Student-Centered Active Learning Improves Performance in Solving Higher-Level Cognitive Questions in Health Sciences Education

Simple Summary

Student-centered active learning (SCAL) shifts the focus from teachers to students and requires new assessments beyond memorization and comprehension. This paper demonstrates the effectiveness of SCAL by analyzing student performance at different cognitive levels in flipped classrooms. The tests measured knowledge, comprehension, application and analysis. SCAL assesses content acquisition and critical skills for health sciences education. Over three academic years, student performance in expository learning was compared with SCAL in the Anatomy and Embryology I course. Opinions from 326 anonymous surveys were also collected. While low-level cognitive performance showed no difference, SCAL significantly improved higher-level problem solving and knowledge application. Despite the benefits of SCAL, it requires more effort from teachers and students, and the current teaching quality assessment system penalizes teachers’ efforts.

Abstract

Student-centered active learning (SCAL) shifts the focus from the teacher to the student. Implementing SCAL requires the development of new forms of assessment beyond memorization and comprehension. This paper aims to demonstrate the effectiveness of SCAL by analyzing student performance at different cognitive levels. In flipped classrooms, students completed tasks with varying cognitive demands. The tests measured knowledge (level 1), comprehension (level 2), application (level 3) and analysis (level 4). This approach to assessment assesses not only the acquisition of content, but also skills that are critical to a health science student’s future career. The results of expository learning were compared with student-centered collaborative learning in the Anatomy and Embryology I course over three academic years. Student opinions were collected through 326 anonymous Wooclap^® (Version: 2019101500) surveys. No differences in performance were found for low-cognitive-level questions. However, SCAL significantly improved performance on higher-cognitive-level questions that required problem solving and application of knowledge. Despite the benefits of SCAL, it requires more effort from both teachers and students. The current assessment system at Universidad Complutense, which measures teaching quality primarily in terms of student satisfaction, tends to penalize efforts to innovate. Many students are attracted to passive learning techniques because they provide a clear and structured path to success. This approach, which focuses on memorizing information for exams, provides a sense of security. Teachers need to have a strong belief in the effectiveness of SCAL methods to persist in their implementation.

1. Introduction

The shift towards active learning in higher education, driven by the Bologna process and EU directives, marks a significant departure from traditional lecture-based teaching practices [1]. Traditional lectures focus on one-way communication, where teachers deliver information and students passively listen and take notes, emphasizing memorization. This method typically involves structured, linear presentations with little flexibility or student input, and assessment often relies on exams that test recall rather than understanding or application [2]. Traditional lecture-based teaching cannot meet the needs of developing higher cognitive levels of learning [3].

In contrast, active learning engages students directly and requires active participation through reading, writing, discussion and problem solving. This approach encourages higher-order thinking skills, such as analysis, synthesis and evaluation. Active learning helps students acquire professional skills that are not achievable through lecture-based instruction [4,5]. In addition, evidence shows that active learning strategies that engage students mentally produce better educational outcomes than traditional lectures [6,7,8].

In student-centered active learning (SCAL), students construct knowledge and teachers guide and facilitate learning. In the veterinary medicine program at Complutense University, we have implemented three SCAL methods: Team-Based Learning (TBL) in laboratory sessions [9]; Flipped Classroom in theory sessions [10,11]; and Problem-Based Learning (PBL) integrated into all courses. TBL emphasizes collaborative learning and student engagement through structured team activities. In TBL, students work in diverse teams to apply anatomy content to real-life problems. The process typically involves several stages: (a) Preparation: Students individually study the assigned material before class to ensure they have a foundational understanding; (b) Readiness Assurance: At the beginning of the class, students complete a short individual quiz to assess their understanding of the pre-assigned material, followed by a team quiz where they discuss and answer the same questions collectively; (c) Application Activities: Teams engage in problem-solving exercises or case studies that require them to apply their knowledge, encouraging critical thinking and collaboration; and (d) Feedback and Reflection: Instructors provide immediate feedback, and students reflect on their learning process and team dynamics to identify areas for improvement [12]. Flipped Classroom is an instructional strategy that reverses the traditional learning environment by delivering instructional content, often online, outside of the classroom. This approach allows classroom time to be used for engaging in interactive, hands-on activities that reinforce and apply the material learned. Key elements of a flipped classroom include: (a) Pre-Class Preparation: Students are assigned to watch video lectures, read articles or complete other preparatory work before coming to class. This independent study provides them with the foundational knowledge needed for in-class activities; (b) In-Class Activities: Classroom time is dedicated to collaborative learning activities, such as discussions, problem-solving tasks, group projects and case studies. These activities encourage students to apply their knowledge, think critically, and engage actively with the material and their peers; and (c) Teacher’s Role: The teacher acts as a facilitator, guiding students through the in-class activities, providing support, and offering immediate feedback. This shift allows for more personalized instruction and addresses individual student needs [13]. PBL is an instructional method where students learn through the experience of solving open-ended problems. Key characteristics of PBL include: (a) Real clinical case: Students are presented with a real clinical case that does not have straightforward solutions. The case is designed to stimulate critical thinking and motivate learning; (b) Student-Centered: Students take responsibility for their own learning by identifying what they need to know and seeking out the necessary information. They work in small groups to research, discuss, and propose solutions to the problems within the clinical case; (c) Facilitator Role: Instructors act as facilitators [14].

This study focuses on the effectiveness of the flipped classroom compared to expository teaching.

The flipped classroom method, based on constructivism, cooperative and active learning, considers individual learning differences [15]. It involves self-directed and self-regulated learning, problem solving, collaboration and inquiry-based activities. Students actively participate and develop skills such as analytical thinking, problem solving and metacognitive activities [16,17,18]. In the flipped classroom, students use theoretical knowledge to solve real-life problems through cognitive exercises.

By comparing the flipped classroom and traditional teaching methods, this study aims to provide evidence of the effectiveness of the SCAL method in developing cognitive skills beyond memorization. Through rigorous assessment and analysis of both quantitative and qualitative data, the research offers valuable insights into how different teaching strategies impact student learning and skill development in the context of anatomy education.

The study has three main research objectives: 1. To evaluate the effectiveness of the flipped classroom. To evaluate the impact of the SCAL method, specifically the flipped classroom, on the development of skills beyond memorization. To compare the performance of students taught through the flipped classroom method with traditional expository teaching; 2. To measure cognitive skills at different levels. Design and implement tests to assess students’ skills at four cognitive levels adapted from Bloom’s Taxonomy [19]. Determine whether the flipped classroom method is more effective in developing these cognitive skills than traditional teaching methods; 3. To analyze student feedback. Collect and analyze students’ opinions about both the flipped classroom and traditional teaching methods. Identify the perceived benefits and challenges of each method from the students’ perspective.

2. Materials and Methods

2.1. Study Design

The study was designed as follows: Participants were first-year veterinary students enrolled in an anatomy course. The same cohort experienced both teaching methods to ensure comparability. The teaching methods used for the study were expository teaching, traditional lecture-based method and flipped classroom, and students prepared by engaging with digitized materials (e.g., videos in H5P format) before class, with class time dedicated to interactive, problem-solving activities. The same anatomical content was taught by the same instructor using both methods to eliminate instructor variability. The research was conducted in the subject Anatomy and Embryology I at the Faculty of Veterinary Medicine of Complutense University of Madrid (UCM), during the academic years 2015/2016, 2022/2023 and 2023/2024.

The assessment tools used for the study were cognitive skills tests and student feedback surveys. The tests were developed based on four cognitive levels from Bloom’s Taxonomy, ensuring that they were comparable in difficulty and scope for both teaching methods. Comparable tests were administered at the end of each teaching method to measure students’ skill development. Surveys were designed to gather students’ opinions on the effectiveness, engagement and challenges of both teaching methods. Likert-scale questions were used for quantification and open-ended questions for qualitative insights.

Test scores were analyzed to compare the effectiveness of the flipped classroom and traditional teaching methods across the four cognitive levels. Open-ended survey responses were analyzed to identify common themes and insights regarding students’ experiences and perceptions. Comments were categorized as positive, negative and suggestions for improvement.

TBL was initially introduced in practical sessions during the 2018/2019 academic year. The pandemic significantly changed the landscape of higher education, necessitating the integration of information and communication technologies (ICT) for the delivery of both theoretical and practical classes. It helped us to introduce active elements in the theorical lessons in a very effective way. In the 2021/2022 academic year, active learning elements were introduced into the traditional theory session for the first time. In the academic year 2022/2023, flipped classroom elements were introduced, in 2023/2024 all the content was flipped. Participants included recent high school graduates, some with previous higher education, and some repeating the subject.

The survey methods used included the university’s virtual campus ‘survey’ tool and ‘Wooclap’. The Wooclap tool proved to be extremely valuable, offering different question formats that allow for instant feedback. This allows opinions to be gathered and cognitive tests to be administered in real time, encouraging interaction within class discussion groups. In addition, Wooclap allows responses to be anonymous or identified, depending on the intended use.

2.2. Theoretical Lectures

A total of 10 lectures for the cardiovascular block were delivered twice or thrice a week for one hour. Traditional lectures involved presenting objectives and content using Microsoft PowerPoint^®, with some interaction through questions and examples of anatomical reasoning.

Flipped Classroom Learning: Flipped classroom sessions focused on practical, student-centered activities. In the academic year 2022/2023, a partial implementation of the flipped classroom method was introduced. This approach combined traditional classroom teaching with the flipped classroom method. Before each theory session, students were required to watch digitized material in H5P format. Passive content, which students need to understand and assimilate independently to develop concepts for anatomical reasoning, was selected for these video flips. This content was later used in problem-solving sessions in the classroom. For the 2023/2024 academic year, the flipped classroom method was implemented for all course content. Students watched H5P interactive videos available on the Virtual Campus four days before class. In-class activities included individual and group cognitive exercises based on real clinical cases, requiring students to apply their knowledge and seek additional information as needed. Groups were color-coded, and discussions were facilitated using portable microphones and thumbs-up/down paddles. In class, students were first given cognitive exercises to complete individually and then with their assigned groups, responding in writing or through Wooclap^®. Some of these exercises, based on real clinical cases, required not only the content taught in the H5P videos, but also the application of knowledge acquired during their training or the search for additional information needed to understand the clinical case. Students were given the opportunity to carry out optional projects on selected topics, either as an individual or in a group.

The flipped classroom method was set to developed skills at each level of Bloom’s Taxonomy. Level 1 Recall: In preparation for the session, students took quizzes within the H5P interactive videos to help them recall anatomical terms and descriptions. Level 2 Understanding: In group discussions students explained anatomical concepts to their peers. Level 3 Application: The practical activities were set up so that students could apply their theoretical knowledge of anatomy to solve a variety of clinical problems. Level 4 Analysis: The practical activities have been designed to require students to identify problems, analyze information needed to solve problems and differentiate between possible solutions. Level 5 Evaluate: In the practical activities, students made critical evaluations and decisions and were able to justify and defend the hypothesis proposed to solve the problems. Level 6 Creation: In the optional individual or group project, students had the chance to integrate their knowledge and to develop their own anatomical reasoning to solve clinical problems.

2.3. Informative Sessions

In 2022/2023, an information session introduced active learning and its teaching strategies to students and teachers, emphasizing their new roles. In 2023/2024, two seminars focused on active learning philosophy and the TBL methodology for practical sessions and flipped learning for theoretical sessions. This session was attended by 170 students who completed an initial 7-question non-anonymous survey. In the academic year 2023/2024, two informative seminars were held on the active learning methods to be used. The first seminar covered active learning in general as a teaching philosophy and introduced the TBL methodology for practical sessions. The second seminar focused on the flipped learning method.

2.4. Student Surveys

Surveys during the 2022/2023 and 2023/2024 information sessions gathered data on students’ academic backgrounds, previous experience with active learning and teaching preferences. In-class surveys used the Wooclap^® tool to assess student opinions on theoretical teaching and active learning experiences. Responses were scored using a Likert scale and analyzed for positive, negative and suggestive comments. To obtain continuous feedback, students were asked at the beginning of the discussion session via Wooclap and using a Likert scale whether the video flip had helped them to learn, and at the end of the session whether the session had helped them to learn. At the end of each thematic block, they were asked again about the experience, with the opportunity to add free comments at the end of the survey. At the end of the whole experience with active methods, a Wooclap (without identification) was carried out so that the students could give their opinion about the active learning process, in which a total of 165 students participated in 2022/2023 and 161 students participated in 2023/2024.

2.5. Learning Outcomes Assessment

Performance data from Anatomy and Embryology I for the academic years 2015/2016, 2022/2023 and 2023/2024 were compared. The number of students taking the test was 158, 193 and 180, respectively. The tests covered the same syllabus and were taught by the same lecturer. Questions were classified according to Bloom’s Taxonomy [20], revised in 2001 [21], which defines cognitive levels. The four cognitive levels were adapted for anatomy teaching (

Table 1. Bloom’s Taxonomy cognitive levels and test question examples adapted for anatomy assessment. Adapted from Thompson and O’Loughlin, 2015.

	Lower Order		Higher Order
Bloom’s Levels	1 (Knowledge)	2 (Comprehension)	3 (Application)	4 (Analysis)
Distinguishing features of questions	Questions are straightforward with answers likely stated verbatim in notes or text Questions usually not placed in a clinical context Students not required to make independent connections from the information		Anatomic information may be placed in a clinical scenario or a new setting (although not all clinical questions are higher order) Students must interpret and make independent connections from the information
Key skills assessed	Identify, recall, repeat, memorize	Describe or distinguish	Infer or predict	In addition to infer or predict, interpret, judge, critique, or analysis
Types of anatomical information assessed	Basic definitions Facts Straightforward recall	Anatomical concepts Basic spatial organization Basic understanding of pathways, blood supply, and innervation	Interaction between two or more body systems Functional aspects of anatomical features beyond memorization	Interaction between two or more body systems and applying information to a potentially new situation Interpretation of anatomical images Potential to use clinical judgment
Type of question	MEM	DI	AR; MEM + AR; AC	AR + SP; ADI
Examples of questions	List the components of the cardiac conduction system and the cardiac innervation system	On a diagram or anatomical prosection, identify the distribution of the major vessels from the heart to the thoracic cavity and to the forelimbs and head	List the vascular shunts present in the embryo and explain anatomically and functionally what you think would happen if they did not disappear after birth	On a volume-rendered CT of a human bovine arch variant, determine anatomically whether the vascular pattern is like that of a bovine aortic arch or another species, and which one it most resembles and why?

AC: Association of concepts; ADI: Anatomy and diagnostic imaging; AR: Anatomical reasoning; AR + SP: Anatomical reasoning to solve real-life problems; DI: Diagram or image interpretation; MEM: Memorization; MEM + AR: Memorization and anatomical reasoning.

) [19]. In this study, four cognitive levels were used: knowledge (level 1), comprehension (level 2), application (level 3) and analysis (level 4). Anomalies were addressed by reassessing questions.

This study evaluates the effectiveness of flipped classroom learning compared to traditional expository teaching, presenting students’ performance data across different cognitive levels and opinions.

3. Results

3.1. Learning Outcomes Assessment

Table 2. Average scores obtained by groups and at each cognitive level.

Year	Total Average Score	Level 1	Level 2	Level 3	Level 4
2015/2016	3.23	4.31	3.05	2.90	2.76
2022/2023	4.11	3.73	4.04	4.20	4.50
2023/2024	4.71	4.15	4.81	4.23	5.66

shows the average scores obtained by the students for all questions, as well as for each question at different cognitive levels. The results compare teaching (year 2016/2016), partially inverted teaching (year 2022/2023) and fully inverted teaching for the entire class and all content (year 2023/2024). In the 2023/2024 academic year, an unexpected result was detected in a level 1 memorization question. Upon review, a reading comprehension issue was found, affecting 69% of students. This led to the question being discarded and replaced with another question at the same cognitive level.

The average scores obtained by the flipped classroom groups for each cognitive level question are shown in

Table 3. Average scores obtained by the flipped classroom groups for each cognitive level question.

		Cognitive Levels
		Level 1	Level 2	Level 3	Level 4
Year 2022/2023 n = 190	Attending to class n = 79 41.57%	4.40	4.90	4.80	5.70
	Not attending to class n = 111 58.43%	3.10	3.20	3.70	3.30
Year 2023/2024 n = 180	Attending to class n = 125 69.44%	6.16	6.26	5.53	6.31
	Not attending to class n = 55 30.56%	3.12	4.96	3.57	5.10

. These scores include both students who attended the class and those who did not.

3.2. Survey Conducted during the Information Session on Active Learning

3.2.1. Academic Year 2022/2023

A total of 170 students responded to the survey. It was found that:

• 27% of the students had experience with problem-based learning.
• 72% had experienced collaborative learning.
• 27% were familiar with flipped learning.

3.2.2. Academic Year 2023/2024

A total of 151 students responded to the survey. The results showed:

• Almost all students indicated they had no prior experience with any form of active learning.
• 79% had experience with collaborative learning.
• 56% knew what flipped learning was.

When asked which form of learning they identified with:

• 10% of the students chose option (a): “Expository teaching, where the teacher tells me everything I need to know”.
• 89% of students chose option (b): “Active teaching, where I learn to think about and use the content I am learning under the guidance of the teacher”.
• 1% of students chose option (c): “I don’t care, I can always be a GoogleVet”.

3.3. Anonymous Survey Conducted at the End of the Thematic Block

The different activities assigned to the students achieved two objectives: (a) enhanced critical thinking by requiring students to integrate theoretical knowledge with practical information and (b) developed problem-solving skills through the iterative process of hypothesising, testing and revising. To find out how students perceive the skills developed, anonymous surveys were conducted at the end of each thematic block. A total of 34 students in year 2022/2023 and 56 students in year 2023/2024 responded to the survey. The results are presented in

Table 4. Students’ surveys at the end of the thematic block.

Survey on the Virtual Campus		2022/2023 (N = 34)	2023/2024 (N = 56)
How important it is for you to be able to use your anatomical knowledge and reasoning skills.	Not at all important	0%	0%
	Low importance.	2%	9%
	Moderately important	26%	14%
	Very important.	26%	55%
	Extremely important.	44%	20%
Of the following statements, mark the one that best describes your ability to formulate anatomical reasoning:	I have not been able to understand what anatomical reasoning is and what it is for	12%	25%
	I understand what anatomical reasoning is, but I still don’t know how to use it well to explain real problems.	62%	64%
	I understand what anatomical reasoning is and how to use it to explain real problems.	21%	7%
	I have learned to make anatomical reasoning and to use it to explain real problems.	6%	4%
In your opinion, was the amount of anatomical reasoning that was presented in class sufficient?	Yes	50%
	No	50%
With regard to the anatomical reasoning presented in class, do you think that they were appropriate for using the content of the lesson?	Yes	71%
	No	29%
With reference to the formative tests given in class and the solutions given by the teacher:	They were not helpful to learn.	21%	29%
	They helped me learn something.	47%	24%
	They helped me to learn quite a lot.	26%	9%
	They helped me to learn a lot.	6%	0%
At the discussion sessions	I have not learned to think or to use anatomical knowledge.		14%
	I have learnt to think and to use a little anatomical knowledge.		46%
	I have learnt to think and use anatomical knowledge.		29%
	I have learned to think and use anatomical knowledge quite a lot.		11%
	I have learned to think and use anatomical knowledge a lot.		0%
In reference to the effectiveness of group learning, please rate your experience with the group.	Not efficient		14%
	Low efficiency		29%
	Somewhat efficient		38%
	Quite efficient		12%
	Very efficient		4%

.

3.4. Anonymous Survey Conducted at the End of the Experience

To find out how students perceive the active learning experience, anonymous surveys were conducted at the end of the year. A total of 164 students in year 2022/2023 and 160 students in year 2023/2024 responded to the survey. The results are presented in

Table 5. Students’ surveys at the end of the year.

End of Year Survey		2022/2023 (N = 148)	2023/2024 (N = 140)
Did you find the video-flip useful for learning?	Yes	68%	46.5%
	No	32%	53.5%
Of the following comments, tick all those that correspond to your experience with active learning in the theory class:	It is a new way of learning that was difficult for me to understand at first.	58%	68%
	It is a way of learning that is not new to me and I have felt comfortable doing it from the beginning.	5%	4%
	Active learning has helped me to think and solve problems.	25%	30%
	I found it a motivating and useful experience for my training as a veterinary professional.	17%	19%
	I have not been able to learn to think or reason anatomically so I consider it a waste of time.	50%	30%
	Nowadays it is not necessary to think because all the information is on Google.	1%	0%
What type of education do you prefer?	I prefer the teacher to be the only one to show and teach the contents to be studied.	52%	56.2%
	I prefer the teacher to explain and teach me to think and direct my learning.	48%	43.8%
To carry out the formative tests in the theory class	I prefer to solve them individually	5%
	I prefer to solve them in pairs	8%
	I prefer to solve them in a group of 3/4 partners	87%
Mark the degree of usefulness that the use of anatomical reasoning has had for you to understand the clinical cases.	I have not found it useful		8.6%
	I found it somewhat useful		35.9%
	I found it useful		38.1%
	I found it very useful		15.1%
	I think it’s absolutely useful		2.1%
Do you think it is important to learn to think in order to be a good veterinary professional?	Yes		100%
	No		0%
In relation to the effectiveness of group learning, please rate your experience with the group.	Not effective		18%
	Poorly effective		28%
	Something effective		38%
	Quite effective		12%
	Very effective		4%
For cognitive exercises, I prefer to work	In groups of 3–4 students	88%	90%
	Individually	6%	4%

and

Table 6. Students’ more frequent comments in open-ended questions at the end of the surveys.

Comments from the Students, Academic Year 2022/2023 (N = 148)
GENERAL	VIDEO-FLIPPED PRECLASS	CLASSROOM-DISCUSSION SESSION
- Be able to download presentations (6) - Make it easier as in the traditional method (2) - Improve technology (2) - Leave notes on paper or upload notes (2) - More information about the methodology (2) - It would be good to have all the video-flips available during the whole course, as it is a more dynamic way of learning the syllabus (2) - Give a twist to the methodology (1) - To also have online activities for those who can’t attend (1) - Use 3D methodology to present information (1) - Upload presentations in advance (1)	- Videos corresponding to the proposed problems (7) - Set up flipped videos in PDF (7) - More anatomical information beforehand (3) - Repeating the content of the video in class (2) - To be able to control the video-flipped (1)	- Formative quizzes and anatomical reasoning to be solved in the session (19) - More time to solve the anatomical reasoning/formative quizzes (6) - Preventing students from being dispersed while discussing (4) - More help with solving anatomical reasoning (4) - Anatomical reasoning and formative tests at the end of the thematic block (3) - Anatomical reasoning at the end of each topic (2) - Solve the anatomical reasoning together (2) - Further explanation Videoflipped in class (2) - Less anatomical reasoning (2) - More theoretical explanation (2)
Comments from the Students, Academic Year 2023/2024 (N = 140)
GENERAL	VIDEO-FLIPPED PRECLASS	CLASSROOM-DISCUSSION SESSION
- Active learning in practical sessions, not in a theoretical class (5) - Active learning seems to me to be a good way to learn, but I don’t think it has been well done / focused. (3) - This type of learning is very different from what is usually used, therefore, there should be a better transition so that students do not reject this method at first (3) - More information on methodology (2) - AA in theory class, not in practice (2) - Very useful practices (2) - Content should be downloadable (1) - More study base, i.e., theoretical written base (1)	- I don’t have time to watch the videos before class (22) - Too much time spent on a single subject (5) - Shorter videos (5) - Videos are very good (4) - Study material is not easily accessible (3)	- More theoretical explanation (11) - More time to solve the ARs (5) - More time to solve the formative tests and anatomical reasoning in the session (3) - More help/direction with anatomical reasoning by the teacher (3) - Giving an answer on the exercise after making us think (2) - I think it is positive that teamwork is worth more than individual work, as this way you can also learn from your colleagues, help them (or vice versa) and remember certain concepts much better (1)

.

To implement active learning, we adopted a progressive approach, ensuring that in all activities, students engaged in individual reflection before participating in group work. We then evaluated the students’ opinions on both the individual and group work described above.

The students’ comments were categorized and presented in

Table 7. Summary and classification of student comments in the 2022/2023 and 2023/2024 surveys.

Academic Year	Comments and Students’ Opinions about the Active Learning Experience
2022–23 (n = 152)	Positive	76 49.66%	Expressing satisfaction	11 7.18%
			With suggestions for improvement included	65 42.48%
	Negative	31 20.36%	Expressing dissatisfaction	26 17.18%
			With suggestions for improvement included	5 3.26%
	Not taken into account	35 22.80%	Disagreement on methodology	18 51.43%
			Comment contradiction	15 42.85%
			Comment of a personal kind	2 5.72%
	Without comment			11 7.18%
2023–24 (n = 148)	Positive	60 40.54%	Expressing satisfaction	14 9.45%
			With suggestions for improvement included	46 31.08%
	Negative	35 23.64%	Expressing dissatisfaction	29 19.59%
			With suggestions for improvement included	6 4.05%
	Not taken into account	24 16.21%	Disagreement on methodology	10 6.75%
			Comment contradiction	9 6.08%
			Comment of a personal kind	5 3.37%
	Without comment			29 19.59%

.

3.5. Students Attending to Discussion Session

A total of 71.55% of students in 2022/2023 and 74.89% of students in 2023/2024 students attended discussion sessions.

4. Discussion

The flipped classroom model has emerged as a transformative approach in modern education, promoting active learning and student engagement in medical science education. This method reverses traditional teaching paradigms by delivering content outside the classroom, usually through videos or digital materials, and devoting classroom time to interactive, student-centered activities [13]. This allows students to use what they have learned to solve real-life problems and to develop skills, such as problem solving and critical thinking, that go beyond academic knowledge.

In this study, the skills acquired by the students were quantified by measuring their ability to memorize, to interpret diagrams or images, to associate concepts, to reason anatomically and to solve real problems involving anatomical reasoning or diagnostic image interpretation. We used different cognitive levels to assess learning outcomes in theoretical classes. To assess the acquisition of the different competences formulated in the learning objectives through active learning, questions with different cognitive levels were used in the theoretical assessments. Although the questions had different cognitive levels, all questions had the same weight. From the results obtained, there were virtually no significant differences in the mean scores for cognitive level 1 questions (memorization questions), regardless of the teaching method used. However, the difference in the assessment of the acquisition of important competences for future veterinary professionals was evident in the questions formulated at cognitive levels 3 and 4. There was a notable difference between traditional teaching and student-centered flipped teaching. From the results obtained using questions with different cognitive levels, there were virtually no significant differences in the mean scores obtained on cognitive level 1 questions (i.e., memorization questions), regardless of the teaching method used. The difference in the assessment of the acquisition of important competences for the future veterinary professional is assessed in the questions formulated at cognitive levels 3 and 4, where a big difference between traditional teaching and student-centered flipped teaching was quantified. The improvement in performance is particularly significant when comparing traditional (year 2015/2016) and flipped learning (year 2022/2023) scores when solving questions at higher cognitive levels.

Another important observation from this study is the importance of class attendance in flipped learning, where students learn to think and share ideas with their peers in groups. The performance of the flipped classroom appeared to be related to student attendance in active learning classes. In both partially and fully flipped groups, the importance of class attendance was clear. Students who attended the flipped classes performed better on all questions. It is noteworthy that in the fully flipped classroom group, for the level 4 question—where students must use knowledge to solve a real-life problem—the results were very good for both students who attended class and those who did not. This is probably because all students take part in the anatomy laboratories, which are taught using Team-Based Learning (TBL), where they are trained to use anatomical information to solve real-life problems. This was also demonstrated with those repeating the subject who, without attending any theoretical or practical classes, maintained the skills acquired in the previous year’s active training. This was only the case for the cognitive question at level 4, indicating that students develop this skill and can use it effectively in the long term.

The traditional assessment system is based on exams where students achieve high scores by memorizing information. In contrast, active learning assessment requires deep reflection and a high degree of personal responsibility, sometimes pushing students beyond their limits [16]. There is a need to validate tools that measure what students learn, rather than just their ability to memorize content. More importantly, it is crucial to validate a tool that can measure the acquisition of other competences. In this sense, we present very positive results on the usefulness of questions with different cognitive levels.

At our school, active learning methods are implemented by only a few teachers; most courses remain teacher-centered. As a result, students are accustomed to traditional teaching methods. During an information session and initial survey, students were asked about their experience with active or collaborative learning. It was confirmed that most students had worked in groups before university but were unclear about the concept of active learning.

Surveys are a convenient tool for receiving and giving feedback to students. Students’ opinions and learning outcomes were analyzed over two academic years. In 2022/2023, the flipped methodology was applied to part of the content. Since the method proved effective, all content was taught using the flipped class model in 2023/2024. This report analyzes the surveys conducted at the information session, after each thematic block and at the end of the experience. In each session, students’ opinions about their learning with flipped videos and in class were recorded [11]. In 2022/2023, many of the comments were aimed at asking for the tools used in traditional teaching and for problems to be solved in the same session rather than the next day. This has been improved in the 2023/2024 experience; in the latter year, the comments related to lack of time.

In the fully flipped classroom year 2023/2024, the most notable finding from the survey was that, after explaining active learning, 89% of students identified with the active learning methodology. Flipped classes consisted of practical lessons with student-centered activities, including peer discussions and feedback to peers and instructors. Comparing the percentages of positive comments, we observe a slight increase in partially flipped classes, while negative comments increase slightly in fully flipped classes. We believe these results reflect some students’ resistance to active methods that require more effort and preparation. Most students preferred working in groups to working individually or in pairs, confirming that collaborative learning is a valuable active learning experience. These findings are in line with those of other researchers [22,23]. Despite the preference for group work over individual work, 18% of students believed group work was not efficient and 29% believed it was poorly effective. Some students complained about peers who preferred to play a passive role rather than participate in group discussions. This passive attitude hindered group discussions and penalized the overall group dynamic. Uneven motivation among students can lead to uneven participation, disrupting the flow of collaborative exercises and diminishing the overall learning experience. The method was found to be too time consuming due to some students’ lack of motivation or experience of working in groups. Participation in the active learning session was registered and attendance was high. This result served as an assessment of student motivation, as attendance at the discussion sessions was not a requirement.

When responding to the surveys, some students emphasized that the course was overloaded and that they were working under time pressure. The use of active learning increased the amount of time needed, and in theoretical classes, traditional lecturing was often seen as an easier and more efficient method. This is likely to have had a negative impact on students’ opinions. As seen in other experiences [23], almost all students were concerned about the stress caused by the lack of time.

In SCAL, it is important to use a variety of strategies to obtain continuous feedback from students to determine whether the preparation materials, H5P videos and classroom sessions have helped them to learn. The cognitive exercises carried out and reviewed in the flipped sessions help students to learn at their own pace. In this case, cognitive exercises refer to activities designed to learn how to use anatomical content through anatomical thinking for problem solving and critical thinking. Each class began and ended with a Wooclap^® survey to assess what students had learned from the H5P video and class session. It is important for students to understand that a survey is not the same as an evaluation of the lesson or the teacher; the focus should be on feedback that provides information for the teacher to understand each student’s experience of the lesson.

Feedback should be collected from the beginning of the experience, as in these SCAL experiences, and at the end of active training methods. Students should not be treated as consumers, asked if they liked the lesson or found it easy. Instead, they should be taught the importance of mistakes as learning opportunities. Understanding their difficulties, thought processes, successes and failures can help make learning effective [24]. Student feedback is crucial as it can show whether the innovative methods used have worked [25]. The impact of feedback on teaching depends on how teachers perceive, process and use the information received [26].

In SCAL experience, teachers and most students disagreed about the most effective pedagogical method for learning anatomy. Teachers preferred collaborative learning, while some students found lectures and note-taking more effective. Teachers rated higher-order cognitive exercises as more effective for learning. In the 2022/2023 and 2023/2024 surveys, 52% and 56% of students, respectively, wanted all the material presented by the teacher in expository lectures. Many students felt that an excellent teacher would provide detailed notes, negating the need for other sources of information. In a practical curriculum such as veterinary medicine, it is surprising that some first-year students value theoretical knowledge over its application. This highlights the importance of information sessions at the beginning of the course. Many students are attracted to passive learning techniques because they provide a clear and structured path to success. This approach, which focuses on memorizing information for exams, provides a sense of security. Students know exactly what is expected of them, and this predictability can be reassuring in a high-stakes environment. However, this comfort comes at a cost: it discourages exploration, critical thinking and the application of knowledge in novel contexts. When students focus solely on what is required for exams, they miss opportunities to engage creatively with the material or develop their own understanding.

In the first academic year of flipped learning, only an information seminar was held at the beginning of the course, before the theoretical classes started. The survey in that year showed that students wanted more information about the methodology. In the last academic year, two information seminars were held—one on TBL before the practical sessions and another on flipped classroom methodology before the theory sessions—which was successful, with only one student complaining about the amount of information on active methods used.

A disadvantage is that traditional and active teaching methods are taught at the same time, creating competition between them and attempts to convince students of the advantages of one system over the other. Cognitive exercises in class were structured to help students construct their thinking models to solve problems. Some classroom content was not taught in the H5P video, a deliberate omission designed to encourage investigative behavior. Both teachers and students noted the lack of time for self-learning, an effort that is neither quantified nor valued. Teachers need to move from the comfort of traditional lectures to the challenge of developing the necessary materials for SCAL.

When students were asked which type of learning they felt more comfortable with, the results showed that half of the class preferred traditional teaching, while the other half favored the flipped classroom and other active learning methods. Despite the apparent rejection of active learning methods by some students, class attendance was very high, a fact also noted by some other authors [27,28]. This contrasts with complaints from other subject teachers about low student attendance in lecture classes. Many teachers believe that traditional lecture-based teaching is not engaging enough for students to attend class. The results confirm that it does not develop competences beyond memorization and understanding of content. Even with evidence of the positive impact of SCAL strategies on learning and retention, it is difficult to convince some students and teachers that learning requires engagement with content at all levels of instruction [29].

In lecture-based classes, students feel comfortable because they know the importance of good notes. If they miss a class, they can copy notes from a classmate or buy them from online platforms. They believe that classmates who do not attend class can achieve better grades by obtaining good notes. This, combined with overcrowded timetables, may explain students’ lack of interest in attending lectures. Some students find traditional teaching methods to be a comfort zone where memorizing content ensures passing exams. They prefer traditional teaching because the nature of exams gives them the impression that exams are less difficult, consisting of short and precise questions on content to be understood and remembered. A general preference for working directly on multiple-choice questions when preparing for exams has been noted by other authors [20].

Despite these findings and the fact that student-centered curricula are a quality requirement for veterinary education in Europe and are in line with European Union (EU) directives and the Standards and Guidelines for Quality Assurance in the European Higher Education Area [30], the delivery of curricula by veterinary educational institutions across Europe remains largely traditional. These guidelines recommend that veterinary institutions provide their faculty with pedagogical training to ensure the quality of teaching. We face the challenge of motivating students who are reluctant to make the extra effort, convincing them of the benefits of abandoning a passive attitude to learning and encouraging them to think, reason and develop a critical mind. We also need to ensure that the great personal and professional benefits of active methods are widely accepted and popularized. Another challenge is to convince our colleagues that the extra effort involved in active methods is worthwhile. We need to demand that teaching quality surveys measure the outcomes of our teaching, rather than the satisfaction of a small number of students who are often not qualified to comment on technical aspects of teaching. The pedagogical preparation of teachers is decisive and has a significant impact on student learning [23].

The SCAL approach is highly pedagogical and should be implemented by individual teachers in their classrooms, as in the active learning experiences presented here. Several active learning strategies have been used to develop SCAL: from introducing a small number of peer discussion questions in class to completely flipping the classroom, delivering content before class and using lecture time for student discussion and problem solving. Over the years, we have gradually introduced active elements, moving to flipped classrooms in the last two academic years, and moving from being dispensers of facts to facilitators of the learning experience.

The effectiveness of SCAL is demonstrated when meaningful learning takes place and students can solve different problems with their new models of thinking and reflection. Students enhanced memory retention and recall abilities, essential for foundational knowledge in anatomy. The following advantages were also present: Improved comprehension and the ability to articulate understanding clearly; Applied anatomical knowledge to solve real-life problems; Developed analytical thinking, problem solving and the ability to interpret clinical information; Learned to perform critical thinking; and, finally, some students learned to integrate knowledge and skills to create new solutions. The effectiveness of the SCAL methods used in this study was quantified numerically based on the students’ scores on questions designed to assess different cognitive levels. Each cognitive level assesses different skills that we wanted to develop.

Teachers need to create an appropriate environment for this type of learning [6]. In flipped learning, students moved from independent to interdependent learning. Final surveys showed that collaborative learning was mutually beneficial and preferred to individual learning. Active learning involved the sharing of knowledge, ideas and experiences [20]. An active classroom not only improves student performance but also promotes a more inclusive learning environment [29]. Active learning has been shown to provide a more structured classroom where learners read before class, engage in activities during class, and practice outside of class, benefiting women and first-generation university students [31]. This study did not evaluate other social aspects of the SCAL experience, and students’ personal comments were not included in the study.

The quality of teaching is crucial to educational success, but the methods used to measure it can have significant implications for both teachers and students. To assess the quality of teaching in an institution, it is essential to evaluate learning outcomes. Relying primarily on student satisfaction surveys to assess teaching quality can have a negative impact on teachers’ willingness to implement new methods. To encourage innovation and ensure a comprehensive understanding of teaching effectiveness, it is essential to develop and use diverse assessment tools that accurately reflect teaching outcomes. The use of questions targeting different cognitive levels helped to measure the different skills acquired through the implementation of active learning.

5. Conclusions

It is strongly recommended that the design of future veterinary education curricula considers and applies a change in teaching and learning philosophy across all subjects in the curriculum. Active, student-centered teaching fosters skills that are crucial for students’ future careers, including self-learning, critical thinking, problem-solving and lifelong learning. To quantify the acquisition of these skills and competences, we have developed an assessment tool that measures the achievement of these competences through questions formulated at different cognitive levels. This tool has proved effective in testing the success of this type of learning, confirming that students not only develop these skills, but also use them effectively in the long term.

Our findings show that SCAL methods are effective in developing these essential skills. However, these methods need to be continually refined based on experience and feedback from students. Furthermore, it is crucial to adapt the SCAL methods to all subjects within the veterinary curriculum to ensure a comprehensive and coherent approach to student learning. In this way, we can further improve the quality of education and better prepare students for their careers in veterinary medicine.