Impact of an ISW-Informed BOPPPS Workshop on Knowledge, Attitudes, and Practice Among Clinical Teachers: A Mixed-Methods Study

Impact of an ISW-Informed BOPPPS Workshop on Knowledge, Attitudes, and Practice Among Clinical Teachers: A Mixed-Methods Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of an ISW-Informed BOPPPS Workshop on Knowledge, Attitudes, and Practice Among Clinical Teachers: A Mixed-Methods Study Xuewen Zhang, Huan Li, Mengqi Liu, Mengjia Ma, Yihan Zhang, Haiyan Zhao, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9030926/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Systematic improvement of clinical teachers’ instructional competence is pivotal for advancing medical education quality. This study aimed to assess the impact of an ISW-informed BOPPPS workshop on clinical teachers’ pedagogical knowledge, attitudes, and teaching practice, explore the challenges and support needs associated with its application in authentic clinical teaching settings. Methods A mixed-methods pre-post study design was adopted. Participants were 60 clinical teachers attending the workshop, with 54 valid questionnaires recovered (90% response rate). Quantitative data were collected using a self-designed questionnaire; Wilcoxon signed-rank test compared pre-training and post-training self-rated instructional competence scores. Thematic analysis was conducted on open-ended responses to supplement quantitative findings. Results After the training, teachers demonstrated high knowledge mastery of BOPPPS components (correct identification > 88.0%) and positive attitudes (agreement > 92.0% for all items). Significant improvements were observed across six self-rated competence dimensions, including instructional design, objective setting, interactive teaching, and teaching confidence (all p < 0.001). In practice, 79.6% integrated BOPPPS with other methods. However, Participatory learning emerged as the primary challenge (75.9%), mainly due to incompatibility with clinical workflow. The primary barrier was insufficient preparation time due to heavy clinical workloads (66.7%). Conclusion The ISW-BOPPPS workshop effectively enhanced clinical teachers’ pedagogical knowledge and competence and facilitated their initial application of the model in classroom teaching. Nevertheless, achieving in-depth and sustainable transformation of teaching behaviors within the complex clinical context remains fraught with considerable challenges. We recommend that future faculty development programs provide clinical practice-aligned teaching support resources and establish sustainable mechanisms for peer communication and feedback, so as to promote the effective implementation of pedagogical innovations in authentic clinical teaching settings. BOPPPS model Instructional Skills Workshop (ISW) clinical teacher development Knowledge-Attitude-Practice (KAP) mixed-methods research medical education Figures Figure 1 1 Introduction Against the backdrop of the global transition to competency-based medical education and the advancement of New Medical Education in China, the teaching competency of clinical faculty has emerged as a critical factor in ensuring the quality of medical education [ 1 , 2 ]. However, a prevalent dilemma in practice is that of knowing but not doing—although teachers possess solid clinical knowledge, their pedagogical approaches largely remain confined to the traditional demonstration-imitation model due to a lack of systematic instructional training, making it challenging for them to meet the demands of student-centered modern medical education [ 3 ]. This dilemma reveals the limitations of conventional faculty development programs, which often focus on knowledge transmission but fail to effectively promote sustained and profound changes in teaching behaviors [ 4 ]. The unique challenges of the clinical environment, such as high workloads, fragmented teaching time, and multitasking pressures, further exacerbate the difficulty of translating theory into practice, hindering the implementation of pedagogical innovations [ 5 ]. To effectively promote the transformation of teaching practices, the Instructional Skills Workshop (ISW) originating from Canada [ 6 ] and its core instructional design model, BOPPPS [ 7 ], have been introduced into clinical faculty development. The BOPPPS model (comprising six phases: Bridge-in, Objective, Pre-assessment, Participatory learning, Post-assessment, and Summary) provides a clear, closed-loop framework for instructional structure. This approach employs structured, interactive cycles of micro-teaching, feedback, and reflection [ 8 ], aiming to help teachers rapidly master the principles of learning objective-oriented and student engagement-centered instructional design [ 9 ]. Empowering clinical teachers with the BOPPPS model through the experiential, collaborative workshop format of ISW is regarded as an effective pathway to connect educational theory with the complexities of clinical teaching practice [ 10 ]. Its core value lies in learning by doing, where immediate feedback facilitates visible adjustments in teaching behaviors. Although existing studies indicate that BOPPPS can enhance classroom engagement and student satisfaction [ 11 , 12 ], related research has predominantly focused on the model’s application in individual classroom sessions or the analysis of students’ immediate feedback [ 13 ]. Most evaluations remain at the level of immediate reactions or knowledge gains at the end of training [ 14 , 15 ], lacking longitudinal tracking and in-depth exploration of the sustained transformation process of teachers’ cognition, attitudes, and behaviors. There is a particular lack of empirical investigation into how teachers internalize, adapt, and persist in using the model in authentic clinical teaching contexts, which limits our understanding of the long-term mechanisms underlying the training’s effectiveness. The Knowledge, Attitude, Practice (KAP) model provides a systematic framework for such assessment. Originating from health behavior science, this model is used to comprehensively evaluate the impact of interventions across cognitive, affective, and behavioral dimensions [ 16 ]. Its core strength lies in its ability to effectively distinguish among knowing what, valuing its worth, and putting it into action [ 17 ]. offering a theoretical lens to reveal the intrinsic mechanisms, key facilitators, and major barriers to behavioral change when clinical teachers adopt new pedagogical methods [ 18 ]. Applying the KAP model to faculty development evaluation helps move beyond describing surface-level outcomes to deeply analyze the processes and conditions of behavioral change. Currently, there is a lack of studies systematically evaluating the effects of ISW-informed BOPPPS training for clinical teachers based on the KAP theory. Therefore, this study employed the KAP model and a mixed-methods approach to systematically evaluate the outcomes of an ISW-BOPPPS workshop implemented at Jining Medical University for clinical faculty[ 19 , 20 ]. It aimed to answer the following questions: To what extent did teachers master the knowledge of the BOPPPS model after the training? Did they attitudinally endorse its value? How did they apply the model in complex clinical teaching environments, what challenges did they encounter, and what behavioral changes occurred? By identifying facilitators and barriers in the KAP transformation process, this study aims to provide empirical evidence and strategic recommendations for optimizing localized clinical faculty development programs and advancing pedagogical reform. 2 Methods 2.1 Study Participants and Training Context 2.1.1 Study Participants This prospective study adopted KAP as the assessment framework to evaluate the effects of the ISW-BOPPPS workshop on clinical teachers. Participants were all clinical faculty members who attended the ISW-BOPPPS workshop organized by Jining Medical University between July 11 and August 24, 2025. The workshop was held in three independent cohorts, and trainees were nominated by ten Grade B and above tertiary hospitals in Shandong Province, with a total of 60 teachers participating across the three cohorts. 2.1.2 Training Intervention: The ISW-BOPPPS Workshop The ISW-BOPPPS workshop was a structured, two-day faculty development program. It applied the core approach of the ISW to provide intensive training in the BOPPPS lesson design model. The program used a closed-loop design built around three connected parts: thematic learning, micro-teaching practice, and iterative refinement based on feedback. Participants were divided into small groups of five. To enhance peer learning, groups were formed to ensure a mix of different professional backgrounds and teaching experiences. Each group was supported by one dedicated facilitator and one observer, creating a supportive mentoring setup. The workshop aimed to improve teaching practice through a continuous process of thematic learning → micro-teaching → structured feedback → reflective iteration. All three cohorts followed the same standardized procedures, as outlined below (Fig. 1): (1) Ice-breaking Activity The workshop commenced with a collaborative activity, such as “Collaborative Tower Building”, centered around the BOPPPS model. Lasting 10–15 minutes, this activity aimed to establish trust and a cooperative atmosphere among participants, guiding them to quickly enter an immersive learning state. (2) Structured Curriculum and Thematic Learning The workshop was structured around four progressive theoretical themes, systematically deconstructing the BOPPPS model: Theme 1 : Overview of the BOPPPS Effective Teaching Model. Elaborating on the theory and design principles of this six-stage instructional model, using illustrative examples to demonstrate mastery of its goal-oriented closed-loop framework. Theme 2 : Design of Participatory learning Activities. Guiding the design and integration of clinical interactive activities—such as case discussions and role-playing—into micro-teaching sessions to stimulate higher-order thinking. Theme 3 : Writing Higher-Order Learning Objectives. Focusing on formulating learning objectives that target application, analysis, evaluation, and creation based on Bloom’s Taxonomy and the SMART principle, thereby enhancing clinical competence. Theme 4 : Classroom Assessment Methods. Explaining the design of formative assessment tools aligned with learning objectives for post-class evaluation, which enables immediate feedback and instructional adjustment. Theoretical explanations were supported by both positive and negative clinical teaching examples, directly serving the subsequent micro-teaching practice. (3)Micro-Teaching and Feedback Cycle (a) Micro-Teaching Practice Each micro-teaching practice lasted 10 minutes and was conducted within the 5-member small groups. Participants designed and delivered a lesson on a self-selected clinical topic, following the BOPPPS model. First Round: Initial Application and Diagnostic Feedback Participants applied the complete BOPPPS model for the first time, focusing on structural familiarity and process flow. This round was designed to identify challenges in pacing and phase transitions, with feedback primarily focused on diagnosing foundational issues to establish a basis for improvement. Second Round: Iterative Optimization and Competency Consolidation Building on diagnostic feedback from the first round, participants refined their original design or selected a new topic. The emphasis shifted to enhancing instructional effectiveness—ensuring logical coherence, active engagement, and alignment among objectives, activities, and assessments. This round emphasized closing the complete “teaching → feedback → optimization” cycle to consolidate teaching competence. (b) Feedback Cycle Mechanism Following each practice, a structured BOPPPS feedback cycle comprising four steps was initiated: One-on-one student self-assessment : The presenting teacher shared their reflections and self-evaluated their performance. Peer Written Feedback : Other group members, acting as learners, completed a standardized feedback form, providing direct assessment of the lesson’s effectiveness. Structured BOPPPS Oral Feedback : Other members provided descriptive, “I”-statement based oral feedback, structured around the six phases of the BOPPPS model. Video Review and Reflection : Participants could conduct in-depth self-reflection by reviewing their teaching videos after the practice, which was not included as part of the in-class training. 2.2 Development of Research Instruments and Data Collection 2.2.1 Survey Instrument This study employed a self-developed questionnaire: KAP-Based Questionnaire for Evaluating BOPPPS Training Effectiveness Among Clinical Teachers. The initial draft was revised through multiple rounds of discussion within the research team and with experienced ISW facilitators. A pilot test was conducted with a small sample of clinical teachers (n=5) to ensure clarity and eliminate ambiguity, leading to further refinement of item wording based on feedback. The English version of the questionnaire is provided as Supplementary file 1. The final questionnaire was structured as follows: (1) Demographic Characteristics : This section captured participant gender, hospital grade, professional title, clinical department, and years of teaching experience. (2) Knowledge : Knowledge was assessed through a sequencing task (placing the six BOPPPS components in correct logical order) and a matching task (linking components with their correct descriptions), which evaluated understanding of the model’s fundamental structure. (3) Attitude : Attitudes were measured using a 7-item, dichotomous scale (Cronbach’s α = 0.899). Participants responded to each item by choosing “Agree” or “Disagree”; no neutral option was provided. This forced-choice design is recognized as effective for robust attitude assessment [21]. The scale evaluated teachers’ endorsement of the model’s value, effectiveness, and their willingness to apply it. Specific dimensions included: (a) The structured design of BOPPPS makes my teaching more logical and organized; (b) Participatory learning can effectively enhance students’ clinical thinking and practical skills; (c) The teaching loop formed by Pre-assessment and Post-assessment helps me adjust teaching strategies in a timely manner; (d) The BOPPPS teaching model reflects the student-centered concept better than the traditional lecture-based approach; (e) Implementing the BOPPPS teaching model in clinical teaching is worth the time and effort invested; (f) I am willing to recommend the BOPPPS teaching model to my colleagues; (g) Overall, I am satisfied with the BOPPPS teaching model. (4) Practice : Practice was assessed through several parts: Behavioral Self-assessment: A retrospective self-evaluation using a 5-point Likert scale (1 = very low, 5 = very high, Cronbach’s α = 0.884). Participants rated their perceived proficiency in six core competencies before and after training: (a) instructional design structure; (b) fostering student participation; (c) setting clear objectives; (d) using diverse methods (e.g., case-based learning); (e) conducting immediate learning assessment; (f) overall teaching confidence. Application Patterns: Items investigated the frequency of applying the complete BOPPPS model, as well as integration with other methods (e.g., CBL, PBL). Barriers and Effects: Items identified implementation challenges and observed positive student outcomes. (5) Open-ended Questions: The questionnaire concluded with three open-ended questions to collect qualitative reflections, complementing the quantitative data: (a) methods and challenges in integrating BOPPPS with other models; (b) most rewarding successful cases or moments during application; (c) suggestions for future institutional support. 2.2.2 Data Collection Three months after the training (December 2025), an electronic questionnaire was distributed online to all 60 participants via Questionnaire Star through the Teacher Development Center of Jining Medical University. Fifty-four complete responses were received, resulting in a valid response rate of 90.0%. All data were encrypted during transmission and storage via the platform. Only de-identified, aggregated data were accessible to the research team members for analysis. 2.3 Data Analysis 2.3.1 Quantitative Data Analysis Statistical analysis of quantitative data was performed using SPSS software (version 25.0). The specific procedures were as follows: Descriptive Analysis: Categorical data collected from the questionnaire, including participants’ baseline characteristics, correct response rates for knowledge assessment items, agreement rates for attitude items, and frequency distributions for practice-related multiple-choice questions, were summarized and presented as frequencies (n) and percentages (%). Comparative Analysis: A paired-design was employed to compare the self-assessment scores for the six teaching competencies before and after the training. The Shapiro-Wilk test indicated that the data were not normally distributed ( p < 0.05). Therefore, the non-parametric Wilcoxon signed-rank test was used to analyze the pre-post differences. Data were reported as Mean ± Standard Deviation (M ± SD) to reflect central tendency and dispersion. The significance level was set at α = 0.05 (two-tailed). 2.3.2 Qualitative Data Analysis The textual data from the three open-ended questions were systematically analyzed using thematic analysis. Through a process of coding, categorizing, and thematic extraction of teachers’ feedback, this analysis provided an in-depth explanation for the quantitative findings from the perspective of clinical teachers’ subjective experiences. It served to uncover the intrinsic drivers and systemic barriers to the translation of practice, thereby enabling triangulation and mutual validation with the quantitative results. 3 Results 3.1 Participant Characteristics The sociodemographic characteristics of the 54 clinical teachers who participated in the ISW-BOPPPS workshop and completed the study are presented (Table 1 ). The sample was predominantly female (72.2%), with the vast majority affiliated with Grade A tertiary hospitals (88.9%). In terms of professional rank, Attending Physicians constituted the largest group (68.5%), followed by Associate Chief Physicians (25.9%). Regarding departmental distribution, teachers from internal medicine departments represented the highest proportion (51.9%), followed by surgical departments (29.6%); other specialties such as Psychiatry were also included (18.5%), indicating coverage of major clinical teaching disciplines. Years of teaching experience were relatively evenly distributed, with the largest proportion having more than 10 years of experience (42.6%), followed by those with 5 years or less (37.0%). The sample profile was characterized by clinical teachers primarily from high-level hospitals, holding mid-level professional ranks, and specializing in Internal medicine, while also demonstrating heterogeneity in departmental affiliation and years of experience, which suggests good representativeness. Table 1 Sociodemographic Characteristics of Clinical Teachers (n = 54) Variables N % Gender Male 15 27.8 Female 39 72.2 Hospital Grade Grade A tertiary hospital 48 88.9 Grade B tertiary hospital 6 11.1 Professional title Resident physician 3 5.6 Attending physician 37 68.5 Associate chief physician 14 25.9 Clinical department Internal medicine 28 51.9 Surgery 16 29.6 Psychiatry 10 18.5 Years of teaching experience ≤ 5 years 20 37.0 6–10 years 11 20.4 > 10 years 23 42.6 3.2 Knowledge Dimension: Mastery of BOPPPS Model Components 3.2.1 Understanding of the Logical Sequence of BOPPPS Components Clinical teachers demonstrated good overall mastery of the logical sequence of the BOPPPS components, with correct response rates for all components reaching 83.3% or higher (Table 2 ). Among these, the Participatory learning component had the highest correct sequencing rate (92.6%), indicating that the pedagogical concept of this core interactive phase was most effectively conveyed. Slightly lower correct rates were observed for Bridge-in (85.2%), Learning Objective (83.3%), and Pre-assessment (83.3%). Overall, the training was effective in knowledge transmission, and established a sound cognitive foundation for subsequent attitude endorsement and practical application. Table 2 Mastery of BOPPPS Component Sequence by Clinical Teachers (n = 54) BOPPPS component Correct sequence (n/%) Incorrect sequence (n/%) Bridge-in 46/85.2 8/14.8 Objective 45/83.3 9/16.7 Pre-assessment 45/83.3 9/16.7 Participatory learning 50/92.6 4/7.4 Post-assessment 47/87.0 7/13.0 Summary 47/87.0 7/13.0 3.2.2 Identification of Core Teaching Behaviors of BOPPPS Component The teaching behaviors corresponding to each BOPPPS component were identified with high accuracy by the clinical teachers (Table 3 ). The correct identification rates were generally no less than 88.9%. Among these, the Pre-assessment, Participatory learning, and Post-assessment components recorded the highest accuracy rates, all reaching 98.1%. This indicates that teachers had the most robust grasp of the core closed loop of “Assessment-Participation-Re-assessment” within the teaching process. In relative terms, although the identification accuracy rate for the Bridge-in component (88.9%) remained high, it was slightly lower than that of other components, which may suggest a certain degree of ambiguity in the practical understanding or design of this phase. Table 3 Identification of BOPPPS Core Teaching Behaviors by Clinical Teachers (n = 54) Descriptions of BOPPPS components and their core teaching behaviors Correct identification (n/%) Incorrect identification (n/%) B:Stimulating interest using cases, videos, or questions 48/88.9 6/11.1 O: stating learning objectives clearly 50/92.6 4/7.4 P1: Assessing prior knowledge via questions or quizzes 53/98.1 1/1.9 P2: Engaging students through discussions, role-play, or simulation 53/98.1 1/1.9 P3: Evaluating objective achievement with quizzes or assessments 53/98.1 1/1.9 S: Summarizing core knowledge and linking to practice 52/96.3 2/3.7 3.3 Attitudinal Dimension: Endorsement of the BOPPPS Model Clinical teachers demonstrated a high level of endorsement for the BOPPPS instructional model (Table 4 ). The data revealed that agreement rates for all seven attitudinal indicators were no lower than 92.6%. Among these, teachers expressed the strongest agreement with the statements that “BOPPPS structured design enhances teaching logic” (94.4%) and that “P2 improves students’ clinical thinking and practical skills” (94.4%). There was widespread recognition of the model’s teaching loop (Pre-/Post-assessment) and its student-centered philosophy. Furthermore, teachers indicated willingness to invest time in using the model (92.6%), recommended it to colleagues (92.6%), and reported an overall satisfaction rate of 92.6%. This strong attitudinal endorsement provides a crucial foundation for facilitating the transition from knowledge to practice. Table 4 Attitudes Toward BOPPPS Model by Clinical Teachers (n = 54) Attitude items Agree (n/%) Disagree (n/%) BOPPPS structured design enhances teaching logic 51/94.4 3/5.6 P2 improves students’ clinical thinking and practical skills 51/94.4 3/5.6 P1 and P3 loop facilitates teaching strategy adjustment 50/92.6 4/7.4 BOPPPS better embodies student-centered 50/92.6 4/7.4 Implementing BOPPPS in clinical teaching is worth the investment 50/92.6 4/7.4 Willing to recommend BOPPPS to colleagues 50/92.6 4/7.4 Overall satisfaction with BOPPPS teaching model 50/92.6 4/7.4 3.4 Practice Dimension: Behavioral Changes and Perceived Outcomes 3.4.1 Pre-Training and Post-Training Comparison of Self-Assessed Teaching Competencies As shown in Table 5 , clinical teachers’ self-assessment scores improved significantly across all six teaching competency dimensions after the BOPPPS workshop (p < 0.001 for all). Score increases ranged from 1.3 to 1.6 points, with the most notable gains observed in “Clear learning objective setting” (4.59 ± 0.53) and “Overall teaching confidence” (4.59 ± 0.53). The standard deviations for all dimensions were markedly lower in the post-training assessments compared to the pre-training baselines (e.g., decreasing from 0.93 to 0.69 for “Instructional Design”). This reduction indicates that the workshop not only enhanced the overall level of teaching competency but also reduced inter-individual variability among the teachers. Table 5 Self-Rated Teaching Competence Before and After Workshop by Clinical Teachers (n = 54) Teaching competence dimension Pre-Training Post-Training P Structured instructional design 3.17 ± 0.93 4.54 ± 0.69 <0.001 Student participation and interaction 2.83 ± 1.07 4.40 ± 0.63 <0.001 Clear learning objective setting 3.07 ± 0.91 4.59 ± 0.53 <0.001 Use of diverse teaching methods (e.g., cases, simulation) 3.22 ± 0.79 4.54 ± 0.50 <0.001 Immediate assessment of learning 3.03 ± 0.89 4.54 ± 0.54 <0.001 Overall teaching confidence 3.04 ± 0.89 4.59 ± 0.53 <0.001 3.4.2 Current Status of Integrating BOPPPS with Other Teaching Methods As shown in Table 6 , BOPPPS was primarily employed as an instructional framework in clinical teaching, with 79.6% of teachers integrating it with other methods. Integration demonstrated a distinct pattern, being most common with Case-Based Learning (CBL) (68.5%) and Problem-Based Learning (PBL) (63.0%), which reflects the central role of cases and problem-solving in clinical education. Qualitative feedback provided concrete examples of this integration: for CBL, teachers described practices such as “using invasive ductal carcinoma of the breast as the core, integrating the six BOPPPS components with CBL case-driven teaching”; for PBL, examples included “initiating the Pre-assessment with a problem-oriented approach”. Practices like “posing case analysis questions after didactic explanation, followed by group discussion” further illustrated blended or adapted applications of these methods. In contrast, integration with the Flipped Classroom (FC) approach was minimal (1.9%). Although some teachers attempted strategies such as “distributing course materials in advance and conducting the class following the BOPPPS phases” and acknowledged its effectiveness, the demanding nature of clinical work made it difficult to routinely organize student pre-class learning. Additionally, 20.4% of teachers reported using BOPPPS in isolation. Reasons included “still in the exploratory phase”, which indicated that some teachers were in the initial stages of adopting the model. Table 6 Integration of BOPPPS with Other Teaching Methods by Clinical Teachers (n = 54) Integrated Teaching Method Total n (%) Case-Based Learning (CBL) 37/68.5 Problem-Based Learning (PBL) 34/63.0 Team-Based Learning (TBL) 13/24.1 Flipped Classroom (FC) 1/1.9 BOPPPS used alone 11/20.4 4 Discussion This mixed-methods study evaluated the impact of a BOPPPS workshop on enhancing the instructional capabilities of clinical teachers. Results demonstrated that the training effectively fostered positive changes at the levels of knowledge acquisition, attitudinal endorsement, and initial behavioral attempts. However, deeper and more sustainable transformation of teaching practices remained significantly constrained by structural factors inherent to the clinical work environment. This finding not only confirms the immediate efficacy of structured faculty development programs but also sharply delineates the challenges of integrating a standardized pedagogical model into the complex milieu of clinical practice. It compels a move beyond simplistic attribution of training outcomes toward a more profound theoretical and practical analysis encompassing individual cognition, contextual adaptation, and systemic support mechanisms. The workshop proved highly effective in achieving its primary objectives. Post-training, teachers reported statistically significant improvements in self-rated competence across multiple dimensions, including instructional design, objective communication, classroom interaction, and teaching confidence ( p 92% for all items) strongly endorsed the structured logic of the BOPPPS model and its student-centered philosophy[ 22 ]. This strong positive attitude, combined with the finding that 60% of teachers reporting relatively frequent application, confirms that “micro-teaching and feedback cycle” can effectively bridge the initial gap between educational theory and teaching practice, facilitating the translation of new knowledge and identification into preliminary classroom behaviors [ 4 , 5 ]. This transformation aligns with the pathway described by the KAP model, where a positive attitude is established as a crucial precursor to behavioral change [ 23 ]. It is important to note that high-frequency application does not equate to genuine mastery or flexible utilization of BOPPPS. This study identified a primary tension in behavioral translation between the standardized instructional model and the variable realities of the clinical setting. The Participatory learning component was a salient challenge (reported by 75.9% of teachers), precisely because its implementation often requires extended time and fixed formats (e.g., structured group discussions, role-plays), which conflict with the opportunistic and fast-paced nature of clinical work [ 24 ]. This tension renders the component susceptible to becoming perfunctory or being the first element abandoned, thereby diluting the model’s core pedagogical essence [ 10 ]. Qualitative feedback from teachers (e.g., “time-consuming to organize”, “difficult to arrange discussions during ward rounds”) substantiates the practical difficulties of implementing this phase in clinical teaching. In-depth analysis reveals that the root of these challenges extends far beyond individual teacher capability deficits, residing instead in a lack of systemic support. Among the ranked barriers, “Heavy clinical workload, insufficient time for lesson preparation” (66.7%) was the most prominent, sharply highlighting the enduring reality within healthcare systems of a value orientation and resource allocation that prioritizes clinical service over teaching [ 25 ]. Under this structural pressure, issues such as “lack of teaching resources” (14.8%) and “student resistance to the new model” (9.26%) intertwine. These factors, combined with a lack of ongoing guidance and insufficient incentives from evaluation systems, coalesce into a negative feedback loop that discourages attempts at and sustained investment in pedagogical innovation [ 26 ].This forces teachers to expend additional, unsystematically supported effort. Consequently, any effort to change practice must therefore shift focus to address the environment itself, rather than solely the individual. The immediate, positive teaching feedback garnered during BOPPPS application served as a key intrinsic driver for continued practice. This positive experience stemmed primarily from direct classroom observation: enhanced student participation (e.g., more active responses, greater engagement in role-plays), improved post-assessment performance, and a more dynamic classroom atmosphere. These teacher perceptions correlated with observed student learning behaviors: all teachers reported increased student attentiveness and interaction; 87.0% noted heightened self-directed learning willingness; and 74.0% observed improved teamwork and case analysis abilities. This suggested that BOPPPS-emphasized interactive design and formative assessment could effectively enhance student engagement and learning efficacy, providing teachers with tangible returns on their pedagogical investment [ 3 ]. Such immediate positive feedback constitutes vital psychological sustenance for maintaining innovative practice amidst challenges[ 27 ]. Based on these findings, promoting the deep and sustainable application of BOPPPS in clinical teaching necessitates a shift from isolated workshops toward a systematic, sustained support framework. Teacher suggestions illuminate the path forward: the pressing need is not for more theory but for accessible clinical teaching case banks, concise clinical-scenario-specific interaction protocols, peer-exchange mechanisms grounded in communities of practice, and institutional incentives that integrate teaching innovation into promotion, performance review, and recognition systems [ 28 , 29 ]. Only through contextual adaptation of the pedagogical model and the concurrent construction of a multi-tiered supportive ecosystem—encompassing resources, community, and institutional policy—can the conflict between individual initiative and environmental constraints be mitigated, enabling BOPPPS to become authentically embedded in routine teaching practice[ 30 ]. 5 Limitations and Future Directions This study employed a single-center design, and participants were recruited from a single institution, which may limit the generalizability of the findings[ 31 ]. Furthermore, the assessment of teaching practices relied primarily on teachers’ self-reported data. Future research could incorporate more objective measures, such as direct classroom observation or analysis of student learning outcomes, for triangulation[ 32 ]. To better elucidate the long-term dynamics of BOPPPS implementation effects and their influencing factors, future multicenter, longitudinal studies are recommended[ 33 ]. 6 Conclusion This study confirms that the ISW-BOPPPS workshop effectively enhanced clinical teachers’ pedagogical knowledge and competence and facilitated their initial classroom application, achieving a positive transmission across the KAP continuum. However, its in-depth implementation faces dual constraints. First, there exists a structural contradiction between the standardized model and the randomness and urgency inherent in clinical work, a challenge particularly prominent in the Participatory learning[ 34 ]. Second, within a systemic ecosystem that often prioritizes clinical practice over teaching, there is a widespread lack of time, resources, and institutional support[ 35 ]. Therefore, to promote the sustainable application of this model, it is necessary to advance in parallel the contextual adaptation of the model itself to clinical settings and the systematic construction of a supportive teaching ecosystem[ 36 ]. Future faculty development initiatives should aim to establish a sustained support system encompassing user-friendly resources, communities of practice, and institutional incentives[ 37 ]. This approach would effectively foster the deep integration and broad translation of pedagogical innovations into clinical practice. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Jining Medical University (Approval No: JNMC-YX-2025-142). All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the Declaration of Helsinki and its later amendments or comparable ethical standards. Consent for publication Written informed consent for publication of the images in the figure was obtained from all identifiable individuals depicted. The images have been anonymized by blurring facial features to protect participant privacy, and consent was obtained for the publication of these anonymized images. Competing interests The authors declare that they have no competing interests. Funding This study was financially supported by Shandong Province Undergraduate Teaching Reform Research Key Project (Z2023307); Shandong Province Undergraduate Teaching Reform Research Project in 2025(Z2025506). Author Contribution X.Z., Q.M., H.L.conceptualized the idea. X.Z.designed of the work. M.L., M.M., Y.Z., H.Z., Z.S., C.Z.performed the analyses and wrote the first draft of the manuscript. Z.S., C.Z.checked and entered the data. X.Z., H.L., Q.M.critically revised the manuscript. All the authors read and approved the final manuscript. Acknowledgement The authors wish to acknowledge the participating trainees for their active engagement in the training and collaboration in data collection, which formed the cornerstone of this work. We thank the volunteer team for their reliable logistical support, including on-site organization and document collation. We also express our appreciation to the trainers of the three Instructional Skills Workshop (ISW) sessions for their professional expertise, rich experience, and high-quality guidance, which provided valuable practical insights for the study. Finally, we extend our thanks to the team members responsible for the organization, registration, and coordination of the three ISW sessions—their diligent and meticulous efforts ensured the smooth conduct of each training activity. Data Availability The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. 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Steiner-Hofbauer V, Holzinger A. How to cope with the challenges of medical education? Stress, depression, and coping in undergraduate medical students. Acad Psychiatry: J Am Association Dir Psychiatric Resid Train Association Acad Psychiatry. 2020;44(4):380–7. 10.1007/s40596-020-01193-1 . Harden RM, Laidlaw JM. Essential skills for a medical teacher: An introduction to teaching and learning in medicine. Korean J Med Educ. 2020;26(4):335–6. 10.3946/kjme.2014.26.4.335 . Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000;55(1):68–78. 10.1037/0003-066X.55.1.68 . Lockyer J, Gondocz ST, Thivierge RL. Knowledge translation: The role and place of practice reflection. J Continuing Educ Health Professions. 2010;24(1):50–6. 10.1002/chp.1340240108 . Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P, Kistnasamy B, Meleis A, Naylor D, Pablos-Mendez A, Reddy S, Scrimshaw S, Sepulveda J, Serwadda D, Zurayk H. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet. 2010;376(9756):1923–58. 10.1016/S0140-6736(10)61854-5 . Polit DF, Beck CT. Generalization in quantitative and qualitative research: myths and strategies. Int J Nurs Stud. 2010;47(11):1451–8. 10.1016/j.ijnurstu.2010.06.004 . Eva KW, Regehr G. Self-assessment in the health professions: a reformulation and research agenda. Acad Med J Association Am Med Colleges. 2005;80(Supplement):46–54. 10.1097/00001888-200510001-00015 . Webster-Wright A. Reframing professional development through understanding authentic professional learning. Rev Educ Res. 2009;79(2):702–39. 10.3102/0034654308330970 . Spencer J. Learning and teaching in the clinical environment. BMJ. 2003;326(7389):591. 10.1136/bmj.326.7389.591 . Bligh J, Brice J. Leadership in medical education. BMJ (online). 2010;340(12 3):c2351. 10.2307/40701997 . Dixon-Woods M, Leslie M, Tarrant C, Bion J. Explaining matching michigan: an ethnographic study of a patient safety program. Implement Sci. 2013;8(1):70–70. 10.1186/1748-5908-8-70 . Gruppen L, Irby DM, Durning SJ, Maggio LA. Interventions designed to improve the learning environment in the health professions: a scoping review. MedEdPublish. 2018;7:211. 10.15694/mep.2018.0000211.1 . Additional Declarations No competing interests reported. Supplementary Files KAPBasedQuestionnaireforEvaluatingBOPPPSTrainingEffectivenessAmongClinicalTeachers.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 07 Apr, 2026 Editor assigned by journal 06 Apr, 2026 Editor invited by journal 16 Mar, 2026 Submission checks completed at journal 13 Mar, 2026 First submitted to journal 13 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9030926","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":619364108,"identity":"2bea40f5-177a-434a-8302-e6b35cc12cd8","order_by":0,"name":"Xuewen Zhang","email":"","orcid":"","institution":"Jining Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xuewen","middleName":"","lastName":"Zhang","suffix":""},{"id":619364109,"identity":"b3d1376b-62be-43c8-a216-c8314ea8a863","order_by":1,"name":"Huan Li","email":"","orcid":"","institution":"Jining Medical 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13:39:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9030926/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9030926/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106874933,"identity":"c7f0a181-ab44-46e7-9a85-22a15145834b","added_by":"auto","created_at":"2026-04-14 10:21:40","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1036744,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the ISW-BOPPPS workshop\u003c/p\u003e","description":"","filename":"Fig.1FlowchartoftheISWBOPPPSworkshop.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9030926/v1/af556dfa01e8def017bb5a91.jpg"},{"id":106961374,"identity":"aa4773b2-99bf-4161-8dd5-2d065df2c531","added_by":"auto","created_at":"2026-04-15 09:25:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2434484,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9030926/v1/57f25d90-891c-436a-998c-e71f693bd394.pdf"},{"id":106874934,"identity":"b5d4ed6c-19fa-41ff-9947-5d83ae3738c4","added_by":"auto","created_at":"2026-04-14 10:21:40","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27533,"visible":true,"origin":"","legend":"","description":"","filename":"KAPBasedQuestionnaireforEvaluatingBOPPPSTrainingEffectivenessAmongClinicalTeachers.docx","url":"https://assets-eu.researchsquare.com/files/rs-9030926/v1/7098911917e5e20723a2450f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of an ISW-Informed BOPPPS Workshop on Knowledge, Attitudes, and Practice Among Clinical Teachers: A Mixed-Methods Study","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eAgainst the backdrop of the global transition to competency-based medical education and the advancement of New Medical Education in China, the teaching competency of clinical faculty has emerged as a critical factor in ensuring the quality of medical education [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, a prevalent dilemma in practice is that of knowing but not doing\u0026mdash;although teachers possess solid clinical knowledge, their pedagogical approaches largely remain confined to the traditional demonstration-imitation model due to a lack of systematic instructional training, making it challenging for them to meet the demands of student-centered modern medical education [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This dilemma reveals the limitations of conventional faculty development programs, which often focus on knowledge transmission but fail to effectively promote sustained and profound changes in teaching behaviors [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The unique challenges of the clinical environment, such as high workloads, fragmented teaching time, and multitasking pressures, further exacerbate the difficulty of translating theory into practice, hindering the implementation of pedagogical innovations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo effectively promote the transformation of teaching practices, the Instructional Skills Workshop (ISW) originating from Canada [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and its core instructional design model, BOPPPS [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], have been introduced into clinical faculty development. The BOPPPS model (comprising six phases: Bridge-in, Objective, Pre-assessment, Participatory learning, Post-assessment, and Summary) provides a clear, closed-loop framework for instructional structure. This approach employs structured, interactive cycles of micro-teaching, feedback, and reflection [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], aiming to help teachers rapidly master the principles of learning objective-oriented and student engagement-centered instructional design [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Empowering clinical teachers with the BOPPPS model through the experiential, collaborative workshop format of ISW is regarded as an effective pathway to connect educational theory with the complexities of clinical teaching practice [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Its core value lies in learning by doing, where immediate feedback facilitates visible adjustments in teaching behaviors.\u003c/p\u003e \u003cp\u003eAlthough existing studies indicate that BOPPPS can enhance classroom engagement and student satisfaction [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], related research has predominantly focused on the model\u0026rsquo;s application in individual classroom sessions or the analysis of students\u0026rsquo; immediate feedback [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Most evaluations remain at the level of immediate reactions or knowledge gains at the end of training [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], lacking longitudinal tracking and in-depth exploration of the sustained transformation process of teachers\u0026rsquo; cognition, attitudes, and behaviors. There is a particular lack of empirical investigation into how teachers internalize, adapt, and persist in using the model in authentic clinical teaching contexts, which limits our understanding of the long-term mechanisms underlying the training\u0026rsquo;s effectiveness.\u003c/p\u003e \u003cp\u003eThe Knowledge, Attitude, Practice (KAP) model provides a systematic framework for such assessment. Originating from health behavior science, this model is used to comprehensively evaluate the impact of interventions across cognitive, affective, and behavioral dimensions [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Its core strength lies in its ability to effectively distinguish among knowing what, valuing its worth, and putting it into action [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. offering a theoretical lens to reveal the intrinsic mechanisms, key facilitators, and major barriers to behavioral change when clinical teachers adopt new pedagogical methods [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Applying the KAP model to faculty development evaluation helps move beyond describing surface-level outcomes to deeply analyze the processes and conditions of behavioral change.\u003c/p\u003e \u003cp\u003eCurrently, there is a lack of studies systematically evaluating the effects of ISW-informed BOPPPS training for clinical teachers based on the KAP theory. Therefore, this study employed the KAP model and a mixed-methods approach to systematically evaluate the outcomes of an ISW-BOPPPS workshop implemented at Jining Medical University for clinical faculty[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. It aimed to answer the following questions: To what extent did teachers master the knowledge of the BOPPPS model after the training? Did they attitudinally endorse its value? How did they apply the model in complex clinical teaching environments, what challenges did they encounter, and what behavioral changes occurred? By identifying facilitators and barriers in the KAP transformation process, this study aims to provide empirical evidence and strategic recommendations for optimizing localized clinical faculty development programs and advancing pedagogical reform.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1 Study Participants and Training Context\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.1 Study Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis prospective study adopted KAP as the assessment framework to evaluate the effects of the ISW-BOPPPS workshop on clinical teachers. Participants were all clinical faculty members who attended the ISW-BOPPPS workshop organized by Jining Medical University between July 11 and August 24, 2025. The workshop was held in three independent cohorts, and trainees were nominated by ten Grade B and above tertiary hospitals in Shandong Province, with a total of 60 teachers participating across the three cohorts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1.2 Training Intervention: The ISW-BOPPPS Workshop\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ISW-BOPPPS workshop was a structured, two-day faculty development program. It applied the core approach of the ISW to provide intensive training in the BOPPPS lesson design model. The program used a\u0026nbsp;closed-loop design\u0026nbsp;built around three connected parts: thematic learning, micro-teaching practice, and iterative refinement based on feedback.\u003c/p\u003e\n\u003cp\u003eParticipants were divided into small groups of five. To enhance peer learning, groups were formed to ensure a mix of different professional backgrounds and teaching experiences. Each group was supported by one dedicated facilitator and one observer, creating a supportive mentoring setup.\u003c/p\u003e\n\u003cp\u003eThe workshop aimed to improve teaching practice through a continuous process of\u0026nbsp;thematic learning \u0026rarr; micro-teaching \u0026rarr; structured feedback \u0026rarr; reflective iteration. All three cohorts followed the same standardized procedures, as outlined below (Fig. 1):\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(1) Ice-breaking Activity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe workshop commenced with a collaborative activity, such as \u0026ldquo;Collaborative Tower Building\u0026rdquo;, centered around the BOPPPS model. Lasting 10\u0026ndash;15 minutes, this activity aimed to establish trust and a cooperative atmosphere among participants, guiding them to quickly enter an immersive learning state.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(2) Structured Curriculum and Thematic Learning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe workshop was structured around four progressive theoretical themes, systematically deconstructing the BOPPPS model:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1\u003c/strong\u003e:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eOverview of the BOPPPS Effective Teaching Model. Elaborating on the theory and design principles of this six-stage instructional model, using illustrative examples to demonstrate mastery of its goal-oriented closed-loop framework.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2\u003c/strong\u003e: Design of Participatory learning Activities. Guiding the design and integration of clinical interactive activities\u0026mdash;such as case discussions and role-playing\u0026mdash;into micro-teaching sessions to stimulate higher-order thinking.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3\u003c/strong\u003e:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eWriting Higher-Order Learning Objectives. Focusing on formulating learning objectives that target application, analysis, evaluation, and creation based on Bloom\u0026rsquo;s Taxonomy and the SMART principle, thereby enhancing clinical competence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 4\u003c/strong\u003e: Classroom Assessment Methods. Explaining the design of formative assessment tools aligned with learning objectives for post-class evaluation, which enables immediate feedback and instructional adjustment.\u003c/p\u003e\n\u003cp\u003eTheoretical explanations were supported by both positive and negative clinical teaching examples, directly serving the subsequent micro-teaching practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(3)Micro-Teaching and Feedback Cycle\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(a) Micro-Teaching Practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach micro-teaching practice lasted 10 minutes and was conducted within the 5-member small groups. Participants designed and delivered a lesson on a self-selected clinical topic, following the BOPPPS model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFirst Round: Initial Application and Diagnostic Feedback\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants applied the complete BOPPPS model for the first time, focusing on structural familiarity and process flow. This round was designed to identify challenges in pacing and phase transitions, with feedback primarily focused on diagnosing foundational issues to establish a basis for improvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecond Round: Iterative Optimization and Competency Consolidation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBuilding on diagnostic feedback from the first round, participants refined their original design or selected a new topic. The emphasis shifted to enhancing instructional effectiveness\u0026mdash;ensuring logical coherence, active engagement, and alignment among objectives, activities, and assessments. This round emphasized closing the complete \u0026ldquo;teaching \u0026rarr; feedback \u0026rarr; optimization\u0026rdquo; cycle to consolidate teaching competence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(b) Feedback Cycle Mechanism\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing each practice, a structured BOPPPS feedback cycle comprising four steps was initiated:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOne-on-one student self-assessment\u003c/strong\u003e: The presenting teacher shared their reflections and self-evaluated their performance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePeer Written Feedback\u003c/strong\u003e: Other group members, acting as learners, completed a standardized feedback form, providing direct assessment of the lesson\u0026rsquo;s effectiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStructured BOPPPS Oral Feedback\u003c/strong\u003e: Other members provided descriptive, \u0026ldquo;I\u0026rdquo;-statement based oral feedback, structured around the six phases of the BOPPPS model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVideo Review and Reflection\u003c/strong\u003e: Participants could conduct in-depth self-reflection by reviewing their teaching videos after the practice, which was not included as part of the in-class training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Development of Research Instruments and Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2.1 Survey Instrument\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a\u0026nbsp;self-developed questionnaire: KAP-Based Questionnaire for Evaluating BOPPPS Training Effectiveness Among Clinical Teachers. The initial draft was revised through multiple rounds of discussion within the research team and with experienced ISW facilitators. A pilot test was conducted with a small sample of clinical teachers (n=5) to ensure clarity and eliminate ambiguity, leading to further refinement of item wording based on feedback. The English version of the questionnaire is provided as Supplementary file 1. The final questionnaire was structured as follows:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(1) Demographic Characteristics\u003c/strong\u003e: This section captured participant gender, hospital grade, professional title, clinical department, and years of teaching experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(2) Knowledge\u003c/strong\u003e: Knowledge was assessed through a sequencing task (placing the six BOPPPS components in correct logical order) and a matching task (linking components with their correct descriptions), which evaluated understanding of the model\u0026rsquo;s fundamental structure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(3) Attitude\u003c/strong\u003e: Attitudes were measured using a 7-item, dichotomous scale (Cronbach\u0026rsquo;s \u003cem\u003e\u0026alpha;\u003c/em\u003e = 0.899). Participants responded to each item by choosing \u0026ldquo;Agree\u0026rdquo; or \u0026ldquo;Disagree\u0026rdquo;; no neutral option was provided. This forced-choice design is recognized as effective for robust attitude assessment [21]. The scale evaluated teachers\u0026rsquo; endorsement of the model\u0026rsquo;s value, effectiveness, and their willingness to apply it. Specific dimensions included: (a) The structured design of BOPPPS makes my teaching more logical and organized; (b) Participatory learning can effectively enhance students\u0026rsquo; clinical thinking and practical skills; (c) The teaching loop formed by Pre-assessment and Post-assessment helps me adjust teaching strategies in a timely manner; (d) The BOPPPS teaching model reflects the student-centered concept better than the traditional lecture-based approach; (e) Implementing the BOPPPS teaching model in clinical teaching is worth the time and effort invested; (f) I am willing to recommend the BOPPPS teaching model to my colleagues; (g) Overall, I am satisfied with the BOPPPS teaching model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(4) Practice\u003c/strong\u003e: Practice was assessed through several parts:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Behavioral Self-assessment: A retrospective self-evaluation using a 5-point Likert scale (1 = very low, 5 = very high, Cronbach\u0026rsquo;s \u003cem\u003e\u0026alpha;\u003c/em\u003e = 0.884). Participants rated their perceived proficiency in six core competencies before and after training: (a) instructional design structure; (b) fostering student participation; (c) setting clear objectives; (d) using diverse methods (e.g., case-based learning); (e) conducting immediate learning assessment; (f) overall teaching confidence.\u003c/p\u003e\n\u003cp\u003eApplication Patterns: Items investigated the frequency of applying the complete BOPPPS model, as well as integration with other methods (e.g., CBL, PBL).\u003c/p\u003e\n\u003cp\u003eBarriers and Effects: Items identified implementation challenges and observed positive student outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(5) Open-ended Questions:\u0026nbsp;\u003c/strong\u003eThe questionnaire concluded with three open-ended questions to collect qualitative reflections, complementing the quantitative data: (a) methods and challenges in integrating BOPPPS with other models; (b) most rewarding successful cases or moments during application; (c) suggestions for future institutional support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2.2 Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree months after the training (December 2025), an electronic questionnaire was distributed online to all 60 participants via Questionnaire Star through the Teacher Development Center of Jining Medical University. Fifty-four complete responses were received, resulting in a valid response rate of 90.0%. All data were encrypted during transmission and storage via the platform. Only de-identified, aggregated data were accessible to the research team members for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Data Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3.1 Quantitative Data Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis of quantitative data was performed using SPSS software (version 25.0). The specific procedures were as follows:\u003c/p\u003e\n\u003cp\u003eDescriptive Analysis: Categorical data collected from the questionnaire, including participants\u0026rsquo; baseline characteristics, correct response rates for knowledge assessment items, agreement rates for attitude items, and frequency distributions for practice-related multiple-choice questions, were summarized and presented as frequencies (n) and percentages (%).\u003c/p\u003e\n\u003cp\u003eComparative Analysis: A paired-design was employed to compare the self-assessment scores for the six teaching competencies before and after the training. The Shapiro-Wilk test indicated that the data were not normally distributed (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05). Therefore, the non-parametric Wilcoxon signed-rank test was used to analyze the pre-post differences. Data were reported as Mean\u0026nbsp;\u0026plusmn;\u0026nbsp;Standard Deviation (M\u0026nbsp;\u0026plusmn;\u0026nbsp;SD) to reflect central tendency and dispersion. The significance level was set at \u003cem\u003e\u0026alpha;\u003c/em\u003e = 0.05 (two-tailed).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3.2 Qualitative Data Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe textual data from the three open-ended questions were systematically analyzed using thematic analysis. Through a process of coding, categorizing, and thematic extraction of teachers\u0026rsquo; feedback, this analysis provided an in-depth explanation for the quantitative findings from the perspective of clinical teachers\u0026rsquo; subjective experiences. It served to uncover the intrinsic drivers and systemic barriers to the translation of practice, thereby enabling triangulation and mutual validation with the quantitative results.\u003c/p\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participant Characteristics\u003c/h2\u003e \u003cp\u003eThe sociodemographic characteristics of the 54 clinical teachers who participated in the ISW-BOPPPS workshop and completed the study are presented (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The sample was predominantly female (72.2%), with the vast majority affiliated with Grade A tertiary hospitals (88.9%). In terms of professional rank, Attending Physicians constituted the largest group (68.5%), followed by Associate Chief Physicians (25.9%). Regarding departmental distribution, teachers from internal medicine departments represented the highest proportion (51.9%), followed by surgical departments (29.6%); other specialties such as Psychiatry were also included (18.5%), indicating coverage of major clinical teaching disciplines. Years of teaching experience were relatively evenly distributed, with the largest proportion having more than 10 years of experience (42.6%), followed by those with 5 years or less (37.0%). The sample profile was characterized by clinical teachers primarily from high-level hospitals, holding mid-level professional ranks, and specializing in Internal medicine, while also demonstrating heterogeneity in departmental affiliation and years of experience, which suggests good representativeness.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic Characteristics of Clinical Teachers (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital Grade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade A tertiary hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade B tertiary hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessional title\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResident physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttending physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociate chief physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical department\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychiatry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears of teaching experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Knowledge Dimension: Mastery of BOPPPS Model Components\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Understanding of the Logical Sequence of BOPPPS Components\u003c/h2\u003e \u003cp\u003eClinical teachers demonstrated good overall mastery of the logical sequence of the BOPPPS components, with correct response rates for all components reaching 83.3% or higher (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Among these, the Participatory learning component had the highest correct sequencing rate (92.6%), indicating that the pedagogical concept of this core interactive phase was most effectively conveyed. Slightly lower correct rates were observed for Bridge-in (85.2%), Learning Objective (83.3%), and Pre-assessment (83.3%). Overall, the training was effective in knowledge transmission, and established a sound cognitive foundation for subsequent attitude endorsement and practical application.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMastery of BOPPPS Component Sequence by Clinical Teachers (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBOPPPS component\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrect sequence (n/%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIncorrect sequence (n/%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBridge-in\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46/85.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8/14.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObjective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45/83.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9/16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45/83.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9/16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipatory learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50/92.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4/7.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47/87.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7/13.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSummary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47/87.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7/13.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Identification of Core Teaching Behaviors of BOPPPS Component\u003c/h2\u003e \u003cp\u003eThe teaching behaviors corresponding to each BOPPPS component were identified with high accuracy by the clinical teachers (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The correct identification rates were generally no less than 88.9%. Among these, the Pre-assessment, Participatory learning, and Post-assessment components recorded the highest accuracy rates, all reaching 98.1%. This indicates that teachers had the most robust grasp of the core closed loop of \u0026ldquo;Assessment-Participation-Re-assessment\u0026rdquo; within the teaching process. In relative terms, although the identification accuracy rate for the Bridge-in component (88.9%) remained high, it was slightly lower than that of other components, which may suggest a certain degree of ambiguity in the practical understanding or design of this phase.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIdentification of BOPPPS Core Teaching Behaviors by Clinical Teachers (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDescriptions of BOPPPS components and their core teaching behaviors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrect\u003c/p\u003e \u003cp\u003eidentification (n/%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIncorrect\u003c/p\u003e \u003cp\u003eidentification (n/%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB:Stimulating interest using cases, videos, or questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48/88.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6/11.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eO: stating learning objectives clearly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50/92.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4/7.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP1: Assessing prior knowledge via questions or quizzes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53/98.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1/1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP2: Engaging students through discussions, role-play, or simulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53/98.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1/1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP3: Evaluating objective achievement with quizzes or assessments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53/98.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1/1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS: Summarizing core knowledge and linking to practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52/96.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2/3.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Attitudinal Dimension: Endorsement of the BOPPPS Model\u003c/h2\u003e \u003cp\u003eClinical teachers demonstrated a high level of endorsement for the BOPPPS instructional model (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The data revealed that agreement rates for all seven attitudinal indicators were no lower than 92.6%. Among these, teachers expressed the strongest agreement with the statements that \u0026ldquo;BOPPPS structured design enhances teaching logic\u0026rdquo; (94.4%) and that \u0026ldquo;P2 improves students\u0026rsquo; clinical thinking and practical skills\u0026rdquo; (94.4%). There was widespread recognition of the model\u0026rsquo;s teaching loop (Pre-/Post-assessment) and its student-centered philosophy. Furthermore, teachers indicated willingness to invest time in using the model (92.6%), recommended it to colleagues (92.6%), and reported an overall satisfaction rate of 92.6%. This strong attitudinal endorsement provides a crucial foundation for facilitating the transition from knowledge to practice.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAttitudes Toward BOPPPS Model by Clinical Teachers (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitude items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree (n/%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDisagree (n/%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBOPPPS structured design enhances teaching logic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51/94.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3/5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP2 improves students\u0026rsquo; clinical thinking and practical skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51/94.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3/5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP1 and P3 loop facilitates teaching strategy adjustment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50/92.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4/7.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBOPPPS better embodies student-centered\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50/92.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4/7.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplementing BOPPPS in clinical teaching is worth the investment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50/92.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4/7.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilling to recommend BOPPPS to colleagues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50/92.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4/7.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall satisfaction with BOPPPS teaching model\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50/92.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4/7.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Practice Dimension: Behavioral Changes and Perceived Outcomes\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1 Pre-Training and Post-Training Comparison of Self-Assessed Teaching Competencies\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, clinical teachers\u0026rsquo; self-assessment scores improved significantly across all six teaching competency dimensions after the BOPPPS workshop (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all). Score increases ranged from 1.3 to 1.6 points, with the most notable gains observed in \u0026ldquo;Clear learning objective setting\u0026rdquo; (4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53) and \u0026ldquo;Overall teaching confidence\u0026rdquo; (4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53). The standard deviations for all dimensions were markedly lower in the post-training assessments compared to the pre-training baselines (e.g., decreasing from 0.93 to 0.69 for \u0026ldquo;Instructional Design\u0026rdquo;). This reduction indicates that the workshop not only enhanced the overall level of teaching competency but also reduced inter-individual variability among the teachers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelf-Rated Teaching Competence Before and After Workshop by Clinical Teachers (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeaching competence dimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-Training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-Training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStructured instructional design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent participation and interaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClear learning objective setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of diverse teaching methods (e.g., cases, simulation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmediate assessment of learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.03\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall teaching confidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2 Current Status of Integrating BOPPPS with Other Teaching Methods\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e, BOPPPS was primarily employed as an instructional framework in clinical teaching, with 79.6% of teachers integrating it with other methods. Integration demonstrated a distinct pattern, being most common with Case-Based Learning (CBL) (68.5%) and Problem-Based Learning (PBL) (63.0%), which reflects the central role of cases and problem-solving in clinical education. Qualitative feedback provided concrete examples of this integration: for CBL, teachers described practices such as \u0026ldquo;using invasive ductal carcinoma of the breast as the core, integrating the six BOPPPS components with CBL case-driven teaching\u0026rdquo;; for PBL, examples included \u0026ldquo;initiating the Pre-assessment with a problem-oriented approach\u0026rdquo;. Practices like \u0026ldquo;posing case analysis questions after didactic explanation, followed by group discussion\u0026rdquo; further illustrated blended or adapted applications of these methods.\u003c/p\u003e \u003cp\u003eIn contrast, integration with the Flipped Classroom (FC) approach was minimal (1.9%). Although some teachers attempted strategies such as \u0026ldquo;distributing course materials in advance and conducting the class following the BOPPPS phases\u0026rdquo; and acknowledged its effectiveness, the demanding nature of clinical work made it difficult to routinely organize student pre-class learning.\u003c/p\u003e \u003cp\u003eAdditionally, 20.4% of teachers reported using BOPPPS in isolation. Reasons included \u0026ldquo;still in the exploratory phase\u0026rdquo;, which indicated that some teachers were in the initial stages of adopting the model.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntegration of BOPPPS with Other Teaching Methods by Clinical Teachers (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntegrated Teaching Method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase-Based Learning (CBL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37/68.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProblem-Based Learning (PBL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34/63.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeam-Based Learning (TBL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13/24.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlipped Classroom (FC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1/1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBOPPPS used alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11/20.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis mixed-methods study evaluated the impact of a BOPPPS workshop on enhancing the instructional capabilities of clinical teachers. Results demonstrated that the training effectively fostered positive changes at the levels of knowledge acquisition, attitudinal endorsement, and initial behavioral attempts. However, deeper and more sustainable transformation of teaching practices remained significantly constrained by structural factors inherent to the clinical work environment. This finding not only confirms the immediate efficacy of structured faculty development programs but also sharply delineates the challenges of integrating a standardized pedagogical model into the complex milieu of clinical practice. It compels a move beyond simplistic attribution of training outcomes toward a more profound theoretical and practical analysis encompassing individual cognition, contextual adaptation, and systemic support mechanisms.\u003c/p\u003e \u003cp\u003eThe workshop proved highly effective in achieving its primary objectives. Post-training, teachers reported statistically significant improvements in self-rated competence across multiple dimensions, including instructional design, objective communication, classroom interaction, and teaching confidence (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Crucially, attitudinal data revealed that an overwhelming majority of teachers (agreement rates\u0026thinsp;\u0026gt;\u0026thinsp;92% for all items) strongly endorsed the structured logic of the BOPPPS model and its student-centered philosophy[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This strong positive attitude, combined with the finding that 60% of teachers reporting relatively frequent application, confirms that \u0026ldquo;micro-teaching and feedback cycle\u0026rdquo; can effectively bridge the initial gap between educational theory and teaching practice, facilitating the translation of new knowledge and identification into preliminary classroom behaviors [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This transformation aligns with the pathway described by the KAP model, where a positive attitude is established as a crucial precursor to behavioral change [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is important to note that high-frequency application does not equate to genuine mastery or flexible utilization of BOPPPS. This study identified a primary tension in behavioral translation between the standardized instructional model and the variable realities of the clinical setting. The Participatory learning component was a salient challenge (reported by 75.9% of teachers), precisely because its implementation often requires extended time and fixed formats (e.g., structured group discussions, role-plays), which conflict with the opportunistic and fast-paced nature of clinical work [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This tension renders the component susceptible to becoming perfunctory or being the first element abandoned, thereby diluting the model\u0026rsquo;s core pedagogical essence [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Qualitative feedback from teachers (e.g., \u0026ldquo;time-consuming to organize\u0026rdquo;, \u0026ldquo;difficult to arrange discussions during ward rounds\u0026rdquo;) substantiates the practical difficulties of implementing this phase in clinical teaching.\u003c/p\u003e \u003cp\u003eIn-depth analysis reveals that the root of these challenges extends far beyond individual teacher capability deficits, residing instead in a lack of systemic support. Among the ranked barriers, \u0026ldquo;Heavy clinical workload, insufficient time for lesson preparation\u0026rdquo; (66.7%) was the most prominent, sharply highlighting the enduring reality within healthcare systems of a value orientation and resource allocation that prioritizes clinical service over teaching [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Under this structural pressure, issues such as \u0026ldquo;lack of teaching resources\u0026rdquo; (14.8%) and \u0026ldquo;student resistance to the new model\u0026rdquo; (9.26%) intertwine. These factors, combined with a lack of ongoing guidance and insufficient incentives from evaluation systems, coalesce into a negative feedback loop that discourages attempts at and sustained investment in pedagogical innovation [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].This forces teachers to expend additional, unsystematically supported effort. Consequently, any effort to change practice must therefore shift focus to address the environment itself, rather than solely the individual.\u003c/p\u003e \u003cp\u003eThe immediate, positive teaching feedback garnered during BOPPPS application served as a key intrinsic driver for continued practice. This positive experience stemmed primarily from direct classroom observation: enhanced student participation (e.g., more active responses, greater engagement in role-plays), improved post-assessment performance, and a more dynamic classroom atmosphere. These teacher perceptions correlated with observed student learning behaviors: all teachers reported increased student attentiveness and interaction; 87.0% noted heightened self-directed learning willingness; and 74.0% observed improved teamwork and case analysis abilities. This suggested that BOPPPS-emphasized interactive design and formative assessment could effectively enhance student engagement and learning efficacy, providing teachers with tangible returns on their pedagogical investment [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Such immediate positive feedback constitutes vital psychological sustenance for maintaining innovative practice amidst challenges[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on these findings, promoting the deep and sustainable application of BOPPPS in clinical teaching necessitates a shift from isolated workshops toward a systematic, sustained support framework. Teacher suggestions illuminate the path forward: the pressing need is not for more theory but for accessible clinical teaching case banks, concise clinical-scenario-specific interaction protocols, peer-exchange mechanisms grounded in communities of practice, and institutional incentives that integrate teaching innovation into promotion, performance review, and recognition systems [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Only through contextual adaptation of the pedagogical model and the concurrent construction of a multi-tiered supportive ecosystem\u0026mdash;encompassing resources, community, and institutional policy\u0026mdash;can the conflict between individual initiative and environmental constraints be mitigated, enabling BOPPPS to become authentically embedded in routine teaching practice[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e"},{"header":"5 Limitations and Future Directions","content":"\u003cp\u003eThis study employed a single-center design, and participants were recruited from a single institution, which may limit the generalizability of the findings[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Furthermore, the assessment of teaching practices relied primarily on teachers\u0026rsquo; self-reported data. Future research could incorporate more objective measures, such as direct classroom observation or analysis of student learning outcomes, for triangulation[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. To better elucidate the long-term dynamics of BOPPPS implementation effects and their influencing factors, future multicenter, longitudinal studies are recommended[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e"},{"header":"6 Conclusion","content":"\u003cp\u003eThis study confirms that the ISW-BOPPPS workshop effectively enhanced clinical teachers\u0026rsquo; pedagogical knowledge and competence and facilitated their initial classroom application, achieving a positive transmission across the KAP continuum. However, its in-depth implementation faces dual constraints. First, there exists a structural contradiction between the standardized model and the randomness and urgency inherent in clinical work, a challenge particularly prominent in the Participatory learning[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Second, within a systemic ecosystem that often prioritizes clinical practice over teaching, there is a widespread lack of time, resources, and institutional support[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, to promote the sustainable application of this model, it is necessary to advance in parallel the contextual adaptation of the model itself to clinical settings and the systematic construction of a supportive teaching ecosystem[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Future faculty development initiatives should aim to establish a sustained support system encompassing user-friendly resources, communities of practice, and institutional incentives[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. This approach would effectively foster the deep integration and broad translation of pedagogical innovations into clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study was approved by the Ethics Committee of Jining Medical University (Approval No: JNMC-YX-2025-142). All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e \u003ch2\u003eConsent for publication\u003c/h2\u003e \u003cp\u003e Written informed consent for publication of the images in the figure was obtained from all identifiable individuals depicted. The images have been anonymized by blurring facial features to protect participant privacy, and consent was obtained for the publication of these anonymized images.\u003c/p\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was financially supported by Shandong Province Undergraduate Teaching Reform Research Key Project (Z2023307); Shandong Province Undergraduate Teaching Reform Research Project in 2025(Z2025506).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eX.Z., Q.M., H.L.conceptualized the idea. X.Z.designed of the work. M.L., M.M., Y.Z., H.Z., Z.S., C.Z.performed the analyses and wrote the first draft of the manuscript. Z.S., C.Z.checked and entered the data. X.Z., H.L., Q.M.critically revised the manuscript. All the authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors wish to acknowledge the participating trainees for their active engagement in the training and collaboration in data collection, which formed the cornerstone of this work. We thank the volunteer team for their reliable logistical support, including on-site organization and document collation. We also express our appreciation to the trainers of the three Instructional Skills Workshop (ISW) sessions for their professional expertise, rich experience, and high-quality guidance, which provided valuable practical insights for the study. Finally, we extend our thanks to the team members responsible for the organization, registration, and coordination of the three ISW sessions\u0026mdash;their diligent and meticulous efforts ensured the smooth conduct of each training activity.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. Reframing medical education to support professional identity formation. 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MedEdPublish. 2018;7:211. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.15694/mep.2018.0000211.1\u003c/span\u003e\u003cspan address=\"10.15694/mep.2018.0000211.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"BOPPPS model, Instructional Skills Workshop (ISW), clinical teacher development, Knowledge-Attitude-Practice (KAP), mixed-methods research, medical education","lastPublishedDoi":"10.21203/rs.3.rs-9030926/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9030926/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSystematic improvement of clinical teachers\u0026rsquo; instructional competence is pivotal for advancing medical education quality. This study aimed to assess the impact of an ISW-informed BOPPPS workshop on clinical teachers\u0026rsquo; pedagogical knowledge, attitudes, and teaching practice, explore the challenges and support needs associated with its application in authentic clinical teaching settings.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods pre-post study design was adopted. Participants were 60 clinical teachers attending the workshop, with 54 valid questionnaires recovered (90% response rate). Quantitative data were collected using a self-designed questionnaire; Wilcoxon signed-rank test compared pre-training and post-training self-rated instructional competence scores. Thematic analysis was conducted on open-ended responses to supplement quantitative findings.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAfter the training, teachers demonstrated high knowledge mastery of BOPPPS components (correct identification\u0026thinsp;\u0026gt;\u0026thinsp;88.0%) and positive attitudes (agreement\u0026thinsp;\u0026gt;\u0026thinsp;92.0% for all items). Significant improvements were observed across six self-rated competence dimensions, including instructional design, objective setting, interactive teaching, and teaching confidence (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In practice, 79.6% integrated BOPPPS with other methods. However, Participatory learning emerged as the primary challenge (75.9%), mainly due to incompatibility with clinical workflow. The primary barrier was insufficient preparation time due to heavy clinical workloads (66.7%).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe ISW-BOPPPS workshop effectively enhanced clinical teachers\u0026rsquo; pedagogical knowledge and competence and facilitated their initial application of the model in classroom teaching. Nevertheless, achieving in-depth and sustainable transformation of teaching behaviors within the complex clinical context remains fraught with considerable challenges. We recommend that future faculty development programs provide clinical practice-aligned teaching support resources and establish sustainable mechanisms for peer communication and feedback, so as to promote the effective implementation of pedagogical innovations in authentic clinical teaching settings.\u003c/p\u003e","manuscriptTitle":"Impact of an ISW-Informed BOPPPS Workshop on Knowledge, Attitudes, and Practice Among Clinical Teachers: A Mixed-Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-14 10:21:36","doi":"10.21203/rs.3.rs-9030926/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-07T12:09:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-06T09:42:37+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-16T09:22:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-13T22:56:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-03-13T13:43:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ddf4e141-b7e4-483d-a522-9e9473ccbab8","owner":[],"postedDate":"April 14th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-14T10:21:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-14 10:21:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9030926","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9030926","identity":"rs-9030926","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}