Nurse Education Today 65 (2018) 46–53

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Nurse Education Today

journal homepage: www.elsevier.com/locate/nedt

Review

The effectiveness of evidence-based nursing on development of nursing T

students' critical thinking: A meta-analysis
⁎
Chuyun Cuia, Yufeng Lia, Dongrong Gengb, Hui Zhanga, Changde Jinc,
a
Graduate College, Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China
b
Jizhou District Hospital, Hengshui, Hebei Province, Hengshui 053200, China
c
School of Nursing, Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China

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

Keywords: Objectives: The aim of this meta-analysis was to assess the effectiveness of evidence-based nursing (EBN) on the
Critical thinking development of critical thinking for nursing students.
Evidence-based nursing (EBN) Design: A systematic literature review of original studies on randomized controlled trials was conducted.
Nursing education Data sources: The relevant randomized controlled trials were retrieved from multiple electronic databases in-
Meta-analysis
cluding Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, Web of Science,
Cumulative Index to Nursing and Allied Health (CINAHL), Chinese BioMed Database (CBM), China National
Knowledge Infrastructure (CNKI), and WanFang Database.
Review methods: In order to make a systematic evaluation, studies were selected according to inclusion and
exclusion criteria, and then according to extracted data and assessed quality. The data extraction was completed
by two independent reviewers, and the methodological quality assessment was completed by another two re-
viewers. All of the data was analyzed by the software RevMan5.3.
Results: A total of nine studies with 1079 nursing students were chosen in this systematic literature review. The
result of this meta-analysis showed that the effectiveness of evidence-based nursing was superior to that of
traditional teaching on nursing students' critical thinking.
Conclusion: The results of this meta-analysis indicate that evidence-based nursing could help nursing students to
promote their development of critical thinking. More researches with higher quality and larger sample size can
be analyzed in the further.

1. Introduction it is imperative and necessary for nursing students to develop critical

Nowadays, as people put more emphasis on health problems, nurses
gradually undertake a social responsibility independently (Yang and
Chu, 2015). Actually, in the current environment of clinical practice,
the nurses are always required to have the ability that they can assess
the characteristics of diseases accurately and deal with relevant nursing
problems in time (Chang et al., 2011). Therefore, critical thinking is an
important and essential ability for nurses (Sharifi et al., 2017). More
and more nursing educators have realized that nursing students should
be taught to establish critical thinking skill (Sullivan, 2012). In 1992,
the National League of Nurses in the United States considered the de-
velopment of critical thinking skill as a core component of all nursing
educational programs (National League for Nursing, 1992). American
Association of Colleges of Nursing (AACN) also regarded critical
thinking as one of the core competencies that undergraduates must
possess (American Association of Colleges of Nursing, 1999). Therefore,
thinking skills in clinical learning programs (Phillips et al., 2017).
Nurses who are faced with complex situations apply critical
thinking in existing knowledge, experience to solving problems flexibly
and make a reasonable judgment through reflection, analysis and rea-
soning (Chang et al., 2011). Critical thinking in nursing profession has
been defined as “the process of reflective and reasonable thinking about
nursing problems without a single solution and is focused on deciding
what to believe and do” (Yildrim and Ozkahraman, 2011, p.257).
In recent years, nursing education has been exploring the methods
of cultivating critical thinking ability for nursing students, such as Taba
teaching, problem-based learning (PBL), simulation training, concept
mapping, and so on. In the early 1990s, based on the basis of evidence-
based medicine, the idea of evidence-based nursing (EBN) arose and
spread widely in the nursing field (Evidence-Based Medicine Working
Group, 1992). There were four key elements in EBN including the best
available external evidence, clinical expertise, patient preferences, and

⁎
Corresponding author.
E-mail addresses: 1213242768@qq.com (C. Cui), jcd1886@sina.cn (C. Jin).

https://doi.org/10.1016/j.nedt.2018.02.036
Received 2 May 2017; Received in revised form 14 January 2018; Accepted 26 February 2018
0260-6917/ © 2018 Published by Elsevier Ltd.
C. Cui et al.
Fig. 1. Flow chart of literature retrieval and selection.
context (Hu and Xing, 2015). Hu pointed out EBN was a process in
which nurses conscientiously combine scientific research with clinical
experience. When nurses planned their nursing activities, obtaining
evidence could be seen as the basis of clinical nursing decision-making
(Hu, 2012; Hu and Xing, 2015).
American Medical Association (AMA) emphasized that EBN played
a key role in the future nursing field, and suggested that EBN should be
incorporated into the nursing curriculum (Institute of Medicine, 2011).
Nurse educators gradually realized that EBN could enhance nursing
students' clinical practice ability and help them to make effective and
wise decisions (Ashktorab et al., 2015). The five-step model of evi-
dence-based practice (EBP) contains learning goals and competences,
which includes introducing questions, finding evidence, evaluating
evidence, applying evidence, and evaluating effect (Evidence-Based
Medicine Working Group, 1992; Boström et al., 2013). In order to de-
liver competences for EBP, curricula need to be grounded in the five-
step model, and also four learning components involving attitudes,
knowledge, skills, and practice should be included (Häggman-Laitila
et al., 2016). The EBN teaching method should not be confined to
classroom instruction (Hu et al., 2015). However, some teachers are
centred on traditional teaching method of nursing, and “instructing” is
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Nurse Education Today 65 (2018) 46–53
still the primary teaching method. Mechanical memory and textbook
content take the best part in nursing classes. Compared with this tra-
ditional teaching mode, EBN teaching method is more scientific. All of
those steps in EBN have a direct correlation with the development of
critical thinking. Hence, in order to improve nursing students' critical
thinking ability, it is imperative to improve nursing education mode,
enhance nursing educators' teaching levels, and cultivate nursing stu-
dents' evidence-based practice ability (Aglen, 2016; Hsu et al., 2015).
A systematic review in 2010 (Gao et al., 2010) including studies
between 1996 and 2009 was conducted to demonstrate whether EBN
had more effect on developing nursing students' critical thinking com-
pared with traditional methods. In another review, the literature search
(Shan et al., 2013) was also identified to examine the teaching method
of EBN could improve critical thinking. The two reviews gave the evi-
dence of the studies that compared EBN with traditional lectures on the
effectiveness of development of nursing students' critical thinking.
However, both of the reviews only focused on four studies and did not
distinguish different measuring instruments among conducting meta-
analyses. Therefore, larger sample and better quality studies are needed
to prove that the EBN is effective for nursing students to improve their
critical thinking.
C. Cui et al.
The objective of meta-analysis in this study was to assess the critical
thinking in nursing students who participated in EBN teaching mode.
Based on the results of the meta-analysis, there was an evidence for
nursing educators to follow and conduct their evidence-based courses.
2. Methods
The Preferred Reporting Items for Systematic Reviews and Meta-
analysis (PRISMA) statement (Moher et al., 2009) and Cochrane
Handbook for Systematic Reviews of Intervention were adopted as
guidelines for performing this meta-analysis and systematic review
(Higgins and Green, 2011).
2.1. Search Strategy
A literature search was conducted by using the following electronic
databases including Cochrane Central Register of Controlled Trials
(CENTRAL), PubMed, EMBASE, Web of Science, Cumulative Index to
Nursing and Allied Health (CINAHL), Chinese BioMed Database (CBM),
China National Knowledge Infrastructure (CNKI), and WanFang
Database. The search included relevant publications from inception to
March 2017. After repeating pre-retrieval to determine search words,
the MESH terms and keywords as following evidence-based nursing,
evidence based nursing, EBN, thinking, thinking skill*, critical thinking,
think critically, critical reasoning were used in combination in the
search. In order to avoid missing detection and guarantee recall ratio,
the references of included articles were manually searched to find any
new relevant studies.
2.2. Selection
Initially, a total of 865 studies were included in the first literature
retrial, non-study was identified through screening references ac-
cording to related studies. 197 studies were detected as duplicates thus
excluded. After screening titles and abstracts of the remaining studies,
further 552 studies were excluded. Then, 116 studies were assessed
through reviewing full text, and 107 studies were excluded. Finally, a
total of 9 studies were included in this meta-analysis (Fig. 1).
2.3. Study Inclusion
Studies were eligible for this meta-analysis if they conformed to
predetermined inclusion and exclusion criteria. Studies were selected
for inclusion if: (1) The studies focused on nursing students who joined
in continuing education; (2) The subjects were designed to compare the
efficacy of EBN teaching versus traditional teaching. (3) The study gave
information about the effect of EBN on nursing students' critical
thinking; (4) RCT was included in the study. The exclusion criteria
were: (1) the essential information was not complete to extract the data
and also could not acquire primary data from authors; (2) duplicate
articles; (3) unpublished documents.
2.4. Data Extraction
Two researchers conducted searches and extracted information in-
dependently. The following information was evaluated from the trial:
the author, published year, study design, education degree, subject,
sample size, outcome measures, and teaching method in intervention
and control groups. Any disagreement between researchers about the
eligibility of a trial was resolved through discussing or consulting with
the third researcher (Changde Jin).
2.5. Risk of Bias Assessment
Assessment of bias risk of the eligible studies was conducted by two
independent reviewers, according to the Cochrane Handbook for
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Nurse Education Today 65 (2018) 46–53
Systematic Reviews of Interventions version 5.1.0 (Davidson et al.,
2005). Evaluation index included randomization sequence generation,
allocation concealment, blinding of participants and study personnel,
blinding of outcome assessors, incomplete outcome data, selective re-
porting and other biases. Based on the information extracted from
primary studies, each domain was rated as “high risk” “unclear risk” or
“low risk”. Studies with “low risk” in all domains were rated as grade A;
one or more but not all domains considered “low risk” were rated as
grade B, the others were rated as grade C.
2.6. Statistical Analyses
All extracted data entered into RevMan 5.3 for statistical analysis.
Weighted mean differences (WMDs) or standard mean differences
(SMDs) with a 95% confidence interval (CI) for continuous outcomes
were selected to estimate the pooled effects size. The results re-
presented the scores of critical thinking. The same evaluation instru-
ments have been combined into the group to complete the meta-ana-
lysis. Heterogeneity in the included studies was evaluated by using the
chi-squared test, corresponding to a P value and I2 statistic. If I2 ≥ 50%,
the random effect model was used to pool data. If I2 < 50%, a fixed-
effect model was used to pool data due to consider the studies to be
homogeneous. Subgroup analysis was performed if there present any
detectable heterogeneity resources.
3. Results
3.1. Characteristics of Included Studies
Nine studies were included in the meta-analysis. All of the studies
represented a total of 1079 nursing students, 541 nursing students were
in the intervention group, and 538 nursing students were in the control
group respectively. All these studies were published from 2006 to 2016
and performed in China. Three studies (Jiang et al., 2006; Ma et al.,
2012; Xie, 2012) were conducted in school, five studies (Fan et al.,
2013; He et al., 2016; Huang et al., 2011; Liu, 2016; Zhong and Yu,
2016) were performed in hospital, and one study (Jiang, 2012) was
conducted in both school and hospital. The characteristics of the in-
cluded studies were summarized in Table 1.
3.2. Outcome Measures
The outcome of this meta-analysis was measured by assessing the
Watson-Glaser Critical Thinking Appraisal (WGCTA) (He et al., 2016;
Huang et al., 2011; Jiang, 2012; Jiang et al., 2006; Xie, 2012) and the
California Critical Thinking Dispositions Inventory (CCTDI) (Fan et al.,
2013; Liu, 2016; Ma et al., 2012; Zhong and Yu, 2016). The WGCTA is
an 80-item assessment tool for measuring critical thinking skills in-
cluding inference, recognition of assumptions, deduction, interpreta-
tions, and evaluation of arguments. Each dimension includes 16 one-
point items, which count 16 points if all correctly answered. A higher
score demonstrates a higher level of critical thinking that individuals
perceived (Watson and Glaser, 1994). The CCTDI is a 75-item assess-
ment tool with seven dimensions, i.e., truth-seeking, open-mindedness,
analyticity, systematicity, self-confidence, inquisitiveness, and maturity
(Facione et al., 1994). This scale is categorized by a six-point Likert-
type scale ranging from 1 (“strongly disagree”) to 6 (“strongly agree”).
The 70-term CCTDI was used in this meta-analysis (CTDI-CV, Chinese
version, The Hong Kong Polytechnic University, Hong Kong, China).
The scores range is from 70 points to 420 points. A higher score de-
monstrates a higher level of critical thinking for individuals.
3.3. Study Quality
All of the included studies were Grade B. Among nine studies, He
(He et al., 2016) reported the randomization methods in detail, and the
C. Cui et al. Nurse Education Today 65 (2018) 46–53

Table 1
Characteristics of included studies.

Study (year) Design Education degree Subject Sample size T/C Intervention Control Measure tool

Fan M 2013 RCT Higher-vocational students Case learning 120 60/60 1. Introducing questions; Traditional CCTDI
2. Finding evidence; teaching
3. Evaluating evidence;
4. Applying evidence.
He H 2016 RCT Undergraduate Case learning 90 45/45 1. Introduce theoretical Traditional WGCTA
knowledge of EBN; teaching
2. Make a skill training of EBN;
3. Conduct EBP through case
learning.
Huang LP RCT Undergraduate/higher-vocational Emergency nursing 120 60/60 1. Make EBN teaching plan; Traditional WGCTA
2011 students 2. Master EBP steps. teaching
Jiang WL RCT Unknown Medical-surgical 80 40/40 1. Introducing questions; Traditional WGCTA
2012 nursing 2. Finding evidence; teaching
3. Evaluating evidence;
4. Make nursing plan;
5. Applying nursing plan.
Jiang YL RCT Undergraduate Psychiatric nursing 120 60/60 1. Introducing questions; Traditional WGCTA
2006 2. Finding evidence; teaching
3. Evaluating evidence;
4. Make nursing plan;
5. Applying nursing plan.
Liu LZ 2016 RCT Postgraduate/undergraduate/ Case learning 224 112/112 1. Introducing questions; Traditional CCTDI
higher-vocational students 2. Finding evidence; teaching
3. Evaluating evidence;
4. Applying evidence.
Ma GP 2012 RCT Higher-vocational students Nursing specialty 100 50/50 1. Introduce theoretical Traditional CCTDI
courses knowledge of EBN; teaching
2. Make a skill training of EBN;
3. Teach the lessons according
to thinking of EBN.
Xie XY 2012 Undergraduate Nursing specialty 115 59/56 1. Make EBN teaching plan; Traditional WGCTA
courses 2. Master theory and skill of teaching
EBN;
3. Conduct EBP through case
learning.
Zhong XW RCT Undergraduate Medical-surgical 110 55/55 1. Introducing questions; Traditional CCTDI
2016 nursing 2. Finding evidence; teaching
3. Evaluating evidence.

T = Experimental group sample size; C = Control group sample size; WGCTA = Watson-Glaser Critical Thinking Appraisal; EBN = Evidence-based nursing; EBP = Evidence-based
practice; CCTDI = California Critical Thinking Disposition Inventory.

Fig. 2. Risk of bias graph.

concrete method was random number table. None of the studies de-
scribed random allocation concealment. Given the nature of interven-
tion, blinding of students and educators in the intervention was not
feasible. Therefore, none of the studies conducted blinding of partici-
pants and personnel. All of the studies described the blind of outcome
assessors. Additionally, all of the studies reported complete outcome
data, selective reporting and other biases. Fig. 2 and Fig. 3 present the
results of risk of bias assessment.
3.4. The Result of Meta-Analysis
3.4.1. Meta-Analysis on WGCTA
Five studies, including 525 nursing students, were evaluated by
using WGCTA. Heterogeneity was identified across the included studies
(I2 = 97%), and the pooled results suggested that EBN teaching method
for nursing students had a highly significant effect on the WGCTA
(MD = 17.26, 95% CI [11.22,23.30], P < 0.00001) (Fig. 4). Con-
sidering that WGCTA contains five dimensions, subgroup analysis was
required. Jiang (Jiang, 2012) did not report the scores of five dimen-
sions, so subgroup analysis was conducted in the other four studies. The

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C. Cui et al.
Fig. 3. Summary of risk of bias assessment.
results as following showed a significant effect on all the domains: in-
ference (MD = 2.58, 95% CI [1.35,3.82], P < 0.0001), recognition of
assumptions (MD = 3.27, 95% CI [2.53,4.01], P < 0.00001), deduc-
tion (MD = 3.29, 95% CI [1.79,4.78], P < 0.0001), interpretations
(MD = 2.84, 95% CI [1.69,3.99], P < 0.00001), and evaluation of
arguments (MD = 3.02, 95% CI [2.46,3.59], P < 0.00001) (Fig. 5).
The sensitivity analyses showed that if any one included study was
excluded, the result was unchanged.
Fig. 4. Forest plot of overall critical thinking score measured by WGCTA.
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Nurse Education Today 65 (2018) 46–53
3.4.2. Meta-Analysis on CCTDI
Four studies, including 554 nursing students, were evaluated by
using CCTDI. Heterogeneity was identified across the included studies
(I2 = 96%), and the pooled results suggested that EBN teaching method
in nursing students had a highly significant effect on the CCTDI
(MD = 36.24, 95% CI [28.37,44.12], P < 0.00001) (Fig. 6). Con-
sidering that CCTDI contains seven dimensions, subgroup analysis was
required. The results showed a significant effect on all the domains
including truth-seeking (MD = 5.96, 95% CI [3.97,7.95],
P < 0.00001), open-mindedness (MD = 4.34, 95% CI [1.64,7.04],
P = 0.002), analyticity (MD = 5.20, 95% CI [4.65,5.76],
P < 0.00001), systematicity (MD = 4.13, 95% CI [3.53,4.72],
P < 0.00001), self-confidence (MD = 5.53, 95% CI [3.15,7.92],
P < 0.00001), inquisitiveness (MD = 5.63, 95% CI [4.02,7.24],
P < 0.00001), and maturity (MD = 9.28, 95% CI [1.62,16.94],
P = 0.02) (Fig. 7). The sensitivity analyses showed that if any one in-
cluded study was excluded, the result was unchanged.
4. Discussion
4.1. Summary of Findings
The objective of this meta-analysis was to assess the effect of EBN
teaching method on developing nursing students' critical thinking. Nine
studies with 1079 nursing students were included in this study. All of
the studies regarded EBN teaching method as intervention group, and
put traditional teaching method as control group. The included studies
utilized different general measuring instruments to measure nursing
students' critical thinking.
The results of the methodological quality evaluation showed that
the domains of allocation concealment and blinding of participants and
personnel were limited. Given the nature of intervention, the educators
need to implement educational interventions and put nursing students
who accepted the teaching methods in different groups. Therefore, the
studies could not fully meet the requirements. The pooled effect size
suggested that the EBN teaching method had significantly higher
overall critical thinking scores in general meta-analysis, and higher
critical thinking scores of each dimension in subgroup analysis.
According to the sensitivity analyses, the results are reasonably stable.
Hence, the results of this meta-analysis could be affected.
There were two different measuring instruments that were used to
assess nursing students' critical thinking skills. The pooled effect size for
critical thinking assessed by both WGCTA and CCTDI revealed that EBN
teaching method was better than traditional method. Five studies uti-
lized the measuring instrument with WGCTA, and the subgroup results
showed significant difference between the EBN group and traditional
group in all dimensions such as inference, recognition of assumptions,
deduction, interpretations, and evaluation of arguments. A higher score
in inference revealed that nursing students in EBN group possessed
more ability of processing problem rather than traditional group. The
difference in recognition of assumptions showed that nursing students
tend to consider problems deeply and closely. Deduction showed that
the EBN group processed more logical thinking than traditional group.
Interpretations revealed that individuals' language expression and
C. Cui et al. Nurse Education Today 65 (2018) 46–53

Fig. 5. Forest plot of dimension scores measured by WGCTA.

Fig. 6. Forest plot of overall critical thinking score measured by CCTDI.

organization ability were more prominent in EBN. The difference in
evaluation of arguments showed that EBN group possessed more com-
prehensive analysis ability. The higher scores in dimensions of the
WGCTA were indicated, the higher nursing competences were obtained
by nursing students (Chang et al., 2011; Mazloomy et al., 2012).
Four studies utilized the measuring instrument with CCTDI; the
subgroup result indicated that the pooled effect sizes for all dimensions
(truth-seeking, open-mindedness, analyticity, systematicity, self-con-
fidence, inquisitiveness, and maturity) of the CCTDI showed significant
differences between two groups. In terms of truth-seeking, it was in-
dicated that EBN group possessed the ability to pursue fact and
distinguishing right from wrong. A higher score in open-mindedness
showed that the EBN group was more tolerant of accepting new things
than traditional group. Analyticity indicated that individuals tended to
look for methods to solve problems through understanding the differ-
ences among things. Systematicity revealed that individuals got in-
tegrating thinking through exploring the link among each branch. The
difference in self-confidence showed that EBN group had more self-re-
cognition than traditional group. Inquisitiveness reflected individuals
were long for getting knowledge. Finally, maturity showed that in-
dividuals made decisions for themselves and expertly solved problem.
With the progress of society and the development of disciplines,

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Fig. 7. Forest plot of dimension scores measured by CCTDI.

nurses have to face more challenges. Critical thinking provides a sig-
nificant way to think and judge problems (Noreen, 2000; Sharifi et al.,
2017). In traditional teaching method, students are too dependent on
their teachers to build the capacity for thinking independently (Yue
et al., 2017). Compared with traditional teaching mode, EBN teaching
method provides a new teaching model for nursing educators. EBN
teaching method, using five-step model, cultivates the ability for nur-
sing students to put forward questions, acquire knowledge actively,
identify authenticity and use rationally. The whole learning process of
which is exactly the utilizing of critical thinking (Shan et al., 2013).
Nursing educators not only can spread knowledge to nursing students
but also could teach them to use evidence-based methods to find and
solve problems (Mehrdad et al., 2012; Schaffer et al., 2013).

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4.2. Strengths and Limitations
There are some strengths in our study. Firstly, all of the reviewed
researches were randomized controlled trials. Secondly, the measure-
ments of the critical thinking were general, and the measuring instru-
ments had been proved to have good reliability and validity. Thirdly,
sensitivity analyses showed the result of the meta-analysis was reliable.
Unfortunately, there are also several limitations in our study. Firstly,
the included RCTs were performed in only one country (China), which
meant there was not published report with other languages on EBN
teaching method for developing nursing students' critical thinking.
Secondly, searched by Google scholars had been planned to find further
relevant studies, but this was not available in China network. Thirdly,
in all of the trials included in the meta-analysis, methodological and
clinical heterogeneity was not excluded. Finally, some unpublished data
might lead bias to the pooled effect.
5. Conclusion
It is believed that EBN teaching method is an effective learning
approach that can make students become good thinkers. As expected,
the results of this meta-analysis suggest that EBN teaching method is an
effective way to promote students' critical thinking, compared with
traditional method. By using WGCTA as measuring instrument for as-
sessing critical thinking skill, EBN has been found that could influence
nursing students' ability of processing problems, such as inference, re-
cognition of assumptions, deduction, interpretations, and evaluation of
arguments. By using CCTDI to assess critical thinking, EBN has been
found that it could affect nursing students' attitude of processing pro-
blem, i.e., truth-seeking, open-mindedness, analyticity, systematicity,
self-confidence, inquisitiveness, and maturity. Therefore, EBN could be
used as a teaching method world widely in future nursing education,
and pay more attention to the cultivating critical thinking. In the fur-
ther research, larger and high-quality studies can be conducted to ex-
amine the results and to provide better evidence for the effective of the
EBN teaching method on development of critical thinking.
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