Metacognitive Skills in Diagnostic Reasoning: Making the Implicit Explicit Daniel J. Pesut, PhD, RN, JoAnne Herman, PhD, RN
Dr. Pesut is currently an Associate Professor at the University of South Carolina, College of Nursing in Columbia, South Carolina. He teaches in both the undergraduate and graduate program. His research interests are in the area of self-regulation. clinical reasoning, and psychiatric mental health counseling/consultation.
I
Dr. Herman is currently an Associate Professor, and Associate Dean for Research and Evaluation at the University of South Carolina, College of Nursing, Columbia, South Carolina. She teaches in both the undergraduate and graduate pr0gra.m. Her research focuses on the psychophysiologic outcomes of self-regulation techniques. This work was supported in part by a grant for instructional innovation from the Provost’s Office, University of South Carolina.
148
Metacognition has emerged as an important concept in skill acquisition, comprehension, and understanding the processes of learning to learn. Metacognition is the self-communication one engages in, or the internal dialogue that one emits before, during, and after performing a task (Meichenbaum & Asamow, 1979). Metacognition is a component of executive cognitive control processes and consists of self, task, and strategy knowledge as well as skills in monitoring, analyzing, predicting, planning, evaluating, and revising (Flavell, 1979; Sternberg, 1988).
Metacognition: Thinking about Thinking Martinelli (1987) described metacognition as an awareness of how to think and what dispositions or behaviors improve thinking. Worrell(l990) provided an analysis of the construct of metacognition and illustrated how metacognitive strategies assist nursing students.’ development of strategic reading skills. Pesut (1984, 1985) used metacognition as an organizing and explanatory concept in a study designed to teach practicing nurses creative thinking skills and help educators guide the creative thinking of students. When confronted with ill-structured situations, Kitchener (1983) proposed there are three levels of cognition: (1) the cognitive, (2) the metacognitive, and (3) the epistemic. Level I, cognitive knowledge, consists of those premonitored cognitive tasks on which knowledge of the world is built: memorizing, reading, computing, perceiving, and acquiring language. Level I knowledge is propositional knowledge or “knowing that.” It could be argued that memorizing, reading, and knowing the content of nursing diagnoses is level I knowledge. Nurses need this propositional knowledge before Volume 3, N u m b 4,October/ Docembar 1992
they understand or comprehend the procedural knowledge involved in clinical and diagnostic reasoning (Kingten, 199l),as well as decision making (Thiele, Holloway, Murphy, Pendarvis, & Stucky,
1991). In Kitchener’s (1983)level 11, or metacognitive domain, activities are defined in terms of the processes that an individual uses to monitor cognitive progress when engaged in a level I activity; for example, the “how” of memorizing, reading, computing, or, in this case, the “how” of making a nursing diagnosis. It can be argued that diagnostic reasoning is “know how” or process knowledge. Level 111, epistemic cognition, is characterized by judgment about the limits of knowledge, the certainty of knowing, and the criteria for knowing. Such knowledge involves ethics, values, and morals. Professional nurses operate in all three levels of cognition. Each level provides the foundation for the next but is not subsumed by it. In other words, although level I knowledge may operate independently of the other two levels, the reverse is not the case. Kitchener (1983)observed that differentiation of these cognitive levels may be developmental in nature. She hypothesized that epistemic cognition emerges in adolescence but may not be fully developed by adulthood.
I
Metacognition surrounds or “frames” the process of probtem solving.
Metacognitive knowledge includes such things as knowing what one knows, knowing when and how one comes to know it, being able to think and plan strategically, the ability to represent knowledge effectively and in ways that permit efficient retrieval, and the ability to monitor and consistently evaluate one’s own competence. Metacognition surrounds or “frames” the process of problem solving. Cognitive strategies are used to make cognitive progress, whereas metacognitive strategies are used to monitor and manipulate cognitive progress (Flavell, 1979).Because diagnosis involves consciousmonitoring and manipulation of cognitive activity, it follows that metacognitive skill influences diagnostic reasoning. Brown (1978)described essential aspects of Nursing Diagnosi8
metacognitive process as (1) analyzing and characterizing the problem at hand, (2) reflecting on what one knows or does not know that may be necessary for a solution, (3) devising a plan for attacking the problem, and (4)checking or monitoring progress. Such a description characterizes the diagnostic reasoning process. Schon (1983) has argued that reflection-in-action, or the dialogue a practitioner has with a problem situation, is the link between the art of practice and the art of research in a discipline. Brown (1978)observed there is an interdependence with the meta-dimensions of a content area and the skills associated with the meta aspects of the content area. She writes: “educationally the distinction between knowing that and knowing how is a viable one with important implications for educational practices. The skills of metacognitionhave recognizable counterparts in real world everyday life situations. Checking the results of an operation against criteria of effectiveness, economy and common sense reality is a metacognitive skill applicable to whatever task is under consideration (p. 80)” (Brown, 1978).
The skills Brown describes are essential aspects of clinical reasoning and the process of making nursing diagnoses. Carnevali (1 984)suggested a model for diagnostic reasoning that involves entry to a data search field, shaping and gathering data, coalescing of cues into clusters or chunks, activatingdiagnostic hypotheses, testing diagnostic hypotheses for goodness of fit, and reshaping the direction of data gathering if the conclusions are not confirmed by the data. The Carnevali (1984)diagnostic reasoning process described the logical order of occurrence of diagnostic reasoning processes. Carnevali hinted at the metacognitive nature of diagnostic reasoning when she described and discussed the use of self-observation for monitoring diagnostic reasoning skills. However, absent from her model are the meta components associated with cognitive activity that guides clinical reasoning. The Carnevali model described what the nurse does, it does not detail how specifically the nurse does it. It presents the logical order of occurrence, but does not give one clue about where to start. The metacognitive skills of monitoring, analyzing, predicting, planning, evaluating, and revisingare essential t o the effective application of the model to care planning. 149
Development of metacognition involvesmovement from conscious other-regulated thinking to conscious self-regulated thinking (Reeve & Brown, 1985). Metacognition tends to improve with age and develops more properly with instruction, but despite this, some adult/college level students demonstrate metacognitive deficiencies (Burley, Brown, & Saunders, 1985).
II
Deficiencies in metacognition can be remedied by formal cognitive behavioral instruction.
I
Deficiencies in metacognition can be remedied by formal cognitive behavioral instruction. Examples of such instruction are the strategic use of overt and covert self-instruction for purposes of attending to a task, stating explicit goals relative to the task, self-observation and monitoring of personal beliefs about control and responsibility for the task at hand, the need for and use of intense extended effort, monitoring feedback to determine how well the task is progressing, and evaluating what worked and did not work after the task is completed (Marzano, 1985).
Metacognitive Skill Acquisition Both authors have been engaged in teaching a course in clinical reasoning at the University of South Carolina College of Nursing. Early in the development of the course, students clearly needed help thinking about their thinking (Pesut, 1985).Instructionally, it was useful to provide the students with cognitive as well as metacognitive experiences. The authors used the following methods to increase the use of metacognitive skills of the students. First, to help the students understand the concept, the authors reminded them of the three perceptual perspectives they developed in their psychiatric mental health course while they were doing interpersonal analyses or process recordings. Process recordings enhance the development and conscious understanding of the perceptual perspectives of self, other, and a “meta” or reflective analytic perspective. Specifically,students were reminded when engaged in an inter150
personal interaction they experienced it from their own subjective perspective. They also experienced empathically what they perceived the other person to be experiencing. In addition, they were consciously analyzingthe verbal and nonverbal behavior of both self and other from an executive cognitive control or meta reflective analytic perspective. By reminding the students of these three perceptual perspectives, we began the process of providing them with a metacognitive awareness. The authors propose that diagnostic reasoning is the process of oscillating back and forth among three frames of reference: an outer metacognitive frame, an inner nursing process frame, and a core nursing diagnosis frame. Second, two models of cognitive functioning about nursing diagnosis were developed. Model 1 is a fundamental blueprint for the development of a nursing diagnosis and care plan. This model reflects what Kitchener (1983)calls level I knowledge and includes the integral parts of a nursing diagnosis and care plan and the relationships among the parts (Figure 1).The second model r e p resents three frames of reference for clinical care planning. The outer frame (level I1 knowledge) represents those “executive” metacognitive skills used to guide the cognitive activities involved in the nursing process inner frame. The core represents the essential components and relationship of a nursing diagnosis (Figure 2). The following discussion explains the models and illustrates the relationships within the models using the metacognitive questions that assist in the self-regulation of clinical reasoning.
Model 1. Nursing Diagnosis: Knowing That The process of clinical reasoning is complex and requires careful consideration of the sequence in which content knowledge and process knowledge are introduced to the students so that they can master both the logical and creative aspects of the process. It has been the experience of the authors that introducing students first to the fundamental elements and relationships of nursing diagnosis provides a schema for future acquisition and development of clinical reasoning skills. This schema is introduced by presenting the Nursing Diagnosis Content Model (Herman, Pesut, & Fore, 1991) displayed in Figure l to the Vdumo 3,Number 4,Octobtul December 1992
b
Problem
Patient Outcome
Evaluation i
I Cues
Etiology
Intervention
Figure 1. Nursing diagnosis content model (model 1). Copyright 1992 by J. Herman. Reprinted by permission.
students. The model graphically illustrates the concepts relevant to nursing diagnosis and care planning and the relationships among the concepts. Specifically, cues are clustered into meaningful units from which patient problems are derived. From the problem, one develops a patient outcome that describes the expected patient status as a consequence of nursing care. The outcome is derived directly from the problem. The outcome must be stated specifically enough so that evaluation criteria are identified. Evaluation is a two-step process that represents the measurement of the patient’s progress toward the expected outcome. The first step is a comparison of the patient’s status to the evaluation criteria. The second step is a judgment about the meaning assigned to the comparison. Identification of an etiology and selection of nursing interventions in the nursing diagnosis content model is a parallel operation. Cues once again are clustered and used to identify the etiology. The process of determining the etiology is the same as the process of determining the problem. Interventions that have a high probability of influencing the etiology are selected for use with the patient. The model emphasizes four functional relationships that are difficult for beginning diagnosticians to understand: (1) the relationship between the problem and the predicted patient outcome, (2) the importance of cues in the determination of an etiology, (3) the value of selecting interventions specific to the etiology, and (4) the development of evaluation criteria that are N d n g Diagnosis
based on the predicted patient outcome. This model may seem simplistic to the advanced clinician, but making these relationships explicit helps novices make sense of the process. Students have commented that model 1 is useful because it clarifies the relationships among cues, problem, etiology, outcome, and evaluation.
Metacognitive Skills in Diagnostic Reasoning: Knowing How Once students are familiar with model 1, they are introduced to the Integrated Model of Clinical Reasoning (see Figure 2). This model is more complex because it represents relationships among metacognitive strategies, nursing process, diagnostic reasoning, and nursing diagnosis. Specifically, the metacognitive skills of monitoring, analyzing, predicting, planning, evaluating, and revising are executive cognitive skills that frame the nursing process, which in turn frames diagnostic reasoning and nursing diagnosis. Metacognitive skills always have been an implicit part of the nursing process. Making the implicit explicit clarifies the relationships among these frames of reference. This model helps the students become aware of and strengthen their metacognitive skills by using metacognitive questions during each step in the diagnostic process. The metacognitive skills ofmonitoring and analyzing are used during data collection and cue clustering. Clinicians gather incredible amounts of data about a particular patient, including signs, 151
Figure 2. Integratedmodel of clinical reasoning (model 2). Copyright 1992 by D. Pesut and J. Herman. Reprinted by permission.
symptoms, behaviors, and characteristics. In addition, the nurse’s past experiences, knowledge, frame of reference, environmental situation, and intuition augment the patient database. Effective clinical reasoning starts with an expansive approach to data collection. That is, students need to be encouraged to assess broadly so that cues to all possible diagnoses will be sampled. If a student uses a restrictive data set at this point in the process, errors in diagnosing are certain to occur. On the other hand, data collection can go on indefinitely if there are no domain parameters. Therefore, it is important to mark the boundaries of the data search field. The distinction between expansive data collection and efficient marking of the data search field is difficult for novice diagnosticians. Therefore, the first question a practitioner must ask is, “What structural model am I going to use to guide data collection?” Using a structural 152
model such as Functional Health Patterns (Gordon, 1987), Taxonomy I-Revised (Carroll-Johnson, 1991), or the ABC PRN REST for Health scheme devised by Kim, McFarland, and McLane (1991) is an excellent way to organize data and narrow the search field. Additional questions students are encouraged to ask themselves as they “frame their thinking” are: What decisions have I made to narrow my data search? Have I used all available types and sources of data? Have I collected all the data I need? Am I clear on the meaning of the data? Once a thorough database has been collected, meaning must be assigned to the data and inferences drawn. Students need to learn how to analyze and cluster data into meaningful units. The challenge is to cluster the data so the inferences drawn lead to the most useful outcomes for the delivery of nursing care and the resolution of paVolumo 3,Number 4,0ct6ber/D.ccHnber 1992
tient problems. Strategic questions diagnosticians need to ask themselves are: What are some possibilities for clustering of the cues? What experiences have I had before with these cues and how did I cluster them? Is there a logic to the cue clusters? Have I distinguished relevant from irrelevant cues?What diagnostichypotheses am I generating based on cues clustered? Are the diagnostic hypotheses within the domain of nursing practice? As with any probabilistic enterprise, there are different configurations data can take, all of which represent some facet of reality. The activities of monitoring and analyzing are critical for making good judgments about what cues to consider, what cues to ignore, the meaning assigned to the cues, and how to cluster the cues in the most efficient manner. The metacognitive skill of predicting is used when determining the problem and etiology. Inferences are predictions or in diagnostic reasoning language-diagnostic hypotheses. Both the problem and the etiology result from the process of inferring from data the presence of a particular human responsejife process and generating or predicting diagnostic hypotheses for the problem and the etiology. The diagnostician must predict the problem that has a high probabilityof being an accurate representation of the patient status as well as an etiology that substantially influences the problem. Accuracy is improved when a large number of hypotheses are identified early in the diagnostic process. A diagnostician’s predictive power about the relationships among the cue clusters, problem, and etiology are based on past clinical experiences, supportive and nonsupportive evidence, and multiple and single hypothesis testing (Gordon, 1987). Skillful diagnosticians often ask themselves questions such as: Is this the best clinical prediction? What problem/etiology can be predicted from the cue clusters? Can I predict whether the problem is a consequence of the etiology?What is the probability of accuracy for each problem/etiology?What evidence supports or does not support the prediction of problem/etiology? How does the prediction for this problem/etiology compare with past clinical experience?These questions encourage use of metacognitive skill and awareness during the prediction phase of clinical reasoning. The metacognitive skill of planning involves both the determination of the patient outcome and the identification of appropriate intervenNursing Diagnosis
tions. A common metacognitive question is, “HOW do I plan to turn the problem into an outcome?” Outcomes are targeted solutions for the patient’s problem and indicate the predicted status of the patient as a result of nursing interventions. Nursing interventions are planned to influence the etiology. There are two methods, logical and creative, for developing nursing interventions. First, the intervention may be a logical, analytic solution that is based on practice experience, research, or theory. Second, given the generative or creative aspects of nursing practice, one can develop innovative solutions to influence the etiology of the problem. Questions to ask during this planning are: Logically, what nursing interventions do I plan to influence the etiology? Creatively, what nursing interventions can I develop to influence the etiology? Are my plans useful, effective, and efficient? Evaluating and revising are the final metacognitive skills used. Evaluation is a clinical judgment regarding the influence a nursing intervention has had on the etiology of a patient’s problem. Evaluations can be categorized as achieved, progressing toward achievement, no change, or a deterioration in status. Based on evaluation data, diagnosticians must reflect and revise their judgments by asking the following questions: Do the nursing interventions need to be revised? Does the patient outcome need to be revised? Does the problem/ etiology need to be revised? Do the cue clusters need to be revised? Does the data search field need to be reshaped? Answers to such questions provide data and feedback about where, specifically, to revise t h i i g , judgment, or action.
Summary Using the concept of metacognition in nursing education in general, and the teaching of clinical reasoning specifically, has great instructional promise. The authors propose that application of a metacognitive framework will assist educators to develop strategies for enhancing diagnostic/clinical reasoning skills of students and practitioners. The metacognitive skills of monitoring, analyzing, predicting, planning, evaluating, and revising provide a framework for the self-regulation of thinking during the clinical reasoning process. Nurse educators and managers who encourage metacognitive skill acquisition are likely to accelerate practitioner’s comprehension, understanding, and 153
Application of a rnetacognitive framework will assist educators deveisp strategies for enhancing d iagnostic/cli nical reasoning skills of students and practitioners.
mastery of the diagnostic reasoning process. The models presented have implications for teaching and learning clinical/diagnostic reasoning because they help nurses understand the relationships among metacognitive skills, the nursing process, diagnostic reasoning, and the development o f a nursing diagnosis. Research and continued development of the notion that diagnostic reasoning is a metacognitive as well as a cognitive process is an area for future educational and clinical investigation.
References Brown, A. (1978). Knowing when, where and how to remember: A problem of metacognitive. In R. Glaser (Ed.), Advances in i m t m t i m l psychology (pp. 77-165). Hillsdale, NJ: Lawrence Earlbaum Associates Publishers. Burlef, J., Brown, B., & Saunders, B. (1985, May). Metacognitive: Theory and application for college readers. Paper presented at the Annual Meeting of the International Reading Association, New Orleans, LA. Carnevali, D. (1984). Strategies for self-monitoringof diagnostic reasoning behaviors: Pathways to professional growth. In D. Carnevali, P. Mitchell, N. Woods,& C. Tanner (Eds.). Diagnostic reasoning in nursing. Philadelphia: Lippincott. Carroll-Johnson, R. (199 1). C h i f i a t i o n of nursing diagnoses: Proceedings of the Ninth Conference of the North American Nursing Diagnosis Association. Philadelphia: Lippincott.
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Flavell, J. (1979). Metacognitive and cognitive monitoring: A new area of cognitivedevelopmental inquiry. Ameriuan Pyhobgist, 34, 906-91 1. Gordon, M.(1987). Nursing diagnosis process and appliccrtion (2nd ed.). New York McGraw-Hill. Herman, J. A., Pesut. D. J., & Fore, V. E. (1991, June) Teaching and lcaming nursing diagnosis: Application of Kolb’s lcaming sty& t h e q . Paper presented at the conference Nursing Diagnosis in Perspective: The Quality and Cost Issue, Williamsburg, VA. Kim, M.,McFarland, G., & McLane, A. (1991). Pocket guidc to nursing diagnoses (4th ed.). St. Louis, MO: Mosby. Kingten, A. J. (1991). Critical thinking and nursing education: Perplexities and insights. Journal of Nursing Education, 30, 152-1 57. Kitchener, K. (1983). Cognition, metacognition and epistemic cognition a three level model of cognitive processing. Human Deuelojnnmt, 26, 222-232. Martinelli, K. (1987). Thinking straight about thinking. The School Administrator, 44(1), 21-23. Marzano, R. (1985). Integrated instruction in thinking skills, learning strategies, traditional content and basic beliefs: A necessary unity. Educational ReSOUICCS Infotmation cntn; ED267 906, PS 015 704. Meichenbaum, D., & Asamow, J. (1979), Cognitive-behavioral modification and metacognitive development: Implications for the classroom. In S. Hollan & P. Kendall (Eds.). Cognitive 6ehuuioral i n t n v m t i m : Theory, research and pratticc (pp. 11-35). New York Academic Press. Pesut, D. (1984). Metacognition: The self-regulation of creative thought in nursing (Doctoral dissertation, University of Michigan, 1981). Dissn2dion Abstmcts Inlcmational, 45(2), 515. Pesut. D. (1985). Toward a new definition of creativity [Editorial]. Nurse Eduafor, 10(1), 5. Reeve, R., & Brown, A. (1985). Metacognition reconsidered: Implications for intervention research. Journal ofAb~wnna1Child Psychology, 13, 343-356. Schon, D. (1983). Thc rejkxtiue practitioner: How profess i m l r think in action. New York Basic Books. Sternberg. R. (1988). The triarchic mind. New York: Viking Press. Thiele, J. E., Holloway,J.. Murphy, D., Pendarvis, J., & Stucky, M. (1991). Perceived and actual decision making by novice baccalaureate students. Western Journal of Nursing Research, 13, 616-626. Worrell, P. (1990). Metacognition: Implications for instruction in nursing education. Journal of Nursing Education, 29, 170-175.
Volume 3,Number 4,0ctokr/Decomber 1992
Dr. Pesut is currently an Associate Professor at the University of South Carolina, College of Nursing in Columbia, South Carolina. He teaches in both the undergraduate and graduate program. His research interests are in the area of self-regulation. clinical reasoning, and psychiatric mental health counseling/consultation.
I
Dr. Herman is currently an Associate Professor, and Associate Dean for Research and Evaluation at the University of South Carolina, College of Nursing, Columbia, South Carolina. She teaches in both the undergraduate and graduate pr0gra.m. Her research focuses on the psychophysiologic outcomes of self-regulation techniques. This work was supported in part by a grant for instructional innovation from the Provost’s Office, University of South Carolina.
148
Metacognition has emerged as an important concept in skill acquisition, comprehension, and understanding the processes of learning to learn. Metacognition is the self-communication one engages in, or the internal dialogue that one emits before, during, and after performing a task (Meichenbaum & Asamow, 1979). Metacognition is a component of executive cognitive control processes and consists of self, task, and strategy knowledge as well as skills in monitoring, analyzing, predicting, planning, evaluating, and revising (Flavell, 1979; Sternberg, 1988).
Metacognition: Thinking about Thinking Martinelli (1987) described metacognition as an awareness of how to think and what dispositions or behaviors improve thinking. Worrell(l990) provided an analysis of the construct of metacognition and illustrated how metacognitive strategies assist nursing students.’ development of strategic reading skills. Pesut (1984, 1985) used metacognition as an organizing and explanatory concept in a study designed to teach practicing nurses creative thinking skills and help educators guide the creative thinking of students. When confronted with ill-structured situations, Kitchener (1983) proposed there are three levels of cognition: (1) the cognitive, (2) the metacognitive, and (3) the epistemic. Level I, cognitive knowledge, consists of those premonitored cognitive tasks on which knowledge of the world is built: memorizing, reading, computing, perceiving, and acquiring language. Level I knowledge is propositional knowledge or “knowing that.” It could be argued that memorizing, reading, and knowing the content of nursing diagnoses is level I knowledge. Nurses need this propositional knowledge before Volume 3, N u m b 4,October/ Docembar 1992
they understand or comprehend the procedural knowledge involved in clinical and diagnostic reasoning (Kingten, 199l),as well as decision making (Thiele, Holloway, Murphy, Pendarvis, & Stucky,
1991). In Kitchener’s (1983)level 11, or metacognitive domain, activities are defined in terms of the processes that an individual uses to monitor cognitive progress when engaged in a level I activity; for example, the “how” of memorizing, reading, computing, or, in this case, the “how” of making a nursing diagnosis. It can be argued that diagnostic reasoning is “know how” or process knowledge. Level 111, epistemic cognition, is characterized by judgment about the limits of knowledge, the certainty of knowing, and the criteria for knowing. Such knowledge involves ethics, values, and morals. Professional nurses operate in all three levels of cognition. Each level provides the foundation for the next but is not subsumed by it. In other words, although level I knowledge may operate independently of the other two levels, the reverse is not the case. Kitchener (1983)observed that differentiation of these cognitive levels may be developmental in nature. She hypothesized that epistemic cognition emerges in adolescence but may not be fully developed by adulthood.
I
Metacognition surrounds or “frames” the process of probtem solving.
Metacognitive knowledge includes such things as knowing what one knows, knowing when and how one comes to know it, being able to think and plan strategically, the ability to represent knowledge effectively and in ways that permit efficient retrieval, and the ability to monitor and consistently evaluate one’s own competence. Metacognition surrounds or “frames” the process of problem solving. Cognitive strategies are used to make cognitive progress, whereas metacognitive strategies are used to monitor and manipulate cognitive progress (Flavell, 1979).Because diagnosis involves consciousmonitoring and manipulation of cognitive activity, it follows that metacognitive skill influences diagnostic reasoning. Brown (1978)described essential aspects of Nursing Diagnosi8
metacognitive process as (1) analyzing and characterizing the problem at hand, (2) reflecting on what one knows or does not know that may be necessary for a solution, (3) devising a plan for attacking the problem, and (4)checking or monitoring progress. Such a description characterizes the diagnostic reasoning process. Schon (1983) has argued that reflection-in-action, or the dialogue a practitioner has with a problem situation, is the link between the art of practice and the art of research in a discipline. Brown (1978)observed there is an interdependence with the meta-dimensions of a content area and the skills associated with the meta aspects of the content area. She writes: “educationally the distinction between knowing that and knowing how is a viable one with important implications for educational practices. The skills of metacognitionhave recognizable counterparts in real world everyday life situations. Checking the results of an operation against criteria of effectiveness, economy and common sense reality is a metacognitive skill applicable to whatever task is under consideration (p. 80)” (Brown, 1978).
The skills Brown describes are essential aspects of clinical reasoning and the process of making nursing diagnoses. Carnevali (1 984)suggested a model for diagnostic reasoning that involves entry to a data search field, shaping and gathering data, coalescing of cues into clusters or chunks, activatingdiagnostic hypotheses, testing diagnostic hypotheses for goodness of fit, and reshaping the direction of data gathering if the conclusions are not confirmed by the data. The Carnevali (1984)diagnostic reasoning process described the logical order of occurrence of diagnostic reasoning processes. Carnevali hinted at the metacognitive nature of diagnostic reasoning when she described and discussed the use of self-observation for monitoring diagnostic reasoning skills. However, absent from her model are the meta components associated with cognitive activity that guides clinical reasoning. The Carnevali model described what the nurse does, it does not detail how specifically the nurse does it. It presents the logical order of occurrence, but does not give one clue about where to start. The metacognitive skills of monitoring, analyzing, predicting, planning, evaluating, and revisingare essential t o the effective application of the model to care planning. 149
Development of metacognition involvesmovement from conscious other-regulated thinking to conscious self-regulated thinking (Reeve & Brown, 1985). Metacognition tends to improve with age and develops more properly with instruction, but despite this, some adult/college level students demonstrate metacognitive deficiencies (Burley, Brown, & Saunders, 1985).
II
Deficiencies in metacognition can be remedied by formal cognitive behavioral instruction.
I
Deficiencies in metacognition can be remedied by formal cognitive behavioral instruction. Examples of such instruction are the strategic use of overt and covert self-instruction for purposes of attending to a task, stating explicit goals relative to the task, self-observation and monitoring of personal beliefs about control and responsibility for the task at hand, the need for and use of intense extended effort, monitoring feedback to determine how well the task is progressing, and evaluating what worked and did not work after the task is completed (Marzano, 1985).
Metacognitive Skill Acquisition Both authors have been engaged in teaching a course in clinical reasoning at the University of South Carolina College of Nursing. Early in the development of the course, students clearly needed help thinking about their thinking (Pesut, 1985).Instructionally, it was useful to provide the students with cognitive as well as metacognitive experiences. The authors used the following methods to increase the use of metacognitive skills of the students. First, to help the students understand the concept, the authors reminded them of the three perceptual perspectives they developed in their psychiatric mental health course while they were doing interpersonal analyses or process recordings. Process recordings enhance the development and conscious understanding of the perceptual perspectives of self, other, and a “meta” or reflective analytic perspective. Specifically,students were reminded when engaged in an inter150
personal interaction they experienced it from their own subjective perspective. They also experienced empathically what they perceived the other person to be experiencing. In addition, they were consciously analyzingthe verbal and nonverbal behavior of both self and other from an executive cognitive control or meta reflective analytic perspective. By reminding the students of these three perceptual perspectives, we began the process of providing them with a metacognitive awareness. The authors propose that diagnostic reasoning is the process of oscillating back and forth among three frames of reference: an outer metacognitive frame, an inner nursing process frame, and a core nursing diagnosis frame. Second, two models of cognitive functioning about nursing diagnosis were developed. Model 1 is a fundamental blueprint for the development of a nursing diagnosis and care plan. This model reflects what Kitchener (1983)calls level I knowledge and includes the integral parts of a nursing diagnosis and care plan and the relationships among the parts (Figure 1).The second model r e p resents three frames of reference for clinical care planning. The outer frame (level I1 knowledge) represents those “executive” metacognitive skills used to guide the cognitive activities involved in the nursing process inner frame. The core represents the essential components and relationship of a nursing diagnosis (Figure 2). The following discussion explains the models and illustrates the relationships within the models using the metacognitive questions that assist in the self-regulation of clinical reasoning.
Model 1. Nursing Diagnosis: Knowing That The process of clinical reasoning is complex and requires careful consideration of the sequence in which content knowledge and process knowledge are introduced to the students so that they can master both the logical and creative aspects of the process. It has been the experience of the authors that introducing students first to the fundamental elements and relationships of nursing diagnosis provides a schema for future acquisition and development of clinical reasoning skills. This schema is introduced by presenting the Nursing Diagnosis Content Model (Herman, Pesut, & Fore, 1991) displayed in Figure l to the Vdumo 3,Number 4,Octobtul December 1992
b
Problem
Patient Outcome
Evaluation i
I Cues
Etiology
Intervention
Figure 1. Nursing diagnosis content model (model 1). Copyright 1992 by J. Herman. Reprinted by permission.
students. The model graphically illustrates the concepts relevant to nursing diagnosis and care planning and the relationships among the concepts. Specifically, cues are clustered into meaningful units from which patient problems are derived. From the problem, one develops a patient outcome that describes the expected patient status as a consequence of nursing care. The outcome is derived directly from the problem. The outcome must be stated specifically enough so that evaluation criteria are identified. Evaluation is a two-step process that represents the measurement of the patient’s progress toward the expected outcome. The first step is a comparison of the patient’s status to the evaluation criteria. The second step is a judgment about the meaning assigned to the comparison. Identification of an etiology and selection of nursing interventions in the nursing diagnosis content model is a parallel operation. Cues once again are clustered and used to identify the etiology. The process of determining the etiology is the same as the process of determining the problem. Interventions that have a high probability of influencing the etiology are selected for use with the patient. The model emphasizes four functional relationships that are difficult for beginning diagnosticians to understand: (1) the relationship between the problem and the predicted patient outcome, (2) the importance of cues in the determination of an etiology, (3) the value of selecting interventions specific to the etiology, and (4) the development of evaluation criteria that are N d n g Diagnosis
based on the predicted patient outcome. This model may seem simplistic to the advanced clinician, but making these relationships explicit helps novices make sense of the process. Students have commented that model 1 is useful because it clarifies the relationships among cues, problem, etiology, outcome, and evaluation.
Metacognitive Skills in Diagnostic Reasoning: Knowing How Once students are familiar with model 1, they are introduced to the Integrated Model of Clinical Reasoning (see Figure 2). This model is more complex because it represents relationships among metacognitive strategies, nursing process, diagnostic reasoning, and nursing diagnosis. Specifically, the metacognitive skills of monitoring, analyzing, predicting, planning, evaluating, and revising are executive cognitive skills that frame the nursing process, which in turn frames diagnostic reasoning and nursing diagnosis. Metacognitive skills always have been an implicit part of the nursing process. Making the implicit explicit clarifies the relationships among these frames of reference. This model helps the students become aware of and strengthen their metacognitive skills by using metacognitive questions during each step in the diagnostic process. The metacognitive skills ofmonitoring and analyzing are used during data collection and cue clustering. Clinicians gather incredible amounts of data about a particular patient, including signs, 151
Figure 2. Integratedmodel of clinical reasoning (model 2). Copyright 1992 by D. Pesut and J. Herman. Reprinted by permission.
symptoms, behaviors, and characteristics. In addition, the nurse’s past experiences, knowledge, frame of reference, environmental situation, and intuition augment the patient database. Effective clinical reasoning starts with an expansive approach to data collection. That is, students need to be encouraged to assess broadly so that cues to all possible diagnoses will be sampled. If a student uses a restrictive data set at this point in the process, errors in diagnosing are certain to occur. On the other hand, data collection can go on indefinitely if there are no domain parameters. Therefore, it is important to mark the boundaries of the data search field. The distinction between expansive data collection and efficient marking of the data search field is difficult for novice diagnosticians. Therefore, the first question a practitioner must ask is, “What structural model am I going to use to guide data collection?” Using a structural 152
model such as Functional Health Patterns (Gordon, 1987), Taxonomy I-Revised (Carroll-Johnson, 1991), or the ABC PRN REST for Health scheme devised by Kim, McFarland, and McLane (1991) is an excellent way to organize data and narrow the search field. Additional questions students are encouraged to ask themselves as they “frame their thinking” are: What decisions have I made to narrow my data search? Have I used all available types and sources of data? Have I collected all the data I need? Am I clear on the meaning of the data? Once a thorough database has been collected, meaning must be assigned to the data and inferences drawn. Students need to learn how to analyze and cluster data into meaningful units. The challenge is to cluster the data so the inferences drawn lead to the most useful outcomes for the delivery of nursing care and the resolution of paVolumo 3,Number 4,0ct6ber/D.ccHnber 1992
tient problems. Strategic questions diagnosticians need to ask themselves are: What are some possibilities for clustering of the cues? What experiences have I had before with these cues and how did I cluster them? Is there a logic to the cue clusters? Have I distinguished relevant from irrelevant cues?What diagnostichypotheses am I generating based on cues clustered? Are the diagnostic hypotheses within the domain of nursing practice? As with any probabilistic enterprise, there are different configurations data can take, all of which represent some facet of reality. The activities of monitoring and analyzing are critical for making good judgments about what cues to consider, what cues to ignore, the meaning assigned to the cues, and how to cluster the cues in the most efficient manner. The metacognitive skill of predicting is used when determining the problem and etiology. Inferences are predictions or in diagnostic reasoning language-diagnostic hypotheses. Both the problem and the etiology result from the process of inferring from data the presence of a particular human responsejife process and generating or predicting diagnostic hypotheses for the problem and the etiology. The diagnostician must predict the problem that has a high probabilityof being an accurate representation of the patient status as well as an etiology that substantially influences the problem. Accuracy is improved when a large number of hypotheses are identified early in the diagnostic process. A diagnostician’s predictive power about the relationships among the cue clusters, problem, and etiology are based on past clinical experiences, supportive and nonsupportive evidence, and multiple and single hypothesis testing (Gordon, 1987). Skillful diagnosticians often ask themselves questions such as: Is this the best clinical prediction? What problem/etiology can be predicted from the cue clusters? Can I predict whether the problem is a consequence of the etiology?What is the probability of accuracy for each problem/etiology?What evidence supports or does not support the prediction of problem/etiology? How does the prediction for this problem/etiology compare with past clinical experience?These questions encourage use of metacognitive skill and awareness during the prediction phase of clinical reasoning. The metacognitive skill of planning involves both the determination of the patient outcome and the identification of appropriate intervenNursing Diagnosis
tions. A common metacognitive question is, “HOW do I plan to turn the problem into an outcome?” Outcomes are targeted solutions for the patient’s problem and indicate the predicted status of the patient as a result of nursing interventions. Nursing interventions are planned to influence the etiology. There are two methods, logical and creative, for developing nursing interventions. First, the intervention may be a logical, analytic solution that is based on practice experience, research, or theory. Second, given the generative or creative aspects of nursing practice, one can develop innovative solutions to influence the etiology of the problem. Questions to ask during this planning are: Logically, what nursing interventions do I plan to influence the etiology? Creatively, what nursing interventions can I develop to influence the etiology? Are my plans useful, effective, and efficient? Evaluating and revising are the final metacognitive skills used. Evaluation is a clinical judgment regarding the influence a nursing intervention has had on the etiology of a patient’s problem. Evaluations can be categorized as achieved, progressing toward achievement, no change, or a deterioration in status. Based on evaluation data, diagnosticians must reflect and revise their judgments by asking the following questions: Do the nursing interventions need to be revised? Does the patient outcome need to be revised? Does the problem/ etiology need to be revised? Do the cue clusters need to be revised? Does the data search field need to be reshaped? Answers to such questions provide data and feedback about where, specifically, to revise t h i i g , judgment, or action.
Summary Using the concept of metacognition in nursing education in general, and the teaching of clinical reasoning specifically, has great instructional promise. The authors propose that application of a metacognitive framework will assist educators to develop strategies for enhancing diagnostic/clinical reasoning skills of students and practitioners. The metacognitive skills of monitoring, analyzing, predicting, planning, evaluating, and revising provide a framework for the self-regulation of thinking during the clinical reasoning process. Nurse educators and managers who encourage metacognitive skill acquisition are likely to accelerate practitioner’s comprehension, understanding, and 153
Application of a rnetacognitive framework will assist educators deveisp strategies for enhancing d iagnostic/cli nical reasoning skills of students and practitioners.
mastery of the diagnostic reasoning process. The models presented have implications for teaching and learning clinical/diagnostic reasoning because they help nurses understand the relationships among metacognitive skills, the nursing process, diagnostic reasoning, and the development o f a nursing diagnosis. Research and continued development of the notion that diagnostic reasoning is a metacognitive as well as a cognitive process is an area for future educational and clinical investigation.
References Brown, A. (1978). Knowing when, where and how to remember: A problem of metacognitive. In R. Glaser (Ed.), Advances in i m t m t i m l psychology (pp. 77-165). Hillsdale, NJ: Lawrence Earlbaum Associates Publishers. Burlef, J., Brown, B., & Saunders, B. (1985, May). Metacognitive: Theory and application for college readers. Paper presented at the Annual Meeting of the International Reading Association, New Orleans, LA. Carnevali, D. (1984). Strategies for self-monitoringof diagnostic reasoning behaviors: Pathways to professional growth. In D. Carnevali, P. Mitchell, N. Woods,& C. Tanner (Eds.). Diagnostic reasoning in nursing. Philadelphia: Lippincott. Carroll-Johnson, R. (199 1). C h i f i a t i o n of nursing diagnoses: Proceedings of the Ninth Conference of the North American Nursing Diagnosis Association. Philadelphia: Lippincott.
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Flavell, J. (1979). Metacognitive and cognitive monitoring: A new area of cognitivedevelopmental inquiry. Ameriuan Pyhobgist, 34, 906-91 1. Gordon, M.(1987). Nursing diagnosis process and appliccrtion (2nd ed.). New York McGraw-Hill. Herman, J. A., Pesut. D. J., & Fore, V. E. (1991, June) Teaching and lcaming nursing diagnosis: Application of Kolb’s lcaming sty& t h e q . Paper presented at the conference Nursing Diagnosis in Perspective: The Quality and Cost Issue, Williamsburg, VA. Kim, M.,McFarland, G., & McLane, A. (1991). Pocket guidc to nursing diagnoses (4th ed.). St. Louis, MO: Mosby. Kingten, A. J. (1991). Critical thinking and nursing education: Perplexities and insights. Journal of Nursing Education, 30, 152-1 57. Kitchener, K. (1983). Cognition, metacognition and epistemic cognition a three level model of cognitive processing. Human Deuelojnnmt, 26, 222-232. Martinelli, K. (1987). Thinking straight about thinking. The School Administrator, 44(1), 21-23. Marzano, R. (1985). Integrated instruction in thinking skills, learning strategies, traditional content and basic beliefs: A necessary unity. Educational ReSOUICCS Infotmation cntn; ED267 906, PS 015 704. Meichenbaum, D., & Asamow, J. (1979), Cognitive-behavioral modification and metacognitive development: Implications for the classroom. In S. Hollan & P. Kendall (Eds.). Cognitive 6ehuuioral i n t n v m t i m : Theory, research and pratticc (pp. 11-35). New York Academic Press. Pesut, D. (1984). Metacognition: The self-regulation of creative thought in nursing (Doctoral dissertation, University of Michigan, 1981). Dissn2dion Abstmcts Inlcmational, 45(2), 515. Pesut. D. (1985). Toward a new definition of creativity [Editorial]. Nurse Eduafor, 10(1), 5. Reeve, R., & Brown, A. (1985). Metacognition reconsidered: Implications for intervention research. Journal ofAb~wnna1Child Psychology, 13, 343-356. Schon, D. (1983). Thc rejkxtiue practitioner: How profess i m l r think in action. New York Basic Books. Sternberg. R. (1988). The triarchic mind. New York: Viking Press. Thiele, J. E., Holloway,J.. Murphy, D., Pendarvis, J., & Stucky, M. (1991). Perceived and actual decision making by novice baccalaureate students. Western Journal of Nursing Research, 13, 616-626. Worrell, P. (1990). Metacognition: Implications for instruction in nursing education. Journal of Nursing Education, 29, 170-175.
Volume 3,Number 4,0ctokr/Decomber 1992
