Effect of online flipped classroom and case-based learning approaches on nursing students' training in primary survey for neurotrauma care: a quasi-experimental study

Online Flipped Classroom (OFC) combined with Case-Based Learning (CBL) has been proposed to strengthen clinical reasoning and confidence in nursing education. Simulation-Based Learning (SBL) remains the standard for experiential practice. Comparative evidence on OFC + CBL versus SBL is limited, particularly when outcomes are assessed only at post-test. The primary aim was to compare OFC + CBL with on-site SBL using a quasi-experimental design. The OFC + CBL group comprised 114 third-year nursing students enrolled in the 2022 academic year. The SBL group served as a historical control, with records from 110 learners in the previous cohort under the same curriculum framework. Outcomes included knowledge test scores and self-reported confidence. As a secondary analysis, pre- and post-test changes were examined within the OFC + CBL group. For the SBL group, only post-test records were available. Statistical analyses included a chi-square test and a Mann–Whitney U test for between-group differences, and a Wilcoxon signed-rank test or McNemar’s test for within-group differences. Learners in the OFC + CBL group demonstrated higher post-test knowledge (Mdn = 7.0, IQR = 6.0–9.0) than those in the on-site SBL group (Mdn = 7.0, IQR = 5.0–8.0), with a significant difference (Z = -2.62, p = 0.009, r = 0.18), particularly on selected reasoning tasks, including breathing assessment, circulation management, and disability assessment. In other domains, post-test outcomes did not differ significantly between the OFC + CBL and SBL groups. Learners in the OFC + CBL group showed knowledge gains ranging from 15 to 57%, and confidence increased after the intervention. However, confidence was self-reported rather than assessed for competence. The practical impact of the change was minimal, and the OFC + CBL pattern can deliver experiential learning in clinical reasoning comparable to traditional on-site SBL. Because only post-test outcomes were measured and the SBL group served as a historical control, the findings should be interpreted cautiously. Further development of OFC + CBL should integrate skill-based training and validated skill assessments to ensure gains in both reasoning and psychomotor competence.