Critical Thinking Level among Medical Sciences Students in Iran

Background. Critical thinking is one of the most important missions of the educational planning system of medical sciences universities around the world. Hence, identifying the level of critical thinking skills and tendency of medical sciences students to think critically is of great importance. *erefore, the aim of this systematic review was to examine the critical thinking level in medical sciences students in Iran. Methods. To extract published studies in the field of critical thinking in Iran, a search was conducted in the databases of PubMed, Web of Science, Scopus, ERIC, and Magiran. *e keywords of critical thinking, medical sciences, and Iran were used for the purpose of the search in the two languages of Persian and English and without any time limit. *e PRISMA flow diagram was applied for the selection of articles, and the Newcastle–Ottawa Scale was used for the evaluation of these papers. Results. After evaluating the quality of searched articles, 80 articles were finally selected for the final analysis.*e total sample of the articles included 12,578 students. *e results indicated that out of 51 articles conducted in the field of critical thinking skills, 48 articles reported these skills at a low level, 2 papers at a medium level, and only 1 paper at a high level in the medical sciences students. Among 29 articles in the field of the level of critical thinking disposition, 13 articles reported their tendency level at a low level, 11 articles at a medium level, and 5 articles at a high level. Conclusion. In general, based on most articles, the level of critical thinking skills in the medical sciences students in Iran was reported to be at a low level and their tendency to critical thinking at a moderate level and low level. *erefore, given the importance of critical thinking for medical sciences students, future studies should consider factors influencing the increase of the critical thinking level in these students. In this regard, formation of some training workshops can also be promising. Furthermore, reviewing the medical sciences curriculum should be taken into consideration by the policymakers and educational planners so as to strengthen the level of critical thinking in the medical sciences students.


Introduction
Critical thinking is a major principle in the universities of the third millennium. Nowadays, along with new functions of universities such as entrepreneurship, critical thinking is also considered a new function [1]. In the age of information explosion and transition from the industrial society to a knowledge-based society, critical thinking is a key necessity in training capable manpower [2]. Owing to the growth of information and communications (e.g., radio, television, and social networks), we are experiencing a large volume of information everyday [3]. erefore, critical thinking helps individuals to differentiate correct information from incorrect information and make an accurate assessment of events [4]. Critical thinking is one of the most important necessities and qualifications of living in the modern world. Health sciences students, as one of the most important pillars of the healthcare systems, should possess critical thinking in order to be able to make better decisions in dealing with different phenomena and situations [5]. Today, it is emphasized that the critical thinking, as a vital skill in the diagnostic and therapeutic decision-making, should be considered in the teaching-learning process [6][7][8][9]; as in the case of providing educational infrastructure, critical thinking can have an impact on the improvement of the quality of the teaching-learning process [10]. Critical thinking is considered as one of the dimensions of thinking and a way of thinking. Critical thinking represents a logical and argumentative thought formed as a regular and organized mental process. It focuses on the way we make decision and what we must believe [11]. Critical thinking is an essential data analysis skill that facilitates the identification, assessment, reasoning, judgment, and decision-making processes [12]. Critical thinking involves critical thinking skills and disposition. Skills form the cognitive aspect and disposition form the emotional aspect of the critical thinking. e cognitive skills forming the core of the critical thinking include the dimensions of the analysis, inference, and evaluation.
Analysis is defined as the ability to diagnose goals in different domains and to discover their relationships. Inference is also defined as the ability to diagnose valid empirical elements and evidence to make a decision about a phenomenon. Assessment is defined as validating different perspectives about a phenomenon [13,14].
Studies emphasize the importance of critical thinking skills. A study on Iranian students in 2016 showed a significantly positive relationship between critical thinking skills and decision-making ability. According to this study, critical thinking skills are one of the most important prerequisites necessary for professional competence and proper decision-making [15]. Another study in 2018 indicated a significantly positive relationship between students' inference and scientific reasoning [8]. A study in 2013 also showed a significantly positive association between decisionmaking (as one of the dimensions of critical thinking skills) and self-efficacy beliefs [16]. Furthermore, a study on Australian students indicated a significant relationship between critical thinking skills and academic performance [17]. Moreover, a study in 2017 showed teaching critical thinking skills significantly improved the students' problemsolving skills [18].
Disposition to critical thinking indicates the inclination to think critically, and it includes the dimensions of openmindedness, truth-seeking, analytical, systematic, critical self-confidence, inquisitiveness, and maturity of judgment [19][20][21][22]. Open-mindedness: people with open-mindedness characteristics are patients against the diversity of beliefs and respect other people's rights. Truth-seeking characteristics: people with truth-seeking characteristics are brave enough to ask questions and are correct in seeking information. Analytical: to be analytical indicates the tendency toward the intelligent study of phenomena and the use of reasoning. Systematic features: individuals with systematic features adopt an orderly strategy in the analysis of events and phenomena.
ese people also have a high level of concentration. Critical self-confidence: individuals with critical self-confidence believe in their abilities and skills. Inquisitiveness: inquisitive people tend to acquire knowledge and new information and enjoy new affairs. Maturity of judgment: cognitive development is an important indication of the maturity of judgment. Individuals who have this characteristic make judgments based on defined and transparent criteria [23].
Ricketts suggests that critical thinking tendencies include the cognitive maturity, mental conflict, and creativity [24]. Mental conflict: mental conflict is indicative of seeking opportunities to use reasoning in various situations. Creativity indicates individuals' talent and ability in inquisitiveness and desire to discover the truth. Cognitive maturity: cognitive maturity is defined as knowing about the complexity of subjects, tolerating others' beliefs, and knowing about one's and others' prejudices.
Several studies have been performed on critical thinking and its relationship with other variables. A study among Canadian students in 2003 showed that the tendency to think critically plays a principal role in critical thinking skills [25]. A significant association has also been reported between the tendency to critical thinking and clinical competence of Korean nurses [26]. Another study in 2017 indicated a significantly positive relationship between the tendency to critical thinking and academic self-efficacy in the Malaysian teachers [27]. Furthermore, a study among Turkish students showed that critical thinking tendencies had a significantly positive effect on social-emotional learning domains [28]. Moreover, a study in 2017 indicated a significantly positive association between critical thinking tendencies, problem-solving, and the desire for empathy [29].
Several studies conducted in Iran on the level of critical thinking in medical sciences students obtained different results. us, there is a need for a comprehensive review of these studies. Consequently, the present study aims to provide a clear and accurate picture of the critical thinking level in medical sciences students in Iran through a comprehensive and systematic review of studies conducted in this regard.

Study Questions.
is systematic review sought to answer this question: (1) What are the features of materials and methods (research method, sampling method, and critical thinking measurement tools) in studies related to the critical thinking of the medical science students in Iran (2) What is the level of Iranian medical sciences students' critical thinking skills (3) What is the level of Iranian medical sciences students' critical thinking disposition

Data Collection and Search Strategy.
e search was carried out at the international databases of PubMed, Web of Science, Scopus, and ERIC and the Persian language database of Magiran (the most comprehensive database in Persian); the search was conducted without the time limit. To find articles related to the purpose and question of the study, the keywords of critical thinking, medical sciences, and Iran were used in combination with the mediator AND.
e search strategy at the databases of PubMed, Web of

Inclusion/Exclusion
Criteria. e inclusion criteria for the study consisted of the publication of articles in Persian and English, the availability of the abstract and full text of articles, conduction of research in Iran, originality of articles (descriptive, analytical, and empirical), and the relevance of article to the purpose and question of the study. e exclusion criteria contained duplication of the titles of articles, letter to editor, and review articles.

e Process of Selecting and Evaluating Articles.
e PRISMA flow diagram was applied to select articles, as shown in Figure 1. e process of searching and selecting articles was designed in accordance with the purpose of the study. In the preliminary search process, out of 486 Persian and English articles extracted, 114 articles were deleted due to duplication. In the next step, in the process of reviewing the title and abstract of the articles, 285 articles were deleted. In the final step, the full text of 87 articles was reviewed and 7 articles were deleted. Finally, 80 articles were included in the study. e quality of these articles was examined using the Newcastle-Ottawa Quality Assessment Scale (case control/ cross-sectional studies) [30,31]. In the studied articles, the target group was medical sciences students. e term "medical sciences" refers to allied health professions. In Iran, medical sciences students refer to students majoring in health sciences.

Data Analyze.
e Newcastle-Ottawa Scale evaluates articles in terms of the three dimensions of the subject selection process, comparability, and results. Based on this scale, the articles were rated in terms of the quality from 0 (the weakest study) to 9 (the strongest study) [31]. Studies scored less than 4 were evaluated as a low quality study. To extract information from the selected studies, the researchers designed a checklist containing the items of the author's name, study title, study design (method), sample, sampling method, data collection tool, and results.

Ethical Considerations.
is study was approved by the university's ethics committee.

Results
After searching, 486 articles were obtained from the Persian and international databases. e Endnote-10 software was used to organize the articles. Using this software, 285 articles were removed due to being repetitive and irrelevant. Subsequently, the researchers investigated the full text of 87 articles. Among the total of 87 articles, 80 articles were finally evaluated in terms of quality and 7 articles were excluded (Table 1). In this regard, 3 articles were excluded due to republishing in various journals, two articles for not referring to critical thinking, and two articles due to the vagueness of the results and the uncertainty of how the scoring was conducted. Subsequently, the results were presented in 8 axes, including the author's name, year of publication, study design (method), sample size, sampling method, data collection tools, results, as well as the language of the articles.
e results indicated that all 80 articles were published during the period 2004-2018. e total sample of the 80 articles was 12,578 students. In the 60 studies performed, most of the samples were female students. Regarding the language of publication, 69 articles were published in Persian and 11 articles in English. e characteristics of the materials and methods of studies investigated are presented in Table 2. e sampling method in 27 articles was reported to be of a census method, the convenience method in 10 articles, the random method in 8 articles, the stratified random method in 19 articles, the systematic random method in one article, cluster random in 7 articles, purposive in one article, and finally, no sampling method in 7 articles (Table 2).
In terms of the study method, 65 articles were conducted using the cross-sectional method (descriptive or analytical), 13 articles using the quasiexperimental method, and one study using the longitudinal method, and one article using the causal-comparative method ( Table 2). e analysis of articles showed that 29 out of 80 articles studied were about critical thinking. Among the total studies conducted regarding critical thinking disposition, 14 studies used the Ricketts critical thinking disposition scale and 15 articles used the California Critical inking Disposition Inventory (CCTDI). ere were also 51 articles on critical thinking skills, 46 of which used the California Critical inking Skills Test, Form B (CCTST, FB), and 5 articles used the Watson-Glaser Critical inking Appraisal (WGCTA) ( Table 2). e range of scores is 0-34 for CCTST-FB, 75-350 for CCTDI, 0-16 for WGCTA, and 33-165 for Ricketts' Critical inking Disposition. erefore, in this study, the level of critical thinking in students was determined based on the cut score and the range of scores mentioned in psychometric studies.
In investigating the selected articles, we encountered two categories of articles. A number of articles focused on critical thinking skills and some articles on critical thinking disposition. us, in this article, the amount of critical thinking is presented in terms of skills and disposition.
Among the articles studied, 42 variables were used along with the critical thinking variable. Of these, 16.66% was related to academic achievement or academic performance and 9.52% was about emotional intelligence. Furthermore, 7.14% of articles focused on self-efficacy and problemsolving learning variables separately. Moreover, 4.76% of articles investigated achievement goal orientation, information literacy, self-esteem, team-based learning, metacognitive, self-directed learning, learning styles, and clinical decision-making variables and 2.38% explored occupational Education Research International therapy, team-based learning, information communication technology, mental health, metacognitive, conflict management styles, creativity, entrepreneurial characteristics, decision-making ability, metacognitive, flipped classroom, teaching quality, evidence-based education, blended learning, clinical decision-making skills, personality traits, thinking style, interpersonal communication skills, learning styles, assertiveness, active educational method, stress coping strategies, motivation, intentional Internet search behavior, collaborative and individual method, clinical decision-making, and reflection on clinical journalism variables.
e results of the second and third questions in the present study showed that students had poor critical thinking skills in 48 articles. ey had average critical thinking skills in 2 articles and high critical thinking skills in only one article. Considering the disposition to critical thinking, in 13 articles, the disposition was low or ambivalence, 11 had moderate disposition, and in 5 studies, the disposition was high or positive (Table 1).

Discussion
Based on the results of this systematic review, the level of critical thinking skills of medical sciences students in most studies was low. In other countries, studies were also conducted to measure students' critical thinking. In this regard, the results of a study in the United States (2009) indicated that the degree of critical thinking skills in pharmaceutical students was at a desirable and above average level [108]. In another study (2004), the level of critical thinking skills in physiotherapy students in Canada was evaluated at a desirable and above average level [109]. Critical thinking skills in nursing students were reported higher than that of the study conducted [110] in Australia (2014).
Regarding the low score of critical thinking skills in Iranian students compared to students from other countries, we believe that the educational system of Iran does not consider enhancing the critical thinking in students. us, the promotion of critical thinking skills in students nowadays is one of the most important challenges faced by medical teachers and educational planners [111].
Since critical thinking can be taught to students, in curriculum design, teaching critical thinking to students should be considered as a priority. To enhance students' critical thinking in the higher education curriculum, the higher levels of Bloom's cognitive domain, including analysis, synthesis, and evaluation, should be highlighted [112,113]. In order to develop critical thinking skills within the framework of medical education curriculum, appropriate teaching methods should be used that are consistent with the nature of critical thinking. In this regard, moving from teacher-centered models to student-centered models is one of the most important principles that should be considered for the teaching of critical thinking. Also, designing a classroom environment to create a challenging dialogue between class members, encouraging learners to participate in class discussions, moving toward problem-based learning, and using active learning strategies in critical thinking education is effective [114][115][116].
Regarding the disposition to think critically in students, in most studies, critical thinking was at a low and moderate level. e results of a study (2016) in nursing students in Turkey indicated that the students' disposition to think critically was at a low level [11]. e results of another study (2018) conducted in Ireland suggest that the rate of critical thinking disposition in first year nursing students was more than that of third year students [117]. Another study (2019) on medical students in China indicated that critical thinking disposition in students was at a positive level [118]. e results of another study (2015) in medical students in China indicated a positive attitude toward critical thinking [119].
In the critical thinking disposition, attention is paid to the individual's attitude and intension and various issues and topics and thinking about them. It is believed that, without critical thinking disposition, critical thinking skills cannot be developed [25]. Also, having critical thinking skills does not guarantee critical thinking disposition, and those with critical thinking disposition do not necessarily have the skills to think critically. erefore, the subject of critical thinking should be taken into account, as well as critical thinking skills and its significance must be fully understood [120]. We believe that critical thinking disposition and critical thinking skills are interdependent. Having critical thinking skills is useless without critical thinking disposition and cannot in practice be used by students. Moreover, if students are inclined to think critically in an educational system, but educational, technological, and cultural infrastructures are unavailable, the disposition to think critically will be reduced after some time.          In studies with a quantitative approach, a questionnaire is the most important data collection tool. Hence, psychometric indices, number of questionnaire items, response time, and compatibility with sociocultural characteristics of respondents should be taken into account in choosing the measurement tools. Researchers should use the qualitative approach and semistructured interviews for accurate diagnosis of critical thinking skills and the tendency to think critically.
Regarding the promotion of critical thinking in health sciences students in Iran, it can be stated that curriculum elements including the objective, learning content, teaching methods, learning activities, and learning assessment should be designed in a way to facilitate the process of critical thinking. e structure and process of teaching-learning in the classroom should be such that the teacher plays the role of facilitator and gives students the opportunity to express their opinion. Learners should be involved in the learning process and have the greatest role and responsibility in their learning. In addition to the role of educational factors, the sociocultural conditions and characteristics of a society are  also influential in the critical thinking of members of a community, including students. In one sentence can state that the critical thinking spirit must be rooted in sociocultural structures of a community. e present study confronted with some limitations. ere might be some studies conducted in line with the purpose of the present study, which, due to nonpublication, was not included in this study. Also, in our study, we studied only studies published in Persian and English, and studies in other languages could not be considered due to language constraints. In the current study, the studies differed in terms of quality, which could affect the accuracy of the results. Nonuniform reporting of articles is another limitation of the present study. e present study, like many qualitative studies, sought to establish a deep understanding of a subject. erefore, the most important strength of the present study was to explain the current level of critical thinking skills and the tendency to think critically in students of health professions in Iran. Another strength of this study is the identification of variables related to critical thinking. erefore, in future studies, researchers can more closely examine the relationship between these variables and critical thinking. e findings of this study alone are not sufficient for planning and making major decisions about critical thinking in health students. However, according to the results of studies on critical thinking in Iranian students, as well as the results of the current study, it is possible to plan and decide to promote critical thinking in students.

Conclusion
In this systematic review, the rate of critical thinking of medical sciences students in Iran was studied. e amount of critical thinking was identified in two aspects of critical thinking skills and critical thinking disposition. e results indicated that critical thinking skills in medical sciences students in Iran were low. Students' disposition to think critically was also moderate and low. us, considering the importance and necessity of critical thinking for medical sciences students, future studies should focus on studying and identifying effective factors in promoting critical thinking in students. Considering that critical thinking can be taught, it is beneficial to hold workshops and critical thinking training courses.
Data Availability e identified datasets analyzed during the current study are available from the corresponding author upon request.

Conflicts of Interest
e authors declare that there are no conflicts of interest.