From Task Executor to Decision-Maker: Competency Transfer in Oncology Cardiopulmonary Rehabilitation Nurses—A Descriptive Phenomenological Study

Abstract

Background and Objective

Outcome-based education (OBE) is increasingly used to develop advanced nursing competencies, yet how these competencies transfer into complex clinical practice—particularly in oncology cardiopulmonary rehabilitation (CP-Rehab)—remains poorly understood. This study explored nurses’ lived experiences of competency transfer and professional role transition within an OBE-structured oncology CP-Rehab training program.

Design and methods

This COREQ-guided descriptive phenomenological study purposively sampled 14 registered-nurse trainees who completed the inaugural OBE specialist program and additionally interviewed 3 clinical tutors for triangulation. All trainees and tutors provided written informed consent. Semi-structured interviews were analysed using Colaizzi’s seven-step framework. Routine training assessment data were used only for complementary descriptive triangulation.

Results

Three core trajectories emerged: (1) cognitive reconfiguration and role transition—visualised OBE goals acted as a cognitive scaffold, shifting nurses from passive task executors to evidence-based decision-makers; (2) a three-dimensional stressor system—competency transfer was hindered by overlapping time, resource, and baseline-competence pressures, exacerbated by diluted mentorship across clinical areas; and (3) contextual synergy versus stagnation—competency actualisation depended on clinical empowerment, with supportive environments enabling advanced practice and resource-constrained settings contributing to role conflict and burnout.

Conclusion

OBE supported professional role transition, but sustained competency transfer was constrained by structural and contextual barriers. The findings suggest that implementation may benefit from an integrated support model combining simulation, longitudinal practice opportunities, digital mentorship, and psychological support. This study-derived recommendation, termed an “OBE+ Smart Ecosystem”, was not the framework implemented in the evaluated program and requires prospective evaluation.

Plain Language Summary

Outcome-based education defines what learners should be able to do, but high assessment scores do not necessarily show whether new skills are used in everyday care. We interviewed 14 nurses who completed an outcome-based oncology cardiopulmonary rehabilitation program and 3 tutors who supervised them. Nurses described a shift from following tasks toward making evidence-informed clinical decisions. However, limited time, uneven access to suitable patients and tutors, and differences in baseline experience made it difficult to use the new competencies consistently. Transfer was more successful when managers protected practice time, supported nurses’ decision-making authority, and integrated rehabilitation activities into routine work. These findings suggest that training programs should combine clear outcomes with staged simulation, continued clinical support, opportunities to practise across settings, and attention to learner workload and wellbeing. Because this study was conducted in one Chinese tertiary hospital, the findings should be applied cautiously in other health systems.

Introduction

Cardiovascular and respiratory diseases, particularly when complicated by oncological conditions such as lung cancer, represent a growing global health burden.¹ As healthcare systems confront ageing populations and rising demand for comprehensive chronic disease management,² oncology cardiopulmonary rehabilitation (CP-Rehab) requires a highly specialised nursing workforce. Modern oncology CP-Rehab requires advanced nursing practice (ANP), including sophisticated clinical reasoning, multidimensional assessment, and autonomous evidence-based decision-making. The central challenge is therefore not only whether advanced competencies can be taught, but whether nurses can enact and sustain them in complex clinical environments.

Outcome-based education (OBE) centres curriculum design, teaching activities, and assessment on predefined competencies.³ Existing nursing evidence is encouraging but is dominated by quantitative evaluations. A systematic review found that OBE can improve nursing students’ knowledge, clinical skills, and core competencies.⁴ A practice-oriented workshop for newly recruited nurses, designed with OBE principles, also improved creativity and problem-solving-related outcomes and generated research outputs during 1-year follow-up.⁵ These studies establish educational effectiveness but provide limited explanation of how competencies are sustained after training or why transfer succeeds in some clinical settings and stalls in others. Such questions are especially important in complex, dynamic specialties such as oncology CP-Rehab.

Evaluations of specialist nursing training still rely predominantly on quantitative metrics such as pass rates and Objective Structured Clinical Examination (OSCE) scores, which cannot fully capture learners’ experiences or the organisational conditions surrounding competency transfer. Direct qualitative evidence on OBE-based specialty training for practising nurses remains scarce. Adjacent qualitative research has shown that transfer from skills training into clinical practice depends on alignment between education and workplace realities, tutor guidance, feedback, and opportunities to practise.⁶ Qualitative nursing research likewise indicates that professional-role transition and perceived competency are shaped by tensions between educational preparation and the clinical environment, with responsibilities shared by educators, healthcare organisations, and learners.⁷ This leaves an important gap concerning the psychological and structural stressors that arise when OBE-defined outcomes encounter resource-constrained oncology CP-Rehab environments.

To address this gap, this descriptive phenomenological study explored the experiences of trainees and tutors to: (1) understand how OBE frameworks influence clinical decision-making and professional role identity; (2) identify multidimensional stressors and structural barriers affecting competency transfer; and (3) examine how clinical environments and training programs interact to support or inhibit sustained practice. The aim was to generate context-sensitive evidence for the design of future OBE training and implementation support.

Methods

Study Design

A descriptive phenomenological design was used to capture the lived experiences of nurses undergoing competency transfer and role transition within an OBE-structured oncology CP-Rehab training program. Tutor interviews were used for triangulation. The study followed the 32-item Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.⁸ Data analysis used Colaizzi’s phenomenological framework,⁹ with NVivo 12 Plus supporting data management and coding.

Participants

Participants were recruited purposively from a major tertiary academic medical centre (a National Centre for Respiratory Medicine) in southern China. Trainee eligibility required completion of the inaugural OBE-based specialist CP-Rehab training program (January–April 2025), a valid Nurse Practicing Certificate, at least 2 years of continuous clinical experience in cardiothoracic surgery or a related field, and written informed consent. Exclusion criteria were more than 10% absence from training modules, transfer to another department, or resignation during the study period.

Tutor eligibility required direct supervision of trainees throughout the 3-month program and at least 5 years of teaching experience in CP-Rehab. Tutors were approached after trainee data saturation to cross-validate emerging interpretations, and written informed consent was obtained from tutors as well as trainees.

Trainee recruitment and interviewing continued until no new themes were identified. Saturation was provisionally assessed after the 12th trainee interview and was tested through 2 further interviews. Tutor interviews were then conducted to examine convergence and divergence with trainee accounts.

Data Collection

Trainee interviews: A semi-structured guide was developed from OBE principles and the study objectives and refined by 2 nursing-education professors. It explored: (1) the influence of OBE goal-setting on clinical reasoning; (2) experiences with the 1:5 tutor-to-student practicum model; (3) structural stressors and coping mechanisms; (4) shifts in professional role identity; and (5) contextual barriers to competency transfer. Interviews occurred within 2 weeks after training in a private hospital room and lasted 30–45 minutes. The interviewer was a female thoracic-surgery nurse who held a bachelor’s degree and the professional rank of nurse-in-charge. She had received qualitative-interview training, was independent of the teaching faculty, and had no role in trainees’ teaching or assessment. She knew the participants through prior clinical work; participants were informed of her research role and the purpose of the study before consent and interview. The same guide was used across participants, reflexive field notes were recorded, and potential assumptions were discussed during peer debriefing. All interviews were audio-recorded and transcribed verbatim. Semi-structured interviews are appropriate for exploring complex professional experiences.¹⁰

Tutor interviews: A parallel semi-structured guide explored tutors’ observations of competency development, barriers to transfer, and recommendations for program improvement. Interviews lasted 25–35 minutes, were conducted separately from trainees to reduce power-related influence, and were audio-recorded and transcribed verbatim.

Ethical considerations: The study was approved by the Medical Ethics Committee of the First Affiliated Hospital of Guangzhou Medical University (Approval No: ES-2025-K088-02). Written informed consent was obtained from all trainee and tutor participants. The study was conducted in accordance with the Declaration of Helsinki. Data were anonymised using participant codes (N1–N14 for trainees; M1–M3 for tutors).

Data Analysis

Trainee and tutor transcripts were analysed concurrently using Colaizzi’s seven-step framework: (1) verbatim transcription within 24 hours; (2) immersive reading; (3) extraction of significant statements; (4) formulation of meanings; (5) clustering of themes; (6) development of an exhaustive description; and (7) validation of the synthesised findings with participants. Tutor data were used to triangulate and deepen trainee-reported themes rather than to generate a separate thematic structure.

Measures to ensure analytic trustworthiness

Several procedures were used throughout data collection and analysis to strengthen credibility, dependability, confirmability, and the transparency of interpretation.

• Peer debriefing: Two independent nursing education professors audited transcripts, codes, and themes; discrepancies were resolved by consensus.

• Member checking: Synthesised findings were returned to participants for review, and feedback received was incorporated into the final interpretation.

• Saturation: Thematic saturation was provisionally identified after 12 trainee interviews and confirmed through 2 additional trainee interviews. Tutor interviews did not generate themes beyond those identified by trainees.

• Reflexivity: The interviewer was a female thoracic-surgery nurse with a bachelor’s degree and the professional rank of nurse-in-charge. Although she knew participants through prior clinical work, she had no teaching or assessment role in the program. Participants were informed of her research role and the study purpose. She documented contextual observations and potential interpretive assumptions in reflexive field notes and discussed these during peer debriefing. Tutor interviews were conducted separately from trainee interviews to minimise power-related influence. These procedures were used to distinguish participant accounts from researchers’ expectations about the program.

Complementary Descriptive Triangulation with Quantitative Data

Routine training assessment data from the same trainee cohort— theoretical examination, case-report, Objective Structured Clinical Examination (OSCE),^11,12 and trainee-satisfaction scores—were incorporated as complementary descriptive context. These data were not used for statistical inference and did not alter the phenomenological design; interpretation focused on convergence or divergence between assessment patterns and interview themes.

Results

Participant and Dataset Characteristics

The final sample comprised 14 trainee nurses and 3 clinical tutors. The trainee sample was entirely female, most participants worked in thoracic surgery, and experience levels varied; full characteristics are presented in Table 1. The 14 trainee interviews generated approximately 87,000 Chinese characters of verbatim transcript. Analysis of trainee and tutor accounts yielded 472 significant statements (111 from tutors), 82 initial codes, and 16 preliminary categories. Six themes were subsequently synthesised into 3 core trajectories for conceptual clarity.

Table 1.

Sociodemographic and Professional Characteristics of Trainee Participants (N=14)

Characteristics	Category	n	%
Gender	Female	14	100.0
Age (years)	25–35	9	64.3
	36–45	5	35.7
Clinical experience	<5 years	2	14.3
	5–10 years	6	42.9
	>10 years	6	42.9
Professional title	Junior nurse	2	14.3
	Senior nurse	2	14.3
	Charge nurse	10	71.4
Clinical department	Thoracic surgery	12	85.7
	Cardiac/transplant surgery	2	14.3

Across trainee accounts, with tutor perspectives used for triangulation, 3 core trajectories described competency transfer: (1) cognitive reconfiguration and role transition; (2) a three-dimensional stressor system; and (3) contextual synergy versus stagnation. Learner-led Plan–Do–Check–Act (PDCA) projects are summarised in Table 2, and complementary descriptive assessment data are reported in Table 3.

Table 2.

Optional Logbook-Based Learner-Led PDCA Projects Used to Apply OBE Competencies in Clinical Practice

Project Focus	Clinical Objective/Advanced-Practice Competency	Implementation Barriers	Tutor Evaluation and Reported Clinical Impact
ICU swallowing dysfunction	Increase screening of swallowing dysfunction in the ICU using standardised assessment.	Complex clinical pathways Difficulty matching staff and material resources	Workflow optimisation Enhanced interdisciplinary coordination
Exercise prescriptions	Formulate individualised, evidence-based exercise prescriptions for postoperative patients.	High cognitive demand when integrating pathology and exercise tolerance Substantial time requirement	Workflow optimisation Enhanced team coordination Reported increase in patient adherence
Respiratory function training	Design individualised respiratory-training plans using defined evaluation indicators.	Intensive time requirement Material-resource consumption	Enhanced team coordination Reported increase in patient adherence

Notes: Bold text denotes column headings. PDCA was an optional Logbook-based assignment: tutors formally introduced, supervised, and evaluated projects; trainees selected topics during training and could continue implementation after the program ended. Reported impacts are tutor evaluations and were not prospectively measured patient outcomes.

Abbreviations: ICU, intensive care unit; OBE, outcome-based education; PDCA, Plan–Do–Check–Act.

Table 3.

Complementary Descriptive Assessment Data from the OBE Training Cohort (N=14)

Assessment Domain	Mean Score (SD)/Rating	Maximum Possible	Qualitative-Context Alignment
Performance metrics
Theoretical knowledge	88.57 (3.7)	100	Consistent with knowledge internalisation in Trajectory 1
Case report / reasoning	85.31 (3.4)	100	Consistent with evidence-based reasoning and role transition
OSCE (clinical skills)	77.82 (8.4)	100	Wider variability was congruent with accounts of competence strain
Trainee satisfaction
Scientific validity and utility	5.0 (0.0)	5	Consistent with positive views of the Logbook framework
Interactivity and feedback	4.7 (0.4)	5	Consistent with benefits of intensive mentorship when accessible
Appropriateness of workload	4.1 (0.6)	5	Lowest rating; congruent with temporal and resource strain accounts

Notes: Bold text denotes column headings and section labels. These routine data are descriptive and are not intended for statistical inference.

Abbreviations: OBE, outcome-based education; OSCE, Objective Structured Clinical Examination; SD, standard deviation.

Trajectory 1: Cognitive Reconfiguration and Role transition—from Task Executor to Decision-Maker

Internalising holistic care through framework-driven reasoning

The structured OBE Logbook served as a cognitive scaffold by requiring assessment across 5 multidimensional domains aligned with the International Classification of Functioning, Disability and Health (ICF).^13,14 Rather than treating isolated symptoms, trainees described linking pathology, function, nutrition, psychological status, and social context. N3 explicitly attributed this systematic approach to the Logbook, while N7 described guideline-based oxygen decisions and tutor M2 independently observed a shift toward identifying patients’ underlying problems. Together, these accounts supported a broader interpretation of framework-guided reasoning. The Logbook also functioned as a reflective learning tool.¹⁵

N3: The Logbook required us to assess patients systematically… This training now makes me proactively evaluate nutritional status and psychological anxiety in my COPD patients simultaneously, leading to more integrated rehabilitation plans.

N6: The case-care module in the Logbook emphasised that each intervention should be supported by evidence. It made me realise that rehabilitation cannot rely only on personal experience or habit; we must seek and follow the best available evidence.

Tutors confirmed this shift: M2 noted, “They can now solve clinical problems independently. Before, they just did tasks without thinking why. Now they ask: what is the patient’s real problem?”

This framework-driven assessment also supported evidence-based decision-making. The shift was evident when trainees moved from habitual responses toward explicit use of guidelines and patient-specific indicators.

N7: In the past, adjusting a patient’s oxygen flow rate relied more on empirical judgment. Now I dynamically adjust the regimen based on guideline standards… making my clinical decisions more evidence-based.

Redefining Professional Identity: from Executor to Autonomous Collaborator

Structured entrustment of advanced tasks—such as leading multidisciplinary team (MDT) discussions, formulating evidence-based reports, and completing practice-based improvement assignments—supported a shift from physician-dependent task execution toward active clinical collaboration.¹⁶

N6: Before training, my role primarily involved executing physicians’ orders. Through this training… I can now more proactively communicate with physicians to provide professional recommendations.

N4 quantified: Previously, 90% of my work followed orders. Now in 30–40% of situations, I make autonomous nursing decisions based on evidence.

Tutors observed this transformation behaviorally: M3 remarked,

They no longer ask simple ‘how to do’ questions; they ask ‘why this, why not that’–that’s a fundamental shift. It shows they are thinking like advanced practitioners.

This role redefinition was linked to an awakening of a rigorous research mindset, establishing a “question-evidence-practice” closed loop.

N6: Interventions cannot rely solely on personal experience or habit, but must be grounded in the best available evidence.

The Logbook included optional learner-led Plan–Do–Check–Act (PDCA) projects as practice-based assignments. Tutors formally introduced, supervised, and evaluated these assignments, while trainees could choose whether to undertake a project. Project topics were selected during the training period, and implementation could continue after the formal program ended. Table 2 summarises projects involving intensive care unit swallowing screening, individualised exercise prescriptions, and respiratory training. These projects provided examples of applying OBE-defined competencies to real workflows: participating trainees identified a clinical problem, planned and initiated an evidence-informed change, reviewed barriers and early effects, and refined practice with tutor guidance. Tutor evaluations indicated workflow optimisation and improved team coordination; these were descriptive observations rather than prospectively measured outcomes.

Complementary descriptive data (Table 3) showed high theoretical-knowledge scores (mean 88.6) but wider variability in OSCE performance (SD 8.4). Without implying statistical association, this pattern was consistent with interview accounts that knowledge acquisition was more uniform than its application in complex scenarios.

Trajectory 2: The Three-Dimensional Stressor System–Time, Resources, and Competence Gaps

Participants described 3 interacting forms of strain—temporal, resource, and competence-related—that impeded transfer. Each dimension was represented in multiple trainee accounts and independently corroborated by tutors, indicating that the problem extended beyond individual learner difficulty.

Temporal strain arose when intensive morning teaching was followed immediately by bedside application. Participants described insufficient time to consolidate new concepts, while Logbook completion extended into late-night work. The issue was therefore not simply a heavy schedule; it was a mismatch between the timing of instruction, opportunities for reflection, and the cognitive demands of application.

N2: We had intensive theory lectures from 8 AM to 12 PM, followed immediately by bedside practice. I felt insufficient time to digest the morning’s content.

N12: In the final month, I often worked until midnight to fulfil Logbook requirements.

Tutor M1 confirmed: “The schedule is too dense… theory in the morning, practice in the afternoon–no time to absorb. They are rushing to complete tasks rather than deeply learning.”

Resource strain reflected both diluted mentorship and inconsistent access to suitable cases. The 1:5 model allowed intensive guidance when tutors and trainees were co-located, but supervision weakened when groups dispersed across wards. At the same time, required case types were not always available, creating delays and unequal practice opportunities.

N13: When we were dispersed… the tutor might be supervising other groups. Feedback was often not as prompt.

Tutor M1 added: “With 1:5, we are stretched thin. After they return to their own wards, full follow-up is impossible. I cannot be everywhere.”

N11 also noted case scarcity: The Logbook required specific case types… sometimes we spent hours searching for suitable patients.

Competence strain emerged when multidisciplinary case demands exceeded trainees’ prior specialty exposure. Nurses experienced uncertainty when moving beyond familiar thoracic-surgery scenarios, particularly when balancing multiple rehabilitation priorities. Tutors distinguished competence in routine cases from the deeper judgement required for atypical, multimorbid cases, suggesting a need for staged rather than abrupt escalation of complexity.

N1 (thoracic surgery nurse) felt “significantly challenged and lacked confidence” when managing post-cardiac surgery cases.

N6 struggled to develop a balanced intervention plan for a patient with multiple complex nursing issues.

Tutor M2 observed: “They can handle routine rehabilitation, but for complex, atypical cases, their knowledge is still shallow. That takes years of exposure, not three months.”

The descriptive assessment pattern in Table 3 was congruent with these accounts: the mean OSCE score was 77.8 (SD 8.4), and workload appropriateness received the lowest satisfaction rating (4.1/5). These values are presented as contextual convergence only and do not establish a statistical relationship with the qualitative themes.

Trajectory 3: Contextual Synergy versus Stagnation–the Moderating Role of Clinical Environment

Realisation of OBE objectives depended on the interaction between the training program and the clinical environment. Trainee and tutor accounts described 2 contrasting pathways. Where managers protected practice opportunities and recognised nurses’ new decision-making role, competencies were reinforced through use. Where staffing shortages and rigid routines displaced rehabilitation work, skills were difficult to maintain.

Positive Synergistic Cycle

When departments granted appropriate decision-making autonomy, adjusted workloads, and visibly incorporated rehabilitation skills into routine care, trainees gained opportunities to test and refine their judgement. Patient improvement and leadership endorsement then reinforced professional confidence and proactive behaviour.

N8 reflected on successfully applying advanced assessments to a critically ill patient: “Witnessing the patient overcome illness… made me feel that nursing transcends mere task execution.” Leadership endorsement—for example, a head nurse incorporating new skills into morning handovers (N10)—further catalysed proactive behaviours. N3 also described how the training enabled her to offer rehabilitation advice even for patients who were not under her direct care.

Tutor M3 highlighted the systemic benefit:

In supportive departments, they thrive. The rehabilitation consultation group used to be overwhelmed with requests. Now, after training, that group is almost silent–because each ward’s own nurses can handle most issues. That is the real outcome.

Negative Blocking Cycle

Conversely, staffing shortages and rigid task allocation repeatedly displaced CP-Rehab practice. Participants could use new skills only in fragments of time, and some described stagnation and frustration. Tutors observed that without protected practice, competence diminished even when training had initially been successful.

N1: It was nearly impossible to secure dedicated time to practice… I could only ‘seize fragments of time’ between routine tasks.

N13 felt learning stagnated, even causing frustration.

Tutor M2 lamented:

In understaffed departments, even if they are scheduled for rehabilitation shifts, they get pulled back to routine clinical work. Skills regress quickly without protected time.

These divergent trajectories highlight that competency transfer is not an automatic educational outcome but a context-dependent process requiring organizational empowerment.

Cross-Cutting Implementation Needs: Envisioning a Sustainable Support Ecosystem

Trainees and tutors identified convergent implementation needs across the 3 trajectories. These suggestions are reported as participant-derived priorities and provide the empirical basis for a future support model; they were not components of the evaluated program.

Spatial and longitudinal extension. Participants wanted learning to extend beyond a short ward-based practicum. Operating-room observation could connect procedures with postoperative complications, while community follow-up could help trainees understand rehabilitation continuity after discharge.

N13: Opportunities to observe in the operating room… and community follow-up would make care continuous.

Tutor M3 supported: “If we could have intraoperative observation, they would understand post‑op complications much better.”

Dynamic and contextualised evaluation. Participants favoured staged feedback and OSCE tasks that resembled clinical decision-making, such as constructing an exercise prescription for a perioperative patient. This would shift evaluation from a final pass/fail event toward progressive assessment of transfer.

N3: OSCE stations could include real-world tasks like developing an exercise prescription for a perioperative patient.

Tutor M1 agreed: “The current assessment is too summative. They need formative, staged feedback–not just a final pass/fail.” Such recommendations align with post-OSCE evaluation guidelines.¹⁷

Psychological scaffolding. Trainees and tutors linked late-night assignments, family responsibilities, and clinical workload to an unsustainable burden. They proposed peer support and stress-management resources, but emphasised that additional support should accompany workload adjustment rather than become another required task.

N10: Add mindfulness-based stress reduction or peer support groups.

Tutor M3 noted the hidden burden: “Many are mothers with families. After work and homework, they stay up until midnight to finish assignments. That is unsustainable.”

Tutor M1 added: If we add more tasks without reducing other burdens, we will burn them out.

Together, these convergent accounts underpin the study-derived “OBE+ Smart Ecosystem” discussed below. The term describes a proposed package of implementation supports rather than the OBE curriculum evaluated in this study.

Discussion

This study explains how competency transfer and professional role transition unfolded among oncology CP-Rehab nurses within an OBE program. Triangulation across trainees, tutors, and routine assessment data indicates that the transition from task executor to decision-maker was neither linear nor guaranteed. OBE provided cognitive structure and explicit performance expectations, but transfer was constrained by temporal compression, limited mentorship and case access, and gaps between baseline experience and complex clinical demands. The clinical environment then reinforced or blocked the use of acquired competencies.

These findings are consistent with previous nursing-education evidence while adding a context-specific explanation of implementation. OBE is grounded in alignment between intended outcomes, teaching, and assessment;³ a systematic review found improvements in nursing knowledge, clinical skills, and core competencies,⁴ and an OBE-informed workshop for newly recruited nurses demonstrated gains in creativity, problem-solving-related skills, and research outputs.⁵ Qualitative transfer research in another clinical-education setting similarly found that skills learned in formal training may not transfer when workplace realities, tutor role-modelling, feedback, and practice opportunities are misaligned.⁶ Research with newly graduated nurses also describes professional-role transition as a process shaped by tensions between educational preparation and clinical reality.⁷ Direct qualitative evidence on competency transfer among practising specialty nurses in OBE programs remains limited; the present study therefore contributes a setting-specific account rather than claiming universal mechanisms.

Cognitive Load Theory (CLT) provides one explanation for the observed gap.^18,19 Immediate movement from dense teaching to complex bedside application increased extraneous load, while multimorbidity and unfamiliar specialties increased intrinsic load. The findings suggest that goal–resource misalignment may be an important implementation mechanism: explicit outcomes can add pressure when programs do not provide adequate time, cases, supervision, and authority to achieve them.

The Cognitive and Structural Paradox of Competency Transfer

Goal-visualisation tools such as the Logbook supported evidence-based reasoning, but the intensive “morning theory–afternoon practice” schedule created a competence-leap risk. Temporal compression reduced opportunities for consolidation, a concern reported by trainees and tutors. Simulation-based learning before direct patient care may provide a safer bridge between theory and practice,^20–22 particularly when cases are uncommon or high risk. Nevertheless, simulation cannot substitute for protected clinical time and accessible supervision. The diluted 1:5 mentorship observed across decentralised wards suggests that future programs should combine staged simulation with tiered supervision and deliberate matching of case complexity to learner readiness.

The Role of Clinical Empowerment in Sustaining Role Transition

A core contribution of this study is the mapping of a psychosocial transition from task execution toward collaboration and evidence-based decision-making. Advanced assignments, MDT discussions, and optional Logbook-based PDCA projects created opportunities for participating trainees to exercise judgement, but these opportunities depended on workload protection and recognition of nurses’ expanded roles. This finding is consistent with qualitative nursing research showing that professional-role transition is shaped by the interaction between graduates’ preparation, workplace realities, and organisational support.⁷ In the present study, supportive departments reinforced emerging autonomy, whereas staffing shortages and rigid task allocation interrupted practice and contributed to frustration. Clinical empowerment should therefore be understood as a key contextual condition—not a guaranteed consequence—of role transition.

Conceptualising the “OBE+” Smart Ecosystem for Sustainable ANP

The “OBE+ Smart Ecosystem” is a study-derived implementation proposal rather than the framework used in the inaugural program. It should therefore be treated as a hypothesis-generating model requiring prospective testing. Its components map directly to the reported barriers and participant recommendations:

• (1)Longitudinal and cross-setting practice: Extend selected learning activities into operating-room observation, community follow-up, and home-based contexts to support continuity of CP-Rehab, consistent with international pulmonary rehabilitation principles emphasising comprehensive, multidisciplinary, and patient-centred care.²³
• (2)Digital and simulation support: Use digital Logbooks and adaptive simulation to provide repeated practice with complex scenarios before patient contact.²⁴ These tools should supplement, not replace, tutor feedback and real clinical exposure.
• (3)Psychological and workload support: Combine peer support or evidence-based stress-management options^25,26 with realistic assignment volumes and protected learning time. Support should reduce rather than add to participant burden.

The optional Logbook-based PDCA projects in Table 2 illustrate one feasible link between predefined outcomes and daily practice. Project topics were selected during training, formally supervised and evaluated by tutors, and could continue beyond the end of the program. They allowed participating trainees to apply assessment, evidence appraisal, and team coordination to real clinical processes. However, participation was elective, and the reported impacts were tutor evaluations rather than prospectively measured patient or service outcomes; future studies should evaluate these effects directly.

Methodological Considerations and Comparison with Previous Literature

Use of trainee interviews, tutor interviews, and routine assessment data strengthened credibility by allowing convergence and divergence to be examined. This design complements OBE theory and predominantly quantitative nursing evaluations^3–5,27 and extends adjacent qualitative transfer literature^6,7 by describing how a specialty-training program interacted with workplace resources, role expectations, and clinical support. Nevertheless, the supplementary quantitative data were routine training metrics rather than outcomes specified a priori; they provide contextual convergence only and should not be interpreted as evidence of causal effectiveness.

Limitations

This study has several limitations. First, it was conducted in a single tertiary hospital in southern China. The Chinese healthcare system, nursing workforce structure, hierarchical role expectations, staffing conditions, and local OBE implementation strategy may differ substantially from those in other countries; transferability should therefore be assessed by readers against their own contexts rather than assumed. Second, the trainee sample was entirely female and predominantly comprised thoracic-surgery nurses (85.7%), which limits variation in perspectives. Third, only 3 tutors participated; their accounts were used for triangulation and cannot represent all educators. Fourth, interviews within 2 weeks after training captured early transition rather than long-term maintenance. Fifth, the assessment data were routine, descriptive measures not designed or powered for statistical inference. Finally, the proposed OBE+ Smart Ecosystem was derived from participant accounts and literature rather than prospectively implemented or tested. Multi-centre and cross-national studies with longer follow-up, diverse nursing roles, and patient or service outcomes are needed.

Conclusion

In this single-centre descriptive phenomenological study, OBE supported a transition among oncology CP-Rehab nurses from task execution toward more evidence-informed clinical decision-making. Sustained competency transfer was nevertheless shaped by interacting pressures involving time, resources, baseline competence, and organisational support. The findings suggest that clear learning outcomes should be paired with staged simulation, accessible mentorship, protected practice opportunities, context-sensitive assessment, and workload support. The proposed OBE+ Smart Ecosystem integrates these participant-derived priorities but requires prospective evaluation. Given the study’s Chinese tertiary-hospital context, these findings should inform rather than be assumed to generalise to other health systems.

Funding Statement

This work was supported by the 2023 Educational Science Cultivation Project of the First Affiliated Hospital of Guangzhou Medical University (Project List Item No. 1; Principal Investigator: Liang Ruan).

Data Sharing Statement

The qualitative data generated during this study are not publicly available due to ethical restrictions (participant confidentiality), but are available from the corresponding author upon reasonable request.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare no conflicts of interest in this work.