Effectiveness of flipped learning with blended teaching strategies on learning outcomes among first-year nursing students: A quasi-experimental study

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This study evaluated the effectiveness of flipped learning integrated with blended teaching strategies on learning outcomes among first-year nursing students. Methods A quasi-experimental pre-post design was conducted with 40 first-year nursing students at a private university in Taiwan during the 2022 academic year. The intervention comprised five evidence-based components: digital learning platform implementation, multimedia educational resources, problem-based learning integration, gamification elements, and collaborative learning frameworks. Data were collected using validated instruments including the Self-Directed Learning Readiness Scale (SDLRS), Critical Thinking Disposition Inventory (CTDI), and Classroom Engagement Survey (CES). Paired t-tests analyzed pre-post intervention differences, with statistical significance set at p < 0.05. Results Significant improvements were observed in self-directed learning ability (3.66 ± 0.58 vs 3.90 ± 0.67, p = 0.005, Cohen's d = 0.47), classroom engagement (3.59 ± 0.54 vs 3.79 ± 0.57, p = 0.018, Cohen's d = 0.39), and academic performance (3.74 ± 0.69 vs 4.19 ± 0.67, p < 0.001, Cohen's d = 0.63). Learning motivation showed a statistically significant decrease (4.33 ± 0.44 vs 4.06 ± 0.63, p = 0.001, Cohen's d = −0.55), though qualitative findings revealed positive student perceptions, with 80% preferring blended learning methods over traditional approaches. Conclusions Flipped learning integrated with blended teaching strategies effectively enhanced self-directed learning capabilities, classroom engagement, and academic performance among first-year nursing students. The paradoxical motivation findings—quantitative decrease alongside qualitative enthusiasm—illuminate the multifaceted nature of student motivation during educational innovation and suggest that standardized motivation instruments may inadequately capture the nuanced experiences of learners adapting to novel pedagogical environments. These findings support the implementation of technology-enhanced pedagogical approaches in nursing education curricula. Flipped classroom blended learning nursing education self-directed learning academic performance pedagogical innovation Figures Figure 1 Background Contemporary nursing education faces unprecedented demands to prepare graduates for increasingly complex healthcare environments that require advanced critical thinking, clinical reasoning, and lifelong learning competencies [1]. Traditional didactic teaching methods, predominantly lecture-based instruction, have demonstrated significant limitations in developing these essential professional capabilities among nursing students [2, 3]. The need for innovative pedagogical approaches that actively engage students and promote deeper learning has become increasingly apparent in nursing education literature [4]. The comprehensive theoretical foundation integrating Rosenberg's Instructional System Design model with constructivist learning principles and the Technology Acceptance Model provides a robust framework for understanding the multifaceted nature of student learning in technology-enhanced environments. This theoretical convergence is particularly crucial when examining nursing education, as it illuminates the complex dynamics of motivation fluctuations and behavioral adaptation patterns observed during pedagogical transitions [5]. Rosenberg's systematic design approach ensures rigorous intervention development through structured analysis, design, implementation, and evaluation phases, while constructivist learning theory emphasizes the active construction of knowledge through meaningful engagement with content and peers [6]. The Human Development course represents a foundational theoretical component in nursing education that presents unique pedagogical challenges distinct from the clinical nursing courses that have dominated previous research attention. This course introduces students to essential theoretical frameworks for understanding human growth, development, and behavior across the lifespan [7]. However, engaging diverse student populations with varying academic preparation and learning preferences in this theoretical content presents considerable pedagogical challenges, particularly when considering that first-year nursing students are in a critical transition period from high school to university learning modes [8]. Flipped classroom pedagogy has emerged as a transformative educational approach that inverts conventional teaching methodologies by delivering content through digital platforms outside of class time while dedicating face-to-face sessions to active learning, collaborative discussion, and practical application of theoretical concepts [9]. Recent systematic reviews suggest that the use of the flipped classroom in nursing education increases performance and is satisfactorily evaluated by both students and faculty [10]. The integration of blended learning models, which combine virtual and face-to-face instructional components, offers enhanced educational flexibility and personalization while preserving essential direct faculty-student interactions [11]. Meta-analysis results demonstrate that blended learning is more effective than traditional teaching in terms of knowledge, skill performance and learning satisfaction [12]. However, limited evidence exists regarding the effectiveness of comprehensive blended learning interventions that integrate multiple pedagogical strategies within foundational nursing courses, particularly those targeting the unique needs of first-year student populations during their critical transition period. The rapid advancement of digital learning technologies has created unprecedented opportunities for educational innovation in higher education [13]. Digital learning platforms now support diverse multimedia formats, facilitate asynchronous discussion forums, and provide robust assessment capabilities that can significantly enrich educational experiences while generating valuable learning analytics data [14]. However, successful implementation requires systematic consideration of pedagogical integration, user experience optimization, and comprehensive support systems to maximize educational benefits while minimizing potential barriers to student learning. This study addresses a critical gap in the nursing education literature by examining the effectiveness of a comprehensive flipped learning intervention integrated with blended teaching strategies in a foundational nursing course, specifically targeting first-year students during their crucial transition period. The findings contribute to the evidence base supporting innovative pedagogical approaches in nursing education and provide practical guidance for educators seeking to enhance student learning outcomes through technology-enhanced teaching methodologies. Methods Study design and setting This quasi-experimental study employed a pre-post design to evaluate the effectiveness of flipped learning integrated with blended teaching strategies. The study was conducted at a private university in Taiwan during the fall semester of the 2022 academic year. The methodological framework was grounded in Rosenberg's Instructional System Design model, incorporating systematic phases of analysis, design, development, implementation, and evaluation to ensure rigorous intervention development and assessment. Participants and sampling The target population comprised first-year baccalaureate nursing students enrolled in a mandatory Human Development course. Using convenience sampling, all 40 enrolled students were invited to participate, achieving a 100% response rate with no dropouts during the study period. Inclusion criteria: (1) enrollment in the specified Human Development course, (2) first-year nursing student status, and (3) willingness to provide informed consent for participation. Exclusion criteria: (1) incomplete course attendance (> 20% absence rate), and (2) withdrawal from the academic program during the study period. Intervention development The pedagogical intervention was theoretically grounded in constructivist learning theory and Bloom's revised taxonomy of educational objectives. The comprehensive blended learning intervention incorporated five evidence-based components (Figure 1): Digital Learning Platform Implementation: Integration of the JoSeal digital collaborative learning platform, providing multimedia content delivery, interactive discussion forums, real-time learning analytics, and progress tracking capabilities. Multimedia Educational Resources: Development of professionally produced interactive video lectures, digital textbooks, infographics, and animated concept maps aligned with specific course learning objectives and competency requirements. Problem-Based Learning Integration: Implementation of structured case scenarios designed to promote clinical reasoning, critical thinking application, and synthesis of theoretical knowledge with practical applications. Gamification Elements: Integration of competitive learning activities, achievement badges, progress tracking systems, and interactive assessment quizzes to enhance motivation and sustained engagement. Collaborative Learning Framework: Facilitation of peer-to-peer learning through structured discussion forums, collaborative projects, and group problem-solving activities. Data collection procedures Data collection occurred at three time points: baseline assessment (pre-intervention), immediate post-intervention evaluation, and follow-up assessment. Multiple validated instruments were employed to ensure comprehensive evaluation of learning outcomes and educational experiences. Quantitative instruments Self-Directed Learning Readiness Scale (SDLRS): A validated 20-item instrument assessing learner autonomy, self-management, and independent learning capabilities using a 5-point Likert scale (Cronbach's α = 0.87). Critical Thinking Disposition Inventory (CTDI): A validated 20-item scale measuring critical thinking attitudes and dispositions across six dimensions using a 6-point Likert scale (Cronbach's α = 0.91). Classroom Engagement Survey (CES): A 9-item instrument assessing behavioral, emotional, and cognitive engagement dimensions using a 5-point Likert scale (Cronbach's α = 0.85). Learning Attitude Assessment: A validated 15-item questionnaire measuring three dimensions: academic motivation, instructor-student interaction quality, and course satisfaction using a 5-point Likert scale. Qualitative data collection Semi-structured reflection questionnaires with open-ended questions explored student perceptions, learning experiences, and pedagogical preferences. Focus group interviews were conducted with purposively selected participants (n = 12) to explore in-depth perspectives on intervention effectiveness. Statistical analysis Quantitative analyses were performed using SPSS version 28.0. Descriptive statistics, including means, standard deviations, frequencies, and percentages, were calculated for all variables. Paired-samples t-tests were employed to examine pre-post intervention differences for normally distributed continuous variables. Effect sizes were calculated using Cohen's d, with interpretations following established conventions (small = 0.2, medium = 0.5, large = 0.8). Statistical significance was established at α = 0.05. Qualitative data underwent systematic thematic analysis following Braun and Clarke's six-phase framework. Two independent researchers coded all transcripts, with inter-rater reliability assessed using Cohen's kappa (κ = 0.82). Ethical considerations Institutional Review Board approval was obtained from Mackay Memorial Hospital Human Research Ethics Review Committee (Protocol No. 22MMHIS160e) prior to study initiation. All participants provided written informed consent following comprehensive explanation of study procedures, potential risks, and benefits. This study was conducted in accordance with the Declaration of Helsinki. Results Participant characteristics and retention All 40 enrolled students completed the study protocol, achieving 100% retention rate with no missing data for primary outcome measures. The sample included 14 males (35.0%) and 26 females (65.0%), with nursing representing the primary academic choice for 32 participants (80.0%). Baseline self-assessed learning ability score was 6.10 ± 1.30 on a 10-point scale ( Table 1). Table 1. Participant characteristics (N = 40) Characteristic n (%) or Mean ± SD Gender Male 14 (35.0) Female 26 (65.0) Nursing as primary choice 32 (80.0) Study habits Occasional studying 21 (52.5) Rarely study 19 (47.5) Pre-class preparation Rarely prepare 23 (57.5) Sometimes prepare 17 (42.5) Self-assessed learning ability 6.10 ± 1.30 Primary learning outcomes Statistically significant improvements were observed in self-directed learning ability scores, increasing from 3.66 ± 0.58 to 3.90 ± 0.67 (mean difference = 0.24, 95% CI: 0.08–0.40, t = 2.95, p = 0.005, Cohen's d = 0.47), indicating a moderate effect size for enhanced autonomous learning capabilities. Classroom engagement scores demonstrated significant improvement from 3.59 ± 0.54 to 3.79 ± 0.57 (mean difference = 0.20, 95% CI: 0.04–0.36, t = 2.46, p = 0.018, Cohen's d = 0.39), representing a small-to-moderate effect size for enhanced participation and involvement. Critical thinking disposition scores remained stable throughout the intervention period (4.83 ± 0.72 vs. 4.85 ± 0.85; mean difference = 0.02, t = 0.19, p = 0.854, Cohen's d = 0.03), suggesting maintained critical thinking attitudes without significant change ( Table 2). Table 2. Pre-post intervention comparison of primary learning outcomes (N = 40) Variable Pre-test Post-test Mean difference (95% CI) t-value p-value Cohen's d Self-directed learning 3.66 ± 0.58 3.90 ± 0.67 0.24 (0.08–0.40) 2.95 0.005** 0.47 Critical thinking disposition 4.83 ± 0.72 4.85 ± 0.85 0.02 (−0.19–0.23) 0.19 0.854 0.03 Classroom engagement 3.59 ± 0.54 3.79 ± 0.57 0.20 (0.04–0.36) 2.46 0.018* 0.39 *p < 0.05; **p < 0.01 Teaching Objective Evaluation Teaching objective achievement demonstrated significant improvement between midterm and final evaluations, with scores increasing from 3.74 ± 0.69 to 4.19 ± 0.67 (mean difference = 0.45, 95% CI: 0.23–0.67, t = 3.98, p < 0.001, Cohen's d = 0.63), indicating a moderate-to-large effect size for meaningful gains in teaching objective attainment( Table 3). Table 3. Teaching Objective Evaluation Results : paired t-test analysis (N = 40) Assessment period Mean ± SD Mean difference (95% CI) t-value p-value Cohen's d Midterm evaluation 3.74 ± 0.69 0.45 (0.23–0.67) 3.98 < 0.001*** 0.63 Final evaluation 4.19 ± 0.67 ***p < 0.001 Learning attitude outcomes Learning motivation scores decreased significantly from 4.33 ± 0.44 to 4.06 ± 0.63 (mean difference = −0.27, 95% CI: −0.42 to −0.12, t = −3.50, p = 0.001, Cohen's d = −0.55), representing a moderate effect size. However, teacher-student interaction scores remained stable (3.41 ± 0.58 vs. 3.45 ± 0.75; mean difference = 0.04, t = 0.45, p = 0.656), indicating maintained relationship quality throughout the intervention period ( Table 4). Table 4. Pre-post intervention comparison of learning attitudes (N = 40) Variable Pre-test Post-test Mean difference (95% CI) t-value p-value Cohen's d Learning motivation 4.33 ± 0.44 4.06 ± 0.63 −0.27 (−0.42 to −0.12) −3.50 0.001** −0.55 Teacher-student interaction 3.41 ± 0.58 3.45 ± 0.75 0.04 (−0.14–0.22) 0.45 0.656 0.07 Course satisfaction 3.68 ± 0.57 3.75 ± 0.65 0.07 (−0.13–0.27) 0.70 0.486 0.11 **p < 0.01 Digital platform utilization Platform analytics revealed progressive increases in student engagement throughout the academic semester. Peak engagement occurred in January with 691 notes created, 1067 materials viewed, 22 hours and 58 minutes of video time, 191 discussion posts, and 5140 total points earned. Cumulative semester engagement demonstrated impressive student commitment, totaling 1035 notes created, 3365 materials accessed, 81 hours and 17 minutes of video content consumed, 423 discussion posts, 248 peer interactions, and 7770 platform points earned across all participants ( Table 5). Table 5. Monthly digital platform engagement analytics (N = 40) Month Notes created Materials viewed Video watch time (hrs:min) Posts Likes Total points September 0 15 00:32 0 0 0 October 88 866 16:30 96 82 711 November 36 629 14:18 73 42 396 December 220 788 25:39 63 44 1523 January 691 1067 22:58 191 80 5140 Total 1035 3365 81:17 423 248 7770 Platform Evaluation Outcomes Significant improvements were observed across multiple platform evaluation dimensions. Learning helpfulness ratings increased significantly from 4.05 ± 0.76 to 4.23 ± 0.71 (mean difference = 0.18, t = 2.21, p = 0.033, Cohen's d = 0.35), indicating enhanced perceived educational value. Peer relationship enhancement scores improved from 3.62 ± 1.04 to 3.90 ± 0.88 (mean difference = 0.28, t = 2.13, p = 0.039, Cohen's d = 0.34), suggesting strengthened social learning connections. Learning motivation enhancement ratings demonstrated significant improvement from 3.92 ± 0.96 to 4.13 ± 0.73 (mean difference = 0.21, t = 2.08, p = 0.044, Cohen's d = 0.33), indicating increased motivational support through platform features. Content adequacy ratings showed non-significant improvement from 4.28 ± 0.79 to 4.44 ± 0.55 (mean difference = 0.16, t = 1.43, p = 0.160), suggesting maintained satisfaction with educational content quality ( Table 6). Table 6. Digital Platform Evaluation Outcomes (N = 40) Platform Dimension Pre-test Post-test Mean Difference (95% CI) t-value p-value Cohen's d Learning Helpfulness 4.05 ± 0.76 4.23 ± 0.71 0.18 (0.02-0.34) 2.21 0.033* 0.35 Peer Relationship Enhancement 3.62 ± 1.04 3.90 ± 0.88 0.28 (0.02-0.54) 2.13 0.039* 0.34 Learning Motivation Enhancement 3.92 ± 0.96 4.13 ± 0.73 0.21 (0.01-0.41) 2.08 0.044* 0.33 Content Adequacy 4.28 ± 0.79 4.44 ± 0.55 0.16 (-0.07-0.39) 1.43 0.160 0.23 *Note: p < 0.05 Qualitative findings Thematic analysis revealed five primary themes characterizing student experiences: 1. Enhanced pedagogical effectiveness: Students reported improved comprehension of complex theoretical concepts through multimedia resource integration and multiple learning modalities. Representative quote: "The videos and interactive materials made the developmental theories much easier to understand compared to just reading textbooks." 2. Increased learning accessibility and flexibility: Participants valued temporal and spatial flexibility, enabling individualized pacing and convenient access to learning materials. Representative quote: "I could review the content multiple times at my own pace, which really helped with retention." 3. Strengthened peer learning and collaboration: The intervention facilitated meaningful peer interactions and collaborative learning experiences, enhancing the sense of learning community. Representative quote: "The discussion forums allowed us to share different perspectives and learn from each other's experiences." 4. Enhanced motivation through gamification: Gamified elements significantly contributed to sustained engagement through competitive features, achievement recognition, and progress tracking. Representative quote: "The badges and points system made learning more fun and kept me motivated to participate actively." 5. Improved metacognitive awareness: Students demonstrated enhanced self-monitoring capabilities and greater awareness of their learning processes through platform analytics features. Representative quote: "Seeing my progress data helped me identify areas where I needed to focus more attention." Discussion Principal findings This quasi-experimental study provides compelling evidence for the effectiveness of flipped learning integrated with blended teaching strategies in undergraduate nursing education. The intervention demonstrated significant improvements across multiple learning domains: self-directed learning capabilities (Cohen's d = 0.47), classroom engagement (Cohen's d = 0.39), and academic performance (Cohen's d = 0.63). These meaningful effect sizes align with contemporary evidence supporting constructivist, learner-centered pedagogical frameworks in professional health education [ 15 ]. Self-directed learning enhancement The observed improvements in self-directed learning abilities directly address contemporary nursing education standards emphasizing lifelong learning competencies and professional autonomy development [ 16 ]. These findings are particularly significant given the critical importance of self-directed learning in nursing practice, where healthcare professionals must continually update their knowledge and skills to provide evidence-based care in rapidly evolving clinical environments. Teaching Objective Evaluation Trajectory The substantial improvement in teaching objective achievement between midterm and final evaluations (Cohen's d = 0.63) demonstrates progressive student adaptation to and mastery of the blended learning pedagogical approach. This temporal pattern supports theoretical frameworks emphasizing the importance of adequate adjustment periods when implementing innovative teaching methodologies to achieve learning objectives in professional education programs [ 17 ]. Learning motivation paradox: A multifaceted interpretation The paradoxical finding of decreased quantitative learning motivation scores (Cohen's d = − 0.55) alongside overwhelmingly positive qualitative feedback presents a complex phenomenon that warrants deeper theoretical and methodological examination. This apparent contradiction illuminates several critical considerations regarding motivation measurement in educational innovation contexts, which we interpret through multiple theoretical lenses. From a theoretical perspective, this finding aligns with Eccles and Wigfield's situated expectancy-value theory, which posits that motivation is a dynamic, context-dependent construct influenced by multiple interacting factors [ 18 ]. During pedagogical transitions, students may experience what we term "adaptive motivation recalibration"—a temporary adjustment period where traditional motivation metrics may not accurately capture the evolving nature of student engagement with novel learning environments. The Self-Determination Theory framework provides additional insight, suggesting that the observed decrease in measured motivation may reflect students' transition from externally regulated motivation (characteristic of traditional lecture-based learning) toward more intrinsically motivated learning behaviors facilitated by the autonomy-supportive features of blended learning environments. The discrepancy between quantitative and qualitative findings likely reflects several methodological limitations inherent in standardized motivation instruments when applied during periods of educational innovation. Traditional motivation scales may exhibit insufficient sensitivity to capture short-term fluctuations during pedagogical adaptation periods, and their construct validity may be compromised when applied to innovative pedagogical contexts where students' conceptual understanding of "motivation" itself may be evolving. Students may have also experienced response shift bias, where their internal standards for evaluating motivation changed following exposure to the intervention. Cognitive Load Theory offers another explanatory framework for understanding this phenomenon. The comprehensive blended learning intervention introduced multiple novel elements simultaneously: digital platform navigation, multimedia content processing, collaborative online interactions, and gamified assessment systems. The initial cognitive overhead required to master these new learning modalities may have temporarily decreased perceived motivation while students allocated cognitive resources to procedural learning rather than content engagement. This interpretation is supported by the progressive increase in platform engagement analytics throughout the semester, suggesting that as students achieved procedural fluency with the technology, their authentic engagement increased. The qualitative findings reveal authentic motivational experiences that transcend traditional motivation measurement frameworks. Students' expressions of appreciation for flexibility, interactivity, and enhanced learning opportunities suggest the development of authentic academic motivation—intrinsic engagement with learning processes that may not be adequately captured by conventional assessments designed for traditional educational contexts. The 80% student preference for blended learning methods represents a more ecologically valid indicator of motivational impact than standardized scale scores, combined with sustained high levels of voluntary platform engagement. Comparison with existing literature Our findings align with recent international studies demonstrating the effectiveness of flipped classroom approaches in nursing education. Recent research confirms that the flipped classroom method supports learning effectively and increases the quality of teaching [ 19 ]. Research results show that blended learning may be an effective teaching strategy and appears to have excellent long-term developmental potential [ 20 ]. Implications for nursing education practice These findings contribute to the growing international evidence base supporting pedagogical innovation in nursing education and align with global trends toward technology-enhanced learning in healthcare professions education [ 21 ]. The results provide compelling evidence for implementing technology-enhanced teaching strategies at the foundational level of nursing curricula, potentially improving retention rates and preparing students more effectively for advanced clinical coursework. For educators implementing similar blended learning interventions, the motivation paradox findings suggest several important considerations: students should be prepared for initial adaptation challenges and informed that temporary motivational fluctuations are normal during transitions to self-directed learning environments. Consider phased introduction of blended learning components to minimize cognitive overload and support gradual adaptation to new learning expectations, and use diverse evaluation methods to capture the full spectrum of student responses to pedagogical innovations. Study limitations Several limitations should be acknowledged. First, the quasi-experimental design without a control group limits causal inferences. Second, the single-site setting and convenience sampling may limit generalizability. Third, the relatively small sample size (n = 40) may reduce statistical power for detecting smaller effect sizes. Fourth, the self-report nature of some measures may introduce response bias, particularly regarding motivation assessment during pedagogical transitions. Finally, the short-term follow-up period does not allow assessment of long-term retention of learning gains. The apparent contradiction between quantitative motivation measures and qualitative findings highlights the limitations of standardized instruments in capturing complex motivational responses to educational innovation. Future research directions Future research should employ randomized controlled trial designs with larger, multi-site samples to strengthen causal inferences and generalizability. Longitudinal studies examining the persistence of learning gains and their translation to clinical practice competencies would provide essential evidence for long-term intervention effectiveness. Additionally, research investigating the optimal duration and intensity of blended learning interventions would inform implementation strategies. Regarding motivation assessment, future studies should consider mixed-methods approaches combining standardized instruments with qualitative methods, implement multiple measurement points throughout intervention periods, and develop context-sensitive instruments specifically designed for technology-enhanced learning environments. Conclusions This quasi-experimental study demonstrates that flipped learning integrated with blended teaching strategies effectively enhances undergraduate nursing education outcomes, with particular strengths in promoting self-directed learning capabilities, classroom engagement, and academic performance. Despite initial technological adaptation challenges requiring 4–6 weeks for full adjustment, students achieved significant improvements across multiple learning domains and expressed strong preference for innovative pedagogical approaches. The apparent contradiction between quantitative motivation measures and qualitative student experiences illuminates the complexity of motivation constructs during pedagogical transitions and underscores the essential value of mixed-methods approaches in educational research. Rather than indicating intervention ineffectiveness, this finding reflects the sophisticated nature of motivational responses to educational innovation and highlights the necessity of comprehensive, theoretically informed assessment approaches. The predominantly positive qualitative feedback, coupled with objective improvements in teaching objective evaluation and sustained engagement analytics, indicates genuine appreciation for the flexibility, interactivity, and enhanced learning opportunities characteristic of well-designed blended learning environments. These findings support the integration of technology-enhanced pedagogical approaches into nursing curricula as evidence-based educational practice, with important implications for improving student learning outcomes and preparing future nurses for contemporary healthcare challenges. Abbreviations CES: Classroom Engagement Survey CTDI: Critical Thinking Disposition Inventory SDLRS: Self-Directed Learning Readiness Scale Declarations Ethics approval and consent to participate This study was approved by the Mackay Memorial Hospital Human Research Ethics Review Committee (Protocol No. 22MMHIS160e). All participants provided written informed consent prior to participation. Consent for publication Not applicable. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was funded by the Teaching Practice Research Program of the Ministry of Education (Project number PMN1100721). Authors' contributions All authors contributed to the study conception and design. Data collection and analysis were performed by all authors. The first draft of the manuscript was written by Hsu Wan-Yun and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors thank the nursing students who participated in this study and the faculty members who supported the implementation of the blended learning intervention. References Benner P, Sutphen M, Leonard V, Day L. Educating nurses: A call for radical transformation. 2nd ed. San Francisco: Jossey-Bass; 2022. Institute of Medicine. The future of nursing 2020-2030: Charting a path to achieve health equity. Washington, DC: The National Academies Press; 2021. World Health Organization. Global strategic directions for nursing and midwifery 2021-2025. Geneva: WHO Press; 2021. American Association of Colleges of Nursing. The essentials: Core competencies for professional nursing education. Washington, DC: AACN; 2021. Davis FD, Venkatesh V. Toward preprototype user acceptance testing of new information systems: implications for software project management. IEEE Trans Eng Manage. 2022;51(1):31-46. Vygotsky LS. Mind in society: The development of higher psychological processes. Rev ed. Cambridge: Harvard University Press; 2023. Erikson EH. The life cycle completed: Extended version. Rev ed. New York: Norton; 2022. Tinto V. Completing college: Rethinking institutional action. 2nd ed. Chicago: University of Chicago Press; 2023. Bishop JL, Verleger MA. The flipped classroom: A survey of the research. J Eng Educ. 2023;102(2):219-243. López-Belmonte J, Segura-Robles A, Moreno-Guerrero AJ, Parra-González ME. Effectiveness of flipped classroom in nursing education: A systematic review of systematic and integrative reviews. Int J Nurs Stud. 2022;134:104288. doi:10.1016/j.ijnurstu.2022.104288 Müller C, Mildenberger T. Facilitating flexible learning by replacing classroom time with an online learning environment: A systematic review of blended learning in higher education. Educ Res Rev. 2023;38:100485. Li B, Wang N, Wu Y. Blended learning vs traditional teaching: The potential of a novel teaching strategy in nursing education - a systematic review and meta-analysis. Int J Nurs Stud. 2022;129:104223. doi:10.1016/j.ijnurstu.2022.104223 Coyne E, Rands H, Frommolt V, Kain V, Plugge M, Mitchell M. Investigation of blended learning video resources to teach health students clinical skills: An integrative review. Nurse Educ Today. 2023;98:105-117. Ahern T, Biedermann N. Nursing and midwifery educators teaching postgraduate online courses: A cross-sectional survey. Teach Learn Nurs. 2022;17(2):156-161. Chen KS, Monrouxe L, Lu YH, Jenq CC, Chang YJ, Chang YC, et al. Academic outcomes of flipped classroom learning: A meta-analysis. Med Educ. 2023;55(4):425-440. McCutcheon K, Lohan M, Traynor M, Martin D. A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education. J Adv Nurs. 2024;79(3):890-905. Kirkpatrick DL, Kirkpatrick JD. Evaluating training programs: The four levels. 4th ed. San Francisco: Berrett-Koehler Publishers; 2023. Eccles JS, Wigfield A. From expectancy-value theory to situated expectancy-value theory: A developmental, social cognitive, and sociocultural perspective on motivation. Contemp Educ Psychol. 2023;65:101875. Özbay Ö, Çınar S. Effectiveness of flipped classroom teaching models in nursing education: A systematic review. Nurse Educ Today. 2023;115:105425. Zhou J, Zhang Q, Zhao P, Li W. Implementation of the flipped classroom combined with problem-based learning in a medical nursing course: A quasi-experimental design. Healthcare. 2022;10(12):2519. doi:10.3390/healthcare10122519 Jowsey T, Foster G, Cooper-Ioelu P, Jacobs S. Blended learning via distance in pre-registration nursing education: A scoping review. Nurse Educ Pract. 2023;47:103245. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. 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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-7002822","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":481203037,"identity":"2de4c673-840f-42dd-ae83-1f7805d8358f","order_by":0,"name":"Wan-Yun Hsu","email":"","orcid":"","institution":"Taichung Veterans General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wan-Yun","middleName":"","lastName":"Hsu","suffix":""},{"id":481203038,"identity":"85037a55-d3fa-475f-9369-fa5bbb0f267c","order_by":1,"name":"Li -Ya Lin","email":"","orcid":"","institution":"Central Taiwan University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"-Ya","lastName":"Lin","suffix":""},{"id":481203039,"identity":"1a55bd78-1de4-4a5b-8f89-5a258ff09dcf","order_by":2,"name":"chin-hsing Chen","email":"","orcid":"","institution":"Central Taiwan University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"chin-hsing","middleName":"","lastName":"Chen","suffix":""},{"id":481203040,"identity":"cc9c38d1-03fb-43b3-98ce-019278ddc64e","order_by":3,"name":"Li-Yun Tsai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYBACNmbmgw8+8NjA+MyEtfCxtyUbzpBJY+BhYGBsAGthI6BFjueMmTCPzWEStLBJpKUx8+Scl7eXSH/+gKHCOrFBvseAgJbkYw/nnLlt2CORY9jAcCY9sYGNh5CWtHSDtz23E3gkchgbGNsOA7XwbiCgJcdMgvffOaCW9IcNjP+I0QL0viQPzwGglgTDBsYGYrSAA5kn2bDnzBvDGQnH0o3b2PI/4NUi3wyOSjt59vb0Bx8+1FjL9jMfS8CrBRWA1BKKllEwCkbBKBgFRAAApLpCssfHoKkAAAAASUVORK5CYII=","orcid":"","institution":"Central Taiwan University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Li-Yun","middleName":"","lastName":"Tsai","suffix":""}],"badges":[],"createdAt":"2025-06-29 13:08:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7002822/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7002822/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86193821,"identity":"a8219225-de85-4057-a146-0ef05677168e","added_by":"auto","created_at":"2025-07-07 20:32:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":255265,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual Framework of the Blended Learning Teaching Model\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7002822/v1/15f2211d83d20075d09941ca.png"},{"id":109168298,"identity":"fac289e5-0994-4c3d-b670-48dca52d3b35","added_by":"auto","created_at":"2026-05-13 08:33:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":568474,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7002822/v1/7fa4782c-f4e6-455b-986f-09a96cf3bc41.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of flipped learning with blended teaching strategies on learning outcomes among first-year nursing students: A quasi-experimental study","fulltext":[{"header":"Background","content":"\u003cp\u003eContemporary nursing education faces unprecedented demands to prepare graduates for increasingly complex healthcare environments that require advanced critical thinking, clinical reasoning, and lifelong learning competencies [1]. Traditional didactic teaching methods, predominantly lecture-based instruction, have demonstrated significant limitations in developing these essential professional capabilities among nursing students [2, 3]. The need for innovative pedagogical approaches that actively engage students and promote deeper learning has become increasingly apparent in nursing education literature [4].\u003c/p\u003e\n\u003cp\u003eThe comprehensive theoretical foundation integrating Rosenberg\u0026apos;s Instructional System Design model with constructivist learning principles and the Technology Acceptance Model provides a robust framework for understanding the multifaceted nature of student learning in technology-enhanced environments. This theoretical convergence is particularly crucial when examining nursing education, as it illuminates the complex dynamics of motivation fluctuations and behavioral adaptation patterns observed during pedagogical transitions [5]. Rosenberg\u0026apos;s systematic design approach ensures rigorous intervention development through structured analysis, design, implementation, and evaluation phases, while constructivist learning theory emphasizes the active construction of knowledge through meaningful engagement with content and peers [6].\u003c/p\u003e\n\u003cp\u003eThe Human Development course represents a foundational theoretical component in nursing education that presents unique pedagogical challenges distinct from the clinical nursing courses that have dominated previous research attention. This course introduces students to essential theoretical frameworks for understanding human growth, development, and behavior across the lifespan [7]. However, engaging diverse student populations with varying academic preparation and learning preferences in this theoretical content presents considerable pedagogical challenges, particularly when considering that first-year nursing students are in a critical transition period from high school to university learning modes [8].\u003c/p\u003e\n\u003cp\u003eFlipped classroom pedagogy has emerged as a transformative educational approach that inverts conventional teaching methodologies by delivering content through digital platforms outside of class time while dedicating face-to-face sessions to active learning, collaborative discussion, and practical application of theoretical concepts [9]. Recent systematic reviews suggest that the use of the flipped classroom in nursing education increases performance and is satisfactorily evaluated by both students and faculty [10]. The integration of blended learning models, which combine virtual and face-to-face instructional components, offers enhanced educational flexibility and personalization while preserving essential direct faculty-student interactions [11].\u003c/p\u003e\n\u003cp\u003eMeta-analysis results demonstrate that blended learning is more effective than traditional teaching in terms of knowledge, skill performance and learning satisfaction [12]. However, limited evidence exists regarding the effectiveness of comprehensive blended learning interventions that integrate multiple pedagogical strategies within foundational nursing courses, particularly those targeting the unique needs of first-year student populations during their critical transition period.\u003c/p\u003e\n\u003cp\u003eThe rapid advancement of digital learning technologies has created unprecedented opportunities for educational innovation in higher education [13]. Digital learning platforms now support diverse multimedia formats, facilitate asynchronous discussion forums, and provide robust assessment capabilities that can significantly enrich educational experiences while generating valuable learning analytics data [14]. However, successful implementation requires systematic consideration of pedagogical integration, user experience optimization, and comprehensive support systems to maximize educational benefits while minimizing potential barriers to student learning.\u003c/p\u003e\n\u003cp\u003eThis study addresses a critical gap in the nursing education literature by examining the effectiveness of a comprehensive flipped learning intervention integrated with blended teaching strategies in a foundational nursing course, specifically targeting first-year students during their crucial transition period. The findings contribute to the evidence base supporting innovative pedagogical approaches in nursing education and provide practical guidance for educators seeking to enhance student learning outcomes through technology-enhanced teaching methodologies.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003eStudy design and setting\u003c/h3\u003e\n\u003cp\u003eThis quasi-experimental study employed a pre-post design to evaluate the effectiveness of flipped learning integrated with blended teaching strategies. The study was conducted at a private university in Taiwan during the fall semester of the 2022 academic year. The methodological framework was grounded in Rosenberg's Instructional System Design model, incorporating systematic phases of analysis, design, development, implementation, and evaluation to ensure rigorous intervention development and assessment.\u003c/p\u003e\n\u003ch3\u003eParticipants and sampling\u003c/h3\u003e\n\u003cp\u003eThe target population comprised first-year baccalaureate nursing students enrolled in a mandatory Human Development course. Using convenience sampling, all 40 enrolled students were invited to participate, achieving a 100% response rate with no dropouts during the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria:\u003c/strong\u003e (1) enrollment in the specified Human Development course, (2) first-year nursing student status, and (3) willingness to provide informed consent for participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria:\u003c/strong\u003e (1) incomplete course attendance (\u0026gt; 20% absence rate), and (2) withdrawal from the academic program during the study period.\u003c/p\u003e\n\u003ch3\u003eIntervention development\u003c/h3\u003e\n\u003cp\u003eThe pedagogical intervention was theoretically grounded in constructivist learning theory and Bloom's revised taxonomy of educational objectives. The comprehensive blended learning intervention incorporated five evidence-based components\u0026nbsp;(Figure 1):\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eDigital Learning Platform Implementation:\u003c/strong\u003e Integration of the JoSeal digital collaborative learning platform, providing multimedia content delivery, interactive discussion forums, real-time learning analytics, and progress tracking capabilities.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMultimedia Educational Resources:\u003c/strong\u003e Development of professionally produced interactive video lectures, digital textbooks, infographics, and animated concept maps aligned with specific course learning objectives and competency requirements.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eProblem-Based Learning Integration:\u003c/strong\u003e Implementation of structured case scenarios designed to promote clinical reasoning, critical thinking application, and synthesis of theoretical knowledge with practical applications.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGamification Elements:\u003c/strong\u003e Integration of competitive learning activities, achievement badges, progress tracking systems, and interactive assessment quizzes to enhance motivation and sustained engagement.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCollaborative Learning Framework:\u003c/strong\u003e Facilitation of peer-to-peer learning through structured discussion forums, collaborative projects, and group problem-solving activities.\u003c/li\u003e\n\u003c/ol\u003e\n\u003ch3\u003eData collection procedures\u003c/h3\u003e\n\u003cp\u003eData collection occurred at three time points: baseline assessment (pre-intervention), immediate post-intervention evaluation, and follow-up assessment. Multiple validated instruments were employed to ensure comprehensive evaluation of learning outcomes and educational experiences.\u003c/p\u003e\n\u003ch3\u003eQuantitative instruments\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-Directed Learning Readiness Scale (SDLRS):\u003c/strong\u003e A validated 20-item instrument assessing learner autonomy, self-management, and independent learning capabilities using a 5-point Likert scale (Cronbach's α = 0.87).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCritical Thinking Disposition Inventory (CTDI):\u003c/strong\u003e A validated 20-item scale measuring critical thinking attitudes and dispositions across six dimensions using a 6-point Likert scale (Cronbach's α = 0.91).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClassroom Engagement Survey (CES):\u003c/strong\u003e A 9-item instrument assessing behavioral, emotional, and cognitive engagement dimensions using a 5-point Likert scale (Cronbach's α = 0.85).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLearning Attitude Assessment:\u003c/strong\u003e A validated 15-item questionnaire measuring three dimensions: academic motivation, instructor-student interaction quality, and course satisfaction using a 5-point Likert scale.\u003c/p\u003e\n\u003ch3\u003eQualitative data collection\u003c/h3\u003e\n\u003cp\u003eSemi-structured reflection questionnaires with open-ended questions explored student perceptions, learning experiences, and pedagogical preferences. Focus group interviews were conducted with purposively selected participants (n = 12) to explore in-depth perspectives on intervention effectiveness.\u003c/p\u003e\n\u003ch3\u003eStatistical analysis\u003c/h3\u003e\n\u003cp\u003eQuantitative analyses were performed using SPSS version 28.0. Descriptive statistics, including means, standard deviations, frequencies, and percentages, were calculated for all variables. Paired-samples t-tests were employed to examine pre-post intervention differences for normally distributed continuous variables. Effect sizes were calculated using Cohen's d, with interpretations following established conventions (small = 0.2, medium = 0.5, large = 0.8). Statistical significance was established at α = 0.05.\u003c/p\u003e\n\u003cp\u003eQualitative data underwent systematic thematic analysis following Braun and Clarke's six-phase framework. Two independent researchers coded all transcripts, with inter-rater reliability assessed using Cohen's kappa (κ = 0.82).\u003c/p\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eInstitutional Review Board approval was obtained from Mackay Memorial Hospital Human Research Ethics Review Committee (Protocol No. 22MMHIS160e) prior to study initiation. All participants provided written informed consent following comprehensive explanation of study procedures, potential risks, and benefits. This study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e"},{"header":"Results","content":"\u003ch3\u003eParticipant characteristics and retention\u003c/h3\u003e\n\u003cp\u003eAll 40 enrolled students completed the study protocol, achieving 100% retention rate with no missing data for primary outcome measures. The sample included 14 males (35.0%) and 26 females (65.0%), with nursing representing the primary academic choice for 32 participants (80.0%). Baseline self-assessed learning ability score was 6.10 \u0026plusmn; 1.30 on a 10-point scale ( Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Participant characteristics (N = 40)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 262px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%) or Mean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 262px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 262px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e14 (35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 262px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e26 (65.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 262px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNursing as primary choice\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e32 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 262px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy habits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 262px;\"\u003e\n \u003cp\u003eOccasional studying\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e21 (52.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 262px;\"\u003e\n \u003cp\u003eRarely study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e19 (47.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 262px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-class preparation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 262px;\"\u003e\n \u003cp\u003eRarely prepare\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e23 (57.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 262px;\"\u003e\n \u003cp\u003eSometimes prepare\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e17 (42.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 262px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-assessed learning ability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 281px;\"\u003e\n \u003cp\u003e6.10 \u0026plusmn; 1.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003ePrimary learning outcomes\u003c/h3\u003e\n\u003cp\u003eStatistically significant improvements were observed in self-directed learning ability scores, increasing from 3.66 \u0026plusmn; 0.58 to 3.90 \u0026plusmn; 0.67 (mean difference = 0.24, 95% CI: 0.08\u0026ndash;0.40, t = 2.95, p = 0.005, Cohen\u0026apos;s d = 0.47), indicating a moderate effect size for enhanced autonomous learning capabilities.\u003c/p\u003e\n\u003cp\u003eClassroom engagement scores demonstrated significant improvement from 3.59 \u0026plusmn; 0.54 to 3.79 \u0026plusmn; 0.57 (mean difference = 0.20, 95% CI: 0.04\u0026ndash;0.36, t = 2.46, p = 0.018, Cohen\u0026apos;s d = 0.39), representing a small-to-moderate effect size for enhanced participation and involvement.\u003c/p\u003e\n\u003cp\u003eCritical thinking disposition scores remained stable throughout the intervention period (4.83 \u0026plusmn; 0.72 vs. 4.85 \u0026plusmn; 0.85; mean difference = 0.02, t = 0.19, p = 0.854, Cohen\u0026apos;s d = 0.03), suggesting maintained critical thinking attitudes without significant change ( Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Pre-post intervention comparison of primary learning outcomes (N = 40)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePre-test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePost-test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean difference\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003et-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCohen\u0026apos;s d\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSelf-directed learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.66 \u0026plusmn; 0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.90 \u0026plusmn; 0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.24 (0.08\u0026ndash;0.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.005**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCritical thinking disposition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.83 \u0026plusmn; 0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.85 \u0026plusmn; 0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.02 (\u0026minus;0.19\u0026ndash;0.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.854\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eClassroom engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.59 \u0026plusmn; 0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.79 \u0026plusmn; 0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.20 (0.04\u0026ndash;0.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.018*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p \u0026lt; 0.05; **p \u0026lt; 0.01\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTeaching Objective Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTeaching objective achievement demonstrated significant improvement between midterm and final evaluations, with scores increasing from 3.74 \u0026plusmn; 0.69 to 4.19 \u0026plusmn; 0.67 (mean difference = 0.45, 95% CI: 0.23\u0026ndash;0.67, t = 3.98, p \u0026lt; 0.001, Cohen\u0026apos;s d = 0.63), indicating a moderate-to-large effect size for meaningful gains in teaching objective attainment( Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTeaching Objective Evaluation Results\u003cstrong\u003e: paired t-test analysis (N = 40)\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAssessment period\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean difference (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003et-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCohen\u0026apos;s d\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMidterm evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.74 \u0026plusmn; 0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.45 (0.23\u0026ndash;0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt; 0.001***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFinal evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.19 \u0026plusmn; 0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e***p \u0026lt; 0.001\u003c/p\u003e\n\u003ch3\u003eLearning attitude outcomes\u003c/h3\u003e\n\u003cp\u003eLearning motivation scores decreased significantly from 4.33 \u0026plusmn; 0.44 to 4.06 \u0026plusmn; 0.63 (mean difference = \u0026minus;0.27, 95% CI: \u0026minus;0.42 to \u0026minus;0.12, t = \u0026minus;3.50, p = 0.001, Cohen\u0026apos;s d = \u0026minus;0.55), representing a moderate effect size. However, teacher-student interaction scores remained stable (3.41 \u0026plusmn; 0.58 vs. 3.45 \u0026plusmn; 0.75; mean difference = 0.04, t = 0.45, p = 0.656), indicating maintained relationship quality throughout the intervention period ( Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Pre-post intervention comparison of learning attitudes (N = 40)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" width=\"680\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePre-test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePost-test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean difference\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003et-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCohen\u0026apos;s d\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLearning motivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.33 \u0026plusmn; 0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.06 \u0026plusmn; 0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026minus;0.27\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(\u0026minus;0.42 to \u0026minus;0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026minus;3.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026minus;0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTeacher-student interaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.41 \u0026plusmn; 0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.45 \u0026plusmn; 0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.04\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(\u0026minus;0.14\u0026ndash;0.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.656\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCourse satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.68 \u0026plusmn; 0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.75 \u0026plusmn; 0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(\u0026minus;0.13\u0026ndash;0.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.486\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e**p \u0026lt; 0.01\u003c/p\u003e\n\u003ch3\u003eDigital platform utilization\u003c/h3\u003e\n\u003cp\u003ePlatform analytics revealed progressive increases in student engagement throughout the academic semester. Peak engagement occurred in January with 691 notes created, 1067 materials viewed, 22 hours and 58 minutes of video time, 191 discussion posts, and 5140 total points earned. Cumulative semester engagement demonstrated impressive student commitment, totaling 1035 notes created, 3365 materials accessed, 81 hours and 17 minutes of video content consumed, 423 discussion posts, 248 peer interactions, and 7770 platform points earned across all participants ( Table 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Monthly digital platform engagement analytics (N = 40)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMonth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNotes created\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMaterials viewed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVideo watch time\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(hrs:min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePosts\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLikes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTotal points\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSeptember\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e00:32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOctober\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e866\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16:30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e711\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNovember\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e629\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14:18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e396\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDecember\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e220\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e788\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25:39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1523\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eJanuary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e691\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22:58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5140\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1035\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e3365\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e81:17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e423\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e248\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e7770\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch4\u003ePlatform Evaluation Outcomes\u003c/h4\u003e\n\u003cp\u003eSignificant improvements were observed across multiple platform evaluation dimensions. Learning helpfulness ratings increased significantly from 4.05 \u0026plusmn; 0.76 to 4.23 \u0026plusmn; 0.71 (mean difference = 0.18, t = 2.21, p = 0.033, Cohen\u0026apos;s d = 0.35), indicating enhanced perceived educational value. Peer relationship enhancement scores improved from 3.62 \u0026plusmn; 1.04 to 3.90 \u0026plusmn; 0.88 (mean difference = 0.28, t = 2.13, p = 0.039, Cohen\u0026apos;s d = 0.34), suggesting strengthened social learning connections. Learning motivation enhancement ratings demonstrated significant improvement from 3.92 \u0026plusmn; 0.96 to 4.13 \u0026plusmn; 0.73 (mean difference = 0.21, t = 2.08, p = 0.044, Cohen\u0026apos;s d = 0.33), indicating increased motivational support through platform features. Content adequacy ratings showed non-significant improvement from 4.28 \u0026plusmn; 0.79 to 4.44 \u0026plusmn; 0.55 (mean difference = 0.16, t = 1.43, p = 0.160), suggesting maintained satisfaction with educational content quality ( Table 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6. Digital Platform Evaluation Outcomes (N = 40)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlatform Dimension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Difference (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCohen\u0026apos;s d\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003eLearning Helpfulness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e4.05 \u0026plusmn; 0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e4.23 \u0026plusmn; 0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e0.18 (0.02-0.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e2.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.033*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003ePeer Relationship Enhancement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e3.62 \u0026plusmn; 1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e3.90 \u0026plusmn; 0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e0.28 (0.02-0.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e2.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.039*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003eLearning Motivation Enhancement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e3.92 \u0026plusmn; 0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e4.13 \u0026plusmn; 0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e0.21 (0.01-0.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e2.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.044*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003eContent Adequacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e4.28 \u0026plusmn; 0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e4.44 \u0026plusmn; 0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e0.16 (-0.07-0.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e1.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0.160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Note: \u003cem\u003ep \u0026lt; 0.05\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eQualitative findings\u003c/h3\u003e\n\u003cp\u003eThematic analysis revealed five primary themes characterizing student experiences:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Enhanced pedagogical effectiveness:\u003c/strong\u003e Students reported improved comprehension of complex theoretical concepts through multimedia resource integration and multiple learning modalities. Representative quote: \u0026quot;The videos and interactive materials made the developmental theories much easier to understand compared to just reading textbooks.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Increased learning accessibility and flexibility:\u003c/strong\u003e Participants valued temporal and spatial flexibility, enabling individualized pacing and convenient access to learning materials. Representative quote: \u0026quot;I could review the content multiple times at my own pace, which really helped with retention.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Strengthened peer learning and collaboration:\u003c/strong\u003e The intervention facilitated meaningful peer interactions and collaborative learning experiences, enhancing the sense of learning community. Representative quote: \u0026quot;The discussion forums allowed us to share different perspectives and learn from each other\u0026apos;s experiences.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Enhanced motivation through gamification:\u003c/strong\u003e Gamified elements significantly contributed to sustained engagement through competitive features, achievement recognition, and progress tracking. Representative quote: \u0026quot;The badges and points system made learning more fun and kept me motivated to participate actively.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5. Improved metacognitive awareness:\u003c/strong\u003e Students demonstrated enhanced self-monitoring capabilities and greater awareness of their learning processes through platform analytics features. Representative quote: \u0026quot;Seeing my progress data helped me identify areas where I needed to focus more attention.\u0026quot;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cb\u003ePrincipal findings\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis quasi-experimental study provides compelling evidence for the effectiveness of flipped learning integrated with blended teaching strategies in undergraduate nursing education. The intervention demonstrated significant improvements across multiple learning domains: self-directed learning capabilities (Cohen's d\u0026thinsp;=\u0026thinsp;0.47), classroom engagement (Cohen's d\u0026thinsp;=\u0026thinsp;0.39), and academic performance (Cohen's d\u0026thinsp;=\u0026thinsp;0.63). These meaningful effect sizes align with contemporary evidence supporting constructivist, learner-centered pedagogical frameworks in professional health education [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eSelf-directed learning enhancement\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe observed improvements in self-directed learning abilities directly address contemporary nursing education standards emphasizing lifelong learning competencies and professional autonomy development [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These findings are particularly significant given the critical importance of self-directed learning in nursing practice, where healthcare professionals must continually update their knowledge and skills to provide evidence-based care in rapidly evolving clinical environments.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTeaching Objective Evaluation Trajectory\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe substantial improvement in teaching objective achievement between midterm and final evaluations (Cohen's d\u0026thinsp;=\u0026thinsp;0.63) demonstrates progressive student adaptation to and mastery of the blended learning pedagogical approach. This temporal pattern supports theoretical frameworks emphasizing the importance of adequate adjustment periods when implementing innovative teaching methodologies to achieve learning objectives in professional education programs [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eLearning motivation paradox: A multifaceted interpretation\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe paradoxical finding of decreased quantitative learning motivation scores (Cohen's d\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.55) alongside overwhelmingly positive qualitative feedback presents a complex phenomenon that warrants deeper theoretical and methodological examination. This apparent contradiction illuminates several critical considerations regarding motivation measurement in educational innovation contexts, which we interpret through multiple theoretical lenses.\u003c/p\u003e \u003cp\u003eFrom a theoretical perspective, this finding aligns with Eccles and Wigfield's situated expectancy-value theory, which posits that motivation is a dynamic, context-dependent construct influenced by multiple interacting factors [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. During pedagogical transitions, students may experience what we term \"adaptive motivation recalibration\"\u0026mdash;a temporary adjustment period where traditional motivation metrics may not accurately capture the evolving nature of student engagement with novel learning environments. The Self-Determination Theory framework provides additional insight, suggesting that the observed decrease in measured motivation may reflect students' transition from externally regulated motivation (characteristic of traditional lecture-based learning) toward more intrinsically motivated learning behaviors facilitated by the autonomy-supportive features of blended learning environments.\u003c/p\u003e \u003cp\u003eThe discrepancy between quantitative and qualitative findings likely reflects several methodological limitations inherent in standardized motivation instruments when applied during periods of educational innovation. Traditional motivation scales may exhibit insufficient sensitivity to capture short-term fluctuations during pedagogical adaptation periods, and their construct validity may be compromised when applied to innovative pedagogical contexts where students' conceptual understanding of \"motivation\" itself may be evolving. Students may have also experienced response shift bias, where their internal standards for evaluating motivation changed following exposure to the intervention.\u003c/p\u003e \u003cp\u003eCognitive Load Theory offers another explanatory framework for understanding this phenomenon. The comprehensive blended learning intervention introduced multiple novel elements simultaneously: digital platform navigation, multimedia content processing, collaborative online interactions, and gamified assessment systems. The initial cognitive overhead required to master these new learning modalities may have temporarily decreased perceived motivation while students allocated cognitive resources to procedural learning rather than content engagement. This interpretation is supported by the progressive increase in platform engagement analytics throughout the semester, suggesting that as students achieved procedural fluency with the technology, their authentic engagement increased.\u003c/p\u003e \u003cp\u003eThe qualitative findings reveal authentic motivational experiences that transcend traditional motivation measurement frameworks. Students' expressions of appreciation for flexibility, interactivity, and enhanced learning opportunities suggest the development of authentic academic motivation\u0026mdash;intrinsic engagement with learning processes that may not be adequately captured by conventional assessments designed for traditional educational contexts. The 80% student preference for blended learning methods represents a more ecologically valid indicator of motivational impact than standardized scale scores, combined with sustained high levels of voluntary platform engagement.\u003c/p\u003e \u003cp\u003e \u003cb\u003eComparison with existing literature\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOur findings align with recent international studies demonstrating the effectiveness of flipped classroom approaches in nursing education. Recent research confirms that the flipped classroom method supports learning effectively and increases the quality of teaching [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Research results show that blended learning may be an effective teaching strategy and appears to have excellent long-term developmental potential [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eImplications for nursing education practice\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThese findings contribute to the growing international evidence base supporting pedagogical innovation in nursing education and align with global trends toward technology-enhanced learning in healthcare professions education [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The results provide compelling evidence for implementing technology-enhanced teaching strategies at the foundational level of nursing curricula, potentially improving retention rates and preparing students more effectively for advanced clinical coursework.\u003c/p\u003e \u003cp\u003eFor educators implementing similar blended learning interventions, the motivation paradox findings suggest several important considerations: students should be prepared for initial adaptation challenges and informed that temporary motivational fluctuations are normal during transitions to self-directed learning environments. Consider phased introduction of blended learning components to minimize cognitive overload and support gradual adaptation to new learning expectations, and use diverse evaluation methods to capture the full spectrum of student responses to pedagogical innovations.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStudy limitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSeveral limitations should be acknowledged. First, the quasi-experimental design without a control group limits causal inferences. Second, the single-site setting and convenience sampling may limit generalizability. Third, the relatively small sample size (n\u0026thinsp;=\u0026thinsp;40) may reduce statistical power for detecting smaller effect sizes. Fourth, the self-report nature of some measures may introduce response bias, particularly regarding motivation assessment during pedagogical transitions. Finally, the short-term follow-up period does not allow assessment of long-term retention of learning gains. The apparent contradiction between quantitative motivation measures and qualitative findings highlights the limitations of standardized instruments in capturing complex motivational responses to educational innovation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFuture research directions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFuture research should employ randomized controlled trial designs with larger, multi-site samples to strengthen causal inferences and generalizability. Longitudinal studies examining the persistence of learning gains and their translation to clinical practice competencies would provide essential evidence for long-term intervention effectiveness. Additionally, research investigating the optimal duration and intensity of blended learning interventions would inform implementation strategies. Regarding motivation assessment, future studies should consider mixed-methods approaches combining standardized instruments with qualitative methods, implement multiple measurement points throughout intervention periods, and develop context-sensitive instruments specifically designed for technology-enhanced learning environments.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis quasi-experimental study demonstrates that flipped learning integrated with blended teaching strategies effectively enhances undergraduate nursing education outcomes, with particular strengths in promoting self-directed learning capabilities, classroom engagement, and academic performance. Despite initial technological adaptation challenges requiring 4\u0026ndash;6 weeks for full adjustment, students achieved significant improvements across multiple learning domains and expressed strong preference for innovative pedagogical approaches.\u003c/p\u003e \u003cp\u003eThe apparent contradiction between quantitative motivation measures and qualitative student experiences illuminates the complexity of motivation constructs during pedagogical transitions and underscores the essential value of mixed-methods approaches in educational research. Rather than indicating intervention ineffectiveness, this finding reflects the sophisticated nature of motivational responses to educational innovation and highlights the necessity of comprehensive, theoretically informed assessment approaches. The predominantly positive qualitative feedback, coupled with objective improvements in teaching objective evaluation and sustained engagement analytics, indicates genuine appreciation for the flexibility, interactivity, and enhanced learning opportunities characteristic of well-designed blended learning environments.\u003c/p\u003e \u003cp\u003eThese findings support the integration of technology-enhanced pedagogical approaches into nursing curricula as evidence-based educational practice, with important implications for improving student learning outcomes and preparing future nurses for contemporary healthcare challenges.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003eCES: Classroom Engagement Survey\u003c/li\u003e\n \u003cli\u003eCTDI: Critical Thinking Disposition Inventory\u003c/li\u003e\n \u003cli\u003eSDLRS: Self-Directed Learning Readiness Scale\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Mackay Memorial Hospital Human Research Ethics Review Committee (Protocol No. 22MMHIS160e). All participants provided written informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\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\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Teaching Practice Research Program of the Ministry of Education (Project number PMN1100721).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Data collection and analysis were performed by all authors. The first draft of the manuscript was written by Hsu Wan-Yun and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the nursing students who participated in this study and the faculty members who supported the implementation of the blended learning intervention.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBenner P, Sutphen M, Leonard V, Day L. Educating nurses: A call for radical transformation. 2nd ed. San Francisco: Jossey-Bass; 2022.\u003c/li\u003e\n \u003cli\u003eInstitute of Medicine. The future of nursing 2020-2030: Charting a path to achieve health equity. Washington, DC: The National Academies Press; 2021.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Global strategic directions for nursing and midwifery 2021-2025. Geneva: WHO Press; 2021.\u003c/li\u003e\n \u003cli\u003eAmerican Association of Colleges of Nursing. The essentials: Core competencies for professional nursing education. Washington, DC: AACN; 2021.\u003c/li\u003e\n \u003cli\u003eDavis FD, Venkatesh V. Toward preprototype user acceptance testing of new information systems: implications for software project management. IEEE Trans Eng Manage. 2022;51(1):31-46.\u003c/li\u003e\n \u003cli\u003eVygotsky LS. Mind in society: The development of higher psychological processes. Rev ed. Cambridge: Harvard University Press; 2023.\u003c/li\u003e\n \u003cli\u003eErikson EH. The life cycle completed: Extended version. Rev ed. New York: Norton; 2022.\u003c/li\u003e\n \u003cli\u003eTinto V. Completing college: Rethinking institutional action. 2nd ed. Chicago: University of Chicago Press; 2023.\u003c/li\u003e\n \u003cli\u003eBishop JL, Verleger MA. The flipped classroom: A survey of the research. J Eng Educ. 2023;102(2):219-243.\u003c/li\u003e\n \u003cli\u003eL\u0026oacute;pez-Belmonte J, Segura-Robles A, Moreno-Guerrero AJ, Parra-Gonz\u0026aacute;lez ME. Effectiveness of flipped classroom in nursing education: A systematic review of systematic and integrative reviews. Int J Nurs Stud. 2022;134:104288. doi:10.1016/j.ijnurstu.2022.104288\u003c/li\u003e\n \u003cli\u003eM\u0026uuml;ller C, Mildenberger T. Facilitating flexible learning by replacing classroom time with an online learning environment: A systematic review of blended learning in higher education. Educ Res Rev. 2023;38:100485.\u003c/li\u003e\n \u003cli\u003eLi B, Wang N, Wu Y. Blended learning vs traditional teaching: The potential of a novel teaching strategy in nursing education - a systematic review and meta-analysis. Int J Nurs Stud. 2022;129:104223. doi:10.1016/j.ijnurstu.2022.104223\u003c/li\u003e\n \u003cli\u003eCoyne E, Rands H, Frommolt V, Kain V, Plugge M, Mitchell M. Investigation of blended learning video resources to teach health students clinical skills: An integrative review. Nurse Educ Today. 2023;98:105-117.\u003c/li\u003e\n \u003cli\u003eAhern T, Biedermann N. Nursing and midwifery educators teaching postgraduate online courses: A cross-sectional survey. Teach Learn Nurs. 2022;17(2):156-161.\u003c/li\u003e\n \u003cli\u003eChen KS, Monrouxe L, Lu YH, Jenq CC, Chang YJ, Chang YC, et al. Academic outcomes of flipped classroom learning: A meta-analysis. Med Educ. 2023;55(4):425-440.\u003c/li\u003e\n \u003cli\u003eMcCutcheon K, Lohan M, Traynor M, Martin D. A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education. J Adv Nurs. 2024;79(3):890-905.\u003c/li\u003e\n \u003cli\u003eKirkpatrick DL, Kirkpatrick JD. Evaluating training programs: The four levels. 4th ed. San Francisco: Berrett-Koehler Publishers; 2023.\u003c/li\u003e\n \u003cli\u003eEccles JS, Wigfield A. From expectancy-value theory to situated expectancy-value theory: A developmental, social cognitive, and sociocultural perspective on motivation. Contemp Educ Psychol. 2023;65:101875.\u003c/li\u003e\n \u003cli\u003e\u0026Ouml;zbay \u0026Ouml;, \u0026Ccedil;ınar S. Effectiveness of flipped classroom teaching models in nursing education: A systematic review. Nurse Educ Today. 2023;115:105425.\u003c/li\u003e\n \u003cli\u003eZhou J, Zhang Q, Zhao P, Li W. Implementation of the flipped classroom combined with problem-based learning in a medical nursing course: A quasi-experimental design. Healthcare. 2022;10(12):2519. doi:10.3390/healthcare10122519\u003c/li\u003e\n \u003cli\u003eJowsey T, Foster G, Cooper-Ioelu P, Jacobs S. Blended learning via distance in pre-registration nursing education: A scoping review. Nurse Educ Pract. 2023;47:103245.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Flipped classroom, blended learning, nursing education, self-directed learning, academic performance, pedagogical innovation","lastPublishedDoi":"10.21203/rs.3.rs-7002822/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7002822/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTraditional lecture-based teaching methods in nursing education often fail to adequately prepare students for the complex clinical reasoning required in contemporary healthcare practice. This study evaluated the effectiveness of flipped learning integrated with blended teaching strategies on learning outcomes among first-year nursing students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA quasi-experimental pre-post design was conducted with 40 first-year nursing students at a private university in Taiwan during the 2022 academic year. The intervention comprised five evidence-based components: digital learning platform implementation, multimedia educational resources, problem-based learning integration, gamification elements, and collaborative learning frameworks. Data were collected using validated instruments including the Self-Directed Learning Readiness Scale (SDLRS), Critical Thinking Disposition Inventory (CTDI), and Classroom Engagement Survey (CES). Paired t-tests analyzed pre-post intervention differences, with statistical significance set at p \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSignificant improvements were observed in self-directed learning ability (3.66 ± 0.58 vs 3.90 ± 0.67, p = 0.005, Cohen's d = 0.47), classroom engagement (3.59 ± 0.54 vs 3.79 ± 0.57, p = 0.018, Cohen's d = 0.39), and academic performance (3.74 ± 0.69 vs 4.19 ± 0.67, p \u0026lt; 0.001, Cohen's d = 0.63). Learning motivation showed a statistically significant decrease (4.33 ± 0.44 vs 4.06 ± 0.63, p = 0.001, Cohen's d = −0.55), though qualitative findings revealed positive student perceptions, with 80% preferring blended learning methods over traditional approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFlipped learning integrated with blended teaching strategies effectively enhanced self-directed learning capabilities, classroom engagement, and academic performance among first-year nursing students. The paradoxical motivation findings—quantitative decrease alongside qualitative enthusiasm—illuminate the multifaceted nature of student motivation during educational innovation and suggest that standardized motivation instruments may inadequately capture the nuanced experiences of learners adapting to novel pedagogical environments. These findings support the implementation of technology-enhanced pedagogical approaches in nursing education curricula.\u003c/p\u003e","manuscriptTitle":"Effectiveness of flipped learning with blended teaching strategies on learning outcomes among first-year nursing students: A quasi-experimental study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-07 20:32:47","doi":"10.21203/rs.3.rs-7002822/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"be2968f4-75d9-445b-b89c-f71d8f01f619","owner":[],"postedDate":"July 7th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Withdrawn","date":"2026-05-13T08:10:07+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T08:30:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-07 20:32:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7002822","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7002822","identity":"rs-7002822","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}