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Concept maps can help build critical thinking in nursing education by

Concept maps can help build critical thinking in nursing education by

by Rachel Adema-Hannes and Maurine Parzen

Preparing, organizing and planning care for patients is challenging for nursing students as they must learn to link theory to practice. Concept mapping has been suggested as an effective strategy to facilitate meaningful learning and promote critical thinking among nursing students (Baugh & Mellott, 1998; Schuster, 2003). Utilization of concept maps is relatively new in its application to the clinical realm.

A pilot project was implemented to evaluate the perceived effectiveness and feasibility of the use of concept maps in a clinical setting. Concept maps were used by 4 groups of third year students (n=32) on a weekly basis to plan care for 1 – 2 assigned patients for 2, 12-week rotations on a Pediatric medical/surgical floor. Students completed simple short answer questions at the end of their rotation, which addressed student’s thoughts on utilization, effect on clinical reasoning and ability to link lab values, medications, pathophysiology and patient issues.

Student’s reported that they enjoyed using concept maps, it allowed them to visualize key connections between identified patient issues, stay organized, and made preparations less time consuming.

Study findings will be described as continued use of concept maps are recommended. Implications for curriculum planning as well as further research will be discussed.

Educational theorists and researchers have found that using learning strategies promoting meaningful learning and the use of metacognitive skills are more likely to produce critically thinking professionals (Baugh & Mellott, 1998). Learning in the clinical setting needs to encourage students to build upon prior knowledge. Faculty need to employ methods whereby students learn concepts in a meaningful way and develop the skills necessary to enable them to continue to acquire knowledge even after formal training. Our goal as faculty is to facilitate the student’s ability to think critically and link theory to practice. The difficulty for faculty is in determining how well students understand the entirety of a patient’s situation. A useful tool in promoting meaningful learning in the clinical setting is concept mapping.

A concept map is a creative teaching method that can enhance a student’s critical thinking and communication skills in clinical settings (Schuster, 2002a). Concept mapping is based on the work by Ausubel, Novak, & Hanesian (1978), comparing meaningful learning versus rote learning (Irvine, 1995). Ausubel (1978), believes that meaningful learning happens if the information presented is significant to the individual who will then link preexisting knowledge with new material (cited in Irvine, 1995). The use of concept maps allows previous experience or knowledge to be incorporated into new ideas. A concept map presents information in a meaningful way using diagrams to uncover the students thought process in relation to patient problems and interventions; a visual representation of a student’s thinking. The use of concept maps in the clinical arena helps students prepare their plan of care for their assigned patient in an organized fashion for their clinical experience. Processing client data using concept maps helps students to form interrelationships with their individual patient issues and helps the student to visualize the patient as a whole.

Through the use of concept maps the student focuses on interrelationships of their client rather than being task focused, thus failing to see the big picture (Kathol, 1998). Visual learners benefit hugely from this method of learning which promotes organization and the ability to process and prioritize new information in a creative fashion. Linear thinkers may be disadvantaged, however concept mapping may be a strategy to push the linear thinkers to a higher level of thinking especially in such a fast pace, complex field as nursing (All, 1997; Harpaz, 2004). Concept maps can also be a powerful tool for identifying and clarifying misunderstandings before new learning is built on incorrect assumptions (Kathol, 1998).

Schuster (2000, 2002a, 2003), has studied and used concept maps extensively in the clinical setting with great success. She has written a text detailing a systemic process of completing a concept map (Schuster, 2002a). This visual map becomes the students pocket guide that they carry with them throughout the day, updating, having discussions with their tutor and serves as an alternative to the traditional 5 column nursing care plan. Castellino and Schuster (2002), reported that students and faculty found concept maps specific to the patient, concise, and organized care. Harpaz and Ehrenfeld (2004), assessed student responses through the use of concept maps and found they encouraged them to think independently, increased orientation in knowledge and in finding connections between the different areas, and gave them more confidence in implementing their knowledge. Faculty reported that concept maps helped change the students from a passive to an active learner, enabled them to evaluate students’ knowledge and most importantly, improved evaluation of the student’s safety to practice in the clinical area. Black et al. (2000), adopted concept mapping in lieu of the nursing process care plan and found that it allowed students to be more focused on synthesis and analysis of client data. In addition, student preparation for clinical demonstrated a focus on realistic goals, interventions and evaluation. Student’s feedback was overwhelmingly positive. Smith (1992), evaluated the use of concept mapping in an immunology nursing course and reported that concept maps encouraged students to learn by themselves and provided the knowledge to implement into the clinical field. Daley (1996), concludes that concept maps help bridge the gap between theory and direct application to patient care.

Baugh and Mellott (1998), emphasize that as nursing educators we are in a position to influence the future of nursing practice by providing our students with meaningful clinical learning assignments that encourage both application and synthesis. Concept maps do just that. However, documentation in the literature using this strategy in clinical is minimal (Kathol et al., 1998; Irvine, 1995; Castellin & Schuster, 2002). In an effort to assist our students to bridge the gap between theory and practice, concept maps were used as a learning tool over two, 12 week rotations on a Pediatric medical / surgical unit.

Students were asked to complete a concept map after review of a journal article based on the work of Schuster (2000), outlining how to complete a concept map with patient data and received a two hour interactive group tutorial. A template was provided to guide the process.

The student was expected to spend approximately 2 hours the night before clinical to prepare for the next morning. Although with practice and the acquisition of more knowledge this time was expected to decrease. Students would collect data from the unit the day before clinical based on a template provided. A map was then constructed using this data. Potential nursing interventions were provided for each issue identified

During clinical, tutor’s had discussions with the student to identify relationships in the client data between the actual client assessment data, use and response of medications, diagnostic tests / results, medical regimen and client responses which were incorporated in appropriate facets of the plan of care. Maps are thus updated and refined throughout the shift to reflect more knowledge and increased understanding.

We found the concept map to be extremely useful in assessing the student’s knowledge, preparedness and ability to make linkages between concepts. When a student failed to recognize a connection or had difficulty understanding concepts the tutor would help transition the student to identify and clarify through the use of questions built on previous learning and point out missing links. Initially the students had some difficulty with the technique however as the term progressed there was marked improved. Use of the concept map was seen as fun and interactive, replacing the traditional tedious paperwork that often accompanies clinical placements from week to week, which is consistent with remarks from other faculty who have used concept maps (Kathol et al., 1998; Irvine, 1995).

At the end of each rotation during course evaluations, students (N=32) were asked to share their thoughts on the use of concept maps. Concept maps were received enthusiastically with positive feedback. Figure 1 records examples of student commentary.

Students rated their ability to link lab values, medications, pathophysiology and patient issues as improved (100%) versus demonstrated no change and as deteriorated.. As well, students rated their clinical reasoning as improved (100%) versus demonstrated no change and as deteriorated. Suggestions were offered to improve upon the use of concept mapping (Figure 2).

Concept maps in the clinical setting provide students with a visual tool to prepare and understand the complex interconnectedness of client data. Through real time discussions students are continually being evaluated and motivated to be self-directed in their learning. It is recommended that students receive an interactive tutorial with clear guidelines in order for them to be successful as they may feel overwhelmed to deviate from standard clinical work-ups (Harpaz & Ehrenfeld, 2004). Working through a real life scenario helps the student work through the process as a starting point for learning this strategy. The map has helped the student organize their thoughts, plan the care of their patient, prioritize and critically think. The overwhelmingly positive response to the concept map in the clinical setting by the students supports further in depth studies to evaluate its ability to link nursing theory to practice using validated tools. In addition, future research could evaluate grading concept maps as a method of incorporating a grade value to the clinical setting, instead of a traditional Pass / Fail. This graded component would help the student place more value on clinical time and effort if a grade were attached to it. Schuster (2003), recommends that in addition to giving performance evaluations, faculty need to assign grades to concept map care plans and since the information contained in a concept map is organized and being reviewed throughout the clinical day that grading would take less time and not be difficult. A concept map care plan grading tool has been developed by Schuster and is available (Tyler, 2004), however validity and reliability needs to be established. The authors wish to evaluate this graded component in future clinical courses.

Nursing is a complex combination of academic and practical skill integration which requires the effective integration of theory to practice. Concept maps represent a clear picture of what student’s are thinking and has been shown to be a successful strategy to use in the clinical area.

Figure 1: Student feedback

“It helped me link concepts and visualize key issues.”

“It was helpful in planning interventions.”

“It made me see things looking at the whole picture. I was able to see how things related.”

“I liked how it incorporated all aspects of the patients care. It allowed us to open our minds.”

“Helps keep me organized, helps me identify the key issues for each of my patients.”

“It’s great for organization, a different way of learning, initiates critical thinking.”

“I was able to retain the information I learned because it was applied during clinical.”

“It forces you to make connections; you see how everything is connected.”

“You learned and demonstrated a lot of connections without writing pages and pages.”

“Allowed me to critically think.”

“I was able to apply all relevant concepts and see how everything related together.”

“I like with concept mapping I was able to engage in meaningful learning; able to link prior knowledge with new knowledge.”

“It was nice that the teacher could see my ideas and school of thoughts.”

“They get you thinking about your patient before you get them not after.”

“It allows you to get organized and incorporate research into patient care.”

“I am a visual learner, this really helped, prompts me to use critical thinking.”

“Use in 2nd year PBL and clinical because concept mapping clarified the nursing process and supports critical thinking development.”

“I myself might have benefited more if it was marked on a weekly basis.”

“More space provided: Also, they should introduce concept mapping in first year.”

“Incorporate nursing theory i.e. prioritization of problems.”

“Ask more questions to get us critically thinking – challenge more.”

“Try to encourage more incorporation of patho and lab values.”

All, Anita C., and Havens, Robyn L. Cognitive/concept mapping: a teaching strategy for nursing. Journal of Advanced Nursing. 1997;25, 1210-1219.

Ausubel, D.R. Educational psychology: A cognitive view. New York: Holt, Rinehart & Winston; 1978.

Black, P., Green, N., Chapin, B.A., and Owens C. Concept mapping: an alternative teaching strategy. Pelican News. 2000;56(4), 6-10.

Baugh, Nancy G., and Mellott, Karen G. Clinical concept mapping as preparation for student nurses’ clinical experiences. Journal of Nursing Education. 1998;37(6), 253 – 256.

Castellino, Ann Rose and Schuster, Pamela McHugh (2002). Evaluation of outcomes in nursing students using clinical concept map care plans. Nurse Educator. 2002;27(4), 149-150.

Daley, B. J. Concept maps: linking nursing theory to clinical nursing practice. Journal of Continuing Education in Nursing. 1996;27, 17-25.

Harpaz, Irit, Balik, Chaya, and Ehrenfeld, Mally. Concept mapping: an educational strategy for advancing nursing education. Nursing Forum. 2004; 39(2), 27-30.

Irvine, Lindesay. Can concept mapping be used to promote meaningful learning in nurse education? Journal of Advanced Nursing. 1995;21(6), 1175-1179.

Kathol, Diane D., Geiger, Marcia L., and Hartig, Jan L. Clinical correlation map: a tool for linking theory and practice. Nurse Educator. 1998;23(4), 31-34.

Schuster, Pamela. Concept maps in clinical settings: improved clinical performance and effective patient care. Dean’s Notes. 2003; 25(2), 1-5.

Schuster, Pamela McHugh. Concept mapping a critical-thinking approach to care planning. Philadelphia, PA: F.A. Davis, 2002a

Schuster, Pamela McHugh. Concept mapping: reducing clinical care plan paperwork and increasing learning. Nurse Educator. 2000;25(2), 76-81.

Smith, B. E. Linking theory and practice in teaching basic nursing skills. Journal of Nursing Education. 1992;31, 16-23.

Tyler, Judith A. Grading concept map care plans: validity and Reliability Part II. Dean’s Notes (National Student Nurses Association). 2004;26(3), 1-2.

Rachel Adema-Hannes, RN, BScN, MS is a Professor of Nursing at Mohawk College. She can be reached at [email protected] or 905-540-4247 x26063.

Maurine Parzen, RN, BScN, MScT, is a Professor of Nursing at Mohawk College. She can be reached at [email protected] or 905-540-4247 x26783.

Effect of Concept Mapping Education on Critical Thinking Skills of Medical Students: A Quasi-experimental Study

Competing Interests: The authors declare that this manuscript was approved by all authors in its form and that no competing interest exists.

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Background

Fostering critical thinking (CT) is one of the most important missions in medical education. Concept mapping is a method used to plan and create medical care through a diagrammatic representation of patient problems and medical interventions. Concept mapping as a general method can be used to improve CT skills in medical students. The aim of this study was to explore the effect of concept mapping on CT skills of medical students.

Methods

This quasi-experimental study was conducted on 100 second-year medical students which take an anatomy course. Participants were randomly assigned into a control group (lecture-based) and an intervention group (concept mapping). CT levels of medical students were assessed using the California Critical Thinking Skills Test. Data were analyzed using independent sample t-test.

Results

Before intervention, CT scores of the intervention and control groups were 6.68 ± 2.55 and 6.64 ±2.74, respectively, and after intervention, they were 11.64 ±2.29 and 10.04 ± 3.11, respectively. Comparison of mean score differences for both groups before and after intervention demonstrated that CT scores in the experimental group significantly increased after intervention (P=0.021).

Conclusions

Medical students who were taught through concept mapping showed an increase in CT scores, compared with those in the control group. Medical students require effective CT skills in order to make sound knowledge-based assessment and treatment choices during patient care. Therefore, instructors and planners of medical education are expected to apply this educational strategy for developing CT skills in medical students.

Introduction

Concept mapping (CM) is a technique developed by Joseph in the 1970s for visualizing the relationships among different concepts. CM is among the academic teaching strategies that have proven to be useful, in the development of active learning. A great number of studies have been conducted on the effectiveness of CM in fostering critical thinking skills (1,2).

Critical thinking (CT) skill can be defined as “the ability to apply higher cognitive skills (e.g., analysis, synthesis, self-reflection, and perspective taking) and or the ability to be open-minded and intellectually honest”. Critical thinking skill is the most important skill every physician needs, because the complex nature of providing healthcare requires physicians to d gather data, integrate and act upon constantly. This skill plays an essential role in the physician’s clinical decision making, which is important in ensuring diagnostic accuracy, appropriate patient management and patient outcomes (3,4).

CT is very important in the medical field because it is t what physicians use to prioritize and make key decisions that can save lives. CT skills of physicians can really mean the difference between someone’s life and death. Deficits in CT among physicians have significant implications for patients, including misdiagnosis, delays in diagnosis, treatment errors, lack of patient centered care or recognition of changes in clinical status (5,6). United Nations Educational, Scientific and Cultural Organization (UNESCO) believes that CT provides students with an up-to-date training system. This is why medical universities and their educators need to develop a medical curriculum that will foster CT skills among medical students (7).

Currently, universities in Iran are still relying on old traditional methods to teach medical students. During the last decade in Iran, medical educators w experienced challenges in providing students with appropriate curricula. They suggested that Iranian medical universities need to change their curriculum from focus on conventional teaching methods. Conventional teaching methods are subject-based, and teachers try to achieve learning objectives through large group lectures. In Lecture Based Learning (LBL), students are passively exposed to factual knowledge and do not learn or apply concepts. However, medical education is moving away from teacher-centered approaches and is incorporating more active learning methods. Active learning process can help foster students’ critical thinking skills (8–10).

As researchers were experiencing difficulty with the active learning methods, they were looking for a learning method that will allow students to retain large amounts of information, integrate critical thinking skills, and solve complex clinical problems. CM has been recognized as an effective educational tool that has been used for over 25 years, and a growing body of literature indicates that its t usage in medical education is increasing (11).

CM is a useful learning tool that creates the opportunity to promote CT skills by providing students opportunities to learn in a meaningful way. This method has helped students to score better on problem solving tests that require recall, transfer and application of knowledge. The map allows students to demonstrate holistic knowledge of a certain topic by showing how concepts on the map are interrelated (12,13).

CM is one of the most effective teaching strategies whose effect on promoting CT has frequently been explored and confirmed. It is a schematic system representing a set of concepts embedded in a framework of propositions. In other words, it is a diagram that shows multiple relationships among concepts (14). There are two prominent methods that medical students can use to create concept maps to promote meaningful learning. The first method requires students to construct their own maps by creating linking phrases between concepts. On the other hand, the other method, which is referred to as the scaffolding expert maps requires students to fill in blank spaces. This latter is effective for introducing students to CM. As it accurately reflects the knowledge structure of learners, it is more effective in demonstrating students’ misunderstanding and misconceptions, it allows students to show how much they have learned, and it uses higher order cognitive processes, such as explaining and reasoning. Theorists believe the lower cognitive load associated with scaffold maps allows the learner to have a sharper focus on concepts involved (15).

Researchers have reported conflicting results about the effect of CM on increasing students’ CT skills (16–18). Further studies are i required to clarify this issue. The purpose of this study was to determine if CM is more effective in teaching medical students anatomy topics compared to traditional lecturing method. We predict that students taught through concept map method will score better on California CT Test compared to students taught through traditional lecturing methods.

Materials and Methods

Study design and participants: This was a two-group quasi-experimental study with a pre- and post-test design. Participants consisted of a total of 108 second-year medical students who were enrolled in Ahvaz Jundishapur University of Medical Sciences (AJUMS) attending an anatomy course in 2017. This course was offered in the third semester of the second-year program in a 12-week course on medical anatomy. None of the participants had previous experience in the use of CM in their curriculum. A research assistant explained the nature and purpose of the study for the participants. All medical students voluntarily took part and signed an informed consent. Codes were provided to participants for the demographic survey to ensure data confidentiality. Participants were provided with detailed verbal and written explanations of the study and were told that they could withdraw from the study at any time. They were also assured that their participation in the research would not affect their success in the course.

Before starting the course classes, the study sample (108 students) was randomly divided into two equal groups, 54 each. One group was considered as the intervention group (concept mapping) and the other was considered as the control group (lecture). The intervention group was taught through concept mapping, while the control group was taught by traditional didactic lecturing alone. The study was conducted for over 12 weeks, starting on September 2017. In the 1st week of the semester, pre-testing of the students’ critical thinking skills in both experimental and control groups was done using California critical thinking Skills Test, form B (CCTST form B), before implementation of CM to identify their critical thinking level. It consisted of 34 multiple choice questions designed for the assessment of CT skills. In this test, each correct answer represents one score. The minimum and maximum obtainable scores are 0 and 34, respectively (19). In Iran, the reliability and validity of this test have already been determined and confirmed (20).

During the first week of the course, in a 2-hour session, the students in the intervention group were taught how to construct a concept map and how to use it appropriately in the context of anatomy. The students in the intervention group were required to present their discussion findings using the CM technique. Every student was required to prepare a concept map for all the presented topics. In each training session, the maps were assessed by the researcher, and the students were given feedback. Participants compared similarities and differences between their concept maps to assist in development of their individual concept map during their anatomy class. Training of the control group was done through traditional lecture method using power point software. The students of both groups passed 12 sessions of “anatomy course” in 12 consecutive weeks in lecture and CM methods, respectively.

A concept map is a diagram that visually illustrates relationships between concepts and ideas. Concept maps are free of color and pictures, and are constructed in a top-to-bottom hierarchy. Most concept maps illustrate ideas as boxes or circles, which are structured hierarchically and connected with lines. These lines are labeled with linking words to help explain the connections between concepts. An example of a mind map created by a medical student in this study can be seen in Figure 1 .

Student concept map. An example of a concept map from one of the medical students in this study

At the end of the semester in the 12th week, a post-test was conducted for both experimental and control groups by administering the CCTST (form B). The results of the pre- and the post-tests of the two groups were compared to assess the effect of using CM on increasing the students’ critical thinking skills. To this aim, the difference between the mean of CT scores before and after intervention in each group was calculated and then the differences between the two groups were analyzed.

The room and time of the anatomy class were different for the two groups, but despite this, the students were in contact with each other in college and dormitory. Therefore, they may have exchanged concept map information with each other.

Data analysis was done using SPSS version 16. Descriptive statistics for some data such as gender, age and GPA was computed using frequencies, percentages, mean and standard deviation. Student characteristics were described, chi-square tests of differences between groups were conducted for categorical variables, and t-tests were performed for continuous variables. Two-group independent t-tests compared the CT scores at the beginning and end of the course between the two measurements.

Results

Out of the 108 subjects participating in the study, 100 completed the questionnaire and returned it (response rate 92.6%). Table 1 presents the students’ demographic characteristics. Subjects were homogenous in terms of gender, age and GPA. In the experimental group, 60% of subjects were females and 40% were males. In the control group, 54% were females and 46% were males. Sex distribution was similar in both groups (p=0.34). The mean age of medical students in both groups was also similar. In the experimental group, the mean age of subjects was 20.96 years (SD =0.88) and in the control group, it was 20.90 years (SD = 0.84). No significant differences were found between the control and experimental groups regarding age (p= 0.53). The grade point average (GPA) of previous semesters of experimental group was 15.20 (SD = 1.24) and that of the control group was 15.46 (SD = 1.17). In relation to students’ GPA, chi-square test did not reveal a significant difference between the two groups (p=0.280).

Table 1

Students’ characteristics in two different experimental and control groups

Variable Control group Experimental group t p. value
male 20(40%) 30(60%) 0.367 0.34
female 23(46%) 27(54%)
Students’ age 0.84 ±20.90 0.88 ±20.96 0.349 0.73
GPA of previous semesters 15.45± 1.17 1.24 ±15.20 1.09 0.28

The analysis scores of CT skills before intervention among both groups revealed that the mean CT scores of experimental and control groups were 6.64 and 6.68, respectively. The scores of experimental group before intervention ranged from 2 to 13 and that of the control group from 2 to 12 ( Figure 2 ).

Critical thinking scores of the control group before and after intervention

The mean CT scores after intervention among the experimental and control group were found to be 10.04 and 11.64, respectively. The post intervention scores ranged from 8 to 17 in the experimental group and from 3 to 16 in the control group ( Figure 3 ).

Critical thinking scores of the experimental group before and after intervention

Table 2 demonstrates the students’ CT skills by group. As shown in Table 2 , before intervention, scores of CT skills in the intervention and control groups did not differ, which indicates that the students’ performance was similar when they started the course. However, after intervention, CT scores were significantly higher in the intervention group. Students in the intervention group performed much better on the CT levels than students in the control group (P=0.004).

Table 2

Comparison of mean and SD of critical thinking skills in experimental and control groups before and after the intervention

Variable Control group Experimental group t p. value
Mean SD Mean SD
Before intervention 6.64 2.74 6.68 2.55 0.076 0.94
After intervention 10.04 3.11 11.64 2.29 2.93 0.004
Difference 3.40 3.34 5.04 4.88 2.34 0.021

The average score obtained in anatomy course at the final exam by the entire medical student group was 5.98. The average score obtained in anatomy course by the experimental group was 6.38 and that of the control group was 5.58 (out of 10). There was a statistically significant difference between the two groups (t=2.67, p=0.009).

Discussion

This study examined the impact of concept mapping on CT skills in the medical students in an anatomy course. The findings indicated that the use of CM had a positive effect on CT skills. This improvement could be achieved as a result of the teaching anatomy course using CM as a learning method. Researchers believe map construction is a useful tool that helps students to develop clinical reasoning skills through additional focus on logic, and it probably stimulates the use of thinking skills, such as analysis, interpretation, and evaluation, and finally promotes the development of CT skills (21).

The findings of our study are consistent with those of Kaddoura and Yang (2016) who analyzed the impact of a concept map teaching approach on nursing students’ CT in the context of pathophysiology and pharmacology. Kaddoura and Yang integrated concept map teaching strategies in courses in order to develop CT skills in their students. They found that using CM in the education of nursing students leads to development of CT skills (22). A recent study was done by Sarhangi et al. on Iranian nursing students, indicating that the CM had a positive effect on CT skills (23). The result of a review article also indicated that CM affects the CT affective dispositions and CT cognitive skills (24).

Correspondingly, the findings of this study are also consistent with those of Nirmala et al. (2011), Deshatty et al. (2013), Moattari et al. (2014), Orique and McCarthy (2015), Mohamed (2017), and Elasrag (2020), who explored the effects of CM in promoting CT skills (2,14,25–28). These researchers concluded that CM is an effective strategy for improving students’ ability to think critically.

In a systematic review on the use of CM in Iran, it was reported that CM had an important effect on improvement of critical thinking skills (29). The reason CT skills are promoted in CM is due to the fact that in this method, the learner has an active role in his/her own learning, which leads to promotion of high level learning. In this regard, these active interactions between learner/instructor and apparent organizing of the concepts allow the learner and instructor to exchange their perspective on how to communicate internal concepts, and they also would be able to discover missing concepts and communications, determine new educational needs, and restart the realignment of the map, which is the very self-assessment process that is part of the main CT skills (1). CM can be used in medical education in order to provide comprehensive and patient-centered care, prepare the medical students for clinical processes and make a connection between theory and clinical courses. Therefore, considering the advantages of this method in terms of increasing higher learning level and increasing medical students’ motivation for learning, using this method in a more practical way in medical students’ education is recommended.

However, our study findings are inconsistent with those of Bixler et al. (2015) who attempted to improve CT skill among fourth-year medical students using small group concept mapping (30). They found no significant increase in CT skills from pre-test to post-test when medical students were educated using a CM method. They proposed that the short time and the limited number of topics to which CM was applied may not provide a sufficient dose to impart a significant improvement on the CT Skills.

Our findings were also inconsistent with those of D’Antoniin et.al (2010) who conducted a quasi-experimental study to determine the effect of CM on CT skills in first-year medical students (31). They found no significant differences between the pre-test and post-test scores of the medical students for CT skills. D’Antoniin et al proposed that there may be a dose effect for using concept mapping, that is, more practice across more different kinds of scenarios may be required to equip students in this complex skill. Of course, this hypothesis requires further studies. Abdoli demonstrated that overall mean CT was not statistically significant after intervention for nursing students in their fourth semester at Isfahan University (32). He argued that perhaps one semester of using CM may not be sufficient to measure the effects of CM on the CT skill of students.

Researchers believe that absence of significance increase in overall CT scores after intervention might be derived from several factors related to the circumstances under which the study is conducted, the participants’ conception and comfort level with participating in the study, seriousness in taking tests, the brevity of the experiment, and participants’ developmental stages. In addition, it may be because that a training course alone is not significantly correlated with the critical thinking, because acquiring critical thinking skills needs a long period of time and continuing education (14,33).

Although there was a significant improvement in the CT skills among the experimental group, the overall scores of the experimental and the control groups were found to be very poor. The reason for the poor CT scores in students needs to be explored in a separate study. These findings were supported by Mohamed et al. (2017), who conducted a study for improving critical thinking of nursing students by the implementation of CM in Cairo University, Egypt. They reported low scores of critical thinking and added that low scores of critical thinking among their study subjects can be attributed to the educational system followed in secondary schools in Egypt (14). It is mainly a pedagogical approach with traditional teacher-centered rather than student-centered learning, where the student is mostly a passive recipient. Such a traditional educational approach does not foster CT skills in students.

The current study also revealed that CM not only leads to improved CT skills in medical students, but also causes a significant increase in students’ scores in anatomy course. Indeed, anatomy topics can be effectively incorporated into concept map, making it easier for medical students to learn anatomy topics. Students being taught anatomy topics through concept map method had higher scores on anatomy course compared to students in the traditional lecturing group. This suggests that concept map is an effective educational tool and should be incorporated into medical education curriculum because it encourages students to become more independent learners and enhances learning of medical courses.

Improving high levels of thinking skills as one of the important missions of medical education makes it necessary to use appropriate approaches for developing CT skills. Most of the research conducted on the effectiveness of concept maps in medical education has focused primarily on the nursing population (24). However, our study included a sample of medical students. There are few studies similar to ours that have taught the intervention group concept map and then reevaluated students’ CT skills. This study builds on previous work to suggest that CM is an effective strategy for developing medical students’ ability to think critically. Using CM in the education of medical students appears to predict the improvement of CT skills, which is one of the most important missions of medical education. It is recommended that program directors and medical faculties evaluate their curricula to integrate concept map teaching strategies in other clinical courses to improve CT abilities in their students.

A limitation of this study was the small sample size and examining only one group of students (medical students). Another limitation was the use of only one course of medical program. In addition, since CM education is not used in other medical schools in Iran, the results of the study cannot be generalized to all medical students. We recommend that future researchers design a study with a larger sample size that includes other fields of medical sciences such as dentistry and pharmacy. Due to inability to keep interactions between the students during practicum under control, the students were likely to influence each other while creating concept maps. For future studies, it would be valuable to use a blinded study design to control for the interaction between experimental and control groups. This will help to reduce information exchange between both groups.

The finding of the current study showed an increase in CT scores in the experimental group as compared to the control group. Therefore, it can be concluded that CM strategy can promote critical thinking skills compared with traditional methods. Accordingly, instructors and curriculum planners are expected to apply this educational strategy for developing CT skills in medical students. The results also suggest that medical curricula need to change based on a student-centered learning approach.

The following recommendations are suggested as implications for future research:

A longitudinal study is recommended that uses CM throughout the whole medical program curriculum, not just one course; it would be a more effective measure of the actual effect of CM on CT skill of medical students over time.

In addition, it is recommended that a comprehensive study be replicated with a larger sample size, and randomly select from multiple different medical schools, in order to provide a more accurate representation of medical students.

A number of participants withdrew during the second stage of the study due to the challenges with administering California Critical Thinking Questionnaire. Future research, should address the challenges associated with administering the California Critical Thinking Questionnaire in order to reduce participant attrition rate.

Finally, we recommend researchers to explain the benefits and advantages of this study to participants prior to the start of their study.

This study was approved by Ethics Committee of Shiraz University of Medical Sciences (Ethics Code of: IR.SUMS.REC.F1202).

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