Midwifery is a practice-based specialty; with education programs aimed at cultivating skilled midwives with solid theoretical knowledge, proficient clinical practice skills, and the interpersonal skills required for caring for pregnant women and infants [11]. The four-year or five-year bachelor's degrees; direct entry midwifery programs were re-established in four university nursing schools in 2016 after several years in abeyance[3]. Baccalaureate midwifery education is still developing in China in the face of a growing urgency to graduate increased numbers of midwives to meet demands under the recently implemented "Three-Child Policy".
Historically, the midwifery education model was theory-based and taught in a traditional lecture-based format. However, such traditional models of midwifery education may no longer meet the needs of students. Students are reported to have often challenges in relation to participation and engagement in their own learning, difficulty integrating theory and practice, and a lack of ability to problem-solve in the clinical environment. [12]. As a consequence, new graduates become comfortable with clinical work only when working at a hospital, with the development of critical thinking skills requiring immersion in authentic and/or simulated clinical settings and interaction with patients. Compared to the traditional training model, some studies have demonstrated the advantages of either CBL or bedside teaching[13–16]. Bedside case-based learning(BCBL) is a specialized form of interactive small-group teaching in the patient's presence in the hospital and is reported to be a better way to integrate theoretical learning with clinical practice for midwifery students[4]. Previous studies have generally focused on either CBL or Bedside teaching as separate approaches. Furthermore, several studies have shown that the practice of bedside teaching has been declining in recent years for a variety of reasons, including an increased patient turnover secondary to reduced lengths of stay, concerns regarding patient privacy, and the higher costs associated with this intensive approach to teaching[13]. With the outbreak of COVID-19, simulation-based education replaced bedside teaching in health professions education[17]. Some studies have shown that the difference in knowledge and skills between non-bedside simulation teaching and bedside teaching is not significant[18–20]. The difference may lie in communication skills and abilities.
In this study, we combined bedside teaching and case-based learning in order to provide more interactive sessions. Our pre-post test design found that the scores for SRSSDL were not significantly different. One reason may be the small sample size with only sixty-seven participants. Although the scores did not show any significant difference in self-directed learning abilities pre- and post-class, students self-reported making progress in three dimensions: awareness, learning activities, and evaluation. The results also showed that students were acquiring new knowledge beyond the prescribed course objectives and raising questions independently.
Several studies are consistent with the results of our study. A study by Kulkarni et al. in 2019 reported highly positive results in the integration of case-based learning strategies in bedside clinics[21]. Their study reported a high level of motivation among the students using this approach (88%). Dubey et al. and Nair et al. also reported similar results; showing 74–98% motivation among the students to learn using additional resources [22, 23]. Moreover, bedside teaching may be more engaging for students by presenting case scenarios and allowing the students to solve problems the way they would as midwives working in wards. This BCBL approach is similar to the approach used by the United States Medical Licensing Exam (USMLE) in their final step 3 (Clinical Case Simulators).
Previous reviews have demonstrated that bedside teaching can improve the communication abilities of medical students and residents[14]. However, our study did not identify any significant improvement in students' interpersonal skills. One possible reason may be that the number of people in each bedside teaching group is limited to ten. In addition, when taking a patient's medical history, not every member of the group can engage in effective nurse-patient conversation. Students self-reported the lowest score in the domains of "share information with others" and "easy to work with others." Clinical instructors may lack relevant teaching skills to encourage students to participate in teamwork.
Previous studies have shown that CBL is effective in teaching specialized nursing courses and increases students' satisfaction and critical thinking skills[24]. Our study compared the pre-and post-class scores of each item in the Chinese version of the Critical Thinking Disposition Inventory (CTDI-CV) and found no statistical differences between pre-and post-class scores in each dimension. One possible reason may be that the clinical instructors themselves lack training in developing critical thinking skills in students. According to Glen[25], critical thinking is considered as an indispensable element of education and a trait of an educated person. The disadvantage is that one is unable to teach critical thinking if one is not a critical thinker oneself. Educators may not have their own critical and reflective thinking developed when they were learners, which makes it difficult for them to facilitate critical thinking as instructors. Approaches to developing those skills in educators may be an area that needs further exploration.
Limitations
The outbreak of COVID-19, which resulted in visiting restrictions at hospitals, presented a serious limitation to further study. In addition, we did not include a control group with a standard teaching model for the analysis. Case-control studies with a larger sample size should be considered in future research to lessen the risk of confounding factors.