Introduction
Nursing education is a crucial component of the health-care system that aims to produce competent, skilled, and compassionate nurses who can effectively contribute to patient care and address the diverse health-care needs of the population. In Uganda, nursing education system typically follows a structured curriculum designed to impart theoretical knowledge, practical skills, and ethical values essential to nursing practice.1 The programs are governed by regulatory bodies such as the Uganda Nurses and Midwives Council (UNMC) as well as the Ugandan National Council for Higher Education, which set standards and guidelines for nursing education institutions.2 Nursing training programs often include a combination of theoretical classroom learning and hands-on clinical training.3 Practical training and clinical rotation in various health-care settings are crucial components of nursing education in Uganda.4 Its curriculum outlines various teaching pedagogies, such as lectures or didactic teaching, simulation-based learning, case-based learning/case studies, and problem-based learning (PBL), aimed at providing comprehensive learning experiences for aspiring nurses.5–7 It places a strong emphasis on developing essential skills, such as critical thinking, patient assessment, clinical decision-making, therapeutic communication, and evidence-based practice.8,9 These skills are vital for nurses to deliver high-quality care and make informed clinical decisions in nursing practice. Musiime10 reported that the traditional (lecture) method is the most used teaching method in Ugandan universities, while case-based learning (CBL) is the most effective teaching method in enhancing student performance, with a prediction potential of 71.1% compared to lecturing, concluding that student performance is a reflection of skills that emerge from the instruction. Globally, studies revealed use of CBL pedagogy is limited in Africa. McLean11 reported use of CBL based on global review articles; 54.9% for North America, Europe (25.4%), Asia (15.5%), South America (2.8%) and Africa (1%). Tsekhmister12 in meta-analysis on worldwide use of CBL to other teaching methods for professional student teaching revealed selected studies conducted in USA, 33%; China, 24%; Germany and Saudi Arabia 9% while no studies were found in Africa.
Case-based learning (CBL) is a student- or learner-centered pedagogy that introduces students to real-life scenarios. It engages students in discussions of patients or clients’ cases, integrated with clinical presentations and health or illness conditions.13 CBL plays a significant role in enhancing critical thinking skills in clinical decision-making in nursing education by providing practical and immersive learning experience.14 CBL presents authentic scenarios and mirroring situations encountered in clinical practice. Students engaged in realistic patient situations, applied theoretical knowledge and decision-making to solve problems. The effectiveness of CBL allows students to gain professional knowledge to become competent in clinical decision-making and the provision of qualitative care to improve patient care outcomes. CBL serves as a bridge between theoretical knowledge and practical applications in real-life cases,15 offering students the opportunity to engage in actual clinical cases in a controlled educational environment. Like many others globally, Uganda’s health-care system demands nurses that swiftly analyze complex situations, make informed decisions, and provide effective patient care.16 CBL enables student to apply their theoretical knowledge to simulated or authentic patient cases, thereby enhancing their understanding of complex concepts.
Frederic Le Play (1829) introduced CBLinto social science during a statistical study of his family budget.17 In 1870, Professor Christopher Columbus Langdell at Harvard University School of Law developed a case study method based on the cognitive influence of inductive experimentation to create learning methods which was legally adopted by the USA as a teaching method.18 CBL was first used in the medical field in 1912 by Dr James Lorrain Smith when teaching pathology at Edinburgh University.11 In the 1990s, CBL was used synonymously with case-based reasoning, which Kolodner (1993) explained as reasoning based on remembering past experiences, and is widely used in psychiatric diagnoses as well as medical education.19
CBL refers to the use of clinical cases to facilitate students’ teaching and learning. Obeagu et al20 Gasim et al21 noted that the aim of CBL is to nurture students to prepare for medical practice using real clinical cases. It joins theory with practice by applying theoretical knowledge to cases using an inquiry-based learning method. CBL as a pedagogy is a two-directional active student-centered method that encourages communication, collaboration, critical thinking, and creativity among learners with the teacher as a facilitator.22 Collaboration helps medical students develop the spirit of teamwork, which is paramount in interprofessional team services in health-care delivery in a clinical setting. Techniques of CBL delivery include live presentations, computer/web-based, diverse modalities, live plus web, live plus book, live simulator, live/self-learning, and paper presentations. The evaluation methods for case-based learning includes surveys, tests, and tests plus survey.11 CBL encourages critical thinking by presenting authentic, multifaceted situations that require analysis, evaluation, and problem-solving Obeagu et al.20 Student nurses are prompted to assess data, identify patterns, consider various perspectives, and make informed decisions, thereby fostering critical thinking skills in clinical decision-making.
Critical thinking is a central competency in nursing education and practice, enabling students to engage in sound clinical reasoning and make evidence-based decisions that enhance patient outcomes. This process involves synthesizing knowledge from various sources to formulate appropriate interventions.23 It equips students with the problem-solving skills to identify issues, evaluate alternatives, and implement solutions in a timely and efficient manner. Nurses with strong critical thinking skills are better equipped to recognize subtle changes in a patient’s condition, anticipate potential complications, and take proactive measures to ensure patient safety, which is crucial for preventing medical errors and providing high-quality care.24 Nurses use critical thinking to appraise research findings, scientific evidence, and best practices analytically to integrate this evidence into their clinical decision-making processes, ensuring that patient care is based on the most current and reliable information available.25 In nursing students it is the ability to apply higher-order reasoning skills in clinical decision-making. It involves purposeful, reflective judgment through which students analyze patient situations, infer possible outcomes, evaluate evidence, and justify nursing interventions. In this study, critical thinking is operationalized using the California Critical Thinking Skills Test (CCTST), a standardized tool with a 34-point total score that assesses performance across key subscales such as analysis, evaluation, inference, deductive, and inductive reasoning using multiple choice tests questionnaire. Higher scores reflect stronger critical thinking abilities, while lower scores indicate limited reasoning capacity. This study is guided by Facione’s Delphi Report on Critical Thinking,26 which provides a comprehensive framework derived from expert consensus in philosophy, education, and psychology. Facione conceptualizes critical thinking as a combination of cognitive skills (interpretation, analysis, inference, evaluation, explanation, and self-regulation) and dispositional attributes that reflects traits such as inquisitiveness, open-mindedness, systematicity, truth-seeking, and confidence in reasoning indicating it is multidimensional in nursing.26 This framework is particularly relevant in nursing education because clinical decision-making demands both cognitive reasoning skills and professional dispositions that support safe, patient-centered care. The study aimed to investigate the impact of case-based learning as a pedagogical tool for enhancing critical thinking skills in clinical decision-making among student nurses at Kampala International University (KIU).
Materials and Methods
Study Design
Study adopted a descriptive design to collect data from 37 Bachelor of Nursing (BN) science students in the fourth academic year of their program to achieve the research objective. The entire population of 37 students was sampled, 28 consented and participated in the study.
Sampling Technique
Criterion purposive sampling was used, which depends on the researcher’s judgment based on students predetermined criteria, to identify and select participants who can provide relevant answers to research questions for CBL topic “anemia in pregnancy”.
Inclusion Criteria
KIU BN science students in their fourth year who have studied related courses such as reproductive health, midwifery, and participated in CBL session specifically on “anemia in pregnancy”.
Exclusion Criteria
Nursing students of KIU who did not consent to participate in CBL pedagogy and those below the academic year because of non-exposure to interrelated courses on the topic of teaching intervention.
Case-based Learning Topic
The focus was on “anemia in pregnancy” as the core clinical case in classroom teaching of one CBL session for 3 h. The participants were exposed for the first time to CBL pedagogy as well as instruction topic in their training period because the study context use mostly lecturing and other methods not CBL.
Study Procedure
Implementation of CBL in classroom involve case presentations in progressive case disclosure to mimic real-life scenarios. Group work where students are divided into small groups to encourage teamwork, discussion and presentation. The teacher acts as a facilitator, guiding discussion with probing questions instead of lecturing. In this study, CBL pedagogy was implemented using Framework for Teaching (FFT) 3rd edition by Charlotte Danielson group and lesson plan structured by researchers focusing on the topic “Anemia in Pregnancy.” The four domains of FFT comprising of planning/preparation, learning environment, learning experience and principled teaching was adopted and pedagogical activities in each domains were adapted as step-by-step approach for this study (see Table 1).
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Table 1 Framework for Teaching for Implementation of Case-based Learning (CBL)
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Instrument for Data Collection
The instrument for data collection was California Critical Thinking Skills Test (CCTST) questionnaire. CCTST subscales of analysis, evaluation, inference, deductive reasoning, and inductive reasoning was adopted and adapted by developing the test items in each of the five subscales from “anemia in pregnancy”. CCTST total scores range from 0 to 34. The subscale scores range were analysis (0–9), evaluation (0–14), inference (0–11), deductive reasoning (0–16), and inductive reasoning (0–14). The sum of the scores of the analyses, evaluation, and inference was the total CCTST score. The inductive and deductive scales join the analysis, inference, and evaluation scales. The validity and reliability of this instrument were based on the Delphi Expert Consensus Report.26 The Pearson correlation coefficient (r =0.68) was calculated using the test–retest method with five student nurses to test the reliability of the test items for the data collection instrument. It was administered individually to participants for 50 min in the classroom after the CBL session.
Data Analysis Method
The collected data were analyzed using percentage, distributive statistics and analysis of variance (ANOVA), with significance set at P <0.05. In addition, a qualitative interpretation of the California Critical Thinking Skill Test Scale Scores was presented with the following measures: not manifest (0–7), weak (8–12), moderate (13–18), strong (19–23), and superior (24–34). The data are presented in the tables and figures.
Results
Figure 1 shows the overall CCTST scores. It was observed that very few 2 (7.1%) participants had a strong score, while majority 26 (92.9%) had a superior CCTST score. From Table 2, participants CCTST total score reported mean value of 27.39, mode 27, median 27, and standard deviation (SD) 2.65. Sub-scale analysis mean score: 5.79, mode 6, median 6, and SD 0.9. Evaluation sub-scale graded mean score of 3.96, mode 4, median 4, and SD 0.5. Inference sub-scale recorded 5.64 mean score and 5, 6, 1.01for mode, median, and SD, respectively. For deductive reasoning, mean score was 5.54, mode and median 6 each and SD 1.24. Inductive reasoning had mean score of 6.46, mode and median 7 each, and SD 0.68. Table 3 presented CCTST sub-scales presented using ANOVA, results indicated that CBL method was a statistically significant factor influencing participants’ scores in analysis (P =0.016), evaluation (P = 0.007), and deductive reasoning (P = 0.025). However, it did not have a statistically significant effect on the inference (P =0.932) or inductive reasoning (P =0.670) subscale scores in this study.
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Table 2 Descriptive Statistics of CCTST Total and Subscale Scores
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Table 3 Impact of Case-based Learning on Critical Thinking in Clinical Decision-making for California Critical Thinking Skill Test (CCTST) Sub-scale Scores
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Figure 1 Qualitative Interpretation of California Critical Thinking Skill Test Overall Scores.
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Discussion
This study showed that CBL has an excellent impact on student nurses’ critical thinking in clinical decision-making. Very few 2 (7.1%) participants had a strong score, the majority 26 (92.9%) had a superior overall CCTST score. The finding of the study were supported by Makoni27 which revealed 98 (78.4%) student nurses and midwives were ranked in grade level 3 and 4 which is acceptable CCTST scale score and 27 (21.6%) of the respondents were graded level 1 and 2 which is very poor in the critical thinking skill test scale. In addition, Obeagu and Tukur28 reported 13 (46.4%) of participants were proficient/safe (level 3), 12 (42.9%) had moderate/developing (level 2) while 3 (10.7%) scaled minimal/unsafe (level 1) in pretest scores. Posttest scores revealed 13 (46.4%) respondents at excellent point (level 4), 13 (46.4%) were proficient/safe (level 3) and 2 (7.1%) had moderate/developing (level 2) in Performance-Based Development System Model (PBDSM) on levels of critical thinking in clinical decision-making of student nurses using CBL.
In addition, participants CCTST total score reported mean value of 27.39, sub-scale analysis mean score 5.79, evaluation 3.96, inference 5.64, deductive reasoning 5.54, and inductive reasoning 6.46 as their mean score values. The above findings indicated that CBL enhances student nurses’ critical thinking in clinical decision-making which is in line with the work of Obeagu and Tukur,28 the authors documented mean scores of 11.75 in pretest and 16.10 out of total score of 20 on student nurses critical thinking in clinical decision making of using CBL. Mostafa et al29 reported that students’ critical thinking skills in clinical decision-making had mean scores of 14 for lecturing and 17 for CBL in partial support of this study findings.
Furthermore, the CBL method of teaching showed a significant factor for CCTST score for the participants; analysis (0.016), evaluation (0.007), and deductive reasoning (0.025); and not a statistically significant factor for their inference (0.932) and inductive reasoning (0.670). There was no study to discuss this findings. However, CBL is a more effective method for educating student nurses to enhance their critical thinking in clinical decision-making in nursing education.
Conclusion
It was observed that CBL, as a teaching pedagogy, has an excellent impact on KIU student nurses’ critical thinking in clinical decision-making, especially analysis, evaluation, and deductive reasoning. However, CBL has little impact on KIU student nurses’ inference and inductive reasoning, advocating the use of more than one student-centered teaching pedagogy to transfer adequate knowledge in the curriculum to student nurses. In addition, this shows the need to strengthen clinical teaching for student nurses to enhance their clinical management skills and bridge the gap in clinical practice among nurses.
Ethical Considerations
Ethical approval was obtained from the Kampala International University Research Ethics Committee (REC number KIU-2024-424), and permission was obtained from students who provided informed consent to participate in this study. The researcher ensured that the rights, dignity, and well-being of the participants were respected by implementing ethical principles of confidentiality, autonomy, justice, and informed consent.
Disclosure
The authors report no conflicts of interest in this work.
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