Abstract
Background. Nowadays, there are a variety of viewpoints on problem-based learning (PBL) and mind mapping teaching outcomes in nursing education, but there are not many thorough assessments that are pertinent.
Objectives. We performed a meta-analysis to evaluate the effect of the PBL method combined with mind mapping on nursing instruction.
Materials and methods. A systematic literature search up to July 2022 was performed, and 1765 related studies were evaluated. The chosen studies comprised 1473 nursing teaching participants as the trial’s baseline, with 770 of them using the PBL model with mind mapping and 703 enrolled as controls. Odds ratio (OR) and mean difference (MD) with 95% confidence intervals (95% CIs) were calculated to assess the effect of the PBL method combined with mind mapping on nursing instructions using dichotomous and continuous methods with a random or fixed effect model. The study protocol was registered in PROSPERO (registration No. CRD 42022432130).
Results. The PBL model with mind mapping reached a significantly higher results of nursing knowledge test (MD: 7.29, 95% CI: 6.88–7.71, p < 0.001) and pediatric practice test (MD: 9.89, 95% CI: 9.04–10.74, p < 0.001), as well as higher students’ ability of independent learning (OR: 3.49, 95% CI: 2.11–5.76, p < 0.001) compared to the controls in nursing teaching.
Conclusions. The PBL model with mind mapping resulted in a significantly higher results of nursing knowledge test, pediatric practice test and students’ ability of independent learning compared to controls in nursing teaching.
Key words: nursing teaching adult, problem-based learning teaching model joint with mind mapping, pediatric practice test, nursing knowledge test, meta-analysis
Introduction
Nursing education is crucial for enhancing the student’s quality of learning, improving their clinical practice abilities and applying information in addition to providing theoretical knowledge.1 As a result of the paradigm shift in medical education, the problem-based method of learning has been successful in many medical education courses both in China and overseas.2 The problem-based learning (PBL) approach can strengthen critical thinking skills in students through interactive collaboration with their peers to analyze and solve complex problems via independent information processing. In medical education, the transition into clinical clerkship after years of pre-clinical studies is frustrating and anxiety-provoking. Therefore, PBL can play a pivotal role in familiarization with various topics, including the structure of effective medical teams, electronic health record utilization and inpatient admission regulation. Moreover, patient-centered scenarios can be represented using the PBL model. Recently, web-based applications have been incorporated alongside PBL to provide realistic exposure to practical clinical activities, including inpatient and outpatient care.3
However, in several studies, the basic implementation of the problem-based method of learning has proven ineffective for assisting students to acquire the necessary knowledge in a systematic manner. Additionally, the model performs poorly for some students in basic specialized courses and is more challenging for individuals with low learning capacities, which can result in learning fatigue and less-than-expected learning outcomes.3, 4, 5 The medical education has evolved in recent years due to the popularity and dissemination of mind mapping technique. Mind mapping is helpful in systemic education because it connects the relatively scattered knowledge acquired through problem-based methods using logic and memory, making abstract problems concrete and making difficult problems easier.6, 7 Students can create visual images to represent their ideas in a meaningful way. Studies have reported that mind mapping application in medical and health-related science education significantly enhanced long-term memorization of factual information, and both mind mapping and PBL approaches encourage the adoption of deeper learning levels in medical students.
Mind maps can be used in the classroom to somewhat counteract the limitations of the problem-based method of learning, and both instructional approaches have complementary benefits that can support student learning.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 The PBL integration with mind mapping had a positive impact on student understanding and overall cognition. In addition, Ravindranath et al. revealed that mind map integration in the PBL model helped students to better summarize discussions and improved the PBL-based learning process.19
There are now a variety of viewpoints on the PBL method and mind mapping teaching outcomes. However, in China, there are not many thorough assessments of employing these 2 educational methodologies in nursing training that are pertinent. We have performed a meta-analysis of studies on the PBL and mind mapping in order to examine the impact of the combined usage of these 2 methods on nursing education in China.
Objectives
The aim of the study was to determine the impact of the problem-based method of learning and mind mapping on nurse training.
Materials and methods
The design of this meta-analysis was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. No ethical approval from the institutional board was required because this study is a meta-analysis of previously published data without individual patient data.21, 22
Eligibility criteria
The primary aim of the included studies centered on evaluating the impact of the problem-based educational model with mind mapping on nursing education and analyzing the PBL teaching approach in combination with mind mapping compared to controls.21, 22
Information sources
The principal objectives of the present study were to investigate the influence of the PBL model of teaching on nursing education, as well as the effect of the problem-based approach and mind mapping as a teaching technique. The study protocol was registered in PROSPERO (registration No. CRD 42022432130). Studies including human participants and publications in any language were reviewed. The inclusion rate was unaffected by the size of the trial. Review articles, comments and studies that did not provide a method for quantifying data were omitted from the list of publications. The course of the study is depicted in Figure 1. The specified inclusion criteria for research studies were as follows: 1) research studies designed as prospective, observational, controlled trial, or retrospective studies; 2) the intended subjects consisted of nursing subjects; 3) the intervention regimen relied on both the PBL educational model and mind mapping technique; and 4) the studies aimed to compare the PBL educational model in combination with mind mapping to controls.
Studies that did not assess the impact of the problem-based method of learning combined with mind mapping in nursing subjects, research on nursing instruction without the PBL approach combined with mind mapping in comparison to controls, and research on nursing instruction without the problem-based method of learning combined with mind mapping were excluded from the analysis.
Search strategy
According to the PICOS concept, we developed a protocol for search strategy and characterized it as follows: nursing subjects were denoted by the letter P (“population”), the problem-based method of learning combined with mind mapping was the “intervention” or “exposure”, whereas the “comparison” or “control” was the “problem-based method of learning combined with mind mapping.” The results of practical tests, nursing knowledge tests and autonomous learning survey were the “outcomes”. There were no constraints on the “study design” of the investigation.22
We conducted a comprehensive search of the OVID, Embase, PubMed, Cochrane Library, and Google Scholar databases (Table 1) through March 2023 using a combination of keywords and correlated terms regarding nursing teaching of adults, PBL combined with mind mapping, practice test results, nursing knowledge test, and self-learning capabilities. To avoid articles that did not demonstrate a relationship between the PBL method combined with mind mapping and controls in nursing teaching individuals, all enrolled papers were merged into a single EndNote file (EndNote; Clarivate, London, UK), duplicates were removed, and the titles and abstracts were reviewed.
Selection process
According to the PRISMA guidelines, 2 authors (MX and QZ) screened the retrieved publications and independently evaluated their eligibility for inclusion in the meta-analysis.
Data collection process
The criteria for data collection included the surname of the primary author, the study period, the publication year, the country or region, the population type, the interventional measures, and the outcomes measures (e.g., nursing knowledge tests, practice tests and autonomous learning abilities). Quantitative and qualitative assessment techniques, the information source, the evaluation of the results, and statistical analysis were also analyzed.23
Data items
When single research evaluating the impact of the problem-based approach of learning coupled with mind mapping and compared to controls in nursing teaching yielded contradictory results, we gathered the data independently.
Risk of bias assessment
Two authors (WY and FS) separately reviewed the methodology of the chosen publications to determine the potential for bias in each research study. The methodological quality was assessed using the Risk of Bias tool from the Cochrane Handbook for Systematic Reviews of Interventions (version 5.1.0).24 Each study was classified into one of the 3 categories used to described the risk of bias (ROB). A low ROB was identified as a study that satisfied all quality criteria. A study was classified as having a moderate ROB if one or more requirements were not met or were not included. If all of the quality criteria were not satisfied or were partially met, the research was deemed to have a high ROB. Inconsistencies or disagreements were solved by the re-evaluation of the original text and referring to the corresponding author (QZ).
Effect measurements
Sensitivity analyses were performed and limited to research that reported and evaluated the effect of the problem-based technique of learning and mind mapping in comparison to a control group. Using sensitivity and subclass analyses, the PBL method of learning was compared to mind mapping and controls.
Synthesis methods
The present meta-analysis calculated the odds ratio (OR) for the student’s ability to self-learn and the mean difference (MD) between knowledge and practice test scores with a 95% confidence interval (95% CI). We computed the I2 index, which has a range of 0–100%. Values at 0%, 25%, 50%, and 75% exhibited absence, minimal, moderate, and significant heterogeneity, respectively.25 To ensure the use of the proper model, we assessed the eligible studies in terms of their similarities and discrepancies, including the effect size and the main population characteristics. Since all studies included undergraduate nursing students, were designed as randomized controlled trials (RCTs), and shared the PBL with mind mapping as intervention, the fixed-effect model was applied in all analyses. We assessed the eligible studies for subclass analysis. The value of p = 0.05 indicated statistical significance for subcategory differences.
Reporting bias assessment
Egger’s regression test for the evaluation of quantitative publication bias and funnel plots displaying the logarithm of ORs compared to their standard errors were used to subjectively and quantitatively measure the publication bias (the publication bias was considered present for p < 0.05).25
Certainty assessment
All p-values were calculated using two-tailed tests. Reviewer Manager v. 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) was used to produce the graphs and to conduct statistical analyses.
Results
Baseline characteristics of the analyzed studies
Twelve articles published between 2018 and 2022 satisfied the inclusion criteria and were chosen from a total of 1765 relevant research studies for the meta-analysis.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20 Table 2 displays the results described in these research articles. A total of 1473 nursing students participated in the baseline trials presented in the chosen studies, with 770 employing the problem-based technique of learning coupled with mind mapping and 703 serving as controls. There were 40–508 people present when the trial first began. Eleven studies presented data organized by the results of nursing knowledge tests, 8 studies data organized by practice tests, and 5 studies data organized by the students’ capacity for autonomous learning.
Nursing knowledge test results
The use of the PBL method in conjunction with mind mapping (Figure 2) resulted in significantly higher scores on the nursing knowledge test (MD: 7.29; 95% CI: 6.88–7.71, p < 0.001). The heterogeneity level (I2 index) between the studies was high (p = 0.002, I2 = 63%).
Practice test results
The practice test outcomes showed significantly higher results (p < 0.001) for the PBL modality in combination with mind mapping, as illustrated in Figure 3, with a MD of 9.89 (95% CI: 9.04–10.74, p < 0.001) and a high level of heterogeneity (p < 0.001, I2 = 76%).
Autonomous learning abilities
The combination of the PBL modality with mind mapping showed a significant improvement in the nursing students’ capacity for independent learning among a total of 179 subjects, compared to 133 subjects in the control groups (Figure 4). The pooled OR was 3.49 (95% CI: 2.11–5.76, p < 0.001) and there was no heterogeneity between the studies (I2 = 0%, p = 0.96).
Due to a lack of data on gender, age and ethnicity, it was not possible to use stratified models to assess the impact of these variables on comparison results. A visual examination of the funnel plot showed general symmetrical distribution (Figure 5). The quantitative evaluations utilizing Egger’s regression test were nonsignificant for the knowledge test, practice test and autonomous learning (p = 0.87, 0.65 and 0.79, respectively), suggesting no publication bias. However, most of the included RCTs were found to have low methodological quality, no bias in selective reporting and minimal outcome data.
Discussion
The studies evaluated in this meta-analysis included 1473 nursing student participants, with 770 of them using the problem-based method of learning paired with mind mapping and 703 enrolled as controls.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 When compared to the controls, the PBL approach with mind mapping reached significantly higher scores in the nursing knowledge test, the practice test and the student’s capacity for independent learning measurements. However, analyzing the results requires caution due to the small sample size (8 out of 12 studies in the meta-analysis) and the sparse study population in several comparisons.
One of the required courses in today’s medical schools is nursing.1, 26 The problem-based method of learning combined with mind mapping is an essential tactic for implementing cutting-edge teaching concepts, deepening teaching reform and improving teaching quality.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 Our results, which are consistent with those of several studies conducted both in China and abroad, suggest that the problem-based method of learning combined with mind mapping aids nursing students in understanding theoretical material while also boosting practical abilities and enjoyment of self-learning. A substantial number of notable primary articles served as the foundation for this meta-analysis.2, 27
Few studies met the inclusion requirements. Some papers omitted the descriptions of the random allocation technique, allocation concealment or blinding. Due to the significant likelihood of bias and the generally poor quality of papers, the results were not very strong. The study’s general conclusions were unaffected by a sensitivity analysis. To collect pertinent research data more thoroughly, improve the standard of the study and provide reliable and accurate results, RCTs should be performed in accordance with methodological principles going forward. Furthermore, there is a limited amount of published research on the simultaneous use of both teaching modes in undergraduate nursing education. Smaller control and intervention groups were utilized in the majority of RCTs included in this study. We believe that these problems could be solved over time and with more research.
This meta-analysis investigated the impact of the PBL approach and mind mapping on teaching methodologies.28, 29, 30, 31, 32, 33, 34 Clarifying potential links and contrasting the effects of the PBL teaching method with mind mapping compared to controls on the outcomes under consideration still require more research, for which larger, more homogeneous samples are needed. This point was made in a prior study that used a related meta-analysis technique and discovered similar beneficial results for the problem-based method of learning paired with mind mapping.35 High evidence RCTs with robust findings are necessary to assess these factors. Since our meta-analysis was unable to determine whether differences in gender, ethnicity and age are related to the outcomes, it is crucial to evaluate these factors in the subsequent studies. In conclusion, as compared to the controls, the problem-based method of learning with mind mapping techniques reached considerably higher nursing knowledge exam results, practice test results and improved student’s ability to learn independently.35, 36, 37, 38, 39, 40
Limitations
There is a possibility of selection bias because several papers were excluded from the meta-analysis. However, the excluded publications did not adhere to the standards for inclusion in our meta-analysis. For 8 out of the 12 selected studies, sample sizes were under 100. Also, we were unable to investigate whether confounding factors such as age, gender or ethnicity had an impact on the results. The study’s objective was to contrast the results of the control group with the PBL strategy using mind maps for nursing education. Owing to the inclusion of erroneous or missing data from previous research, bias may have been exacerbated. Additionally, the nutritional status of the participants and their age and gender were possible sources of bias. Regrettably, some unreported studies and data gaps can skew the effect being investigated.
Conclusions
The combination of the PBL approach with mind mapping compared to controls in nurse training had significantly increased learning outcomes, as shown in the scores of nursing knowledge tests, practice tests and the student’s capacity for independent learning. Thus, the combination of these 2 modalities, PBL and mind mapping, is suitable for nursing education and promotes better learning abilities. Due to the small sample size of 8 out of the 12 studies in the meta-analysis and the dearth of studies in several comparisons, careful interpretation of the results is required. Further studies with higher quality and larger sample sizes are warranted to explore more suitable teaching modalities in nursing to improve educational quality.
