The effect of team active learning in prior problem-solving versus afterward problem- solving on medical students' achievement

The effect of team active learning in prior problem-solving versus afterward problem- solving on medical students' achievement | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The effect of team active learning in prior problem-solving versus afterward problem- solving on medical students' achievement Nasreldin Ahmed, Mona Eid Al Atawi, Hiba Salah Abdelgadir, Basma Alzawawi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5757594/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Collaborative learning is a vitally important active learning process for improving the backgrounds of learners by gaining diverse learning experiences and mastery of skills, such as critical thinking and problem-solving. This study examines the difference in the effectiveness of active learning on medical students' learning and achievement when students were asked to collaborate in a team to solve a clinical problem before new information was studied versus having problems presented after that information was studied. Method This is an experimental quantitative design study. Participants were divided into two experimental groups (prior problem-solving group & afterward problem-solving group). Each group consisted of 30 students. The experiment had two phases: a training phase during which the selected students were trained in using the deliberate-reflection strategy, and a test phase one week later, during which students solved two new cases using the deliberate-reflection strategy. The afterward problem-solving group was given two problems to elaborate upon individually and then in pairs using the deliberate-reflection strategy (team discussion). Then the situational interest and cognitive load were measured by questionnaire. After this, they were asked to study a text about the causes of jaundice, the same questionnaire measured the situational interest and cognitive load. The prior problem-solving group studied a text about the causes of jaundice and was given two problems to elaborate upon and discuss in teams using the deliberate reflection strategy (Team discussion). Also, they were asked about their situational interest and cognitive load. At the end the two groups were prone to knowledge tests about the causes of Jaundice. Results The study findings showed no significant difference between the two experimental groups those who had jaundice text before problem-solving and those who had jaundice text after problem-solving. Although both groups had the same knowledge test at the same time after the experiment. The study timing and lack of motivation and cohesion affected the results of the experiment. Conclusion Deliberate reflection and collaborative learning are techniques that actively engage learners in experiential learning environments and increase their relevance and performance. However, many studies have shown significant results in favor of deliberate reflection and collaborative learning. Both techniques are recommended for medical schools. Better preparations with enough time for the experiment are recommended. Team active learning Collaborative learning prior problem-solving afterward problem-solving Figures Figure 1 Introduction Active learning is necessary in higher education teaching [ 1 ]. It has a positive effect; it helps students engage and work collaboratively to enhance their learning [ 2 ]. Many theories appeared to be the main explanation for this positive effect [ 3 , 4 ]. Some theories account for the changes in incentive structure brought about by certain forms of collaborative learning, while others relate that to task structure. The effect of collaborative learning has many theoretical perspectives that justify this such as the motivational, social cohesion perspectives, cognitive perspectives, and developmental perspectives [ 3 , 4 ]. Collaborative learning is a perception frequently employed in education, involving the collaboration of two or more individuals towards a common goal. The motivational perceptions concentrate on goal structures under which students work. Group members achieve structured goals and are encouraged and work with each other to the maximum to get their rewards [ 5 ]. Therefore, the members rely on each other’s input which helps the group to be rewarded. The group incentive induces students to encourage goal-directed behaviors among their group members [ 2 , 5 , 6 ]. In a review of 64 studies of collaborative learning methods that provided rewards on the amount of group members’ learning, 50 (78%) studies had significant positive effects on achievement, and none had negative effects [ 2 ]. The social cohesion perspective depends on team-building activities to prepare for collaborative learning and self-evaluation [ 7 ]. The learners are helping and caring for each other to succeed in the required task. Active learning is a teaching method whereby a student is responsible for arrangements in the educational process by practicing, evaluating, and improving his/her current mental abilities to solve complex educational problems [ 8 ]. Active learning engages the students mentally and physically in acquiring knowledge, thought, and action to solve problems [ 9 ]. According to another concept, active learning means engagement in the learning system by removing passive situations and being directly dependent on an educator [ 10 ]. The active learning core goal is to turn the learner's position from a passive observer into an active participant [ 11 ]. In the deliberate reflection technique, when addressing clinical cases through the reasoning for and against one's diagnostic theories, listing the results of patients that suit and refute them promotes the situational interest of medical students in the cases compared to the more traditional method of differential diagnosis [ 12 ]. It is rational to believe that this deliberate reflection technique will enhance education in medical colleges reported to be a good predictor of participation in teaching and learning results in studies with audiences outside of medical education [ 13 ]. Reflection has been seen as the key to understanding. Engaging students in study when addressing problems is supposed to stimulate knowledge gaps to be found and interest in learning and latter being a significant driving force in education. This assumption, while technically valid, still lacks empirical proof [ 12 ]. However, some authors argued that task structure could play a major role in active learning [ 5 ]. For instance, an activity or exercise should only be presented to students after direct instruction about a topic is given. This is because the cognitive load of working memory will be lower if students first master principles and facts. Students’ prior knowledge becomes a necessity for the success of a specific activity or exercise [ 14 ]. This is supported by cognitive load theory, which explains the total working memory needed for a person to learn. Human long-term memory stores information and processing new information needs mental effort to have cognitive load and working memory for better outcomes [ 14 ]. Thus, presenting the problem first in prior problem-solving in their view is less efficient. This is because intrinsic cognitive load deals with the inherent complexity of the information that needs to be processed and can be influenced by learners’ prior knowledge [ 15 ]. Thus, some authors hypothesized that collaborative learning could reduce element interactivity and its associated cognitive load. Appropriate collaborative learning can introduce a collective working memory created by communicating and coordinating knowledge held by each member of the group [ 16 ]. Collaboration has powerful effects on student learning, particularly for low-achieving students. Many factors may affect the impact of collaborative learning among peers, such as student characteristics, group composition, and structure goals. Practical reflection is presumed to increase interest in understanding more about a subject, through engagement in learning and teaching results. On the other hand, this argument lacks empirical evidence, particularly in medical learning. Some researchers studied the impacts of intentional focus on clinical cases on the commitment of medical students to learning and teaching results [ 17 ]. As awareness about human teaching and growth has evolved at a fast rate, it has also improved the potential to shape more successful educational strategies. Nevertheless, taking advantage of these developments involves incorporating perspectives from multiple fields -from biological and neuroscience to psychology, sociology, developmental, and learning sciences- and combining them with the awareness of the effective strategies developing in teaching [ 18 ]. Cooperative learning, although its simple nature has attracted substantial interest from researchers, leading to its consideration from various viewpoints. (19) The argument is that active learning such as prior problem solving aims to optimize the knowledge associated with intrinsic cognitive load and reduce other unnecessary knowledge hence, active learning can lead the members to develop an effective experience of group work, and every member can acquire a specific type of knowledge [ 20 ]. Such results can be found if the environment is well structured with better coordination of collaborative activities. This requires the learner to agree on task-related strategies, resolve conflicts, build upon each other’s ideas, reach a consensus, and create a chronological order of activities. Other studies showed negative findings in problem-prior sessions regarding the learning process and group formulation and their dynamics [21 22]. Groups can ineffectively share or underutilize information or bring obstruction and social lazing. Such events might not lead to positive learning outcomes [ 23 ]. Although there is consensus about the effectiveness of active learning, the argument about the effectiveness of problem-prior sessions and problems after the sessions needs to be investigated and documented. Therefore, the researcher decided to design the current study to examine the difference in the effectiveness of active learning on medical students' learning when students are asked to collaborate in a team to solve a clinical problem before new information is studied versus having problems presented after that information is studied. Materials and Methods Study Design This is an experimental quantitative design study used to compare two groups of medical students and examine the effectiveness of team active learning on their learning and achievement. This was examined by comparing two experimental groups. The students were acquired to study a subject and presented with clinical problem-solving before the subject versus after it and were asked to elaborate in teams to solve problems. Students' achievements were measured through individual knowledge tests across two groups. Population The study was conducted on first-year male and female medical students in the 2019–2020 academic year. The first-year medical students were considered newly enrolled in the College of Medicine after a two-year preparatory program. The random sampling technique was used to select the sample from the total population (225), and the number of respondents reached (60), they were divided into two experimental groups (Prior Problem-Solving Group and afterward Problem-Solving Group). The sample size was calculated using the Raosoft® Sample size calculator. Data Collection Methods The study was computer-based. The experiment had two phases: a training phase during which the selected students were trained in using the deliberate-reflection strategy, and a test phase one week later, during which students solved two new cases using the deliberate-reflection strategy. Knowledge Test Questionnaire A questionnaire about the causes of jaundice was developed by an internal medicine consultant and reviewed by another internal medicine consultant. The questionnaire was about the first-year medical students' level. Tested with a small group of students and slight modifications were made. (See Appendix 4) Deliberate reflection exercise for the training phase: All participants worked individually and in pairs during the deliberate reflection exercise training phase. They were provided with two clinical cases to elaborate upon by using the deliberate reflection approach to diagnose these two cases. They worked individually using the deliberate reflection exercise for the first case and in pairs for the second case. They were instructed to write down the most likely diagnosis in the first column on a given table (See Appendix 3: the Case) following these instructions: In the subsequent columns, write down the findings in cases that are in favor of the diagnosis, then the findings against it. List the findings expected to be present if the diagnosis was true but are absent in the case. If the first diagnosis was incorrect, consider alternative diagnoses and write them down one in each row of the first column of the table. Participants were asked to proceed in the same way by analyzing each diagnosis and indicating the findings that speak in favor of it, those against it, and the findings expected to be encountered if the diagnosis were true but were not present in the case. Based on this analysis, the last column indicates the order of likelihood of the considered diagnoses. Then they must write “1” for the most likely diagnosis,”2” for the second one, and “3” for the third diagnosis. (See table 1) Table (1): The process of deliberate reflection. Diagnostic hypotheses Findings that support the diagnosis Findings that speak against the diagnosis Findings expected to be present if the diagnosis were true but absent in the case Likelihood Asthma Chest tightness, Dyspnoea, Cough, Wheezing, Attacks after exercise or exposure to allergens, Remission of symptoms, Hypoxemia Age of onset Without a history of allergy No family history of asthma Accessory muscles use Prolongation of the expiratory phase 1 Chronic obstructive pulmonary disease (COPD) Attacks triggered by exercise. Age of onset middle-age Long-time smoker, Dyspnoea, Rhonchi Wheezing, Hypoxemia Dyspnoea and cough: episodic Sputum production Chronic, persistent cough Respiratory acidosis Decreased breath sounds 3 Pulmonary embolism Dyspnoea, Wheezing, Chest tightness, ECG, Smoker Non-pleuritic chest pain (tightness), Normal respiratory frequency, Jugular veins: no, abnormalities, X-ray without abnormalities Tachypnoea, Haemoptysis, History of risk factors for DVT (immobilization, etc.) 2 The test phase: Only two days after the deliberate reflection exercise the two groups entered the test phase. According to the plan, the test phase should start one week after the training phase. The reason the students were busy studying for the year's final exam. This delay was due to the long time for IRB to approve the study proposal. At the beginning of the test, the after-problem-solving group was given two problems about the causes of jaundice to elaborate upon individually using the deliberate-reflection strategy. Then they were asked to discuss the two problems in pairs (group discussion) using the deliberate reflection approach. Then situational interest and cognitive load were measured by a questionnaire. Then situational interest and cognitive load were measured by a questionnaire. Then a text (Causes of Jaundice) was given to the participants to study. After this, the same questionnaire was used to measure the situational interest and cognitive load. The other group, the prior-problem-solving group provided a text about the causes of jaundice to study. They were required to show their situational interest in the text. Using the deliberate reflection method, this group was given two problems (causes of jaundice) to elaborate upon and discuss in a team (Team discussion). Then their situational interest and cognitive load were measured. Then both groups were prone to knowledge tests about the causes of Jaundice. (See Fig. 1) Data Management and Analysis Plan After the initial data was collected from the participants, it was analyzed using the Statistical Package for Social Sciences (SPSS) version 25. In addition, several statistical methods, such as t-tests, percentages, and standard deviation, were used to identify the changes in the student’s knowledge test between the two groups (prior knowledge, afterward knowledge, and control). Results A total of 60 students participated in the study. 28 prior problem-solving groups were given the text of jaundice to study before problem-solving. There were 27 males and only one female in this group. 32 students in the after-problem-solving group were given the same text after problem-solving. There were 26 males and 6 females in this group. The response of females was limited because they had final examinations earlier than males. (See Table 2) Table (2): Demographic distribution of participants. Prior problem-solving participants (N = 28) Gender N % Female 1 4% Male 27 96% After problem-solving participants (N = 32) Female 6 19% Male 26 81% The mean knowledge for those who received the jaundice text to study before problem-solving was 21.7, and it was 20.8 for those given the text to study after the problem-solving. The knowledge test results between the two groups showed no significant difference between the two groups ( p -value 0.77). (See Table 3) Table (3): Comparison of knowledge test between the two groups. The groups N Mean Std. Dev F .082 P. Value .776 Prior problem- solving 28 21.7 8.7 After problem-solving 32 20.8 10.8 The frequency output of the Cognitive knowledge about the text of jaundice between the two groups showed no significant difference ( P-value = .084). From the prior solving problem group 3 students had zero scores out of 10, 7 had 2 out of 10, 12 scored 3/10, 5 scored 4/10, and 1 scored 5/10. From the after problem-solving group 2 had zero scores out of 10, 9 (2/10), 16 (3/10), 4 (4/10), and 1 (5/10). (See Table 4) Table (4) : The frequency output of cognitive knowledge about the text Prior problem-solving (N = 28) Score N % Nothing at all 3 10% 2 7 25% 3 12 43% 4 5 18% Quite a lot of 5 1 4% After problem-solving (N = 33) Nothing at all 2 6.3% 2 9 28.1% 3 16 50% 4 4 12.5% Quite a lot of 5 1 3.1% P. value = .084 Discussion Our study aimed to examine the difference in the effectiveness of active learning on medical students' learning when students are asked to collaborate in a team to solve clinical problems before new information is studied versus having problems presented after that information is studied. Engaging students in a study when addressing problems accelerates knowledge and is a significant driving force in teaching and learning. The study findings showed no significant difference between the two experimental groups those who had jaundice text before problem-solving and those who had jaundice text after problem-solving . Both groups had the same knowledge test at the same time after the experiment. This can be explained by poor preparation for the study. The plan was to conduct the test phase one week after the training phase. During this week the students should be familiar with active learning and do some groupwork activities. At that time the students were busy preparing for the final exam. They had not experienced the deliberate reflection technique and collaborative learning process before. The preparatory phase was too short and only a few days after which they had the test phase. They had to enroll in the test phase, one week after the preparatory phase, but that was not the case. So, students' preparation for the deliberate reflection technique and collaborative learning is important for the success of the experiment. Slavin in his study mentioned that collaborative learning has a positive effect when students are well-prepared to be engaged and work collaboratively hence, they can enhance their learning [ 2 ]. New teaching methods mostly depend upon the skill taught to the students and may be influenced by the ability and interest of the students (24). Besides that, motivation is one of the most significant things in the learning process. The participants were not motivated by the importance of the deliberate reflection technique in their future. The most important factors for collaborative learning are students' motivation and social cohesion [ 3 , 4 & 13 ]. These two factors; motivation and social cohesion did not exist in this experiment. A few days during the final year exams, the students were requested by the class instructor to participate in this experiment. Even social cohesion was lacking when the participants were asked to work in pairs, most of them worked individually to finish the task. For the success of such an experiment, and students’ motivation they should be informed early, explaining the strategies used (Collaborative learning) and the deliberate technique that will enhance their learning. A well-planned and structured reflection enhances medical students’ interest and may be useful for teachers concerned with improving students’ motivation for learning [ 25 ]. Generally, reflection in practice is assumed to enhance interest in a topic, increase engagement, and better learning outcomes. Teachers can employ this relatively easy procedure, with simulated and real scenarios to motivate their students and help them expand their knowledge. It is an important requirement for their professional development [ 23 ]. Student motivation and interest among learners are significant for the success of deliberate reflection and collaborative learning [ 25 , 26 ]. In our study, the time to explain deliberate reflection and collaborative learning to the students was short. Deliberate reflection was strange to the participants, and mostly the first time during their learning lifespan. The student's interest in learning is another important factor for the success of deliberate reflection and collaborative learning. Lockyer et al . in their study, revealed that students might learn more if they are interested in the reflection process [ 27 ]. In this experiment, the situational interest measurement was filled by a few students who showed poor interest in the process. The data collected showed that the situational interest was not enough to represent the study population. Also, the given cases seemed difficult for both groups although the first group was given the jaundice text to study before the test. Difficulty may inhibit students' interest in learning through such a process. Conclusion & Recommendations Deliberate reflection and collaborative learning are educational techniques, rather than a single, specific process, characterized by the active involvement of the learners in classroom events carefully planned by teachers [ 25 ]. In this experimental study, the students were not actively engaged in learning since deliberate reflection and collaborative learning are techniques that the students were not familiar with and the duration between the training and test phases was short and fast. In addition, participants were not motivated to be involved in the activity because it was enjoyable and interesting to take part in. They respond by being part of the experiment because of their teacher not the early call by the researchers. Recommending this process to be adopted in students' education is a necessity. Structured reflection will enhance medical students’ interest and may be useful for teachers concerned with students’ motivation [ 26 ]. Deliberate reflection and collaborative learning are characterized by interdependence and a person's success that leads to the success of others in the group. Deliberate reflection and collaborative learning provide benefits to all group members. With enough time and better preparation for the experiment, better results can be obtained. Students should practice deliberate reflection techniques individually and in a group before enrolling in the study. Further research is requested with good preparation by experts in deliberate reflection and collaborative learning. Limitations The experiment was conducted in a noticeably short time because the IRB office approval was late, leading to poor preparation. Some other institutes refuse data collection because of the late IRB. Students' interest and engagement in the experiment were very low since they had a short time for training and absorption of the new approach ( Deliberate reflection ) because they had to prepare for their final exams. We think the lack of motivation and social cohesion among the participants, who were asked to participate during a stressful period, most likely affected the results. Declarations Ethics approval and consent to participate Ethics approval was obtained from the Ethics Board of the Research Committee in King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia. See index 1 for the IRB. After all aspects of the study were explained, informed written consent was obtained from all the participants (see index 2). The information collected from the participants was secured and used for research purposes only. All identities were kept private and not disclosed in the study reports or related publications. Clinical trial number: Not applicable. Funding : No funding was received for this project. Availability of data and materials Data is available for sharing upon request to the first author. Conflict of Interest: None . Competing interests: The authors declare no competing interests Author contributions Nasreldin Ahmed : Conceptualization, integrity, accuracy of the data analysis, and critical revision of the manuscript: Mona Eid Al Atawi : Study concept and design Hiba Salah Abdelgadir : Data curation, reviewing, and editing the manuscript Basma MH Zawawi : Administrative and technical support References Bonwell CC, Eison JA. Active learning: Creating excitement in the classroom. 1991 ASHE-ERIC higher education reports. ERIC Clearinghouse on Higher Education, The George Washington University, One Dupont Circle, Suite 630, Washington, DC 20036-1183; 1991. Slavin RE, Hurley EA, Chamberlain A. Cooperative learning and achievement: Theory and research. Handbook of psychology: Educational psychology. 2003 Jul; 7:177-98. Slavin RE. When and why does cooperative learning increase achievement? Theoretical and empirical perspectives. The Routledge Falmer Reader in Psychology of Education. 2004:271-93. Slavin RE. Cooperative learning in elementary schools. Education 3-13. 2015 Jan 2;43(1):5-14. Slavin RE. Cooperative learning. Longman; 1983. Slavin RE. When does cooperative learning increase student achievement? Psychological bulletin. 1983 Nov;94(3):429. Cohen EG. Restructuring the classroom: Conditions for productive small groups. Review of educational research. 1994 Mar;64(1):1-35. Analized T. Teaching principles and methods. Pegem A Publishing. 2008. Collins III JW. The Greenwood dictionary of education. (No Title). 2011. Edwards S. Active learning in the middle grades: This article offers examples of developing students’ participation as a central tenet of ideal middle-level education that is intellectually active, socially active, and physically active. Middle School Journal. 2015 May 1;46(5):26-32. Yenen ET, Dursun F. The Effect of Active Learning Approach on Student Achievement in Secondary School 5th Grade English Course. Novitas-ROYAL (Research on Youth and Language). 2019;13(2):175-86. Ribeiro LM, Mamede S, Moura AS, de Brito EM, de Faria RM, Schmidt HG. Effect of reflection on medical students’ situational interest: an experimental study. Medical education. 2018 May;52(5):488-96. Rotgans JI, Schmidt HG. Situational interest and learning: Thirst for knowledge. Learning and Instruction. 2014 Aug 1; 32:37-50. Sweller J. load. During problem-solving: On/learning. Cognitive Science. 1988;12(2). Sweller J. Element interactivity and intrinsic, extraneous, and germane cognitive load. Educational psychology review. 2010 Jun; 22:123-38. Kirschner F, Paas F, Kirschner PA. Task complexity as a driver for collaborative learning efficiency: The collective working‐memory effect. Applied Cognitive Psychology. 2011 Jul;25(4):615-24. Ribeiro LM, Mamede S, de Brito EM, Moura AS, de Faria RM, Schmidt HG. Effects of deliberate reflection on students’ Engagement in learning and learning outcomes. Medical Education. 2019 Apr;53(4):390-7. Darling-Hammond L, Flook L, Cook-Harvey C, Barron B, Osher D. Implications for the educational practice of the science of learning and development. Applied developmental science. 2020 Apr 2;24(2):97-140. Clipa, O., Delibas, C-S., & Mâţă, L. Teachers’ Self-Efficacy and Attitudes towards the Use of Information Technology in Classrooms. Education Sciences, 2023. 13(10), 1001. Kalyuga S. Enhancing transfer by learning generalized domain knowledge structures. European Journal of Psychology of Education. 2013 Dec; 28:1477-93. Heath EF. Two cheers and a pint of worry: An online course in political and social philosophy. Journal of Asynchronous Learning Networks. 1998 Mar 1;2(1):15-33. Hiltz SR. Collaborative learning in asynchronous learning networks: Building learning. In Web Net 98'World Conference of the WWW, Internet, and Intranet Proceeding 1998 (pp. 134-154). Beers PJ. Negotiating common ground: Tools for multidisciplinary teams. Open Universiteit; 2005 Nov 25. Priyamvada Saarsar. Exploring the Constructivist Approach in Education: Theory, Practice, and Implications. IJRAR June 2018, Volume 5, Issue 2 Ribeiro L, Mamede S, Moura AS, de Brito EM, Delbone de Faria RM, Schmidt H. Effect of reflection on medical students' situational interest. Medical Education. 2017 Jan 1. Lockyer J, Gondocz ST, Thivierge RL. Knowledge translation: the role and place of practice reflection. Journal of Continuing Education in the Health Professions. 2004 Dec;24(1):50-6. Gleason BL, Peeters MJ, Resman-Targoff BH, Karr S, McBane S, Kelley K, Thomas T, Denetclaw TH. An active-learning strategies primer for achieving ability-based educational outcomes. American journal of pharmaceutical education. 2011 Nov 10;75(9):186. Additional Declarations No competing interests reported. Supplementary Files Appendices.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5757594","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":440734819,"identity":"9addc1be-3258-4587-a08a-05f42e3b0675","order_by":0,"name":"Nasreldin Ahmed","email":"","orcid":"","institution":"Alfaisal University","correspondingAuthor":false,"prefix":"","firstName":"Nasreldin","middleName":"","lastName":"Ahmed","suffix":""},{"id":440734820,"identity":"8bffd75f-45bb-4047-acbd-1c580c80adae","order_by":1,"name":"Mona Eid Al Atawi","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Mona","middleName":"Eid Al","lastName":"Atawi","suffix":""},{"id":440734822,"identity":"24f7a369-e7a5-4e32-b469-83019afa1c0d","order_by":2,"name":"Hiba Salah Abdelgadir","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBACA2YeEGUBxIkNDB+AFBs7cVokwFoYZ4C0MBPSwgDXksAA0U5Iizk778GPP2ok7Prbk9s+2/zaJs/HzMD44WMObi2WzXzJ0jzHJJJnnHnYPDu377ZhGzMDs+TMbXgcdpjHQJqBTSKZ4UZiM3Nuz21GoBY2Zl78Wox//vgnkSwP0mLZc9ueGC1mErxtEnYGIC0MP24nEqGFL82at08iwRDoF8behtvJbcyMzfj9cv7s4Zs/vtnYyx1Pf8zw489t2/ntzQc/fMSjBQaAUQ8EjG1gsoGweiCwh1B/iFI8CkbBKBgFIwwAAPuCTyRwkzR8AAAAAElFTkSuQmCC","orcid":"","institution":"Alzaiem Alazhari University","correspondingAuthor":true,"prefix":"","firstName":"Hiba","middleName":"Salah","lastName":"Abdelgadir","suffix":""},{"id":440734824,"identity":"5cbdde45-1ead-4840-9cb5-58b74c7aa999","order_by":3,"name":"Basma Alzawawi","email":"","orcid":"","institution":"King Abdulaziz University","correspondingAuthor":false,"prefix":"","firstName":"Basma","middleName":"","lastName":"Alzawawi","suffix":""}],"badges":[],"createdAt":"2025-01-03 10:38:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5757594/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5757594/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80295398,"identity":"d7607cbd-d758-4f39-b6f3-195677971bf7","added_by":"auto","created_at":"2025-04-10 08:34:07","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":79747,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5757594/v1/d477def340013bcc59fb786d.jpg"},{"id":80299143,"identity":"417f6e0c-0495-413e-a24a-8a38745296b1","added_by":"auto","created_at":"2025-04-10 08:58:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":937190,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5757594/v1/2b9411a9-8bbb-4ff8-928c-c9bb45f78fc4.pdf"},{"id":80297371,"identity":"536ff2b9-1453-429d-b67e-1c52b86f81ef","added_by":"auto","created_at":"2025-04-10 08:42:07","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":191028,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-5757594/v1/da1f88161ab98a1b8853b1b8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effect of team active learning in prior problem-solving versus afterward problem- solving on medical students' achievement","fulltext":[{"header":"Introduction","content":"\u003cp\u003eActive learning is necessary in higher education teaching [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It has a positive effect; it helps students engage and work collaboratively to enhance their learning [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Many theories appeared to be the main explanation for this positive effect [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Some theories account for the changes in incentive structure brought about by certain forms of collaborative learning, while others relate that to task structure. The effect of collaborative learning has many theoretical perspectives that justify this such as the motivational, social cohesion perspectives, cognitive perspectives, and developmental perspectives [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Collaborative learning is a perception frequently employed in education, involving the collaboration of two or more individuals towards a common goal.\u003c/p\u003e \u003cp\u003eThe motivational perceptions concentrate on goal structures under which students work. Group members achieve structured goals and are encouraged and work with each other to the maximum to get their rewards [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Therefore, the members rely on each other\u0026rsquo;s input which helps the group to be rewarded. The group incentive induces students to encourage goal-directed behaviors among their group members [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In a review of 64 studies of collaborative learning methods that provided rewards on the amount of group members\u0026rsquo; learning, 50 (78%) studies had significant positive effects on achievement, and none had negative effects [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe social cohesion perspective depends on team-building activities to prepare for collaborative learning and self-evaluation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The learners are helping and caring for each other to succeed in the required task.\u003c/p\u003e \u003cp\u003eActive learning is a teaching method whereby a student is responsible for arrangements in the educational process by practicing, evaluating, and improving his/her current mental abilities to solve complex educational problems [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Active learning engages the students mentally and physically in acquiring knowledge, thought, and action to solve problems [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. According to another concept, active learning means engagement in the learning system by removing passive situations and being directly dependent on an educator [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The active learning core goal is to turn the learner's position from a passive observer into an active participant [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the deliberate reflection technique, when addressing clinical cases through the reasoning for and against one's diagnostic theories, listing the results of patients that suit and refute them promotes the situational interest of medical students in the cases compared to the more traditional method of differential diagnosis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. It is rational to believe that this deliberate reflection technique will enhance education in medical colleges reported to be a good predictor of participation in teaching and learning results in studies with audiences outside of medical education [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eReflection has been seen as the key to understanding. Engaging students in study when addressing problems is supposed to stimulate knowledge gaps to be found and interest in learning and latter being a significant driving force in education. This assumption, while technically valid, still lacks empirical proof [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, some authors argued that task structure could play a major role in active learning [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. For instance, an activity or exercise should only be presented to students after direct instruction about a topic is given. This is because the cognitive load of working memory will be lower if students first master principles and facts. Students\u0026rsquo; prior knowledge becomes a necessity for the success of a specific activity or exercise [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This is supported by cognitive load theory, which explains the total working memory needed for a person to learn. Human long-term memory stores information and processing new information needs mental effort to have cognitive load and working memory for better outcomes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Thus, presenting the problem first in prior problem-solving in their view is less efficient. This is because intrinsic cognitive load deals with the inherent complexity of the information that needs to be processed and can be influenced by learners\u0026rsquo; prior knowledge [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, some authors hypothesized that collaborative learning could reduce element interactivity and its associated cognitive load. Appropriate collaborative learning can introduce a collective working memory created by communicating and coordinating knowledge held by each member of the group [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Collaboration has powerful effects on student learning, particularly for low-achieving students. Many factors may affect the impact of collaborative learning among peers, such as student characteristics, group composition, and structure goals.\u003c/p\u003e \u003cp\u003ePractical reflection is presumed to increase interest in understanding more about a subject, through engagement in learning and teaching results. On the other hand, this argument lacks empirical evidence, particularly in medical learning. Some researchers studied the impacts of intentional focus on clinical cases on the commitment of medical students to learning and teaching results [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs awareness about human teaching and growth has evolved at a fast rate, it has also improved the potential to shape more successful educational strategies. Nevertheless, taking advantage of these developments involves incorporating perspectives from multiple fields -from biological and neuroscience to psychology, sociology, developmental, and learning sciences- and combining them with the awareness of the effective strategies developing in teaching [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Cooperative learning, although its simple nature has attracted substantial interest from researchers, leading to its consideration from various viewpoints. (19)\u003c/p\u003e \u003cp\u003eThe argument is that active learning such as prior problem solving aims to optimize the knowledge associated with intrinsic cognitive load and reduce other unnecessary knowledge hence, active learning can lead the members to develop an effective experience of group work, and every member can acquire a specific type of knowledge [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Such results can be found if the environment is well structured with better coordination of collaborative activities. This requires the learner to agree on task-related strategies, resolve conflicts, build upon each other\u0026rsquo;s ideas, reach a consensus, and create a chronological order of activities. Other studies showed negative findings in problem-prior sessions regarding the learning process and group formulation and their dynamics [21 22]. Groups can ineffectively share or underutilize information or bring obstruction and social lazing. Such events might not lead to positive learning outcomes [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Although there is consensus about the effectiveness of active learning, the argument about the effectiveness of problem-prior sessions and problems after the sessions needs to be investigated and documented. Therefore, the researcher decided to design the current study to examine the difference in the effectiveness of active learning on medical students' learning when students are asked to collaborate in a team to solve a clinical problem before new information is studied versus having problems presented after that information is studied.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis is an experimental quantitative design study used to compare two groups of medical students and examine the effectiveness of team active learning on their learning and achievement. This was examined by comparing two experimental groups. The students were acquired to study a subject and presented with clinical problem-solving before the subject versus after it and were asked to elaborate in teams to solve problems. Students' achievements were measured through individual knowledge tests across two groups.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePopulation\u003c/h3\u003e\n\u003cp\u003eThe study was conducted on first-year male and female medical students in the 2019\u0026ndash;2020 academic year. The first-year medical students were considered newly enrolled in the College of Medicine after a two-year preparatory program.\u003c/p\u003e \u003cp\u003eThe random sampling technique was used to select the sample from the total population (225), and the number of respondents reached (60), they were divided into two experimental groups (Prior Problem-Solving Group and afterward Problem-Solving Group).\u003c/p\u003e \u003cp\u003eThe sample size was calculated using the Raosoft\u0026reg; Sample size calculator.\u003c/p\u003e\n\u003ch3\u003eData Collection Methods\u003c/h3\u003e\n\u003cp\u003eThe study was computer-based. The experiment had two phases: a training phase during which the selected students were trained in using the deliberate-reflection strategy, and a test phase one week later, during which students solved two new cases using the deliberate-reflection strategy.\u003c/p\u003e\n\u003ch3\u003eKnowledge Test Questionnaire\u003c/h3\u003e\n\u003cp\u003eA questionnaire about the causes of jaundice was developed by an internal medicine consultant and reviewed by another internal medicine consultant. The questionnaire was about the first-year medical students' level. Tested with a small group of students and slight modifications were made. (See Appendix 4)\u003c/p\u003e\n\u003ch3\u003eDeliberate reflection exercise for the training phase:\u003c/h3\u003e \u003cp\u003eAll participants worked individually and in pairs during the deliberate reflection exercise training phase. They were provided with two clinical cases to elaborate upon by using the deliberate reflection approach to diagnose these two cases. They worked individually using the deliberate reflection exercise for the first case and in pairs for the second case. They were instructed to write down the most likely diagnosis in the first column on a given table (See Appendix 3: the Case) following these instructions:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIn the subsequent columns, write down the findings in cases that are in favor of the diagnosis, then the findings against it.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eList the findings expected to be present if the diagnosis was true but are absent in the case.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIf the first diagnosis was incorrect, consider alternative diagnoses and write them down one in each row of the first column of the table.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eParticipants were asked to proceed in the same way by analyzing each diagnosis and indicating the findings that speak in favor of it, those against it, and the findings expected to be encountered if the diagnosis were true but were not present in the case.\u003c/p\u003e \u003cp\u003eBased on this analysis, the last column indicates the order of likelihood of the considered diagnoses. Then they must write \u0026ldquo;1\u0026rdquo; for the most likely diagnosis,\u0026rdquo;2\u0026rdquo; for the second one, and \u0026ldquo;3\u0026rdquo; for the third diagnosis. (See table 1)\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;(1): The process of deliberate reflection.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnostic hypotheses\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFindings that support the diagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFindings that speak against the diagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFindings expected to be present if the diagnosis were true but absent in the case\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLikelihood\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChest tightness, Dyspnoea, Cough, Wheezing, Attacks after exercise or exposure to allergens, Remission of symptoms, Hypoxemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge of onset\u003c/p\u003e \u003cp\u003eWithout a history of allergy\u003c/p\u003e \u003cp\u003eNo family history of asthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAccessory muscles use\u003c/p\u003e \u003cp\u003eProlongation of the expiratory phase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic obstructive pulmonary disease (COPD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttacks triggered by exercise.\u003c/p\u003e \u003cp\u003eAge of onset middle-age\u003c/p\u003e \u003cp\u003eLong-time smoker, Dyspnoea, Rhonchi Wheezing, Hypoxemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDyspnoea and cough: episodic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSputum production\u003c/p\u003e \u003cp\u003eChronic, persistent cough\u003c/p\u003e \u003cp\u003eRespiratory acidosis\u003c/p\u003e \u003cp\u003eDecreased breath sounds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary embolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDyspnoea, Wheezing, Chest tightness, ECG, Smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-pleuritic chest pain (tightness), Normal respiratory frequency, Jugular veins: no, abnormalities, X-ray without abnormalities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTachypnoea, Haemoptysis, History of risk factors for DVT (immobilization, etc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eThe test phase:\u003c/h2\u003e \u003cp\u003eOnly two days after the deliberate reflection exercise the two groups entered the test phase. According to the plan, the test phase should start one week after the training phase. The reason the students were busy studying for the year's final exam. This delay was due to the long time for IRB to approve the study proposal.\u003c/p\u003e \u003cp\u003eAt the beginning of the test, the after-problem-solving group was given two problems about the causes of jaundice to elaborate upon individually using the deliberate-reflection strategy. Then they were asked to discuss the two problems in pairs (group discussion) using the deliberate reflection approach. Then situational interest and cognitive load were measured by a questionnaire. Then situational interest and cognitive load were measured by a questionnaire. Then a text (Causes of Jaundice) was given to the participants to study. After this, the same questionnaire was used to measure the situational interest and cognitive load.\u003c/p\u003e \u003cp\u003eThe other group, the prior-problem-solving group provided a text about the causes of jaundice to study. They were required to show their situational interest in the text.\u003c/p\u003e \u003cp\u003eUsing the deliberate reflection method, this group was given two problems (causes of jaundice) to elaborate upon and discuss in a team (Team discussion). Then their situational interest and cognitive load were measured.\u003c/p\u003e \u003cp\u003eThen both groups were prone to knowledge tests about the causes of Jaundice. (See Fig.\u0026nbsp;1)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Management and Analysis Plan\u003c/h3\u003e\n\u003cp\u003eAfter the initial data was collected from the participants, it was analyzed using the Statistical Package for Social Sciences (SPSS) version 25. In addition, several statistical methods, such as t-tests, percentages, and standard deviation, were used to identify the changes in the student\u0026rsquo;s knowledge test between the two groups (prior knowledge, afterward knowledge, and control).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 60 students participated in the study. 28 prior problem-solving groups were given the text of jaundice to study before problem-solving. There were 27 males and only one female in this group. 32 students in the after-problem-solving group were given the same text after problem-solving. There were 26 males and 6 females in this group. The response of females was limited because they had final examinations earlier than males. (See Table\u0026nbsp;2)\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;(2): Demographic distribution of participants.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePrior problem-solving participants (N\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAfter problem-solving participants (N\u0026thinsp;=\u0026thinsp;32)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean knowledge for those who received the jaundice text to study before problem-solving was 21.7, and it was 20.8 for those given the text to study after the problem-solving.\u003c/p\u003e \u003cp\u003eThe knowledge test results between the two groups showed no significant difference between the two groups (\u003cem\u003ep\u003c/em\u003e-value 0.77). (See Table\u0026nbsp;3)\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;(3): Comparison of knowledge test between the two groups.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStd. Dev\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003cp\u003e.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cem\u003eP. Value\u003c/em\u003e\u003c/p\u003e \u003cp\u003e.776\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior problem- solving\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter problem-solving\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe frequency output of the Cognitive knowledge about the text of jaundice between the two groups showed no significant difference (\u003cem\u003eP-value\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.084). From the prior solving problem group 3 students had zero scores out of 10, 7 had 2 out of 10, 12 scored 3/10, 5 scored 4/10, and 1 scored 5/10.\u003c/p\u003e \u003cp\u003eFrom the after problem-solving group 2 had zero scores out of 10, 9 (2/10), 16 (3/10), 4 (4/10), and 1 (5/10). (See Table\u0026nbsp;4)\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;(4)\u003c/b\u003e: \u003cb\u003eThe frequency output of cognitive knowledge about the text\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePrior problem-solving (N\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNothing at all\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuite a lot of 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAfter problem-solving (N\u0026thinsp;=\u0026thinsp;33)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNothing at all\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuite a lot of 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP.\u003c/em\u003e value\u0026thinsp;=\u0026thinsp;.084\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study aimed to examine the difference in the effectiveness of active learning on medical students' learning when students are asked to collaborate in a team to solve clinical problems before new information is studied versus having problems presented after that information is studied. Engaging students in a study when addressing problems accelerates knowledge and is a significant driving force in teaching and learning. The study findings showed no significant difference between the two experimental groups those who had jaundice text \u003cb\u003ebefore problem-solving\u003c/b\u003e and those who had jaundice text \u003cb\u003eafter problem-solving\u003c/b\u003e. Both groups had the same knowledge test at the same time after the experiment. This can be explained by poor preparation for the study. The plan was to conduct the test phase one week after the training phase. During this week the students should be familiar with active learning and do some groupwork activities. At that time the students were busy preparing for the final exam. They had not experienced the deliberate reflection technique and collaborative learning process before. The preparatory phase was too short and only a few days after which they had the test phase. They had to enroll in the test phase, one week after the preparatory phase, but that was not the case. So, students' preparation for the deliberate reflection technique and collaborative learning is important for the success of the experiment. Slavin in his study mentioned that collaborative learning has a positive effect when students are well-prepared to be engaged and work collaboratively hence, they can enhance their learning [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. New teaching methods mostly depend upon the skill taught to the students and may be influenced by the ability and interest of the students (24). Besides that, motivation is one of the most significant things in the learning process. The participants were not motivated by the importance of the deliberate reflection technique in their future.\u003c/p\u003e \u003cp\u003eThe most important factors for collaborative learning are students' motivation and social cohesion [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e \u0026amp; \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These two factors; motivation and social cohesion did not exist in this experiment. A few days during the final year exams, the students were requested by the class instructor to participate in this experiment. Even social cohesion was lacking when the participants were asked to work in pairs, most of them worked individually to finish the task. For the success of such an experiment, and students’ motivation they should be informed early, explaining the strategies used (Collaborative learning) and the deliberate technique that will enhance their learning. A well-planned and structured reflection enhances medical students’ interest and may be useful for teachers concerned with improving students’ motivation for learning [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Generally, reflection in practice is assumed to enhance interest in a topic, increase engagement, and better learning outcomes. Teachers can employ this relatively easy procedure, with simulated and real scenarios to motivate their students and help them expand their knowledge. It is an important requirement for their professional development [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Student motivation and interest among learners are significant for the success of deliberate reflection and collaborative learning [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, the time to explain deliberate reflection and collaborative learning to the students was short. Deliberate reflection was strange to the participants, and mostly the first time during their learning lifespan.\u003c/p\u003e \u003cp\u003eThe student's interest in learning is another important factor for the success of deliberate reflection and collaborative learning. Lockyer \u003cem\u003eet al\u003c/em\u003e. in their study, revealed that students might learn more if they are interested in the reflection process [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In this experiment, the situational interest measurement was filled by a few students who showed poor interest in the process. The data collected showed that the situational interest was not enough to represent the study population. Also, the given cases seemed difficult for both groups although the first group was given the jaundice text to study before the test. Difficulty may inhibit students' interest in learning through such a process.\u003c/p\u003e "},{"header":"Conclusion \u0026 Recommendations","content":"\u003cp\u003eDeliberate reflection and collaborative learning are educational techniques, rather than a single, specific process, characterized by the active involvement of the learners in classroom events carefully planned by teachers [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In this experimental study, the students were not actively engaged in learning since deliberate reflection and collaborative learning are techniques that the students were not familiar with and the duration between the training and test phases was short and fast. In addition, participants were not motivated to be involved in the activity because it was enjoyable and interesting to take part in. They respond by being part of the experiment because of their teacher not the early call by the researchers.\u003c/p\u003e\u003cp\u003eRecommending this process to be adopted in students' education is a necessity. Structured reflection will enhance medical students’ interest and may be useful for teachers concerned with students’ motivation [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Deliberate reflection and collaborative learning are characterized by interdependence and a person's success that leads to the success of others in the group. Deliberate reflection and collaborative learning provide benefits to all group members.\u003c/p\u003e\u003cp\u003eWith enough time and better preparation for the experiment, better results can be obtained. Students should practice deliberate reflection techniques individually and in a group before enrolling in the study.\u003c/p\u003e\u003cp\u003eFurther research is requested with good preparation by experts in deliberate reflection and collaborative learning.\u003c/p\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThe experiment was conducted in a noticeably short time because the IRB office approval was late, leading to poor preparation. Some other institutes refuse data collection because of the late IRB. Students' interest and engagement in the experiment were very low since they had a short time for training and absorption of the new approach (\u003cem\u003eDeliberate reflection\u003c/em\u003e) because they had to prepare for their final exams. We think the lack of motivation and social cohesion among the participants, who were asked to participate during a stressful period, most likely affected the results.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was obtained from the Ethics Board of the Research Committee in King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia. See index 1 for the IRB. After all aspects of the study were explained, informed written consent was obtained from all the participants (see index 2). The information collected from the participants was secured and used for research purposes only. All identities were kept private and not disclosed in the study reports or related publications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: No funding was received for this project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available for sharing upon request to the first author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest: None\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNasreldin Ahmed\u003c/strong\u003e: \u0026nbsp;Conceptualization, integrity, accuracy of the data analysis, and critical revision of the manuscript:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMona Eid Al Atawi\u003c/strong\u003e: Study concept and design\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHiba Salah Abdelgadir\u003c/strong\u003e: Data curation, reviewing, and editing the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBasma MH Zawawi\u003c/strong\u003e: Administrative and technical support\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBonwell CC, Eison JA. Active learning: Creating excitement in the classroom. 1991 ASHE-ERIC higher education reports. ERIC Clearinghouse on Higher Education, The George Washington University, One Dupont Circle, Suite 630, Washington, DC 20036-1183; 1991.\u003c/li\u003e\n\u003cli\u003eSlavin RE, Hurley EA, Chamberlain A. Cooperative learning and achievement: Theory and research. Handbook of psychology: Educational psychology. 2003 Jul; 7:177-98.\u003c/li\u003e\n\u003cli\u003eSlavin RE. When and why does cooperative learning increase achievement? Theoretical and empirical perspectives. The Routledge Falmer Reader in Psychology of Education. 2004:271-93.\u003c/li\u003e\n\u003cli\u003eSlavin RE. Cooperative learning in elementary schools. Education 3-13. 2015 Jan 2;43(1):5-14.\u003c/li\u003e\n\u003cli\u003eSlavin RE. Cooperative learning. Longman; 1983.\u003c/li\u003e\n\u003cli\u003eSlavin RE. When does cooperative learning increase student achievement? Psychological bulletin. 1983 Nov;94(3):429.\u003c/li\u003e\n\u003cli\u003eCohen EG. Restructuring the classroom: Conditions for productive small groups. Review of educational research. 1994 Mar;64(1):1-35.\u003c/li\u003e\n\u003cli\u003eAnalized T. Teaching principles and methods. Pegem A Publishing. 2008.\u003c/li\u003e\n\u003cli\u003eCollins III JW. The Greenwood dictionary of education. (No Title). 2011.\u003c/li\u003e\n\u003cli\u003eEdwards S. Active learning in the middle grades: This article offers examples of developing students\u0026rsquo; participation as a central tenet of ideal middle-level education that is intellectually active, socially active, and physically active. Middle School Journal. 2015 May 1;46(5):26-32.\u003c/li\u003e\n\u003cli\u003eYenen ET, Dursun F. The Effect of Active Learning Approach on Student Achievement in Secondary School 5th Grade English Course. Novitas-ROYAL (Research on Youth and Language). 2019;13(2):175-86.\u003c/li\u003e\n\u003cli\u003eRibeiro LM, Mamede S, Moura AS, de Brito EM, de Faria RM, Schmidt HG. Effect of reflection on medical students\u0026rsquo; situational interest: an experimental study. Medical education. 2018 May;52(5):488-96.\u003c/li\u003e\n\u003cli\u003eRotgans JI, Schmidt HG. Situational interest and learning: Thirst for knowledge. Learning and Instruction. 2014 Aug 1; 32:37-50.\u003c/li\u003e\n\u003cli\u003eSweller J. load. During problem-solving: On/learning. Cognitive Science. 1988;12(2).\u003c/li\u003e\n\u003cli\u003eSweller J. Element interactivity and intrinsic, extraneous, and germane cognitive load. Educational psychology review. 2010 Jun; 22:123-38.\u003c/li\u003e\n\u003cli\u003eKirschner F, Paas F, Kirschner PA. Task complexity as a driver for collaborative learning efficiency: The collective working‐memory effect. Applied Cognitive Psychology. 2011 Jul;25(4):615-24.\u003c/li\u003e\n\u003cli\u003eRibeiro LM, Mamede S, de Brito EM, Moura AS, de Faria RM, Schmidt HG. Effects of deliberate reflection on students\u0026rsquo; Engagement in learning and learning outcomes. Medical Education. 2019 Apr;53(4):390-7.\u003c/li\u003e\n\u003cli\u003eDarling-Hammond L, Flook L, Cook-Harvey C, Barron B, Osher D. Implications for the educational practice of the science of learning and development. Applied developmental science. 2020 Apr 2;24(2):97-140.\u003c/li\u003e\n\u003cli\u003eClipa, O., Delibas, C-S., \u0026amp; M\u0026acirc;ţă, L. Teachers\u0026rsquo; Self-Efficacy and Attitudes towards the Use of Information Technology in Classrooms. Education Sciences, 2023. 13(10), 1001.\u003c/li\u003e\n\u003cli\u003eKalyuga S. Enhancing transfer by learning generalized domain knowledge structures. European Journal of Psychology of Education. 2013 Dec; 28:1477-93.\u003c/li\u003e\n\u003cli\u003eHeath EF. Two cheers and a pint of worry: An online course in political and social philosophy. Journal of Asynchronous Learning Networks. 1998 Mar 1;2(1):15-33.\u003c/li\u003e\n\u003cli\u003eHiltz SR. Collaborative learning in asynchronous learning networks: Building learning. In Web Net 98\u0026apos;World Conference of the WWW, Internet, and Intranet Proceeding 1998 (pp. 134-154).\u003c/li\u003e\n\u003cli\u003eBeers PJ. Negotiating common ground: Tools for multidisciplinary teams. Open Universiteit; 2005 Nov 25.\u003c/li\u003e\n\u003cli\u003ePriyamvada Saarsar. Exploring the Constructivist Approach in Education: Theory, Practice, and Implications. IJRAR June 2018, Volume 5, Issue 2 \u003c/li\u003e\n\u003cli\u003eRibeiro L, Mamede S, Moura AS, de Brito EM, Delbone de Faria RM, Schmidt H. Effect of reflection on medical students\u0026apos; situational interest. Medical Education. 2017 Jan 1.\u003c/li\u003e\n\u003cli\u003eLockyer J, Gondocz ST, Thivierge RL. Knowledge translation: the role and place of practice reflection. Journal of Continuing Education in the Health Professions. 2004 Dec;24(1):50-6.\u003c/li\u003e\n\u003cli\u003eGleason BL, Peeters MJ, Resman-Targoff BH, Karr S, McBane S, Kelley K, Thomas T, Denetclaw TH. An active-learning strategies primer for achieving ability-based educational outcomes. American journal of pharmaceutical education. 2011 Nov 10;75(9):186. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Team active learning, Collaborative learning, prior problem-solving, afterward problem-solving","lastPublishedDoi":"10.21203/rs.3.rs-5757594/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5757594/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCollaborative learning is a vitally important active learning process for improving the backgrounds of learners by gaining diverse learning experiences and mastery of skills, such as critical thinking and problem-solving. This study examines the difference in the effectiveness of active learning on medical students' learning and achievement when students were asked to collaborate in a team to solve a clinical problem before new information was studied versus having problems presented after that information was studied.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis is an experimental quantitative design study. Participants were divided into two experimental groups (prior problem-solving group \u0026amp; afterward problem-solving group). Each group consisted of 30 students. The experiment had two phases: a training phase during which the selected students were trained in using the deliberate-reflection strategy, and a test phase one week later, during which students solved two new cases using the deliberate-reflection strategy. The afterward problem-solving group was given two problems to elaborate upon individually and then in pairs using the deliberate-reflection strategy (team discussion). Then the situational interest and cognitive load were measured by questionnaire. After this, they were asked to study a text about the causes of jaundice, the same questionnaire measured the situational interest and cognitive load. The prior problem-solving group studied a text about the causes of jaundice and was given two problems to elaborate upon and discuss in teams using the deliberate reflection strategy (Team discussion). Also, they were asked about their situational interest and cognitive load. At the end the two groups were prone to knowledge tests about the causes of Jaundice.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study findings showed no significant difference between the two experimental groups those who had jaundice text before problem-solving and those who had jaundice text after problem-solving. Although both groups had the same knowledge test at the same time after the experiment. The study timing and lack of motivation and cohesion affected the results of the experiment.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDeliberate reflection and collaborative learning are techniques that actively engage learners in experiential learning environments and increase their relevance and performance. However, many studies have shown significant results in favor of deliberate reflection and collaborative learning. Both techniques are recommended for medical schools. Better preparations with enough time for the experiment are recommended.\u003c/p\u003e","manuscriptTitle":"The effect of team active learning in prior problem-solving versus afterward problem- solving on medical students' achievement","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-10 08:34:02","doi":"10.21203/rs.3.rs-5757594/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"43199b9c-5c05-43fc-8903-1e86be71432f","owner":[],"postedDate":"April 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-10T08:34:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-10 08:34:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5757594","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5757594","identity":"rs-5757594","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}