|Year : 2019 | Volume
| Issue : 2 | Page : 108-114
The role of metacognition in teaching clinical reasoning: Theory to practice
Ken Kosior, Tracy Wall, Sarah Ferrero
Department of Physical Therapy, School of Health Sciences, Quinnipiac University, Hamden, Connecticut, USA
|Date of Web Publication||5-Nov-2019|
Dr. Tracy Wall
Quinnipiac University, 275 Mt Carmel Ave., Hamden, Connecticut 06518
Source of Support: None, Conflict of Interest: None
The ability to think critically in an uncertain and complex health-care environment is a paramount skill needed for health profession students to transition to clinical practice. Experts and educators in health profession education have unintentionally created confusion regarding operationalizing critical thinking, clinical reasoning, and clinical decision-making. In the purest form, health profession educators are referencing the cognitive abilities of a clinician to transfer thinking skills from an academic to a clinical setting. The problem with teaching clinical reasoning in health professions is that the ability to transfer knowledge and skill to patient care is often inefficient. Metacognitive awareness provides a theoretical and practical construct to make previously unconscious cognitive processes overt. The benefit of integrating and scaffolding pedagogical practices to emphasize explicit student knowledge and regulation of cognition may benefit health profession educators in teaching future clinicians how to handle cognitively complex problems. Making clinical reasoning overt through metacognitive awareness provides health profession educators a framework which helps to teach and assess cognitive strategies associated with clinical reasoning. Metacognitive awareness operationalizes a complex construct to allow a definitive way for health profession educators to instruct the cognitive system, resulting in enhanced clinical reasoning. Learning the components of metacognitive awareness is essential to a solid foundation for students and faculty. As students receive further instruction and feedback on cognitive strategies, the potential exists to improve metacognitive judgments. Case-based learning, simulated and standardized patient interactions, and experiential learning all provide pedagogical tools to promote metacognitive awareness in health profession students. Through serial assessment of metacognitive awareness, health profession educators may also gain valuable insight into how students develop cognitive strategies for future clinical reasoning. The increased ability to plan and evaluate cognitive processes may aid health profession students and educators in attaining more meaningful thinking for complex problem-solving in clinical practice.
Keywords: Clinical reasoning, critical thinking, dual-process theory, metacognition
|How to cite this article:|
Kosior K, Wall T, Ferrero S. The role of metacognition in teaching clinical reasoning: Theory to practice. Educ Health Prof 2019;2:108-14
| Background and Purpose|| |
Critical thinking and clinical reasoning
According to Halpern, critical thinking identifies the reality of using cognitive skills or strategies to increase the probability of a favorable conclusion. Critical thinking is a purposeful, reasoned, and deliberate cognitive process. Using cognitive steps in problem-solving, formulating inferences, and making decisions based on prior knowledge and judgments are hallmarks of critical thinking. Critical thinkers manage cognitive load appropriately, without encouragement, and often without conscious intent, in a variety of settings. “When we think critically, we are evaluating the outcomes of our thought processes – how good a decision is or how well a problem is solved.” Deliberate instruction and practice of critical thinking accompanied by deconstructed cognitive training improves the probability that students will identify when a particular cognitive skill is needed or can transfer strategic processing across domains through metacognitive monitoring.
The complexity and uncertainty permeating health care cultivates a need for a level of critical thinking previously untapped in educational preparation. Health profession students, like physicians, need to learn to monitor their cognitive strategies and make decisions in an unpredictable environment. These decisions can be particularly awkward, involving a complex web of diagnostic and therapeutic uncertainties, patient preferences and values, and even costs. The complexity in health care today emboldens our students to crave the checklist, the black-and-white protocol, and algorithmic processing, leading to a false sense of predictability. The truth about health care is that unpredictability, omission of facts, inaccurate tests and measures, and cognitive bias toward any resemblance of certainty have become a growing epidemic. While some responsibility for what goes wrong in failed patient diagnosis and treatment falls on the health system, a greater measure of accountability lies with the ways in which healthcare professionals reason. Effectively utilizing the strategies of cognition to ultimately make sound clinical judgments has led to a growing awareness of the need for explicit training in clinical decision-making during medical training.
Health profession educators and practitioners agree that clinical reasoning is an essential cognitive skill for effective clinical practice. Over the past 30–40 years, this topic has been researched in an attempt to define, operationalize, and instruct health profession students. Review of the literature in medicine identified themes in the research stemming from understanding clinical reasoning as a skill or process; quantifying reasoning related to the sum of knowledge and memory; and distinguishing among the various mental representations or schema that contribute to countless perspectives on clinical reasoning. In nursing, the cognitive training is occurring through operationalizing critical thinking as a predisposition of knowledge and experience combined with reflective strategies related to processing information for clinical practice. Scheffer and Rubenfeld established a definition for nurses through a consensus process, resulting in the robust definition including the following elements of habit of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in nursing distinctly possess the cognitive skills of analyzing, applying, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge.
As noted in physical therapy, clinical reasoning consists of multiple component skills including critical thinking, hypothesis testing, synthesizing, and self-reflection. In physical therapy, Furze et al. noted that clinical decision-making, critical thinking, and clinical reasoning have been used interchangeably to describe the same process. Christensen et al. also defined clinical reasoning in physical therapy as a nonlinear, recursive cognitive process in which the clinician synthesizes information collaboratively relevant to the continuum of care and health profession context and setting. These definitions imply a conscious awareness of the cognitive processes associated with clinical reasoning. The conscious, social, and experiential implications of the cognitive organization of novice and expert athletic trainers further outline the collaborative and interactive dynamic. This dynamic exposes students and clinicians to multiple perspectives for thinking, increase frameworks of knowledge, and value of continual feedback.
In the psychology literature, there is no consensus or percentage of students who inherently possess cognitive knowledge or awareness. In fact, multiple authors were alarmed by the number of college students who had little to no metacognitive knowledge, cognitive strategies, or reflective abilities about themselves., While the multifaceted components of clinical reasoning make translation and application into health profession education daunting, the need for pedagogical and educational intervention on health profession student metacognition is paramount. Many definitions of clinical reasoning provide labels of the construct but fail to deconstruct the cognitive strategies or the reflective abilities needed for clinical practice. In addition, most definitions create a gap in how students, clinicians, and educators can deliberately practice the cognitive skill of “clinical reasoning” as they progress toward professional development. The absence of framework adds to the cognitive complexity and confusion in understanding clinical reasoning. As educators look to tackle this challenging problem, we must articulate and emulate the fundamental elements of clinical reasoning through enabling overt cognitive processing; this cognitive processing can then be modeled, practiced, and evaluated as a curricular thread to advance students toward becoming a clinical practitioner.
In the medical and health profession literature, the role of dual processing as a framework for teaching cognitive processing has emerged. In this model, two paths for decision-making are presented. System I processes are subconscious, nonverbal, and autonomous and align with a common perception of a clinician's intuition. Conversely, System 2 processes are conscious, verbal, and deliberate, with a common annotation being the analytical process. The fundamental thread is that both systems are cognitive processes deconstructed to a level palatable for teaching and learning. Inherently, students and clinicians possess variable levels of conscious awareness of formally unconscious thoughts.
Recently, Prokop examined the use of dual-processing theory in physical therapy and identified “a vital element to accurately manage the use of both types of processing is the awareness of the accuracy of thought process.” The awareness of one's own cognition remains a challenging skill to teach to physical therapy students. The meta-components of dual processing favor deliberate and transparent implementation of cognitive strategies in physical therapy education. Metacognition, like other psychomotor skills, is malleable through training to handle cognitive complexity and knowledge-lean conditions., Whether we are instructing students on their awareness of cognitive strategies or intuitive, “gut reactions,” Making cognition explicit when instructing students on their awareness of cognitive strategies or intuitive reactions is vital. Deconstructing the metacognitive elements of clinical reasoning in a similar educational fashion as of other fundamental skills in health professions education may enable students and faculty to understand the content and components of clinical reasoning. Health profession educators would then have an objective and structured means for students to demonstrate and evaluate clinical reasoning in the same manner as other clinical skills such as utilization of evidence-based practice.
In order to build on the content and concepts of metacognition, educators need to develop more expert and conscious levels of processing. Developmental assessment of a skill is confounded without a reliable and accurate means of determining levels of competence. The competency of metacognitive awareness provides a tangible link between critical thinking and clinical reasoning. The processes of clinical reasoning and critical thinking are both ill-defined cognitive processes. The potential overt components of metacognitive knowledge and regulation afford the acquisition of cognition as both knowledge and a skill. Through instruction and awareness, students and educators can promote the transformation of cognitive knowledge into new forms, rendering expressible forms into clinical reasoning and practice.
| Position and Rationale|| |
An overt cognitive process
Hummel and Holyoak identified problem complexity as foundational to human thought in that we first identify the level of problem structure followed by the ability to code and integrate relevant knowledge. Specific instruction in recognizing the structure and difficulty of problems can improve the likelihood that students will diagnose these problems, even when the topic is different. The foundations of how critical thinking and reasoning transfer from one topic to the next lie in two factors: familiarity of specific problem structure and the awareness of knowledge needed to solve the problem. The structural correlation and coding or manipulation of thought is at the foundation of novice learner's cognitive awareness. The recognition, definition, and representation of problem-solving needed for clinical reasoning mirror the fundamental variables of a metacognitive process as defined by Sternberg's 1985 triarchic theory of human intelligence. Sternberg's theory proposes that meta-level components of executive processing guide problem solving by planning, monitoring, and evaluating the problem-solving process. These meta-components make up what Flavell termed as “metacognition” in the late 1970s. Metacognition can also be described as “cognition about cognitive phenomena,” or more succinctly, “thinking about thinking.” Hennessey expanded metacognition to include an awareness of one's own thinking, content of one's conceptions, and an ability to monitor and regulate one's cognitive processes in relationship to further learning through the application of heuristics as a means of effectively organizing problem-solving strategies in general. Brown  and Baker, defined two integral components of metacognition: knowledge of cognition and regulation of cognition. Elaborating on this knowledge and regulation may enable physical therapy educators to promote overt cognitive processing in a deliberate manner, forming a basis for clinical reasoning pedagogy. In the practical sense, focusing instruction on one processing strategy or another may be less important than engaging students in various means of reasoning aimed at optimizing learning and transfer through explicit cognitive awareness.
Metacognitive awareness – Knowledge and regulation
Knowledge of cognition refers to what individuals know about their own cognition or about cognition in general and is often delineated out into three different kinds of metacognitive awareness: declarative, procedural, and conditional knowledge., Declarative knowledge refers to the knowing “about” things. Procedural knowledge refers to knowing “how,” and conditional refers to knowing the “why” or “when” aspects of cognition. Metacognitive knowledge refers to acquired knowledge about cognitive processes, knowledge that can be used to control cognitive load. Schraw describes metacognition as a set of multifaceted general skills rather than domain-specific tasks linking cognitive knowledge and regulation.
Regulation of cognition refers to how individuals think about their cognitive processes or how aware of thinking and learning an individual is. Metacognition regulation is what enables a student who has been taught a problem-solving strategy in one context to retrieve and deploy that strategy in a similar but new context. Although several regulatory skills have been described in the literature, the following three essential skills span all accounts: planning, monitoring, and evaluation., Planning involves the selection of appropriate strategies and the allocation of cognitive resources that affect performance; for example, deliberate study methods, order of thoughts, and allocation of attention before beginning a task. Monitoring refers to an individual's parallel awareness of comprehension and cognitive performance, such as the ability to promote and impart intermittent self-testing while learning. Evaluation implies rendering judgments on one's regulatory processes in the absence of enough information during learning or problem-solving. Examples include re-assessing goals of a treatment plan or establishing a diagnosis of a patient.
Engaging in clinical reasoning requires students to monitor their cognitive processes (System I and II), reflect on the progress that is being made toward an appropriate outcome, ensure diagnostic accuracy, and evaluate effective utilization of time and mental energy. The conscious awareness about thinking exemplifies the role of metacognitive monitoring as an executive function that directs complex cognitive processes. Metacognition as a skill is made overt and conscious during teaching by enabling instructors to model their previously unconscious and concealed thoughts in an observable and transparent manner. The visual and exposed aspect of metacognition lends to a variety of pedagogical techniques that are both structured and creative, just as the process of clinical reasoning is.
Teaching cognitive processing that is transferable across domains for problem-solving and clinical reasoning is the benefit of metacognitive knowledge and awareness. Flavell stated the central and essential meaning of “cognitive structure” ought to be a set of cognitive attributes that are in one way or another interrelated to constitute an organized whole. In teaching through metacognition, we address “structure,” or the ensemble of two or more elements together with one or more relationships interlinking these cognitive elements. Metacognition is the cognitive awareness of the learning process and is a critical component in successful teaching and learning. Metacognition is a key variable in clinical reasoning that enables self-regulated learners to choose the best way to approach a learning task. Metacognition includes the ability to know when, why, and how to apply different cognitive strategies to solve different types of problems. Health profession students who can effectively implement the skills of metacognition will have more organized thoughts for learning, problem-solving, and clinical practice.
Quantifying metacognitive awareness
The data and research continue to mount in the failed attempts to assess clinical reasoning in health profession students. Standardized instruments such as the Health Science Reasoning Test and California Critical Thinking Skills Instrument and their subcomponents lack adequate diversity to capture the complex elements of cognitive processing. More formative means of assessing clinical reasoning such as concept mapping, think aloud, reflective writing, and verbalization techniques offer insights into students' current state of cognitive processing, but fail to establish a level of competence and identify the elements of deficit.,
The Metacognitive Awareness Inventory (MAI), developed and validated by Schraw and Dennison, is a 52-item self-report inventory assessing the knowledge and regulation of cognition, which uses a 5-point Likert-type scale ranging from “1 – always false” to “5 – always true,” in which students report levels of agreement with all the items. Strong agreement results in higher scores. Items are broken down into eight subcomponents under the two broadest categories, namely, knowledge of cognition and regulation of cognition. The original authors noted that the factors were reliable (i.e., α = 0.90) and intercorrelated (r = 0.54), and the two-factor analysis indicated that the MAI is reliable and demonstrates predictive validity in measuring metacognition with regard to the knowledge and regulation of cognition. Knowledge of cognition corresponded to what students know about their thinking, the strategies used, and the context under which strategies are most useful. Regulation of cognition corresponded to knowledge about the ways that students plan, implement, and monitor their learning through self-reflection. These strongly intercorrelated factors suggest that both categories of metacognition, knowledge and regulation, may work in concert to help students gain cognitive awareness.
One limitation of the MAI is the need for further research into divergent and convergent validity. Similarly, reliability and validity testing of the MAI was premised on the cognitive strategies associated with reading comprehension and math testing accuracy,, but has not been fully examined for multifaceted cognitive processing likely needed for clinical reasoning.
The ability to reflectively regulate and identify processing strategies provides a tangible measure of a cognitive process that is both deliberate and conscious, emulating the desirable attributes of clinical reasoning. Using a reliable instrument to assess the subcomponents of metacognition may enable educators to accurately determine the development milestones of students as they progress toward a level of competence and mastery needed for clinical practice. Simultaneously, the assessment of metacognition in a robust and meaningful manner aids educators in identifying educational touchpoints to overtly engage students in metacognitive strategies and reflection.
Future research is needed to correlate MAI scores and effective clinical reasoning in didactic, laboratory, and simulated learning experiences. Proven links between metacognitive awareness and clinical reasoning may unlock unforeseen potential to quantify cognition in the clinical realm.
Explicitly teaching metacognition
The ability of faculty to deconstruct the cognitive processes needed to solve the clinical problems affords students an overt activity that provides valuable modeling and feedback in metacognitive regulation. As Flavell depicts and case-based learning (CBL) enacts, students are forced to search for cognitive knowledge in solving clinical problems and simultaneously developing cognitive actions or strategies for monitoring cognitive knowledge. In this light, CBL enables the faculty and educator to uncover knowledge gaps and limitations in a student's metacognitive regulation that ensure more proficient clinical problem-solving.
Thistlethwaite et al. conducted a systematic review of CBL in health professional education including medicine, nursing, and allied health professions. CBL was found to promote a deeper learning when utilized in a structured and guided manner. It was also noted that it promotes reflective thinking and deeper conceptual understanding to allow for future application. Limitations of CBL appeared in the empirical data regarding specific knowledge acquisition, and more research is needed to explore retrieval following CBL.,, More importantly, CBL is being used as a framework for educating students on the interprofessional roles and models of practice., The introductory structure and continual modeling and explicit feedback occurring in CBL for problem-solving form a solid foundation of cognitive strategies while making more complex thinking apparent to the student for evaluation.
In order to develop better refined CBL pedagogies and assessments, Gilliland examined how entry-level physical therapy students approach clinical problem solving by examining the types of hypothesis and reasoning errors students make during their progression through a doctoral physical therapy curricula. First-year students followed protocols to rule in and rule out, made more assumptions, had more bias, and made more analytical errors, whereas 2nd- and 3rd-year students utilized less protocols and used deductive reasoning. As students progressed through the curricula, they made fewer analytical errors. This study provided valuable information about how students think to help design appropriate CBL activities that are overt and scaffolded to progress students into more adaptive and flexible thinkers.
Deconstructing the cognitive processes is needed to solve the problems. Modeling, feedback, and reflection are crucial. CBL promotes the clinical application of didactic knowledge while promoting problem-solving skills and refinement through structured cognitive activities. Trommelen et al. utilized five CBL activities with external reflection to assist students in the application of knowledge. Their preliminary findings suggest external reflection along with the CBL-promoted clinical reasoning, specifically flexibility of thinking and structure of memory as measured by the Diagnostic Thinking Inventory.
Standardized and simulated patients
Utilization of standardized patients (SP) in medicine, nursing, athletic training, occupational, and physical therapy curricula allows students to deliberately practice reasoning, communication, reflection in action, and domain-specific skills in a safe and authentic environment.,,,,,,, The structured learning environment provided by an SP enables students to test their knowledge of cognition while planning, monitoring, and evaluating thought in real time. SP feedback and video review engage student self-reflection to enhance their metacognitive awareness. The practice environment of simulation affords students with opportunities to apply cognitive knowledge; practice psychomotor skills; practice reflection in action; and actively regulate cognition during safe and low-risk clinical decision-making conditions.,,,,,,,,
The SP encounter poses a parallel-assessment pedagogy with MAI. As an educational experiment, students and faculty can determine their level of metacognitive awareness and growth from the experience with the hope of consciously improving on their ability to regulate their cognition more effectively in the next patient encounter.
Experiential learning in health profession education
One means of learning is by doing. Beard and Wilson defined the role of experiential learning as an “experience that actively immerses and reflectively engages the inner world of the learner, with the intricate “outer world” of the learning environment to create memorable rich and effective experiences. As students embark on more discipline-specific application of knowledge, skills, and cognition, the educational opportunities need to offer more socio-cultural and experiential learning. While CBL and simulation scaffold the experiential learning, full immersive learning creates constant real-time opportunity to apply the steps and cognitive functions necessary to examine evidence and evaluate decisional making that directly impacts patient care. The immersive clinical experience makes thinking explicit by simultaneously focusing on integrating the knowledge and skills that students have gained in the curriculum with the variables of the environment around them. In experiential learning, students are forced into ongoing cognitive planning, evaluation, and monitoring, to integrate and organize knowledge and thoughts for practical application.
As noted in the medical literature, the clinical environment provides the educational tools to recognize, activate, and encourage a cognitive process which identifies the relevant pathophysiologic information and inter-related multi-morbidity. Early exposure to patient care enables students to rehearse both psychomotor and cognitive skills in a controlled manner with the added value of faculty/clinical educator feedback and guided self-reflection., With every subsequent clinical experience, health profession students are enhancing their metacognitive awareness through modeling of expert cognition and overtly reflecting on the effectiveness of their own cognitive strategies. The cumulative effects of experiential learning on cognition allow the student to effectively plan, evaluate, and monitor future cognitive strategies used in patient care.
The role of metacognition and application of dual-process theory in promoting this cognitive process is possible during experiential practice with explicit instructions, the use of de-biasing in both processes, and active interaction with specific knowledge in memory. Occupational therapy students reported that participation in a learning experience with actual clients allowed for examination of their own clinical reasoning strategies and assessment of how reasoning skills change over time when presented with clinical challenges.
The developmental nature of clinical reasoning leads to frequent disparity between theoretical knowledge and clinical skill acquisition needed for effective patient care. The experiential learning of a novice is further enhanced by a clinical educator who directly promotes overt knowledge of cognition and regulation of cognition that is scaffolded. This circular process of pattern recognition and formative feedback provides students with the opportunity to identify any gaps in knowledge, an opportunity to “fill in the blanks” and obtain new knowledge, or adjust cognitive strategies to recall information more effectively. Retrospectively, experiential learning enables the student to identify what was different than expected and what strategies they will use to determine a new plan of action for similar patient cases moving forward. Both the overt thinking and encouraged reflection of the experiential learning reinforce the metacognitive process that is required to make effective clinical decisions.
| Discussion|| |
Metacognitive awareness, both in knowledge and regulation, defines a means for instructing the cognitive systems needed for clinical reasoning. Deliberate training and transparency in pedagogical practices aimed at targeting metacognitive awareness aids students and faculty by making previous unconscious cognitive processes overt. As students receive further education and feedback on strategies to identify, monitor, evaluate, and plan cognitive thoughts, the potential exists to improve metacognitive judgments in the discipline-specific practice of each health profession.
Learning the components of metacognitive awareness is essential to a solid foundation from which students and future clinicians can reason. Subsequently, the increased ability to plan and evaluate cognitive processes may aid students in attaining more meaningful thinking for complex problem-solving. Through regular assessments of metacognitive awareness, students and educators can determine overall competence in metacognitive awareness and identify areas for instructional emphasis in an individual learner.
Preliminary research is promising, and based on the role of metacognition, it may be beneficial to consider creating scaffolded CBL experiences with reflection. These experiences will assist the students with deconstructing the problem, thinking about how to solve the problem, and identifying strengths and weaknesses in their decisions. Early in the curriculum, faculty should consider designing pedagogical practices that consider where the students are in their learning process. Assessing metacognitive awareness at the start of a curriculum also affords an initial exposure, framework, and instructional opportunity from which students can build future cognitive strategies. Foundational modules of health profession curriculums and courses should implant instructional design to be more simplistic and overt to allow the students to explore and expand the cognitive strategies they typically utilize for problem-solving. Some examples of teaching strategies would be (1) the use of protocols or trial and error for decision during a CBL activity followed by guided reflection and modeling by the faculty; (2) creating an SP experience that focuses on the practice of interview skills followed by a review of the video and a guided reflection to assess strengthens and weaknesses; and (3) clinical faculty modeling and guiding students during an interview or with basic skills during experiential learning experience. Under the guidance of an expert clinician or faculty, embedding cognitive processing practices within the context of patient care integrates theoretical constructs of metacognition as an effective teaching strategy to enhance the transparency of clinical reasoning.
As the students move along the curricular continuum, the pedagogical practices should become more autonomous and complex, requiring greater integration of the knowledge and synthesis of cognitive variables as they attempt to deconstruct problems and develop a more robust decision-making process. As the students prepare to head into experiential learning, the CBL and simulated patient experiences must encapsulate the integration of knowledge and regulation of cognition that may adequately bridge a pedagogical gap from didactic CBL to the authentic clinical practice. During their scaffolded experiences, students must use strategies to identify, monitor, evaluate, and plan cognitive thoughts as they work through the simulations. For example, students can overtly identify their use of dual processing as they work through a complex CBL activity by asking them the how and why of their decisions; through this activity, students not only create a plan for the case, but map out their thought process. After outlining their cognitive strategies, students can then reflect on both the strengths and weaknesses of their thought process and case plan. Reassessment of metacognitive awareness can also reinforce the use of cognitive strategies introduced earlier for both students and faculty and produce tangible evidence of change over time.
| Conclusion|| |
Deliberately scaffolded pedagogical practices which emphasize explicit student knowledge and regulation of cognition may benefit health profession educators in teaching future clinicians to handle clinically complex problems. The research supports CBL, simulation/SP interactions, and experiential learning to assist health profession educators in promoting metacognitive awareness. Threaded assessment of metacognition throughout the curriculum may also provide tangible evidence of the student progression. The modeling, practice, and evaluation of metacognition may provide much-needed guidance in the quest to teach clinical reasoning to health profession students.
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Conflicts of interest
There are no conflicts of interest.
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