Critical Thinking and Self-Efficacy Using Mind Mapping Learning Technique for Patient Care among Nursing Students

Poor quality and substandard healthcare to patients leading to harmful results are of the many global public health challenges in recent times, potentially devastating, and often preventable. Millions of patients suffer injuries due to medication errors, misdiagnoses, and surgical complications contribute to avoidable deaths and severe health outcomes each year (1). Around 1 in every 10 patients is harmed in health care and more than 3 million deaths occur annually due to unsafe and substandard care. In low-to-middle income countries, as many as 4 in 100 people die from unsafe care (2)

Pakistan, located in South Asia, is one of the lower-middle-income countries which has a population of over 220 million with diverse ethnic population (3). The stats show that 82.8% of patients were not satisfied with the care they received (4).

Nurse-led interventions can substantially significantly improve patient outcomes which may result in reduction in hospital readmission rates by 25% (5), improvement in patient satisfaction scores by 15% (4), helping to promote a positive and constructive work environment and decrease in reducing nurse turnover rates by 20% (6) and enhancing improvement in patient safety (7).

A mind mapping learning technique is a brainstorming technique which is used to visually organize random information into an orderly manner. It features one main idea being the focus point as the central point of the diagram, with subtopics branching out and connecting to supporting ideas (8).

Critical thinking is the way of analyzes critically and adapting to new challenges situations. It encompasses a range of essential skills such as, the ability to analyze arguments, draw inferences through inductive or deductive reasoning, assess and evaluate situations, and make informed decisions or solve problems (9).

Critical thinking is a core nursing competency that enables accurate assessment, analysis, and informed clinical decision-making. Mind mapping is an effective learning strategy for nursing students, enhancing understanding and promoting analytical and critical thinking skills (10).

   Improved self-efficacy is often necessary for better academic results and overcoming challenges among nursing students (11). By fostering critical thinking and self-efficacy, mind mapping learning technique can contribute to produce more confident and competent nursing professionals, which is essential for positive health outcomes and patient safety (12).

A quasi-experimental one-group pretest–posttest study was conducted at Saida Waheed FMH College of Nursing, Lahore, to evaluate the effect of the Mind Mapping Learning Technique on critical thinking, self-efficacy, and quality of patient care among nursing students. Using a purposive sampling technique, 57 undergraduate BSN students from the 3rd and 4th academic years (aged 18–25 years) were recruited, while students with severe psychiatric or medical conditions were excluded. Data were collected using validated instruments, including a demographic questionnaire, the 25-item Critical Thinking Questionnaire (CThQ), the Schwarzer and Jerusalem General Self-Efficacy Scale, and the physical category of the Wandelt and Ager Quality Patient Care Scale (QUALPACS), with permission obtained from the original developers. The intervention was implemented over 16 weeks and comprised 32 structured sessions incorporating conceptual, creative, clinical, and collaborative mind-mapping activities aimed at enhancing analytical thinking, confidence, clinical reasoning, and patient care competence. Pre- and post-intervention assessments were conducted using the same tools, and data were analyzed using SPSS version 25 with descriptive statistics and the Wilcoxon Signed Rank Test, considering p ≤ 0.05 as statistically significant. Ethical approval was obtained from the Institute Research Ethics Board of The University of Lahore, written informed consent was secured, confidentiality and anonymity were maintained, and participants were informed of their right to withdraw at any time without penalty.

Table 1: Demographic characteristics of the participants (n=57)

Table 1 shows that the majority of participants were aged 22–25 years (63.2%), followed by aged 18–21 (36.8%). In terms of gender distribution, 57.9% were females and 42.1% were male. Academic status data revealed that 26 (45.6%) participants were from final year and 31 (54.4%) were from third year.

Table 2: Comparison of Critical Thinking Before and After Intervention group (N=57)

Table 2 showed a marked improvement in critical thinking levels following the intervention. Participants with low critical thinking decreased from 54.4% to 1.8%, while those with high critical thinking increased from 1.8% to 75.4%, with the highest gain observed in the high-level group. The statistically significant results (p < 0.001) confirm that the intervention effectively enhanced participants’ critical thinking skills.

Table 3: Comparison of Self-Efficacy Before and After Intervention group (N=57)

Table 3 demonstrated a substantial improvement in self-efficacy levels after the intervention. Low self-efficacy decreased from 74.5% to 7%, while high self-efficacy increased from 3.5% to 78.9%, with the greatest gain observed in the high self-efficacy group. Overall, the statistically significant changes (p < 0.001) indicate that the intervention effectively enhanced participants’ confidence and perceived ability to manage challenges.

Table 4: Comparison of Quality of Patient Care Before and After Intervention group (N=57)

Table 4 revealed a marked improvement in quality of patient care following the intervention. The proportion of students providing poor care decreased from 93% to 3.5%, while those delivering best care increased from 3.5% to 61.4%, with corresponding rises in mean scores. Improvements were also observed in the better and average care categories, with the greatest gain noted in the better care group. Overall, the findings demonstrate that the intervention significantly enhanced nursing students’ clinical competency and quality of patient care across all performance levels.

Table 5: Critical Thinking, Self-Efficacy and Quality of Patient Care Before and After Intervention Analysis (n=57)

Wilcoxon Signed Test with p<0.05 value as significant

Table 5 demonstrated a highly significant improvement in critical thinking, self-efficacy, and quality of patient care scores following the intervention (p < .001). The findings indicate that the mind mapping learning technique effectively enhanced

Table 5 demonstrated a highly significant improvement in critical thinking, self-efficacy, and quality of patient care scores following the intervention (p < .001). The findings indicate that the mind mapping learning technique effectively enhanced participants’ clinical competence, confidence, and ability to deliver high-quality patient care.

The results of the current quasi-experimental study indicated a statistically significant increase in critical thinking, self-efficacy among nursing students for quality of patient care who participated in the mind mapping learning technique intervention. These findings provide evidence to support the alternative hypothesis and reinforce the importance of supportive and engaging learning environment and help to prepare the nursing students to think critically and act confidently in high-pressure or high-stress clinical environments.

According to current study findings nursing students were within age group of 18–25 years, showing the common enrollment trend in undergraduate nursing programs. Similar age distributions have been documented in studies conducted in Pakistan, where the majority of nursing students fall into this young adult age range (13). The Majority of nursing students are females 33(57.9%). This pattern is generally documented in the literature, as females continue to represent the majority of nursing students (14). However, a contrasting study from India reported a higher percentage of male nursing students (15), reflecting gender diversity is gradually increasing in some areas. In the current study the majority of nursing students participating in the intervention were from third year as compared to the fourth year. This pattern aligns with previous research (13), perhaps as a result of a more balanced academic load than in the final year. In contrast, a research conducted in Karachi indicated a higher representation of fourth-year nursing students (16). These demographic features may have favorably influenced the effectiveness of mind-mapping, since learners at this stage tend to be more flexible to new instructional methodologies and motivated to develop their clinical decision-making abilities.

One of the most notable findings of the mind mapping learning technique was the extensive enhancement in overall critical thinking among nursing students. These results closely coincide with the findings of Wu and Wu (10) and Elasrag and Elsabagh (17) who professed that mind-mapping improved critical thinking among undergraduate nursing students (p < .001) rather significantly. However, a study conducted in Benue State, Nigeria contradicted these findings as it mind-mapping intervention did not result in a considerable change in critical thinking among nursing students. It may be possible due to comparatively shorter intervention duration and contextual differences in instructional delivery (18).

This study indicates a significant improvement in nursing students’ analytical skills and attention to detail, showing improved critical thinking for patient care. The cognitive benefits of same nature were observed in the studies by Mohamed El-Sayed, Mahmoud Abdel-Azeem (19) and Ernawati and Dewi (20) where organized interventions such as mind mapping improved nursing students’ critical thinking and decision-making abilities; however, the visual, organizational, and integrative thinking techniques combined together in the current study, rather uniquely, which may have contributed to the superior gains observed in overall critical thinking.

Significant improvements in applied critical thinking skills were also displayed by the participants as evidently observed in this intervention. Similar effects were observed in other studies as well; for example, YANG, LI (21) demonstrated improved problem-solving and integrative thinking among nursing students following structured mind mapping exercises and Lestari, Wibowo (22) reported increased analytical skills and clinical reasoning after mind mapping interventions.

Significant improvements indicated that the mind-mapping intervention enhanced both nursing students’ ability to approach patient information from multiple perspectives and strengthened their critical evaluation of diverse sources, leading to more operative and conversant clinical decision-making. Our results showed consistency with the De Jesus study (23).

The results strongly suggest that the mind mapping learning technique intervention is greatly effective in enhancing critical thinking self-efficacy among nursing students transitioning to clinical rotations for quality of patient care. This intervention may prove to be particularly effective in promoting active engagement, deeper analysis of patient information when it is compared to traditional lecturers’ methods (24) and concept mapping interventions (25) educational orientations (26), or simulated-based learning (27), resulting in fostering nursing students’ confidence in clinical decision-making. 

Overall, the results give us clearly indication that mind-mapping is highly effective when it comes to improving nursing students’ critical thinking abilities. These results are in line with Zheng, Johnson (28), who reported that as compared to traditional teaching methods, the collaborative mind-mapping significantly enhanced nursing students’ self-efficacy, and motivation.

   The present study demonstrated a substantial improvement in nursing students’ quality of patient care following the mind-mapping intervention. These results align with a quasi-experimental study conducted among maternity nurses, which discovered that nurses’ performance significantly improved after implementing a mind-mapping strategy intervention, and intrapartum women reported higher satisfaction with the quality of patient care (29). This aligns with previous studies indicating that mind-mapping increased patient-reported satisfaction when combined with standardized patient simulation (30). Zhang, Jiao (31) also reported improvements in clinical care performance following mind-mapping interventions.

The findings of this study highlight that the mind-mapping learning technique is an effective, student-centered strategy to enhance nursing education outcomes. Overall, this study provides a framework for innovative teaching practices in nursing programs across Pakistan and similar contexts, supporting the development of competent, confident, and patient-centered nurses capable of delivering higher-quality care.

The study demonstrated that the mind-mapping learning technique was effective in significantly improving critical thinking, self-efficacy, and quality of patient care among nursing students. Post-intervention results showed remarkable improvements across all three domains, indicating that mind mapping encourages active engagement, reflection, and integration of theory with practice. The findings confirm that visual and student-centered learning approaches enhance not only cognitive skills but also clinical confidence and performance in patient care. Therefore, mind mapping can be considered a powerful educational tool to promote higher-order thinking and professional competence in nursing education.

Acknowledgements

The authors thank the administrative and technical support provided by Saida Waheed FMH College of Nursing, Lahore and the nursing students who participated in the study.

Funding Source

There is no funding source which supports this research in the design of the study, data collection, analysis, interpretation, or in writing the manuscript.

Conflict of Interest

The authors declare that there is no conflict of interest regarding the publication of this study.

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