Effects of an integrated CBL-OSCE model on clinical judgment among undergraduate nursing students: a quasi-experimental study

Effects of an integrated CBL-OSCE model on clinical judgment among undergraduate nursing students: a quasi-experimental study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of an integrated CBL-OSCE model on clinical judgment among undergraduate nursing students: a quasi-experimental study Qingqing Feng, Tang Tang, Lei Zhang, Min Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8077625/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Developing robust clinical judgment is a core outcome of undergraduate nursing education. Although case-based learning (CBL) and the Objective Structured Clinical Examination (OSCE) are widely used, evidence regarding the educational impact of an integrated CBL-OSCE model in nursing practicum training remains limited. Methods: A quasi-experimental study was conducted among 123 senior undergraduate nursing students allocated by natural classes to either an experimental group receiving an integrated CBL-OSCE intervention (n = 62) or a control group receiving traditional skills training (n = 61). Outcomes included course performance, the Lasater Clinical Judgment Rubric (LCJR), and a self-reported Clinical Reasoning and Reflection Scale. Independent t-tests and repeated-measures ANOVA were performed. Results: Compared with controls, the experimental group achieved significantly higher final examination scores (93.09 ± 4.71 vs. 90.11 ± 5.19, P = 0.001, Cohen’s d = 0.61) and overall course scores (94.87 ± 2.83 vs. 92.86 ± 3.77, P = 0.001, d = 0.60). A significant time × group interaction was observed for LCJR total score (F(1,121) = 10.652, P = 0.001, η² = 0.081), with the experimental group demonstrating larger improvements across all LCJR dimensions, particularly interpreting (η² = 0.503) and responding (η² = 0.494). Self-reported clinical reasoning improved significantly within both groups, though without between-group differences (P > 0.05). Conclusion: The integrated CBL-OSCE model led to greater gains in clinical judgment and practical performance than traditional skills training. Embedding CBL throughout instructional activities and aligning assessments with OSCE principles appears to support the development of higher-order decision-making abilities in nursing students. Clinical judgment Case-based learning OSCE Simulation Nursing education Quasi-experimental study Figures Figure 1 Figure 2 Background Preparing nursing students to deliver safe and effective patient care increasingly requires strong clinical judgment and decision-making abilities, particularly in modern healthcare environments characterized by complexity and uncertainty [ 1 ]. Therefore, identifying educational approaches that better integrate theory with practice has become a key priority in undergraduate nursing education. The Objective Structured Clinical Examination (OSCE) has become a widely accepted method for evaluating clinical competence through standardized, scenario-based skill assessment [ 2 ]. Likewise, case-based learning (CBL) facilitates the development of analytical and critical thinking skills by immersing learners in realistic clinical problems [ 3 ]. Although both methods have demonstrated educational value and are frequently used in nursing programs [ 4 ], they are often implemented independently. Evidence remains limited regarding the effectiveness of an integrated CBL-OSCE approach that simultaneously supports learning and assessment throughout the practicum experience. In China, nursing skills training traditionally emphasizes repetitive technical practice of isolated procedures [ 5 ]. While this approach effectively builds foundational psychomotor skills, it often fails to cultivate clinical judgment, teamwork, and humanistic care competencies required in real clinical settings [ 6 ]. As a result, nursing students may struggle to transfer theoretical knowledge into accurate clinical decision-making when first entering real patient care settings. To address this challenge, we developed an integrated instructional model within the Comprehensive Nursing Practicum course that embeds CBL throughout learning activities and aligns performance assessment with OSCE standards. This closed-loop “teach–practice–assess” structure aims to strengthen students’ clinical judgment by engaging them in scenario analysis, collaborative simulation, and authentic performance evaluation linked to expected clinical outcomes. Preliminary observation suggested that this model may enhance both clinical judgment and practical competence compared with traditional teaching. However, empirical evidence is needed to support its effectiveness. Therefore, this study conducted a quasi-experimental evaluation of the integrated CBL-OSCE model, with the objective of determining whether it improves nursing students’ clinical judgment and course performance compared with traditional skills training. Methods 1.1 Study Participants A quasi-experimental study was conducted using convenience sampling. A total of 123 fourth-year undergraduate nursing students from the 2022 cohort were included. Students were assigned to either the experimental group (n = 62; Classes 1 and 3) or the control group (n = 61; Classes 2 and 4) based on their pre-existing class enrollment, ensuring natural group allocation without disruption to teaching schedules. The study flowchart is presented in Fig. 1. 1.2 Intervention The Comprehensive Nursing Practicum is a required capstone course for fourth-year undergraduate nursing students, aimed at systematically enhancing clinical competence and professional readiness through structured practical skills training. Using the 7th edition of Fundamental Nursing (People’s Medical Publishing House) as the primary textbook, the original 18 units were reorganized into five integrated modules: (1) Basic Nursing and Aseptic Techniques, (2) Life Support and Monitoring, (3) Medication and Infusion Therapy, (4) Specialized Nursing Skills, and (5) Comprehensive Specialty Practice. This curriculum not only emphasizes foundational nursing skills but also incorporates essential clinical procedures from internal medicine, surgery, obstetrics, pediatrics, and emergency care, forming a coherent and holistic practice-oriented training framework. The course was delivered entirely offline over 63 laboratory hours from September 2024 to January 2025, with two 3-hour sessions per week. To ensure instructional fidelity, three instructors with more than three years of teaching experience implemented the curriculum concurrently for both groups in separate laboratories. All instructors completed standardized training in case-based teaching prior to course initiation to ensure consistency in instructional content and assessment approaches. 1.2.1 Experimental Group Teaching Methods 1.2.1.1 Instructional Preparation Instructor Preparation A standardized instructional plan integrating case-based learning with OSCE assessment was developed. The teaching team collaboratively designed clinical cases that aligned with the Fundamental Nursing curriculum and established corresponding OSCE stations and scoring rubrics. Prior to implementation, all instructors participated in collective lesson planning to ensure consistency in case analysis depth, procedural instruction, and evaluation standards. Student Preparation Course materials, including case briefs, guided learning outlines, and OSCE procedure requirements, were provided in advance through an online learning platform. Students were expected to review the clinical background and preview relevant operational skills prior to each session. This preparatory strategy facilitated the establishment of an initial clinical reasoning mindset and improved readiness for active participation in case discussion and skill practice. 1.2.1.2 Implementation of Teaching Case Analysis and Scenario Introduction The instructional process was centered on standardized clinical cases rather than isolated skill demonstrations. Using the example of “Emergency Response and In-hospital Management of Multiple Casualties After a Traffic Accident,” instructors facilitated structured case analysis by directing students to identify key clinical cues (e.g., active bleeding in Patient Wang, early shock signs in Patient Zhang), define nursing priorities, and determine appropriate interventions. Theoretical knowledge—including principles of shock management and aseptic techniques—was systematically integrated with relevant nursing procedures such as wound care, catheterization, and intravenous infusion. This approach aimed to strengthen students’ holistic nursing perspective and clinical reasoning at the cognitive level. Group Simulation and Collaborative Practice This stage represented the core process of skills internalization, during which students participated in small-group role-play and collaborative practice in the simulation laboratory. Within the same case scenario, each student assumed a distinct clinical responsibility, including performing pressure bandaging and fixation to control active bleeding, conducting indwelling catheterization to prepare the critically ill patient for emergency surgery, and implementing rapid intravenous fluid resuscitation to stabilize vital signs. Throughout the training, instructors maintained continuous supervision, emphasizing adherence to standardized operational procedures, effective team communication, and strict compliance with key patient safety protocols such as the “Three Checks and Eight Verifications,” while delivering immediate formative feedback to promote accurate skill mastery and enhance coordinated teamwork. OSCE-Based Comprehensive Assessment Upon completion of the teaching sessions, the clinical cases were directly transformed into OSCE examination stations, achieving a closed-loop process integrating “instruction, practice, and assessment.” Assessment components aligned fully with instructional objectives and included evaluation of individual technical proficiency (e.g., wound dressing, catheterization, intravenous therapy) as well as teamwork, clinical reasoning, communication, professionalism, and patient safety awareness. The OSCE’s high-fidelity clinical scenarios allowed for a comprehensive appraisal of students’ integration of knowledge, skills, and professional attributes under simulated time-pressured conditions. 1.2.2 Control Group Teaching Methods Students in the control group received traditional skills-based training delivered through a teacher-centered format. Instruction followed the textbook sequence, with instructors first providing theoretical explanations and standardized demonstrations of each procedure. Students then practiced individually, focusing on core fundamental nursing skills such as intravenous infusion and urinary catheterization. During these sessions, instructors circulated to provide corrective guidance, with primary emphasis on refining procedural accuracy and technical standardization. After completing the training, students underwent conventional single-skill examinations that assessed operational proficiency; however, these assessments did not include clinical case analysis, scenario-based performance evaluation, or OSCE components designed to measure integrated clinical judgment. 1.3 Evaluation Content and Methods 1.3.1 Course Performance Assessment The course performance evaluation consisted of formative assessment (30%) and summative assessment (70%). The formative assessment included scenario-based peer evaluation (40%), student attendance scores (40%), and instructor comprehensive evaluation (20%). The summative assessment comprised a practical skills examination, covering both fundamental nursing procedures and specialized nursing techniques. Both groups were assessed using identical examination content and uniform evaluation criteria administered by the same instructional team. 1.3.2 Clinical Thinking Ability Students' clinical thinking ability was comprehensively evaluated using the Lasater Clinical Judgment Rubric (modified by Professor Hui Hu's research team at Hubei University of Chinese Medicine) [ 7 , 8 ] and the Clinical Reasoning and Reflection Self-Assessment Scale (developed by Professor Xiaofeng Kang's research team at Peking Union Medical College School of Nursing) [ 9 ]. The Lasater Clinical Judgment Rubric comprises four dimensions [ 10 ]: Noticing, interpreting, responding, and reflecting, utilizing a multi-level scoring system including proficient, developing, and beginning levels, with higher total scores indicating stronger clinical judgment ability. The Clinical Reasoning and Reflection Self-Assessment Scale contains 26 items [ 11 ] rated on a 5-point Likert scale ranging from "strongly disagree" (1 point) to "strongly agree" (5 points), yielding total scores between 26–130 points, where higher scores reflect better clinical reasoning and reflection abilities. Upon course completion, electronic versions of both instruments were distributed to all students along with explanations of the survey purpose, significance, and completion methods. The questionnaire response rate was 100%. The study was approved by the Institutional Review Board (Ethics Approval No: ERB20240010). 1.4 Bias Control Measures Multiple strategies were implemented to minimize potential biases associated with the quasi-experimental design. First, students were assigned to groups based on pre-existing class enrollment to avoid disruption of teaching schedules; this natural allocation preserved ecological validity while baseline comparisons confirmed group equivalence prior to intervention. Second, all instructors received standardized training in case-based teaching and evaluation procedures, and unified scoring rubrics were applied to ensure consistency in skill assessment. To reduce performance and detection bias, different instructors assisted in monitoring practice sessions and scoring performance examinations, and students were not informed of specific research hypotheses. Additionally, identical teaching environments, laboratory conditions, and training hours were maintained across groups to minimize contamination effects. Despite these measures, the potential for instructor influence and group interaction effects cannot be fully excluded. 1.5 Statistical Analysis The normality of continuous variables was assessed using the Kolmogorov-Smirnov test. Normally distributed measurement data were expressed as mean ± standard deviation. Between-group comparisons were performed using independent samples t-test for normally distributed data and Mann-Whitney U test for non-normally distributed data. Repeated measures data were analyzed using repeated measures analysis of variance (ANOVA). All statistical analyses were conducted using IBM SPSS Statistics version 25.0, with a significance level set at P < 0.05. Results 2.1 Baseline characteristics All 123 students completed the study, with 61 in the control group and 62 in the experimental group. As shown in Table 1 , no statistically significant differences were observed between the two groups in demographic characteristics, including age, gender distribution, or intention to pursue a nursing career (all P > 0.05), indicating good baseline comparability. 2.2 Course performance As presented in Table 2 , students in the experimental group achieved significantly higher final examination scores (93.09 ± 4.71 vs. 90.11 ± 5.19; t = 3.337, P = 0.001) and overall course scores (94.87 ± 2.83 vs. 92.86 ± 3.77; t = 3.332, P = 0.001) compared with the control group. No significant difference was found in formative assessment scores (P > 0.05). 2.3 Clinical reasoning and reflective ability Based on the Clinical Reasoning and Reflection Self-Assessment Scale (Table 3 ), post-intervention scores were higher in the experimental group (112.38 ± 16.67) than in the control group (107.42 ± 14.75); however, this difference did not reach statistical significance (t = 1.747, P = 0.083). Within-group analysis indicated significant improvements after the intervention in both the control group (P < 0.05) and the experimental group (P < 0.001), suggesting a positive impact of both teaching approaches on self-perceived reasoning ability. These comparative results are summarized in Table 3 . 2.4 Clinical judgment Between-group comparisons showed that students in the experimental group achieved a significantly greater improvement in clinical judgment following the intervention (21.66 ± 6.96 vs. 31.67 ± 5.57, P < 0.001). Significant gains were observed across all four core dimensions: noticing (6.19 ± 2.04 vs. 8.84 ± 1.59, P < 0.001), interpreting (3.69 ± 1.52 vs. 5.79 ± 1.24, P < 0.001), responding (3.64 ± 1.12 vs. 5.47 ± 1.16, P < 0.001), and reflecting (8.02 ± 2.93 vs. 11.50 ± 2.36, P < 0.001). The control group also demonstrated significant improvement in overall clinical judgment (21.62 ± 6.38 vs. 27.10 ± 6.52, P < 0.001), but the magnitude of change was consistently smaller than that of the experimental group across all evaluated domains. Moreover, the control group’s knowledge assessment scores increased significantly after training (6.11 ± 1.87 vs. 7.69 ± 1.93, P < 0.001). Repeated-measures ANOVA further confirmed significantly stronger training effects in the experimental group. Notable time × group interaction effects were detected for noticing (F(1,121) = 6.197, P = 0.014, η² = 0.049), interpreting (F(1,121) = 6.164, P = 0.014, η² = 0.048), responding (F(1,121) = 4.454, P = 0.037, η² = 0.036), and reflecting (F(1,121) = 12.138, P = 0.001, η² = 0.091), as well as the total score (F(1,121) = 10.652, P = 0.001, η² = 0.081). Effect size analysis demonstrated large effects for interpreting (η² = 0.503) and responding (η² = 0.494) and small-to-medium effects for the remaining dimensions and total score. These findings highlight the practical significance and educational value of the instructional innovation. The corresponding results are illustrated in Fig. 2 . Table 1 Comparison of General Characteristics Between the Two Groups of Nursing Students (n(%)) Group Control Group (n = 61) Experimental Group (n = 62) t/χ 2 P-value Age(years), mean ± SD 20.08 ± 0.28 20.13 ± 0.34 0.92 0.36 Gender, n (%) Male 10(16.4) 12(19.4) 0.425 0.67 Female 51(83.6) 50(80.6) Future career intention in nursing Yes 58(95.1) 58(93.5) 0.135 1 No 3(4.9) 4(6.5) Table 2 Comparison of Assessment Scores Between the Two Groups (Mean ± SD) Group Formative Assessment Score Final Examination Score Overall Course Score Control Group (n = 61) 96.99 ± 3.14 90.11 ± 5.19 92.86 ± 3.77 Experimental Group (n = 62) 97.53 ± 1.80 93.09 ± 4.71 94.87 ± 2.83 t 1.1678 3.3366 3.3319 P-value 0.245 0.001 0.001 Table 3 Two-group Nursing Student Clinical Reasoning and Reflection Scale Scores Item Control Group Experimental Group t P-value Pre-training 100.03 ± 12.65 101.71 ± 12.817 0.508 0.614 Post-training 107.42 ± 14.75 112.38 ± 16.67 1.747 0.083 t 2.321 3.178 P-value 0.023 0.002 Conclusion This quasi-experimental study provides strong evidence that the integrated CBL-OSCE teaching model is more effective than traditional skills-based training in improving nursing students’ clinical competence and clinical judgment. The significantly higher final examination and overall course scores in the experimental group demonstrate that aligning learning activities with performance-based assessments strengthens knowledge integration and supports clinical application. By immersing students in realistic clinical scenarios from the outset, the CBL-OSCE model encourages active engagement in analytical reasoning, collaborative decision-making, and authentic performance evaluation, resulting in more contextualized and deeper learning. This design effectively bridges the gap between procedural proficiency and higher-level reasoning—transitioning from simply “knowing how” to also “knowing why” and “knowing when” to act. The strongest support for the effectiveness of the integrated CBL-OSCE model lies in the significant and comprehensive improvements observed across all dimensions of clinical judgment measured by the Lasater Clinical Judgment Rubric. The experimental group’s greater gains in noticing, interpreting, responding, and reflecting directly address a well-recognized and persistent deficiency in contemporary nursing education. Clinical reasoning and judgment are essential competencies, enabling nurses to interpret complex clinical information, make timely and logical decisions, and implement appropriate interventions in rapidly changing environments [ 12 ][ 13 ]. Critical clinical reasoning, in particular, is a pivotal skill for nurses to analyze situations and make rapid, sound decisions [ 14 ], and is indispensable for delivering high-quality care [ 15 , 16 ]. Nevertheless, studies consistently report that a majority of practicing nurses possess only low-to-moderate levels of critical thinking skills [ 17 , 18 ], with novices and student nurses often struggling to make appropriate clinical decisions in high-pressure, fast-paced settings [ 19 , 20 ]. Research in China [ 21 ] corroborates this, indicating shortcomings in critical thinking and evidence-based practice among nursing staff, who often lack proficiency in identifying and resolving clinical problems [ 22 , 23 ]. Alarmingly, over half of new graduate nurses fail to promptly identify issues and employ multiple strategies for prudent decision-making [ 24 ]. Even among experienced nurses, some remain prone to relying on anecdotal experience over systematic clinical reasoning [25]. Against this backdrop, our findings robustly indicate that the integrated CBL-OSCE model provides an effective educational framework to systematically address this critical competency gap. By creating a closed-loop instructional process of case analysis, simulated practice, and structured feedback, the model fosters a learning environment that necessitates continuous clinical decision-making, observation of consequences, and dynamic adjustment of actions. This repeated, structured engagement in the complete clinical judgment process—especially the guided, deep reflection during debriefing and OSCE feedback sessions—addresses fundamental deficiency in traditional, procedure-centric training and is paramount for cultivating the higher-order cognitive skills essential for navigating future clinical complexities. Interestingly, although both groups exhibited significant within-group improvements on the self-reported Clinical Reasoning and Reflection Scale, the between-group difference was not statistically significant. Two plausible explanations may be considered. First, metacognitive abilities such as reasoning self-efficacy may require extended clinical exposure before the impact of instructional differences becomes clearly distinguishable. Second, subjective ratings may be less sensitive to subtle behavioral changes than observer-rated instruments such as the LCJR. This finding reinforces the need for multimethod evaluation strategies in nursing education research to fully capture both perceived and demonstrated learning outcomes. This study has several limitations. The use of convenience sampling and allocation based on natural classes may introduce selection bias. Additionally, instructors were involved in both delivering the intervention and evaluating outcomes, which could increase the risk of performance and detection bias, despite standardized training. The single-center setting and relatively small sample size may also limit the generalizability of the results. Future research should include multicenter randomized controlled trials with larger samples and follow-up assessments to examine long-term effects. Implementation of blinded assessment procedures will further strengthen the rigor of subsequent evidence. Abbreviations Abbreviations Full Name CBL Case-Based Learning OSCE Objective Structured Clinical Examination LCJR Lasater Clinical Judgment Rubric SPSS Statistical Package for the Social Sciences ANOVA Analysis of Variance SD Standard Deviation Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Anhui Medical University (Ethics Approval No: ERB20240010). Written informed consent was obtained from all participants. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Authors' contributions QF: Conceptualization, Methodology, Writing - original draft. TT: Data curation, Formal analysis. ML: Supervision, Validation. LZ: Supervision, Writing - review & editing. All authors read and approved the final manuscript. Funding This work was supported by the Anhui Provincial Department of Education Quality Engineering Projects (Grant Nos. 2024jyxm0599 and 2023jyxm0988). The funding bodies had no role in the design of the study, collection, analysis, interpretation of data, or in writing the manuscript. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Trial registration Not applicable. This study is an educational intervention and does not fall under the category of clinical trials. Acknowledgements Not applicable. References Chen Q, et al. Effects of a blended emergent research training programme for clinical nurses on nursing research competence and critical thinking (Part 2): A quasi-experimental study. J Clin Nurs. 2022;31(5–6):755–69. Franzese CB. Pilot study of an Objective Structured Clinical Examination (the Six Pack) for evaluating clinical competencies. 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Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 14 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviewers agreed at journal 06 Mar, 2026 Reviewers invited by journal 06 Mar, 2026 Editor invited by journal 09 Feb, 2026 Editor assigned by journal 03 Dec, 2025 Submission checks completed at journal 02 Dec, 2025 First submitted to journal 02 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8077625","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":602140800,"identity":"d3433e9a-e35f-4cec-bdff-b02773bf70c4","order_by":0,"name":"Qingqing Feng","email":"","orcid":"","institution":"Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Qingqing","middleName":"","lastName":"Feng","suffix":""},{"id":602140808,"identity":"95e18eb4-b10f-4a43-9ddd-28082ccc855b","order_by":1,"name":"Tang Tang","email":"","orcid":"","institution":"Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Tang","middleName":"","lastName":"Tang","suffix":""},{"id":602140811,"identity":"a8a6587e-2df4-4c44-8807-fe8d403d1a79","order_by":2,"name":"Lei Zhang","email":"","orcid":"","institution":"Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Zhang","suffix":""},{"id":602140812,"identity":"5e934a48-575d-4adb-8ee6-a4e9682370a1","order_by":3,"name":"Min Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAr0lEQVRIiWNgGAWjYBACNvYGBoYPFQw8xGvh5znAwDjjDClaJGckMDBztpHiMIMD2ambGefVyZizH2D88DGHKC1nt90u3HaYx7IngVly5jZitBzs3XZ75rYDPAYHEtiYeYnScph3223eOXU8BucfEKlFsg2kpYGZx+AGsbbw8/Buuznj2GGglofNxPmFTf7tthsfaursDc4nH/zwkRgtSICxgTT1o2AUjIJRMApwAwAMMDk7a70RNAAAAABJRU5ErkJggg==","orcid":"","institution":"Anhui Medical University","correspondingAuthor":true,"prefix":"","firstName":"Min","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2025-11-10 13:38:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8077625/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8077625/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104547235,"identity":"64fe7b3f-9c3e-494b-8959-d8966d62a94e","added_by":"auto","created_at":"2026-03-13 07:34:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":249152,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u0026nbsp;\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8077625/v1/6a629135ef0717ba89d51acf.png"},{"id":104547234,"identity":"c74abf4a-46d5-47f0-8858-fcf541abac99","added_by":"auto","created_at":"2026-03-13 07:34:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34686,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChanges in clinical judgment scores measured by the Lasater Clinical Judgment Rubric\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8077625/v1/271f55236344c1a0f69ee290.png"},{"id":104780949,"identity":"ba68f307-e09c-49bd-9c14-19e5827392e4","added_by":"auto","created_at":"2026-03-17 07:54:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1097984,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8077625/v1/05944a0f-3c55-4ccc-a7e6-75997b9fc3e9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of an integrated CBL-OSCE model on clinical judgment among undergraduate nursing students: a quasi-experimental study","fulltext":[{"header":"Background","content":"\u003cp\u003ePreparing nursing students to deliver safe and effective patient care increasingly requires strong clinical judgment and decision-making abilities, particularly in modern healthcare environments characterized by complexity and uncertainty [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Therefore, identifying educational approaches that better integrate theory with practice has become a key priority in undergraduate nursing education.\u003c/p\u003e \u003cp\u003eThe Objective Structured Clinical Examination (OSCE) has become a widely accepted method for evaluating clinical competence through standardized, scenario-based skill assessment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Likewise, case-based learning (CBL) facilitates the development of analytical and critical thinking skills by immersing learners in realistic clinical problems [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although both methods have demonstrated educational value and are frequently used in nursing programs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], they are often implemented independently. Evidence remains limited regarding the effectiveness of an integrated CBL-OSCE approach that simultaneously supports learning and assessment throughout the practicum experience.\u003c/p\u003e \u003cp\u003eIn China, nursing skills training traditionally emphasizes repetitive technical practice of isolated procedures [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While this approach effectively builds foundational psychomotor skills, it often fails to cultivate clinical judgment, teamwork, and humanistic care competencies required in real clinical settings [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. As a result, nursing students may struggle to transfer theoretical knowledge into accurate clinical decision-making when first entering real patient care settings. To address this challenge, we developed an integrated instructional model within the Comprehensive Nursing Practicum course that embeds CBL throughout learning activities and aligns performance assessment with OSCE standards. This closed-loop \u0026ldquo;teach\u0026ndash;practice\u0026ndash;assess\u0026rdquo; structure aims to strengthen students\u0026rsquo; clinical judgment by engaging them in scenario analysis, collaborative simulation, and authentic performance evaluation linked to expected clinical outcomes. Preliminary observation suggested that this model may enhance both clinical judgment and practical competence compared with traditional teaching. However, empirical evidence is needed to support its effectiveness.\u003c/p\u003e \u003cp\u003eTherefore, this study conducted a quasi-experimental evaluation of the integrated CBL-OSCE model, with the objective of determining whether it improves nursing students\u0026rsquo; clinical judgment and course performance compared with traditional skills training.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Study Participants\u003c/h2\u003e \u003cp\u003eA quasi-experimental study was conducted using convenience sampling. A total of 123 fourth-year undergraduate nursing students from the 2022 cohort were included. Students were assigned to either the experimental group (n\u0026thinsp;=\u0026thinsp;62; Classes 1 and 3) or the control group (n\u0026thinsp;=\u0026thinsp;61; Classes 2 and 4) based on their pre-existing class enrollment, ensuring natural group allocation without disruption to teaching schedules. The study flowchart is presented in Fig.\u0026nbsp;1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Intervention\u003c/h2\u003e \u003cp\u003eThe Comprehensive Nursing Practicum is a required capstone course for fourth-year undergraduate nursing students, aimed at systematically enhancing clinical competence and professional readiness through structured practical skills training. Using the 7th edition of Fundamental Nursing (People\u0026rsquo;s Medical Publishing House) as the primary textbook, the original 18 units were reorganized into five integrated modules: (1) Basic Nursing and Aseptic Techniques, (2) Life Support and Monitoring, (3) Medication and Infusion Therapy, (4) Specialized Nursing Skills, and (5) Comprehensive Specialty Practice. This curriculum not only emphasizes foundational nursing skills but also incorporates essential clinical procedures from internal medicine, surgery, obstetrics, pediatrics, and emergency care, forming a coherent and holistic practice-oriented training framework. The course was delivered entirely offline over 63 laboratory hours from September 2024 to January 2025, with two 3-hour sessions per week. To ensure instructional fidelity, three instructors with more than three years of teaching experience implemented the curriculum concurrently for both groups in separate laboratories. All instructors completed standardized training in case-based teaching prior to course initiation to ensure consistency in instructional content and assessment approaches.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e1.2.1 Experimental Group Teaching Methods\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section4\"\u003e \u003ch2\u003e1.2.1.1 Instructional Preparation\u003c/h2\u003e \u003cp\u003e \u003cb\u003eInstructor Preparation\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA standardized instructional plan integrating case-based learning with OSCE assessment was developed. The teaching team collaboratively designed clinical cases that aligned with the Fundamental Nursing curriculum and established corresponding OSCE stations and scoring rubrics. Prior to implementation, all instructors participated in collective lesson planning to ensure consistency in case analysis depth, procedural instruction, and evaluation standards.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eStudent Preparation\u003c/h3\u003e\n\u003cp\u003eCourse materials, including case briefs, guided learning outlines, and OSCE procedure requirements, were provided in advance through an online learning platform. Students were expected to review the clinical background and preview relevant operational skills prior to each session. This preparatory strategy facilitated the establishment of an initial clinical reasoning mindset and improved readiness for active participation in case discussion and skill practice.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section4\"\u003e \u003cdiv class=\"Heading\"\u003e1.2.1.2 Implementation of Teaching\u003c/div\u003e \u003cp\u003e \u003cb\u003eCase Analysis and Scenario Introduction\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe instructional process was centered on standardized clinical cases rather than isolated skill demonstrations. Using the example of \u0026ldquo;Emergency Response and In-hospital Management of Multiple Casualties After a Traffic Accident,\u0026rdquo; instructors facilitated structured case analysis by directing students to identify key clinical cues (e.g., active bleeding in Patient Wang, early shock signs in Patient Zhang), define nursing priorities, and determine appropriate interventions. Theoretical knowledge\u0026mdash;including principles of shock management and aseptic techniques\u0026mdash;was systematically integrated with relevant nursing procedures such as wound care, catheterization, and intravenous infusion. This approach aimed to strengthen students\u0026rsquo; holistic nursing perspective and clinical reasoning at the cognitive level.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eGroup Simulation and Collaborative Practice\u003c/h3\u003e\n\u003cp\u003eThis stage represented the core process of skills internalization, during which students participated in small-group role-play and collaborative practice in the simulation laboratory. Within the same case scenario, each student assumed a distinct clinical responsibility, including performing pressure bandaging and fixation to control active bleeding, conducting indwelling catheterization to prepare the critically ill patient for emergency surgery, and implementing rapid intravenous fluid resuscitation to stabilize vital signs. Throughout the training, instructors maintained continuous supervision, emphasizing adherence to standardized operational procedures, effective team communication, and strict compliance with key patient safety protocols such as the \u0026ldquo;Three Checks and Eight Verifications,\u0026rdquo; while delivering immediate formative feedback to promote accurate skill mastery and enhance coordinated teamwork.\u003c/p\u003e\n\u003ch3\u003eOSCE-Based Comprehensive Assessment\u003c/h3\u003e\n\u003cp\u003eUpon completion of the teaching sessions, the clinical cases were directly transformed into OSCE examination stations, achieving a closed-loop process integrating \u0026ldquo;instruction, practice, and assessment.\u0026rdquo; Assessment components aligned fully with instructional objectives and included evaluation of individual technical proficiency (e.g., wound dressing, catheterization, intravenous therapy) as well as teamwork, clinical reasoning, communication, professionalism, and patient safety awareness. The OSCE\u0026rsquo;s high-fidelity clinical scenarios allowed for a comprehensive appraisal of students\u0026rsquo; integration of knowledge, skills, and professional attributes under simulated time-pressured conditions.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003cdiv class=\"Heading\"\u003e1.2.2 Control Group Teaching Methods\u003c/div\u003e \u003cp\u003eStudents in the control group received traditional skills-based training delivered through a teacher-centered format. Instruction followed the textbook sequence, with instructors first providing theoretical explanations and standardized demonstrations of each procedure. Students then practiced individually, focusing on core fundamental nursing skills such as intravenous infusion and urinary catheterization. During these sessions, instructors circulated to provide corrective guidance, with primary emphasis on refining procedural accuracy and technical standardization. After completing the training, students underwent conventional single-skill examinations that assessed operational proficiency; however, these assessments did not include clinical case analysis, scenario-based performance evaluation, or OSCE components designed to measure integrated clinical judgment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Evaluation Content and Methods\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e1.3.1 Course Performance Assessment\u003c/h2\u003e \u003cp\u003eThe course performance evaluation consisted of formative assessment (30%) and summative assessment (70%). The formative assessment included scenario-based peer evaluation (40%), student attendance scores (40%), and instructor comprehensive evaluation (20%). The summative assessment comprised a practical skills examination, covering both fundamental nursing procedures and specialized nursing techniques. Both groups were assessed using identical examination content and uniform evaluation criteria administered by the same instructional team.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e\u003cb\u003e1.3.2 Clinical Thinking Ability\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eStudents' clinical thinking ability was comprehensively evaluated using the Lasater Clinical Judgment Rubric (modified by Professor Hui Hu's research team at Hubei University of Chinese Medicine) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and the Clinical Reasoning and Reflection Self-Assessment Scale (developed by Professor Xiaofeng Kang's research team at Peking Union Medical College School of Nursing) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The Lasater Clinical Judgment Rubric comprises four dimensions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]: Noticing, interpreting, responding, and reflecting, utilizing a multi-level scoring system including proficient, developing, and beginning levels, with higher total scores indicating stronger clinical judgment ability. The Clinical Reasoning and Reflection Self-Assessment Scale contains 26 items [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] rated on a 5-point Likert scale ranging from \"strongly disagree\" (1 point) to \"strongly agree\" (5 points), yielding total scores between 26\u0026ndash;130 points, where higher scores reflect better clinical reasoning and reflection abilities. Upon course completion, electronic versions of both instruments were distributed to all students along with explanations of the survey purpose, significance, and completion methods. The questionnaire response rate was 100%. The study was approved by the Institutional Review Board (Ethics Approval No: ERB20240010).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e1.4 Bias Control Measures\u003c/h2\u003e \u003cp\u003eMultiple strategies were implemented to minimize potential biases associated with the quasi-experimental design. First, students were assigned to groups based on pre-existing class enrollment to avoid disruption of teaching schedules; this natural allocation preserved ecological validity while baseline comparisons confirmed group equivalence prior to intervention. Second, all instructors received standardized training in case-based teaching and evaluation procedures, and unified scoring rubrics were applied to ensure consistency in skill assessment. To reduce performance and detection bias, different instructors assisted in monitoring practice sessions and scoring performance examinations, and students were not informed of specific research hypotheses. Additionally, identical teaching environments, laboratory conditions, and training hours were maintained across groups to minimize contamination effects. Despite these measures, the potential for instructor influence and group interaction effects cannot be fully excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e1.5 Statistical Analysis\u003c/h2\u003e \u003cp\u003eThe normality of continuous variables was assessed using the Kolmogorov-Smirnov test. Normally distributed measurement data were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Between-group comparisons were performed using independent samples t-test for normally distributed data and Mann-Whitney U test for non-normally distributed data. Repeated measures data were analyzed using repeated measures analysis of variance (ANOVA). All statistical analyses were conducted using IBM SPSS Statistics version 25.0, with a significance level set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Baseline characteristics\u003c/h2\u003e \u003cp\u003eAll 123 students completed the study, with 61 in the control group and 62 in the experimental group. As shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, no statistically significant differences were observed between the two groups in demographic characteristics, including age, gender distribution, or intention to pursue a nursing career (all P \u0026gt; 0.05), indicating good baseline comparability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Course performance\u003c/h2\u003e \u003cp\u003eAs presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, students in the experimental group achieved significantly higher final examination scores (93.09 ± 4.71 vs. 90.11 ± 5.19; t = 3.337, P = 0.001) and overall course scores (94.87 ± 2.83 vs. 92.86 ± 3.77; t = 3.332, P = 0.001) compared with the control group. No significant difference was found in formative assessment scores (P \u0026gt; 0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Clinical reasoning and reflective ability\u003c/h2\u003e \u003cp\u003eBased on the Clinical Reasoning and Reflection Self-Assessment Scale (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e), post-intervention scores were higher in the experimental group (112.38 ± 16.67) than in the control group (107.42 ± 14.75); however, this difference did not reach statistical significance (t = 1.747, P = 0.083). Within-group analysis indicated significant improvements after the intervention in both the control group (P \u0026lt; 0.05) and the experimental group (P \u0026lt; 0.001), suggesting a positive impact of both teaching approaches on self-perceived reasoning ability. These comparative results are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Clinical judgment\u003c/h2\u003e \u003cp\u003eBetween-group comparisons showed that students in the experimental group achieved a significantly greater improvement in clinical judgment following the intervention (21.66 ± 6.96 vs. 31.67 ± 5.57, P \u0026lt; 0.001). Significant gains were observed across all four core dimensions: noticing (6.19 ± 2.04 vs. 8.84 ± 1.59, P \u0026lt; 0.001), interpreting (3.69 ± 1.52 vs. 5.79 ± 1.24, P \u0026lt; 0.001), responding (3.64 ± 1.12 vs. 5.47 ± 1.16, P \u0026lt; 0.001), and reflecting (8.02 ± 2.93 vs. 11.50 ± 2.36, P \u0026lt; 0.001).\u003c/p\u003e \u003cp\u003eThe control group also demonstrated significant improvement in overall clinical judgment (21.62 ± 6.38 vs. 27.10 ± 6.52, P \u0026lt; 0.001), but the magnitude of change was consistently smaller than that of the experimental group across all evaluated domains. Moreover, the control group’s knowledge assessment scores increased significantly after training (6.11 ± 1.87 vs. 7.69 ± 1.93, P \u0026lt; 0.001).\u003c/p\u003e \u003cp\u003eRepeated-measures ANOVA further confirmed significantly stronger training effects in the experimental group. Notable time × group interaction effects were detected for noticing (F(1,121) = 6.197, P = 0.014, η² = 0.049), interpreting (F(1,121) = 6.164, P = 0.014, η² = 0.048), responding (F(1,121) = 4.454, P = 0.037, η² = 0.036), and reflecting (F(1,121) = 12.138, P = 0.001, η² = 0.091), as well as the total score (F(1,121) = 10.652, P = 0.001, η² = 0.081).\u003c/p\u003e \u003cp\u003eEffect size analysis demonstrated large effects for interpreting (η² = 0.503) and responding (η² = 0.494) and small-to-medium effects for the remaining dimensions and total score. These findings highlight the practical significance and educational value of the instructional innovation. The corresponding results are illustrated in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of General Characteristics Between the Two Groups of Nursing Students (n(%))\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003cp\u003e(n = 61)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eExperimental Group\u003c/p\u003e \u003cp\u003e(n = 62)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003et/χ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAge(years), mean ± SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e20.08 ± 0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e20.13 ± 0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGender, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e10(16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e12(19.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e0.425\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e51(83.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e50(80.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eFuture career intention\u003c/p\u003e \u003cp\u003ein nursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e58(95.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e58(93.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e3(4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e4(6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab2\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Assessment Scores Between the Two Groups (Mean ± SD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eFormative Assessment Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eFinal Examination Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eOverall Course Score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003cp\u003e(n = 61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e96.99 ± 3.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e90.11 ± 5.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e92.86 ± 3.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eExperimental Group\u003c/p\u003e \u003cp\u003e(n = 62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e97.53 ± 1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e93.09 ± 4.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e94.87 ± 2.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e1.1678\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e3.3366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e3.3319\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0.245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab3\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTwo-group Nursing Student Clinical Reasoning and Reflection Scale Scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eExperimental Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePre-training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e100.03 ± 12.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e101.71 ± 12.817\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e0.508\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e0.614\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePost-training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e107.42 ± 14.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e112.38 ± 16.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e1.747\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e2.321\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e3.178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis quasi-experimental study provides strong evidence that the integrated CBL-OSCE teaching model is more effective than traditional skills-based training in improving nursing students’ clinical competence and clinical judgment. The significantly higher final examination and overall course scores in the experimental group demonstrate that aligning learning activities with performance-based assessments strengthens knowledge integration and supports clinical application. By immersing students in realistic clinical scenarios from the outset, the CBL-OSCE model encourages active engagement in analytical reasoning, collaborative decision-making, and authentic performance evaluation, resulting in more contextualized and deeper learning. This design effectively bridges the gap between procedural proficiency and higher-level reasoning—transitioning from simply “knowing how” to also “knowing why” and “knowing when” to act.\u003c/p\u003e\u003cp\u003eThe strongest support for the effectiveness of the integrated CBL-OSCE model lies in the significant and comprehensive improvements observed across all dimensions of clinical judgment measured by the Lasater Clinical Judgment Rubric. The experimental group’s greater gains in noticing, interpreting, responding, and reflecting directly address a well-recognized and persistent deficiency in contemporary nursing education. Clinical reasoning and judgment are essential competencies, enabling nurses to interpret complex clinical information, make timely and logical decisions, and implement appropriate interventions in rapidly changing environments [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. Critical clinical reasoning, in particular, is a pivotal skill for nurses to analyze situations and make rapid, sound decisions [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e], and is indispensable for delivering high-quality care [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. Nevertheless, studies consistently report that a majority of practicing nurses possess only low-to-moderate levels of critical thinking skills [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e], with novices and student nurses often struggling to make appropriate clinical decisions in high-pressure, fast-paced settings [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Research in China [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] corroborates this, indicating shortcomings in critical thinking and evidence-based practice among nursing staff, who often lack proficiency in identifying and resolving clinical problems [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. Alarmingly, over half of new graduate nurses fail to promptly identify issues and employ multiple strategies for prudent decision-making [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. Even among experienced nurses, some remain prone to relying on anecdotal experience over systematic clinical reasoning [25]. Against this backdrop, our findings robustly indicate that the integrated CBL-OSCE model provides an effective educational framework to systematically address this critical competency gap. By creating a closed-loop instructional process of case analysis, simulated practice, and structured feedback, the model fosters a learning environment that necessitates continuous clinical decision-making, observation of consequences, and dynamic adjustment of actions. This repeated, structured engagement in the complete clinical judgment process—especially the guided, deep reflection during debriefing and OSCE feedback sessions—addresses fundamental deficiency in traditional, procedure-centric training and is paramount for cultivating the higher-order cognitive skills essential for navigating future clinical complexities.\u003c/p\u003e\u003cp\u003eInterestingly, although both groups exhibited significant within-group improvements on the self-reported Clinical Reasoning and Reflection Scale, the between-group difference was not statistically significant. Two plausible explanations may be considered. First, metacognitive abilities such as reasoning self-efficacy may require extended clinical exposure before the impact of instructional differences becomes clearly distinguishable. Second, subjective ratings may be less sensitive to subtle behavioral changes than observer-rated instruments such as the LCJR. This finding reinforces the need for multimethod evaluation strategies in nursing education research to fully capture both perceived and demonstrated learning outcomes.\u003c/p\u003e\u003cp\u003eThis study has several limitations. The use of convenience sampling and allocation based on natural classes may introduce selection bias. Additionally, instructors were involved in both delivering the intervention and evaluating outcomes, which could increase the risk of performance and detection bias, despite standardized training. The single-center setting and relatively small sample size may also limit the generalizability of the results. Future research should include multicenter randomized controlled trials with larger samples and follow-up assessments to examine long-term effects. Implementation of blinded assessment procedures will further strengthen the rigor of subsequent evidence.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"92%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38.3838%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61.6162%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFull Name\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38.3838%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCBL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61.6162%;\"\u003e\n \u003cp\u003eCase-Based Learning\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38.3838%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOSCE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61.6162%;\"\u003e\n \u003cp\u003eObjective Structured Clinical Examination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38.3838%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLCJR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61.6162%;\"\u003e\n \u003cp\u003eLasater Clinical Judgment Rubric\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38.3838%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSPSS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61.6162%;\"\u003e\n \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38.3838%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eANOVA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61.6162%;\"\u003e\n \u003cp\u003eAnalysis of Variance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38.3838%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61.6162%;\"\u003e\n \u003cp\u003eStandard Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Anhui Medical University (Ethics Approval No: ERB20240010). Written informed consent was obtained from all participants.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQF: Conceptualization, Methodology, Writing - original draft. TT: Data curation, Formal analysis. ML: Supervision, Validation. LZ: Supervision, Writing - review \u0026amp; editing. All authors read and approved the final manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Anhui Provincial Department of Education Quality Engineering Projects (Grant Nos. 2024jyxm0599 and 2023jyxm0988). The funding bodies had no role in the design of the study, collection, analysis, interpretation of data, or in writing the manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This study is an educational intervention and does not fall under the category of clinical trials.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChen Q, et al. Effects of a blended emergent research training programme for clinical nurses on nursing research competence and critical thinking (Part 2): A quasi-experimental study. J Clin Nurs. 2022;31(5\u0026ndash;6):755\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFranzese CB. Pilot study of an Objective Structured Clinical Examination (the Six Pack) for evaluating clinical competencies. Otolaryngol Head Neck Surg. 2008;138(2):143\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerkowitz AL, Chang BS. Development and implementation of a case-based collaborative learning flipped classroom preclinical neurology course. J Neurol Sci. 2024;462:123097.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Y, et al. The dynamic case-based learning model: conducive to enhancing the practical learning effectiveness of dermatology for medical students. BMC Med Educ. 2025;25(1):957.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGillespie M, Peterson BL. Helping novice nurses make effective clinical decisions: the situated clinical decision-making framework. Nurs Educ Perspect. 2009;30(3):164\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchroers G, Shrikanth S, Pfieffer J. Undergraduate nursing student experiences in American clinical learning environments: A descriptive study. Nurse Educ Today. 2023;129:105895.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang F, et al. Improving clinical judgment by simulation: a randomized trial and validation of the Lasater clinical judgment rubric in Chinese. BMC Med Educ. 2019;19(1):20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee KC. The Lasater Clinical Judgment Rubric: Implications for Evaluating Teaching Effectiveness. J Nurs Educ. 2021;60(2):67\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSezer E, et al. Lasater clinical judgment rubric in nursing education: a Turkish validity and reliability study. BMC Nurs. 2025;24(1):70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Y, Bai YJ, Lu YL, Li YX. Application of case discussion of multi-professional students in cultivating clinical thinking abilities of nursing undergraduates. Chin J Nurs Educ. 2021;18(9):1672\u0026ndash;9234.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerger S, Krug K, Goetz K. Encountering uncertainty and complexity in decision-making: an observational study of clinical reasoning among medical and interprofessional groups of health care students. J Interprof Care. 2023;37(2):262\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRogers M, Steinke M. An examination of student nurse practitioners' diagnostic reasoning skills. 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Nurse Educ Pract. 2021;53:103055.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical judgment, Case-based learning, OSCE, Simulation, Nursing education, Quasi-experimental study","lastPublishedDoi":"10.21203/rs.3.rs-8077625/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8077625/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Developing robust clinical judgment is a core outcome of undergraduate nursing education. Although case-based learning (CBL) and the Objective Structured Clinical Examination (OSCE) are widely used, evidence regarding the educational impact of an integrated CBL-OSCE model in nursing practicum training remains limited.\u003c/p\u003e\n\u003cp\u003eMethods: A quasi-experimental study was conducted among 123 senior undergraduate nursing students allocated by natural classes to either an experimental group receiving an integrated CBL-OSCE intervention (n = 62) or a control group receiving traditional skills training (n = 61). Outcomes included course performance, the Lasater Clinical Judgment Rubric (LCJR), and a self-reported Clinical Reasoning and Reflection Scale. Independent t-tests and repeated-measures ANOVA were performed.\u003c/p\u003e\n\u003cp\u003eResults: Compared with controls, the experimental group achieved significantly higher final examination scores (93.09 ± 4.71 vs. 90.11 ± 5.19, P = 0.001, Cohen’s d = 0.61) and overall course scores (94.87 ± 2.83 vs. 92.86 ± 3.77, P = 0.001, d = 0.60). A significant time × group interaction was observed for LCJR total score (F(1,121) = 10.652, P = 0.001, η² = 0.081), with the experimental group demonstrating larger improvements across all LCJR dimensions, particularly interpreting (η² = 0.503) and responding (η² = 0.494). Self-reported clinical reasoning improved significantly within both groups, though without between-group differences (P \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003eConclusion: The integrated CBL-OSCE model led to greater gains in clinical judgment and practical performance than traditional skills training. Embedding CBL throughout instructional activities and aligning assessments with OSCE principles appears to support the development of higher-order decision-making abilities in nursing students.\u003c/p\u003e","manuscriptTitle":"Effects of an integrated CBL-OSCE model on clinical judgment among undergraduate nursing students: a quasi-experimental study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-13 07:34:31","doi":"10.21203/rs.3.rs-8077625/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-14T20:44:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30564545881748778532133255977543912183","date":"2026-03-14T19:37:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127377507730670080840850802992047382943","date":"2026-03-06T15:35:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-06T14:49:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-09T15:52:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-03T09:39:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-02T09:07:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-12-02T08:18:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0bd32eab-fdb1-4441-b4d2-a915ba1432d6","owner":[],"postedDate":"March 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-13T07:34:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-13 07:34:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8077625","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8077625","identity":"rs-8077625","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}