Metacognition in oral health education: A pedagogy worthy of further exploration

Abstract Aim This study aimed to investigate the perceptions of dental students and teachers about introducing metacognition pedagogy within an established clinical professional curriculum to provide primary data informing its feasibility. Methodology and method A qualitative study using phenomenography methodology was undertaken as part of a master’s dissertation. Semi-structured interviews were conducted on 16 participants which included 9 clinical teachers and 7 dental students. Findings Metacognition pedagogy was positively perceived by most of the participants as being beneficial to students’ learning in oral health education. A few reported some negativity. All participants identified some challenges to be addressed if a metacognition pedagogy was to be implemented in the undergraduate curriculum. Conclusion According to the perceptions of most participants in the study, metacognition emerged as a potential factor in improving student learning and exam performance, and facilitating the development of critical thinking, professionalism, and clinical skills. In the context of rigorous, demanding, and challenging courses, and recognising the complexities and uncertainties inherent in health professional working environments, metacognition emerges as a valuable tool, fostering self-awareness, regulation, and adaptability. Ultimately, metacognition has the capability to shape more adept learners and clinicians, yielding benefits for students, teachers, and patients alike.


Introduction
Oral health care courses are intensive, demanding, and challenging.This training is compressed into a packed curriculum, requiring students to keep up and develop required competencies for safe and independent dental practice as outline by the General Dental Council's 'Preparing for Practice' (GDC 2015) guidelines.The curriculum requires students to work at pace.This involves learning efficiently, understanding theory, and applying this as they develop clinical skills.Not having effective learning may compromise the learning, development, and progression of oral health students.Metacognition is prized for offering strategies that support student learning (Muijs and Bokhove 2020).

What is metacognition
Metacognition strategies allows individuals to 'think about thinking' to plan, organise, monitor, and evaluate their learning (Flavell 1976).It enables students to regulate learning and progress and consider alternative strategies (Schraw 1998).It does this by equipping learners with frameworks to follow.These are based on interactive and iterative cognitive and behavioural strategies (Table 1).Metacognition provides a foundation for developing self-regulatory and independent learning skills (Coskun et al. 2011).It could improve students' learning strategies, supporting how they learn.

What is the evidence for metacognition teaching in higher education
The literature about metacognition provides a rich array of metacognitive strategies.In higher education,

Practice points
Metacognition is prized for offering strategies that support student learning.There is much evidence-informed practice for metacognition intervention.Most teachers and students felt that metacognition should be taught in oral health education.Metacognition serves as an educational pedagogical tool but also as a wider wellbeing initiative.Metacognition is not being taught explicitly and entirely as a pedagogy in oral health education due to perceived complexity, limited metacognition knowledge, course guidance and faculty pedagogy training and development.metacognition strategies have led to multiple educational benefits related to higher achievements for students.These include improved learning rates, higher exam grades and better critical thinking, as reported in students studying Science (Tanner 2012;Cook et al. 2013), Maths (Pate and Miller 2011), Nursing (Fonteyn and Cahill 1998;Higgs et al. 2008;Norris and Gimber 2013), Psychology (Conlon and Brewer 2018) and Pharmacy (Schneider et al. 2014).This suggests that metacognition is capable of supporting students across a range of disciplines.Metacognition supports critical thinking.Critical thinking can be applied to problem solving in relation to professional issues (Shen and Liu 2011;Taylor et al. 2017).Metacognition specifically assists dental students with behavioural review, reflection and regulation for better and improved learning (Supplementary Appendix A).Metacognition offers a unique opportunity for them to understand the specific drivers to human behaviour accurately and scientifically and offers a humanistic approach to modify unprofessional behaviours (Eichbaum 2014, p. 70).In addition, metacognition can assist with the development of leadership and management skills.Helping individuals work towards the need when challenging the group, conforming, feeling empowered, not being ostracised, and diffusing fears, has been associated with courageous leadership (Eichbaum 2014, p. 71).Such metacognitive frameworks provide an increased awareness of oneself, one's experiences and others, and what's around them.Specifically, cueing one to continuously monitor, adapt and regulate, producing better outcomes.Metacognition has been argued to be foundational to leadership development (Gardner et al. 2005).In clinical education, critical thinking metacognitive frameworks have been applied to clinical practice.These have supported learners with clinical reasoning.Helping to assist learners transferring and applying their theoretical knowledge to clinical contexts.These frameworks assisted nursing students in diagnoses and treatment planning, whilst mitigating medical errors (Fonteyn and Cahill 1998;Nendaz and Perrier 2012).These frameworks could be adapted to dental cases and would provide support to dental students to accurately identify, collect and process information, determine diagnoses, and provide accurate decisions regarding treatment options.Nursing students had also developed better clinical performances using metacognition (Medina et al. 2017).Self-questioning techniques used when approaching clinical skills (Colbert et al. 2015) assisted novice learners with identifying, refining, METACOGNITION This is the process of thinking about one's own thinking.METACOGNITION KNOWLEDGE This is the thinking process to enable learners to understand who they are as learners and how they learn: Knowledge of themselves as learners How their brains are wired for growth.How memory works.Growth mindset versus fixed mindset.The impact that motivation, interest, and wellbeing have on learning.What previous experiences they had with the topic and what strategies helped them learn and remember; identify their strengths and weaknesses.This knowledge will help them identify how these may impact their learning, so they can do something about them, and make the most of them.

Knowledge of the task
This is how one perceives the difficulty of a task, the content, length, and the type of assignment.Knowledge of strategies, how to use them, when and how to apply the strategies.
Strategies for learning, but are not limited to and include concept maps, mind maps, flashcards, mnemonics, paraphrasing, acronyms, interleaving, study cycle, spaced practice, elaboration, highlighting, summarising, taxonomies, self-questions, notetaking framework, reading comprehension selfquestions, self-testing, and exam strategies.Strategies for problem solving, critical thinking and clinical reasoning, but are not limited to and include cognitive and behavioural processes and selfquestions.

METACOGNITION REGULATION
This is what learners do about their learning.It describes how they make adjustments to control their learning.This involves planning, monitoring, and evaluating:

Planning and organising
Assessing the task and allocation of resources and setting the learning goals.

Monitoring
Active processing of assessing, understanding, and determining whether learning strategies are effective.Assessment of their own learning.

Evaluating learning
Identifying gaps in learning.Analysis of performance.Determining if their planning and organising and use of strategies were effective.If not, then to replace them with effective strategies.Revising learning goals.HOW TEACHERS CAN PROMOTE METACOGNITION LEARNING Use of Cognitive Wrappers -self-questions to increase monitoring skills in exams and clinical performances.These are designed to be used before and after assessments, assignments, or performances.These allow learners to see evidence of how strategies might have been successful and feedforward into changing behaviour.Consider (short/long) essays versus multiple-choice questions for deeper, meaningful, and conceptual thinking.
Teaching descriptive, analytical, evaluative, and reflective writing and thinking styles.Use of Structured Clinical Reasoning Exercises.These encourage students to practise collecting patient data and information effectively, assessing patient's condition, generate and test hypotheses, and weigh and prioritise demands to determine a differential diagnosis, an optimal diagnosis and the best action or treatment for the patient's case.With an understanding of metacognition, teachers are well placed to support students in developing and using metacognition by modelling -verbalising their thought processes, scaffolding tasks -like worked examples, and providing feedback on their use of metacognition.Promote and develop metacognition talk in the classroom.Questions for students to ask themselves as they plan, monitor, and evaluate their thinking in how 'learning to learn' is going on in class, assignments, quizzes/exams, and the course as a whole.Provide opportunities for self-reflection, feedback, and reciprocal teaching, in clinical sessions and classrooms.This promotes a deeper approach to learning.Develop a classroom culture that acknowledges confusion as an integral part of learning.This helps to identify a lack of understanding which is an important part of developing self-awareness.Promote 'Muddiest Point' talk in the classroom -what students are most confused about and use word clouds to help visualise and create discussions around these areas.Encourage and develop reflexive and critical thinking using case base/problem solving exercises in classrooms and interactive workshops.Students keep learning and reflective journals throughout their studies and practices.
Adapted from the works by Schraw 1998, Tanner 2012, and EEF 2019.and developing skills that they will use in their clinical practice.They helped deconstruct the cognitive processes needed to learn, understand, and manage clinical cases.Given that metacognition supports learners in learning, professionalism, leadership, management, critical thinking, clinical reasoning, and clinical skills, it could be said that metacognition potentially offers widespread and general support to oral health students' learning and professional development and understanding of clinical practices.
Whilst there is much evidence-informed practice for metacognition intervention, there are few studies cited in oral health education.This does not mean metacognition teaching is absent.Many educational programmes advocate processes of metacognition such as self-regulation, goal setting, critical thinking, and reflection, without using the term metacognition and explicitly teaching metacognition pedagogy.This signifies an under-representation of metacognition in higher education (Dennis and Somerville 2022).Concerningly, it indicates underutilisation of metacognition, with learners not benefiting from a greater emphasis upon it.Before we can start advising or implementing a new pedagogic approach, it would be necessary to investigate the perceptions of the dental faculty -the teachers and students, as they are the key stakeholders.Given the lack of studies published in this area, a key aim of the study reported here investigates the perceptions of dental students and teachers about introducing metacognition pedagogy within an established clinical professional curriculum to provide primary data informing its feasibility.The following research questions were formulated: 1. Preparedness Assessment: What do clinical teachers and dental students feel about how prepared students are for their academic and clinical teaching sessions?2. Metacognition's Contribution: What are their views of the contribution, if any, teaching metacognition might make to students' learning in these sessions?3. Metacognition in Professional Practice: What do they perceive as the role and importance of metacognition in professional practice?4. Supports and Barriers: What do they see as the main supports and barriers to teaching metacognition?

Methodology and method
Phenomenography analysis was utilised because it qualitatively maps out the different ways in which people experience, conceptualise, perceive, and understand various aspects of phenomena in the world around them (Marton 1986).It is an appropriate approach to investigating the perceptions of metacognition.It generates the variation in the ways different people ascribe meaning to metacognition through their eyes, of which there are limited numbers of ways (Marton 1986).These are the hierarchal categories of description of the variation.This forms the outcome space.By exploring this variation, one can design programmes that identify the variation in learners' perceptions of metacognition.The results will ultimately help to tailor a metacognition taught programme to address the needs and wants of all the students and teachers, helping to minimise errors.Data was collected using qualitative semi-structured interviews using pre-planned questions based on the study's aim and questions, to dental students and teachers in 2020 -2021.All interviews lasted approximately 30 minutes, were remotely conducted, transcribed, and recorded via Microsoft Teams.All participants were known to the researcher.They were chosen as they were involved in the researcher's teaching so they can inform their educational practice accurately.Inclusion and exclusion criteria were applied (Supplementary Appendix B).Participants were sent an email to invite them to take part voluntarily, and were given a consent form, information sheet, and a metacognition pre-interview script (Supplementary Appendix C).This pre-interview script gave a summary about metacognition.This was given to all participants.Metacognition is not considered to be a well-known phenomenon (Lai 2011).The few students and teachers that I had spoken to about metacognition whilst planning this research, expressed a lack of awareness and understanding about metacognition.This created a potential issue, that participants' perceptions would be limited.Therefore, the pre-interview script was necessary and would help to mitigate the risks of participants not enriching the interview with breadth, depth, and richness.

Participants
Purposeful sampling was used to select a broad representation of participants.This would enable selecting a variety of age ranges, gender, student years, previous student degree, teachers who are general, special interest and specialist dentists and whether full or part time employed.This would help to ensure getting the widest range of perceptions representative of the faculty.In addition, it will enable me to decipher any relationships between these groups (Mays and Pope 1995).All the teachers had been in their teaching posts from eight years to fifteen years.
The sample size was guided by data analysis and when theoretical saturation occurred (Mays and Pope 1995).That is when, there was no additional data being discovered about the categories, and all the categories had been explored (no same or new things were being said).That is when the data collection stopped.A total of 16 interviews were conducted.This included 9 teachers and 7 students.The descriptive characteristics of the participants can be found in Table 2.

Findings
The interview transcripts formed the empirical material for data analysis.Data analysis employed the approach of Sjostrom and Dahlgren (2002).This includes a strategic, strongly iterative, and comparative process.The stages of analysis included: 1. Familiarisation: Reading and re-reading interview transcripts from multiple perspectives.2. Compilation: Extracting significant information sections from the responses to the questions.3. Condensation: Reducing and summarising these answers.4. Grouping: Organising answers into categories.5. Comparison: Comparing categories and establishing boundaries between them, followed by naming the categories to highlight their essence.6. Final Interpretation: Describing the character of each category and identifying resemblances between them.
This analysis revealed three categories of description, highlighting the variations in how participants perceived metacognition pedagogy in oral health education.
The outcome space reports these variations diagrammatically.It reveals their hierarchical relationship with a logical interconnection and considers domains which were directed by the interview questions (Supplementary Appendix D).The variations are presented below and described by quotations from the interview.
Rita Bagga led participant recruitment, interviews, and data collection, as well as reviewing interview transcripts.Anne McKee and Rita Bagga collaborated on data analysis, focusing on identifying themes and generating the outcome space.It was the utmost importance to mitigate any concerns related to participation for both teachers and students.All participants were assured that their involvement or non-involvement in the study, along with the content of their responses in interviews, would have no negative consequences on their professional or educational relationships/outcomes.The confidentiality of their participation and interview content was strictly maintained, fostering a sense of trust and comfort for all participants throughout the research, thus reinforcing the ethical conduct of this study (Sin 2010;Tavakol and Sandars 2014).All these assurances were clearly communicated to participants and conveyed through the participant information sheet.

Variation 1: No awareness and disinterest in metacognition pedagogy
Few participants negatively perceived metacognition pedagogy.They could not see how metacognition could help learners with their learning or struggling students achieve more.They reported factors such as mental health issues and learning difficulties negatively affecting learning that metacognition could not mitigate.
The university needs to do more to support students with learning needs.Their study skills course did not help hugely.King's Inclusion Plans and Personalised Assessment Arrangements are simply not enough to support us in our learning and exams … I am not sure how metacognition will help those struggling with the course.(3 rd year student) There were also some concerns about whether teachers would support metacognition given the possible lack of willingness to teach alongside existing duties.They reported that only a few teachers may be interested in teaching metacognition considering how full their teaching responsibilities were already day to day.Also, there was some disinterest from students in learning about something new, given the tightly packed and intensive undergraduate curriculum.They felt there was already too much to learn and were concerned about adding more learning in the curriculum.The participants suggested that metacognition should be an optional course, but acknowledged if optional, then student engagement could be low.
Not all teachers will want to teach metacognition -it may not be in their comfort zone … we are also really busy running clinics and supervising students, so may not have time to teach metacognition.(General Dentist) All the participants felt that there was some element of 'complexity' associated with metacognition despite reading the pre-interview metacognition script but realised this could be due to their unfamiliarity with it.
All the participants in this variation made some suggestions of there being 'clever' students who do well in exams.They perceived exam success as mostly correlating with intelligence.They did not consider other potential factors that could be contributing to successful learning and exam performance.
Some students are very clever, and we all know who those students are … perhaps they are just naturally clever … they always do well in exams … they pick up things quickly on clinics … (General Dentist) Variation 2: Interested in metacognition pedagogy, need to know how to apply Most of the participants were found to be in this variation.Students were aware of some learning strategies and had some understanding about how they were using them and were practising a few of them already.They understood that these strategies had worked successfully before in their past exams helping with achieving higher exam attainment.They were unaware of the term metacognition before reading the pre-interview script and were not entirely sure how metacognition could help them with their learning further.Nevertheless, they felt that metacognition strategies could help with exam success and preparation for seminars.They were keen to explore this further and welcomed metacognition strategies in the undergraduate curriculum.
I did not know that metacognition could help with learning … I am interested in finding more about this to help with learning.(5 th year student who holds a prior degree) The participants suggested introducing metacognition through interactive seminars with smaller group sizes to facilitate its understanding and adoption.They also noted that incorporating multiple learning exercises and activities could be beneficial.
Variation 3: Have engaged with metacognition pedagogy and know how to apply aspects Few participants were found in this variation.They felt that metacognition could help learners to learn better, develop better critical thinking, clinical skills and clinical reasoning and professionalism.They welcomed a structured and formal educational programme focussing on teaching students how to learn better in the oral health undergraduate curriculum.Specifically assisting students to achieve more with their academic, clinical and professionalism domains.They emphasised the significance of teaching students the learning process to enhance learning outcomes, given the challenges and demands of these intensive courses.They expressed concerns about the time and effort needed to develop a new metacognition course.They stressed the importance of support from faculty management and experts in metacognition to maximise its effectiveness.
The university needs to support teaching students about how to learn better.Many students struggle with learning year after year.This problem is getting worse … implementing some sort of structured learning programme would be useful for dental and dental therapy hygiene students … (Consultant/Specialist) Interestingly, the teachers who had completed teacher training courses had a deeper understanding of metacognition.Many were integrating elements of metacognition in their teaching such as reflection and promoting critical thinking even though they did not explicitly refer to these as metacognition in their modules.
Metacognition will be useful, as students will learn more about critical thinking and clinical reasoning as well as problemsolving, which is what students need, especially during the BDS clinical years.The students are being taught aspects of this in some modules.(Consultant/Specialist)

Across all the variations 1, 2 and 3
Teachers reported that some of their students were 'unprepared' for seminars and clinical practice sessions frequently.They highlighted that some final-year students were unprepared for clinical sessions.Specifically, they had not grasped clinical procedures effectively or recall knowledge accurately, despite being taught theory and clinical skills and having much repeated practise.This 'unpreparedness' had been prevalent in the last five years and the situation was getting slightly worse year after year.Additionally, many students did not feel confident in their clinical skills.They felt this was primarily due to having limited experience with patient treatments and clinical practice.
We do not have sufficient patients in clinics to treat, or clinical sessions, so my confidence in clinical practice is impacted.(3 rd year student) Some students will arrive well prepared for seminars and clinical sessions, and they will have read up, prepared and are able to present their findings clearly … However, some students may face challenges and will need support and guidance … which is acceptable … Nevertheless it is essential for all students to eventually take more ownership of their learning.(Consultant/Specialist)

Discussion
In relation to students 'unpreparedness' for clinical sessions, these interviews did take place during the COVID-19 pandemic restrictions.Students during this time had reduced and limited contact with patient treatments, clinical practice and teaching.So, this could have contributed to their level of 'unpreparedness' in clinical practice sessions.That said, greater metacognitive ability would have enabled students to identify gaps in their knowledge and experience which they would want to address.Consequently, if metacognition was embedded in dental programmes, then this could have enabled students to help themselves in identifying and addressing clinical deficiencies.We also know there is a potential poor correlation between self-confidence or perceived competence and actual competence (Lai and Teng 2011).This highlights the need for more robust training and measurements of 'unpreparedness.'Disquietingly, the literature has reported dropped clinical standards of newly qualified dentists (Tipton 2014;Ray et al. 2018) highlighting this issue of 'unpreparedness' and thus learning deficit further.This could be due to competencies reached without minimum experience requirements (McGleenon and Morison 2021).With the move towards descriptive based competency (Ray et al. 2018) and given the challenges that dental schools face securing patient numbers, new clinical sites and extra teachers for supervision can mean that students simply do not have the opportunity to refine their learned skills on multiple patients (also reported in this study).Conversely, this could also signify that learning theory and clinical skills with repeated practise and patient care training may not be enough (Green and Rasmussen 2018, p. 107).In the dental field, there is no same clinical procedure or outcome.In short, learning would need to be transferred and applied to new and different dynamic clinical situations and environments which can be subject to uncertainties, time constraints and limited resources.Uniquely, metacognition could help scaffold this learning.Hong et al. (2015) reported that metacognitive strategies could support these students in determining the difficulties of the tasks, plan, modify and regulate their actions accordingly, and monitor their performances, using the information around them.Interestingly, dental students and teachers requesting more structured help with learning has been reported in the literature (Hook et al. 2002;Nothnagle et al. 2011;Ray et al. 2018), a finding that aligns with this study's findings.
In variation 1, some participants felt that metacognition could not assist students with learning and those with learning difficulties.This could be due to limited participants' knowledge of metacognition and learning difficulties.It could also mean that the participant assumes that the perceived ineffective study skills programme would be similar and have the same outcomes to metacognition strategies, when in fact the two are not the same.Metacognition unfamiliarity has also been reported in the literature (Lai 2011).Just learning about studying skills is not as strongly associated with higher achievement (Callan et al. 2016).Instead, metacognitive strategies involve an awareness of thinking, as measured by the appropriate use of strategies within a context, is related to higher achievement (Callan et al. 2016).Therefore, metacognition would benefit these learners more so.Metacognitive learners will have an increased awareness of 'thinking about thinking' how best to learn in line with their unique needs and goals specific to the task (Table 1).Furthermore, the literature does report that metacognition helps those with learning difficulties.Metacognitive strategies could help compensate their limited working memory, reading and comprehension, including difficulties with organising information and staying focussed on the task (Goldup and Osler 2000).
It was also noted by some of the participants that exam success mostly correlates with intelligence.Instead, the literature reports that success mostly correlates with positive, effortful, purposeful behaviour and actions concerning learning, and adopting a growth mindset (Dweck 2012).Teaching metacognition could help to reinforce good learning behaviours such as motivation, effort, purposeful action, and interest, ensuring learning success (Limeri et al. 2010).Furthermore, it will help to reinforce metacognition constructs of knowledge and regulation (McGuire and McGuire 2015).This will ensure that students understand they own their learning, learning is a process, it's something they do themselves, it involves a change in knowledge, beliefs, attitudes, and actions.Furthermorethey can identify factors impacting their learning and can therefore do something about it (Table 1).
Challenges were reported with metacognition pedagogy across all the variations in this study's findings.Metacognition unfamiliarity, complexity and its perceived 'fuzzy' concept has been reported in this study's findings and in the literature (Tarricone 2011).This could be due to limited pedagogical knowledge, educator training and internal faculty teaching developmental programmes.Consequently, introducing a new educational pedagogy for students and teachers to learn and teach respectively could be challenging (also reported in this study's findings).Naturally, there would also be varying levels of interest and motivation.Nevertheless, teachers who incorporate metacognition into their teaching could reap numerous benefits.This includes improved student understanding of knowledge and mastery, refined communication with better teacher and student relationships, more engaged and motivated learners, reduced student dependency, and the opportunity to create more effective and dynamic learning environments (EEF 2019).Additionally, the intrinsic rewards of facilitating learning and positively impacting students' lives contribute to a fulfilling teaching experience.An introduction to metacognition to both students and teachers could help alleviate confusion and reinforce its usefulness.Encouragingly, the Education Endowment Foundation (EEF 2019) provides evidence that metacognition can be taught successfully by teachers, even across different subjects and has achieved great academic success, as demonstrated in primary and secondary education.This suggests that effective metacognition teaching and learning can be applied to higher education including health professional education as supported by the studies cited in the above section titled "What is the evidence for metacognition teaching in higher education." Contrarily, there needs to be an acceptance that not everyone will view metacognition as a simple 'fix' to successful learning.In addition, learning processes and outcomes are affected by multiple factors (Entwistle and Ramsden 1983).Nevertheless, we would argue that metacognition could help many students to learn better.We cannot assume all learners will have learned all these strategies and know how to use them.If the strategies are there, students are more likely to use them.
There were also uncertainties in costs, time, and efforts in implementing such a new course within the faculty.This was not surprising given the limited published metacognitive course guidance in clinical education.To help mitigate some of these challenges, support from faculty educational management team may be needed.This could mean that more time and effort could be taken up in constructing this new course.Nonetheless, the EEF (2019) have stipulated that only small tweakings would be needed, running alongside the existing curriculum.In short, metacognitive strategies should be taught in conjunction with specific subject content.Essentially, embedding the concepts of metacognition deeply in subject specific practice, rather than individualistic acquisition of knowledge that occurs frequently in their basic sciences.This gives great value to metacognition learning, as students would find it easier to transfer these generic tips to specific tasks.This would fundamentally assist regulating their behaviours appropriately and accordingly in their own practices.Explicit teaching of metacognition learning strategies does not simply denote by 'telling' but describes all the activities that a teacher orchestrates to effect learning in their students.This affords the use of modelling, scaffolding, reflection, feedback, think aloud and reciprocal teaching in classrooms, clinical practice settings, and workshops (Table 1).Consequently, students come to appreciate the participatory, peer and social context of learning.The EEF (2019) have proposed a seven-step model for teaching metacognition strategies (Supplementary Appendix E).Eichbaum (2014) presents an innovative approach, integrating humanities with metacognition into a unified medical curriculum using a colloquium.The colloquium comprises of weekly discussions, based on small talks, triggering questions and recommended readings around topics on metacognition, critical thinking, professionalism, medical ethics, leadership, and health care systems integrating with basic and clinical sciences.Essaystyle questions from the colloquium are integrated into the science end-block examination questions for metacognition testing.The questions are aimed at assessing whether students have intellectually integrated and assimilated the context (rather than just the content).
Given the evidence-informed practice for metacognition intervention, and the current challenges dental schools are facing, along with the reported learning deficit and 'unpreparedness' cited in the literature and identified in this study's findings, universities should now consider teaching metacognition in oral health education as an adjunct to existing pedagogies to bolster learning.That said, faculty educational management leaders will have to make their own choicesthat is academic freedom.However, we would argue that metacognition pedagogy would be beneficial to many students.The interest by most participants in this study, as reported in variations 2 and 3, further supports its inclusion.

Study limitations
Firstly, it is not claimed that these findings are generalisable and can be applied to all students and teachers.In doing so, a larger scale study would be needed with some quantitative data and more qualitative data.This would serve the purpose of enriching, examining, explaining, and triangulating the data for wider and deeper insights.This would make the findings more generalisable and ensure that the limitations of one type of data are balanced by the strengths of the other.Furthermore, whilst the outcome space serves to communicate ways in which people perceive metacognition, it does not suggest all the possible ways.
Secondly, some of the participants were uncertain about the definition of metacognition.Efforts were taken to mitigate this using the pre-interview script (Supplementary Appendix C) and opportunities for discussions relating to questions/ queries participants may have had before the interview.Unfortunately, this may have resulted in some of the negativity reported in variation 1.Further elaboration on how metacognition is taught, how it could assist with learning and the favourable educational outcomes achieved would have been needed.That said, towards the end of the interview many of the participants in variation 1 had viewed aspects of metacognition more positively and covered variations 2 and 3.
Lastly, efforts were taken to limit the researcher's influence on the interviews due to their interest in metacognition, inevitably this may have happened.On the other hand, the participant's interest in metacognition would not have been aroused if it were not for the researcher's familiarity with metacognition.

Conclusion
According to the perceptions of most participants in this study, metacognition emerged as a potential factor in improving student learning and exam performance, and facilitating the development of critical thinking, professionalism, and clinical skills.It is evident that both teachers and students welcomed the structured guidance that metacognition offers, particularly in the context of rigorous, demanding, and challenging courses.
In the ever-evolving landscape of health professional education, we advocate the inclusion of metacognition in university curricula.Metacognition equips students with the awareness and self-regulation needed to navigate dynamic and uncertain healthcare environments.It fosters agility, flexibility, and adaptability in critical thinking and learning processes, laying the foundation for lifelong learning and self-directed growth (Eichbaum 2014).
In essence, metacognition holds the potential to cultivate better learners, enhance student 'preparedness,' boost motivation, and elevate engagement in teaching and learning sessions.The ultimate beneficiaries of this pedagogical approach are students, teachers, and patients alikea pedagogy worthy of further exploration.
Further research is imperative to comprehensively evaluate the efficacy and practicality of integrating metacognition pedagogy into health professional education.This should encompass an examination of metacognition's impact on diverse aspects, including exam success, critical thinking, problem-solving, professionalism, leadership and management, clinical reasoning, clinical skills, and overall wellbeing.These insights will provide valuable guidance on the design and implementation of metacognition interventions, especially considering the limited research in this area and the misalignment between current metacognition teaching practice and evidence-informed metacognition strategies in education.
Furthermore, the findings from such research may pave the way for metacognition to be formally incorporated into the learning outcomes of healthcare regulatory bodies, emphasising its role as a prerequisite for the development of essential skills in healthcare professionals.Metacognition's inclusion in learning outcomes may usher in a new era of evidence-based and effective healthcare education Use of KWL charts (what do I know, what do I want to know, what did I learn), 'You, Do, Plan and Review' process and 'Think-Pair-Share' activities.Support teachers to develop knowledge of metacognition through faculty development.

Table 1 .
Understanding and applying metacognition and how teachers can promote metacognition learning.