BACKGROUND AND PURPOSE
As health care professionals who use a patientcentered approach for managing a patient's plan of care, physical therapists (PTs) must effectively and efficiently integrate data from diverse health care perspectives. As PT educators, creating an environment that develops a student's critical thinking ability to support a patient-centered approach is our primary goal. The question as to which teaching and learning strategies may assist us in effectively developing active learning environments that foster student ability within a patient model is of paramount concern. Researchers within higher education and the scholarship of teaching and learning (SoTL) are continually seeking evidence-based support for the effectiveness of diverse teaching and learning strategies. While the development of critical thinking has been proposed as an outcome of physical therapist educational programs, evidence supporting effective teaching and learning strategies that foster this development is limited. One teaching and learning strategy that has recently emerged in higher education is the non-linear learning technique, mind mapping (MM). Mind mapping, with its interrelated branching, may be a beneficial strategy to assist PTs and student PTs to critically think and link information for the development of an integrated patientcentered plan of care. The authors suggest that faculty must first realize the tenets associated with the teaching and learning strategy of MM in order to effectively utilize it for the promotion of student critical thinking skills. Thus, the purpose of this position paper is to discuss the tenets and theoretical rationale associated with MM, explore current literature on the concept, and inform PT educators of this teaching and learning strategy.
Position and Rationale
Mind maps are often confused with concept maps, which have been widely utilized in primary and secondary educational environments to promote critical thinking skills using a linear learning approach.1 Concept maps have been used in the classroom as a means to develop a student's individual knowledge base while promoting knowledge sharing.2 Much has been written on the numerous benefits resulting from concept maps, based upon its visual representation of information which fosters what Novak termed a “graphic reconstruction of knowledge.”2 The concept map is proposed to foster meaningful learning of new information via its integration with existing content knowledge. This mapping technique is supported by the cognitive learning theory, which suggests that learning must be meaningful in order to link new knowledge with previous knowledge.3
The constructive theory of learning further supports the underlying premise associated with concept maps, suggesting that to make sense of one's experiences, meaning must be attached. In the development of the concept map, meaning is attached to the information via graphic reconstruction and representation.4 Concept maps are considered a graphic representation presented in a structured outline format, which seeks to demonstrate the relationship between ideas (Figure 1).
Concept maps seek to establish relationships using a hierarchical process. This process can be viewed similarly to a tree with primary, secondary, and tertiary notions stemming from the base, which is the key concept of interest. Between branches, prepositional phrases are used to cross-link concepts, ideas, and thoughts.5 Concept maps have been used across the academic landscape, including in the preparation of health professionals in nursing6 and medicine.7
Adult learning literature supports the notion that relational linking of new information to old information promotes cognitive knowledge development in the learner.8 Given the vast experiences a learner can relate to newly acquired information to develop a meaningful representation of what is learned, concepts maps are being explored as a means to support adult learning. While evidence supporting the use of concept maps in adult student learning is emerging,9 concerns surrounding its effectiveness across learning environments (academic versus non-academic), learning styles, and educational applications10 exist. Additional concern comes from the perceived level of expertise and complex set of rules required to develop a concept map, which may result in decreased learner motivation.10
In a recent critical analysis of mapping as a learning strategy in health education, 46 published papers were reported to use mapping as a learning strategy.11 This review, however, did not differentiate between concept mapping and mind mapping. When looking further at the 46 papers, only 22 referred to MM specifically. Also, of the 46 papers, 24 of them employed an additional learning strategy, making it difficult to isolate the effects of mapping. Ten used collaborative learning strategies, 10 used instructor scaffolding of material and feedback, and 4 used instructorgenerated maps as a learning tool. We would argue that concept maps and MM should be differentiated, and that viewing data from both types of maps as a single data pool reduces the significance of each. As noted by Pudelko et al, one must consider interferences and limitations placed on learning when all forms of mapping are combined. As educators, we seek to use a variety of teaching and learning strategies that will compliment and maximize the learning environment for our students. Pudelko's suggestion that the use of feedback, scaffolding, and mapping fostered a positive learning environment in the majority of studies warrants further investigation to evaluate potential differences of mapping strategies used and learning strategies employed.
We propose that, by design, MM supports the integration of material to a different depth than concept maps and warrants discernment of papers based upon the type of mapping strategy employed. Doing so allows meaningful insight into the effectiveness of both strategies. Also, while looking at the effectiveness of mapping as a teaching and learning strategy, one must control for secondary variables that might influence the learning environment, such as additional learning strategies, instructor feedback, and prior mapping experiences. This paper seeks to explore the tenets associated with MM, how they are used specifically in PT curricula, and whether effective knowledge integration and application might emerge from its use in health science education.
The mind map uses the same underlying theoretical premise as concept maps as a teaching and learning strategy. Mind mapping (MM), a visual, non-linear learning technique,5 has been less explored in research. This non-linear approach to learning seeks to engage the learner in thinking through exploring concepts using visuospatial relationships and pictorial depictions. These relationships emerge from a central theme via peripheral branches, which can be further interrelated, resulting in an idea map that encompasses a radius of 360 degrees.
According to Buzan and Buzan,12 MM should be constructed on blank paper that is larger than standard computer paper, providing the opportunity to move outside the boundaries of conventional size. To further engage creativity, the use of colored pens or pencils is encouraged. The use of multicolor and textured writing tools affords mappers a means to express themselves creatively. In the center of the mind map, the central theme or topic of the mind map is captured. This central positioning of the main topic allows the mapper 360 degrees of freedom to develop and explore concepts and relationships associated with the topic via the emerging branches from this central theme. Branches represent different categories that the mapper perceives as relevant to the topic of the mind map. From these branches, sub-branches are created. A key tenet of the mind map is that each of the branches and sub-branches should contain pictures and phrases of major themes to aid in recalling information. The mapper actively engages in synthesizing, integrating, and linking the sub-branches, creating a meaningful, non-linear representation of the information (Figure 2).
Meaningful representation developed by the mind mapper supports a richer and deeper integration of information that can foster both declarative (explicit) and non-declarative procedural (implicit) knowledge associated with critical thinking and long-term learning.8
Recently, several programs for creating mind maps using a computer interface have been developed, offering options for inserting images directly from the mapper's computer and providing access to an array of color options. In our review of the literature, we did not find support that any method of creating a mind map (paper and pencil or computer interface) is more effective than another. To date, the few studies published on mind maps have used the paper and pencil approach.
While MM has been utilized in various disciplines outside of health care, including marketing,13 economics,14 finance,15 and executive education in business,16 its use in health professions has remained limited to medicine17,18 and physical therapy.19 Farrand et al17 investigated 50 medical students to determine whether mind maps are superior to traditional note-taking when recalling short- and long-term factual information. The data indicate that both short-term (P = .016) and long-term (P = .013) factual recall were significantly better in the mind map group when compared to the traditional note-taking group. Using a similar study design, the findings of Wickramasinghe et al20 did not support the benefits of mind mapping on short-term memory. Despite the difference, the authors reported that all subjects in the mind map group perceived that mind maps were useful for memorizing information.
D'Antoni et al18 investigated whether a relationship existed between mind mapping and critical thinking, as measured by the Health Sciences Reasoning Test (HSRT) and content knowledge development. During orientation, first-year medical students (n = 131) were randomly assigned to a standard notetaking (SNT) group or MM group. Subjects in the MM group were given a 30-minute presentation on how to mind map prior to their topical reading and note-taking assignment. The SNT group was asked to use their preferred note-taking strategy for this assignment (could not include MM). No significant differences in either critical thinking or content knowledge scores on the pre- and postquizzes between the 2 types of note-taking groups were demonstrated. Although mind mapping was not found to increase shortterm recall of content-based information or critical thinking compared to SNT, the authors inferred that the brief introduction to mind mapping was enough to enable the novice mind mappers to integrate the material and perform similarly to SNT subjects. The authors further suggested that the absence of a significant difference between the groups demonstrated that students using mind maps can successfully retrieve information in the short-term, and therefore, did not put them at a disadvantage compared to SNT students.
In a pilot study, Pinto Zipp et al19 explored perceptions of student PTs regarding effectiveness of mind mapping on supporting their ability to organize, prioritize, and integrate material presented in a course. Doctor of Physical Therapy (DPT) students (n = 21) enrolled in a neurorehabilitation course were required to create mind maps based upon assigned readings for 6 diagnoses. Students were asked to complete 2 surveys (a demographic survey and a post-course survey) to assess their perceptions of the usefulness of the MM learning technique. Only 38% of the students perceived that mind mapping enabled them to better organize material, 9.5% perceived that it helped them prioritize information, and 33.3% suggested that it helped integrate course material. All students successfully completed the course requirements, which included the development of an integrated patient-centered evaluation, practical examinations, and formal written assessments using an evidenced-based/casebased approach.
Additionally, perceptions of the 2 faculty members teaching the course were obtained with regard to the effectiveness of mind mapping in supporting student ability to organize, prioritize, and integrate material presented in the course. Both faculty members perceived that mind mapping improved student organization, prioritization, and integration of course material. While faculty and student perceptions were not consistent, the data provided evidence that mind mapping did not negatively affect learning outcomes. Instead, faculty perceived positive effects for creating an active student-driven learning environment. Although the authors are encouraged by these findings, the small sample size and the fact that the data obtained are perceptions pose limitations. Therefore, continued investigation is warranted to support MM utility as a teaching and learning strategy in the health sciences.
Upon completion of their educational program, over 50% of the students in this cohort qualitatively reported that they used their own MMs during clinical experiences and that it helped them think in an integrated manner about patient-centered care practices. A recent graduate stated:
As I sit at my desk today, after a long week of studying I feel the need to thank you for introducing me to mind maps. I can't believe that an assignment I once disliked very much has become such a major part of my study plan. After I review a chapter, I close all my notes and make a mind map of everything I remember and how everything is connected. I can not believe how well this has worked for me! I am able to make so many connections from different classes. I can not thank you enough!
We believe that this sentiment further supports mind mapping as a positive learning strategy for connecting information that aides in creating an integrated patient-centered plan of care.
In the literature, the proposed freeform5 associated with mind mapping has been suggested to foster creative thinking. Some infer that mind maps are simple associations without clear links made between ideas and are often too visually complex and difficult for others to view, thereby potentially missing the big picture.5 While this may be true, educators should remember that a key tenet of MM is that it is an individually developed, meaningful representation of information for the purpose of personal learning. The qualitative data noted further supports the personal utility of mapping for some learners.
Few studies that assessed MM's effectiveness on meaningful learning and critical thinking did so only after a brief introduction to what mind mapping was, which was then followed by immediate application. Immediate usage, after only an initial introduction to mind mapping, could have been a major factor as to why novice users did not adequately demonstrate individualized meaningful representation of the information. This can subsequently result in a lack of support for a richer and deeper integration associated with critical thinking and long-term learning. We suggest that mind mapping be considered a skilled technique, and as with any learning of a skill, thoughtful practice is necessary to develop from a novice learner/performer to a master performer.
Recognizing the issue with testing the effectiveness of mind mapping as a learning strategy after only a brief introduction or experience, we designed an immersion model of MM. We have utilized this MM immersion model for more than 6 years in a neurological rehabilitation course as a means to encourage students to actively participate in self-directed, thoughtful, and creative thinking for the promotion and retention of ideas and associations. As course instructors, we infused a MM learning module for students prior to the development of mind maps throughout the semester, resulting in the MM immersion experience.
During the 4-month semester, students learn how to develop a mind map via a faculty-based lecture/learning module, which is followed by the independent creation of 6 mind maps based on required readings. Mind maps must be developed prior to class meetings and explore chapter topics, including stroke, traumatic brain injury, cognition and perceptual dysfunction, Parkinson's disease, traumatic spinal cord injury, and vestibular disorders. Mind maps are constructed by students to serve as an aide for linking topics presented in the readings. As an additional part of the immersion model, students individually received faculty feedback on each mind map by using a faded format over the course period to develop greater connections between links presented in their maps. When combined, we believe that the reflective mind maps and the guided feedback assist students in expanding their clinical decision making skills as the course progresses.
Recently, as part of the course requirements, we explored changes in student critical thinking skills using a voluntary and anonymous online version of the reliable Health Science Reasoning Test (HSRT).21 Following this brief MM immersion experience in this third-year class (prior to their final year-long clinical experience), a positive change (pre-MM HSRT score of 21.4 to post-MM of 23.1) in student critical thinking scores was observed. Specifically, changes in critical thinking sub-scores of induction (pre-MM of 7.6 to post-MM of 8.0), deduction (pre-MM of 6.1 to post-MM of 6.9), and evaluation (pre-MM of 4.8 to post-MM of 5.1) abilities appeared to drive the total score change. The post-mind mapping immersion HSRT scores for this student cohort are similar to that of physical therapy experts (24.1) reported by Huhn et al.22
Additionally, our findings are consistent with other works that analyze student PT critical thinking skills using the California Critical Thinking Skills Test (CCTST). Vendrely,23 using a single-group pretest-posttest design, reported a significant increase (P = .032) in the composite CCTST scores of student PTs following their academic program. Bartlett and Cox,24 also using the CCTST scores, reported a significant increase (P < .001) from student PTs throughout academic and clinical portions of their study.
The authors are encouraged that the data from the small sample of student PTs, taken pre- and post-MM infusion during 1 academic semester, is consistent with the critical thinking abilities discovered by Huhn et al,22 Bartlett and Cox, and Vendrely. While the sample size limits instructor ability to find significant differences, we believe MM immersion to be a teaching and learning strategy that aides in the development of student PT critical thinking skills. Given the positive changes noted throughout the semester following MM usage, the authors infer that continued use of MM over the curriculum may lead to further development of student critical thinking skills and the advancement of novice mind mappers to experienced mind mappers.
Based on the qualitative and quantitative data obtained from our teaching and learning experiences, we continue to use the MM immersion model as a strategy to support the integration of course material and student critical thinking skills. To meet the needs of our students, faculty must continue to explore and evaluate the efficacy of various teaching and learning strategies to develop critical thinking skills needed for patient-centered care. Emerging literature in higher education recognizes MM as a potential teaching and learning strategy that actively engages the learner in synthesizing and integrating information in a meaningful, non-linear manner. 17–20 The self-identified relationships that the mapper constructs may support a richer and deeper integration of information, resulting in declarative (explicit) and non-declarative procedural (implicit) knowledge and the promotion of critical thinking for long-term learning.8 The literature supports that students often possess the ability to recall factual knowledge (declarative learning).8 Implicit learning (non-associative, associative, and procedural forms of learning) occurs infrequently. as these memories are less accessible to recall and unconsciously performed. While traditional learning experiences seek to develop declarative knowledge, teaching and learning techniques (mind mapping) can foster the development of explicit and implicit knowledge, leading to enhanced critical thinking skills.
Critical thinking is a dimension of clinical reasoning capability proposed by Christensen et al25 and is intimately linked to reflective thinking abilities.27 Critical thinking can be defined as the awareness of assumption, and how assumptions connect to applied reasoning within the context of a situation to create knowledge and generate appropriate actions.28 It is this dimension of critical thinking that enables complex thinking to emerge. Complex thinking is the dynamic interdependent relationship between many elements,28,29 which enables discernment of all information pertinent to the situation in order to think through a situation with seamless reasoning.29
The expert developmental trajectory proposed by Sprague and Stuart offers educators insight into the student's developmental process via a 4-stage model.8 In the Stages of the Development of Mastery model,8 competence and consciousness are the 2 dimensions discussed. Initially, novices are in the “unconscious incompetence state,” given that they do not have a skill set in a particular domain and do not understand what they need to learn to develop that mastery. In this stage, the educator plays a major role in organizing learning experiences that will enable them to acquire the knowledge needed to progress. As they acquire knowledge, they advance to the “conscious incompetence state,” where they now are aware of what they need to learn based on what they currently know. With increased knowledge, students move into the “conscious competence stage,” where it is evident that while their actions are still conscious and deliberate, they now have competence in their domain. Mastery of their domain is only met when students move into the “unconscious competence stage.” In this stage, actions are automatic and instinctively driven from knowledge acquisition and experience. Research on expert-novice differences indicates that experts access, organize, and apply knowledge differently than novices. They organize their knowledge into conceptual chunks, allowing them to access information proficienctly.30,31 As they recognize meaningful patterns in the presented material, experts are able to skip steps.32
Finally, we believe that the most important step for clinical practice is for experts to link information to deeper principles, enabling them to transfer and apply knowledge to new and different situations. Mind mapping provides students personally meaningful practice in linking acquired knowledge for the development of an integrated patient-center plan of care.33,34
DISCUSSION AND CONCLUSION
Upon reviewing the literature presented in this position paper, one might ask, “if evidence shows that visually displayed information enhances learning, why does mind mapping not show measurable improvements in learning or critical thinking?” Reflecting on Novak's constructivist perspective, yet using recall tests as the outcome measure, does not adequately allow for the assessment of true elements proposed by this approach and may contribute to the lack of significant findings in support of MM. Based on the findings of Karpicke and Blunt,35 comparing concept maps (encoding event) to that of a retrieval practice in science education suggests that learning strategies that support retrieval may be more effective in supporting learning than the elaborate strategy of concept mapping. While we have proposed in this position paper that concept maps are different from MM, given that they can be classified as an elaborative strategy, one might infer that they too would not be as effective as retrieval learning strategies. Although this may be the case in coursework that focuses on didactic-based knowledge acquisition, physical therapist educational programs are expected to develop students into entry-level practitioners who demonstrate not just an understanding of the content, but the ability to translate that understanding into application of their craft.
To make this transition from knowledge acquisition to knowledge integration, we suggest that the encoding associated with the elaborative process can support long-term memory as it supports the integration of information. The authors argue that the lack of evidence supporting the ability of MM can be attributed to 2 points. First, most of the work done on mapping has been specifically on concept mapping, which does not require the mapper to relate, connect, or integrate the material in a visual manner. Instead, concept maps encourage a linear word-based presentation of information11 without deep integrated connections between concepts and pictures, which is key in the elaborative processing of information for long-term memory. Second, the few studies that did use MM did so as a singular event. Students were instructed how to create mind maps and engaged in a learning experience for which they had to map relevant points. Either the map quality or mapper's critical thinking abilities were then immediately assessed.
We support the argument that previous research11 investigating MM suggests that to effectively encode information via the mind map strategy of learning, students would need more than 1 experience with mapping. Given the encouraging sign that the mappers did not show any negative effects18 in learning, we suggest that if students were given more experience with MM than that of traditional note-taking, MM would be more beneficial to meaningful learning and the development of critical thinking.
Wainwright et al36 identified factors that influence the clinical decision making of novice and experienced PTs, reporting that novices used informative factors such as academic content, faculty mentorship, theories, and anticipated patient performance. In contrast, experts used directive factors such as medical record information and observing patient ability and behavior. As scholars of teaching and learning, we propose that exploring MM within physical therapist education programs would aid in the creation of rich learning experiences for the development of evidence-based critical thinking skills in novice students. Empirical support from the cognitive sciences shows that visually displaying information enhances learning37 and allows for dual coding38 of information by more than 1 sensory modality, as is the case with MM (not necessarily with concept maps).32–34
Given the opportunity to manipulate a complex set of relationships by using a mind map, students will be more likely to understand, analyze, and remember those relationships, resulting in what Biggs37 has termed a “deep” approach to learning. Faculty must provide students with a clear understanding of how to mind map and offer opportunities to create maps to properly develop their abilities as a mapper. Although the introduction of MM to the learning environment may initially increase contextual interference in the field of motor learning while simultaneously limiting performance, the long-term benefit to learning is evidenced by the mapper's ability to retain and transfer information to new situations using critical thinking.
The authors acknowledge the detractors associated with mapping, as proposed by Pudelko et al, but have attempted to provide a clear description to identify differences compared to the widely used and researched concept maps. We believe that mind maps are different from concept maps and that the immersion model presented here effectively addresses many of the recommendations put forth by Pudelko et al. Based on our description and utilization of mind mapping, we support its use as a learning tool to aid students in becoming autonomous entry-level physical therapists. Future work is necessary to assess if the MM learning approach definitively promotes critical thinking skills in students.
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