Effects of problem-based learning and flipped classroom educational methods on patient safety knowledge, attitudes and skills among nursing students: A systematic review and network meta-analysis

Aim: To compare the effects of problem-based learning (PBL) and flipped classroom (FC) on patient safety knowledge, attitudes and skills among undergraduate nursing students. Background: Patient safety is central to healthcare quality and nursing education is essential for developing safety competencies. PBL and FC are widely used active pedagogies, but their head-to-head comparative effectiveness remains uncertain. Design: Systematic review and network meta-analysis conducted according to PRISMA-NMA guidelines (PROSPERO: CRD420261280066). Data sources: PubMed, Scopus, Web of Science, Embase, CINAHL and Cochrane Library were searched from inception to 6 January 2026, supplemented by Google Scholar, trial registries and reference screening. Methods: Interventional studies comparing PBL or FC with conventional education were eligible. Risk of bias was assessed using RoB 2 and ROBINS-I and certainty using CINeMA. Random-effects frequentist network meta-analyses were performed using netmeta in R. Results: Thirteen studies involving 979 participants were included, with eight contributing to the network meta-analysis. FC improved knowledge (SMD = 1.06, 95% CI 0.40–1.72) and skill (SMD = 0.92, 95% CI 0.35–1.49), but not attitude (SMD = 0.33, 95% CI −0.30 to 0.95). PBL ranked highest across all three domains (P-scores of 0.73–0.96), although each PBL estimate was based on a single study. Heterogeneity was substantial and certainty ranged from low to very low. Conclusion: At low to very low certainty, FC and PBL may enhance patient safety knowledge and skill, whereas effects on attitudes remain uncertain. Because no head-to-head trial exists, no firm ranking of the two pedagogies is currently possible; adequately powered direct comparisons are needed. Registration: The systematic review protocol has been successfully registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD420261280066).