International Journal of Nursing Studies 68 (2017) 16–24

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Comparison of the effectiveness of two styles of case-based learning

implemented in lectures for developing nursing students’ critical
thinking ability: A randomized controlled trial
Shaohua Honga,* , Ping Yub
a
Faculty of Nursing, Qianjiang College of Hangzhou Normal University Hangzhou, 310036, China
b
School of Computing and Information Technology, University of Wollongong, Wollongong, NSW 2522, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: To explore and compare the effectiveness of two styles of case-based learning methods,
Received 7 September 2016 unfolding nursing case and usual nursing case, implemented in lectures for developing nursing students’
Received in revised form 13 December 2016 critical thinking ability.
Accepted 13 December 2016
Methods: 122 undergraduate nursing students in four classes were taught the subject of medical nursing
for one year. Two classes were randomly assigned as the experimental group and the other two the
Keywords: control group. The experimental group received the lectures presenting unfolding nursing cases and the
Case-based study
control group was taught the usual cases. Nineteen case-based lectures were provided in 8 months in two
Learning
Critical thinking
semesters to each group.
Nursing education research Results: The two groups started with a similar level of critical thinking ability as tested by the instrument
Education of Critical Thinking Disposition Inventory—Chinese version (CTDI-CV). After receiving 19 case-based
Nursing learning lectures for 8 months, both groups of students significantly improved their critical thinking
Baccalaureate ability. The improvement in the experimental group was significantly higher than that in the control
Nursing process group (with the average total score of 303.77  15.24 vs. 288.34  13.94, p < 0.05). The experimental
Holistic nursing group also had significantly better improvement in six out of seven dimensions whereas the control
group showed improvement in only three out of seven dimensions of CTDI-CV.
Conclusions: The study suggests the feasibility of implementing case-based learning in lectures.
Unfolding nursing cases appear to be significantly more effective than the usual nursing cases in
developing undergraduate nursing students’ critical thinking ability in the subject of medical nursing.
Further research can implement the unfolding nursing cases in other nursing subjects.
© 2016 Elsevier Ltd. All rights reserved.

What is already known about the topic?
 Critical thinking is an essential skill for clinical reasoning and
good nursing practice.
 Case-based learning is useful in developing nursing students
clinical knowledge, holistic care and critical thinking skills.
 The effectiveness of implementing case-based learning in
lectures is unclear.
What this paper adds?
 Implementing nursing cases, either single-episode or multi-
episode, in nursing lectures is feasible.
* Corresponding author.
E-mail addresses: marissahong@163.com, 34847588@qq.com (S. Hong).
 Lectures with multi-episode cases are more effective than those
with single-episode in developing nursing students critical
thinking skills.
1. Introduction
The goal of university nursing education is not only to teach
theoretical knowledge, but also to develop students’ ability to
critically analyze evidence in order to reach optimal care decisions
when faced with complicated clinical issues (Simpson and
Courtney, 2002; Ward and Morris, 2016). Scheffer and Rubenfeld
(2000) state that the skills of critical thinking in nursing include
analyzing, applying standards, discriminating, information seek-
ing, logical reasoning, predicting and transforming knowledge.

http://dx.doi.org/10.1016/j.ijnurstu.2016.12.008
0020-7489/© 2016 Elsevier Ltd. All rights reserved.
 S. Hong, P. Yu / International Journal of Nursing Studies 68 (2017) 16–24
Turner (2005) suggests that critical thinking is characterized by
analysis, reasoning, inference, interpretation, knowledge, and
open-mindedness. Gupta and Upshur (2012) suggest that certain
qualities of an individual, such as honesty and courage to question
claims in the face of persuasion, authority or social pressure, are
critical. For decades, critical thinking has been a flourishing
concept that has been developing throughout nursing education
and practice (Kaddoura, 2013). Researchers generally agree that it
is an important ability for clinical reasoning and one of the most
important competencies for good nursing practice to ensure
optimal patient outcomes (Thompson and Rebeschi, 1999; Lasater,
2011; Perez et al., 2015). A nurse with competence in critical
thinking brings to care practice confidence, contextual sensitivity,
creativity, flexibility, inquisitiveness, intellectual integrity, intui-
tion, open-mindedness, perseverance, and reflection (Scheffer and
Rubenfeld, 2000). Technology development, the need for clear
communication, and patient safety all require nurses to have
critical thinking ability (Missen et al., 2014). Therefore, developing
nursing students’ critical thinking ability is one of the essential
learning objectives for any clinical nursing course.
Despite its importance, nursing academics are challenged by
the difficulty of creating a relevant, stimulating classroom learning
environment that is conducive to the development of students’
critical thinking ability when they usually have to teach a
substantial amount of content in lectures with limited support
and restricted contact hours (Mandernach, 2006). Despite being
criticized as an ineffective pedagogy for developing critical
thinking ability, classroom lectures are still the major channel
for knowledge delivery (Lighthall et al., 2016). Case-based learning
(CBL) provides an opportunity to develop students’ critical
thinking and problem solving skills in classroom lectures (Tomey,
2003; Srinivasan et al., 2007).
Case-based learning is a long established pedagogy that has
been widely implemented in various disciplines. Mclean (2016)
defines CBL as a tool that involves matching clinical cases in health
care-related fields to a body of knowledge in that field, in order to
improve clinical performance, attitudes, or teamwork. In nursing
education, CBL is considered to be a participatory teaching-
learning method that facilitates the active and reflective learning of
students for the development of critical thinking and effective
problem solving skills (Tomey, 2003). In implementing CBL, a
lecturer can apply various approaches to introduce simulated cases
into a class, such as the guided inquiry, case seminars, role plays,
and simulated patient care (Srinivasan et al., 2007; Marlow et al.,
2008; Thistlethwaite et al., 2012). Application of CBL in teaching
can achieve various learning outcomes (Macho-Stadler and
Elejalde-Garcia, 2013). Students can acquire adequate knowledge
about patient care by accessing real cases. They can gain better
understanding of various individual perspectives, which is useful
for developing their mindset for cooperation, as well as continuous
knowledge development (Forsgren et al., 2014). It also provides a
better opportunity for students to improve their patient assess-
ment skills and nursing care experience (Braeckman et al., 2014;
Raurell-Torreda et al., 2015). The knowledge and experience that
students acquire from virtual patient care will enable them to
better understand holistic care and thus prepare them for their
professional roles in the future (Forsgren et al., 2014). Because of
these benefits, CBL has been widely adopted in nursing education
in many countries to develop nursing students’ critical thinking
ability (Huckstadt and Hayes, 2005; Yoo and Park, 2014; Chan et al.,
2016).
Critical thinking plays an important role in burgeoning
nursing practice and it is necessary for all nurses to develop
critical-thinking skills for job satisfaction and improved patient
outcomes (Robert and Petersen, 2013; Turkel, 2016). With the
adoption and development of holistic nursing in hospitals in
17
China, critical thinking ability has become a core competence
for a registered nurse (Liu et al., 2008a). To meet this demand,
Chinese nursing educators are attempting to improve the
methods for developing students’ critical thinking ability. Many
have trialed integration of the pedagogy of CBL in clinical
nursing courses and there have been some satisfactory out-
comes (Liu et al., 2008b; Jin et al., 2011; Zhou et al., 2012; Gao
et al., 2016). For example, Liu et al. (2014) compared CBL with
traditional lectures delivered to undergraduate nursing stu-
dents. They found that the group receiving CBL were
significantly more capable in both problem solving and clinical
decision making than the control group. Another controlled trial
for junior nurses’ training program found that training nurses to
analyse cases had significantly enhanced their critical thinking
ability (Jin et al., 2011). With the development of internet
technology, online CBL or case-based discussion provides a
useful channel for teachers and students to interact with each
other; as well as enabling a teacher to provide personalized
guidance to individual students outside the classroom (Chen
et al., 2008).
The challenge for the implementation of CBL is a lack of suitable
nursing cases. In China, the available nursing cases published in the
authoritative text books usually only contain a single episode that
focuses solely on the disease. They seldom introduce other
conditions of a patient, such as psycho-social issues. This lags
behind the advancement in modern nursing care that not only
focuses on the disease but also values a patient’s spiritual needs
(Baldacchino, 2006). The rationale for only providing the key
message might be that it makes it easier for students to focus on
the “standard answers” in the text book. Such simplicity is the
weakness of this style of case because it only shows one aspect of
clinical nursing practice, lacking information about each “patient’s
illness journey” and the holistic nursing care process (Kopp et al.,
2014). Unlike the standard textbook description, in reality the
patient problems nurses encounter are often ill-structured,
challenging students’ ability to identify, analyze, judge and link
theory with practice and problem solving (Jonassen, 1997; Kapur
and Kinzer, 2007; Choi and Lee, 2008). Therefore, nursing
educators need to present adequate context to students to enable
them to experience the real world situation, and help them to
develop critical thinking and problem solving abilities for this
situation, which gradually prepares them to cope with complicated
patient problems in their future career.
Some researchers suggest that it is beneficial to apply multi-
episode nursing cases with simulated models when providing
virtual patient care training in a laboratory class (Nicholson, 2011;
Zhou et al., 2012). The reason is because this kind of nursing case
is more closely related to the real world nursing situation. With
the development of the case story, the simulated model can show
students the change of “clinical expressions” and the other
“problems”. With vivid and intuitive design, the case can better
illustrate nursing practice and stimulate students to craft
solutions in the process (Zhou et al., 2012). But these multi-
episode cases are often designed for use in the laboratory setting
with a virtual patient and are usually suitable for use by small
group classes of 5 to15 students (Botezatu et al., 2010;
Thistlethwaite et al., 2012; Zhou et al., 2012). Little is known
as to whether CBL with multi-episode cases can be applied
effectively in classroom lectures with 50–100 students or more
without the support of virtual patient models and whether it will
be more effective than applying the usual single-episode nursing
cases in such a learning environment.
The aim of this study, therefore, was to trial the implementation
of CBL with multi-episode nursing cases in lectures and to compare
its effectiveness with implementing the usual single episode case
in the same learning environment.
18 S. Hong, P. Yu / International Journal of Nursing Studies 68 (2017) 16–24

2. Methods considered in designing a medical teaching case include relevant,

realistic, engaging, challenging and instructional information.
2.1. Study setting and population Following this guideline we reviewed nursing records from a
general hospital and carefully selected the ones which were
The study was conducted in the Nursing School of Qianjiang representative of the sequence of a patient’s illness journey as the
College of Hangzhou Normal University in China. The study original material. We edited the original patient reports and
population was 122 undergraduate junior nursing students, all provided the description in accordance with the student’s
aged between 20 and 22 years. All the students were enrolled for knowledge level and the requirements of the subject outline.
the first time in the Medical Nursing course and had not previously We designed 23 unfolding nursing cases for the subject. They
learnt the nursing cases that were applied for this experiment. covered the essential content for nursing care of the respiratory
Because the students were randomly assigned by computer into system, the cardiovascular system, communicable disease, the
four classes on entry to the university, further randomization in neurological system, the gastrointestinal system, kidney disease,
research design was at the class level. We randomly assigned two the hematological system and diabetes mellitus. Nineteen cases
classes to the experimental group, and the other two to the control were integrated into lectures for classroom learning and the other
group. In total, there were 58 students in the experimental group 4 were handed over to students for group discussion and self-study
and 64 in the control group. We compared the academic after class. The case stories and questions were designed following
performance in the major subjects in the previous school year the holistic care model. They displayed the various aspects of the
in the two groups of students and did not find any significant longitudinal development of a patient’s condition from entering a
differences between the two groups (see Table 1); therefore, we are hospital to discharge. These included the disease history and
reasonably confident that the students’ academic performances in clinical appearance, the treatment and care plans, and the
the two groups were similar. Previous research indicates that there associated social, mental and psychological situations. We
is relationship between students’ critical thinking ability and attempted to describe the case story as accurately and vividly as
academic performance (Stupnisky et al., 2008). Therefore, the possible to engage the students so they could experience the
outcome measure of this study was the critical thinking ability process of holistic nursing care.
before and after the experiment between the two groups of The control group was given the usual single episode cases.
students. These cases were adopted from the authoritative cases in the text
book and reference books that had been used and validated for
2.2. The teaching approach years. Twenty three typical cases were selected; 19 were used for
classroom learning and the remaining four for group discussion
The study was conducted in the subject of Medical Nursing that and self-study after class. Therefore, the same number of cases and
was run for one school year, i.e. two semesters. The lecture time case-based lectures were delivered to both control and experi-
was 13 weeks per semester, 2 lectures per week in the first mental groups.
semester and 1 lecture in the second semester. There was a total of
150 teaching hours, including 115 lecture hours and 35 h of 2.2.2. Organization of the two styles of the CBL classes
laboratory and clinical visiting. Both the experimental and the The unfolding case lecture was sequenced in three steps:
control group were taught in similar learning environments. Each introduction, unfolding case-based lecture, and summary. The first
group was taught by randomly assigning one of the two lecturers part provided the students with an introduction to the disease. This
with equal qualifications for teaching Medical Nursing and the two included the definition, epidemiology, etiology and risk factors. All
were swapped between groups in the middle of each semester. The important knowledge about disease care, such as clinical features
same textbook, reading list and teaching hours were provided to all and lab test results, treatment, and possible strategies for nursing
students, as well as equal numbers of nursing cases in the lecture care was presented in conjunction with the unfolding case story to
time. The differences between the two groups were the nursing guide students to further explore the knowledge by critical
cases used and the organization of the two styles of CBL lectures. thinking questions; we believed that this teaching design would
gain students’ attention better than a normal lecture, and could
2.2.1. The nursing cases for the two groups save the normal lecture time for in depth study of the case. Before
A series of multi-episode nursing cases for the medical nursing the class was over, there would be about 10 min left for students to
subject were designed for the experimental group in accordance reflect and summarize the case study content at the conclusion
with the subject outline. We named our multi-episode nursing stage.
cases “unfolding nursing cases”, because the case stories gradually The nursing process is the core practice of holistic nursing care
unfolded following the time sequence of a patient’s illness journey and it requires nurses to work with critical thinking (Funnell et al.,
in response to the disease, the treatment and nursing care. 2009). The main steps in the nursing process include: assessment,
According to Kim et al. (2006), the key elements that need to be diagnosis, planning, implementation and evaluation (Nursingpro-
cess.org, 2016). It is a dynamic process which requires nurses to
always adjust the care plan according to changes in the patient’s
Table 1
Comparison of the academic performance between the two groups of students in condition. Although our students had learnt the theory of holistic
the major subjects in the previous school year. nursing in previous subjects, they needed more opportunity to
practice it. The unfolding nursing cases would provide them with
Subjects Experimental Control group t value P value
group (n = 64) (two tail)
this opportunity to apply and further understand this theory
(n = 58) Mean SD because it presented a complete nursing process by gradually
Mean SD unfolding the changes in the case story. This would provide the
Immunology 78.72 10.37 77.63 11.88 0.542 0.589 opportunity for the students to observe, identify, analyse, make
Pathology 79.33 9.63 79.42 10.78 0.051 0.96 judgment and link theory with practice for problem solving in the
Pharmacology 74.97 7.39 77.77 11.73 1.559 0.122 patient’s illness journey.
Fundamental Nursing 76.00 7.29 74.63 7.41 1.032 0.304 Fig. 1 shows our teaching process of delivering unfolding case-
Health Assessment 78.40 7.95 80.80 8.87 1.568 0.120
Medical Statistics 83.02 6.13 82.80 6.46 0.220 0.826
based lectures for the experimental group. Episode 1 was used to
lead students to consider how to assess a patient. This was
 S. Hong, P. Yu / International Journal of Nursing Studies 68 (2017) 16–24
Fig. 1. Outline of the content and process of unfolding CBL lectures.
followed by Episode 2, which required the students to conduct a
nursing diagnosis and make a care plan for the patient. To enable
the students to understand the impact of the disease on a person,
detailed information about the patient’s disease, psycho-social
issues and other conditions was given, as well as information about
the clinical features and treatment of the disease via the case story.
Students were allowed to consult the relevant section of the text
book in making the care plan for the patient. Episode 3 was
unfolded to allow the students to implement nursing interventions
and to predict the corresponding changes in the patient’s
condition. Afterwards the lecturer would guide the students to
critically analyze their own care plans by making comparisons
with the nursing strategies suggested by the text book. Some cases
provided “interventions” given to this “patient”. In this case, the
lecturer guided the students to critique the interventions and
explain reasons. Then, usually there would be Episode n to
illustrate the development of the patient’s illness process. This
required students to reassess and revise their care plan. They were
also requested to make a discharge care plan for the patient when
the “case ending” part was presented. This learning process guided
the students to go through a complete holistic nursing process in
the classroom and students had the opportunity to actively engage
in critical thinking by going through the virtual patient care.
The usual CBL class started with a didactical lecture to explain
everything about the disease care, including clinical appearance,
clinical diagnosis, treatment, nursing diagnosis, nursing care and
health education. To attract students’ attention and help them to
better understand the knowledge to be delivered, the lecturer
could use any visual aids and other facilities, such as slides,
pictures and short videos. This usually took three quarters of the
total teaching time. The remaining one quarter of the time (usually
Fig. 2. Outline of the content and process of the usual CBL lectures.
19
about half an hour) was given to students for in-class case-based
discussion. This teaching process was the typical CBL lecture style
in the nursing school at Qianjiang College, where this experiment
was implemented, and thus was given to the control group as
comparison.
Fig. 2 provides a model of teaching organization for the usual
case-based lecture. It followed the traditional teaching process that
only presented the case story to the students after introducing
them to the theory about disease care. The single-episode case
included three stages of the holistic nursing care process:
assessment, diagnosis and plan. Case discussion was used to help
students to further understand the key aspects of patient care.
After the case was presented, several questions were asked to lead
the students to identify the information about patient assessment,
to make a proper nursing diagnosis based on the result of
assessment, and then to make a nursing plan for the “patient”. The
examples of the teaching plans for the two styles of CBL lectures
are presented in Appendix A and Appendix B.
2.3. Learning outcome evaluation
The learning outcomes of the two styles of CBL lectures were
measured and compared by their impact on students’ critical
thinking ability before and after the lectures, both between groups
and intra-group to test any significant changes in critical thinking
ability in each group and whether the extent of change was similar
between the two groups.
2.3.1. Measurement of students’ critical thinking ability
Several measurement tools have been developed to measure
critical thinking skills in students. The major tools include Watson-
Glaser Critical Thinking Appraisal (WGCTA) (Watson and Glaser
1964), the California Critical Thinking Disposition Inventory
(CCTDI) (Facione et al., 1992) and the California Critical Thinking
Skill Test (CCTST) (Facione and Facione 1994). Chinese research
suggests that WGCTA has a weak split-half reliability (0.54) in
testing for Chinese students, and needs to be further modified to fit
with Chinese culture (Zhu and Shen, 2004). The CCTDI and the
CCTST have been specifically developed and used for the
population of nurses and nursing students (Fero et al., 2010).
The CCTDI assesses internal motivation toward critical thinking, for
example, the disposition to use or not to use one’s reasoning and
20 S. Hong, P. Yu / International Journal of Nursing Studies 68 (2017) 16–24

reflective judgment when solving problems (Facione and Facione,
2001), while CCTST is more likely to measure the participant’s
ability to draw conclusions (Facione et al., 2002). Therefore, we
believe that the CCTDI was the best to fit our research aim of
evaluating which style of CBL lecture is optimal in developing
critical thinking skills of nursing students.
The CCTDI has been proved to be a proper instrument suitable
to assess critical thinking ability of nursing students in different
cultural contexts (Yeh, 2002; Iskifoglu, 2014). To take the language
and cultural differences into consideration, we adopted its Chinese
version, the CTDI-CV that has been translated, modified and
validated by Chinese scholars Peng et al. (2004) instead of the
original instrument. The test for the CTDI-CV indicated a good
overall CVI (0.89) and alpha (0.90), indicating that it has
satisfactory content validity and internal consistency (Peng
et al., 2004).
According to the explanation from Facione et al. (2000), scores
of 40 or more in one dimension of CCTDI indicate the person has a
positive critical thinking ability in this dimension; and scores of
280 or more in total suggest a positive critical thinking ability in
general. The CTDI-CV retained the same seven dimensions of the
original CCTDI that include truth-seeking, open-mindedness,
analyticity, systematicity, self-confidence, inquisitiveness and
maturity (Facione et al., 1992); the total scoring points and
assessment criteria remained consistent as well (Peng et al., 2004).
We tested the students’ critical thinking ability by CTDI-CV
before including them in the two styles of CBL lectures and after
completing these lectures. The second CDTI-CV test was taken after
the teaching interventions, when each group of students had
received one of two styles of CBL lecture training for two
semesters.
2.4. Statistical analysis
truth seeking, systematicity and self-confidence, suggesting low
performance in these three dimensions; and the total scores were
less than 280. These results indicated that both groups had a
similar, low level of critical thinking skill before enrolling in the
CBL lectures.
In the second CDTI-CV test, there were 52 and 53 valid
questionnaires collected from the experimental and control group
respectively after each group had received one of two styles of CBL
lecture training for two semesters. The average total CDTI-CV
scores were higher than 280 in both groups, achieving positive
critical thinking after receiving the CBL training. In comparison
with the control group, the magnitude of improvement in the
experimental group was significantly higher; achieving the
average score of 303.77  15.24 in CDTI-CV, 15.43 points higher
(5.35%) than the control group that received the usual CBL training
(288.34  13.94). Scores in six single dimensions, including truth-
seeking, open-mindedness, analyticity, systematicity, inquisitive-
ness and maturity, were significantly higher in the experimental
group than those in the control group. Only the dimension of self-
confidence had no significant difference between the two groups
(see the “after” column in Table 2).
The intra-group comparison before and after the two semesters
of CBL training suggests that the improvement in the students’
CDTI-CV scores was significant in some dimensions and in the total
scores (p < 0.001). The extent of increase in the CDTI-CV score was
higher in the experimental group, with a 25.06 point (8.99%)
increase compared with that of the control group, which had a 9.36
point (3.36%) increase. Comparison of each dimension of the CDTI-
CV score revealed a significantly higher extent of improvement in
six dimensions except inquisitiveness in the experimental group in
comparison with the control group, which had only achieved
significant improvement in three of the seven dimensions: truth-
seeking, systematicity and self-confidence (see Table 3).

We used SPSS 19.0 software to analyze the data. The t-test was
used to test the difference in learning outcomes between the two
groups. P < 0.05 means the difference was significant.
3. Results
Before starting the CBL lectures, each of the 122 students
completed the CTDI-CV questionnaires but 16 of the question-
naires were excluded from data analysis because of incomplete
responses or selecting more than one option for one question to
cause ambiguity in answers. Consequently, there were 106 CTDI-
CV questionnaires valid and included in data analysis 51 from the
experimental group and 55 from the control group. There was no
statistically significant difference in average score in each domain
of CTDI-CV, as well as the total score between the two groups (see
“before” column in Table 2). Both groups scored less than 40 in
4. Discussion
Students’ performance in learning can be influenced by the
form of the cases and the organization of the case-based learning
class (Bagdasarov et al., 2013). There are many challenges in
implementing CBL, such as limited teaching hours, unavailability
of adequately simulated patient cases and clinical patient
resources, and shortage of teaching staff (Hays, 2008). In particular,
the shortage of tutors due to budget constraints has made it
difficult to run a small group CBL class with 10–25 students. In
many universities in China, lectures are the major delivery channel
for nursing education programs, usually with 50 to 100 or even
more students taught by one lecturer (Zhang and Liu, 2014). In our
example, more than 75% of the learning hours of Medical Nursing
have to be arranged for lectures, due to time constraints and staff
shortages. The large number of students increases the distance

Table 2
Comparison of each dimension and the total CDTI-CV scores between the two groups of students before and after receiving one of the two styles of CBL training.

Before After

Experimental group (n = 51) Control group t value P value Experimental group (n = 52) Control group t value P value
Mean SD (n = 55) (two tail) Mean SD (n = 53) (two tail)
Mean SD Mean SD

Truth-seeking 36.43 5.66 37.38 5.53 0.874 0.384 43.58 3.54 40.49 2.93 4.870 <0.001
Open-mindedness 41.25 4.51 40.62 4.25 0.748 0.456 43.87 3.51 41.70 3.04 3.384 0.001
Analyticity 41.84 5.14 43.13 3.49 1.514 0.133 44.31 3.85 42.83 2.92 2.215 0.029
Systematicity 36.92 5.07 37.27 4.90 0.362 0.718 42.33 3.94 39.30 3.38 4.221 0.000
Self-confidence 38.22 4.59 37.33 5.60 0.889 0.376 41.19 4.18 39.92 4.08 1.571 0.119
Inquisitiveness 42.86 4.89 41.82 4.29 1.171 0.244 44.38 4.02 42.28 3.67 2.798 0.006
Maturity 41.18 4.88 41.44 3.60 0.314 0.755 44.12 4.04 41.81 3.23 3.228 0.002
Total CDTI-CV 278.71 21.80 278.98 20.27 0.068 0.946 303.77 15.24 288.34 13.94 5.415 0.000
score
 S. Hong, P. Yu / International Journal of Nursing Studies 68 (2017) 16–24 21

Table 3
The intra-group comparison of each dimension and the total CDTI-CV scores in each group of students before and after completing one of two styles of CBL lectures.

Experimental group t value P value Control group t value P value

(two tail) (two tail)
before (n = 51) after (n = 52) before (n = 55) after (n = 53)
Mean SD Mean SD Mean SD Mean SD

Truth-seeking 36.43 5.66 43.58 3.54 7.690 <0.001 37.38 5.53 40.49 2.93 3.634 <0.001
Open-mindedness 41.25 4.51 43.87 3.51 3.282 0.001 40.62 4.25 41.70 3.04 1.513 0.133
Analyticity 41.84 5.14 44.31 3.85 2.757 0.007 43.13 3.49 42.83 2.92 0.478 0.633
Systematicity 36.92 5.07 42.33 3.94 6.042 <0.001 37.27 4.90 39.30 3.38 2.497 0.014
Self-confidence 38.22 4.59 41.19 4.18 3.440 0.001 37.33 5.60 39.92 4.08 2.746 0.007
Inquisitiveness 42.86 4.89 44.38 4.02 1.727 0.087 41.82 4.29 42.28 3.67 0.604 0.547
Maturity 41.18 4.88 44.12 4.04 3.332 0.001 41.44 3.60 41.81 3.23 0.568 0.571
Total CDTI-CV 278.71 21.80 303.77 15.24 6.773 <0.001 278.98 20.27 288.34 13.94 2.785 0.006
score

between the lecturer and the students, making it difficult for a
lecturer to conduct face-to-face interaction, while attending to
each student’s learning needs equally. Another concern is that
allowing a student to provide oral comments or discussion in a
lecture environment may interrupt the lecturer’s sequence of
speech. Therefore, CBL is not often considered the optimal teaching
method for lectures.
The motivation of this study was to explore the feasibility of
implementing CBL in lectures with the belief that high quality
nursing cases can effectively connect theoretical knowledge with
clinical practice and increase interaction in the classroom, thus
improving students’ learning outcomes even in situations of
limited resources (Bosque, 2012). The identified limitation of a
single episode CBL had motivated us to pursue unfolding cases, and
compare their effect with the usual single episode CBL approach.
We measured the effect of the two styles of CBL lectures on
developing nursing students’ critical thinking ability in lectures.
The results indicated that it was possible to apply CBL in lectures,
and the unfolding CBL lectures were more effective in developing
the students’ critical thinking ability than the usual ones.
The usual single episode CBL lectures follows a sequence of
lecture and then Case-based discussion. The lecture was imparted
to students in order to enable the students to clearly understand
the disease care before participating in the CBL section. However,
this lecturer-centered learning process makes students less
engaged in the class and the didactic lectures often bored students
(Chapman and Calhoun, 2006; Kaddoura, 2011). In addition, it is
hard for the lecturers to notice most of the students while
simultaneously giving a lecture. Research indicated that students
who believe they are anonymous often feel less personally
responsible for learning and less likely to attend class, and
consequently this is detrimental to promoting critical thinking and
student learning in the classroom context (Cooper and Robinson,
2000). It was not clear whether this more limited engagement also
influenced the students’ will to participate in the following case-
based discussion in our experiment, but students may tend not to
apply critically what they learn by passive learning to practice
(Petress, 2008; Kaddoura, 2011).
Another limitation of the usual CBL lecture is the incomplete-
ness of single episode nursing cases. Single episode nursing cases
directly introduce to students the patient’s assessment results, and
then invite them to think about the nursing problems and how to
prepare relevant interventions. This kind of CBL does not provide a
story “plot” or show a complete nursing process. However, holistic
patient care in real nursing practice requires critically considering
various aspects of the patient’s issues, and the nursing plan needs
to be revised whenever the patient’s condition changes (Thur-
mond, 2001; Lunney, 2009; Robert and Petersen, 2013). It is
difficult for undergraduate students to make a proper holistic
nursing plan and to properly understand the nursing process due
to lack of ongoing information about the patient. This reduced the
effectiveness of developing clinical reasoning for the usual CBL
lecture group.
Unlike the usual CBL, the unfolding CBL that was introduced in
this study created a scenario that was close to the “real nursing
situation”. The closer the case to the reality, the more effective it
would be to attract and motivate the students to solve the
problems and encourage self-directed learning (Yoo et al., 2010).
Students can explore and develop relevant knowledge through
simulated activities, and acquire skills that match the real situation
(Kulak and Newton, 2015). By unfolding each episode of the case
story and motivating students to answer the relevant critical
thinking questions, the students were guided through a complete
nursing process in the classroom. This virtual process not only
enabled them to experience the holistic nursing care process that
led to the patient care outcomes, but also predicted and assessed
the immediate impact of their intervention, and validated these by
comparing their predictions with the “truth” when the next
episode was unfolded. By encouraging students to engage in
independent learning and to critically link theory to practice, this
unfolding CBL approach helped the students to develop a mind
map about a complete holistic nursing process (Brandon and All,
2010), thus making the learning process more engaging in
developing their critical thinking skills.
A meta-analysis suggests that a greater amount of time should
be spent by students in active, meaningful learning and thinking
processes (Colliver et al., 2003). Unfolding CBL lectures create a
student-centered learning approach that allows students plenty of
engagement. There is no didactic lecture in the whole learning
process. Instead, students are given time to learn the theoretical
knowledge on their own and then critically use the knowledge to
solve the problems raised in the unfolding case. The teacher
provides necessary help or explanations to ensure the students can
complete the learning process smoothly. By this independent
problem solving training, students could connect the theoretical
knowledge with real nursing practice which often requires critical
thinking skills (Profetto-Mcgrath, 2005). The bulk of lecture time
was given to students to form solutions and discuss with peers and
present findings or opinions. Discussion with classmates provided
an opportunity to have greater understanding of the problem
situation and preliminary treatment strategies, and compare,
improve or validate their understanding and strategies. This
learning experience helped them to develop skills in patient
assessment and problem solving, and better prepare them for
clinical practice (Raurell-Torreda et al., 2015).
Although our study achieved a significantly improved learning
outcome for the unfolding CBL group, there were some limitations
that can be resolved in future studies. The study was only
conducted for two semesters in one subject. The validity and
reliability of the finding can be further tested by implementing the
22 S. Hong, P. Yu / International Journal of Nursing Studies 68 (2017) 16–24
unfolding nursing cases in other nursing subjects. It is also useful to
follow up with the students to identify any impact of the unfolding
CBL on their performance in their first year nursing practice.
Students’ feelings and experiences of unfolding case-based
lectures also need to be further explored.
5. Conclusion
This study explored and demonstrated the feasibility of
implementing unfolding CBL lectures in university nursing
education. Unfolding CBL lectures were more effective than the
usual CBL lectures in developing students’ critical thinking ability
as demonstrated by its implementation in the subject of medical
nursing. It could also lead to better learning outcomes than the
usual CBL when applied appropriately in lectures. In the future, the
unfolding CBL lectures can be implemented in other nursing
subjects. Further study is also needed to investigate the impact of
the unfolding nursing cases on students’ performance in first year
clinical practice.
Conflicts of interest
None.
Ethical approval
Ethical approval was given by the education department of
Hangzhou Normal University Qianjiang College. Reference num-
ber: +86-0571-28865576.
Funding
The research was funded by the Fund of Higher Education
Pedagogy Reform Project of Zhejiang province, China, in 2013. The
funder was a government organization and offered financial
support to our research.
Acknowledgements
This study was funded by the Higher Education Teaching
Reform Project of Zhejiang Province 2013. The authors would like
to thank all the students who participated in the CBL lectures and
responded to the questionnaires. Dr Madeleine Cincotta is
acknowledged for her contribution in copy editing the final draft.
Appendix A. An example of teaching plan for unfolding CBL
lecture on the topic of nursing care for patients with asthma
The total teaching time is 120 min.
Part I. Brief introduction
Introduce asthma: the definition, epidemiology, etiology and risk factors
(10 min).
Part II. Case based learning
An unfolding nursing case of asthma (100 min in total).
Episode 1. Admission
Spring, afternoon.
A 14 year old boy was admitted into the respiratory department because of
shortness of breath and wheezing.
Question 1. How would you assess the patient if you were on duty?
Tips: The teacher should guide the students to discuss how to do the nursing
Appendix B. An example of teaching plan for usual CBL lecture
assessment for a patient with respiratory problems, and to think about the
possible problems that might be indicated by “shortness of breath and wheezing”
on the topic of nursing care for patients with asthma
(Control the time in 10 minutes).
Episode 2. Patient assessment
The nurse took the patient’s vital signs and did some physical examinations
and recorded the data: Temperature 36.7  C, pulse 106 bpm, respiration 28
bpm, blood pressure 113/75 mmHg. The patient was conscious and alert, but
agitated, preferred sitting. Oral speech was often interrupted by shortness of
breath. He had expiratory dyspnea, purple lips and his thorax looked full.
Chest auscultation found that there was wheezing in both lungs, but no
moisture was detected.
Question 2. Can you give a primary nursing diagnosis according to the above
clinical features? Then discuss what intervention should be given
immediately?
Tips: it is not necessary to discuss the clinical features for asthma right now. Focus
on identifying the most important problem that needs to be solved first (Control
the time in 10 minutes).
Episode 2 continues. Further assessment of illness history
The patient complained that the symptoms started after a 100 m race at
school. He had a history of asthma since he was 4 years old, but the symptoms
did not appear for nearly 5 years. He did not take any medicine at present. He
was allergic to fish and shrimp. He had two parents and a sister and they were
all healthy.
Clinical diagnosis: Asthma.
Question 3. Can you describe the clinical features of asthma according to this
patient’s clinical indicators and history? What other specific clinical features
may an asthma patient have?
Question 4. Read the “level of severity for asthma” in the text book, and assess
this patient’s level of severity.
Tips: Guidance should be given to students to help them distinguish the clinical
features of asthma in general, including abnormal lab test results (Control the
time in 15 minutes for questions 3 and 4).
Episode 2 continues. Treatment plan
Doctor’s treatment plan included bed rest, oxygen inhalation and medication
for improving respiratory symptoms. Medicines prescribed included ventolin
metered-dose inhaler and Salmeterol Fluticasone.
Question 5. The boy asks why he has to take two medicines. How would you
explain this to him?
Tips: the teacher should guide the students to discuss the remedies for asthma.
Then to discuss the boy’s condition and explain why the above two medicines
could help him (Control the time in 10 minutes).
Question 6. What other nursing diagnoses can you propose for the patient?
What nursing interventions should be given to him?
Tips: the teacher should allow the students to express their own opinions about
the case. The students can be divided into groups of 4 to 6 individuals and each
group focus on discussing one problem, and then share their answers with the
class in a short presentation. Students are allowed to consult the text book, but
must link the discussion with the case (Control the time in 20 minutes).
Episode 3. Implementation and evaluation
You have made your nursing plan and the patient has been given oxygen and
medications. Now the patient is lying in bed. His symptoms were greatly
improved.
Question 7: Please discuss how you would evaluate the outcomes of your
interventions (Control the time in 10 minutes).
Episode 4: the second day
The boy’s symptoms were improved. He lay on the bed with eupnea under
low flow oxygen inhalation (1.5L/min) but he looked worried. The nurse
found out that he was worried about the possibility of failing the middle term
school test that would take place one week later.
Question 8: how could you help him?
Tips: the teacher should remind the students to link the relevant knowledge that
they learned in the subject or from their life experience to solve this problem
(Control the time in 10 minutes).
Episode 5: discharge
Four days later, the patient recovered well and was ready to be discharged. His
mother worried about another asthma attack.
Question 9: please discuss the patient’s discharge care plan. You may consider
which further information needs to be gathered before formulating the
discharge plan.
Tips: the teacher should guide the students to think about health education for an
asthma patient in general before formulating a proper discharge care plan based
on this case. (Control the time in 15 minutes)
Part III. Summary
Invite one student to present a summary of the nursing intervention for an
asthma patient. Then provide brief comments. (Control the time in 10 minutes)
The total teaching time is 120 min.
Part I. Lecture—introduce asthma and its nursing care in detail (85 min in total).
1. The definition of asthma, epidemiology, etiology and risk factors (10 min).
2. The clinical appearance of asthma (20 min).
3. Lab tests, examinations and diagnosis of asthma (10 min).
 S. Hong, P. Yu / International Journal of Nursing Studies 68 (2017) 16–24
4. Treatment of asthma (20 min).
5. The nursing diagnosis and nursing interventions for asthma (20 min).
6. Health education (5 min).
Tips: try to use any visual aids and other facilities to help students to understand
and learn.
Part II. Case study
A usual asthma case (35 min in total).
The case story
Mr. Lou was a 40 year-old man who was admitted to the respiratory
department because he suffered from wheezing, cough, dyspnea and chest
tightness for half a day. His wife said all the symptoms started after his
exposure to pollen.
Physical examinations: temperature 37.5  C, pulse 126 bpm, respiration 32
bpm, blood pressure 133/70 mmHg. The patient was agitated and could only
speak fragmented words. He preferred to sit upright and lean forward. He had
purple lips and his thorax was full. Chest auscultation found that there was
wheezing and stridor in both lungs.
Questions
1. What health problems did this patient suffer from?
Tips: the teacher should guide the students to recognize the patient’s clinical
appearances, and to think about all the possible health problems that may be
indicated by these appearances instead of directly given the answer (Control the
time in 10 minutes).
2. What laboratory examinations were necessary for further diagnosis?
Tips: this question should be discussed in light of responses to Question 1. Students
should be questioned about the reason (Control the time in 5 minutes).
3. Please propose the appropriate nursing diagnosis and nursing problems,
and then make a nursing plan for the patient.
Tips: the teacher should allow the students to express their own opinions about
the nursing diagnoses and the nursing care plan. They should give the rationale
for their answers. Students are allowed to consult the text book, but must connect
the information with the case (Control the time in 20 minutes).
References
Bagdasarov, Z., Theil, C.E., Johnson, J.F., Connelly, S., Harkrider, L.N., Devenport, L.D.,
Mumford, M.D., 2013. Case-based ethics instruction: the influence of contextual
and individual factors in case content on ethical decision-making. J. SciEng
Ethics 19 (3), 1305–1322.
Baldacchino, D.R., 2006. Nursing competencies for spiritual care. J. Journal of
Clinical Nursing. 15 (7), 885–896.
Bosque, E., 2012. Toward salience: an application of integrative, case-based, nursing
education for neonatal advanced practice. J. Adv. Neonatal Care 12 (5), 292–302.
Botezatu, M., Hult, H., Tessma, M.K., Fors, U.G.H., 2010. Virtual patient simulation for
learning and assessment: superior results in comparison with regular course
exams. J. Med. Teach. 32 (10), 845–850.
Braeckman, L., Kint, L.T., Bekaert, M., Cobbaut, L., Janssens, H., 2014. Comparison of
two case-based learning conditions with real patients in teaching occupational
medicine. J. Med. Teach. 36 (4), 340–346.
Brandon, A.F., All, A.C., 2010. Constructivism theory analysis and application to
curricula. J. Nurs. Edu. Perspect. 31 (2), 89–92.
Chan, A.W., Chair, S.Y., Sit, J.W., Wong, E.M., Lee, D.T., Fung, O.W., 2016. Case-based
web learning versus face-to-face learning: a mixed-method study on University
nursing students. J. Nurs. Res. 24 (1), 31–40.
Chapman, D.M., Calhoun, J.G., 2006. Validation of learning style measures:
implications for medical education practice. J. Med. Educ. 40 (6), 576–583.
Chen, C., Wu, J.P., Yang, S., 2008. Accelerating the use of weblogs as an alternative
method to deliver case-based learning. J. Int. J. E-Learn. 7 (2), 331–349.
Choi, I., Lee, K., 2008. A case-based learning environment design for real-world
classroom Management problem solving. J. TechTrends: Linking Res. Pract.
Improve Lear 52 (3), 26–31.
Colliver, J.A., Feltovich, P.J., Verhults, S.J., 2003. Small group learning in medical
education: a second look at the Springor, Stanne and Donovan meta-analysis. J.
Teach. Learn. Med. 15 (1), 2–5.
Cooper, J.L., Robinson, P., 2000. The argument for making large classes seem small.
New Directions Teach. Learn. 2000 (81), 5–16.
Facione, P.A., Facione, N.C., 1994. The California Critical Thinking Skill Test (CCTST)
Form A & Form B. Test Manual. California Academic Press, Millbrae, CA.
Facione, P.A., Facione, N.C., 2001. California Critical Thinking Disposition Inventory:
Inventory Manual. California Academic Press, Millbrae, CA.
Facione, P.A., Facione, N.C., Giancario, C.A.F., 1992. The California Critical Thinking
Disposition Inventory (CCTDI). Test Administration Manual. The California
Academic Press, Millbrae CA.
Facione, P.A., Facione, N.C., Giancario, C.A.F., 2000. The California Critical Thinking
Disposition Inventory, CCTDI Scoring Supplement. The California Academic
Press, Millbrae, CA.
Facione, P.A., Facione, N.C., Blohm, S.W., Giancarlo, C.A., 2002. The California Critical
Thinking Skills Test: Test Manual. California Academic Press, Milbrae, CA.
23
Fero, L.J., O’Donnell, J.M., Zullo, T.G., Dabbs, A.D., Kitutu, J., Samosky, J.T., Hoffman, L.
A., 2010. Critical thinking skills in nursing students: comparison of simulation-
based performance with metrics. J. Adv. Nurs. 66 (10), 2182–2193.
Forsgren, S., Christensen, T., Hedemalm, A., 2014. Evaluation of the case method in
nursing education. J. Nurse Educ. Pract. 14 (2), 164–169.
Funnell, R., Koutoukidis, G., Lawrence, K., 2009. Tabbner's Nursing Care, fifth ed.
Elsevier Pub, Australia, pp. 72.
Gao, X., Luo, S., Mu, D., Xiong, Y., Guanjian, L., Wan, C., 2016. Effects of problem-based
learning in paediatric education in China: a meta-analysis. Jo. Evid.-Based Med.
9 (3), 136–143.
Gupta, M., Upshur, R., 2012. Critical thinking in clinical medicine: what is it? J. Eval.
Clin. Pract. 18 (5), 938–944.
Hays, R., 2008. A practical guide to curriculum design: problem based, case-based or
traditional? Clin. Teach. 5 (2), 73–77.
Huckstadt, A., Hayes, K., 2005. Evaluation of interactive online courses for advanced
practice nurses. J. Am. Acad. Nurse Pract. 17 (3), 85–89.
Iskifoglu, G., 2014. Cross-cultural equivalency of the California critical thinking
disposition inventory. Educ. Sci. Theory Pract. 14 (1), 1–20.
Jin, L.P., Ning, Y.J., He, Y.J., 2011. Application of case analysis to cultivating critical
thinking disposition in junior nurses. Chin. J. Nurs. 46 (9), 852–854 (Article in
Chinese).
Jonassen, D.H., 1997. Instructional design models for well-structured and ill-
structured problem-solving learning outcomes. Educ. Technol. Res. Dev. 45 (1),
65–94.
Kaddoura, M.A., 2011. Critical thinking skill of nursing students in lecture-based
teaching and case-based learning. Int. J. Scholarsh. Teach. Learn. 5 (2), 1–18.
Kaddoura, M., 2013. New graduate nurses’ perceived definition of critical thinking
during their first nursing experience. Educ. Res. Q. 36 (3), 3–21.
Kapur, M., Kinzer, K.Ch., 2007. Examining the effect of problem type in a
synchronous computer-supported collaborative learning (CSCL) environment.
Educ. Technol. Res. Development 55 (5), 439–459.
Kim, S., Phillips, W.R., Pinsky, L., Brock, D., Phillips, K., Keary, J., 2006. A conceptual
framework for developing teaching cases: a review and synthesis of the
literature across disciplines. Med. Educ. 40 (9), 867–876.
Kopp, B., Hasenbein, M., Mandl, H., 2014. Case-based learning in virtual groups –
collaborative problem solving activities and learning outcomes in a virtual
professional training course. Interact. Learn. Environ. 22 (3), 351–372.
Kulak, V., Newton, G., 2015. An investigation of the pedagogical impact of using
case-based learning in a undergraduate biochemistry course. Int. J. Higher Educ.
4 (4), 13–24.
Lasater, K., 2011. Clinical judgment: the last frontier for evaluation. Nurse Educ.
Pract. 11 (2), 86–92.
Lighthall, G.K., Bahmani, D., Gaba, D., 2016. Evaluating the impact of classroom
education on the management of septic shock using human patient simulation.
Simul. in Healthc. 11 (1), 19–24.
Liu, M., Yin, L., Ma, E., Lo, S.H., 2008a. Confirmatory factor analysis of competency
inventory for registered nurse. J. Chin. J. Nurs. 43 (3), 204–206 (Article in
Chinese).
Liu, F., Wang, H., Zou, Y., Zhu, X., Yang, Y., Luo, F., Gao, H., 2008b. Application of
nursing cases forum to cultivate the critical thinking ability of nursing students.
Chin. J. Nurs. 43 (1), 19–22 (Article in Chinese).
Liu, Y., Chang, Z., Yang, G., Yang, C., 2014. The effect of cooperative learning combined
with case study on nursing students’ problem-solving and decision-making
ability. J. Chin. J. Nurs. Educ. 11 (3), 197–200 (Article in Chinese).
Lunney, M., 2009. Critical Thinking to Achieve Positive Health Outcomes: Nursing
Case Studies and Analyses, 2nd ed. Wiley-Blackwell., mes, IA.
Macho-Stadler, E., Elejalde-Garcia, M.J., 2013. Case study of a problem-based
learning course of physics in a telecommunications engineering degree. J. Eur. J.
Eng. Educ. 38 (4), 408–416.
Mandernach, B.J., 2006. Thinking critically about critical thinking: integrating
online tools to promote critical thinking. InSight Collect. Fac. Scholarsh. 1 (5),
41–50.
Marlow, A., Spratt, C., Reilly, A., 2008. Collaborative action learning: a professional
development model for educational innovation in nursing. Nurse Educ. Pract. 8
(3), 184–189.
Mclean, S.F., 2016. Case-based learning and its application in medical and health-
care fields: a review of worldwide literature. J. Med. Educ. Curric. Dev. 3 (4), 39–
49.
Missen, K., McKenna, L., Beauchamp, A., 2014. Graduate nurse program
coordinators’ perceptions of role adaptation experienced by new nursing
graduates: a descriptive qualitative approach. J. Nurs.Educ. Pract. 4 (12), 134–
141.
Nicholson, A.C., 2011. Comparison of selected outcomes based on teaching
strategies that promote active learning in nursing education. Diss. Abstr. Int.:
Section B: The Sci. Eng. 71 (7B), 4177.
Nursingprocessorg, 2016. The 5 Steps of the Nursing Process. http://www.
nursingprocess.org/Nursing-Process-Steps.html (Accessed 2016.07.08).
Peng, M., Wang, G., Chen, J., Chen, M., Bai, H., Li, S., Li, J., Cai, Y., Wang, J., Yin, L., 2004.
Validity and reliability of the chinese critical thinking disposition inventory. J.
Chin. J. Nurs. 39 (9), 644–647 (Article in Chinese).
Perez, E.A., Canut, M.T.L., Pegueroles, A.F., Llobet, M.P., Arroyo, C.M., Merino, J.R.,
2015. Critical thinking in nursing: scoping review of the literature. Int. J. Nurs.
Pract. 21 (6), 820–830.
Petress, K., 2008. What is meant by active learning? Education 128 (4), 566–569.
Profetto-Mcgrath, J., 2005. Critical thinking and evidence-based practice. J. Prof.
Nurs. 21 (6), 364–371.
24 S. Hong, P. Yu / International Journal of Nursing Studies 68 (2017) 16–24
Raurell-Torreda, M., Olivet-Pujol, J., Romero-Collado, A., Malagon-Aguilera, M.C.,
Patino-Maso, J., Baltasar-Bague, A., 2015. Case-Based learning and simulation:
useful tools to enhance nurses’ education? Nonrandomized controlled trial. J.
Nurs. Scholarsh. 47 (1), 34–42.
Robert, R.R., Petersen, S., 2013. Critical thinking at the bedside: providing safe
passage to patients. J. MEDSURG Nurs. 22 (2), 85–93 (118).
Scheffer, B.K., Rubenfeld, M.G., 2000. A consensus statement on critical thinking in
nursing. J. Nurs. Educ. 39 (8), 352–359.
Simpson, E., Courtney, M., 2002. Critical thinking in nursing education: literature
review. Int. J. Nurs. Pract. 8 (2), 89–98.
Srinivasan, M., Wilkes, M., Stevenson, F., Nguyen, T., Slavin, S., 2007. Comparing
problem-based learning with case-based learning: effects of a major curricular
shift at two institutions. Acad. Med. 82 (1), 74–82.
Stupnisky, R.H., Renaud, R.D., Daniels, L.M., Haynes, T.L., Perry, R.P., 2008. The
interrelation of first-year college student’s critical thinking disposition,
perceived academic control, and academic achievement. Res. High. Educ. 49
(6), 513–530.
Thistlethwaite, J.E., Davies, D., Ekeocha, S., Kidd, J.M., Macgougall, C., Matthews, P.,
Purkis, J., Clay, D., 2012. The effectiveness of case-based learning in health
professional education. A BEME systematic review: BEME Guide No. 23. Med.
Teach. 34 (6), 421–444.
Thompson, C., Rebeschi, L.M., 1999. Critical thinking skills of baccalaureate nursing
students at program entry and exit. Nurs. Health Care Perspect. 20 (5), 248–252.
Thurmond, V.A., 2001. The holism in critical thinking: a concept analysis. J. Holist.
Nurs. 19 (4), 375–389.
Tomey, A.M., 2003. Learning with cases. J. Contin. Educ. Nurs. 34 (1), 34–38.
Turkel, M.C., 2016. Describing self-reported assessments of critical thinking among
practicing medical surgical registered nurses. Medsurg Nurs. 25 (24), 244–250.
Turner, P., 2005. Critical thinking in nursing education and practice as defined in the
literature. Nurs. Educ. Perspect. 26 (5), 272–277.
Ward, T.D., Morris, T., 2016. Think like a nurse: a critical thinking initiative. ABNF J.
27 (3), 64–66.
Watson, G., Glaser, E., 1964. Watson-Glaser Critical Thinking Appraisal Manual.
Harcourt Brace Jovanoich, New York.
Yeh, M.L., 2002. Assessing the reliability and validity of the Chinese version of the
California critical thinking disposition. Int. J. Nurs. Stud. 39 (2), 123–132.
Yoo, M.S., Park, J.H., 2014. Effect of case-based learning on the development of
graduate nurses’ problem-solving ability. Nurse Educ. Today 34 (1), 47–51.
Yoo, M.S., Park, J.H., Lee, S.R., 2010. The effects of case-based learning using video on
clinical decision making and learning motivation in undergraduate nursing
students. J. Kor. Acad. Nurs. 40 (6), 863–871.
Zhang, F., Liu, Y., 2014. The strategies of group class in higher medical colleges.
Zhejiang Med. Educ.. 13 (4), 1–3 (Article in Chinese).
Zhou, X., Sun, J., Chen, T., Wu, W., Liu, A., Yan, X., 2012. The design of the cases in
simulation teaching. Chin. J. Nurs. Educ. 9 (1), 15–17 (Article in Chinese).
Zhu, X., Shen, N., 2004. Research on the reliabilities and validities of watson-Glaser
critical thinking appraisal and california critical thinking disposition inventory.
Journal of Nursing Science. 19 (21), 56–58 (Article in Chinese).