A simulation-based approach for investigating the dynamics of rebound effects in the circular economy: A case of use-oriented product/service system.

Current research in Circular Economy (CE) fails to address the occurrence of Rebound Effects (RE), which are systemic and behavioural responses to the implementation of interventions hindering the potential sustainability benefits. This paper aims to advance the academic discussion and the practical consideration of RE by exploring the potential of using System Dynamics (SD) to enable the ex-ante identification of potential RE of CE initiatives. A five-stage simulation-based approach for the identification and mitigation of potential rebound effects (AIMRE) is proposed. Its application is demonstrated in a use-oriented product/service system (PSS) case focused on a high-end dress rental service. The AIMRE enables the representation of the magnitude and reasons for RE occurrence through 14 scenarios. The finding highlights the importance of considering the interplay between consumers' and companies' decision-making processes in quantifying, understanding, and mitigating RE occurrence.

Associations between PTSD and temporal discounting: The role of future thinking.

BACKGROUND AND OBJECTIVES: Despite documented alterations in future thinking in posttraumatic stress disorder (PTSD), our understanding of how individuals with PTSD make future-oriented decisions is limited. We tested the hypothesis that increased discounting in association with PTSD reflects failure to spontaneously envision future rewarding situations. METHODS: Thirty-seven trauma exposed war-zone veterans completed a standard temporal discounting task as well as a temporal discounting task accompanied by episodic future thinking cues. RESULTS: Severity of PTSD symptoms was associated with preference for sooner, smaller rewards in the standard task. Consistent with our hypothesis, when participants engaged in future thinking, greater PTSD symptom severity was no longer associated with steeper discounting. Moreover, difficulty anticipating future events, as measured contemporaneously in a separate task (Verfaellie et al., 2024), mediated the relationship between PTSD symptom severity and degree of discounting in the standard task. Among PTSD symptom clusters, the severity of avoidance and negative alterations in cognition and mood was related to steeper discounting. Measures of depression and alcohol use were not associated with discounting. LIMITATIONS: The sample included mostly male, predominantly White veterans who experienced primarily combat-related trauma. CONCLUSIONS: PTSD-associated alterations in temporal discounting reflect failure to spontaneously imagine future positive events. Two common correlates of PTSD, depression and alcohol use, could not account for the observed associations between PTSD and future-oriented decisions.

Combating COVID-19 health disparities in Black, Indigenous, and People of Colour Communities-A call for critical systems thinking.

RATIONALE: The Black, Indigenous, and People of Colour populations in the United States are disproportionately affected by the emerging health threat SARS-CoV-2, which causes COVID-19. AIMS AND OBJECTIVES: This paper aims to demonstrate the usefulness of critical systems thinking by using scenario planning based on epidemiological data and tying epidemiology with soft systems methodology to investigate COVID-19 disparities among disproportionately affected Black, Indigenous, and People of Colour populations. METHODS: Using a review of the COVID-19 literature and publicly available US COVID-19 data, critical systems thinking is applied in a scenario planning example and a call to link soft systems methodology with epidemiology. RESULTS: According to the four plausible Endgame scenarios, levels of community transmission as well as the current state transmission are based on the driving forces of the scenarios. In addition, soft systems methodology explores the effect on stakeholders and strengthens the picture of disease burden beyond sole reliance on traditional data sources. CONCLUSION: This analysis underscores employing critical systems thinking to critically assess diverse methods appropriate for the ongoing complexity of global crises. It is argued that critically engaged subjectivity should be given space alongside data-dependent objectivity. COVID-19 disparities are reliant on the social determinants of health's effects as driving forces on disease transmission in Black, Indigenous, and People of Colour populations. It is moreover argued that critical systems thinking is demonstrated by linking epidemiological evidence with scenario planning and soft systems methodology. This in turn supports a critical systems thinking approach to uncover the state of health disparities among minoritized communities under COVID-19.

Forever young: The end of history illusion in children.

The "end of history" illusion in adults (Quoidbach et al., 2013) is an asymmetrical pattern in which people accept that they've changed in the past but don't believe they will change in the future. We explore here whether the same psychological forces that cause the illusion in adults exist in the minds of children. Two studies with 4- to 11-year-olds (N = 256) suggest that they do, even in a within-subject design where the same child is asked questions about the past and the future. A third study (N = 83) finds that this illusion does not persist when children are asked about other people. These studies suggest that even young children believe that although they used to be different in the past, from this point on, they will remain forever young.

Critical thinking pedagogical practices in medical education: a systematic review.

Introduction: The development of critical thinking (CT) has been a universal goal in higher education. A systematic review of the literature was conducted to evaluate the effectiveness of currently used pedagogical practices to foster CT/ clinical reasoning (CR)/ clinical judgment (CJ) skills and/or dispositions in undergraduate medical students. Methods: PubMed, Web of Science and Scopus databases were searched from January 2010 to April 2021 with a predefined Boolean expression. Results: Of the 3221 articles originally identified, 33 articles were included by using PICOS methodology. From these, 21 (64%) reported CR pedagogical practices and 12 (36%) CT pedagogical practices. Discussion: Overall, pedagogical practices such as cognitive/visual representation, simulation, literature exposure, test-enhancing and team-based learning, clinical case discussion, error-based learning, game-based learning seem to enhance CT/CR skills and/or dispositions. Further research is required to identify the optimal timing, duration and modality of pedagogical interventions for effectively foster CT/CR in medical education.

Applying the WHO-INTEGRATE evidence-to-decision framework in the development of WHO guidelines on parenting interventions: step-by-step process and lessons learnt.

BACKGROUND: Development of guidelines for public health, health system, and health policy interventions demands complex systems thinking to understand direct and indirect effects of interventions within dynamic systems. The WHO-INTEGRATE framework, an evidence-to-decision framework rooted in the norms and values of the World Health Organization (WHO), provides a structured method to assess complexities in guidelines systematically, such as the balance of an intervention's health benefits and harms and their human rights and socio-cultural acceptability. This paper provides a worked example of the application of the WHO-INTEGRATE framework in developing the WHO guidelines on parenting interventions to prevent child maltreatment, and shares reflective insights regarding the value added, challenges encountered, and lessons learnt. METHODS: The methodological approach comprised describing the intended step-by-step application of the WHO-INTEGRATE framework and gaining reflective insights from introspective sessions within the core team guiding the development of the WHO guidelines on parenting interventions and a methodological workshop. RESULTS: The WHO-INTEGRATE framework was used throughout the guideline development process. It facilitated reflective deliberation across a broad range of decision criteria and system-level aspects in the following steps: (1) scoping the guideline and defining stakeholder engagement, (2) prioritising WHO-INTEGRATE sub-criteria and guideline outcomes, (3) using research evidence to inform WHO-INTEGRATE criteria, and (4) developing and presenting recommendations informed by WHO-INTEGRATE criteria. Despite the value added, challenges, such as substantial time investment required, broad scope of prioritised sub-criteria, integration across diverse criteria, and sources of evidence and translation of insights into concise formats, were encountered. CONCLUSIONS: Application of the WHO-INTEGRATE framework was crucial in the integration of effectiveness evidence with insights into implementation and broader implications of parenting interventions, extending beyond health benefits and harms considerations and fostering a whole-of-society-perspective. The evidence reviews for prioritised WHO-INTEGRATE sub-criteria were instrumental in guiding guideline development group discussions, informing recommendations and clarifying uncertainties. This experience offers important lessons for future guideline panels and guideline methodologists using the WHO-INTEGRATE framework.

Mapping complex public health problems with causal loop diagrams.

This paper presents causal loop diagrams (CLDs) as tools for studying complex public health problems like health inequality. These problems often involve feedback loops-a characteristic of complex systems not fully integrated into mainstream epidemiology. CLDs are conceptual models that visualize connections between system variables. They are commonly developed through literature reviews or participatory methods with stakeholder groups. These diagrams often uncover feedback loops among variables across scales (e.g. biological, psychological and social), facilitating cross-disciplinary insights. We illustrate their use through a case example involving the feedback loop between sleep problems and depressive symptoms. We outline a typical step-by-step process for developing CLDs in epidemiology. These steps are defining a specific problem, identifying the key system variables involved, mapping these variables and analysing the CLD to find new insights and possible intervention targets. Throughout this process, we suggest triangulating between diverse sources of evidence, including domain knowledge, scientific literature and empirical data. CLDs can also be evaluated to guide policy changes and future research by revealing knowledge gaps. Finally, CLDs may be iteratively refined as new evidence emerges. We advocate for more widespread use of complex systems tools, like CLDs, in epidemiology to better understand and address complex public health problems.

A causal counterfactual graph neural network for arising-from-chair abnormality detection in parkinsonians.

The arising-from-chair task assessment is a key aspect of the evaluation of movement disorders in Parkinson's disease (PD). However, common scale-based clinical assessment methods are highly subjective and dependent on the neurologist's expertise. Alternate automated methods for arising-from-chair assessment can be established based on quantitative susceptibility mapping (QSM) images with multiple-instance learning. However, performance stability for such methods can be typically undermined by the presence of irrelevant or spuriously-relevant features that mask the intrinsic causal features. Therefore, we propose a QSM-based arising-from-chair assessment method using a causal graph-neural-network framework, where counterfactual and debiasing strategies are developed and integrated into this framework for capturing causal features. Specifically, the counterfactual strategy is proposed to suppress irrelevant features caused by background noise, by producing incorrect predictions when dropping causal parts. The debiasing strategy is proposed to suppress spuriously relevant features caused by the sampling bias and it comprises a resampling guidance scheme for selecting stable instances and a causal invariance constraint for improving stability under various interferences. The results of extensive experiments demonstrated the superiority of the proposed method in detecting arising-from-chair abnormalities. Its clinical feasibility was further confirmed by the coincidence between the selected causal features and those reported in earlier medical studies. Additionally, the proposed method was extensible for another motion task of leg agility. Overall, this study provides a potential tool for automated arising-from-chair assessment in PD patients, and also introduces causal counterfactual thinking in medical image analysis. Our source code is publicly available at https://github.com/SJTUBME-QianLab/CFGNN-PDarising.

Adopting a systems-thinking approach to optimise dietary and exercise referral practices for cancer survivors.

PURPOSE: Service referrals are required for cancer survivors to access specialist dietary and exercise support. Many system-level factors influence referral practices within the healthcare system. Hence, the aim of this study was to identify system-level factors and their interconnectedness, as well as strategies for optimising dietary and exercise referral practices in Australia. METHODS: A full-day workshop involving national multidisciplinary key stakeholders explored system-level factors impacting dietary and exercise referral practices. Facilitated group discussions using the nominal group technique identified barriers and facilitators to referral practices based on the six World Health Organisation (WHO) building blocks. The systems-thinking approach generated six cognitive maps, each representing a building block. A causal loop diagram was developed to visualise factors that influence referral practices. Additionally, each group identified their top five strategies by leveraging facilitators and addressing barriers relevant to their WHO building block. RESULTS: Twenty-seven stakeholders participated in the workshop, including consumers (n = 2), cancer specialists (n = 4), nursing (n = 6) and allied health professionals (n = 10), and researchers, representatives of peak bodies, not-for-profit organisations, and government agencies (n = 5). Common system-level factors impacting on referral practices included funding, accessibility, knowledge and education, workforce capacity, and infrastructure. Fifteen system-level strategies were identified to improve referral practices. CONCLUSION: This study identified system-level factors and strategies that can be applied to policy planning and practice in Australia.

Toward Sustainable Adoption of Integrated Care for Prevention of Unplanned Hospitalizations: A Qualitative Analysis.

Introduction: Complex chronic patients are prone to unplanned hospitalizations leading to a high burden on healthcare systems. To date, interventions to prevent unplanned admissions show inconclusive results. We report a qualitative analysis performed into the EU initiative JADECARE (2020-2023) to design a digitally enabled integrated care program aiming at preventing unplanned hospitalizations. Methods: A two-phase process with four design thinking (DT) sessions was conducted to analyse the management of complex chronic patients in the region of Catalonia (ES). In Phase I, Discovery, two DT sessions, October 2021 and February 2022, were done using as background information: i) the results of twenty structured interviews (five patients and fifteen professionals), ii) two governmental documents on regional deployment of integrated care and on the Catalan digital health strategy, respectively, and iii) the results of a cluster analysis of 761 hospitalizations. In Phase II, Confirmation, we examined the 30- and 90-day post-discharge periods of 49,604 hospitalizations as input for two additional DT sessions conducted in November and December 2022. Discussion: The qualitative analysis identified poor personalization of the interventions, the need for organizational changes, immature digitalization, and suboptimal services evaluation as main explanatory factors of the observed efficacy-effectiveness gap. Additionally, a program for prevention of unplanned hospitalizations, to be evaluated during the period 2024-2025, was generated. Conclusions: A digitally enabled adaptive case management approach to foster collaborative work and personalization of care, as well as organizational re-engineering, are endorsed for value-based prevention of unplanned hospitalizations.

The perceived controllability of negatively-valenced episodic future thinking modulates delay discounting.

Intertemporal decision-making is important for both economy and physical health. Nevertheless, in daily life, individuals tend to prefer immediate and smaller rewards to delayed and larger rewards, which is known as delay discounting (DD). Episodic future thinking (EFT) has been proven to influence DD. However, there is still no inconsistent conclusion on the effect of negative EFT on DD. Considering the perceived controllability of negative EFT may address the issue (Controllability refers to the extent to which progress and result of an event could be controlled by ourselves). In the current study, we manipulated EFT conditions (baseline, neutral EFT, negative-controllable EFT and negative-uncontrollable EFT), delayed time (i.e. 1 week, 1 month, 3 months, 6 months, 1 year and 3 years) and reward magnitude (small, large). We mainly found that when experiencing negative-uncontrollable EFT compared to negative-controllable EFT in the delayed time of 6 months with large rewards, individuals chose more delayed rewards, suggesting that negative-uncontrollable EFT effectively reduced DD under conditions of both large-magnitude reward and longer delayed time. The current study provides new insight for healthy groups on optimising EFT. In that case, individuals are able to gain long-term benefits in financial management and healthcare.

Cognitive styles and psi: psi researchers are more similar to skeptics than to lay believers.

Introduction: Belief in psi, which includes psychic phenomena such as extra-sensory perception and post-mortem survival, is widespread yet controversial. According to one of the leading and perhaps most tested hypotheses, high belief in psi can be explained by differences in various aspects of cognition, including cognitive styles. Most of this research has been conducted with lay individuals. Here, we tested the hypothesis that academic researchers who investigate psi may exhibit different cognitive styles than lay individuals interested in psi, and are more similar to skeptics. Methods: We measured two cognitive styles-actively open-minded thinking (AOT) and the need for closure (NFC)-and assessed differences among four heterogeneous groups regarding belief in psi and involvement in related research. Specifically, our study included academic psi researchers (N = 44), lay individuals who believe in psi (N = 32), academics who are skeptics of psi (N = 35), and lay individuals who are skeptics (N = 33). Results: We found group differences in AOT (p = 0.003) but not in NFC scores (p = 0.67). Post hoc tests showed no significant difference in AOT scores between academics who conduct psi research (4.5 ± 0.3) and academic skeptics (4.5 ± 0.3; p = 0.91) or lay skeptics (4.5 ± 0.4; p = 0.80). The lay psi group had significantly lower AOT scores (4.2 ± 0.4) than the other three groups (ps: 0.005-0.04), indicating a decreased willingness to consider a range of evidence when forming an opinion, including evidence that challenges their beliefs. AOT was negatively associated with psi belief in the two skeptic groups combined (r = -0.29, p = 0.01), but not in the psi groups (r = -0.03, p = 0.78). Discussion: Our research shows that academics who work with psi differ from lay psi individuals, but not from skeptics, in actively open-minded thinking. In other words, despite their high belief in psi phenomena, psi researchers demonstrate a commitment to sound reasoning about evidence that is no different from that of skeptics.

Certainty in holistic thinking and responses to contradiction: Dialectical proverbs, counter-attitudinal change and ambivalence.

The present research examined whether consideration of individuals' certainty in their holism can enhance the ability of this individual difference to predict how they respond to contradiction-relevant outcomes. Across four studies, participants first completed a standardized measure of holistic-analytic thinking. Then, they rated how certain they were in their responses to the holism scale or were experimentally induced to feel high or low certainty. Next, participants were exposed to dialectical proverbs (Study 1a and 1b), to a counter-attitudinal change induction (Study 2), or to a paradigm of attitudinal ambivalence (Study 3). Results revealed that participants with higher certainty in their holistic thinking exhibited higher preference for dialectical proverbs (Study 1a and 1b), changed their attitude less following a counter-attitudinal task (Study 2) and showed weaker correspondence between objective and subjective ambivalence (Study 3). Beyond examining new domains and discovering novel findings, the present work was designed to be the first to show moderation of previously identified effects in the domain of holistic thinking and responses to contradiction.

Transacting in Objectification: Racism, Psychoanalysis, and the Temptations of Empiricism.

This article examines five contributions published in the early volumes (1913-1917) of The Psychoanalytic Review, written by John E. Lind and Arrah B. Evarts. It reflects on how they address the topic of race and its relation to psychoanalytic theory, highlighting the ways of purported neutrality of empirical research and how it serves a fantasy through which racism is enacted and sustained.

Evaluation of cross-cultural adaptation and validation of the Persian version of the critical thinking disposition scale: methodological study.

INTRODUCTION: Assessing critical thinking disposition is crucial in nursing education to foster analytical skills essential for effective healthcare practice. This study aimed to evaluate the cross-cultural adaptation and validation of the Persian version of the Critical Thinking Disposition Scale among Iranian nursing students. METHOD: A total of 390 nursing students (mean age = 21.74 (2.1) years; 64% female) participated in the study. Face and content validity were established through feedback from nursing students and expert specialists, respectively. Construct validity was assessed using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). The EFA was used to explore the number of factors and the items that were loading on them. The CFA was used to confirmed the fidnings of the EFA on the same sample. Convergent and discriminant validity were examined, along with reliability through internal consistency and test-retest reliability. RESULTS: EFA revealed a two-factor structure, comprising "Critical Openness" and "Reflective Skepticism," explaining 55% of the total variance. CFA confirmed the model's fit (χ² = 117.37, df = 43, χ²/df = 2.73, p < 0.001; RMSEA = 0.067; CFI = 0.95; TLI = 0.93, SRMR = 0.041). Convergent and discriminant validity were supported, with significant factor loadings (p < 0.001) ranging from 0.61 to 0.77. The CTDS exhibited strong internal consistency (α = 0.87) and excellent test-retest reliability (ICC = 0.96). CONCLUSION: The validation of the CTDS in Persian language settings provides a reliable tool for assessing critical thinking disposition among Iranian nursing students. The two-factor structure aligns with previous research, reflecting students' propensity towards critical openness and reflective skepticism. The study's findings underscore the importance of nurturing critical thinking skills in nursing education.

From the mathematical model to the patient: The scientific and human aspects of artificial intelligence in gastrointestinal surgery.

Recent medical literature shows that the application of artificial intelligence (AI) models in gastrointestinal pathology is an exponentially growing field, with promising models that show very high performances. Regarding inflammatory bowel disease (IBD), recent reviews demonstrate promising diagnostic and prognostic AI models. However, studies are generally at high risk of bias (especially in AI models that are image-based). The creation of specific AI models that improve diagnostic performance and allow the establishment of a general prognostic forecast in IBD is of great interest, as it may allow the stratification of patients into subgroups and, in turn, allow the creation of different diagnostic and therapeutic protocols for these patients. Regarding surgical models, predictive models of postoperative complications have shown great potential in large-scale studies. In this work, the authors present the development of a predictive algorithm for early post-surgical complications in Crohn's disease based on a Random Forest model with exceptional predictive ability for complications within the cohort. The present work, based on logical and reasoned, clinical, and applicable aspects, lays a solid foundation for future prospective work to further develop post-surgical prognostic tools for IBD. The next step is to develop in a prospective and multicenter way, a collaborative path to optimize this line of research and make it applicable to our patients.

Childhood emotional abuse and depression symptoms among Chinese adolescents: The sequential masking effect of ruminative thinking and deliberate rumination.

BACKGROUND: This study delves into the relationship between childhood trauma and adolescent depression symptoms, specifically examining the distinct roles of ruminative thinking and deliberate rumination in mediating this connection. The focus is on exploring whether these cognitive processes, namely ruminative thinking and deliberate rumination, operate differently and sequentially in mediating the impact of childhood emotional abuse (CEA) on the development of depression symptoms among Chinese adolescents. METHODS: The study involved gathering data from 489 adolescents, with a relatively balanced gender distribution (44.79 % males and 55.21 % females). The average age of the participants was 16.92 years, with a standard deviation of 0.67. Data collection took place in two Chinese high schools, and participants were tasked with completing assessments related to CEA, ruminative thinking, deliberate rumination, and depression symptoms. The interplay among these variables was then examined using a serial mediation model. RESULTS: The findings of the study indicate that CEA not only exhibited a direct association with adolescent depression symptoms but also exerted indirect effects through distinct mediating mechanisms involving ruminative thinking and deliberate rumination. Specifically, ruminative thinking was identified as a mediator, whereas deliberate rumination emerged as a buffer in the relationship between CEA and depression. Additionally, ruminative thinking and deliberate rumination partially masked the effect of CEA on adolescent depression symptoms in a sequential pattern. CONCLUSIONS: Regarding the link from CEA to adolescent depression symptoms, ruminative thinking is an adverse mediator while deliberate rumination appears to play a benign role. Consequently, the promotion of a shift from ruminative thinking to deliberate rumination is proposed as a promising strategy for alleviating the detrimental effects of CEA on adolescent depression.

An exploration into the relationship between insomnia and repetitive negative thinking among cancer survivors.

OBJECTIVE: Insomnia and repetitive negative thinking (RNT) are both prevalent among cancer survivors, yet little work has investigated their interrelationship. To explore the hypothesis that RNT and insomnia are related, we conducted secondary analyses on data from a pilot clinical trial of cognitive behavioral therapy for insomnia (CBT-I) for cancer survivors. METHODS: This study analyzed survey data from 40 cancer survivors with insomnia who participated in a pilot randomized trial of CBT-I. Correlations and linear regression models were used to determine associations between aspects of RNT and related constructs (fear of cancer recurrence [FCR], cancer-specific rumination, worry, and intolerance of uncertainty) and sleep (insomnia and sleep quality), while accounting for psychiatric symptoms such as anxiety and depression. Treatment-related change in RNT was examined using a series of linear mixed models. RESULTS: Evidence for an association between RNT and insomnia among cancer survivors emerged. Higher levels of FCR and cancer-related rumination were correlated with more severe insomnia symptoms and worse sleep quality. Notably, FCR levels predicted insomnia, even after controlling for anxiety and depression. Results identified potential benefits and limitations of CBT-I in addressing RNT that should be examined more thoroughly in future research. CONCLUSIONS: RNT is a potential target to consider in insomnia treatment for cancer survivors.

The impact of applying unfolding case-study learning on critical care nursing students' knowledge, critical thinking, and self-efficacy; a quasi-experimental study.

BACKGROUND: The unfolding case-study learning approach is a growing modernized learning strategy implemented in different health disciplines. However, there is a lack of existing research that examines the effects of unfolding case studies in advanced nursing courses. AIM: To examine the impact of applying an unfolding case-study learning approach on critical care nursing students' knowledge, critical thinking, and self-efficacy. METHODS: This posttest-only, quasi-experimental study was conducted at XXX University in Palestine. A single-stage cluster sampling was used to assign nursing students enrolled in the critical care nursing course into experiment and conventional groups. The intervention group (n= 91) underwent unfolding case-study learning for selected cardiovascular topics, whereas the conventional group (n= 78) was taught using the traditional teaching methods. The posttest assessment was conducted using Knowledge Acquisition tests, Yoon`s Critical Thinking Disposition Instrument (YCTD), and the Self-Efficacy for Learning and Performance instruments. The Social Constructivist Theoretical Framework was integrated into the study. RESULTS: Homogeneity was achieved between both groups concerning Age, Gender, and GPA. The experiment group scored significantly higher than the conventional group regarding the posttest knowledge acquisition tests (7.12 vs. 5.49, respectively, t=-12.7, P<0.001, CI: -1.89 to -1.38), critical thinking (4.32 vs. 3.63 respectively, t=17.390, p<0.001, CI: -77 to -61) and self-efficacy (6.12 vs. 4.4 respectively, t=-30.897, p<0.001, CI: -1.82 to -1.60). Multivariate analysis revealed that 69 % of the variations of posttest scores were influenced by critical thinking scores (Adjusted R Squared=0.690, F=3.47, P=0002, η2=0.969). Similarly, self-efficacy has been shown to contribute by 74 % to the variations of scores after conducting the study program (Adjusted R Squared=0.743, F=4.21, P=0001, η2=0.974). However, the variations of both critical thinking and self-efficacy scores were not significantly influenced by the contribution of knowledge acquisition (p=0.772 and 0.857, respectively) and students' GPA (p=0.305 and 0.956, respectively). CONCLUSIONS: Irrespective of knowledge level and GPA, the unfolding case-study learning approach can enhance the critical thinking and self-efficacy of students enrolling in advanced nursing courses.