Keywords
nursing student, student, undergraduate, baccalaureate and nursing,
problem based learning, problem based, concept map, conceptual map, conceptual maps, concept maps, conceptual mapping, concept mapping, simulation, case study, learning, teaching, education, nursing education, traditional teaching, lectures, teaching methods and skill,
thinking, critical thinking, clinical reasoning, critical judgment and clinical judgment,
randomized controlled trial, trial, evaluation study, comparative study, experimental study, observational study, cohort study, pre test, pretest, post test, posttest, quasi-experimental studies.
Authors
- de Oliveira, Larissa Bertacchini BScN
- de Araujo Puschel, Vilanice Alves BScN, PhD
- Diaz, Leidy Johanna Rueda BScN
- de Almeida Lopes Monteiro da Cruz, Dina BScN, PhD
Abstract
Review question/objective: The review objective is to synthesize the best available evidence on the effectiveness of teaching strategies for the development of critical thinking among nursing undergraduate students.
The review question is: What is the effectiveness of teaching strategies in promoting the development of critical thinking in undergraduate nursing students?
Background: In 1991, the National League for Nursing (NLN) identified critical thinking (CT) as a core competency in the practice of nursing.1 Similar to the USA, CT has become a major concern of undergraduate nursing courses, particularly in regards to the way by which professors should instruct their students to think and develop CT. Based on this, the United Nations Educational, Scientific and Cultural Organization (UNESCO, 1998)2 recommends the introduction of innovative educational approaches that enable the development of critical thinking and creativity.
During the 1990s, as sponsored by the Committee on Pre-College Philosophy of the American Philosophical Association (APA), an interdisciplinary group of 46 international experts from the fields of humanities, social sciences, and education met to reach a consensus on CT, which could support future research work.3 These experts produced a worldwide recognized report, titled Delphi Report, in which they established that "critical thinking is the purposeful, self-regulatory judgment that leads to interpretation, analysis, evaluation and inference, as well as the explanation of the evidential, conceptual, methodological, criteriological or contextual considerations on which judgment is based".3(p.2)
According to Huang et al.,4 CT involves higher mental abilities, it is a prerequisite for effective judgment and the expansion of knowledge and is required in a healthcare professional who can be capable of accessing and interpreting information appropriately. With the aim of addressing the challenges of teaching and assessing the CT skills of health professionals, the "North American Millennium Conference on Critical Thinking" was organized. The conference enabled the development of strategies for inclusion in the principles of CT as well as the preparation of methods for assessing CT in the curricula of professions in the health field. The product of this conference culminated in a consensus that includes critical thinking as a core competence for nurses and emphasizes the teaching of this skill by professors.4
Two literature reviews on nursing education indicated the need to instruct nurses with CT skills has increased as a response to the rapid change in the health care environment.5-6 According to the authors, CT is needed not only in the clinical practice environment, but also required as a comprehensive component in Nursing education programs for the development of students' CT skills.5-6 Chang et al.7 claim that CT skills had a positive correlation to nurses' competence.7
Critical thinking is the focus of interest of professors and researchers around the world, with the need to educate critical and reflective practitioners in knowing how to act and making a difference in society becoming increasingly clear.1-23 Thus, this systematic literature review aims to evaluate the evidence available in the literature on the effectiveness of teaching strategies used for the development of CT among undergraduate nursing students.
In a preliminary search in the Cochrane Database of Systematic Reviews, Joanna Briggs Institute Library of Systematic Reviews, PubMed, and PROSPERO, three systematic reviews were found,24,26,27 as well as a protocol for a systematic review related to the effectiveness of strategies for addressing CT in nursing students.25
Yuan, Willians and Fan24 conducted a systematic review to identify and gather available evidence on the development of CT among nursing students by using problem-based learning (PBL).24 Studies in English and Chinese, published within the period from 1990 to 2006, were included. 24 Evidence has shown that PBL did not promote the development of CT skills among undergraduate nursing students.24 Further, Tang and Sung25 prepared a protocol for systematic review in order to synthesize the best available evidence on the effectiveness of PBL to address CT with nursing students.25 For inclusion in the systematic review, the authors will at first consider experimental studies that used PBL as an intervention strategy for nursing students, and those that assessed CT skills as a result of studying through the means of the California Critical Thinking Disposition Inventory.25 Publications in English and Chinese will be selected.25
Kong et al.26 conducted a systematic review and meta-analysis to determine the effectiveness of PBL to indoctrinate CT among undergraduate nursing students as compared to the strategy of traditional lectures. Nine articles were included in the meta-analysis. Despite the moderate heterogeneity (I2= 45%), the result of the meta-analysis indicated that nursing students who underwent PBL, as compared to those who attended lectures, had significantly higher CT levels (SMD = 0.33; 95%IC= 0.13-0.52; p = 0.0009).26
The systematic review conducted by Chan sought to assess how CT is perceived and which strategies and obstacles are potentially involved in the teaching and learning process of CT among studies with a qualitative design, published between 2002 and 2011.27 Seventeen studies were selected from the databases, including The British Nursing Index, Ovid MedLine, CINAHL, PsycINFO, and Scopus.27 The results showed that the concept of CT has undergone several changes over time, and there remains a lack of explanation among teachers and students in the field.27 The teaching strategies for promoting CT frequently discussed were questioning and reflective writing.27 The authors identified a need to conduct a systematic review that assesses the effectiveness of new teaching strategies and interventions for improving the competence of educators to teach CT as well as for promoting CT development among nursing students.
As mentioned earlier, studies included in previous systematic reviews on this topic have emphasized on teaching by PBL and have neglected other teaching strategies used in nursing education. This favors the study of only one type of teaching strategy and disfavors comparisons between any other types of existing strategies.
Based on this, Chan27 also indicated the need for a systematic review of quantitative studies to be conducted, in order to identify the most effective teaching strategies for CT among nursing students that are currently available.27 Hence, the present systematic review will examine research that addresses this urgent and current need. Thus, the aim of this systematic review is to highlight the teaching strategies that promote CT in students of undergraduate courses in nursing.
Article Content
Inclusion criteria
Types of participants
This review will consider studies on undergraduate students at any year level of a nursing program. Undergraduate nursing students from any country, and any undergraduate baccalaureate or baccalaureate equivalent course will also be considered.
Types of intervention(s)/phenomena of interest
The interventions which this review will examine include, but are not limited to, problem-based learning,11-15 case study,16 simulation,17-18 conceptual maps,19-23 and other teaching methods that specifically address the teaching and development of CT.
The review will consider teaching strategies (individuals and/or groups) which were used with undergraduate students in nursing to promote the development of CT. Only studies that implemented and evaluated the effectiveness of such strategies will be included.
Comparator/control intervention
This systematic review will compare studies using in the intervention group any teaching strategies and using in the control group any teaching strategies OR traditional teaching OR no specific intervention.
Types of outcomes
This review will consider studies that include CT as an outcome measure. It will include but not be limited to studies that assess skills in inference, recognition of assumptions, deduction, interpretation and evaluation, analysis skills, induction, deduction and, critical response development. The specific instruments will include the Watson-Glaser Critical Thinking Appraisal instrument,28 the California Critical Thinking Skills Test, 29 The Cornell Critical Thinking Test,30 The Ennis Weir Critical Thinking Essay,31 and the California Critical Thinking Disposition Inventory.32
Types of studies
This systematic review will consider all randomized controlled trials (RCTs) to determine the effectiveness of teaching strategies for the development of CT in nursing undergraduate students. In the absence of RCTs, other experimental study designs including non-randomized controlled trials, quasi-experimental, before and after studies and observational studies, such as comparable cohort studies, will also be included in the review.
Search strategy
The search strategy used for the review will focus on finding articles published in Portuguese, English and Spanish.
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken, followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies.
The databases to be searched include:
CINAHL
PubMed
Embase
PsycINFO
Cochrane Central Register of Controlled Trials (CENTRAL)
ERIC
LILACS
Web of Science
Scopus.
The search for unpublished studies will include:
ProQuest Dissertations and Theses
Cybertesis
Biblioteca Digital de Teses e Dissertacoes
Trove
Diva
RCAAP- Repositorio Cientifico de Acesso Alberto de Portugal
Theses Canada
Ethos
DART-Europe E-Theses Portal
National ETD Portal.
Assessment of methodological quality
Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data collection
Data will be extracted from papers included in the review independently by two reviewers, using standardized data extraction tools from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument JBI-MAStARI (Appendix II) Two reviewers will extract data independently for assurance of data accuracy. Discrepancies between the reviewers will be resolved by discussion or where resolution is not successful, by a third reviewer. The data extracted will include precise details about the populations and participant characteristics, inclusion and exclusion criteria, study settings and designs; descriptions of interventions, outcomes measures and results, and the number and reasons for withdrawal and dropout. If there is any data missing in the included studies, the authors will be contacted to retrieve statistical data if possible.
Data synthesis
Quantitative papers, where possible will be pooled in a statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. The presence of heterogeneity will, where possible be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation.
Conflicts of interest
The reviewers have no conflicts of interest in conducting this review.
Acknowledgements
This study is part of an international partnership project between the School of Nursing of University of Sao Paulo (Brazil) and the University of Surrey (England) and also interfaces with a multicenter study being developed by members of the Red Iberoamericana de Investigacion en Educacion en Enfermeria (RIIEE) with the focus on identifying teaching strategies employed by teachers to create and foster the nursing students and CT.
References
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Appendix I: Appraisal instruments
Appendix II: Data extraction instruments
MAStARI data extraction instrument[Context Link]
Keywords: Critical thinking; undergraduate student; education