Abstract
Objective. To assess factors impacting metacognition during the advanced pharmacy practice experience (APPE) year (final year of the Doctor of Pharmacy program) for student pharmacists at five different institutions.
Methods. Student pharmacists completed a pre- and post-APPE year survey that collected data on demographics, curricular and co-curricular experiences, and the 19-item modified metacognition assessment inventory (MAI). Additionally, the post-APPE survey collected data on learning activities completed during the APPE year. Matched survey responses were analyzed to identify associations between change in MAI score and individual experiences.
Results. One hundred thirty-nine matched responses were analyzed. A significant improvement in overall student pharmacist metacognition was seen in matched pre- vs post-APPEs surveys. Several significant, moderate to weak correlations were associated with a change in MAI score over the APPE year.
Conclusion. The APPE year resulted in a significant change in student pharmacists’ metacognition at five institutions. This improvement was multifactorial as individual factors had minimal association with the change in metacognition.
INTRODUCTION
Metacognition was originally defined by Flavell as the “knowledge and cognition about cognitive phenomena as well as monitoring of one’s own memory, comprehension, and cognitive enterprises.” 1 Metacognition encompasses both knowledge of cognition (metacognitive knowledge) and regulation of cognition (metacognitive regulation). 1-5 Metacognition, including both metacognitive knowledge and regulation, is vital in the essential skills of pharmacists: clinical reasoning and critical thinking. 1 Student pharmacists’ intrinsic ability to “think about thinking” can heavily influence their confidence and performance as a learner now and also in their future as a practitioner. 1-8
While not explicitly stated in the ACPE Standards for Doctor of Pharmacy (PharmD) degree programs, student pharmacists and pharmacists possessing greater metacognitive awareness may have improved ability to develop and apply clinical reasoning, and would therefore be important to address. 2, 6-9 The impact on clinical reasoning is not only intrinsic for the learner or practitioner, but there is also new evidence showing the impact of metacognition on patient outcomes. 10 Additionally, metacognition is linked with self-regulated and lifelong learning, both of which are essential skills for pharmacists as they navigate advances in practice and newly published literature. 3, 11, 12 To produce competent and impactful practice-ready graduates, the Academy must promote metacognition within learners to enable continuous reflection along with knowledge and skill acquisition throughout their careers. 2, 3, 7-13 Metacognition is often intertwined with a person’s level expertise, as an expert must be able to be aware and monitor their thinking. 13, 14 While expertise itself is a product of time and experience, pharmacy educators can promote and facilitate metacognition within student pharmacists to aid in the transition to practitioners and experts. 13, 14
Various strategies, activities, experiences, and approaches have been proposed to enhance metacognition in health professions students. 2-5, 7, 8-20 In the didactic setting, methods include structured and specific learning objectives to guide learners, activities that allow them to monitor their understanding, and opportunities to evaluate their thinking during the learning and assessment processes. 2, 3, 7, 8, 11, 13, 15-19 One medical school has incorporated an entire course focused on metacognition to stress the importance of the topic and facilitate development of this skill through readings, reflective activities, and group dialogue. 9 Other proven methods to enhance metacognition in classroom-based environments include examination reviews and use of guided reflections. 3 However, a study in nursing education revealed the deficiencies in students’ metacognition within a clinical simulation, supporting the need to identify and implement strategies to facilitate this skill in health professions students. 20
In clinical education, suggested strategies to develop metacognition include mastery goal setting with reflective exercises, utilization of written and verbal communication to explain thought processes and reasoning, and scaffolded activities that increase autonomy. 2-4, 7, 8, 11, 12, 16 Additionally, modeling and coaching by clinical educators have been proposed to facilitate metacognition in health professions education. 16 However, research is lacking in the experiential education setting to support the development of student metacognition in health professions education. 3 Identifying opportunities or characteristics of clinical learning environments that contribute to improved metacognition would be beneficial in developing competent, autonomous pharmacists. Therefore, the objective of this study was to assess factors impacting student pharmacists’ metacognition throughout advanced pharmacy practice experiences (APPEs) in their final year of the PharmD program.
METHODS
This preliminary study was conducted at five schools of pharmacy throughout the United States and consisted of two anonymous surveys. Doctor of Pharmacy students in their final year at all institutions were invited to participate in the study at the beginning of their APPE year. The APPE year commenced in May for all institutions, with the duration of individual APPEs varying from four to six weeks. Student pharmacists were invited by email to complete the electronic pre-APPE survey in May 2019 via Qualtrics (Qualtrics LLC, Provo, UT). All student pharmacists also received email invitations to complete the electronic post-APPE survey at the end of the APPE year in April 2020. For both surveys, student pharmacists received a follow-up reminder email one week after the initial invitation, with both surveys available for three weeks. Participation in the study was voluntary across all institutions; however, two institutions incentivized participation by selecting five recipients for a gift card award through a random drawing.
Metacognition was assessed using a modified version of the Metacognitive Awareness Inventory (MAI). 21, 22 The original MAI is a 52-item self-report instrument created to measure knowledge of cognition and regulation of cognition. 21 Harrison and colleagues further examined the function of the MAI within higher education and, based on the results, created a shortened, modified 19-item MAI that resulted in a better model fit. 22 This modified MAI uses a five-point Likert scale to assess metacognitive knowledge (eight items) and metacognitive regulation (11 items). Metacognitive knowledge relates to the awareness of individuals to their thought process and learning, while metacognitive regulation is the planning for learning. 22 The MAI can have a total score of up to 95, with higher scores indicating a higher degree of metacognition. 22
After consenting, participants created a unique identifier to be used in both the pre-APPE and post-APPE surveys. The pre-APPE surveys collected data on baseline demographics, metacognition as assessed by the modified MAI, and participation in curricular and co-curricular activities (educational, cultural, self-awareness, leadership, innovation/entrepreneurship, and professionalism) prior to APPEs. 6 The post-APPE survey similarly collected data on student pharmacists’ demographics, metacognition (using the modified MAI), participation in curricular and co-curricular activities during the APPE year, and details about their APPE year (eg, type of clinical experiences, learning activities, and performance).
Following completion of the study, survey results from all institutions were combined for data analysis. Results from the pre-APPE and post-APPE surveys were matched using the unique student identifiers. Data were analyzed to assess for changes in MAI scores and factors influencing any changes to those scores. Only matched responses, using unique identifiers from student pharmacists who completed both the pre-APPE and post-APPE surveys, were included in the data analysis. Paired t tests were used to analyze the change in pre-APPE and post-APPE MAI scores. A Spearman correlation was conducted on the paired data to evaluate associations with the change in MAI score. A p value <0.05 was considered statistically significant. The project was deemed exempt by all five institutional review boards.
RESULTS
Of the 560 eligible participants, 245 completed the pre-survey (44% response rate), 257 completed the post-survey (46% response rate), and 139 completed both, making them eligible for inclusion in the data analysis (25% response rate). Baseline characteristics and co-curricular experiences for matched respondents are detailed in Table 1 and Table 2, respectively.
Baseline Characteristics of Matched Respondents Who Participated in a Study Evaluating the Impact of Advanced Pharmacy Practice Experiences on Student Pharmacist Metacognition (N=139)
Co-curricular Experiences of Matched Study Respondents Before and During the APPE Year (N=139)
The pre-APPE combined metacognitive median score was 72 (interquartile range [IQR] 65-80), with a metacognitive knowledge median of 32 (IQR 29-36) and metacognitive regulation median of 40 (IQR 36-45). There was a significant enhancement in all post-APPE median metacognitive scores: combined (74, IQR 69-82, p<.01), metacognitive knowledge (32, IQR 30-36, p=.03), and metacognitive regulation (42, IQR 38-46, p<.01). Significant associations between the change in metacognition and student characteristics are shown in Table 3. Pre-APPE metacognition had a moderate association in the change in metacognition (0.50, p<.01), while other significant factors only had a weak association.
Significant Factors Associated with Pre-APPE, Post-APPE, and Change in Metacognition for Matched Study Respondents (N=139)
DISCUSSION
In this study, there was a significant change in overall student metacognition during the APPE year. Additionally, specific factors such as higher pre-APPE combined metacognition scores, professional work experience, quantity of self-reflections, and participation in professionalism journal clubs were associated with positive change in metacognition. With limited literature evaluating factors impacting metacognition in experiential education, this expands on existing literature by evaluating the change over the APPE year and the associated factors impacting metacognition.
For health professions students, including student pharmacists, there is a lack of evidence regarding factors and activities that impact metacognition in the experiential setting. 3 Within pharmacy education, Martirosov and Moser introduced the concept of metacognition and assessed student metacognition before and after a semester-long team-based learning course for second-year student pharmacists at one institution. 15 Their study found that after the course, there was a significant improvement in metacognition, as measured by the 52-item MAI (77% vs 84%, p<0.01). 15 Their study points to an option to enhance metacognition during the didactic curriculum, but no evaluation was done within experiential education. 15 A recent article in experiential education showed the enhanced metacognitive accuracy of student pharmacist self-assessment as compared with faculty assessment of student performance on entrustable professional activities (EPA) between introductory pharmacy practice experiences and the beginning of APPEs; however, there was no overall difference noted in accuracy enhancement throughout the APPE year. 12 The only EPA with enhanced metacognitive accuracy was for documentation in an electronic health record, possibly due to the reflective nature and/or increased experience with documentation. 12
During APPEs, student pharmacists participate in numerous patient care and learning activities, but commonalities across experiences are some level of self-directed learning, self-assessment, reflection upon feedback, and growth in clinical knowledge. 6 While metacognitive skills are assumed to grow throughout APPEs, this current study provides evidence of that metacognitive change, as there was significant improvement in combined metacognition, metacognitive knowledge, and metacognitive regulation at the end of the APPE year. For factors associated with the change in metacognition, pre-APPE combined metacognition had the strongest association, potentially indicating that students with strong metacognition prior to APPEs may already possess the processes needed to achieve higher metacognitive growth during the APPE year. This points towards the need not only to facilitate metacognition in experiential education, but to do so in the didactic curriculum so that metacognition can further increase during APPEs.
When evaluating other individual factors associated with a change in metacognition during the APPE year, there were only weak associations, pointing to a multifactorial impact. Outside of pre-APPE metacognition, the second largest association with the change in metacognition was with the quantity of self-reflections. This aligns with previous studies highlighting the importance of intentional reflection to facilitate metacognition. 3, 5, 11, 12, 18 Work experience, although a weak association in the current study, does align with expertise and enhanced metacognition within the literature. 11, 12, 18 The observational nature of this study did not allow for control of time and the experiences themselves, which were potentially responsible for the enhanced metacognition over the APPE year. Based on the current study as well as previous literature, causative factors during the APPE year resulting in metacognitive growth may be due to clinical experience, time, the educator and structure of the learning experiences, and intentional reflection. 11-14, 23 For experiential preceptors looking to facilitate metacognitive growth, implementing regular reflective exercises and activities, such as professionalism journal clubs, on their rotation may help. Future research is warranted to evaluate these interventions alone and in combination within pharmacy experiential education. An additional area needed for future research is the impact of metacognition on patient outcomes for health professions students. 2, 3, 7, 8, 10 In a study in obstetrics, physicians with a higher metacognition were more likely to have better maternal and neonatal outcomes. 10 Their study, in non-trainees, shows an impact on patient outcomes; however, there is a lack of data from this study or others in relation to learner metacognition and its influence on patient outcomes. Finally, research evaluating longitudinal metacognitive changes in student pharmacists in the curriculum as a whole, including both didactic and experiential learning, is warranted.
This study serves as an important preliminary study, measuring the change in metacognition over the APPE year for student pharmacists. However, there are limitations which may impact the findings. First, student pharmacists from the five different schools of pharmacy had varying institutional-based factors, such as varied duration of APPEs, assignment requirements, and geographical practice patterns. 6 However, this is generalizable across the Academy, reflecting the inherent differences among programs and expanding generalizability. Additional limitations include the weak associations found, as noted above. Finally, the paired overall matched response rate was low (25%), which impacts generalizability and must be taken into consideration when reviewing the results. 24 Despite this limitation, the current study represents the largest sample evaluating metacognition change in experiential education among health professions students to date.
CONCLUSION
A significant change in overall metacognition was noted during the APPE year for student pharmacists at five institutions. The improvement was multifactorial as individual factors had minimal association with the change in metacognition. There may be opportunities for institutions to further incorporate learning activities to enhance student metacognition within the didactic and experiential curricula, such as introducing metacognition concepts and implementing or expanding intentional reflective activities. Additional studies are warranted to identify how experiential education can impact metacognitive growth in student pharmacists.
- Received April 5, 2021.
- Accepted August 27, 2021.
- © 2022 American Association of Colleges of Pharmacy
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