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

References:

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 15^th, 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 16^th, 2016
3. Owen L. Anderson and Krathwohl-Understanding the New Version of Bloom’s Taxonomy. 2013. Accessed February 18^th, 2016
4. Metacognition defined by dictionary.reference.com
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.

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.

References:

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.

The Benefit of Student-Generated Questions

by Theresa Brush, Pharm.D., PGY-1 Pharmacy Practice Resident, Suburban Hospital

How many times have you sat in a classroom and had an instructor ask, “Do you have any questions?” What follows, most often, is silence. The silence does not necessarily indicate a lack of interest by students, but they may feel uncomfortable asking questions or have not sufficiently digested the information in order to even ask one. A possible solution to this problem has been explored — student generated questions.

Questions are such an integral part learning.  Indeed, “the act of asking questions and the consequent search for answers is key to active learning.”¹ Student-generated questions are exactly as the name implies; students create their own questions regarding the subject matter and this, in turn, directs their learning.

But how can we help students create good questions?  One of the methods that has been successfully used to develop student-generated questions is called the Question Formulation Technique (QFT).² The QFT is a step-by-step process that helps students learn how to produce their own questions, improve them, and strategize how to use them. This six-step process includes:

1. The Teacher Designs the Question Focus

• The teacher presents a Question Focus in the form of a statement, visual, or auditory stimulus that focuses and attracts student attention. This focus is not in the form of a question but rather a prompt from which students develop questions.

2. Students Brainstorm Questions

• Working in small groups, students brainstorm and record lots of questions. Students produce as many questions as they can.  They should not stop to discuss, judge, or answer any of the questions.  The questions should be written down exactly as stated.  Any statements should be changed into questions.

3. Students Improve Their Questions

• Students then improve their questions by categorizing them into one of two categories:  open-ended and close-ended.  At this point the teacher should have a discussion about the advantages and disadvantages of both types. Students are then asked to change at least one of their open-ended questions into a closed-ended question.  And vice versa. This step furthers students’ understanding of how the phrasing of questions can affect the depth, quality, and value of the answer.

4. Students Prioritize Their Questions

• The teacher then offers criteria or guidelines for selecting questions. For example, the criteria may be, “Choose the three questions you want to explore further.” Students then select their priority questions based on the criteria.

5. Students and Teachers Decide on Next Steps

• Students and teachers decide together on how to use the questions. For instance, the questions may be used to stimulate discussion during the next class.

6. Students Reflect on What They Have Learned

• The teacher reviews the steps of the QTC and has students reflect on what they have learned through the process.

This method of having students develop their own questions encourages them to go deeper into their thinking and (hopefully) develop a new thirst for learning.² One study demonstrated the impact of student-generated questions on learning.³ In an undergraduate psychology course, students were given the opportunity to earn extra credit by submitting questions to the instructor concerning the material covered in class the previous week. The questions could be regarding concepts that were unclear, additional information the student would like to explore, or how the issue applies to other courses or relates to other concepts. The performance of students who developed questions was compared to students who did not write questions. The results demonstrated that the slope of improvement in performance on the exams was directly proportional to the number of questions generated. These results provide some evidence regarding the effectiveness of student-generated questioning to motivate learning and promote deeper understanding.

Not only have student-generated questions helped improve students’ understanding of course material, but student-generated questions can be used to evaluate and assess students’ learning. Instructors can use student-generated questions to construct multiple-choice examinations and open-ended essay questions.⁴ Learning activities that involve student-generated questions help students shift from merely acquiring knowledge (from the teacher) to learning knowledge (self-directed learning), increasing their confidence about the subject matter, and promoting more diverse and flexible thinking.⁵  However, student-generated assessment questions have been criticized because it forces students to focus their attention on finding details in the material around which they can construct questions.  This may limit their understanding of the material and they may not comprehend “the big picture.” If a teacher uses this technique, awareness of this criticism should force the instructor to use a set of parameters for students to follow when creating questions.  Moreover, students should be encouraged to give feedback on how to improve the use of this technique.

Techniques to improve student-generated questions can be used to enhance class participation and engagement as well as to construct evaluations and assessments. This QFT is a great tool for instructors to have within their toolbox and promotes deeper learning.

References:

1. Chin C. Student-Generated Questions: Encouraging Inquisitive Minds in Learning Science. Teaching and Learning [Internet]. 2002 Jun [cited 2016 Feb 3];23(1):59-67.

1. Rothstein D, Santana Luz. Teaching Student to Ask Their Own Questions [Internet]. Cambridge (MA):Harvard Education Letter; 2011 Sep [cited 2016 Feb 3].

1. Berry JW, Chew SL. Improving Learning Through Interventions of Student-Generated Questions and Concept Maps. Teaching of Psychology. 2008;35:305-312.

1. Pittenger AL, Lounsbery JL. Student-Generated Questions to Assess Learning in an Online Orientation to Pharmacy Course. American Journal of Pharmaceutical Education. 2011;75(5) Article 94.

1. Yu FY. Scaffolding student-generated questions: Design and development of a customizable online learning system. Computers in Human Behavior. 2009;25:1129-1138.

Breaking Down the Barriers that Hinder Class Participation

by Teyrra Crawford, Doctor of Pharmacy Candidate 2018, University of Maryland School of Pharmacy

“Show of hands. How many students think the answer is choice A.”

As instructors work to incorporate review questions and checkpoints in their presentations, many students decline to participate out of a fear of being wrong.¹ The lecturer is unaware of their students’ gaps in understanding the material and students miss opportunities for clarity out of fear of saying the “wrong” thing.

So how can we bridge the gap? How can instructors encourage students to be open and engaged during class discussions and when review questions are posed?  By creating a classroom that is psychologically safe – that’s how. The concept of psychological safety, simply stated, is the idea of “feeling safe”² in the situation or environment. This is not about physical safety (although that may be a factor), it is more about the student’s comfort in sharing their thoughts without fear of being attacked or judged by their peers or the instructor. But the fear of being wrong is not the only barrier. In addition, students need to know their input is appreciated and, regardless of a difference of opinion, respected.

Let’s revisit the example about asking the students to select the correct choice for a checkpoint question:

Several students raise their hands for the various answer choices: A, B, and C. While the students still have their hands raised for answer choice C the instructor points to one of those students and asks her to explain how she arrived at that answer choice.

Depending upon the age of the students/participants as well as the content, this type of “on the spot” attention may invoke anxiety or withdrawal from the student (from a behaviorist perspective) as well as others (from a social learning perspective). The goal in creating a psychologically safe classroom environment based on mutual respect and openness, as well as providing a variety of opportunities for meaningful participation that results in learning success. By establishing a culture within the classroom that fosters active participation and engagement by the students, it will lay the basis for a classroom that is psychologically safe.

Understanding that every student learns differently based on personality and experience, “putting someone on the spot” may be counterproductive and make the student feel less “safe.”³ But fear not instructors — all is not lost! There are several strategies that can be employed to inspire students to actively participate. Instead of students raising their hands, if they have access to electronic devices, they can submit their answer choices through a polling system via the internet, or using software and devices designed to increase interaction. Classroom response devices and online polling, test student knowledge and providing a way to share the results while maintaining a level of anonymity. These classroom aids (like ActivClassroom, iClicker, RW poll) can be used to teach and reinforce concepts throughout the course while still tracking the individual progress and challenges of the individual student. Such technology has been integrated at Ron Clark Academy Middle School⁴, a school that focuses on making learning fun and effective for students. It can also be used in health professional education!  In a comparative study conducted between 2008 and 2009 at an Indian medical school, clicker technology was used during lecture activities and the researchers measured it’s impact on test scores. The results showed that test scores and retention up to 12 weeks after the course were both higher in the group that used clickers.⁵

Due to budget restrictions, using such tools may not be an option. However there are other ways in which instructors can cultivate an environment where students enjoy sharing. Instead of simply stating that a student is “right” or “wrong”, open the response to the entire class for feedback. In an article published on Education Week’s website, an instructor discusses the strategy of “sticking with the student” that she learned from the book, The Skillful Teacher.⁶ In the article, McCaffrey suggests how to engage the student after a less than optimal answer is given without making the student feel like he was on the hot seat. The instructor has to be conscious of their own body language and tone when responding. Additionally, when responding to answers, the instructor should praise the student’s thinking, while encouraging them to think a little more about the answer.  Sometimes the instructor should reword the question to help the students explore the concepts more deeply. Another strategy she suggests using is “turn and talk” session. Using this strategy, students have an opportunity to discuss their responses with peers before having to provide individual responses to the teacher.  This relieves some of the immediate pressure from one student while actively engaging thought and participation from the rest of the class.⁷ Instructors can incorporate “get to know me” exercises so that students may become more at ease with their peers.

While different tools help to engage students, the fundamental component of building a psychologically safe classroom is consistency.⁸ For example, let’s say students have been allowed to turn in homework two days late without penalty. Let’s assume, mid-way through the course, a student turns in an assignment a day late and receives a zero. Such inconsistency incites anxiety in students and can destabilize that feeling of “safety” in the classroom. Once standards are set in place, they should stay in place.  Or if changes must be made, adequate explanation for the change should be provided to support consistency and trust between the students and the instructor.

Some points to remember:

1. Set the tone, be clear of what expectations are, and be consistent!
2. Provide a variety of opportunities for students to participate and show what they know!
3. Do some research and prepare activities in advance to maximize outcomes, minimize confusion, and reduce stress.
4. HAVE FUN!!  Your enthusiasm will rub off on your learners!

****Please share your comments and experiences with establishing and thriving a psychologically safe classroom!****

References

1.    Schreiner CS. Handbook of research on assessment technologies, methods, and applications in higher education. Hershey, PA: Information Science Reference; 2009. p. 53-57.

2.    Preisler J. Being Safe vs. Feeling Safe [Internet]. Fosteringperspectives.org. 2016 [cited 2016 Feb 1].

3.    Nilson L. Teaching at its best. Bolton, MA: Anker Pub. Co.; 2003. p. 129-131.

4.    YouTube. The Ron Clark Academy ActivClassroom - Top Ten Ways [Internet]. 2016 [cited 2016 Feb 1].

5.    Datta R, Datta K, Venkatesh M. Evaluation of interactive teaching for undergraduate medical students using a classroom interactive response system in India. Medical Journal Armed Forces India. 2015;71(3):239-245.

6.    McCaffrey B. Sticking With Students: Responding Effectively to Incorrect Answers [Internet]. Education Week Teacher. 2014 [cited 2016 Feb 10].

7.    Phillips M. Creating an Emotionally Healthy Classroom Environment [Internet]. Edutopia. 2014 [cited 2016 Jan 31].

8.    Coetzee M, Jansen C. Emotional intelligence in the classroom. Cape Town: Juta; 2007. p. 31-32.

9.    Jordan R, Lin Foo M, Hooley R. Science engineering - McGraw Center - Princeton University [Internet]. Princeton.edu. 2010 [cited 2016 Feb 1].