critical thinking skills among nursing students

ANA Nursing Resources Hub

Search Resources Hub

Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

Images sourced from Getty Images

Related Resources

Item(s) added to cart

What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What Is Critical Thinking In Nursing?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

5. Can I Be a Nurse If I Cannot Think Critically?

#1 Duquesne University Graduate School of Nursing is Ranked #1 for Veterans by Militaryfriendly.com for 7 years running

• Adult-Gerontology Acute Care Nurse Practitioner
• Executive Nurse Leadership and Health Care Management
• Family Nurse Practitioner
• Forensic Nursing
• Nursing Education and Faculty Role
• Psychiatric-Mental Health Nurse Practitioner
• Clinical Leadership
• Admissions & Aid
• About Duquesne
• Why Duquesne Online?

Developing Critical-Thinking Skills in Student Nurses

April 8, 2020

View all blog posts under Articles | View all blog posts under Master of Science in Nursing

Critical thinking skills for nurses include problem-solving and the ability to evaluate situations and make recommendations. Done correctly, critical thinking results in positive patient outcomes, Srinidhi Lakhanigam, an RN-BSN, said in a Minority Nurse article.

“Critical thinking is the result of a combination of innate curiosity; a strong foundation of theoretical knowledge of human anatomy and physiology, disease processes, and normal and abnormal lab values; and an orientation for thinking on your feet,” Lakhanigam said in “Critical Thinking: A Vital Trait for Nurses.” “Combining this with a strong passion for patient care will produce positive patient outcomes. The critical thinking nurse has an open mind and draws heavily upon evidence-based research and past clinical experiences to solve patient problems.”

Since the 1980s, critical thinking has become a widely discussed component of nurse education, and a significant factor for National League for Nursing (NLN) nursing school accreditation. Nursing school curriculum is expected to teach students how to analyze situations and develop solutions based on high-order thinking skills. For nurse educators who are responsible for undergraduate and graduate learners , teaching critical thinking skills is crucial to the future of healthcare.

Characteristics of Critical Thinkers

A landmark 1990 study found critical thinkers demonstrate similar characteristics. The Delphi Report by the American Philosophical Association (APA) identified these cognitive skills common to critical thinkers:

Interpretation

Critical thinkers are able to categorize and decode the significance and meaning of experiences, situations, data, events, and rules, among others.

Critical thinkers can examine varying ideas, statements, questions, descriptions and concepts and analyze the reasoning.

Critical thinkers consider relevant information from evidence to draw conclusions.

Explanation

Critical thinkers state the results of their reasoning through sound arguments.

Self-regulation

Critical thinkers monitor their cognitive abilities to reflect on their motivations and correct their mistakes.

In addition, critical thinkers are well-informed and concerned about a wide variety of topics. They are flexible to alternative ideas and opinions and are honest when facing personal biases. They have a willingness to reconsider their views when change is warranted.

In nursing, critical thinking and clinical reasoning are inextricably linked, columnist Margaret McCartney said in the BMJ . While experienced nurses are able to make sound clinical judgements quickly and accurately, novice nurses find the process more difficult, McCartney said in “Nurses must be allowed to exercise professional judgment.”

“Therefore, education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills,” McCartney said. “Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgments and decisions are reached in complex healthcare environments.”

Teaching Critical Thinking to Nurses

In 2015, a study in the Journal of College Teaching & Learning found a positive correlation between critical thinking skills and success in nursing school. The study said, “It is the responsibility of nurse educators to ensure that nursing graduates have developed the critical thinking abilities necessary to practice the profession of nursing.”

To help new nurses develop critical-thinking skills, the professional development resources provider Lippincott Solutions recommended nurse educators focus on the following in the classroom:

Promoting interactions

Collaboration and learning in group settings help nursing students achieve a greater understanding of the content.

Asking open-ended questions

Open-ended questions encourage students to think about possible answers and respond without fear of giving a “wrong” answer.

Providing time for students to reflect on questions

Student nurses should be encouraged to deliberate and ponder questions and possible responses and understand that perhaps the immediate answer is not always the best answer.

Teaching for skills to transfer

Educators should provide opportunities for student nurses to see how their skills can apply to various situations and experiences.

In the Minority Nurse article, Lakhanigam also said students who thirst for knowledge and understanding make the best critical thinkers. The author said novice nurses who are open to constructive criticism can learn valuable lessons that will translate into successful practice.

At the same time, however, critical thinking skills alone will not ensure success in the profession , Lakhanigam said in the article. Other factors count as well.

“A combination of open-mindedness, a solid foundational knowledge of disease processes, and continuous learning, coupled with a compassionate heart and great clinical preceptors, can ensure that every new nurse will be a critical thinker positively affecting outcomes at the bedside,” Lakhanigam said.

Another element that ensures success as both an educator and student is earning a nursing degree from a school that focuses on student accomplishments. At Duquesne University’s School of Nursing, students learn best practices in healthcare. The online master’s in nursing program prepares educators to train the next generation of nurses.

About Duquesne University’s online Master of Science in Nursing (MSN) Program

Duquesne University’s MSN curriculum for the Nursing Education and Faculty Role program focuses on preparing registered nurses (RNs) for careers as nurse educators. Students enrolled in the online master’s in nursing program learn the skills needed in the classroom and for clinical training. RNs learn how to empower student nurses to work to their fullest potential.

The MSN program is presented entirely online, so RNs can pursue their career goals and continue personal responsibilities simultaneously.  Duquesne University has been recognized for excellence in education as a U.S. News & World Report Best Online Graduate Nursing Program and best among Roman Catholic universities in the nation.

For more information, contact Duquesne University today.

Critical Thinking: A Vital Trait for Nurses: Minority Nurse

Consensus Descriptions of Core CT Skills And Sub-Skills: Delphi

Margaret McCartney: Nurses must be allowed to exercise professional judgment: BMJ

Predicting Success in Nursing Programs: Journal of College Teaching & Learning

Turning New Nurses Into Critical Thinkers: Wolters Kluwer

The factors affecting the critical thinking skills among nursing students – an integrative literature review

• Articles in this Issue

Published Online : Oct 20, 2022

Page range: 174 - 180, received : sep 03, 2021, accepted : jan 26, 2022, doi: https://doi.org/10.2478/pielxxiw-2022-0021, keywords critical thinking , nursing students , nursing care , nursing education, © 2022 danuta zarzycka et al., published by sciendo, this work is licensed under the creative commons attribution 4.0 international license..

Aim. Review and analysis of available articles focused on factors affecting development of nursing students critical thinking.

Material and methods. Integrative review of articles published between 2011 and 2021, available in the electronic databases PubMed, Scopus, Web of Science and EBSCO. Searching was based on keywords “critical thinking”, “nursing”, “nursing care”, “nursing education” which were connected by Boolean logic operators “and” as well as “or”.

Results. There are several factors significant to advancement of critical thinking. Prevalent teaching methods, which promote development of critical thinking, constitute active learning strategies, concept mapping, simulation, problem-based learning, case study and learning methods based on evidence. Moreover, cultural and individual factors like empathy, emotional intelligence and caring behaviour show a significant relationship with critical thinking.

Conclusions. Critical thinking represents an important meta-competence for nurses. Critical thinking contributes to adequate gathering of the information about patient, selection of those and formulating accurate diagnoses, progression of problem-solving skills and making decisions, improves communication with the patient. Analysis of relevant literature made it possible to indicate factors affecting critical thinking.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Critical thinking skills in nursing students: a comparison between freshmen and senior students

Affiliations.

• 1 School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, IR Iran.
• 2 Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, IR Iran.
• 3 Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, IR Iran.
• PMID: 25830160
• PMCID: PMC4377532
• DOI: 10.17795/nmsjournal25721

Background: Critical thinking is one of the most important concepts in the field of education. Despite studies published on nursing students' critical thinking skills (CTS), some suggest that there is not enough evidence supporting the relationship between content of nursing education programs and nursing students' CTS.

Objectives: Given the existing discrepancies, this study aimed to compare the critical thinking skills of freshmen and senior nursing students.

Patients and methods: This comparative study was conducted on 150 undergraduate freshmen and senior nursing students in Kashan University of Medical Sciences, during 2012. The students in the first and the last semesters of their study in nursing were entered in the study using the census method. Data were collected using a questionnaire including questions on demographic data and the California Critical Thinking Skills Test, form B. Data analysis was performed using the SPSS v.13 software. Descriptive statistics were calculated. Moreover, independent sample t-test and Spearman and Pearson's correlation coefficients were used in the data analysis.

Results: Both the freshmen and senior nursing students had low CTS. The mean critical thinking scores were 11.79 ± 4.80 and 11.21 ± 3.17 for the freshmen and the senior students, respectively (P = 0.511). Moreover, no significant correlation was found between the students' score in CTS and their age, gender, high school grade point average (GPA), rank in university entrance examination (RUEE) and interest in the nursing profession.

Conclusions: The students were low skilled in critical thinking and their CTS did not significantly change during their nursing degree. Thus it may be concluded that the nursing education program did not affect the CTS of its students. Longitudinal studies are suggested for assessing nursing students' critical thinking over time. Moreover, revising the curriculum and preparing nursing educators for implementing innovative and active teaching strategies are suggested.

Keywords: Mental Competency; Nursing; Students; Thinking.

PubMed Disclaimer

Similar articles

• An Innovative Evaluation in Fundamental Nursing Curriculum for Novice Nursing Students: An Observational Research. Shen L, Zeng H, Jin X, Yang J, Shang S, Zhang Y. Shen L, et al. J Prof Nurs. 2018 Sep-Oct;34(5):412-416. doi: 10.1016/j.profnurs.2018.05.002. Epub 2018 May 2. J Prof Nurs. 2018. PMID: 30243698 Review.
• The Effect of Concept Maps on Undergraduate Nursing Students' Critical Thinking. Garwood JK, Ahmed AH, McComb SA. Garwood JK, et al. Nurs Educ Perspect. 2018 Jul/Aug;39(4):208-214. doi: 10.1097/01.NEP.0000000000000307. Nurs Educ Perspect. 2018. PMID: 29629932 Review.
• A comparison of educational strategies for the acquisition of nursing student's performance and critical thinking: simulation-based training vs. integrated training (simulation and critical thinking strategies). Zarifsanaiey N, Amini M, Saadat F. Zarifsanaiey N, et al. BMC Med Educ. 2016 Nov 16;16(1):294. doi: 10.1186/s12909-016-0812-0. BMC Med Educ. 2016. PMID: 27852292 Free PMC article.
• Critical thinking dispositions and skills of senior nursing students in associate, baccalaureate, and RN-to-BSN programs. Shin K, Jung DY, Shin S, Kim MS. Shin K, et al. J Nurs Educ. 2006 Jun;45(6):233-7. doi: 10.3928/01484834-20060601-08. J Nurs Educ. 2006. PMID: 16780012
• The relationship of critical thinking skills and critical thinking dispositions of baccalaureate nursing students. Profetto-McGrath J. Profetto-McGrath J. J Adv Nurs. 2003 Sep;43(6):569-77. doi: 10.1046/j.1365-2648.2003.02755.x. J Adv Nurs. 2003. PMID: 12950562
• Higher Vocational Nursing Students' Clinical Core Competence in China: A Cross-Sectional Study. Wang S, Huang S, Yan L. Wang S, et al. SAGE Open Nurs. 2024 Mar 1;10:23779608241233147. doi: 10.1177/23779608241233147. eCollection 2024 Jan-Dec. SAGE Open Nurs. 2024. PMID: 38435341 Free PMC article.
• Brazilian undergraduate nursing students' critical thinking need to be increased: a cross-sectional study. Nes AAG, Riegel F, Martini JG, Zlamal J, Bresolin P, Mohallem AGDC, Steindal SA. Nes AAG, et al. Rev Bras Enferm. 2022 Nov 28;76(1):e20220315. doi: 10.1590/0034-7167-2022-0315. eCollection 2022. Rev Bras Enferm. 2022. PMID: 36449978 Free PMC article.
• Medication administration and anxiety: an observational study with nursing students. Marletta G, Sorvillo I, Paduret G, Romano R, Nitro M, Muscella G, Di Monte MC, La Sala R, Sarli L, Artioli G, Primosa F. Marletta G, et al. Acta Biomed. 2022 Oct 26;93(5):e2022309. doi: 10.23750/abm.v93i5.13803. Acta Biomed. 2022. PMID: 36300204 Free PMC article.
• Trend of tendency to critical thinking among medical students in Tehran University of Medical Sciences, 2010-2015: A longitudinal study. Najafi M, Motlagh MK, Najafi M, Kashani AS, Ostadzar NF, Zarghi N, Shirazi M. Najafi M, et al. J Educ Health Promot. 2022 Jan 31;11:29. doi: 10.4103/jehp.jehp_1373_20. eCollection 2022. J Educ Health Promot. 2022. PMID: 35281392 Free PMC article.
• The Effects of Nursing Education on Critical Thinking of Students: A Meta-Analysis. Kantek F, Yıldırım N. Kantek F, et al. Florence Nightingale Hemsire Derg. 2019 Feb 1;27(1):17-25. doi: 10.26650/FNJN363168. eCollection 2019 Feb. Florence Nightingale Hemsire Derg. 2019. PMID: 34267959 Free PMC article.
• Athari Z, Sharif M, Nematbakhsh M, Babamohammadi H. [Evaluation of critical thinking skills in isfahan university of medical sciences' students and its relationship with their rank in university entrance exam rank]. Iran J Med Edu. 2009;9(1):5–12.
• Anajafi F, Zera'at Z, Soltan Mohammadi Z, Ghabchipour K, Kohan F. [Critical thinking skills of engineering and human sciences students]. Bimonthly Educ Strateg Med Sci. 2009;2(1):9–10.
• Eslami-Akbar R, Moarefi F. [A comparison of the critical thinking ability in the first and last term baccalaureate students of nursing and clinical nurses of Jahrom University of Medical Sciences in 2007]. J Jahrom Univ Med Sci. 2010;8(1):37–45.
• Khosravani S, Manoochehri H, Memarian R. Developing critical thinking skills in nursing students by group dynamics. Internet J Adv Nurs Prac. 2005;7(2):1–12.
• Yildirim B, Ozkahraman S. Critical thinking in nursing process and education. Int J Hum Social Sci. 2011;1(13):257–62.

LinkOut - more resources

Full text sources.

• Europe PubMed Central
• PubMed Central

Research Materials

• NCI CPTC Antibody Characterization Program
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

• Open access
• Published: 25 June 2024

Advancing arrhythmia education through the CDIO approach: a new paradigm in nursing student training

• Yu Chen 1   na1 ,
• Heling Wen 1   na1 ,
• Zheng Huang 2 ,
• Rui Zhang 2 &
• Lei Peng 3  

BMC Nursing volume  23 , Article number:  427 ( 2024 ) Cite this article

Metrics details

The accurate diagnosis and effective management of arrhythmias are crucial, with nurses playing a key role in the early detection and treatment, significantly impacting patient outcomes. Improving education on arrhythmias among nurses, especially in critical care and perioperative settings, can enhance patient safety and the quality of care.

A total of 116 trainee nurses were randomly divided into two groups: one utilizing the conceive-design-implement-operate (CDIO) model and the other employing a traditional lecture-based learning (LBL) method, to undergo arrhythmia training. The studyassessed the effects of the two teaching methods and investigated the students’ attitudes toward these educational practices, with all participants completing pre- and post-course tests.

The CDIO model significantly enhances nursing students’ arrhythmia proficiency, yielding higher test scores and sustained improvement after 24-week compared to the traditional LBL method, alongside markedly better self-learning enthusiasm, understanding, satisfaction with the teaching approach and effectiveness, and interest in learning arrhythmia. The CDIO model in nursing arrhythmia courses boosts theoretical knowledge and application, showing potential in clinical skill enhancement.

Conclusions

Our study introduces the CDIO model in nursing arrhythmia courses, with improvement in knowledge and skills, and promise for broader application.

Peer Review reports

Introduction

Arrhythmia encompasses any deviation from the normal cardiac rhythm, manifesting as tachycardia, bradycardia, or irregular heartbeats. This condition originates from disruptions in the cardiac electrical system, varying from benign to life-threatening. Severe arrhythmias can compromise cardiac function and elevate risks of stroke, heart failure, or sudden cardiac arrest. The diagnostic and therapeutic approach for arrhythmias typically involves electrocardiographic monitoring and may include pharmacological interventions, lifestyle modifications, or procedural treatments. The choice of therapy is contingent upon the specific arrhythmia type, its etiological factors, and the patient’s overall health condition. Crucially, arrhythmias in hospitalized patients are pivotal in determining prognosis, necessitating timely identification and management to mitigate associated risks.

Nurses often are front-line responders to cardiac emergencies such as cardiac arrests and tachycardia in hospitalized patients, playing a vital role in the timely identification and intervention of lethal arrhythmias. Their rapid and accurate interpretation skills are critical in enhancing patient outcomes, highlighting their pivotal role in acute cardiac care [ 1 ]. Recent advancements in medical science and technology have led to an increased demand for arrhythmia monitoring across all patient demographics, regardless of their specific ward or department [ 2 ]. Prompt detection and effective management of patient deterioration significantly impact patient outcomes. The issue of “failure to rescue”, a global healthcare concern, is partly due to nurses’ challenges in detecting and managing patient deterioration, particularly in identifying and handling cardiac arrhythmias [ 3 ].Furthermore, a study by Goodridge et al. found that among surgical nurses, 48% of abnormal electrocardiograms (ECGs) were not interpreted satisfactorily, potentially affecting the medical safety of surgical patients. This emphasizes the necessity for improved training and support for nurses in ECG interpretation to ensure patient safety and quality care in surgical settings [ 4 ].

Recent research underscores the imperative for ongoing education and training to equip nurses with the proficiency needed for accurate cardiac rhythm interpretation, a cornerstone of exemplary patient care and treatment outcomes [ 2 ]. Studies indicate a strong correlation between nurses’ arrhythmia training and their ability to diagnose and manage high-risk arrhythmias, especially in critical care settings such as the Coronary Care Unit (CCU), Intensive Care Unit (ICU), and Emergency Department [ 5 , 6 , 7 ]. In these settings, patients often present clinical instability and are under continuous non-invasive cardiac monitoring.

In contrast, nurses in surgical wards generally receive less training in arrhythmia management, which is concerning given that perioperative arrhythmias are a common and potentially severe complication in surgical patients [ 8 ]. Atrial fibrillation (AF), prevalent in 16–30% of post-cardiac and thoracic surgeries, poses serious risks, including organ hypoperfusion, pulmonary edema, and myocardial infarction. The incidence of perioperative arrhythmias in non-cardiothoracic surgeries varies between 4 and 20%, influenced by the type of surgery, patient health, and surgical stressors [ 9 ]. Notably, the incidence of arrhythmias, particularly AF, can range from 2 to 60% in cardiothoracic and esophageal surgeries [ 10 ].These findings necessitate vigilant monitoring and proactive management of arrhythmias in perioperative settings to avert severe complications. Enhancing the medical safety of perioperative surgical patients thus mandates essential arrhythmia training for nurses in surgical departments, aligning with the broader goal of optimizing patient outcomes and safety in high-risk clinical environments.

Theoretical knowledge and practical skills of arrhythmia is an essential skill for all nurses [ 11 ]. Timely identification and management of life-threatening arrhythmias by nurses can reduce mortality rates and improve patient outcomes [ 12 ]. A study shows that most practicing nurses exhibit a positive attitude towards the diagnosis of arrhythmias, but the majority demonstrate a lower level of proficiency in arrhythmia diagnosis [ 13 ]. Another study found that nursing students have a certain gap compared to practicing nurses in both theoretical knowledge and practical skills [ 14 ]. The deficiencies in arrhythmia knowledge and skills among nurses and nursing students may stem from insufficient education and training, making it crucial to provide appropriate educational opportunities to improve the competency of nursing personnel in managing arrhythmias [ 15 , 16 ]. Providing training in arrhythmia management to nursing students may positively impact their future practice capabilities, establishing a foundational knowledge base that facilitates specialized training requiring a solid understanding of arrhythmias [ 17 ].

Within the realms of clinical medicine and nursing education, traditional lecture-based learning (LBL) method presents distinct advantages and drawbacks. Its primary utility lies in the efficient dissemination of comprehensive theoretical knowledge and professional insights to large student cohorts, forming an essential foundation for their educational journey. LBL method ensures a standardized method of content delivery, which is fundamental for upholding the quality and consistency of nursing education [ 18 ]. Nevertheless, the limitations of LBL method are significant. It often lacks dynamic interaction and engagement, which may lead to reduced student interest and participation. Given the practical nature of nursing, LBL method might fall short in addressing the hands-on skills and real-world applications critical for clinical practice [ 19 , 20 ]. Additionally, its generalized approach may not cater to the varied students’ learning style. Research suggests that compared to more interactive and experiential teaching methodologies, LBL method might not be as effective in promoting deep learning or in fostering long-term retention of knowledge [ 7 ]. Therefore, while LBL method is valuable for knowledge transmission, its efficacy is greatly enhanced when integrated with interactive, learner-centered educational strategies.

The Conceive-Design-Implement-Operate (CDIO) educational framework is a pioneering approach that focuses on a hands-on, practical learning process [ 21 ]. This model was developed as a response to the growing need for students to be adept not only in knowledge but also in skills such as problem-solving, teamwork, and innovation [ 21 , 22 ]. The CDIO framework was initially conceptualized and developed by a group of engineering educators from the Massachusetts Institute of Technology (MIT). The development of this framework was driven by the recognition that traditional education often lacked sufficient emphasis on real-world problem-solving and practical skills. This model allows students to engage in learning through the actual experience of practices, rather than through theoretical study alone. These advantages align well with the pedagogical characteristics of clinical medicine and nursing, as these disciplines are inherently practice-oriented, necessitating the cultivation of students adept in both theoretical knowledge and practical skills to serve patients and enhance healthcare quality.

In recent years, the CDIO model has gradually gained wider application within the nursing education system. Instructors utilize the CDIO model in various nursing student training programs, such as cardiovascular health behavior modification, orthopedic nursing, and the cultivation of core competencies [ 23 , 24 , 25 ]. Xinyang Su et al. found that the CDIO model can stimulate the independent learning and critical thinking abilities of nursing interns, promote the organic integration of theory and practice in orthopedic nursing [ 23 ]. Xinyue Dong et al. discovered that the CDIO model enhances nursing students’ health education skills, increases their perception of clinical decision-making, and optimizes their ability to conduct behavior change counseling [ 24 ]. Another study indicated that within the training of neurosurgical nurses, the CDIO model can improve students’ core competencies and general self-efficacy [ 25 ]. Currently, we are not clear on whether the new CDIO teaching model is more suitable for arrhythmia education among nursing students compared to traditional teaching methods. It remains to be explored whether this model offers advantages over the traditional LBL teaching approach in terms of both theory and practice of arrhythmia, and these questions are worth investigating to answer.

Our research hypothesizes that the CDIO approach can better achieve the objective of enhancing arrhythmia education among nursing interns. By comparing it with the traditional LBL method, this study aims to assess the effectiveness of these two distinct teaching methodologies in arrhythmia, particularly in the capability of diagnosing arrhythmias, and to investigate student attitudes towards this educational practice. To our knowledge, no studies have yet analyzed the effectiveness of the CDIO approach in the education of arrhythmias among nursing interns.

Study design

This is a randomized controlled trial with two groups, encompassing three arrhythmia tests and a quantitative questionnaire survey. The study was conducted at a training and research hospital during the academic year 2022–2023. The PASS 15.0 (Power Analysis and Sample Size) Software (UT, USA) was utilized for the calculation of sample size. Prior to initiating the research, we estimated the sample size using the outcomes from our preliminary study. With an alpha of 0.05 and a power of 0.9, we determined a requirement for 52 subjects in each group. Accounting for a 10% loss of samples, the adjusted number of subjects for each group was established at 58 participants per group. A total of 116 third-year nursing students were enrolled in the study during their internships in Department of Surgery. These students were randomly divided into two groups using a digital randomization method. Fifty-eight nursing students were trained using the CIDO method as the experimental group, while the other fifty-eight were taught using the traditional LBL method as the control group. This research was conducted with the approval of the Institutional Review Board and Ethics Committee of the Affiliated Tumor Hospital of Chengdu Medical College, and informed consent was obtained from each participant (Ref: 36-2-1). This study was conducted in accordance with the 2013 revision of the Declaration of Helsinki [ 26 ].

Teaching implementation

The cdio model for arrhythmia course.

This course categorizes arrhythmias into two types: tachyarrhythmias and bradyarrhythmias, with each type of arrhythmia covered over two class periods, each lasting 45 min. The specific steps of CDIO for arrhythmia teaching are as follows (Fig.  1 ) :

Study design. Control group: traditional LBL method; Experimental group: CDIO method

Conceive (C):

Before the class, the instructor will present students with typical electrocardiogram (ECG) cases of arrhythmias, posing questions and introducing the course’s objectives and content through these cases. Questions might include: What diagnosis is currently being considered for the patient? What are the common clinical symptoms? What are the ECG findings? How does it differ from other arrhythmias? What are the treatment options? etc. After posing these questions, students are encouraged to make preliminary attempts at answering them, becoming familiar with the course content and objectives. This approach is designed to create a sense of urgency and to stimulate their enthusiasm for learning. The questions are centered around the student’s learning outcomes for arrhythmia teaching: (1) Understanding the definition and classification of arrhythmias. (2) Mastering the ECG diagnosis and differential diagnosis of arrhythmias. (3) Learning about the treatment methods for arrhythmias.

Design (D):

Before class, tasks with the potential to attract students are designed to stimulate their enthusiasm for learning. Teachers organize students into groups (8–10 members each, with a group leader elected to assist the teacher with educational activities and to distribute tasks within the group), design, and assign learning tasks. Starting from typical cases, problems, and assigned tasks, students engage in group discussions on cases and learning materials, formulate learning plans, and prepare slides for subsequent classroom presentations.

Implement (I):

In classroom teaching, teachers play a mediating role, guiding students to focus on learning tasks to facilitate their completion. Students utilize learning materials provided by the teacher and consult other relevant resources to analyze typical cases in the driving phase and answer related questions. They work in groups to summarize and organize the issues encountered during group discussions, presenting the content in slideshow format in the classroom and providing feedback to the teacher, a process that lasts 20 min. Based on the students’ group discussion learning, the instructing teacher summarizes and delivers theoretical knowledge lectures, addresses questions raised by the students, and explains difficult concepts and challenging points, a process that lasts 10 min.

Operate (O):

In classroom teaching, teachers use actual patient records from the hospital to guide students in reviewing knowledge. Students are encouraged to express their diagnostic and treatment opinions, which are then evaluated and corrected by the teacher. Students engage in task output through active participation and answering questions, allowing the teacher to observe the quality of their output in real-time. When a student’s logical thinking is found to be poor, their answers incomplete or incorrect, timely feedback and critique are provided to deepen their understanding of the concepts and continuously improve the quality of their output. The teacher will give a final explanation for questions with a low correctness rate and conclude the session once it is confirmed through classroom Q&A that students have a basic grasp of the knowledge points. This process lasts 15 min.

LBL method for ECG course

The LBL method for ECG course comprised four sessions, each lasting 45 min. Prior to the class, the teacher provided the students with an arrhythmia textbook for preview. Throughout the course, the teacher conducted a 40-minute lecture to elucidate various arrhythmias, which was followed by an approximately 5-minute Q&A session (Fig.  1 ).

Assessment of teaching effect and students’ attitudes

To assess the students’ understanding and application of knowledge, the two groups had the same examinations, including one test before course and two after course which was adopted before training, one week and 24-week after training respectively. According to the Bloom’s Taxonomy, all questions in the test were categorized into two aspects, basic theoretical knowledge (25 points) and clinical case analysis (25 points). The basic theoretical knowledge section consisted of 25 multiple-choice questions on arrhythmias, with each question worth 1 point. Similarly, the clinical case analysis section assessing students’ application of knowledge included 25 questions on arrhythmia cases, with each also worth 1 point. The format for both sections was multiple-choice, and each question had only one correct answer. The examples of questions that pertain to both basic theoretical knowledge and clinical case analysis are included in the Supplemental Materials (Figure S1 - S2 ). The questions in the three tests were assessed to ensure consistency in difficulty levels by two different teachers. The total score was 50 points and the test time was 60 min. We calculated the total score, theoretical and application scores of each test for each student.

To assess the students’ evaluation of learning attitudes and effects, a questionnaire survey was adopted at the end of the course, including self-learning enthusiasm, study load, systematization of teaching content, understanding of teaching content, student-teacher interaction, satisfaction of teaching mode, satisfaction of teaching effect, development of self-confidence, team collaboration and interest in learning arrhythmia (Supplemental Table S1 ). The 5-level Likert scoring method was adopted for each question, with 5 points for very satisfied/strongly agreed, 4 points for satisfied/agreed, 3 points for neutral, 2 points for dissatisfied/disagreed and 1 point for very dissatisfied/strongly disagreed.

Statistical analysis

Data normality was evaluated using the Shapiro–Wilk test. Data were presented as mean ± standard deviations (SDs) or median (interquartile range, IQR) values, as appropriate according to data distribution. Ages were compared with the Mann–Whitney U test. Arrhythmia test scores before training of the two groups were compared by t-test. For the analysis of the arrhythmia test scores at different time points, comparisons were analyzed using analysis of variance (ANOVA) for repeated measures. For the 5-level Likert scores of students’ evaluation of learning attitudes and effect, the Mann–Whitney U test was applied. Statistical analyses were conducted in SPSS 26.0 (SPSS Inc., Chicago, USA). All tests were two-tailed, and significance was set at p  < 0.05.

Baseline information of participants

A total of 116 nursing students undergoing internships were enrolled in this study and were randomly divided into two groups. All enrolled nursing students were female. The experimental group comprised 58 nursing students and utilized the CDIO method, while the control group consisted of 58 nursing students and used the LBL method. Upon comparison of factors such as age and arrhythmia test scores before the start of the curriculum, no significant differences were found between these two groups ( z =-0.407, p  > 0.05 for age; t  = 0.857, p  > 0.05 for total arrhythmia test scores; t  = 0.105, p  > 0.05 for theoretical arrhythmia test scores; t  = 1.384, p  > 0.05 for application arrhythmia test scores; Table  1 ).

Arrhythmia test scores in two groups

The arrhythmia test scores for the two groups are presented in Fig.  2 . One week prior to the commencement of the arrhythmia course, the students underwent a pre-test assessment. In the experimental group, the mean total score was 22.31 ± 3.03, with mean scores for theoretical knowledge and application being 11.86 ± 2.77 and 10.45 ± 2.17, respectively. For the control group, the corresponding mean scores were 21.85 ± 2.82 for the total, 11.91 ± 2.52 for theoretical knowledge, and 9.93 ± 1.84 for application. There were no significant differences between the experimental and control groups ( p  > 0.05), indicating that the baseline characteristics of these two groups were comparable.

Scores of arrhythmia tests in Con ( n  = 58) and Exp ( n  = 58) groups at different time points. A , Theoretical Score; B , Application Score; C , Total Score. Con: control group with the traditional LBL method. Exp: experimental group with the CDIO model. Data are presented as mean ± standard deviation (SD). *** p  < 0.001 vs. Pre-Course in Con group, ^^^ p  < 0.001 vs. Pre-Course in Exp group, ### p  < 0.001 vs. scores in Con group at 1w and 24w after course ,## p  < 0.01 vs. scores in Con group at 24w after course

There were marked increases in the experimental group’s total scores, theoretical knowledge scores, and application scores: 22.31 ± 3.03 at baseline, 38.90 ± 4.33 one week after training and 34.10 ± 4.38 twenty-four weeks post-training ( F  = 283.159, p  < 0.001); 11.86 ± 2.77 at baseline, 20.29 ± 2.51 one week after training and 17.88 ± 3.13 twenty-four weeks post-training ( F  = 126.013, p  < 0.001); 10.45 ± 2.17 at baseline, 18.60 ± 3.08 one week after training and 16.22 ± 3.61 twenty-four weeks post-training ( F  = 172.044, p  < 0.001), respectively. Similarly, in the traditional group, these scores were as following: 21.85 ± 2.82 at baseline, 34.43 ± 4.76 one week after training and 30.84 ± 4.51 twenty-four weeks post-training ( F  = 163.439, p  < 0.001); 11.91 ± 2.52 at baseline, 18.12 ± 3.26 one week after training and 16.71 ± 3.43 twenty-four weeks post-training ( F  = 69.933, p  < 0.001); 9.93 ± 1.84 at baseline, 16.31 ± 3.15 one week after training and 14.14 ± 3.44 twenty-four weeks post-training ( F  = 102.690, p  < 0.001), respectively.

One week after training, the experimental group’s total scores, theoretical knowledge scores, and application scores were significantly higher than those of the traditional group (38.90 ± 4.33 vs. 34.43 ± 4.76, F  = 27.962, p  < 0.001; 20.29 ± 2.51 vs. 18.12 ± 3.26, F  = 16.182, p  < 0.001; 18.60 ± 3.08 vs. 16.31 ± 3.15, F  = 15.714, p  < 0.001).

Twenty-four weeks post-training, the experimental group showed total scores, theoretical knowledge scores, and application scores of 34.10 ± 4.38, 17.88 ± 3.13, and 16.22 ± 3.61, respectively. Conversely, the control group exhibited scores of 30.84 ± 4.51 for total, 16.71 ± 3.43 for theoretical knowledge, and 14.14 ± 3.44 for application. Significant disparities were observed between the two groups in terms of total and application scores 24 weeks after training ( F = 15.540, p  < 0.001 and F = 10.140 , p  = 0.002, respectively), whereas the theoretical knowledge scores did not differ significantly. The detailed statistic and p value of arrhythmia test scores ware showed in Supplemental Table S2 .

Comparison of students’ attitudes

A total of 116 questionnaires were distributed, all of which were returned, yielding a recovery rate of 100%. When comparing the experimental group with the control group, significant improvements were noted in the experimental group in various aspects. These improvements included self-learning enthusiasm ( z =-2.197, p  = 0.028), comprehension of the teaching content ( z =-2.566, p  = 0.010), student-teacher interaction ( z =-2.621, p  = 0.009), satisfaction with the teaching mode ( z =-2.362, p  = 0.018), satisfaction with the teaching effectiveness ( z =-2.696, p  = 0.007), development of self-confidence ( z =-3.358, p  = 0.001), team collaboration ( z =-7.843, p  < 0.001), and interest in learning about arrhythmia ( z =-2.173, p  = 0.030). However, the organization of teaching content was found to be similar between the two groups ( z =-1.030, p  = 0.303). Additionally, a total of 72.4% students in the experimental group reported an increased study load ( z =-3.392, p  = 0.001) (Fig.  3 ).

Five-level likert scores of students’ attitudes in Con ( n  = 58) and Exp ( n  = 58) groups. A , Self-Learning Enthusiasm; B , Study Load; C , Systematization Of Teaching Content; D , Understanding Of Teaching Content; E , Student Teacher Interaction; F , Satisfaction Of Teaching Mode; G , Satisfaction Of Teaching Effect; H , Development Of Self-Confidence; I ,Team Collaboration; J , Interest In learning Arrhythmia. Con: control group with the traditional LBL method. Exp: experimental group with the CDIO model. ns: no significant difference, * p  < 0.05 Exp vs. Con, ** p  < 0.01 Exp vs. Con, *** p  < 0.001 Exp vs. Con

Proficiency in managing arrhythmias is crucial for nurses as it directly affects patient safety [ 27 , 28 ]. Traditional teaching methods have proven less effective in educating nurses about arrhythmias, highlighting an urgent need to explore new methods to enhance the educational outcomes for nursing students in this area [ 29 , 30 ]. For the first time, we investigated the application of the CDIO model in teaching arrhythmia to nursing students. Our findings indicate that, compared to the traditional LBL method, the CDIO model significantly improves students’ theoretical knowledge and practical skills in managing arrhythmias. Additionally, student feedback suggests that the CDIO model outperforms the LBL method in terms of self-learning enthusiasm, understanding of teaching content, student-teacher interaction, students’ satisfaction of teaching mode, and more.

In nursing education, the LBL method remains the mainstream approach, but it is prone to inducing passive learning, which diminishes student engagement, interest, and motivation for independent learning [ 31 , 32 ]. Given the limitations of the LBL method, it is imperative that we seek innovative teaching approaches. It has been shown that the new methods significantly elevate the caliber of nursing education by promoting active engagement and critical analysis, and also positively impact patient care [ 33 , 34 , 35 , 36 ]. Our study indicates that the CDIO model group participants outperformed the control group in both theoretical knowledge assessment and application capability evaluation, with a statistically significant difference after training ( F  = 12.116, p  = 0.001 for theoretical knowledge; F  = 23.681, p  < 0.001 for application capability; Table S2 ). The CDIO teaching model integrates students into the curriculum with practical problems right from the “Conceive” phase. Moreover, during the “Operate” phase, the study of actual cases further transforms arrhythmia theoretical knowledge into practical applications. Numerous studies underscore the efficacy of the CDIO framework in nursing education, particularly its role in enhancements in the understanding and application of knowledge [ 23 , 24 , 37 , 38 ]. A study on nursing students in orthopedic internships demonstrated that the CDIO model significantly enhances clinical competencies, analytical thinking, and self-directed learning by effectively integrating theoretical understanding with practical skills, thereby enriching problem-solving abilities and teaching effectiveness [ 23 ]. Furthermore, another research indicated that online courses utilizing the CDIO model surpassed traditional methods in theoretical knowledge and practical skill assessments, thereby bolstering health education proficiency and clinical decision-making acumen [ 24 ]. Additionally, a study on CDIO model for nursing students in respiratory and critical care medicine internships indicated that students in the CDIO group scored higher than those in the control group in both theoretical and practical exams, demonstrating effective teaching [ 37 ]. Moreover, in endocrinology nursing skill training, the CDIO model has shown advantages over traditional approaches, with students outperforming the control group in Mini-Clinical Evaluation Exercise scores, instructor evaluations, and patient satisfaction surveys [ 38 ]. Collectively, these studies highlight the CDIO model’s multifaceted applications in nursing education, proving its effectiveness in enhancing both knowledge and its application.

This improvement in teaching effectiveness may stem from the unique instructional design of the CDIO model. In our CDIO model for teaching arrhythmias, the “Conceive” phase starts with presenting typical arrhythmia cases, immersing nursing students in scenarios. Case-related questions encourage students to preview content and consult relevant literature, sparking their interest. In the “Design” phase, students actively engage in problem-solving, enhancing self-directed learning and enthusiasm. The “Implement” phase features group presentations and teacher feedback, with the teacher transitioning from “knowledge delivery” to “activity guidance.” In the “Operate” phase, in-hospital arrhythmia cases strengthen knowledge integration and practical skills.

Student feedback is an important basis for evaluating teaching methods, helping to develop more scientific course designs and teaching strategies to improve teaching effectiveness. Therefore, we observed student feedback on the application of the CDIO model in teaching arrhythmias from multiple perspectives.

We found that the CDIO model kindles students’ self-learning enthusiasm. The introduction of cases before classroom sessions requires students to be proactive in their learning process prior to classroom teaching, seeking and utilizing various resources to solve problems. The act of confronting challenges and solving problems in itself serves as an incentive, encouraging students to actively seek solutions, thereby bolstering their self-learning enthusiasm [ 37 ]. Through the practical activities during the “Operate” phase, students are able to see the direct outcomes and significance of their learning, thereby further stimulating their self-learning enthusiasm.

We found that compared to the traditional LBL method, CDIO increases students’ study load, as traditional teaching methods only require passive knowledge reception. The CDIO model necessitates active student participation in classroom activities. Additionally, they must confront immediate feedback from peers and teachers, a process that could heighten their energy expenditure. The increase in the study load has also been observed in other studies of non-traditional teaching models that transform students from passive recipients in the classroom to active participants [ 39 , 40 ].

Our study found that the CDIO model group does not have an advantage over the traditional LBL group in terms of the systematization of teaching content. The CDIO model focuses on cultivating students’ ability to apply knowledge in arrhythmia, making it challenging for students to ensure a balanced and in-depth understanding across all types of arrhythmias during their learning process. The autonomous nature of student learning may lead to inconsistencies in the content and depth of learning, thereby affecting the systematic construction of the knowledge system. Furthermore, the shift of teachers from traditional knowledge transmission to guiding and collaborating in learning could also impact the systematic organization and conveyance of teaching content.

The abstract nature of arrhythmia knowledge presents a challenge for nursing students’ learning. How to enhance students’ understanding of teaching content is a crucial focal point in the reform of teaching methods [ 41 , 42 ]. The CDIO model emphasizes deepening theoretical knowledge through the study of actual clinical cases. By applying abstract theories to the analysis and handling of specific cases, students can intuitively grasp the application of theory in practice. This “learning by doing” approach aids in enhancing students’ understanding of teaching content.

Our study found that increased student teacher interaction is a significant characteristic of the CDIO model. This approach transforms the classroom into a platform for student teacher interaction, fostering a more active, interactive, and personalized learning environment. Teachers facilitate student participation in discussions and assist students in recognizing their progress and areas needing improvement. Concurrently, students are encouraged to provide feedback to teachers. This bidirectional communication mechanism enhances the interaction between teachers and students, promoting continuous improvement in teaching methods and the learning process. Increased student teacher interaction has been observed in various student-centered, new teaching models that emphasize active student participation and collaborative student teacher interaction [ 43 , 44 ].

Consistent with other studies, our research found that students’ satisfaction of teaching mode was significantly higher in the CDIO model group compared to the traditional control group [ 45 ]. In the CDIO model, the use of real-world cases for student analysis and learning serves to increase interest and satisfaction; CDIO emphasizes active student engagement in the learning process and self-resolution of practical problems, positioning students in a leading role within educational activities. This enhances their sense of participation, which is also a contributing factor to increased satisfaction.

Our study followed the CDIO process, guiding students to participate throughout. We investigated whether the CDIO model surpasses the traditional LBL method in knowledge retention after 24-week. Our findings suggest that after the implementation of the CDIO model, students’ scores in application abilities exceeded those achieved through traditional LBL method, while scores based on memory of theoretical knowledge showed no statistical difference in delayed tests. This indicates that the CDIO model is more beneficial for long-term improvement in application abilities in teaching students about arrhythmias.

Our study pioneers the CDIO model’s application in arrhythmia courses for nursing students, enhancing their theoretical knowledge and application capability. This effective, innovative approach shows promise in clinical skills enhancement, particularly in arrhythmia identification and management. While further research is needed to address potential biases and explore applicability to broader groups, initial findings suggest the CDIO model significantly improves learning outcomes, satisfaction, and interest among nursing students, meriting further exploration and potential expansion to additional trainees.

Study limitation

The study presented here encounters several main limitations. Firstly, the investigation was primarily focused on trainee nurses, which limits the generalizability of the findings. To validate the effectiveness of the proposed combined method, it’s imperative to conduct future studies with a more diverse participant pool, such as internal and surgical resident physicians, dentists, and public health service personnel, among others. Secondly, due to the limited sample size of this study, additional research with a larger cohort is essential to fully evaluate the impact of the method. Moreover, this study did not explore the longer-term retention and application of knowledge by the participants. Future research should include more time points, such as 36-week and 48-week post-class assessments, to investigate the durability of retained knowledge.

Data availability

Please contact the corresponding author for data availability.

Hernandez-Padilla JM, Granero-Molina J, Marquez-Hernandez VV, Suthers F, Lopez-Entrambasaguas OM, Fernandez-Sola C. Design and validation of a three-instrument toolkit for the assessment of competence in electrocardiogram rhythm recognition. Eur J Cardiovasc Nurs. 2017;16(5):425–34.

Article   PubMed   Google Scholar  

Scruth EA. Cardiac rhythm monitoring: competency, accuracy, and meaningful use. Clin Nurse Spec. 2014;28(2):86–8.

Cooper S, Kinsman L, Buykx P, McConnell-Henry T, Endacott R, Scholes J. Managing the deteriorating patient in a simulated environment: nursing students’ knowledge, skill and situation awareness. J Clin Nurs. 2010;19(15–16):2309–18.

Goodridge E, Furst C, Herrick J, Song J, Tipton PH. Accuracy of cardiac rhythm interpretation by medical-surgical nurses: a pilot study. J Nurses Prof Dev. 2013;29(1):35–40.

Zhang H, Hsu LL. The effectiveness of an education program on nurses’ knowledge of electrocardiogram interpretation. Int Emerg Nurs. 2013;21(4):247–51.

Article   CAS   PubMed   Google Scholar  

Rahimpour M, Shahbazi S, Ghafourifard M, Gilani N, Breen C. Electrocardiogram interpretation competency among emergency nurses and emergency medical service (EMS) personnel: a cross-sectional and comparative descriptive study. Nurs Open. 2021;8(4):1712–9.

Article   PubMed   PubMed Central   Google Scholar  

Wen H, Hong M, Chen F, Jiang X, Zhang R, Zeng J, Peng L, Chen Y. CRISP method with flipped classroom approach in ECG teaching of arrhythmia for trainee nurses: a randomized controlled study. BMC Med Educ. 2022;22(1):850.

Melduni RM, Koshino Y, Shen WK. Management of arrhythmias in the perioperative setting. Clin Geriatr Med. 2012;28(4):729–43.

Subramani Y, El Tohamy O, Jalali D, Nagappa M, Yang H, Fayad A. Incidence, Risk Factors, and Outcomes of Perioperative Atrial Fibrillation following Noncardiothoracic Surgery: A Systematic Review and Meta-Regression Analysis of Observational Studies. Anesthesiol Res Pract 2021, 2021:5527199.

Karamchandani K, Khanna AK, Bose S, Fernando RJ, Walkey AJ. Atrial fibrillation: current evidence and management strategies during the Perioperative Period. Anesth Analg. 2020;130(1):2–13.

Atwood D, Wadlund DL. ECG interpretation using the CRISP Method: a guide for nurses. AORN J. 2015;102(4):396–405. quiz 406 – 398.

Keller K, Eggenberger T, Leavitt MA, Sabatino D. Acute Care nurses’ Arrhythmia Knowledge: defining competency. J Contin Educ Nurs. 2020;51(1):39–45.

Buluba SE, He J, Li H. ICU nurses’ knowledge and attitude towards electrocardiogram interpretation in Fujian Province, China: a cross-sectional study. Front Med (Lausanne). 2023;10:1260312.

Rubbi I, Carvello M, Bassi V, Triglia C, Di Lorenzo R, Cremonini V, Artioli G, Ferri P. The skill of nursing students trained in the evaluation of electrocardiographic trace: a comparison with emergency nurses. Acta Biomed. 2021;92(S2):e2021507.

PubMed   Google Scholar  

Coll-Badell M, Jimenez-Herrera MF, Llaurado-Serra M. Emergency nurse competence in Electrocardiographic Interpretation in Spain: a cross-sectional study. J Emerg Nurs. 2017;43(6):560–70.

Taggar JS, Coleman T, Lewis S, Jones M. Screening for Atrial Fibrillation–A cross-sectional survey of Healthcare professionals in Primary Care. PLoS ONE. 2016;11(4):e0152086.

Jang KS, Hwang SY, Park SJ, Kim YM, Kim MJ. Effects of a web-based teaching method on undergraduate nursing students’ learning of electrocardiography. J Nurs Educ. 2005;44(1):35–9.

Alaagib NA, Musa OA, Saeed AM. Comparison of the effectiveness of lectures based on problems and traditional lectures in physiology teaching in Sudan. BMC Med Educ. 2019;19(1):365.

Alhazmi A, Quadri MFA. Comparing case-based and lecture-based learning strategies for orthodontic case diagnosis: a randomized controlled trial. J Dent Educ. 2020;84(8):857–63.

Gao J, Yang L, Zhao J, Wang L, Zou J, Wang C, Fan X. Comparison of problem-based learning and traditional teaching methods in medical psychology education in China: a systematic review and meta-analysis. PLoS ONE. 2020;15(12):e0243897.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Fan Y, Zhang X, Xie X. Design and development of a Course in Professionalism and Ethics for CDIO Curriculum in China. Sci Eng Ethics. 2015;21(5):1381–9.

Robinson K, Kirkpatrick HFR. G Rowe: a template for change? De-risking the transition to CDIO. Australasian J Eng Educ. 2013;1(19):39–49.

Google Scholar  

Su X, Ning H, Zhang F, Liu L, Zhang X, Xu H. Application of flipped classroom based on CDIO concept combined with mini-CEX evaluation model in the clinical teaching of orthopedic nursing. BMC Med Educ. 2023;23(1):219.

Dong X, Zhang Z, Zhang X, Lu M, Zhao Y, Lin Y, Zhang Y. Effects of an online training program on cardiovascular health behavior modification on nursing students’ health education competency. Nurse Educ Today. 2023;127:105829.

Zhang Na TL, Zhang C, Zhongyong W. Application of CDIO teaching mode in the cultivation of core competence of neurosurgery nurses. Chin J Mod Nurs. 2019;25(24):3059–62.

World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects. World Med J. 2013;59(5):199–202.

Amini K, Mirzaei A, Hosseini M, Zandian H, Azizpour I, Haghi Y. Assessment of electrocardiogram interpretation competency among healthcare professionals and students of Ardabil University of Medical Sciences: a multidisciplinary study. BMC Med Educ. 2022;22(1):448.

Yaser Tahboub ODYU. Nurses’ Knowledge and practices of Electrocardiogram Interpretation. Int Cardiovasc Res J. 2019;3(3):80–4.

Habibzadeh H, Rahmani A, Rahimi B, Rezai SA, Aghakhani N, Hosseinzadegan F. Comparative study of virtual and traditional teaching methods on the interpretation of cardiac dysrhythmia in nursing students. J Educ Health Promot. 2019;8:202.

Kim S, Kim CG. Effects of an Electrocardiography Training Program: Team-based learning for early-stage Intensive Care Unit nurses. J Contin Educ Nurs. 2020;51(4):174–80.

Butler JA. Use of teaching methods within the lecture format. Med Teach. 1992;14(1):11–25.

Tsai JM, Chen CH, Hsu CY, Liao HC, Tsai LY. Team-based learning complemented by interactive response system: application of a strategy on the course of human growth and development for nursing students. Taiwan J Obstet Gynecol. 2023;62(4):510–5.

Pivac S, Skela-Savic B, Jovic D, Avdic M, Kalender-Smajlovic S. Implementation of active learning methods by nurse educators in undergraduate nursing students’ programs - a group interview. BMC Nurs. 2021;20(1):173.

Wolf M, Seiler B, Vogelsang V, Sydney Hopf L, Moll-Koshrawi P, Vettorazzi E, Ebenebe CU, Singer D, Deindl P. Teaching fiberoptic-assisted tracheoscopy in very low birth weight infants: a randomized controlled simulator study. Front Pediatr. 2022;10:956920.

Gao X, Wang L, Deng J, Wan C, Mu D. The effect of the problem based learning teaching model combined with mind mapping on nursing teaching: a meta-analysis. Nurse Educ Today. 2022;111:105306.

Yang KH, Chen H, Liu CJ, Zhang FF, Jiang XL. Effects of reflective learning based on visual mind mapping in the fundamentals of nursing course: a quasi-experimental study. Nurse Educ Today. 2022;119:105566.

Zhang Teng WH, Zhao Qian L, Xin H, Yapeng. Effect of CDIO teaching method on self-learning ability and academic self-efficacy of nursing interns. Chin J Med Educ. 2024;44(02):101–4.

Hu Peng XR. Application research of CDIO model in endocrine specialist clinical nursing skill training for nursing undergraduates. Nurs Res. 2018;32(9):1456–60.

Hu X, Zhang H, Song Y, Wu C, Yang Q, Shi Z, Zhang X, Chen W. Implementation of flipped classroom combined with problem-based learning: an approach to promote learning about hyperthyroidism in the endocrinology internship. BMC Med Educ. 2019;19(1):290.

Rui Z, Lian-Rui X, Rong-Zheng Y, Jing Z, Xue-Hong W, Chuan Z. Friend or foe? Flipped Classroom for Undergraduate Electrocardiogram Learning: a Randomized Controlled Study. BMC Med Educ. 2017;17(1):53.

Varvaroussis DP, Kalafati M, Pliatsika P, Castren M, Lott C, Xanthos T. Comparison of two teaching methods for cardiac arrhythmia interpretation among nursing students. Resuscitation. 2014;85(2):260–5.

Chen Y, Nasrawi D, Massey D, Johnston ANB, Keller K, Kunst E. Final-year nursing students’ foundational knowledge and self-assessed confidence in interpreting cardiac arrhythmias: a cross-sectional study. Nurse Educ Today. 2021;97:104699.

Chen L, Lin T, Tang S. A qualitative exploration of nursing undergraduates’ perceptions towards scaffolding in the flipped classroom of the fundamental nursing practice course: a qualitative study. BMC Fam Pract. 2021;22(1):245.

Xu G, Lin Y, Ye Y, Wu W, Zhang X, Xiao H. Combination of concept maps and case-based learning in a flipped classroom: a mixed-methods study. Nurse Educ Pract. 2024;76:103918.

Zhang Luoling SN, Li Z. Application of CDIO education mode on obstetrics and gynecology nursing teaching on associate to bachelor degree students. Chin J Mod Nurs. 2017;23(22):2932–5.

Download references

Acknowledgements

This study was supported by grants from Medico-Engineering Cooperation Funds from University of Electronic Science and Technology of China (No.ZYGX2021YGLH223) and Chengdu Science and Technology Bureau(2022-YF05-01940-SN).

Author information

Yu Chen and Heling Wen contributed equally to this work.

Authors and Affiliations

Department of Cardiology, School of Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China

Yu Chen & Heling Wen

Department of Surgery, The Affiliated Tumor Hospital of Chengdu Medical College, Chengdu, 610021, China

Zheng Huang & Rui Zhang

Institute of Nephrology, Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China

You can also search for this author in PubMed   Google Scholar

Contributions

(I) Conception and design: Yu Chen and Zheng Huang; (II) Administrative support: Yu Chen, Rui Zhang, and Zheng Huang; (III) Provision of study materials or nurses: Rui Zhang and Zheng Huang; (IV) Collection and assembly of data: Yu Chen, Lei Peng, Rui Zhang and Zheng Huang; (V) Data analysis and interpretation: Lei Peng，Heling Wen and Yu Chen; (VI) Manuscript writing: Lei Peng, Heling Wen and Yu Chen; (VII) Final approval of manuscript: All authors.

Corresponding authors

Correspondence to Rui Zhang or Lei Peng .

Ethics declarations

Consent for publication.

Not applicable.

Human ethics and consent to participate

The Institutional Review Board and Ethics Committee of the Affiliated Tumor Hospital of Chengdu Medical College approved the study protocols and written informed participants’ consent (Ref: 36-2-1). Before enrolment, all participants provided written consent, wherein they were informed that they could freely withdraw from the study. There would be no negative consequences from opting not to participate in the study. All methods were carried out in accordance with relevant guidelines and regulations, including the Chinese Prevention of Cruelty to Human Subjects Act and the Code of Practice for the Care and Use of Human Subjects for Scientific Purposes.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Chen, Y., Wen, H., Huang, Z. et al. Advancing arrhythmia education through the CDIO approach: a new paradigm in nursing student training. BMC Nurs 23 , 427 (2024). https://doi.org/10.1186/s12912-024-02118-1

Download citation

Received : 23 February 2024

Accepted : 20 June 2024

Published : 25 June 2024

DOI : https://doi.org/10.1186/s12912-024-02118-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Lecture-based learning

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.10(6); 2024 Mar 30
• PMC10945204

Approaches for boosting self-confidence of clinical nursing students: A systematic review and meta-analysis

Elahe ramezanzade tabriz.

a Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

Masoumeh Sadeghi

b Department of Epidemiology, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran

c Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

Ensieh Tavana

Hamid heidarian miri.

d Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

Fatemeh Heshmati Nabavi

e Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

f School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

Associated Data

Self-confidence is a key element in successfully promoting achievement strivings among the healthcare workforce. Targeted interventions can strengthen this characteristic in nursing students, thus improving the quality of hospital services.

We evaluated the effect of educational interventions on boosting self-confidence in nursing students using systematic review and meta-analysis.

A comprehensive search was used to screen the related studies in Scopus, PubMed, Embase, Web of Science, and PsycINFO. Peer-reviewed literature in English until June 2023 was reviewed. Inclusion criteria were controlled trials, either non-randomized studies of intervention (NRSI) or randomized (RCTs). Studies were assessed for methodological quality by the Cochrane Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) and the Cochrane "Risk of Bias" tool for RCTs (RoB 2.0) and quality assessment tool for before-after (pre-post) studies with no control group. The main outcome was the self-confidence score of nursing students because of educational methods or intervention/s. Using the inverse variance weights method, a pooled standardized mean difference (SMD) estimate with a corresponding 95% confidence interval (CI) was determined. Random-effects meta-analysis was used to assess conceptual heterogeneity using Stata.

Twenty-two studies were selected involving 1758 participants and 940 cases of nursing students in the intervention group on boosting self-confidence (Fourteen Randomized controlled trials, Five Quasi-experimental, and three Before-After studies). The post-intervention self-confidence results in the nursing student's intervention group were significantly greater (SMD) (SMD for Controlled experimental design = 0.51; 95% CI = 0.14–0.89), (SMD for Quasi-experimental = 0.04; 95% CI = −0.33-0.41), (SMD for Before-After (Pre-Post) = 2.74; 95% CI = 1.85–3.63). The random-effect meta-analysis of 22 interventional studies determined that educational interventions are significantly associated with the improving self-confidence of nursing students. The intervention showed a moderate impact on the research units, according to Cohen's d results. Also, the results of simulation learning intervention (SMD = 0.42; 95% CI = 0.03–0.81) showed a significant relationship between intervention and outcome in studies.

Conclusions

Analysis of our findings revealed the successful impact of most interventional approaches in boosting self-confidence, especially in the long term. It can be concluded that self-confidence is a multifactorial concept that can be improved by using targeted combination intervention strategies.

1. Introduction

Clinical education is a critical component of nursing education and is often considered the cornerstone of professional development [ 1 , 2 ]. Universities worldwide are currently exploring teaching-learning strategies that foster clinical thinking, decision-making, and student-centered learning within the clinical setting [ 3 ]. In many cases, clinical education accounts for approximately half of the training time for nursing students. Therefore, it is essential that all students are able to proficiently apply the skills they have learned upon completion of their studies [ 4 ]. One influential factor in enhancing the quality of clinical services is the presence of self-confidence in both students and educated nurses. Self-confidence is integral to clinical competence and serves as an important indicator of ability and proficiency [ 5 ]. Self-confidence can be defined as an indication of a belief in one's individual abilities and skills. It plays a crucial role in a student's judgment, performance, and knowledge translation [ 6 ]. By building self-confidence, nursing students can achieve improved academic performance, job satisfaction, enhanced communication, and the capacity for more independent practice. This, in turn, positively impacts individuals receiving nursing care [ 7 , 8 ].

On the other hand, previous academic and clinical experiences provide students with the self-confidence and competence necessary to handle everyday situations. However, the complex and delicate healthcare environment poses unique challenges for nursing students [ 9 ]. These challenges may lead to anxiety and stress, hindering the successful performance of clinical procedures [ 10 ]. Thus, it is crucial for nursing students to possess adequate knowledge and practical skills before commencing clinical practice. This not only ensures patient safety but also fosters self-confidence and fosters effective relationships with patients [ 11 ]. Therefore, nurse educators must continually identify, implement, and evaluate teaching-learning strategies that promote the development of students' clinical competence and self-confidence [ 12 ]. Identifying and formulating these strategies is a significant challenge for nursing educators seeking to enhance nursing students' skills, self-confidence, and knowledge [ 13 ].

Therefore, appropriate approaches and interventions in teaching clinical skills need to be adopted for better success of nursing students in their profession and to improve and enhance their self-confidence and increase their professional competence. However, how effective are the interventions used in improving the self-confidence of clinical nursing students? Or what is the change in self-confidence of clinical nursing students following the use of relevant educational interventions? Due to the scant of a review and coherent study, we evaluated the effect of educational interventions on boosting self-confidence in nursing students using systematic review and meta-analysis. The results of this study will pave the way for improvements in clinical nursing education. The implementation of the identified strategies has the potential to reduce stress, enhance self-confidence, improve functional ability, and foster feelings of satisfaction and well-being among nursing students.

2.1. Protocol registration

The current meta-analysis was done based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane Handbook for Systematic Reviews of Interventions (Version 5.3) guidelines. This meta-analysis was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42023466725).

2.2. Search strategy

The online databases including PubMed, Web of Science (ISI), Embase, PsycINFO, and Scopus were searched systematically until June 2023, to identify relevant interventional studies. A mixture of the Medical Subject Headings (MeSH) and non-MeSH keywords were applied to retrieve studies because of increasing sensitivity and specificity. The following keywords were chosen: "self-concept" OR "self-perception" OR "self-efficacy" OR "self-confidence" AND "nursing students" as MeSH terms. In the following, Google Scholar and references list of retrieved studies and reviews were also searched for additional pertinent studies. Duplicate studies were excluded using EndNote software.

2.3. Eligibility criteria

2.3.1. types of studies.

This review was focused on interventional studies, such as randomized controlled trials (RCTs) and non-randomized controlled studies or quasi-experimental, and before-after studies. The inclusion criteria were original articles in English, year of publication until June 2023. Also, we specifically looked for studies that used methods or intervention/s either in a clinical or theory class setting, with self-confidence as the main variable.

2.3.2. Types of participants

Individuals, who were undergraduate nursing students and have learned clinical methods in the academic environment under the supervision of a mentor or clinical educator.

2.3.3. Types of interventions

All educational methods or intervention/s used to promote self-confidence in clinical nursing students were included.

2.3.4. Types of comparators

Relevant traditional clinical training and education were taken into consideration in the comparator group.

2.3.5. Outcome measures

The main outcome was changes in the self-confidence score of nursing students as measured by validated tools following educational methods or intervention/s.

2.3.6. Exclusion criteria

Animal experiments, observational studies; case reports, case series, editorials, literature reviews, conference proceedings; commentaries; insufficient original data, and duplicated publications were excluded.

2.4. Selection studies

In the initial step, the two reviewers (ERT and FHN) independently reviewed the title and abstract of searched articles to select relevant items in accordance with inclusion and exclusion criteria. This process, facilitated by EndNote software (version X.9.3.3), resulted in the initial selection of 84 potentially relevant articles. In the second step, the full text of these articles was reviewed to identify studies meeting the inclusion criteria, resulting in the selection of 22 relevant articles. Fig. 1 illustrates the study selection process as per the PRISMA guidelines [ 14 ].

Flow diagram of review process (PRISMA).

2.5. Quality assessment of included studies

The risk of biases in the included studies was evaluated using the updated Cochrane "Risk of bias" tool for RCTs (RoB 2.0), the Cochrane Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool, and the quality assessment tool for before-after (pre-post) studies without control group designed by the National Heart, Lung, and Blood Institute (NHLBI).

For randomized trials, the RoB 2.0 tool considers five following domains: (1) the randomization process, (2) missing data outcome, (3) interventions, (4) outcome measurement and (5) selection of the result. The domains are rated as low, some concern, or high risk, and the overall assessment of bias risk is assigned to each study [ 15 ]. The ROBINS-I tool is a valid tool to assess the quality of nonrandomized studies, was used for Non-randomized Study Intervention (NRSI) studies and can assess the risk of bias in domains such as subject selection, missing data, confounding risk, variations from intended interventions, outcome measures, intervention classification, and selective reporting. Each domain is classified as low, moderate, serious, or critical risk, and an overall assessment of bias risk is provided for each study [ 16 ]. The tool to ass quality for before-after (pre-post) studies without a control group, designed by NHLBI was applied and included 12 items. Reviewers could select no, yes, or cannot determine (CD)/not applicable (NA)/not reported (NR) in response to each item. The study is then rated as either good, fair, or poor quality based on the ratings of the different items and the presence of flaws in the study implementation or design [ 17 ].

2.6. Data extraction

The data retrieved from the searches was imported into Endnote, and duplicates were removed. Two reviewers independently screened the title and abstract and a third reviewer was available to resolve any disputes.

Data extraction was performed by two authors (ERT and MS) by a predesigned and standardized data extraction form and recorded the data in a Microsoft Excel sheet. The following information was considered in the data extraction: 1. study's characteristics and bibliography including first author, year of publication, country, study design, duration, and method of measuring self-confidence. 2. Sample characteristics include the sample size, gender, age, etc. 3. Interventions and comparisons, such as the other method/interventions for education for nursing students 4. Results of studies include the mean and standard deviation (SD) of the control group and experimental group. If any study data was unclear or missing, the corresponding author was contacted via email.

2.7. Statistical analysis

The calculation of the pooled standardized mean difference with 95% confidence intervals (SMD with 95% CI was utilized as efficiency outcome pooled estimation) was done to visually inspect the trials by forest plots to test for heterogeneity. A random-effects meta-analysis was performed to take account of the heterogeneity of the research's populations because of conceptual heterogeneity. Inverse-variance weights were used to obtain the pooled estimates and their associated 95% CIs.

We evaluated heterogeneity among studies by the I 2 statistic [ 18 ] (I 2  = 0% shows no heterogeneity while I 2  ≥ 50% shows substantial heterogeneity). The statistical significance of heterogeneity was also examined using Cochran's Q statistic. To establish which research had the most effect on the heterogeneity and evaluate the robustness of pooled estimates, sensitivity analysis was carried out ( Fig. 2 ) [ 19 , 20 ]. On the basis of the type of study design, subgroup analyses were conducted.

A Risk of Bias Summary (ROB tool). BRisk of bias graph (ROB tool) Domains. C. Risk of bias summary (ROBINS-I).

To evaluate publication bias, funnel plots were visually inspected ( Fig. 3 ). The adjusted rank correlation test and Egger's regression asymmetry test were used for formal statistical assessments of funnel plot asymmetry. Begg's adjusted rank correlation test and the trim-and-fill method were also used [ 21 , 22 ]. The SMD was plotted against the square root of the standard error inverse. All statistical tests, except for the heterogeneity test, were two-tailed and a significance threshold of less than 0.05 was set. Stata version 17.0 was used for statistical analyses.

Forest plot of studies that investigated the influence of educational interventions on boosting the self-confidence (sepratad by study designs). Diamond represents the summary standardised mean difference (pooled SMD) estimate and its width shows corresponding 95% CI with random effects estimate. The size of the square and its central point reflects the study specific statistical weight (inverse of variance) and point estimate of the SMD and horizontal line reflects corresponding 95% CI of the study. I 2 test and Cochran's Q statistic were used to assessing the statistical heterogeneity (P < 0.10) across studies.

3.1. Study characteristics

Using a comprehensive literature search, 1166 studies were identified as relevant. After removing duplicate studies and screening abstracts and titles, 153 studies were selected for an in-depth full-text review. Twenty-six Studies had pre-determined eligibility criteria to be included in the systematic review. Finally, 22 studies (fourteen RCTs, five Quasi-experimental, and three before-after studies) were considered in the meta-analysis. These studies reported the self-confidence scores of nursing students as the main outcome, with complete statistical data on 1758 participants and 940 nursing student cases in the intervention group for boosting self-confidence ( Fig. 1 ).

Five studies were conducted in the USA [ 9 , [23] , [24] , [25] , [26] ], nine in Asia (Taiwan, Jordan, South Korea, Singapore, and Saudi Arabia) [ [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] ], and six in Europe (Turkey, France, Norway) [ [36] , [37] , [38] , [39] , [40] , [41] ], and two in Brazil [ 41 , 42 ]. Seventeen studies included simulation learning [ 9 , [23] , [24] , [25] , [26] , 28 , 30 , 31 , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] ], three studies included learning-teaching methods based on the course plan [ 29 , 32 , 33 ], one study included a skill demonstration video delivered by smartphone [ 27 ] and one included Web-based education [ 36 ]. The studies used different self-confidence measurement tools, with the Self-Confidence with Learning Scale [ 37 , 41 , 42 ], Confidence Level tool (CL) [ 24 , 25 ], Confidence in Communication Self-Assessment Survey [ 27 , 28 ], and Confidence Scale (C-scale) [ 34 , 35 ] being the most commonly used. Table 1 indicates a summary of the characteristics of the selected articles.

Main Characteristics of the included studies on self-confidence-related interventions among nursing students.

3.2. Quality assessment of selected studies

The methodological quality of 26 studies was assessed. Seventeen randomized controlled studies were evaluated by the RoB 2 risk of bias tool, and the RCTs were found to moderate the risk of bias ( Fig. 2 -A, Fig. 2-B). All RCT studies based on the Rob 2 tool were low risk in Random sequence generation (selection bias) and the majority of studies (more than 70%) were unclear or high risk in Incomplete outcome data (attrition bias). The ROBINS-I tool showed that 5 NRSIs had a Low risk of bias ( Fig. 2 -C). According to the results of ROBINS-I's tool, five non-randomized studies had a low risk of bias in Bias in the classification of interventions and Bias because of deviations from considered interventions, and a high risk of Bias because of confounding. Four pre-post studies by the Quality Assessment Tool for Before-After (Pre-Post) Studies with no control group, were determined to have good quality for methodological quality assessment, but all the before and after studies did not report data in the group-level interventions, follow-up rate, and blinding of outcome assessors, and individual-level outcome efforts. ( Table 2 ).

Quality assessment for before-after (pre-post) studies with No control group.

*NA, not applicable; NR, not reported.

3.3. Interventions

The interventions used in the included studies for boosting self-confidence among nursing students are discussed below.

3.3.1. Simulation learning

Simulation is an activity that replicates the clinical environment reality and is designed to demonstrate decision-making, procedures, and critical thinking through various methods and tools. In nursing education, simulation can be in the form of fixed mannequins, patient role-playing scenarios, or computer software-connected mannequins. Simulators include not just mechanical devices, but also any role-playing, scenario, or case study. Although simulation has different levels, evidence shows that it is more efficient and effective than traditional teaching and lecture-based methods [ 23 , 35 , 43 , 44 ]. The purpose of simulation learning is to alleviate certain psychological problems or boost self-confidence. Out of the 17 studies employing this intervention, 7 studies found no significant association between the outcome and intervention [ 25 , 34 , 35 , 37 , 39 , 41 , 42 ], while others reported a strong association between the outcome and intervention [ 9 , 23 , 24 , 26 , 28 , 30 , 31 , 36 , 38 , 40 ].

3.3.2. Web-based education

The self-confidence of students was significantly boosted using web-based education interventions, where courses were introduced and registered. In these courses, a homework module was used to provide homework, and students would upload their completed homework to the system. Quiz and test modules were available for students to take exams and complete all required forms. The source module allowed for uploading notes, videos, and PowerPoint presentations. The website contents, as well as videos and presentations prepared by instructors, were accessible to the students [ 45 ]. Only one out of the 22 studies focused on the web-based intervention and its effect on self-confidence [ 10 ].

3.3.3. Video delivered by smartphone on skill demonstration

One of the most effective ways to provide educational materials to nursing students is through smartphones. In this intervention, no significant difference was detected in the level of self-confidence among students, but there was an improvement in their skills and knowledge. Both groups were given a DVD demonstration, with identical video clips available on smartphones and DVDs. Additionally, text messages were sent to both groups via smartphones three times a week to remind and encourage them to watch the videos. Post-test data were collected two weeks after the pre-test step [ 27 ].

3.4. Meta-analysis

The control and intervention groups were comparable because there was no significant difference in mean scores before the intervention across studies. However, the post-intervention result in the intervention group was significantly greater (Standardized Mean Difference [SMD]) (SMD for Controlled experimental design = 0.51; 95% CI = 0.14–0.89), (SMD for Quasi-experimental = 0.04; 95% CI = −0.33-0.41), (SMD for Before-After (Pre-Post) = 2.74; 95% CI = 1.85–3.63)). Therefore, the random-effects meta-analysis of 22 interventional studies showed that educational interventions were significantly associated with improving nursing students' self-confidence. The interventions had a moderate impact on the research units, as indicated by Cohen's d results. Furthermore, the positive SMD values in all studies confirmed consistent findings ( Fig. 3 ).

Considering that most studies used simulation learning interventions, we conducted a separate analysis specifically on this common intervention. Based on the analyses performed, the SMD value was estimated to be 0.42 with a 95% CI ranging from 0.03 to 0.81. Despite the absence of a significant relationship between the intervention and outcome in some studies, the aggregated results demonstrated a significant relationship. According to Cohen's d effect size table, the impact of this intervention falls within the medium range ( Fig. 4 ).

Meta-analysis of the Simulation-based education interventions vs traditional approaches on boosting the self-confidence in nursing students (controlled experimental studies). Diamond represents the summary standardised mean difference (pooled SMD) estimate and its width shows corresponding 95% CI with random effects estimate.

The sensitivity analysis consistently showed a mean change in self-confidence within a range of summary SMDs: 0.31 to 0.46. This indicates that the meta-analysis model was robust. To investigate the possibility of publication bias, a Funnel plot was used. This plot displays the weighted mean difference against the standard error, which represents the level of study accuracy. A relatively small asymmetry was observed in the plot, suggesting the presence of publication bias ( Fig. 5 ).

Sensitivity analysis of the Simulation-based education interventions vs traditional approaches on boosting the self-confidence in nursing students (controlled experimental studies).

Further analysis by Egger statistical test and Begg's adjusted rank correlation, as well as plot visual inspection, reinforced the suspicion of publication bias. However, we used the Trim and Fill approach with a random-effects model ( Fig. 6 ). The findings of this method were consistent with the classical meta-analysis results, verifying each other's results. Moreover, no additional studies were found through the trim and fill method. These findings indicate a comprehensive search of all eligible studies in the databases.

Begg's funnel plot for assessing the presence of publication bias. Weighted mean difference was plotted against the precision of the study (p = 0.03, for Begg's adjusted rank correlation test and p = 0.06, for Egger's regression asymmetry test).

4. Discussion

Our study is the first systematic review and meta-analysis investigating the effect of various interventions on increasing the self-confidence of clinical nursing students. Self-confidence is a subjective and acquired factor that can be influenced by various factors, like role, sense of self, perspective, sense of efficacy self-esteem, and experiences related to the context or setting [ 6 ]. However, there are interventions that can significantly affect self-confidence.

Self-confidence is recognized as a central element in the success of practice and education for nursing students. Therefore, it is important to address self-confidence through organizational and individual interventions worldwide. A wide range of interventions can provide appropriate approaches to boost self-confidence. The present systematic review evaluated the effect of educational interventions on boosting nursing students’ self-confidence. The interventions analyzed in the included articles consisted of simulation learning, videos provided by smartphones, and web-based education. The majority of these interventions had positive effects on boosting self-confidence and improving mental health. Simulation learning, in particular, is a practical method that can have a more effective impact by using models closest to the clinical situation. Additionally, this type of intervention can be performed in the nurses' own work environment, making it more efficient. In our review, high-fidelity simulation (HFS) was employed as a potent instrument to identify teaching-learning strategies among nursing students. However, some studies reported a neutral effect of this intervention. While HFS was found to improve competence and self-confidence in students, it was unable to boost caring parameters [ 44 ]. Further studies are needed to identify educational approaches that can enhance students' competence and self-confidence in the clinical environment.

In a study comparing conventional and simulation-based teaching techniques in undergraduate nursing students, significant results were not achieved after a single simulation session [ 46 ]. However, when both educational methods were used effectively, the self-confidence and critical thinking abilities of nursing students were strengthened successfully [ 47 ]. Nursing educators should be encouraged to develop training programs specifically designed to boost self-confidence and critical thinking ability [ 10 ]. It is important to note that some studies found a significant impact of simulation interventions on self-confidence. In these studies, the self-confidence and knowledge of students in the intervention group were significantly enhanced in comparison to the control group [ 39 ]. Other studies also revealed the positive impacts of simulation on clinical learning, self-confidence, intimate partner violence, and decision-making skills [ 24 , 26 , 40 ]. Simulation learning has also shown effectiveness in directing nursing students toward the acquisition of knowledge and critical thinking for learning CPR (Cardiopulmonary resuscitation) [ 33 ]. Further research is needed to completely understand the self-confidence concept in the context of simulation learning and assess the role of the nurse educator in the simulation and clinical setting in promoting and developing self-confidence in prelicensure nursing students. The web‐based education has effectively enhanced self‐confidence levels and reduced nursing students’ anxiety levels in clinical decision‐making courses. Computer‐assisted and other educational methods have had a positive influence on the self‐confidence of nursing students in the clinical decision‐making course [ 48 , 49 ]. The results of studies have demonstrated the suitability of delivering learning content via smartphones to nursing students. Although no significant difference was observed in the self-confidence of nursing students, their skills and knowledge were boosted through the intervention. Therefore, smartphones can be considered a complementary and useful tool for learning nursing skills. No significant differences were detected in the post-intervention self-confidence of nursing students between the groups, although their skills and knowledge had been enhanced. In line with these findings, previous studies observed no significant difference in nursing students' self-confidence levels while performing urinary catheterization for female and male patients between the intervention (iPods) and control (no technology) groups [ 32 ].

4.1. Limitations

Our findings should be interpreted cautiously in the context of the limitations of the available data. Few studies have employed similar interventions, so the results should be cautiously generalized. Another was the small sample size in some included studies, meaning that statistical power decreased, inconsistency increased, and the magnitude of intervention effects decreased. Nonetheless, some studies with appropriate sample sizes found no significant association between self-confidence and intervention. It should be noted that the results may be influenced by the demographic profiles of the participants and the heterogeneity of the groups.

4.2. Implications

In clinical nursing practice and education, self-confidence is an essential factor. Besides helping students complete their tasks accurately, it enables better communication with patients. Nurse educators can support students in the promotion of self-confidence by understanding effective teaching-learning strategies and their role in developing self-confident nursing practice. By applying these strategies, nurse educators can enhance the training and preparation of future professional nurses, allowing students to learn based on their motivations and gain self-confidence.

5. Conclusion

Nursing decision-makers and professors can use appropriate methods to increase the nursing students’ confidence based on the needs and potential of their resources and human resources. Based on the findings, the most effective interventional strategies were education and simulation-based learning skills. However, it should be acknowledged that the outcomes of intervention programs to boost self-confidence require a long time, and further studies are needed to track the persistence of change. The complexity of nursing students' self-confidence suggests that interventions should be multidimensional and combined. Nevertheless, the comprehensive implementation of such interventions may come at a high cost, and it is necessary to provide the required executive conditions, such as participant preparation and the commitment of key individuals, before the intervention. Therefore, concerns such as spatial, temporal, and feasibility constraints should also be considered when applying these interventions.

CRediT authorship contribution statement

Elahe Ramezanzade Tabriz: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Data curation, Conceptualization. Masoumeh Sadeghi: Writing – review & editing, Methodology, Formal analysis. Ensieh Tavana: Software, Formal analysis. Hamid Heidarian Miri: Writing – review & editing, Formal analysis, Conceptualization. Fatemeh Heshmati Nabavi: Writing – review & editing, Methodology, Investigation, Formal analysis, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.heliyon.2024.e27347 .

Appendix A. Supplementary data

The following is the Supplementary data to this article.

• Skip to main content

Update your browser for the best possible experience

As of January 1st, 2020, Internet Explorer (versions 11 and below) is no longer supported by Evolve. To get the best possible experience using Evolve, we recommend that you use another web browser. For HESI iNet users click here .