Concept map is a novel metacognitive approach in education that can improve critical thinking and decision making skills in students and nurses. Therefore, the current systematic review and meta-analysis was conducted aimed to determine the effect of the concept map approach in nursing education.

The present systematic review and meta-analysis was performed to analyze the published studies in the no time limit until Sep. 2024 according to the PRISMA 2020 guideline. Articles related to the purpose of the study were obtained from MagIran, SID, ProQuest, PubMed, Scopus, and Web of science (WoS) databases, and Google Scholar search engine using relevant and validated keywords. Heterogeneity among studies was examined using the I² index and Egger’s regression intercept was used to examine the publication bias.

In the initial search, 579 studies were found, of which finally 44 articles with a sample size of 1722 people in the intervention group, and 1712 people in the control group were included in the meta-analysis. As a result of combining the studies, the educational performance score in the intervention group increased more than the control group [95% confidence interval: (1.693 ± 0.194, P < 0.001)]. The results of the subgroup analysis showed that the positive effect of performing concept map is more in the nursing students than working nurses, although this result was not statistically significant (P ˃ 0.05).

The results of this study showed that the concept map has significantly increased the performance of nursing education. The results of this study can be considered by educational and therapeutic policy makers.

As we move forward, nurses in the field of health care face more complex issues and problems that require critical thinking to make decisions [1]. Critical thinking enhances the nurse's clinical decision-making power in diagnosing the patient's needs and choosing the best nursing decisions and actions [2, 3]. This type of thinking is an important aspect of professional practice in nursing, midwifery, and health, which is considered essential for nursing functions, especially in clinical fields [4, 5]. As a matter of fact, critical thinking is an essential part of clinical decision-making and nurses'competency [6].

Critical thinking is a cognitive process in which a person makes judgments and decisions by examining the reasons and analyzing the available information and drawing conclusions from them [7]. In other words, critical thinking is a purposeful, self-regulatory reflective judgment process that leads to the producing a logical solution to a problem and making appropriate decisions in the individual [8]. This is while the Conventional educational systems in universities deliver people with a lot of theoretical information to the society, but these people are unable to solve the small problems of the society in practice [9]. In fact, the traditional teaching method in universities conveys a mixture of information and theoretical concepts to students [10]. On the contrary, it does not convey to them the ability to analyze, prioritize and organize emerging knowledge, which is a requirement for critical thinking and will lead to effective and meaningful learning [11]. Therefore, to develop critical thinking, the role of educational centers as a reservoir of information and professors as speakers and transmitters of information should be changed [12]. On the other hand, instead of acquiring and retaining information, students should increase their thinking and reasoning skills and apply them in practice after processing the information [8].

Despite the importance of critical thinking, recent studies in educational and clinical environments have shown that nursing students largely lack appropriate critical thinking skills [13]. Traditional education methods all focus on a linear model of thinking [14]. Therefore, they cannot be used in the current complex educational environment. Meanwhile, the concept map is a new metacognitive approach in education that can improve the critical thinking and decision-making skills of students and nurses [15].

Concept map is one of the active teaching methods and a schematic and two-dimensional tool for presenting a set of concepts in the framework of propositions [16]. In fact, a concept map is a schematic presentation of the connection of one concept with another concept, as well as their connection with other concepts around a specific topic, which is arranged in a hierarchical pattern [17]. Knowledge that is learned in a meaningful way such as a concept map remains in the mind for a longer period of time, and improves critical thinking skills and problem solving ability in students and nurses [18].

Various studies have been conducted on the effect of the concept map approach in nursing education worldwide, there are inconsistencies in their results. These studies were conducted in small and limited populations and did not examine potential factors such as age, sample size, and population studied. Despite the importance of the topic, a wide search of studies and sources did not show any study that systematically examines the effect of the concept map approach in nursing education. Therefore, the current systematic review and meta-analysis was conducted aimed to investigate the effect of the concept map approach in nursing education in order to obtain a clear result. It is hoped that the systematic review of the studies will improve the critical thinking and decision-making skills of students and nurses.

The present systematic review and meta-analysis, which examined the impact of the concept mapping approach in nursing education, was conducted according to the PRISMA 2020 guidelines [19].

In this study, MagIran, SID, PubMed, ProQuest, Web of Science, Scopus, and Google Scholar databases were searched with the keywords “Conceptual Map”, “Concept map”, “Nursing” and their combinations. There was no restriction on the year of publication in this study, and all studies were reviewed without time limit until November 2023. In this regard, Medical Subject Headings (MeSH) were used. In order to search for studies, a search strategy defined for each database was used. In addition, a reference list of all found studies was manually searched to find additional studies. Searches were conducted in both Persian and English. The Persian equivalent of these keywords was used to search in internal databases. For example, the PubMed search strategy was defined as follows:

The inclusion criteria for the study were: interventional nature of the study, access to the full text of the article, having sufficient data to enter meta-analysis, and unrelated studies, observational studies, review articles, theses, case reports, letters to the editor, abstracts, and replicated studies were excluded from the analysis. Studies without a control group were also excluded from the study. Also, studies that had low scores on the JBI checklist were excluded from the study. According to the inclusion and exclusion criteria, the titles and abstracts of the articles were reviewed independently by two researchers, and relevant cases were separated and their full text was reviewed. In case of disagreement between the two researchers, it was resolved through discussion, and if no agreement was reached, a third person was consulted.

Risk of bias was assessed by two authors independently using the Cochrane Risk of Bias tool for allocation sequence, allocation concealment, blinding, incomplete outcomes, and selective reporting in randomized controlled clinical trials and using the ROBINS-I tool in quasi-experimental studies.

Then, essential information about the articles, such as the name of the first author, year of publication of the article, sample size, location of the study, mean and standard deviation of the educational performance score before and after the intervention of the case group and the control group, the study population, and the qualitative assessment score, were recorded in a previously prepared form.

The Joanna Briggs Institute checklist was used to assess the quality of studies [20]. The JBI checklist has 13 different questions. For scoring, “Yes” was given if mentioned, “No” if not mentioned, and “NA” if not reported. The minimum and maximum scores based on the number of “Yes” were 0 and 13, respectively. Studies of high and moderate quality (score higher than 7) were included, although in the present study, there were no studies that scored less than 7 and were excluded from the study. The risk of bias was rated using a low, high, and unclear rating scale. The quality of studies was independently assessed by two authors (AF and ZHB).

In this study, the indicator investigated was the effect of the concept map approach in nursing education, which was used to combine the results of different studies from the mean and standard deviation of the intervention group and the control group in each study. The data were analyzed using Comprehensive Meta-Analysis software (CMA, Version 2.0, New England, NJ, USA). The standardized mean with a 95% confidence interval was calculated as the effect size. In the present study, the heterogeneity of studies was analyzed using the I2 index, and an I2 index of less than 50% was considered as"low heterogeneity"and greater than 50% as"high heterogeneity". Subgroup analysis and meta-regression were used to further investigate the source of heterogeneity. Egger's regression intercept was used to examine publication bias. The significance level was set at 0.05.

Using search strategies in different databases, a total of 579 studies were found, and 210 duplicate and overlapping studies were excluded. After checking the titles and abstracts, 316 studies were excluded due to lack of relevance to the topic of the study. Then, the full text of the remaining 53 studies were carefully examined, of which 9 studies were excluded due to not meeting all the inclusion criteria. Therefore, 44 articles related to the inclusion criteria were included in the meta-analysis. The steps of the PRISMA 2020 flow diagram are depicted in Fig. 1.

PRISMA 2020 flow diagram of the present study

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The total sample size of all articles included in the study was 1722 people in the intervention group and 1712 people in the control group. The oldest study was from 2005 and the most recent study was from 2022. The spectrum of the qualitative assessment of the studies based on the JBI checklist was between 9 and 13. The characteristics and data of the articles included in the systematic review and meta-analysis are presented in Table 1.

According to the results of the meta-analysis, there was a lot of heterogeneity between the studies (I² = 95.58), therefore, the random effects model was used to combine the studies and the final results. As a result of the combination of studies, the score of education effect in the intervention group showed a significant increase of 1.693 ± 0.194 (CI: 95%) more than the control group, which was statistically significant (P < 0.001). Forest plot (Fig. 2) shows the estimate obtained by combining all studies and the standardized mean difference in each study. The 95% confidence interval is shown by the horizontal line of each square (Fig. 2). According to the results of Egger’s regression intercept shown in Fig. 3, there was a publication bias in the studies at the 0.01 level (P < 0.01). The results of the sensitivity analysis showed that the final result does not change significantly by removing any of the studies (Fig. 4).

Forest plot of the studies included in the meta-analysis before and after the intervention in the control and intervention groups

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Funnel plot of the studies included in the meta-analysis before and after the intervention in the control and intervention groups

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Sensitivity analysis chart before and after intervention in control and intervention groups based on random effects model

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Meta-regression in this study was used to investigate the relationship between potential factors such as the year of study (Fig. 5) and sample size (Fig. 6) with the standardized mean difference before and after the intervention in the control and intervention groups. The results showed that the relationship between the year of the study and the sample size with the mean difference before and after the intervention in the control and intervention groups was not significant (P ˃ 0.05), (Figs. 5 and 6).

Meta-regression of the relationship between the year of the study and the standardized mean difference before and after the intervention in the control and intervention groups

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Meta-regression of the relationship between the sample size and the standardized mean difference before and after the intervention in the control and intervention groups

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Considering the high heterogeneity among the studies, subgroup analysis was performed according to the study population. The results showed that the positive effect of the intervention was greater in the population of nursing students than in the group of nurses, but the difference between the two groups was not statistically significant (P ˃ 0.05), (Table 2).

The present study was conducted aimed to determine the effect of the concept map approach in nursing education using the systematic review and meta-analysis methods. After combining the data from 44 reviewed articles, the results showed that the educational performance in the intervention group increased significantly more than the control group, which indicates the positive effect of using the concept map approach in nursing education. The systematic review and meta-analysis study by Yue et al., [61] has also shown the positive effect of the concept map approach in nursing education, which is consistent with the present study. The slight difference with the results of this study may be due to the number of articles included in the meta-analysis (11 articles versus 48 articles), and the fact that a relatively considerable number of studies included in the present study were conducted after 2017. The results of the present study showed that the use of the concept map model can significantly impact the teaching process outcomes, particularly in enhancing learning among nursing students and nurses. The findings of various studies also indicate this effect [35, 41, 57, 60]. In the study by Chen et al., the use of the concept map model significantly influenced critical thinking and learning in students [28]. Similarly, in the study by Dehghanzadeh, the use of this model had a significant effect on the teaching and learning process of nursing students [58]. Additionally, in another study, this model had a significant impact on the critical thinking skills of nurses and led to improvements in the design of nursing care for patients [57].

In explaining the results, it can be said that the use of the concept map model can enhance the understanding of concepts and their relationships among learners [62]. It improves critical thinking [13] and clinical reasoning in learners [63] and enriches learning experiences [64]. Furthermore, utilizing this model in teaching can facilitate conditions for active learning [65].

The meta-regression results showed that with the increase in the year of conducting the study, the effect of the intervention also has an upward trend. Although this result was not statistically significant, it was probably due to the development of educational methods in universities and medical training centers for students and nurses, an increase in the literacy level of healthcare personnel, and an increase in educational facilities and equipment.

Egger's test indicated bias (P < 0.01), this may be due to the lack of searching databases in different languages. Therefore, it is suggested that further studies should search all databases in different languages.

The results of the subgroup analysis showed that the positive effect of the intervention was greater in the population of nursing students than in the group of nurses. Because students are in the middle of their studies and usually have no other job than studying, but nurses are usually more busy and may have other responsibilities such as wife and father/mother roles, so nurses show less interest in learning than students. Academic progress of students requires having a positive attitude towards the field of study and strong motivation. The attitude towards the field of study is apparently considered an individual matter. This is while the educational attitude from the perspective of psychology and sociology has a wide social dimension in addition to individual components. Among the social factors, we can mention the social environment, surrounding people, parents, teachers and other groups that are effective in creating, cultivating and consolidating positive or negative attitudes towards the field of study in students [66].

In today's advanced world, one of the indicators of a person's success is academic progress, without which the development of any country will not be possible [67]. The development of any country is directly related to its progress of science, knowledge and technology, and scientific progress cannot be achieved unless people with creative thinking are trained. Academic progress is both effective in the development of the country and at smaller levels leads to finding a suitable job and position, and as a result, sufficient income [68]. Productivity and improving the quality of the education system are among the most influential factors in the development of countries. The experiences of developed countries such as Japan in the field of comprehensive development also emphasize investment in educational and human resources [69].

One of the strengths of the study was estimating the extent of the standardized mean difference before and after intervention in control and intervention groups by reviewing 48 published papers for the first time. One of the limitations of this study was the high heterogeneity in the studies (more than 90%). This heterogeneity forced us to use meta-regression based on potential factors such as publication year and sample size, as well as subgroup analysis based on the study population, which resulted in some reduction of heterogeneity, but still high heterogeneity within subgroups, Which may be due to cultural factors and educational contexts. Other limitations include the lack of identical reporting of articles, the non-random selection of samples in some studies, the lack of uniform execution method, and the lack of full text of articles presented at the conference.

WoS:

Web of Science

MeSH:

Medical Subject Headings

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

JBI:

Joanna Briggs Institute

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This study is the result of research approved by the Student Research Committee of Kermanshah University of Medical Sciences (50003263). We would like to thank the esteemed officials of that center for accepting the financial expenses of this study.

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A.F and A.J contributed to the design, R.J, A.F, Z.B and A.J participated in most of the study steps. A.J and R.J prepared the manuscript. A.J and A.F assisted in designing the study, and helped in the, interpretation of the study. All authors have read and approved the content of the manuscript.

Correspondence to Amir Jalali.

The present study was approved by the Ethics Committee of Kermanshah University of Medical Sciences (IR.KUMS.REC.1402.270). In order to conduct this study, all the ethical issues of the Declaration of Helsinki were observed from the search for articles to the publication of the results.

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The authors declare no competing interests.

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