March 30, 2016

Knowledge Dimensions: Factual, Conceptual, Procedural, and Metacognitive

by Tara Bastawrous, PharmD., PGY-1 Pharmacy Practice Resident at Kaiser Permanente of the Mid-Atlantic States.

Personally, I learn the best through questions and answer. I appreciate professors and preceptors who take the time to make study guides and cases where I need to find the answers in the reading materials. I enjoy preceptors asking me questions because — although it may be intimidating or nerve racking when I do not know the answer immediately — searching for the answers makes me remember the concept. In searching for answers, I am able to make connections and relate the information to previously learned material. I learn best through questions and plan to use this excellent teaching and learning tool with students I will precept in the future.

Questions need to be properly constructed in order for students to gain the most out of the learning experience. They should not be asked to confuse or intimidate students, but rather to stimulate critical thinking and apply prior knowledge to the current concept. Students can effectively learn from answering questions, but their answers can also assist the teacher. Teachers are able to assess the student’s prior knowledge and based on  student’s responses can guide further instruction, choosing what to focus on and the level of difficulty.1

Not only should questions be planned both in the classroom and at clinical practice experiences, but students should also be taught to ask questions. Students need to feel that they have the freedom to ask scholarly questions to gain better insight or clarity. Questions should provoke higher-level thinking, no matter the academic proficiency of the student, as this will help engage and motivate the student.2

Questions can be constructed based on the 4 knowledge dimensions: factual, conceptual, procedural, and metacognitive. Anderson and Krathwohl first developed these 4 dimensions, ranging from concrete to abstract.  Factual questions seek recall information from textbook, guidelines, or studies on the concept being asked. They ask about details from reliable, published data.  Students must remember specific, applicable information from various sources. Factual questions are asked to assess understanding and prompt analysis of a disease state, situation, or others work.1 An example of a factual question might be “According to the American Diabetes Association, when should anti-diabetic medications be initiated in a patient?” By reviewing these essential facts, terminology, and details, the learner will be better prepared to solve a problem.3

Conceptual questions ask students to further describe the factual information, to become aware of the “interrelationships between the elements of a larger structure”. Learners are asked “why” — to explain their answer, providing the principles or theories that support their answers. These types of questions also help learners to classify elements into categories, further differentiating information and analyzing correlations to the pertinent subject matter.1,3 An example of conceptual questions would be: “How are the American Diabetes Association and the American Association of Clinical Endocrinologists Guidelines for Diabetes similar and different?” Another conceptual question would be, “Why do the guidelines recommend against using insulin and sulfonylureas concomitantly?”

Procedural questions assess the learners’ ability to choose from well-established methods and select the most appropriate algorithm, technique, or criteria based on the particular situation.1 An example of a procedural question would include: “Based on this patients A1C and fasting blood glucose level, which medications are recommended by the American Diabetes Association for initial therapy?” 

Studies have shown only about 20% of questions are procedural, with another 20% being higher level.2 These types of questions help the learner apply their knowledge, skills, and techniques to problems in the pertinent subject matter.3

Metacognitive questions ask learners to reflect on experiences and identify possible areas of improvement. Metacognition is defined as “higher-order thinking that enables understanding, analysis, and control of one’s cognitive processes, especially when engaged in learning.”4  The learners’ answers to metacognitive questions help the teacher assess the learners’ personal motivations and values, which could help shape how the material is taught.1 By “thinking about one’s own thinking” learners are able to approach problems utilizing their strengths and preferences, and examining their weaknesses.  An example of a metacognitive question would be: “Thinking back on the patient encounter, how well do you think you did? How do you think you could have improved your patient interviewing and counseling skills for future consults?” These questions also help train learners to use their knowledge strategically and reflectively when solving problems.3

In one study, the questions overwhelmingly (91.2%) asked by clinical teachers were lower level questions, with most being factual type. The authors state this may be because teachers have not been taught how, or the importance of, asking higher order questions.6

Higher-order questions promote higher-order thinking. Higher-order questions “causes cognitive processing and organization of information that’s builds more elaborate mental structures.” 2 Teachers and preceptors should be taught to formulate higher-order questions to stimulate such thinking.

It has been shown that teachers mostly ask lower-level cognitive questions. Lower-level cognitive questions can hamper the learners’ ability to develop higher order critical thinking skills. These skills are important to allow students to practice recalling knowledge they have learned and applying them to new situations. Critical thinking is especially important when problem-solving and determining the best treatment for a patient based on various factors and barriers. By asking students questions in the factual, conceptual, procedural, and metacognitive domains of knowledge, they will be able to learn in a “full circle” and understanding the bigger picture.1,2

  1. 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): Article 155.  Accessed February 15th, 2016.
  2. Saphier J, Haley-Speca M, Gower M. Dimensions of Questioning. The Skillful Teacher: Chapter 9: Action, MA. Research for Better Teaching, 2008; 208-214. Accessed February 16th, 2016
  3. Owen L. Anderson and Krathwohl-Understanding the New Version of Bloom’s Taxonomy. 2013. Accessed February 18th, 2016
  4. Metacognition defined by
  5. Gall M, Ward B, Berliner D, et al. Effects of questioning techniques and recitation on student learning. American Educational Research Journal. 1978; 15: 175-199
  6. Sellapah S, Hussey T, Blackmore A, et al. The use of questioning strategies by clinical teachers. Journal of Advanced Nursing. 1998; 28: 142-148.

March 25, 2016

Effective online teaching strategies for student success

by Htet Htet Zaw, Pharm.D, PGY-1 Pharmacy Practice Resident, Holy Cross Hospital

In the United States, enrollment in online classes grew from 9.6% in 2002 to 33.5% in 2012.  And enrollment continues to grow due to technology and innovations in education. Online delivery of education is very important to adult learners as it enables them to meet family, work, and other responsibilities. Although online learning continues to grow at a quick pace in higher education, faculty members may be reluctant to adopt it and some students may be hesitant to enroll in online courses due to lack of face-to-face contact, a focus on grading rather than learning, and the perceived need for technological expertise.  Success in online classes requires learners to take responsibility for controlling the factors that affect learning and instructors to facilitate successful student learning experiences.1-6

It is important for the instructors to know their online audience in order to deliver a quality learning experience that meets the needs of all learners. First, the instructor should examine learner demographics and consider culture differences that could affect online learners and their social interactions. Second, consider the unique problems and issues that learners may encounter in the online environment.

During the orientation session, instructors should be very clear about the materials learners will need to complete the course and provide explicit instructions.  This includes a well-developed course syllabus, a list of weekly activities, a description of the assignments and their due dates as well as how to participate in discussion boards, how to access the grade book and instructor feedback, and the instructors’ contact information.

Although providing explicit and well-written instructions will provide a great foundation for an online class, many students will experience a sense of separation that may lead to them to dropping the class or, worse, failing. This is not simply caused by the physical distance between students and instructors but also due to a communication gap and a psychological separation called the transactional distance (TD).  The transactional distance (TD) is a "psychological and communications space to be crossed; a space of potential misunderstanding between the inputs of instructor and those of the learner.’’ To provide a successful learning experience, instructors need to shorten or decrease the transactional distance. There are three key interactive components that work together to shorten the transactional distance:

Dialogue is the amount of interaction that takes place between instructor and student … and student to student. Dialogue and transactional distance are inversely related. The more communication and greater variety of communication strategies that instructor employes to increase dialogue, the smaller the transactional distance. Synchronous teaching activities with real time voice communication, chats and threaded discussion groups are good examples of high dialogue strategies.   Recorded audio and textbooks are examples of low dialogue.

Structure refers to the rigidity or flexibility of the educational objectives, teaching strategies, and evaluation methods, as well as the extent to which an instructor accommodates each individual learner’s needs. It is important to consider the amount of information and degree of challenge presented to the learners. Limiting the amount of supplementary resources and structuring information in chunks can make information easier to process and remember.  Providing clear directions also shortens the transactional distance.

Learner autonomy means the learner, rather than the instructor, determines goals, learning experiences, and evaluation decisions. The level of autonomy required for the learner increases as transactional distance increases since it requires independent learning and self-motivation.1-6

The diagram above shows how dialog and structure relate to transactional distance. High structure typically means high transactional distance, while high dialogue reflects low transactional distance. This means that as a course the structure increase and communication reduces, the greater the transactional distance. With less structure and more dialog, transactional distance decreases. And as transactional distance increases, a higher level of autonomy is required. Thus, we can design courses for different degrees of learner autonomy by varying dialog and structure. For example, learning autonomy would typically be different in first-year undergraduate courses vs. master degree courses.4

TD is closely related to the concept of immediacy — the level of dialogue between the teacher and the student. Immediacy refers to the physical or psychological closeness between student and teacher. One study showed that there is a statistically significant positive relationship between instructor immediacy and student affective learning, cognition, and motivation.3 Instructor can improve immediacy by selecting verbal and non-verbal communication behavior that promote physical or psychological closeness. In an online community, this can be achieved by the word selection of written messages found in emails and discussion forums, use of emoticon, and animated moves to express immediacy behavior. When synchronous web-based teaching method is used, verbal interactions that can improve immediacy includes the use of humor, frequent use of the student's name, using self-disclosures, and letting students share personal examples.2

Another study analyzed various activities in online courses to determine which teaching methods favor teacher-student immediacy. The teaching strategies that can enhance immediacy include creating collaborative activities between students, forums of voluntary participation, and discussion boards as well as asking questions and requesting summaries. The study also found that replying quickly to student questions or requests — on the same day — created a sense of “online” closeness between the students and teachers.2

Although there is no face-to-face contact, instructors can design courses where learners can master the course content as well as improve their problem solving and critical thinking skills. Understanding transactional distance and utilizing strategies that increase immediacy can increase the chances of success.


  1. Andrade MS. Teaching online: A theory-based approach to student success. Oream, Utah: Journal of Education and Training Studies [Internet]. 2015 3(5):1-9.
  2. Fahara MF, Castro AL. Teaching strategies to promote immediacy in online graduate courses. Open Praxis [Internet]. 2015;7:363-76.
  3. Baker C. The impact of instructor immediacy and presence for online student affective learning, cognition, and motivation. Journal of Educators Online [Internet]. 2010;7: Article 1.
  4. Moore, M. G. Towards a theory of independent learning and teaching. Journal of Higher Education,[Internet]. 1973: 44; 661-679.
  5. Kushnir LP, Berry KC. Inside, Outside, Upside Down: New Directions in Online Teaching and Learning. International Association for Development of the Information Society; 2014 July 01 [cited 2016 March 15]
  6. Teaching Online [Internet]. Pittsburgh, PA: Duquesne University 2015.
  7. Stavredes, T. Effective online teaching: foundations and strategies for student success. [Internet]. San Francisco, CA : Jossey-Bass, 2011.