Clinical practice in the operating room (OR) is a crucial component of undergraduate nursing education, serving as an essential stage for developing hands-on skills and professional competence[1]. Unlike general ward placements, OR internships require student nurses to quickly adapt to highly specialized procedures and multiple clinical roles[2]. Traditional teaching methods often place students in passive learning positions, hindering their ability to engage effectively in clinical scenarios, which may negatively affect the overall internship outcome.

The BOPPPS (Bridge-in, Objectives, Pre-assessment, Participatory Learning, Post-assessment, Summary) model is a student-centered teaching approach that has shown significant advantages over traditional instructional methods in various educational contexts. Studies have demonstrated its effectiveness in improving students' theoretical knowledge, practical skills, and self-learning abilities in fields such as thoracic surgery [3] and nursing education[4]. The model enhances student engagement, critical thinking, and academic achievement [5]. In thoracic surgery education, BOPPPS led to higher examination scores and improved student satisfaction, interaction, and analytical abilities compared to traditional approaches[3]. A meta-analysis of nursing education studies revealed that BOPPPS significantly improved theoretical scores, practical scores, self-learning ability, and student satisfaction with teaching effectiveness [4]. These findings suggest that the BOPPPS model is a valuable framework for enhancing teaching effectiveness across various disciplines.

Scenario-based simulation has emerged as an effective pedagogical strategy in nursing education, enhancing students' clinical competence, critical thinking, and decision-making abilities. Multiple studies have demonstrated the positive impact of simulation on nursing students' skills. Sullivan-Mann et al. [6]found that increased exposure to simulation scenarios significantly improved critical thinking scores. Similarly, Görücü et al. [7] conducted a meta-analysis revealing that simulation-based education enhances clinical decision-making skills in undergraduate nursing students. Wong et al. [8]identified specific pedagogical approaches for simulation-based learning, emphasizing the importance of assigned roles and structured phases to enhance clinical competence. Woda et al. [9] compared different cohorts and found that supplementary simulation, in addition to traditional clinical experiences, led to better patient assessments. These findings collectively support the use of simulation as a valuable tool in nursing education, providing students with immersive experiences that bridge theoretical knowledge and practical skills.

Although multimodal teaching strategies have been increasingly adopted in nursing education[10, 11], the combined application of the BOPPPS model and scenario-based simulation remains underexplored in the context of OR clinical training. To address this gap, the present study investigates the implementation of an integrated BOPPPS–scenario simulation approach in the OR teaching of nursing interns, with a focus on evaluating its impact on theoretical knowledge acquisition, practical skill development, self-directed learning ability, and teaching satisfaction.

Both groups underwent a 6-week clinical internship based on the national curriculum and competencies required for operating room nursing. The curriculum included both theoretical instruction and technical skills training. To ensure instructional consistency, both groups were supervised by the same teaching faculty—experienced charge nurses with over five years of operating room teaching experience and formal preceptor certification. One lead instructor oversaw overall quality control throughout the teaching process.

The control group received traditional teaching methods. During the first week, students attended centralized theoretical lectures for the first three days, followed by focused hands-on skills training on day four. Instructors demonstrated basic operating room techniques, which were then observed and practiced by the students. From weeks 2 to 6, instruction followed a progressive sequence based on the complexity of surgical cases: obstetrics (cesarean section), general surgery (thyroidectomy), and gynecology (laparoscopic hysterectomy).

Additionally, students attended two 90-minute theory sessions per week, each consisting of:

The instructional content for the first week was the same as the control group. From weeks 2 to 6, however, students in the experimental group were taught using the BOPPPS teaching model integrated with scenario-based simulation.

In accordance with the clinical internship curriculum, guided by the Operating Room Nursing Practice Guidelines, and tailored to the characteristics of operating room nursing education, the teaching approach was designed based on authentic clinical cases. Each stage of the BOPPPS model—Bridge-in, Objective, Pre-assessment, Participatory learning, Post-assessment, and Summary—was combined with scenario-based simulation (see Table 1). Total time per simulation session did not exceed 2 hours. Table 2 illustrates the instructional flow using a cesarean section case as an example.

Operating room nursing education places strong emphasis on hands-on practice. However, traditional lecture-based “spoon-feeding” teaching—where instructors unilaterally impart knowledge—makes it difficult for students to engage in realistic clinical scenarios. Under conventional methods, students remain passive learners lacking motivation and interest; they often feel fatigued by clinical assessments, which leads to unsatisfactory examination performance [15, 16]. Contemporary nursing education paradigms call for integrating clinical practice with theoretical knowledge in training [17–20]. In the present study, the experimental group achieved significantly higher theoretical and practical exam scores than the control group (P < 0.05), indicating that the BOPPPS combined with scenario-based simulation approach effectively enhanced students’ mastery of operating room knowledge and skills. This outcome is consistent with the findings of Wen et al. [21]. Multiple studies have demonstrated its effectiveness in improving students' theoretical knowledge, practical skills, and self-learning abilities compared to traditional teaching methods[3, 4, 22]. In nursing education, the BOPPPS model has been found to enhance students' examination scores, self-learning ability, and satisfaction with teaching effectiveness [4]. Grounded in communicative and constructivist learning theory, the BOPPPS approach emphasizes active student participation, interaction, and feedback[23, 24]. Through a collaborative, inquiry-driven learning process—where students are the principal actors and instructors serve as guides—this model actively engages students in educational activities. As students complete learning tasks, they consolidate theoretical knowledge and strengthen practical skills, ultimately achieving better learning outcomes. Furthermore, by guiding students to review the simulated clinical scenario and the entire operative process, instructors help them integrate theoretical knowledge with the case details, promoting deeper reflection, problem analysis, and the exploration of effective solutions[25]. This teaching method not only stimulates students’ interest and reinforces their theoretical understanding, but also significantly improves their clinical practical skills. At the same time, it cultivates teamwork and interpersonal communication abilities, laying a solid foundation for students’ future professional development.

Beyond improving academic performance, the BOPPPS combined with scenario simulation strategy also proved beneficial in enhancing students’ self-directed learning ability. During the implementation of this teaching method, instructors introduced actual surgical cases and guided the nursing interns to perform perioperative care simulations in small groups. This approach helped students become familiar with the workflow of surgical nursing collaboration and encouraged them to actively identify and resolve problems during the simulation[26]. As a result, it effectively improved their understanding of the content, reduced the monotony of the class (compared to traditional lecture-based teaching), and made learning more practical and engaging [27]. Through scenario-based simulation training, students were able to reinforce their theoretical knowledge[28] and learn to proactively conduct safety checks during the simulated surgeries, recognizing the importance of the “Time-out” procedure. The instructor’s retrospective debriefing further enabled students to grasp key points of perioperative nursing: preoperative preparation, intraoperative responsibilities, surgical steps, and postoperative transfer and handover. This process helped students realize that every detail of nursing coordination is crucial to the success of an operation[29]. More importantly, this teaching method markedly improved the students’ self-directed learning ability. Under the dual influence of simulated scenarios and real surgical training, students not only mastered technical operations but also developed the capacity to independently observe changes in patient conditions and analyze potential complications. Unlike the rote memorization of standard nursing procedures, the scenario-driven educational approach encourages students to actively think and problem-solve, thereby enhancing their clinical judgment and adaptability. Scenario simulation effectively integrates theoretical instruction with practical application; it allows students to apply theoretical knowledge to future clinical practice[30]. Through continuous practice and feedback, learners can organically integrate and apply what they have learned, which in turn strengthens their self-directed learning capability and initiative[31].

Furthermore, student feedback results (Table 5) indicated that the combined BOPPPS and scenario simulation model greatly increased the learners’ satisfaction with the teaching experience. As shown in Table 5, the experimental group nursing students reported a much higher level of satisfaction with the BOPPPS plus scenario-based simulation teaching compared to the control group. This high satisfaction can be attributed to the unique demands of operating room nursing work. OR practice is highly specialized and requires not only a solid foundation of theoretical knowledge but also strong practical skills from students. When confronted with a heavy and intense workload of scheduled and emergency surgeries, nursing interns often experience the dilemma of having “understood it but not remembered it, and known it but not retained firmly” [32]. Moreover, the strict requirements, complex procedures, and person-to-person variability in OR teamwork often leave students feeling perplexed and at a loss as to how to begin, placing considerable pressure on their memory and learning and thereby affecting their learning outcomes [33]. Therefore, clinical teaching in the operating room must be closely tailored to the characteristics of the OR environment, the nature of surgical nursing tasks, and the psychological profile of nursing students. In this study, the interns exposed to clinical scenario simulation showed very high satisfaction, confirming that this method had a positive effect on their learning process. Through the BOPPPS combined with scenario simulation approach, students were able to acquire necessary clinical knowledge and skills in a safe, controlled environment and apply them flexibly in real clinical situations[11]. This teaching strategy not only increased the students’ satisfaction and confidence in learning, but also effectively alleviated the anxiety and negative emotions that can arise during the learning process[10, 11, 34] .

The BOPPPS teaching model is a student-centered, instructor-facilitated interactive educational approach that emphasizes clear learning objectives and active student participation. When combined with scenario-based simulation, this method fosters deep engagement and interactive classroom discussions, facilitating students’ internalization of knowledge. Through scenario-based simulation, nursing interns are immersed in realistic or near-realistic clinical situations, thereby encouraging independent thinking and clinical decision-making. This integrated approach significantly enhances critical thinking, teamwork, and clinical reasoning capabilities among nursing students. Therefore, the combined BOPPPS and scenario simulation approach provides valuable insights and practical guidance for clinical teaching in the operating room and can be effectively applied in other specialized nursing internships as well.