Enhancing the critical thinking skills, and knowledge acquisition of nursing students using problem-based learning: A quasi-experimental study

Abstract

BACKGROUND:

Problem-based learning (PBL) as a teaching methodology not only increases students’ knowledge, but also fosters their critical thinking skills (CTS). We aimed to examine the impact of PBL regarding the enhancement of CTS, the acquisition of knowledge, and the perceptions of nursing students.

MATERIALS AND METHODS:

This quasi-experimental research was carried out in 2023 using a single-group pretest-posttest design. Individuals involved were 36 third-year bachelor of science nursing students from Sirjan School of Medical Sciences, Sirjan, Iran, through census sapling. Experimental intervention was the practice of a problem-centered learning approach for ten classroom sessions. Data were gathered at baseline and subsequently after the intervention through valid and reliable questionnaires. Students’ perceptions of PBL experience (n = 10) were obtained through a focus group discussion (FGD). For quantitative data, frequency count, mean, and standard deviation were used for the description of variables. Also, two independent samples t, paired t, Mann–Whitney U, and Wilcoxon tests were employed for inferential statistics. Qualitative data were examined through content analysis according to Graneheim and Lundman.

RESULTS:

Quantitative analysis proved that there was a statistically meaningful difference in pre-test and post-test scores in relation to CTS (71.76 ± 7.80 vs. 130.35 ± 9.71), and knowledge acquisition (8.94 ± 2.06 vs. 12.25 ± 2.34), respectively. Also, the same statistically significant trend was observed between male and female participants (P = 0.001). Qualitative data revealed that PBL has an influence on student engagement, motivation, and feedback, and makes students active and lifelong learners.

CONCLUSIONS:

It was found that problem-based learning has significant positive effects on the critical thinking and knowledge acquisition of nursing students. Therefore, problem-based learning can be used in nursing education for effective and proper training.

Introduction

Nursing students at the undergraduate level are required to dedicate a significant amount of time to learning in the classroom to acquire essential clinical knowledge before honing their clinical skills. Clinical knowledge and skills are indispensable components of nursing competence. To achieve this objective, and considering the future professional career of nursing students, it is imperative for them to foster CTS when encountering patients in their practice to provide effective care.[1] Lack of students’ experience with higher order CTS along with their inability to tackle situations in the face of challenges has been recognized as an area of concern among nurse educators.[2] Similarly, research sheds light on teaching students through active learning methods to construct new knowledge,[3] and this issue becomes more salient for nursing students as their learning due to its practicality in the real world must be through active methods of learning.

The discussion of empowering nursing students with higher-order thinking skills has significantly evolved and CT and problem-solving skills have been considered fundamental components in which students must be equipped in the 21^st century.[4] Based on adult learning theories, learners are self-directed, have a wealth of experiences, and are motivated by internal factors.[5] Similarly, constructivists emphasized interaction which aligns with the collaborative and interactive nature of nursing education.[6] To this end, PBL as a constructivist approach has been frequently used in teaching nursing students to promote the use of previous knowledge and participatory involvement.[7] PBL was established to address concerns regarding the effectiveness of traditional teaching methods in nurturing complex cognitive skills. Studies have shown that incorporating adult learning principles and constructivist approaches in nursing education can enhance student engagement, promote active learning, and promote the enhancement of CT and problem-solving skills.[8,9]

In a comprehensive review and meta-analysis conducted by Sharma et al.,[10] findings highlighted that PBL seems to augment the CTS of nursing students, particularly in terms of their ability to analyze and assess. The authors concluded that PBL is an effective approach compared to traditional methods in fostering students’ CTS. Likewise, a meta-analysis by Liu and Pasztor investigating the impacts of problem-centered learning strategy on CT showed that PBL improved CTS. The findings of this study signified that additional research is needed to examine the effectiveness of PBL in different contexts and based on other factors.[11] Conversely, the findings of a systematic review by Haobin Yuan et al.[12] on enhancing nursing students’ CT by means of PBL revealed that CTS of nursing students cannot be fostered by the application of PBL. They suggested further research to fully understand the effect of PBL on enhancing CT within the nursing education context.

To the best of our knowledge, teaching nursing students in our context is not based on problem-solving and critical thinking, even though, attempts are made for meaningful learning. In a systematic review by Jafari et al.,[13] findings revealed that Medical Sciences students in Iran have poor CTS. This is accentuated by the fact that students are inexperienced with higher order CTS.[2] Based on the available contradictory research findings of the impact of PBL on CTS, the present study was undertaken to teach nursing students with a PBL approach to investigate whether they arrive at high-level thinking skills and their knowledge improves. Furthermore, their perception of PBL use in their learning was another matter of investigation. In light of these considerations, this study endeavors to assess: 1) the development of CTS; 2) the impact of PBL on knowledge acquisition; and 3) the perspective of nursing students of PBL experience in our context. By rigorously examining these objectives, our study provides a significant contribution to the current research on PBL and student learning. It is essential to note that research on PBL in nursing education, focuses on traditional outcomes or specific skills. Our study addresses the dual focus on critical thinking and knowledge acquisition, which may not be extensively covered in previous research. Also, data is collected through the combination of quantitative data (using validated questionnaires) and qualitative insights (from focus group discussions). This mixed-methods approach enriches the understanding of student perceptions and the nuances of the PBL experience. Last but not least, we believe that the results of this study advocate for the integration of PBL into nursing curricula, promoting an active learning environment that prepares students for complex clinical situations. All these points add to the importance of conducting this research.

Materials and Methods

Study design and setting

This quasi-experimental research employing the one-group pretest-posttest design was conducted at the Sirjan School of Medical Sciences, Sirjan, Iran. To comply with ethical standards, individuals were given the choice to take part in the study and provided verbal consent. Additionally, anonymity and confidentiality of participants’ data were assured throughout the study. A briefing session was also conducted before the research began to explain the study objectives, and any questions were addressed.

Study participants and sampling

Participants included 36 third-year bachelor of science nursing students at Sirjan School of Medical Sciences in 2023. Students were selected on census sampling. The inclusion criteria were: (1) fifth-semester students studying Nursing who were enrolled in the Nursing of Children’s Diseases Course; (2) completion of both the pretest and posttest; and (3) willingness to participate in the research. The exclusion criteria included: (1) students retaking the Children’s Diseases Course; (2) missing more than three classroom sessions; and (3) not completing both the pretest and posttest.

PBL implementation

Before the initiation of the study, participants were briefed on the procedures of PBL instruction during a two-hour session. Participants were organized into six distinct groups, with each group comprising six members. They were also instructed to arrange their seats in a horseshoe shape during class hours to facilitate more communication and collaboration during class discussions. They were taught by the PBL approach for ten sessions, each lasting 90 minutes. Moreover, PBL implementation was undertaken by a member of the research team (MD) who is an expert in the field of nursing.

The following topics related to the Nursing of Children’s Diseases Course were selected for PBL teaching. Each topic was covered in two sessions. They included: 1) kidney disorders (urinary tract infection); 2) respiratory disorders (asthma); 3) digestive system disorders (gastroesophageal reflux); 4) heart disorders (Kawasaki syndrome); and 5) nervous system disorders (seizures).

To implement PBL, we followed the seven-step model developed by Maastricht University.[14] The seven steps involved were: 1) engaging in a discussion about the case to ensure a shared understanding of the problem; 2) pinpointing the questions that need to be addressed for clarity on the case; 3) brainstorming existing knowledge within the group to explore potential solutions; 4) evaluating the outcomes from the brainstorming session; 5) establishing learning objectives to target areas where knowledge is still needed; 6) conducting independent research, either individually or in small groups; and 7) discussing the findings. The theoretical framework and intervention model of problem-based learning is depicted in Figure 1.

Figure 1.

The theoretical framework and intervention model of PBL

Data collection and technique

In the quantitative phase, data was collected using three different questionnaires. They included A) the demographic characteristics; B) Rickett’s critical thinking disposition inventory; and C) the knowledge test. These instruments (B and C) were used to administer pre-test and post-test measures to students. Rickett’s critical thinking disposition inventory encompasses 33 items, including three dimensions of innovativeness (11 items), cognitive maturity (9 items), and engagement (13 items). Items are responded on a five-point Likert scale ranging from one (absolutely disagree) to five (absolutely agree). The minimum and maximum scores obtained are 33 and 165, respectively. The reliability coefficient of this questionnaire was reported as 0.086.[15] Pakmehr et al.[16] in Iran, validated this questionnaire. For validation of this questionnaire in the present study, its reliability was measured by using Cronbach’s alpha, which yielded a value of 0.80, signifying that the test is reliable.

The knowledge test has 20 questions in the format of four multiple-choice questions. The lowest and highest scores obtained were zero and 20, respectively. These questions were compiled from the PBL learning topics. To determine the validity, five experts in the field of Nursing assessed the face and content validity, and necessary amendments were taken into account. The reliability coefficient of this questionnaire was measured and proved by Cronbach’s alpha 0.78.

In the qualitative phase, the perceptions of ten students (six females and four males) regarding the PBL experience were obtained through an FGD, which lasted for approximately three hours. In this regard, the true perspectives embedded in the PBL experience in our context were identified. Focus groups utilize group dynamics, incorporating aspects of interpersonal interaction and participant observation.[17] The total number of participants in our focus group was ideal for gathering data as recommended by the literature.[18] Participants were asked to elaborate on the following questions and each participant had the opportunity to talk freely. Participants were at ease to express their opinions and the goal was to facilitate communication and engagement among them.

• What is your experience related to PBL teaching?

• What are the positive aspects of learning by PBL?

• How does your experience with PBL affect your learning?

Statistical analysis

Concerning quantitative data, frequency, mean, and standard deviation were used for the description of variables. Also, two independent samples t, paired t, Mann-Whitney-U, and Wilcoxon tests were employed for inferential statistics. The analysis of the data was performed using SPSS software, version 26 (with a significance level <0.05), developed in Chicago, IL, USA.

Qualitative data were examined through content analysis as outlined by Graneheim and Lundman.[19] The FGD session was recorded and subsequently transcribed. Verbatim transcription was used to identify units of data. Then each data unit was simplified and assigned a unique code. Codes that were both similar and distinct were identified and combined, if possible. Then, various categories began to emerge. Finally, the identified categories were discussed by the research team for reliability.

Ethical consideration

This study was approved by the Ethics Committee of Sirjan School of Medical Sciences, Sirjan, Iran under the ethics code IR.SIRUMS.REC.1402.032.

Results

Thirty-six students took part in this study, of which 21 (58.30%) were female and 15 (41.70%) were male. All students were between 21 and 23 years old. Concerning marital status, 34 (94.45%) students were single, and 2 (5.55%) were married. In terms of residence, 28 (77.80%) students lived in university housing, whereas 8 (22.20) lived in Sirjan with their families. In addition, a majority of 30 (83.30%) students had a desire to pursue future education in nursing, while 6 (16.70) students were hesitant to do so. Findings revealed that the mean total score of CT and knowledge of nursing students after the intervention was 130.35 ± 9.71 and 12.25 ± 2.34, respectively. The difference between the total pre-and-post test scores exhibited statistical significance [Table 1]. Among the dimensions of CT, the highest mean score was related to mental engagement (54.00 ± 7.79).

Table 1.

Mean score of nursing students’ CT and knowledge before and after the intervention

Variables		Mean (SD)				P
		Pre-test		Post-test
Critical thinking disposition
Innovation		24.85 (3.20)		44.26 (2.68)		<0.001**
Cognitive maturity		19.50 (3.08)		32.09 (2.53)		<0.001**
Mental engagement		27.41 (4.07)		54.00 (7.79)		<0.001**
Total		71.76 (7.80)		130.35 (9.71)		<0.001**
Knowledge
Knowledge score		8.94 (2.06)		12.25 (2.34)		<0.001*

*P from paired t tests; **P from Wilcoxon test; P<0.05 is considered as statistically significant

In addition, as shown in Table 2, significant differences were observed in critical thinking and knowledge in male and female participants. The mean total score of CT and knowledge of male students before the intervention was 72.21 ± 8.90 and 8.08 ± 1.80, respectively, whereas the mean total score after the intervention was 130.79 ± 4.91 and 12.12 ± 2.66, showing a statistically significant difference (P < 0.001). Likewise, the mean total scores of critical thinking and knowledge of female students before (71.20 ± 6.41 vs. 10.03 ± 1.89) and after (129.80 ± 13.81 vs. 12.41 ± 1.93) the intervention demonstrated a statistically significant effect (P = 0.001). Regarding the dimensions of critical thinking, there was an increase in the mean total scores of post-intervention values for each gender, indicating a statistically significant difference [Table 2].

Table 2.

Comparison of the mean score of CT and knowledge before and after the intervention in male and female participants

Variables		Assessment		Mean (SD)				P
				Male (n=15)		Female (n=21)
Critical thinking disposition
Innovation		Pre-test		24.58 (3.11)		25.20 (3.38)		0.607**
		Post-test		44.89 (2.49)		43.47 (2.77)		0.190**
		P		<0.001**		0.001
Cognitive maturity		Pre-test		20.21 (2.94)		18.60 (3.11)		0.202**
		Post-test		32.53 (1.98)		31.53 (3.07)		0.451**
		P		<0.001**		0.001**
Mental engagement		Pre-test		27.42 (4.19)		27.40 (4.05)		0.837**
		Post-test		53.37 (2.56)		54.80 (11.55)		0.354**
		P		<0.001**		0.001**
Total		Pre-test		72.21 (8.90)		71.20 (6.41)		0.811**
		Post-test		130.79 (4.91)		129.80 (13.81)		0.104**
		P		<0.001**		0.001**
Knowledge
Knowledge score		Pre-test		8.08 (1.80)		10.03 (1.89)		0.004*
		Post-test		12.12 (2.66)		12.41 (1.93)		0.718*
		P		<0.001*		0.001*

P-value from two independent samples t and paired t-tests; **P-value from Mann-Whitney-U and Wilcoxon tests. P<0.05 is considered as statistically significant

To explore the perception of Nursing students regarding their experience of problem-based learning, an FGD was held. Students’ perceptions of the PBL experience were categorized into four main themes including 1) active learning; 2) life-long learning; 3) motivation; and 4) feedback [Table 3].

Table 3.

Student’s perception of PBL based on responses from the FGD

Students perception of problem-based learning experience
1) Active learning		⁘ active involvement in learning activities ⁘ using real-life clinical problems ⁘ collaborative discussions and group work ⁘ opportunities to exchange ideas with peers ⁘ deepening previous knowledge
Sample participants’ statements:     The PBL approach kept me engaged and on my toes throughout the entire learning process. I couldn’t just sit back and passively listen. I had to be an active participant (Male student).     It was really hard for me to gain mastery over subject matter, but group discussions during PBL helped deepen my understanding of the material. Hearing how my classmates approached the problems gave me new insights (Female student).     I have a feeling that I can succeed better. PBL teaching sessions in the format of being engaged with open-ended problems made me realize there were some gaps in my previous knowledge and my understanding was more superficial (Female student).
2) Life-long learning		⁘ instilling a sense of autonomy ⁘ fostering independent and self-directed learning skills ⁘ enhancing professional/career advancement ⁘ being responsible and accountable for learning
Sample participants’ statements:     Working through the complex, open-ended problems in the PBL sessions has helped me develop a problem-solving mindset that I can apply to any challenge I encounter in the future (Male student).     I now feel that I can more confidently encounter with patients in real practice as the PBL format has equipped me with the ability to think creatively, consider multiple perspectives, and identify innovative solutions that will be invaluable as a life-long learner (Female student).     During PBL implementation, we had the freedom to explore topics that were of particular interest to me. This has strengthened my ability to identify and pursue my own learning goals (Male student).
3) Motivation		⁘ more student satisfaction with learning ⁘ being enthusiastic during PBL activities ⁘ willing to be taught by PBL again ⁘ positive learning environment
Sample participants’ statements:     The PBL approach really motivated me throughout the course. I felt more engaged and invested in the process. This course is more enjoyable and satisfying (Female student).     I found the PBL activities to be much more interesting and relevant to my future nursing practice compared to traditional lecture-based classes (Male student).
4) Feedback		⁘ providing feedback on students’ learning ⁘ sharing thoughts and knowledge with my peers ⁘ conveying insightful views to peers ⁘ willing to learn from mistakes ⁘ reflecting on knowledge
Sample participants’ statements:     Understanding my areas of weakness through the feedback I receive is quite illuminating. When I am informed about my mistakes in a supportive environment, I am able to learn more effectively in relation to the specific field of study (Male student).     It is essential for us to engage in reflection on the whole activities following problem-based learning. We must critically evaluate our actions and plan for self-improvement (Female student).     I believe that my peers enhance their learning when I articulate my insights related to the subject matter. Furthermore, I deepen my comprehension when I delve into the topics covered during the teaching session (Female student).

Discussion

The present study seeks to investigate three main objectives concerning the incorporation of PBL in nursing education. Detailed explanations of the findings based on the objectives of this study are provided as follows.

Impact of PBL on critical thinking

Quantitative data shows that the level of CT as well as the three dimensions of it after the intervention increased. It can be inferred that PBL is an effective approach to improving the CT of nursing students. This conclusion aligns with the results of Lopez et al.[20] highlighting that nursing students who received instruction through PBL demonstrated superior CTS, and more independent learning when compared to other teaching methods. Also, this finding is supported by the research conducted by Nur Amanda and Wahyuningsih, stating that higher levels of critical thinking were observed in post-test scores of students instructed by PBL in comparison to the group taught by lecture.[21] It is assumed that the application of PBL in teaching can make students active and the more actively students use their cognitive abilities, the greater chances that problems will be solved. Therefore, students’ CTS improve and they learn how to solve problems systematically. Our statement is reinforced by research findings that PBL increases CTS in different subjects such as biology, and economics.[22,23] In addition, the significant increases observed for the three dimensions of critical thinking disposition suggest that the PBL experience fostered an enhanced propensity for innovation and creativity (innovative disposition), a greater sense of cognitive maturity and prudence in decision-making (cognitive maturity), and a heightened level of mental engagement and motivation to tackle complex problems (mental engagement).

More analysis of the findings revealed that there was an increase in the total post-test scores of both male and female participants in terms of CTS; however, male students obtained a higher score in comparison to female students, except for the mental engagement dimension. This finding contradicts the research results of the study conducted by Mousazadeh et al.[24] on effective factors in critical thinking disposition among nursing students, stating that female students obtained higher scores not only for the total mean score of CTS but also for the three dimensions of critical thinking. The gender differences in critical thinking disposition may be ascribed to elements such as socialization and learning preferences.

Impact of PBL on knowledge

In terms of knowledge acquisition, findings indicated a statistically significant increase between pre- and post-test total scores. Also, the same trend was observed between male and female students, indicating a higher score for female students. It is assumed that nursing students due to their future careers need to have the clinical knowledge to solve problems they face in their day-to-day care. Thus, through the PBL approach nursing students are capable of continuously integrating their knowledge and skills and applying them in pertinent contexts.

The research conducted by Ajai and Imoko indicated that there were no significant differences in achievement and retention scores between male and female students who were instructed in Algebra through the use of PBL.[25] This study is not in line with our investigation. Conversely, Kassab et al.[26] found a significantly higher learning and group performance in female students in comparison to male students using PBL tutorials.

Students perception of PBL experience

Concerning the third objective of this study, qualitative data aligns closely with the benefits of PBL reported in the literature. PBL experience makes students active learners by fostering student engagement and participation compared to the traditional passive learning format.[21] This can be due to the real nature of PBL which uses authentic, real-world problems, and by the collaborative nature of PBL students engage with course material, rather than simply memorizing information. Wafaa and Nahed observed that PBL helps nursing students become more active and self-directed in their learning, as they take a more interactive role in applying knowledge to solve complex problems.[27] The emergence of lifelong learning as a key theme corresponds with recent research demonstrating PBL’s ability to develop crucial self-directed learning skills for nurses’ ongoing professional development. Wong found that PBL-based programs helped nursing students cultivate reflective capacity and a growth mindset, which are crucial for continued learning and improvement throughout one’s career.[28] Additionally, the nursing students’ heightened “motivation” aligns with studies highlighting PBL’s positive impact on student interest and intrinsic drive to learn. Rotgans and Schmidt explained how the real-world relevance and collaborative nature of PBL can foster a sense of purpose and engagement in students, as they see the direct applicability of their learning.[29] Finally, the emphasis on “feedback” underscores the importance of structured support and assessment in PBL environments. Wijnen et al.[30] emphasized the crucial role of the instructor in facilitating meaningful feedback and guiding students’ self-reflection throughout the PBL process.

The positive aspects of the PBL approach identified in the present study are essential components of students learning as evidenced by constructivist theories of learning.[9,31]

The combination of quantitative and qualitative results offers a thorough comprehension of how PBL impacts critical thinking and knowledge acquisition. Quantitative analysis demonstrates the effectiveness of PBL in improving CT, and knowledge while qualitative data shed light on the various ways in which PBL supports cognitive development, student engagement, motivation, feedback provision, and active learning. By incorporating multiple data sources and methods, the validity and reliability of the findings are enhanced, ultimately strengthening the credibility of the study.

Limitation and recommendation

This study has its limitations. First, this study sought the opinion of students in a single course at the Sirjan School of Medical Sciences. We need to bear in mind that a single course within a term and only some sessions of PBL practice do not guarantee the acquisition of CTS. It is believed that PBL can be effective in a long-term duration. In this regard, findings should be interpreted with a degree of caution. Second, we conducted a quasi-experimental study, and no control group or comparison was considered. Therefore, threats to the internal validity of this design prevent making the causal inference. Third, the restricted sample size in this study limits the applicability of its findings. Therefore, we suggest that future research be conducted with a larger sample size. Fourth, the long-term outcomes of PBL intervention were not assessed in this study. Subsequent investigations may enhance the sample size and incorporate a broader range of institutions to augment the generalizability of the findings and facilitate comparisons on a national scale. Incorporating other active learning methods could further promote the development of CTS. Extending the duration of intervention periods may provide students with additional time to thoroughly cultivate their CTS, potentially enhancing the outcomes. The study established a basis for comprehending how PBL impacts CT and knowledge acquisition among Nursing students.

Conclusion

Although the clinical environment is so complicated and multidimensional,[32] nurses play a significant role in patient care.[33] Teaching nursing students problem-solving skills has significant implications for both patient care and health policy. By equipping future nurses with the ability to analyze complex situations, think critically, and make effective clinical decisions, nursing education fosters a workforce capable of addressing the diverse challenges present in healthcare settings. Furthermore, as nurses play an increasingly pivotal role in shaping health policy, their proficiency in problem-solving enables them to contribute meaningfully to policy development and implementation. This can lead to more responsive and effective healthcare systems that prioritize patient-centered care and address systemic issues, ultimately improving health outcomes. Besides, understanding the importance of patient mortality can lead to the implementation of teaching methods that can equip nursing students with essential nursing skills to provide optimal care to reduce mortality and prevent unnecessary death. Policymakers should not disregard the implications that ill health care might have on health care. Considering Problem-based learning as an appropriate pedagogical approach, teachers must allocate a part of their teaching methodology to the incorporation of PBL in the classroom setting. The incorporation of PBL within educational environments is a strategic response to the intricate and interrelated challenges present in contemporary society. This approach cultivates competencies that equip students to navigate future uncertainties.[34,35] Quantitative and qualitative data of this study provided compelling evidence of the efficacy of PBL in enhancing CTS and academic performance among nursing students.

List of abbreviations

PBL = Problem-based learning

CTS = Critical thinking skills

CT = Critical thinking

FGD = Focus group discussion

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This study was approved by the Ethics Committee of Sirjan School of Medical Sciences, under the ethics code IR.SIRUMS.REC.1402.032. In addition, the Education Development Center, Sirjan School of Medical Sciences financially supported this study.