Online argumentation-based learning aided by digital concept mapping during COVID-19: implications for health management teaching and learning

Dorit Alt (Kinneret College on the Sea of Galilee, Jordan Valley, Israel)
Lior Naamati-Schneider (Hadassah Academic College, Jerusalem, Israel)

Health Education

ISSN: 0965-4283

Article publication date: 6 August 2021

Issue publication date: 1 March 2022




The COVID-19 pandemic has affected educational systems worldwide, forcing them to abruptly shift from face-to-face to online teaching and learning. This case study illustrates how a traditional lecture-based activity for undergraduate students in a Management of Health Service Organizations program was transformed into an argumentation-based learning activity using the technique of digital concept mapping and was deployed in an online format during the COVID-19 lockdown.


The students were tasked with solving an ill-structured problem bearing significance for their future professional lives and connected to the contents of their course (entitled “Assimilation of service quality in health systems”). The activity was composed of two phases. In Phase 1, participants were asked to provide five arguments to establish their proposed solution to the problem by using a concept map on a digital platform (Mindomo). In Phase 2, they were asked to substantiate their arguments. Reflective journals were used to ascertain how the participants viewed the activity. Thematic analysis was used to analyze the qualitative data by searching for themes demonstrating different epistemological positions.


Six themes were inductively derived from the students' reflections: (1) transitioning from passive to active learning; (2) generating epistemic change; (3) social perspective-taking; (4) domain-based knowledge; (5) prior knowledge and experience; and (6) online collaboration with other students. Episodes, thoughts and feelings expressed by the students were reported so as to increase the reliability of the recurrent and common themes.


This study mainly shows that combining constructivist teaching and learning tools with advanced technology in an online course enables the development of lifelong learning capabilities among students in the health management professions.



Alt, D. and Naamati-Schneider, L. (2022), "Online argumentation-based learning aided by digital concept mapping during COVID-19: implications for health management teaching and learning", Health Education, Vol. 122 No. 1, pp. 18-36.



Emerald Publishing Limited

Copyright © 2021, Emerald Publishing Limited


The outbreak of the COVID-19 pandemic generated multiple challenges in the realm of health. Aside from coping with the clinical reality of severe illness, treating numerous patients simultaneously and dealing with an unknown virus, the healthcare system has been forced to face additional problems caused by the pandemic: the lack of professional knowledge in treating the novel Coronavirus, the need to provide aid and care using advanced technological methods, maintaining a distance when caring for hospitalized patients and those in the community, and providing digital, online services for the general public.

Coping swiftly with this wide array of sudden, urgent needs – which are liable to continue over a long period of time or reappear in the future – requires the directors and staff in the healthcare system to demonstrate diverse capabilities. These include independent and adaptive learning, cooperating to solve current complex problems, high-order thinking capabilities, a highly developed professional ethos, intellectual flexibility and digital literacy. These capabilities are becoming an essential and inseparable part of the array of tasks that characterize healthcare professionals in the 21st century (Berkhout et al., 2018; Wachter and Wehrwein, 2015).

The prevailing assumption is that academia must assume an important role in training doctors and medical staff by developing and honing these skills. Today, in the conceptual age (William, 2017), which is characterized by rapid changes, there is a greater perception that teaching and learning methods need to be altered from passive to active. This will enhance additional skills necessary in training healthcare professionals that are better suited to this era and its particular demands (Harris and Bacon, 2019). The COVID-19 crisis has unexpectedly created opportunities for accelerating the change that is needed in teaching methods by compelling the teaching staff and students to immediately adjust their teaching and learning methods to distance learning without adequate prior preparation. Alongside the challenges it poses, the crisis also offers an opportunity for changing methods and objectives in healthcare education while, at the same time, adapting the study program to the needs of students in the healthcare system. The change is also liable to be challenging since it requires establishing learning objectives and outcomes that demand changing students' epistemological perspective on the nature of knowledge and learning. It requires a transition from a teacher-centered pedagogical perception to one that promotes learning activities that revolve around the students and develop their abilities. These changes might pose various difficulties as lecturers and students alike are unaccustomed to these new teaching methods and prefer to adhere to traditional, and therefore familiar and comfortable, ones (Alt, 2018).

Consequently, it is imperative to apply constructivist approaches through distance learning in times of crisis and to provide the medical staff with suitable training. If these steps are not taken, learning will be based on prevailing traditional teaching that will potentially fail to yield lifelong learning skills that the medical staff requires and needs (Harris and Bacon, 2019). The current study attempts to demonstrate how constructivist pedagogy can be applied to solving a problem by using argumentation in distance learning. It describes how a traditional face-to-face activity for undergraduate students in a Management of Health Service Organizations program was replaced by an argumentation-based learning activity using digital concept mapping (CM) and deployed in an online setting during the COVID-19 pandemic.

Another aim is to ascertain how the students perceived the activity and its implications 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; Muis et al., 2015), and their implications for pedagogy in healthcare professions. This study's main objective is to shed light on this prompt instructional shift from the participants' perspective, by analyzing qualitative data reflecting their epistemological and ontological standpoints. Second, lifelong learning skills. This study specifically aims to uncover the main challenges and opportunities of the suggested online argumentation-based learning activity with CM for nurturing health management students' lifelong learning skills such as high-order thinking skills, critical thinking and problem-solving skills. In sum, the aim of this paper is twofold: first, to present an innovative online argumentation-based learning activity aided by CM corresponding to the call for skills required for medical staff; second, to evaluate the outcomes of the proposed instructional initiative (i.e. the epistemological shift from teacher-centered to student-centered paradigm, and acquisition of lifelong learning skills) through the subjective eyes of the participants.

This study may enhance our understanding of how to use online learning effectively so as to develop students' epistemological change and lifelong learning skills, when distance teaching is required. These abilities will enable medical professionals to better contend with a variety of needs in the conceptual age and with the changes in and dynamics of technological and medical knowledge.

Literature review

The restrictions placed on higher education following the COVID-19 pandemic have challenged the instructional methodology practiced thus far, forcing higher-education faculty and students to teach and learn differently. This may be challenging for health professional educators who often lack formal education qualifications and, as a result, adopt pedagogical approaches of face-to-face learner interaction aligning with how they themselves were taught, despite the imperative to embrace online and constructivist approaches to teaching and learning (Seymour-Walsh et al., 2020). In line with the research objectives, in this section, we will discuss an innovative pedagogical approach of argumentation-based learning, which can be used online, and its potential impact on students' high-order thinking skills and their epistemological point of view regarding the nature of knowledge and learning in health education. Second, we will illustrate how CM can be used online to support students' enrollment in argumentation-based learning and enhance 21st-century skills such as critical thinking and problem-solving skills. Each section will highlight the skills which medical personnel and medical managers might gain by experiencing first-hand this innovative technology-enabled pedagogy practiced online during the lockdown.

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. Theoretically informed practices may assist health-profession educators and course designers in effectively responding to the COVID-19 crisis, and in creatively and innovatively exploring novel approaches intended to develop and deliver quality online education (Seymour-Walsh et al., 2020).

The literature contains various definitions of argumentation (Toulmin, 2003; Walton, 2006). Despite the differences between them, all the definitions point to argumentation as a means to rationally resolve divergent opinions in critical discussions (Noroozi et al., 2012). Developing such decision-making skill sets is highly relevant in the context of global public health crises during which there is a constant, real-time need to make rational, well-founded decisions. Such skills are key components in Burkle's (2019) health crisis management model and are deemed essential requisites for fulfilling the strategic and operational phase requirements of mitigation, response, recovery and rehabilitation during sudden-onset disasters and other time-limited crises.

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 and Clark, 2008). Based on the Piagetian equilibration model of socio-cognitive conflict (Piaget, 1985), such processes should provide learners with an opportunity to review their ideas/beliefs which, in turn, motivate them to reconcile the cognitive conflict by explaining their views to the members of their group (Cheng, 2014).

An example of a didactic method that bridges argumentation, domain-specific knowledge and moral values is the Values and Knowledge Education (VaKE) approach (Patry et al., 2013). This approach exposes students to dilemmas relevant to their profession, clarifies the importance of their moral values and allows the students to form an independent opinion while emphasizing practices of dialogue and argumentation. This practice is largely informed by the social cognition theory (Selman, 1980), which asserts that a key factor in promoting social cognition is enhancing one's ability to understand another's feelings and viewpoints and acknowledge that another's viewpoint may differ from one's own. Role-playing skills entail understanding another's cognitive and emotional attributes (i.e. moods, feelings and attitudes).

Argumentation is suggested as a means to improve higher-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 (Blumberg, 2009; Wilson, 2016). Procedural knowledge pertains 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. This type of knowledge involves two main components: knowledge of cognition and regulation of cognition (Brown, 1987; Jacobs and Paris, 1987). Weinberger and Fischer (2006) maintain 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. For example, Medina et al. (2017) maintain that metacognition is an essential skill to confront medical errors, which can occur because the pharmacist did not ask “do the orders make sense for the indication?” (i.e. metacognitive monitoring) or “did I check to ensure I entered things [in the computer database] correctly?” (p. 1). Harris and Bacon (2019) underscored the advantages of active learning versus passive learning in producing students' cognitive skills in healthcare-profession education. Based on their findings, student-centered learning techniques contribute to lower- and higher-order cognition more than passive learning methods do. They encourage educators to equalize instructional design “with the needs of the student and the demand of the workforce at the center of priority” (p. 143). Based on this premise, and in line with the current research objectives, the question of how an argumentation-based learning activity can be designed during a prompt shift to online learning, and how it might affect students' thinking skills lies at the core of the preset investigation.

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 and Buehl, 2016; Schraw and Olafson, 2002). These beliefs are divided into teacher-centered instruction in which the teacher is perceived as the sole transmitter of knowledge and the student as the recipient of the knowledge, and student-centered instruction, which underscores the importance of experience and active learning (Chan and Elliott, 2004). Relying on their previous experience, students may be accustomed to the traditional way of learning, which corresponds to an absolutist point of view (Kuhn et al., 2000). From this point of view, knowledge is composed of facts that are yet to be discovered.

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 and 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).

Epistemological beliefs are often reported as valuable precursors of students' cognition, motivation for learning, learning approaches, adaptive learning and achievement (Greene et al., 2018; Muis et al., 2015). However, while it is widely acknowledged that personal epistemology impacts students' beliefs about learning, prior research falls short of addressing the use of educational programming to efficiently impact individuals' epistemic beliefs.

Encouraging students to reach the highest level of epistemological beliefs – evaluativism – is considered a foremost learning goal in health education (Cira et al., 2020; Hinneburg et al., 2020; Horntvedt et al., 2018). 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). Indeed, searching for evidence is considered a key competence for health practitioners. However, undergraduate programs continue to provide predominantly traditional, frontal classroom-teaching strategies that have limitations in facilitating the fostering of critical competencies required in real clinical contexts (Park et al., 2020). Healthcare researchers suggest shifting education from merely providing decontextualized knowledge to a more innovative type of teaching that focuses on the use of scientific evidence to promote students' clinical reasoning and produce safe and effective healthcare outcomes (Park, 2011).

Holding higher epistemic beliefs seems to pose a challenge for clinicians; however, it may also provide opportunities for formulating important clinical questions specifically in times of uncertainty. This notion is strengthened by Cheng et al. (2020) who focus attention on the unique needs and concerns of healthcare students in the face of the COVID-19 pandemic and highlight the importance of designing learning activities to enhance students' critical thinking as a core skillset necessary in the discovery of facts and problems during times of crisis. Web-based experiential learning strategies are suggested to improve students' engagement and experience in learning environments aimed at helping students and clinicians recognize the existence of uncertainties in healthcare practices (Park et al., 2020). Therefore, it seems worthwhile to evaluate how an argumentation-based learning activity can be employed in an online setting imposed on higher education during the COVID-19 period, and how it might affect students' epistemological point of view.

Web-based platforms for argumentation-based learning

During the first COVID-19 lockdown, in March–April of 2020, faculty members were required to design quality online courses that support a community of learners capable of working together online to mitigate the teaching and learning challenges posed by the crisis. The faculty, previously resistant to any form of technology-enabled teaching, needed to become acquainted with an abundance of technological platforms communicated by hastily assembled online trainings (Fernandez and Shaw, 2020). Nonetheless, they often failed to complement an appropriate and effective technological tool to their teaching methodology while suddenly being immersed in online teaching. Therefore, and in accordance with this research objectives, it is crucial to show how various digital learning technologies can be used to support social-constructivist online teaching activities and be leveraged to promote interaction as “the key to effective online learning and ironically the antithesis of social distancing” (p. 3). The following paragraphs describe how CM can aid online argumentation-based learning towards facilitating students' lifelong learning skills such as critical thinking.

Several online settings have been found to support sharing, constructing and representing arguments in multiple formats. For example, Noroozi et al. (2012) revealed a variety of recommended external knowledge representation tools designed to represent argumentation in Argumentation-Based Computer-Supported Collaborative Learning (ABCSCL), such as Issue-Based Information Systems (IBIS). Such knowledge representation tools help learners clarify their arguments, argue more effectively and find patterns of evidence.

Asterhan and Schwarz (2016) assert that although such computer-supported collaborative learning efforts might support argumentation, research that establishes this conjecture is still limited. To address this problem in the current study, a technology-enabled CM method was used for the first time to facilitate argumentation processes. Concept maps (Novak and Gowin, 1984) have been employed in education systems for over 30 years (Kinchin, 2014). Yet, their utilization in argumentation has been considerably less common in higher education, and minimal attention has been paid to their use in online learning. CM is a learning method and educational tool using diagrammatic interrelationships between concepts representing subject knowledge. Concept maps should not merely list random textual information but rather should depict the structure of knowledge in propositional statements that illustrate the interrelationships between the given concepts in a map (Novak, 1981).

Through CM, students are expected to be able to transfer applied didactic objectives from the classroom to their clinical practice, where critical thinking and problem-solving skills are vital for success. This premise has been reinforced by several empirical studies that demonstrate the benefits of CM used in concert with problem-based learning (PBL) in facilitating students' 21st-century skills. For example, Joshi and Vyas (2018) maintain that concept maps should be used to solve epidemiological problems in community medicine, which focus on public health concepts, mathematical calculations and “applied” interpretations. Similarly, CM's effectiveness in academic problem-solving performance, as well as in declarative knowledge questions and their perceptions regarding CM, was examined among medical students (Baig et al., 2016). These researchers found that CM improved academic performance in problem-solving but not in declarative knowledge. Students' perception of the effectiveness of CM was positive. Another benefit of using CM is fostering students' ability to self-regulate their learning processes (Chularut and DeBacker, 2004; Naderifar, 2018; Roy, 2011). However, while concept maps have been shown to be an effective tool for facilitating students' critical thinking, CMs' contribution to their self-regulation abilities in face-to-face or online courses has been insufficiently investigated (Barnard et al., 2009).

This study

The literature surveyed above reflects how argumentation-based learning supported by digital CM has the potential to enhance students' lifelong learning skills, such as domain knowledge, critical thinking, problem-solving skills and self-regulation abilities, and shape their epistemic beliefs. This research sought to elucidate how such innovative pedagogy can be employed online during times in which a massive shift away from frontal learning and teaching in traditional settings with physical interactions has been imposed on teachers and students. Another aim was to reveal the main challenges and opportunities for health management students. To this end, Management of Health Service Organizations students' reflective journals were analyzed to delve deeper into the questions of how the participants perceived the activity and its outcomes during the COVID-19 period. Thematic analysis was used to analyze the qualitative data by searching for themes and patterns indicating different epistemological and ontological standpoints.



Data for the analysis were gathered from 65 Israeli undergraduate students enrolled in a Management of Health Service Organizations program, covering patient-doctor relations, quality of service in the healthcare system, and ethics and patient rights. The program instructs students on the fundamentals of marketing, finance, organizational behavior, communications, legal issues and strategies. The students were enrolled in a 3rd-year course entitled “Assimilation of service quality in health systems.” The participants' mean age was 25.70 years (SD = 6.02), and 85% were females. The distribution regarding ethnicity was: 72% Jewish students; 28% Arab (Muslim and Christian) minority students.

Data were gathered following the intervention, as described in the next section. Prior to obtaining participants' consent, it was explained to them that the materials used in this study would be processed anonymously and that they had the option not to allow the use of these materials for research purposes. Finally, participants were assured that no identifying information would be processed. The study was pre-authorized by the college's Ethics Committee.

The intervention

VaKE (Patry et al., 2013) was designed and piloted in this study. VaKE is deemed a useful teaching tool that combines morality and values-centered education with knowledge content, emphasizing social behavior and the development of critical thinking in a PBL environment. In line with VaKE, the participants 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 information 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. Mindomo, a popular internet platform for designing concept maps, was utilized. To facilitate the assessment of their maps, well-established criteria were provided to the students in advance of the activity (Panadero et al., 2013).

Data collection

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. At the outset, participants were given reflective prompts (Tripto et al., 2016), such as “Describe the main challenges raised during the activity,” or “Describe what worked well during the learning activity.” This practice encourages students to document their thoughts during an activity and prompts them to think and write about their learning in a multidimensional way (Alt and Raichel, 2020; Zohar and Barzilai, 2013). In addition, the students were encouraged to contemplate things that have the greatest personal significance for them. The entries were typically 8–10 paragraphs in length.

Data analysis

65 entries were analyzed in line with the deductive and inductive approaches. Based on the deductive approach, initial categories were generated based on our theoretical review: (1) epistemic change; (2) social perspective-taking; (3) domain-based knowledge (including factual, conceptual, procedural and metacognitive knowledge); and (4) online collaboration with other students by means of digital CM. The inductive approach facilitated the identification of additional meaningful categories. According to Strauss (1987), both these aspects of inquiry are absolutely essential throughout the analysis. Thus, both logically derived categories and those that may have “serendipitously” arisen from the data may find their way into the research (Merton, 1968).

Thematic analysis was used in the present study for identifying, and reporting additional themes found within the data (Braun and Clarke, 2006). This highly flexible approach provides a rich and detailed account of data with only a few prescriptions and procedures. It is a practical, effective technique, recommended for examining the viewpoints of different participants and summarizing key features of a large set of data (King, 2004). 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. No software was used. Episodes, thoughts and feelings expressed by the students served to increase the reliability of the recurrent and common themes.

Researchers' positionalities

The first author is a researcher specializing in the field of 21st-century instruction, learning and assessment. Her research centers on promoting lifelong learning skills via formal and non-formal learning environments. The second author is a researcher in the fields of healthcare management, medical education, and healthcare policy and marketing. These different but complementary backgrounds allowed the researchers to approach the study with extensive prior knowledge of the subject matter and to address certain topics, such as structuring the learning activity, with greater ease. To attain deeper reflexivity, the authors discussed their respective theoretical, research and practical perspectives throughout the research and writing process. In addition, the researchers kept a reflexive journal of the research process (Tobin and Begley, 2004). This self-critical account was used to document the logistics of the research, methodological issues that arose and each researcher's personal reflections (Lincoln and Guba, 1985). This assessment process ensured the logic and traceability of the research.


Six categories were detected in the analysis of the students' reflective journals: (1) transitioning from passive to active learning; (2) generating epistemic change; (3) social perspective-taking; (4) domain-based knowledge (including factual, conceptual, procedural and metacognitive knowledge); (5) prior knowledge and experience; and (6) online collaboration with other students.

From passive to active learning

When writing in their journals, the students claimed for the most part that this teaching method was new to them. For example, Shada described the work process as being not just different but contradictory to previous learning processes she had experienced: “Usually we were asked to read articles and then relate our opinion based on the article. In this assignment, we were asked to do exactly the opposite: to first say what we think and claim, and then to justify and strengthen our claim with the help of articles.”

Rotem noted that this was a new and unfamiliar method that increased her sense of creativity and her motivation to complete the assignment: “During the academic year we have to submit many assignments, and the processes and ideas behind them are very similar. Using the [concept] map caused me to be creative and to think in a different way. It appears that the process is regarded as a transition between the traditional way of learning and a method that places the learner at the center of the learning process.”

Epistemic change

During the learning process, the students experienced a perceptual change regarding the learning process and the acquisition of knowledge. At the outset, having no previous knowledge of the topic, the students made use of their intuition when building the first concept map. In the course of the assignment, when asked to provide a basis for their arguments, the students were exposed to a variety of directions that presented a complex reality about the topic which either contradicted or supported their initial point of view. In the following example, Roni reports on the complexity of the use of accreditation, which cast doubt upon her initial perception:

I approached the assignment about accreditation, knowing absolutely nothing about the topic. I heard about the concept of “accreditation” during the lesson for the first time, and I understood that it was something that has become compulsory for every hospital and ensures the assimilation of quality in the hospital. However, during the assignment, I learned other aspects of accreditation, including points about the heavy workload and burdens that are placed upon the nurses and the medical staff and the additional issues they are forced to deal with that are not connected to caring for patients.

Half of the students described their journey of gaining an understanding about acquiring knowledge and providing a firm foundation for it. It began with their personal feelings and intuition while building the first map. However, during construction of the second map, the understanding grew that it is necessary to establish the facts before making rational decisions. This was described by Orli:

The activity helped me to grasp the rationale for the decision and to understand the issue of accreditation. I had to search for scientific knowledge sources that presented well-based, reliable arguments. Today I feel that my opinion and my understanding of the topic are based on facts and not merely on general knowledge or personal feelings. The professional knowledge showed me the degree of importance of the accreditation process and its numerous advantages, provided it is done in a manner suitable to the organization.

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, as explained by Shiran,

My initial opinion was against accreditation, but as time went by, I became avidly in favor of accreditation. I understood that my former negative opinion stemmed from a lack of budgets, and I had heard from nurses that it was all a deception. As we progressed with the assignment and talked while we were writing, I believed that my initial opinion had been mistaken and that the other members in my group were correct. We found articles in favor [of accreditation], we discussed it, and persevered in finding its positive aspects. During a lesson in Ethics, there was a lecture about accreditation given by a guest lecturer. I was fascinated when she explained that there was no difference in the number of errors or infections between hospitals with accreditation and those without it. It made me wonder about the deception that accreditation presents and whether it is truly beneficial.

Rachel emphasized that the assignment had encouraged her to take an interest in the opposing side. She explained the challenge the assignment placed before her in this aspect, “compelling” her to investigate aspects that contradicted her initial assumption:

We had to understand the other side in order to form a basis for our opinion. We had to understand that every coin has two sides. The objective, among other things, is to improve the level of service and the quality of care, and to decrease the incidences of illness and death. Since I was under the impression that there was apparently no benefit to accreditation, I came to the conclusion that it currently does more harm than good. Reading the articles presented me with other opinions, and cooperating with other members of the group helped us focus on our opinions and formulate a basis for them.

Erez also explained that the process increased his interest in “the other side” and exposed him to opinions that were contradictory to his own. He was compelled to listen and to understand them. “During the process of searching for material on the Internet, I was exposed to a wide variety of opinions about accreditation, including opinions of people who were critical of it. I listened to opposing opinions in order to understand the reasons for them, with the idea that they might influence my opinion about it.” Six students reported using the practice of role-playing in order to enable them to closely explore and better understand opinions differed from their own. This was explained by Gila:

I was initially in favor of accreditation. I believed that hospitals underwent a refreshing process related to everything connected to quality of service when they were being examined by an external factor. Progressing from the first map to the second brought many challenges, discussions, and questions. I found myself asking whether I would change my opinion if I were in the position of a nurse in a hospital, and for a moment, I was skeptical.

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.

Factual knowledge

The students reported that they were exposed to vast amounts of knowledge in the course of the assignment. The assignment enriched their world of knowledge about accreditation, its advantages, and disadvantages. This stage was important for the beginning of the formulation of the second map and marked the beginning of the way toward establishing an argument. Yifat, for example, explained

I accumulated a vast amount of knowledge. I read and enriched my knowledge of the topic. I read studies that had been conducted that examined the accreditation process and its advantages. I think that I accumulated knowledge above and beyond what I needed, which helped me to reinforce my opinion (in favor of accreditation).

The students reported that the CM helped them remember the vast amounts of material and concepts they had learned on the topic. Hussein reported: “The activity definitely helped us to understand the topic of accreditation in hospitals. When you process the material that you read and learn, you assimilate it and remember it for a longer period of time.”

An additional characteristic that contributed to recalling the learning material was the visualization of the map. The use of visual aids such as colors and different backgrounds helped students to remember the material better, as explained by Maytal:

The map helped a lot. The visual aspect of the map helps organize and focus the material, keeps it in order, and mainly helps in remembering the topic. It is a visual map that is rich in colors that also serve as a factor that helps you remember.

Conceptual knowledge

A recurrent theme in the students' reflective reports was related to conceptual knowledge. This type of knowledge refers to patterns and interrelationships among the basic elements within a larger structure that enable them to function together – for example, knowledge about similarities and patterns in factual knowledge elements. The students predominantly emphasized the contribution of the CM to organizing their knowledge and identifying the connections between arguments, as described by Gabi:

I learned how to use the program and to develop a comprehensive manner of thinking and looking at several arguments simultaneously and to identify the various connections between them. However, I noticed that some of the articles were compatible with several arguments, and I felt I needed to thoroughly assess the degree of compatibility.

Ehud described how the digital CM helped him not only to organize the learning material but also to organize his thinking and to identify connections between concepts. “Building the map helped me to organize my thoughts and to return frequently to the main position and all the arguments, and to ensure that I didn't repeat myself. It also helped me to begin to consolidate thoughts about connections without the limitations of a pattern, program, or specific application.”

Procedural knowledge

The assignment presented the students with a dilemma. To find a solution, they had to make use of various research strategies. Unlike factual knowledge, which is based on primary research, the students were required to research the existing reality in order to form an opinion about the topic. Their research journey contributed to a better understanding of the phenomenon and encouraged the students to study the topic more deeply. This was explained by Yael:

The process was far from simple and required comprehensive searching day and night and many hours of reading in Hebrew and English. Even if I found a basis that was close to my argument, I didn't compromise at all because I wanted precise proof so that it would not be possible to contradict my argument. While reading the articles, I was surprised to find more advantages to the accreditation program. Whenever I found an additional advantage, I immediately looked for more articles that supported the advantage. I then added supplementary arguments to the map.

Similarly, Sigal and Rinat explained that the assignment forced them to comprehensively seek information, including information that contradicted their arguments. This enabled them to receive a clearer picture of the issue and to better substantiate their positions regarding accreditation.

The activity contributed to a better understanding of the evidence and strengthened my personal position on the topic. It also helped me to thoroughly understand the idea behind the accreditation process and why it is so important for improving and people's lives.

I think that using the map to present our arguments compelled us to delve deeply into things, to focus, and to learn the topic thoroughly: What do the hospitals need? What is the objective? What is required of the medical staff? We asked ourselves questions; we learned to recognize both sides and all the positions and opinions regarding accreditation.

Metacognitive knowledge

The students described how the activity helped them to self-regulate their learning. One of the tools that significantly promoted this was the table of criteria used to evaluate the concept map that was constructed together with the instructors. Sigal explained: “The criteria helped me build the assignment in stages. I worked on the map, stage by stage, according to the sections in the guidelines. That way, I made sure not to miss a single point and to complete the assignment well.” Leah also explained:

Before we began preparing the second map, we read the criteria in order to know what we were expected to present. While we were preparing the map, we looked at the criteria again to see if we were headed in the right direction. When we finished preparing the map, we reread the criteria again and saw that we had constructed the map well, and according to the criteria. We conducted an examination of each of the five arguments that we had raised to verify that each of them was presented and explained precisely and to make sure that each was presented completely on the map.

The students also mentioned that the predetermined schedule for preparing the assignment, as well as the constraints due to COVID-19, had caused them to realize the importance of the resource of time in learning and to utilize it properly. Shachar described her insights regarding the learning process:

I think there are two main things that I need to do to improve my part in the process. The first is to break the terrible habit of postponing assignments until the last minute. That means doing things on time, allocating the work over a number of days, and finishing the assignment easily in a relaxed manner without pressure and without having to stay up late at night to finish it.

However, the students repeatedly made a point of stressing the difficulty of independent learning mainly in searching for quality sources of information that supported their arguments, in clarifying values that arose from the dilemma, and in adhering to schedules, as described by Maytal:

The main difficulties began with finding articles. There was also difficulty thinking of values that arose from the dilemma that required a different way of thinking. Since we were a large group, we were able to brainstorm together and to come up with ideas. Because of COVID-19, I had to work [at my job] 16 hours each day, and it was difficult to adhere to the schedule and submit all the assignments, but you eventually learn that anything is possible.

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. For example, Shaul had previously worked in medical centers. His experience there served as an additional information source for understanding the issue of accreditation. Despite this, he still needed additional supportive evidence in order to consolidate his opinion into a well-established argument, as he described:

I have experience working in medical centers, so I have seen and understood the importance of the accreditation processes and their significant contribution. Reading professional literature on the topic, together with the findings of the other group members only bolstered my opinion. Today I have no doubt that accreditation is obligatory for large health organizations. There is proof of this in literature that accreditation plays a significant role in improving the quality and level of care for both the patients and the medical staff. However, I think that regarding smaller organizations, it is necessary to adapt the method of implementation and application of accreditation so as to better serve them in the best possible way.

Online collaboration with other students

According to the students' reports, using the Internet platform (Mindomo) for constructing concept maps helped group members to cooperate efficiently, as stated for example by Osnat: “The advantage of the map is that you can see all the ideas of members of the group in an organized manner.” However, many students reported difficulties that arose due to the COVID-19 restrictions, which hindered optimal cooperation between the group members, notwithstanding the variety of available technological tools. This was noted by Ehud: “Because of the Coronavirus crisis, we could not meet, and we had to conduct ‘virtual’ discussions. We held group Zoom meetings, phone calls, and a WhatsApp group. It's a bit more difficult to work as a group in this way.”

Galit also explained that it would have been preferable to meet in person in order to divide the workload equally among the students. As the process progressed and they understood the constraints, the group learned to “overcome” the difficulty and found ways to promote optimal group work using technological tools,

In light of the situation that we were forced to deal with, we had to do the assignment online. It was extremely difficult to meet together and to conduct discussions about the assignment in an orderly way. Even when we held online meetings, only one person would work on the map, while the rest of us attempted to express ourselves and help build the map. Despite these difficulties, we learned to overcome the problems and to use other programs such as Zoom or Google Meet and to schedule meetings to build the map. We learned how to upload data to the Internet and to make do with what was available.

In addition to the difficulties in communication among the group members, the students also attested to experiencing some technological problems. They were unfamiliar with the Mindomo digital platform and had to learn it from the instructor. They were also assisted by fellow group members, as described by Aviv:

All the members of the group experienced problems while building the map because it was the first time we had ever constructed this type of map and use this digital platform. Some of the difficulties stemmed from the situation in the country, which was far from ideal, in which we were forced to conduct some of the meetings by Zoom. In the beginning, it was complicated, and we were certain that we wouldn't succeed, but after several attempts, we succeeded in connecting all the knowledge that was required and in creating a detailed map.


This research sought to show how constructivist learning can be performed online for health management students during the COVID-19 period. It demonstrates how the promotion of argumentation-based learning with digital CM might elicit new and different beliefs and conceptions of learning and knowledge, encourage social perspective-taking, spur high-order thinking skills and enable online collaboration.

The students entered the process basing their arguments primarily on intuition and “black or white” definitions that had been presented during short lectures at the beginning of the course, and thus exhibited beliefs regarding the existence of absolute truths. As the learning process progressed, the students were exposed to an array of different viewpoints. They recognized the complexity of the topic, and thus reached a higher level of epistemological belief in which knowledge is seen as inherently subjective, generated by human minds. Finally, the requirement to base their arguments on facts advanced them to a higher epistemological level – evaluativism – where they recognized the significance of weighing evidence and addressing contradictory knowledge claims (Kuhn et al., 2000). During times of crisis, with significantly important decisions before them, public health officials, as well as individual physicians, are expected to utilize rational, evidence-based decision-making strategies. The response to the COVID-19 pandemic around the world has, however, been characterized by governments, health institutions and physicians advocating management strategies inconsistent with rational, evidence-based reasoning (Djulbegovic and Guyatt, 2020). Students who have experienced an epistemic change during constructivist practices will demonstrate an ability to alter preconceived epistemic beliefs of how the health professions should be taught, and how critical thinking skills should be attained.

The activity described in the present study also promoted socio-moral thinking skills and “role-taking” practices. The students examined the situation from another person's perspective, considered and evaluated others' perspectives while engaging in social interactions and reading academic materials (Kim et al., 2018). This practice is related to the social cognition theory (Selman, 1980), and role-taking skills which enable a person to understand another's cognitive and emotional aspects. Incorporating an ethical dimension in the problem, in line with the VaKE approach, led to a role-taking practice that may have contributed to the students' cognitive-moral development. Socio-moral thinking skills are perceived to be invaluable during times of crisis. For example, Wang and Tang (2020) maintain that tackling health inequities during the COVID-19 outbreak is of high importance. The lack of health-equity assessment during the current crisis has been evident. Therefore, it is suggested to place an emphasis on equity in health education in an effort to strengthen the health system and emergency responses during public-health crises that may arise in the future. Such learning initiatives that nurture socio-moral thinking in a time of a global crisis have the potential to produce a generation of professional practitioners who aspire to prioritize solutions dedicated to collaboration and social justice (Siry, 2020).

With reference to domain-based knowledge, factual knowledge was more prevalent in the earlier stages of the activity, while the students were constructing the first map. However, designing the second map elicited higher-level thinking needed to identify patterns, similarities and interrelationships among the elements in the map. The activity, which necessitated a profound understanding of the materials and problem-solving skills, provided scaffolds for students to self-regulate their learning. These competencies are especially important in times of crisis, and particularly for health practitioners during a global pandemic. Throughout the COVID-19 crisis, practitioners have been forced to rethink key ideas, traditions, conventions and even values in order to adapt to ever-changing circumstances. Skills aimed beyond the immediately known and familiar are required to contend with the new situation in which existing models or solution strategies are unavailable or unproductive.

In addition, students' prior knowledge was found contributive to their ability to recognize and take advantage of deep structural content. Researchers maintain that compared to learners with less domain knowledge, more knowledgeable learners tend to be more sensitive to structural features relevant to the domain (Braithwaite and Goldstone, 2015). For example, experts may have more experience understanding situations in terms of the abstractions relevant to their field, or their rich prior knowledge allows them to circumvent limitations in their working memory (Day and Goldstone, 2012).

In recent years, most medical programs have been grappling with major calls for curricula change, particularly in educational technologies. This has become more prominent during the current health crisis (Torda, 2020). In our study, the CM digital platform enabled real-time collaboration among the students. This element of the activity was extremely important during the COVID-19 lockdown, during which the students could not physically meet each other. The students emphasized their preference to meet their group members face-to-face, and in their efforts to overcome the situation imposed on higher education, they found creative ways to communicate in order to accomplish the learning goals. The experiences gained by using such collaborative digital platforms during the lockdown might inspire innovative changes that will ultimately have long-term benefits for medical education.

Nevertheless, several challenges were put forth by the students. For example, some of them were unfamiliar with the digital CM platform required to be used in constructing their arguments. Others struggled to understand its functions during the process and were not fully aware of the options available for sharing the map with the group. Some reported failing to self-regulate their learning adequately; for example, how to optimally manage their time during the pandemic.


The present study features several limitations that merit mention and opens avenues for future research. First, it was conducted in a single country and was limited exclusively to health management students; therefore, the results cannot necessarily be generalized to students of other countries and health study tracks. A cross-cultural examination is needed to substantiate the findings. Second, several researchers (Braun and Clarke, 2006; Nowell et al., 2017) point to the disadvantages of thematic analysis, asserting that the lack of clear and concise rules around this analysis may sustain the “anything goes” critique of qualitative research. The flexibility of thematic analysis can lead to inconsistency when developing themes derived from the research data. Future studies should use multiple methods and data sources to develop a comprehensive understanding of the implications of the online learning activity investigated in the current research.

Conclusions and implications

The reality of the COVID-19 pandemic lockdown has challenged the types of conventional teaching, widely practiced in health education and created an opportunity to tip the scale towards active rather than passive methods of teaching and learning. New and renewed learning activities are now required, characterized by learning objectives for medical education that are relevant to the changing demands of the 21st century. The COVID-19 period has galvanized educators into by stressing the pressing need for adapted and appropriate instructional methods that meet the needs of the profession in the present and the emerging ever-changing challenges that are yet unknown. As part of this process, we must train students of health management by developing the necessary qualifications in the early stages of their studies in medical schools, nursing schools and medical management schools, as well as in the advanced stages of learning and professional training. Applying novel teaching and learning activities informed by constructivist pedagogical approaches can ensure the continuity of effective health education during the COVID-19 crisis, and beyond. Online activities aimed at advancing 21st-century skills relevant to health profession in times of uncertainty should be seen as an opportunity to enhance the potential for long-term improvement of health professionals' education and development, thus preparing the health workforce to better adapt to new situations.

This study shows that combining constructivist teaching and learning tools with advanced technology, through an online course that encourages active learning, facilitates the acquisition of lifelong learning abilities among students in the health management professions. This constitutes another step toward adapting the health system and its practitioners to the mounting demands and needs of the 21st century. The authors' hope is that this study might encourage health-profession educators to use the experience gleaned during this global pandemic to re-examine the current teaching and learning demands in health education. It may also encourage educators to broaden their educational approach toward incorporating lifelong learning skills, such as problem-solving and critical thinking, which could greatly benefit health professionals in times of crisis. Developing these skills at the initial training stage would enable medical practitioners to better cope as professionals with the wide range of needs of the staff working in the health system today. This would mean reforming and adapting the system to the new and dynamic present-day reality, which demands demographic, environmental, cultural, social and technological changes.

Although still preliminary, these findings point to potentially exciting new avenues for future research, the findings of which are likely to have an impact on online setting design. Such future efforts might increase the potential of implementing innovative instructional strategies that promote lifelong learning skills through online learning environments. These endeavors pertain to the use of technology in learning environments built upon a sound pedagogy, and to the question of how health-profession educators and students engage with novice practices of learning and teaching that are adapted to a time of turmoil and crisis. These include the epistemic change of teachers and learners, learners' skills and ethical aspects related to the profession.

Teaching and learning experiences gleaned during the COVID-19 crisis signal the necessity to shift from a focus on content to a focus on competency-based education. Increasing flexibility in terms of content taught and stressing learning outcomes instead of teaching goals might better help in fostering a new generation of health professionals who can think critically and advance from simply applying prior knowledge to new situations to solving complex problems that require innovation. These strategies include developing an awareness of practices and existing knowledge and honing skills that improve adaptability in the search for innovative approaches to solving problems in times of uncertainty.

Health curriculum designers should also consider incorporating technology in health education in a way that enables students to develop their collaborative skills and abilities. Students' knowledge and experience gained during the pandemic associated with distant peer-collaboration might contribute to their future professional careers, which will likely demand such skills. Thus, in view of the new and constant health challenges our society is facing, future educational efforts must devise innovative approaches using technology-enabled teaching methods that afford students the opportunity to nurture critical thinking skills, professional values and ethics, and improved collaborative skills.


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Further reading

Chan, Z.C.Y. (2017), “A qualitative study on using concept maps in problem-based learning”, Nurse Education in Practice, Vol. 24, pp. 70-76.

Greene, J.A. and Yu, S.B. (2016), “Educating critical thinkers: the role of epistemic cognition”, Policy Insights from the Behavioral and Brain Sciences, Vol. 3 No. 1, pp. 45-53.

Corresponding author

Dorit Alt can be contacted at:

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