Losing Sleep Over Poor Performance

by Zak Cerminara, PharmD; PGY2 Oncology Pharmacy Resident, University of Maryland School of Pharmacy

I realize the irony of this essay as I write it with only five hours left until I have to wake up. Personally I struggle with the daily decision between staying up to work on a project or finishing homework or catching up on the emails and going to bed at a reasonable time. While I am sure that most people, me included, are aware that the lack of sleep is not healthy for your body or mind, does everyone really understand how detrimental sleep deprivation can be?

A lot of people are cognizant of the fact that young adults should get seven to eight hours of sleep every night, but how many people actually accomplish this? A Gallup survey in 2013 found that 59% of Americans get seven or more hours of sleep each night.  This means that over 40% get less!  And 14% of Americans say they get less than five hours of sleep per night. This is a substantial difference when compared to the original survey conducted in 1942. Back then 84% of Americans reported getting seven or more hours of sleep each night with the average person getting almost eight hours per night. While you might expect that people today willingly sleep fewer hours and are satisfied with the amount of sleep they get, 43% of people in the 2013 survey said they would be happier if they got more sleep.¹

Knowing that there is this large gap between the amount of sleep we get compared to what we should be getting is one thing. But how does the lack of sleep impact our performance? Sleep is important for our bodies — it's the time when our bodies repair and grow. But sleep also important for our mental state, including memory and cognitive function. During sleep our brains consolidate the memories and experiences from the day — and this facilitates learning as we process the day’s events.  Students may think that staying up to study for a big exam will benefit them (e.g. spending additional time learning the material) but, in actuality, they are doing themselves a disservice.

Sleep loss not only causes fatigue and sleepiness but it also leads to neurocognitive and psychomotor performance impairments. One meta-analysis found that sleep-deprived individuals performed at a level comparable to the ninth percentile of those who had adequate sleep.² Lack of sleep has been shown to impact the prefrontal cortex, which is responsible for higher brain functions including memory, reasoning, and language. One study found that shortening sleep duration lead to decreased memory encoding and knowledge retention, suggesting that the hippocampus may be affected.³

A study conducted with first-year college students found that for every hour delay in sleep, the predicted GPA decreased by 0.13 on a 4.0 scale. This study sought to determine favorable and negative health related variables and their relation to GPA. The study found that the variables that had the highest correlation to poor GPA were later weekday and weekend wake up time as well as later weekday and weekend bedtimes.⁴ Another study compared the sleep habits of the lowest and highest quintile of performers base on their GPA. They did not find any significant difference in total hours of sleep between the two groups, but they did find that students with the highest GPAs went to bed earlier and woke up earlier when compared to students who performed less well academically.⁵

I know that some of you might be saying: “I’m in [law / medical / pharmacy / graduate] school. There aren’t enough hours in the day to get everything done. Plus, I think I am smart enough to know if I were experiencing the detrimental effects of sleep deprivation on my academic performance.” Actually, you probably don’t.

In a slightly barbaric study, investigators examined the impact of sleep deprivation on performance.⁶ They found that after just one night of sleep deprivation, college students (n=44) scored significantly lower on a cognitive task when compared to a group of students who were not sleep deprived. Amazingly, the sleep deprived students ranked their concentration, effort, and estimated performance significantly higher than those students who were not sleep deprived.⁶ This suggests that while you feel like you are performing well, you lack an awareness of how detrimental sleep deprivation impacts your performance!

A recent study looked at the sleep patterns of pharmacy students.⁷ Not surprisingly, the investigators found that students who reported sleeping an average of 6 hours or less each night were statistically more likely to report feeling tired when waking up and throughout the day.  Those who got less sleep were also more likely to feel excessively sleepy during class and when studying course materials. When looking at actual academic outcomes, comparing the grades of those who slept more or less than an average number of hours during the week was not statistically different. This finding mirrors previous studies. However, it is important to note that most of the students in the study slept well under the recommended number of hours each night, averaging about six hours of sleep per night.  Thus most of the students were sleep deprived! The most compelling finding of this study was the relationship between the number of hours slept the night before an exam and academic performance. The authors found that those with a GPA less than 2.5 slept an average of 4.60 hours the night before a test, while those with GPAs above 3.5 slept an average of 5.53 hours before the test.⁷ There is one caveat. While one might assume that these students are studying when they stayed up late the night before an exam, the author’s acknowledge they don’t know with certainty what these students were actually doing.

So what can educators do to help learners get more sleep? The most obvious solution is to make certain the amount of work students are expected to do outside the classroom is reasonable. While homework and outside projects are certainly beneficial to learners, paying attention to the amount as well as the sequencing of assignments is key. Overburdening the learner with a bunch of assignments all due the same week is a recipe for disaster! Parsing out big assignments into small chunks helps learners stay on task. Furthermore, ensuring that concepts are taught well during class sessions (e.g. using active learning strategies) is another way educators can help. If learners spend hours of time outside the classroom trying to relearn or memorize concepts because they were poorly understood in class, it’s a waste of time. Using audience response questions and working through practice problems in class can help the teacher gauge student learning. Lastly, explicitly coaching students about how to manage their time is another strategy – including encouraging learners to get a good night’s sleep!

So the next time you are considering staying up late to finish work, consider a few things: Could it wait until tomorrow? What level of cognition does the work require? And is it worth staying up to finish if there is a strong likelihood that you won’t perform as well or may need to redo parts of it tomorrow? Maybe you should get a good night’s of sleep instead.

References

1. Jones JM. In U.S., 40% Get Less Than Recommended Amount of Sleep. Gallup, Inc. December 13, 2013. [Internet]  Accessed September 20, 2015.
2. Pilcher JJ, Huffcut AI. Effects of sleep deprivation on performance: a meta-analysis. Sleep 1996;19:318–26.
3. Alhola P, Polo-Kantola P. Sleep deprivation: impact on cognitive performance. Neuropsychiatr Dis Treat. 2007;3:553-567.
4. Trockel MT, Barnes MS, Egget DL. Health-related variables and academic performance among first-year college students: implications for sleep and other behaviors. J Am Coll Health 2000;49:125–30.
5. Eliasson AH, Lettieri CJ, Eliasson AH. Early to bed, early to rise! Sleep habits and academic performance in college students. Sleep Breath. 2010;14:71-5.
6. Pilcher JJ, Walters AS. How sleep deprivation affects psychological variables related to college students' cognitive performance. J Am Coll Health. 1997;46:121-6.
7. Zeek ML, Savoie MJ, Song M, et al. Sleep duration and academic performance among student pharmacists. Am J Pharm Educ 79(5): Article 63.

Meeting the Unique Needs of Non-traditional Students

by Imran Chughtai, Pharm.D., PGY1 Pharmacy Resident, Holy Cross Hospital 

The National Center for Education Statistics (NCES) states non-traditional students have one or more of these characteristics:¹ 

• Entry to college delayed by at least one year following high school
• Having dependents
• Being a single parent
• Being employed full time
• Being financially independent
• Attending part time
• Not having a high school diploma

Institutions of higher education have seen an increasing number of adult learners with life demands returning to school.¹ These non-traditional students experience social and financial burdens more than the traditional student. Due to non-traditional students’ life experience, they frequently have a keen understanding of the economic, professional, and social success that can be gained from higher education.¹ Non-traditional students require a unique approach to teaching and need to be taught differently than traditional students. 

Instructional methods that appeal to adult learners are most effective for non-traditional students. Methods that allow non-traditional students to talk about and use their past experiences, collaborate with peers, and reflect are often more successful.² “According to tacit theory, adult learners acquire their metacognitive skills from peers, teachers, and the local culture.”² An example includes mentoring where teaching occurs through role modeled behaviors. Educators of non-traditional students tend to gravitate to this framework because it facilitates learning in the absence of a traditional academic setting. In essence, the educator is meeting learning objectives by individualizing the “classroom.

A major problem faced by non-traditional students is the high risk of dropping out.³ In the study described by Gilardi and Guglielmetti (2011) the number one reported risk factor for dropping out was the student’s employment status -- 35% of students who dropped out had permanent jobs and 49% of students had temporary jobs. Evidence supports a negative relationship between the weekly hours worked and the rate of retention.³ 

A successful educator can mitigate the demands of employment by engaging students via non-traditional teaching methods, such as distance learning or “e-learning,” and thus increasing the “perceived quality of [the learning] experience.”³ By creating a flexible teaching/learning process the non-traditional learner is motivated to persevere through the rigors of higher education. The non-traditional student will meet learning objectives when he/she perceives the instructional will result in a meaningful learning experience.  This can be enhanced by the addition of social support from peers. For example, non-traditional student experience greater success with content that has “implications and applications of theoretical knowledge in their own professional context.”³ 

Learning assessment tools such as the Learning and Study Strategies Inventory (LASSI)² can be used to help adult learners identify their pre-existing learning strategies and preferences. The educator can use that information to introduce new learning strategies that may be more effective for the student and it encourages students to develop metacognitive strategies. Repetition, presenting information in similar, but not duplicate environments, is essential to strengthen course material.  Moreover, educators should force students to re-examine their pre-existing learning strategies (less than optimal strategies) and adopt new ones that will allow for optimal learning.

Non-traditional students are often self-directing and goal-oriented – and this can be used to the educator’s advantage! These attributes are key in promoting lifelong learning. Non-traditional learners often pursue higher education for professional development and advancement. This can provide motivation to increase engagement in the learning process.

When compared to traditional students, non-traditional students are more likely to⁴ …

• Ask questions in class or contribute to discussions (80% vs. 72%)
• Prepare two or more drafts of papers and assignments (61% vs. 40%)
• Come to class prepared (87% vs. 76%)

One study found that successful non-traditional students often used social supports, programs, and services to overcome time constraints.⁴ Social supports included study groups and online communication with teachers.  Face-to-face meetings are not always time friendly for non-traditional students. Non-traditional students also benefit from online-lectures or discussion boards which allowed remote participation without having to physically be present on campus.

The educator needs to use instructional methods that have fluidity in order to integrate the adult learners’ professional experience and individual learning preferences. The educator should use a student’s stated goals to tailor the learning objectives and activities so that the student has a more meaningful experience.  The non-traditional student has unique needs but they can be successful if educators employ appropriate methods and strategies. 

References

1. Ross-Gordon JM. Research on adult learners: Supporting the needs of a student population that is no longer nontraditional. Peer Review 2011; 13(1).
2. Kenner C., Weinerman, J. Adult learning theory: Applications to non-traditional college students. Journal of College Reading and Learning 2011, 41(2): 87-96.
3. Gilardi S., Guglielmetti C. University life of non-traditional students: Engagement styles and impact on attrition. The Journal of Higher Education 2011; 82(1), 33-53.
4. Wyatt LG. Nontraditional student engagement: Increasing adult student success and retention. The Journal of Continuing Higher Education, 2011; 59(1), 10-20.

Self-Assessment is Essential to Lifelong Learning

by Nkem P. Nonyel, Pharm.D., PGY1 Pharmacy Practice Resident, Holy Cross Hospital 

Self-assessment is the process of ongoing reflection, self-judgment, and self-monitoring to summarize one’s strengths and clarify areas for improvement. This includes learning from one’s experiences; judging one’s personal, educational, and professional performance; examining personal characteristics based on evidence, external standards, and explicit criteria for the purpose of future quality and performance improvements. Research has shown that self-assessment can improve learner's communication skills, and can result in behavior change.¹ 

Self-assessment skill is beneficial to every learner. McMillan and Hearn state “Students need to self-assess to know when they are learning, how much effort they must expend for success, when they have been successful, when they are wrong, and which learning strategies work well for them”¹ The reinforcement of one’s knowledge, skills, values, and behaviors can enhance one’s self-esteem and influence motivation by strengthening self-efficacy and readiness to change. Self-assessment is an essential for lifelong learning for students, educators, and professionals.

Self-assessment can help learners “to discover their own learning potential” by developing self-awareness of their own beliefs and potential misconceptions. It may be used to promote ongoing appraisal of the qualities of one’s performance, and reinforce one’s cognitive abilities and skills. Through self-assessment, one can discover one’s likes and dislikes, knowledge gaps, and opportunities for self-improvement. Self-assessment may also be used to improve morale, strengthen commitment to competent performance, and enhance motivation to take responsibility for one’s professional growth. Self-assessment is facilitated by using and incorporation feedback from peers, teachers and/or preceptors as a learner sets goals and formulates action plans.

Self-assessment involves reflection, planning, acting, evaluating, and recording. Self-assessment could be completed using paper or electronic methods. Other self-assessment activities might include keeping a journal or diary of activities, proofreading and revising one’s work, asking questions to clarify doubts, recording and reviewing audiotape or videotape of one’s own performance.

Teachers should engage and assist learners as they perform their own self-evaluation. The teacher can do so by first explaining to learners how he/she sets and evaluates his/her own goals. Next, the teacher can use thought-provoking questions to stimulate the learners’ thinking about pertinent concepts that should be addressed during goal setting. Such questions allow the learners to assess their thought-process while completing a task, evaluate their strengths and challenges during the assignment/project, and assess the amount of time invested in the assignment/project versus what they gained from the assignment/project.

It is common for any learner to over-estimate their performance. Video recording a student’s performance, either during oral presentations or practical activities, allows students to view themselves and critique their performance.  An educator can either videotape the learners or encourage them to videotape themselves.  Videos should be reviewed in private or with the instructor to avoid shaming. The educator may have the students complete a written self-evaluation immediately following an activity before they view the video, and again after viewing the recording. This way, the student is able to differentiate between the perception and reality of their performance. The University of Maryland School of Pharmacy uses videotaping during Objective Structured Clinical Examination (OSCE).

An educator can also model self-evaluation and the need for continuous performance improvement by videotaping some of his lectures, and having learners watch and critique his performance and provide feedback on his communication skills and teaching style. The educator may intermittently hand out evaluation forms, or use a suggestions box to seek the learners' opinion on how well the class is going, what the teacher is satisfactorily engaging the learners well or not.

Assigning learners to write Personal Learning Plan may help them become active participant in their education since they can create goals based on their perceive personal and professional needs. A written Personal Learning Plan will also facilitate dialogue between educators and learners because learners will have the opportunity to meet with the educators to review the set goals and the activities to ensure the attainment of the goals. Educators may also assign reflection essays to students to prompt them to reflect on ways to bridge gaps in knowledge and skills.

Self-assessment is an essential metacognitive skill that learners use to gauge their general background knowledge but determine the best strategies to problem-solve.⁴ In a study to evaluated the implementation of self-assessment among student health care practitioners and its impact on learning, Dearnley and Meddings noted that self-assessment enhanced the student’s ability to think reflectively and to achieve their academic potential.⁶ 

Students can tell that they have learned when they can use self-testing, self-questioning, summarizing, repeating or explaining to improve their understanding of pertinent concepts.⁴ Teachers can tell that students have learned from self-assessment, not merely from grades, but when they “develop reflective skills to become self-regulated and lifelong learners”, consistently use analytical methods to approach problems, apply their knowledge and skills across a variety of situations, and require less prompting.⁴ 

Reference

1. McMillan J, Hearn J. Student self-assessment: the key to stronger student motivation and higher achievement. Educational Horizons 2008: 40-49.
2. Bose S, Oliveras E, Edson WN. How can Self-assessment improve quality of the healthcare. USAIDS Quality Assurance Project 2001; 2(4).
3. Krueger JL. Pharmacy students’ application of knowledge from classroom to introductory pharmacy practice. American Journal of pharmaceutical education 2013; 77(2) article 31
4. Kurnaz MA, Cimer SO. How do students know that they have learned? An investigation of students’ strategies. Procedia Social and Behavioral Sciences 2010; 3666-3672.
5. Sarget J, Armson H, Chesluk B, et al. The process and dimensions of informed self-assessment: aconceptual model. Academic Medicine 2010; 85(7); 1212-1220.
6. Dearnley CA, Meddings FS. Student self-assessment and tis impact on learning – a pilot study. Nurse Education Today 2007; 27; 333-340

Constructive Conflict

by John Dolan, PGY1 Pharmacy Practice Resident, Carroll County Hospital 

Conflict is a part of our daily lives. Whenever there are multiple people in a room, there will be multiple opinions. Conflict arises when there are differing needs, emotions, or perceptions. Conflict can arise from a threat to something tangible or — more commonly in a classroom — intangible, such as ideas, values, and beliefs. While hot-button issues often provoke different viewpoints, conflict is not always over “big issues.” Sometimes a deadline or how to organize group work can provoke a disagreement. Adult learners are just as likely to conflict with their teachers as other students.¹ As a rowing coach, I often provide instruction to adults. They are doctors, lawyers, engineers, and teachers. They are intelligent and have different ideas and perspectives. Handling disagreements among the group can be a delicate matter.  Depending on how the conflict is managed, it can ruin a practice or lead to improvement.

Conflict can descend into animosity and personal animus, creating barriers to understanding and learning. My rowers are usually tired, in pain, and working hard.  It’s easy for them to react emotionally. When confrontation becomes the dominating theme, it can endanger the learning process, and alienate learners from each other. Therefore, it’s critical that both teachers and learners use confrontation in a constructive manner and minimize destructive conflict. It can be helpful to approach conflict resolution in adult education using the same tools successfully employed in business and politics.

Constructive confrontation forces us to re-examine our preconceived notions or beliefs, and gives us an opportunity to see something from another person’s viewpoint. It often resembles collaboration, because there is a dynamic tension in which there is give and take from both sides.  Conversely, individuals who engage in destructive confrontation are more concerned with “winning” and “losing.” Under these conditions, the responses can range from avoiding or withdrawing, to labeling, attacking, or controlling the dialog. Making sweeping generalizations like “[blank] always happens” or attacking with “you would say that” or speaking over the other party is a conflict that does not seek to build consensus or encourage dialog.

There are many conflict resolution models.^2,3,4 You can attempt to “force” a win, “accept” a loss, or compromise. Some argue that one should not compromise, but rather “negotiate interests.” This is the foundation of Fisher and Ury’s “Getting to Yes” and the Harvard Negotiation Project.⁴ 

Rahim and his colleagues argue that there is no “best” way to resolve conflict.² Instead, they propose a model in which one is either motivated by concern for the self or concern for others. Once this is recognized, one must chose from one or more styles of conflict management such as compromising, avoiding, obliging, integration, and domination.² 

Regardless of the model, there are several common recommendations for making conflict constructive:

• Create a safe space. All parties should remember that they are in a learning environment. There probably isn’t a “right” answer to the disagreement.  It is important to keep in mind that everyone is present to learn – including the teacher!
• Seek understanding. Fully elucidate the other “side’s” perspective. Often when restated, we come to see that there is not always conflict in the belief, but rather a different path.
• Define the problem. There is no point in arguing if you aren’t clear what you are disagreeing about. Too often students don’t take a step back and define their interests, goals, and beliefs.
• Align. If you’ve clearly defined the problem and truly understand the other viewpoint, this is much easier to accomplish. Realize where each position happens to be congruent. Visualize conflict as a path from point A to point B. While the starting and ending point are the same, there are multiple ways to get there – and conflict arises where these paths diverge.  Sometimes we watch video of a good race to have a common goal.
• Pause. Taking a moment to breath can make all the difference. It will be perceived as thoughtfulness – and can trigger reflection. Reacting too quickly can lead to misunderstandings, and further widen the gulf between two perspectives. I give my rowers a water break before we talk.
• Use “I” statements. Be careful about assuming someone’s identity, even with good intention. Instead of “You said…”, say “I understand your point to be…” Ground statements in observable facts, if possible. I videotape practice to provide an objective viewpoint.
• Agree to disagree. Help students understand that total agreement is not always possible if they remain wedded to their beliefs.^3,4

As Socrates said, “Know thyself.” Understanding how each student approaches conflict can also be useful. I’ve learned that there are many different personalities in a boat. Successful conflict management is based on having the proper tools and knowing each rower. Consider using a tool such as the Thomas-Kilmann Inventory⁵, the Kraybill Conflict Style Inventory⁶, or the Mouton-Blake Managerial Grid Model⁷ to assess each student's innate styles of conflict management.

Dealing with conflict is a ongoing process; the participants are continually reevaluating themselves and each other. The path might start at “A,” but there is not always an endpoint to a discussion or disagreement. In order to foster constructive conflict, educators must recognize this and constantly search for ways to align their students’ paths. 

References

1. Johnson DW, Johnson RT. Conflict in the Classroom: Controversy and Learning. Review of Educational Research. 1979 Winter;49(1):51-69. Abstract available from: http://www.jstor.org/stable/1169926
2. Rahim M. Toward a Theory of Managing Organizational Conflict. The International Journal of Conflict Management. 2002;13(3):206. Abstract available from: http://psycnet.apa.org/psycinfo/2003-00976-004
3. Walker M, Harris G. Negotiations: Six Steps to Success. Upper Saddle River, NJ: Prentiss Hall; 1995.
4. Fisher R, Ury W. Getting to Yes: Negotiating Agreement Without Giving In. 3rd ed. New York, NY: Penguin Books; 2011
5. Thomas-Kilmann Conflict Mode Instrument [Internet]. Sunnyvale, CA: CPP, Inc; 2009 [cited May 13, 2015]. Available from: https://www.cpp.com/products/tki/index.aspx.
6. Style Matters: The Kraybill Conflict Style Inventory [Internet].: Riverhouse Press; 2015 [cited May 13, 2015]. Available from: http://www.riverhouseepress.com.
7. Blake R, Mouton J. The Managerial Grid III: The Key to Leadership Excellence. 3rd edition ed. Gulf Publishing; 1994.

Helping Learners with ADD/ADHD to be Successful

by Sarah Jaffery, Pharm.D., PGY1 Community Pharmacy Practice Resident, University of Maryland School of Pharmacy

Most educators will agree that ensuring each student has an effective learning experience is no easy task.  This becomes all the more daunting when teaching students with learning difficulties. A well-known disorder that may act as a barrier in the learning process for students is Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD). ADD/ADHD is commonly thought of as a pediatric disorder, but up to 65% of children diagnosed with this disorder continue to have symptoms into adulthood.¹ More than 4% of adults are estimated to have ADHD.²  Although ADD/ADHD is not considered a learning disability, it can certainly have detrimental effects on daily functioning including impairments in educational performance.¹ To be an effective teacher to a student with ADD/ADHD, it is necessary to have an awareness of the medical components of this disorder, a solid foundation in behavioral management, and proficiency in instructional design.³

According to the diagnostic criteria for ADD/ADHD, adults who are not diagnosed during

childhood need to exhibit five or more inattentive and/or hyperactive-impulsive symptoms for at least six months.  These symptoms need to be severe enough to interfere with social, academic, or occupational functioning. Inattention symptoms might include difficulty remaining focused during lectures; beginning tasks but quickly losing focus and getting sidetracked; difficulty keeping materials in order; poor time management; failure to meet deadlines; and losing belongings such as school materials, wallets, keys, and paperwork. Hyperactive-impulsive symptoms include leaving one’s seat during a class; feeling restless; inability to stay still for a long period of time; talking excessively; and interrupting or taking over what others are doing.⁵ Not only do these behaviors make it more difficult for the adult with ADD/ADHD to be successful in school, but they can be disruptive to other learners too.

Several strategies can be employed to foster a more conducive learning environment for students with ADD/ADHD. These strategies require the educator to spend extra time with students to ensure everyone is on the same page and working towards the same goal. An educator may suggest the following strategies to students with ADD/ADHD at the start of a class or learning experience:³

• Sit near the front with your back to the class to keep other students out of view and thus minimize distractions
• Participate in peer tutoring and cooperative/collaborative learning
• Study in an area with minimal stimuli
• Take extra time to complete tasks and assignments
• Set specific times and routines for studying
• Report to a mentor or study buddy who encourages assignment completion and organization

Educators’ views and beliefs regarding their learners influence how they approach teaching. These views guide instructors’ ideas about which methods of teaching best suit the learner’s needs. A research report developed by the Learning & Skills Research Centre of the UK aimed to propose an alternative way for educators to think about learning and suggests a more person-centered and well-informed approach to teaching students with learning difficulties. First, a variety of teaching strategies / methods should be used - not just one. Next, there should be a focus on the purpose of learning rather than the outcome, as this takes into account the emotional and psychological aspects of learning and promotes participation. In addition, the learner’s fundamental values, stage of development, inclinations, and capabilities should be explored and should guide the teaching. Finally, to teach effectively, learning activities should take place in controlled settings (e.g. in the classroom and labs) as well as real-life (e.g. at home and on the job). This will help students test and apply the knowledge learned in a controlled setting in situations meaningful to them. Moreover, it provides opportunities for interactions with and to learn from people other than the teacher.⁴

Another strategy to help students with ADD/ADHD improve their learning capacity is teaching metacognition, or thinking about learning. Studies have shown that students who utilize metacognitive strategies tend to be better learners. Given that students with ADD/ADHD do not typically thrive in academic settings, they may benefit from training in metacognitive thinking. A study conducted in children and adults with ADD/ADHD demonstrated that training students to adopt metacognitive strategies is helpful.⁶ Students were coached to think about and monitor their learning. They were taught active reading strategies, listening skills, and organization skills, among others. There was an emphasis on being attentive when listening and studying as well as organizing and creating material to help with recall. This work resulted in positive outcomes including decreased inattention symptoms and improved academic/intellectual functioning.⁴ A more recent study explored the efficacy of a 12-week metacognitive therapy group intervention, focused on time management and organization, in adults with ADHD.⁷ Strategies used to promote metacognition in this study included teaching practical skills like using a daily planner, along with time management skills to help them organize and complete complicated projects. There were significant improvements in ADHD symptoms of those participants in the metacognitive therapy group when compared to the symptoms of participants in a control therapy group. It seems intuitive that training the brain to reflect on one’s learning, something that individuals with ADD/ADHD have difficulty doing, would be a beneficial behavioral technique.

It is clear that teaching is less effective using a one-size-fits-all approach. Creating an effective learning environment requires effort from both the educator and the student. For the educator, it is important to understand the medical aspects of ADD/ADHD as well as to be skillful in behavioral management and instructional design. If the educator has an in-depth knowledge regarding a variety of teaching approaches that can be used to meet the individual student needs, the likelihood of success is greater.

References:

1. Adler LA. Epidemiology, impairments, and differential diagnosis in adult ADHD:introduction. CNS Spectr. 2008;13:8(Suppl 12):4-5.
2. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the UnitedStates: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006. 163(4):716-732.
3. TeacherVision: Teaching Children with ADHD. [online] 1998 Sept. ERIC Clearinghouse on Disabilities and Gifted Education. (Accessed 2015 Mar 24)
4. Dee L, Devecchi C, Florian L, et al. Being, having and doing: theories of learning and adultswith learning difficulties. LSRC Research Report.
5. Rabiner D. New Diagnostic Criteria for ADHD. Attention Deficit Disorder Association. (Accessed 2015 Apr 1)
6. Thompson L and Thompson M. Neurofeedback combined with training in metacognitive strategies:effectiveness in students with ADD. Appl Psychophys Biof. 1998. 23(4):243-263.
7. Solanto MV, Marks DJ, Wassersein J, et al. Efficacy of meta-cognitive etherapy for adult ADHD. Am J Psychiatry. 2010;167(8):958-68.

Teaching Empathy

by Kumaran Ramakrishnan, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

To teach the pathophysiology of Parkinson’s, a teacher can use a lecture with a PowerPoint. The lecture can teach the pathophysiology of the disease or the therapeutic guidelines for treating the symptoms.  But how can the student learn empathy for a patient with a debilitating condition like Parkinson’s disease?  Or how to understand and relate to the patient?  Numerous articles have been published stating that empathy increases not only are the patient’s positive perception of the physician but also health outcomes. One study found that patients who’s physicians had high empathy scores were more likely to achieve better disease control as evidence by lower A1c and LDL-C measurements.¹ Similar results have been seen in patients with the other disease states such as the common cold. The Accreditation Council for Pharmacy Education (ACPE) requires schools of pharmacy to include empathy in the curriculum in order to provide high quality health care to patients with diverse backgrounds.

http://ezradew.com/wp-content/uploads/2013/12/empathy-.jpg

Unfortunately health professional students become less empathetic as they progress through school. One longitudinal study of medical students found the greatest erosion of empathy was in the third professional year.² This erosion of empathy appears to occur when students focus too much on applying their classroom-based knowledge to real patient situations.  A similar longitudinal study has not been conducted in pharmacy students, but there have been reports that interventions can increase empathy among pharmacy students at different stages in their career. 

One study conducted in the second professional year of pharmacy school, engaged students in simulation activities.  Students were asked to act as though they had lost the use of their dominant hand, vision, and speech. There were small and large group discussions after each activity to engage the students.³ The Jefferson Scale of Empathy-Health Profession (JSE-HPS) was administered before the interventions, seven days, and ninety days after these activities. The JSE is a tool designed to measure empathy in medical students, and JSE-HPS has been adapted for other health professionals.⁴ The tool is widely used in studies to measure empathy for both students and practitioners alike. The results showed that while there was an increase in the scores seven days after the activities, JSE-HPS scores returned to baseline 90 days later. When comparing the scores with a control group, there is little difference in the net increase in empathy scores.³ 

In another study, students watch a play featuring two actors — an elderly patient with a “demanding personality’ and an assistant manager who “cared more about rules and regulations than the elderly person’s concerns.” After the play, students engaged in a discussion about the stimulated encounter and how they would use the information in the future. The JSE was administered before the play, immediately after the play, seven days, and 26 days later. Similar to the previous study, while there was a significant increase between the pre-test and immediate posttest, by day 26, the scores were nearly back to baseline.⁵ 

Several other methods have been employed to teach empathy.  Students have been asked to keep a nutritional diary,⁶ participate in a 7-day active learning assignment about diaetes,⁷ and use community resources for patients with a chronic disease.⁸ All of these studies show short-term increases in empathy but scores return to pre-intervention levels in the long run. This provides a unique challenge as any method used must not only increase empathy but maintain it. A solution might be use interventions throughout the curriculum. Accrediting agencies, such as the Accreditation Council for Pharmacy Education, have incorporated empathy into their standards. The ACPE standards mention empathy has an important component of professional communication, ethical behavior, and professionalism. Since empathy is such an important trait for effective health care professionals to possess, it is essential for teachers to understand how to teach empathy.  The studies have shown that several methods, while effective in the short term, have little effect in the long term.  For students to learn empathy and be effective professionals it is important to integrate empathy exercises throughout the curriculum – not just in one isolated course. 

References:

1. Hojat M, Louis D, Markham F, Wender R, Rabinowitz C, Gonnella J.  Physicians' empathy and clinical outcomes for diabetic patients. Acad Med. 2011;86(3):359-364.
2. Hojat M1, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, Veloski J, Gonnella JS. The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Acad Med. 2009 Nov 2009;84(11):1182-91. 
3. Lor K, Trong J, Ip E, Barnett, M. A randomized prospective study onoutcomes of an empathy intervention among second-year student pharmacists . APJE. 2015;79; Article 18. 
   
4. Fjortoft N,Van Winkle L, Mohammadreza H. Measuring empathy in pharmacy students. AJPE 2011;75: Article 109.  
5. Van Winkle L, Fjortoft N, Hojat M. Impact of aworkshop about aging on the empathy scores of pharmacy and medical students. AJPE. 2012 2012;76: Article 9. 
   
6. Whitley H. Active-learning diabetes simulation in an advanced pharmacy practice experience to develop patient empathy. APJE. 2012;76; Article 203. 
   
7. Trujillo J HY. A nutrition journal and diabetesshopping experience to improve pharmacy students’ empathy and cultural competence. APJE. 2009 37; Article 37.
8. Chen JT, LaLopa J, Dang DK. Impact of patient empathy modeling on pharmacy students caring for the underserved. AJPE. 2008,;72: Article 40.

Narrative Evaluation System

by Caroline Kim, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy 

Years ago, I attended elementary school in South Korea. My report card consisted of a letter grade accompanied by a short narrative from my teachers.  These comments stuck with me more than the grades.  They gave me insight into my performance beyond numbers.  They explained areas where I needed to improve — even if I earned a high grade — and areas where I did well despite a poor grade.  The finality of my letter grades was inescapable, but the comments were a source of motivation for further learning.

The purpose of evaluation in education is to guide student development, promote excellence, aid in defining the successful completion of a program, and provide performance evidence.¹  The traditional grading system might be effective in promoting high standards, but it fails to capture abstract details related to student performance. Traditional grading systems also provide little room for feedback to guide the future learning process.  I would argue that there is a need for a more effective method of evaluation beyond numerical and letter ‘grade’ classification systems.

The Narrative Evaluation System (NES) is a nontraditional grading system, which provides constructive feedback on student’s performance using a narrative format.  In construct, NES draws heavily from Walter Fisher’s narrative paradigm theory. ²  The theory states that narration and storytelling are the basis of all human communication. ²  In the NES system, the evaluator takes into account the objectives of the course when evaluating the strengths and weaknesses of a student’s performance.  Like traditional evaluation models, NES also recognizes noteworthy student performance.  In addition, NES encourages cooperation and collaboration by personalizing descriptions of student performance. ³ This helps to promote closer relationships between students and instructors.

NES does have some drawbacks.  NES requires a larger time commitment from educators. ³  In order to summarize student performance into a narrative, educators are required to keep detailed notes on each performance and provide suggestions on how students can improve in the future.  NES explores more dimensions of the evaluation process and educators must devote more time and energy to constructive criticism.  Simply put, NES is more difficult than  the simple categorization required in traditional grading systems.  Even after providing narrative comments, some institutions force educators to use traditional grading systems — allowing a comparison between students using the same grading scale.  The NES system supplements traditional evaluation.³   Students who have been evaluated using the narrative evaluation system often request letter grades — in one study more than two thirds did so.⁴ The most common reason for requesting letter grades was to understand the narrative evaluation by comparing their performance to grades that they are familiar.⁴ 

Very few studies have analyzed the impact of NES on future success.  One study examined whether graduates from a program that used NES remained competitive when it came to admissions into graduate and professional programs.³ When comparing students who graduated from the University of California at Santa Cruz (UCSC) — which uses a narrative grading system — with other University of California campuses which assign traditional grades, the investigators found that UCSC students generally performed as well if not better in terms of acceptance rates into graduate and professional schools.³ 

In another study, a survey of UCSC students and alumni explored their attitudes towards NES.  The survey respondents indicated they preferred NES because it pointed out strengths and weaknesses, and helped them grow personally and professionally.  They appreciated how NES promoted cooperation, scholarship, and creativity. ⁴ However, 62% of undergraduate students surveyed and 54% of alumni surveyed reported some quibbles with NES.⁴ The problems included the length of time it took to receive the narrative, failure to receive a constructive narrative, or evaluations that were similar to and provided little addition information beyond letter grades. ⁴ Despite these challenges, 82% of undergraduate students and 78% of alumni favored NES over a traditional letter grade.<sup>4 

Figure 1. This table summarizes a surveyed undergraduate and alumni opinions of NES.4</sup>

Survey Questions	Undergraduate (%)		Alumni (%)
	Yes	No	Yes	No
NES influenced decision to attend the school	58	42	48	52
Favored NES over letter grades	82	14	78	18
Requested letter grades	32	68	N/A	N/A
Believed NES worked in their favor	N/A	N/A	62	37
Experienced a problem with NES	62	38	54	46

Another study compared the effect of NES and a conventional grade system on learning and motivation.⁵  During the study students were asked to perform certain learning tasks during 3 distinct teaching sessions.  Students were randomized to receive either narrative or numerical grades when completing the learning tasks in sessions 1 and 2, and then took a post-test after session 3.⁵ Results showed that students who received narrative evaluations had the highest post-test performance.  Moreover, traditional grades depressed creativity and weakened student interests in the subject matter.⁵ 

Currently, at least seventeen colleges and universities in United States and Canada use narrative evaluation (NES).  Some have used this system for over fifty years.  NES can guide students in their learning and help them improve on their weaknesses.  The NES model provides a more complete picture of the student and helps students to distinguish themselves as individuals.  Although it may be time-consuming, educators should consider implementing NES – perhaps in conjunction with traditional grades — to enhance the learning process. 

References

1. Hanson J, Rosenber A, Lane L.Narrative Descriptions should Replace Grades and NumericalRatings for Clinical Performance in Medical Education in the United States. Frontiers in Psychology.  Nov 2013; 4: 1-10.
2. Fisher W. The Narrative Paradigm: In the Beginning. Journal of Communication. Dec 1985;35(4): 74-89.
3. Affirmation of Accreditation Self-Study Report. University of California at Santa Cruz. [Internet].  1994 Nov: 22-29. [cited 2015 Mar 8].
4. Wong M. Assessment and Evaluation of Past and Present Student Attitudes toward the UC Santa Cruz Narrative Evaluation System. University of California at Santa Cruz. [Internet]. 1992 Jun. [cited 2015 Mar 9]
5. Butler R,Nisan M. Effects of no Feedback, Task-related Comments, and Grades on Intrinsic Motivation and Performance. Journal of Educational Psychology. Jun 1986; 78(3): 210-216.