Medical education institutions continually explore innovative pedagogical approaches to enhance learning outcomes. Among these, numerous teaching strategies have garnered attention, offering distinct methodologies to engage students and improve learning efficacy. Effective lesson planning must cater to the diverse needs of students and support various teaching-learning modalities [33, 34]. Recognizing the interconnectedness of healthcare education disciplines, this systematic review, while centered on medical education, also included studies from nursing and health services management. These fields share common pedagogical frameworks and rely on active learning strategies to cultivate critical thinking and practical skills. The inclusion of nursing and health services management studies expands the scope of this review, offering valuable insights into the broader applicability of BOPPPS across healthcare education settings.
Traditional instructional frameworks, though widely used, often fail to foster active engagement. Table 2 presents a comparative analysis of these strategies, showcasing their theoretical foundations and practical benefits. For example, Understanding by Design (UbD) emphasizes goal-setting and planning, the Madeline Hunter Lesson Cycle focuses on teaching sequences, and the 5E Model promotes exploratory learning. While these frameworks have unique strengths grounded in cognitive, behaviorist, or constructivist theories, their practical applications may not fully integrate comprehensive, student-centered engagement. BOPPPS distinguishes itself with its holistic and structured framework that emphasizes participatory learning and continuous assessment, and this can be particularly valuable in environments where student engagement is traditionally low. Its integration of pre-assessment, participatory activities, and post-assessment ensures a cohesive learning experience. Beyond its primary application in medical education, BOPPPS has demonstrated effectiveness in nursing and health services management, making it a versatile model for clinical and healthcare education. This versatility suggests that BOPPPS can be adapted to various educational contexts, provided that careful attention is paid to institutional and cultural factors. Table 3 outlines our adaptation of BOPPPS, highlighting its structured approach and potential impact on diverse healthcare disciplines. However, prior studies, such as one focusing on Chinese medical students [35], have raised concerns about limited scope and variable methodological quality. Addressing these gaps, our study aims to evaluate the global applicability of BOPPPS, considering diverse cultural and educational contexts with rigorous inclusion standards.
In this systematic review, we examined 16 studies that implemented BOPPPS across various healthcare disciplines, including medicine, nursing, and health services management. Our findings indicated a significant improvement in the final examination scores of medical students, including nursing students when BOPPPS was employed. This improvement suggests that BOPPPS aids students in comprehending and applying knowledge more effectively during classroom learning, ultimately resulting in enhanced academic performance. Such improvement is pivotal for nurturing the clinical knowledge and skills of medical students, which are essential for their future roles as healthcare professionals. Another noteworthy outcome was the increase in student satisfaction. Most of the reviewed studies indicated that students favored BOPPPS teaching and reported higher satisfaction levels when compared to traditional teaching. This suggests that BOPPPS not only improves academic performance but also boosts students’ overall engagement and enthusiasm for the subject, making it a viable option for both motivation and learning outcomes in a variety of healthcare education settings.
This is particularly significant in maintaining student motivation and interest, especially in challenging medical courses. Our review also revealed improvements in classroom interaction. This heightened interaction could be beneficial in fostering collaboration skills that are vital for clinical practice, as well as improving communication between peers and between students and teachers. Through the adoption of BOPPPS teaching, there was an increased level of interaction among students and between students and teachers. This heightened interaction is critical for promoting collaboration, communication, and engagement among students, contributing to the establishment of a more positive and cooperative learning environment. Such interaction, once nurtured, could further contribute to the integration of teamwork and communication into students’ professional practice.
Furthermore, we observed enhancements in learning initiatives. Students exhibited higher levels of initiative in BOPPPS-modeled classrooms and were more willing to actively participate in the learning process. This reflects the success of BOPPPS in encouraging students to take an active role in mastering knowledge, rather than passively receiving information. In this context, we recommend that healthcare educators in diverse settings incorporate pre-assessment and post-assessment methods to monitor and support students’ learning initiatives effectively. Such learning initiative is vital for the long-term learning and professional development of medical students.
However, BOPPPS did not show consistent or significant improvements in problem-solving skills and critical thinking skills across the included studies. There could be several potential reasons behind this observation. Firstly, the nature of BOPPPS, which focuses on a structured and holistic approach to teaching, may prioritize the delivery of content and student engagement over explicitly targeting problem-solving and critical thinking skills. The emphasis on clear learning objectives and predefined activities might not inherently stimulate the development of these higher-order cognitive skills. Secondly, the evaluation criteria used in the studies might not have adequately captured the nuances of problem-solving and critical thinking. If the assessment tools primarily measured factual recall or lower-order cognitive skills, it might not have effectively reflected the impact of BOPPPS on more complex cognitive processes. Furthermore, the timeframe of most included studies may have been insufficient to capture the gradual development of these higher-order skills, which often require prolonged exposure to specific teaching methodologies. To address this, we suggest future research explore more specific interventions targeting critical thinking and problem-solving within the BOPPPS framework, as well as extending study durations to better evaluate these outcomes.
It is important to note that the outcomes of classroom interaction and self-study ability varied depending on the use of continuous or categorical variables, which may be attributed to the limited sample size in some studies. This suggests that future research should aim to standardize assessment tools and ensure larger, more diverse sample sizes to improve the reliability of results. In studies where sample sizes were constrained, the impact on statistical power becomes a pertinent consideration. Smaller samples may lead to increased variability, making it challenging to draw definitive conclusions. This emphasizes the need for future research endeavors to strive for larger and more diverse samples, ensuring the robustness and generalizability of findings. We will revise the discussion to provide more detailed insights into these factors, particularly the influence of different assessment methods (continuous vs. dichotomous variables) and sample size on the consistency of the results.
Overall, the study comparing the BOPPPS teaching strategy with traditional teaching yielded a positive conclusion. There are several reasons why BOPPPS is considered superior to traditional teaching strategies. First and foremost, traditional medical theory instruction often relies on cramming teaching, lacking clearly defined teaching objectives. Consequently, students may struggle to comprehend the learning objectives, leaving them without specific learning targets or a clear direction. In contrast, BOPPPS places students at the center of the classroom teaching process. This approach enables teachers to better understand students’ learning needs, leading to well-defined teaching objectives. Importantly, students can identify their own learning goals within BOPPPS, which provides direction and motivation, empowering them to become active participants in their learning journey. Teachers optimize the teaching mode by setting reasonable and effective teaching goals. Activities like pre- and post-tests allow for careful selection and tailoring of the teaching and learning content. Consequently, BOPPPS offers students clear teaching objectives and encourages active engagement, resulting in significant improvements in teaching effectiveness. Secondly, traditional teaching strategies often involve teachers delivering lectures while students passively receive information, characterized by rote learning and knowledge transfer. In contrast, BOPPPS places students at the forefront of the classroom, facilitating communication and discussion among peers and providing students with an active role in the learning process. Medical teaching teachers assume a guiding role, offering support and guidance throughout students’ learning journey. This approach fosters increased peer-to-peer interaction, encourages active identification, and stimulates critical thinking among students. Consequently, students’ independent learning abilities and their understanding of clinical knowledge are greatly enhanced. The application of BOPPPS cultivates students’ autonomy and self-study skills, thereby fostering their learning thinking, enthusiasm, and initiative, all of which are valuable in their future professional contexts. Thirdly, the BOPPPS places strong emphasis on student-teacher interaction, requiring teachers to possess advanced teaching abilities, rooted in a solid foundation of medical teaching skills and relevant theoretical knowledge. Teachers are expected to promptly address student learning issues and actively engage with students. Consequently, teachers’ teaching abilities are greatly improved, allowing them to achieve the desired medical practice teaching objectives more effectively.
Limitations
Several key limitations emerged in this review, primarily related to geographic concentration, publication bias, and substantial heterogeneity. Firstly, while our systematic review aimed to examine international studies on BOPPPS, all 16 studies included in the final analysis were conducted in China. This geographic concentration raises questions about the broader adoption of BOPPPS in clinical and health education globally.
Several factors may explain this observation. First, BOPPPS aligns closely with pedagogical priorities and challenges in Chinese educational settings, particularly in addressing active learning gaps in large-scale, test-driven environments. Second, while our search strategy included both English- and Chinese-language databases, many BOPPPS studies are published in Chinese, contributing to language and publication biases that are common in healthcare education research. Third, our inclusion criteria required studies to meet specific methodological standards, which may have excluded potentially relevant but lower-quality international studies.
The geographic concentration of studies in China has important implications for the generalizability of our findings. While the positive results observed in the Chinese context suggest that BOPPPS holds promise, these findings may not fully reflect the effectiveness of the teaching model in different educational and cultural settings. For example, differences in teaching styles, student characteristics, and institutional resources could affect how BOPPPS is implemented and its resulting impact in other countries. Future research should focus on including studies from a wider range of cultural and geographic contexts, which will help address the limitations posed by geographic concentration and enhance the global applicability of BOPPPS.
Another important limitation of this study is the potential for publication bias. While Egger’s test did not reveal statistically significant evidence of bias, the asymmetry observed in the funnel plot indicates a possible overrepresentation of studies with positive findings. This could arise from selective reporting of smaller studies with favorable outcomes, as studies with null or negative results are less likely to be published. Additionally, heterogeneity in study design and context may contribute to the observed asymmetry.
The substantial heterogeneity among the included studies further complicates the interpretation of the pooled effect size. Variations in study designs, sample sizes, and teaching contexts could contribute to differences in the observed effects, making it challenging to draw definitive conclusions regarding the overall impact of BOPPPS. This heterogeneity may reduce the robustness of the pooled effect size, limiting the generalizability of the findings to diverse healthcare education settings. The observed heterogeneity suggests that the impact of BOPPPS may vary depending on the specific characteristics of the educational environment and population studied. Future research should aim to address this heterogeneity by including studies with more homogeneous designs, larger sample sizes, and standardized outcome measures. Sensitivity analyses could also be performed to assess the influence of different study characteristics on the overall effect size.
Despite these limitations, the findings of our review hold broader implications for global healthcare education. The principles underlying BOPPPS—active learning, student engagement, and participatory learning—are universal. To ensure its broader applicability, future studies should explore BOPPPS implementation in diverse cultural and educational contexts, with particular attention to the unique challenges faced in different geographical regions. The successful implementation of BOPPPS across diverse settings requires careful consideration of potential barriers, such as resistance from educators or logistical challenges in curriculum redesign. Future studies should explore strategies to overcome these challenges, such as professional development programs for educators or collaborative approaches to curriculum adaptation.
Challenges and future directions
Implementing BOPPPS in healthcare education is not without challenges. Firstly, significant investments in teacher training are necessary to familiarize educators with the framework and ensure its effective integration. Secondly, resistance to change from educators and institutions accustomed to traditional methods can impede widespread adoption. Lastly, adapting existing curricula to align with BOPPPS involves substantial logistical and resource considerations.
To address these challenges, future research should also focus on identifying specific strategies for overcoming resistance and resource limitations. This could include developing professional development programs for educators and exploring collaborative approaches to curriculum redesign. Future research should address several critical gaps. For instance, there is a lack of large-scale randomized controlled trials (RCTs) examining the long-term impact of BOPPPS on academic performance and skill development. Additionally, studies exploring BOPPPS in diverse cultural contexts are necessary to determine its generalizability. Robust mixed-methods approaches combining quantitative and qualitative data would provide a holistic understanding of its impact. Longitudinal studies tracking students’ progress across various healthcare disciplines would also be valuable.
By addressing these implementation challenges and broadening its research base, BOPPPS has the potential to serve as a cornerstone teaching strategy in global healthcare education.
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