Content area
Aim
To assess the effectiveness of integrating Case-Based Learning (CBL) with Task-Driven Learning (TDL) in the clinical education of nursing interns specializing in cardiology.
Background
Traditional lecture-based learning (LBL) may not adequately prepare nursing interns for clinical problem-solving in cardiovascular specialties. Combining CBL with TDL methodologies could potentially enhance theoretical understanding and practical application skills.
Design
A randomized controlled trial was conducted at Beijing Friendship Hospital, focusing on nursing interns in the cardiology department.
Methods
Nursing interns were randomly assigned to two groups: one group received a combination of Case-Based Learning (CBL) and Task-Driven Learning (TDL) (n = 220), while the other group underwent Lecture-Based Learning (LBL) (n = 218). The study was conducted from June 2021 to March 2024. Evaluation was based on examination scores, nursing round skills and an anonymous questionnaire survey.
Results
The CBL-TDL group engaged in more pre-class preparation and displayed significantly better post-internship theoretical knowledge (92.21 SD 5.73 vs 91.03 SD 4.43, P = 0.016) and ward round skills (means 90.99 SD 7.19 vs 86.62 SD 5.78, P < 0.001) than the LBL group. Higher satisfaction in the CBL-TDL group was noted across several educational aspects (P < 0.01), particularly in motivation to learn (OR 2.50, 95 %CI (1.80–3.45), P = 0.006) and practical skill (OR 2.40, 95 %CI (1.70–3.40), P = 0.002), although they reported less free time consumed.
Conclusions
The synergistic application of CBL and TDL methodologies enhances the theoretical understanding and practical application skills of nursing interns in cardiovascular specialties, suggesting a valuable pedagogical strategy for improving clinical problem-solving abilities.
1 Introduction
The cardiovascular specialty, a clinical discipline marked by robust professionalism and practicality, encompasses a broad spectrum of complex diseases and the application of various emergency and interventional treatment methods in cardiology. In the realm of nursing education, the circulatory system stands as a focal point in internal medicine nursing, presenting content that often poses challenges in comprehension and mastery ( Brown et al., 2016). Historically, teaching models have relied on Lecture-Based Learning (LBL), a method grounded in lectures( Zhao and Potter, 2016). This teacher-centric, spoon-feeding approach involves the teacher elucidating relevant courses while interns adopt a passive listener role, resulting in a unidirectional flow of knowledge ( Solomon, 2020; Zhang et al., 2022). Despite the irreplaceable advantages of the LBL model, it bears notable shortcomings, such as an overemphasis on knowledge instillation and a lack of sufficient quality education ( Trullas et al., 2022).The clinical internship phase for nursing interns serves as a pivotal juncture in their transition to specialized nurses and stands as a primary avenue for enhancing their clinical practice capabilities. To address these evolving challenges, it is crucial to innovate teaching methods. Notably, relying on a single teaching method in cardiology internships has proven inadequate.
CBL and TDL are particularly suited for cardiology nursing education due to the complexity of cardiovascular care, which requires nurses to integrate knowledge from multiple areas, including pharmacology, patient assessment and emergency care. Case-Based Learning (CBL) enhances critical thinking and clinical reasoning by engaging students with real-world cases, promoting the application of theoretical knowledge in clinical contexts ( Li et al., 2019; Tuin et al., 2024). Task-Driven Learning (TDL) encourages students to independently solve tasks relevant to cardiology, fostering skills such as patient assessment and emergency response, which are crucial in cardiology nursing ( Foley and Dowling, 2019). Unlike traditional lecture-based methods, the combined application of CBL and TDL actively involves students through realistic clinical scenarios and targeted practical exercises, significantly enhancing their critical reasoning, knowledge integration and decision-making abilities—qualities essential for navigating the complexities of cardiology nursing. However, despite this supportive evidence in general nursing education, we acknowledge a critical gap: very limited research specifically evaluates the integrated application of CBL and TDL methods within the specialized context of cardiology nursing internships. A recent comprehensive scoping review by Donkin et al. ( Donkin et al., 2023). explicitly identified and emphasized the blended CBL with variant task centred methods in fully online environments across all pre-registration health programmes. They concluded that most evidence addressed short term knowledge gains, with “minimal reporting of higher order competencies or psychomotor skill development. Given this significant research gap, we now contrast Donkin et al.’s online scope with our face-to-face design and justify the latter for cardiology’s psychomotor and team-based demands. Our study aimed to investigate whether combining CBL and TDL methods can effectively meet the specialized learning needs of nursing interns in cardiology units, thereby enhancing their theoretical knowledge, clinical reasoning and clinical performance .
2 Methods
In this randomized controlled trial, 438 cardiology nursing interns were assigned to a CBL-TDL group (n = 220) or a traditional LBL group (n = 218) via randomization with concealed allocation. Over a 16-week internship, the CBL-TDL arm completed weekly case-based pre-class tasks, pre-tests, group disscussions, bi-weekly teaching rounds, and structured feedback; the LBL arm received standard lectures and supervised clinical rounds. Primary outcomes were theoretical exam and clinical skills scores, alongside a validated satisfaction survey. Data were analyzed with independent and paired t-tests, chi-square tests, and multivariate logistic regression (α = 0.05). A comprehensive description of the study design, intervention procedures and statistical analyses is provided in the Supplemental material of Methods.
3 Results
3.1 Demographic Characteristics and Pre-Class Preparation
The study population consisted of 438 nursing students, with a mean age of 21.16 SD 0.831 years. Of these, 338 (77.2 %) were female.
3.2 Academic Performance
Theoretical knowledge and practical skills before and after the internship are presented in
Table 2. Initially, the CBL-TDL group's pre-internship theoretical knowledge scores were not different from those of the LBL group (86.92 SD 5.62 vs 85.68 SD 6.91, P = 0.039). Post-internship, both groups showed improvement in theoretical knowledge, with the CBL-TDL group achieving significantly higher scores (92.21 SD 5.73 vs 91.03 SD 4.43, P = 0.016). Although there was no significant difference in pre-internship ward round skills scores between the groups (82.78 SD 6.82 vs 83.55 SD 7.68, P = 0.268,
Table 2), post-internship scores were significantly higher in the CBL-TDL group (90.99 SD 7.19 vs 86.62 SD 5.78, P < 0.001).
3.3 Intra-Group Comparisons
The comparison of intra-group theoretical knowledge scores and ward round skills scores was conducted to evaluate the internal progress of each group. This analysis helps to understand how the CBL-TDL and LBL interventions influenced both cognitive (theoretical) and practical (clinical) skills development during the internship.
3.4 Factors Influencing Satisfaction
Factors influencing satisfaction were evaluated in both the intervention and control groups to assess the broader impact of the teaching methods on the learning experience. This evaluation provides insight into how the interventions affected intern motivation, clinical engagement and perceived skill development, which are important factors in the overall success of the teaching methods. To evaluate the potential effect on teaching methods, we compared the scores on the post-course questionnaire between the CBL-TDL and LBL groups. The CBL-TDL group had significantly higher scores than the LBL group in terms of satisfaction with teaching methodology, teamwork ability, motivation to learn, clinical thinking ability, comprehension ability, practical ability and teacher-student communication and interaction (P < 0.05,
Multifactor regression analysis revealed that pre-class preparation, clinical thinking skills, self-learning skills and teamwork skills contributed significantly and positively to teaching satisfaction in the CBL-TDL group (
Table 4). However, no statistically significant difference was found in satisfaction levels among the top 5 metrics in the LBL group (P > 0.05,
4 Discussion
4.1 Cardiology Nursing Interns Require Comprehensive Skills
Cardiology encompasses a broad spectrum of conditions, including hypertension, coronary heart disease, arrhythmias and heart failure, collectively termed cardiovascular diseases. This specialty involves a diverse array of medications, many of which are vasoactive and high-risk. Clinical teaching for nursing interns aims not only to imbue them with the competencies of a general nurse( Zelenikova et al., 2023) but also to deepen their understanding of cardiology-specific ailments, medication administration and patient monitoring ( Burgess et al., 2020; Li et al., 2022a). Given the rapid advancements in medical technology and the evolution of treatment paradigms, nursing education must meet heightened expectations. However, despite the recognized need for advanced educational methods tailored to cardiology nursing interns, there remains a notable lack of research specifically examining the combined effectiveness of CBL and TDL in this specialized context ( Donkin et al., 2023).It should equip students with agility, robust self-learning capabilities and the effective application of knowledge and skills. Interns must proficiently use contemporary monitoring equipment and seamlessly integrate into the highly changed working environment. This necessitates superior teaching methodologies for cardiology nursing interns ( Astin et al., 2015). Consequently, it's imperative to foster student initiative, kindle their passion for independent learning and judiciously employ teaching strategies that enhance their grasp and application of specialized knowledge, always prioritizing patient care in clinical settings.
4.2 Combining CBL with TDL Enhances Critical Thinking and Clinical Practice Skills
Cardiology nursing education faces unique challenges and traditional Lecture-Based Learning (LBL), being teacher-centered, often stifles interns' creativity and initiative, leading to suboptimal learning outcomes( Bingjie et al., 2022). Integrated models, such as combining Case-Based Learning (CBL) and Task-Driven Learning (TDL), are increasingly recommended to overcome these limitations ( Thrower et al., 2020; Zhang et al., 2020; Zhao et al., 2020). CBL integrates real-world cases and promotes the application of theory through group discussions, while TDL emphasizes task completion, fostering problem-solving and critical thinking( Liu and Su, 2018).
Our study found that the CBL-TDL group scored significantly higher in both post-class theoretical knowledge and ward round skills compared with the LBL group. Similar to findings in dental education ( Heitkamp et al., 2018), CBL-TDL also enhanced student satisfaction, particularly in developing clinical thinking and practical skills. Satisfaction in the LBL group showed no significant change. This suggests that CBL-TDL not only improves learning efficiency but also nurtures teamwork, communication skills and clinical reasoning.
A meta-analysis in medical education( Jia et al., 2018) supports the combined use of problem-based and lecture-based models to boost knowledge, skills and satisfaction. While CBL shares similarities with Problem-Based Learning (PBL), TDL distinguishes itself by requiring interns to apply both theoretical knowledge and practical skills to complete tasks. The CBL-TDL approach promotes autonomous learning and enhances critical thinking and problem-solving, as evidenced by the improvement in ward round skills( Richardson et al., 2023). However, it is important to note that this approach is time-consuming, as students in the CBL-TDL group spent more time on coursework compared with the LBL group ( Yuan et al., 2011).
4.3 Integrated Teaching Methods Promote Theoretical Understanding and Application in Clinical Practice
The integration of CBL with TDL may provide a comprehensive approach( Zhao et al., 2020) that seamlessly aligns theoretical knowledge with practical application, thereby enhancing the educational trajectory for nursing interns. By leveraging the synergies of these combined methodologies, nursing interns are better positioned to assimilate specialized theoretical concepts and apply them proficiently in addressing clinical challenges. Studies, inclusive of those by Musick et al. ( Musick, 2006) affirm that the confluence of methodologies such as TDL and CBL leads to a structured curriculum, defined learning objectives and augmented resources, consequently elevating pedagogical quality and facilitating efficient acquisition of foundational skills.
Our results demonstrated that the CBL-TDL group showed significantly greater improvements in both theoretical knowledge and clinical skills compared with the LBL group. These findings align with the study's objective of evaluating the effectiveness of CBL-TDL in enhancing both cognitive and practical competencies. By incorporating baseline covariates, such as pre-class preparation time etc., we ensured that the analysis accurately captured the impact of the intervention on learning outcomes. The amalgamation of TDL and CBL in pedagogical frameworks introduces pertinent clinical cases into academic discourse, engendering an environment conducive to comprehensive discussions, collaborative communication and independent analytical reasoning. Consequently, our findings reveal a significant uptick in students' satisfaction with clinical teaching methodologies, which translates to richer interactions between educators and students, fortified team cohesion and refined practical abilities.
4.3.1 Limitations
The present study, while offering valuable insights into the efficacy of the CBL-TDL approach in cardiology clinical teaching, has several limitations. Firstly, the study relied on self-developed questionnaires, which, despite expert validation, did not undergo full psychometric testing, limiting the robustness of the conclusions regarding the instrument's reliability and validity. To mitigate this, we refined the items through expert consultation and pilot testing to ensure better alignment with the defined dimensions ( Jiao et al., 2021; Zhao et al., 2020). Although the content-validated questionnaire performed adequately in this trial, multicentre replication and Rasch analysis will be undertaken to further solidify its psychometric properties and to facilitate benchmarking against international instruments. Future studies could certainly integrate our tools with established questionnaires to further confirm reliability and enhance comparability. Secondly, the sample was restricted to nursing interns from a single hospital, which may limit the generalizability of the findings, as the participants may not fully represent the broader nursing intern population in terms of educational background, experience and demographics( Li et al., 2022b). Thridly, the lack of blinding for participants to their assigned teaching method may introduce potential bias, although steps were taken to minimize this impact. Future studies should consider employing standardized, psychometrically validated instruments to more accurately measure teaching outcomes, satisfaction and critical thinking abilities. We acknowledge that our study focused on immediate post-intervention outcomes and did not include a long-term follow-up. Due to practical constraints of the internship schedule and the fact that interns moved on to other rotations, no follow-up assessment was conducted after the internship. We note that this is a limitation because it remains uncertain whether the improvements in clinical problem-solving skills. Future studies should include follow-up assessments (e.g., months after the internship or in early professional practice) to evaluate the long-term retention and application of the skills gained from CBL-TDL. Lastly, patient satisfaction was not assessed in this study due to practical constraints and ethical considerations; future studies are recommended to include patient perspectives, offering a more comprehensive evaluation of nursing interns' clinical competencies and educational effectiveness.
5 Conclusions
In conclusion, the CBL-TDL teaching approach demonstrated superior outcomes in enhancing theoretical knowledge, practical skills and overall satisfaction among nursing students compared with the traditional LBL method. The findings suggest that incorporating CBL-TDL into nursing education may better prepare students for clinical practice and foster essential skills such as clinical thinking, self-learning and teamwork.
Ethics approval and Consent for publication
The authors confirmed that all the study protocol for involving human data was in accordance to guidelines of national/international/institutional or Declaration of Helsinki and was proved by the Institutional Review Board of Beijing Friendship Hospital. All the written consents of the participants were obtained for the publication.
Ethics approval and Consent for publication
The authors confirmed that all the study protocol for involving human data was in accordance to guidelines of national/international/institutional or Declaration of Helsinki in the manuscript. This study was approved by the IRB. All the written consents of the participants were obtained for the publication.
Authors' contributions
MY Liu, YH Liu and JJ Zhang were contributed to the conception and study design/obtaining funding; YH Liu and L Zhang, writing the article; YH Liu, X Sun, LP Wu and MY Liu, critical revision of the article; JJ Zhang and G Liu, obtaining and processing the medical data; MY Liu and YH Liu and JJ Zhang, the data collection/analysis and interpretation.
Authors' contributions
MY Liu, YH Liu and JJ Zhang were contributed to the conception and study design/obtaining funding; YH Liu, Li Zhang, X Sun and LP Wu writing the article; YH Liu and MY Liu, critical revision of the article; JJ Zhang and G Liu, obtaining and processing the medical data; MY Liu and YH Liu and JJ Zhang, the data collection/analysis and interpretation.
Funding
This work was supported by the
CRediT authorship contribution statement
Xing Sun: Writing – review & editing. Li-Ping Wu: Writing – review & editing, Conceptualization. Li Zhang: Writing – original draft. Jing-jing Zhang: Conceptualization, Writing – original draft. You-Hua Liu: Writing – review & editing, Conceptualization, Writing – original draft. Guang Liu: Validation. Liu MingYuan: Writing – original draft, Funding acquisition, Conceptualization, Writing – review & editing, Project administration, Data curation.
Declaration of Competing Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Appendix A Supporting information
Supplementary data associated with this article can be found in the online version at
Appendix A Supplementary material
Supplemental Table 1. Randomization Process
Supplemental Table 2. The details of the CBL+TDL versus LBL
Supplemental Table 3. Theoretical Evaluation
Supplemental Table 4 Ward Round Evaluation
Supplementary material
Supplementary material
Table 1
| Item | CBL-TDL (n = 220) | LBL (n = 218) | t / χ² | P value | Mean Diff (95 % CI) | Cohen’s d |
| Age, yrs | 21.11 SD 0.82 | 21.23 SD 0.84 | 1.513 | 0.131 | −0.12 (−0.28 – 0.04) | −0.14 |
| GPA (0–4) | 3.38 SD 0.27 | 3.42 SD 0.32 | 1.398 | 0.163 | −0.04 (−0.10 – 0.02) | −0.14 |
| ATPP, min | 85.48 SD 20.33 | 68.60 SD 18.45 | 9.120 | < 0.001 | 16.88 (13.24 – 20.52) | 0.87 |
| Gender, n (%) | 1.873 | 0.069 | — | — | ||
| Male | 42 (19.1) | 58 (26.6) | ||||
| Female | 178 (80.9) | 160 (73.4) |
Table 2
| Item | CBL-TDL (n = 220) | LBL (n = 218) | t | P value | Mean Diff (95 % CI) | Cohen’s d |
| Pre-class theoretical score | 86.92 SD 5.62 | 85.68 SD 6.91 | 2.061 | 0.039 | 1.24 (0.06 – 2.42) | 0.20 |
| Post-class theoretical score | 92.21 SD 5.73 | 91.03 SD 4.43 | 2.410 | 0.016 | 1.18 (0.22 – 2.14) | 0.23 |
| Pre-class ward-round score | 82.78 SD 6.82 | 83.55 SD 7.68 | 1.110 | 0.268 | −0.77 (−2.13 – 0.59) | −0.11 |
| Post-class ward-round score | 90.99 SD 7.19 | 86.62 SD 5.78 | 7.007 | < 0.001 | 4.37 (3.15 – 5.59) | 0.67 |
Table 3
| Item | CBL–TDL group ( N = 220) | LBL group ( N = 218) | 95 % confidence interval | P value |
| Satisfaction with teaching methodology | 4.52 SD 0.21 | 3.89 SD 0.25 | (3.80–4.90) | 0.015 |
| Teamwork ability | 4.28 SD 0.32 | 3.70 SD 0.38 | (3.65–4.40) | 0.012 |
| Motivation to learn | 3.95 SD 0.38 | 3.45 SD 0.44 | (3.40–4.30) | 0.042 |
| Free time consumed | 3.60 SD 0.34 | 4.18 SD 0.35 | (3.55–4.50) | 0.030 |
| Clinical thinking | 4.68 SD 0.26 | 4.10 SD 0.22 | (4.05–5.00) | < 0.001 |
| Comprehension ability | 4.38 SD 0.35 | 3.85 SD 0.32 | (3.80–4.70) | 0.044 |
| Communication skills | 4.48 SD 0.31 | 3.90 SD 0.34 | (3.85–4.80) | 0.017 |
| Practical skill | 4.75 SD 0.24 | 4.20 SD 0.27 | (4.15–5.10) | < 0.001 |
| Lecturer-student interaction | 4.25 SD 0.34 | 3.68 SD 0.33 | (3.60–4.60) | 0.043 |
Table 4
| Positive Contribution | CBL-TDL group, n(%) | OR Value | 95 % CI | P value |
| Pre-class preparation | 187 (85 %) | 1.30 | (1.10–1.70) | 0.021 |
| Lecturer-student interaction | 172 (78 %) | 1.25 | (0.95–1.65) | 0.127 |
| Motivation to learn | 180 (82 %) | 2.50 | (1.80–3.45) | 0.006 |
| Practical skill | 176 (80 %) | 2.40 | (1.70–3.40) | 0.002 |
| Teamwork skill | 178 (81 %) | 1.75 | (1.25–2.45) | 0.038 |
| Clinical thinking skill | 174 (79 %) | 1.15 | (0.85–1.55) | 0.380 |
Table 5
| Positive Contribution | LBL group, n(%) | OR Value | 95 % CI | P value |
| Clinical thinking skill | 160/73 % | 1.20 | (0.70–2.10) | 0.511 |
| Practical skill | 145/67 % | 1.35 | (0.75–2.40) | 0.320 |
| Motivation to learn | 155/71 % | 1.10 | (0.60–2.00) | 0.744 |
| Teamwork skill | 150/69 % | 1.25 | (0.70–2.20) | 0.453 |
| Free time consumed | 165/76 % | 1.15 | (0.65–2.05) | 0.632 |
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