Team-Based Learning

Whitney Pittman, PharmD

PGY2 Pharmacy Resident

Children's National Health System

Team-based learning (TBL) is a form of group-learning that encourages students to prepare prior to class and then apply their learning once in the classroom. Students are assigned to a permanent team of 5-7 people which holds them accountable for each other’s learning¹. Modules are taught in a three-step cycle: preparation, in-class readiness assurance testing (iRAT), and application-focused exercise².

How To Use Team-Based Learning

Each module can either consist of a single class session or can cover material over several sessions. Students are expected to prepare for class by either watching informational videos, completing readings, or reviewing PowerPoint lectures. At the beginning of class, students complete a test individually to assess their knowledge on the material. This test is referred to the “individual Readiness Assurance Test” or iRAT¹. This encourages the student to come to class prepared. Students then get into their respective groups and complete the test with their group members. This test is referred to as the “group Readiness Assurance Test” or gRAT¹. The test is typically multiple-choice and students grade the test themselves, which fosters discussion amongst group members of why the right answer correct and why the other answer choices are not the best option. At this point, the instructor provides a mini lecture of the material and engages the class in discussion. The final part of the class session is an application activity that requires teams to make a specific resolution to a problem¹.

Four Principles of Team-Based Learning²

1.      Permanent groups should be properly formed (e.g., various intellectual capacities, members of each healthcare profession)

2.      Students are held accountable for pre-learning and working as part of a team.

3.      Teams promote learning and team development

4.      Students must receive regular feedback

Team-Based Learning in Pharmacy Schools

Thirty-three percent of pharmacy schools in the United States are utilizing TBL as part of their curriculum³.  Authors of “Team-Based Learning in US Colleges and Schools of Pharmacy” issued surveys to different colleges of pharmacy in hopes to characterize the use of TBL. Authors sought to identify factors among faculty members that affect implementation and perceptions that impact TBL. Faculty members reported that student preparation and engagement during class was increased as a result of implementing TBL³. Different measures of effectiveness include grades for the entire course, final exam grades, and summative assessments. Authors concluded that TBL enhances engagement, improves preparation prior to class, and promotes achievement³.

Examples of TBL

My pharmacy school curriculum utilized TBL in two separate courses. The first was during Pharmacotherapy Self-Care. Each week, we were required to read a chapter from the Non-Prescription Handbook and read two patient cases relating to the topic that week. When we first arrived to class, we individually took a quiz that was worth 10 points. As a class, the instructors would lead a discussion about the patient cases and potential non-prescription treatment options. At the end of class, we would take a quiz within our groups that was worth 5 points. The point breakdown held us as students accountable to do the reading prior to class and not rely on our group members. At the end of class, we took a group quiz that had different questions than the individual quiz, but focused on the same information. The whole session promoted self-instructed learning, analysis of the information, and group discussions to foster working as part of a team.

My second experience of TBL was as part of an interprofessional education course. All first-year health science students were required to take a weekly course where we were broken up into groups of about nine learners, each of various health professions. Prior to class, we completed readings or watched instructional videos pertaining to that day’s topic. We took an individual quiz immediately followed by a group quiz consisting of the same questions. The rest of the class session consisted of a discussion among groups and then an exercise where we applied the material to a scenario. TBL was the best way to teach this course because each group consisted of different members of the healthcare team and encouraged discussion of the scenario from each perspective.

At the end of each semester, both courses required us to provide feedback about our team members. This also held each student accountable because we if one person wasn’t prepared, the whole group would notice.

In conclusion, team-based learning is an effective instructional method for encouraging individual preparation, fostering working as part of a team, and application of materials presented during class.

References

1. Brame CJ. Team-based learning [Internet]. Nashville, TN: Vanderbilt University. Center for Teaching. [cited 2018 Sep 29]. Available from: https://cft.vanderbilt.edu/guides-sub-pages/team-based-learning/

2.  What is TBL? [Internet]. Huntingon, WV: Team-Based Learning Collaborative. [cited 29 S018 Sep 29]. Available from: http://www.teambasedlearning.org/definition

3.  Allen RE, Copeland J, Franks AS, Karimi R, McCollum M, Riese DJ 2nd, Lin AY. Team-based learning in US colleges and schools of pharmacy. Am J Pharm Educ. 2013 Aug 12;77(6):115.

Optimizing self-actualization in a learner

Optimizing Self-Actualization

O'Neal Malcolm, Pharmacist, University of Maryland Medical Center

     Over the years I’ve had the opportunity to precept pharmacy students with various backgrounds, interests and motivation.  I have encountered students who appeared to excel academically, but seemed severely preoccupied with life events that affected their learning.  In fact, some students shared with me some social, academic and home issues that left them feeling dull and unexcited about finishing the final few months of their last Advanced Pharmacy Practice Experience (APPE) rotation.  Those students were more inclined to focus on solving their “life” problems rather than engaging in active learning, and some expressed extremely low interest in pharmacy careers after graduation.  To be fair, some of the issues students shared with me would be overwhelming for anyone who had to deal with them, and while I didn’t get a sense that they were clinically depressed, they lacked motivation. There is a strong correlation between motivation and academic performance among pharmacy students (Pate, Payakachat et al. 2017).

     My goal as a preceptor is to ensure that students successfully complete the rotation’s learning requirements, and are inspired to be highly competent pharmacists in any position. I believe I was successfully able to achieve those goals based on students’ feedback, and progress reports from past students.  For students in situations described above, it was different because they didn’t demonstrate any learning difficulties, but appeared more self-defeated compared to other students who completed the rotation.  Such students seemed to be thinking of putting learning on the “back burner” a few months before graduation. It was therefore important for me in those circumstances to find away to not just merely provide verbal encouragement to those students during the rotation, but to implement practical strategies within the rotation’s design and curriculum that would shift their focus back to learning and achieving.  This posed a challenge because I would have to modify the curriculum which would take time and energy, both of which are fleeting.  None-the-less it was worth the effort, plus the situation gave me an opportunity to re-review previous Continuing Education (CE) information and notes on strategies for improving motivation in students. The review of CE notes led me to the concept of Maslow's Hierarchy of Needs. 

     Maslow's Hierarchy of Needs posit a five-stage model of human needs, often portrayed as ranked levels within a pyramid.  In ascending order these include: (1) physiological (e.g. food, home, clothing and rest), (2) safety (e.g. absent parents and unsafe neighborhood), (3) love/belonging (e.g. friendships, family relations, and extracurricular activities), (4) esteem (e.g. confidence, achievement, and recognition), and (5) self-actualization (desire for self-fulfillment).  Lower needs should ideally be gratified before higher-tiered needs can be attained.  The first four tiered needs are considered deprivation needs; which means that an individual who did not achieve one or more of those needs will be motivated towards achieving the deficient need(s) ( Burleson & Andrew, 2018). 

Aside from directing students to resources and possible programs, It is near impossible to address all deficient needs for students such as clothing, shelter, and adequate sleep (physiological needs).  It was possible, however, to address safety needs such as providing clearly defined rotation expectations and learning behaviors/outcomes, providing daily schedules of assignments/activities, and allowing students to feel comfortable expressing their thoughts whether through answering questions, asking questions, or providing feedback, without fear of ridicule.  I developed opportunities to address ‘belonging’ needs such as informing students regularly that they were a valued member of the department’s team, and that all of their efforts are appreciated (Burleson & Andrew, 2018).

     I’ve utilized a modified Maslow type questionnaire to elicit and address students’ current basic and learning needs.  Implementation of the Maslow type questionnaire would be conducted after obtaining consent from students. Results of the questionnaire often demonstrate that low motivated students have little to no deficiency of stages 1-4, but seemed to be lacking self-actualization (stage 5).  While it was a relief that I wouldn’t have to contend with any deficiency needs for stages 1-4, and focus more on their growth needs (self-actualization), I wondered how I would practically optimize self-actualization over 5 weeks. 

     Self-actualization according to Maslow is a desire for growth and fulfillment of ones  potential or meaning in life.  Maslow suggested that few individuals would fully attain self-actualization since it is impacted by deficiency needs (stage 1-4) (Selva, 2018).  Finding practical examples of self-actualization was challenging since most studies reviewed discussed self-actualization as a theoretical concept versus stages 1-4 where practical examples could be found.  A few studies and online resources highlighted techniques that were integrated into the curriculum (Janowiak and Hackman 1994, Jackson, Santoro et al. 2014).  These include: (1) using "real" life scenarios to make learning meaningful, (2) utilizing metacognitive activities in lesson plan, (3) assigning students to self-expressive projects, and (4) allowing students to be involved in creative activities and projects (SUNY Cortland,1994).  Specifically, students discussed and reviewed with me weekly cases of patient and provider encounters; and for the metacognitive activity students engaged in weekly self-reflection of rotation activities focused on goals achieved, skills learned/acquired, strategies used to solve problem(s), and self-assessment/evaluation of progress towards completing requirements for the rotation. Creative activities involved students creating color coded medication reminders to improve medication adherence; and others collaborated on a “high-risk re-admitted patients” project with an interdisciplinary team consisting of a physician, nurse, social worker, community health worker, and pharmacist.

Weekly self-reflection sessions with students demonstrated improvement in motivation and desire to learn and achieve.  Students involved in performance improvement exercises expressed favorable satisfaction, and those involved in collaborative project felt a sense of satisfaction by being a member of a valued team.  All students believed that the learning activities focused on self-actualization kept them busy and productive, and less focused on their problems.

     Preceptors can contribute to identifying students’ need(s) to improve ability to learn and achieve.  This does, however, require time and effort to get to know the students’ need(s) by (if applicable) using motivational and theoretical constructs such as Maslow’s Hierarchy.  Maslow's Hierarchy of Needs allowed me to use a systematic approach and framework for addressing barriers to learning.  The more a preceptor understands the learning needs of his/her students, the higher the probability of minimizing learning obstacles and optimizing learning.

Application of Maslow’s Hierarchy of Needs has resulted in struggling students successfully completing the rotation. Previous students have shared updates such as pursuing PGY1 and/or PGY2 pharmacy residency programs; or working in leadership positions.

References

Burleson, S., & Andrew, C. (2018). Maslow’s Hierarchy of Needs and Its Relation to Learning and Achievement. Retrieved from https://edis.ifas.ufl.edu/pdffiles/WC/WC15900.pdf

Jackson, J. et al. (2014). Improving Patient Care Through the Prism of Psychology: application of Maslow’s Hierarchy to Sedation, Delirium and Early Mobility in the ICU. Journal of critical care, 29(3), 438-444.

Janowiak, J. J., & Hackman, R. (1994). Meditation and college students' self-actualization and rated stress. Psychol Rep, 75(2), 1007-1010.

Pate, A. et al. (2017). Measurement of Grit and Correlation to Student Pharmacist Academic Performance. American Journal of Pharmaceutical Education 81(6): 105.

Selva, J. (2018). What is Self-Actualization: A definition plus examples. Retrieved, from https://positivepsychologyprogram.com/self-actualization/

SUNY Cortland. (1994). Suggestions for application of Maslow's theory to education, Retrieved from http://web.cortland.edu/andersmd/MASLOW/SUGGEST.HTML

Dual-Coding Theory: Is it still seen?

By: David M. Lewis, PharmD

PGY-1 Pharmacy Practice Resident

Shady Grove Medical Center

What is Dual-coding Theory1,2

In 1971 and in 1986, Allan Paivio developed the theory of dual coding. This was a way to explain an aspect of human cognition. It was the idea that a person’s recall and recognition was enhanced by the use of nonverbal and verbal information together. It is essentially the theory that there are two separate pathways for translating or “coding” information into memory, one verbal and one visual, and that these are connected yet operating independently. An example would be if someone were to show a picture of a bike and on the picture there was the word “bike” and this would be accompanied by someone verbalizing that the image was a bike. This would all be done at once and the idea was that the person would have better memory of the image that was shown in a future point in time. The theory expects essentially increase memory capacity that all learners would see benefit if visual information is layered over linguistic information that is completely verbal.

Is Dual-coding an effective learning style?2,3

Some studies dating back to the 1980’s, there has been efforts to try and explain the best way for a person to learn and retain information. Two of the many ways to learn included dual-coding and the learning styles hypothesis. The dual-coding learning style, like described above, is the idea that a person’s recall and recognition was enhanced by the use of nonverbal and verbal information together. However, the learning styles hypothesis suggests that all people have a certain style through which they prefer to process information. If people are presented certain preferred process, then learning could be improved in some way. This theory suggests that a learner’s preference should be considered by educators and if the they match the form of instruction to the learner’s preferred “learning style”, then the learner will retain more information or will learn at an increased rate.

In a recent study of 204 university students, the study tested these two cognitive models, the learning styles hypothesis and dual-coding, which make contradictory predictions about how learners process and retain visual and auditory information. In this study, it showed that students in the visual condition considerably outperformed those in the auditory condition regardless of learning style. Therefore, the results regarding dual-coding were clear, and the initial predictions were confirmed that participants of the study would perform better in the visual condition regardless of learning style. When learners were asked to process both visual (nonverbal) and linguistic (verbal) information simultaneously, they retained substantially more information, twice as much, as those who were prompted to focus only on auditory/linguistic information.

Perspective

Being someone that grew up with the idea of the learning styles hypothesis was the best way to learn, I was unaware of the dual-coding theory. Looking back on my education, I realized that dual-coding was more integrated into my education than originally may have thought. In addition, I realized that I prefer the ideas dual-coding learning and it actually allowed me to better retain information. Looking at the bigger picture in regards to teaching in general, we may not necessarily use photos directly in hand, but

we tend to use technology to aid in education and inadvertently end up using the dual-coding theory. The evolution of dual-coding theory is quite evident. Educators today could be using dual-coding through the multimedia applications in their classrooms. These multimedia applications make use of text, image, audio and video at the same time in correlation with teaching methods of verbal presentation of information.

As someone that is going through this teaching certificate program and we talk about the best to know your students; the best way to approach learning; and the many different ways of teaching. I feel that dual-coding is something I would want to integrate into my teaching style. Would I embrace it as my only teaching style? I don’t think that would be fair and it would be setting students up for potentially failure. Dual-coding is great for retaining or in other words memorizing information. However, as a clinician there isn’t one correct answer for a certain disease state because there are always different patient factors that would guide a person to a different solution. I think dual-coding should be integrated more into teaching because dual-coding is great in “theory”, but not necessarily the best theory.

References

1. Clark JM, Paivio A. Dual Coding Theory and Education. Educational Psychology Review. 1991;(3)3:149-210.

2. Questia. Dual-Coding Theory. https://www.questia.com/library/education/educational-psychology/learning-styles-and-theories/dual-coding-theory. (Accessed 2018 Sept 22).

3. Cuevas J, Dawson BL. A test of two alternative cognitive processing models: Learning styles and dual coding. Theory and Research in Education. 2018, Vol. 16(1) 40–64.

Building Blocks: Longitudinal vs. Blocked Structured Curriculum

Christine Dimaculangan

PGY-2 Ambulatory Care Resident

University of Maryland School of Pharmacy

During my career as a pharmacy student, the learning model was a longitudinal model or a model in which we learned everything through subject matters (i.e. pharmacology, immunology, pharmaceutics, etc.). As I was ending my career as a pharmacy student, the pharmacy curriculum at my alma mater was preparing to change over to the module-based learning model. What does this mean for students? Is this learning model something that all pharmacy schools should be striving towards?  In this piece, I will be exploring what makes the blocked learning module a model that we should or should not be moving forward with in the world of pharmacy education.

Module-based learning “packages course content into shorter, logically self-contained units which cover the content usually covered by a conventional longer course.”¹ This model (theoretically) allows for students to grasp concepts in its entirety before moving unto another subject matter. It also allows for students to hone in on what subject matter they truly need to focus on; in cases where students might not succeed in grasping concepts in the first go around, they are able to just focus on what they may have missed in the initial session. Cornford also mentions in his article how advantageous it is to teach in such a model because of the flexibility it lends itself. It may be simpler to create content in the classroom when the curriculum is in the module format because it has a more focused approach, as opposed to a generalized approach in the traditional setting.

Along with the other things mentioned previously, this “shorter” and “condensed” model lends itself to allow specific concepts to be addressed at the forefront. It also allows for additional experts in each area to bring their knowledge to the table and bring differences in perspectives, allowing for a more enriching environment. While it may seem like something that takes more work than anticipated, in the long run, the flexibility may overturn the complications of planning. In the long run, students may retain the information better because of how condensed and specific it is.

While there may be excellent points to use this kind of model, there are always cons and areas of improvement that should be taken into consideration. After all, nothing is perfect. Due to the condensed nature of this model, it is noted that there might not be adequate time to ensure feedback is given, both from the perspective of the student and of the professor. There is also the question of whether the condensed version of these topics may be too condensed and whether or not everything that students should know is encompassed in the information that is presented. Given its nature, there are not many times where a review or recap is done, and this is in order to get all the new information disseminated appropriately.

Module-based learning may sometimes also be called problem-based learning and in a literature review by Albanese and colleagues, they found that students performed as well (if not better), faculty tended to enjoy teaching in this manner, and found that this model is more nurturing in nature. Despite such great feedback, there were instances where students taught in this model scored lower on science examinations and felt less prepared in the basic sciences.  They concluded that before such changes were to occur to a traditionally structured curriculum, that certain things should be taken into consideration: the extent faculty is involved in the curriculum, cost of the education, individualized processing of the material, and the high utilization yielded by students who have learned through this approach.²

Take home point: The grass may not be greener on the other side. As a student, I have heard of this approach but was not exposed to this kind of a model. Having heard and read about this approach, I would have liked to incorporate a little bit of this model and see how it would fair me during my clinical practice today.  While there may be benefits to this model there are also some disadvantages to learning with this type of model. The beauty with using this model is that it may work for some students and may not with others, even more reason to have a hybrid approach; a little bit of a problem-based approach and a little bit of the traditional approach. In education, it is about disseminating information in a way where students feel in control with what they learn, because that internal motivation is what will give them the drive to continuously curious. Module-based learning is another way to combat the internal motivation, or lack thereof.

References:

1.    Cornford IR. Ensuring effective learning from modular courses: a cognitive, journal of Vocational Education and Training, 49:2,237-251.

2.    Albanese MA, Mitchell S. Problem-based learning: a review of literature on its outcomes and implementation issues. Acad Med 1993 Aug;68(8):615.

Student/Peer Facilitators

By: Dana E. Lee, PharmD

PGY-1 Pharmacy Practice Resident

Howard County General Hospital

What is peer facilitation?

Peer facilitation is a process where students or peer colleagues who are more advanced in their learning process facilitates or leads activities to support fellow colleagues' learning. Some examples of peer facilitation can be undergraduate TA's who facilitate class reviews or peer tutors who have just completed the same learning process. Another example would be fourth-year APPE students who can facilitate courses (ex: Abilities lab) for student pharmacists in year one to three of their pharmacy educational career.

Is student facilitation effective?

One study published in the American Journal of Pharmaceutical Education reviewed the impact of student versus faculty facilitators on motivational interviewing student outcomes. Faculty and student facilitators were both asked to teach second-year pharmacy students about motivational interviewing (MI) and then the second-year pharmacy students self-assessed their attitudes, confidence, and competence in MI skills.¹ The students in the study had said that faculty facilitators may be more intimidating and less relatable whereas student facilitators made them feel more comfortable.¹ The study concluded that peer facilitation can be equally as effective as faculty facilitation. This suggested equivalence can provide an opportunity to utilize more student facilitators and lessen faculty workload.¹

In a recent study published in the Currents in Pharmacy Teaching and Learning, second year pharmacy students were used to introduce a pharmaceutical care model to first year students. The study had shown that peer teaching events outside a lecture hall can allow for effective learning, connections to be made between the student facilitator and other students, and allow for relevant advice to be provided from peers who have just gone through the same curriculum.² Other studies have also shown that peer-to peer learning provides not only professional support but emotional and personal support as well.³ Not only can be it be effective for the students who are learning from their peer facilitators, but the students who are facilitating the learning of their peers have an opportunity to review their own knowledge, skills, and practices.⁴

Perspective:

Aristotle had recognized peer instruction to be beneficial, so this is not a new concept. Students appreciate the chance to work with peer facilitators and can obtain help from peer facilitators about other classes that students are taking.⁵ It has also been shown that students who are less vocal with faculty feel more comfortable to ask questions with peer facilitators.⁶

Personally, I had the privilege of being a peer student facilitator during my third year and fourth year of pharmacy school. I not only facilitated abilities lab for one full year, I was able to create assignments, and be involved with creating and implementing instructional materials. It gave me an ability to connect with students, provide advice that is more relevant for the students, and allowed me to grow not only as a student but also as a leader. I was able to review material for myself but also see students at eye level with their questions because I had recently experienced the same learning material. Therefore, peer facilitation can be beneficial for the students, the professors who are utilizing them, and for student facilitators themselves. Students who are peer educators can become great partners to the professors who are teaching the courses and grow in leadership.⁷ Student facilitators can also restructure material and provide feedback about the courses they are facilitating⁸ thus can be a valuable evaluation tool for the professor's instructional methods as well. 

So if the use of peer facilitation is quite effective and equally efficacious to faculty teaching, this begs the question, why don't we get more students involved in peer teaching? It is time for us to consider how we can really advocate for more student involvement in active learning activities. This can lessen faculty workload and be great learning experiences for the students. Integration of student peer facilitation in instructional design or as methods of instructional delivery should continue to be utilized and considered for current and future learning activities, as it may be of benefit for all parties involved.

References:

1.   Widder-Prewett, R, Draime, JA, Cameron G, Anderson, D, Pinkerton M, Chen, AMH. Impact of student vs. faculty facilitators on motivational interviewing student outcomes. Am J Pharm Educ. 2017; 81(6): Article 107. https://www.ajpe.org/doi/abs/10.5688/ajpe816107

2.   Kolar, Claire, Hager, Keri, Janke, Kristin. Using peer teaching to introduce the Pharmaceutical care model to incoming pharmacy students. 2018 Feb 10(2): 170-77. https://www.sciencedirect.com/science/article/pii/S1877129717300199

3.   Biech, Elaine. Chapter 14: Peer-to-peer learning. Wiley. 2015 May. https://onlinelibrary.wiley.com/doi/pdf/10.1002/9781119154761.ch14

4.   Burgess, Annette, Diggele Christie van, Mellis Craig. Students as facilitators in a teacher training program: motivation for leadership roles. Adv Med Educ Pract. 2015;6: 615-620.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4654533/

5.   Velez, JJ, Simonsen JC, Cano J, Connors JJ. Teaching partnerships: the use of peer facilitators in the college classroom.  Journal of Agricultural Education. 2010. 51(4): 49-58. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=2ahUKEwiY7q7D3M_dAhXndN8KHf9sBRwQFjAAegQIAxAC&url=http%3A%2F%2Fwww.jae-online.org%2Fattachments%2Farticle%2F1516%2FVol%252051%2520No%25204%2520pg%252049%2520-%2520Velez.pdf&usg=AOvVaw2P1hgmzcwTvNly0uIju9Hk

6.   Campbell, Elaine. Students as facilitators: an evaluation of student-led group work. Practitioner Research in Higher Education. 2015. 9(1): 52-58. https://files.eric.ed.gov/fulltext/EJ1130318.pdf

7.   Owen, Julie. Peer educators in classroom settings: effective academic partners. Wiley. New Directions for Student Services. 18 Mar 2011. https://onlinelibrary.wiley.com/doi/pdf/10.1002/ss.384

8.   Ashwin, Paul. Peer facilitation and how it contributes to the development of a more social view of learning. Research in Post-Compulsory Education. 2008. 8(1): 5-18. https://doi.org/10.1080/13596740300200137