Critical thinking in nursing and midwifery learning: Quantitative and qualitative review

Abstract

BACKGROUND:

This study tried to make a quantitative and qualitative review of the scientific production of the mobilization of critical thinking in nursing and midwifery learning.

MATERIALS AND METHODS:

The search was carried out in the “Web of Science” and “PubMed” databases between 2001 and 2021, resulting in 43 articles using several keywords “critical thinking,” “learning”, “nursing,” “midwifery”. The study will be split into two parts: A quantitative review in the form of a bibliometric analysis and a qualitative one in the form of a literature review. The quality of the articles has been verified by assessing the risk of bias (selection bias, detection bias, and interpretation bias) and using the Standards for Quality Improvement Reporting Excellence method.

RESULTS AND OBSERVATIONS:

The selected articles were the subject of a quantitative study leading to several results: chronology of publications, types of publications, number of publications, top journals of publications, etc. The same articles have been processed to produce a full qualitative review of the experimental studies.

CONCLUSION:

The results showed that the total and annual articles need to be higher. Experimental studies, especially quasi-experimental, are far higher than reviews or descriptive studies. The qualitative research showed a controversial relationship between critical thinking and learning improvement.

Introduction

The literature has long reported the importance and necessity of critical thinking in developing the capacities of nursing and midwifery students, thus facilitating the exercise of their jobs in a professional environment.

Several research works have recently focused on the factors and forms of learning that can improve learners’ critical thinking. We cite interprofessional learning based on problem-solving,[1] case studies,[2,3,4] self-assessment,[5] integrated training (simulation and critical thinking),[5,6] participatory education,[3] repeated simulation,[7] and “Escape Room”. These publications have all shown a correlation between the factors cited and the induction of motivation and curiosity or even creativity among students.

This work will try to make a cartography of the actual level of research in critical thinking about learning in the nursing and midwifery field. To reach this goal, this work will develop a double quantitative and qualitative analysis of critical thinking in the learning of nursing and midwifery students. Such studies are essential to know where we are and what we expect in the future, especially with the significant development of all the elements around human health, such as sciences, technologies, education, and AI.

On the other hand, significant challenges have been experienced in recent years, especially with the appearance of COVID-19, with all the demanding conditions accompanying it. It can be described as a precursor to several epidemiologies that may appear in the future and how we can manage it;[8,9,10,11,12] hence, the need to develop critical thinking in the health field, giving us the tools and reflexes necessary to handle different situations.

Materials and Methods

Study design and setting

The first part of the study is a bibliometric analysis of the scientific production of using critical thinking in nursing and midwifery learning. It deals with different aspects like the chronology of publications, topics of publications, top publishing journals, etc.

The second is a review of scientific production linking critical thinking to nursing and midwifery learning. The results showed relevant information like the study’s design, instrument used, intervention period, findings, etc.

Study participants and sampling

The research used two popular databases search: “PubMed” and “Web of Sciences” from 2001 until 2021.

Several keywords were used. The keywords used are critical thinking, learning, nursing, and midwifery.

We have also adopted truncations and the addition of “*” for better precision in the search and words such as “critical think*”, “learn*”, “nurs*”, and “midwi*”.

Flowchart

The search identified 85 articles. After merging the two databases, 48 papers remain. Five were discarded due to their nonconformity,[13,14,15,16,17] leading to a final result of 43 articles illustrated in the PRISMA flowchart as shown in Figure 1.

Figure 1.

PRISMA flowchart of the articles selection method

Data collection tool and technique

The data were managed by Zotero software, allowing us to collect articles and keep the most relevant of them, as shown in Figure 1.

The content of those articles was transferred and proceeded by Excel software, allowing us to extract the essential elements of studies and define the main topics on which we will focus.

Quantitative results

Qualitative results

The quantitative results show that experimental studies are the most published papers in two decades. A full review of those articles is shown below in Table 1.

Table 1.

Review of experimental studies dealing with critical thinking in nursing and midwifery

Design	Sample	Intervention	Instrument	Findings	Author, year
Cross-sectional study	139 nursing students	Semester	Demographic questionnaire, Kolb’s Learning Style Standard Questionnaire, and the California Critical Thinking Skills Questionnaire	No relationship between critical thinking and academic achievement was identified.	Shirazi, et al. (2019)
Quasi-experimental	78 nursing students	1 week	Self-reported questionnaire	S-PBL is an effective strategy for improving nursing students’ learning transfer	Son (2020)
Quasi-experimental	103 nursing students	5 months	The self-reflection and insight scale (SRIS) and Taiwan Critical Thinking Disposition Inventory (TCTDI)	Experiential Learning Program has a significant impact on self-reflection and critical thinking.	Cheng, et al. (2020)
Quasi-experimental	20 undergraduate nursing and 28 midwifery students	10 hours	Five 2-h training sessions	Interprofessional education has been able to enhance the overall critical skills of students.	Aein, et al. (2020)
Case study	38 nursing students	1-hour test	California critical thinking questionnaire	An increased score of critical thinking among students with “learning based on participatory education”	Salar, et al. (2020)
Quasi-experimental	40 nursing students	16 weeks	Standardized self-report questionnaires, including the California Critical Thinking Skills Test-B (CCTST-B) and the Metacognitive Awareness Inventory (MAI)	No significant changes were observed in the students’ critical thinking skills and metacognitive awareness after performing the lecture method.	Gholami, et al. (2016)
Comparative study	80 nursing students	18 weeks	The critical thinking disposition inventory (CTDI-CV)	The “nursing case-based learning” was a practical course to develop the critical thinking abilities of nursing students.	Li, et al. (2019)
Randomized controlled trial	295 undergraduate nursing students	1 year	Final examination, Process Assessment	Using blended case-centered learning showed promising results in improving students’ academic performance.	Yu, et al. (2021)
Quasi-experimental	90 nursing students	16 weeks	Standardized self-administered questionnaires of critical thinking, problem-solving, and self-directed learning abilities	Outcomes were not statistically different between groups.	Choi, et al. (2014)
Quasi-experimental	44 mental healthcare nurses	5 weeks	Semi-structured and open-ended interview	The experimental group with PBL had better skills but no significant difference for the group with LBL in the pretest and post-test scores.	Hung, et al. (2015)
Cross-sectional study	149 sophomore nursing students	2 months	Self-reported questionnaires	Teaching methods are necessary to increase nursing students’ critical thinking disposition and learning competence.	Oh, et al. (2021)
Investigation	76 nursing students	1 semester	California Critical Thinking Skill Test	PBL improved the participant’s metacognition and problem-solving process but not critical thinking.	Choi (2004)
Cross-sectional study	3,047 nursing students	2 months	Ocio-demographic date Metacognitive Ability Scale (Kanitical Thinking Disposition Inventory-Chinese Version)	The metacognitive ability of the 5-year vocational nursing students was not high, and the SDL ability and CT ability were both at a medium level.	Jin, et al. (2021)
Case study	Six students/preceptor dyads	6 months	Stakes phases of data analysis	Contextual learning can be a model of clinical learning in nursing education.	Forneris, et al. (2007)
Quasi-experimental	46 undergraduate nursing students	1 semester	The California Critical Thinking Skills Test Form A	Nursing students improved their critical thinking skills in China by experiencing a PBL approach to learning.	Yuan, et al. (2008)
Crossover study	76 undergraduate nursing students	1 semester–hour	California Critical Thinking Dispositions Inventory, California Critical Thinking Dispositions Inventory Chinese Version	No significant differences between groups were significant.	Yu, et al. (2013)
Quasi-experimental	50 nursing students	6 months	The California Critical Thinking Disposition Inventory (CCTDI), the Critical Thinking Disposition Inventory-Chinese Version (CTDI), self-designed data from.	The cooperative learning-based clinical practicum helps promote students’ critical thinking dispositions.	Zhang, et al. (2021)
Prepost test	54 nursing students	17 weeks	Descriptive Information Questionnaire, the ATI Critical Thinking Test, the Pre-Post Critical Thinking Test	No significant differences between the problem-based learning method and the lecture method.	Lyons (2008)
Randomized controlled trial	122 undergraduate nursing students	8 months	Critical Thinking Disposition Inventory Chinese version (CTDI-CV)	Improvement in the experimental group was higher than that in the control group.	Hong, et al. (2017)
Prepost test	14 novice nurses	6 weeks	Traditional multiple-choice examinations, Survey	Most nurses graduating from the program have remained in their clinical units.	Celia, et al. (2001)
Prepost test	47 nursing students	4 weeks	Critical-Thinking Disposition, Self-Directed Learning Ability, Simulation Effectiveness, Open-Ended Questions	No statistically significant differences emerged between the assessments on critical thinking or self-directed learning ability before and after the virtual simulation.	Kang, et al. (2020)
Quasi-experimental	230 nursing and 134 midwifery students		California Critical Thinking Disposition Inventory, Kolb Learning Style Inventory	A statistically significant difference was found between critical thinking dispositions based on learning styles.	Karadag, et al. (2018)
Comparative study	40 nursing students	1 semester	The California Critical Thinking Disposition Inventory (CCTDI)	Concerning critical thinking, a significant relationship was found between the PBL and lecture groups.	Dehkordi, et al. (2008)
Quasi-experimental	115 nursing and midwifery students		The California Critical Thinking Disposition Inventory (CCTDI)	Critical thinking disposition does not improve in a short time by using active strategies.	Iranfar, et al. (2012)
Quasi-experimental	55 nursing students	16 weeks	California critical thinking questionnaire, t-test	The tendency to critical thinking was higher in the group that was trained by a virtual learning-based learning method than in the trained group that was introduced in the traditional way.	Ghadi, et al. (2018)
Quasi-experimental	72 nursing students	2 week	The researchers used the learning motivation scale, learning attitudes scale, and learning satisfaction scale.	The students learning with the contextual game showed better skills, including critical thinking tendency, than those who received the traditional instruction.	Chang, et al. (2020)
Semi-experimental	55 nursing students	8 weeks	California Critical Thinking Skills Test Form B (CCTST), College Academic Self-Efficacy Scale (CASES)	Integrative education methods significantly enhanced students’ critical thinking and academic self-efficacy.	Roshangar, et al. (2020)
Randomized controlled trial	108 midwifery students	12 months	Questionnaire, test	Problem-based learning teaching methodology affects problem-solving skills and critical thinking.	Kousar, et al. (2021)

Below [Table 2] is a summary of the main results obtained from the quantitative and qualitative reviews.

Table 2.

Mains quantitative and qualitative critical thinking review results in nursing and midwifery learning

Critical thinking in nursing and midwifery learning
Type of review	Main results
Quantitative	The scientific production of critical thinking in nursing and midwifery learning still needs improvement. However, the last decade knew a gap of about 220% compared with the first one.
	Compared to descriptive and review studies, experimental studies present almost 65% of the production.
	Quasi-experimental studies present approximately half of all the experimental works; what remains is split between RCT, cross-sectional, etc.
	“Journal of Nursing Education” and “Nurse Education Today” are the journals that have published the most articles in the last two decades
Qualitative	Experimental studies showed that the relationship between using critical thinking and improving learning among nursing and midwifery students is controversial.
	Descriptive/qualitative studies showed that critical thinking in nursing and midwifery could be very promising for helping students learn.
	Several review studies have reported that learning styles like problem-based learning and classic-based learning might help improve students’ critical thinking skills.

Discussion

Critical thinking in nursing and midwifery science is relatively recent. The analysis of Figure 2 shows that scientific production can be split into two periods [2001-2010] and [2011-2021].

Figure 2.

Timeline of publications distribution between 2001 and 2021

[2001-2010]: The number of publications is relatively limited to one publication per year, except in 2008, which records four publications. It should also be noted that there are some empty years with zero publications, such as 2002, 2003, 2005, and 2006. In total, over a decade, the number of publications was 12.

[2011-2021]: The number of publications has increased remarkably, between one (only in 2016) and eight (in 2020). No year is empty. The total number is 31.

The total production remains low, with a maximum of eight articles per year; however, a trend of 220% has been recorded between the two decades.

As shown in Figure 3, the most dominant category of the articles listed from 2001 to 2021 is experimental studies (28 articles),[1,2,3,4,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41] followed by descriptive and qualitative studies (eight articles),[5,6,42,43,44,45,46,47] and finally reviews (seven articles).[7,48,49,50,51,52,53]

Figure 3.

Number of papers published between 2001 and 2021 according to their kind

This difference is explained by the fact that the integration of critical thinking in nursing and midwifery remains relatively recent, requiring more experimental work to define the subjects and produce data. These can then be used to develop studies in descriptive or qualitative form or reviews.

Approximately half of the experimental studies [Figure 4] are a quasi-experimental design; the rest is split between randomized controlled trial, cross-sectional, etc. This is explained by the simplicity of this type of study compared to the rest, especially randomized controlled trials. Quasi-experimental studies are optimal when randomized controlled trials are difficult or impossible, and intervention and control groups are not deliberately allocated.

Figure 4.

Distribution of experimental studies between 2001 and 2021 according to their kind

Concerning the descriptive/qualitative studies [Figure 5] and reviews [Figure 6], the total number is minimal, with eight and seven articles, respectively. The nature of these studies explains this, as the theme of critical thinking is recent, requiring quantitative data and time to launch such works.

Figure 5.

Distribution of descriptive/qualitative studies between 2001 and 2021 according to their kind

Figure 6.

Distribution of review studies between 2001 and 2021 according to their kind

Figure 7 shows the number of articles dealing with the theme of critical thinking in nursing and midwifery sciences, published in internationally indexed journals. The “Journal of Nursing Education” and “Nurse Education Today” are at the top of the ranking with six publications each, followed by the “International Journal of Environment Resources Public Health” with three publications, then the other journals do not exceed two publications.

Figure 7.

Number of papers produced between 2001 and 2021 according to the publication journals

The quantitative and qualitative review analysis performed in this study may be very useful for every researcher willing, to begin with the state of the art on applying critical thinking in nursing and midwifery.

The actual results can also be used to define new lines of research on critical thinking, which can be linked to the simulation tools in nursing and midwifery. Simulation has been growing these last years, and it was an exciting method, especially during the Mondial lockdown due to COVID-19.

As a limitation of our study, we could only find substantial production on critical thinking in nursing and midwifery after 2001. Also, we note the absence of similar studies on the same topic; we could not compare and extract some conclusions and interpretations according to our research.

Conclusion

Developing techniques and care practices increase significantly, which impose a significant challenge on academic training to support these continuous changes. Critical thinking is an exciting tool for dealing with many difficulties in nursing or midwifery practice. Our analysis attempts to provide a current map of the state of the work carried out and identified to date in scientific production. A significant transformation has been observed in the last 20 years, particularly in the previous decade, both quantitatively and qualitatively. Regarding the nature of production, experimental studies generally take over because the ground is still empty, and many paths remain to be dug. Qualitative studies and reviews still need improvement without data and further studies. It is important to note that a few scientific journals in the field are active. A problem that also limits production in the themes of critical thinking in the nursing and midwifery disciplines.

Finally, according to our study, one of the essential elements that need to be clarified and are not standard at an international scale is the critical thinking evaluation tool. The need for further studies is imminent, and more experimental works should be done with a performant and accurate evaluation tool.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.