Teaching Strategies for Developing Clinical Reasoning Skills in Nursing Students: A Systematic Review of Randomised Controlled Trials

Round 1

Reviewer 1 Report (Previous Reviewer 1)

Dear authors

The presentation of the manuscript much improved. It is necessary that the results of the included studies be mentioned in detail

Author Response

For research article

Author Response File: Author Response.docx

Reviewer 2 Report (Previous Reviewer 2)

Noticing that this is a resubmission if a previously rejected article, this research has addressed part of my concerns in the previous review. It appears that the topic of this work is suitable for this special issue.

The introduction section is improved and also the whole article is more completed. The writing style is in general improved as well.

Still, some improvement should be made before accepting this work. Some comments are as follows:

-The concerns regarding the RQ from the last review is not resolved. The research questions should be improved so as to reflect the broader aim of this research with these questions. Meanwhile, some RQ is not addressed throughout the work (E.g. which outcomes were studied?).

- New concerns is developed regarding the figure 1. In the last filter “reports excluded (n=30)” is confusing.

- Given that the authors has incorporated ideas from the other reviewer to include new database and extended the timeframe of review. Still, the same 17 articles was left behind after the whole process, thus the quality of this systematic review is not really improved in terms of the width.

-It is reported that there are studies, both effective ad ineffective reported for two groups. Not sure how did the authors get to the conclusion. In particular, the authors advocate a virtual simulation “Chang er al., 2021”, which only last for 40 mins which perhaps does not really fit into the conclusion. Also, I think the outcome could have been study more in depth. Studies could have been proved effective in some situation, if the authors would like to state one teaching method is as good as the traditional one (line 243), but ineffective if the control group is with no teaching.

Nil.

Author Response

Comments 3: Given that the authors has incorporated ideas from the other reviewer to include new database and extended the timeframe of review. Still, the same 17 articles was left behind after the whole process, thus the quality of this systematic review is not really improved in terms of the width. 

Response 3: Thank you for pointing this out. We agree with this comment. Therefore, we have made the following changes. The first journal reviewers advised us to focus only on RCTs, so we eliminated quasi-experimental studies. Besides we performed a second review of the literature in the SCOPUS database introducing seven new articles, so the sample size was 17. Moreover, in this last review, we decided to focus only on nursing students, then 2 articles were removed and therefore we had a final sample size of 15 final articles.  

Comments 4: It is reported that there are studies, both effective and ineffective, reported for two groups. Not sure how did the authors get to the conclusion. In particular, the authors advocate a virtual simulation “Chang er al., 2021”, which only lasts for 40 mins which perhaps does not really fit into the conclusion. Also, I think the outcome could have been studied more in depth. Studies could have been proved effective in some situations, if the authors would like to state one teaching method is as good as the traditional one (line 243), but ineffective if the control group is with no teaching. 

Response 4: We also agree with your comments. We have, accordingly, made the following changes. We specify in the discussion section more in-depth which skills improved in nursing students and in which context, line 176 to line 246.  

We also added the outcomes that have proven effective, line 214-221: 

“The different learning methods impact on various learning outcomes and students' variables. Team-based learning [28], reflective training [29] the person-centred education program [30], web-based concept mapping [33] and teaching cognitive-behavioural approaches [34] have proven to be effective in enhancing problem-solving abilities, knowledge and reasoning process, and consequently improve the quality of nursing practical education to. Team-based learning increased problem-solving ability scores significantly while in the control group decreased [28]. Reflective training, developed in China, based on the new mentoring approach, was effective on nursing students to explore, think about, and solve problems actively during an internship and consequently improve their disposition for critical thinking [29]. The person-centred education program using design thinking can effectively improve how nursing students perceive individualised care. Using design thinking allowed the students to apply their theoretical knowledge of the program to plan innovative solutions that may effectively resolve real health problems [30]. These programs were developed in 5 or 6 days [30, 34], 1 week or 3 weeks [28, 33] and 1 year [29]” 

Besides in reference to the effectiveness of the studies we added information about the extend time of the intervention and the sample, line 222-231: 

“The education program focused on improving ethical decision-making had statistically significant improvements in nursing students' self-efficacy in communication confidence, complex ethical decision-making skills and decreased communication difficulty [31]. The case-based learning was more effective with lectures than without them, in developing students' critical thinking abilities [32]. This study was one of the longest developed with 300 hours during one school year. This long learning intervention could have a positive impact in the study sample. Therefore, the time of the learning intervention could be a limitation in the studied RCTs. The one-time self-instruction guide was ineffective in impacting students' diagnostic accuracy in solving case studies [35], and it is possible that only one day of intervention is not enough” 

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report (Previous Reviewer 2)

Thank you for taking my comments into consideration. The discussion is in-depth and convincing. I just wonder if this version provided is the latest since some response to comments in not reflected in this version.

Response 1: the change in RQ is not included in this v2.

Response 2: The last exclusion (n=15) is not shown in anywhere in the v2.

Author Response

v

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Dear authors

I would like to thank you for giving me the opportunity to review the manuscript entitled " Clinical reasoning in nursing students-educational strategies”. As a systematic review, this study does not have the necessary standards, it has very poor writing, and the synthesis of the results is not done well. I won't go into too much detail and will make some points:

Title

1. Systematic review should be identified in the title.

Abstract

2. Abstract is not informative. Please follow the PRISMA 2020 for Abstracts.

Methodology

3. According to the number of retrieved studies, it seems that the process of selecting keywords and searching has not been done well. Why isn't Scopus used for searching?

4. A search query must be provided for each database separately.

5. I suggest to use appropriate sub-headings for this section: Protocol and registration, Search process and eligibility criteria, Study selection, Risk of bias / quality assessment, Data collection process and synthesis of results

6. Why is the risk of bias of the studies not evaluated?

7. The figure is very messy.

Results

8. The synthesis of studies is not well done and is not informative.

Conclusion

9. What about conclusion?

Reviewer 2 Report

This research provides a critical review of the past studies regarding the education strategies to nurture clinical reasoning in nursing students. It appears that the topic of this work is suitable for this special issue. Still, significant improvement should be made before accepting this work. Some comments are as follows:

-English standard of this work should be improved. The title is not clear as well.

-The introduction is not well constructed. The context, necessity of this research is not explained clearly. This part regarding detailed descriptions of different teaching strategies seems to be “artificial” as it correctly maps with the results.

-The research questions should be improved so as to reflect the broader aim of this research with these questions. Meanwhile, some RQ is not addressed throughout the work (E.g. which outcomes were studied?).

-Not sure why it is empty in section 3?

-The description of line 131 (25 articles did not meet the selection criteria) seems not to be correct.

-It seems that only the authors only report the teaching strategies in section4 while the effectiveness is not mentioned. Therefore, it is hard to come up to conclusion in Section 5, that problem based learning is more effective. Meanwhile, the time of intervention should be took into consideration when such judgement is made.

- the discussion part does not really integrate all the results. In most cases, it just repeat individual results of one of the article identified.

The English standard could be further improved. It is suggested to unify the use of tense used in each section. Also, the title could be further improved.

Reviewer 3 Report

dear author.

Thank you for reading. 

I wanted to congratulate you on your work. You have done a very good job. However, I would like to make a number of clarifications that I think would improve the quality of your report.

- The inclusion criteria are described in a veiled manner in the text. Could you make them explicit, as well as the exclusion criteria?

- You adequately describe the process of double-blind reading of the abstracts of the initially selected research papers and the establishment of a scoring process with CASPE for the finally selected papers. In this regard:

-- Could you indicate the criteria for inclusion/exclusion of a paper in case of conflicting opinions? Was there 100% agreement between the researchers on the papers included/excluded? 

-- The results of the CASPE surveys should be included in the results section, not in the methodology section, as it does not condition the selection process but illustrates the quality of the selected papers. 

-- Could you indicate the degree of consensus reached by the researchers when rating the papers evaluated with CASPE? Are the CASPE scores given as a result of the papers analysed the average of the two raters? 

--Indicate the identity of the researchers who carried out this process. Were they the authors of the work? Did any external researcher participate?

- The boxes in Figure 1 should be improved. They are partially legible.

- The Discussion section offers a reflection of the results found in your research, and denotes an apparent comparison of the results of your work with other similar work or aspects to be taken into account. Please modify this section accordingly. 

- 33% aprox of the papers referenced are more than 5 years old. You could replace them with more up-to-date references. Please justify it conveniently. 

Kinds Regards

Reviewer 4 Report

Thank you for the opportunity to review your article, I agree that clinical reasoning is a vital skill for health professionals to learn and that with some variations in your article you will be able to articulate this as well.  I do find that, which an important topic, you have not clearly demonstrated the importance in your article introduction.  This may be a matter of language and article structure though and I believe you can make this clear with revisions.  I do also have a number of other comments which I hope you will find helpful in a subsequent draft submission.

Thank you again and I hope to be able to review a later submission with corrections.

Comments for author File: Comments.pdf

There are some sections where English language expression was in need of correction, however there are others where language was easy to follow and read.  I would encourage you to seek some editorial support on English language expression if it is not your first language.