The Value of Team-Based Learning

Sara Gholamrezaeiboushehrinejad
PGY-1 Pharmacy Resident
Holy Cross Hospital

Team-based learning (TBL) is a structured form of small-group learning that emphasizes student preparation out of class and application of knowledge in class. Students are organized strategically into diverse teams of 5-7 students that work together throughout the class.  Before each unit or module of the course, students prepare by reading prior to class.1 TBL was originally designed by Professor Larry Michaelsen during the 1980s, in the United States of America, for use in business schools. 2 Following individual answers, students join teams and work through problems, appealing when they are incorrect. 3 TBL provided the opportunity to continue teaching in a manner that was engaging, catered for large numbers of students, provided immediate feedback, involved students in decision making, and promoted active small group and class discussions. 2 In the first class of the module, students participate in a “Readiness Assurance Process,” or RAP. Specifically, students complete a test individually (the “Individual Readiness Assurance Test,” or iRAT); and then complete the test with their group members (the “group Readiness Assurance Test,” or gRAT). Both the individual scores and the group scores contribute to the students’ grades. 1 

This process motivates students by holding them accountable to themselves and one another, while introducing them to a variety of thought processes devoted to a single problem. To increase motivation and introduce a fun gaming environment, instructors often group their students into teams and have them compete on various classroom learning tasks. 3 Various teachers have found that team-based learning can be especially helpful in dealing with a number of situations that can be and often are particularly challenging for teachers. Four situations in which this is true are when teachers are faced with: larger classes, classes with a high level of student diversity, courses with extended meeting times, and courses that emphasize thinking skills. 4 Recent systematic reviews provide evidence of positive outcomes in terms of student experience and academic achievement, particularly when compared to traditional lectures. The interactive nature of TBL encourages healthcare students to develop their communication and collaboration skills, providing a valuable learning experience. 2

TBL is designed to get students actively engaged in the learning process by ensuring that most face-to-face course time is spent on Application Exercises, where teams of students work together on significant, challenging problems toward a common goal. Unlike many other teaching techniques, TBL is a highly structured, whole-course learning framework that incorporates a sequence of carefully designed readiness assurance and application activity cycles carried out by intentionally selected permanent teams, coupled with summative peer evaluation. The power of TBL comes from the integrated nature of the strategy – it is more than a collection of techniques or activities. 4

When teachers are faced with the responsibility of teaching large classes of 100 or more students and seek advice on how best to do this, they frequently get technical suggestions: get more organized, try to make your lectures lively, use more audiovisual materials, and so on. But technical changes like those do not have the ability to make a significant impact on the two biggest problems with large classes from a learning perspective: student anonymity and passivity. Teachers frequently have classes in which students are diverse in terms of key factors such as prior preparation, age, related background experiences, ethnicity, attitudes toward the subject, and so forth. Team-based learning creates conditions in which people who are very different from one another learn that they need to work together and that they can work together. They find ways to make their differences an asset rather than a liability. 3

Reference: 

1. Brame, C. J. (2013). Team-based learning. Vanderbilt University Center for Teaching. Retrieved [12/10/2021] from https://cft.vanderbilt.edu/guides-sub-pages/team-based-learning

2. Burgess, A., van Diggele, C., Roberts, C. et al. Team-based learning: design, facilitation and participation. BMC Med Educ 20, 461 (2020). https://doi.org/10.1186/s12909-020-02287-y

3. Team-Based Learning. Yale Poorvu Center for Teaching and Learning. Retrieved [12/10/2021] from https://poorvucenter.yale.edu/Team-Based-Learning 

4. Michaelsen LK, Knight AB, and Fink LD. The Value of Team-Based Learning in Particularly Challenging Teaching Situations. Stanford University. Retrieved [12/10/2021] from https://tomprof.stanford.edu/posting/474 

Layered Learning Model

Olyad Begna
PGY1 Pharmacy Resident
Holy Cross Hospital

The layered learning practice model (LLPM) involves training pharmacy residents to precept pharmacy students under the supervision of a clinical pharmacist.¹ The model is used by many residency programs to provide teaching experience for new residents. The layered learning model is being routinely utilized as the need for pharmacy practice experiential sites increases with the increase in the number of pharmacy schools. The number of pharmacy schools increased by 65% between 2000 and 2015 from 80 to 132.² According to the American Association of Colleges of Pharmacy (AACP), as of January 2021, there are 140 pharmacy schools across the nation and the demand for experiential sites continues to increase. Moreover, the increase in the number of pharmacy students graduating has led to an increase in the number of applicants seeking post-graduate residency training who need preceptorship experience. Due to the primary departmental responsivities of clinical pharmacists, accommodating an increasing number of pharmacy students is becoming challenging for institutions. LLPM is one approach that can be implemented to meet the increase in the demand for preceptorship. Some studies at community teaching hospitals have demonstrated that LLPM can increase medication reconciliation rates, discharge counseling, and the overall number of pharmacy interventions. ^(3,4) In addition, learners have reported an overall positive experience with LLPM.⁵

The LLPM model involves a minimum of three layers consisting of a senior preceptor, a pharmacy resident, and a pharmacy student.¹ The senior preceptor oversees the entire rotation experience with responsibility for the submission of evaluations and patient care. The second level of precepting consists of the pharmacy resident, who serves as the primary preceptor for the pharmacy student. Pharmacy students are incorporated into the third level of the learning model with active involvement in patient care activities. Loy et al reported on the implementation of the LLPM at a tertiary medical center with a 4-step process which includes orientation, pre-experience planning, implementation, and postexperience evaluations.¹ There are various benefits to implementing LLPM in teaching medical institutions which include maximizing the number of learners, improving efficiency, and enhancing quality improvement opportunities.¹ For the resident, the LLPM provides teaching experiences at different learning levels, enhances leadership skills, and increases clinical and teaching decision-making. For health care institutions, even though there is not enough data to support improved patient outcomes, implementation of LLPM may increase pharmacy presence in clinical practice and can lead to an increase in pharmacist interventions and improve medication safety and patient satisfaction.³

Integration of LLPM into a residency program helps to encourage team-based learning between residents and pharmacy students and helps residents expand their roles as practitioner learners.¹ The LLPM also allows residents to engage in precepting other residents by participating in a teaching certificate program to fulfill the American Society of Health-System Pharmacists (ASHP) requirements. ASHP developed the Pharmacy Practice Model to expand pharmacist care for patients by capitalizing on the pharmacists' role in patient care teams, encouraging pharmacist training and board certification, expanding the use of technology, as well as promoting leadership roles in medication management and outcomes.⁶ With pharmacy residents sharing precepting duties with clinical pharmacists via LLPM, senior pharmacy clinicians may not have to compromise on their patient care responsibilities and have more time to actively participate in patient care tasks as well as continuing education programs. In addition, the American College of Clinical Pharmacy (ACCP) also encourages residency programs to incorporate a teaching experience component for pharmacy residents to develop as competent clinicians.⁷ Moreover, LLPM can help residents grow their leadership skills as they precept pharmacy students and directly get involved in patient care teams. Feedback from senior clinical pharmacists, residents and pharmacy students should regularly be assessed to continuously improve the learning experience. Feedback and evaluation can also be used to implement changes in applying the LLPM, such as improving orientation structure and updating objectives and expectations.  

There are some limitations to the LLPM, which include not being adopted at all practice sites and lack of enough data supporting the quality of learning for the pharmacy resident and student.¹ In addition, there need to be more studies conducted to compare LLPM to traditional precepting models head-to-head in evaluating learning and other outcomes. To be successful, the LLPM relies on the participation of all three levels, and a deficit in any of the layers of teaching can negatively affect the outcome for learners.

References

1. Loy BM, Yang S, Moss JM, Kemp DW, Brown JN. Application of the Layered Learning Practice Model in an Academic Medical Center. Hosp Pharm. 2017;52(4):266-272. doi:10.1310/hpj5204-266.

2. American Association of Colleges of Pharmacy. Academic pharmacy's vital statistics. http://www.aacp.org/about/pages/vitalstats.aspx. Accessed November 12, 2021. [Ref list]

3. Advancing the pharmacy practice model in a community teaching hospital by expanding student rotations. Delgado O, Kernan WP, Knoer SJAm J Health Syst Pharm. 2014 Nov 1; 71(21):1871-6. [PubMed] [Ref list]

4. Expanding care through a layered learning practice model. Bates JS, Buie LW, Amerine LB, Savage SW, Eckel SF, Patel R, Valgus JM, Rao K, Daniels R Am J Health Syst Pharm. 2016 Nov 15; 73(22):1869-1875. [PubMed] [Ref list]

5. A Study of Layered Learning in Oncology. Bates JS, Buie LW, Lyons K, Rao K, Pinelli NR, McLaughlin JE, Roth MT Am J Pharm Educ. 2016 May 25; 80(4):68. [PubMed] [Ref list]

6. American Society of Health-System Pharmacists. Pharmacy Practice Model Summit: Executive summary. Am J Health Syst Pharm. 2011; 68: 1079– 1085. [Google Scholar]

7. Havrda DE, Engle JP, Anderson KC, et al. Guidelines for resident teaching experiences. Pharmacotherapy. 2013; 33: e147– 161. [PubMed] [Google Scholar]

 

Impact of a Peer Teaching Model in Pharmacy Schools

Ryan Nguyen, PharmD
PGY-1 Pharmacy Resident
Sinai Hospital

Developing new, effective methods to engage students in their learning is often a significant challenge in higher education settings. Pharmacy schools, in particular, have been gradually implementing andragogic approaches to optimize student preparedness for the transition to advanced pharmacy practice experiences (APPEs) and subsequent post-graduate work. In order to succeed as a pharmacist, students must have a robust foundational knowledge of drug information, strong communication skills, and effective problem-solving capabilities. As part of the curricula of many pharmacy schools, students are expected to be heavily involved in their learning. Various learning activities such as breakout counseling sessions, simulated case scenarios, and objective structured clinical examinations (OSCEs) have been employed to further students’ learning beyond the classroom. Nevertheless, teaching methods are constantly evolving as pharmacy schools aim to produce the most well-equipped pharmacists to tackle the dynamic healthcare landscape. 

One teaching method that has been increasingly discussed throughout the literature is the peer teaching model. As the name suggests, pharmacy students would be involved in actively teaching concepts to their respective classmates or student learners from other healthcare specialties. This collective effort toward active learning allows students to work closely with their colleagues to bridge any gaps in knowledge. In order for students to be able to effectively teach certain concepts, they must first gain enough baseline knowledge through their own studies. Not only does this hopefully motivate students to become self-directed learners, but also students will be more confident as they transition into their APPEs.

Tsai et al. describe the implementation of a “Pre-APPE Readiness (PAR) Block” for third professional (P3) year students prior to the start of their APPEs. Based on a pre-assessment that evaluated students’ knowledge of general medication information, the authors noted that a significant number of students had difficulty retaining drug information learned during the earlier years of pharmacy school. Thus, the authors developed a six-week course in which each student was assigned a unique drug from a list of the top two hundred most commonly prescribed drugs. Four students were selected to present each week based on the specific drugs they were assigned. For instance, during a given week, one student would present on nitroglycerin and another student would present on sildenafil due to the established drug-drug interaction. The goal of these pairings was to aid students in understanding the relationships between certain drugs, whether they were synergistic, antagonistic, or analogous. Course facilitators summarized the key points at the end of each presentation and assisted the presenter in answering any questions from the student audience. Finally, each session concluded with a brief quiz with immediate feedback to assess for any knowledge gaps. Ultimately, the authors found that after the implementation of the PAR Block, there were significantly less students who performed poorly on the pre-assessment that was administered before the start of APPEs.1

By the same token, Delnero and Vyas describe the impact of a peer-taught interprofessional education (IPE) activity involving pharmacy and physician assistant (PA) students. Prior to the activity, students formed teams consisting of one PA student and four to five pharmacy students. The main premise of the activity was that teams would be teaching each other in breakout sessions about key skills related to physical assessment, inhaler counseling, or diabetes education. For example, the PA student would provide instruction about performing lung auscultation and the pharmacy student would provide education about appropriate administration of various inhalers. Overall, the authors concluded that the IPE activity led to improved confidence and enhanced interprofessional attitudes.2 

Based on the two educational models implemented in the previously discussed studies, peer teaching appears to be an effective learning method for pharmacy students. Peer teaching adheres to the concepts of andragogy in which students are self-directed and draw from their own baseline knowledge to provide education to their colleagues. Additionally, peer teaching is supported by the notions of cognitive and social congruence in which students share the same knowledge framework. Based on these theories, students are better able to relate to one another and address gaps in knowledge.3 Thus, peer teaching models should continue to be incorporated into the curricula of pharmacy schools and be used in conjunction with other active learning methods to enhance student engagement.

References:

1. Tsai T, Vo K, Ostrogorsky TL, et al. A peer-teaching model to reinforce pharmacy students' clinical knowledge of commonly prescribed medications. Am J Pharm Educ. 2021;85(5):8451. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174616/

2. DelNero T, Vyas D. Peer teaching in an interprofessional education activity focused on professional skills development. Pharmacy (Basel). 2021;9(2):112. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8293411/

3. Loda T, Erschens R, Loenneker H, et al. Cognitive and social congruence in peer-assisted learning - A scoping review. PLoS One. 2019;14(9):e0222224. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6733464/

Residency Preparation Programs for the Fourth-Year Pharmacy Student

Ami Patel, PharmD
PGY1 Pharmacy Resident
University of Maryland Medical Center

Post-graduate training for pharmacy students is competitive, and the match rate decreases every year. There are so many more residency candidates than there are residency spots in programs all over the country.1 Students are doing more and more every year to stand out to “match” to a position in a residency program. Because of this competition, some pharmacy schools across the country have developed a residency preparation curriculum to help guide interested and qualified students through their own “mini-residency” to increase their students’ success (and school match rates). 

Developed in 2012, the first program of its kind is called the “Pharmacotherapy Scholars” at the University of Pittsburgh School of Pharmacy.2 This program really set the precedence for residency preparation programs. Its curriculum includes first-choice clinical rotations at the UPMC health-system, intermittent clinical knowledge examinations, personal mentor advising, team-based mentoring, peer-to-peer learning, longitudinal research, and professional development sessions about various topics. Their overall residency match rate was 93% in the 64 students that enrolled and completed the program from fall 2013 to spring 2019. This program is an exceptional example of the Dick and Carey model. The instructional goal of this program was simply to achieve high match rates for fourth-year pharmacy students interested in residency. The performance objectives were updated with each clinical rotation and research meeting to ensure learners were reaching expectations and completing the required work. The intermittent clinical exams were the assessment instruments. Evaluations and feedback done after every rotation and every curriculum experience helped improve the program and refine it for the rest of the year and for future years. The program was developed in a linked approach, which is why its instructional methods of following the Dick and Carey model has led to this program’s success and for other pharmacy schools to adopt a similar approach.  Since there were many steps of this program, feedback, and changes to the program as it was implemented, the Pittsburgh program aligns with the Dick and Carey model. 

Another program that followed closely to the University of Pittsburgh was the University of Buffalo.3 When creating their program, they more closely followed the linear ADDIE model. Since this program was able to develop their model from other programs (such as the University of Pittsburgh), they offer many of the same components of the program, but the evaluation process occurs only at the end of the program at the University of Buffalo. This is indicative of the ADDIE model vs the Dick and Carey model.  The ADDIE model has five phases, including analysis, design, develop, implement, and evaluate. The Buffalo program aligns with this closer than the Dick and Carey model due to the more linear approach to the program. This program also was very successful in their match rates at 91% vs the national average in the 60% range. Although the instructional methods differed between both programs, they had a similar end result.

In conclusion, instructional methods were very crucial to the development of these residency preparation programs at the two schools of pharmacy; however, although different methods were used, results were similar and the programs were successful. Both programs focused on the input, output, and design of the curriculum. However, the ADDIE model is more structured and evaluations are only done at the end, which can be disadvantage in newer programs. Meanwhile, the Dick and Carey model has evaluations at every phase. However, in pharmacy schools that are beginning residency preparation programs, I believe that the Dick and Carey model is a better initial choice. The evaluations at each part of the program and the many detailed steps will allow more acute changes to be made often, leading to a better overall experience for the program if obstacles were to arise. The ADDIE model would be a great choice after the program is established and overcomes any initial obstacles.  This is an important conclusion; the instructional design and methods used to create a curriculum is not black and white.4 As future educators, we should keep this in mind when developing our own educational methods. There is no clear answer, but there can be many right ones. Choosing the right instructional design and methods is an individualized approach based on instructor preference and what aligns with the focus and the objectives of the course best. 

References

1. National Matching Services, Inc. ASHP Match Statistics. https://www.natmatch.com/ashprmp/stats.html. Accessed October 24, 2021.

2. Coons J, Benedict N, Seybert A, et al. A Pharmacotherapy Scholars Program to Provide Intensive Training to Enhance Pharmacy Students’ Postgraduate Readiness. Am J Pharm Educ. 2019 Nov;83(9):7327. 

3. Slazak E, Prescott G, Doloresco F, et al. Assessment of a Scholars Program Designed to Enhance Pharmacy Students’ Competitiveness for Postgraduate Residency Training. Am J Pharm Educ. 2020 Jul;84(7). 

4. Khalil M, Elkhider I. Applying learning theories and instructional design models for effective instruction. Adv Phys Educ. 2016 Jun;40(2):147-156. 

Service Learning in HealthCare Education

Victoria Fusco, PharmD
PGY1 Pharmacy Resident
MedStar Union Memorial Hospital

Hands-on experience in the education of health care professionals has been widely accepted as a core component of instructional design. Nursing programs typically have formal hands-on experience (i.e., clinicals) from the start of instruction whereas medical and pharmacy programs typically have two or three didactic years followed by clinical rotation years. In these programs, students begin working with patients and applying their skills before graduation and stepping into new practitioner roles. In a review article, this approach to learning has historically been one-sided and focuses on how the student can benefit.1 In recent years, perspectives in health education have shifted the focus equally on student learning and service to patients and communities.1 Service-learning can be defined as, “a structured learning experience that combines community service with explicit learning objectives, preparation, and reflection, in which students learn about the context in which the service is provided, the connection between the service and their academic coursework, and their roles as citizens.”1

The benefits of service-learning have been described as creating community-responsive, culturally competent healthcare practitioners, cultivating citizenship, and achieving social change, and transforming relationships between communities and educational institutions. 1 My experience with service-learning began my first year of pharmacy school. Notre Dame of Maryland University School of Pharmacy created an innovative Advocaring program that pairs students with community-based organizations for the course of their four years of study.2 While students are not ready to be clinical practitioners on day one, they can begin to learn to value the basics of human interaction, respect, cultural awareness, and respect.1 My first Advocaring assignment was at the Arc of Baltimore. As a group of 10 pharmacy students, we were responsible for providing health education through interactive activities about topics such as healthy eating, proper handwashing, and stress management for children and adults with developmental disabilities. We had a pharmacist mentor who would oversee our work and help guide us through the process and debrief afterword. These experiences provided us with a chance to work on our communication skills, build rapport with the community, better understand the needs of our underserved communities in Baltimore, MD. 

In addition to building on the soft skills early on necessary to be health care professionals, we were responsible for developing education events for service-learning. For example, our group identified that the children would benefit from a lesson around hand-hygiene given flu season was approaching. We designed an interactive lesson to explain what germs were, why they can be dangerous, and how we can help prevent spreading our germs by washing our hands. Next the group worked together to draft materials for the session and made necessary edits based on evaluation by our mentor. After implementing the group would meet with the pharmacist and evaluate the event and submit a reflection. This process, also known in instructional design as the ADDIE process, was repeated as we encountered new community groups and continued to identify needs. 

As healthcare continues to focus on a patient-centered approach, how can instructional design incorporate more service-learning? An article about incorporating service-learning into medical education recommends building university-community partnerships, establishing structure, funding, and recognition for faculty as a few ways to get started.3 The article suggests service-learning activities can be categorized into three categories: 1. educational/training (i.e. diabetes education) 2. Clinic/community-based (i.e. health fair for elderly), 3. Advocacy, policy, and outreach (autism awareness, fundraising).3 The service should be meaningful, have academic integrity and put the student in a position of responsibility and ownership.3 An important part of instructional design and service learning is reflection. Best practices for reflection in service-learning include setting goals, knowing the audience, making time, sharing expectations, identifying resources, reviewing skills, creating transparent evaluations, demonstrating the importance of different types of reflection, and embracing/capitalizing on teachable moments. 3 Typical pedagogical learning measured student outcomes through exams and quizzes for example. Student service-learning should still be assessed but may be better suited by written reflections, open-ended questions, or poster-presentations to share the experience with faculty and other students. 3 

In summary, service-learning has the potential to develop healthcare students and improve the lives of underserved communities through the identification of community needs and instructional design. 

References: 

1. Kayser C. Cultivating community-responsive future healthcare professionals: Using service-learning in Pre-Health Humanities Education. Journal of Medical Humanities. 2017;38(4):385–95. 

2. The advocaring program [Internet]. Notre Dame of Maryland University. [cited 2021 Oct 18]. Available from: https://www.ndm.edu/colleges-schools/school-pharmacy/resources/advocaring-program. 

3. Stewart T, Wubbena A. An overview of infusing service-learning in medical education. International Journal of Medical Education. 2014;5:147-156. 

Simulation-Based Learning (SBL) and its Application to Pharmacy Education

Sara Foreman, PharmD
PGY-1 Pharmacy Resident
Suburban Hospital Johns Hopkins Medicine

Pharmacists across the country are increasingly transitioning from a traditional role of dispensing medications from behind the counter to a more patient-focused clinical role. Clinical pharmacists are progressively serving as part of a team that provides bed side and emergency care to patients in hospitals and other clinical facilities. The nature of this clinical work is dynamic and stressful, and typically involves techniques and pharmacotherapy not widely covered by students in PharmD and Bachelor of Pharmacy curriculums.1 Simulation-based Learning (SBL) is a proven, innovative learning technique that mimics real-world scenarios allowing students to not only practice and improve their clinical knowledge and skills with no risk to a patient, but to also improve critical thinking and decision-making in high stakes environments. Simulation has been defined as: “an event or situation made to resemble clinical practice as closely as possible”.2 This method of teaching will enable pharmacy students across the country to improve both rudimentary and advanced skillsets and their own confidence in wide variety of clinical situations.  

Currently, multiple forms of SBL are being utilized around the country in pharmacy education.3 These forms vary in technological complexity and differ mainly on the focus of which skill(s) are being emphasized by the specific training. One of the most advanced forms of SBL currently is the high-fidelity patient simulator mannequin.4 This form is most associated with simulation-based training in healthcare. These simulator mannequins are software-driven and load data to mimic human actions and physiology and respond accordingly to physiological and pharmacological interventions of students. Some mannequins are advanced enough to be disease specific (such as a cardiopulmonary simulator), while some are designed to simulate a variety of disease states.4 More, less-technically complex forms of SBL include the use of standardized patients. Standardized patients are live people who are portraying patients and all the associated medical history, emotions, and personality associated with medical patients in a clinical setting. Standardized patients are a very widely utilized form of simulation-based learning and are commonly used to develop students’ communication and intervention skills.2 The most complex and immersive form of SBL is the full environment simulation.4 It is the incorporation of high-fidelity mannequins, standardized patients, healthcare professionals, and other ancillary equipment to re-create a real-life clinical environment. This type of SBL is expensive and requires extensive planning to execute correctly. Therefore, full environment simulation is less common and is typically shared between multiple different healthcare education programs (i.e., nursing/PharmD/MD students) when implemented.5  

Multiple pharmacy schools across the country have successfully implemented SBL into their core curriculum.2 At both the University of Pittsburgh and Rhode Island College of Pharmacy, simulation has been integrated into the pharmacology, therapeutic, and medicinal chemistry coursework. In both programs, PharmD students participate in the SBL laboratories alongside both nursing and medical students.5 Furthermore, University of Minnesota holds a yearly professional workshop for medical, nursing, public health, and pharmacy students called “Disaster-10” that reproduces a mass-casualty event at an office building using standardized patients and high-fidelity mannequins. The program’s objective is to assess the effectiveness of live simulations for teaching emergency response skills to students and professionals.6 This form of instructional design forces students to “think outside the box” and induces further knowledge recall by the learners based upon their experiences within the simulation. As technology progresses, these forms of instructional design become more feasible to implement into pharmacy school and medical professional programs.   

A pilot study in nursing students assessed the outcomes of simulation on the clinical skills of the students and suggested that simulation-based teaching coupled with clinical experience led to an overall improvement in their clinical knowledge and recollection.7 Another study of found that the use of SBL in PharmD curriculum showed significant improvement of students’ clinical skills performance and increased their knowledge of the pharmacotherapy of hypertension. The students involved in the study also expressed high levels of satisfaction with this SBL type of learning experience.5 

Unfortunately, some colleges and universities are experiencing pushback when inquiring about the possibility of substituting simulation for some aspects of Introductory Pharmacy Practice Experiences (IPPEs). This standard has precluded use of any simulation experience, regardless of the quality and nature of the simulation, as acceptable for IPPE credit. Some administrators of colleges and schools of pharmacy have argued that simulation should be considered an alternative for some portion of the required IPPEs, and most educators would agree that a student’s ability to learn and retain how to treat a patient with is best served by being involved with actual patients or via high-fidelity simulation versus shadowing a clinical preceptor.2

There are many clear advantages to SBL in pharmacy education: patient safety/quality, the ability to directly address gaps in clinical conditions and settings, a completely safe learning environment that poses no risk to patients or the learner, the ability to practice difficult skills and build confidence about complex procedures or pharmacotherapy. However, there are some disadvantages that critics of SBL have voiced as well. The most obvious being, simulation is not real life. Real human factors are not portrayed well in simulations as they are in the real world. Because of this, students’ take away from the simulation is dependent on how engaged they are and how willing they are to take the simulation seriously.7 From an instructional design perspective, it may be difficult to predict the students’ level of engagement. If a student is fully committed, they are likely to benefit from the simulation, but if the student thinks the simulation is unrealistic and are unengaged, their learning will be hampered, and the learning will be sub-optimal. Another key disadvantage to simulation-based learning is the large focus on specific skills or competencies. An SBL exercise using a blood pressure task trainer vastly improved PharmD students’ abilities to measure blood pressure but did little to none to develop their communication and assessment skills.5 

Another key drawback to SBL is the cost of the equipment. High-fidelity simulators typically cost around $30,000 a piece, and require maintenance, training for educators, and technical support for the software inside them.4 The ability to provide real-time immediate feedback to the students based on their medical interventions is a great advantage of teaching using SBL, but to do so requires faculty resources to conduct simulations and assess the students.1 Much of the published literature in support of teaching via SBL is subjective. However, some studies have demonstrated that students who receive simulation training in combination with clinical experiential education exhibit better assessment and management skills than students who receive only one form of training. 

Furthermore, the implementation of instructional design using simulation-based learning allows pharmacy school students to learn/retain the skills necessary to excel as pharmacists in clinical settings and has evidence to support this evolutionary form of teaching.

References: 

 

1. Lavelle BA, McLaughlin JJ. Simulation-based education improves patient safety in Ambulatory Care. Agency for Healthcare Research and Quality.  (Dr. LaVelle, formerly); HealthPartners Medical Groups and Clinics (Ms. McLaughlin). https://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-Lavelle_33.pdf. Accessed October 15, 2021.

2. Vyas D, Bray BS, Wilson MN. Use of simulation-based teaching methodologies in US colleges and Schools of Pharmacy. American Journal of Pharmaceutical Education. https://www.ajpe.org/content/77/3/53. Published April 12, 2013. Accessed October 14, 2021. 

3. Cheema E. The need to introduce simulation-based teaching in pharmacy education in Saudi Arabia. Pharmacy (Basel, Switzerland). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163641/#:~:text=The%20use%20of%20simulation%20in,in%20sound%20clinical%20decision%2Dmaking. Published July 3, 2018. Accessed October 16, 2021. 

4. Sarfati L, Ranchon F, Vantard N, et al. Human‐simulation‐based learning to prevent medication error: A systematic review. Wiley OnlineLibrary.https://onlinelibrary.wiley.com/doi/abs/10.1111/jep.12883. Published January 31, 2018. Accessed October 13, 2021. 

5. Seybert AL, Barton CM. Simulation-based learning to teach blood pressure assessment to Doctor of Pharmacy Students. American journal of pharmaceutical education. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1913304/. Published June 15, 2007. Accessed October 15, 2021. 

6. A simulation center for all of Minnesota and beyond! M Simulation. https://msimulation.umn.edu/. Published 2021. Accessed October 13, 2021. 

7. Seybert AL, Kobulinsky LR, Mckaveney TP. Human patient simulation in a pharmacotherapy course. American journal of pharmaceutical education. https://pubmed.ncbi.nlm.nih.gov/18483603/. Published April 2008. Accessed October 13, 2021. 

Self-Directed Learning

Clynton Musngi, PharmD
PGY-1 Pharmacy Resident
MedStar Union Memorial Hospital

“Teacher, teacher! What is 12x12?” “Professor! Can you tell me why cefazolin is effective against MSSA and not vancomycin?” Growing up, educators starting from kindergarten through 12th grade, and even through graduate school, have been vital to our learning experiences and attainment of knowledge. As students, we were highly dependent on the educator to provide us and teach us information of what we needed to know to pass an exam and succeed in our careers. Lecture-based classrooms has traditionally been and continues to be the style of learning environment for schools. But is this the most effective way of learning? It depends.

Don’t get me wrong. Classroom lectures is an effective method in higher education, given that a high amount of information may be relayed to a big crowd of students. But what if you need application-based learning to grasp a bigger understanding of a concept. Or once you’re out of school, how will you function independently? Once we get to a certain stage in our education and career, we must become adult learners.

Malcom Knowles keyed the term andragogy, which is the art and science of adult learning.1,2 Self-directed learning is a branch of adult learning, in which learners take the initiative, with or without the help of an educator, in recognizing their learning needs, formulating learning goals, identifying essential resources for learning, choosing, and implementing learning strategies, and evaluating their outcomes.2,3,4 As professionals, we are constantly seeking new and updated information relating to our profession, which is a life-long learning skill.4,5 Students sought learning styles that are most beneficial to them. With innovation of technology growing exponentially and students’ way of thinking are changing, educators are urged to develop teaching and learning methods that enable students to transition from dependent to self-directed learners. 

From personal experience, pharmacy school had a mix of mostly lecture-based classrooms with self-directed learning mostly occurring in the last year during experiential learning. Introduction of self-directed learning should be introduced and implemented in the didactic curriculum, as this allows for skill development over time.5 This is not to be confused with self-paced learning and self-regulation. To differentiate, the former is having students complete learning activities with deadlines, while the latter involves individuals guiding goal-directed activities over time in their own best self-interest.5 To differentiate even further, self-regulated learning stems from cognitive psychology and is imposed by the instructor, while self-directed learning stems from adult education and the student themselves design the environment.5 

As mentioned earlier, learners must take initiative to recognize their learning needs and goals, identify resources, establish a timeline, and have a faculty member complete an evaluation.2,3,4 In order to develop the skill of self-directed learning, a school’s curriculum should introduce self-paced directed activities early on to help students develop a self-directedness.5 Over time, the learning environment can transition to instructor led to student led. Ways to move forward with this development to self-directed learning can be through flipped classrooms.5 Flipped classroom allows students to first obtain foundational information from faculty-provided material.5 That information can then be utilized during class to answer questions or create a direction for discussion. This allows for knowledge application and expansion to deepen the learning experience, which may model and assist in the development of skills needed for self-direction.5 

But how do we assess self-directed learning itself? Unfortunately, there is no literature that objectively assesses this skill set.5 Only the knowledge of the students can be assessed through examination and experiential learning. 

Although self-directed learning is an effective method of education, challenges of willingness to change, lack of expertise by the learner, and time are limiting factors to implementation.5 The actual content learners must learn may be tough enough for learners to unsuccessfully utilize self-directed learning and rely on instructors for help.

References:

1. Culatta R, Kearsley, G. Andragogy (malcom knowles). Instructional Design. 2021

2. Pappas, C. The adult learning theory – andragogy – of malcom knowles. eLearning Industry. 2013 May

3. Guiter GE. Self-directed learning (SDL): a brief comprehensive analysis. Weill Cornell Medicine-Qatar. 2014

4. Manning G. Self-directed learning: a key component of adult learning theory. BPA Studies. 2007; 2(2)

5. Robinson JD, Persky AM. Developing self-directed learners. AJPE. 2020 Mar; 84 (3) 847512

Terror Management Theory and its Application to Healthcare Education

Lily Lin, PharmD
PGY-1 Pharmacy Resident
Adventist Shady Grove Medical Center

Terror Management Theory, or TMT, is a theory first developed by Greenberg, Solomon, and Pyszczynski in 1984 to explain the need for self-esteem and the creation of belief systems that are exclusive and protective. The motivation behind this theory is the primal urge to survive and the associated fear of death. According to this theory, individuals are inclined to follow cultures with defined values that make their lives significant.1 For instance, in many religions, values are related to following the teachings of the deity or deities and doing so can not only give followers a sense of self-worth and approval from others but also potentially lead to a proposed better “outcome” such as reincarnation or paradise after death. 

Because these belief systems are so deeply ingrained into an individual’s sense of self-worth, contradicting ideas are viewed as a personal attack. Other cultures may have differing ideas on what values are significant in a person and therefore an esteemed individual from one culture may be considered worthless in another. This leads to an immediate aversive and aggressive reaction when these values are called into question and can explain why stereotypes and prejudice towards other cultures has been perpetuated and even sometimes lauded. When trying to address these topics, maintaining a non-accusatory and neutral attitude during the conversation and allowing for the other person to discuss their feelings openly will help them to feel less threatened.

There are four types of initial reactions to ideas contradicting a person’s worldview – assimilation, derogation, annihilation, and accommodation. In assimilation, the person will attempt to convert the person with a conflicting worldview to their own. In derogation, the opposing worldview will be belittled and dismissed. Annihilation involves aggression and violence to eliminate those with opposing worldviews, and accommodation attempts to reconcile aspects of the opposing worldview with their own.2 As with the stages of grief or the stages of change, it is important to assess what type of response the person has and address it accordingly, and it can be a repetitive process to work towards tolerance and acceptance.

The basic purpose of healthcare is to prevent mortality, and therefore it can come into conflict with worldviews that offer death transcendence when mortality salience occurs. For example, with the current COVID-19 pandemic, a TMT healthcare model explains that individuals apply both proximal and distal defenses to avoid the thought of mortality. In proximal defenses, this involves actively avoiding thoughts related to the pandemic by avoiding exposure to information and minimizing the perception of the threat. Distal defenses involve strengthening the belief in one’s worldview to boost one’s sense of self worth and the perception that death can be avoided.3 In a maladaptive response, this can lead to engaging in high-risk behaviors and/or developing a distrust in healthcare that can lead to not seeking proper treatment. 

These coping mechanisms lead to a lack of accurate information and a false sense of immortality that require intervention with proper education. It is important to recognize these diversions so that the method of education can also be tailored for what is needed. For example, Jessop et al. found that individuals who associated driving faster with a higher self-esteem were more likely to engage in riskier driving behaviors and less likely to heed warnings related to mortality compared with those who do not.4 Hansen et al. found that warnings related to mortality led to more positive attitudes towards smoking in those who associate smoking with high self-esteem. These individuals responded more to warnings devaluing the act itself, such as stating that smoking decreases attractiveness or brings “severe damage” to those around them. However, the effects of these types of warnings were delayed, as initially individuals had a negative response to the warning, as their self-esteem was being called into question.5 This suggests that when attempting to rectify high-risk behaviors in these patients, it may be beneficial to use intrapersonal and interpersonal justification more than the prevention of mortality. In addition, these individuals may need additional reinforcement for subconscious behavioral change to happen after the initial conscious aversive reaction. These situations also parallel the vaccine hesitancy situation. Healthcare providers often educate patients on the positive effects of obtaining the COVID-19 vaccine, such as drastically decreasing the probability of severe illness requiring hospital stay. However, this appeal to mortality often falls on deaf ears, seeing as how our country’s percentage of fully vaccinated individuals is a meager 56%. 6 According to TMT, for patients that are identified to have strong beliefs against the vaccine and/or aversive reactions to recommendations, healthcare providers should instead focus more on social benefits of getting the vaccine such as protecting their family members or that refusing the vaccine is not a sign of strength or looking “cool”. 

TMT explains why it is extremely important to perform an audience analysis prior to providing education, particularly in a healthcare setting. A patient’s worldview will affect how they react to and process information regarding mortality and self-esteem. Maintaining a non-aggressive stance, addressing the individual’s perception of their values, and managing the aversive initial reaction that will occur are all part of the continued reinforcement that will allow a person to correct high-risk behaviors and maladaptive coping mechanisms that are associated with increased mortality.

References:

1. Terror Management Theory in Social Psychology - iResearchNet [Internet]. Psychology. 2016. Available from: http://psychology.iresearchnet.com/social-psychology/social-psychology-theories/terror-management-theory/

2. Kessel CV, Heyer KD, Schimel J. Terror management theory and the educational situation. Journal of Curriculum Studies. 2019 Sep 4;52(3):428–42.

3. Pyszczynski T, Lockett M, Greenberg J, Solomon S. Terror Management Theory and the COVID-19 Pandemic. J Humanist Psychol. 2021 Mar;61(2):173–89. 

4. Jessop DC, Albery IP, Rutter J, Garrod H. Understanding the Impact of Mortality-Related Health-Risk Information: A Terror Management Theory Perspective. Personality and Social Psychology Bulletin. 2008 May 9;34(7):951–64. 

5. Hansen J, Winzeler S, Topolinski S. When the death makes you smoke: A terror management perspective on the effectiveness of cigarette on-pack warnings. Journal of Experimental Social Psychology. 2010 Jan;46(1):226–8.

6. US Coronavirus vaccine tracker. USAFacts. 2021 Oct 5.

The Hidden Curriculum: What are we really teaching our students?

Chaya Lachman
PGY1 pharmacy resident
Carroll Hospital Center

“By the end of this class, you should be able to…” Many of us are familiar with this standard opener for learning objectives. We used them as students to guide our focus and prepare for exams, and now as lecturers and future educators we use them to guide our students and illustrate for them what we would like them to learn. There is another realm of learning, however, that occurs in an educational environment, termed by Philip Jackson in his book Life in Classrooms as the hidden curriculum.

The hidden curriculum, Jackson explains, are “the norms and values that are implicitly, but effectively, taught in schools and that are not usually talked about in teachers’ statements of goals.” These values are often created by the relationship and interactions between the students and instructors. According to Jackson, the most successful students and teachers are those that have mastered both the covert and the hidden curricula (1). In 1994, Dr. Frank Hafferty applies this definition specifically to medical students in his essay The hidden curriculum, ethics teaching, and the structure of medical education. Hafferty discusses the impact of directly teaching medical ethics versus allowing students to naturally pick up on medical ethics through observation of their instructions and preceptors and concludes with a proposed framework for managing the hidden curriculum (2).

Many aspects are included in the hidden curriculum. From which students the professors choose to call on the most, to which activities are considered required versus elective, to how professors interact with their colleagues around students, students subconsciously notice these choices and begin altering their value system to accommodate them. Students see their teachers as role models. They pick up on little details such as emotions relayed while providing patient case examples and intuitively understand when professors are passionate about their subject material. While this can seem very intimidating for the instructor, Hafferty maintains that this is, in fact, positive. While classes directly teaching medical ethics can be helpful, students tend to learn this topic best when they can observe it naturally (2).

How does one go about altering the hidden curriculum? Step number one, according to Hafferty, is to simply be mindful and observant. Know that students are watching and learning. The most impressionable students are often the youngest ones and the ones who are newest to the profession as they are completely reliant on the educators to shape their knowledge of the work culture. In addition to observing yourself as a teacher to see what biases you may be projecting, provide opportunities for others to observe you and provide feedback. Be receptive to both formal and informal evaluations from students. Ask your colleagues what hidden messages you are projecting. Consider inviting an outsider who can provide an unbiased view (2).

In addition to removing negative components of the hidden curriculum, work towards consciously adding positive components. Choose to incorporate patient case examples that highlight compassion. Be respectful when interacting with colleagues and coworkers. Strive to be inclusive of all students in the classroom. Initiate conversations about medical ethics. Utilize the hidden curriculum to promote the topics you want your students to internalize (3).

Many factors help mold learners as they transition from students to contributing professionals. While not discussed as frequently as the covert academic curriculum, the hidden curriculum is important for shaping the characters of students as future healthcare professions. As educators or future educators, we should be mindful of the messages we are subliminally transmitting. When we strive to eliminate our negative, biased views and replace them with compassionate, ethical ones, we are helping to create the next generation of caring and ethical healthcare professionals.

References:

1. Jackson PW. Life in Classrooms. New York (NY): Teachers College Press; 1990.

2. Hafferty, F W; Franks, R. The hidden curriculum, ethics teaching, and the structure of medical education. Academic Medicine: 1994 Nov;69(11):861-71. https://journals.lww.com/academicmedicine/Abstract/1994/11000/The_hidden_curriculum,_ethics_teaching,_and_the.1.aspx

3. Eastwood GL. Ethical Leadership in the Hidden Curriculum. Int J Leadersh Educ: 2021 Fall;65-72. https://scholarlycommons.law.case.edu/cgi/viewcontent.cgi?article=1129&context=ijel 

The Effect of Constructive, Positive and Negative, Destructive Feedback on Learners

Sumeen Mirza, PharmD
PGY1 Pharmacy Resident
University of Maryland Medical Center

Feedback in the setting of clinical education is defined as “specific information about the comparison between a trainee’s observed performance and a standard, given with the intent to improve the trainee’s performance”1. In the healthcare profession, or any area of work, improvement in performance is something everyone strives for thus, feedback is an important aspect of learning to help with this improvement. However, feedback may not always be given to the learner accurately. In fact, in a study done involving attending surgeons and surgery residents, 90.9% of attending surgeons felt they gave successful, effective feedback, however, only 16.7% of surgery residents agreed with this statement (p< 0.001).2 This discrepancy shows that giving effective and constructive feedback may be a difficult task to accomplish. 

When feedback is given in an ineffective and destructive way, it can have detrimental effects. This kind of feedback is general, subjective, confrontational, contain personal judgment, contain negative reinforcement, and is domineering. It can be demotivating and result in a decrease in self-esteem in the learner. This form of feedback can also lead to the learner avoiding feedback and having hesitance to ask questions when and if they have any.3 In two studies done involving undergraduate students who received destructive criticism, students who received destructive feedback reported more anger and tension, were more likely to handle disagreements that occurred with the source of the destructive feedback in the future with avoidance or resistance (rather than compromise and collaboration), set lower goals for themselves, and reported lower self-efficacy than those who received constructive cristisms.4 

In contrast, constructive, effective feedback is specific, timely, nonjudgmental, and objective. This type of feedback is more reflective, respectful, and allows there to be a safe environment for communication between the learner and teacher. Another benefit of this type of feedback is that it helps learners become more active in their learning, helping them correct gaps in their performance and motivating them to learn more in the future.3 In a cross-sectional study involving “Emergency Nursing” clinical practice, nursing students filled out a questionnaire in which they evaluated the feedback that their teachers provided. The studied showed that high quality positive feedback is associated with the students giving their teachers’ higher grades (p=0.027), students giving a “very high” evaluation to the contribution of this feedback (p=0.002), and over-self-evaluation (p=0.02). High quality negative feedback is associated with student’s having a more accurate self-evaluation (p=0.015).5 This study shows the importance and benefit of teachers giving high quality positive and negative feedback to learners.  

There are many models available to help teachers give constructive, effective feedback. One such feedback model is the “Feedback Sandwich.” This type of model involves the start and end of the of the feedback session to consist of positive feedback, and the critical, negative feedback to be sandwiched in between the two positive feedback time periods. This type of feedback is more instructor focused and can lose its effectiveness if used consistently. Another feedback model is the Pendleton model. This model is more of a learner centered model in which the learner is first asked to assess themselves and answer what they think went well. After the leaner is asked how they can improve or what can be done differently. For both assessments the learner makes, the teacher reinforces the positive comments made, acknowledges the area of improvement, and helps the learner figure out a way they can improve or do things differently. After, both the teacher and learner come up with a mutually agreed upon plan.6 

In conclusion, it is important for teachers to learn how to give effective feedback since the effects of giving destructive or inaccurate feedback are detrimental to the learner’s growth and emotional well-being. Providing constructive, effective feedback is extremely beneficial to help a learner improve and grow, especially in clinical practice settings for future healthcare professionals. 

References:

1. van de Ridder JM, Stokking KM, McGaghie WC, ten Cate OT. What is feedback in clinical education?. Med Educ. 2008;42(2):189-197. doi:10.1111/j.1365-2923.2007.02973.x

2. Sender Liberman A, Liberman M, Steinert Y, McLeod P, Meterissian S. Surgery residents and attending surgeons have different perceptions of feedback. Med Teach. 2005;27(5):470-472. doi:10.1080/0142590500129183

3. Sarkany D, Deitte L. Providing Feedback: Practical Skills and Strategies. Acad Radiol. 2017;24(6):740-746. doi:10.1016/j.acra.2016.11.023

4. Baron RA. Negative effects of destructive criticism: impact on conflict, self-efficacy, and task performance. J Appl Psychol. 1988;73(2):199-207. doi:10.1037/0021-9010.73.2.199

5. Plakht Y, Shiyovich A, Nusbaum L, Raizer H. The association of positive and negative feedback with clinical performance, self-evaluation and practice contribution of nursing students. Nurse Educ Today. 2013;33(10):1264-1268. doi:10.1016/j.nedt.2012.07.017

6. Hardavella G, Aamli-Gaagnat A, Saad N, Rousalova I, Sreter KB. How to give and receive 
feedback effectively. Breathe (Sheff). 2017;13(4):327-333. doi:10.1183/20734735.009917

The Fine Line Between “Spoon-Feeding” and Guiding Your Learner

Meskerem Abebe, PharmD
PGY-1 Pharmacy Resident
Holy Cross Hospital

Most of us had experienced bad teaching at some point in our student lives. But the question is whether that experience is purely due to lack of competency as perceived by your educator or if there are other factors that were simply overlooked from the learner’s perspective. In my fourth year of pharmacy school, I had a preceptor who expected everything but have done nothing to guide me through the learning experience and I also had a preceptor whom on day one of my rotations asked me how I learn best and followed through. These two examples might be on two extreme opposite ends, but it is my belief that educators need to meet their learners where they are and guide them through where they expect them to be. Providing proper guidance is almost impossible without getting to know your learners’ backgrounds. If you don’t make the effort to get to know them, it’ll be hard to find out how much of an impact, if any, you have made in their learning experiences. Therefore, the first thing an educator should consider is balancing between spoon-feeding and guiding the learner appropriately. 

Even though the meaning of spoon-feeding is well understood, there’s not a well-defined instructional practice that illustrates it.1 What is considered an example of spoon-feeding? A well-organized syllabus with objectives fully spelled out, a well-designed course or an exam review session where the teacher explains the answers to each question in detail? Moreover, besides being able to spot spoon-feeding in an instructional system, it is also crucial to identify learners background and level of education to differentiate the concept of spoon-feeding based on their past learning experiences.1 For instance, most pharmacy schools in the US do not require a bachelor’s degree to join their program. As a result, first year pharmacy students have different backgrounds; some completed their bachelor’s degree, some simply went through the pre-requisite requirements and others come with a few years of work experiences. In this case, would it be appropriate to set the same expectations for the entire classroom in their first year of school? I believe instructors need to take careful considerations and draw a line between the fear of spoon feeding and leaving their learners unguided.

Another concept that is often considered spoon-feeding is the use of an explicit assessment criteria. A fundamental goal of higher education must be to support learners to manage their own earning.2,3 As a result, clearly stating expectations, outlining course objectives as well as creating a well-defined assessment is the paramount of supporting students to enhance their learning experiences. The EAT framework is a research-based pedagogy that states that the purposes, processes, and requirements of assessment are clear and explicit to students.4 It includes three dimensions of practice; assessment literacy, assessment feedback and assessment design. These three dimensions are interconnected and each of them have a series of four areas for lecturers, students, and program leaders/ directors to consider. The assessment literacy component urges lecturers to clarify the requirement of the discipline, student entitlement, how assessment elements fit together and what constitutes good academic practice. This will provide students with diverse backgrounds to have equal opportunity and access to learning environments. 

Teaching should never be a “one size fits all” approach. Instructors should focus more on making effort to close the gap between learners’ background and their level of expectations and pay less attention to crossing the line of appropriate guidance. At the end of the day the most important thing is helping students reach their destinations by enhancing their own learning.  

References

1. Going Beyond the Spoon-feeding Metaphor. Faculty Focus | Higher Ed Teaching & Learning. Published May 31, 2017. Accessed September 30, 2021. Available at https://www.facultyfocus.com/articles/effective-classroom-management/going-beyond-spoon-feeding-metaphor/

2. Balloo K, Evans C, Hughes A, Zhu X, Winstone N. Transparency Isn’t Spoon-Feeding: How a Transformative Approach to the Use of Explicit Assessment Criteria Can Support Student Self-Regulation. Frontiers in Education. 2018;3:69. doi:10.3389/feduc.2018.00069

3. Boud, D. (2000). Sustainable assessment: rethinking assessment for the learning society. Stud. Contin. Educ. 22, 151–167. doi: 10.1080/713695728.

4. EAT Framework. Accessed September 30, 2021. Available at https://www.eatframework.com/eat-framework

Teaching the Physical Exam Assessment in Pharmacy School

Ibtihal Makki
PGY1 Pharmacy Resident
University of Maryland Medical Center

The physical exam has been considered an essential component of education for medical students and residents since the inception of medicine. It is also essential for other healthcare professionals including nurses and physician assistants. Traditionally, pharmacists have not been integrated into the physical exam process. However, given the national shortages in primary care physicians and pharmacists advocating for provider status, pharmacists have expanded their role to include “primary care” type services. This includes the ability to measure and interpret blood pressure, heart rate, administer vaccinations, triaging symptoms that warrant emergency intervention, and perform physical examination. Especially over the last 20 years, with the expansion of ambulatory care services provided by pharmacists, the ability to competently perform and evaluate physical examinations has become vital for pharmacists.  In fact, in 2006, the Accreditation Council for Pharmacy Education (ACPE) added addressing physical assessment techniques in its standards for pharmacy school curriculums.  Furthermore, the Pharmacy Practice Supplement to the Center for Advancement of Pharmaceutical Education (CAPE) included the ability to perform and evaluate the physical assessment to the educational outcomes expectations in 2004.  

The aspects of the physical exam that pharmacists across practice settings are likely familiar and more comfortable with include blood pressure readings, point of care blood glucose, and diabetic foot examinations. However, examining a patient in general involves three major components including (1) interview and health history, (2) survey and vital signs, and (3) the physical exam itself. The physical examination involves the entire body and can be comprehensive or more focused. Pharmacists will often perform a more focused exam based on the patient’s reported concerns and presenting symptoms. This makes an accurate and comprehensive collection of health history and symptomatology especially important. As described by Dr. Melanie Dodd at the 2019 American Society of Health-System Pharmacists (ASHP) conference, various techniques are employed in the physical examination and heavily involve the use of the performer's hands including “inspection, palpation, percussion, and auscultation. ” After her presentation, the attendees broke out into session to further explore four of the major areas of the physical examination: musculoskeletal, neurological, cardiovascular, and pulmonary.4 These sessions included performing a wide variety of assessments including fall risk determination, pupil dilation, listening to lung vibrations, and orthostatic measurements.4

Given the involved and complex nature of the physical examination, the attainment of such skills requires formal instruction and constant practice. As such, pharmacy schools have begun to incorporate these skills into their curricula. Furthermore, the practice setting of the pharmacist highly influences the differential importance of different aspects of the exam. For example, a pharmacist practicing in ambulatory care might focus more on physical exam findings that require chronic disease state management as compared to a pharmacist practicing in emergency medicine who would tailor the physical exam to identify problems requiring prompt intervention. 

Practically, performing the physical exam provides an avenue for pharmacists to provide direct patient care and document and bill for their services. This is essential when considering efforts for pharmacists to be granted provider status. Pharmacy curricula should incorporate physical examination skills to prepare students for the evolving role of pharmacists in healthcare, including the knowledge and confidence for performing and interpreting physical exams. From a public health standpoint, pharmacists providing these services can increase access to care for patients in more remote areas and/or patients who have limited access to primary care physicians. This can have profound impacts in detecting and triaging various conditions that can be effectively managed with medications such as hypertension and hyperlipidemia, potentially mitigating more serious consequences of these disease states being untreated such as myocardial infarction or stroke. In the long term, this can decrease health inequity and decrease medical costs associated with high disease burden.

References:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073103/ (Bolesta) 

2.  Accreditation Council for Pharmacy Education. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. January 15, 2006. http://www.acpe-accredit.org/pdf/ACPE_Revised_PharmD_Standards_Adopted_Jan152006.pdf. 

3. 2005 and 2006 AACP Pharmacy Practice Educational Outcomes and Objectives Supplements Task Force. Pharmacy Practice Supplemental Educational Outcomes Based on CAPE 2004. American Association of Colleges of Pharmacy. http://www.aacp.org/resources/education/Documents/PharmacyPracticeDEC006.pdf 

4. Aislinn Antrim A. Pharmacy in Transition: Physical Assessments. Pharmacy Times. https://www.pharmacytimes.com/view/pharmacy-in-transition-physical-assessments.  Published 2021. Accessed October 1, 2021.

An Evaluation of Virtual Learning During the COVID-19 Pandemic on Healthcare Education

Renee Mott, PharmD
PGY-1 Pharmacy Resident
Suburban Hospital – Johns Hopkins Medicine

During the COVID-19 pandemic, virtual learning quickly became the norm, however, virtual learning existed prior to March 2020. The earliest form of virtual learning was created in 1982 when a distance education program was created by The Western Behavioral Sciences Institute1. From here, availability of online courses quickly increased. In 1985, Nova Southeastern University in Florida became the first university in the United States to offer a fully online graduate program2. By 2015, the National Center for Education Statistics estimated approximately 43% of students were participating in online courses1. Technology has allowed for continued education throughout the past nearly 2 years of pandemic-life, but can virtual learning truly replace in-person learning in healthcare education?

Medical school in the United States consists of 4-years of intense training. The first two years, MS1 and MS2, are preclinical years where students attend lectures and learn the complex systems of the human body. While the COVID-19 pandemic quickly put a stop to in-person education, it is possible this was not a major disruption in learning for medical students in their preclinical years. A 2017 survey of MS2 students illustrated most students prefer to watch lectures on their own time rather than attending class at scheduled times3. While medical students in their preclinical years miss out on in-person opportunities like small group learning or labs, virtual learning is a reasonable option for these students. However, for MS3 and MS4 students in their clinical years, virtual learning significantly impacts their education. During these years’ medical students spend time in hospitals and clinics putting their knowledge and skills to use while gaining real world experience essential for learning to successfully care for patients. These experiences also help guide medical students in their decision of what specialty to pursue. It has been said “medicine is learned by the bedside and not in the classroom”4, but the COVID-19 pandemic has forced educators and medical students to quickly adapt to a virtual world.  

Analogous themes emerge when evaluating the impact of the COVID-19 pandemic on pharmacy education and nursing education. Both pharmacy and nursing students have clinical requirements as part of their programs, which require students meet a predetermined number of direct patient care hours prior to graduation. The question we must now ask is what can educators do from an instructional design perspective to enhance virtual learning during the COVID-19 pandemic?  

Many surveys and papers have emerged since the beginning of the COVID-19 pandemic which focus on the remote delivery of healthcare education3,5,6. One of the first things educators can do from an instructional design perspective when evaluating didactic education is create a virtual classroom similar to an in-person classroom3. Creating a private, quiet space to facilitate the virtual classroom is of utmost importance. Educators should lead by example, ensuring they have their camera on at an appropriate angle with an appropriate background. Encouraging or requiring students to use audio and video helps keep the class focused and engaged. 

Educators should also become comfortable with the technology available to them for use in their virtual classroom3. Platforms such as Zoom and Microsoft Teams include features like screensharing, polling, chat, and creating breakout rooms which can enhance virtual education3. Screensharing allows for students to view PowerPoint presentations in real-time similar to sitting in a large lecture hall, polling questions and chat features allow for active participation in class activities, and breakout rooms allow for small group discussion similar to “think-pair-share” exercises often utilized in healthcare education.  

Arguably the most crucial step educators can do when designing virtual learning experiences for students pursing a healthcare degree is listen to get to know their learners. A 2020 survey of pharmacy students revealed the many challenges student learners faced when suddenly shifting to a virtual learning format in Spring 20205. Students describe feeling that virtual learning was “detrimental to [their] education” for reasons including lack of quiet space to work at home, difficulties with technology including WiFi connection, and inability to work directly with other classmates to understand material5. It is also important to recognize the impact this rapid change has had on student’s mental health. If comfortable and appropriate, educators can have open discussions about this with their students. 

When designing virtual education for students pursing a degree in healthcare whom are in their clinical years of their programs, the challenges are greater. There is no way to truly replicate in-person clinical education in a virtual format, as certain aspects of patient care require physical contact. For example, a medical, pharmacy, or nursing student whom is learning to take blood pressure using a blood pressure cuff, stethoscope, and sphygmomanometer cannot possibly take the blood pressure of a patient through a computer screen. While not every aspect of clinical education is possible to achieve in a virtual format, participation in direct patient care activities has continued during the COVID-19 pandemic via methods such as telemedicine and virtual rounds3. Policies on use of these methods may differ by health system and should be addressed on a local level. 

Overall, the COVID-19 pandemic caused a rapid shift to a virtual world. Virtual learning is not ideal for students pursing a degree in healthcare nor can it fully replace in-person learning. However, there are ways to optimize virtual delivery of healthcare education and allow for students to continue progressing towards graduation. 

References: 

1. Thompson E. History of Online Education. [Internet]. 2021 May 27 [cited 29 September 2021]. Available from:  https://thebestschools.org/magazine/online-education-history/ 

2. eLearners.com. Nova Southeastern University ONline. [Internet]. [cited 29 September 2021]. Available from: https://www.elearners.com/colleges/nova-southeastern-university/ 

3. Hilburg R, Patel N, Ambruso S, Biewald MA, Farouk SS. Medical Education During the Coronavirus Disease-2019 Pandemic: Learning From a Distance. Adv Chronic Kidney Dis. 2020; 27(5): 412-417. doi: https://doi.org/10.1053/j.ackd.2020.05.017. 

4. Stanfordmedicine.edu. 10 Osler-isms to Remember in Your Daily Practice. [Internet]. 2014 November 25 [cited 29 September 2021]. Available from: https://stanfordmedicine25.stanford.edu/blog/archive/2014/10-Osler-isms-to-Remember-in-Your-Daily-Practice.html 

5. Nagy DK, Hall JJ, Charrois TL. The impact of the COVID-19 pandemic on pharmacy students' personal and professional learning. Curr Pharm Teach Learn. 2021 Oct;13(10):1312-1318. doi: 10.1016/j.cptl.2021.07.014. 

6. Jeon E, Peltonen LM, Block L, Ronquillo C, Tayaben JL, Nibber R, Pruinelli L, Perezmitre EL, Sommer J, Topaz M, Eler GJ, Shishido HY, Wardaningsih S, Sutantri S, Ali S, Alhuwail D, Abd-Alrazaq A, Akhu-Zaheya L, Lee YL, Shu SH, Lee J. Emergency Remote Learning in Nursing Education During the COVID-19 Pandemic. Stud Health Technol Inform. 2021 May 27;281:942-946. doi: 10.3233/SHTI210317. 

Microlearning

Brian Gac, PharmD
PGY1 Pharmacy Resident

Children’s National Hospital

The landscape of education and instructional design is one that is ever in flux. This is not only because educational research is a relatively new development only becoming established within the past two hundred years or so, but because the rapid rise of new technologies continuously affect how we engage with new information. Historically, apart from self-teaching, education has been achieved in formal lecture settings, whether it be large-scale classrooms or individual training. This presents certain challenges, as students may not always be in a mindset conducive to learning when scheduled lectures take place. With the advent of the internet and even more recently with portable and handheld devices, there has been a revolution in the way information is disseminated. Microlearning is a new method of formalized training that combines the benefits of directed teaching from an expert source with the convenience of allowing students to learn on a schedule that is effect for them.

If you have heard of the language learning mobile application Duolingo, you are at least on some level familiar with the idea of microlearning. Information is broken up into “small and understandable fractions,” where “the learning speed is chosen by students themselves.”1 Microlearning contains some key characteristics that make it advantageous.2 Learning is performed is short periods of time that require little from individual sessions. Sessions are narrow in scope and are ideally fun and engaging and presented in a casual and informal way. Microlearning does have its limitations, however. With lessons broken up into small, simple fragments, it is not a conducive method for learning complex skill or processes. Learning is done individually, and relevant practice is still required. And learning still needs to be achieved in a focused manner, with many individuals believing that they can multi-task learning with other requirements, an idea that is not borne out by data. Still the opportunities for implementing microlearning as a new method of teaching are promising.

The possibilities for the utilization of microlearning are promising. One study divided a class of seventh grade students into two groups, one of which received inform in a traditional didactic fashion with large amounts of information being delivered in a short amount of time and the other group received information using microlearning.1 The students received information on the same topics for five weeks and then were evaluated on their learning without prior notification during the sixth week of the study. The traditional learning group passed the evaluation at a rate of 64% while 82% of learners in the microlearning group passed the exam, for an 18% difference between the two groups. This difference is striking, though perhaps highlights one of the disadvantages of microlearning, that its utility may be limited to simple topics and would you to be implemented more strategically for adult learners.

Despite the complexities of healthcare education curricula, this is not to say there is not a role for microlearning for aspiring physicians, pharmacists, and other medical professionals. In fact, many proprietary microlearning platforms for students in the health professions already exist. As of September, 2020, the self-directed learning platform SketchyMedical boasted 30,000 active subscriptions, prompting an injection of outside investment to the tune of $30 million.3 The platform produces short-form animations covering a variety of topics geared towards medical students using story telling and mnemonic devices that allow them to learn information in an easily digestible, self-directed manner. Platforms such as SketchyMedical are contributors to a striking finding by the American Medical Association in 2019: 23.5% of medical students were not attending lectures at all and about 17% “almost never” view video lectures.4 With such a large percentage of students choosing not to engage with the formal education they are paying exorbitant amounts of money for, one might view this as a crisis needing addressing. But in the written Chinese language, the character for “crisis” also contains the character for “opportunity.”

Instead of responding with a knee-jerk reaction to compel students to attend lectures with class credit or punishments of various kinds. Institutions should implement their own microlearning materials to provide students with an alternative form of consuming information. While, of course, this would be no substitute for the entire curriculum, it seems perfectly poised for basic information that provides the foundation of learning throughout school. Often, conversations around new technologies are premised on whether or not they will supplant existing methods entirely. But this argument does not consider that instructional design is not zero-sum; beginning to utilize a new system does not preclude us from continuing to use the old. No student is identical to another and different methods will work best for different people and will even work best for the same person at different times. Embracing new methods allows us to further individualize learning and maximize educational outcomes.

References:

1. Sirwan Mohammed G, Wakil K, Sirwan Nawroly S. The Effectiveness of Microlearning to Improve Students’ Learning Ability. Int J Educ Res Rev. 2018;3(3):32-38. doi:10.24331/ijere.415824

2. Jomah O, Masoud AK, Kishore XP, Aurelia S. Micro Learning: A Modernized Education System. 2016;7(1):8.

3. This Test Prep Service has a Cult Following Among Med Students. Soon it Will Have an Animation Studio. dot.LA. Published September 24, 2020. Accessed October 3, 2021. https://dot.la/sketchy-medical-2647784595.html

4. Why some medical students are cutting class to get ahead. American Medical Association. Accessed October 3, 2021. https://www.ama-assn.org/residents-students/medical-school-life/why-some-medical-students-are-cutting-class-get-ahead

The Socratic Method

Shila Mortazavi Pharm.D.
PGY1 Pharmacy Resident
Howard County General Hospital

As its name suggests, the Socratic method is an approach to teaching that originated from the renowned Athenian philosopher Socrates and is based upon engaged dialogue. According to Delić and Bećirović this method consists of five distinct stages starting with wonder and the postulation of questions by the student.1 In the subsequent stage, the teacher would then look to the student to form a hypothesis to the initial wonder. In response to the student’s primary hypothesis, the next stage would involve the teacher performing a cross-examination of the primary hypothesis by providing counterexamples to prove or refute the hypothesis. The following stage is the acceptance or rejection of the hypothesis in which the student can accept or reject the counterexamples. In the final stage, the student can act upon the discoveries from the dialogue between the teacher and student.1 Traditionally in this method, the teacher serves as a mere guide that incorrectly reasons with the student throughout the discussion to allow them to draw their own conclusions and develop a higher level of critical thinking.

In the writings of Socrates’s students such as Plato, most emphasize the cross examinations performed by Socrates as the critical point where the truth-value of a statement is discovered, which was a point referred to as the elenchus.4 While the origins of these lessons were intended initially to challenge philosophers on topics that related to their morals and ethics, these same methods can also be used to guide active classroom discussion in higher education. One structured application of this method is called the Socratic seminar, and much like the fishbowl approach employs a design where students are arranged in two rows of concentric circles.2 In this method, the students are provided reading materials to review, then asked to participate in one of two ways: the outside row of students observe while the inside row of students engages in a dialogue with the instructor. In this model, the students are not necessarily debating each other on the text that they have read but are instead working together to develop a more critical understanding of the text. The teacher is an expert in the subject matter and guides the discussion by posing questions and mediating the discussion. When the discussion of the inner circle concludes, the outer circle, who has thus far been exclusively observing the conversation, provides relevant feedback to the inner circle on their discussion.2,3 Similar to other models of instructional system design, there is a strong emphasis on students closely analyzing and gathering information before the discussion. This method also encourages students to discuss and develop critical knowledge on the topic through discussion and requires that they reflect and evaluate their discussion with appropriate feedback.

In terms of instructional design, the Socratic seminar could prove valuable in many ways. A study was conducted where middle school students took part in a Socratic seminar after reading a text on their own.3 Surprisingly, 80% of the student sample had shown evidence of performing metacognitive activity or higher-order formal operation. This meant that students focused on forming abstract thoughts to create a hypothesis which they then systematically tested. Polite et al. also found that middle school students who were involved in the Socratic seminars were largely comfortable with utilizing different degrees of conflict resolution skills. About 80% of the students had at least some conflict resolution skills and that about 66% of these students were able to utilize elaborate resolution skills such as the agreeing-to-disagree outcome.3 In the realm of higher education, it is not uncommon for students to have to digest primary literature. The Socratic seminar model could be applied and promote a more abstract discussion rather than stressing specific data points and trends. These discussions could also help students hoping to become future practitioners more critically assess what research and clinical guidelines they chose to implement in their personal practice. For instance, the ACC/AHA guidelines for hypertension management promote the use of thiazides, calcium channel blockers, angiotensin-converting-enzyme inhibitors, or angiotensin II receptor blockers as first line agents. A further discussion into different aspects of the evidence behind these recommendations such as the studies’ inclusion or exclusion criteria, their demographic representation, or follow-up time all could challenge upcoming health care practitioners to consider commonly applied therapeutic generalizations more carefully. Ethically speaking, such discussions could help develop providers that are higher level critical thinkers that take the extra steps to ensure that their interventions for patient research they are utilizing to treat their patients would serve a purpose in their patient on a case-by-case basis.

While the Socratic seminar could prove incredibly useful in higher education, there are several limitations one must consider before employing the model. This model is not ideal for every type of lesson, such as lessons that require the instructor to provide facts and. This type of teaching approach should rather be left to courses where material is more sensitive to interpretation and students have a wider breadth of foundational knowledge. This model also heavily relies on student participation and interest, and without these key elements, the model’s effectiveness would be diminished. However, despite its weaknesses, in terms of crafting professionals through higher education, the Socratic seminar utility is clear. This method of teaching would encourage abstract thought, empower critical thinking, and in the case of pharmacy students, help develop pharmacists who are better prepared to face scrutiny or cross-examination when it comes to making clinical decisions.

References:

1. Delić H, Bećirović S. Socratic Method as an Approach to Teaching. European Researcher, vol. 111, no. 10, 2016, doi:10.13187/er.2016.111.511.

2. Griswold J, Shaw L, Munn M. Socratic Seminar with Data: A Strategy to Support Student Discourse and Understanding. Am Biol Teach. 2017 Aug;79(6):492-495. doi: 10.1525/abt.2017.79.6.492. Epub 2017 Aug 8.

3. Chowning JT. Socratic Seminars in Science Class: Providing a structured format to promote dialogue and understanding. Sci Teach. 2009 Oct;76(7):36-41.

4. Richard Robinson, Plato's Earlier Dialectic, 2nd edition (Clarendon Press, Oxford, 1953). Reprinted in Gregory Vlastos (ed.), The Philosophy of Socrates (Anchor, 1971). Edited in hypertext by Andrew Chrucky, June 2, 2005.

“See many, Do many, Teach many”

Paige Ruffier, PharmD
PGY1 Pharmacy Resident
Children’s National Hospital

In 1890, William Halsted became the first Chief of Surgery at John Hopkins Hospital. At the time, surgical residents were either self-taught or underwent an apprenticeship1. Halsted’s model of “see one, do one, teach one” is a procedural training methodology that seeks to promote progressive skill development while prioritizing adequate supervision and patient safety2. It is important to note that Halsted was not only interested in developing a methodology to train surgeons, but also interested in developing teachers and role models1. The “see one, do one, teach one” approach has now expanded far greater than just the setting of aspiring surgeons. Before we dive into how “see one, do one, teach one” can be extrapolated into settings outside of the medical field, let’s first further explore each aspect of it.

The first component, “see one”, represents the learner’s direct observation of the skill. In addition to strictly observing the skill completed with expert technique, this is when the learner can take advantage of asking the expert any clarifying questions. The next component, “do one”, represents the learner’s completion of the skill independently. It is here when the expert may chime in with feedback that will be crucial to the learner’s continued success. The last component, “teach one”, represents the learner teaching the skill to a new learner. At this point the learner has essentially transitioned from the learner to the expert, as they begin to instruct a new learner. The “see one, do one, teach one” approach is a cycle that continues to pay it forward to each future generation of learners.

“See one, do one, teach one” can be attractive to many. The process not only has educators instructing students initially, but also encourages students to be autonomous with their own learning early on3. Additionally, the “see one, do one, teach one” approach is simple and relatively easy to follow. However, as with any instructional design model, it poses challenges. For example, what if you have a learner that is able to complete the skill independently, but has many errors? Do we want that learner teaching a new learner when they haven’t yet mastered the skill themselves? There are no guardrails in place.

In today’s times, the phrase “see one, do one, teach one” has transitioned to “see many, do many, teach many4.” We know that not all people learn the same way or at the same speed. By changing one to many, this considers the differences in rates that learners learn, as well variation in complexity of the skill (as we would suspect that more challenging skills will need more repetition). Furthermore, when we bring this methodology back to its original audience of surgeons-in-training, the adaptation to “see many, do many, teach many” is preferred in terms of patient safety and ensuring patients are provided the utmost level of care.

Outside of the medical field, we can find the “see many, do many, teach many” practice applied in a variety of learning environments. For example, learning to drive a car. You first need to observe an expert (someone with an active driver’s license) driving on many occasions. It is typical for a teenager (who is the learner), to observe a parent (the expert). The next component, “do many”, is typically when the teenager will practice under supervision of the parent. The teenager will then obtain a driver’s license and be able to drive oneself independently. The last component, the “teach many”, is demonstrated when the teenager is then comfortable to drive other’s around (thus serving as the expert). We can also apply this to pharmacy education. Whether a pharmacy student is learning to administer immunizations, provide medication counseling, or even perform patient chart review, the “see many, do many, teach many” method can be applicable to various aspects within pharmacy school curriculums.

The “see many, do many, teach many” instructional process really can be appropriate in almost all settings in which a learner is learning any sort of new skill.

References:

1. Kotsis SV, Chung KC. Application of the "see one, do one, teach one" concept in surgical training. Plast Reconstr Surg. 2013;131(5):1194-1201. doi:10.1097/PRS.0b013e318287a0b3

2. Heath JK. See One, Do One, Teach One, Tell All. Chest. 2020;158(5):1820-1821. doi:10.1016/j.chest.2020.05.566

3. Cooksey A. See One, Do One, Teach One. Knowledge Quest: Journal of the American Association of School Librarians. September 11, 2017. Accessed September 25, 2021. https://knowledgequest.aasl.org/see-one-one-teach-one/

4. Rohrich RJ. "See one, do one, teach one": an old adage with a new twist. Plast Reconstr Surg. 2006;118(1):257-258. doi:10.1097/01.prs.0000233177.97881.85

The Use of Rubrics in the Pharmacy Curriculum

Allison Loi, PharmD
PGY1 Pharmacy Resident
Safeway Pharmacy Mid-Atlantic Division

Throughout pharmacy school, student pharmacists encounter various evaluation methods that assess their knowledge acquisition, problem-solving capability, application of skills, and critical-thinking ability. With new learning experiences, questions related to grading and assessment always seems to be topic of interest among student learners such as "exactly where did I lose points?" and "what could I have done to get a better grade?" To help facilitate student learners from novice to competent, rubrics are incorporated into various learning experiences throughout the pharmacy school curricula, such as patient counseling activities and assessment and plan development.

O'Donnell et al., defined a rubric as a scaled tool with levels of achievement and descriptions of each criterion for each level of performance.1 Essentially a rubric is a document that defines what is expected from the student and what will be assessed for a particular project, presentation, or evaluation. Typically, rubrics are designed as a grid-type structure consisting of evaluative criteria, scoring strategy, and quality statements.2 The evaluative criteria describe the critical elements of a student's work related to the learning outcomes being assessed. The evaluative criteria are skills, knowledge, and behavior that the learner must demonstrate. For example, as part of a new prescription medication patient counseling activity, the evaluative criteria might include an introduction and patient history, basic counseling points, patient education, organization and succinctness, verbal, and nonverbal communication.3 The next component of a rubric is a scoring strategy to rate each criterion which is often combined with levels of performance such as "not meeting," "meeting," or "exceeding" expectations. Although the scoring scale can be either numerical or descriptive, the important aspect is that the different levels reflect variance in quality and not a shift in importance. The last component of a rubric is the quality statements that describe each level of performance.

According to Heidi Andrade, a rubric expert, an effective rubric goes beyond a grading/answer key.4 An effective rubric serves as a teaching and learning tool. For the instructor, a rubric for a learning activity helps clarify the learning goals, promotes objectivity and consistency in grading, and is a tool for providing timely, useful, and focused feedback.1,2,4 In a review paper by Cockett and Jackson on rubrics in higher education, students identified that they used the rubric as a guide to prepare for the learning activity, better understand what is expected of them, and what to do to be successful.2 Also, the review paper noted that students used rubrics to assess their progress and reflect on their competency in completing work.2 Overall, the review paper by Cockett and Jackson on rubrics in higher education concluded that student self-assessment, self-regulation, and understanding of assessment criteria were enhanced using rubrics.2

Rubrics are embedded in the pharmacy curriculum for various learning activities to communicate teaching and learning expectations and provide informative feedback, so students are "practice-ready" upon graduation. For example, a SOAP note rubric may be integrated with the various pharmacotherapy courses as it is required for students to document patient care activities accurately and concisely.3 The SOAP note serves as a learning tool to provide clear assessment criteria and a resource for students to self-assess progress toward competence.

Although evidence suggests that rubrics are most effective when co-created with students and other faculty members, this is not always feasible due to time constraints and the availability of resources.1,2,4 However, it is still important to seek feedback from students and evaluators to revise the rubric as needed to make it as effective a tool as possible. Other challenges of using rubrics as part of the assessment process include reduced creativity, can cause performance anxiety and inter-rater reliability issues. 1,2,4

In summary, effective rubrics can serve the purposes of teaching and learning as well as evaluation. For instructors, a rubric is a tool to establish clear rules for evaluation and to define criteria for performance to meet learning goals. In contrast, rubrics provide students with clear expectations of performance, an opportunity to self-assess progress and receive timely, detailed feedback.

References:

1. O'Donnell, Jean A et al. “Rubrics 101: a primer for rubric development in dental education.” Journal of dental education vol. 75,9 (2011): 1163-75.

2. Cockett, Andrea, and Carole Jackson. “The use of assessment rubrics to enhance feedback in higher education: An integrative literature review.” Nurse education today vol. 69 (2018): 8-13. doi:10.1016/j.nedt.2018.06.022

3. Sherman, Justin J, and Christa D Johnson. “Assessment of pharmacy students' patient care skills using case scenarios with a SOAP note grading rubric and standardized patient feedback.” Currents in pharmacy teaching & learning vol. 11,5 (2019): 513-521. doi:10.1016/j.cptl.2019.02.012

4. Andrade HG. Teaching with rubrics: the good, the bad, and the ugly. College Teaching. 2005;53(1):27-31.