Integrating debate-based learning with World Café methodology to enhance critical thinking in nursing students: A quasi-experimental study

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Traditional didactic teaching methods inadequately develop these essential skills in nursing students. While debate-based learning and World Café methodology individually show promise for fostering analytical reasoning, their combined effectiveness remains unexplored. Methods : This quasi-experimental study involved 108 senior baccalaureate nursing students over 12 weeks. The intervention group (n=65) received integrated debate-based learning with World Café methodology, while controls (n=43) received World Café methodology alone. Primary outcomes measured critical thinking disposition, self-directed learning readiness, classroom engagement, and collaborative competencies using validated instruments administered at baseline and post-intervention. Results : The intervention group demonstrated significantly greater improvements compared to controls: self-directed learning readiness (Cohen's d=0.62, p=0.003), collaborative competencies (Cohen's d=0.51, p=0.013), classroom engagement (Cohen's d=0.58, p=0.005), and critical thinking disposition (Cohen's d=0.44, p=0.032). Academic performance (p=0.007) and course satisfaction (p=0.022) were also significantly higher in the intervention group. Conclusions : Integrating debate-based learning with World Café methodology significantly enhances critical thinking competencies and collaborative learning in nursing students. This evidence-based pedagogical approach supports curriculum transformation to better prepare graduates for complex clinical decision-making. Critical thinking Nursing education Active learning Collaborative learning Debate-based learning World Café methodology Nursing pedagogy Background Contemporary healthcare requires nursing professionals equipped with sophisticated critical thinking skills and evidence-based decision-making capabilities [1,2]. Critical thinking encompasses systematic analysis, reflective reasoning, and evidence synthesis to inform clinical judgments [3]. However, traditional lecture-based nursing education demonstrates limited effectiveness in developing these competencies, leaving graduates unprepared for complex clinical practice demands [4]. Active learning methodologies show promise for enhancing critical thinking development in nursing education. Two approaches demonstrate particular potential: debate-based learning and World Café methodology. Debate-based learning engages students in structured argumentation, requiring comprehensive literature review, position formulation, and evidence synthesis, thereby promoting analytical reasoning [5]. World Café methodology facilitates collaborative knowledge construction through structured conversations in rotating small groups, encouraging diverse perspectives and collective meaning-making [6]. While evidence supports the individual effectiveness of these approaches, their integrated implementation remains unexplored. Theoretical foundations suggest synergistic potential: debate-based learning emphasizes structured argumentation and analytical reasoning, while World Café methodology promotes inclusive participation and collaborative knowledge construction. This pedagogical integration may generate effects beyond either approach implemented independently. Given the cognitive demands of contemporary nursing practice, educational interventions must comprehensively develop critical thinking competencies. This study evaluated the comparative effectiveness of integrated debate-based learning with World Café methodology versus World Café methodology alone for enhancing critical thinking among senior nursing students. Methods Study design This quasi-experimental comparative study employed a two-group parallel design with repeated pre-post measures over one academic semester (12 weeks) in a nationally accredited baccalaureate nursing program at a research university in Taiwan. The study was conducted between September 2023 and December 2023 . Participants Senior nursing students enrolled in a mandatory professional seminar course were recruited through convenience sampling. Inclusion criteria comprised: (1) fourth-year baccalaureate nursing student with cumulative GPA ≥2.5, (2) completed all prerequisite clinical requirements, and (3) provided written informed consent. Exclusion criteria included: (1) previous formal debate training, (2) concurrent participation in experimental educational interventions, and (3) documented learning disabilities requiring specialized accommodations. Sample size calculation using G*Power 3.1.9.7 with parameters of two-tailed independent t-test, medium effect size (Cohen's d=0.6), α=0.05, and power=0.80 indicated minimum n=86. To accommodate potential 20% attrition, 108 eligible participants were recruited and allocated using computer-generated block randomization (block size=6) stratified by gender and baseline academic performance. Randomization and blinding Randomization sequences were generated using R software version 4.3.0 with random seed setting. Block randomization with varying block sizes (4, 6, 8) was implemented to ensure allocation balance. Randomization was performed by an independent statistician not involved in data collection or analysis. Given the nature of educational interventions, participant blinding was not feasible; however, outcome assessors were blinded to group allocation during data collection and entry. Interventions Intervention group (n=65): Participants received integrated debate-based learning with World Café methodology across three structured phases: Preparation phase (weeks 1-2): Evidence-based literature review training using PICO framework, critical appraisal workshops utilizing standardized checklists, and team formation with balanced academic performance distribution. Implementation phase (weeks 3-10): Weekly sessions combining structured debates using Oxford Parliamentary format addressing contemporary nursing practice dilemmas, immediately followed by World Café reflective sessions incorporating multiple stakeholder perspectives (patients, families, healthcare teams, healthcare systems). Each debate addressed predetermined topics including evidence-based practice implementation, ethical decision-making, patient safety initiatives, and interprofessional collaboration challenges. Consolidation phase (weeks 11-12): Culminating debate tournament with standardized peer evaluation rubrics and comprehensive synthesis seminar integrating learning experiences. Control group (n=43): Participants received World Café methodology exclusively, maintaining equivalent contact hours (24 hours total) and addressing identical content topics following established design principles [7]. Sessions incorporated the same stakeholder perspectives and reflection components without the debate structure. Intervention fidelity Intervention fidelity was ensured through multiple strategies: (1) 16 hours of standardized faculty training with competency assessment, (2) detailed intervention protocols with session-by-session scripts, (3) real-time monitoring using structured checklists, (4) audio recording of 25% of sessions for fidelity assessment, and (5) weekly debriefing sessions with intervention facilitators. Outcome measures Five validated instruments with established psychometric properties were employed: Self-Directed Learning Readiness Scale (SDLRS): 40-item instrument measuring learner autonomy, self-management, and learning motivation. Scores range from 40-200 with higher scores indicating greater readiness (Cronbach's α=0.91) [8]. Student Course Engagement Questionnaire (SCEQ): 23-item multidimensional instrument assessing behavioral, emotional, and cognitive engagement. Scores range from 23-115 with higher scores indicating greater engagement (Cronbach's α=0.89) [9]. Attitudes Toward Thinking and Learning Survey (ATTLS): 20-item instrument measuring collaborative learning orientation and knowledge construction approaches. Scores range from 20-100 with higher scores indicating stronger collaborative orientation (Cronbach's α=0.88) [10]. California Critical Thinking Disposition Inventory-Short Form (CCTDI-SF): 26-item instrument measuring critical thinking disposition across seven subscales. Scores range from 26-156 with higher scores indicating stronger critical thinking disposition (Cronbach's α=0.87) [11]. Professional Self-Concept in Nursing Instrument (PSCNI): 27-item instrument measuring professional identity development. Scores range from 27-162 with higher scores indicating stronger professional self-concept (Cronbach's α=0.85) [12]. Data collection procedures Trained research assistants, blinded to group allocation and not involved in intervention delivery, administered all assessments using standardized protocols. Baseline assessments were conducted during week 1 prior to intervention initiation. Post-intervention assessments were administered during week 12 immediately following intervention completion. Data collection occurred in quiet, private settings with consistent environmental conditions. Statistical analysis Data analysis was performed using IBM SPSS Statistics version 29.0. Descriptive statistics characterized participant demographics and baseline measures. Normality assumptions were assessed using Shapiro-Wilk tests supplemented by visual inspection of histograms and Q-Q plots. Homogeneity of variance was evaluated using Levene's tests. Primary analyses examined between-group differences in change scores (post-intervention minus baseline) using independent samples t-tests for normally distributed data and Mann-Whitney U tests for non-parametric data. Effect sizes were calculated using Cohen's d with 95% confidence intervals, interpreted as small (0.2), medium (0.5), and large (0.8) effects. Multiple comparison corrections were applied using the Benjamini-Hochberg false discovery rate procedure, maintaining family-wise error rate at α=0.05. Secondary analyses examined within-group changes using paired samples t-tests or Wilcoxon signed-rank tests as appropriate. All statistical tests were two-tailed with significance set at p<0.05. Ethical considerations This study received approval from Mackay Memorial Hospital Institutional Review Board (Protocol No. 20MMHIS250e) and was conducted according to Declaration of Helsinki principles. All participants provided written informed consent after comprehensive disclosure of study procedures, potential risks and benefits, confidentiality protections, and voluntary withdrawal rights. No financial compensation was provided to participants. Results Participant flow and characteristics Of 120 initially eligible students, 108 consented to participate and were randomized. All participants completed the 12-week intervention period, achieving 100% retention with no missing outcome data. Baseline demographic and academic characteristics showed no significant between-group differences, confirming successful randomization effectiveness (Table 1). The intervention group included 9 male (13.8%) and 56 female (86.2%) participants with mean age 21.8±1.2 years. The control group comprised 12 male (27.9%) and 31 female (72.1%) participants with mean age 22.1±1.4 years. No significant differences were observed in age (p=0.221), gender distribution (p=0.062), or cumulative GPA (p=0.518). Primary outcomes Both groups demonstrated statistically significant within-group improvements from baseline to post-intervention across all measured domains (all p<0.001). However, the intervention group achieved substantially greater improvements compared to the control group across all primary outcomes (Table 2). Between-group analyses revealed statistically significant differences favoring the intervention group. Self-directed learning readiness showed the largest improvement (t₁₀₆ = 3.03, p = 0.003, Cohen's d = 0.62, 95% CI [0.21, 1.02]), representing a medium to large effect size. Classroom engagement (t₁₀₆ = 2.88, p = 0.005, Cohen's d = 0.58, 95% CI [0.18, 0.98]), collaborative competencies (t₁₀₆ = 2.53, p = 0.013, Cohen's d = 0.51, 95% CI [0.11, 0.90]), and critical thinking disposition (t₁₀₆ = 2.17, p = 0.032, Cohen's d = 0.44, 95% CI [0.04, 0.83]) all demonstrated statistically significant improvements with medium effect sizes. Professional self-concept showed positive trends favoring the intervention group but did not reach statistical significance after multiple comparison correction (t₁₀₆ = 1.16, p = 0.248, Cohen's d = 0.22, 95% CI [-0.16, 0.61]). Secondary outcomes Academic performance, measured by final course grades, was significantly higher among intervention group participants (M = 4.49, SD = 0.45) compared to control group participants (M = 4.25, SD = 0.47), representing a moderate effect size (t₁₀₆ = 2.74, p = 0.007, Cohen's d = 0.53, 95% CI [0.14, 0.92]). Course satisfaction ratings similarly favored the intervention group (M = 4.43, SD = 0.49) over the control group (M = 4.20, SD = 0.46), with a moderate effect size (t₁₀₆ = 2.32, p = 0.022, Cohen's d = 0.48, 95% CI [0.09, 0.87]) (Table 3). Qualitative insights Post-intervention focus group interviews with purposively selected participants (n=12, 6 from each group) revealed four primary themes characterizing the intervention experience: (1) enhanced intrinsic motivation for learning through intellectual challenge and competition, (2) creation of intellectually stimulating learning environments promoting active engagement, (3) accelerated analytical reasoning development through structured argumentation practice, and (4) strengthened collaborative competencies through diverse perspective integration. Participants reported increased confidence in evidence-based argumentation, enhanced appreciation for healthcare complexity, and improved comfort with ambiguous clinical scenarios. Discussion This study provides compelling evidence that integrating debate-based learning with World Café methodology significantly enhances critical thinking competencies compared to World Café methodology alone. These findings have important implications for evidence-based nursing education transformation and graduate preparation for contemporary healthcare demands. Critical thinking development The significant improvement in critical thinking disposition (Cohen's d = 0.44) represents a clinically meaningful effect with substantial practice implications. This finding aligns with meta-analytic evidence supporting active learning methodologies in nursing education [ 13 , 14 ]. The integrated approach appears to facilitate critical thinking development through complementary mechanisms: structured argumentation requiring systematic evidence synthesis, perspective-taking promoting cognitive flexibility, collaborative knowledge construction fostering analytical reasoning, and metacognitive reflection enhancing self-awareness of thinking processes. These improvements are consistent with constructivist learning theory and social cognitive theory, where meaningful learning emerges through active knowledge construction within collaborative social contexts [ 15 ]. The debate component necessitates comprehensive literature review, rigorous evidence appraisal, and defendable position formulation—cognitive processes directly aligned with evidence-based practice competencies essential for contemporary nursing practice. Self-directed learning enhancement The substantial improvement in self-directed learning readiness (Cohen's d = 0.62) represents the strongest effect observed and carries particular significance given the imperative for lifelong learning in nursing. Healthcare professionals must continuously assimilate emerging evidence, adapt competencies to evolving practice environments, and maintain currency with technological innovations [ 16 ]. The debate preparation component appears to cultivate intrinsic motivation and autonomous learning capabilities that enhance graduate preparedness for self-directed professional development. From a theoretical perspective, this enhancement likely reflects increased self-efficacy beliefs and intrinsic motivation consistent with self-determination theory [ 17 ]. The structured yet autonomous debate preparation provides optimal challenge levels that foster competence development while maintaining learner autonomy and relatedness through collaborative preparation processes. Collaborative competency development Significant improvements in collaborative competencies (Cohen's d = 0.51) and classroom engagement (Cohen's d = 0.58) demonstrate the approach's effectiveness in cultivating participatory learning environments. These findings are particularly relevant given increasing emphasis on interprofessional collaboration and team-based care delivery in contemporary healthcare systems [ 18 ]. The World Café component provides structured opportunities for inclusive participation and perspective sharing, while the debate structure introduces intellectual rigor and accountability for evidence-based positions. These collaborative competency improvements likely reflect enhanced communication skills, increased comfort with diverse viewpoints, and strengthened abilities to synthesize multiple perspectives—capabilities directly transferable to interprofessional practice contexts and patient care team dynamics. Implications for nursing education These findings support systematic curriculum transformation incorporating integrated active learning approaches. Key implementation considerations include: Faculty development requirements: Effective implementation demands comprehensive preparation encompassing pedagogical content knowledge, group facilitation skills, debate moderation expertise, and performance assessment capabilities. The 16-hour training protocol employed represents minimum foundation requirements with ongoing mentorship and competency assessment essential for sustainable implementation. Resource allocation considerations: The integrated approach requires increased instructional time allocation, flexible classroom configurations supporting small group activities, comprehensive library and database access for evidence-based preparation, and technology infrastructure supporting collaborative platforms. Assessment adaptation needs: Traditional summative assessments inadequately capture the complex competencies developed through integrated active learning approaches. Performance-based assessments evaluating analytical reasoning processes, evidence synthesis quality, and collaborative problem-solving effectiveness provide more authentic evaluation aligned with intended learning outcomes. Systematic curriculum integration: Optimal implementation involves coordinated integration across multiple courses rather than isolated interventions, promoting competency reinforcement, progressive skill development, and sustained learning culture transformation. Global applicability and cultural considerations While conducted in Taiwan's educational context, the theoretical foundations and pedagogical principles underlying this intervention demonstrate broad applicability across diverse cultural settings. However, implementation should thoughtfully consider local educational traditions, student communication preferences, cultural power distance orientations, and institutional learning expectations. The structured nature of both debate and World Café methodologies provides sufficient flexibility for cultural adaptation while maintaining core educational principles. Future research should systematically examine implementation effectiveness across diverse cultural contexts, particularly comparing outcomes in collectivist versus individualist societies, to optimize global applicability and cultural responsiveness. Limitations Several limitations warrant acknowledgment and consideration for future research. The single-institution design conducted within Taiwan's higher education context limits generalizability across diverse educational systems, student populations, and cultural settings. The 12-week intervention duration provides limited evidence regarding long-term competency retention, clinical practice transfer, or professional development sustainability. The quasi-experimental design, while appropriate for educational research contexts, precludes causal inferences equivalent to randomized controlled trials. Convenience sampling may introduce selection bias, potentially limiting external validity to volunteer participants with higher baseline motivation levels. Reliance on self-report outcome measures may introduce social desirability bias, though the use of validated instruments with strong psychometric properties and blinded outcome assessment mitigates this concern. Additionally, the inability to blind participants to intervention allocation, while unavoidable in educational research, may influence outcome reporting. Future research directions Several priority research directions emerge from these findings: (1) multi-site randomized controlled trials across diverse institutional and cultural contexts to establish broader generalizability, (2) longitudinal follow-up studies extending into clinical practice settings to assess competency retention and patient care outcomes, (3) mechanistic investigations using neuroimaging or cognitive assessment tools to examine specific cognitive processes underlying observed improvements, (4) comparative effectiveness research systematically examining optimal pedagogical combinations and dosing parameters, and (5) technology-enhanced implementation studies addressing scalability, accessibility, and cost-effectiveness considerations. Conclusions This quasi-experimental study demonstrates that integrating debate-based learning with World Café methodology significantly enhances critical thinking competencies, self-directed learning readiness, classroom engagement, and collaborative capabilities in nursing students. The moderate to large effect sizes observed suggest clinically meaningful educational benefits with substantial implications for nursing practice preparation and patient care quality. The evidence supports nursing education curriculum transformation incorporating interactive, evidence-based pedagogical approaches that more effectively prepare graduates for contemporary healthcare's analytical and collaborative demands. The synergistic integration of structured argumentation with inclusive collaborative dialogue generates educational benefits exceeding either approach implemented independently. Nursing educators should consider systematic adoption of this evidence-based innovation, particularly for courses addressing complex healthcare issues requiring sophisticated analytical reasoning and collaborative problem-solving capabilities. However, successful implementation requires comprehensive faculty development, adequate resource allocation, appropriate assessment system adaptation, and thoughtful curricular integration planning. These findings contribute to the expanding evidence base supporting active learning methodologies in nursing education and provide practical guidance for educators seeking to enhance critical thinking development. The integrated pedagogical approach represents a promising, evidence-based strategy for preparing nursing graduates equipped with essential competencies for safe, effective, and collaborative healthcare delivery. Abbreviations ATTLS: Attitudes Toward Thinking and Learning Survey; CCTDI-SF: California Critical Thinking Disposition Inventory-Short Form; GPA: Grade Point Average; PSCNI: Professional Self-Concept in Nursing Instrument; SCEQ: Student Course Engagement Questionnaire; SDLRS: Self-Directed Learning Readiness Scale Declarations Ethics approval and consent to participate This study received ethical approval from the Mackay Memorial Hospital Institutional Review Board (Protocol No. 20MMHIS250e) and was conducted according to Declaration of Helsinki principles. All participants provided written informed consent after comprehensive disclosure of study procedures, potential risks and benefits, confidentiality protections, and voluntary withdrawal rights. Consent for publication Not applicable. Availability of data and materials The datasets supporting this study's conclusions are available from the corresponding author upon reasonable request and completion of appropriate data sharing agreements ensuring participant confidentiality protection and institutional approval. Competing interests The authors declare no financial or non-financial competing interests that could inappropriately influence this work. Funding This study received support from the Teaching Practice Research Program of the Ministry of Education, Taiwan (Grant No. PMN1090421). The funding agency had no role in study design, data collection and analysis, data interpretation, or manuscript preparation and submission decisions. Acknowledgements We extend our sincere gratitude to the nursing students who voluntarily participated in this study and the faculty colleagues who provided instructional and logistical support throughout the intervention period. Special recognition goes to the research assistants who maintained rigorous data collection protocols and the independent statistician who conducted the randomization procedures. We also acknowledge the institutional support provided by Teaching Practice Research Program of the Ministry of Education (Project number PMN1090421). Author Contribution 1.4. wrote the main manuscript text. And 2.3. prepared figures 1-3. All authors reviewed the manuscript. References Institute of Medicine. The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press; 2011. Benner P, Sutphen M, Leonard V, Day L. Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass; 2010. Facione PA. Critical thinking: A statement of expert consensus for purposes of educational assessment and instruction. Millbrae, CA: California Academic Press; 1990. National League for Nursing. A vision for teaching with simulation. New York, NY: National League for Nursing; 2015. Kennedy RR. In-class debates: Fertile ground for active learning and the cultivation of critical thinking and oral communication skills. Int J Teach Learn High Educ. 2007;19(2):183-190. Brown J, Isaac D. The World Café: Shaping our futures through conversations that matter. San Francisco, CA: Berrett-Koehler Publishers; 2005. Brown J, Isaac D, World Café Community. The World Café book: Shaping our futures through conversations that matter. San Francisco, CA: Berrett-Koehler Publishers; 2005. Guglielmino LM. Development of the self-directed learning readiness scale. Doctoral dissertation, University of Georgia; 1977. Handelsman MM, Briggs WL, Sullivan N, Towler A. A measure of college student course engagement. J Educ Res. 2005;98(3):184-191. doi:10.3200/JOER.98.3.184-192 Galotti KM, Clinchy BM, Ainsworth K, Lavin B, Mansfield AF. A new way of assessing ways of knowing: The attitudes towards thinking and learning survey (ATTLS). Sex Roles. 1999;40(9-10):745-766. doi:10.1023/A:1018816728669 Facione PA, Facione NC. The California Critical Thinking Disposition Inventory test manual. Millbrae, CA: California Academic Press; 1992. Arthur D. Measurement of the professional self-concept of nurses: Developing a measurement instrument. Nurse Educ Today. 1995;15(5):328-335. doi:10.1016/S0260-6917(95)80004-2 Abrami PC, Bernard RM, Borokhovski E, Waddington DI, Wade CA, Persson T. Strategies for teaching students to think critically: A meta-analysis. Rev Educ Res. 2015;85(2):275-314. doi:10.3102/0034654314551063 Huber CR, Kuncel NR. Does college teach critical thinking? A meta-analysis. Rev Educ Res. 2016;86(2):431-468. doi:10.3102/0034654315605917 Vygotsky LS. Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press; 1978. American Nurses Association. Nursing: Scope and standards of practice. 3rd ed. Silver Spring, MD: American Nurses Association; 2015. Deci EL, Ryan RM. Self-determination theory: Basic psychological needs in motivation, development, and wellness. New York, NY: Guilford Publications; 2017. Institute for Healthcare Improvement. The triple aim: Care, health, and cost. Health Aff. 2008;27(3):759-769. doi:10.1377/hlthaff.27.3.759 Tables Table 1. Participant characteristics and baseline outcome measures (N=108) Characteristic Experimental Group (n=65) Comparison Group (n=43) Test Statistic p-value Demographic Variables Age (years), M ± SD 21.8 ± 1.2 22.1 ± 1.4 t₁₀₆ = -1.23 0.221 Gender, n (%) χ² = 3.48 0.062 Male 9 (13.8) 12 (27.9) Female 56 (86.2) 31 (72.1) Cumulative GPA, M ± SD 3.64 ± 0.51 3.58 ± 0.48 t₁₀₆ = 0.65 0.518 Baseline Outcome Measures Self-directed learning readiness 69.86 ± 11.34 71.23 ± 10.87 t₁₀₆ = -0.63 0.528 Collaborative competencies 61.45 ± 9.68 62.89 ± 9.12 t₁₀₆ = -0.78 0.438 Classroom engagement 29.01 ± 5.06 29.74 ± 4.89 t₁₀₆ = -0.75 0.453 Critical thinking disposition 4.68 ± 0.83 4.52 ± 0.77 t₁₀₆ = 1.02 0.311 Professional self-concept 4.10 ± 0.76 4.18 ± 0.71 t₁₀₆ = -0.55 0.582 *p<0.05; ***p<0.001 Table 2. Between-group differences in change scores from baseline to post-intervention (N=108) Outcome Variable Experimental Group (n=65) M ± SD Comparison Group (n=43) M ± SD t-value p-value Cohen's d (95% CI) Self-directed learning readiness 8.53 ± 9.94 3.00 ± 8.12 3.03 0.003* 0.62 (0.21-1.02) Collaborative competencies 6.31 ± 8.97 2.18 ± 7.23 2.53 0.013* 0.51 (0.11-0.90) Classroom engagement 2.95 ± 4.60 0.74 ± 3.36 2.88 0.005* 0.58 (0.18-0.98) Critical thinking disposition 0.42 ± 0.62 0.17 ± 0.53 2.17 0.032* 0.44 (0.04-0.83) Professional self-concept 0.23 ± 0.72 0.08 ± 0.61 1.16 0.248 0.22 (-0.16-0.61) *p < 0.05 following Benjamini-Hochberg correction for multiple comparisons Table 3. Academic performance and satisfaction outcomes (N=108) Outcome Variable Experimental Group (n=65) M ± SD Comparison Group (n=43) M ± SD t-value p-value Cohen's d (95% CI) Final course evaluation 4.49 ± 0.45 4.25 ± 0.47 2.74 0.007* 0.53 (0.14-0.92) Course satisfaction rating 4.43 ± 0.49 4.20 ± 0.46 2.32 0.022* 0.48 (0.09-0.87) *p < 0.05 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6989212","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":494079113,"identity":"1f37ab66-13a3-4b6e-9355-75e46f1e21a1","order_by":0,"name":"Wan-Yun Hsu","email":"","orcid":"","institution":"Taichung Veterans General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wan-Yun","middleName":"","lastName":"Hsu","suffix":""},{"id":494079115,"identity":"19f8f574-d3c3-4985-91ea-2f700f8652cf","order_by":1,"name":"Li -Ya Lin","email":"","orcid":"","institution":"Central Taiwan University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"-Ya","lastName":"Lin","suffix":""},{"id":494079116,"identity":"51000145-e083-45d2-b279-dde8a8c313f1","order_by":2,"name":"Chin-Hsing Chen","email":"","orcid":"","institution":"Central Taiwan University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Chin-Hsing","middleName":"","lastName":"Chen","suffix":""},{"id":494079118,"identity":"1e9fd1d0-7164-4d4c-b16b-ff3ce5de8dc2","order_by":3,"name":"Li-Yun Tsai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYBACNmbmgw8+8NjA+MyEtfCxtyUbzpBJY+BhYGBsAGthI6BFjueMmTCPzWEStLBJpKUx8+Scl7eXSH/+gKHCOrFBvseAgJbkYw/nnLlt2CORY9jAcCY9sYGNh5CWtHSDtz23E3gkchgbGNsOA7XwbiCgJcdMgvffOaCW9IcNjP+I0QL0viQPzwGglgTDBsYGYrSAA5kn2bDnzBvDGQnH0o3b2PI/4NUi3wyOSjt59vb0Bx8+1FjL9jMfS8CrBRWA1BKKllEwCkbBKBgFRAAApLpCssfHoKkAAAAASUVORK5CYII=","orcid":"","institution":"Central Taiwan University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Li-Yun","middleName":"","lastName":"Tsai","suffix":""}],"badges":[],"createdAt":"2025-06-27 07:53:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6989212/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6989212/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108602601,"identity":"8dcdddcb-af66-487f-ab73-4715b05eaff1","added_by":"auto","created_at":"2026-05-06 11:43:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":241129,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6989212/v1/71722436-87ac-4a6c-bdb8-07727782d5fc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Integrating debate-based learning with World Café methodology to enhance critical thinking in nursing students: A quasi-experimental study","fulltext":[{"header":"Background","content":"\u003cp\u003eContemporary healthcare requires nursing professionals equipped with sophisticated critical thinking skills and evidence-based decision-making capabilities [1,2]. Critical thinking encompasses systematic analysis, reflective reasoning, and evidence synthesis to inform clinical judgments [3]. However, traditional lecture-based nursing education demonstrates limited effectiveness in developing these competencies, leaving graduates unprepared for complex clinical practice demands [4].\u003c/p\u003e\n\u003cp\u003eActive learning methodologies show promise for enhancing critical thinking development in nursing education. Two approaches demonstrate particular potential: debate-based learning and World Caf\u0026eacute; methodology. Debate-based learning engages students in structured argumentation, requiring comprehensive literature review, position formulation, and evidence synthesis, thereby promoting analytical reasoning [5]. World Caf\u0026eacute; methodology facilitates collaborative knowledge construction through structured conversations in rotating small groups, encouraging diverse perspectives and collective meaning-making [6].\u003c/p\u003e\n\u003cp\u003eWhile evidence supports the individual effectiveness of these approaches, their integrated implementation remains unexplored. Theoretical foundations suggest synergistic potential: debate-based learning emphasizes structured argumentation and analytical reasoning, while World Caf\u0026eacute; methodology promotes inclusive participation and collaborative knowledge construction. This pedagogical integration may generate effects beyond either approach implemented independently.\u003c/p\u003e\n\u003cp\u003eGiven the cognitive demands of contemporary nursing practice, educational interventions must comprehensively develop critical thinking competencies. This study evaluated the comparative effectiveness of integrated debate-based learning with World Caf\u0026eacute; methodology versus World Caf\u0026eacute; methodology alone for enhancing critical thinking among senior nursing students.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis quasi-experimental comparative study employed a two-group parallel design with repeated pre-post measures over one academic semester (12 weeks) in a nationally accredited baccalaureate nursing program at a research university in Taiwan. The study was conducted between September 2023 and December 2023\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSenior nursing students enrolled in a mandatory professional seminar course were recruited through convenience sampling. Inclusion criteria comprised: (1) fourth-year baccalaureate nursing student with cumulative GPA \u0026ge;2.5, (2) completed all prerequisite clinical requirements, and (3) provided written informed consent. Exclusion criteria included: (1) previous formal debate training, (2) concurrent participation in experimental educational interventions, and (3) documented learning disabilities requiring specialized accommodations.\u003c/p\u003e\n\u003cp\u003eSample size calculation using G*Power 3.1.9.7 with parameters of two-tailed independent t-test, medium effect size (Cohen\u0026apos;s d=0.6), \u0026alpha;=0.05, and power=0.80 indicated minimum n=86. To accommodate potential 20% attrition, 108 eligible participants were recruited and allocated using computer-generated block randomization (block size=6) stratified by gender and baseline academic performance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRandomization and blinding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRandomization sequences were generated using R software version 4.3.0 with random seed setting. Block randomization with varying block sizes (4, 6, 8) was implemented to ensure allocation balance. Randomization was performed by an independent statistician not involved in data collection or analysis. Given the nature of educational interventions, participant blinding was not feasible; however, outcome assessors were blinded to group allocation during data collection and entry.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterventions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIntervention group (n=65): Participants received integrated debate-based learning with World Caf\u0026eacute; methodology across three structured phases:\u003c/p\u003e\n\u003cp\u003ePreparation phase (weeks 1-2): Evidence-based literature review training using PICO framework, critical appraisal workshops utilizing standardized checklists, and team formation with balanced academic performance distribution.\u003c/p\u003e\n\u003cp\u003eImplementation phase (weeks 3-10): Weekly sessions combining structured debates using Oxford Parliamentary format addressing contemporary nursing practice dilemmas, immediately followed by World Caf\u0026eacute; reflective sessions incorporating multiple stakeholder perspectives (patients, families, healthcare teams, healthcare systems). Each debate addressed predetermined topics including evidence-based practice implementation, ethical decision-making, patient safety initiatives, and interprofessional collaboration challenges.\u003c/p\u003e\n\u003cp\u003eConsolidation phase (weeks 11-12): Culminating debate tournament with standardized peer evaluation rubrics and comprehensive synthesis seminar integrating learning experiences.\u003c/p\u003e\n\u003cp\u003eControl group (n=43): Participants received World Caf\u0026eacute; methodology exclusively, maintaining equivalent contact hours (24 hours total) and addressing identical content topics following established design principles [7]. Sessions incorporated the same stakeholder perspectives and reflection components without the debate structure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention fidelity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIntervention fidelity was ensured through multiple strategies: (1) 16 hours of standardized faculty training with competency assessment, (2) detailed intervention protocols with session-by-session scripts, (3) real-time monitoring using structured checklists, (4) audio recording of 25% of sessions for fidelity assessment, and (5) weekly debriefing sessions with intervention facilitators.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFive validated instruments with established psychometric properties were employed:\u003c/p\u003e\n\u003cp\u003eSelf-Directed Learning Readiness Scale (SDLRS): 40-item instrument measuring learner autonomy, self-management, and learning motivation. Scores range from 40-200 with higher scores indicating greater readiness (Cronbach\u0026apos;s \u0026alpha;=0.91) [8].\u003c/p\u003e\n\u003cp\u003eStudent Course Engagement Questionnaire (SCEQ): 23-item multidimensional instrument assessing behavioral, emotional, and cognitive engagement. Scores range from 23-115 with higher scores indicating greater engagement (Cronbach\u0026apos;s \u0026alpha;=0.89) [9].\u003c/p\u003e\n\u003cp\u003eAttitudes Toward Thinking and Learning Survey (ATTLS): 20-item instrument measuring collaborative learning orientation and knowledge construction approaches. Scores range from 20-100 with higher scores indicating stronger collaborative orientation (Cronbach\u0026apos;s \u0026alpha;=0.88) [10].\u003c/p\u003e\n\u003cp\u003eCalifornia Critical Thinking Disposition Inventory-Short Form (CCTDI-SF): 26-item instrument measuring critical thinking disposition across seven subscales. Scores range from 26-156 with higher scores indicating stronger critical thinking disposition (Cronbach\u0026apos;s \u0026alpha;=0.87) [11].\u003c/p\u003e\n\u003cp\u003eProfessional Self-Concept in Nursing Instrument (PSCNI): 27-item instrument measuring professional identity development. Scores range from 27-162 with higher scores indicating stronger professional self-concept (Cronbach\u0026apos;s \u0026alpha;=0.85) [12].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTrained research assistants, blinded to group allocation and not involved in intervention delivery, administered all assessments using standardized protocols. Baseline assessments were conducted during week 1 prior to intervention initiation. Post-intervention assessments were administered during week 12 immediately following intervention completion. Data collection occurred in quiet, private settings with consistent environmental conditions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis was performed using IBM SPSS Statistics version 29.0. Descriptive statistics characterized participant demographics and baseline measures. Normality assumptions were assessed using Shapiro-Wilk tests supplemented by visual inspection of histograms and Q-Q plots. Homogeneity of variance was evaluated using Levene\u0026apos;s tests.\u003c/p\u003e\n\u003cp\u003ePrimary analyses examined between-group differences in change scores (post-intervention minus baseline) using independent samples t-tests for normally distributed data and Mann-Whitney U tests for non-parametric data. Effect sizes were calculated using Cohen\u0026apos;s d with 95% confidence intervals, interpreted as small (0.2), medium (0.5), and large (0.8) effects. Multiple comparison corrections were applied using the Benjamini-Hochberg false discovery rate procedure, maintaining family-wise error rate at \u0026alpha;=0.05.\u003c/p\u003e\n\u003cp\u003eSecondary analyses examined within-group changes using paired samples t-tests or Wilcoxon signed-rank tests as appropriate. All statistical tests were two-tailed with significance set at p\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received approval from Mackay Memorial Hospital Institutional Review Board (Protocol No. 20MMHIS250e) and was conducted according to Declaration of Helsinki principles. All participants provided written informed consent after comprehensive disclosure of study procedures, potential risks and benefits, confidentiality protections, and voluntary withdrawal rights. No financial compensation was provided to participants.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant flow and characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf 120 initially eligible students, 108 consented to participate and were randomized. All participants completed the 12-week intervention period, achieving 100% retention with no missing outcome data. Baseline demographic and academic characteristics showed no significant between-group differences, confirming successful randomization effectiveness (Table 1).\u003c/p\u003e\n\u003cp\u003eThe intervention group included 9 male (13.8%) and 56 female (86.2%) participants with mean age 21.8\u0026plusmn;1.2 years. The control group comprised 12 male (27.9%) and 31 female (72.1%) participants with mean age 22.1\u0026plusmn;1.4 years. No significant differences were observed in age (p=0.221), gender distribution (p=0.062), or cumulative GPA (p=0.518).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth groups demonstrated statistically significant within-group improvements from baseline to post-intervention across all measured domains (all p\u0026lt;0.001). However, the intervention group achieved substantially greater improvements compared to the control group across all primary outcomes (Table 2).\u003c/p\u003e\n\u003cp\u003eBetween-group analyses revealed statistically significant differences favoring the intervention group. Self-directed learning readiness showed the largest improvement (t₁₀₆ = 3.03, p = 0.003, Cohen\u0026apos;s d = 0.62, 95% CI [0.21, 1.02]), representing a medium to large effect size. Classroom engagement (t₁₀₆ = 2.88, p = 0.005, Cohen\u0026apos;s d = 0.58, 95% CI [0.18, 0.98]), collaborative competencies (t₁₀₆ = 2.53, p = 0.013, Cohen\u0026apos;s d = 0.51, 95% CI [0.11, 0.90]), and critical thinking disposition (t₁₀₆ = 2.17, p = 0.032, Cohen\u0026apos;s d = 0.44, 95% CI [0.04, 0.83]) all demonstrated statistically significant improvements with medium effect sizes.\u003c/p\u003e\n\u003cp\u003eProfessional self-concept showed positive trends favoring the intervention group but did not reach statistical significance after multiple comparison correction (t₁₀₆ = 1.16, p = 0.248, Cohen\u0026apos;s d = 0.22, 95% CI [-0.16, 0.61]).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcademic performance, measured by final course grades, was significantly higher among intervention group participants (M = 4.49, SD = 0.45) compared to control group participants (M = 4.25, SD = 0.47), representing a moderate effect size (t₁₀₆ = 2.74, p = 0.007, Cohen\u0026apos;s d = 0.53, 95% CI [0.14, 0.92]).\u003c/p\u003e\n\u003cp\u003eCourse satisfaction ratings similarly favored the intervention group (M = 4.43, SD = 0.49) over the control group (M = 4.20, SD = 0.46), with a moderate effect size (t₁₀₆ = 2.32, p = 0.022, Cohen\u0026apos;s d = 0.48, 95% CI [0.09, 0.87]) (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative insights\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePost-intervention focus group interviews with purposively selected participants (n=12, 6 from each group) revealed four primary themes characterizing the intervention experience: (1) enhanced intrinsic motivation for learning through intellectual challenge and competition, (2) creation of intellectually stimulating learning environments promoting active engagement, (3) accelerated analytical reasoning development through structured argumentation practice, and (4) strengthened collaborative competencies through diverse perspective integration. Participants reported increased confidence in evidence-based argumentation, enhanced appreciation for healthcare complexity, and improved comfort with ambiguous clinical scenarios.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides compelling evidence that integrating debate-based learning with World Caf\u0026eacute; methodology significantly enhances critical thinking competencies compared to World Caf\u0026eacute; methodology alone. These findings have important implications for evidence-based nursing education transformation and graduate preparation for contemporary healthcare demands.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCritical thinking development\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe significant improvement in critical thinking disposition (Cohen's d\u0026thinsp;=\u0026thinsp;0.44) represents a clinically meaningful effect with substantial practice implications. This finding aligns with meta-analytic evidence supporting active learning methodologies in nursing education [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The integrated approach appears to facilitate critical thinking development through complementary mechanisms: structured argumentation requiring systematic evidence synthesis, perspective-taking promoting cognitive flexibility, collaborative knowledge construction fostering analytical reasoning, and metacognitive reflection enhancing self-awareness of thinking processes.\u003c/p\u003e\u003cp\u003eThese improvements are consistent with constructivist learning theory and social cognitive theory, where meaningful learning emerges through active knowledge construction within collaborative social contexts [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The debate component necessitates comprehensive literature review, rigorous evidence appraisal, and defendable position formulation\u0026mdash;cognitive processes directly aligned with evidence-based practice competencies essential for contemporary nursing practice.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSelf-directed learning enhancement\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe substantial improvement in self-directed learning readiness (Cohen's d\u0026thinsp;=\u0026thinsp;0.62) represents the strongest effect observed and carries particular significance given the imperative for lifelong learning in nursing. Healthcare professionals must continuously assimilate emerging evidence, adapt competencies to evolving practice environments, and maintain currency with technological innovations [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The debate preparation component appears to cultivate intrinsic motivation and autonomous learning capabilities that enhance graduate preparedness for self-directed professional development.\u003c/p\u003e\u003cp\u003eFrom a theoretical perspective, this enhancement likely reflects increased self-efficacy beliefs and intrinsic motivation consistent with self-determination theory [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The structured yet autonomous debate preparation provides optimal challenge levels that foster competence development while maintaining learner autonomy and relatedness through collaborative preparation processes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCollaborative competency development\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSignificant improvements in collaborative competencies (Cohen's d\u0026thinsp;=\u0026thinsp;0.51) and classroom engagement (Cohen's d\u0026thinsp;=\u0026thinsp;0.58) demonstrate the approach's effectiveness in cultivating participatory learning environments. These findings are particularly relevant given increasing emphasis on interprofessional collaboration and team-based care delivery in contemporary healthcare systems [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The World Caf\u0026eacute; component provides structured opportunities for inclusive participation and perspective sharing, while the debate structure introduces intellectual rigor and accountability for evidence-based positions.\u003c/p\u003e\u003cp\u003e These collaborative competency improvements likely reflect enhanced communication skills, increased comfort with diverse viewpoints, and strengthened abilities to synthesize multiple perspectives\u0026mdash;capabilities directly transferable to interprofessional practice contexts and patient care team dynamics.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplications for nursing education\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThese findings support systematic curriculum transformation incorporating integrated active learning approaches. Key implementation considerations include:\u003c/p\u003e\u003cp\u003eFaculty development requirements: Effective implementation demands comprehensive preparation encompassing pedagogical content knowledge, group facilitation skills, debate moderation expertise, and performance assessment capabilities. The 16-hour training protocol employed represents minimum foundation requirements with ongoing mentorship and competency assessment essential for sustainable implementation.\u003c/p\u003e\u003cp\u003eResource allocation considerations: The integrated approach requires increased instructional time allocation, flexible classroom configurations supporting small group activities, comprehensive library and database access for evidence-based preparation, and technology infrastructure supporting collaborative platforms.\u003c/p\u003e\u003cp\u003eAssessment adaptation needs: Traditional summative assessments inadequately capture the complex competencies developed through integrated active learning approaches. Performance-based assessments evaluating analytical reasoning processes, evidence synthesis quality, and collaborative problem-solving effectiveness provide more authentic evaluation aligned with intended learning outcomes.\u003c/p\u003e\u003cp\u003eSystematic curriculum integration: Optimal implementation involves coordinated integration across multiple courses rather than isolated interventions, promoting competency reinforcement, progressive skill development, and sustained learning culture transformation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eGlobal applicability and cultural considerations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWhile conducted in Taiwan's educational context, the theoretical foundations and pedagogical principles underlying this intervention demonstrate broad applicability across diverse cultural settings. However, implementation should thoughtfully consider local educational traditions, student communication preferences, cultural power distance orientations, and institutional learning expectations.\u003c/p\u003e\u003cp\u003eThe structured nature of both debate and World Caf\u0026eacute; methodologies provides sufficient flexibility for cultural adaptation while maintaining core educational principles. Future research should systematically examine implementation effectiveness across diverse cultural contexts, particularly comparing outcomes in collectivist versus individualist societies, to optimize global applicability and cultural responsiveness.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSeveral limitations warrant acknowledgment and consideration for future research. The single-institution design conducted within Taiwan's higher education context limits generalizability across diverse educational systems, student populations, and cultural settings. The 12-week intervention duration provides limited evidence regarding long-term competency retention, clinical practice transfer, or professional development sustainability.\u003c/p\u003e\u003cp\u003eThe quasi-experimental design, while appropriate for educational research contexts, precludes causal inferences equivalent to randomized controlled trials. Convenience sampling may introduce selection bias, potentially limiting external validity to volunteer participants with higher baseline motivation levels.\u003c/p\u003e\u003cp\u003eReliance on self-report outcome measures may introduce social desirability bias, though the use of validated instruments with strong psychometric properties and blinded outcome assessment mitigates this concern. Additionally, the inability to blind participants to intervention allocation, while unavoidable in educational research, may influence outcome reporting.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFuture research directions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSeveral priority research directions emerge from these findings: (1) multi-site randomized controlled trials across diverse institutional and cultural contexts to establish broader generalizability, (2) longitudinal follow-up studies extending into clinical practice settings to assess competency retention and patient care outcomes, (3) mechanistic investigations using neuroimaging or cognitive assessment tools to examine specific cognitive processes underlying observed improvements, (4) comparative effectiveness research systematically examining optimal pedagogical combinations and dosing parameters, and (5) technology-enhanced implementation studies addressing scalability, accessibility, and cost-effectiveness considerations.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis quasi-experimental study demonstrates that integrating debate-based learning with World Caf\u0026eacute; methodology significantly enhances critical thinking competencies, self-directed learning readiness, classroom engagement, and collaborative capabilities in nursing students. The moderate to large effect sizes observed suggest clinically meaningful educational benefits with substantial implications for nursing practice preparation and patient care quality.\u003c/p\u003e\u003cp\u003eThe evidence supports nursing education curriculum transformation incorporating interactive, evidence-based pedagogical approaches that more effectively prepare graduates for contemporary healthcare's analytical and collaborative demands. The synergistic integration of structured argumentation with inclusive collaborative dialogue generates educational benefits exceeding either approach implemented independently.\u003c/p\u003e\u003cp\u003eNursing educators should consider systematic adoption of this evidence-based innovation, particularly for courses addressing complex healthcare issues requiring sophisticated analytical reasoning and collaborative problem-solving capabilities. However, successful implementation requires comprehensive faculty development, adequate resource allocation, appropriate assessment system adaptation, and thoughtful curricular integration planning.\u003c/p\u003e\u003cp\u003eThese findings contribute to the expanding evidence base supporting active learning methodologies in nursing education and provide practical guidance for educators seeking to enhance critical thinking development. The integrated pedagogical approach represents a promising, evidence-based strategy for preparing nursing graduates equipped with essential competencies for safe, effective, and collaborative healthcare delivery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eATTLS: Attitudes Toward Thinking and Learning Survey; CCTDI-SF: California Critical Thinking Disposition Inventory-Short Form; GPA: Grade Point Average; PSCNI: Professional Self-Concept in Nursing Instrument; SCEQ: Student Course Engagement Questionnaire; SDLRS: Self-Directed Learning Readiness Scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from the Mackay Memorial Hospital Institutional Review Board (Protocol No. 20MMHIS250e) and was conducted according to Declaration of Helsinki principles. All participants provided written informed consent after comprehensive disclosure of study procedures, potential risks and benefits, confidentiality protections, and voluntary withdrawal rights.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets supporting this study\u0026apos;s conclusions are available from the corresponding author upon reasonable request and completion of appropriate data sharing agreements ensuring participant confidentiality protection and institutional approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no financial or non-financial competing interests that could inappropriately influence this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received support from the Teaching Practice Research Program of the Ministry of Education, Taiwan (Grant No. PMN1090421). The funding agency had no role in study design, data collection and analysis, data interpretation, or manuscript preparation and submission decisions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our sincere gratitude to the nursing students who voluntarily participated in this study and the faculty colleagues who provided instructional and logistical support throughout the intervention period. Special recognition goes to the research assistants who maintained rigorous data collection protocols and the independent statistician who conducted the randomization procedures. We also acknowledge the institutional support provided by Teaching Practice Research Program of the Ministry of Education (Project number PMN1090421).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e1.4. wrote the main manuscript text. And 2.3. prepared figures 1-3. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eInstitute of Medicine. The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press; 2011.\u003c/li\u003e\n\u003cli\u003eBenner P, Sutphen M, Leonard V, Day L. Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass; 2010.\u003c/li\u003e\n\u003cli\u003eFacione PA. Critical thinking: A statement of expert consensus for purposes of educational assessment and instruction. Millbrae, CA: California Academic Press; 1990.\u003c/li\u003e\n\u003cli\u003eNational League for Nursing. A vision for teaching with simulation. New York, NY: National League for Nursing; 2015.\u003c/li\u003e\n\u003cli\u003eKennedy RR. In-class debates: Fertile ground for active learning and the cultivation of critical thinking and oral communication skills. Int J Teach Learn High Educ. 2007;19(2):183-190.\u003c/li\u003e\n\u003cli\u003eBrown J, Isaac D. The World Caf\u0026eacute;: Shaping our futures through conversations that matter. San Francisco, CA: Berrett-Koehler Publishers; 2005.\u003c/li\u003e\n\u003cli\u003eBrown J, Isaac D, World Caf\u0026eacute; Community. The World Caf\u0026eacute; book: Shaping our futures through conversations that matter. San Francisco, CA: Berrett-Koehler Publishers; 2005.\u003c/li\u003e\n\u003cli\u003eGuglielmino LM. Development of the self-directed learning readiness scale. Doctoral dissertation, University of Georgia; 1977.\u003c/li\u003e\n\u003cli\u003eHandelsman MM, Briggs WL, Sullivan N, Towler A. A measure of college student course engagement. J Educ Res. 2005;98(3):184-191. doi:10.3200/JOER.98.3.184-192\u003c/li\u003e\n\u003cli\u003eGalotti KM, Clinchy BM, Ainsworth K, Lavin B, Mansfield AF. A new way of assessing ways of knowing: The attitudes towards thinking and learning survey (ATTLS). Sex Roles. 1999;40(9-10):745-766. doi:10.1023/A:1018816728669\u003c/li\u003e\n\u003cli\u003eFacione PA, Facione NC. The California Critical Thinking Disposition Inventory test manual. Millbrae, CA: California Academic Press; 1992.\u003c/li\u003e\n\u003cli\u003eArthur D. Measurement of the professional self-concept of nurses: Developing a measurement instrument. Nurse Educ Today. 1995;15(5):328-335. doi:10.1016/S0260-6917(95)80004-2\u003c/li\u003e\n\u003cli\u003eAbrami PC, Bernard RM, Borokhovski E, Waddington DI, Wade CA, Persson T. Strategies for teaching students to think critically: A meta-analysis. Rev Educ Res. 2015;85(2):275-314. doi:10.3102/0034654314551063\u003c/li\u003e\n\u003cli\u003eHuber CR, Kuncel NR. Does college teach critical thinking? A meta-analysis. Rev Educ Res. 2016;86(2):431-468. doi:10.3102/0034654315605917\u003c/li\u003e\n\u003cli\u003eVygotsky LS. Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press; 1978.\u003c/li\u003e\n\u003cli\u003eAmerican Nurses Association. Nursing: Scope and standards of practice. 3rd ed. Silver Spring, MD: American Nurses Association; 2015.\u003c/li\u003e\n\u003cli\u003eDeci EL, Ryan RM. Self-determination theory: Basic psychological needs in motivation, development, and wellness. New York, NY: Guilford Publications; 2017.\u003c/li\u003e\n\u003cli\u003eInstitute for Healthcare Improvement. The triple aim: Care, health, and cost. Health Aff. 2008;27(3):759-769. doi:10.1377/hlthaff.27.3.759\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Participant characteristics and baseline outcome measures (N=108)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eExperimental Group (n=65)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eComparison Group (n=43)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTest Statistic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDemographic Variables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years), M \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21.8 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.1 \u0026plusmn; 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et₁₀₆ = -1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.221\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026chi;\u0026sup2; = 3.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (27.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56 (86.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 (72.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCumulative GPA, M \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.64 \u0026plusmn; 0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.58 \u0026plusmn; 0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et₁₀₆ = 0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.518\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline Outcome Measures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSelf-directed learning readiness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e69.86 \u0026plusmn; 11.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71.23 \u0026plusmn; 10.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et₁₀₆ = -0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.528\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCollaborative competencies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61.45 \u0026plusmn; 9.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62.89 \u0026plusmn; 9.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et₁₀₆ = -0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.438\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eClassroom engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29.01 \u0026plusmn; 5.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29.74 \u0026plusmn; 4.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et₁₀₆ = -0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.453\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCritical thinking disposition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.68 \u0026plusmn; 0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.52 \u0026plusmn; 0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et₁₀₆ = 1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.311\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eProfessional self-concept\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.10 \u0026plusmn; 0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.18 \u0026plusmn; 0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003et₁₀₆ = -0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.582\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05; ***p\u0026lt;0.001\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Between-group differences in change scores from baseline to post-intervention (N=108)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" width=\"737\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome Variable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperimental Group (n=65) M \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComparison Group (n=43) M \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCohen\u0026apos;s d (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eSelf-directed learning readiness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e8.53 \u0026plusmn; 9.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e3.00 \u0026plusmn; 8.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e3.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e0.62 (0.21-1.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eCollaborative competencies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e6.31 \u0026plusmn; 8.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e2.18 \u0026plusmn; 7.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e2.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e0.013*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e0.51 (0.11-0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eClassroom engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e2.95 \u0026plusmn; 4.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e0.74 \u0026plusmn; 3.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e2.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e0.005*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e0.58 (0.18-0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eCritical thinking disposition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e0.42 \u0026plusmn; 0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e0.17 \u0026plusmn; 0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e2.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e0.032*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e0.44 (0.04-0.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 167px;\"\u003e\n \u003cp\u003eProfessional self-concept\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e0.23 \u0026plusmn; 0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e0.08 \u0026plusmn; 0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e0.248\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e0.22 (-0.16-0.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p \u0026lt; 0.05 following Benjamini-Hochberg correction for multiple comparisons\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Academic performance and satisfaction outcomes (N=108)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" width=\"709\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome Variable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eExperimental Group (n=65) M \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eComparison Group (n=43) M \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003et-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCohen\u0026apos;s d (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFinal course evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.49 \u0026plusmn; 0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.25 \u0026plusmn; 0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.007*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.53 (0.14-0.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCourse satisfaction rating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.43 \u0026plusmn; 0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.20 \u0026plusmn; 0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.022*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.48 (0.09-0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p \u0026lt; 0.05\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Critical thinking, Nursing education, Active learning, Collaborative learning, Debate-based learning, World Café methodology, Nursing pedagogy","lastPublishedDoi":"10.21203/rs.3.rs-6989212/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6989212/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Critical thinking competencies are fundamental for evidence-based nursing practice and patient safety. Traditional didactic teaching methods inadequately develop these essential skills in nursing students. While debate-based learning and World Café methodology individually show promise for fostering analytical reasoning, their combined effectiveness remains unexplored.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This quasi-experimental study involved 108 senior baccalaureate nursing students over 12 weeks. The intervention group (n=65) received integrated debate-based learning with World Café methodology, while controls (n=43) received World Café methodology alone. Primary outcomes measured critical thinking disposition, self-directed learning readiness, classroom engagement, and collaborative competencies using validated instruments administered at baseline and post-intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The intervention group demonstrated significantly greater improvements compared to controls: self-directed learning readiness (Cohen's d=0.62, p=0.003), collaborative competencies (Cohen's d=0.51, p=0.013), classroom engagement (Cohen's d=0.58, p=0.005), and critical thinking disposition (Cohen's d=0.44, p=0.032). Academic performance (p=0.007) and course satisfaction (p=0.022) were also significantly higher in the intervention group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Integrating debate-based learning with World Café methodology significantly enhances critical thinking competencies and collaborative learning in nursing students. This evidence-based pedagogical approach supports curriculum transformation to better prepare graduates for complex clinical decision-making.\u003c/p\u003e","manuscriptTitle":"Integrating debate-based learning with World Café methodology to enhance critical thinking in nursing students: A quasi-experimental study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-05 07:03:50","doi":"10.21203/rs.3.rs-6989212/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"be2968f4-75d9-445b-b89c-f71d8f01f619","owner":[],"postedDate":"August 5th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Withdrawn","date":"2026-05-06T11:25:53+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T11:41:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-05 07:03:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6989212","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6989212","identity":"rs-6989212","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}