Effects of the BOPPPS model combined with case-based learning on knowledge acquisition and learning engagement in undergraduate nursing students: a multi-cohort quasi-experimental study

BACKGROUND: Healthcare-Associated Infection (HAI) prevention is a crucial competency in nursing education but is often taught through didactic lectures with limited application. This study evaluated the effectiveness of combining the Bridge-in, Objective, Pre-assessment, Participatory Learning, Post-assessment, and Summary (BOPPPS) model with Case-Based Learning (CBL) for HAI education using a non-equivalent control group design. METHODS: A quasi-experimental study with a historical control group was conducted over three consecutive academic years (2023-2025). Second-year nursing undergraduates enrolled in an elective HAI module participated. The 2023 cohort (control group, n = 21) received traditional lecture-based learning (LBL). The 2024 (n = 18) and 2025 (n = 25) cohorts (intervention group, total n = 43) received instruction redesigned using the BOPPPS framework with CBL. Knowledge acquisition was assessed via identical pre- and post-course tests, analyzed using analysis of covariance (ANCOVA) with pre-test scores as covariates. Post-course perceptions were measured using an 8-dimension, 5-point Likert-scale questionnaire. Data were analyzed following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines adapted for educational interventions. RESULTS: Baseline characteristics were comparable (pre-test score: LBL = 54.00 ± 6.49 vs. BOPPPS-CBL = 52.30 ± 7.11, p = 0.360, Cohen's d = 0.17). ANCOVA revealed that the BOPPPS-CBL group achieved significantly higher post-test scores after adjusting for baseline differences (adjusted mean = 87.19 vs. 73.61; mean difference = 13.58, 95% CI: 11.14-16.03, F(1,61) = 123.46, p < 0.001, partial eta-squared = 0.669). Within-group improvements were significant for both conditions (both p < 0.001). The intervention group reported significantly higher scores across all seven positive perception dimensions (all p < 0.001 after Bonferroni correction), including self-directed learning (4.07 ± 0.80 vs. 3.19 ± 0.68, Cohen's d = 1.15) and teacher-student interaction (3.98 ± 0.80 vs. 2.76 ± 0.94, Cohen's d = 1.43). Notably, they also reported higher perceived learning burden (3.98 ± 0.86 vs. 2.29 ± 0.96, p < 0.001, Cohen's d = 1.90). Sensitivity analyses showed consistent intervention effects across the 2024 and 2025 cohorts (cohort-by-interaction p = 0.737). Qualitative feedback highlighted enhanced knowledge application and autonomous learning skills. CONCLUSIONS: The BOPPPS-CBL model appears to be effective in enhancing HAI knowledge acquisition and fostering positive learning engagement among undergraduate nursing students. The increased perceived cognitive effort may represent 'productive cognitive engagement' rather than 'productive germane load'. This structured, active learning strategy offers a promising approach for teaching critical infection control competencies, though resource implications and design limitations warrant consideration. Institutions adopting this model should ensure rigorous case design and faculty development.