Developing Cognitive Skills Through Active Learning: A Systematic Review of Health Care Professions

Game-Based Learning

Nine studies^8–16 were available to investigate the effect of GBL on lower-order cognition. Five of the 9 studies (56%) provided support for the use of GBL for enhancing knowledge. For example, Aljezawi and Albashtawy⁸ investigated knowledge acquisition and performance in nursing students participating in passive and GBL methods. While both groups were successful at attaining knowledge gains, the GBL group showed significantly greater knowledge acquisition both at initial posttest and 10 weeks following the intervention.⁸ Furthermore, Tivener and Hetzler⁹ found that, while athletic training students in both passive and audience response system groups showed statistically significant increases in knowledge, students in the “clicker” group demonstrated higher knowledge acquisition as compared to those in the passive learning environment.

Correspondingly, 3 of 9 studies (33%) suggested that GBL produced similar gains in lower-order thinking as compared to passive learning methods. For instance, Blakely et al¹⁵ performed a systematic review of 16 studies concluding both passive and gaming instruction increase student knowledge; however, neither technique can be deemed more helpful to students than another. In contrast, 1 of the 9 studies on GBL (11%) revealed this active learning method to be less successful than passive lecture at increasing lower-order cognition in students of health care-related professions. Rondon et al¹⁶ found that speech-language and hearing students (N = 29) in the passive learning conditions performed better at short- and long-term intervals when compared to students learning via GBL methods.

Problem-Based Learning

Seventeen studies^17–33 were available to describe the effectiveness of PBL on increasing student knowledge. Ten of the 17 studies (59%) were in support of PBL for improving lower-order cognition in health care professions students. Tsou et al¹⁷ found that PBL was successful at preparing medical students (N = 236) for license examination and at improving students' self-perceived knowledge and understanding of basic medical sciences. Likewise, Ho et al¹⁸ found that speech-language pathology student performance on PBL tutorials was correlated with overall scores on clinical evaluations and standardized competency assessments. Of significant relevance, support for PBL was found in a systematic review and meta-analysis by Galvao et al.¹⁹ In a collection of 5 studies, authors found that students participating in PBL had higher midterm and final exam scores than those partaking in passive instructional methods.¹⁹

In addition to the 10 studies recommending PBL over passive learning, an additional 7 studies (41%) rated PBL to be similar in effectiveness to passive learning techniques for increasing lower-order cognition. For example, Takkunen et al²⁶ found PBL had no effect on exam scores as compared to the passive approach. However, it should be noted, PBL tutors perceived a greater benefit of active learning in lower performing students.²⁶ Overall, 100% of studies researching PBL indicated increases in knowledge equal or greater to passive learning practices.

Flipped Classroom

Eight studies^34–41 considered the effects of the FC intervention on students' attainment of lower-order cognition. Four of the 8 studies (50%) indicated successful knowledge production with FC instruction. Koo et al³⁴ discovered that FC design was more successful at improving overall final grades as compared to passive techniques.³⁴ Similarly, Gillispie³⁵ found that the FC method was successful at increasing scores on both multiple-choice exams and objective structured clinical examinations. Gross et al³⁶ used the FC format to measure knowledge in students across 3 exams. As compared to passive methods, FC resulted in a significant improvement in exam scores.³⁶ Moreover, the positive effects of FC were greater in female students as well as students with lower grade point averages.³⁶

Three of the 8 studies (38%) found the active method to be of similar or equal success to the passive approach. In a study of 82 medical students, Hsu et al³⁷ found no statistically significant difference in exam performance between students learning in FC and passive conditions. In contrast to these results, 1 study (11%) found poor results for flipping the classroom. Murray et al⁴¹ found FC did not significantly improve doctor of physical therapy student performance on knowledge, comprehension, or application aspects of lower-level cognition. Furthermore, the findings suggested students' prior academic performance might have had a significantly larger impact on knowledge retention in all performance areas than the teaching pedagogy used in the didactic setting.⁴¹

Team-Based Learning

Eight studies^42–49 deliberated the value of TBL on student knowledge. All 8 studies (100%) deemed TBL as a successful practice for increasing lower-order cognition. Echeto et al⁴² researched the effects of both passive learning and TBL on senior-year dental students. Students receiving the TBL intervention scored higher on examinations, mean course scores, and final passing grades as compared to students learning through the passive method.⁴² Likewise, Kalra et al⁴³ found that 72% of medical students who learned with a jigsaw version of small-group TBL perceived better understanding of course material. Furthermore, Wong and Driscoll⁴⁴ compared the active learning techniques of independent study and jigsaw on performance of physical therapy students. Outcomes revealed significantly higher performance on course content quizzes after the jigsaw activity as compared to students who performed independent study.⁴⁴ It should also be noted 2 of the 8 studies demonstrated TBL to be successful at increasing short-term knowledge retention; however, no difference was seen between team-based and passive learning at the long-term interval.^46,48

Case-Based Learning

Five studies^50–54 inspected the connection between CBL and lower-order cognition in health care professions students. All 5 studies (100%) agreed on CBL as a successful method of improving student knowledge. A cross-sectional study by Ciraj et al⁵⁰ investigated CBL in medical students, concluding that mean exams scores were higher in the CBL student group as compared to the non-CBL group. In addition, CBL was perceived by students and faculty to improve learning, retention, and understanding of course content.⁵⁰ Furthermore, Speicher et al⁵¹ performed a review aimed at providing athletic training educators a rationale for implementing CBL. Authors found students who engaged in a form of CBL using multiple-case examination and cueing were more apt to recall their learning and use it when faced with novel cases in the clinical environment.⁵¹

Simulation

Eight studies^55–62 contained in this review aimed at analyzing the effects of simulation learning on health care professions students' lower-order cognitive skills. All 8 studies (100%) reinforced the use of simulation as an instructional method for increasing knowledge in students. Tivener and Gloe⁵⁵ sought to determine through a mixed-methods study whether athletic training students gain knowledge from participation in high-fidelity simulation. Study results suggest that high-fidelity simulation is an effective instructional technique for increasing knowledge and improving skills in professional-level athletic training students.⁵⁵ In further support of simulation, Aqel and Ahmad⁵⁶ designed an experimental pretest/posttest study to examine the effectiveness of both a lecture and low-fidelity simulation intervention against a lecture and high-fidelity simulation intervention. While knowledge and skill was increased across both groups, nursing students in the high-fidelity simulation group showed greater improvements in knowledge and skill as compared to their low-fidelity simulation counterparts.⁵⁶ Furthermore, study results concluded both groups did not retain knowledge 12 weeks after training; a significant difference in favor of the high-fidelity simulation was found for better long-term retention of skills.⁵⁶

One randomized control trial comparing simulation-based teaching to passive instruction was located. In this study, Salem⁵⁷ discovered students in the simulation group did not demonstrate significant advantages in knowledge retention, although they did exhibit significantly greater skill performance and efficiency. Likewise, Shin et al⁵⁸ used a descriptive, cross-sectional, and comparative design to investigate the effect of passive methods versus a combination of active methods including high-fidelity simulation on competency and performance in nursing students. The study rated both competency and performance as significantly higher in the active learning group as compared to the passive learning group.⁵⁸

Other Techniques

An additional 31 studies^63–93 using unique or combined techniques addressed lower-order cognition resulting from active learning pedagogies. Twenty-three of these 31 studies (74%) were in support of the use of active learning to increase knowledge in health care professions students. For example, Gingerich et al⁶³ used a within-subjects design to assess the effectiveness of write-to-learn activities. Authors found write-to-learn assignments to be beneficial in raising exam scores for psychology students both immediately and 8.5 weeks after the educational intervention.⁶³

However, 7 of 31 studies (23%) on lower-order cognition also found mixed results with active learning or outcomes similar to passive methods. For example, Waltz et al⁶⁴ performed a review of 22 studies. While 15 studies reported positive results, 7 studies were unable to support the effectiveness of active learning methods.⁶⁴ Studies included within this review lacked consistent definitions of active learning and commonly failed to provide estimate measures for reliability and validity, leading authors to conclude insufficient evidence is available to recommend the use of active learning methods over traditional in nursing professions education.⁶⁴ Only 1 study (3%) by Mahler et al⁶⁵ found poor effects for active learning on improving knowledge. When the use of self-directed learning was compared to both lecture and traditional workshop formats for medical students, authors found individual test scores from self-directed learning were significantly lower than both passive lecture and workshop formats.⁶⁵

Of the 61 studies in support of active learning, 68.9% (n = 42/61) were deemed moderate-level evidence or higher. Furthermore, an additional 21 studies (25%) suggested active learning techniques were equally successful as passive lecture at facilitating lower-order thinking. Of these 21 studies, 81% were considered moderate-level evidence or higher. Despite the potency of these results, 3 (3.5%) studies still remained in support of passive learning methods over active learning techniques. After exhaustive review of literature, we recommend that health care professions educators use active learning techniques over passive learning techniques to stimulate the production of students' lower-order cognition in the didactic setting. (Grade A recommendation)

Problem-Based Learning

Thirty-six studies^{17,19,22,24,26,27,31–33,90,93–118} were located in reference to PBL and higher-order cognition. Out of the 36 studies, 30 studies (83%) were in support of using PBL to improve higher-order cognition. Jones et al⁹³ aimed to determine whether the use of PBL would promote higher levels of critical thinking in nursing students as compared to passive teaching approaches. Students in the PBL group had more pronounced increases in critical thinking and communication levels.⁹³ Students within this group also rated PBL as instrumental to their motivation to seek additional information regarding the course concepts.⁹³ Furthermore, in a PBL study by Baker⁹⁴ music therapy students indicated improved confidence and reported feeling substantially more competent in making clinical decisions. In further support, the systematic review by Nkosi and Thupayagale-Tshweneagae⁹⁵ confirmed that PBL boosted self-esteem, confidence, scholarship, and the analysis component of critical thinking in nursing students.

Mala-Maung et al⁹⁶ reported similar results in medical students, finding that the use of PBL correlated to improvements in problem solving, critical thinking, and decision making. Moreover, Baker et al⁹⁷ performed a study using the Learning Skills Profile to determine the effects of a PBL curriculum on job-related skills. Problem-based learning was responsible for producing increases in all 12 elements of the Learning Skills Profile.⁹⁷ Statistically significant increases occurred on 8 personal learning skills: leadership, help, sense making, information gathering, theory, quantitative, action, and initiative.⁹⁷ Additionally, 6 job skills showed significant improvements: help, sense making, information gathering, information analysis, theory, and technology.⁹⁷ Also, Richmond et al⁹⁸ compared passive learning to small- and large-group PBL to determine which instructional method would best promote higher-level thinking. Study results found that, when students received active learning instruction, they scored significantly better on higher-level test questions as compared to students who received traditional passive instruction.⁹⁸

In addition to the 30 studies in support of PBL over passive methods, 5 studies (14%) showed mixed results or deemed PBL to be of similar effectiveness to passive learning for generating higher-order learning skills. For example, Coker¹¹⁵ used the Self-Assessment of Clinical Reflection and Reasoning as well as the California Critical Thinking Skills Test to evaluate the clinical reasoning and critical thinking skills of occupational therapy students. While students increased their overall scores, statistically significant improvements occurred only in evaluation, inductive, and deductive reasoning, while no changes were made in the scores for inference and analysis areas.¹¹⁵ Also, Hur and Kim³³ found that medical students learning by PBL achieved better participation and problem-solving skills, but results were mixed between passive and PBL students for teamwork.

Moreover, a review by Kowalczyk¹¹⁶ aimed to identify teaching methods demonstrating positive effects on radiologic sciences students' critical thinking skills. Thirteen studies investigated critical thinking skills in PBL curriculum.¹¹⁶ However, only 6 of these 13 studies were able to demonstrate significant differences in critical thinking scores.¹¹⁶ Furthermore, the authors were unable to provide evidence assessing the effectiveness of other active learning techniques such as collaborative learning and concept mapping. Overall, Kowalczyk¹¹⁶ was unable to support the use of active learning for enhancing radiological sciences students' critical thinking skills.

On the other hand, 1 study (3%) identified PBL to be unsuccessful at marking changes in higher-order thinking. Pardamean¹¹⁷ measured critical thinking in dental students using the Health Science Reasoning Test (HSRT), finding that students showed no significant continuous or incremental improvement in their overall critical thinking skills scores achievement during their PBL dental education.

Simulation

Six studies^{55,58,61,119–121} examined the effects of simulation learning on higher-order thinking. Of these 6 studies, 5 (83%) identified simulation to be beneficial in promoting higher-order thinking in students. Allaire¹¹⁹ used the HSRT to measure the critical thinking skills in dental hygiene students using virtual patient simulation. While the simulation learning did not demonstrate a significant gain in HSRT scores between passive and active learning groups, students learning with virtual patient simulation perceived simulation as successful for promoting critical thinking, problem solving, and confidence in the clinical setting.¹¹⁹ Shin et al⁵⁸ also found high-fidelity simulation, in combination with case studies, standardized patients, and reflection activities, to be more successful as compared to passive learning at improving critical thinking and human understanding. Likewise, Kaddoura¹²⁰ reported recent nursing graduates viewed simulation as successful at improving self-perceived critical thinking and confidence. Moreover, Ohtake et al¹²¹ found that physical therapy students perceived the simulation experience as valuable in reflecting upon previous knowledge and experience in addition to the integration of classroom knowledge to clinical practice.

In contrast to these findings, 1 study (17%) found simulation ineffective. Shinnick and Woo⁶¹ found that human patient simulation produced no statistically significant gains in critical thinking as measured by the HSRT. However, of particular interest, the authors found that critical thinking scores and improvements were most associated with age, baseline knowledge, and self-efficacy.⁶¹ Despite the presence of some negative results, the majority of studies included in this review support simulation as effective in improving higher-order thinking in health care professions students.

Case-Based Learning

Five studies^{50,52,85,122,123} included in this review investigated CBL and higher-order cognition. All 5 studies (100%) supported CBL for enhancing higher-order cognition. For example, Harman et al¹²² examined nutrition students' perspectives of learning after completion of a CBL course. Active learning was found to produce higher cognitive learning as well as better problem solving and communication skills.¹²² Students indicated these improvements aided in the development of interpersonal skills, leading to success in team building including constructive criticism and negotiating abilities.¹²² Likewise, Yoo and Park⁸⁵ found CBL positively affected sophomore nursing students. Students in the CBL group improved in regard to communication skills, problem-solving ability, and learning motivation as compared to students learning through passive methods.⁸⁵ Moreover, medical students in a study by Ciraj et al⁵⁰ agreed that CBL promoted independent learning, communication, and analytical skills. Faculty of these students rated the improvement in clinical reasoning as the largest advantage pertaining to the CBL method.⁵⁰ Trujillo et al⁵² also compared instructor-led and student-led CBL methods. While instructor-led CBL emerged more successful than student-led approaches, the authors expressed that active learning produced increases in doctor of pharmacy student confidence in critical thinking, problem solving, and decision-making abilities as well as the pursuit of lifetime learning.⁵²

Other Techniques

A total of 22 other studies^{3,9,41,45,49,68,70,74,81,85,87–89,116,124–131} using other combined active learning techniques addressed the effects of active instruction on higher-order cognition. Eighteen (82%) studies supported the use of active learning techniques for the promotion of higher-order cognitive skills necessary for successful transition to clinical practice. For example, 2 studies used service learning for evidence of success in health care professions students. Atler and Gavin⁸¹ found service learning beneficial for developing interaction skills as well as increasing confidence in occupational therapy students, while Hebert and Hauf¹²⁶ found service-learning successful at improving civic responsibility and interpersonal skills as compared to passive learning.

Four of the 22 unique studies (18%) found mixed results regarding higher-order cognition and active learning techniques or found results similar to passive methods. For example, Morey¹²⁷ found no significant difference in critical thinking improvement between Web-based and passive instruction. Similarly, Murray et al⁴¹ discovered FC did not significantly improve physical therapy students' performance on higher-order cognition question exams as compared to passive face-to-face methods. In summary, regardless of the specific technique, active learning appears to be equally if not more successful at producing higher-order thinking in health care professions students.

Of the 58 studies in support of active learning, 56.9% (n = 33/58) were deemed moderate-level evidence or higher. Furthermore, an additional 9 studies (15.5%) suggested active learning techniques were equally successful as traditional lecture at facilitating higher-order cognitive thinking. Of these 9 studies, 88.9% were considered moderate-level evidence or higher. Despite the potency of this literature, 2 (3.4%) studies still remained in support of traditional learning methods over active learning techniques. After comprehensive review of literature, we recommend that health care professions educators use active learning techniques over traditional instruction to stimulate the production of students' higher-order cognition in the didactic setting. (Grade A recommendation)