The goal of this interventional study is to evaluate the effectiveness of a composite active learning strategy, integrating the Flipped Classroom model and Team-Based Learning (TBL), for improving Evidence-Based Practice (EBP) competence in second-year undergraduate nursing students.

The main questions it aims to answer are:

• Does the educational intervention significantly improve students' self-reported knowledge of EBP concepts?
• Does the educational intervention significantly improve students' self-reported skills in EBP processes (e.g., critical appraisal)?
• Does the educational intervention significantly improve students' attitudes towards EBP?

Participants, who were all second-year nursing students enrolled in a specific academic year, took part in a mandatory 64-hour EBP educational module. Their main tasks were:

• To complete a validated self-assessment questionnaire (the Evidence-Based Practice Competence Questionnaire, EBP-COQ) at baseline (March 2024) and immediately following the intervention (April 2024).
• To engage in the "Core EBP" module of the course (12 hours), which was delivered using a Team-Based Learning (TBL) strategy. This module comprised:
• Asynchronous individual preparatory study (Flipped Classroom phase) of provided scientific articles and lecture notes, conducted 1-2 weeks prior to each session.
• Participation in three in-person, 4-hour interactive sessions (12 contact hours total), following the structured TBL cycle of Readiness Assurance (iRAT and tRAT) and Team Application exercises.

1. Background and Rationale

   Evidence-Based Practice (EBP) is a fundamental competency for healthcare professionals, integral to delivering high-quality, safe, and effective patient care. International nursing organisations and educational frameworks consistently mandate the integration of EBP competencies into undergraduate curricula. However, significant variability persists in how EBP is taught, with traditional, lecture-based methods often proving insufficient for developing the complex skills required for its application in clinical practice.

   Contemporary educational research advocates for active, student-centred learning strategies to effectively teach EBP. The Flipped Classroom (FC) model and Team-Based Learning (TBL) are two such pedagogies. FC facilitates preparatory acquisition of foundational knowledge, thereby liberating in-class time for higher-order learning activities. TBL provides a structured framework for applying knowledge through collaborative problem-solving, critical discussion, and peer feedback, which are essential for mastering EBP steps like critical appraisal and clinical integration.

   While the individual effectiveness of FC and TBL has been explored, there is a paucity of research evaluating a structured, composite intervention that sequentially combines these methodologies specifically to enhance EBP competence in nursing students within a European context. This study aims to address this gap.

2. Study Design and Setting

   This is a quasi-experimental, single-centre study employing a pre-test/post-test design without a control group. The study was conducted within the Bachelor of Nursing degree programme at the University of Modena and Reggio Emilia (Modena site), Italy.

   The target population was the entire cohort of second-year nursing students enrolled in the academic year 2023-2024. This stage was selected as students begin to synthesise theoretical knowledge with clinical practice, representing a pivotal point for EBP skill development.

3. Participant Recruitment and Ethical Considerations

   All eligible students were invited to participate. The study protocol, including participant information sheets and consent forms, was reviewed and approved by the Institutional Ethical Committee for Research (CEAR) of the University of Modena and Reggio Emilia prior to commencement. Participation was entirely voluntary, and written informed consent was obtained from all participants. Refusal to participate did not affect academic standing or access to the educational module.

   To ensure confidentiality and data protection, a strict anonymisation procedure was implemented. Participants created a unique personal code to link their pre- and post-intervention questionnaires, ensuring no directly identifiable data was stored with the research data.

4. Detailed Description of the Educational Intervention

   The intervention was a dedicated, credit-bearing EBP module integrated into a broader 64-hour "Evidence-Based Nursing" course within the second-year curriculum. The experimental intervention specifically targeted the Core EBP module (12 contact hours), delivered exclusively using a Team-Based Learning (TBL) strategy.

   Teaching Team: The module was delivered by a single experienced academic with an established track record in EBP pedagogical research.

   Pedagogical Model: Team-Based Learning (TBL).

   Pre-Session (FC Phase): One to two weeks prior to each in-person session, students engaged with preparatory materials (e.g., selected scientific articles and specific lecture notes) hosted on the university's Moodle platform.

   In-Session (TBL Phase): The intervention consisted of three 4-hour sessions (12 contact hours total) conducted over a five-week period. Sessions were structured according to TBL principles:

   • Readiness Assurance Process: Each session began with a 10-item multiple-choice Individual Readiness Assurance Test (iRAT), followed by the same test taken in permanent, instructor-formed teams (tRAT). Immediate feedback was provided via the Immediate Feedback Assessment Technique (IF-AT).
   • Appeals Process: Teams could submit written justifications to challenge test questions, requiring consultation of the preparatory materials.
   • Application-Focused Exercises: The majority of each session (2.5 to 3 hours) was dedicated to solving complex clinical cases. These exercises followed the "4 S" framework (Significant Problem, Same Problem, Specific Choice, and Simultaneous Report) to practice formulating PICO questions, bibliographic searching, appraising research articles, and integrating evidence into clinical decision-making.

5. Outcome Measurement and Data Collection

   The primary outcome was the change in self-reported EBP competence, measured using the validated Italian version of the Evidence-Based Practice Competence Questionnaire (EBP-COQ). The instrument assesses three domains: Attitudes (13 items), Skills (6 items), and Knowledge (6 items), using a 5-point Likert scale.

   Data collection occurred at two time points:

   • Pre-test (T0): Administration of the EBP-COQ during the recruitment and baseline phase on 4th March 2024.
   • Post-test (T1): Administration of the EBP-COQ immediately following the final session on 22nd April 2024.

6. Statistical Methods

Data analysis will be perform using statistical software (SPSS, version 27.0). Descriptive statistics will summarise participant characteristics. The primary analysis will involve paired-sample t-tests to compare mean scores for the total EBP-COQ and its three subscale scores (Attitudes, Skills, Knowledge) between T0 and T1. The threshold for statistical significance will beset at p < 0.05. To estimate the magnitude of change, Cohen's d effect sizes will be calculate for significant comparisons. Sensitivity analysis will be performed using Wilcoxon signed-rank test. The relationship between individual preparation (iRAT) and team gain (tRAT-iRAT) will be assessed via Spearman's correlation, to evaluate the collaborative learning impact. Data will be handle using a complete-case analysis strategy (listwise deletion).

Inclusion Criteria:

• Being a Nursing Student
• Enrolled as a second-year student in the Bachelor of Nursing degree at the study site (University of Modena and Reggio Emilia, Modena campus) for the 2023-2024 academic year.
• Attended the first lecture of the course where the study was presented (or were otherwise fully informed about it).
• Provided written informed consent to participate in the research.

Exclusion Criteria:

• Not formally enrolled in the second year of the Nursing programme at the study site for the 2023-2024 academic year.
• Had already obtained recognition/validation of the academic credit for the specific Evidence-Based Practice (EBP) course unit before the study began.
• Were absent for the entire duration of the EBP educational module.
• Declined to give informed consent to participate in the research.

The Individual Participant Data (IPD) collected for this study contains detailed and sensitive personal information. To ensure the confidentiality and privacy of our participants in compliance with stringent EU and Italian data protection regulations (GDPR), the data will not be made publicly available. The data will be kept securely within the institutional responsibility of the University of Modena and Reggio Emilia for the purposes outlined in this protocol.