Metacognition and learning transfer under uncertainty

Introduction

Humans sometimes have difficulty making accurate and logical decisions. This is due to the inherent limitation of human cognition in terms of the ability of an individual to comprehend and comprehensively respond to, a large amount of information available in a given situation [1]. This weakness may lead to erroneous thoughts that can interfere with rational decision making. The development of metacognitive skills can help overcome some of these weaknesses. Indeed, decision-making theories suggest that rational clinical decisions stem from a careful assessment of the available information and rely on a thoughtful evaluation of the options available for selection [2]. For decades, nursing decision-making studies had focused consistently on the characteristics of the situation (e.g., complexity, ambiguity) and the situation’s surrounding conditions (e.g., stress, time constraints), while the role of metacognition (e.g., awareness of self-abilities, prior knowledge) had largely been overlooked [3], [4], [5]. Metacognition, was once considered separate from the cognitive skills [6]. However, recently, investigators have acknowledged the importance of metacognition, and more studies on the independent role of metacognition in decision-making are now being conducted [7, 8].

Metacognition refers to individuals’ abilities to reflect upon their own actions, thoughts, and perceptions. It explains what enables an individual who has been taught skills in a particular context to retrieve these skills in a similar but new context [9, 10]. However, the emergency environment does not always offer the circumstances to act thoughtfully. Indeed, nurses are required to immediately comprehend the emergency situation and quickly decide upon an action where no to little margin for error is allowed [11]. When actions must be taken quickly and without the availability of all the necessary information the alternative method is to solve the problem, based on previous outcomes with similar cases. The ability of nurses to adapt strategies from previously encountered or learned situations, and transfer these strategies to new contexts is one of the most important skills, not only at workplace but also personally. Transfer of learning or experience refers to the ability to retrieve previous knowledge, skills, and competencies obtained from training and/or experience to the workplace [12, 13].

A distinction between two notions of knowledge transfer (i.e., earlier static and dynamic transfer) was proposed by [14]. Earlier static hypothesizes that the transfer concept is as simple as transferring knowledge obtained from one situation to another. Meanwhile, the concept of dynamic transfer conceptualizes transfer as the act of individuals in situations in which they do not have sufficient knowledge. While the two notions of transfer are different, they have in common the process of how students use knowledge or metacognitive skills in order to understand and act in a particular situation. Transfer is thought to be linked to the ability to use knowledge and metacognitive skills [13], thus, access to previous knowledge is a prerequisite for effective transfer.

The larger concept of transfer was originally introduced by cognitive and behavioral scientists to explore the actual extent to which past experiences impact the performance in a new situation [15]. Reflection of individuals on what they have learned from the past and generating new solutions from existing knowledge and skills helps with learning transfer [16]. This implies the importance of reflection. Without reflection, individual actions might be subjected to the superficial aspects of the situation, leading to errors [2]. However, wrong actions could be avoided if the individual spends time to think and reflect upon the situation and to analyze it carefully. To do this, metacognitive competence is required.

Two aspects of metacognition were identified: knowledge about cognition and regulation of cognition [17]. Metacognitive knowledge is the stored knowledge in long-term memory that one retrieves when thinking about an issue, whereas metacognitive regulation is the ability of the individual to regulate one’s thought perception [17]. Metacognitive knowledge can be declarative; it deals with knowledge about one’s abilities and skills, or strategies; or procedural knowledge which involves the use of these abilities or skills one has gained in various situations. Studies in cognitive psychology suggest that metacognitive abilities are strongly associated with problem-solving, memory, and comprehension [18, 19]. In the clinical practice context, investigators have continuously demonstrated that metacognition skills can help nurses to comprehend, evaluate and adjust their own thinking process in response to practice demands [8, 17]. It also can help nurses to monitor, justify and solve clinical problems [17] and, consequently to improve self-efficacy, clinical decision-making, and critical thinking ability [8, 20, 21].

Literature has identified active simulated training approaches as a key player in knowledge and skills transfer, since training in this context is target oriented [22], [23], [24], [25]. Such simulated clinical activities can enhance students’ abilities to relate their prior knowledge, skills and experiences to the current simulated situation, and obtain new knowledge and metacognition skills, that they can transfer to a real clinical setting [22]. Although the concept of knowledge transfer in simulation remains debatable, transferring knowledge from the simulated environment to a real-life clinical setting, is influenced by variables such as simulation design, students’ metacognitive skills and prior knowledge [22, 26].

Students need to be prepared with appropriate knowledge that is not limited to a specific environment or a particular situation, if nursing students are to adapt to the varying demands of their clinical practice. While the decades long debate of the theory–practice gap is well acknowledged, educators often give the impression that transfer between simulation and clinical practice is relatively uncomplicated for students [27]. It is likely that the ease by which transfer between simulation and clinical practice is achieved has been over simplified. Few investigators have acknowledged how metacognition can serve as a route to support transfer of learning to clinical settings [28], [29], [30]. Indeed, nursing students and educators are often unaware of the importance of learning transfer in relation to metacognition [30]. Therefore, this study aimed to investigate a possible relationship between metacognition and learning transfer in nursing students after engaging in an urgent and cognitively demanding clinical situation. Examining the relationship between metacognition and learning transfer in an interaction simulation scenario is appropriate to produce concrete results that may provide an understanding of students’ abilities. For nurses to successfully manage an urgent and cognitively demanding clinical situation, well-developed metacognitive skills are required [6, 31].

Methods

A one-group, post-test-only study design, where research data was measured after exposing participants to a specific intervention, was used in this study. The study was conducted in Saudi Arabia, in a western region nursing school between, June and July 2022.

Materials

As a requirement for the critical care and emergency nursing course, a set of an emergency care scenarios are designed to be delivered to the fourth-year nursing students to equip them with the necessary skills in how to manage critical cases. A full body patient simulator (HAL^®) was utilized to conduct the emergency care scenarios. The patient simulator (HAL^®) physiological features allow educators to pre-program a number of simulated conditions. HAL is easy to use with wireless control and documentation.

Results

Discussion

In the current study to assess metacognitive awareness of nursing students, the results revealed a moderate level of metacognitive awareness. Some current studies have shown that nursing students have poor to moderate levels of metacognitive skills [8, 10]. Ye et al. [10] surveyed 384 undergraduate nursing students using College Student Metacognitive Ability Scale and found undergraduate nursing students achieved moderate levels of metacognitive scores. Another study conducted by [8] using the Metacognitive Ability Scale found of 3,000 vocational nursing students in both junior and senior years, showed that the overall metacognitive ability of nursing students was low.

Other studies showed that nurses with higher levels of metacognitive abilities were are able to apply knowledge and expertise to a clinical situation to make decisions and eventually provide better patient care [36, 37]. Correspondingly, nursing students with higher metacognitive skills performed better [38]. It is acknowledged that improving nursing students’ metacognitive skills enhances knowledge transfer and decision-making [39, 40].

In this study, the results further demonstrated a significant positive correlation between participants’ metacognitive awareness and academic achievements reflected by a high GPA (p=0.006). In this regard, there is a growing body of evidence that there is a strong relationship between students’ metacognitive abilities and their academic achievement [13, 41]. Such a relationship may provide educators the appropriate tool to screen students and determine those in need of direct instruction related to metacognition skills. This may become especially important in large classes where tracking students is difficult.

The current study results also showed a strong and positive correlation between metacognitive awareness and learning transfer (p=0.0001). This result supported the knowledge transfer theory of [27, 42] analyses of metacognition in nursing education. Transfer learning is the process of using previously learned knowledge and skills in a new situation [43]. Some studies showed a positive significant relationship between thinking about a clinical learning experience and thinking about the transfer of learning [16], supporting the notion that metacognition may heighten the transferring of knowledge and skills. Other studies highlighted the difficulties encountered by nursing students that interfere with transferring their theoretical knowledge into clinical practices [44]. Academic educators should ensure that their nursing students are equipped with cognition skills necessary for clinical practice. While metacognition skills represent a promising approach to facilitate learning transfer and may have wider implications for nursing education and clinical practice, further studies are needed to determine which other factors are involved [45].

Transfer learning in this study had a positive correlation with the frequency of having clinical training experience (p=0.021). Training in clinical settings allows students to actively integrate the knowledge and skills gained from classrooms with the learning variables of the clinical environment around them to create unforgettable rich and effective experiences [2]. Indeed, clinical practice forces students to go through an ongoing process of cognitive planning, evaluation, and monitoring to organize knowledge and thoughts for practical application.

Finally, transfer learning also had a positive relationship with the confidence of participants in their decisions regarding the patient condition (p=0.0001). Most recent studies about knowledge transfer have discussed the role of metacognitive awareness in nursing students’ self-confidence with respect to clinical decision-making [7]. Previous work has shown that transfer learning is a major influence on decision-making [46]. However, in the current study this may indicate the presence of overconfidence bias in decision-making, based on the results that the accuracy of assigning CTAS Level for the patients at the triage was potentially incorrect. This overconfidence may represent a lack of metacognitive abilities in participants participating in the current study, and may justify the lack of correlation between the metacognitive awareness and confidence.

Implications

The study results may raise opportunities for future research. Further research, such as a longitudinal and comparative study, will be necessary to enhance the study findings. For example, according to the current study findings, there is a positive correlation between knowledge transfer and metacognition awareness. Further study could elaborate on this point, providing important information in how these two constructs develop and interact in students over time. This could help in identifying the factors shaping students’ metacognition skills that are specific for nursing profession.

The study findings may also have pedagogical implications. Increasing clinical training hours through enhancing student autonomy, exploring additional forms of clinical training or developing their own training plan of education are suggested. Clinical settings require students to use their metacognitive abilities to solve problems, recall information, and think critically. It is expected that students are able to apply previously acquired knowledge and skills to clinical situations. A foundation for promoting recall and transfer of knowledge using metacognitive skills and specific for the profession of nursing has not been established yet.

Finally, the ability of nursing students to successfully solve complex clinical problems represents key metacognitive competencies for students’ practice success and beyond. However, nursing students may not understand the importance of metacognitive skills and may not be guided to develop or use these skills. For students to perform effectively in clinical practice, they need to reflect on their process of learning, be competent thinkers, and know when to retrieve and apply previously learned knowledge, experiences and skills to clinical situations for effective decision making. To develop such skills the use of high-fidelity simulation scenarios and standardized patients may help assist in obtaining desired outcomes.

Limitations

The current study has several methodological limitations that can impact the generalizability of the results. First, the study has used a one-group, post-test-only design, and therefore it is impossible to fully establish causality. The design could be improved by considering the use of control and intervention groups or a pre-test and post-test design in future studies. Second, the study used a non-randomized sampling method which may have impacted the interpretation of the results. Third, this study included only fourth year nursing students from one institution, through convenience sampling. This sample may not fully represent the general population of nursing students and should be addressed in future studies.

Conclusions

Based on the current study result measures, the overall metacognitive ability of nursing students who participated was of a moderate level. Positive correlation was found between academic achievement and both metacognition and knowledge transfer. Further, there is significant correlation between learning transfer and frequency of clinical settings-based training. This study may imply that academic achievement may be used as a potential screening tool to identify students requiring metacognitive training and that metacognitive abilities can be enhanced indirectly through considering factors that may influence the transfer of learning such as increasing the hours of clinical training. Further research using multi-centre approaches and designs are required to validate the current study findings.