Team-Based Learning Promotes Self-Reflection and Creates Lifelong Learners

by Austin Simmons, PharmD, PGY1 Pharmacy Practice Resident, Magnolia Regional Health Center

During the first two years of any healthcare provider’s schooling, students often find themselves navigating their curriculum and trying to remember all of the little details that are thrown their way. Most students don’t engage in much self-reflection during this period due to workload demands. Then comes the third and fourth years of school. This is when students try to piece it all together and decipher what they know and what they will need to work on as they transition from student to independent practitioner. I believe team-based learning prepares students to transition from dependent learners to lifelong learners and promotes self-reflection.

Team-based learning is built on the constructivist theory which states that learners process new material and integrate it with existing understandings in order to form a new cognitive structure that is unique to them.¹ Hrynchak and Batty wrote about team-based learning and provide an analysis of how constructivist theory plays a role in student development. Essentially, the professor is a facilitator for learning.  The students encounter inconsistencies between their preconceptions and new experiences.  In team-based learning, the focus is on relevant problems and accompanied by group interactions, and this often leads to reflection.² They go on to explain that team-based learning can be used in large classes that are divided into smaller groups.  The goal should be to maximize the diversity within the teams.² Let’s take a look at the framework team-based learning uses to promote self-reflection and build lifelong learners.

Classically, the design of team-based learning is a three-step process that involves student preparation, readiness testing, and application-focused exercises.³ Now, how does this framework promote learning and increase student self-awareness? Let me draw from my own experience.  At my pharmacy school, we had a class called case studies. The intent of this class was for the students to prepare before the class session and use prior knowledge.  We would then engage in collaborative work discussing a patient case in our assigned small group. Then after our small group discussion, the classroom as a whole would come together and the professor would facilitate a conversation by asking each small group questions related to the patient case. The instructor would also encourage the entire class to openly respond to these questions. It was during these interactions, in our teams and the entire class, that we’d encounter inconsistencies between our preconceptions and the perspectives of our instructor as well as other students.² Doing so, in theory, prompts each student to reflect on his/her own understanding of the material. But what are the individual processes or parts that make team-based learning work and what are the important takeaways for a student and instructor?

From my own experience, I found that the immediate feedback from my classmates and the instructor allowed me a way to rapidly assess how well I understood the material. Our class was a 3-hour session which included the time for our small group discussion. If we discussing a case about a patient with diabetes, I might ask myself: what do the blood glucose data mean?  What are the blood glucose goals for the patient? I would rapidly assess and begin self-reflection by asking myself if I needed to review more about the treatment of diabetes. The immediate feedback is a big part of what makes team-based learning work and vital to increasing self-reflection.⁴

I believe it is important to keep in mind that all aspects of the team-based learning framework must be implemented and the intentional guidance provided by an instructor is essential.⁵ Martirosov and Moser found that a student’s understanding and performance were significantly reduced in the absence of appropriate guidance.⁵  To maximize learning, the instructor must ask probing questions. For example, a patient case about diabetes helped promote self-reflection by getting students to think through the data and recommend starting a medication, perhaps an angiotensin receptor blocker (ARB). Then the instructor would ask questions about why they think the patient should receive an ARB instead of an ACE inhibitor. By prodding the students to explain their choices, it forces them to reflect on that choice and critically examine the thought process. An instructor is the glue that prompts high-level cognitive processing and pulls forth the student’s previous knowledge.  In this way, team-based learning helps students put the pieces together.

Team-based learning is an excellent instructional strategy that many curriculums have used. Team-based learning requires students to engage in reflection because it frequently challenges their preconceived understanding of the material and, in turn, promotes life-long learning.  With guidance from the instructor, students must defend their choices, and this helps them “put it all together.” I firmly believe team-based learning helps students develop lifelong learning skills and helps them become excellent healthcare practitioners.

References:

1. Moon J. A Handbook of Reflective and Experiential Learning. 1st ed. Hoboken: Taylor and Francis; 2004.
2. Hrynchak P, Batty H. The educational theory basis of team-based learning. Medical Teacher [Internet]. 2012 [cited 2020 Nov 3];34(10):796-801.
3. Overview - Team-Based Learning Collaborative [Internet]. Team-Based Learning Collaborative. 2020 [cited 2020 Nov 3].
4. Whittaker A. Effects of Team-Based Learning on Self-Regulated Online Learning. International Journal of Nursing Education Scholarship [Internet]. 2015 [cited 2020 Nov 4];12(1):45-54.
5. Martirosov A, Moser L. How Team-Based Learning Can Promote the Development of Metacognitive Awareness and Monitoring. American Journal of Pharmaceutical Education [Internet]. 2020;84(11): Article 848112.

Teaching Health Profession Students the Skills Needed to Maintain Wellbeing

by Anna Carroll Harris, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Numerous studies have been published exploring burnout among healthcare workers. Health profession students are also prone to burnout due to the vigorous course load required to obtain their degrees. The WHO defines burnout as a syndrome that is directly correlated with an environment that exposes workers or students to chronic stress and where the stressors are not successfully handled. It is characterized by feelings of emotional exhaustion, amplified feelings of negativism towards one’s job, and decreased professional worth.

The occurrence of burnout not only affects those working and learning in the healthcare industry, but also the patients to whom they provide care. For example, pharmacists who are experiencing increased levels of stress and emotional exhaustion may feel a sense of depersonalization towards patients they are caring for. This in turn can lead to medication errors and harmful events for patients.¹ It is imperative that schools and colleges of pharmacy, and other health professional degree programs, help students develop the skillset and positive behavior practices that needed to maintain their wellbeing and prevent burnout throughout their careers.²

Many professional organizations have noted the need to provide health profession students and healthcare practitioners with resources to encourage a state of well-being and prevent burnout. The American Association of Colleges of Pharmacy has published two policies, a 2017 and 2018 statement, in response to the increasing realization that burnout is prevalent. Both statements encourage and hold schools and colleges of pharmacies accountable for effectively promoting wellness and implementing management methods directed to students, faculty, preceptors, and staff.³ In reaction to these statements, schools and colleges of pharmacy across the country are putting programs into place that foster an environment for creating and maintaining well-being. For example, the Ohio State University College of Pharmacy has a “Wellness Corner” dedicated to providing faculty, staff, and students an environment that promotes and protects well-being. They have been recognized across their campus as having a strong culture of wellness by implementing evidence-based wellness strategies and providing tools to achieve a sense of wellbeing.⁴

The University of Kentucky College of Pharmacy completed a study where they “nudged” pharmacy students to adopt well-being behaviors. Over a span of 4 months, a series of optional well-being challenges were embedded in their pharmacy management course. These challenges included limiting smartphone use, emphasizing feelings of gratitude, good sleep hygiene, and engaging in regular exercise. Participants completed a reflection at the end of the course that explored reasons for participation, prior behaviors, and if participants planned to continue to implement the new behaviors after completion of the challenges. The majority of participants indicated that they planned on maintaining the positive behaviors moving forward.⁵

The specific stressors that lead to burnout have been identified in many studies. A study that included pharmacy students in an urban Midwestern region identified strategies that pharmacy students utilized to protect their wellbeing and prevent burnout. Students participating in a social and administrative science course were to write a reflection on factors that they believed had the greatest impact, either positively, negatively or mixed, on their wellbeing during pharmacy school. Four specific themes emerged as strategies that students use to cope with stressors during pharmacy school:⁶

1. Availability and accessibility of institutional resources
2. Personal time management and organizational strategies
3. Personal, mental, and physical health strategies
4. Activities that maintain social relationships

These results provide schools and colleges of pharmacy specific ways they can augment their campuses' attempts to foster wellbeing. Ensuring that institutional resources, such as the medical library and faculty, are readily available to students can help reduce stress and maintain wellbeing. Offering counseling and health services to those who needed them is supportive of students’ wellbeing. A few of the wellness activities mentioned in the Ohio State University College of Pharmacy “Wellness Corner” were a take five-station, a mental timeout area where students could play a game or create a craft, as well as monthly wellness walks. Ensuring that students maintain a healthy balance between schoolwork and leisure activities can reduce stress. Emphasizing the need for students to take time for themselves to socialize with friends and family and maintain hobbies is important.

In the unprecedented times of a pandemic, providing students with resources and teaching them skills to protect their well-being is more essential than ever. With COVID-19 disrupting the lives and wellbeing of so many, health profession students are dealing with the added stressors of helping take care of family members and serving on the frontlines of healthcare, in addition to their demanding coursework.⁷ The loss of person-to-person contact and being isolated away from one’s family has taken a toll on many students. What once provided a means for students to reset and take a break from the rigors of academic coursework is now discouraged.  Schools and colleges need to find creative ways to provide ongoing support to their students, faculty, and staff.  See Table 1.

Table 1: Examples of support during a pandemic

Virtual group exercise	Email check-ins	Virtual mentorships programs
Virtual game nights	Virtual group meditations	PPE drives/mask-making
Virtual book clubs	Virtual dinner dates	Virtual tutoring

As health profession students graduate, they will continue to experience stressful times and emotional exhaustion that can lead down the path of burnout. Health profession programs should work to implement programming and strategies early in their curricula that can provide students with a skillset to prevent burnout. General professional development courses, which are often part of the curriculum, would be a great place to embed lectures about managing stress and including periodic wellbeing challenges for students. These longitudinal courses should be pass/fail due to the nature of the content and should encourage students to adopt and execute tactics that best fit their personal circumstances and needs. Learning about and implementing these healthy habits while in school can help students cope with the stressors they will face throughout their careers.

References

1. World Health Organization. Burn-out an "occupational phenomenon": International Classification of Diseases. Accessed November 18, 2020.
2. Hagemann TM, Reed BN, Bradley BA, et al. Burnout among clinical pharmacists: Causes, interventions, and a call to action. J Am Coll Clin Pharm 2020; 3:832–842.
3. American Association of Colleges of Pharmacy. AACP Statement on Commitment to Clinician Well-being and Resilience. Accessed November 18, 2020. https://accpjournals.onlinelibrary.wiley.com/doi/full/10.1002/jac5.1256
4. The Ohio State University College of Pharmacy. Wellness Corner. https://pharmacy.osu.edu/wellness-corner. Access November 18, 2020.
5. Cain J. Effectiveness of Issuing Well-being Challenges to Nudge Pharmacy Students to Adopt Well-being Protective Behaviors. Am J Pharm Educ 2020; 84(8) Article 7875.
6. Abraham O, Babal, JC, Brasel KV, Gay S. Strategies first year doctor of pharmacy students use to promote well-being. Currents in Pharmacy Teaching and Learning. 2021; 13:29–35.
7. Schlesselman LS, Cain J, DiVall M. THE COVID-19 PANDEMIC ACROSS THE ACADEMY: Improving and Restoring the Well-being and Resilience of Pharmacy Students during a Pandemic. Am J Pharm Educ 2020; 84 (6) Article 8144.

Community Baby Showers: An Innovative Approach to Teaching New Mothers Sleep Safety

by Megan Carter, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Ahlers-Schmidt C R, Schunn C, Hervey A M, et al. Redesigned community baby showers to promote infant safe sleep. Health Education Journal 2020; 79(8): 888-900.

When looking through the Health Education Journal, this article piqued my interest because I was aware of the importance of safe sleeping habits for infants.  My mom works for the Alabama Department of Public Health and has been reviewing infant death cases for about 15 years.  Although she doesn't reveal details about the cases she reviews, she has shared a couple of particularly heart-wrenching stories regarding babies who died.  Unfortunately, these stories are not rare, as nearly 3500 infant deaths in the USA are due to sleep-related causes. Unfortunately, although we know much more about sleep safety during infancy, this number has not declined in recent years.¹ These kinds of deaths are preventable if parents are properly educated about how to create a safe sleeping environment.  This study aimed to provide sleep safety education to mothers, specifically mothers from low-income communities, in a relaxed environment. The authors assessed a novel approach that could increase knowledge and health-promoting behaviors.

The authors of this study designed their educational intervention — including recruitment, lesson plans, materials, and assessments — around constructs from the Health Beliefs Model.  The intervention was delivered at community "baby showers" conducted in Sedgwick County, Kansas, and targeted women who were pregnant or who had recently delivered.  Upon arrival at the shower, participants were asked to complete a pre-assessment and information card.  Organizers divided the women into tour groups of 3-5 participants with a volunteer guide who led the women around the various vendor and educational booths for brief presentations.  The last stop for each tour group was the Safe Sleep Crib Demonstration.  Certified nurses or safe sleep instructors used a demonstration crib with safety-approved items to demonstrate their effectiveness as well as examples of unsafe items that are a hazard to infants.  Instructors provided tips for removing hazardous items from the infant's sleep environment.  The sessions were not time-constrained, allowing time for participants to ask questions.  After the shower, participants took home a safety-approved portable crib, blanket, and educational handouts/materials.

These events were held twice yearly (March and October) from Spring 2015 to Spring 2019 and recruited women using a variety of means including fliers at churches and clinics, maternal and child health programs, social media posts, and through partner organizations.  The program specifically targeted locations that served low-income communities, as this was the population that was most at-risk for sleep-related infant deaths.  During the study period, nine “community baby shower” events were conducted. The participants came from a range of racial and ethnic backgrounds: Non-Hispanic Black (30.4%), Non-Hispanic White (30.4%), and Hispanics (25.1%).  Greater than 70% of participants had only a high school education or less and greater than 70% were on Medicaid or uninsured.  It is also notable that less than half of participants received prenatal care from a private provider and about 20% received care from a county health department, community center, or received no routine care. The pre-assessment consisted of true/false statements developed around the Health Belief Model constructs on infant sleep safety and were compared to the responses to the same questions given as a post-assessment.  McNemar's test for paired dichotomous variables was used to analyze differences in pre- and post-assessment responses along with the McNemar odds ratio statistic.  The following true/false questions were included on the pre- and post-assessments:

• My baby is at risk of dying of SIDS
• Loose blankets in the crib can cause infant death
• Sleeping with my baby can cause infant death
• Putting my baby alone, on the back in a crib will help protect her
• My baby will choke on his back
• People tell me different things about how my baby should sleep and I don't know what to do.
• I can't keep my baby warm without blankets.
• I don't have room for a crib in my room.

The results of the study demonstrated statistically significance (p<0.001) improvements in the participants' responses in all but two of the assessment questions.  Responses to questions about knowledge and intentions showed changes in sleep positions, sleep locations, crib items, and plans to discuss safe sleep with others.  Overall, these results appear promising and events such as the community baby shower provide an excellent opportunity to teach sleep safety to mothers.

The results look promising, but as with any study, statistically significant results don't always equate to an improvement in outcomes.  This study did have several strengths, as the participants are representative of the target population and the assessment questions were based on the Health Belief Model and evaluated by the Medical Society of Sedgwick County's Safe Sleep Taskforce.  On the flip side, this study was conducted in one community, so may not be generalizable to other communities.  The study also targeted individuals from low-income areas with lower education, so the results may not apply to mothers in higher-income neighborhoods with greater levels of education.  The recruiting methods did yield a diverse participant population but relatively few dates that the event was held likely limited many women from attending.  Another potential issue was the true/false statements included in the assessment.  Several of the statements are subjective and others are potentially confusing, which may have contributed to some of the nonsignificant results.  Improving the clarity of these statements could improve the accuracy and validity of this study.  While the results were promising, I would be interested to see if the participants put their new knowledge into practice.  Are mothers able to identify hazardous materials in their home? Do they remove or replace these items?  Have the rates of infant death or hospital visits due to unsafe sleeping habits improved in this county as a result of the educational intervention?  Additionally, the results could have been biased as the group who developed the program assessed the results.  Moreover, there was no control group who received instruction in a more “traditional” manner.

Overall, this study proves that educational programs that structure their lesson plans around the Health Belief Model and offered in non-traditional environments can lead to changes in behavioral intentions.  It is important to recognize that instructional programs can be implemented outside of the traditional classroom settings and that informal community events can a venue where patients can learn about important health topics in a fun and engaging way.

References

1. About 3,500 babies in the US are lost to sleep-related deaths each year. (2018, January 09). Retrieved November 30, 2020, from https://www.cdc.gov/media/releases/2018/p0109-sleep-related-deaths.html
2. Ahlers-Schmidt C R, Schunn C, Hervey A M, et al. Redesigned community baby showers to promote infant safe sleep. Health Education Journal 2020; 79(8): 888-900.

The Importance of Post-Exam Quality Assurance

by Karmen Garey, PharmD, PGY-1 Baptist Memorial Hospital – North Mississippi Pharmacy Resident, University of Mississippi School of Pharmacy

From the students’ perspective, once they hit “submit” after completing an exam they think “Thank goodness that’s done!” However, for teachers, there is still some critical work to do. Now it’s time to review the performance data to ensure the examination was fair and measured what was intended. Here are a few tips and strategies to assess the quality of an exam.

Make certain the exam (as a whole) is a “good” one 

Before the exam is administered to students, a good exam should be written with the following goals in mind:^1,2

• An exam should address multiple levels of Bloom’s taxonomy — from knowledge recall to application and analysis.
• The exam should include a variety of questions that test a range of concepts that map back to the learning objectives.
• The consistency of the exam's performance over time is important. An exam should routinely perform the same from year to year despite some changes to the questions.
• An exam should measure the learning outcomes and course material it was designed to test.

Make certain the questions included on the exam are “good” ones

There are two types of questions that should be included on exams: mastery questions and discriminating questions.  Mastery questions are those questions that students are expected to excel on.³ This type of question is typically a “knowledge level” question in Bloom’s Taxonomy. The questions often test factual recall and the recognition of fundamental material.²  These questions might be called “gimmie questions” by the students; however, teachers include these questions to ensure that students have a firm understanding of the basic but super important concepts or facts.  Discrimination questions, on the other hand, are intended to identify students who have a deeper knowledge of the material and separate students into different performance levels (e.g. identify "A", "B", and "C" students).  Higher-performing students are expected to answer these questions correctly more often than lower-performing students.  This type of question often targets the comprehension, application, analysis, synthesis, or evaluation cognitive level in Bloom’s taxonomy. These questions require an in-depth knowledge of the subject matter.²

Next, let’s look at the distractors.  Does each question include appropriate distractors?³ A distractor is an answer choice that, while wrong, sounds and appears like it could be plausible. A good distractor should be clear and concise and should be similar in structure and content to the correct response. Savvy test-takers have learned to spot answers that seem different in some way, so even small variations in the style, subject matter, and length of the answer choices can provide clues. 

Next, is the question stem clearly written.  Is it clear what the learner is being asked?  Or is the question open to interpretation?  When writing questions, it is important to ensure that the question is not misconstrued.  Sometimes students will overthink a question and try to find the hidden meaning when there is none. To avoid this problem, use words that are unambiguous.  Avoid phrasing that could be cryptic.

Finally, is the answer to the question correctly keyed.  If a lot of students selected the “wrong” answer, it's possible that the question was miskeyed.  While this is not something that happens often, it does happen! So it is always a good idea to double-check that the correct answer was selected on the answer key. 

Some other things to consider as you look at the post-exam performance data.  How did the exam scores look last year? While a group of students performing much better or much worse than previous year’s students is not always an indication that the exam is invalid, it should prompt additional questions.

• Was the material taught in a manner that was different from previous years?
• Was the exam formatted or delivered differently?
• Could the students this year have been less (or better) prepared in some way to comprehend the material?
• Is cheating suspected?
• If there are multiple instructors, did students received different messages about the content?

The answers to these questions may not be obvious or even relevant, but it is something to keep in mind.

Use the post-exam statistical analysis to identify problem questions³

As technology becomes a more integral part of exam delivery, it enables a wealth of data that can be used for post-exam quality assurance. Most post-exam statistical analysis tools report similar elements; however, the names may be slightly different. ExamSoft is among the most common exam delivery tools available today and routinely reports these statistics:

• Item Difficulty represents the difficulty of a question. It reports the percentage of students who correctly answered the question. The lower the percentage the more difficult the question. There is not a set number that the item difficulty should be but the number should be used to ensure the intent behind the question matches the number. For example, if the teacher wants the item to be a mastery question, the difficulty should be 0.90 to 1.00 with very few students getting the question wrong.  If the question is meant to separate those who have a firm grasp on the material vs. those who don’t, lower levels are acceptable. An instructor may have a difficulty “cutoff” number in mind where anything below 0.6 (for example) prompts additional analysis of the question.

• Upper/Lower 27%, Discrimination Index, and Point Biserial are each calculated differently but they report a similar concept. Stated simply, they all determine whether the top performers on the exam achieved better results on a question compared to those who did not perform well. If the top performers don’t out-perform the poor performers, the question should be assessed to determine why.
  • Upper 27% / Lower 27% - what percentage of the top 27%  vs. the bottom 27% of performers got the question correct.
  • Discrimination Index – this represents the difference in performance between the best performers vs. the lowest performers.
  • Point Biserial – indicates whether those who answered correctly on a specific item correlates with doing well on the exam overall.  In other words, does performance on this question predict whether a student did well (or not so well) on the exam? 

 

Correlation with Overall Exam was	Point Biserial
Very good	>0.3
Good	0.2-0.29
Moderate	0.09-0.19
Poor	<0.09

So, let’s look at the statistical analysis from two example questions. 

• This was a mastery question — students are expected to do well on this question. It’s a fundamental concept that all students should know.
• The Discrimination index = 0.04 which indicates almost no discrimination between the top and bottom performers. In this case, because it’s a mastery question and we expected all students to perform well on this question.  Thus, we don’t expect this question to discriminate between the best and worse performers.
• The Point Biserial = 0.10 indicating this question only moderately correlate with doing well on the exam overall. Again, the top and bottom performers performed quite similarly on this question, so there won’t be a strong correlation between the performance on this question and the overall exam.
• If this question was not intended to be a mastery question, perhaps the material was taught particularly well … or maybe there was cheating involved

Now let’s take a look at a question where only 66% of the students selected the correct response.

• Item difficulty = 0.66 so 66% of the students selected the correct response. This is not a bad thing but it is important to make sure the students who understood the material were more likely to get this question right.
• This is intended to be a discriminating question, so let’s make certain it’s actually discriminating between the best and worse performers.
• Look at the Upper vs. Lower 27%: 82% of the top performers got this question correct. Only 46% of those who performed the poorest on this exam got this question correct.
• Discrimination Index: 0.36. This question did a good job discriminating between the best and worst performers on this exam.
• Point Biserial = 0.28 Performance on this question has a good correlation with the student’s overall exam performance.

While there are no hard rules for how to analyze an examination, the strategies I’ve outlined in this blog post are some of the best practices every teacher should follow. It is important to follow a systematic process and establish “cut-offs” in advance. The key is to be clear and consistent from exam to exam.

References

1. Brame C. Writing Good Multiple Choice Test Questions. 2013. Accessed December 3, 2020.
2. Omar N, Haris SS, Hassan R, Arshad H, Rahmat M, Zainal NFA, et al. Automated Analysis of Exam Questions According to Bloom's Taxonomy. Procedia - Social and Behavioral Sciences. 2012;59:297–303. Accessed December 1, 2020.
3. Ermie E. Psychometrics 101: Know What Your Assessment Data Is Telling You. Examsoft. 2015. Accessed November 18, 2020.

A Hopeful Pharmacist-Led Educational Program to Reduce Prescription Errors

by Spencer Harris, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of:  Gursanscky J, Young J, Griffett K, Liew D, Smallwood D. Benefit of targeted, pharmacist-led education for junior doctors in reducing prescription writing errors - a controlled trial. Journal of Pharmacy Practice and Research. 2018;48(1):26–35.

Writing a safe and properly-formatted prescription is no easy task. Not only does the prescriber need to include the patient’s name, date of birth or address, the date of the writing, the name of the drug, the dose, the dosage form, the instructions on how to take it, the quantity, the number of refills, and the signature of the authorizing provider but the prescriber must write a prescription that is safe for the patient. Factor in the multitude of patients a physician sees, the innumerable questions that she receives, the monotony of writing dozens of prescriptions every day, and many other variables that add stress on her shoulders, it's understandable there will be an error here and there. While understandable, it is not something that can be accepted or overlooked. Each year, according to the FDA’s Wedwatch website, more than one hundred thousand reports about medication errors are documented. A subset of these reports are related to errors in prescribing errors, both in the sense of missing information and prescribing inappropriate therapy.  These errors affect patient health outcomes; this is inexcusable. I have witnessed these errors firsthand, as I am sure nearly every person who has worked in a pharmacy has.

Educational programs might be one way to address this problem. But an educational program must be efficient and compatible with the constant bustle of healthcare, where there is no time to waste. It is for this reason that I read the study by Gursanscky and his colleagues from Monash University in Australia with high hopes.

The investigators implemented a pharmacist-led approach to teaching junior physicians (who write a notably large proportion of prescriptions in teaching hospitals) about prescription writing.  They compared this approach to an online education program (based on the National Inpatient Medication Chart Training course) and to a control group that did not receive any additional instruction. The study was a cluster-randomized trial that enrolled all junior doctors in the general medical units at an Australian tertiary hospital (twelve interns and four registrars). The junior physicians were divided equally into four person-groups who were randomly assigned to either the pharmacist-led intervention (one group), the e-learning intervention (one group), or the control arm (two groups).

The pharmacist-led intervention consisted of three very brief (10-minute) sessions per week for four weeks.  During these sessions, a clinical pharmacist discussed types of errors, their frequency, and severity. Over the four weeks, the pharmacist discussed each error type, why it was unsafe, its consequences, and how to avoid it. Following each tutorial, the pharmacist addressed participant questions. A full report on the intervention can be found in the original study.

Data was collected for three weeks before the intervention and for four weeks during the intervention. The data collected was the prescription error rate among all groups. An error was defined as a prescription that had incomplete patient or prescriber details or which was “illegible, incomplete, or incorrect.” The error rates were then compared using a Chi-square analysis for the pre- and post-intervention periods.

The results (n= 9,657 prescriptions analyzed) showed that the pharmacist-led group had a significantly lower rate of errors in the post-intervention period. Interestingly, the error rates in both the control group and the e-learning group increased significantly in the post-intervention period.

Table 1: Rate of Errors per Total Orders Before and After the Intervention Period

	Control	E-learning	Pharmacist-led
Pre-intervention	0.49	0.58	0.58
Post-intervention	0.59	0.63	0.37
p-value	<0.001	0.025	<0.001

This study addresses a real-world problem that negatively impacts patients and places a substantial burden on the healthcare system. Additionally, the study clearly describes the design of the educational intervention and outcome measures (e.g. the prescription writing error and its methods of data collection).  The number of prescriptions that were analyzed over the course of the study is very large (n=9,657). With that large of a sample, it is likely that the measured error rate is small but there is always the possibility of bias in the selection process. This study also has some flaws that can leave it weak in the eyes of reasonable readers. Specifically, the sample size of providers is small with only sixteen physicians, four per group.  The study duration was relatively short — approximately two months. These shortcomings may have led to the odd and significant increase in the error rate among the e-learning group and control group. Why would a course designed by professionals to instruct providers on how to write prescriptions result in a higher prescription error rate? Of course, the e-learning course could be poorly designed in some way, but I believe that the more likely reason is there was a small number of participants in the group.  Thus the changes in error rates observed in the control and pharmacist-led intervention groups might be due to chance as well.

Personally, I believe a pharmacist-led approach can and should result in a lower error rate, but I believe that this study must be replicated on a larger scale before any conclusions can be made about the effectiveness of this approach. None-the-less, the study is still relevant. The reason is simple; there are preventable medication errors being made all over the world and they lead to problems that directly affect patients. Until this problem is solved, we should be looking for answers and taking action to find good practices for reducing the errors. While this study is not of the highest quality, the intervention is simple and practical to implement.

Therefore, I urge those who are involved in the training of prescribers to use this study as a template to provide pharmacist-led instruction on prescription-writing. A successful program should include frequent but brief tutorials with an opportunity to ask questions. We must actively make efforts to provide our patients with the high-quality healthcare that they deserve.

References

1. Gursanscky J, Young J, Griffett K, Liew D, Smallwood D. Benefit of targeted, pharmacist-led education for junior doctors in reducing prescription writing errors - a controlled trial. Journal of Pharmacy Practice and Research. 2018; 48(1):26–35.
2. Working to Reduce Medication Errors [Internet]. U.S. Food and Drug Administration. FDA; 2019.  Accessed October 23, 2020.

Educating Older Adults Reduces Inappropriate Benzodiazepine Use

by Hallie Butler, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Review and Analysis of: Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of Inappropriate Benzodiazepine Prescriptions Among Older Adults Through Direct Patient Education: The EMPOWER Cluster Randomized Trial. JAMA Intern Med. 2014;174(6):890–898.

Shared decision making has been encouraged because it not only uses evidence but also considers the patient’s preferences and values to help choose the most effective therapy. The American Board of Internal Medicine initiated the Choosing Wisely campaign to assist providers and patients when deciding which therapies should be discontinued. The idea is that we need to de-escalate or discontinue therapies in older adults, those older than 65 years of age, that are unnecessary or may cause harm. The American Geriatrics Society took part in this campaign and they recommend against the use of benzodiazepines as a treatment for insomnia in older adults. The reason: benzodiazepines cause cognitive impairment and drastically increase the risk of falls and fractures. Unfortunately, benzodiazepines are commonly prescribed.  While research has consistently shown that the risks of benzodiazepines in the elderly far outweigh their benefits, older adults are more likely to be prescribed medications from this class than younger adults.² Even though physicians are aware of the risks of benzodiazepines, more than 50% of them continue to prescribe them to their older patients. The objective of the EMPOWER trial was to implement and measure the effectiveness of a direct-to-patient education program for older adults receiving long-term benzodiazepine therapy. In this study, they assessed rates of dose reduction and cessation of benzodiazepine use.¹ 

This study was a 2-arm, parallel-group, pragmatic cluster randomized control trial. Thirty community pharmacies participated. These pharmacies had at least 20% or more of their patients age 65 or older. There were 303 participants in this study ranging in age from 65 to 95 years old. The pharmacies were randomly assigned to either the intervention or control groups. All of the participants including the pharmacists, patients, evaluators, and prescribers were all blinded to the outcome assessment. To be eligible for this study, the patient had to have at least 5 active prescriptions with at least one being a benzodiazepine. They also had to receive a refill of a benzodiazepine for three consecutive months prior to study enrollment. Patients that had a diagnosis of severe mental illness or dementia, had a current prescription for an antipsychotic and/or cholinesterase inhibitor or memantine in the previous three months, or who were a resident of a long term care facility, were excluded. ¹

The educational intervention included a booklet on self-efficacy and social learning theory. Each of the participants completed a self-assessment about their opinions on benzodiazepine use and then received information on the harms associated with their use. Knowledge statements were presented with the purpose of creating a cognitive dissonance regarding the safety of benzodiazepine use. The participants were also educated on certain drug interactions and listened to peer champion stories to promote self-efficacy. The study team discussed with the patients about treatment options that were equally or more effective substitutions and educated them on how to taper off their benzodiazepine. The taper schedule was based on a 21-week protocol. The protocol was picture-based and showed the diminishing dose from a full pill to half pill, and finally a quarter pill. The participants were encouraged to speak with their providers and/or pharmacist about deprescribing. All of the reading material was written at a sixth-grade level and in 14 point font.¹ This should make it accessible to nearly all participants.  The control group received usual care and there was no active effort to educate these participants about the risks of benzodiazepine use.

The complete cessation of benzodiazepine use in six months was the primary outcome. In order to be classified as complete cessation, the patient must have had no benzodiazepine prescriptions or renewals at the time of the six-month follow-up and sustained for at least three consecutive months. The investigators verified this using pharmacy profiles. The study team defined a dose reduction as at least 25% or more reduction in dose compared to baseline for at least three consecutive months. Every participant had a complete follow-up at their pharmacy in six months. One research nurse and one investigator, who was blinded to group allocation, used a protocol to independently assess the outcomes.¹

Complete cessation was achieved in 27% of participants vs 5% in controls. There was an 8-fold higher probability of participants who received the intervention to discontinue benzodiazepine therapy. In addition, 11% of the intervention group reduced their benzodiazepine dose. This study suggests that teaching adults with an evidence-based approach, in a way that makes them question the safety and necessity of benzodiazepine use, is a safe and effective method to address over-prescribing. In previous studies that did not include a direct patient educational program, efforts to have physicians deprescribe benzodiazepine had a smaller impact. 

Systematically recruiting participants through community pharmacies is just one of the many strengths of this study.¹ Some other strengths would be the blinding of all participants and how they objectively assessment of drug discontinuation rates. I believe one weakness of this study was the six-month time frame for patient follow-up. With a longer follow-up period, the intervention could have proven to be more or less effective — there might have been a higher discontinuation rate or, perhaps, there might have been a high relapse rate.

Educators should pay attention to this particular study for several reasons. The patient education techniques these researchers used had a significant impact on patient behavior. This is a major accomplishment as many older adults are very reluctant to stop benzodiazepine use.² The educational intervention was well designed. It included different forms of instruction and promoted self-efficacy.  Promoting self-efficacy can help patients improve other chronic illnesses as well such as hypertension and diabetes. Patients must believe that they can make a difference in their health outcomes. A picture-based drug-tapering protocol is a great instructional tool because it is friendly to all ages, languages, and health literacy levels. A larger font should also be used when distributing materials to older adults as many of them have visual impairments. The strategies employed in this study can be used in a wide array of disease states and can be used as a model to get patients more involved in their care.

References

1. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of Inappropriate Benzodiazepine Prescriptions Among Older Adults Through Direct Patient Education: The EMPOWER Cluster Randomized Trial. JAMA Intern Med.2014;174(6):890–898.
2. Pereto A. Data: Seniors prescribed benzodiazepines most often. Athena Health. Accessed November 25, 2020.

Training Pharmacy Students to Manage Opioid Overdoses and Administer Naloxone

by Cole Sisson, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Kwon M, Moody AE, Thigpen J, Gauld A. Implementation of an Opioid Overdose and Naloxone Distribution Training in a Pharmacist Laboratory Course Am J Pharm Educ 2020; 84 (2): Article 7179.

Opioid overdoses caused almost 47,000 deaths in the US in 2018 and, according to the CDC, the number of deaths has been growing since 1999.¹ With the continuing increases in deaths due to prescribed and synthetic opioids, it is more important than ever that Americans be knowledgeable about and have access to overdose reversal agents like naloxone, which is a life-saving medication when administered correctly to those experiencing an overdose. Naloxone is commonly carried by emergency medical personnel and first responders, but the average person can be trained on its use.  Wide-spread availability of naloxone can expand the likelihood that someone will have access to this medication when needed. Naloxone dispensing and training is especially important in community settings like pharmacies, however many patients (and even some pharmacists) are reluctant to use naloxone due to a lack of confidence using an injectable medication and stigma related to opioid use. Integrating training about opioid overdoses and naloxone prescribing in pharmacy school curriculums can increase knowledge among new pharmacists entering the profession who can advocate for increased use and availability of these rescue medications.

At the Notre Dame of Maryland School of Pharmacy, Kwon and faculty colleagues designed, implemented, and evaluated an opioid overdose education and naloxone distribution (OEND) program.² They designed a program based on the 5 E’s learning method: Engage, Explore, Explain, Elaborate, and Evaluate.  To measure knowledge and attitudinal change, the investigators used the Opioid Overdose Knowledge Scale (OOKS) and Attitude Scale (OOAS) before and after the OEND program. The faculty engaged a class of P3 pharmacy students in a patient care laboratory session consisting of four parts: an interactive introductory presentation, a hands-on session with various placebo forms of naloxone, a large group review of the information learned in the first two parts, and then a patient counseling and overdose care scenario to test the newly learned skills. The students received prompt feedback after completing the scenarios. Afterward, the students took the post-test OOKS and OOAS evaluations.

Fifty-six students completed the OEND program. When compared to the baseline, the mean OOKS score increased significantly (p<0.001) in each knowledge domain including risk factors for overdose, signs of overdose, actions to care for an overdose victim, and general knowledge about naloxone. Similarly, the mean score in the OOAS evaluation increased significantly (p<0.001) from pre- to post-test, and the largest mean increases in the categories of self-perceived confidence in counseling and dispensing naloxone and counseling on how to rouse and stimulate someone experiencing overdose. As a longitudinal measure of knowledge retention, the pharmacy faculty also included naloxone counseling and overdose care in the final examination for the students that semester. The students were required to counsel a standardized patient on a randomly selected naloxone dosage form, and, in another station, care for a standardized patient who was experiencing an apparent overdose. The mean total score was very high on both of these stations and nearly all students achieved at or above the passing score. While this was not a direct re-administration of the standardized Opioid Overdose Knowledge Scale, it served as a good proxy for retained knowledge by the students.

This study evaluated the effectiveness of a well-designed instructional program and used standardized questionnaires (the OOKS and OOAS) to assess learning. The immediate results following the completion of the program showed significant increases in pharmacy student knowledge and attitudes related to managing an opioid overdose and dispensing naloxone.  While retention of this material was very strong, students were informed that these topics would be tested during the final examination, so it is possible that students did not retain this information so much as relearned it for the exam. This program was implemented with one student cohort at one pharmacy school, so additional studies will be needed to determine the generalizability of these findings to other colleges/schools of pharmacy. 

Similar OEND programs have been implemented and evaluated but none of the reports are as robust as the study by Kwon. Monteiro et al. evaluated an interprofessional workshop focused on increasing knowledge, skills, and attitudes of students towards opioid misuse.  The interprofessional teams included health professional students from medicine, nursing, pharmacy, physical therapy, and social work. While this study only assessed pre- and post- OOKS scores among the medical students, the results demonstrated significant improvements in knowledge.³ In another study, Schartel et al. evaluated the success of a program for P1 pharmacy students in a lab course.  However, they only taught students about and evaluated the use of one naloxone dosage form and, while knowledge improved significantly, they did not assess changes in student attitudes.⁴ 

Pharmacists are one of the most accessible health professionals and many patients ask a pharmacist about a health issue before seeing care from a physician. Implementing training programs in pharmacy curricula can help bridge the gaps in access and increase community awareness about managing opioid overdoses.  Training pharmacists to dispense and teach patients how to use naloxone products can help slow the escalating number of deaths in the US due to the opioid crisis. Interactive and well-designed programs like the one implemented by Kwon and colleagues are an effective way to increase both knowledge and attitudes towards opioid overdoses.

References

1. “Understanding the Epidemic” [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2020 [cited 2020Dec6]. https://www.cdc.gov/drugoverdose/epidemic/index.html
2. Kwon M, Moody AE, Thigpen J, Gauld A. Implementation of an Opioid Overdose and Naloxone Distribution Training in a Pharmacist Laboratory Course. Am J Pharm Educ 2020; 84 (2): Article 7179.
3. Monteiro K, Dumenco L, Collins S, et al. An interprofessional education workshop to develop health professional student opioid misuse knowledge, attitudes, and skills. J Am Pharm Assoc 2017; 57 (2): S113–S117.
4. Schartel A, Lardieri A, Mattingly A, Feemster AA. Implementation and assessment of a naloxone-training program for first-year student pharmacists. Curr Pharm Teach Learn. 2018; 10 (6): 717-722.

Supportive Counseling and Its Impact on Expecting Mothers

by Layla Langdon, Doctor of Pharmacy Student, University of Mississippi School of Pharmacy

Summary and Analysis of: Esfandiari M, Faramarzi M, Nasiri-Amiri F, et al. Effect of supportive counseling on pregnancy-specific stress, general stress, and prenatal health behaviors: A multicenter randomized controlled trial [Internet]. Patient Education and Counseling 2020;103 (11): 2297-2304 

This article caught my attention because we have been studying women’s health and the impact of the mother’s behaviors and stress on a developing baby. Also, as a student pharmacist, I am very interested in pursuing a career in pediatrics, and a child’s health really starts in the womb. This study attempted to demonstrate the impact of an educational support program on a woman’s pregnancy-related and general stress as well as prenatal health behaviors. Pregnancy-related stress is often the result of worrying about maternal and fetal health, parental responsibility, physical symptoms, labor pain, childbirth, and the cost of raising a child.¹ All of these factors weigh on a woman and starts to take a toll on her health and can lead to a poor pregnancy outcome. Using supportive counseling to supplement usual antenatal care, this study aimed to reduce maternal stress and promote healthy behaviors that would benefit the mother and the developing child.

To test this theory, pregnant women between gestational age 6 and 32 weeks with no comorbidities were recruited to participate in this randomized, control study. The participating women were divided into two groups with 40 participants each. Women in both groups completed four questionnaires at baseline including the Revised Prenatal Distress (NUPDQ), Spielberger State-Anxiety Inventory (STAI-Y), Prenatal Health Behaviors Scale (PHBS), and the Perceived Stress Scale (PSS-14).  In addition, all of the women provided a saliva sample to measure salivary cortisol concentration. Each participant was advised to fast and avoid alcohol for at least 24 hours before the salivary sample was taken. Changes in the NUPDQ, STAI-Y, and PHBS were the primary outcomes for this study, and the PSS-14 and the salivary cortisol assay were considered secondary outcomes.

The control group received only usual antenatal care based on Iranian national guidelines. Each participant in this group received midwifery examinations, assessments of the mother’s and fetus’s health, and education about personal hygiene, sexual activity, signs of a high-risk pregnancy, common pregnancy complaints, nutritional and medicinal supplements, and use of fertility health services. In addition to usual antenatal care, the intervention group received weekly supportive counseling conducted by a female expert psychologist. These supportive counseling sessions consisted of face-to-face instruction with 12 to 14 women in each group. This gave the women the opportunity to interact with one another.  During these sessions, they discussed their stress and anxiety.  The instructor also designed group work and guided exercises to address unhealthy behaviors. The program targeted pregnancy-related worries such as health problems and costs, parental responsibility, physical symptoms, infantile health, parenting, labor pain, and childbirth phobia. Six weeks after completing the educational program, all participants in both groups again completed the four questionnaires and provided a salivary sample to measure their cortisol.

The results revealed there were significant improvements in the mean NuPDQ, STAI-Y, PHBS, and PSS-14 scores in the intervention group, including in the subscales of these instruments, when compared to the control group. Specifically, there were large effect size improvements in the medical and financial problems, infant health, physical symptoms, and labor and delivery subgroups of the NuPDQ and the four subgroups of the PHBS (See Table 1). The salivary cortisol levels improved in both the intervention and control groups but there were no significant differences in the mean change observed. 

Table 1. Mean Pre (T0) and Post (T1) Scores and Differences for Selected Outcomes Following an Educational Support Program for Pregnant Women

	Intervention			Control
	T0 Mean	T1 Mean	Change	T0 Mean	T1 Mean	Change
Primary Outcomes
NuPDQ	11.85	5.6	-6.97	9.42	11.32	2.62
STAI-Y	44.4	35.8	-7.2	40.65	41.82	.52
PHBS
Harmful Behavior of Health	4.17	2.42	-1.72	4.37	4.82	0.42
Health Promoting Behavior	20.2	23.67	3.53	20.45	20	-0.51
Harmful Physical activity of Health	5.52	3.6	-1.91	5.57	5.62	0.03
Health Promoting Physical activity	3.97	7.07	2.88	3.1	2.95	0.06
Secondary Outcomes
PSS-14	23.45	16.82	-7.20	21.82	21.77	-0.53
Serum Cortisol	23.32	20.25	-3.32	17.57	14.98	-2.61

One of the strengths of this study was the use of four different questionaries to evaluate the effect of supportive counseling on pregnancy-specific, general stress, and healthy behaviors. Another strength of this study is that the supportive counseling provided to the experimental group was provided in small groups with only 12 to 14 participants per group. This allowed each participant to develop relationships with other pregnant women who may be experiencing the same struggles. This study also aimed at improving each participant's self-esteem and maximizing their adaptive skills. These are important objectives because pregnant women often feel incapable of birthing and raising a child. The weaknesses of this study are that the questionnaires used were all based on self-evaluation. The authors do not discuss the sustainability of the program and don’t report outcomes after delivery – so the health outcomes of the babies is unknown. The findings of this study probably should not be generalized to complicated pregnancies.  While salivary cortisol was included as a measurement of stress, it does not correlate well with psychological stress.

In future studies, it would be helpful for each participant to complete a session with a mental health professional. This would allow a more personalize assessment and help the participants identify and analyze the specific stressors they are experiencing. Also, the addition of this session could be used as an external evaluation. Although this is a subjective measurement similar to the self-evaluations, an assessment performed by a mental health professional would be consistent for all participants. Future studies should gather data through the entire pregnancies, including delivery, plus three months postpartum.  This is important to truly determine the long-term effect of supportive counseling on pregnancy-related stress and outcomes.

A similar study analyzed the effect of a supportive intervention in pregnant women who were depressed using the Postnatal Depression Scale (EPDS >12).³ In this study, the intervention group received the same number of counseling sessions, six visits, but over eight weeks. That study also concluded that supportive counseling in addition to usual prenatal care improved outcomes. Specifically, the participants reported improvements in depressive symptoms, depressive severity, and quality of life. Another study found that supportive counseling improved the patient’s satisfaction during delivery.⁴ Although these studies had minor differences in terms of the number of counseling sessions provided, the program duration, and the number of participants, they all concluded that supportive counseling subjectively improved pregnancy-related stress 

While the supporting counseling program appears to have been effective, it would have been helpful if the intervention were described in more detail. This would allow other health professionals, such as pharmacists and nurses, to implement a similar program. However, this study is important because it demonstrated the benefits of adding supportive counseling to usual prenatal care. This may also improve the health of the fetus and allow for a smoother birthing experience. Overall, I believe that providing supportive counseling to pregnant women should be the standard of care during all pregnancies.

 

References

1. Esfandiari M, Faramarzi M, Nasiri-Amiri F, et al. Effect of supportive counseling on pregnancy-specific stress, general stress, and prenatal health behaviors: A multicenter randomized controlled trial [Internet]. Patient Education and Counseling 2020;103 (11): 2297-2304.
2. Nast I, Bolten M, Meinlschmidt G, Hellhammer DH. How to Measure Prenatal Stress? A Systematic Review of Psychometric Instruments to Assess Psychosocial Stress during Pregnancy. Paediatric and Perinatal Epidemiology. 2013;27(4):313–22.
3. Neighmond P. To Prevent Pregnancy-Related Depression, At-Risk Women Advised To Get Counseling [Internet]. National Public Radio. NPR; 2019 [cited 2020Oct19].
4. Segre LS, Brock RL, O'Hara MW. Depression treatment for impoverished mothers by point-of-care providers: A randomized controlled trial. J Consult Clin Psychol 2015; 83 (2): 314-24.
5. Pasha H, Basirat Z, Hajahmadi M, Bakhtiari A, Faramarzi M, Salmalian H. Maternal expectations and experiences of labor analgesia with nitrous oxide.. Iranian Red Crescent Med J 2012; 14 (12): 792-7.

Understanding Patient Medication Experiences through Theater

by Alexandra Frazier, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Cernasev A, Kuftinec S, Bortz R, Schommer JC, Ranelli PL. Using Theater as an Educational Tool for Understanding Medication Experiences from the Patient Perspective [Internet]. Am J of Pharm Educ. 2020; 84(4): Article 7606. doi:10.5688/ajpe7606

As student pharmacists, a great deal of our education is dedicated to learning how to provide medication counseling and handle patient interactions in various pharmacy practice settings. This training not only involves learning how to provide the essential information patients need to use medications wisely but also delivering that information with empathy, listening actively to patients, and applying motivational interviewing techniques. Though pharmacy students are trained on how to assist patients struggling to acquire medications, students in other healthcare professions do not always receive formal instruction about how to assist patients experiencing access barriers. Healthcare professionals should be knowledgeable about the issues that may arise when medications are prescribed to patients, be prepared to handle these situations efficiently, and be able to express empathy for patients in difficult situations.

This unique study examined the effectiveness of theater as an educational tool for healthcare professionals.¹ The American Alliance for Theatre and Education (AATE) defines drama-based learning strategies as “an improvisational, non-exhibitional, process-centered form of drama in which participants are guided by a leader to imagine, enact, and reflect upon human experiences.”² I was captivated by this study because it allowed healthcare practitioners to gain perspective into patients’ experiences in an innovative way.¹

From April 2015 to March 2016, adults in the U.S. completed the self-administered the National Consumer Surveys on the Medication Experience and Pharmacist Roles. Comments from this survey were compiled detailing participants’ medication experiences. These comments were then used as the inspiration for a theatrical script written by Syl Jones and performed by Mixed Blood Theatre. The play, Go Ask Alice, included a total of seven scenes that explored multiple patient scenarios as well as a mock drug advertisement. There were two performances of Go Ask Alice – one in Minneapolis, Minnesota on November 29, 2016, and the other in Duluth, Minnesota on November 30, 2019. The play lasted ~60 minutes and was followed by a talk-back session facilitated by one of the authors that lasted ~30 minutes. These talk-back sessions were not led by any guided questions but instead allowed audience members to discuss the play openly with one another. Members of the audience were asked to complete a survey before the performance, immediately after the talk-back session, and then three weeks later. These assessments each contained the same seven statements regarding patient medication experiences and asked participants to rate their agreement with each statement. The two additional questionnaires were administered after the play which contained demographic questions and open-ended questions asking for feedback on the experience. The findings from the seven statements were summarized with descriptive statistics and inductive thematic analysis was performed on the open-ended questions.¹

A total of 225 health professions students attended the two performances; 161 participants completed the post-performance survey and only 58 completed the 3-month follow-up survey. There was a significant increase in the survey scores before vs. after the performance. Some of the key results of this survey are detailed in Table 1. During the qualitative analysis, the responses to the open-ended questions were merged into six categories then ultimately two themes: 1) barriers faced by patients when seeking health care services and 2) major hindrances and contributors to the patients’ medication experience. Overall, the results show that theatrical performance may be an effective educational tool to understand the human experience from a patient’s perspective.¹

Table 1: Pre- and Post-Performance Survey Results

Survey Item	Before Performance, Mean (SD)	After Performance, Mean (SD)	P-value
I am able to fully empathize with patients	3.6 (0.9)	3.9 (0.9)	<.001
I am fully aware of all the challenges patients experience with taking their medications	3.0 (1.1)	3.4 (1.1)	<.001
I am fully aware of the attitudes patients hold toward their medications	2.8 (0.9)	3.5 (1.0)	<.001
I am fully aware of all the challenges patients experience with filling their medications	3.0 (1.0)	3.6 (1.1)	<.001
I am fully aware of the roles of medications in society	3.3 (0.9)	3.6 (0.9)	<.001
I fully understand the process of prior authorizations	2.9 (1.2)	3.5 (1.1)	<.001
I fully understand the effect of the medication experience on a patient’s family	2.9 (0.9)	3.5 (1.1)	<.001

 

One of the biggest strengths of this study is the longitudinal assessment of audience members’ perspectives before and after the performance as well as three months following the play. This was an effective way to discern the audience’s initial perceptions and how Go Ask Alice affected their understanding of patients’ medication experiences. The post-performance talk-back session could be seen as both an advantage and disadvantage. The session allowed audience members to explore their feelings and reactions to the play, which would be advantageous for learners. However, this discussion could have influenced the results of the surveys by emphasizing all the aspects of patient experience that audience members were supposed to get from the play but did not. Another disadvantage of this study is the cost and access! The two performances cost roughly 25000.  Only 225 were in attendance and the two plays were held in a relatively small geographical area (both in Minnesota). Because of this, Go Ask Alice was not widely available. A wider audience (from different geographic areas) may not have the same of reaction to the play. There was also some concern from the audience that too much medical jargon was used in the script.

I feel like the analysis method used to evaluate the rate of agreement with the seven statements was appropriate, as was the use of a thematic analysis for the evaluation of the open-ended questions. For this qualitative analysis, one researcher read the comments several times and identified the main codes and categories. After this, a second researcher evaluated the codes and categories.  If needed, the second researcher debated the coding and classifications with the first researcher.  Based on both the results of this study and my personal experience with drama-based educational techniques, I do believe theater is an effective way to teach healthcare providers to see experiences from patients’ perspective. Moreover, this is an entertaining way to present information when real-life experience may not be a practical option.

Another study explored the negative impact of medication-related burden (MRB) and patients’ lived experience with medication (PLEM) therapies or medical conditions.³ This study concluded that because of the impact MRB has on patients’ beliefs and behaviors toward medications, healthcare practitioners need to have better insights into PLEM to improve patients’ medication therapy and outcomes.³ Though theatre models have been used to educate healthcare students in various situations, there is little literature on the appeal of such techniques to trainees.⁴ Another study concluded that the drama-based learning technique used had a generally positive influence on medical students’ perceptions.⁴

Because patient-centered care has the potential to strongly impact patient health outcomes, healthcare providers need to understand the struggles patients might face and be able to express empathy.⁵ This study explored an innovative teaching method that allowed audience members to understand and experience medication issues from a patient perspective.¹ Based on the feedback received from the audience, it seems that the educational tool was successful in achieve its goal but it’s impact was limited to a small audience.¹ In the future, such plays could be recorded for mass viewing or even adapted into active learning exercises for re-enactment by students in the health professions. Future healthcare professionals may benefit from the incorporation of drama-based learning strategies into their curricula, especially in areas where understanding the patient’s perspective is critically important.

References:

1. Cernasev A, Kuftinec S, Bortz R, Schommer JC, Ranelli PL. Using Theater as an Educational Tool for Understanding Medication Experiences from the Patient Perspective [Internet]. Am J of Pharm Educ. 2020; 84(4): Article 7606.
2. DBI Network: Activating learning through the arts [Internet]. Austin: The University of Texas at Austin; c2020. Drama-based Pedagogy; 2020. Available from: https://dbp.theatredance.utexas.edu/about
3. Mohammed MA, Moles RJ, Chen TF. Medication-related burden and patients’ lived experience with medicine: a systematic review and metasynthesis of qualitative studies [Internet]. BMJ Open. 2016; 6: e010035. doi: 10.1136/bmjopen-2015-010035
4. Keskinis C, Bafitis V, Karailidou P, Pagonidou C, Pantelidis P, Rampotas A, Sideris M, Tsoulfas G, Stakos D. The use of theatre in medical education in the emergency cases school: an appealing and widely accessible way of learning [Internet]. Perspect Med Educ. 2017; 6: 199-204.
5. Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, Jordan J. The Impact of Patient-Centered Care on Outcomes [Internet]. J of Fam Prac. 2000; 49(9): 796-804.

The Importance of Educating Caregivers Too

by Lydia Kneemueller, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of:  Alnazly EK. The impact of an education Intervention in caregiving outcomes in Jordanian caregivers of patients receiving hemodialysis: A single group pre-and-post test. International Journal of Nursing Sciences 2018; 5(2): 144-150.

I feel that caregiver education is often overlooked.  I think it’s equally important that we address the needs of caregivers as well as patients. As baby boomers continue to age, the needs of caregivers will only increase and the current pandemic has only made their burden greater. I found a study that specifically addresses caregiver education.  The study looked at the level of stress that caregivers experience and evaluated the impact of an educational program on caregiver burden and perceptions of life.¹

This study was carried out in Jordan at four outpatient hemodialysis facilities located in three different cities.¹ Each caregiver filled out a questionnaire about socio-demographics which also included questions about their health such as headaches, difficulty sleeping, hypertension, and heartburn. In addition, the participants completed a 15-item questionnaire to measure the burden of physical and emotional caregiving tasks on a 5-point scale. Lastly, participants had a 15-item questionnaire that was used to measure caregiver perception of their life, in which a score of 4 or greater indicates the caregiver’s perception of life has changed for the better.¹

During the educational program, caregivers were provided information about how to perform caregiving tasks such as diet and nutrition, food recipes, weight control, blood pressure monitoring, infection, fistula care, quinine catheter care, skin hygiene, bleed precaution, medications, fall prevention, available resources, and involving other family members in patient care¹. Methods of teaching included lectures, small group discussions, return demonstration, videos on DVDs, and written materials which were developed at a 5th-grade reading level. The instruction was provided during one 4-hour session. After the session, behavioral skills were observed using simulations and scored using a checklist. The caregiver burden assessment was administered two weeks after the educational session in order for caregivers to have time to implement the newly acquired skills.

During this study, 169 caregivers completed the pre and post questionnaires. The participants had between 1 and 15 years of experience serving as a caregiver, most were female (55.6%), and their ages ranged from 26 to 70 years old. Many of the caregivers indicated they had a high level of difficulty meeting the patient’s dietary needs.  They also expressed concerns about finances and finding help with caregiving tasks.

Following the education intervention, there was a positive change in the caregiver perception scores which suggests that the instructional activities likely had a positive impact on the caregiver’s life perceptions.  See Table 1. In fact, almost all scores significantly improved. The only scores that did not increase to above 4 were the time for social activities (pre 2.30 to post 3.65) and financial well-being (pre 2.86 to post 3.99). It is clear that the intervention provided a positive increase in scores on all change in life perception characteristics evaluated. 

Table 1:  Changes in Caregiver Perceptions (Pre vs. Post Scores)

Characteristic	Difference in Scores
Self Esteem	+ 1.55
Physical Health	+ 2.31
Time for family activities	+ 1.84
Ability to cope with stress	+ 1.06
Relationship with friends	+ 1.46
Future outlook	+ 1.64
Level of energy	+ 1.36
Emotional well-being	+ 1.12
Roles in life	+ 1.13
Time for social activities	+1.35

 

One of the weaknesses of this study is that since hemodialysis is life-long, these results may not be the same for caregivers who care for patients with short-term health conditions. Moreover, hemodialysis requires very hands-on, intense caregiving skills similar to the level of care that patients with cerebral palsy and dementia require. This study also did not have a control group, so while the pre and post-intervention assessments showed an improvement, there was no control group to compare the effectiveness of the educational program.  Because the patients were not blinded and likely want to please the investigators, their responses may have been biased.  The three assessments were appropriate to measure and could be applied to caregivers in all levels of care.

Another study that provided education to caregivers of patients with dementia had a similar impact on caregiver burden.² The dementia study was a randomized, controlled study that evaluated the effects of an education program that consisted of 5 weekly sessions that covered topics about treatment, ways to improve patient communication, and methods to help control patient’s unusual behaviors.² Family members who participated in the education program had a significant reduction in caregiving burden one month following the educational program, whereas the group that did not have any education had increased levels of burden. In another study, an assessment of the effectiveness of educational intervention for improving the complementary feeding (weaning) practices of primary caregivers of children was evaluated.³ The findings showed that caregivers randomly selected for the educational intervention demonstrated improvements in complementary feeding and hygiene practices.³

These studies demonstrate the importance of educating our caregivers and that such interventions can positively impact caregiver burden and quality of life. These studies have made me realize how important it is to educate not only patients but also their caregivers — to make sure they understand the medications and how to perform caregiving activities. Improving the lives of caregivers hopefully results in better patient care which is my goal as a student pharmacist.

References

1. Alnazly E K. The impact of an education Intervention in caregiving outcomes in Jordanian caregivers of patients receiving hemodialysis: A single group pre-and-post test. International Journal of Nursing Sciences 2018; 5(2): 144-150.
2. Pahlavanzadeh S, Heidari FG, Maghsudi J, Ghazavi Z, Samandari S.(2010). The effects of family education program on the caregiver burden of families of elderly with dementia disorders.Iran J Nurs Midwifery Res. 2010; 15(3): 102-108.
3. Arikpo, D., Edet, E. S., & Chibuzor, M. T. (2018). Educational interventions for improving primary caregiving complementary feeding practices for children ages 24 months and under. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd011768.pub24.

Reducing the Stress of Parents of Children with Type 1 Diabetes

by Katherine Blackburn, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of:   Whittemore R, Coleman J, Delvy R, et al. An eHealth Program for Parents of Adolescents With T1DM Improves Parenting Stress. The Diabetes Educator 2020;46(1):62-72.

Most parents' lives are full of stress with demands from multiple sources. Their work-life can demand one thing while their children's lives require something else. When do parents even find time to cook dinner? For parents of children living with a chronic illness, such as type 1 diabetes, their stress levels are much higher when compared to the average parent. However, it is vital that parents of children with type 1 diabetes learn how to manage their stress so that their stress does not adversely affect their child's life and care. A recently published study evaluated the benefits of a six-month educational program, called Type 1 Teamwork.¹ The investigators measured parental stress before and after using this innovative online program.

Type 1 Teamwork offers on-demand, online seminars and other activities focusing on the transfer of care responsibilities to the child, effective communication skills, and stress management. The study was a randomized control trial that recruited parents or guardians of a child between the ages of 11 and 16 with type 1 diabetes who were willing to commit to the six-month study and spoke fluent English. The eligible participants were randomly assigned to participate in the Type 1 Teamwork program or a control group. The participants in the Type 1 Teamwork group were immediately granted access to the online programming featuring diabetes information, tips for diabetes management, and skills for efficient communication between parents and children.  One of the goals of this program was to reduce parental stress. The program requested parents log into the portal once a week to review educational materials. The control group was given access to the Type 1 Teamwork program after completion of the study. To determine the primary outcomes of reducing parenting stress, the researchers utilized the Pediatric Inventory for Parents (PIP) and the Perceived Stress Scale. On both of these inventories, a higher score means a higher stress level. In addition to reducing parenting stress, researchers also analyzed parent anxiety, parent depressive symptoms, parent support for their child's autonomy, family conflict, and the child's A1C levels. To analyze the results, researchers used histograms and quantile-quantile plots to establish normality. For the primary outcome, they used an unadjusted, repeated measures regression model comparing parent's stress reported at baseline, three-months, and six-months in the two groups.¹

At baseline, 36% of parents participating in the study exhibited elevated depressive symptoms while 40% of parents exhibited elevated state anxiety symptoms. The average child’s baseline A1C was 7.9%. Parents reported that 75% of children used an insulin pump and 69% used a continuous glucose monitor to manage their diabetes. Researchers found that using Type 1 Teamwork deceased parent’s overall stress, improved communication between family members, and helped parents delegate responsibilities to their child to optimize their care. Parents also reported lower emotional distress and decreased struggles with parental roles and communication. However, because this was an online program focused on alleviating parenting stress, the program did not address ways to lower depression and anxiety symptoms other than encouraging parents to seek other treatment. While there were several benefits to participating in the Type 1 Teamwork program, the average A1C did not change over the six-month study.¹

One of the main strengths of this study was its broad eligibility criteria. These criteria allowed for people of all backgrounds, races, and geographic locations. However, most of the participants were married white women with a relatively high income. A potential weakness is the lack of objective verification – all results were self-reported by the parents.  Since the participants were not blinded, they may have been biased toward reporting positive results.¹ Though the study has weaknesses, I believe utilizing on-demand, online programs like Type 1 Teamwork can help reduce parental stress and can teach them new ways of communicating with their children.¹

In another study that examined parenting stress of fathers of children with type 1 diabetes, the investigators found that stress exhibited by the father can adversely impact both the mother and child’s stress response.² These fathers were also given the Pediatric Inventory for Parents to evaluate their overall stress levels; however, their results were much lower than the women in this study. In a third study completed in Germany, parents who attended weekly meetings with other families who also have children with Type 1 Diabetes exhibited lower psychological stress and improve parenting behaviors.³

High levels of parental stress can not only impact the parent’s mental health but also affect the care their child receives. Online programs, such as Type 1 Teamwork, offer support for parents and their children from the comfort of their home and at a time that is convenient, thereby reducing barriers to participation.¹ Educators should be aware of programs available for parents of children with Type 1 Diabetes to provide support materials they can review and choose from, such as the Diabetes Empowerment Foundation, which offers material for the person with diabetes, parents, and partners.⁴ Educators need to consider the circumstances each parent faces as well. Do they have a support system present? Are they the main caregiver for their child? Does the parent have time to incorporate meetings into their schedule? Are they financially stable? It is important to consider all factors of the patients when making recommendations because if educators overwhelm them with too much information, it can cause their stress levels to increase even more.

References

1. Whittemore R, Coleman J, Delvy R, et al. An eHealth Program for Parents of Adolescents With T1DM Improves Parenting Stress. The Diabetes Educator 2020;46(1):62-72.

2. Mitchell SJ, Hilliard ME, Mednick L, et al. Stress among Fathers of Young Children with Type 1 Diabetes. Fam Syst Health 2009; 27(4):314-324.

3. Sabmann H, de Hair M, Danne T, Lange K. Reducing stress and supporting positive relations in families of young children with type 1 diabetes: A randomized controlled study for evaluating the effects of the DELFIN parenting program. BMC Pediatrics 2012;12:152.

4. Diabetes Empowerment Health, Support & Wellbeing [Internet]. 2019 [cited 2020 Oct 9]. Available from: http://www.diabetesempowerment.org