The effectiveness of outcome based education on the competencies of nursing students: A systematic review

    The effectiveness of outcome based education on the competencies of nursing students: A systematic review Katherine Tan, Chong Mei Chan, Pathmawathy Subramaniam PII: DOI: Reference:

S0260-6917(18)30056-X doi:10.1016/j.nedt.2017.12.030 YNEDT 3744

To appear in:

Nurse Education Today

Received date: Revised date: Accepted date:

2 May 2017 17 October 2017 28 December 2017

Please cite this article as: Tan, Katherine, Chan, Chong Mei, Subramaniam, Pathmawathy, The effectiveness of outcome based education on the competencies of nursing students: A systematic review, Nurse Education Today (2018), doi:10.1016/j.nedt.2017.12.030

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ACCEPTED MANUSCRIPT Title/Author biography Page

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THE EFFECTIVENESS OF OUTCOME BASED EDUCATION ON THE COMPETENCIES OF NURSING STUDENTS: A SYSTEMATIC REVIEW

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Katherine Tan, PhD candidate Department of Nursing Science Faculty of Medicine University of Malaya 50603 Kuala Lumpur, Malaysia

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Dr.Chong Mei Chan, PhD, MSC( Community Health ), BNSc, RN Senior Lecturer Department of Nursing Science Faculty of Medicine University of Malaya 50603 Kuala Lumpur, Malaysia Email: [email protected]. Dr.Pathmawathy a/p Subramaniam Doctorate in Health Sciences, M.Ed Nurse Consultant Nursing Synergy Private Limited 47640 Subang Jaya Selangor, Malaysia Email: [email protected].

Corresponding author: Katherine Tan, PhD candidate Department of Nursing Science Faculty of Medicine University of Malaya 50603 Kuala Lumpur, Malaysia Tel: +60379493675 Fax:+60379494636 Email: [email protected]. [email protected].

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Disclosure : The authors declare no personal conflict of interests.

Acknowledgement:

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The study was funded by postgraduate research grant (PG077-2016A) from the University of Malaya.

Author contribution:

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The authors, Katherine Tan and Dr.Chong Mei Chan have substantially contributed to the conception and design, data extraction, analysis and appraising the quality of the papers as well as drafting and critically revising the content of the review paper.

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Word count : 5366

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Dr.Pathmawathy has critically reviewed the final intellectual content of the paper.

ACCEPTED MANUSCRIPT INTRODUCTION Educating nurses for the 21st century practice is increasingly demanding due to the complexities

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of global healthcare and in meeting the learning styles of the Generation Y nursing students

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(Eckleberry-Hunt & Tucciarone, 2011; Thorne (2006)). Literatures revealed that the didactic

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method of traditional approach fails to appeal to the learning styles of Generation Y student

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nurses (Johanson, 2012; McCurry & Martins, 2010). Preparation of future nurses remains a great concern as nurse graduates must adequately be equipped with competencies to meet the

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demands of the workplace and profession (Klein, 2006). These concerns have led to a more learner centred nursing curriculum which focusses on the outcomes of learning rather than

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Valiga, 2012).

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maintaining with the content-saturated teacher-centred curriculum (Spector & Odom, 2012;

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Thus, Outcome-based Education ( OBE ), a performance based and learner-centred approach in education offers a powerful and appealing way of reforming and managing nursing education (Singh & Ramya, 2011). OBE emphasize on what learners should know, understand, demonstrate and how to adapt to future life roles (Killen, 2000). The nursing profession which require high level of competencies cannot have the exception of ignoring the quality of the product. For this reason, the effectiveness of OBE in improving the competencies of nursing students should be explored in depth before embracing OBE.

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BACKGROUND Newly employed nursing graduates seemed academically equipped as they enter the clinical

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setting but lacks the ability to apply their knowledge to practice especially in transferable skills

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such as problem solving, leadership, communication and critical thinking skills (Mtshali, 2005).

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The study by Arumugam, Thayalan, Dass, and Maniam (2014) showed that unemployment among graduate nurses in Malaysia was of major concern. The key findings were 65% of their

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respondents felt they did not have adequate skills and could not promote themselves during interview, 55% felt they did not have the necessary skills and confidence to apply for jobs

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outside the country and 65% strongly felt that primarily they lack English language proficiency and communication skills. Planners of nursing education is challenged to transform nursing

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curriculum into one which can narrow the theory-practice gap in order to prepare nurses capable of outstanding practice in the 21st century (Benner, 2012). Thus, OBE may be the effective approach to uplift the nurses’ competencies. Organizing education based on results and outcomes rather than curriculum coverage forms the basic concept of authentic Outcome-based education (Spady, 1988). OBE involves “starting with a clear picture of what is important for students to be able to, then organizing curriculum, instruction, and assessment to make sure this learning ultimately happens”(Spady, 1994, p. 1). The concept of OBE is considered synonymous with concepts such as competency-based education ( CBE ) and performance-based education (Morcke, Dornan, & Eika, 2013; Mtshali, 2005). Frank et al. (2010, p. 641) defines competency-based education as an “outcomes-based

ACCEPTED MANUSCRIPT approach to the design, implementation, assessment, and evaluation of [….] education programs”. Essentially competency based education focuses on learner performance and

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achieving learning outcomes (Pijl-Zieber, Barton, Konkin, Awosoga, & Caine, 2014) similar to the

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core principles of OBE. This review refers to OBE approaches as both OBE and CBE, and nursing

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competencies as “ measurable behaviors, knowledge, actions and skills essential to the nursing practice” as defined by the National League for Nursing Accrediting Commission ( NLNAC ) cited

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by Fitzpatrick (2009).

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The primary focus of OBE is achievement of intended outcomes. Spady ( 1994,p.49 ) describes outcomes as “…….what students actually can do with what they know and understand”,

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basically involving “…..actual results of learning that students visibly demonstrate”(p.76)

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described by verbs rather than just knowing or involving purely mental processes.

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Despite criticism, OBE is still appealing and has been widely advocated and implemented in medicine (Davis, 2003; Harden, 2007; Mukhopadhyay & Smith, 2010) ; pharmacy education (Ho et al., 2009); engineering (Adbdullah et al., 2009; Akir, Eng, & Malie, 2012) and in nursing (Kim, 2012; Singh & Ramya, 2011). As mentioned by Harden, Crosby, and Davis (1999), “ Although OBE has obvious appeal, research documenting its effects is fairly rare”. Nevertheless, some of the effects of OBE documented are improvement of generic and professional capabilities of pharmacy students (Ho et al., 2009); improved in medical knowledge and practical skills (Castel et al., 2011) and increased nursing students learning satisfaction (Goudreau et al., 2009).

ACCEPTED MANUSCRIPT Although OBE has been advocated and implemented in nursing education, this initiative lacks strong empirical research on the effectiveness of OBE approaches on competencies of nursing

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students.

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The purpose of this systematic review was to appraise and synthesize the best available

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empirical evidence to investigate the effectiveness of OBE approaches on the competencies of

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nursing student. The findings from this review aims to add more empirical evidences of OBE approaches in supporting the justification for the adoption of OBE to improve the quality of

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nurse graduates.

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Search Strategy

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REVIEW METHODOLOGY

The search strategy employed is based on the guidance of the Centre for Reviews and Dissemination ( CRD, 2009 ). Relevant studies were identified using combined approaches of electronic database search, hand-searching journals and visually scanning references from retrieved studies. The literature search was performed in July 2016. The initial search using search terms “outcome based education” AND “nursing curriculum” were entered into Google Scholar to identify pre-existing reviews addressing the question of interest (CRD, 2009). One qualitative systematic review (Dioso, 2012) on OBE in the Malaysian context was retrieved but failed to address the review question. Subsequently, a thorough search was made of eight electronic databases namely CINAHL, EBSCO host, SCIENCE DIRECT, PROQUEST, WEB OF SCIENCE, PUBMED, EMBASE, and SCOPUS without geographical or language filters but were

ACCEPTED MANUSCRIPT limited to articles published from 2006 to 2016. The search was conducted using combinations of keywords, MEsH terms and by breaking down the review question into concepts. The

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following is an example of a search syntax used : (“nursing students” OR “student nurses” OR

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“nursing graduates” OR “pre-licensure student nurses” OR “pre-licensure nursing students” OR

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“ Diploma student nurses” OR “baccalaureate nursing students”) AND (“outcome based education” OR "outomes-based education" OR "outcome based approach" OR "outcomes-

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based approach" OR "outcome based curriculum" OR "competency-based education" OR

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"competency-based approach" OR "competency-based curriculum" OR "competency -based teaching learning method"). The detailed search syntax for all databases search is available on

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request.

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reference list of articles.

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Subsequently, landmark papers and potential studies were also identified by scanning

This review aims to answer the following question: Can the implementation of OBE approaches as compared to the conventional nursing curriculum improve the competencies of nursing students? The review question is framed following the PICO elements/clauses: P ( Population ) – nursing students, I ( Intervention ) – OBE approaches, C ( Comparison ) – conventional nursing curriculum, O ( Outcome ) – improve nursing competencies. Study Inclusion and Exclusion Studies that met all the following criteria were retrieved and assessed for its methodological quality. 1.

The paper concerned nursing education/courses and nursing students.

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And investigated OBE and CBE approaches/interventions.

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And provided empirical or observational data from an experiment or observation of

And reported the effects of OBE approaches on the competency of nursing students.

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4.

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the effects of OBE approach

Exclusion criteria:

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1. Studies which do not evaluate the effectiveness of outcome-based approaches in the

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delivery of modules or subjects in nursing education; 2. studies of samples from post-graduate nursing students and other healthcare

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be different;

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professional students, as at this higher level, the skills set and outcomes measure would

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3. studies with incomplete reports.

Study screening and selection

There were 646 potential relevant publications identified through electronic database searching and none from other sources. The search hits were imported into EndNoteX7 and 180 duplicate records were removed. The remaining 466 records were screened initially by title and 280 records were excluded. In the second stage, 186 articles were screened for abstract and 121 abstract were rejected at this stage, which leaves 65 articles forwarded to the third stage for rigorous full text review according to the eligibility criteria. In this third stage, 55 articles were excluded as it could not meet all the inclusion criteria. Due to the limited number of relevant studies, a total of 10 eligible studies were maintained. After another rigorous full text review,

ACCEPTED MANUSCRIPT another three studies were excluded (Applin, Williams, Day, & Buro, 2011; Choi, Lindquist, & Song, 2014; Gholami et al., 2016) as these studies examined the effects of Problem-based

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learning ( PBL ) which is one of the many OBE teaching strategies but it does not examine the

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concept of OBE as a whole. Another study by Hsieh and Hsu (2013) was also excluded as the

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type of intervention was not reported although the study had focused on the outcome-based concept of assessment. The researchers contacted the corresponding author to obtain the

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missing information of the study via email but there was no respond. The study mainly

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identified the factors which had the greatest impact on students’ nursing competency but does not suggest that OBE approach improves nursing students’ competencies.

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As a result, a final total of six articles were subjected for critical quality appraisal. Figure 1

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illustrates the review process based on the PRISMA Flow Diagram.

Quality Appraisal

The six included articles were all quantitative studies, thus the standardised tool for assessing the quality of quantitative studies by the Alberta Heritage Foundation for Medical Research ( AHFMR ) was used (Kmet, Lee, & Cook, 2004). AHFMR composed of 14 items assessing the methodological features such as objective of the study, study design, sample/participants, risk of bias assessment, sample size, statistical methods, control of confounding factors and reported results and conclusions. The maximum possible score was 28 points. The summary score for each paper was calculated by summing the total score obtained across relevant items and dividing by the total possible score. The minimum threshold for inclusion of studies is determined by considering the distribution of the quality scores and the consideration of

ACCEPTED MANUSCRIPT limited number of relevant articles. Thus, two reviewers ( KT and CMC ) who had independently assessed the methodological quality of the articles had decided that the median quality score of

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50% and above would be the selected cut-point for article inclusion. Cohen’s kappa for inter-

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rater agreement between the 2 reviewers was 0.667 which is categorised as good agreement.

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The third reviewer was not needed as consensus was met. Due to the limited number of relevant studies, the quality scores of 0 – 50% were considered as low quality ( high risk of bias )

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and studies would be excluded, 50-75% were considered as moderate quality ( moderate risk of

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bias ) and 75-100% were considered as high quality ( low risk of bias ) were established. Table 1 summarizes the overall quality score for the 6 studies and the inter-rater agreement for

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inclusion of studies is attached.

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Data extraction and synthesis

A self- developed Data Extraction Form adapted from the Cochrane Collaboration was used by the two reviewers ( KT and CMC ) independently to extract data from the included studies. Any discrepancies were resolved through discussion and reconciled by mutual consensus. Data extracted included details about author, year of publication, study design, study location, characteristics of sample participants, OBE interventions, comparison interventions, key outcome measures in the domains of knowledge, skills, and attitude/behaviour and finally the key conclusions. Given the heterogeneity of the study designs and outcome measures, a metaanalysis was not possible. Review findings were organized into primary outcome measures ( competencies in terms of knowledge, skills, and attitude ) and secondary outcome measures (

ACCEPTED MANUSCRIPT eg, student satisfaction, metacognitive abilities and cognitive load ). Finally, another reviewer ( PS ) critically reviewed the data.

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In summary, this study design employed is a systematic review of interventional experimental

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studies which aim to investigate the effectiveness of OBE approaches on the competencies of

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nursing students. Relevant studies were identified using combined approaches of electronic database search without geographical or language filters but were limited to articles published

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from 2006 to 2016, handsearching journals and visually scanning references from retrieved

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studies.

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Overview of the included studies

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RESULTS

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The six included studies were published between 2009 and 2016 as described in Table 2. Three of the studies were conducted in Iran (Nadery, Baghaei, Mohammad pour, Aliramaei, & Ghorbanzadeh, 2012; Soheili, Maslak, Mohamadpour, Khalkhali, & Rahmani, 2015; Valizadeh, Mohammadpour, Parvan, & Lakdizaji, 2009) and had to be translated to English from Farsi by a translator who is proficient in both English and Farsi, two were conducted in Taiwan (Fan, Wang, Chao, Jane, & Hsu, 2015; Hsu, Pan, & Hsieh, 2016), and one in China (Wu, Wang, Wu, & Guo, 2014). Five of the studies employed a quasi- experimental design and one study employed the two groups pre-test and post-test experimental design. Participants in two of the six studies were second year nursing students enrolled in medical-surgical nursing course at college in Taiwan (Fan et al., 2015; Hsu et al., 2016). Another study by Wu et al. (2014) involved fifth year nursing undergraduates from two different classes. The other three studies involved nursing

ACCEPTED MANUSCRIPT students taking Intensive Care Unit ( ICU ) Course (Nadery et al., 2012), senior nursing students undergoing clinical training at the haemodialysis ward (Valizadeh et al., 2009) and senior

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nursing students enrolled in the coronary care unit course (Soheili et al., 2015) respectively.

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Demographics ( eg, age, gender, marital status, prior school performance) were reported for all

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six studies. Overall sample sizes were small, ranging from 26 to 312 participants and were

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Methodological quality

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mostly recruited via purposive and convenience sampling method.

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Given the limited number of relevant studies, all the six studies were included in the review. The methodological quality of four of the studies with quality scores ranging from 50%-54% were considered moderate and two of the studies with quality scores of 75%-79% were considered high quality. In the experimental study by Hsu et al. (2016), random allocation of participants was reported but there was lack of blinding of participants and assessors which is also rarely possible with educational research interventions. In the five quasi-experimental studies, three studies reported random allocation of their participants but the sample sizes for these studies are too small and two studies lack random allocation but participants and assessors were blinded. Only two included studies reported the control of confounding factors during their analysis of data. Overall the methodological quality of the included studies was only moderate as the sample sizes were too small to yield an appropriate effect size.

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Findings of the review

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The findings of the review ( Table 3 ) is presented according to the major components of the

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OBE/CBE conceptual framework which emphasizes on the OBE interventions including

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specification of learning outcomes, instructional strategies and assessment of outcome

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measures.

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OBE interventions

Two studies compared outcome-based education approaches with traditional objective based

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training (Hsu et al., 2016; Valizadeh et al., 2009). Four studies compared competency-based

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education approach with conventional teaching/training method (Fan et al., 2015; Nadery et

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al., 2012; Soheili et al., 2015; Wu et al., 2014). The study by Hsu et al. (2016) employed the outcome-based framework focussing primarily on outcome-based course design using concept mapping in the teaching strategies as compared to the objective-based curriculum design focussing mainly on lecture and group discussion. Similarly, the CBE curriculum employed by Fan et al. (2015) in their study also incorporated concept mapping as one of their instructional strategies as compared to traditional formal lectures.Valizadeh et al. (2009) used the OBE method of training in which the expected outcomes of the training in the hemodialysis ward were first determined via the Delphi Technique. Similarly, the CBE model was employed in which the educational outcomes of education at ICU (Nadery et al., 2012) and the communication competencies of nursing students (Soheili et al., 2015) were determined by the Delphi Technique prior to the interventions for the respective studies. Both these studies

ACCEPTED MANUSCRIPT reported that the training outcomes and the expected competencies as identified are made known to the participants prior to starting their respective training programs. However, the

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details of the OBE instructional strategies were not reported clearly in these three mentioned

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studies. Wu et al. (2014) used the nursing core competency standard education model

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incorporating teaching strategies such as problem-based learning (PBL ), scenario simulation, role playing, case analysis and cooperative learning as compared to the conventional teaching

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method comprising mainly lecture in the training of nursing undergraduates. It should be noted

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that in view of the heterogeneity of OBE interventions, it may cause bias in the results of the

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Primary outcome measures

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outcomes measured.

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Effect of OBE approaches on knowledge Nursing students’ knowledge acquisition was measured in four of the studies (Fan et al., 2015; Nadery et al., 2012; Valizadeh et al., 2009; Wu et al., 2014). Among these studies, the study by Fan et al. (2015) showed that the experimental group ( OBE approach ) had higher final grades in their medical-surgical nursing course than the control group ( t(307) = 3.04, p=.003 ). In the study by Wu et al. (2014), there was no significant difference between the experimental ( CBE ) group and the control group with regards to the mean scores of theoretical knowledge examination ( 76.08 ± 4.69 vs. 77.97 ± 6.31, p=0.160 ).The pre and post quasi-experimental studies by Nadery et al. (2012) and Valizadeh et al. (2009) showed a significant increase in the post test scores of cognitive skills with the experimental groups compared to the control groups with the both p values of less than 0.05. The cognitive skills in both of these studies were

ACCEPTED MANUSCRIPT evaluated using self-administered questionnaire and the details of the questionnaires were not reported. The study by Hsu et al. (2016) reported the use of the Knowledge Test of Neurological

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Nursing in its formative evaluation but the test scores was not reported, thus it was

Effect of OBE approaches on skills performance

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inconclusive whether there was knowledge gained following the OBE curriculum design.

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All the six included studies have looked into the evaluation of skills performance following OBE

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and CBE interventions showed improvement in skills in the experimental group except for the study by Hsu et al. (2016) which revealed an insignificant statistical difference in mean nursing

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competency scores between the experimental and control group ( 231.74 ± 27.34 vs 234.32 ±

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29.61 ).The study by Fan et al. (2015) demonstrated that the experimental group had higher

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final grades in their clinical practicum than the control group t( 307) = 3.38, p=0.001 after the implementation of the CBE curriculum. In the same study, significant improvement was shown in the total score for the self-evaluated core competencies ability in the experimental group after adjusting for metacognitive ability ( 5.14 vs. 4.92, p < 0.001 ).However, there was no difference in the 5-mini –OSCE scores for both groups. In the study by Wu et al. (2014), the mean scores of health information collection ( p=0.009 ), physical assessment ( p=0.001), scenario simulation ( p = 0.039 ) and communication skills ( p=0.046 ) in the experimental group were significantly higher than those of the control group, with the p value set 0.05. The study by Nadery et al. (2012) also showed that the clinical skills scores of the experimental group were significantly higher than the control group ( 162 ± 10.72 vs. 117 ± 25.01, p<0.05 ). Soheili

ACCEPTED MANUSCRIPT et al. (2015) revealed that communication skills scores were also higher in the intervention group after being trained with CBE ( p = 0.007 ).

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Three of the studies have used self-rated questionnaire to evaluate the skills performance and

Effect of OBE approaches on attitude/behaviour

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two studies, evaluation was done through observation using checklist.

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In the study by Valizadeh et al. (2009), the behavioural skills of nursing students during carrying

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out clinical procedures in the experimental group are significantly better in terms of mean clinical competency scores as compared to the control group ( 113.75±8.62 vs.102.42±9.68 ).

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The evaluation was done through observation following a checklist.

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Secondary outcome measures Participants’ satisfaction

Only one study (Hsu et al., 2016) evaluated participants’ satisfaction with outcome-based approach. The study reported that the mean learning satisfaction scores of the experimental group ( 41.79 ± 7.92 ) were higher than the control group( 41.60±9.64 ). Nevertheless, the experimental group students found that the use of concept mapping is productive but it has not affected their learning satisfaction. The study also demonstrated that the objective-based approach to neurological care education did not have any effect on students’ learning satisfaction.

Higher order thinking skills

ACCEPTED MANUSCRIPT Two of the included studies have considered evaluating the effect of OBE approaches on the cognitive load of students and the metacognitive abilities. Cognitive load refers to the mental

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stress and cognitive burden as described by Hsu et al. (2016). The study demonstrated that the

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mean cognitive load rating for the experimental group ( 9.75 ± 2.10 ) was lower than the

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control group ( 9.86 ± 2.01 ) following the use of concept mapping as an outcome-based approach intervention. However, the difference in the mean ratings between the two groups

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was not statistically significant after adjusting covariates. Nevertheless, the study concluded

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that the outcome-based approach using concept mapping could lower the cognitive load of students and cause higher learning satisfaction.

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Fan et al. (2015) looked into the metacognitive abilities which involves the evaluation of mental

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processes such as critical inquiry, reasoning, judgment, and creativity in solving problems. The

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study results revealed that there was a significant increase in the metacognitive inventory posttest scores from the pre-test scores of the experimental group ( p < 0.001 ) as compared to the control group. The findings from these 2 studies demonstrate that outcome-based interventions can have positive effects on the higher thinking order of nursing students.

DISCUSSION This systematic review, to some extent have demonstrated that OBE/CBE approaches in nursing education may contribute to the improvement in nursing competencies in the areas of

ACCEPTED MANUSCRIPT knowledge acquisition, skills performance, behaviour, and in contributing to higher learning satisfaction and achieving higher order thinking processes. In the competency area of

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knowledge, three of the studies (Fan et al., 2015; Nadery et al., 2012; Valizadeh et al., 2009)

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demonstrated higher knowledge acquisition and cognitive skills following OBE approaches. Four

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studies have revealed improvement in skills performance with evidence of achieving higher final grades in clinical practicum and self-evaluated core competencies ability (Fan et al., 2015);

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higher performance in health information collection, physical assessment, scenario simulation,

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and communication skills (Wu et al., 2014); higher scores in clinical skills in intensive care nursing (Nadery et al., 2012) and an improvement in communication skills of senior nursing

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students (Soheili et al., 2015). The behavioural skills which were reported in the study by

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Valizadeh et al. (2009) did not specify clearly which aspect of behaviour was assessed. Only one

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study (Hsu et al., 2016) reported higher learner satisfaction scores following outcome-based course design using concept mapping in neurological nursing but the difference was not statistically significant as the time of intervention was only 12hours which may be too short a duration to cause a significant effect on learners’ satisfaction. Evaluating students’ satisfaction can be very subjective but it is important in any course or training evaluation as students are regarded as the primary stakeholder, whose satisfaction is one of the important quality indicators of teaching (Roh, Lee, & Mennenga, 2014). On this basis, it is certainly recommended that future research on OBE should evaluate learners’ satisfaction.

The positive effects in most of the included studies may be contributed by the following factors identified in the review. Firstly, it was reported in two studies (Soheili et al., 2015; Valizadeh et

ACCEPTED MANUSCRIPT al., 2009) that the expected outcomes and core competencies of specific disciplines were defined by Delphi studies and standardized at the start of the training followed by the

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appropriate teaching methods to achieve the expected outcomes and competencies. Teaching

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steps were also designed and pre-programmed so that it can be followed clearly by the

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students (Nadery et al., 2012). This is an important aspect in the implementation of OBE method of curriculum and training as it demonstrates clarity of focus and designing down

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principles of OBE (Killen, 2000; Mukhopadhyay & Smith, 2010; Spady, 1994).

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Secondly, the incorporation of more appealing student centred instructional strategies such as concept mapping, reflective writing and clinical application of knowledge (Fan et al., 2015);

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problem based learning, scenario simulation and role playing (Wu et al., 2014); more hands-on

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teaching methods in groups (Nadery et al., 2012). These strategies require active participation

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of learners and in the process it engages learners. These claims are supported by Frantz and Mthembu (2014) whose systematic review highlighted that nursing students prefer learning styles which incorporate live examples and lots of interaction and using real-life experiences as teaching methodologies.

Thirdly, it was noted that all the selected participants were senior undergraduate nursing students and post registration nursing students undergoing specialized training. It could suggest that due to the level of maturity and greater learning experiences, these learners could adapt to the outcome-based approach of learning better. In addition, the theory underpinning OBE framework as mentioned by Morcke et al. (2013) is the Constructive Alignment Theory of learning (Biggs & Tang, 2011) where interconnected knowledge forms the basis of effective teaching. The OBE approaches which incorporate this theory can be beneficial to senior

ACCEPTED MANUSCRIPT students as they possess previous experiences which help them to build upon and construct new knowledge. Thus, future studies comparing the effects of OBE between junior and senior

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nursing students are recommended.

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The method of assessment and evaluation that was used to measure the competencies is an

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important aspect in this review. Three of the included studies (Fan et al., 2015; Hsu et al., 2016; Soheili et al., 2015) used self-rated competency questionnaire to evaluate the level of nursing

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competencies among learners. In OBE assessment, learners are encouraged as active

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participants in judging their own work (Mtshali, 2005). Nevertheless, according to Ross (2006), “self-assessment introduces construct irrelevant variance ( eg, inflation of grades, motivated by

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self-interest, underestimate achievement… ) that threatens the validity of grading”. The study

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concluded that the validity and reliability of self-assessment by students can be enhanced

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through proper training given to students about self-assessment and students’ self-assessment is compared against teacher judgments ( considered as the gold standard ). This should be considered for future research. Furthermore, a competency approach to assessment which is based on student’s performance in the clinical setting could have more validity as it takes into account the capacity of the student to integrate knowledge, values, attitudes and skills in practice (Fordham, 2005). In addition, a study by Casey and Clark (2014) pointed out the involvement of patient in the assessment of nursing students will add to the validity of students performance in practice. All of the included studies did not mention of follow up of assessment as, according to Spady (1994) one of the core principles of OBE is everyone can learn but at a different pace and that

ACCEPTED MANUSCRIPT students should be given the expanded opportunities to learn in terms of time. With this in mind, longitudinal studies to examine the effects of OBE should be considered.

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In any given educational research, confounding factors such as students’ demographic

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characteristic, previous experiences and academic performance, the learning environment and

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the quality of the teacher/faculty can greatly affect the performance of the students (Hsieh & Hsu, 2013). Thus, controlling these confounding factors during data analysis is important to see

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the true effect of the intervention. However, from the review findings, only two studies (Fan et

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al., 2015; Hsu et al., 2016) have considered controlling of confounders where it was revealed by Hsu et al. (2016) that there was no statistical significant in mean nursing competencies scores

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as compared to a positive effect in the study by Fan et al. (2015). This inconsistency should

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further justify the need to consider controlling of confounders in future studies on OBE.

The review findings also demonstrated the improvement of metacognition abilities and reduction of cognitive load among nursing students following outcome-based approaches. The effect of OBE on higher order thinking skills and mental processes of information in learners is greatly encouraged in any form of learning particularly in complex learning such as in nursing education (Chabeli, 2006). This area of cognitive skills evaluation needs further exploration to strengthen the empirical evidence to suggest that OBE can improve higher mental capabilities of nurses.

Lastly, five out of the six included studies were mainly from Asian countries and only one from Western country. Considering the concept of OBE is founded in United States and have been

ACCEPTED MANUSCRIPT adopted by many countries such as US, Australia, New Zealand, Canada, Hong Kong, Africa, this search result was disconcerting. The probable speculations could be the review was limited to

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10 years of publication and the study design used may not meet the inclusion criteria of this

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review. Thus, the researchers hope to consider further exploration in this area of interest in

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order to update this review with new evidences from the countries that were mentioned.

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Limitations

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Generally, the review evidences is not sufficiently robust to ascertain the effectiveness of OBE approaches compared to conventional approaches due to only six primary studies were

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identified, the small sample sizes in the included studies and lack of high methodological quality

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of these studies. The heterogeneity of the studies and small sample sizes also limits the ability

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to generalize the findings. It is also possible that not all relevant studies were retrieved and included in this review despite following a thorough search strategy. In addition, the evidences which mainly come from Asian countries may not be generalizable to other countries.

CONCLUSION

In summary, the findings from this review does suggest that OBE approaches in nursing education can have a positive effect on nursing students’ competencies in terms of knowledge acquisition, skills performance and attitude, in addition to improving higher thinking abilities, reducing cognitive load and achieving higher learner satisfaction. Only one study revealed that there was no difference in achievement of competency between OBE approach and the conventional methodology of training of nursing students. Based on the limitations as

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with larger sample sizes, evaluating other outcome measures such as student satisfaction,

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Adbdullah, S., O.K. Rahmat, R. A. A., Zaharim, A., Muhamad, N., Md. Deros, B., Kofli, N. T., . . . Azhari, C. H. (2009). Implementing Continual Review of Programme Educational Objectives and Outcomes for OBE Curriculum Based on Stakeholders’ Input. European Journal of Scientific Research, 29(1), 89 - 99. doi: http://www.eurojournals.com/ejsr.htm Akir, O., Eng, T. H., & Malie, S. (2012). Teaching and Learning Enhancement Through Outcome-Based Education Structure and Technology e-Learning Support. Procedia - Social and Behavioral Sciences, 62, 87-92. doi: 10.1016/j.sbspro.2012.09.015 Applin, H., Williams, B., Day, R., & Buro, K. (2011). A comparison of competencies between problembased learning and non-problem-based graduate nurses. Nurse Education Today, 31(2), 129134. doi: http://dx.doi.org/10.1016/j.nedt.2010.05.003 Arumugam, N., Thayalan, X., Dass, L. C., & Maniam, M. (2014). Unemployment among Graduate Nurses in Malaysia: A Case Study. Asian Social Science, 10(9). doi: 10.5539/ass.v10n9p227 Benner, P. (2012). Educating nurses: a call for radical transformation-how far have we come? J Nurs Educ, 51(4), 183-184. doi: 10.3928/01484834-20120402-01 Biggs, J., & Tang, C. (2011). Teaching for Quality Learning at University. What the student does (pp. 389). Casey, D., & Clark, L. (2014). Involving patients in the assessment of nursing students. Nursing Standard, 28(47), 37-41. Castel, O. C., Ezra, V., Alperin, M., Nave, R., Porat, T., Golan, A. C., . . . Karkabi, K. (2011). Can outcomebased continuing medical education improve performance of immigrant physicians? J Contin Educ Health Prof, 31(1), 34-42. doi: 10.1002/chp.20099 Chabeli, M. M. (2006). Higher order thinking skills competencies required by outcomes-based education from learners. Curationis, 29(3), 78-86 79p. Choi, E., Lindquist, R., & Song, Y. (2014). Effects of problem-based learning vs. traditional lecture on Korean nursing students' critical thinking, problem-solving, and self-directed learning. Nurse Education Today, 34(1), 52-56. doi: http://dx.doi.org/10.1016/j.nedt.2013.02.012 CRD. (2009). Systematic Review. CRD's Guidance for undertaking reviews in healthcare. Davis, M. H. (2003). Outcome-based education by Davis, Dundee Medical School. JVME, 30 (3), 227-232. Dioso, R. I. (2012). Qualitative Systematic Review of Literatures on Outcome-Based Education for Nursing Students. Malaysian Journal of Nursing, 3(3), 9-14. doi: http://www.researchgate.net/publication/256847093 Eckleberry-Hunt, J., & Tucciarone, J. (2011). The challenges and opportunities of teaching "generation y". J Grad Med Educ, 3(4), 458-461. doi: 10.4300/JGME-03-04-15 Fan, J.-Y., Wang, Y. H., Chao, L. F., Jane, S.-W., & Hsu, L.-L. (2015). Performance evaluation of nursing students following competency-based education. Nurse Education Today, 35(1), 97-103 107p. doi: 10.1016/j.nedt.2014.07.002 Fitzpatrick, J. J. (2009). How Do We Know Competence? Nursing Education Perspectives (National League for Nursing), 30(5), 271-271. Fordham, A. J. (2005). Using a competency based approach in nursing education. Nursing Standard, 19(31), 41-48. Frank, J. R., Snell, L. S., Cate, O. T., Holmboe, E. S., Carraccio, C., Swing, S. R., . . . Harris, K. A. (2010). Competency-based medical education: theory to practice. Med Teach, 32(8), 638-645. doi: 10.3109/0142159X.2010.501190

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Frantz, J., & Mthembu, S. (2014). . South Africa Journal of Higher Education, 28(6), 1814 - 1829. Gholami, M., Moghadam, P. K., Mohammadipoor, F., Tarahi, M. J., Sak, M., Toulabi, T., & Pour, A. H. H. (2016). Comparing the effects of problem-based learning and the traditional lecture method on critical thinking skills and metacognitive awareness in nursing students in a critical care nursing course. Nurse Education Today, 45, 16-21. doi: http://dx.doi.org/10.1016/j.nedt.2016.06.007 Goudreau, J., Pepin, J., Dubois, S., Boyer, L., Larue, C., & Legault, A. (2009). A second generation of the competency-based approach to nursing education. International Journal of Nursing Education Scholarship, 6(1), 1p-15. doi: 10.2202/1548-923X.1685 Harden, R. M. (2007). Outcome-based education--the ostrich, the peacock and the beaver. Med Teach, 29(7), 666-671. doi: 10.1080/01421590701729948 Harden, R. M., Crosby, J. R., & Davis, M. H. (1999). AMEE Guide No. 14: Outcome-based education: Part 1--An introduction to outcome-based education. Med Teach, 21(1), 7. Ho, S. S., Kember, D., Lau, C. S., Au Yeung, M. Y., Leung, D. Y., & Chow, M. S. (2009). Outcomes based approach to pharmacy curriculum development. American Journal of Pharmaceutical Education, 73(1), 1-9. Hsieh, S.-I., & Hsu, L.-L. (2013). An outcome-based evaluation of nursing competency of baccalaureate senior nursing students in Taiwan. Nurse Education Today, 33(12), 1536-1545. doi: http://dx.doi.org/10.1016/j.nedt.2013.01.012 Hsu, L.-L., Pan, H.-C., & Hsieh, S.-I. (2016). Randomized comparison between objective-based lectures and outcome-based concept mapping for teaching neurological care to nursing students. Nurse Education Today, 37, 83-90. doi: http://dx.doi.org/10.1016/j.nedt.2015.11.032 Johanson, L. (2012). Teaching the millennial generation: considerations for nurse educators. Nurse Educ, 37(4), 173-176. doi: 10.1097/NNE.0b013e31825a875a Killen, R. (2000). Outcomes-based Education : Principles and Possibilities. Unpublished manuscript. (Unpublished). Australia. Kim, H. S. (2012). Outcomes-based curriculum development and student evaluation in nursing education. J Korean Acad Nurs, 42(7), 917-927. doi: 10.4040/jkan.2012.42.7.917 Klein, C. J. (2006). Linking competency-based assessment to successful clinical practice. Journal of Nursing Education, 45(9), 379-383. Kmet, L., M., Lee, R., C., & Cook, L., S. (2004) Standard Quality Assessment Criteria For Evaluating Primary Research Papers From A Variety of Fields. (pp. 1-22). Canada: Alberta Heritage Foundation for Medical Research. McCurry, M. K., & Martins, D. C. (2010). Teaching undergraduate nursing research: a comparison of traditional and innovative approaches for success with millennial learners. Journal of Nursing Education, 49(5), 276-279. doi: 10.3928/01484834-20091217-02 Morcke, A. M., Dornan, T., & Eika, B. (2013). Outcome (competency) based education: an exploration of its origins, theoretical basis, and empirical evidence. Advances in Health Sciences Education, 18(4), 851-863. doi: 10.1007/s10459-012-9405-9 Mtshali, N. G. (2005). Developing an outcomes-based curriculumCurriculum Development in Nursing. Process and Innovation (pp. 176-194). London & New York: Routledge ( Taylor & Francis Group ). Mukhopadhyay, S., & Smith, S. (2010). Outcome-based education: principles and practice. J Obstet Gynaecol, 30(8), 790-794. doi: 10.3109/01443615.2010.505305 Nadery, A., Baghaei, R., Mohammad pour, Y., Aliramaei, N., & Ghorbanzadeh, K. (2012). Comparison of the Effect of Competency-Based Education Model and Traditional Teaching on Cognitive and Clinical Skills Learning among ICU Nursing Students. Iranian Journal of Medical Education, 12(9), 698-708 611p.

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Pijl-Zieber, E. M., Barton, S., Konkin, J., Awosoga, O., & Caine, V. (2014). Competence and competencybased nursing education: finding our way through the issues. Nurse Educ Today, 34(5), 676-678. doi: 10.1016/j.nedt.2013.09.007 Roh, Y. S., Lee, S. J., & Mennenga, H. (2014). Factors influencing learner satisfaction with team-based learning among nursing students. Nursing & Health Sciences, 16(4), 490-497. doi: 10.1111/nhs.12118 Ross, J. A. (2006). The Reliability, Validity, and Utility of Self Assessment. Practical Assessment, Research and Evaluation, 11(10), 1-13. Singh, M., & Ramya, K. R. (2011). Outcome Based Education. International Journal of Nursing Education, 3(2), 87-91. Soheili, A., Maslak, M. H., Mohamadpour, Y., Khalkhali, H., & Rahmani, A. (2015). THE EFFECT OF IMPLEMENTING COMPETENCY BASED EDUCATION MODEL ON NURSING STUDENTS' COMMUNICATION SKILLS. Journal of Urmia Nursing & Midwifery Faculty, 13(4), 328-337 310p. Spady, W. G. (1988). Organizing for Results : The Basis for Restructuring and Reform. Educational Leadership, 4-8. Spady, W. G. (1994). Outcome-based Education : Critical Issues and Answers. Arlington, VA: American Association of School Administrators. Spector, N., & Odom, S. (2012). Initiaveto Advance Innovations in nursing education. Journal of Nursing Regulation, 3(2), 40-44. Thorne, S. E. (2006). Nursing education: key issues for the 21st century. Nurse Educ Today, 26(8), 614621. doi: 10.1016/j.nedt.2006.07.010 Valiga, T. M. (2012). Nursing education trends: future implications and predictions. Nurs Clin North Am, 47(4), 423-434. doi: 10.1016/j.cnur.2012.07.007 Valizadeh, S., Mohammadpour, Y., Parvan, K., & Lakdizaji, S. (2009). The effect of outcome-based education on nursing students' clinical competency. Iranian Journal of Medical Education, 9(2), 157-165 159p. Wu, F.-q., Wang, Y.-l., Wu, Y., & Guo, M. (2014). Application of nursing core competency standard education in the training of nursing undergraduates. International Journal of Nursing Sciences, 1(4), 367-370. doi: http://dx.doi.org/10.1016/j.ijnss.2014.10.010

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Figure 1 : Review Process and selection of articles based on Prisma Flow Diagram

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097

For more information, visit www.prisma-statement.org.

ACCEPTED MANUSCRIPT Table 1 : Overall quality score for included studies Average Score (%)

Risk of bias

Rater 2

Hsu et al. 2016

75

75

75

Low

Fan et al. 2015

79

78.6

79

Low

Wu et al.2014

53.6

50

52

Nadery et al 2012

50

57

54

Valizadeh et al.2009

50

50

Soheili et al.2015

50

50

Include

High

Include

Moderate

Moderate

Include

Moderate

Moderate

Include

High

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Moderate

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Moderate

Moderate

Include

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50

Number of observed agreements: 5 ( 83.33% of the observations) Number of agreements expected by chance: 3.0 ( 50.00% of the observations) Kappa= 0.667

Include/Exclude study

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Rater 1

Inter rater Reliability

Level of quality

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Overall score ( 100% )

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Research Paper

SE of kappa = 0.287

95% confidence interval: From 0.104 to 1.000 The strength of agreement is considered to be 'good'.

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Fan et al. Taiwan/2015

Quasi experimental

312 secondyear undergraduate

Outcome-based concept mapping

The experimental group of student nurses were exposed to outcome-based neurological nursing training using concept mapping. Delivered by a welltrained graduate student with 30 years of clinical experience in the neurological field. To complete 12 h of neurological nursing education separately, including 4 h of laboratory exercises. Learning outcomes were determined. Teaching strategies were in the form of lecture, group discussion, concept demonstration and concept map construction in groups of 7-8 students.

The control group was exposed to objective based neurological nursing training. Intervention in the form of teaching. Delivered by an instructor of neurological nursing. Learning objectives were set. Teaching strategies includes lecture and group discussion. They also had to complete 12 h of neurological nursing education separately, including 4 h of laboratory exercises.

High

The experimental group (Group L) received the CBE approach. As an example, oncology was covered in an 8-

The control group (Group C) received 126 h (7-

High

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213 sophomore college nursing students enrolled in medical or surgical curriculum. Experimental group ( Class A & B ) n=107 Control group ( Class C & D ) n= 106

Content

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2 group pretest and post-test experimental design

Methodological Quality

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Hsu et al. Taiwan/2016

Comparison

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Participants

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Study Study (Country/Year) design

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Table 2 : Characteristics of eligible studies included for analysis

Competency Based Education ( CBE )

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hour unit across a 1.5week period, allowing students to build on their previous knowledge in identifying and solving problems to focus on the clinical application of knowledge rather than theoretical knowledge. Concept mapping was used to establish students' foundational knowledge (e.g., human anatomy and physiology)of oncology concepts to match a competency related to the application of basic biomedical sciences knowledge to explain the condition in oncology patients. Other learning activities were similar to those of the control group. To enhance the students' critical thinking capacity, written reflections were required at the end of the simulation course on pain assessment, to explore and cultivate students' critical inquiry, reasoning, judgment, and creativity in problem-solving situations.

hour/week ∗ 18 weeks) of traditional formal lectures and the course content followed human anatomy systems along with nursing interventions. The learning activities for each system included case presentations, group discussions, and simulation courses related to specific topics.

Core competency teaching places more importance to the cultivation of comprehensive ability of practice. The existing curriculum was restructured and additional courses were added with greater emphasis on more patient contact and professionalism based on core competencies. The new curriculum also adapted many diverse teaching methods that incorporate the traditional classroom teaching methods and PBL, scenario simulation and role playing.

The conventional teaching method is applied on the control group. Lessons are usually taught by the teacher introducing skills using multimedia courseware and blackboard accompanied by a

Wu et al. China/2014

Quasi experimental design

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nursing students from 2 campuses undergoing a medicalsurgical nursing course Experimental group n=163 Control group n=149

73 five year nursing undergraduates from 2 different classes. Intervention group – n=42 ( from the class o f 2007 ) Control group – n= 31 ( from the class of

Nursing core competency education/teaching

Moderate

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A course assessment was carried out which involves student self- evaluation, teacher evaluation and final examination. The major clinical nursing courses were evaluated by using 1. Comprehensive theoretical knowledge examination 2. Objective structured clinical examination In this study, the intervention group completed 3699 class hours and 283.5 credits based on the new curriculum.

Competency Based Education ( CBE )

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28 nursing students taking ICU course Experimental group ( 2 groups ) n=13 students Control group ( 2 groups ) n=15 students

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Quasiexperimental study

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Nadery et al. Iran/2012

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2008 )

The experimental group of 13 students underwent competency-based training in the internship ICU Course, is required to learn how to apply the developed clinical skills notebook for recording in the duration of 3 weeks. In the competency-based method all teaching steps are designed and preprogrammed. Only 1 developmental test required and the students still had to attend the classes until the end of the period. The teachers are required to identify the learning problems of each student and would try to solve them and giving them feedback. The teacher applied both the individual teaching methods like doing procedures individually, independently or under supervision and individual studying and group teaching methods like helping others with their procedure, observing the teacher or experienced nurses and clinical conferences.

verbal explanation or lecture. Practical work for students is then assigned, followed by feedback from the teacher. The control group completed 3492 class hours and 275 credits.

The traditional approach requires the control group of 15 students to attend the ICU internship course in 9 days during 3 weeks supervised by a teacher. There is no precise educational program or evaluation, but every teacher teaches the students based on his own experiences and available clinical facilities. The traditional clinical training method includes

Moderate

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Quasiexperimental study with pre-post survey design

26 nursing students in th their 7 Semester undergoing clinical training at the hemodialysis ward. Experimental group ( 2 groups ) n=12 students Control group ( 2 groups ) n = 14 students

Outcome-Based Education method of training

Soheili et al. Iran/2015

Quasiexperimental study

34 senior nursing students in th their 8 Semester enrolled in the coronary care

Competency Based Education ( CBE )

The OBE method of training was employed in the clinical education in the hemodialysis ward. The Delphi Technique was employed to determine the expected outcome of the training in the hemodialysis ward. A list of important competencies required was determined. Students’ cognitive skills were measured by pre and post-test and their behavioural skills were observed via checklist.

Traditional training

Moderate

The communication competencies were first determined by Modified Consensus Technique. The intervention group was taught via the competency based education model which was conducted in 4 steps: 1.Defining the tasks and activities that

Traditional teaching method

Moderate

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Valizadeh et al. Iran/2009

patient care, performing practical procedures independently or under teachers’ supervision, observation. Feedbacks to the students are disordered and are verbal.

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students were expected to achieve. ( Delphi ) 2 Standardizing competences to clarify the students' roles and responsibilities. 3 Conducting the educational program and subordinating it. 4 Evaluation ( based on self –reporting questionnaire ) The subjects were given guidelines designed for the clinical period according to the CBE Model and which included the list of main communication skills, goals, resources, action plans and the period’s content. The teacher was asked to teach according to the principles of CBE Model.

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unit course. Intervention group ( 2 groups ) n=18 students Control group ( 2 groups ) n = 16 students

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Table 3 : Results of main outcome measures for the 6 eligible studies

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Primary Outcomes Study/Year

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Significant increases of mean nursing competency scores in both groups from the pre-test to the post-test. There were no statistically significant differences in mean nursing competency score between the experimental group and the control group. The mean nursing competency score of the experimental group (mean = 231.74, SD = 27.34) was lower than the control group (mean = 234.32, SD = 29.61) at the post-test.

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Correct concept relationships (18.03 vs. 16.43), hierarchies (121.43 vs. 107.29), cross-links (57.46 vs. 36.86), and examples (4.43 vs. 3.71) of a scenario-based concept map had a higher mean score in Class A than Class B, but no significant difference.

Behaviour/Attitude

Fan et al. Taiwan/2014

The experimental group (Group L) had higher final grades in their medical–surgical nursing course than the control group (Group C), t(307) = 3.04, p = .003.

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Skills

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Secondary Outcomes

Experimental group had higher final grades in their clinical practicum than the control group t(307) = 3.38, p = .001, There was no difference in the 5station mini-OSCE scores for both groups. There was significant improvement in the total score for self- evaluated core competencies ability in the experimental group than in the control

Learning satisfaction The mean learning satisfaction scores of the experimental group (mean = 41.79, SD = 7.92) were higher than the control group(mean = 41.60, SD = 9.64 The experimental group's answers to open-ended questions showed more positive impression with concept map training (n =62) than the control group (n=52).

Cognitive Load The mean cognitive load scores of the experimental group (mean= 9.75, SD = 2.10) were lower than the control group (mean = 9.86,SD = 2.01) at the post-test.

Metacognitive abilities There was significant improvement in the total score for metacognitive ability in the experimental group than in the control group ( B=0.10, p< 0.05 ), after adjusting for covariates.

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The mean score of nursing comprehensive theoretical knowledge examination did not show any significant difference between the experimental and control group.

The objective structured clinical examination was used to evaluate students' clinical thinking, communicating and adaptability. The evaluation results shown that the mean score of the health information collection ( p=0.009), physical assessment (p=0.001), scenario simulation ( p=0.039 ) and communication skills ( p=0.046) in the experimental group were significantly higher than those of the control group.

Nadery et al. Iran/2012

The independent t-test on pretest scores on cognitive skills showed there was not a statistically significant difference between the two groups (p>0.05). But post-test scores on cognitive skills in the experiment group were significantly higher than those of the control group (P<0.05).

The results showed the mean and standard deviation scores in clinical skills obtained from the experiment group students (competency-based education) and control (traditional training) were 162±10.72 and 117±25.01, which were significantly greater in the experimental group (p< 0.05).

Valizadeh et al Iran/209

The mean cognitive scores of the experimental group in post-test is significantly higher than the control

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Wu et al. China/2014

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group ( B=0.28, p< 0.05 ), after adjusting for the metacognitive ability.

Students’ clinical competency in the experimental group was significantly higher than the control group.

The mean behavioural skills scores of the experimental group in post-test ( 113.75 ±8.62) is significantly higher than

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In the comparison of the communication skills scores of the two groups, the results showed that the intervention group's average was higher after being trained with the competency-based education and the difference was significant statistically (p=0.007). However, the difference wasn’t significant in other dimensions.

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the control group ( 102.42±9.68) in all cases and in total.

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group in all cases and in total. There was statistically significant difference between the 2 groups ( z=3.63, p=0.000)

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Highlights Positive effects on nursing students’ competencies were observed after OBE interventions.



Improvement in knowledge acquisition, nursing skills and attitudes were identified as primary

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Reduced cognitive load, higher thinking abilities and higher learner satisfaction were highlighted

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

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outcome measures.

as secondary outcome measures.

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and to explore other outcome measures.

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This review indicate the need for more robust experimental study designs with larger sample sizes

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