Nursing teaching ward rounds sit at the heart of clinical education, particularly in demanding specialties such as obstetrics. During these bedside teaching sessions, students present cases, discuss care plans, and practice the professional routines they will one day perform independently. Yet the researchers behind the new trial argue that conventional ward-round teaching tends to privilege technical knowledge and procedural competence while giving short shrift to two qualities that patients notice most: empathy and patient-centered thinking. A student may master the mechanics of a labor assessment but remain oblivious to the anxiety, fear, or loss of control experienced by the woman on the other side of the conversation.

To close that gap, the research team designed an integrated model that fuses empathy mapping with the BOPPPS framework, a six-stage instructional structure widely used in health professions education. BOPPPS stands for Bridge-in, Objectives, Pre-assessment, Participatory Learning, Post-assessment, and Summary. The sequence opens with a hook that captures attention, states clear learning goals, checks what students already know, then immerses them in active, participatory learning before closing the loop with post-assessment and a summary that consolidates key lessons. The structure is attractive to educators because it imposes discipline on teaching sessions that might otherwise drift, but critics have long noted that BOPPPS by itself says nothing about the emotional and perspectival dimensions of clinical care.

That is where empathy mapping enters. An empathy map is a visual tool, borrowed originally from design thinking, that organizes what a patient might be thinking and feeling, seeing and hearing, saying and doing, along with the pains they suffer and the gains they hope for. In the intervention arm of the trial, students first attended a 45-minute empathy-mapping workshop where they learned to construct these maps from clinical vignettes. They then carried that skill into three 70-minute nursing teaching ward rounds delivered over four weeks, each following the full BOPPPS sequence and each incorporating explicit exercises in which students populated empathy maps for real or composite obstetric patients. A standardized lesson plan, a Gibbs Reflective Journal form, and a detailed empathy-mapping guide with a completed example based on a fictional composite case ensured that every session unfolded with high fidelity across instructors.

The trial’s design reflects a growing sophistication in education research. Rather than randomizing individual students—an approach that risks contamination as classmates share notes and compare experiences—the investigators enrolled 100 nursing interns in 20 naturally formed clinical rotation clusters and randomized the clusters one-to-one to either the integrated model or routine nursing teaching ward rounds. Both arms received an identical 45-minute communication-skills session and the same three 70-minute ward rounds over four weeks, isolating the empathy-mapping workshop and its ward-round integration as the only meaningful difference between groups. The primary outcome was critical-thinking disposition, a stable inclination to engage in purposeful, self-regulated, analytical judgment, measured at baseline and within one week after the intervention. Secondary outcomes included empathy, self-reported communication skills, self-directed learning, and satisfaction with the ward rounds, with satisfaction assessed after the third session.

The statistical architecture was equally careful. All analyses used mixed-effects models that included a random intercept for rotation cluster, correctly accounting for the fact that students within the same rotation group are more alike than students chosen at random. The four repeat-measured outcomes were additionally adjusted for their baseline scores, and p values across the five outcomes were Holm-adjusted to guard against the inflated false-positive risk that comes with testing multiple endpoints. The analysts also ran multiple-imputation and cluster-robust sensitivity analyses to confirm that missing data or clustering assumptions had not distorted the picture.

The results were striking in both magnitude and consistency. In the primary analysis, which included all 20 randomized clusters and 93 interns with complete outcome data—46 in the intervention arm and 47 in the control arm—every outcome favored the integrated model. Adjusted mean differences were 15.85 points for critical-thinking disposition, 4.43 points for empathy, 4.55 points for self-reported communication skills, 2.38 points for self-directed learning, and 6.54 points for satisfaction, with confidence intervals that excluded the null in every case and Holm-adjusted p values at or below 0.005. The largest effect, on critical-thinking disposition, is particularly noteworthy because disposition—the habitual willingness to think critically—is considered a harder target than critical-thinking skill itself, and because it is often assumed that empathy training and analytical rigor trade off against each other. This trial suggests the opposite: explicitly rehearsing the patient’s perspective may sharpen, rather than soften, a student’s analytical posture.

Why might a visual tool as simple as an empathy map move so many needles at once? The researchers point to a mechanistic synergy between the two components. BOPPPS supplies scaffolding—clear objectives, pre-assessment that surfaces misconceptions, participatory learning that demands engagement, and post-assessment that cements learning—while empathy mapping injects a concrete cognitive task into that scaffolding. Constructing a map forces students to articulate what a patient sees, hears, thinks, fears, and hopes, converting an abstract exhortation to ‘be empathetic’ into an actionable exercise with a tangible output. When that exercise is threaded through participatory learning on a live ward round, students must defend their inferences about the patient’s inner world in front of peers and instructors, which arguably exercises exactly the evidentiary reasoning and perspective-checking that define critical thinking.

The authors are appropriately measured about the limits of their findings. All outcomes except satisfaction were self-reported within one week of the intervention, so it remains unknown whether the gains persist over months or translate into observable clinical performance measured by examiners, standardized patients, or patient-reported outcomes. The study took place at a single tertiary teaching hospital in China and focused on obstetric nursing, leaving open questions about generalizability to other specialties, cultures, and training systems. The sample, though adequate for the detected effects, is modest, and the trial’s reliance on naturally formed rotation clusters means cluster sizes and instructor effects—documented in the supplementary analyses of intracluster correlations and design effects—introduce variance that larger multicenter trials would need to model explicitly.

Even with those caveats, the trial arrives at a moment when nursing educators worldwide are grappling with burnout, depersonalization, and the erosion of patient trust in high-volume clinical environments. If a 45-minute workshop plus three structured ward rounds can move critical-thinking disposition by more than fifteen points on a standardized scale, the cost-effectiveness of the approach becomes compelling. The study was supported by Teaching Reform Project grants from Central South University, and its full lesson plans, empathy-map templates, reflective-journal forms, and satisfaction questionnaires are published as open supplementary materials, lowering the barrier for other institutions to replicate the model. The authors call for longer-term follow-up and performance-based assessments to determine whether the observed differences endure and change what students actually do at the bedside. In the meantime, the trial makes a persuasive case that the future of clinical teaching may belong to models that refuse to choose between rigor and compassion—and instead build both into the same hour of a student’s education.

Subject of Research: A cluster-randomized controlled trial of a nursing teaching ward-round model integrating empathy mapping into the BOPPPS framework in obstetric clinical education

Article Title: Evaluating a nursing teaching ward-round model integrating empathy mapping into a BOPPPS framework: a cluster-randomized controlled trial

Article References: Evaluating a nursing teaching ward-round model integrating empathy mapping into a BOPPPS framework: a cluster-randomized controlled trial. (n.d.). https://doi.org/10.1186/s12909-026-10462-w

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10462-w

Keywords: BOPPPS, empathy mapping, nursing education, nursing teaching ward rounds, critical-thinking disposition, cluster-randomized controlled trial, obstetric nursing, nursing students, self-directed learning, communication skills, medical education, patient-centered care

The research team, led by Yuko Inoue of the University of Tokyo and Institute of Science Tokyo, together with Rebecca Wilson of the University of Bristol, Naoko Adachi, and corresponding author Shiho Kino, drew on an unusually powerful data source: the 2022 Programme for International Student Assessment, or PISA, administered by the Organisation for Economic Co-operation and Development. PISA is best known for benchmarking the academic performance of fifteen-year-olds, but the 2022 cycle included a retrospective question asking students whether they had felt lonely during the pandemic-related school closures. By harvesting responses from 91,591 students across 35 OECD countries, the investigators assembled a dataset large and geographically broad enough to detect patterns that smaller, single-country studies could easily miss.

The headline number is sobering on its own. Overall, 42.8 percent of students agreed or strongly agreed that they had felt lonely while schools were shut, and 14.3 percent strongly agreed. In other words, roughly two in five adolescents across some of the world’s wealthiest democracies reported experiencing loneliness during a period when the school, for most of them the primary arena of social life, had effectively disappeared. Because the question was retrospective, asked in 2022 about the closure period, the authors are careful to frame the measure as perceived loneliness during that time rather than a real-time clinical diagnosis. Still, the sheer scale of agreement across such a diverse sample underscores how disruptive the closures were to adolescent social connectedness.

Methodologically, the study goes well beyond simple percentages. The team used multilevel ordinal logistic regression, a statistical framework appropriate when the outcome, loneliness, is measured on an ordered scale and when students are nested within schools and countries, allowing the model to account for clustering at each level. The central exposure of interest was parental education, used as a proxy for socioeconomic status, with the highest parental attainment categorized and tertiary education, meaning university-level degrees, serving as the reference point for the most advantaged group. The models adjusted for an unusually rich set of covariates: the duration of school closures, students’ perceived learning during closures, difficulties with self-directed learning, self-efficacy in self-directed learning, and measures of family and school support. This adjustment strategy matters because these factors plausibly lie on the pathway between socioeconomic background and loneliness, and ignoring them could distort the estimated associations.

The first major result concerns gender. Female students had significantly higher odds of reporting greater loneliness than male students, with an odds ratio of 1.80 and a 95 percent confidence interval of 1.66 to 1.95. An odds ratio of this magnitude, and with a confidence interval that does not come close to crossing 1.0, indicates a robust and substantial difference: girls were nearly twice as likely as boys to report elevated loneliness during the closures. This aligns with a broader literature suggesting that adolescent girls tend to derive more of their emotional support from peer networks and may be more sensitive to interruptions in face-to-face contact, although the PISA data cannot disentangle the underlying psychological mechanisms.

The second and more surprising result emerges from the interaction between gender and parental education. In epidemiological terms, an interaction tests whether the effect of one factor depends on the level of another. Here, the researchers found a statistically significant interaction, with particularly elevated odds of loneliness among female students whose parents had attained tertiary education. The odds ratio for the interaction term was 1.35, with a 95 percent confidence interval of 1.11 to 1.65. Translated into plain language, the protective effect that higher socioeconomic status is often assumed to confer on adolescent mental health did not extend to loneliness during the closures, and for girls from university-educated families the burden was actually amplified relative to what the main effects alone would predict.

Why might this counterintuitive pattern arise? The authors themselves are measured, noting that adolescents with tertiary-educated parents are not necessarily protected from loneliness. Several plausible explanations circulate in the wider literature. Families with more resources may have maintained academic continuity through devices, tutors, and parental supervision, but academic support is not the same as peer connection. Highly educated parents were also more likely to work in jobs compatible with strict remote work, potentially meaning tighter household isolation rather than looser rules. Adolescent girls in such households may have experienced heightened pressure around self-directed learning and achievement, and the loss of structured social time may have hit hardest among those most embedded in school-based friendship networks. The PISA data cannot adjudicate among these hypotheses, but the interaction finding signals that policymakers should not assume socioeconomic advantage automatically buffers emotional wellbeing during educational disruptions.

The study’s limitations deserve honest treatment. The loneliness measure is a single self-report item, which is efficient for cross-national surveys but cannot capture the depth, duration, or clinical significance of loneliness. Retrospective reporting introduces recall bias, since students answered in 2022 about experiences that had occurred up to two years earlier, and mood at the time of reporting may color memories of the closure period. The cross-sectional design precludes causal inference: the associations describe who reported loneliness, not what caused it. Parental education, while a widely used and defensible proxy, is only one dimension of socioeconomic status and may behave differently across the 35 countries in the sample. Finally, the data cover OECD countries only, so the findings cannot be generalized to low- and middle-income settings where school closures often lasted longer and support infrastructures were thinner.

Even with those caveats, the implications are concrete. The authors conclude that emotional and academic support must be provided across gender and socioeconomic groups during educational disruptions, not targeted narrowly at disadvantaged households. Schools planning for future closures, whether from pandemics, natural disasters, or other emergencies, should build in structured social contact, monitor loneliness as systematically as they monitor learning loss, and pay particular attention to girls, who bore a consistently heavier emotional load in this data. The work was supported by grants from the Japan Society for the Promotion of Science, including a Grant-in-Aid for JSPS Fellows (24KJ0065) and a Grant-in-Aid for Early-Career Scientists (22K17266), and the authors report no competing interests. As a secondary analysis of publicly available OECD data, the study required no new ethical approval. What it delivers is a warning worth heeding: when schools close, loneliness does not discriminate by parental diploma, and the adolescents who seem safest on paper may be quietly struggling the most.

Subject of Research: Adolescent loneliness and socioeconomic and gender differences during COVID-19 pandemic-related school closures

Article Title: Adolescent loneliness and socioeconomic factors during the pandemic-related school closures: a cross-sectional study using retrospective PISA data

Article References: Inoue, Y., Wilson, R., Adachi, N., & Kino, S. (2026). Adolescent loneliness and socioeconomic factors during the pandemic-related school closures: a cross-sectional study using retrospective PISA data. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-03018-3

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03018-3

Keywords: adolescent loneliness, school closures, COVID-19, PISA 2022, socioeconomic status, parental education, gender differences, mental health, OECD countries, public health, self-directed learning, health equity