by Diana Berescu, Pharmacy Practice Resident, Howard County General Hospital
As part of this teaching course, I have worked with
students in various settings either through facilitating a case discussion or
precepting. I found myself wondering about the differences in self-learning and
critical thinking between students. From my experience, those who possess these
skills appear to perform at or exceed expectations and I came across a research paper by Schneider and
colleagues that supports this observation. Specifically, the paper looked at
the impact of metacognition, also known as “thinking about thinking,” on test
performance. But I was left with the question: how do we as
teachers/preceptors/facilitators help students develop these skills?
Critical thinking and self-learning are challenging to
teach and require some innate motivation from the student. We know that these
skills are important for life-long learning after graduation and they are even
stressed by the Accreditation Council for Pharmacy Education (ACPE). Self-learning skills that are addressed in a pharmacy curriculum
include reflection, planning, learning, evaluation and recording. These skills
are necessary for promoting critical thinking in both students and
post-graduate pharmacists (Janke et al. 2012). Metacognition is a
skill that is necessary to empower self-learning and understanding of one’s
knowledge gaps. A
study of 107 pharmacy students assessed the correlation between their
metacognitive skills and summative exam performance (Schneider et al. 2014). Students were
asked to predict their performance and the authors reported that higher
performing students were better at accurately identifying incorrect answers more
than lower performing students. This study supports the development of
metacognitive skills in pharmacy students.
There
are different strategies for developing metacognitive skills, but in this essay
I focus on reflection and questioning. Self-reflection was
assessed among 94 pharmacy students who divided into two groups (Austin et al. 2008). Group 1 completed
a standardized test consisting of 24 questions without interference. Group 2
completed the same test but there were two additional questions. The first
prompt on the test asked students to rate their own confidence on a scale from
1-10 for question 13. The second prompt occurred at question 18 and utilized
“reflection in action” by asking students to provide a brief written
explanation and justification of why they selected the answer. The authors
reported that for the first 12 questions performance did not differ between the
two groups. Following the first prompted question, group 2 had improved
performance which persisted for the remainder of the test. While there are some
limitations due to design, small sample size and lack of validation of the
whole instrument, this study suggests that incorporating questions that require
the student to self-assess and self-reflect may improve performance. The
findings of these results can be applied to pharmacy courses by inserting similar
questions prompting reflection throughout assessments. These answers can be
free-text and would not be graded but may support developing metacognitive
skills.
Reflection and questioning can also be used by
students in experiential settings. Problem-based learning involves students
learning through problem solving and reflecting on experiences. Metacognitive
questioning has also been described to support the development of metacognitive
skills in students (Hmelo-Silver et al. 2006). Preceptors
facilitate learning and help students develop application of theory and
critical thinking. There is evidence to suggest that lower level questions (defined
by Bloom’s taxonomy as “knowledge”
questions) do not encourage critical thinking. A survey consisting of acute
care clinical scenarios was administered to 126 nursing facilitators. The
authors found that most questions were knowledge questions (59%) (Philips et al. 2017). In addition, the
authors reported that nursing facilitators with teaching education or
qualifications asked more high-level questions which were defined as application,
analysis, synthesis and evaluation. Best strategies for effective questioning
for pharmacy students were outlined by Tofade and colleagues. Outside of Bloom’s
taxonomy, they outlined three different strategies for formulating questions: two
methods described instructor-generated questions and the third described student-generated
questions. This third strategy required students to create their own questions
and may lead to deep learning and greater understanding of the course material.
Questioning defined as “thinking out loud” also supports metacognition.
Questions that may help students include: “what are my goals for learning?” and
“does this material make sense to me?” (Tofade et al. 2013). This combination
of reflection and questioning can help students learn metacognition. Teachers
can challenge students by asking high-level questions and using other
questioning strategies.
There are several ways reflection and questioning can
be applied to facilitate metacognition. The first may be to have students
develop their own learning plan or objectives prior to a rotation or even a
lecture: “what are my goals for this learning activity?” They can use Bloom’s
taxonomy to identify both lower and higher level learning objectives. In
addition, facilitators can provide prompts that at different intervals to
self-assess or reflect. For example, one could provide students with a list of
questions for self-assessment. Questions can include: “Does the disease and
treatment make sense to me?” or “why were other treatment options not used?” To
take this a step further, the student can then present this information to the
facilitator and explain his or her thought process (thinking out loud). The
facilitator can ask questions that would deepen the student’s learning and
continue to develop metacognition.
The strategies of reflection and questioning have been
shown to improve metacognition in pharmacy students and can be applied in both
classroom and clinical practice settings.
References
Armstrong P. Bloom’s Taxonomy. Center for Teaching. Vanderbilt
University. Link: https://cft.vanderbilt.edu/guides-sub-pages/blooms-taxonomy/
Austin Z, Gregory PA, Chiu S. Use of reflection-in-action and
self-assessment to promote critical thinking among pharmacy students. Am J
Pharm Educ. 2008;72(3):48. Link: https://www.ncbi.nlm.nih.gov/pubmed/18698383/
Hmelo-Silver, C. E. ,
& Barrows, H. S. (2006). Goals and Strategies of a Problem-based Learning
Facilitator. Interdisciplinary Journal of Problem-Based Learning,
1(1). Link: http://docs.lib.purdue.edu/ijpbl/vol1/iss1/4/
Janke KK, Tofade T. Making a Curricular Commitment to Continuing
Professional Development in Doctor of Pharmacy Programs. Am J Pharm Educ. 2015;79(8):112.
Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4678737/
Mitchell R, Regan-smith M, Fisher MA, Knox I, Lambert DR. A new measure
of the cognitive, metacognitive, and experiential aspects of residents'
learning. Acad Med. 2009;84(7):918-26. Link: https://www.ncbi.nlm.nih.gov/pubmed/19550190
Phillips NM, Duke MM, Weerasuriya R. Questioning skills of clinical
facilitators supporting undergraduate nursing students. J Clin Nurs. 2017.
Link: http://onlinelibrary.wiley.com.ezp.welch.jhmi.edu/doi/10.1111/jocn.13761/epdf
Schneider EF, Castleberry AN, Vuk J, Stowe CD. Pharmacy students'
ability to think about thinking. Am J Pharm Educ. 2014;78(8):148. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4226285/
Tofade T, Elsner J, Haines ST. Best practice strategies for effective
use of questions as a teaching tool. Am J Pharm Educ. 2013;77(7):155. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3776909/
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