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Table of Contents
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 159-165

Impact of a Case-based–Team-based learning model on critical thinking and self-efficacy of nursing Undergraduates in China

1 Associate Professor, Department of Obstetrics, Gynecological and Pediatric Nursing, Nursing School of Yangzhou, China
2 Registered Nurse, Hemodialysis Unit of Huadong Hospital Affiliated Fudan University, China
3 Lecturer, School of Foreign Languages of Yangzhou University, China
4 Lecturer, Department of Chemistry and Medicine, Guangling College of Yangzhou University, China
5 M.M Candidate, Nursing School of Yangzhou University, China

Date of Submission30-May-2020
Date of Decision22-Sep-2020
Date of Acceptance24-Dec-2020
Date of Web Publication19-Feb-2021

Correspondence Address:
Dr. Yuexia Liao
Nursing College of Yangzhou University, No. 136 of Jiangyang Road, Yangzhou City, 225001, Jiangsu Province
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCN.IJCN_51_20

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Different education systems or cultural backgrounds may influence the effectiveness of various educational approaches. The purpose of this article is to report the impact of an integrated case-based and team-based learning (CB-TBL) approach on critical thinking, self-efficacy and learning interesting of nursing undergraduates. We conducted quasi-experimental and qualitative study on 118 nursing undergraduates from 20 teams who were taking a course on nursing management from September 2017 to January 2018. The teams researched their assigned topics, identified a case study, carried out the investigation, created PowerPoint presentations, reported and discussed the topic and posted them on the course management system blackboard site. Data gathering was based on two valid and reliable questionnaires: Chinese version of the Critical Thinking Disposition Inventory (CTDI-CV) and the Self-efficacy Integrated Scale. Open-ended questions were also designed for the evaluation of students' feedbacks and views on educational methods. The results showed that more than 90% of participants found the CB-TBL model interesting. We found that the post-test average score was higher than the pre-test one in the CTDI-CV, the General Self-Efficacy Scale and the Academic Self-Efficacy Scale. The participants and teaching supervision team also responded positively to the CB-TBL approach, which greatly stimulated the students' learning interest. This article may be of value to nursing educators who wish to replace traditional learning with informal learning (student-centred active learning) so as to enhance not only the students' knowledge but also the advancement of critical thinking and self-efficacy.

Keywords: Case-based learning, critical thinking, interest in learning, learning self-efficacy, nursing undergraduates, team-based learning

How to cite this article:
Liao Y, Wang S, Weng D, Han T, Yang Y, Chen R, Sun X. Impact of a Case-based–Team-based learning model on critical thinking and self-efficacy of nursing Undergraduates in China. Indian J Cont Nsg Edn 2020;21:159-65

How to cite this URL:
Liao Y, Wang S, Weng D, Han T, Yang Y, Chen R, Sun X. Impact of a Case-based–Team-based learning model on critical thinking and self-efficacy of nursing Undergraduates in China. Indian J Cont Nsg Edn [serial online] 2020 [cited 2021 Jun 23];21:159-65. Available from: https://www.ijcne.org/text.asp?2020/21/2/159/309860

  Introduction Top

Current methodologies for teaching nursing in classroom and clinical settings include lecturing, discussion, demonstration, web-based learning and simulating. Conventional teacher-centred learning was prevalent in Chinese nursing education in the past decades.[1] The most obvious advantage of conventional teacher-centred learning was its ability to impart knowledge to students in a limited amount of time. However, this kind of teaching method resulted in students receiving information passively, which ultimately led to dissatisfactory learning outcomes with respect to developing students' capability for critical thinking and long-term knowledge retention.[2],[3] Currently, nursing schools around the world are shifting from teacher-centred pedagogies to student-centred models that feature group-based work.[4],[5] The importance of the student-centred approach has long been emphasised in nursing higher education; student-centred modes such as problem-based learning (PBL), case-based learning (CBL), flipping classrooms based on team-based learning (TBL) and other evidence-based teaching strategies are constantly being practiced, innovated and explored.[4],[6],[7]

CBL uses a case-based established approach engaging students in discussion of specific scenarios that resemble or typically are real-world examples. Developed in the 1980s by Larry Michaelsen in the United States, TBL emphasises collaborative and in-depth learning. These methods were designed to assist students in achieving their desired learning goals and improving their teamwork.[8],[9],[10],[11] They also have been widely applied in higher education medical programmes, such as nursing, medicine, pharmacy, dentistry and allied health education. TBL teaching practice has shown positive educational outcomes in terms of knowledge acquisition, participation and team performance.[8],[12],[13] CBL and TBL have proven to be strategies that can produce notable pedagogical benefits in teaching and learning because it improves medical students' teamwork and their autonomous learning ability, their problem-solving capability and communication skills, as well as their professionalism and personal development.[14],[15] However, there are still some problems, especially as the teaching method has not been fully elaborated in recent literature. Some academics have raised questions such as 'Does it really work?' or 'Can student-directed activities get out of control?'[8]

CBL and TBL impact both teaching and learning by guiding students to take the initiative when it comes to participation in learning via individual work, group discussions and class discussions.[16],[17],[18] Any learning approach is rooted in its own historical and cultural context, meaning that different education systems or cultural backgrounds may influence the effectiveness of various educational approaches. In China, although some nursing educational reforms have focused on student-centred strategies in recent years and CBL or TBL has also been practiced, in practical terms, many challenges have emerged.[1],[19] Most nursing curricula teaching is disease oriented; clinical practice is still a quite different and complex domain. Furthermore, scant literature has considered the effects of CBL or TBL on Chinese undergraduate nursing students. The following question needs to be urgently addressed: How can we render CBL or TBL sufficient to improve nursing undergraduates' abilities to deal with complicated clinical situations?

In this study, according to specific guidelines or researches,[20],[21] we integrated the CBL and the team-based teaching–learning approaches and tried to examine the consequences of the integrated approach on critical thinking, self-efficacy and learning interest of nursing undergraduates. We selected some commonly used representative questionnaires to evaluate the current situation of nursing undergraduates, with regard to critical thinking ability and self-efficacy. The case-based and TBL (CB-TBL) pre-test and post-test questionnaire results were then compared.

  Methods Top


This study adopted a quasi-experimental and qualitative design to evaluate the effects of CB-TBL on nursing undergraduates in terms of learning interest, critical thinking ability and self-efficacy and to collect data on the acceptability of CB-TBL in an educational setting characteristic of teacher-centred learning. This study was approved by the Teaching Committee of Yangzhou University. This is an organisation that provides guidance, research, consultation and supervision on the teaching work of the whole university and consists of more than 30 educators from various colleges of Yangzhou University.


The 3rd-year student participants included those who enrolled on the 4-year nursing programme at the Nursing School of Yangzhou University and Guangling College of Yangzhou University (in Yangzhou City, Jiangsu Province, in the east of China) in 2015. The mean age of the participants was 20.38 ± 0.69 years (19–21 years). There were 47 students from Nursing School of Yangzhou University and 71 students from Guangling School of Yangzhou University, and 13 were male. All of the participants were explained about the design, procedure and tasks of the CB-TBL and were free to choose as a member of the groups between the control and the CB-TBL group. They all were only willing to sign up for the CB-TBL groups and were not willing to participate in the control groups.

Case-based and team-based learning procedure

The CB-TBL was implemented from September 2017 to January 2018. The instructor assigned team tasks in the first class. All 20 teams from two classes were established and prepared the teamwork more than 4 weeks ahead. CB-TBL model were implemented one time in one class every week. The CB-TBL experiment was conducted according to generally recognised CBL and TBL guidelines.[20],[21] Each team was composed of 4–6 members including one leader.

The experiment was divided into six steps: (1) Decide on a study topic. Each team chose one from the list of required study topics. These were common topics related to nursing management practice, such as outpatient and emergency room management, operating theatre management, nosocomial infections, communication and conflict, nurses' salary and narcotic and analgesic drug management. (2) Identify a case study. First, the students needed to find a worthwhile case; then, they were required to study the case following the research guidelines prescribed by the teachers. The framework included: 'What?'; 'How many or how much?'; 'Why?' and 'How to solve it?'. (3) Carry out the investigation. Each member of the teams collected relevant information (such as audio-video materials, references and relevant reports), conducted field interviews and exchanged and discussed the problems that arose during the research process. (4) Prepare presentations. Each team was asked to prepare a PowerPoint presentation of their research results. (5) Report and discuss. Each team reported their research results for 15–30 min and discussed them with other teams under the teacher's guidance. (6) Peer assessment and teacher's comments. Finally, the teams entered the mutual evaluation stage and the teacher made a final summary. Students reviewed the teams' PowerPoint presentations and the cases, reported and answered the questions and comprehensive performance of teamwork to be graded.

Data collection and analysis

All participants of this study were given the pre-test (September 2017 before the first class) and post-test (January 2018 after the last class) surveys by online questionnaires. 103 students submitted the online questionnaires effectively before CB-TBL, and 109 students did so after CB-TBL. The data collection tools included a personal information section with three items (class and grade, age and gender), the Chinese version of the Critical Thinking Disposition Inventory (CTDI-CV)[22] derived from the California Critical Thinking Disposition Inventory (CCTDI)[22],[23] and the Self-efficacy Integrated Scale (SEIS).[24],[25],[26],[27]

CCTDI and CTDI-CV measure the constituents of critical thinking disposition according to seven dimensions: truth-seeking, analyticity, open-mindedness, systematicity, self-confidence, inquisitiveness and maturity.[22],[23] The CTDI-CV is composed of 70 items, with a six-item Likert scale. The content validity of CTDI-CV is 0.89, and the Cronbach alpha is 0.90.[22] The CTDI-CV is designed to assist the nursing students in reflecting on their own critical thinking capabilities.[22]

The SEIS consists of the following three scale forms: (1) the General Self-Efficacy Scale that contains ten items on a Likert scale and focuses on five aspects: study aptitude, talent, environmental sense, goal achievement and self-expectation;[24] (2) the Learning Self-Efficacy Scale that contains 12 items to measure students' self-efficacy, i.e., general learning ability;[25],[26] (3) the Self-Efficacy Scale for Self-Regulated Learning that contains nine items to measure the individual's self-efficacy.[27]

SPSS 22.0 (SPSS Inc., Chicago, IL, United States) was the software used for data analysis, while independent t-tests and one-way ANOVA tests were the data analysis methods used. The quantitative data are expressed as means ± Standard deviations. In all the data analyses, we followed the principle that P < 0.05 is considered statistically significant.

Finally, we conducted a post-test survey which included seven reflective questions [Table 1] and some open-ended questions, such as 'What is your experience of participating in the CB-TBL?'; 'What difficulties have you encountered and how did you cope with them?' and 'Do you have any suggestions for the future students involved in a curriculum like this or CB-TBL?' Two teaching supervision teams inspected our teaching activities and provided some positive comments and constructive suggestions.
Table 1: Course organisation evaluation (n=109)

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  Results Top

Case-based and team-based learning increased the Chinese version of the critical thinking disposition inventory scores

We analysed differences between the CTDI-CV pre-test and post-test scores using t-tests and found that the students scored higher in the CTDI-CV tests after CB-TBL practice (282.9 ± 30.1 vs. 292.5 ± 32.0, P = 0.025), including in terms of truth-seeking (P = 0.023), open-mindedness (P = 0.018), analyticity (P = 0.044) and maturity (P = 0.027), as shown in [Table 2].
Table 2: The mean scores of Chinese version of the critical thinking disposition inventory and self-efficacy scores for pre- and post-test

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A further point to note is that, as mentioned in Section 'Participants', all the participants were only willing to be assigned to CB-TBL groups. According to some reports, the critical thinking skill of nursing students increased with their accumulation of knowledge and clinical experiences over their education period.[28],[29] Therefore, we conducted a cross-sectional survey among the students of the Nursing School of Yangzhou University and Guangling School of Yangzhou University, who were 1st-year students (57) and 4th-year students (36) and were never involved in CB-TBL experience, to compare the sores of CTDI-CV with the pre-test and post-test, respectively. There was no significant difference in gender among the three groups. We compared the pre-test data of the CB-TBL with the 1st year group and the post-test data with 4th-year group using t-tests and one-way ANOVA tests. This comparison was attempted based on reports which indicated that the critical thinking skill of nursing students increased with their accumulation of knowledge and clinical experiences.[28],[29] Pre-test did not show significant differences between the study group and the comparison group. However, we found that CB-TBL participants scored significantly higher in the CTDI-CV tests compared to the comparison group in the post-test, especially in the students' analyticity and maturity [Table 3]. Therefore, we conclude that the CB-TBL teaching mode may improve students' critical thinking abilities.
Table 3: The mean scores of Chinese version of the critical thinking disposition inventory and self-efficacy among three groups

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Case-based and team-based learning increased the self-efficacy scores

To analyse the effect of CB-TBL on the self-efficacy of nursing students, we compared the pre- and post-test SEIS scores. The results revealed that the participants obtained higher mean scores in general self-efficacy (P = 0.004) and academic self-efficacy (P < 0.001), as shown in [Table 2]. There was almost no difference in the self-efficacy scores for self-regulated learning between the pre- and post-tests. Further, we compared the data of the self-efficacy on the pre and post-test groups and the comparison groups as indicated above. We found that there was no significant difference between groups in the pre-test, but the CB-TBL participants scored significantly higher in the general self-efficacy and learning self-efficacy tests, especially in learning self-efficacy tests in the post-test [Table 3], compared to the comparison group from 4th year. Therefore, the conclusion can be drawn that the CB-TBL teaching mode may improve students' learning self-efficacy.

Case-based and team-based learning stimulated students' learning interest

The students were surveyed about their experiences after the CB-TBL experiments [Figure 1]. 90.8% of them were very interested in CB-TBL practice, and 82.57% of them agreed that the CB-TBL approach helped them to cooperate with others better. Over 80% of participants believed that CB-TBL improved their ability to discover, analyse and solve problems. 60%–80% of students maintained that the CB-TBL sessions were helpful in improving their communication skills, organising ability and contingency capability. 88.1% of the students agreed that CB-TBL encouraged them to perform better in literature research and in creatively solving problems.
Figure 1: Students' evaluation on effects of case-based and team-based learning in terms of improving students' integrated abilities. The graph above represents the 'agree' percentages of the participants about 'case-based and team-based learning is help for improving your abilities' with the maximum being 100%. 109 participants finished the survey from 118 participants who were engaged in the case-based and team-based learning practice in this study

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Of course, some problems were also reflected in the students' questionnaires. For example, a few students responded that they did not actively listen to other teams' work reports, and a few students felt under time pressure to prepare sufficiently for the course timetable.

Case-based and team-based learning classroom activities were profitable

Quantitative data

[Table 3] contains the following findings: (1) 82.57% of the students agreed that the CB-TBL approach was appropriate for the curriculum and that the frequency and proportion of CB-TBL teaching was rational; (2) 80.73% of students agreed that the CB-TBL assignments were scientifically formulated and were also feasible and achievable; (3) 75.23% of students agreed that the teachers were helpful because they also provided timely help and guidance; (4) 78.90% of students agreed that in the initial stage, the teachers' instruction, the instruction manuals and the course network platform provided adequate information for students; and (5) 85.32% of participants agreed that CB-TBL was more conducive to learning how to solve practical problems in clinical work.

Qualitative data

Most of the students prepared their presentations carefully and went on to perform their presentations well. Students' comments included the following: 'I like CB-TBL very much. It gave us an opportunity and a challenge to learn effectively'. 'We prepared our presentations and discussed them together for more than 10 h'. 'The discussion based on a typical case was very interesting'. 'We also liked to join other teams' discussion'. 'Through active participation, I now feel more confident.'

Further, the teaching supervision team commented: 'The students prepared and presented very well'. 'The classroom atmosphere is very active'. 'This lesson is a student-centred education and different from teacher-centred'. 'Teachers play a guiding and regulating role in the process. It is a nice attempt at teaching method reform'. They also evaluated our CB-TBL classroom as an efficient one on the basis of specified teaching objectives.

On the whole, the CB-TBL approach was widely accepted and helpful for nursing undergraduates; one of the students noted that 'CB-TBL served as a good combination of theory and practice, which is useful for us to put our knowledge into practice'.

  Discussion Top

It is well known that implementing education in accordance with students' aptitude and local context has always been a golden rule in teaching practice. In this study, our aim was to observe the effects of CB-TBL on nursing undergraduates in China. We found that CB-TBL is very helpful for Chinese nursing students' learning. Generally speaking, students who enter the stage of CB-TBL are supposed to have taken some basic nursing courses for about 2 years. Meanwhile, the average score of CTDI-CV in the pre-tests was above 280, which showed that these nursing students had a certain degree of positive critical thinking ability.[28] Besides, in the CB-TBL teaching practice, the most appropriate size of each team is four to six members, each member taking on a different role, and thus encouraging multiple thinking.[30] This enabled students to gain considerably from a high level of commitment and brainstorming.[31]

Critical thinking, an essential skill for nurses, is characterised as a higher-level thinking ability that involves one's knowledge, experiences, disposition and intellectual level.[32],[33],[34] Critical thinking can help nurses make the right clinical decisions and improve the quality of care when faced with increasingly complex health-care conditions.[35],[36] With better critical thinking skills, nurses are more likely to safeguard and enhance the welfare of patients and improve their quality of life.[37] Improving critical thinking is also beneficial to the personal career development of nursing staff. Therefore, cultivating nursing students' critical thinking is of crucial importance.[38]

In China, conventional teacher-centred teaching is a principal method before students enter higher education; this teaching method is inadequate for cultivating students' critical thinking levels.[39],[40] Therefore, we carried out this educational experiment on our nursing students to observe whether the CB-TBL approach is effective in developing critical thinking. In this experiment, we observed that students were actively involved in teaching activities, that their teamwork also improved and their knowledge was also enriched and that the students and the supervision group responded well afterward.

Bandura, in his famous self-efficacy theory, defined self-efficacy as 'an individual's belief in his or her ability to succeed in a specific situation or accomplish a specific task'.[41],[42],[43],[44] Generally, a learner with greater self-efficacy is more motivated to learn, which can lead to greater academic achievements.[41],[45] In the CB-TBL method, students' learning activities are completed through team activities. In this process, team members learn from each other and discuss with and encourage each other, which greatly enhances students' self-efficacy. In the course of this experiment, we also found a significant improvement in students' general self-efficacy and learning self-efficacy.

Conventionally, the learning of Chinese students is completed under the teacher-oriented education mode. The advantage of Chinese-style education lies in the fact that students can build solid basic skills under the guidance of teachers, but it is insufficient in such factors as cultivating interest, active exploration, teamwork, continuous creation and building confidence.[1],[46] The educators believed that there is a developing trend to use TBL as a teaching method to engage health care students in the world.[47] Presentation and discussion based on true cases can help the students to improve their abilities. At the end of this CB-TBL experiment, we conducted a feedback survey on this teaching mode.

In particular, it should be emphasised that the results of the CB-TBL teaching method in cultivating students' interests were satisfactory. It is generally believed that learning interest is the key to further exploration and practice.[48],[49],[50] Therefore, the CB-TBL approach combined with some forms of conventional teaching structure would be a superior way of guiding nursing students' development compared with traditional approaches. The results are consistent with findings of other studies on medical and pharmacy education,[51],[52] as well as findings of a study on nursing students in Korea.[53]

Therefore, it is of practical significance to introduce the CB-TBL teaching method to Chinese educational culture.


This study also has some limitations. The first limitation is that no students agreed to participate in the control groups. To remedy this, we conducted a cross-sectional survey in which we used the CDTI-CV and self-efficacy scores of students who did not participate in the CB-TBL teaching activities as comparison groups. In addition, the relationship between critical thinking and self-efficacy is interconnected and mutually reinforcing. In this study, we discussed them separately; in future studies, we may further explore the correlation between them. Finally, we found that CB-TBL has a positive effect on teaching, but it is very time-consuming, meaning that large-scale application will consume enormous numbers of class hours. Underlining what was mentioned above, it would be better to combine CB-TBL with the conventional teaching mode.

  Conclusion Top

In this study, the CB-TBL teaching method with integrated design and has achieved satisfactory results in cultivating nursing undergraduates' multidimensional abilities. This article may be of value to nursing educators who wish to replace traditional learning with informal learning (student-centred active learning) so as to enhance not only the students' knowledge but also the advancement of critical thinking and self-efficacy. However, it is also essential to take the students' cultural context, learning habits and training programme into consideration while carrying out CB-TBL.

Financial support and sponsorship

This study was funded by Yangzhou University (grant number 2019jj-jg03), Nursing School of Yangzhou University (grant number: HLYG2017-4) and Guangling College of Yangzhou University (grant number: JGYB17018). The sponsors have no role in the study design, data collection, analysis and interpretation of data.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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