Nurse Education in Practice 76 (2024) 103918

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Nurse Education in Practice

journal homepage: www.elsevier.com/locate/issn/14715953

Combination of concept maps and case-based learning in a flipped

classroom: A mixed-methods study
Guiru Xu 1, Yan Lin 1, Yuping Ye , Weiwei Wu , Xuan Zhang, Huimin Xiao *
School of Nursing, Fujian Medical University, Fuzhou, China

A R T I C L E I N F O A B S T R A C T

Keywords: Aim: This study aimed to evaluate the impact of a hybrid learning method on the academic achievements,
Concept maps learning skills and experiences of undergraduate nursing students.
Case-based learning Background: Case-based learning is a student-centered approach that is commonly integrated into the flipped
Flipped classroom
classroom model in nursing education. However, effectively combining the flipped classroom model and case-
Nursing education
based learning into a hybrid learning format is challenging. To address this gap, this study integrated concept
maps with case-based learning and the flipped classroom and evaluated the impact of this hybrid learning
method on the academic achievements, learning skills and experiences of undergraduate nursing students.
Design: A mixed-methods approach, including a quasi-experimental study and semi-structured interviews, was
employed.
Methods: A total of 277 undergraduate nursing students participated, with 136 students in the control group
undergoing case-based learning and 141 students in the experimental group taught using the hybrid learning
approach, which combined concept maps, case-based learning and a flipped classroom. The study assessed self-
directed learning, critical thinking, learning strategy and curriculum grades in both groups before and after the
intervention. Additionally, students in the experimental group participated in semi-structured interviews.
Results: The quantitative findings indicated that both case-based learning and the hybrid learning method
(combined concept maps, case-based learning and a flipped classroom) had similar impacts on the curriculum
grades, self-directed learning, cognitive maturity and learning strategy of nursing students. The qualitative re­
sults further demonstrated how the hybrid approach facilitated integrated learning, promoted self-evaluation,
aided adaptation to the flipped classroom and enhanced teacher-student interaction.
Conclusions: Combining case-based learning, a flipped classroom and concept maps is an effective learning
approach for undergraduate nursing students. It may improve students’ self-directed learning, cognitive maturity
and learning strategy. Additionally, concept maps are a beneficial supplement to case-based learning and a
flipped classroom in terms of guiding integrated learning, promoting self-evaluation, enhancing adaptation to a
flipped classroom and increasing interaction between teachers and students and between classmates.

1. Introduction education (Diel et al., 2021; Yao et al., 2023). However, the integration
of FC and CBL into hybrid learning is challenging due to the potential
Nursing practice is evolving to become more dynamic, unpredictable fragmentation of knowledge through micro-learning videos. To address
and responsive. Nursing students are increasingly expected to identify, this, the current study incorporated concept maps (CMs) into a hybrid
analyze, assess and apply theory to address unstructured patient sce­ learning method that combines FC and CBL and examined its impact on
narios (Hwang et al., 2022). Case-based learning (CBL) is a learning achievements, skills and experiences.
student-centered approach that enables students to actively evaluate CBL is an active learning strategy centered on students and patients
clinical scenarios and tackle challenges (Shohani et al., 2023). It is (Thistlethwaite et al., 2012). In the practical application of CBL, students
frequently integrated into the flipped classroom (FC) model in nursing engage in self-directed and collaborative learning to understand

* Corresponding author.
E-mail address: huimin_xiao@126.com (H. Xiao).
1
Guiru Xu and Yan Lin contributed equally as a first author of this study.

https://doi.org/10.1016/j.nepr.2024.103918
Received 8 September 2023; Received in revised form 7 February 2024; Accepted 8 February 2024
Available online 14 February 2024
1471-5953/© 2024 Elsevier Ltd. All rights reserved.
G. Xu et al. Nurse Education in Practice 76 (2024) 103918

essential materials, discuss clinical cases and devise solutions. CBL has September 2019 and January 2020. They were all third-year students
been shown to enhance nursing students’ theoretical comprehension, and were assigned to two classes, with 136 students in class A and 141
clinical reasoning, independence, problem-solving capabilities and more students in class B. A cluster sampling method was adopted to assign the
(Chan et al., 2016; Gholami et al., 2017; Pilcher, 2018). However, two classes into the control or experimental groups. Class A was the
topic-specific scenarios in CBL may not cover all aspects of the required control group and underwent CBL and class B was the experimental
knowledge. This can lead to students overlooking critical information group and was taught using the CCF.
elements, limiting the development of comprehensive knowledge sys­
tems. Previous research has indicated that the time spent on consoli­ 2.3. Intervention
dating students’ expertise was limited in CBL, hindering the
co-construction of meaningful learning at a higher level (This­ This study was conducted using the geriatric nursing course, a 27-
tlethwaite et al., 2012; Chan et al., 2016). Nordquist et al. (Nordquist hour mandatory course for third-year undergraduate nursing students.
et al., 2012) also found that most students perceived CBL discussions as The course comprised 15 hours of lectures and 12 hours of seminars.
superficial, rarely delving deeply into the topics raised. Thus, CBL re­ Three teachers were responsible for both groups. All the teachers were
quires robust facilitation to maintain focused discussions. females with master’s or doctoral degrees and 13 years of teaching
The FC is a blended learning method that replaces traditional class­ experience on average.
room lectures with ‘homework’ or out-of-classroom education (Pilcher,
2018; Oliver and Luther, 2020). Its group learning environment trans­ 2.3.1. Experimental group
forms into a dynamic, interactive space where teachers can guide stu­ The experimental group was taught using the CCF (Fig. 1), which
dents towards a deeper and more participatory application of encompassed three main sections:
fundamental concepts and subjects (Sullivan, 2022). Prior studies on
nursing education, including meta-analyses (Xu et al., 2019; Barran­ 2.3.1.1. Before class. The instructors designed and uploaded nine case
quero-Herbosa et al., 2022), have demonstrated that FC can significantly scenarios, 45 pre-class videos and a 10-session pre-test online through
enhance students’ academic performance, self-directed learning abilities the Xuexitong system. Students underwent self-learning on the Xuex­
and critical thinking disposition. However, student satisfaction with FC itong system, had a group discussion on the cases and prepared for in-
is relatively low, likely due to the heavy learning load (Ding et al., 2021; class presentations. Additionally, the instructors created 51 CMs for
Dong et al., 2021). Additionally, micro-learning resources are likely to use during the in-class stage.
fragment knowledge, which may hinder the development of a robust
knowledge system (Lundin et al., 2018; Ma et al.,2019). Therefore, 2.3.1.2. In class. The instructors used the CMs to provide a brief review
exploring innovative approaches to building an online self-guided of the pre-learned material before introducing the cases. They then
learning program complemented by offline teacher-guided classes is invited a student to present their group’s answers to the case, using the
crucial. CMs to guide students in integrating and gaining a deeper understanding
CMs are graphical tools used to represent knowledge and they were of the information, particularly in connecting old knowledge to new
developed based on Ausubel’s constructivist theory (Ausubel,1963). information.
According to Ausubel, learners think and learn through concepts.
Meaningful learning occurs when new information is integrated into an 2.3.1.3. After class. Instructors uploaded the CMs and related teaching
existing knowledge schema (Ausubel,1963). CMs enable learners to resources to the online learning platform to aid students in knowledge
integrate knowledge by subsuming, gradually distinguishing and consolidation and further exploration. The platform also provided
reconciling concepts. They aid in organizing individual thoughts by question-and-answer services for students and teachers, allowing stu­
linking related concepts in circles or boxes. CMs have been shown to dents to ask questions and receive timely answers both before and after
enhance students’ knowledge integration, compensate for knowledge classes.
isolation deficiencies, strengthen autonomous learning abilities and
reduce learning anxiety (Thomas et al., 2016; Chen and Hwang, 2019; 2.3.2. Control group
Machado and Carvalho, 2020; Kusumadewi, Kusmaryono 2022). In the control group, a CBL approach (Fig. 2) was employed
Prior studies have combined CMs with CBL or FC as an alternative to following Williams’ CBL process (Williams, 2005). The instructors
traditional lecture-based approaches in medical education (Fischer created nine case scenarios and distributed them to students before
et al., 2019; Peñuela-Epalza, De la Hoz 2018; Nighojkar et al., 2021). classes. Students were expected to preview the textbooks and become
However, there is limited research exploring the impact of integrating familiar with the cases. During classes, the instructors delivered
CMs into CBL-based FC tutorials on nursing education quality from a knowledge using the CBL method and posed questions related to the
comprehensive perspective. Therefore, this study aimed to investigate cases and preview work. After classes, students were tasked with
the effects of combined CMs and CBL in FC (CCF) on academic drawing analytical conclusions for the cases based on the teacher’s ex­
achievements, learning skills and experiences among undergraduate planations to solidify their understanding.
nursing students.
2.4. Outcome measures
2. Methods
2.4.1. Curriculum grades
2.1. Study design Curriculum grades were assessed to measure students’ academic
achievement and included a formative evaluation (50%) and a final test
This was a mixed-methods study that combined a quasi-experimental (50%). The formative evaluation of the control group included atten­
design with semi-structured qualitative interviews. dance (5%), homework (20%), quizzes (15%) and an experimental
report (10%); that of the experimental group involved attendance (5%),
2.2. Setting and sample online course learning (video viewing 10%, online quizzes 5%, discus­
sion 5% and homework 5%), classroom participation (10%) and an
Based on Betihavas et al., (2016) study on the FC and academic experimental report (10%).
outcomes, a sample size of 210 with an effect size of 0.5 was calculated
using G*power. In this study, 277 undergraduate nursing students were
recruited from a medical university in Fuzhou, southeast China, between

2
G. Xu et al. Nurse Education in Practice 76 (2024) 103918

Fig. 1. Concept maps in the case-based flipped classroom for the experimental group.

Fig. 2. Case-based learning in the control group.

2.4.2. The Self-Directed Learning Instrument (SDLI) “What did not work well and why?”.
The SDLI was used to measure nursing students’ self-directed
learning in our study. It was developed by Cheng et al. (2010) and in­ 2.5. Data collection
cludes four dimensions and 20 items. It is scored on a 5-point Likert
scale, with higher total scores indicating better self-directed learning. Its Curriculum grades were provided by the three instructors based on
Cronbach’s α coefficient was 0.916 in Cheng’s (Cheng et al., 2010) study students’ academic performance. Research assistant A (YY) collected
and 0.930 in this study. questionnaire data using the SDLI, the CTDI-CV and the CSLDQ before
and after the course. A total of 277 valid questionnaires were collected,
2.4.3. The Critical Thinking Disposition Inventory-Chinese Version (CTDI- with a 100% effective participation rate. Following the course, 33 vol­
CV) unteers from the experimental group also participated in semi-
The critical thinking of participants was evaluated using the CTDI- structured interviews. Research assistant B (LY) conducted these in­
CV. It was developed by Peng et al. (2004). The CTDI-CV covers seven terviews on an individual basis, with each interview lasting between 20
dimensions and has 70 items. Each item is scored on a 6-level scale. A and 60 minutes.
total score of greater than 280 points indicates positive critical thinking
ability. The Cronbach’s α coefficient of CTDI-CV was 0.900 in a previous
2.6. Data analysis
study (Peng et al., 2004) and 0.924 in our study.
SPSS version 25.0 was used to analyze the quantitative data.
2.4.4. The College Students’ Learning Strategy Questionnaire (CSLDQ)
Descriptive statistics such as the mean and standard deviation were used
The CSLDQ that was designed by Yang (2002) was used to evaluate
for continuous variables when the data were normally distributed.
the learning strategy of nursing students in the present study. The
Otherwise, medians and interquartile ranges were used. A chi-square
CSLDQ evaluates four dimensions and has 49 items. A 5-point Likert
analysis was used to compare the differences in baseline variables be­
scale is used in its scoring system. Higher total scores indicate a stronger
tween the two groups. Independent sample t-tests, Mann–Whitney U
ability to use learning strategies. The Cronbach’s α of the CSLDQ was
tests and analyses of covariance were used to detect significant differ­
0.933 in a study by Yang (2002) and 0.969 in the present study.
ences between the two groups. A paired t-test or a Wilcoxon test was
employed to detect significant differences within groups. A P < 0.05 was
2.4.5. Semi-structured interview questions
considered statistically significant.
Open-ended questions were developed to explore the learning ex­
The first and second authors, who had a background in nursing ed­
periences of the students taught using the CCF. These included “How
ucation and qualitative research methodology, analyzed the interviews
was your experience with the CCF?” “What worked well and why?” and
using qualitative content analysis (Graneheim and Lundman, 2004).

3
G. Xu et al. Nurse Education in Practice 76 (2024) 103918

After the interview, the audio was transcribed. The interview transcripts

0.572

0.698

0.457

0.829

0.871
were then read several times to ensure overall understanding. Mean­

P4
ingful sentences or paragraphs were identified, condensed in the context
of an interview and extracted to form primary codes. Then, related
primary codes were classified into the same sub-themes based on simi­

–0.566

–0.388

–0.744

–0.216

–0.162
larity and dissimilarity analyses. Afterwards, similar subcategories were

z4
merged to form a main category and the study themes were ultimately
determined. In cases of disagreement, the first two authors reflected on
and discussed them to come to an agreement.

0.177

0.079

0.714

0.920

0.246
P3
2.7. Ethical approval and informed consent

The Ethics Committee of the corresponding author’s university

–1.350

–1.754

–0.367

–0.101

–1.161
provided ethical approval for this study. Prior to the study, all adult

z3
participants were informed of the objectives and procedures of the study
and were informed of their right to not participate or to withdraw from
the study at any time. Informed consent was obtained from all students

0.004*

0.019*

0.009*

0.041*

0.037*
who agreed to participate, and none declined participation or withdrew

P2
from this study.

3. Results

–2.885

–2.337

–2.629

–2.041

–2.089
z2
3.1. General characteristics of participants

The average age of student participants ranged from 20 to 21 years,

＜0.001*

＜0.001*

＜0.001*
with 87.0% being female and 13.0% being male. Approximately 44.0%

0.001*

0.038*
of the students selected nursing as their first choice on their national

P1
college entrance examination application, while 46.0% chose nursing as
their second choice. Additionally, 60.1% of participants desired to work
as nurses after graduation, 31.8% were unsure and 8.1% desired to work

–4.029

–3.935

–4.070

–3.358

–2.079
in other disciplines.
z1

3.2. Comparison of curriculum grades between the two groups

(66.00,77.00)

(19.00,24.00)

(19.00,23.00)

(13.00,16.00)

(13.00,16.00)
Table 1 shows that there was no significant difference in the
(n=136)
Post-test

formative evaluation, final exam scores, or total course scores between

72.00

22.00

21.00

14.00

15.00
the two groups (P > 0.05).

measures within experimental groups at pre-test and post-test.

3.3. Comparison of the self-directed learning between and within the two
Control Group

(18.00,23.00)

(18.00,22.00)

(12.00,15.00)

groups (12.00,15.25)

measures within control groups at pre-test and post-test.

68.22±8.86
(n=136)
Pre-test

Table 2 indicates that significant improvements were observed in the

21.00

20.00

13.00

14.00

experimental and control groups in the total self-directed learning score

(P < 0.05) or its dimensions (P < 0.05) between pre-test and post-test.
measures between two groups at post-test.
measures between two groups at pre-test.
However, there was no significant difference between the two groups
(19.00,24.00)

(19.00,24.00)

(13.00,16.00)

(13.00,16.00)

in the total self-directed learning scores or its dimensions at the pre-test

72.13±9.45

and post-test (P > 0.05).

(n=141)
Post-test

22.00

21.00

15.00

15.00

3.4. Comparison of the CTDI between and within the two groups
Comparison of SDL between and within two groups.

Regarding the CTDI (Table 3), significant differences were found in

14.00 (12.00,15.25)
Experimental group

the “analytical ability” (P < 0.05) and “cognitive maturity” (P < 0.05)
dimensions in the experimental group between pre-test and post-test and
(60.00,74.00)

(18.00,22.00)

(18.00,22.00)

(12.00,15.00)
(n=141)
Pre-test

Table 1
66.00

20.00

19.00

13.00

Comparison of curriculum grades between the two groups.

z1/P1 Comparison of outcome
z2/P2 Comparison of outcome
z3/P3 Comparison of outcome
z4/P4 Comparison of outcome

Variables Experimental Control Group t P

Group
Plan and implementation

Formative 95.20（93.10, 94.40（92.00, 0.966

* With a power >0.98.

–0.043
evaluation 96.30） 97.75）
Learning motivation

Final exam 78.00（71.00, 77.00 (71.00, 0.756

Self-management

–0.240
Communication

84.00） 85.00)
Total Grades 84.50（78.43, 84.90（77.45, 0.479
Total score

–0.708
90.05） 89.75）
Table 2

Item

Note: Curriculum grades were assessed basing the formative evaluation (50%)
Note:

and the final test (50%).

4
G. Xu et al. Nurse Education in Practice 76 (2024) 103918

Table 3
Comparison of CTDI between and within two groups.
Item Experimental Group Control Group t1/z1 P1 t2/z2 P2 t3/z3 P3 t4/z4 P4

Pre-test Post-test Pre-test Post-test

(n=141) (n=141) (n=136) (n=136)

Total 278.50 281.50 275.59 279.39 -1.104 0.270 0.985 0.326 –1.185 0.236 –1.199 0.231
（251.00,305.00） （264.00,306.00） ±31.08 ±28.40
Find the 37.50 38.00 38.00 38.00 –0.762 0.446 –0.825 0.410 –1.197 0.231 –0.047 0.962
truth (33.00,45.00) (34.00,42.00) (32.00,42.00) (34.00,42.00)
Open mind 42.00 42.00 40.88±7.12 42.00 –0.506 0.613 -0.485 0.627 –1.502 0.134 –0.888 0.375
(37.00,46.00) (38.00,45.25) (38.00,45.00)
Analytic 41.46±6.28 43.26±5.43 40.50 42.49±5.64 –2.634 0.009* –1.867 0.062 –0.689 0.491 1.155 0.249
ability (37.00,45.00)
Systematic 37.00 38.00 37.00 37.67±6.04 0.072 0.943 –0.026 0.980 –0.327 0.744 –0.450 0.652
ability (34.00,41.00) (34.00,42.00) (34.00,41.00)
Confidence 39.00 38.00 39.00 37.57±6.38 –1.253 0.210 –1.866 0.062 –0.515 0.606 –0.902 0.367
(36.00,44.00) (34.00,44.00) (35.00,44.00)
Curiosity 42.25±6.36 42.66±5.67 40.00 41.50 –0.614 0.540 –0.415 0.678 –1.315 0.188 –1.637 0.102
(37.00,46.00) (37.00,45.00)
Cognitive 39.00 42.00 40.00 42.00 –2.490 0.013* –2.381 0.017* –0.028 0.978 –0.154 0.878
maturity (35.00,43.00) (38.00,46.00) (32.00,45.00) (37.00,46.00)

Note：z1/P1 Comparison of outcome measures within experimental groups at pre-test and post-test.
z2/P2 Comparison of outcome measures within control groups at pre-test and post-test.
z3/P3 Comparison of outcome measures between two groups at pre-test.
z4/P4 Comparison of outcome measures between two groups at post-test.
* With a power >0.98.

in the “cognitive maturity” dimension (P < 0.05) in the control group learning, adapting to FC, promoting self-evaluation and increasing
between pre-test and post-test. However, there was no significant dif­ teacher-student interaction.
ference between the two groups in the total CTDI scores or its di­
mensions at the pre-test and post-test (P > 0.05). 3.6.1. Guiding integrated learning
Students expressed that CMs could guide integrated learning by
3.5. Comparison of the CSLDQ between and within the two groups enriching their thinking from a basic level to a more comprehensive,
cross-linked level in the conceptual hierarchy. Student # 25 mentioned:
For the CSLDQ (Table 4), significant differences were observed in the “The CMs connect relevant knowledge and help us better understand the
total score and its dimensions in the experimental group (P < 0.05) and teaching content. For example, in medicine administration, the CMs
in the control group (P < 0.05) between pre-test and post-test. Mean­ draw our attention to previous knowledge about its function, mecha­
while, significant differences were observed between the two groups in nism, precautions and side effects.” Student # 2 said: “Previously, we
the total scores and in two dimensions (meta-cognitive strategy and may have simply assumed the causal link between health conditions
source management strategy) at the pre-test (P < 0.05). However, there from geriatric nursing books. The CCF taught me that everything is
was no significant difference between the two groups in the total CTDI interconnected, which helps us consider nursing challenges and goals in
scores or its dimensions at the post-test (P > 0.05). a more comprehensive and clinical manner.”.

3.6. Perspectives of students on the CCF 3.6.2. Adapting to FC

Students noted that the CMs reduced cognitive burden and helped
The qualitative data revealed four categories: guiding integrated them adapt to blended learning. Student # 12 stated: “FC, especially

Table 4
Comparison of CSLDQ between and within two groups.
Item Experimental Group Control Group z1 P1 t2/z2 P2 z3 P3 z4 P4

Pre-test Post-test Pre-test Post-test

(n=141) (n=141) (n=136) (n=136)

Total 152.00 173.00 161.50 171.00 4.993 <0.001* 3.547 <0.001* 2.466 0.014 0.808 0.369
(142.00,170.00) (150.00,189.00) (148.00,177.00) (153.50,190.50)
Cognitive 34.00 38.00 35.48±5.93 38.14±5.84 5.375 <0.001* 3.729 <0.001* 2.636 0.008 0.168 0.682
Strategy (31.00,38.00) (34.00,43.00)
Meta-cognitive 55.00 64.00 58.79±9.30 63.49±9.53 5.447 <0.001* 4.116 <0.001* 2.558 0.011 0.861 0.354
Strategy (51.00,62.00) (55.00,70.00)
Source 22.00 25.00 24.00 25.00 3.860 <0.001* 2.952 0.003* 1.717 0.086 2.393 0.123
Management (20.00,25.00) (21.00,28.00) (21.00,26.00) (23.00,28.00)
Strategy
Affective 43.00 46.00 43.84±6.83 45.93±6.91 3.659 <0.001* 2.506 0.013* 2.063 0.039 0.557 0.456
Strategy (39.00,48.00) (40.00,51.00)

Note:
z1/P1 Comparison of outcome measures within experimental groups at pre-test and post-test.
z2/P2 Comparison of outcome measures within control groups at pre-test and post-test.
z3/P3 Comparison of outcome measures between two groups at pre-test.
z4/P4 Comparison of outcome measures between two groups at post-test.
* With a power >0.98.

5
G. Xu et al. Nurse Education in Practice 76 (2024) 103918

online teaching micro-videos, tend to fragment knowledge. Fortunately, natural relationship between concepts from different subdomains
the CMs connected related concepts through links, allowing me to grasp through linking phrases and cross-links (Popova-Gonci and Lamb,
the whole picture.” Student # 16 said: “Concepts and their relationships 2012). They also show the systemic connections between old and new
were visually expressed by CMs. When I used them after class, I could knowledge (Novak and Cañas, 2006). In our study, the 51 CMs were well
quickly remember everything from the mental picture formed and the designed to review knowledge and guide student discussion in class. By
information was much more organized.”. watching and learning from the visual CMs, students could individually
connect knowledge in meaningful and elaborate ways, contributing to
3.6.3. Promoting self-evaluation comprehensive, organized conceptual networks of expertise (Nighojkar
The display of knowledge through CMs in the CCF offered students a et al., 2021). Therefore, students might have experienced a higher level
practical approach to analyze, reflect on and summarize their learning of integrative learning.
status. Student # 8 said: “In comparison to the teacher provided CMs, I Secondly, the CCF enables students to adapt easily to FC. This was
identified weaknesses in my learning structure, delved deeper into the achievable because CMs reduced the learning burden in FC by con­
potential causes and took action.” Student # 1 said: “During our pre­ necting fragmented information points (Kinchin, 2014). The brief and
sentations, everyone can see our case analysis results on the screen. If polished micro-courses recommended by FC neglect the intrinsic link
the analysis results are incorrect or incomplete, we will assess where we between information, which may result in the fragmentation of stu­
made mistakes.” Student # 2 said: “The CCF sets higher standards for dents’ knowledge (Ma et al., 2019). CMs have been recommended as an
self-directed learning compared with traditional educational paradigms. effective tool to integrate enormous volumes of learning materials into a
If I don’t complete the learning exercises before class, I won’t be able to diagram (Hill, 2006). In the present study, we employed 51 CMs to show
keep up with the pace of my teachers and classmates in class. Therefore, the entire structure of knowledge points in geriatric nursing, with the
I will adjust my study schedule for the next class.”. goal of ensuring the distinctive benefits of FC. Consequently, students
may avoid becoming disoriented due to the fragmented learning process
3.6.4. Increasing teacher-student interaction and progressively accept FC.
During teaching using the CCF, students reported increased inter­ Thirdly, the CCF can increase nursing students’ self-evaluation of the
action with teachers both before and after class. Student # 6 said: “If you learning process. Similarly, some researchers demonstrated that CMs
have any questions, you can ask the teacher directly online. On the Xuexi helped students assess their cognitive transformational processes
Tong platform, you can also communicate with your peers. Your ques­ (Popova-Gonci and Lamb, 2012; Rahnama and Mardani-Hamooleh,
tions are visible to everyone, and you can discuss and resolve them 2017). This is most likely because CMs provide a detailed, clear and
collaboratively.” Student # 13 said: “Even after class, we could leave any visual framework for presenting concepts and relationships and it can be
questions we have on the platform. Teachers would answer them or used for a follow-up learning approach (Hilbert and Renkl, 2007).
provide suggestions or comments online.”. Consequently, when students in our study saw the CMs in class or read
the CMs after class, they could make in-depth comparisons between
4. Discussion their understanding of the learning materials and these intuitive CMs,
assisting them to recognize misconceptions (Hwang et al., 2013),
Our study’s teaching program combined CMs, CBL and FC in an determine new educational needs and reorganize their conceptual net­
undergraduate nursing course. The results of our quantitative analyses works (Johnstone and Otis, 2006; Hwang et al., 2013).
showed that CBL and the CCF had similar impacts on the curriculum Additionally, the CCF is beneficial for increasing teacher-student
grades, self-directed learning, cognitive maturity and learning strategy interaction. This finding is consistent with those of previous studies
of nursing students. The qualitative findings provided additional support (Wei, 2021; Yeh, 2022). The CCF, characterized by student-centered
for how the CCF may facilitate integrated learning, promote self- active learning, provides a sequential and progressive learning
evaluation, adapt to FC and enhance teacher-student interaction. method. In our study, students learning using the CCF were encouraged
Our findings indicated that both CBL and the CCF had similar effects to watch lecture videos and engage in joint discussions on clinical sce­
on the curriculum grades, self-directed learning, cognitive maturity and narios before class, potentially fostering greater dialogue among stu­
learning strategy of nursing students, consistent with previous studies dents. During class, teachers could guide students to express their
(Rezaee and Mosalanejad, 2015; Busebaia and John, 2020; Fan et al., viewpoints through presentations, initiate group discussions and
2020). This similarity is attributable to the emphasis of both teaching actively participate in debates on new topics. Our study also used the
strategies on CBL, an active learning approach and a student-centered Xuexitong platform, an online virtual learning management system that
learning approach. Cognitive science researchers have proposed that offered discussion boards and chat rooms to students and professors.
classrooms employing active learning strategies may enhance student
engagement, knowledge retention and the transferability of content 4.1. Limitations
(Hood Cattaneo, 2017). In our study, both teaching models were rooted
in CBL principles; however, the CCF aligns with CMs, online learning This study has several limitations. Firstly, we only examined the
environments and video learning resources more than CBL. Students effects of the CCF on the geriatric nursing course at a Chinese institution.
being taught using either the CCF or CBL were encouraged to actively Therefore, caution should be exercised when applying our findings to
and interactively apply their knowledge to real-world issues and arrive other populations. Secondly, the quasi-experimental study design may
at solutions with the guidance of their instructor. They placed a greater not have entirely mitigated the potential impact of the Hawthorne effect.
emphasis on cultivating higher-order thinking skills in students than Future research could benefit from employing more robust study
passively imparting information. Therefore, the observed learning gains designs.
in each teaching approach were likely a result of the active-learning
instructional style (Riddell et al., 2017). 5. Conclusions
The qualitative data collected from the experimental group indicated
some unique characteristics of the CCF. Firstly, the CCF contributes to The current study suggests that the combination of CBL, FC and CMs
integrative learning through the use of CMs, which is consistent with the is an effective learning approach for undergraduate nursing students.
findings of previous studies (Vacek, 2009; Aberdeen et al., 2010; Khrais This student-centered, active teaching approach can potentially enhance
and Saleh, 2017). Integrating knowledge from various curricula and students’ self-directed learning, cognitive maturity and learning strate­
employing student-centered pedagogies are critical to developing an gies. Notably, CMs are beneficial supplements to CBL and FC, guiding
integrative strategy. As a student-centered tool, CMs demonstrate the integrated learning, fostering self-evaluation, aiding adaptation to FC

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and increasing interaction between teachers and students and between Fan, J.Y., Tseng, Y.J., Chao, L.F., Chen, S.L., Jane, S.W., 2020. Learning outcomes of a
flipped classroom teaching approach in an adult-health nursing course: a quasi-
classmates.
experimental study. BMC Med. Educ. 20 (1), 317. https://doi.org/10.21203/
rs.2.16988/v1.
Consent for publication Fischer, K., Sullivan, A.M., Krupat, E., Schwartzstein, R.M., 2019. Assessingthe
effectiveness of using mechanistic concept maps in case-based collaborative
learning. Acad. Med. 94 (2), 208–212. https://doi.org/10.1097/
Not applicable. acm.0000000000002445.
Gholami, M., Saki, M., Toulabi, T., Kordestani Moghadam, P., Hossein Pour, A.H.,
Funding Dostizadeh, R., 2017. Iranian nursing students’ experiences of case-based learning: a
qualitative study. J. Prof. Nurs. 33 (3), 241–249. https://doi.org/10.1016/j.
profnurs.2016.08.013.
No funding was obtained for this study. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research:
concepts, procedures and measures to achieve trustworthiness. Nurse Educ. Today
24 (2), 105–112. https://doi.org/10.1016/j.nedt.2003.10.001.
CRediT authorship contribution statement Hill, C.M., 2006. Integrating clinical experiences into the concept mapping process.
Nurse Educ. 31 (1), 36–39. https://doi.org/10.1097/00006223-200601000-00010.
Xiao Huimin: Writing – review & editing, Writing – original draft, Hilbert, T.S., Renkl, A., 2007. Concept mapping as a follow-up strategy to learning from
texts: what characterizes good and poor mappers? Instr. Sci. 36 (1), 53–73. https://
Software, Resources, Project administration, Methodology, Investiga­ doi.org/10.1007/s11251-007-9022-9.
tion, Conceptualization. Wu Weiwei: Methodology. Zhang Xuan: Hood Cattaneo, K., 2017. Telling active learning pedagogies apart: from theory to
Methodology. Lin Yan: Software, Investigation. Ye Yuping: Investiga­ practice. J. N. Approaches Educ. Res. 6 (2), 144–152. https://doi.org/10.7821/
naer.2017.7.237.
tion, Data curation. Xu Guiru: Writing – review & editing, Writing –
Hwang, G.J., Yang, L.H., Wang, S.Y., 2013. A concept map-embedded educational
original draft, Software, Methodology. computer game for improving students’ learning performance in natural science
courses. Comput. Educ. 69, 121–130. https://doi.org/10.1016/j.
compedu.2013.07.008.
Declaration of Competing Interest Hwang, G.J., Chang, C.Y., Ogata, H., 2022. The effectiveness of the virtual patient-based
social learning approach in undergraduate nursing education: a quasi-experimental
The authors declare that they have no known competing financial study. Nurse Educ. Today 108, 105164. https://doi.org/10.1016/j.
nedt.2021.105164.
interests or personal relationships that could have appeared to influence
Johnstone, A.H., Otis, K.H., 2006. Concept mapping in problem based learning: a
the work reported in this paper. cautionary tale. Chem. Educ. Res. Pract. 7 (2), 84–95. https://doi.org/10.1039/
b5rp90017d.
Data availability statement Khrais, H., Saleh, A., 2017. The outcomes of integrating concept mapping in nursing
education: an integrative review. Open J. Nurs. 07 (11), 1335–1347. https://doi.
org/10.4236/ojn.2017.711096.
The dataset is avaliable from the corresponding author on reasonable Kinchin, I.M., 2014. Concept mapping as a learning tool in higher education: a critical
request. analysis of recent reviews. J. Contin. High. Educ. 62 (1), 39–49. https://doi.org/
10.1080/07377363.2014.872011.
Kusumadewi, R.F., Kusmaryono, I., 2022. Concept maps as dynamic tools to increase
Acknowledgement students’ understanding of knowledge and creative thinking. Prem. Educ.: J.
Pendidik. Dasar Dan. Pembelajaran 12 (1), 12. https://doi.org/10.25273/pe.
v12i1.11745.
We thank the involved teachers and the students. Lundin, M., Bergviken Rensfeldt, A., Hillman, T., Lantz-Andersson, A., Peterson, L., 2018.
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