The Effectiveness of Problem-based Learning on Nursing Students' Critical Thinking: A systematic review.

Abstract

Review question/objective The review question: Is Problem-based learning an evidence-based teaching and learning strategy to promote nursing students' critical thinking? The review objective is to synthesize the best available evidence related to the effectiveness of Problem-based learning on nursing students' critical thinking. Background Problem-based learning (PBL) is a teaching and learning strategy, which emphasizes a student-centered approach, and encourages student to be self-directed in their learning. PBL problems come from clinical cases, and are the learning triggers for group discussion. Through minimal guidance from a tutor, learning issues related to case problems are generated via a brain storming discussion process. In the process of problem-solving, students learn to gather patient-related information, interpret objective and subjective results, and develop individualized care plans on a patient-centered basis. In PBL, students learn to study independently, collaborative learning, autonomy, clinical reasoning, as well as self directed and lifelong learning1. The PBL approach encourages learners to consider related health issues of clinical cases from diverse angles such as physical, psychological, social, economic, health, political, and cultural perspectives2. PBL is deemed to outweigh the traditional didactic method of teaching that is the passive received learning approach3. PBL is regarded as a suitable teaching and learning strategy for nursing, and directly relates to nursing clinical practice to deal with and solve patients' problems. Students in PBL use inquiry and critical thinking to seek a range of information, and to cluster knowledge toward hypothesis about the problems3. Thus, problem-based learning has been widely implemented in health care education, and also has been documented in literature to be an effective learning strategy to help increase clinical skills, problem-solving, and clinical reasoning for health care professionals3. The nursing competencies for the 21st century require nurses to think critically to provide effective and safe care in the complex context of current health care systems1, 4–5. The National League of Nursing of America in as early as 1980 proposed innovative teaching and learning strategies in nursing education, expected to promote nursing students to be actively involved in self-regulated learning, to transform traditional one-way delivery of knowledge to cultivate patient-centered teaching and learning model. The innovative model helps nursing students to foster the ability of health informatics, communication skills, collaborative skills, reflection, cultural sensitivity, critical thinking, as well as evidenced-based health care6. Critical thinking is a self-regulatory judgment process that relies on interpretation, analysis, and evaluation4. According to Brookfield, the four components of critical thinking include identifying and interpreting the world, promoting the importance of the context, exploring the alternatives, and expending thought process through self reflection7. The dimensions of critical thinking on cognitive skills are interpretation, analysis, inference, explanation, evaluation, and self-regulation4. Critical thinking is goal-oriented and meaningful, and necessary for clinical decision-making in nursing. There are differences between problem-solving and critical thinking. Problem-solving focuses on seeking a solution for a problem; critical thinking stresses the process of raising questions on all aspects of a situation, and further to critique solutions, it is a problem-solving and decision-making process4. In Shin, Lee, Ha, and Kim's study it was reported that there is an urgent need for nursing education to develop an appropriate teaching strategy to enhance nursing students' critical thinking8. Nursing education should prepare nursing students to be able to think quickly, identify and connect the relations in thinking, continue inquiry, and comprehensive ability to respond to complex clinical situations9–10. Properly and carefully used PBL in nursing education can help students to achieve the desired results from the PBL approach3. A systematic review which included four papers on education strategies to foster health professional students' clinical reasoning skills indicated that three of the four studies used PBL as the intervention and showed it to result in significant improvement in critical thinking11. A study of long-term effects of PBL on medical graduates found that compared with students in a conventional learning program, they reported to have better collaboration skills, problem-solving skills, information gathering skills, and self-directed learning12. Students of a biology course in PBL group had better learning satisfaction, critical thinking, cooperative work, information organization, as well as communication skills13. In addition, nursing students in PBL benefited by showing an improvement in autonomous learning, critical thinking, problem-solving, and communication14. Furthermore, a literature review exploring the influences of learning styles in nursing education found learners exposed to PBL develop the ability to reflect and think critically, the skills needed in acquiring knowledge and professional practice15. A systematic review including 30 papers on medical education using PBL approach as a learning strategy did not find it to have an impact on knowledge acquired due to the limitation of weak research study methodology design16. A review study including six papers searched from 1999-2008 was conducted by Oja on the effectiveness of PBL on nursing students' critical thinking. The review include all types of study design using PBL as teaching approach; the results indicated that more rigorously designed studies are needed to examine the effectiveness of PBL on critical thinking17. However, in Oja's review study, none of the included papers were published in Chinese and after 200917. In addition, there is inconsistency on the effectiveness and impact of PBL in health care professional education across disciplines, thus, the aim of this review is to establish the best available evidence regarding the effectiveness of problem-based learning on critical thinking for nursing students. This systematic review will target on nursing students with PBL as the intervention, focus on critical thinking as the outcome. Inclusion criteria Types of participants This review will consider studies that include nursing students. Types of intervention(s)/phenomena of interest This review will consider studies that used problem-based learning as intervention. Types of outcomes This review will consider studies that evaluated critical thinking skills as the study outcome, measured by using California Critical Thinking Disposition inventory (CCTDI) Types of studies This review will consider experimental studies. In the first instance, randomized controlled trials (RCTs) will be sought. In the absence of RCTs, other research designs such as non-randomized controlled trials and before and after studies will be considered for inclusion. Observational, cohort, case control and qualitative studies will be excluded. Search strategy The search strategy aims to find published studies in peer review journals written in English and Chinese. 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 articles. 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. Additional hand searches in relevant journals such as International Journal of Nursing Studies, Nurses Education Today, Journal of Nursing Education will also be conducted. The databases to be searched include: PubMed, CINAHL, EMBASE, PsycINFO, PsycARTICLES, Cochrane Library, Centre for Reviews and Dissemination, Index (via EBSCOhost), as well as Chinese publication databases. The Chinese databases will include: (1) http://www.ceps.com.tw (Chinese Electronic Periodical Services) (2) http://www.cetd.com.tw (Chinese Electronic Theses & Dissertations Service) (3) http://www.ncl.edu.tw/journal/journal_docu01.htm (National Central Library) The review will search for unpublished studies in the following databases: (1)http://mednar.com/mednar/ (2)http://www.proquest.com/en-US/catalogs/databases/detail/pqdt.shtml Initial keywords to be used will be “problem-based learning”, “problem-based”, “teaching learning strategy”, “nursing”, “nursing students”, “nursing education”, “critical thinking”. Corresponding words in Chinese will be used to search Chinese language databases. 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 standardised 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 Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II).The data extracted will include specific details about the intervention characteristics, populations characteristics, study designs (including statistical analysis) and outcomes of significance to the review question and specific objectives. Data synthesis Quantitative results will, where possible, be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible, the findings will be presented in narrative form. Conflicts of interest None Acknowledgements None