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Advan. Physiol. Edu. 26: 210-221, 2002;
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ADV PHYSIOL EDUC 26:210-221, 2002
© 2002 American Physiological Society

TEACHING WITH TECHNOLOGY

STUDENT CRITICAL THINKING IS ENHANCED BY DEVELOPING EXERCISE PRESCRIPTIONS USING ONLINE LEARNING MODULES

C. Jayne Brahler1, Ian J. Quitadamo2 and Emily C. Johnson3

1 Department of Health and Sport Science, University of Dayton, Dayton, Ohio 45469
2 Department of Biological Sciences, Central Washington University, Ellensburg 98926
3 Department of Exercise Science, Washington State University, Pullman, Washington 99164

Abstract

Developing the ability to think critically is an important element of undergraduate physiology education and is influenced by many factors, including the learning environment, the social context of the learning environment, and the instructor’s approach to teaching. In this work, we describe online learning modules (OLM) that were designed to promote higher-order critical thinking skills in students enrolled in an upper-division Exercise Testing and Prescription course. The OLM provided students with an online learning environment in which to review clinical physiological details from authentic patient case data and develop exercise prescriptions (ExRx), by requiring students to critically analyze authentic patient case histories and collaborate on computer-based learning activities. On the basis of assessment data, we conclude that the OLM helped exercise science students develop the critical thinking skills necessary for development of effective exercise prescriptions by requiring them to think critically while concurrently reinforcing lecture-presented exercise science content.

Key words: critical thinking; collaborative group learning; exercise prescription; technology-enhanced learning; learning environment; social context

Development of critical thinking skills in college students is a goal for many college instructors in higher education who seek to prepare their students for postgraduate, real-world situations (7, 8, 26). Despite the importance of these skills, the unfortunate reality is that many college graduates lack the ability to think critically (8, 15, 29, 28), partially owing to 1) large class sizes (33); 2) limited budgets; 3) time constraints that are perceived not to allow for activities that promote critical thinking, such as in-depth inquiry and small group problem solving (11); and 4) external pressure to prepare students to pass standardized college exams that do not require critical thought (30). Furthermore, many instructors were not educated in a manner that supported development of critical thinking skills and thus lack a clear model for how to cultivate these skills in students (20, 31). Online learning modules (OLM) may offer the opportunity to create learning activities that promote critical thinking.

One area of applied physiology that requires significant critical thinking is the development of exercise prescriptions (ExRx). Exercise is commonly used as a preventive and rehabilitative modality in clinical medicine and in corporate fitness programs. Professionals in exercise science, physical therapy, nursing, and other allied health fields are often responsible for developing such exercise prescriptions. For exercise to be an effective therapeutic modality, it is necessary to develop a prescription that is specific to the individual requiring intervention. The effectiveness of an ExRx is dependent on many physiological and nonphysiological factors. Development of effective exercise prescriptions for different types of subjects requires significant content knowledge in areas such as normal physiology, basic pathophysiology, and physiological responses to exercise stress, as well as consideration of logistical constraints faced by subjects for whom the prescription is being developed. Evaluating and synthesizing the physiological and nonphysiological factors to develop an effective exercise prescription plan requires significant critical thinking.

The concept of critical thinking has numerous definitions (16, 17, 36). Garrison (1992) characterizes critical thinking as a five-stage problem-solving process (17), with each stage characterized by critical reasoning skills (23) as shown in Table 1. These problem-solving stages and critical thinking skills align closely with the processes that students must work through to develop effective ExRx. For this reason, Garrison’s critical thinking model was selected for the present study, and the instructor-assessed student critical thinking performance using Garrison’s five-stage problem-solving process as the criterion for critical thinking.


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  		TABLE 1 Activities characterizing Garrison’s problem-solving stages and Henri’s critical thinking skills

 
Development of student critical thinking skills is dependent on many variables, including the learning environment, the social context of learning, and the teaching style of the instructor (22–26, 30, 32, 33, 35). Learning environments that feature small group collaborative learning promote critical thinking skill development in college students (5, 10, 12) through critical reflection (34). The instructor also plays a pivotal role in cultivating critical thinking skills, as well as serving as the domain-specific content expert. Effective teachers facilitate student critical thinking skill development when they implement learning activities that have authentic, real-world contexts and personal relevance to the student (3). Additionally, well designed, open-ended questions and investigative activities by the instructor facilitate critical thinking (6, 13). Instructors promote critical thinking when they 1) pose questions that have more than one correct answer, 2) provide an appropriate length of time for students to think before responding, and 3) avoid asking questions that require only a "yes" or "no" response (6, 22).

The purpose of this study was to determine whether students enrolled in an upper-division Exercise Testing and Prescription class engaged in critical thinking while collaboratively developing exercise prescription plans using online learning modules designed with attention to factors known to promote critical thinking.

METHODS

OLM were designed and developed using Active Server Page (ASP) and JavaScript (computer programming languages), with OLM content generated from a Microsoft SQL7 database. Developing in these platforms allowed students to reorder, edit, rearrange, and recall their responses from the database easily.

The instructional design incorporated into the OLM represented a balance between two important pedagogical models: 1) a construct-driven model (31), which focused on critical thinking and problem-solving skills that are generalizable across disciplines; and 2) a task-centered model, which focused on students generating domain-specific content after reading a prepared patient case history (31). While the students were learning the "process" for solving problems (15), the instructor assessed the quality of the students’ critical thinking performance on the basis of the five stages, skills, and activities of the critical thinking process proposed by Garrison and Henri (33) (Table 1).

Each OLM presented students with a patient case history (Table 2), developed by the course instructor, that was followed by a series of questions, decision points, and requests for rationale (Figs. 1–5). The OLM allowed students to easily reorder, rearrange, revise, substitute, and modify their work as they progressed through learning activities and provided students with a sequential and logical process for developing ExRx. Each OLM was designed to provide students with a structured learning environment that provided a process for developing ExRx for specific patient case studies. The key prompts (14, 27) for students included the following:


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  		TABLE 2 Case presentation: hypertension case study #2

 


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  		FIG. 1 Developing a pathological problem list.

 


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  		FIG. 5 Providing a rationale for each ExRx.

 
Review a patient case study (Table 2);

Develop a pathological problem list (Fig. 1);

Develop a non-pathological problem list (Fig. 2);



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  		FIG. 2 Developing a nonpathological problem list.

 
Prioritize and reorganize problems in the lists (Figs. 1 and 2);

Analyze problems in the lists (Fig. 3);



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  		FIG. 3 Analyzing problems in the list. BMI, body mass index; LDL, low-density lipoprotein. Note: the remainders of the responses are concealed in this screen capture by the scrolling text box but are accessible by the students in the online environment.

 
Develop ExRx plans (Fig. 4);



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  		FIG. 4 Developing exercise prescription (ExRx) plans. OLM, online learning module. The term differential prescription (DfRx) refers to consideration of more than 1 ExRx at a time to determine the best fit for the person in consideration. Students developed several ExRx for each patient case and took into consideration physiological and nonpathological problems to select the best prescription. Note: the acronym DfRx was used in the OLM described herein and corresponds to the ExRx acronym used in this paper.

 
Provide a rationale for each ExRx (Fig. 5); and

Discuss ExRx with the class.

Subjects
The Institutional Review Board at Washington State University (WSU) approved this study. Participants in this study were junior and senior undergraduate college students (n = 7) and represented the entire class enrollment in an Exercise Testing and Prescription class at WSU. Students were given an opportunity to provide informed consent for participating in this research study and were informed that their grade would be unaffected regardless of their participation in this study. All students provided informed consent and developed ExRx in the OLM (n = 7). However, one male student elected not to complete the survey administered at the end of the class, so the results of the survey are for only six students, including three females and three males.

Implementation of OLM
The Exercise Testing and Prescription class was an upper-division three-credit class for Exercise Science majors, and included three one-hour lectures and a two-hour laboratory each week. The OLM learning sessions took place during the weekly two-hour laboratory sessions. Lecture and laboratory topics covered pathological and nonpathological special conditions, such as hypertension, cardiovascular disease, obesity, pregnancy, advanced age, and diabetes with an OLM available for each condition. After a one-hour lecture, students were self-selected into groups of two or three per computer terminal and worked collaboratively to analyze two patient case histories and develop ExRx. Students applied information from lectures and their textbooks to the OLM case studies. The cases were discussed as a class for the last 20 minutes of laboratory. A typical example of an OLM is shown in Table 2 and Figs. 1–5. This particular OLM is structured around a case study of a 51-year-old male with hypertension (Table 2). To show how the OLM is used, Figs. 1–5 include some student-generated responses and some author-generated explanations; however, the OLM do not contain such information when students begin developing ExRx.

Throughout the OLM activities, students were encouraged to rethink their conclusions and revise their original hypotheses or problem lists as discussion within their group provided additional information.

The OLM prompted students to move from simple, routine task orientation to questioning and evaluating their work at a higher cognitive level. The course instructor was available at all times during the laboratory sessions to guide and facilitate student critical thinking, and to provide content expertise and feedback. Students also accessed course texts (1, 2, 21) as they worked in collaborative teams to analyze pathological, physiological, and logistical problems that affect the client and prepare an ExRx. They shared dynamic, free-flowing conversation within their own groups, with members of other groups, and with the instructor and came to a consensus within their group before entering data into the OLM. Laboratory activities culminated in a class-wide discussion that focused on student-generated problem lists and analyses and on the ExRx that the students had developed. During this discussion, the instructor guided and facilitated student critical thinking by asking probing questions that required students to elaborate, justify, or provide rationales for their choices. The instructor provided "what if" scenarios to challenge the students and to further their understanding of the course material. The instructor also provided supplementary content expertise during the final discussion when needed.

Assessment
Four main student performance items were assessed in this study:

Student-student interactions that took place as students worked collaboratively to analyze patient case histories and develop ExRx by use of the OLM;

Teacher-student interactions that took place as the instructor served as a facilitator for promoting critical thinking and as a content expert for mastering domain-specific content;

Self-reported evaluation of the learning environment, activities, and student learning; and

Course instructor evaluation of the accuracy and completeness of the final OLM product as well as content mastery.

Assessment 1.
The instructor observed student-student interactions that took place while students worked in collaborative groups to solve patient case problems and assessed these competencies by means of content analysis, an analytical approach that elucidates critical dimensions of the learning process (33, 34). The instructor observed each student’s critical thinking abilities on the basis of Garrison’s (17) and Henri’s (23) criteria as the students worked collaboratively through the problem-based OLM activities and presented prescriptive solutions to complex clinical problems. In this way, the instructor qualitatively evaluated the learners’ thinking processes so that particular areas of conceptual confusion could be identified. The intent of the first assessment item was to look for critical thinking indicators that were developed within a social context (33). Instructor evaluation of student performance for critical thinking and problem-solving skills was based on the five stages and skills of the critical thinking process proposed by Garrison and Henri (33) (Table. 1).

Assessment 2.
As students worked in collaborative groups to solve patient case problems and during the class discussion, the instructor listened for conceptual gaps in student understanding. Once a conceptual gap was recognized, the instructor involved the students in a series of prescriptive activities designed to address their particular confusion. Through student-student and teacher-student interactions, the instructor examined each group’s hypotheses and rationales for a specific exercise prescription and through this recursive, reflective process guided student development of both exercise prescription and critical thinking skills. For the first and second assessment items, the instructors qualitatively assessed these stages and skills on an ongoing basis.

Assessment 3.
The third assessment item was evaluated by reviewing student self-reported data on a survey completed by students after the final laboratory class (Table 3). Student self-evaluation of learning efficacy and course satisfaction, as they related to the OLM, was assessed using selected questions from an online course assessment tool (Flashlight Silhouette can be found at URL: http://www.ctlt.wsu.edu).


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  		TABLE 3 Student survey responses to open-ended questions

 
Assessment 4.
The final assessment item was performed by the course instructor, and focused on the accuracy and completeness of the student’s problem lists, problem analyses, and ExRx plans developed in the OLM, as well as student mastery of domain-specific content through the use of a paper-and-pencil test administered at the end of a specific class unit that incorporated concepts learned in multiple OLM units.

RESULTS

Assessments 1 and 2
The instructor observed activities supporting every one of Garrison’s problem solving stages (17) and Henri’s critical thinking skills (23) (Table 1) in every group for each OLM implemented. Students engaged in critical dialogue with other students and with the instructor as they defended their ExRx, questioned the ExRx put forth by others, and revised their ExRx on the basis of new insights gained during group discussions. Working within the OLM appeared to facilitate students’ analytical discussions, critical thinking, and idea generation.

Assessment 3
See Table 3 for survey responses. Quantitative assessment of the effects of the OLM and student-student and teacher-student interactions on student learning using the quantitative survey tool (Flashlight) revealed several key points. Students moderately to strongly felt that the course instructor emphasized students becoming responsible, self-reliant, confident, and productive learners within a collaborative social context. Students strongly felt that the emphasis placed on small group collaborative learning helped them to work through a complex problem-solving process with creativity, critical evaluation, and reflection with real-world, authentic tasks. Students moderately to strongly felt that their individual performance in constructing a prescription plan was more effective using collaborative small groups than working alone and felt that they got much more from the class than would have been the case without small-group learning. As the centerpiece of the collaborative group learning, students strongly felt that their experiences with problem solving and critical thinking processes as structured by the OLM (and facilitated by the course instructor) allowed them to understand each clinical situation, examine and evaluate relevant case study data associated with the clinical scenario, and make informed criticisms, judgments, and prescriptive solutions for each case.

Assessment 4
The instructor judged the final ExRx product for each student group as excellent, and students demonstrated competency on knowledge of course content.

DISCUSSION

Success in the modern workplace requires individuals to work cooperatively in small groups and to employ critical thinking skills to derive solutions to complex problems (6, 26). To better prepare for success on the job, students must engage in problem-solving activities that require critical thinking, take place in a social context, and represent an authentic postcollege work environment (24).

In this study, each OLM provided authentic patient case histories and required students to apply the same set of analytical and evaluative skills that would be required of them in clinical and nonclinical settings when developing ExRx. OLM components that supported the problem solving and critical thinking processes included 1) reviewing a patient case history, 2) developing comprehensive pathological and nonpathological problem lists for the patient, 3) prioritizing the problems in the pathological problem list, 4) determining patient data that were missing but which would have been helpful to know, 5) analyzing each problem in the problem list and relating each problem to the physiological underpinnings by use of a physiological "systems" approach, 6) developing ExRx plans and providing a rationale for each, 7) selecting the most effective ExRx from the three ExRx developed, and 8) discussing, defending, and modifying the selected plans during a critical, reflective class discussion. One advantage of this particular process was that it was nonlinear and required students to conceptualize and critically reflect on formulating their own prescriptive plans at each stage of development. Another advantage was that the instructional design shifted some organizational responsibilities away from the instructor. Rather than having to prompt students to reconsider their responses, and think more deeply about their prescriptive plans, the OLM provided these prompts, thus allowing the instructor to be an active participant in critical discussions and to serve as a content expert.

Because student groups worked collaboratively and in a social context through the problem-based OLM activities and presented their prescriptive solutions in a class discussion format, the instructor was able to observe each student’s critical thinking abilities (18). In this way, the instructor was able to qualitatively evaluate the learners’ thinking processes [based on Garrison’s (17) and Henri’s (23) criteria] and identify particular areas of conceptual confusion. If a conceptual gap was recognized, the instructor was able to involve the students in a series of prescriptive activities designed to address the particular conceptual confusion. Through this recursive, reflective process, the instructor facilitated development of critical thinking skills.

Nontraditional instructional approaches that support student-centered, small-group collaborative learning may enhance student critical thinking skills and result in high-quality educational outcomes while not requiring significant additional instructor time or energy to teach a course (39). With proper design of learning activities, computer technology appears to be able to support the development of student critical thinking skills (27). However, for computer-enhanced instruction to be a boon rather than a bane, it is important that instructors maintain their emphasis on teaching and learning and not focus unduly on the technology (27). For the computer-enhanced tools used in this study, learning, rather than technology, was the focus. The OLM described in this study for developing ExRx could be replicated in a worksheet using a word processing program or even as a paper-and-pencil activity. However, the online version implemented in the present study may offer the advantages of students being able to easily reorder, rearrange, revise, substitute, and modify work easily while developing ExRx.

The small sample size in this study limits the generalizability of our results to other groups; large classes may yield different results. Whether these results can be replicated on a larger scale and in other disciplines would require further investigation.

In conclusion, on the basis of the preliminary data presented in this paper, the authors conclude that developing ExRx in OLM may be successful in enhancing student critical thinking through collaborative small group interactions. In addition, students may develop excellent ExRx by using an OLM as described in this study.

Acknowledgments

We thank Dr. Steve Hines, a Washington State University faculty colleague in the School of Veterinary Sciences, who worked with C. J. Brahler to develop the online schematic for exercise prescription, John Tomoso, a computer science student who completed the computer programming for the OLM, and the Student Learning Center for providing the computer classroom laboratory.

This work was completed at Washington Sate University, Pullman WA.

Address for reprint requests and other correspondence: C. J. Brahler, Univ. of Dayton-Health and Sport Science, Rm 40G, Frericks Convocation Center, 300 College Park, Dayton, OH 45469-1210 (E-mail: jayne.brahler{at}notes.udayton.edu).

Received for publication June 11, 2001. Accepted for publication June 16, 2002.

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