Action research on implementing the BOPPPS model in teaching mechanical prophylaxis techniques for deep vein thrombosis

Abstract

Objective

To explore the application effects of the BOPPPS model in teaching mechanical prophylaxis techniques for deep vein thrombosis (DVT).

Methods

Following the “Plan-Act-Observe-Reflect” four-step process of action research, continuous improvements were made to the teaching process of DVT mechanical prophylaxis techniques based on the BOPPPS model. Data were collected by designated personnel and the teaching effectiveness was evaluated.

Results

Through three rounds of action research, the overall practical training scores for DVT mechanical prophylaxis techniques among students from the 2019–2021 cohorts were 84.45 ± 4.75, 88.43 ± 3.92, and 91.15 ± 4.58, respectively. The self-evaluation scores for DVT prophylaxis awareness were 95.93 ± 2.78, 97.39 ± 2.54, and 98.47 ± 2.47, all of which were statistically significant (P < 0.01). Cohen’s d effect sizes further confirmed substantial improvements.

Conclusion

Implementing the BOPPPS model in teaching DVT mechanical prophylaxis techniques helps improve students’ knowledge, skills, and prevention awareness. The action research method contributes to the standardization and scientific design of the curriculum.

Introduction

Background

Deep vein thrombosis (DVT) of the lower extremities is a critical complication frequently encountered in hospitalized patients. The annual incidence of first-time symptomatic DVT is estimated at 50 to 100 per 100,000 adults worldwide [1], with approximately 300,000 to 600,000 cases reported annually in the United States and Europe [2–3]. In China, surgical inpatients face significant risk, with 32.7% classified as moderate risk and 53.4% as high risk for venous thromboembolism (VTE) [4]. To mitigate these risks and enhance patient safety, current clinical guidelines recommend a range of mechanical prophylaxis techniques—including ankle pump exercises, graduated compression stockings (GCS), venous foot pumps, and intermittent pneumatic compression (IPC) devices—tailored to individual patient risk levels [5,6,7].

Nurses play a critical role in these interventions by conducting risk assessments, implementing prophylactic measures, educating patients, and monitoring outcomes [8–9]. The competence and adherence of nursing staff to these protocols directly influence the overall incidence of DVT [10,11,12]. Although most prior studies [13,14,15] on DVT prevention training have focused on in-service healthcare professionals, Al-Mugheed [16] explored the flipped classroom method to enhance nursing students’ knowledge on VTE. However, a significant gap remains in nursing students’ training, as fundamentals of nursing textbooks offer limited coverage of these techniques.

To address this educational shortfall, our Nursing School integrated a specialized module on DVT mechanical prophylaxis techniques into the “Surgical Nursing” laboratory curriculum in 2021. This module was developed using the BOPPPS teaching model—a framework renowned for its effectiveness in student-centered clinical education [17–18]. The model comprises six components: Bridge-in (engaging students by linking new content with prior experiences), Objectives (clearly articulating the learning goals), Pre-assessment (evaluating baseline knowledge), Participatory Learning (facilitating interactive and hands-on learning activities), Post-assessment (providing immediate feedback and reinforcing key concepts), and Summary (consolidating the session’s main points).

The implementation followed the “Plan-Act-Observe-Reflect” four-step process of action research [19–20], and after three cycles, significant teaching outcomes were achieved.

Objective

The study aimed to evaluate the effectiveness of the BOPPPS teaching model and action research framework by assessing improvements in multiple domains: theoretical knowledge, practical competence, awareness, and attitudes toward DVT prevention.

Subjects and methods

Study subjects

The study was conducted from 2021 to 2023. We enrolled approximately 160 sophomore undergraduate nursing students annually. A total of 470 students students from the 2019–2021 cohorts were included (see Table 1). The inclusion criteria were as follows: (a) enrollment as an undergraduate nursing student in the specified cohorts; (b) successful completion of prerequisite theoretical courses in Pulmonary Embolism, Perioperative Nursing, and Deep Vein Thrombosis; (c) registration in the “Mechanical Prophylaxis Techniques for Deep Vein Thrombosis” course; (d) provision of informed consent in accordance with ethical guidelines. Students were excluded if they declined participation. Notably, no participants dropped out during the study period. This study was carried out in strict adherence to the ethical principles outlined in the Declaration of Helsinki.

Table 1 Participants’ demographic data

Setting

This study took place at a medical college within a comprehensive university in eastern China. The institution enrolls approximately 240 undergraduate students in nursing and medical programs, 300 diploma-level nursing students, and 30 postgraduate students in nursing and medicine each year.

Data collection

We collected data during the action research design implemented in three cycles. The first cycle was conducted from 04/01/2021 to 06/30/2021, the second from 03/01/2022 to 05/31/2022, and the third from 03/01/2023 to 05/31/2023.

The assessment is conducted in groups, guided by clinical cases and framed within holistic nursing, with a total score of 100 points. The breakdown includes 50 points for case analysis, which covers thrombosis risk assessment, selection of prophylaxis tools, operation complications, and health education; and 50 points for technical skills.

A self-designed “DVT prophylaxis Attitude Survey” was used, consisting of 20 items. The survey employs a Liker.

t 5-point scale, ranging from “Strongly Disagree” to “Strongly Agree,” with scores of 1 to 5 points, respectively. Higher scores indicate a more positive attitude towards DVT prevention among nursing students.

Data analysis

Statistical analysis was conducted using SPSS 25.0 software. Descriptive statistics for continuous variables were presented as mean ± standard deviation. A one-way ANOVA was used to analyze the data across the three groups, with P < 0.05 indicating statistical significance.

Methods

In our study, we employed the “Plan-Act-Observe-Reflect” framework of action research, which is particularly effective in nursing education for enhancing teaching methods and bridging the gap between theory and practice [21]. This iterative process allowed for continuous refinement of our teaching strategies.

Action research group members and division of labor

The group consisted of six members. The Deputy Director of the Nursing Department was responsible for developing the action research plan; the “Surgical Nursing” course lead organized collective lesson planning and evaluated teaching outcomes; two instructors with five years of teaching experience, both head nurses in orthopedics and surgery, were responsible for implementing the plan; two teaching assistants assisted with practical training, assessment, and data collection.

Action research implementation

First cycle

The subjects were undergraduate nursing students from the 2019 cohort. The BOPPPS teaching model was employed, and the course duration was 120 min.

• 1. Bridge-in: A case study of a postoperative lung cancer patient was used to prompt a discussion among students on how the responsible nurse should select appropriate mechanical prophylaxis tools for DVT.

• 2. Objectives: The learning objectives were to understand the risks and prevention strategies for DVT in perioperative patients, become familiar with the selection and application of mechanical prophylaxis techniques, understand potential complications, and patient education. Additionally, students were expected to master the Caprini risk assessment method [22–23] and the practical application of DVT prophylaxis techniques.

• 3. Pre-assessment: An 8-minute electronic questionnaire was completed and submitted by the students before the class.

• 4. Participatory Learning: The instructor demonstrated the procedures and addressed questions, followed by group practice sessions for the students.

• 5. Post-assessment: Each group completed an operational assessment, with a total score of 100 points—50 points for case analysis and 50 points for the practical application of techniques.

• 6. Summary: The instructor provided feedback on common issues observed in both theoretical and practical assessments, guiding students in summarizing and reflecting on their learning.

• 7. Issues Identified: It was found that students had an incomplete understanding of DVT risk factors. During practical sessions, students did not adequately consider the patient’s condition when selecting appropriate mechanical prophylaxis techniques. For instance, pneumatic compression pumps were used without confirming the presence of DVT, and GCS were applied without measuring the actual leg circumference. Additionally, the content of health education was found to be too general. After consulting with experts and conducting collective lesson planning, improvement measures were developed and implemented in the second cycle.

Second cycle

The subjects of the second cycle were undergraduate nursing students from the 2020 cohort. Based on the findings from the first cycle, the following improvements were made:

• 1. Curricular Adjustment:

  The order of certain chapters in the “Surgical Nursing” course was adjusted. Chapter 7 “Perioperative Nursing” (3 h of theory), Chap. 36 “Deep Vein Thrombosis” (1 h of theory), and “Mechanical Prophylaxis Techniques for Deep Vein Thrombosis” (3 h of lab) were scheduled consecutively.

• 2. Participatory Learning:

  • We incorporated professional ethics and clinical judgment into the curriculum. Elements of moral and professional education were integrated into the teaching process. For example, different sizes of GCS (Graduated Compression Stockings) were placed in the preparation area, requiring students to measure the patient’s actual leg circumference to select the appropriate size. Case information included notes such as “Doppler ultrasound of both lower limbs performed, report pending.” This prompted students to wait for the report before choosing pneumatic compression treatment. The approach helped foster critical thinking. During the process of assisting patients with wearing GCS, students were reminded to ensure the patient was kept warm; if not, the patient would complain, “I feel cold!” This was designed to cultivate professional nursing ethics.

  • Health education was delivered using the ‘Teach-Back’ method [24] to ensure patient comprehension.

• 3. Unchanged Sections: Other components of the BOPPPS model remained consistent with the first cycle.

• 4. Issues Identified: Low enthusiasm was observed during case introductions and participation in practical exercises. After conducting focus group interviews, improvement measures were developed and implemented in the third cycle.

Third cycle

The subjects of the third cycle were undergraduate nursing students from the 2021 cohort.

• 1. Bridge-in: Real hospital scenarios were used to create case videos with simulated patients. These videos were posted on the online teaching platform three days before the class, with students assigned to group discussions.

• 2. Participatory Learning: The practice cases were based on real patient cases and were designed to follow clinical nursing thinking. Students were required to complete the selection of “DVT Mechanical Prophylaxis Tools,” perform “DVT Mechanical Prophylaxis Techniques,” and provide “Patient Health Education” based on the case information.

• 3. Post-assessment: If a key point in any step was missed, students were required to repeat the test to ensure mastery.

• 4. Unchanged Sections: Other components of the BOPPPS model remained consistent with the second cycle.

• 5. Issues Identified: After the completion of the third cycle, the expected objectives were achieved, no more issues identified.

Results

After completing the three cycles of action research, we developed the “Teaching Design Plan for Mechanical Prophylaxis Techniques for Deep Vein Thrombosis Based on the BOPPPS Model.” This plan integrates the iterative improvements identified in each cycle to enhance the educational experience and effectiveness. Please refer to Table 2 for a detailed overview of the teaching design plan.

Table 2 Teaching design plan

The overall practical training scores for DVT mechanical prophylaxis techniques among students from the 2019, 2020, and 2021 cohorts were 84.45 ± 4.75, 88.43 ± 3.92, and 91.15 ± 4.58, respectively. The self-assessment scores for DVT prevention awareness were 95.93 ± 2.78, 97.39 ± 2.54, and 98.47 ± 2.47, respectively, all showing statistical significance (P < 0.01). See Table 3.

Table 3 Assessment scores and DVT prophylaxis awareness self-assessment scores

The histogram analysis (Fig. 1) shows that Prevention Awareness Self-Assessment Scores improved significantly over the years, with most scores in 2019 between 90 and 96, rising to above 98 by 2021. Similarly, Total Scores also increased, with scores mostly in the 80–85 range in 2019, shifting to above 95 in 2021. This demonstrates the growing effectiveness of the BOPPPS model in enhancing student awareness and overall performance.

Fig. 1

Distribution of prevention awareness and total scores

The operational, case analysis, and total scores all showed a consistent improvement from 2019 to 2021, as indicated by increasing means and narrowing interquartile ranges in Fig. 2. This suggests that students’ practical skills, application of theoretical knowledge, and overall performance in DVT mechanical prophylaxis techniques improved significantly over the three years.

Fig. 2

Scores across 2019–2021 cohorts

Cohen’s d effect sizes were calculated to quantify the magnitude of the differences in scores between the cohorts (Fig. 3). For the Operational Score, the effect size between 2019 and 2020 was medium, reflecting a significant initial improvement in students’ practical skills. However, the effect size between 2020 and 2021 was smaller, indicating a more modest further improvement.

Fig. 3

Cohen’s d effect size

In contrast, the effect sizes for Case Analysis and Total Scores were above medium across both periods (2019–2020 and 2020–2021), suggesting a consistent and substantial enhancement in students’ ability to apply theoretical knowledge and overall performance in DVT mechanical prophylaxis techniques. The largest effect sizes were observed in the Prevention Awareness Self-Assessment Scores, particularly between 2020 and 2021, demonstrating a strong and statistically significant improvement in students’ awareness and attitudes towards DVT prevention.

Discussion

The BOPPPS teaching model enhances nursing students’ DVT prophylaxis skills

Research [23,24,25] conducted in recent years has highlighted concerns regarding the accuracy rates of nursing students in applying key DVT prophylaxis measures. Specifically, one study [26] reported accuracy rates of 16.0%, 24.1%, and 29.7% for three major prophylaxis methods, including the use of the Caprini Risk Assessment Scale. This indicates the need for undergraduate nursing students to better master DVT prophylaxis knowledge and skills during classroom teaching. This study, based on the BOPPPS teaching model, primarily relies on constructivism and emphasizes student-centered, teacher-assisted participatory practice teaching.

By introducing pre-class case studies, the model stimulates students’ motivation to learn. The pre-assessment phase helps understand students’ learning foundations and clarifies teaching objectives. During participatory learning, students work in groups to complete practice tasks based on real case information. They actively engage in the practice process. This approach fosters habits of self-directed learning and critical thinking. The post-assessment phase provides timely feedback on operational issues and enhances students’ self-evaluation abilities.

Nursing students’ learning attitudes directly influence the growth of their practical abilities. Through various forms of education, theory and practice are effectively integrated. This helps develop students’ abilities to systematically analyze problems. It improves nurse-patient communication skills. It also increases students’ motivation for DVT prophylaxis. Table 2 shows that the overall scores in practical training for DVT mechanical prophylaxis techniques and prophylaxis awareness of students from the 2019–2021 cohorts have significantly increased each year, demonstrating statistical significance. effectively enhances nursing students’ knowledge and skills in DVT mechanical prophylaxis. This aligns with findings from similar studies [27–28], suggesting that the BOPPPS model is beneficial and should be adopted and promoted.

Integrating BOPPPS with professional ethics enhances professional responsibility

Nursing students must master comprehensive professional knowledge, solid operational skills, clinical thinking abilities, humanistic care awareness, and communication skills [29]. Professional ethics serve as a fundamental guideline for university teachers in teaching, educating, and addressing doubts [30–31]. Existing studies [32,33,34] show that integrating professional ethics into the BOPPPS model helps enhance teaching effectiveness. This study refined the teaching objectives for professional ethics in DVT mechanical prophylaxis techniques. We thoroughly explored and integrated ethical elements throughout the BOPPPS teaching process.

In the Bridge-in phase, we posed questions based on real lung cancer nursing scenarios to help students connect prior learning with new course content, thereby enhancing critical thinking skills. During Participatory Learning, we subtly integrated professional ethics education into nursing technique operations. Teachers emphasized empathy and privacy protection during demonstrations, while students practiced to strengthen their humanistic care awareness and communication skills. In the Summary phase, students applied scientific thinking to solve health problems, internalizing and enhancing their ethical standards and professional qualities. This approach shaped their professional values and sense of responsibility, effectively integrating value shaping, knowledge transmission, and ability cultivation. Consequently, professional courses and ethical education proceeded in parallel, achieving the goal of moral and talent cultivation, and making nursing laboratory teaching more meaningful.

Action research ensures the teaching quality of newly introduced skill courses

The scientific and standardized design of courses determines the quality and implementation effectiveness. The teaching design of newly introduced experimental projects requires continuous improvement. Action research is a participatory method where researchers and participants collaboratively engage in practical problem-solving through self-reflective inquiry in real-life situations [35,36,37]. This approach integrates the research process with addressing practical issues, allowing for immediate application and iterative learning.

This study followed the four steps of action research—Plan, Act, Observe, Reflect—to continuously achieve the integration of knowledge, skills, and attitude objectives, improve the teaching process of DVT mechanical prophylaxis techniques, and enhance the dual-role teacher team’s curriculum design and teaching quality management capabilities. Based on the issues identified in each round of implementation, expert consultation and collective lesson planning were conducted to develop improvement measures and apply them in the next cycle. This not only helps ensure teaching effectiveness but also promotes the awareness and dissemination of course quality improvement, enhancing teachers’ leadership in the curriculum.

Limitations

Despite the positive outcomes observed, this study has several limitations. First, the study was conducted within a single nursing school, which may limit the generalizability of the findings to other institutions or student populations. Second, the duration of the study was relatively short, and the long-term retention of the knowledge and skills acquired by the students remains uncertain. Additionally, the self-assessment method used to evaluate students’ attitudes towards DVT prevention may be subject to bias, as students might overestimate their understanding or confidence.

Conclusion

In summary, the implementation of DVT mechanical prophylaxis techniques based on the BOPPPS model helps improve students’ knowledge, skills, and prevention concepts. Integrating professional ethics into the curriculum enhances students’ professional qualities, and the action research method contributes to the standardization and scientific nature of curriculum design. Future research should aim to address these limitations by including a more diverse sample, extending the study duration, and observing long-term outcomes to form a replicable and effective experience model. Continuous refinement and adaptation of the teaching model, along with collaboration with clinical practice bases, will be essential in ensuring the replicability and effectiveness of the approach in enhancing nursing education.