scores | Level III/A |
| S02 | Akkurt Yalcinturk and Dissiz (2024) | Turkey | Randomized controlled trial | Undergraduate nursing students | 71 participants, divided into EG (n = 36) and CG (n = 35) | Clinical simulation | Assessment; Diagnosis; Intervention | Communication skills, skills related to evaluation of individuals cognitive capacity, diagnostic ability, ability to identify interventions | Level I/A |
| S03 | Arrue et al. (2017) | Spain | Non-randomized experimental study | 3rd-year undergraduate nursing students | 64 participants | Debate | Assessment; Intervention | Identification (Declarative Knowledge, DK), provision of a rationale and evidence for nursing interventions (Argumentative Knowledge, AK). | Level II/A |
| S04 | Ataee et al. (2019) | Iran | Randomized controlled study | 7th and 8th semester bachelor nursing students | 37 participants, divided into EG (n = 19) and CG (n = 18) | Theoretical classes + Laboratory activities | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Skills and self-efficacy | Level I/B |
| S05 | Avelino et al. (2016) | Brazil | Cross sectional study | Nursing students and practicing nurses | 51 participants, 25 nursing students | Online course | Diagnosis; Intervention; Outcomes | Relevance, critical reflection, support from tutors, and support from peers | Level III/A |
| S06 | Avelino et al. (2016) | Brazil | Mixed methods cross sectional study | 2nd, 3rd and 4th-year undergraduate nursing students, graduate students, and nurses | 51 participants | Online course | Diagnosis; Record/Standardized language | Students' perceptions about the strategy | Level III/B |
| S07 | Badowski et al. (2021) | USA | Cohort/Longitudinal study | Junior and Senior level nursing students | 97 participants | Virtual simulation | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Nursing process and critical thinking | Level III/B |
| S08 | Bitencourt et al. (2022) | Brazil | Case report | 3rd-year undergraduate nursing students | 35 participants | Problematization | Assessment; Diagnosis; Intervention; Outcomes; Evaluation; Record/Standardized language | Authors' perceptions | Level V/A |
| S09 | Bittencourt et al. (2011) | Brazil | Case report | Graduate nursing students | Not informed | Concept map | Assessment; Diagnosis | Critical thinking | Level V/A |
| S10 | Boonkong et al. (2022) | Thailand | Non-randomized experimental study | 3rd-year nursing students | 70 participants | Case-based learning | Assessment; Diagnosis; Intervention; Outcomes; Evaluation; Record/Standardized language | Knowledge and nursing care ability | Level II/B |
| S11 | Burns et al. (2010) | USA | Non-randomized experimental study | 1st-year undergraduate nursing students | 125 participants | Lecture + Clinical simulation | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Knowledge of the nursing process and attitudes toward use of the nursing process | Level II/A |
| S12 | Burucu and Arslan (2021) | Turkey | Qualitative research | 2nd-year undergraduate nursing students | 10 participants | Case-based learning | Assessment; Diagnosis | Nursing students' perceptions | Level III/B |
| S13 | Buxton (2011) | USA | Case report | Undergraduate nursing students | Not informed | Dramatization | Assessment; Diagnosis; Intervention; Outcomes; Evaluation; Record/Standardized language | Nursing students' perceptions | Level V/A |
| S14 | Carvalho et al. (2017) | Brazil | Systematic review | Undergraduate nursing students that participated in the studies included in the SR | 463 participants | PBL, conceptual maps + PBL, simulation scenarios, tutoring, reflective essays and theoretical teaching with clinical laboratory | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Critical thinking | Level I/A |
| S15 | Chang et al. (2021) | Taiwan | Mixed methods randomized controlled study | 2nd-year undergraduate nursing students | 107 participants, divided into EG (n = 58) and CG (n = 49) | Clinical simulation vs. Lecture + Discussion | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Confidence in communication, satisfaction with interactive animation and satisfaction with standardized patient simulation | Level I/A |
| S16 | Choi et al. (2014) | South Korea | Non-randomized experimental study | 1st-year undergraduate nursing students | 90 participants, divided into EG (n = 46) and CG (n = 44) | PBL vs. Lecture | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Critical thinking, problem solving, self-directed learning | Level II/A |
| S17 | Cogo (2009) | Brazil | Qualitative research | 2nd-year undergraduate nursing students | 20 participants | Online course | Assessment | Students' perception of the use of the strategy | Level III/A |
| S18 | Cook et al. (2022) | USA | Case report | Prelicensure nursing students | 75 participants | Virtual simulation | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Assessment skills, dosage calculations, communication, interaction, teamwork | Level V/A |
| S19 | Costa and Luz (2015) | Brazil | Methodological study | 4th and 5th-year undergraduate nursing students | 21 participants | Online course | Diagnosis | Students' perceptions about the strategy | Level III/B |
| S20 | Davis et al. (2023) | USA | Non-Randomized experimental study | 1st and 2nd-year undergraduate nursing students | 40 participants | Simulation + Tutoring | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Clinical judgment | Level II/A |
| S21 | Demiray et al. (2023) | Turkey | Descriptive study | Senior-year undergraduate nursing students | 39 participants | Web-based simulation | Assessment | Ability to take anamnesis | Level III/B |
| S22 | Díaz-Rodríguez et al. (2022) | Spain | Randomized controlled study | 1st-year undergraduate nursing students | 379 participants, divided into EG (n = 192) and CG (n = 178) | Theoretical classes + Electronic record system vs. Theoretical classes + Study sessions with books | Assessment; Diagnosis; Intervention; Outcomes; Evaluation; Record/Standardized language | Knowledge, case planning, time to complete the case plan, time to autonomous learning preparing for the final examination, and satisfaction. | Level I/A |
| S23 | Fero et al. (2010) | USA | Non-randomized experimental study | Prelicensure undergraduate nursing students | 36 participants | Videos vs. Clinical simulation | Assessment; Intervention | Performance and critical thinking | Level II/B |
| S24 | Forsgren et al. (2014) | Sweden | Qualitative research | 2nd-year undergraduate nursing students | 103 participants | Case-based learning | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Students' perceptions about the strategy | Level III/B |
| S25 | Freitas and Carmona (2011) | Brazil | Case report | 3rd-year undergraduate nursing students | 35 participants | Case-based learning | Diagnosis; Record/Standardized language | Professors' perceptions about the strategy | Level V/A |
| S26 | Fung et al. (2021) | Hong Kong | Non-randomized experimental study | Final-year undergraduate nursing students | 188 participants | Virtual simulation | Assessment; Diagnosis; Intervention; Evaluation | Perceived clinical competence, learning needs and satisfaction | Level II/A |
| S27 | García-Pazo et al. (2023) | Spain | Cross sectional study | 3rd-year undergraduate nursing students | 111 participants | Virtual reality | Assessment | Self-efficacy, immersion, and satisfaction | Level III/A |
| S28 | Garrett (1990) | USA | Randomized controlled study | 1st-year nursing students | 34 participants, divided into EG (n = 18) and CG (n = 16) | Clinical simulation vs. Case-based learning | Assessment; Diagnosis | Diagnostic ability | Level I/B |
| S29 | Goyatá et al. (2012) | Brazil | Cross sectional study | 2nd-year undergraduate nursing students | 42 participants | Web-based learning | Assessment; Diagnosis | Students' perceptions about the strategy | Level III/B |
| S30 | Guzmán-Almagro et al. (2022) | Spain | Cross sectional study | 3rd-year undergraduate nursing students | 69 participants | Case-based learning | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Overall evaluation, case study evaluation, attitudes towards Nursing diagnoses and satisfaction | Level III/A |
| S31 | Hargreaves et al. (2021) | USA | Case report | Undergraduate nursing students | Not informed | Virtual simulation | Assessment; Diagnosis; Intervention; Outcomes; Evaluation; Record/Standardized language | Critical thinking, strong communication skills, documentation requirements | Level V/A |
| S32 | Hong and Yu (2017) | China | Randomized controlled study | 1st-year undergraduate nursing students | 106 participants, divided into EG (n = 51) and CG (n = 55) | Case-based learning | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Critical thinking | Level I/A |
| S33 | Hsu and Hsieh (2006) | Taiwan | Non-randomized experimental study | Junior and senior undergraduate nursing students | 43 participants | Web-based learning | Assessment | Nursing assessment skills, students' perceptions on learning effectiveness | Level II/B |
| S34 | Ienopoli et al. (2022) | Italy | Randomized controlled study | 1st, 2nd and 3rd year undergraduate nursing students | 113 participants, divided into EG (n = 68) and CG (n = 45) | Case-based learning + Tutoring vs. Case-based learning | Assessment; Diagnosis | Diagnostic reasoning, decision making and knowledge | Level I/B |
| S35 | Irwin (2013) | USA | Non-randomized experimental study | 1st-year associate degree nursing students | 224 participants, divided in four groups (Group 1: 110, Group 2: 33, Group 3: 34, Group 4: 43) | Laboratory classes vs. Case-based learning vs. Clinical simulation | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Nursing process examination, clinical judgement/critical thinking skills, nursing process planning skills | Level II/A |
| S36 | Jang et al. (2021) | South Korea | Mixed methods non-randomized experimental study | Undergraduate nursing students | 91 participants, divided into EG (n = 45) and CG (n = 46) | Clinical simulation vs. Lecture + Skill laboratory | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Self-confidence, knowledge, and clinical performance | Level II/A |
| S37 | Johannsson and Wertenberger (1996) | Canada | Cross sectional study | Undergraduate nursing students | 18 participants | Videos | Assessment; Intervention | Nursing assessment skills | Level III/B |
| S38 | Kalati et al. (2023) | Iran | Non-Randomized experimental study | 2nd-year undergraduate nursing students | 26 participants | Blended learning | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Nursing process scores and critical thinking | Level II/B |
| S39 | Karadag et al. (2016) | Turkey | Randomized controlled study | 2nd-year undergraduate nursing students | 70 participants, divided into EG (n = 35) and CG (n = 35) | Clinical simulation vs. Case-based learning | Assessment; Diagnosis; Intervention | Students' perceptions on the contribution of training method to learning, planning care and intervention, identification of diagnoses and nursing intervention | Level I/A |
| S40 | Kennedy et al. (2009) | USA | Qualitative research | 1st-year undergraduate nursing students | 8 participants | Electronic record system | Assessment; Diagnosis; Intervention; Outcomes; Evaluation; Record/Standardized language | Students' perceptions about the strategy | Level III/C |
| S41 | Kern et al. (2006) | USA | Descriptive study | 1st-year associate nursing students | 168 participants | Concept map | Assessment; Diagnosis; Intervention; Outcomes | Students' perceptions and evaluation of nursing care plans by the faculty | Level III/B |
| S42 | Kestel and Korkmaz (2023) | Turkey | Non-Randomized experimental study | 1st-year undergraduate nursing students | 186 participants, divided into EG (n = 83) and CG (n = 103) | Blended learning | Assessment; Diagnosis; Intervention; Outcomes | Nursing care plan preparation skills | Level II/A |
| S43 | Khatiban et al. (2019) | Iran | Randomized controlled study | 3rd-year undergraduate nursing students | 84 participants, divided into EG (n = 42) and CG (n = 42) | Clinical practice + Assessment form training vs. Clinical practice | Assessment | Skills and attitude | Level I/B |
| S44 | Kim and Jung (2016) | South Korea | Cross sectional study | Undergraduate nursing students | 62 participants | Electronic record system | Assessment; Diagnosis; Intervention; Outcomes; Record/Standardized language | Connect time, satisfaction, knowledge, confidence, anxiety | Level III/B |
| S45 | Ko and Kim (2014) | South Korea | Non-randomized experimental study | 4th-year undergraduate nursing students | 65 participants, divided into EG (n = 33) and CG (n = 32) | Clinical simulation vs. Lecture | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Critical thinking disposition, problem solving process and clinical competence | Level II/B |
| S46 | Kurt et al. (2023) | Turkey | Cross sectional study | 1st-year undergraduate nursing students | 148 participants | Online course | Diagnosis | Ability to make nursing diagnoses | Level II/B |
| S47 | Ku et al. (2002) | Taiwan | Non-randomized experimental study | 1st-year undergraduate nursing students | 49 participants | Theoretical classes + Clinical practice | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Problem solving | Level II/B |
| S48 | Lambie et al. (2015) | USA | Case report | Sophomore undergraduate nursing students | 36 participants | Clinical simulation | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Authors' perception on clinical reasoning of nursing students | Level III/A |
| S49 | Lee (2018) | South Korea | Non-randomized experimental study | Senior undergraduate nursing students | 183 participants, divided into EG (n = 95) and CG (n = 88) | TBL vs. Lecture | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Core competencies, clinical competence skills, problem-solving ability, communication competence, critical thiking ability and self-leadership | Level V/A |
| S50 | Lee and Brysiewicz (2009) | South Africa | Non-randomized experimental study | 3rd-year undergraduate nursing students | 70 participants, divided into EG (n = 31) and CG (n = 39) | PBL teaching program focused on problem solving skills | Assessment; Diagnosis; Intervention | Students' ability to identify issues, gather data, formulate an interim patient problem list, identify preliminary nursing interventions, perform self-assessment of learning needs, formulate a revised patient problem list based on learning that occurred during independent study in the second step of the triple jump, identify revised nursing interventions | Level II/A |
| S51 | Lee and Son (2023) | South Korea | Randomized controlled study | 3rd-year undergraduate nursing students | 92 participants, divided into EG (n = 46) and CG (n = 46) | PBL + Clinical simulation vs. Clinical practice | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Performance confidence, clinical judgement, and knowledge | Level II/B |
| S52 | Lee et al. (2019) | Taiwan | Randomized controlled study | 2nd-year undergraduate nursing students | 100 participants, divided into EG (n = 49) and CG (n = 51) | Clinical simulation vs. Case-based learning | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Competences and clinical performance | Level I/A |
| S53 | Leighton et al. (2021) | USA | Cross sectional study | All periods | 159 participants | Clinical simulation vs. Clinical practice | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Students' perceptions about learning needs | Level I/A |
| S54 | Lira and Lopes (2011) | Brazil | Randomized controlled study | 3rd-year undergraduate nursing students | 30 participants, divided in the EG (n = 15) and CG (n = 15) | PBL vs. Theoretical classes | Diagnosis | Correct identification of defining characteristics, nursing diagnoses and related factors, and knowledge | Level III/B |
| S55 | LuPone (2017) | USA | Non-randomized experimental study | 1st-year undergraduate nursing students | 22 participants | Clinical simulation | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Critical thinking, querying evidence, conjecturing alternatives, drawing valid conclusions and clinical decision making | Level I/B |
| S56 | May and Cole (2014) | USA | Case report | Undergraduate nursing students | Not informed | Clinical simulation + Game-based learning | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Author's perceptions | Level III/A |
| S57 | Maurício et al. (2022) | Brazil | Randomized controlled study | Undergraduate nursing students | 51 participants, divided in the EG (n = 27) and CG (n = 24) | Clinical reasoning self-instructional guide | Diagnosis | Diagnostic and etiological accuracy and number of clues | Level II/C |
| S58 | McCormick et al. (2013) | USA | Randomized controlled study | Undergraduate nursing students | 84 participants | Clinical simulation + Case-based learning vs. Lecture + Videos | Assessment | Knowledge | Level I/B |
| S59 | McDonald et al. (2018) | Australia | Integrative review | Undergraduate nursing students | Not informed | e-Learning | Assessment | Skills and knowledge | Level V/B |
| S60 | McKenna et al. (2011) | Australia | Qualitative research | Final-year undergraduate nursing students | 9 participants | Clinical simulation | Assessment | Student's perceptions about the intervention | Level I/C |
| S61 | Merritt (2020) | USA | Non-randomized experimental study | Graduate nurse practitioner students | 179 participants | Virtual simulation | Diagnosis | Diagnostic accuracy, self-reported knowledge and competence in assessment and diagnosis skills | Level V/A |
| S62 | Mixon (1989) | USA | Randomized controlled study | Senior undergraduate nursing students | 42 participants, divided into EG (n = 22) and CG (n = 20) | Electronic record system | Assessment; Diagnosis; Record/Standardized language | Diagnostic ability, decision making | Level III/B |
| S63 | Morales-Mann and Kaitell (2001) | Canada | Descriptive study | 2nd-year undergraduate nursing students | 35 participants | PBL | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Students’ perceptions | Level II/C |
| S64 | Morey (2012) | USA | Mixed methods randomized controlled study | Final-year undergraduate nursing students | 45 participants, divided into EG (n = 24) and CG (n = 21) | Web-based learning vs. Case-based learning | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Critical thinking | Level I/B |
| S65 | Muehlbauer et al. (2023) | USA | Cross sectional study | Final-year undergraduate nursing students | 101 participants | Case-based learning | Assessment; Intervention | Correct identification of nursing interventions | Level III/B |
| S66 | Munn et al. (2021) | USA | Mixed methods non-randomized experimental study | Final-year undergraduate nursing students | 43 participants | Clinical simulation + Case-based learning | Assessment; Intervention; Outcomes; Evaluation | Confidence in pediatric nursing knowledge, skills, and clinical judgement/decision-making abilities | Level I/B |
| S67 | Muranaka et al. (1997) | Japan | Non-randomized experimental study | Undergraduate nursing students | 54 participants | Web-based learning | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Understanding the nursing process, scientific thinking, problem solving | Level III/A |
| S68 | Nakatani et al. (2000) | Brazil | Qualitative research | 2nd-year undergraduate nursing students | Not informed | Problematization | Diagnosis; Record/Standardized language | Performance in activity reports | Level II/A |
| S69 | Nanavaty (2018) | USA | Qualitative research | Licensed practical nursing students | 60 participants | Art-based learning | Assessment | Students' perceptions about nursing assessment | Level II/C |
| S70 | Nes et al. (2021) | Norway | Qualitative research | 1st-year undergraduate nursing students | 9 participants | Flipped-classroom + Case-based learning | Assessment | Students' perceptions about the strategy | Level III/C |
| S71 | Newsom and Tilman (1990) | USA | Randomized controlled study | 1st-year undergraduate nursing students | 50 participants, divided into EG (n = 24) and CG (n = 26) | Guided discussion | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Knowledge and problem-solving performance | Level III/B |
| S72 | Nirmala and Shakuntala (2011) | India | Non-randomized experimental study | Final-year undergraduate nursing students | 84 participants, divided into EG (n = 40) and CG (n = 44) | Concept map | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Critical thinking | Level III/B |
| S73 | O'Halloran (2022) | USA | Case report | 1st-year undergraduate nursing students | 7 participants | Concept map + Clinical simulation | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Students' perceptions about the strategy | Level I/B |
| S74 | Okuroglu et al. (2021) | Turkey | Non-randomized experimental study | 1st-year undergraduate nursing students | 98 participants, divided into EG (n = 49) and CG (n = 49) | Theoretical classes + Skill laboratory + Clinical simulation vs. Theoretical classes + Skill laboratory | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Nursing process evaluation, clinical stress | Level II/B |
| S75 | Onarici and Karadağ (2021) | Turkey | Randomized controlled study | Undergraduate nursing students | 64 participants, divided into EG (n = 32) and CG (n = 32) | Clinical simulation | Assessment; Intervention | Cognitive performance, satisfaction and self-confidence, simulation design, knowledge | Level V/A |
| S76 | Ordu and Caliskan (2023) | Turkey | Randomized controlled study | 1st-year undergraduate nursing students | 91 participants, divided into EG (n = 42) and CG (n = 49) | Web-based learning + Concept map | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Knowledge and skills | Level II/A |
| S77 | Ordu and Çaliskan (2023a) | Turkey | Randomized controlled trial | 2nd-year undergraduate nursing students | 92 participants, divided into EG (n = 46) and CG (n = 46) | Virtual game simulation | Assessment; Diagnosis; Outcomes | Perceptions of nursing diagnoses | Level I/A |
| S78 | Ordu and Çalıskan (2023b) | Turkey | Randomized controlled study | 1st-year undergraduate nursing students | 102 participants, divided into EG (n = 51) and CG (n = 51) | Virtual simulation vs. Theoretical classes | Diagnosis | Nursing diagnosis, goal setting and diagnosis prioritization knowledge | Level I/A |
| S79 | Orique and McCarthy (2015) | USA | Non-randomized experimental study | 1st-year undergraduate nursing students | 49 participants | PBL + Concept map | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Critical thinking | Level I/A |
| S80 | Ozkan et al. (2020) | Turkey | Descriptive study | Undergraduate nursing students | 164 participants | Theoretical classes + Case-based learning | Diagnosis | Nursing diagnosis accuracy | Level I/A |
| S81 | Plunkett and Olivieri (1989) | USA | Text and opinion | NA | Not informed | Clinical simulation | Diagnosis | Authors' perceptions | Level II/A |
| S82 | Pobocik (2015) | USA | Non-randomized experimental study | Undergraduate nursing students | 37 participants, divided into EG (n = 19) and CG (n = 18) | Case-based learning + Electronic record system | Assessment; Diagnosis; Record/Standardized language | Diagnostic accuracy, confidence levels and GPA | Level III/B |
| S83 | Polaski et al. (1988) | USA | Case report | NA | Not informed | Lectures + Individual and group activities + Clinical simulation + Discussion | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Authors' perceptions | Level V/B |
| S84 | Priddy and Crow (2011) | USA | Case report | 1st-year undergraduate nursing students | Not informed | Case-based learning | Assessment; Diagnosis; Intervention; Outcomes; Evaluation; Record/Standardized language | Authors' perceptions | Level II/A |
| S85 | Qaisar et al. (2023) | Marocco | Cross sectional study | 1st-year undergraduate nursing students | 68 participants | Case-based learning | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Students' perceptions | Level V/B |
| S86 | Rababa and Masha'al (2020) | Jordan | Randomized controlled study | Undergraduate nursing students | 102 participants, divided into EG (n = 51) and CG (n = 51) | Clinical simulation vs. Lectures | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Critical thinking | Level V/B |
| S87 | Sá Tinôco et al. (2023) | Brazil | Non-randomized experimental study | 2nd-year undergraduate nursing students | 11 participants | Game-based learning | Diagnosis | Correct identification of nursing diagnoses and diagnostic indicators. | Level III/B |
| S88 | Santos et al. (2014) | Brazil | Integrative review | Undergraduate and graduate nursing students | Not informed | Electronic tools, written case studies, and lecture and theoretical-practical lessons | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Teaching and learning strategies | Level I/A |
| S89 | Seo and Eom (2021) | South Korea | Non-randomized experimental study | Final-year undergraduate nursing students | 45 participants, divided into EG (n = 25) and CG (n = 20) | Clinical simulation vs. Clinical practice | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Clinical reasoning, problem-solving process, self-efficacy and clinical competency | Level II/B |
| S90 | Shin et al. (2015) | South Korea | Cross sectional study | Final-year undergraduate nursing students | 144 participants, divided in two cohort groups (Cohort 1 = 73, Cohort 2 = 71) | Clinical simulation vs. Theoretical classes | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Competency and self-evaluated learning achievement by students, satisfaction on clinical practicum and general self-confidence at graduation | Level V/C |
| S91 | Silva et al. (2018) | Brazil | Case report | 4th-year undergraduate nursing students | Not informed | Problematization | Assessment; Diagnosis; Intervention; Outcomes; Evaluation; Record/Standardized language | Professors' perceptions about the strategy | Level II/A |
| S92 | Sohn et al. (2013) | South Korea | Non-randomized experimental study | 3rd-year undergraduate nursing students | 25 participants | Clinical simulation + PBL | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Self-efficacy | Level III/A |
| S93 | Sousa et al. (2016) | Brazil | Randomized controlled study | 2nd to 4th-year undergraduate nursing students | 37 participants, divided into EG (n = 20) and CG (n = 17) | Electronic record system vs. Case-based learning | Diagnosis; Record/Standardized language | Students' progress in solving questions and clinical cases regarding nursing diagnosis | Level V/A |
| S94 | Souto (2020) | Brazil | Randomized controlled study | 4th-year undergraduate nursing students | 34 participants, divided into EG (n = 17) and CG (n = 17) | Clinical simulation | Diagnosis | Diagnostic accuracy | Level II/B |
| S95 | Sunnqvist et al. (2016) | Sweden | Qualitative research | 4th term undergraduate nursing students | 9 participants | Virtual simulation | Assessment | Students' perceptions about the strategy | Level I/A |
| S96 | Taylor et al. (2023) | USA | Case report | Undergraduate nursing students | 80 participants | PBL | Assessment; Diagnosis; Intervention; Outcomes; Evaluation | Authors' perceptions | Level I/B |
| S97 | Tinôco et al. (2021) | Brazil | Non-randomized experimental study | 2nd-year undergraduate nursing students | 32 participants, divided into EG (n = 16) and CG (n = 16) | Virtual simulation + PBL vs. Theoretical classes | Diagnosis | Clinical reasoning | Level III/A |
| S98 | Vihos et al. (2022) | Canada | Mixed methods non-randomized experimental study | 2nd-year undergraduate nursing students | 50 participants, divided into EG (n = 25) and CG (n = 25) | Web-based learning vs. Theoretical classes | Assessment | Clinical Judgement | Level V/A |
| S99 | Walshe et al. (2013) | Ireland | Cross sectional study | Final-year undergraduate nursing students | 34 participants | PBL + Clinical simulation | Assessment | Patient assessment, clinical decision making, and technical and communication skills | Level II/A |
| S100 | Wang et al. (2004) | Taiwan | Descriptive study | Post-RN baccalaureate nursing students | 114 participants, 47 full-time students and 67 part-time students | Theoretical classes + Clinical practice | Assessment; Diagnosis; Intervention; Evaluation | Problem solving | Level III/B |
| S101 | Yuan (2021) | China | Descriptive study | Undergraduate nursing students | 54 participants | Clinical simulation | Assessment | Nursing assessment and communication skills | Level III/B |
| | | |
| | ||
| Knowledge | 20 | 21.3 |
| Skills | 7 | 7.4 |
| Attitude | 4 | 4.3 |
| | ||
| Critical thinking | 14 | 14.9 |
| Problem-solving | 7 | 7.4 |
| Communication | 6 | 6.4 |
| Clinical competence | 5 | 5.3 |
| Decision-making | 4 | 4.3 |
| Clinical judgement | 4 | 4.3 |
| Clinical reasoning | 2 | 2.1 |
| Teamwork | 1 | 1.1 |
| | ||
| Diagnostic accuracy/ability/reasoning | 18 | 19.1 |
| Nursing process planning (assessment, diagnosis, interventions, outcomes, evaluation) | 12 | 12.8 |
| Nursing assessment ability | 5 | 5.3 |
| Identification of nursing interventions | 2 | 2.1 |
| | ||
| Self-efficacy/Self-confidence | 12 | 12.8 |
| Satisfaction | 7 | 7.4 |
| Stress/Anxiety | 2 | 2.1 |
| Self-leadership | 1 | 1.1 |
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