Effect evaluation of the 7E teaching model based on real clinical cases in nursing students' clinical rounds: A quasi-experimental study

Abstract

Aim

To evaluate the effectiveness of the 7E teaching model based on real clinical cases in nursing students' clinical rounds.

Background

Nursing rounds, as an integral component of clinical teaching, are designed to reinforce professional knowledge, foster critical thinking and enhance practical skills. However, the traditional teacher-centered approach often results in passive learning and low efficiency. Therefore, it is crucial to explore methods that engage students, promote active learning and cultivate clinical reasoning and practical abilities.

Design

Quasi-experimental study.

Methods

Fifty nursing students who participated in clinical internships from July 2022 to April 2023 were assigned to the control group, receiving traditional rounds. An additional 52 students, who interned at the same hospital from July 2023 to April 2024, formed the experimental group and received rounds based on the 7E model using real clinical cases. Critical thinking, self-efficacy and clinical practice abilities were compared between the two groups. Clinical practice was assessed using the Nursing-Mini-CEX scale, covering eight dimensions: nursing interview, physical examination, nursing diagnosis, nursing interventions, health consultation, humanistic care, organizational effectiveness and overall evaluation. Data were analyzed using SPSS 27.0 software with t-tests and chi-square tests.

Results

After the intervention, the experimental group demonstrated significantly higher critical thinking, self-efficacy and clinical practice abilities compared with the control group (P < 0.05).

Conclusion

The 7E teaching model based on real clinical cases is more effective than the traditional round approach, significantly enhancing nursing students' critical thinking, self-efficacy and clinical practice abilities.

1 Introduction

With ongoing economic and social development, alongside advances in medical technology and health sciences, nursing education and practice have undergone profound changes ( ^{Kassabry et al., 2024}). The contemporary nursing practice environment is dynamic, unpredictable and responsive ( ^{Zhang et al., 2019}). Nursing students (hereafter referred to as "students") often face unstructured patient scenarios that require the ability to identify, analyze and apply theory to practice to solve problems successfully ( ^{Li et al., 2019}). Therefore, nursing educators must address the gap between theory and practice in clinical teaching, fostering critical thinking and problem-solving skills to prepare students for the workforce.

Nursing rounds are an integrated teaching activity that combines theory and clinical practice, playing a crucial role in students' clinical training ( ^{Sheng et al., 2019}). However, most nursing rounds in China remain teacher-centered and use traditional "rote-learning" methods, resulting in low student engagement, suboptimal learning outcomes and poor continuity in rounds ( ^{Zhu et al., 2016}). Although students are taught comprehensive nursing theory in school, real clinical scenarios often differ from textbook descriptions, requiring students to develop independent exploration and critical thinking skills to identify and address complex issues, make sound clinical judgments and implement effective care strategies. Thus, clinical round designs should be based on real clinical cases, showcasing the entire nursing process and guiding students to systematize fragmented knowledge, enhancing their ability to apply and deeply understand the material.

Case-based learning (CBL) is a student-centered teaching approach that uses real clinical cases as teaching materials, integrating them with the teaching theme. Through interactive discussions and Q&A, this method connects theory with practice, enhancing students' understanding and comprehension of the diagnostic and treatment process. Its key characteristics are "case-guided, student-centered and teacher-facilitated" ( ^{Chamala et al., 2021; Liang et al., 2021}). CBL has been widely adopted in nursing education to improve students' problem-solving abilities, critical thinking and motivation to learn ( ^{McLean, 2016}). However, relying solely on CBL may lack systematic structure, making it challenging to fully meet the demands of clinical nursing education.

The 7E teaching model, based on constructivist theory, is an inquiry-based teaching approach comprising seven stages: Elicit, Engagement, Exploration, Explain, Elaborate, Evaluate and Extend ( ^{Nurochmah and Surgandini, 2021}). This model encourages autonomous student inquiry, enhancing the flexibility and depth of exploration, with features of systematization, cyclicity and practicality ( ^{Amini and Usmeldi, 2020}). It not only promotes autonomous learning and the construction of knowledge frameworks but also extends knowledge to clinical practice, fostering students' comprehensive abilities. Studies have shown that the 7E model is more effective than traditional learning methods in enhancing students' critical thinking and self-directed learning skills ( ^{Utami and Widowati, 2022}). Additionally, Tseng et al. reported that the 5E learning cycle, a multi-dimensional teaching strategy, is more effective than traditional methods in promoting nursing students' self-efficacy and critical thinking ( ^{Tseng et al., 2022}).

In recent years, there has been limited research on the application of the 7E model in nursing clinical teaching. Given this gap, the present study combines CBL and the 7E model to explore the effectiveness of the 7E teaching model, based on real clinical cases, in nursing students' clinical rounds. The primary outcomes are students' critical thinking, self-efficacy and clinical practice abilities.

2 Methods
2.1 Study design

This study employed a quasi-experimental design.

2.2 Participants

Fifty nursing students who completed their clinical internship at our hospital from July 2022 to April 2023 were assigned to the control group, receiving traditional teaching rounds. An additional 52 students, who interned at the same hospital from July 2023 to April 2024, formed the experimental group, which followed rounds based on the 7E teaching model using real clinical cases. Both groups received identical teaching content and the instructors had the same qualifications. The same internship curriculum and textbooks were used, with the only difference being the teaching method. All participants were informed that their participation was voluntary and they could withdraw at any time. The study was conducted in accordance with the Declaration of Helsinki and approved by the hospital Ethics Committee(YXLL-2024–181).

2.2.1 Inclusion criteria

1. Undergraduate nursing students enrolled in a four-year, nationally recognized program
2. Students in the fourth year of their program, undergoing clinical internships
3. Informed consent and voluntary participation in the study

2.2.2 Exclusion criteria

1. Students who interrupted their internship for any reason
2. Students who did not complete the tests or surveys

2.2.3 Sample size calculation

The sample size was calculated using G*Power 3.1.9.2. A t-test was used to compare the mean differences between two independent groups. The parameters were set as α = 0.05, power = 0.80 and effect size d = 0.58, based on previous research ( ^{Tseng et al., 2022}). The calculation indicated that each group required at least 48 participants, with a total sample size of 96. In this study, 102 participants were selected, with 52 in the experimental group and 50 in the control group.

2.3 Research procedure

The study compared two groups of nursing students: the control group, which followed traditional teaching rounds and the experimental group, which followed the 7E model based on real clinical cases. Prior to the internship, all participants completed pre-assessments, including the "Critical Thinking Skills Scale" and the "General Self-Efficacy Scale. " During the internship, students rotated through nine departments, with each department conducting regular teaching rounds. After each round, instructors assessed students' clinical practice abilities using the Nursing-Mini-CEX scale, covering areas such as nursing interview, physical examination, nursing diagnosis, nursing interventions, health consultation, humanistic care, organizational effectiveness and overall evaluation. On completion of all department rotations, the researchers collected the Nursing-Mini-CEX results for each student and asked all participants to complete post-assessment surveys, consistent with the pre-assessments. Finally, statistical analysis was conducted using SPSS 27.0 software to compare the teaching effectiveness of the two models.

2.4 Teaching strategy
2.4.1 Case selection and internship arrangement

In line with the internship curriculum and clinical needs and considering the common diseases nursing students are likely to encounter in real clinical settings, this study selected nine departments for teaching interventions: Respiratory, Neurology, Gastroenterology, Cardiology, Orthopedics, Thoracic Surgery, Urology, Obstetrics and Gynecology and Intensive Care. These departments were chosen based on prevalent diseases and clinical characteristics and the following conditions were selected as case examples for teaching rounds: chronic obstructive pulmonary disease, ischemic cerebrovascular disease, peptic ulcer, coronary artery disease, fractures, pneumothorax, urinary tract stones, cervical cancer and acute respiratory distress syndrome (ARDS). Students were divided into groups of 5–6 for rotation in these departments. The Obstetrics and Gynecology rotation lasted for 2 weeks, while all other rotations lasted 4 weeks, with one teaching round conducted in each department.

2.4.2 Control group

The control group followed the traditional nursing teaching round model:

1. Pre-Round: The lead instructor prepared a teaching round plan and developed a PowerPoint presentation.
2. During Round: The round followed a structured format: case presentation, nursing assessment, nursing diagnosis, interventions and outcome evaluation. After the explanation, the lead instructor demonstrated physical examination at the bedside. Throughout the process, students primarily listened and responded to the instructor’s questions.
3. Post-Round: The lead instructor summarized the round.

2.4.3 Experimental group

The experimental group followed the 7E teaching model based on real clinical cases during the teaching rounds.

2.4.3.1 Establishment of the teaching team

A teaching team was established, led by the Deputy Director of the Nursing Department, responsible for education, with one teaching secretary. The team included 20 members: clinical nursing teaching supervisors and lead instructors from each department. Of the team, 12 members held senior titles (associate professor or above) and 8 held intermediate titles, all with a minimum of 3 years of clinical nursing teaching experience.

The team’s responsibilities were as follows: The Deputy Director oversaw member selection, process improvements, supervision of key activities and overall quality control. Lead instructors managed the teaching process and quality within their departments, ensuring each student participated in the teaching rounds and took on assigned tasks. Teaching supervisors monitored the entire process and assessed its effectiveness. The teaching secretary was responsible for recording meeting minutes and documenting the teaching process through photography.

2.4.3.2 Development of the teaching round implementation plan

1. Setting Teaching Objectives

Guided by Bloom's Taxonomy of Educational Objectives, the teaching goals encompassed the cognitive, skill and affective domains. The specific objectives for the 7E-based teaching rounds using real clinical cases were as follows:(1) Cognitive Objectives: Understand the concept, etiology, pathogenesis, clinical manifestations, nursing diagnoses and interventions for [XXX] disease; (2) Skill Objectives: Enhance clinical practice ability, enabling students to apply theoretical knowledge to nursing tasks such as patient interviews and physical examinations. Students should demonstrate the ability to independently and correctly perform basic nursing procedures with logical and holistic thinking; (3) And Affective Objectives: Foster professional ethics, emphasizing humanistic care and a patient-centered approach. Students should reflect on their practice and continually improve, demonstrating the capacity to independently and competently provide nursing care.

2. Development of the Teaching Round Implementation Plan

The teaching team created the initial plan through literature review, brainstorming and expert consultation. A pilot group of students tested the plan with one teaching round based on real clinical cases. The team conducted real-time tracking and improvements: Before the rotation, the teaching team collectively prepared teaching cases. During the internship, periodic meetings were held to evaluate and improve the teaching process. After the rotation, a final meeting was held to review, summarize and provide feedback on the entire teaching process, leading to the final teaching round implementation plan for nursing students.

3. Specific Implementation Process for the Teaching Ward Rounds

Before the Ward Round:

1. Elicit:

(1) The lead instructor announces the case for the ward round, defines the learning objectives, key points and difficult areas and outlines the standard procedure for the session.

(2) Assignment of tasks:

(i) Students are required to familiarize themselves with the patient's condition and review relevant knowledge and skills related to the case based on the learning objectives.

(ii) 2–3 key questions related to the case are to be prepared for in-depth analysis.

(iii) Students prepare a PowerPoint presentation for the case discussion.

2. Engagement:

(1) Students consult textbooks, literature and evidence-based medicine resources to study the disease and explore possible solutions.

(2) Students gather comprehensive patient data through patient/family interviews, reviewing medical records, consulting relevant documents and speaking with supervising doctors.

(3) Collaborative ward rounds: Students follow the lead instructor during physician rounds to gradually become familiar with and master the ward round process. Through observation and participation, they enhance their understanding and skills in patient interviewing and physical examination.

(4) Under the guidance of department doctors and the lead instructor, students learn the standardized steps for conducting physical examinations.

3. Exploration

CBL Case Discussion: Students work in small groups to discuss the case, organize and analyze patient data and collectively review related theoretical knowledge. They focus on evaluating the accuracy and completeness of information gathering and engage in deep discussions about issues encountered during self-study.

Any ambiguities or uncertainties in the discussion are resolved by students through reviewing textbooks, literature, online resources, or simulated scenarios. If the issue remains unresolved, students compile their questions and seek further guidance from the lead instructor.

Finally, students collaborate to complete the case presentation PowerPoint.

4. Explain:

The lead instructor and department doctors provide detailed answers and guidance based on the students' feedback and questions.

During the ward round

5. Elaborate: Formal Ward Round

（1）Location: Teaching Room → Bedside → Teaching Room

（2）Timing: 3–5 days after the case is assigned

（3）Personnel: Director of Nursing Department, Lead Instructor, Clinical Instructors, Clinical Teaching Supervisors, Intern Students

（4）Content: Patient-centered teaching using the nursing process

(i) Teaching Room: Students present the topic of the ward round, explaining the objectives and key challenges. Case presentation: Students report the case, including a brief medical history, chief complaints, tests and current treatment and care provided. Disease-related knowledge is taught, covering: Disease overview; Etiology; Pathophysiology; Clinical manifestations; Significance of positive findings; Diagnosis and treatment; and Clinical instructors supplement and refine the content during the presentation. (ii) Bedside Round: The round team enters the patient’s room sequentially. Both teachers and students greet the patient and family members. The student conducts a nursing interview, including observation, inquiry and physical examination, integrating the “Ten Key Information Points” about the patient. The lead instructor provides additional guidance during the interview. The student performs a physical examination, with the lead instructor assisting in auscultation, palpation and percussion to evaluate the student’s examination skills and the accuracy of positive findings. After the examination, the patient is informed about their condition and health education is provided before the team leaves the room. (iii) Teaching Room: Following the bedside round, students engage in a discussion based on the earlier presentations and bedside findings. Discussion points included: Evaluation of the implementation, effectiveness and challenges of the current nursing measures. Analyzing the reasons for unimplemented care measures and exploring improvement strategies. Identifying new nursing issues and prioritizing them (e.g., primary and secondary priorities). Formulating personalized nursing plans and measures based on nursing assessments. Identifying potential nursing problems and exploring prevention and monitoring methods. During the discussion, students can present different viewpoints, exchange ideas and learn from each other. Clinical instructors provide feedback, guidance and necessary corrections.

After the ward round

6. Evaluation: Round summary:

Student Evaluation: The lead instructor encourages students to use the structured GAS (Gather-Analyze-Summarize) method for team performance review. Phase 1 (G): Each student shares their overall impressions of the ward round. The teacher may pose open-ended questions to prompt further reflection, such as: “What was the most valuable experience during this round?” or “What did you learn from your communication with the patient?” These questions help students express their thoughts and feelings comprehensively. Phase 2 (A): Guided by the lead instructor, students recount the ward round, reflecting on the strengths and weaknesses of each phase. For instance, “Which parts of the round went well and why?” Phase 3 (S): Students begin by summarizing their own performance, identifying areas for improvement. For example: “What aspects of my practice should I focus on for future rounds?” Following this, students provide mutual feedback, sharing insights and suggestions. Throughout the process, the lead instructor offers positive reinforcement to encourage students to express their views and adopt peers' recommendations.

Teacher Evaluation: The lead instructor synthesizes the key knowledge students should have gained from the case, highlighting the strengths and weaknesses of the ward round and suggesting improvements. The lead instructor also incorporates ideological education into the feedback. Lastly, the lead instructor evaluates whether the educational objectives for the round were met and identifies knowledge areas that students need to strengthen.

7. Extend:

Student Understanding: If students encounter knowledge gaps or uncertainties during the ward round, they are encouraged to consult relevant materials to confirm and deepen their understanding.

Case Assignment: The lead instructor assigns similar patient cases to the students, asking them to apply the nursing process, including nursing interview, physical examination, nursing diagnosis and care plan formulation. During this process, the teacher uses the Nursing-Mini-CEX scale to assess students' clinical practice abilities. The evaluation covers areas such as nursing interview, physical examination, nursing diagnosis, nursing interventions, health consultation, humanistic care, organizational effectiveness and overall evaluation. This comprehensive assessment provides a clear picture of the student's abilities in clinical practice.

Case Report Writing: Under the teacher's guidance, students are required to write a parallel case report. This report should include a case summary, patient characteristics, identified issues (based on patient or family narratives and behaviors), communication techniques used (e.g., listening, venting, reassurance, encouragement), outcomes and personal reflections (including emotional responses to patient suffering). The report must be written in simple, accessible language, ensuring clarity, detail and readability, while also protecting patient privacy and avoiding discriminatory or derogatory language.

2.5 Research tools
2.5.1 General information questionnaire

This questionnaire includes gender, age and pre-service training performance.

2.5.2 Critical Thinking Disposition Inventory (CTDI-CV)

The Critical Thinking Disposition Inventory (CTDI-CV), adapted by ^{Peng et al. (2004)}, assesses nursing students' critical thinking skills. The scale consists of seven dimensions: Truth-Seeking, Open-Mindedness, Analytical Thinking, Systematic Thinking, Confidence in Critical Thinking, Inquisitiveness and Cognitive Maturity. Each dimension includes 10 items, for a total of 70 items, of which 30 are positively worded and 40 negatively worded. A 6-point Likert scale is used: 6 (Strongly Agree) to 1 (Strongly Disagree), with reverse scoring for negative items. The maximum score is 420 and scores ≥ 280 indicate positive critical thinking traits. The scale has a Cronbach's α of 0.90, with individual dimensions ranging from 0.60–1.0, demonstrating high internal consistency. The content validity index is 0.89.

2.5.3 General Self-Efficacy Scale (GSES)

The GSES, adapted by ^{Wang et al. (2001)}, comprises 10 items scored on a 4-point Likert scale, ranging from 1 (Strongly Disagree) to 4 (Strongly Agree). The total score ranges from 10 to 40, with scores of 10–19 indicating low self-efficacy, 20–29 indicating moderate self-efficacy and 30–40 indicating high self-efficacy. Higher scores reflect stronger self-efficacy. The Cronbach’s α for the scale is 0.87.

2.5.4 Clinical practice evaluation (Nursing-Mini-CEX)

The Nursing-Mini-CEX scale, adapted by ^{Yi et al. (2017)} based on the Mini-CEX, assesses clinical nursing performance across eight areas: nursing interview, physical examination, nursing diagnosis, nursing interventions, health consultation, humanistic care, organizational effectiveness and overall evaluation. Each item is rated on a 9-point scale, categorized into three levels: 1–3 (unsatisfactory), 4–6 (satisfactory) and 7–9 (excellent). The Cronbach’s α for the scale is 0.78, with a split-half reliability coefficient of 0.842, indicating good reliability and validity.

2.6 Data analysis

Data were analyzed using SPSS 27.0. Categorical data are presented as frequencies or percentages and analyzed using the Chi-square test. Normally distributed continuous data are expressed as means ± standard deviations, with inter-group comparisons performed using independent samples t-tests and intra-group comparisons using paired t-tests. Non-normally distributed continuous variables were analyzed using the Mann-Whitney U test. A P-value < 0.05 was considered statistically significant.

3 Results
3.1 General Information

A total of 102 nursing students meeting the inclusion criteria participated in this study. The experimental group consisted of 52 students, including 10 males (19.2 %) and 42 females (80.8 %), with an average age of (21.08 ± 0.682) years and a pre-service training score of (83.02 ± 4.889). The control group included 50 students, with 9 males (18.0 %) and 41 females (82.0 %), an average age of (20.98 ± 0.795) years and a pre-service training score of (82.64 ± 4.881). No significant differences were found between the groups in terms of gender, age, or pre-service training scores (P > 0.05), indicating comparability ( ^{Table 1}).

3.2 Critical thinking skill

The comparison of critical thinking skill between the two groups is shown in ^{Table 2}. Scores from the Critical Thinking Disposition Inventory (CTDI-CV) were compared within and between groups before and after the intervention. Before the intervention, there were no significant differences between the groups in total scores or across individual dimensions (P > 0.05). After the intervention, the experimental group showed significantly higher scores than the control group in both total scores and all dimensions (P < 0.001).

Within-group comparisons, using paired samples t-test, revealed that the experimental group had significantly higher scores in total and across all dimensions after the intervention (P < 0.001). In contrast, the control group showed a significant increase in total score post-intervention (t = 3.326, P = 0.002), but only the dimension of "Confidence in Critical Thinking" showed a significant improvement (t = 2.075, P = 0.043). Although improvements were observed in other dimensions, they were not statistically significant (P > 0.05). In terms of the magnitude of improvement, the experimental group demonstrated a greater increase in both total score and "Confidence in Critical Thinking" compared with the control group.

3.3 Self-efficacy

The comparison of self-efficacy between the two groups is shown in ^{Table 3}. Scores from the General Self-Efficacy Scale (GSES) were compared within and between groups before and after the intervention.

Before the intervention, no significant differences in self-efficacy scores were observed between the groups (P > 0.05). Post-intervention, the experimental group demonstrated significantly higher self-efficacy scores compared with the control group (P < 0.001). Additionally, the experimental group's self-efficacy scores showed significant improvement after the intervention (P < 0.05). In contrast, the control group's self-efficacy scores did not show significant changes after the intervention (P > 0.05).

3.4 Clinical practice ability

The clinical practice abilities of the two groups were assessed using the Nursing-Mini-CEX scale. Following ward rounds, each participant's supervisor rated the students' performance in eight areas: nursing interview, physical examination, nursing diagnosis, nursing interventions, health consultation, humanistic care, organizational effectiveness and overall evaluation, as outlined in the Nursing-Mini-CEX scale. The results, presented in ^{Table 4}, showed that the experimental group scored significantly higher than the control group in all eight areas, with statistical significance (P < 0.05).

4 Discussion
4.1 Improving critical thinking skills

The results of this study indicate that the experimental group scored significantly higher than the control group in both overall critical thinking skill and individual dimensions, consistent with findings by ^{Nekouei et al. (2024)}. This suggests that the 7E teaching model significantly enhances nursing students' critical thinking. By using real clinical cases, the 7E model stimulates students' interest, emphasizes independent exploration and promotes group collaboration. During this process, students engage in case discussions, followed by teacher-led feedback and guidance. This approach not only deepens their understanding of the material but also hones their ability to analyze clinical problems critically. In clinical practice, individuals with critical thinking skills tend to exhibit key traits such as confidence, creativity, flexibility, curiosity, integrity and patience ( ^{Kim, 2018}). These traits enhance their ability to tackle complex problems and prepare them for future professional development. Furthermore, both groups showed significant improvements in critical thinking scores after the teaching sessions, with statistical significance. This indicates that regardless of whether traditional or innovative teaching methods are used, clinical practice has a positive impact on enhancing students' critical thinking skills. The limited exposure to critical thinking training before clinical practice and fewer opportunities to engage with real clinical issues likely contributed to the increase in critical thinking following clinical rotations.

4.2 Improving self-efficacy

Self-efficacy refers to an individual's confidence and expectation of successfully completing a task, reflecting nursing students' confidence in performing their duties. This study found that the experimental group scored significantly higher in self-efficacy than the control group, consistent with findings by ^{Utami and Widowati (2022)}. High self-efficacy among nurses has been associated with better performance and higher-quality care, making it a critical predictor of professional behavior ( ^{Zarshenas et al., 2022}). Recognizing its importance is vital for enhancing professional competence. Research also suggests a positive correlation between the accumulation of successful experiences and self-efficacy levels, with students who gain more success showing greater confidence ( ^{Rocher, 2020; Sahin-Taskin, 2018}). In this study, the 7E teaching model based on real clinical cases was implemented to provide students with opportunities to achieve these successful experiences. Through problem creation and case-based learning, instructors guided students to transition from passive recipients to active participants, fostering greater interest in learning. During this process, students engaged in collaborative discussions, hands-on practice and active participation in each phase of the model. They received timely feedback, which helped them recognize their progress, build confidence and accumulate successful experiences, ultimately enhancing their self-efficacy.

4.3 Improving clinical practice ability

In this study, the Nursing-Mini-CEX scale was used to evaluate nursing students' clinical practice ability. Although theoretical exams assess the systematic and comprehensive understanding of knowledge, they often fail to measure students' depth of understanding and their ability to apply knowledge in practice. Practical skills assessments primarily focus on technical proficiency, lacking an evaluation of problem-solving abilities in real-world contexts. The Nursing-Mini-CEX, based on authentic clinical work scenarios, is guided by the nursing process and assesses nursing students on various aspects, such as nursing interviews, physical examinations, nursing diagnoses, nursing interventions, health consultation and humanistic care. This comprehensive evaluation offers a clear picture of students' clinical performance, contributing to the improvement of their overall competence and the quality of education ( ^{Guo et al., 2017}).

The results of this study show that, after applying the Nursing-Mini-CEX to assess the clinical practice ability of the two groups, the experimental group scored significantly higher than the control group. This suggests that the 7E teaching model, based on real clinical cases, significantly enhances nursing students' clinical practice abilities. The reasons for this are as follows: Elicit, Engage and Explore Phases: In these stages, students are placed in real clinical situations where they actively gather data, learn standardized physical examination techniques, prepare PPT presentations and collaboratively discuss patient treatment and nursing interventions. This process not only heightens their sense of real-world experience but also sparks their interest in learning and promotes their problem-solving abilities. Elaborate Phase (Formal Ward Rounds): During the bedside rounds led by the nursing students, they present the case and deliver their PPT, with clinical instructors offering professional guidance. Students communicate directly with patients, conduct physical examinations and take the lead in nursing tasks. This phase deepens their understanding and application of disease knowledge and enhances their operational skills, observational abilities, communication skills and overall humanistic care. It also boosts their enthusiasm and confidence in learning. Evaluate Phase: Through self-assessment, peer evaluation and feedback from instructors, students engage in a detailed review of the patient's overall condition, focusing on key issues and often-overlooked details. This process, which includes filling in gaps and organizing knowledge for sharing and discussion, not only improves their comprehensive nursing concepts but also contributes to a higher satisfaction with the teaching rounds. The structured GAS review method used during self-assessment helps students reflect on their learning process more deeply and identify areas for improvement. Extend Phase: Students are encouraged to transfer knowledge into their daily clinical practice, which helps prepare them for the transition to full clinical roles. Additionally, by writing parallel medical records, students learn to use narrative nursing techniques, listen, comfort and engage in empathetic communication with patients. This process encourages students to recognize individual patient differences, foster a harmonious nurse-patient relationship and approach problems from multiple perspectives, facilitating emotional exchanges ( ^{Ni et al., 2021}). As students accumulate experience in writing parallel medical records, they become better at understanding patient feelings and expressing care appropriately, further enhancing their humanistic care approach.

4.4 Limitations

This study has several limitations that need to be considered when interpreting the results. First, the study was conducted at a single teaching hospital and the intervention was implemented in only nine departments. This may introduce bias, limiting the generalizability of the findings. Future research should consider conducting larger-scale validation studies across multiple hospitals and regions to enhance the external validity of the results. Second, the lack of randomization in participant allocation could lead to potential external factors influencing the students' performance during the different teaching modes, thereby affecting the accuracy of the results. Third, the sample in this study consisted only of full-time fourth-year undergraduate nursing students from a single institution, which may limit the diversity and representativeness of the sample. Future studies could include nursing students from various educational backgrounds to comprehensively evaluate the applicability and effectiveness of the 7E teaching model based on clinical real-life cases.

5 Conclusion

This study demonstrated that the 7E teaching model, based on clinical real-life cases, significantly improved nursing students' critical thinking, self-efficacy and clinical practice abilities. The results showed that the 7E model outperformed traditional teaching strategies in these areas. Therefore, nursing educators should consider integrating Case-Based Learning (CBL) with the 7E model in future clinical education, tailoring standardized educational plans to suit different teaching contexts and student populations. This approach will contribute to the overall improvement of nursing students' clinical practice, learning attitudes and critical thinking skills.

Funding

The study was supported by the Shanxi Province General Teaching Reform and Innovation Project ( J20230455).

CRediT authorship contribution statement

Tao Xu: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software, Writing – original draft, Writing – review & editing. Liping Cui: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing. Chao Li: Data curation, Investigation, Software, Writing – review & editing.

Declaration of Competing Interest

The 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.

Table 1

Comparison of General Information Between the Two Groups.

Variable	Experimental Group (n = 52)	Control Group (n = 50)	χ2/t	P
	n(%)	n(%)
	Mean±SD	Mean±SD
Gender
Male	10(19.2)	9(18.0)	0.025	0.873
Female	42(80.8)	41(82.0)
Age	21.08 ± 0.682	20.98 ± 0.795	−0.662	0.510
Pre-service Training Score	83.02 ± 4.889	82.64 ± 4.881	0.392	0.696

Table 2

Comparison of Critical Thinking skill Between the Two Groups.

Dimension	Experimental Group (n = 52)		Control Group (n = 50)		t a	P
	Mean±SD		Mean±SD
Truth-Seeking	Pre-test	37.52 ± 2.02	Pre-test	37.54 ± 2.42	−0.047	0.963
	Post-test	41.58 ± 1.83	Post-test	38.14 ± 1.93	9.239	< 0.001
	t b	12.651	t b	1.278
	P	< 0.001	P	0.207
Open-Mindedness	Pre-test	40.87 ± 1.50	Pre-test	40.90 ± 1.36	−0.122	0.903
	Post-test	43.46 ± 1.85	Post-test	41.14 ± 2.91	4.782	< 0.001
	t b	7.161	t b	0.599
	P	< 0.001	P	0.552
Analytical Thinking	Pre-test	42.38 ± 2.39	Pre-test	42.08 ± 3.45	0.517	0.606
	Post-test	46.96 ± 1.86	Post-test	43.00 ± 3.12	7.748	< 0.001
	t b	11.228	t b	1.591
	P	< 0.001	P	0.118
Systematic Thinking	Pre-test	37.35 ± 2.41	Pre-test	37.72 ± 4.15	0.554	0.581
	Post-test	43.35 ± 2.15	Post-test	39.28 ± 3.59	6.904	< 0.001
	t b	11.729	t b	1.936
	P	< 0.001	P	0.059
Confidence In Critical Thinking	Pre-test	38.37 ± 3.12	Pre-test	37.84 ± 3.05	0.859	0.392
	Post-test	42.77 ± 2.03	Post-test	39.10 ± 3.51	6.438	< 0.001
	t b	8.824	t b	2.075
	P	< 0.001	P	0.043
Inquisitiveness	Pre-test	41.19 ± 2.42	Pre-test	41.12 ± 2.72	0.142	0.887
	Post-test	45.54 ± 1.98	Post-test	41.90 ± 2.89	7.376	< 0.001
	t b	9.724	t b	1.396
	P	< 0.001	P	0.169
Cognitive Maturity	Pre-test	40.96 ± 2.10	Pre-test	41.54 ± 3.62	−0.984	0.328
	Post-test	45.38 ± 2.07	Post-test	42.08 ± 4.14	5.069	< 0.001
	t b	11.295	t b	0.705
	P	< 0.001	P	0.484
Total Score	Pre-test	278.63 ± 6.87	Pre-test	278.74 ± 8.21	−0.070	0.944
	Post-test	309.04 ± 4.97	Post-test	284.64 ± 9.00	16.852	< 0.001
	t b	22.472	t b	3.326
	P	< 0.001	P	0.002

Table 3

Comparison of Self-Efficacy Between the Two Groups.

Variable	Experimental Group (n = 52)		Control Group (n = 50)		t a	P
	Mean±SD		Mean±SD
Self-Efficacy	Pre-test	26.85 ± 1.851	Pre-test	27.48 ± 1.741	−1.780	0.078
	Post-test	34.67 ± 1.801	Post-test	27.80 ± 1.784	19.355	< 0.001
	t b	24.286	t b	0.977
	P	< 0.001	P	0.333

Table 4

Comparison of Nursing-Mini-CEX Scores Between the Two Groups.

Variable	Experimental Group (n = 52)	Control Group (n = 50)	t a	P
	Mean±SD	Mean±SD
Nursing Interview	6.35 ± 0.711	5.38 ± 0.945	5.817	＜0.001
Physical Examination	6.06 ± 0.669	4.72 ± 1.031	7.741	＜0.001
Nursing Diagnosis	6.35 ± 0.883	5.54 ± 1.110	4.066	＜0.001
Nursing Interventions	6.92 ± 0.788	6.44 ± 0.884	2.915	0.004
Health Consultation	6.44 ± 0.938	5.98 ± 0.769	2.727	0.008
Humanistic Care	6.88 ± 0.878	6.08 ± 0.853	4.691	＜0.001
Organizational Effectiveness	6.27 ± 0.770	5.86 ± 0.808	2.619	0.01
Overall Evaluation	6.67 ± 0.734	6.22 ± 0.790	3.003	0.003