General description on research questions and objectives

This qualitative study sought to ascertain the implications of argumentation-based learning online activity in relation to two learning outcomes:  First, students’ epistemological beliefs, regarding the nature of learning, often reported as valuable precursors of their adaptive learning (Greene et al., 2018), and second, students’ high-order thinking skills. This study’s main objective is to shed light on this instructional activity, by analyzing qualitative data reflecting the participants’ epistemological and ontological standpoints, and their perceived thinking levels experienced during the activity.

Theoretical Framework

Argumentation-based Learning and Epistemological Beliefs

Teachers’ and students’ epistemological point of view regarding the nature of knowledge and learning might influence their approach to teaching and learning and how they make important instructional decisions and/or set their learning goals (Fives & Buehl, 2016). There are three distinct levels of epistemological belief.  Absolutists believe that knowledge is finite and unchanging and that objective truth exists. Multiplists hold a higher level of epistemological belief in which knowledge is seen as inherently subjective, consisting not of facts but of opinions, generated by human minds, indefinite and not subject to evaluation (Asterhan & Schwarz, 2016; Kuhn et al., 2011). The highest level is called evaluativism, according to which individuals recognize the significance of weighing evidence and addressing contradictory claims (Kuhn et al., 2000).

Encouraging students to reach the highest level of epistemological beliefs – evaluativism – is considered a foremost learning goal in health education. Evidence-based decision-making programs (Hinneburg et al., 2020) and evidence-based practices for physicians, medical and nursing students (Cira et al., 2020) are considered imperative for ensuring patient safety. Students should recognize the value of weighing evidence, which can be achieved by continually practicing teaching and learning methods that encourage conscious use and application of a wide variety of knowledge sources. This requires formulating structured queries; and conducting searches of resources from which trustworthy and reliable evidence can be acquired (Horntvedt et al., 2018).

Argumentation-based Learning and High-order Thinking Skills

Encouraging high-order thinking skills is deemed important in health education (Medina et al., 2017). These skills can be developed by carefully designing learning activities within courses and the curriculum as a whole, such as argumentation-based learning.  The term “argument” in this paper refers to the artifacts that a student creates when asked to justify claims, whereas the term “argumentation” refers to the process of constructing these artifacts (Sampson & Clark, 2008). Argumentation is suggested as a means to improve high-order thinking skills of conceptual, procedural, and metacognitive knowledge (Asterhan and Schwarz, 2016) rather than mere factual knowledge. Factual knowledge pertains to the basic elements that students must know to be sufficiently acquainted with a discipline or solve problems (Anderson et al., 2001). Beyond merely memorizing facts, conceptual knowledge refers to understanding similarities and patterns in factual knowledge and is centered on the interrelationships among the basic elements within a larger structure (Wilson, 2016). Procedural knowledgepertains to knowing “how” to do something, for example, how to use particular methods to achieve a specific learning goal (Anderson et al., 2001). Metacognitive knowledge is the knowledge of general strategies for learning and thinking. Weinberger and Fischer (2006) maintained that these types of knowledge can be achieved by encouraging students to construct arguments to justify their position. Advancing higher-order thinking skills is considered an important learning outcome in health education (Medina et al., 2017).

Methodology Participants Data for the analysis were gathered from 65 Israeli undergraduate students enrolled in a Management of Health Service Organizations program. The students were enrolled in a 3rd-year course entitled ‘Assimilation of service quality in health systems.’ Data were gathered following the intervention, as described in the next section. The study was pre-authorized by the college’s Ethics Committee. The intervention The students were presented with a problem relevant to their course content, dealing with accreditation. The students were asked to argue for or against the implementation of the accreditation process within hospitals. The task had two phases. In Phase 1, participants were asked to detail five arguments to establish their decision by using a concept map. Group work was allowed, although individual work was preferred and encouraged. In Phase 2, relying on the materials taught in their courses, the students were asked to search for and obtain the necessary supporting in¬formation to substantiate their arguments and to associate ethical values with at least two of the arguments they had provided. Next, the participants were instructed to specify and explain in detail the differences or similarities between their respective arguments. Data collection and analysis The students were asked to contemplate their personal learning process during the activity and to submit a reflective journal at the end of it. In the journal they were instructed to write about their self-perceived progress from the point of their preliminary argument to a more complex one and to describe their challenges and gains in light of the experience. 65 reflective journal entries were analyzed. Each entry was summarized to provide a general view of the essence of participants’ reports. Next, the entries were coded. The most important data were filtered and clustered into categories. To increase interrater reliability, two researchers engaged in the iterative dialogue aimed at capturing the essence of the research findings.

Results Five main categories were detected in the analysis: Epistemic change During the learning process, the students experienced a perceptual change regarding the learning process and the acquisition of knowledge. It began with their personal feelings and intuition while building the first argument. However, during construction of the second argument, the understanding grew that it is necessary to establish the facts before making rational decisions. Social perspective-taking During the assignment, the students were provided with an opportunity to reexamine their ideas/beliefs, which, in turn, motivated them to reconcile the cognitive conflict by explaining their views to their group members. The students realized that there is a discrepancy between their existing knowledge and the point of view of others. This raised doubts about the validity of one’s point of view. Domain-based knowledge Based on the literature review, argumentation is suggested to improve conceptual, procedural, and metacognitive knowledge rather than merely factual knowledge. Analysis of the students’ journals revealed that for many of them, the assignment helped develop high-level thinking, on a continuum from conceptual to procedural and metacognitive knowledge, rather than merely supporting factual knowledge. Prior knowledge and experience This theme deals with students’ ability to relate to their own background knowledge. The participants reported that the opportunity they were given throughout the experience to apply prior knowledge in the activity helped them during the learning process. Some drew upon prior knowledge acquired throughout their lifetime which was found to be beneficial when proposing a solution to the dilemma they had been given. Online collaboration with other students According to the students’ reports, using an e-platform for constructing the arguments helped group members to cooperate efficiently. However, the students also attested to experiencing some technological problems. They were unfamiliar with the digital platform and had to learn it from the instructor.

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