Facilitating Student Success in Remediation Programs

by Madison Gray, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Some colleges of pharmacy and other professional schools have programs in place to identify students early who are underperforming so that they can provide additional help and coaching before they fail a course.¹ Many of these strategies focus on tutoring and supplemental academic assistance to address underperformance and, ultimately, prevent failure.^1,2  Course failure is not only associated with a significant financial burden but also psychological and social consequences.¹ So, what is the most appropriate approach to remediation? Should remediation programs focus on course/content review or strategies for success? Several remediation approaches have been described in the literature for various professional schools and range from course repetition to developing individual remediation plans.² Individualized remediation that focuses on helping students become self-regulated learners is, in my opinion, a more effective approach to ensuring a student’s long-term success.^1-3

Years of research have identified self-regulated learning to be a differentiating factor separating high and low-performing students.³ Three key factors underly the success of self-regulated learning including preparation, performance, and self-reflection.³ Self-regulated learning requires the identification of barriers, appropriate time management skills, motivation, and strategic study habits.³

Many factors affect student performance and individual barriers often exist that impact each student’s ability to develop a self-regulated learning behavior.^1,3 Sansgiry and colleagues evaluated the effect of these factors on both high and low-performing students.  They found that test competence (which includes test anxiety) was one differentiating factor between the two groups.¹ They defined test competence as a “student’s ability to manage and cope with the amount of study material for examinations and/or tests.”¹ Many students (69.3%) reported feeling some type of anxiety during testing and some students even report experiencing physical symptoms.¹ Some other barriers affecting student performance include access to learning materials and technological barriers.¹ Identifying barriers for students is the first step in addressing issues that may hinder their success. Strategies to identify and address these barriers should be a routine part of the remediation process and could include interviews, surveys, and student self-reflection.

Self-regulated learning is a behavior that requires well-developed time management skills.³ Students who try to learn course material in a short amount of time tend not to perform as well as those who develop study plans whereby the learning effort is distributed over an extended period of time.^3,4 Appropriate time management skills that allow for more time for studying may also help decrease test anxiety and increase the student’s confidence in their preparation.^3,4 A study by Hartwig and colleagues assessed the study habits of college students in correlation with their grade point averages (GPAs).⁵ Students who reported scheduling study times over an extended period rather than cramming the day (or two) before an exam trended toward higher GPAs although the results were not statistically significant⁵. Remediation programs that encourage students to set goals, create tasks, and use schedules will help teach time-management skills that can be used in and out of the classroom.⁴ Effective time-management skills are necessary for both academic and career success.⁴ Once a student has good time management skills, learning how to use other study strategies may be helpful.^4,5

Students who use a variety of strategies to study, such as re-reading material, summarizing, note-taking, flashcards, and self-testing, are more likely to be successful.⁵ These different strategies have been studied and some of these strategies are used by high performing students more often when compared to low performing students.^3,5 In the study by Hartwig and colleagues, a survey administered to college students included questions about study strategies, self-testing, and study schedules.⁵ Self-testing correlated with higher GPAs versus other study strategies.⁵ The majority of students who reported using self-testing as a study strategy also reported that they did so to test themselves on how well they learned the material.⁵ Notably, re-reading was also associated with higher GPAs among the surveyed students; however, other studies have not found this association.⁵ These are just a few positive study strategies that can be utilized by college students to promote self-regulated learning.^3,5 Having students reflect back on their study habits to determine what works and what doesn’t work is one strategy that can be utilized during remediation programs.^3,5 Some students are not accustomed to having to study and this creates a challenge when they get to college.¹ They may go from previously not having to study (at all!) to learning how to study.^1,2 An individualized remediation program is an opportunity to address some of these challenges.^1,2

Course repetition is used by many schools and colleges of pharmacy.² This approach to remediation focuses on academic competence by requiring students to simply repeat the course they have failed.^1,2 Course repetition aims to re-expose students to the same course material in the hopes they achieve higher performance.^1,2 Some programs allow students to continue in the program and repeat the course once it is offered again while other programs require that the course be successfully passed prior to moving forward within the program.^1,2 The later strategy often involves students sitting out for a year and this obviously has significant financial implications.^1,2 Course repetition is not individualized and often does not address the underlying issues that contributed to the failure. This approach to remediation fails to address the non-cognitive barriers to students’ success.

Programs that focus on individualized remediation allow students to actively participate in the remediation process and help set them up for success both in the classroom and their careers. In an individualized remediation program, students must identify their barriers (with guidance) and engage in self-reflection. Such programs help students develop plans to address their identified barriers. Additionally, individualized programs should aim to promote self-regulated learning behaviors by giving students experience creating goals, formulating learning tasks, and developing time-management skills. Individualized programs should also focus on helping students develop new study strategies such as self-testing and summarizing. By identifying and addressing the non-cognitive barriers that often cause students to fail, remediation programs can foster the development of self-directed behaviors that enable students to be successful in subsequent coursework … and life.

 

References:

1. David M, Fuller S, Hritcko P, et al. A Review of Remediation Programs in Pharmacy and Other Health Professions. Am J Pharm Educ [Internet]. 2010;74(2): Article 25.
2. Sansgiry S, Bhosle M, Sail K. Factors That Affect Academic Performance Among Pharmacy Students. Am J Pharm Educ [Internet]. 2006;70(5): Article 105.
3. McKeirnan K, Colorafi K, Kim A, et al. Study Behaviors Associated with Student Pharmacists’ Academic Success in an Active Classroom Pharmacy Curriculum. Am J Pharm Educ [Internet]. 2020;84(7):Article 7695
4. Britton B, Tesser A. Effects of Time-Management Practices on College Grades. J Educ Psychol [Internet]. 1991 [cited 2021 Jan 10];83(3):401-10.
5. Hartwig M, Dunlosky. Study strategies of college students: Are self-testing and scheduling related to achievement? Psychon Bull Rev [Internet]. 2012;19:126-34.

Mindfully Teaching and Learning

by Alisha S. Nicks, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

Before you clicked on the link to read this blog post, were you thinking about your to-do list? Or perhaps you were reflecting on a decision you made last week that you wish you could change? While our physical bodies are in the present moment, our minds often drift to thinking about mistakes of the past or planning for the future. Mindfulness, as defined by Jon Kabat-Zinn, Ph.D., is purposefully paying attention to the present moment in a non-judgmental manner.¹ Psychological and educational research shows that Dr. Kabat-Zinn’s mindfulness-based stress reduction (MBSR) program teaches individuals the power of paying attention to the present, models a conscious way of living, and provides healthy coping mechanisms for stress.²

MBSR is an eight-week training program centered around formal mindfulness practices, including mindful attention to breathing through sitting meditation and body awareness through Hatha yoga. MBSR also teaches participants to informally practice mindfulness through attentiveness in everyday activities, such as walking, talking, driving, and eating. In a systematic review assessing the efficacy of MBSR on stress management, MBSR interventions positively impacted both psychological and physiological measures of stress. Although an eight-week MBSR course may not be feasible for most schools to provide to their students, faculty, and staff, instructors can create “mindfulness moments” throughout the curriculum. Including mindfulness techniques in one’s instruction can motivate students to become more self-aware as well as build positive relationships.³ The results of one study in an early childhood education program showed that students who participated in an “awareness of the breath” activity at school also engaged in mindfulness-based conflict resolution strategies with friends and family.⁴

What if instead of telling students to focus on some end result, we encouraged them to focus on the actual pursuit itself?
– Amy Burke: Mindfulness in Education, Learning from the Inside Out

Health professional students often struggle with stress from challenging coursework, extracurricular activities, and personal responsibilities. Moreover, they often struggle with internal pressure to meet personal expectations of perfection and a fear of failure.⁵ After a case discussion I facilitated with students at the University of Mississippi School of Pharmacy, a few third-year students asked me for advice on how to prepare for pharmacy licensure exam. They seemed anxious about an exam that is more than 18 months away. After sharing a few recommendations, I encouraged them to focus on the materials they are learning now, taking action now to really understand what they are currently learning, rather than worrying about the exam or life post-graduation. Mindfulness is not turning a blind eye to present difficulties or future responsibilities. It involves conscious acceptance and intentional responses to current circumstances.

Mindfulness begins by observing one’s internal state (emotions and thoughts) as well as external environment (sensations) but without judgment or automatically reacting.  The five facets of mindfulness are described below (see Table 1).

Table 1: Five Facet Mindfulness Questionnaire⁷

Scales	Definition	Sample Item
Observe	Tendency to observe, notice, or attend to internal and external phenomena	I intentionally stay aware of my feelings.
Describe	Tendency to describe or label sensations, perceptions, thoughts, emotions, etc. with words	My natural tendency is to put my experiences into words.
Accept without judgment	Tendency to accept without making judgments or evaluations	I disapprove of myself when I have irrational ideas.
Nonreactive	Tendency not to react to one’s experience	I watch my feelings without getting lost in them.
Act with Awareness	Tendency to focus undivided attention on the current activity or avoiding automatic pilot; concentration	I easily get lost in my thoughts and feelings.

Instructors play a critical role in setting the tone of the learning environment and engaging students in the learning process. In a commentary exploring the lessons that teachers can learn from actors about living in the present moment, Daniel R. Malcom reflects on his lectures as a junior faculty member that focused on information delivery but neglected to fully engage learners.⁶ Dr. Malcom suggests being reliably in the present moment with learners as a key strategy for creating learner-centered environments and strengthening relationships between teacher and learner.

In a study conducted in Ireland regarding stress and stress management, student pharmacists were interviewed in a series of focus groups. Students who did not have strong and regular interactions with instructors felt a lack connectedness and this hindered their access to support systems and resources. Focus group participants recommended integrating mindfulness practices into the curriculum instead of didactic lectures on stress management to encourage active learning. In a clinical trial evaluating the impact of a four-week mindfulness course, student pharmacists experienced improvements in stress and became more skillful at the observing facet of mindfulness.⁷ Although additional evidence is needed to assess the impact of mindfulness on learning outcomes, techniques listed in Table 2 have shown to reduce stress and increase wellbeing. 

Table 2: Mindfulness Strategies and Practices for Educational Settings³

 

Setting/ Audience	Learning Objective	Mindfulness Strategies	Example of Practice	Benefits
Educators	Understand how to treat students with respect, fairness, and non-judgment	Cultivate self-awareness to identify preconceived notions or judgments that may stand in the way of treating students equitably	Practice moment-by-moment awareness of your thoughts and feelings by focusing on bodily sensations or taking deep breaths	Educators become more reflective, thoughtful, and culturally responsive in their language and actions toward students
Educators	Proactively manage the stresses of teaching and leading	Educators recognize triggers of their own stress and emotional reactions	Pause and take several deep breaths whenever a strong emotional reaction is triggered, to cultivate self-awareness rather than reactivity	Educators can manage stress, personal hardship, and trauma
Elementary & Secondary Education Students	Cultivate focus and attention	Integrate a deliberate pause to help students settle their minds and bodies in preparation for learning	Begin class with a “mindful moment” where students are guided through either (1) sitting and noticing their bodily sensations or (2) slow and deliberate movement (e.g., deep breaths with movements such as raising their arms over their heads and down to their sides in repetition)	Students learn to slow down, quiet down their nervous systems, and check in with themselves and any feelings or thoughts that might need attention as they get ready to learn
Elementary & Secondary Education Student	Increase academic confidence, reduce stress, and manage anxiety	Use mindful breathing to help students self-regulate when under stress	Teach students to recognize the symptoms of anxiety in the body (e.g., elevated heart rate, fast-moving thoughts) and to practice taking several slow, deep, and full breaths to signal ease to the body when they feel these symptoms	Students are better able to manage stress and anxiety by practicing a healthy behavior

The highest function of education is to bring about an integrated individual who is capable of dealing with life as a whole.
– Krishnamurti: Education and the Significance of Life

Being more aware of the present moment is a healthy coping mechanism as students navigate virtual learning environments which have been required due to restrictions during the COVID-19 pandemic. Studies show that virtual learning settings create new challenges for students and many feel less confident in their ability to master the material.⁸ Mindfulness can serve as a constructive way to support student and faculty resilience during these unprecedented times. Incorporating techniques such as mindful breathing before exams and mindful appreciation of positive moments during instructional activities can inspire perseverance and reduce burnout. While mindfulness has proven to enhance emotional regulation, some people do not respond to these practices as there is no one-size-fits-all wellness model. Therefore, institutions should provide mindfulness activities and courses as an option to help teachers and learners become skilled in responding intentionally rather than reacting irrationally to life’s circumstances. Mindfulness can create meaningful connections between students and teachers both in and out of the classroom.

References

1. O’Driscoll M, Byrne S, Kelly M, et al. A Thematic Analysis of Pharmacy Students’ Experiences of the Undergraduate Pharmacy Degree in Ireland and the Role of Mindfulness. AJPE [Internet]. 2019;83:6457.
2. Sharma M, Rush SE. Mindfulness-Based Stress Reduction as a Stress Management Intervention for Healthy Individuals. J Evid Based Complementary Altern Med [Internet]. 2014;19:271–286.
3. Browning A. Mindfulness in Education: An Approach to Cultivating Self-Awareness That Can Bolster Kids' Learning. WestEd(2020). Accessed: February 6, 2021.
4. Ager k, Albrecht NJ, and Cohen M. Mindfulness in Schools Research Project: Exploring Students’ Perspectives of Mindfulness—What are students’ perspectives of learning mindfulness practices at school? Psychology 2015; 6 (7): 896-914.
5. Murry LT, Witry MJ. ‘Wasting Time Inside My Mind’: Exploring Student Pharmacists’ Perspectives on Engaging in Mindfulness Oriented Meditation Using Concepts From Education Research. Pharmacy Education [Internet]. 2020;204–214. Accessed: February 6, 2021.
6. Malcom DR. Being Present With Learners and the Deeper Lessons From Acting. Am J Pharm Educ [Internet]. 2020; 84: Article 8062.
7. O’Driscoll M, Sahm LJ, Byrne H, et al. Impact of a Mindfulness-Based Intervention on Undergraduate Pharmacy Students’ Stress and Distress: Quantitative Results of a Mixed-Methods Study. Curr Pharm Teach Learn [Internet]. 2019;11:876–887.
8. Schlesselman LS, Cain J, DiVall M. Improving and Restoring the Well-Being and Resilience of Pharmacy Students During a Pandemic. Am J Pharm Educ [Internet]. 2020; 84: Article 8144.