The Art of Giving Feedback to Adult Learners

Anna Trinh, PharmD, MS
PGY-1 Pharmacy Resident
Adventist Shady Grove Medical Center

Feedback serves as the compass guiding learners, especially adult learners, in their educational path. It offers valuable sources of information regarding their performance, progress, and educational achievements. Feedback helps bridging between their current grasp of the subject matter and their desired level of proficiency. Therefore, it is important to have a thorough understanding of the roles, types, and components of effective feedback in the learning process.

The multifaceted nature of feedback becomes apparent when we consider its various roles in education. Not only does it reinforce existing strengths, but also highlighting areas that need attention. Moreover, feedback acts as a corrective tool, offering learners the opportunity to rectify errors and misconceptions in their learning process. This aspect is crucial as it steers learners towards a deeper understanding of the subject matter. Furthermore, feedback operates as a powerful motivator, reinforcing learners' progress and providing recognition for their accomplishments. Additionally, feedback plays a pivotal role in nurturing self-regulation skills among learners. It empowers them to take charge of their educational journey, fostering independence and autonomy, which is also one of the characteristics of adult learning.

Feedback can be classified into different categories. For example, positive feedback encourages and supports learners, while negative feedback highlights areas for improvement; specific feedback offers clear suggestions, while general feedback oversees the entire process; descriptive feedback neutrally describes performance, while evaluative feedback involves subjective judgment2. Research indicates that certain forms of feedback, such as video, audio, or computer-assisted instructional feedback, outperform others like programmed instruction, praise, rewards, or punishment1. Controlling feedback, delivered with a rigid "should" tone, proves to be counterproductive, while extrinsic rewards correlate negatively with task performance1. In general, positive, specific, and descriptive feedback prove to have more positive outcomes than negative, general, or evaluative feedback, even though outcomes may vary with contexts, learner characteristics, and feedback providers2. 

Within the healthcare educational setting, particularly for pharmacy students in both the classroom and experiential learning, educators can provide feedback using different strategies. As emphasized in an article by John Hattie and Helen Timperley on "The Power of Feedback" (2007), effective feedback should address three fundamental questions that guide learners: “Where am I going? (What are the goals?), How am I going? (What progress is being made toward the goal?), and Where to next? (What activities need to be undertaken to make better progress?)1”. For instance, in the classroom, providing examples of a "good" answer and posing thought-provoking questions helps foster critical thinking and self-reflecting skills. It is important to create an environment where students feel comfortable asking questions about their performance and seeking clarification on feedback as this helps promote ongoing learning and improvement. In experiential settings, educators can offer examples of both exemplary and less effective performance to help students grasp the expectations and identify areas for improvement. Another strategy is to engage students in reflective discussions about their experiences, encourage them to evaluate their performance, identify challenges, and propose strategies for improvement. Additionally, setting clear expectations and rubrics at the beginning, and tailoring feedback to each learner's specific needs, also prove to be highly beneficial for learners.

When it comes to offering feedback to adult learners, it is crucial to take into account their unique learning traits and attributes. According to Malcom Knowles, adult learning theory underscores differences between adult and child learners, emphasizing adult independence, self-direction, intrinsic motivation, problem-centered approaches, and goal orientation3. These principles inform ways that help provide effective feedback for adult learners, such as involving them in goal setting, acknowledging their experience, and delivering relevant, challenging feedback aligned with learning objectives. Encouraging social interaction among learners fosters peer and self-feedback. Therefore, it is important to provide feedback that is both actionable and in alignment with learners' goals. Additionally, respecting learners' emotions, explaining the reasoning behind feedback, and fostering a space for questions and interactions are all necessary strategies for enhancing the feedback process.

In summary, feedback plays a critical role in education, particularly within the context of adult learning. The intricacies and personalized use of feedback are fundamental for optimizing learning outcomes. Both educators and learners must navigate the complexities of providing and receiving feedback, taking into account its multifaceted nature and being willing to adjust their approaches. If feedback is used effectively, it can serve as a reliable guide to help learners achieve their educational goals.

References:

1. Hattie, J., & Timperley, H. (2007). The Power of Feedback. Review of Educational Research, 77(1), 81–112. https://doi.org/10.3102/003465430298487

2. What are the best practices for giving constructive feedback to adult learners? Best Practices for Constructive Feedback to Adult Learners. https://www.linkedin.com/advice/0/what-best-practices-giving-constructive-feedback-3c. Published August 25, 2023. 

3. Kaufman D. M. (2003). Applying educational theory in practice. BMJ (Clinical research ed.), 326(7382), 213–216. https://doi.org/10.1136/bmj.326.7382.213

Evidence-Based Study Skills Incorporated into Classroom Learning

 Michael Lucas, Pharm.D.

Studying is no doubt a huge part of becoming academically successful. However, it is not only the amount of time spent studying that is important, but the quality of the studying. Not all students are aware of different study techniques that provide stronger methods of learning. There are many different studying methods all of which vary in their degree of effectiveness. The book “Make It Stick: The Science of Successful Learning,” breaks down the learning process to a science and explains the findings on which study tactics are more beneficial. Evidence based study strategies should been incorporated into the course and lecture design.     

The many different study strategies include but are not limited to, rereading, quizzing, massed learning, spaced learning, and interleaved learning. Reflections from the past can also provide learning. From my college experience, most individuals would practice the study method of massed learning also known as cramming. Rereading and cramming all of an exam’s material in the shortest amount of time may seem like the most time effective method and get one through the exam, but by the time of the final exam, most of the material will be forgotten. Make it stick states that allowing time for forgetting to occur (spaced learning) between tasks can lead to longer term retention when compared to cramming. 

Quizzing and interleaving learning are other methods that have been shown to be effective study methods. “Make it stick” describes a study that involved middle school students who took a routine low stakes quiz for certain units of the course. During these quizzes, there were also review statements given to the students. The results showed the material that was quizzed on was an entire letter grade higher than material that had not been quizzed on. The test result for the material reviewed as statements showed no difference from nonreviewed material. This shows the lack of efficacy of only rereading material and the benefits of quizzing. Interleaving is practicing (or studying) two or more subjects/skills in mixed fashion. Interleaving has been shown to be more effective than massed practicing in a college classroom experiment. In this experiment two groups were tasked with finding the volume of four obscure solids. Initially the group doing problems in clusters (massed) had higher scores than those doing mixed problems(interleaved). However, in the final a week later, the group that did practice problems in a mixed or interleaved fashion scored an average of 63% correct compared to an average of 20% correct in the group where students did massed practice.

These concepts about learning should be applied in the instructional design of the course as well as lectures. Educators can easily incorporate spaced and interleaved learning with quizzing. At the beginning of every class, a low stakes quiz should be taken on the previous class’s material. This would be effective because assuming a 3-credit course split across 3, 1-hour sessions (i.e., Monday-Wednesday-Friday schedule), enough time has passed for some forgetting to occur. Similarly, this course’s material has interleaved with courses that are on the Tuesday and Thursday schedule. Lastly, learning can be done through reflection. By having a brief reflection after an exam regarding how the students felt about the exam, how prepared they were and what they could do to improve for the final, may lead to improve study strategies for some students. This will ultimately lead to an overall better grade and understanding of the material.

Incorporating study strategies in the classroom will only be beneficial if the student is able to pay attention and learn material in the class. The conventional learning style of teaching lecturing to the class can cause the student’s attention to drift while active learning can keep students more engaged and can help students learn more. A study conducted at Harvard showed that although students think they are learning more during traditional style lectures, their exam scores were actually higher after active learning session. Therefore, selecting a different class teaching format in the instructional design may be more appropriate. Although the different formats will not be discussed in this paper, a few examples are flipped classroom and team-based-learning. 

In summary, instructors can incorporate active learning methods and evidence-based study skills into the design of their course/lectures. Keeping students engaged will help them learn the material while incorporating spaced/interleaved learning with low stakes quizzes will help reinforce that learned material and help retain that material long term. Reflections after exams can help students to realize areas of improvement in their study skills. 

References

1.) Brown, P. C., McDaniel, M. A., & Roediger, H. L. (2014). Make it stick: The science of successful learning. Belknap Press of Harvard Univ. Press. 

2.) Reuell, P. (2019, September 5). Lessons in Learning. Harvard Gazette. https://news.harvard.edu/gazette/story/2019/09/study-shows-that-students-learn-more-when-taking-part-in-classrooms-that-employ-active-learning-strategies/ 

Self-Assessment in Pharmacy Education

Simran Rohatgi, PharmD
Pharmacy Resident

University of Maryland Medical Center

    Lifelong learning is widely accepted as an essential component of a career in healthcare. Pharmacists must keep up with the dozens of new drugs approved in the United States annually, not to mention approvals of established drugs for new indications, guideline updates, and primary literature. Pharmacy students receive constant feedback to guide their learning as they progress through both didactic and experiential components of their curricula. After graduation, however, this feedback may become less frequent as supervision becomes less direct, requiring pharmacists to gauge their own performance and guide their own learning accordingly. Incorporating self-assessment into pharmacy curricula may help future pharmacists learn to identify gaps in their own knowledge in preparation for this transition. 

In 2022, a research team at Monash University in Australia conducted a study to characterize the self-assessment skills of 162 third-year pharmacy students. Students developed action plans for an oncology case, reviewed an expert response to the case, then used a rubric to assess their own action plans two days later. The following month, students completed an end-of-course assessment containing a similar case for which they were asked to develop an action plan. Course examiners reviewed and scored the initial action plans, as well as the action plans developed for the end-of-course assessment.1

Based on previous literature, this group hypothesized that students would have a “low to moderate ability to self-assess, with low-performing students being more likely to overestimate their performance.” When students were divided into tertiles based on their scores on the action plan, it was found that middle and higher tertiles underestimated their own performance, on average, with more significant underestimation observed in the higher tertile. Students in the lower tertile, on average, overestimated their performance. There was a weak, positive correlation observed between academic performance on the action plan and self-assessment accuracy, but no correlation between performance on the end-of-course assessment question and self-assessment accuracy. Additionally, there was no difference observed between student scores on the initial action plan and the end-of-course assessment action plan, implying that the self-assessment exercise did not lead to an improvement in performance.1

     

    A limitation discussed by the authors was that students likely do not have a clear understanding of the value of self-assessment, which may have impacted the way they completed these assessments.1 Additionally, knowing that they will receive expert feedback may lower students’ motivation to conduct a thoughtful self-assessment. The fact that self-assessments are submitted to faculty may also impact how they evaluate themselves; for instance, grading themselves lower to avoid appearing overconfident. 

In their 2010 review, Motycka and colleagues also emphasize the importance of self-assessment in pharmacy education, and the role it plays in the development of skills needed for independent learning as a practitioner. Additionally, they highlight that self-assessment plays an important role in the decision of a practitioner to ask for assistance when necessary.2 While it is undoubtedly true that self-assessment is an important tool to incorporate into pharmacy education, the results of the study at Monash University suggest that students often lack the ability to self-assess accurately. Motycka and colleagues make several recommendations to address this issue, including emphasizing external feedback, using learning tools that work in conjunction with feedback and self-assessment such as Objective Structured Clinical Examinations (OSCEs), and developing a “reflective thinking process.”2 

For Doctor of Pharmacy programs, the Accreditation Council for Pharmacy Education requires “examples of tools used by students to document self-assessment of, and reflection on, learning needs, plans, and achievements and professional growth and development.”3 This highlights, again, the importance of introducing the concept of self-assessment early. However, simply incorporating self-assessment into the curriculum alone may not be sufficient for helping students develop lasting skills. Discussing the value of self-assessment, and how the practice benefits pharmacists at all points in their careers, may encourage students to place a higher value on developing these skills. 

References 

1. Abeyaratne C, Nhu T, Malone D. Self-Assessment of Therapeutic Decision-Making Skills in Pharmacy Students. Am J Pharm Educ. 2022;86(4):8696. doi:10.5688/ajpe8696

https://pubmed.ncbi.nlm.nih.gov/34507958/

2. Motycka CA, Rose RL, Ried LD, Brazeau G. Self-assessment in pharmacy and health science education and professional practice. Am J Pharm Educ. 2010 Jun 15;74(5):85. doi: 10.5688/aj740585. PMID: 20798800; PMCID: PMC2907850.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907850/

3. Accreditation Council for Pharmacy Education. Ann Pharmacother. 2004;38(1):195-196. doi:10.1345/aph.1n044

https://www.acpe-accredit.org/pdf/Standards2016FINAL2022.pdf

Rethinking Examinations in Pharmacy School Education: A Critical Appraisal through the Lens of Instructional Design.

Mariam Momani, PharmD

Examinations have been a staple of education, including pharmacy school education, for a long time. These assessments are typically used to evaluate a student's understanding of course material, but their efficacy in promoting meaningful learning and ensuring the development of competent professionals is a subject of ongoing debate. While examinations can have a place in the educational process, a more holistic approach that incorporates various assessment methods is necessary to better align with instructional design principles and promote comprehensive learning. 

Instructional design is a systematic process of creating, implementing, and evaluating instructional materials and strategies to facilitate effective learning. It encompasses several principles and methods aimed at maximizing learning outcomes. When examining the role of examinations in pharmacy school education, we must evaluate their alignment with these principles and consider how they should be applied by educators. 

Instructional Design and Examinations

One fundamental principle of instructional design is the use of a diverse range of assessment methods to measure different types of learning outcomes. Examinations, often relying heavily on multiple-choice questions, may not adequately assess higher-order cognitive skills such as critical thinking, problem-solving, and practical application of knowledge. Educators should consider incorporating various assessment types, including case-based assessments, oral examinations, and hands-on practical evaluations, to holistically evaluate students' abilities. 

Formative assessments that provide ongoing feedback to learners, allows them to monitor their progress and make improvements. Examinations, especially high-stakes ones, often serve as summative assessments, providing limited opportunities for formative feedback. Educators should integrate regular formative assessments throughout the learning process to help students identify areas of weakness and address them proactively. Authentic assessment tasks mirror real-world situations and require students to apply their knowledge and skills in practical contexts. Traditional examinations may fall short in this regard, as they often assess memorization rather than practical application. Pharmacy educators can enhance the authenticity of assessments by incorporating clinical simulations, patient case studies, and medication management exercises into their evaluation methods.

Instructional design principles emphasize active learning, where students are actively engaged in the learning process. When examinations are used exclusively, it may cause students to engage only in passive learning and rote memorization. To foster active learning, educators should incorporate collaborative activities, group discussions, and problem-based learning methods. Effective instructional design encourages the practice of timely and constructive feedback. Examinations typically offer limited opportunities for detailed feedback, hindering students' ability to reflect on their performance and make meaningful improvements. Pharmacy educators should consider integrating post-examination feedback sessions and self-assessment activities to promote reflective learning.

The Limitations of Examinations

While exams can play a useful and convenient role in assessing certain aspects of pharmacy education, they have several inherent limitations that must be acknowledged. Examinations often encourage surface learning strategies, where students memorize only the information needed to pass the test, rather than with the intention of deep understanding and critical application of the knowledge. This misalignment with instructional design principles can lead to graduates who lack the problem-solving skills required in real-world pharmacy practice. High-stakes examinations can induce a lot of test anxiety, which can negatively impact students' performance and overall learning experience. This anxiety may undermine the ultimate goal of pharmacy education and hinder their ability to apply knowledge effectively in clinical settings. Examinations may inadvertently introduce assessment bias, favoring students who excel in test-taking but not necessarily in practical skills or patient-centered care. This can result in a disconnect between assessment outcomes and the competencies required for pharmacy practice. Traditional examinations may not effectively assess the transferability of knowledge and skills to diverse pharmacy practice settings. Graduates may struggle to adapt their knowledge to evolving healthcare challenges and emerging patient needs.

Alternative Assessment Strategies

To align pharmacy school education more closely with instructional design principles and address the limitations of examinations, educators can consider implementing alternative assessment strategies. Objective Structured Clinical Examinations (OSCEs) may simulate real clinical encounters, allowing students to demonstrate their practical skills and decision-making abilities. Using case studies can allow students to apply their knowledge to real patient scenarios, fostering problem-solving skills and critical thinking. These methods may promote authentic assessment and active learning. Incorporating peer and self-assessment into coursework may encourage reflection and self-regulated learning. It provides opportunities for formative feedback and continuous improvement. Lastly, keeping electronic portfolios may allow students to compile evidence of their learning journey, including reflections, achievements, and experiences, which can promote self-assessment, reflection, and documentation of learning experiences.

Conclusion

While examinations have been a traditional method of assessment in pharmacy school education, their efficacy in promoting comprehensive learning and aligning with instructional design principles is questionable. Pharmacy educators must critically appraise their use of examinations and consider alternative assessment strategies that align more closely with instructional design principles. By embracing diverse assessment methods, including OSCEs, case-based learning, peer and self-assessment, and e-portfolios, pharmacy schools can better prepare students for the challenges of real-world pharmacy practice. This approach promotes active learning, critical thinking, authentic assessment, and continuous improvement—key elements of effective instructional design. Ultimately, a more balanced and holistic approach to assessment will contribute to the development of competent and patient-centered pharmacy professionals.

References:

1. Smith, J. K., & Worsfold, K. (2002). Assessment in higher education: Student learning, teaching, programs, and institutions. Assessment & Evaluation in Higher Education, 27(5), 359-369.

2. Van Der Vleuten, C. P. M. (2016). The assessment of professional competence: Developments, research and practical implications. Advances in Health Sciences Education, 21(2), 259-266. doi:10.1007/s10459-015-9610-6

Content Integration in Pharmacy Education

Makenzie Harrison, PharmD
PGY2 Psychiatry Pharmacy Resident
University of Maryland School of Pharmacy

    Behaviorism, one of the most common learning theories, requires repetition and reinforcement for sustained learning.1 Pharmacy education has traditionally been executed through “silo-like” courses where a single or select few faculty members are responsible for the content.2 A recent survey of faculty members from 94 pharmacy schools regarding curricular integration demonstrated a variety of methods being used such as themed content alignment, skills laboratories, multi-disciplinary case studies and examinations, introductory and advanced pharmacy practice experiences (IPPE/APPEs), capstone course, team-based learning, and performance-based assessments. Out of the schools surveyed, only seven indicated no formal curricular integration between science and practice. In a perception analysis of curricular integration on knowledge-acquisition, high-order thinking, and application to clinical practice (in the case of APPEs), over half of the 145 respondents strongly agreed or agreed that curricular integration improve learner performance in the aforementioned domains.3 

Learners also acknowledge the benefits of content integration as demonstrated in a study of pharmacotherapy and evidence-based medicine (EBM) courses aligned over the course of one semester. Instructors coordinated and incorporated landmark trials with cardiology and infectious disease pharmacotherapy courses and evaluated benefit through the ACE (Assessing Competency in Evidence-Based Medicine) tool utilizing data from a non-aligned semester as the comparator and found a statistically significant difference in learner performance in the intervention group. Learners completed both post-assessment and -semester evaluations, the latter evaluating skills gained proportional to time invested and alignment aiding EBM and pharmacotherapy understanding. The majority of learners responding strongly agree or agree (79.6%, 94.2%, and 69.9%, respectively) and 90.3% of learners were in favor of continuing to incorporate landmark trials within pharmacotherapy courses. 4

Data from both faculty and learners supports formal content alignment and curricular integration within pharmacy education, so what is holding us back? Curricular integration exists in multiple forms, such as horizontal, vertical, and spiral integration, the latter combining both preceding methods. Implementation of integration allows for the reinforcement of content over time and progression of learner skills from novice to mastery, further reinforcing the learning theory of behaviorism.1,2 There are many challenges facing curricular integration from both logistical and professional standpoints. As new therapeutics are developed and guidelines updated, the amount of content to be taught in the same amount of time presents a challenge for course designers. Faculty who delivers the content are also faced with the challenge of removing content that is no longer clinically relevant but potentially still important to them. With the degree of content growth, it is imperative for designers to ensure content is not repeatedly rehashed, but rather streamlined through collaboration.2 One method to content integration and streamlining is through team-based learning (TBL).

A defined application of content integration through team-based learning is demonstrated by The Regis Model. This model was designed to integrate “biological, pharmaceutical, social/behavioral/administrative pharmacy and clinical sciences using a teaching methodology that is [learner]-centered emphasizing high-order learning” to meet increasing demands for pharmacy education to shift away from knowledge transmission towards enhanced critical thinking and problem-solving. Learners are organized into small groups in which application-based activities are completed after independent study.  Seven courses with sequences are administered over the first three professional years to implement horizontal and vertical integration (which, when combined, exhibits spiral integration). For example, one of the courses, integrated pharmacotherapy (IP), is facilitated by a multidisciplinary team around an individual disease state. After developing learning objectives as a team, faculty utilizes a template for learner resources to cover the following elements: introduction, anatomy, physiology, biochemistry, etiology, presentation, diagnostics, classification, goals of treatment, non-pharmacotherapy, pharmacotherapy (formulation, ADME, interactions, etc.), therapeutic application of EBM, research opportunities, and public health factors (screening, prevention). While the IP course is being administered, learners are concurrently enrolled in integrated laboratory (IL) which provides hands-on activities that align with the disease state being covered in IP – emphasizing horizontal integration. Vertical integration is demonstrated through the introduction of topics earlier in the didactic curriculum then revisited later. The ratio of basic science versus clinical application is also modified based upon the learners’ academic year, focusing more on basic science earlier in the curriculum and clinical application towards the end of didactic training – exhibiting spiral integration.5

In this case of integrated curriculum through team-based learning, we see results complementary to studies previously published. Both learners and faculty agreed there is a positive impact of TBL in the administration of integrated curriculum. Learners demonstrated improved confidence in independent learning, teamwork, critical thinking, an expression of professional opinions while faculty noted enhanced preparedness for class, engagement, and self-responsibility for learning.5 

Team-based learning via The Regis Model is just one approach to integrating pharmacy curriculum, however other methods exist. The key takeaway from this discussion is that content alignment and integration of coursework produces more confident, prepared learners who can solve real-world problems in a growingly interprofessional environment, demonstrated through objective improvements in performance during their didactic training. 

References

1. Badyal DK, Singh T. Learning Theories: The Basics to Learn in Medical Education. Int J Appl Basic Med Res. 2017;7(Suppl 1):S1-S3. doi: 10.4103/ijabmr.IJABMR_385_17

2. Sun D, Kinney J, Hintz A, Beck M, Chen AMH. Advancing Pharmacy Education by Moving From Sequenced "Integration" to True Curricular Integration. Am J Pharm Educ. 2023;87(6):100056. doi:10.1016/j.ajpe.2023.100056

3. Poirier TI, Fan J, Nieto MJ. Survey of Pharmacy Schools' Approaches and Attitudes toward Curricular Integration. Am J Pharm Educ. 2016;80(6):96. doi:10.5688/ajpe80696

4. Bowers BL, Sperry M, Englin EF, Wombwell E. Evidence-Based Medicine and Pharmacotherapy Content Alignment [published online ahead of print, 2023 Jun 28]. Am J Pharm Educ. 2023;100554. doi:10.1016/j.ajpe.2023.100554 

5. Nelson M, Allison SD, McCollum M, et al. The Regis Model for pharmacy education: A highly integrated curriculum delivered by Team-Based Learning™ (TBL). Curr Pharm Teach Learn. 2013; 5(6): 555-563. doi:10.1016/j.cptl.2013.07.002

Pass/Fail Grading in Pharmacy Education

Katie Zimmerman, PharmD, MS
PGY-1 Pharmacy Resident
MedStar Harbor Hospital

The current grading system used in education has origins in the grading scale implemented by Yale president Ezra Stiles in 1785 and was based on the descriptions Optimi, Second Optimi, Interiores, and Perjores1 . Prior to that time, assessments were used as a formative learning tool instead of an evaluative one - meaning that they were used to identify gaps in a student’s learning and assess how to address them moving forward in a student’s education1 . In the early 1900s, American education began to prioritize standardized communication between different academic institutions which led to the A-F grading system being adopted in many schools, including pharmacy schools, across the country1,2. Systems like this, which can induce a spirit of competition between students as well as which can cause students to focus solely on their grade instead of the ongoing learning process, have been debated by scholars for as long as grading has been practiced. 

In more recent years, there has been a movement toward a pass/fail or a modified pass/fail grading system in the pharmacy school setting. The aim of this shift in practice is to emphasize student learning over attainment of letter grades. In fact, the University of Buffalo School of Pharmacy just launched a new modified pass/fail grading system in its school with the goal of “graduating pharmacists who provide high-quality patient care, engage in research and scholarship, and take a leadership role in advancing the practice of pharmacy” because “letter grades are not always an accurate measure of learning.”3 Educators at this institution hope that by shifting the focus from a grade to what was learned and what needs to be reviewed students will be better able to understand and apply the information moving forward3 . On top of the emphasis on learning, students in schools which have transitioned to pass/fail grading systems have increased well-being, increased motivation, and collaborate better with their fellow students while having a decreased sense of competition, anxiety, and stress3,4.

A recent study surveyed US pharmacy schools which utilize pass/fail grading. Of the eight schools which responded, all of them used a pass/fail system for introductory pharmacy practice experience (IPPE) courses with the majority (88%) also using them for didactic, elective, laboratory, and interprofessional courses as well as advanced pharmacy practice experiences (APPEs)4 . The institutions used differing language (ex. pass, no pass, satisfactory, unsatisfactory, etc.) within each of their pass/fail systems as well as had varying minimum pass levels ranging from 70% to 90%4 . One institution calculated a GPA based on each student's numerical grade while other institutions provided class rank, overall percentile, or comments from APPE preceptors4 . The individual schools all had their own processes to address student failure/remediation to determine student progression within the program4. 

A concern some in the field have from this pass/fail system is whether or not a graduate is adequately prepared for what comes after their PharmD program. Are they looked upon poorly for residency consideration? Are adequately prepared for the North American Pharmacist Licensure Examination (NAPLEX)? The survey respondents also differed in how information was communicated to residency program directors with some calculating a GPA and others including more qualitative information or an explanation of how the pass/fail system worked at their institution4 . The Medical College of Wisconsin School of Pharmacy has graduated three cohorts using the pass/fail system which have exceeded the national average for residency placement rates3 . With regard to passing licensing exams, these students have also matched or exceeded the national level for NAPLEX pass rates3. 

While the adoption of pass/fail grading systems in US pharmacy schools lacks standardization, it does not inhibit students’ prospects as they move forward into pharmacy careers. Students also experience less stress and anxiety while increasing their collaboration with others during their time in school. Given these facts, all pharmacy schools should consider a shift to pass/fail grading in their institutions for experiential learning as well as didactic and laboratory courses. Adoption of these methods in more schools will increase data surrounding best practices to allow schools to continue to adjust their pass/fail systems for the benefit of their students. 

References: 1. Lee C. What is the history of grading? Turnitin. October 14, 2020. Accessed September 30, 2023. https://www.turnitin.com/blog/what-is-the-history-of-grading. 2. McNutt C. A Brief History of Grades and Gradeless Learning. Human Restoration Project. August 8, 2022. Accessed September 30, 2023. https://www.humanrestorationproject.org/writing/a-brief-history-of-grades-andgradeless-learning. 3. Ponushis A. Are grades failing students? American Association of Colleges of Pharmacy. 2023. Accessed September 30, 2023. https://www.aacp.org/article/aregrades-failing-students. 4. Spiess JP, Walcheske E, MacKinnon GE, MacKinnon KJ. Survey of Pass/Fail Grading Systems in US Doctor of Pharmacy Degree Programs. Am J Pharm Educ. 2022;86(1):8520. doi:10.5688/ajpe8520

Self-Directed Learning’s Place in Pharmacy Curriculum

William Cappuccio
PGY-1 Resident University of Maryland Medical Center

When I was a pharmacy student, the COVID-19 Pandemic had forced us into online learning environments. This was the first time that I was introduced to the concept of Self Directed Learning (SLD). Robinson and Colleagues (2020) define SLD as a process where students take responsibility for learning well beyond what is presented by an external body. (2) The external body is represented as a teacher, lecture, or classroom in which the responsibility of learning falls on the instructor and their materials. During the Pandemic, many of my colleagues felt cheated because they believed that the amount of money they were paying for tuition should not constitute the need for SLD. Yet, for pharmacists to improve their practice, it is essential for them to be lifelong learners. They must develop the ability to learn about subjects without the guidance of an instructor. This independence is important for a pharmacist because they need to be able to take information they have gathered and implement into their own practice. This leaves the question of SLD’s place in pharmacy learning? Here I will dive into the basics of Self-Directed Learning, its place in pharmacy practice, and whom it is best used for within the pharmacy curriculum.

Helping a learner develop the skill of Self Directed Learning is a 6 step process. It includes: developing goals for study, developing an assessment to know when the learner has reached their goals, identify structure and sequence of activities to achieve their goal, lay out a timeline to complete their activities, identify resources to complete their activities, and locate a mentor/faculty member to provide feedback on their plan (2). This process is extensive and can be a lot for a learner to take on especially as a P1 student. What is important to note is that implementing this process should be a sequential process(2). It should happen gradually as the student progresses out of the classroom and into experiential learning space. As this happens the responsibility of learning should then shift from teacher to student. Yet many times this is often implemented too early in a curriculum and is often an expectation from the beginning of a student pharmacist’s career. This can easily overwhelm the student resulting in a loss of motivation. Timing is everything in a student’s career and experience, and it is up to the instructor to understand when students should be comfortable enough to learn independently.

Self Directed learning is best facilitated when the learner is intrinsically motivated, or has the desire to look into pharmacy related information themselves. Akbar and colleagues (2017) found that in medical students, when they scored high on intrinsic motivation inventory (IMI), it correlated with a higher self directed learning readiness scale (SLRDS). (3). What is great about graduate professions is that students are usually intrinsically motivated to learn about their selected field of study. After all they did choose the profession! Yet, not all students find intrinsic motivation easy to come by. Many factors can  influence their motivation and what drives them to be motivated can often be halted by factors out of their control.

There are also often barriers within an academic system that can impede SLD development and impact intrinsic motivation. Douglass and colleagues (2014) report three stages in which barriers are developed to self directed learning: student-controlled, faculty-controlled, and administration-controlled(1). Student-controlled barriers included the ability to be proactive in class, proactive with other students, proactivity outside of class, develop good study habits, and understanding their own learning styles. Faculty-controlled barriers included difficult class structure, curriculum design, and professor attitudes and traits. Administration-controlled barriers included lack of infrastructure, resources, and student incentives. It's easy to list the multitudes of barriers to learning, but it's hard to overcome these barriers. Resources are always limited, even in higher-education settings such as pharmacy schools. With limited resources it's important to direct them to the barriers that can be overcome and focus on skills that the student can learn and be responsible for honing themselves.

So with all these issues where does this leave Self-Directed Learning? In my opinion it is an essential skill for a pharmacist. Yet, it is something that is learned over time and is a skill that is continuously developed even after a student graduates and starts their career as a pharmacist. Its implementation should be layered into the curriculum starting with small activities such as drug information questions, pre-readings for lecture, or learning how to use drug information materials such as Micromedex. It then progresses into more complex activities such as setting learning goals for a rotation, implementing research project deadlines, or independent searches for complex patient related questions from a multidisciplinary team. This won't happen without the student’s own motivation to be a lifelong learner. I don’t think this is something they solely develop on their own. They learn it through examples of other pharmacist’s passion and their peers. They also learn it through praise and support from their peers and mentors. There are barriers to developing SLD skills and intrinsic motivation, but many can be overcome by giving students investigational skills to be independent. Resources are always limited, but delegating resources to the barriers the easiest to overcome is the best way to improve student’s ability to be successful Self-Directed Learners. In summary, Self Directed Learning is the essence of a true pharmacist and requires training to be able to utilize this essential skill. 

References:

1. Douglass, Carolinda, and Sherrill R. Morris. "Student perspectives on self-directed
learning." Journal of the Scholarship of Teaching and Learning (2014): 13-25.

2. Robinson, Jennifer D., and Adam M. Persky. "Developing self-directed learners."
American Journal of Pharmaceutical Education 84.3 (2020).

3. Akbar, S., M. Claramita, and T. N. Kristina. "Intrinsic motivation and self-directed
learning relationship: Strive for adult learning character formation." South-East