Metacognitive Awareness Among Learners Enrolled in Athletic Therapy Programs in Ireland

Participants and Study Design

A cross-sectional study was conducted, and undergraduate athletic therapy students studying in Ireland were recruited. Participants were eligible if they were over the age of 18 years and studying undergraduate athletic therapy in an ARTI-accredited third-level institution. Ethical approval was granted by the Dublin City University Research Ethics Committee. Students were required to read a plain-language statement and provide informed consent before completing the survey. A sample size calculation indicated a requirement of 199 athletic therapy students studying in Ireland. The calculation was completed with the confidence level set at 95% and the margin of error set at 5%, using an online sample size calculator (http://www.raosoft.com/samplesize.html).

Instrumentation

An anonymous 62-question survey was used. Section 1 examined demographic information including gender, year of study, educational history, student status (ie, mature student or not, with a mature student classified as over the age of 23 years at the commencement of the undergraduate degree), and completion and setting of clinical immersive placement. Section 2 examined metacognitive awareness using the Metacognitive Awareness Inventory (MAI), a 52-item, self-reported inventory (Table 1).¹⁰ It consists of 2 subscales: KC (17 items) and RC (35 items) with 8 defined subcategories. Knowledge of cognition was categorized into procedural (4 items), declarative (8 items), and conditional (5 items). Regulation of cognition included the subcategories of planning (7 items), information management strategies (10 items), monitoring (7 items), debugging strategies (5 items), and evaluation (6 items). For each item, participants rated their response using a 5-point Likert scale and indicated how true or false each statement related to them, ranging from 1 = always false to 5 = always true. Responses were summated to give a total MAI (ie, TMAI) with a maximum achievable score of 260.²⁹ The higher the scoring on the MAI, the better the individual’s metacognitive ability.¹⁰ The Cronbach α coefficients for TMAI (0.82) and Total knowledge of cognition (TKC; 0.78) and Total regulation of cognition (TRC; 0.82) subscales demonstrate good internal consistency.

Table 1.Metacognitive Awareness Inventory

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Procedures

The survey was administered online (Qualtrics, LLC) and was open from February 2 to March 31, 2023. The survey was advertised by word of mouth and social media and distributed to the program chairs of all 3 ARTI-accredited universities via e-mail for distribution to all their undergraduate athletic therapy students (years 1–4).

Data Analysis

Responses were downloaded from Qualtrics and analyzed using SPSS (version 28; IBM Corp). Data were screened for missing data or invalid responses. Frequencies and descriptive statistics were examined from the eligible responses, including the mean, minimum, maximum, total score, and standard deviation. Means and standard deviations of each of the 8 subcomponents of metacognition were calculated. A total overall score for TKC and TRC were summated, and total mean overall score (TMAI) was calculated. Normality was examined, and data were found to be nonnormally distributed.

Spearman’s rank correlation coefficient was used to examine the relationships between the main components of metacognition (TKC and TRC). The strength of the relationship was identified as small (r = 0.10–0.29), medium (r = 0.30–0.49), or large (r = 0.50–1.0).³⁰ Kruskal-Wallis tests were conducted to examine differences between the years of study and TMAI, TKC, and TRC scores. Mann-Whitney U tests were used to analyze differences between completion of a clinical immersive placement and gender for TMAI, TKC, and TRC scores. Effect sizes were classified as small (r = 0.2), medium (r = 0.5), and large (r = 0.8).³⁰ Significance for statistical tests was P ≤ .05.

Participant Demographics

Two hundred and ninety-three undergraduate athletic therapy students studying in Ireland opened the survey. Sixty were excluded due to incomplete responses (ie, completed only demographic data). Thus, 233 participants were included in the analysis, representing a response rate of 56% from all eligible athletic therapy students. Participant demographics are presented in Table 2. A similar proportion of men (45.5%) and women (54.5%) completed the survey. A comparable number of students in years 2 (26.2%), 3 (31.3%), and 4 (26.2%) participated in the study, respectively, of which 8.2% were mature students.

Table 2.Descriptive Statistics

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Total Metacognitive Awareness Inventory

The overall TMAI score was found to be 183.9 ± 49.0. A summary of the mean MAI scores and all 8 subcomponents of metacognitive awareness are presented in Table 3. A significant and positive correlation was found between TKC and TRC (r = 0.69, P < .001). No statistically significant difference was evident across the 4 years of study in athletic therapy for TMAI scores (P > .05).

Table 3.Scoring of Metacognitive Awareness Inventory (MAI) Questions

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Significantly higher TMAI scores with a small effect size were observed in those that did not complete a clinical immersive placement (Md = 3.67) compared with those who did (Md = 3.51, P = .03, r = 0.17). No significant difference was found between completion of placement and TKC scores (P > .05). No significant differences in the TMAI scores between men and women were noted (P > .05). No significant gender differences were observed for TKC and TRC scores (P > .05).

Facilitating Metacognitive Teaching Strategies

Athletic therapy programs in Ireland should be reviewed to consider where metacognitive strategies can be effectively implemented. Educators need to be familiar with the appropriate teaching methods to facilitate metacognitive awareness.³⁴ This should allow students to take active participatory roles in their learning, both inside and outside the classroom to enhance learning. Knowledge of cognition and regulation of cognition can be improved with the use of teaching strategies that have been proven to be effective.^16,23 These include think-aloud protocols, reflection, judgments of understanding (asking learners to make prospective or retrospective judgments on their learning), problem-based learning, concept mapping, exam wrappers (reflective questions posed before and after assessments), and structured debriefing prompts (What went well in the clinical encounter? What didn’t go well? Next time, what would you do differently?).^7,34,35 In this study, TRC values were lower in than those of Rivas et al and Chan et al findings in psychology and nursing students.^6,31 Regulation of cognition can be specifically improved by the implementation of strategies that promote substantial reflective evaluation such as case-based learning and standardized patients or simulation. These teaching strategies allow educators and clinical preceptors to ask reflective and debriefing questions so that students can identify gaps in their knowledge and remediate these gaps through planning and goal-setting tasks. This facilitates students’ regulatory control of their learning.^11,24,36,37

In our research, we observed no differences in metacognitive awareness between the 4 different years of study, like a study by Welch et al in medical students.³⁸ This is contrary to what many educators and researchers expect, ie, metacognitive awareness develops as students progress through their formal education. This may be suggestive of insufficiently developed metacognitive awareness, resulting in students needing to be explicitly taught metacognition.²⁵ The development of metacognitive awareness is proposed to start early in life, continues into adolescence and adulthood, and becomes more explicit and effective under the conscious control of learners as they age.^9,25,33,39 However, these metacognitive skills can remain incompletely developed, resulting in poor metacognitive awareness.²⁵ Student learners need to be consciously aware of how to think about their thinking and be able to manage it.³³ Metacognition is an essential educational tool to do this. Educators also need to be cognizant to explicitly teach it in their curricula as an essential cognitive skill, to prevent a theory-to-practice gap from occurring, whereby the theory of metacognition exists evidently in the literature but may not be practiced within the classroom setting, to optimize student learning.^7,24,40

No gender differences in metacognitive awareness were observed in this study, suggesting no need to adapt metacognitive teaching strategies based on gender. In the past, researchers have been inconsistent and inconclusive regarding the examination of gender and metacognitive awareness.⁴¹ In addition, metacognition is a very individualized process in which educators must be cognizant of providing student learners many different metacognitive strategies to aid their own individualized development of metacognitive awareness.

Clinical Immersive Placement and Metacognitive Awareness

Learners in this study that had not yet completed a clinical immersive placement displayed significantly higher TMAI than those that had, with a small effect size. Further analysis revealed no significant differences in TKC and TRC between the groups. The results are surprising, as one would expect the immersive experiential learning experience to enhance metacognitive awareness, as reflective practice is an essential component to athletic therapy practice and metacognition. Many questions remain as to what type of reflective practice is being practiced by athletic therapy students; is it superficial reflection or deep and meaningful reflection? Even more critically, are the students actively engaging in this process to further develop their metacognitive awareness? Other questions remain regarding preceptors’ metacognitive awareness and the role it plays during supervision of clinical immersive experiences.

Educators and clinical preceptors are responsible for exemplifying their own metacognitive awareness by being metacognitive role models.⁴² This can be demonstrated in a number of ways such as through think-aloud and reflective discussions, by describing their thought processes explicitly for students to develop these metacognitive skills. Students may have difficulty reflecting on their own learning processes or have a lack of knowledge of their own strengths and weaknesses regarding learning, ultimately affecting the strategies they could use to improve their learning.^7,17 Students must be adequately equipped, guided, and taught what metacognitive learning strategies are and how, when, and why to implement them.^8,17 This should be completed in both the classroom and during clinical immersive placement experiences. This will foster learning environments that promote metacognitive awareness.⁷

Limitations

Some limitations to this study exist. First, the use of self-reported questionnaires (MAI) have limitations such as social desirability bias and central tendency bias.^29,43 This may have led to issues with honesty and accuracy of responses. As metacognition is not directly observable, self-reporting measures such as the MAI are needed to measure metacognitive awareness, limiting researchers to a small number of suitable ways to measure metacognitive awareness. Convenience sampling was used in this study; however, a large response rate of 56% was recorded. In this study, we examined athletic therapy undergraduate students studying in Ireland only, thus limiting the generalizability of the results to other health care students and some athletic therapy students internationally.

Future Directions

Future researchers should explore postbaccalaureate athletic therapy metacognitive awareness. In addition, future researchers should seek to investigate athletic therapy educators’ understanding, knowledge, and implementation of metacognitive awareness as an educational framework and toolkit. Future investigators could examine if metacognition is embedded and taught in athletic therapy curricula and the establishment of best practices for implementing and developing metacognitive awareness in higher education. Finally, investigating athletic therapy clinical supervisors’ and preceptors’ understanding and use of metacognitive awareness during clinical immersive placement experiences is recommended.

Declaration of Interest

The authors report no financial or business interests in this research.