Backchannel Communication to Improve Instruction and Learning

by Claire Calcote, PharmD, PGY1 Pharmacy Practice Resident, St. Dominic Jackson Memorial Hospital

If you are unfamiliar with backchannel communication, it involves using secondary ways to communicate “behind the scenes” of the primary method of communication, like during a lecture presentation. Its use within higher education has grown exceptionally, even before the COVID-19 pandemic. Backchannels have always existed within the classroom - like passing notes or private conversations with a nearby classmate. Now, multiple platforms allow students to submit comments, ask questions, or share supplemental materials without interrupting the primary communication channel (e.g., the teacher’s presentation). Essentially, the discussions and thoughts already occurring within the classroom are given an open environment to foster dialog. These channels don’t cure all problems - like distracting outside conversations, disengaged students surfing non-educational websites, and reserved learners who hesitate to ask for clarification or further explanation. However, a backchannel can create an additional outlet for discussions, engage both introverted and extroverted students, and reveal gaps in learners’ comprehension, which ultimately enriches instruction and enhances learning.

Several benefits of secondary communication through backchannels have been documented.^2,3 By providing an additional outlet for discussions and participation, student engagement is enhanced.² Backchannels also provide opportunities to engage those who are less likely to speak up during lectures or ask questions. Group collaboration can be facilitated when a backchannel is used.³ Additionally, these platforms foster an open environment for exchanging resources. Students can comment and clarify misunderstandings regarding lecture content.  And faculty can respond if needed.² This ultimately builds teamwork and collaboration skills, which are important outside of the classroom. Lastly, from an instructor perspective, the backchannel can reveal gaps in student comprehension, so efforts can be made to review or refocus specific content.³

While it is unclear when backchannel communication using modern technology first occurred, its formal use was described in the early two-thousands.¹ In 2006, a paper described a backchannel communication method using online chatrooms during graduate courses at the University of California, Berkley over a period of two years. Authors analyzed over 200,000 chat room entries, plotting chatroom communication over time to assess utilization trends.¹ They concluded that participation increased over time, with a small number of students participating most frequently.¹

I recently had some experiences working with a backchannel communication method during a course where I was the teaching assistant.  I wondered — is there a relationship between course performance and backchannel engagement? During this four-week course for second-year Doctor of Pharmacy students, a backchannel communication was available using a tool called Discord which includes Voice over Internet Protocol (VoIP) messaging, instant messaging, and digital media distribution platform. The instructor created a separate sever within Discord and enrolled the entire class, including teaching assistants and other faculty who contributed to the instruction. Additionally, students were assigned to small groups in the Discord community for active learning activities and other assignments throughout the course. During each class session, students had required to complete assignments or assessments that involved communicating with their group members in Discord. Individuals often used the general chat feature to communicate with other members of their group, the teaching assistants, and the instructors. Discord possesses helpful features like private messaging and both audio and video calling; therefore, students can contact anyone in the community to get clarification.  The system also provides a mechanism for urgent notification if emergent situations arise. Since Discord is popular among the gaming community, a select number of students were eager to engage on Discord as they were familiar with the platform.

During the first few days a majority of the class seemed hesitant to engage on Discord outside of the required in-class activities. However, as the course progressed, open discussions about lecture content occurred, with some students exchanging graphics and primary literature articles. Additionally, encouraging reminders before exams and amusing captioned pictures were exchanged between students and faculty. Students took the initiative to create topic-specific threads within the platform to organize the discussions for exam preparation. The experience aligned with the University of California, Berkley’s findings – backchannel communication participation increases over time, with a select number of individuals engaging the most.

By the second week of the module, particularly following the first exam, students were more likely to directly contact and communicate with the lead instructor and other faculty members. Questions became more specific and targeted as students began to study the materials. From a class administration perspective, in the event of a student emergency, participants were able to notify the faculty through Discord and devise alternative ways for the student to receive the instruction materials. These direct communication features were appealing from a faculty point of view, as they served as a more immediate way to communicate (when compared to email) and messages could be sent without disclose personal information. Platform use persisted until the conclusion of the four-week course, with students continuing to discuss and clarify lecture content prior to their final exam. After grades were finalizing, it was noted by the lead instructor that those who engaged the most within the backchannel were the highest performers within the course.

My observations coincide with experiences reported in a 2020 case study at the University of Aizu in Aizuwakamatsu, Japan.⁴ Professors used external personal social networking systems (SNS) like Twitter, Facebook, and Line for backchannel communication, which allowed students to interact and collaborate on assignments. Participants included those in four Japanese undergraduate English as a Foreign Language (EFL) courses and they were observed over one academic year.⁴ Interaction via the backchannel could be in any language of the students’ choice.  Initially, participants were hesitant to use the various SNS options for backchannel communication; however, reluctance was overcome once students realized the privacy of the backchannel. The study ultimately concluded that backchannel communication provided a comfortable outlet to engage with other classmates who they most likely would not interact with face-to-face.⁴

Backchannel communication can be used to overcome various classroom obstacles. Although multiple platforms exist, a single backchannel would be easier for faculty to maintain, monitor, and respond to. Students will need to learn about backchannel communication etiquette and faculty will need to set expectations on when and how to use the system.  Ideally, the backchannel would be used during the main channel (e.g. the lecture time) to prompt student engagement. This should be continued through several lectures to overcome potential participation hesitancy. Additionally, instructors should routinely send prompts in the backchannel that requires student response or collaboration related to the learning objectives of the course.  Creating a backchannel communication channel can increase classroom discussions, heighten student participation, and reveal misunderstood content.  In so doing, instruction and learning are ultimately enhanced.

References:

1. Yardi S. The Role of the Backchannel in Collaborative Learning Environments. In Barab S A , Hay KE, & Hickey DT. (Eds.), The International Conference of the Learning Sciences: Indiana University. 2006;(2):852-858.
2. Bruff D. Active Learning in Hybrid and Physically Distanced Classroom. In: Vanderbilt University Center for Teaching [Internet]. 2020.
3. Bruff D. Backchannel in Education – Nine Uses. In: Agile Learning: Derek Bruff’s blog on teaching and learning [Internet]. 2010.
4. Ilic P. Exploring EFL Student Use of Digital Backchannels During Collaborative Learning Activities. JALT CALL Publications. 2021;64-74.

Benefits of “Near-Peer” Teaching

by Allison Graffeo, PharmD, PGY-1 Pharmacy Practice Resident, University of Mississippi Medical Center

Near-peer teaching involves students learning from more senior peers, individuals who are one or two years ahead of them in school or post-graduate training.¹ It is a well-established model used by medical education programs; however, not fully established in pharmacy education. Some educators criticize this method, stating that it would lower the quality of teaching, be difficult to implement and be unethical to use students as teachers. However, using near peers in the classroom, practice labs, and experiential learning environment allows pharmacy students to learn from a peer who has been through similar (and recent) experiences. In addition, it contributes to the more senior peers’ growth to teach and develop their professional skills.²

There are two distinct types of near-peer teaching models most commonly employed: classroom-based and experiential learning. The classroom-based model incorporates senior peers to lead lectures, discussion, and other activities in classes or practice labs serving as an assistant to the faculty member. This model engages students to learn from their senior peers who use a similar language. When using near peers in the experiential learning setting, the instructor integrates learners (often at multiple stages of development) to address real-world problems or to gain research experience. Over the last decade, many authors and researchers have investigated the applicability of these near-peer teaching models in pharmacy education.

At the University of Toronto, near-peer teaching was assessed in an experiential teaching model that was led by a clinical pharmacist/preceptor and assisted by a recent graduate PharmD student with 3 years of previous hospital experience.  The learners included a pharmacy resident who had been with the institution for 6 months, a third-year pharmacy (cooperative “Co-op”) student, and a fourth-year pharmacy (Structured Practical Experience Program “SPEP”) student. The recently graduated PharmD and resident were considered the senior peers to the third- and fourth-year students. These clinical experiences consisted of patient-care rounds on a hemodialysis unit with a medical team. The lead pharmacist would provide articles on specific topics to the students and residents to prepare for patient and therapeutic discussions. Senior learners led the discussions, and all members of the group were expected to be in attendance to bring various experiences to discussions. This allowed the senior peers to use concepts and language that the third- and fourth-year students could more easily understand and relate to while also having the preceptor available to explain concepts more deeply and fill in the gaps. These sessions occurred at least three times a week and included minimal direction from the pharmacist to allow the senior peers to take the lead.² Although the expected hierarchy was for the students to rely on the resident, it turned into a collaborative group with each member of the team contributing. This method provided a unique and positive approach, particularly with regard to collaboration with healthcare teams and the students reported that they greatly benefited from having a near-peer role model. They explained that they felt comfortable approaching the recently graduated pharmacist and resident and they developed a better understanding of pharmacy interventions.

The Oregon State University College of Pharmacy recently assessed the effectiveness of a classroom-based near-peer teaching model.  They measured third-year pharmacy students’ knowledge and confidence related to frequently prescribed medications. There was a total of 98 third-year pharmacy students involved in the “RxReady” near-peer teaching series which occurred immediately prior to their advanced pharmacy practice experiences (APPEs). Twenty-four students were randomly selected and were required to study a certain medication and present a 10-minute presentation to other students (with a faculty member present). Students who participated in the presentation had to complete pre- and post-quizzes (test of knowledge) as well as a survey to determine the effectiveness (change in student confidence) of this teaching style.³ Out of the 96 students who took part in the pre- and post-quizzes and surveys, there was a 15% increase (p<.001) in post-scores compared to the initial quiz and survey. Additionally, 96% of students achieved a higher score on the final knowledge assessment compared to the initial ones. Student confidence scores significantly improved after the presentations (IQR [(0-0.5) – 1]; p<.05).² Targeted questions on the surveys included recalling dosing and formulations, side effects, pharmacokinetics and pharmacodynamics, drug-drug interactions, and counseling points.³ This method may be a useful way to assist students with learning gaps and prepare students to give presentations and engage in patient education during the APPEs.

Lastly, a review article examined six educational research studies that assessed the various models for near-peer teaching. The paper examined near-peer teaching activities in pharmacy schools. Of the six studies included in the review, surveys and questionnaires were used to assess knowledge, problem-solving skills, attitudes, and values towards near-peer teaching methods. These studies revealed that near-peer teaching was accepted and had a positive impact on students’ experiences. Students strongly agreed that near-peer teaching promoted collaboration and that they were excellent role models.¹

The purpose of experiential learning is for students to see real-life situations which reinforce drug knowledge, help develop communication skills, and provide opportunities to practice problem-solving. Near-peer teaching enhances student experiences by providing mentorship and assistance from a senior peer. However, barriers remain within pharmacy programs to implement near-peer teaching as a structured teaching model. To be most effective, senior peers should be assigned a faculty preceptor to ensure all daily responsibilities are being met and are receiving adequate feedback. Additionally, senior peers could create “notebooks” including classroom-based and experiential learning activities which they can pass down and updated annually, aiding the transition from student “learner” to senior “near-peer” teacher. If pharmacy schools routinely had near-peer teachers throughout their curriculum, it would not only provide a unique learning environment for students and residents but help to increase the confidence and clinical skills of pharmacists.^1,2,3

 

References: 

1. Aburahma MH, Mohamed HM. Peer teaching as an educational tool in Pharmacy schools; fruitful or futile. Curr Pharm Teach Learn. 2017;9(6):1170-1179.
2. Leong C, Battistella M, Austin Z. Implementation of a Near-Peer Teaching Model in Pharmacy Education: Experiences and Challenges. Can J Hosp Pharm. 2012;65(5):394-398.
3. Tsai T, Vo K, Ostrogorsky TL, McGregor JC, McCracken CM, Singh H. A Peer-Teaching Model to Reinforce Pharmacy Students’ Clinical Knowledge of Commonly Prescribed Medications. Am J Pharm Educ. 2021;85(5): Article 8451.

Best Practices in Preceptor Training and Development

by Natasha Lewis, PharmD,  PGY1 Pharmacy Practice Resident, Mississippi State Department of Health Pharmacy

A preceptor is a teacher who facilitates practice-based learning. They serve as an instructor or coach for students and residents, providing them with support as well as direct instruction that facilitates their professional development. Preceptors practice in a variety of settings and have different teaching styles and expectations. New and experienced preceptors may inquire about ways to start or improve their teaching skills as a preceptor. Others may feel that they lack time or resources to be an effective preceptor. Successful preceptor development and training should include educational activities and resources to meet the diverse needs of all students. Many of these qualities, such as assessing a learner’s clinical skills, developing relationships with other healthcare professionals, and being a positive role model should all be part of the preceptor’s professional development. Since preceptors play a vital role in a student/resident’s clinical learning, preceptor training programs are essential to keep them up to date on learning theories and practices to prepare future health professionals with the knowledge and critical thinking skills to be successful. The purpose of this article is to evaluate the literature pertaining to pharmacy preceptor development activities.

A recently published article entitled “A Scoping Review of Pharmacy Preceptor Training” identified and evaluated the literature pertaining to preceptor training programs. This article provided evidence-based options for colleges and schools to use in their preceptor training program.¹ Many of the preceptor training programs were face-to-face sessions and web-based modules, combined with written materials such as a preceptor manual, pre-session assignments, and self-study readings.¹ The responses to these programs were generally positive and described as beneficial.  The participants indicated that easy access to the training was important.  They also found that preceptor training was a great opportunity to share ideas, could illicit positive changes in behavior and attitudes, and a great way to gain insight into learning science.¹

In the scoping review, the authors suggested using online preceptor self-reflection/self-assessment tools as part of their training programs.¹ One program provided preceptors with a computer-mediated support network following a development workshop.^1,4 This workshop covered ways to provide feedback and teaching skills in patient care settings, and rotation design.⁴ After several of these programs, preceptors reported feeling adequately trained to be effective educators while still meeting their employment responsibilities.⁴

The University of Iowa College of Pharmacy’s constellation of preceptor development and training programs is a great example of a comprehensive program that follows best practices.² Their program includes four development tools: live events, printed documents, one-on-one experiences, and web-based programs.²

 

Preceptor Development and Training Programs
Live	Print	One-on-One	Web
Regional events On-campus programs State association educational seminars	Preceptor manual Preceptor newsletter National organization resources	Practice site visits Student feedback Available experiential faculty and staff	On-demand CPE webinars On-the-fly training videos Monthly journal club

Web-based programs were developed to provide preceptors with the convenience of learning and developing skills at their own pace. The program created a web-based development tool with four 30-minute modules for initial preceptor development.² They were made available online to be completed at the preceptors’ convenience. Periodically, new modules were added to the website with content relating to learning strategies, ethics, generational learning, continuing professional development, and mentoring.² Several other opportunities were created to complement these program elements, such as clinical topics, monthly journal club, and a preceptor discussion guide to facilitate dialogue with students.² At the end of the modules, preceptors were asked to complete an anonymous evaluation of the program. Preceptors highly rated several of these modules, stating that it helped improve their clinical practice, enhanced their knowledge, skills, attitudes, and values.

Printed documents included newsletters and manuals with guidance on educational philosophies, resources, policies, and curriculum.² The guides were created by faculty and staff members of the professional experience program.² Preceptors were also provided with links to websites with helpful resources.

Live educational events provide preceptors with networking opportunities, discussions, and continuing education credit on specific practice-based teaching skills.² Examples of these events include dinners, annual events, and workshops held for professionals within the field. These events afforded preceptors with a safe space to interact with other preceptors and gain knowledge, or “preceptor pearls” based on successful experiences of others.²

One-on-one training provide preceptors with the opportunity to open their practice site to students and provide quality practice experience while also increasing students’ communication skills with other professionals.² Students gain actual experience on site, while also building a relationship with their preceptors. This type of training provides students/residents with the opportunity to provide an assessment before and after the experience.² Students/residents interact with patients, as well as the staff at these practice sites, to gain a better understanding of what the preceptor does every day and learn more about the preceptor’s role.² After engaging in several of these activities, students rated their preceptors as “good” and “excellent”.^2,4 Several instructors reported that they felt more confident in guiding student learners.

Dental preceptors are encouraged to use the iCARE method for precepting, which stands for Inquire, Cultivate, Advise, Reinforce, and Empower.³ It is used to assist students with gathering and analyzing important information, assessing the patient’s condition, coming to a diagnosis, and developing a treatment plan and course of action.³ This process has been successful in providing students room to reflect on their knowledge and thought process while also providing time for preceptors to assess the learners’ understanding of key concepts and the scientific literature.

1. Inquire: Ask the student about the patient’s history, condition, diagnosis, and treatment plan options
2. Cultivate: What evidence does the student use to support the diagnosis and treatment?
3. Advise: Preceptor discusses information that student did not bring forth or perhaps overlooked. This helps build upon the student’s knowledge for future cases.
4. Reinforce: Preceptor discusses with the student what was completed well and areas for improvement
5. Empower: Students evaluate and reflect on the process. They propose changes they would like to make.

Medical preceptors often use the One-Minute Preceptor method to teach their students.³ This provides open communication between the preceptor and students while also providing time to teach clinical topics.³ When discussing a clinical case, the preceptor and student completed five tasks:

1. Get a commitment: The student is encouraged to commit to the next steps in a patient case. This can range from forming a diagnosis to creating a treatment plan. The student’s knowledge of the subject is applied to formulate a plan for the patient.
2. Probe for supporting evidence: The preceptor asks for evidence that supports the student’s plan. This provides the student an opportunity to explain how they at their plan.
3. Teach general rules: After listening to the student’s thought process and ideas, the preceptor then provides information to address general concepts.
4. Reinforce what was done right: The preceptor reinforces what the student completed correctly when analyzing the case. This creates a positive relationship between the preceptor and student, increasing the student’s confidence.
5. Correct mistakes: The preceptor corrects any mistakes and provides an explanation on anything missed. They can also prompt the student to critique their own process.

Both of these teaching approaches provide a great communication framework.³  Training preceptors to routinely use these communication and questioning strategies can enhance the student’s learning, problem-solving skills, and confidence.

Preceptor development and training programs provide resources and instruction to improve field-based teaching. By offering a variety of methods, preceptors have options to choose from for self-directed learning. Preceptor training and development programs are especially beneficial for new practitioners. With the guidance and assistance from these programs, preceptors can become comfortable and confident, adding their own personal touches to these experiences, demonstrating interest and enthusiasm for teaching, and with a caring attitude. Regardless of the profession, it is important to continuously improve our skills as healthcare practitioners and teachers to prepare the future members of our profession for the benefit of patients. 

References:

1. Knott GJ, Mylrea MF, and Glass BD. A Scoping Review of Pharmacy Preceptor Training Programs. Am J Pharm Educ 2020; 84(10): Article 8039.
2. Vos SS, Trewet CB. A comprehensive approach to preceptor development. Am J Pharm Educ. 2012 Apr 10;76(3): Article 47.
3. Sakaguchi, Ronald L. Facilitating Preceptor and Student Communication in a Dental School Teaching Clinic. Journal of Dental Education 2010; 74(1): 36-42.
4. Bolt J, Baranski B, Bell A, Semchuk WM. Assessment of Preceptor Development Strategies across Canadian Pharmacy Residency Programs. Can J Hosp Pharm 2016;69(2):144-8.

Finding Direction With Layered Learning

by Anna Rhett, PharmD, PGY1 Community Pharmacy Resident, the University of Mississippi School of Pharmacy

If you cannot see where you are going,
ask someone who has been there before.
-J Loren Norris, an international speaker on leadership

As a learner, sometimes you might feel like a tourist in a foreign city, trying to understand the map. You want to reach the city’s biggest attractions, but you’re stuck going in circles. A great way to solve this problem is to find a tour guide — someone who can help you reach your destination. Not only will you find what you’ve been looking for more quickly, but you often will gain insight along the journey you would have never otherwise obtained.

While formal education is often more complex than looking for exciting landmarks, well-designed instruction can model these behaviors in more ways than you would expect. Like pursuing a popular destination, students today pursue degrees. Rather than booking a tour with a helpful guide, students seek out guidance from teachers. Like stepping off of a tour bus and waving goodbye to the tour guide who has led you through a new city, students must “wave goodbye” to their teachers when completing the curriculum of study.

But what about the pseudo-teachers who are not paid to teach but still teach? These “stand-in” teachers are often learners themselves who have progressed further in their curriculum and thus have acquired slightly more knowledge. Whether it’s a more senior student, resident, fellow, or graduate student, these more advanced learners help less advanced students gain an understanding of expectations of the learning environment. In academic circles, when there are learners at different levels learning together, this model of instruction is known as “layered learning.”

Healthcare education, specifically, is no stranger to the layered learning practice model (LLPM). For many years, aspiring physicians have presented patient cases to attending physicians and reported to chief residents for daily assignments. The LLPM also reframes traditional clinical services by creating a team of learning to deliver care. The LLPM team includes a healthcare provider, or preceptor, at the “top of the totem pole” and individuals of varying levels of clinical skill, ranging from first-professional-year students to third-postgraduate-year fellows.

In pharmacy, the LLPM has been used successfully to expand services and meet the needs of learners.¹  At the University of Oklahoma Health Sciences Center, introductory pharmacy practice experience (IPPE) students were integrated into advanced pharmacy practice experience (APPE) adult medicine rotations. During these experiences, IPPE students reported significant improvement in their ability to describe the role of a clinical pharmacist, identify information in a patient’s medical record, find answers to drug information questions, critically evaluate primary literature surrounding medications, and successfully educate patients about their medication regimens.²

Not only has the LLPM had a positive impact from a clinical perspective, but learners report having a positive experience.¹ While reflecting on their time spent with more experienced learners, IPPE students reported experiencing a foreshadowing of what was to come in their APPE year.² Another benefit of the LLPM is increased student comfort. Preceptors can sometimes (unintentionally) intimidate students.  In an LLPM, students may feel more comfortable asking questions and learning with someone who isn’t far removed from their present circumstances.

The LLPM also serves as a beneficial experience for the more advanced team members. “Teaching is the highest form of understanding,” Aristotle once said. The LLPM allows the more advanced individuals to step into a teaching role. By serving as an educator, they can become more confident talking about and demonstrating their clinical knowledge. Explaining various principles and practices can aid in mastering their craft.

On the surface the LLPM may appear to be a simple way to teach, some challenges come with implementing this model. It may be difficult for preceptors to differentiate between the abilities and needs of individual learners. While some students may need more supervision and explanation, a more advanced student may be able to quickly jump into projects and patient care assignments. Adding in residents, fellows, and other post-graduate trainees can be challenging to balance, as those individuals function at a higher level. It may be difficult to create an effective learning environment that challenges residents and fellows while not overwhelming a first-year student.¹ 

Another hurdle of incorporating more advanced individuals is that while they can offer a level of expertise beyond that of a student, preceptors must not lose sight of the fact that residents and fellows are still learners themselves. While it’s great to integrate residents and fellows into academic experiences whenever possible, these individuals will have varying competency levels, especially when it comes to areas of practice where they may not have much prior experience. Another concern is the receptiveness of the more advanced learners when it comes to serving as a teacher. While some will be eager to step into the role, others may not have an interest in teaching. Students may be put at a disadvantage if an uninterested resident or fellow is left on their own to manage a group of learners, essentially serving as their primary preceptor.¹

Some teachers may be hesitant to implement a layered learning model in their practice setting; however, layered learning can be a success with thoughtful planning and strategic thinking. Some strategies for effectively teaching a group who varying levels of knowledge, skills, and abilities include using differentiation, making use of intentional grouping, and promoting an environment that celebrates collaboration.

In the academic setting, “differentiation” refers to a personalized approach to instruction that recognizes the specific learning needs of individuals rather than using a one-size-fits-all method. For example, when it comes to layered learning, a teacher might use an educational video to build on first-year students’ knowledge of foundational principles and then ask thought-provoking questions that require a higher level of expertise to the residents. Another helpful tool is intentional grouping. Intentional grouping is when teachers organize students based upon similar interests or backgrounds. For example, a preceptor might form smaller groups within the layered learning team. These smaller groups may consist of a first-year student, a fourth-year student, and a resident, all of whom have an interest in cardiology. This intentional grouping with shared interests can keep all parties engaged and provide the less experienced learners with mentorship. Lastly, collaboration is key to making the most of layered learning. It is crucial to keep everyone communicating and working alongside each other toward common goals. Teachers should promote conversation by having students self-reflect on strengths and weaknesses within the group. Hearing peers articulate their ideas and experiences builds community and increases empathy, while also helping less-advanced individuals develop the shared language needed to work on healthcare teams.³ 

Henry Ford said it best: “If everyone is moving forward together, then success takes care of itself.” Whether it be through serving as a mentor for those who are standing where you’ve stood or receiving advice from those who have reached the destinations you are seeking, the layered learning practice model has all of the necessary ingredients to create opportunities for learners of all levels. Any milestone can be reached more easily when working together, whether it be finding that historic landmark in a foreign city or mastering a key concept needed to deliver optimal patient care. Through the LLPM, students, residents, post-graduate trainees, and students alike can venture out into their careers without their eyes glued to maps, but rather looking outward at what lies new on the horizon.

References

1. Loy BM, Yang S, Moss JM, Kemp DW, & Brown JN. Application of the Layered Learning Practice Model in an Academic Medical Center. Hospital Pharmacy. 2017; 52(4):266–272.
2. Smith WJ, Bird ML, Vesta KS, Harrison DL, & Dennis VC. Integration of an Introductory Pharmacy Practice Experience With an Advanced Pharmacy Practice Experience in Adult Internal Medicine. American Journal of Pharmaceutical Education. 2012; 76(3):Article 52.
3. Soika B. USC Rossier School of Education: How to Address a Wide Range of Skills and Abilities in Your Classroom [Internet]. Los Angeles: Brian Soika. 2020 Jul- [cited 2021 Nov 30].

The Vicious Cycle of Sleep Deprivation, Decreased Academic Performance, and Poor Mental and Physical Health

by Kendall Kara, PharmD, PGY1 Pharmacy Practice Resident, G.V. Sonny Montgomery VA Medical Center

Inadequate amounts of sleep can have detrimental effects on test scores, GPA, mental health, and physical health.1,2,3 Adequate sleep is essential to physical and mental wellbeing. A lack of sleep leading to poor outcomes in all aspects of students’ lives can lead to a “vicious” cycle.2 According to the CDC, 1 in 3 adults do not get enough sleep per night. The suggested number of hours of sleep per night varies based on age. For adults 18-60 years old, at least 7 hours of sleep is recommended.¹ If you ask any college or graduate student if they consistently get 7 hours of sleep every night the answer is probably “no”.

A lack of sleep and a lack of daytime alertness has negative impacts on cognitive function and learning by disrupting the prefrontal cortex that helps control language, creativity, consolidation of memory, and reasoning skills. Studies have shown that slow-wave sleep can help consolidate fact-based learning whereas REM sleep can help consolidate procedural memory.⁶ Lack of sleep not only affects test performance and GPA but also causes daytime sleepiness, impaired concentration in class, and decreased memory capacity.3 The amount of time we have each day is finite.  So the longer students stay up to study, the less time they have for sleep. Thus “pulling all-nighters” and late-night study sessions can be detrimental to their success in school.

A lack of sleep has been shown to have a negative impact on academic performance in multiple clinical trials. Having recently graduated from pharmacy school, I found the study entitled “Sleep Duration and Academic Performance Among Student Pharmacists'' was very relatable.³ Professional school is very demanding, but it is a time when students get the least amount of sleep. In this study, students were asked to complete a questionnaire about their sleep patterns during a typical school week and the night before an examination, as well as the frequency of daytime sleepiness. More than half of the 364 students surveyed reported they do not get the recommended 7 hours of sleep per night (54.7%), went to bed later (52.2%) the night before, and woke up earlier (67.5%) the morning of an exam, and reported feeling tired almost every morning when waking up (54.4%). Students who reported shorter sleep durations the night prior to an exam had significantly lower test scores and lower semester GPAs.³  An increase in sleep by one hour was associated with an 11% increase in the course grade. This cycle of studying, lack of sleep, decreased concentration in class, daytime sleepiness, and poor test performance is a vicious cycle many students experience.

Another study titled “Test Anxiety and Poor Sleep: A Vicious Cycle” was designed to examine if test anxiety affects sleep quality and duration among undergraduate students taking a statistics class.² It is already well established that test anxiety has a negative impact on test performance but adding the element of poor sleep to this equation has not been well tested. The researchers used multiple tests to measure students' baseline sleep quality and quantity, depression, anxiety, and insomnia. The students were also sent a Sleep Mood Study Diary that they were asked to fill out every day for 6 days leading up to the exam. The questions from this diary assessed sleep onset latency, total sleep time, and sleep efficiency. Students were assessed for test anxiety the mornings before and after the exam. Study results revealed that students who had even minor amounts of anxiety had worse test scores. Anxiety was also associated with poor sleep quality. Poor sleep quality resulted in increased anxiety and caused further sleep disruption, again leading to a vicious cycle that ultimately had negative academic consequences. The combination of text anxiety and poor sleep resulted in lower test scores (up to 4.96 points) in many students.²  In this study it is unclear what starts the beginning of the cycle. Do anxious people sleep less, which causes anxiety and decreased test performance? Or, does sleep deprivation cause poor test performance that ultimately causes anxiety?

Inadequate sleep not only affects academic performance but also impacts mental and physical health.^3,4 Lack of sleep is associated with mental health issues such as irritability, hyperactivity, poor impulse control, impaired memory, depression, anxiety, mood swings, and increased perceived stress. Physically, lack of sleep is associated with an increased risk of infection, slowed metabolism, heart disease, high blood pressure, obesity, diabetes, and all-cause mortality.⁴

So how can we break these vicious cycles? It is important that teachers and faculty are aware of that many of their students are sleep deprived. Teachers and administrators have the opportunity to positively impact the overall well-being of students starting from the very beginning of their program.3 Educating students about healthy sleep habits, self-care, doing regular wellness checks, and scheduling tests at appropriate hours are ways teachers can positively impact the overall well-being of students.^3,5

There are many recommendations to ensure students (and their teachers!) are getting high-quality sleep, but here are 6 important “counseling points” to help students develop healthy sleep habits:⁵

1. Limit caffeine intake and other stimulants. I know this is hard for many students because they can become dependent on caffeine to get through the day and stay awake at night to study. Cutting back on caffeine intake, and not consuming caffeine 8 hours before bedtime can help students fall asleep easier.⁵
2. Reduce screen time. Putting away the phone, computer, and TV an hour or so before bedtime can help with falling asleep faster. Lights from devices can disrupt the secretion of melatonin which can make it harder to fall asleep.⁵
3. Plan ahead and create a study schedule in advance. Setting specific and regular times to study before tests rather than cramming the night before can help improve overall sleep quality and test performance.
4. Diet and exercise. It’s very easy to tell people about the importance of diet and exercise but it’s difficult to actually practice what you preach. Maintaining a healthy lifestyle can help with overall well-being including improved sleep.⁵
5. Prioritize your sleep just as much as you prioritize school and studying. Setting a bedtime that allows you to get 7 hours of sleep every night. Tracking your sleep can help increase accountability to yourself.⁵
6. Finally, know when to seek help. If sleep deprivation is negatively impacting academic performance or mental/physical health, it is important that students feel comfortable talking to teachers about their struggles. Teachers, faculty, and staff should be judgment-free resources for finding students the help they need to succeed.⁵

References

1. 1 in 3 adults don't get enough sleep [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2016 [cited 2021Oct27].
2. Hamilton N, Freche R, Zhang Y, Zeller G, Carroll I. Test anxiety and poor sleep: A vicious cycle. Int J Behav Med 2021;28(2):250–8.
3. Zeek ML, Savoie MJ, Song M, Kennemur LM, Qian J, Jungnickel PW, et al. Sleep duration and academic performance among student pharmacists. Am J Pharm Educ. 2015;79(5): Article 63.
4. Sleep health [Internet]. Sleep Health | Healthy People 2020. [cited 2021Oct27]. Available from: https://www.healthypeople.gov/2020/topics-objectives/topic/sleep-health?topicid=38
5. Sleeping to succeed [Internet]. Learning Center. 2020 [cited 2021Oct27].
6. Sleep clinic Seattle: Sleep doctor Kirkland, Washington (n.d.). Retrieved January 25, 2022, from https://www.soundsleephealth.com/

Using Team-Based Learning in Health Professions Education

by Carlos Logan Magana, PharmD, PGY1 Pharmacy Practice Resident, North Mississippi Medical Center

Team-based learning (TBL) has been around since the 1980s.  This strategy has been used in academic settings to supplement education through peer collaboration whereby students work in smaller groups when in large classroom settings.  This teaching strategy has been used widely in health professions education. TBL helps student develop their communication skills while making the learning environment stimulating.  I believe TBL should be used in combination with other teaching methods to help augment student learning.  This can benefit students both academically and professionally.

TBL has four key components.  The instructor must carefully form and manage groups, give frequent feedback, create problem-solving activities, and engage students in a peer evaluation process.  TBL sessions are conducted during class time and but the precise sequence of activities can vary depending on the course topic. When entering the classroom, students take an individual knowledge assessment where they are quizzed on pre-readings.  This is followed by a team-based assessment where teams work together to establish a consensus on answers. The group test is followed by facilitator feedback where the questions are discussed, and the answers explained.  Following these assessments, the instructor provides problems or activities that students worked on for the majority of the in-class time.  Groups work together using their pooled knowledge. There is a final debriefing about these activities.  Finally, the instructor has some closing messages and summarizes the key concepts addressed in the activity.

A method that is similar to TBL, but has some important differences, is called problem-based learning (PBL).  PBL also involves small student groups but the sessions are led by a facilitator who guides the students through a case from beginning to end. The team aspect is similar to TBL but PBL is more resource-intensive because it requires a greater number of facilitators and the pace of the activity is driven by the facilitator.  This differs with TBL does not (typically) require multiple facilitators and gives the learners more control over the learning environment and pace. Thus TBL is a hybrid teaching and learning method that blends aspects of small group activities with large group presentations.

TBL has gained traction in health professions education perhaps because it enables students to develop their team interaction skills.  It is also a great way for learners to spend time with facilitators who are experts in their field which allows for current information to be taught. TBL is more structured than PBL. In TBL, students must be prepared for the class content. This method also allows learners to learn from their peers – to get different points of view.  This constant influx of new thoughts and viewpoints is helpful for the learner to grow outside of their own personal bubble and implement new ideas into their own knowledge.  Finally, facilitators learn from each other based on their experiences and from learners that they have worked with throughout the year.

A few studies have explored the impact of TBL on learning outcomes. One study evaluated the TBL method in the second year of the curriculum at the Boonshoft School of Medicine.  The study was conducted over two consecutive academic years (2003-2004) and (2004-2005).  This study looked at the exam scores of 2nd-year medical students which included courses consisting of topics that emphasized foundational knowledge such as physiology, pathology, and pharmacology.  Teaching methods of these courses included lectures, lab exercises, clinical case discussions, independent study modules, and TBL modules.  All courses determined the overall course grade using multiple-choice question examinations.  There were a total of 28 examinations, and the investigators divided scores into two subgroups as follows: designated TBL-related pathology-based questions (TR PBQs) and designated TBL-unrelated questions (TU PBQs).  Once data was collected data showed that student scores in the TR area had overall improved mean scores on examination questions compared to the TU scores.  Indeed, not only did the highest quartile students in the TR group perform better (89.3% and 85.5%), so did the lowest quartile students (77.5% and 69.6%).  This kind of analysis is important because it documents that the lower quartile of the class also had a significant improvement in their scores (not just the high-performing students).  Thus, TBL can benefit students who may be struggling in their classes. The study concluded that TBL helps enhance mastery of content.

Another study published in 2017 surveyed first-year medical students in the Sydney Medical Program.  In total 144 out of 169 students completed a questionnaire regarding both TBL and PBL methods in their courses.  Overall students preferred TBL, with 85% agreeing it helped to enhance peer learning experiences compared to 37% in the PBL group.  It is also noted that 93% agreed that their team members made adequate efforts in team discussions compared to 46% with PBL.  While these are just some examples of student satisfaction of TBL there are others regarding their fondness of the facilitators and team feedback in TBL over PBL as well as other perceived benefits such as knowledge gained and examination preparedness. 

Most literature supports the use of the TBL method in health professions education. While there are many teaching methods that could be used in any curriculum, some will be more effective than others depending on course content and the audience. TBL is helpful but it is not all-encompassing. Learning is complex and teaching should involve a variety of methods. It is also crucial to use subjective data such as learner feedback and satisfaction along with performance data such as examination scores.  TBL is a truly welcomed addition to the teaching methods available to faculty and should be considered when teaching clinical decision-making and problem-solving skills.

References

1. Burgess A, van Diggele C, Roberts C, and Mellis C. Team-Based Learning: Design, Facilitation and Participation. BMC Medical Educ 2020; 20: Article 461.
2. Koles P, Stolfi A, Borges N, Nelson S, and Parmelee D. The Impact of Team-Based Learning on Medical Studentsʼ Academic Performance. Academic Medicine 2010; 85(11): 1739-1745.
3. Burgess A, Bleasel J, Haq I, Roberts C, Garsia R, Robertson T, and Mellis, C. Team-based learning (TBL) in the medical curriculum: better than PBL?BMC Medical Educ 2017; 17(1): Article 243.

The Influence of Emotions on Learning

by Jonathan Newbaker, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

In ‘The Righteous Mind’ by Jonathan Haidt, the author introduces the concept of the elephant and the rider.¹ In this analogy, the rider is our logical, reasoning self and the elephant is our reactive, emotional self. His point is that the rider, our reasoning, seems to guide our emotions and decision; however, the reality appears to be the opposite. Haidt argues that our intuition and emotions have a much larger subliminal impact on our decision-making than we are consciously aware. Emotion management, other than perhaps recommendations to seek counseling when needed, is not commonly discussed in the academic setting. Given the impact that emotions can have on logic and reason, it’s a topic worth exploring as recent studies are showing emotions are a driving force in information collection and strongly influences memory. In this essay, I will explore a definition of emotions, the correlation of emotions to learning, and some data on how the two intersect. In addition, the application of these findings will be discussed for health profession educators to consider when teaching.

Emotions can be considered a distinct form of cognition in that they are often the first process to occur in a situation before logical reasoning.² These feelings can be defined in terms of their valence and arousal.³ The valence of emotions, a term borrowed from the fields of physics and chemistry, describes them as positive or negative.³ The term arousal refers to how activating or deactivating the emotions are.³ Activating emotions energize us, whereas deactivating emotions lead to a loss of energy.³ These various combinations of valence and arousal are displayed in the table below. 

	Valence – Positive	Valence – Negative
Arousal – Activating	Excitement, joy	Anxiety, fear
Arousal - Deactivating	Contentment, calmness	Depression, shame

Activated and deactivated states as well as positive and negative emotions can predispose students to particular methods of processing and applying information.³  One study compared emotions (positive or negative) to the students’ information processing method (global processing or local processing).⁴ To induce the emotional state, the researchers had the students watch either a positive or negative emotionally evocative video or an emotionally neutral video (control). After viewing the video, students were asked to compare three geometric figures. The control figure was a triangular-shaped arrangement of three circles. This was to be contrasted to comparison item 1, a triangular assortment of three cubes, and to comparison item 2, a rectangular assortment of circles. When a student uses global processing, they will pick up on the triangular assortment of the differing shapes (i.e., triangular circles to triangular squares), whereas when a student uses local processing they will pick up on the presence of the same shapes in a different arrangement (i.e., triangular circles to rectangular circles).⁴ The results showed that students with positive emotional states were more likely to employ global processing than students who were shown the negative or neutral videos. The latter two groups had a stronger tendency to focus on specific details using local processing. Using two emotionally positive videos, one emotionally neutral video, and two emotionally negative videos, the researchers then tested for group differences in global bias scores using a 5 × 2 × 2 ANOVA (Video Group × Sex × Ethnicity). The video type was the only factor that had a significant effect (p = 0.042).⁴ The two positive emotion videos produced significantly greater global bias scores than the two negative emotion films (p = 0.035).⁴ In contrast, the global bias scores for the two negative clips did not differ from each other.⁴ The results suggest that various emotionally-charged delivery methods may change the way learners perceive and process information.

Unfortunately, the conclusion is not so straight forward and we cannot conclude that “positive emotions lead to improved processing and recall”. For example, some research shows that negative events are more likely to be spontaneously remembered than positive events.⁵ Researchers of one study analyzed involuntary memories in groups of traumatized subjects and contrasted these with involuntary memories among subjects who had an overwhelmingly happy experience. They found that the vividness of trauma-related memories was more significant than non-trauma memories (p < 0.005).⁵ Of note, the mean number of trauma flashbacks was lower than the mean number of non-traumatic flashbacks (p < 0.01), with happy memories being the most abundant.⁵ This data indicates that, although trauma is not a prerequisite for memory recall, it does play an important role in the amount of detail that one is able to recall. To tie this into learning, some negative experiences may have beneficial long-term effects and prompt behavior changes.  Therefore, mistakes which provoke negative emotions can be beneficial but students need to be taught how to view these events as opportunities for improvement rather than solely negative events.

The difficulty in providing standardized emotional experiences for students is that they are unique individuals and their emotional response to situations are different. It is possible that one student may feel positive emotions during an encounter with a professor and another student is offput by the same encounter. Therefore, feedback from both the educator and the learner should be incorporated at multiple points throughout a given semester to assess the students’ perspective and emotional state. In addition, this would afford the educator an opportunity to encourage the student to identify and manage any deactivating emotions.

It is clear that emotions play a significant role in how students perceive and remember information.  Thus, instruction techniques and methods for questioning students should consider the emotions they might evoke and the desired educational outcome. For example, playing a video that evokes excitement or joy might be great when global processing is preferred. However, when attention to detail is ideal, the educator could consider creating an environment that fosters a negative emotional state such as providing a grave clinical situation (or simulation) that drives the students towards local processing. Moreover, the educator should emphasize the importance of learning from mistakes which evoke negative, activating emotions. Negative events such getting a “bad grade” or making an ill-conceived recommendation during patient care rounds can leave a last impression on a student but, if managed by the teacher well, they can be “teachable moments” that motivate learning and behavior change. However, if handled poorly, these negative events can be demotivating, causing students to withdraw and avoid.

Lastly, it is important to gather feedback (either formally or informally) at regular intervals to assess the learners’ emotional states. Watch for non-verbal clues!  This should be considered along with formal assessments of student performance. Individuals will process the same experience in different ways, so it is critically important for health professions educators to pay attention to emotional clues and “check in” with students.

 

Resources:

1. Haidt J. The Righteous Mind. New York City, NY: Vintage; 2012.
2. Zajonc, R. B. Emotions. The handbook of social psychology. McGraw-Hill. 1998. P. 591–632.
3. McConnell MM, Eva KW. The Role of Emotion in the Learning and Transfer of Clinical Skills and Knowledge. Academic Medicine 2012; 87 (10): 1316–1322.
4. Fredrickson BL, Branigan C. Positive emotions broaden the scope of attention and thought-action repertoires. Cogn Emot 2005;19(3):313-332.
5. Berntsen D. Involuntary Memories of Emotional Events: Do Memories of Traumas and Extremely Happy Events Differ? Appl Cognit Psychol 2001;15(7): P. S135–S158.

Test Anxiety and Academic Performance

by Arlesha N. Armstrong, Pharm.D., PGY-1 Pharmacy Practice Resident, Magnolia Regional Health Center

American educator Booker T. Washington once said that “Success is to be measured not so much by the position that one has reached in life as by the obstacles which he has overcome”. One obstacle that many students at all levels of formal schooling find difficult to overcome is test anxiety. It is often silent and yet incredibly loud. The first and most important step is recognizing test anxiety and the effects it can have on a student and their future. Test anxiety encompasses more than just being “worried about the test” or “hoping to get a good grade”. For some students, the level of anxiety negatively impacts performance and can become unbearable. Test anxiety encompasses two broad domains: emotionality (physiological components such as perspiration and headaches) and worry (psychological components such as heightened sense of threat, increased distraction, and motivational disturbances)¹. Test anxiety is something that should be taken seriously and acted on. 

So how can educators notice the signs? The emotional symptoms in students might not be readily apparent, but the physical symptoms might be seen with close observation. Watching students and how they behave during “normal” classroom days compared to exam days may reveal subtle indications of their level of anxiety. Is the student quieter or more talkative than normal? Are they excessively sweating or noticeably breathing? Is the student shaking their leg, twitching, scratching and tapping, or pulling on clothes or hair? Although these can be normal behaviors, noticing differences in students’ behaviors surrounding exams can lead to conversations with them.

Text anxiety is surprisingly common.  Between 15 and 40% of students report experiencing some level of anxiety during examinations and other forms of assessment.³  Some students may have been told that they are overly dramatic or that they worry too much.  That they should learn to relax a little. After a while, the student may begin to think that this is just the way that they are and will have to just “live with it.” Although anxiety disorders are highly treatable, according to the Anxiety and Depression Association, only about one-third of people suffering from anxiety receive treatment. It is not a part of life. it is not a rite of passage.  It can be treated but far too often it’s not.

Physical Symptoms:	Emotional Symptoms:
·       Excessive sweating ·       Nausea, vomiting, or diarrhea ·       Stomach pain or “butterflies” ·       Rapid heartbeat ·       Shortness of breath ·       Headaches, Lightheaded or Faint ·       Restless or fidgety	·       Self-doubt ·       Fear ·       Stress ·       Hopelessness ·       Inadequacy ·       Anger ·       Nervousness

Test anxiety can have unfortunate detrimental effects on a student that leads to negative impacts on their performance. Anxiety can cause the student to procrastinate, reduce their ability to focus long enough to study, and lead to feelings of paralysis because they feel so overwhelmed. In some cases, the student might even become physically sick and cannot make it through the exam. These symptoms don’t just impact young children but can impact older students as well. Indeed, as a student advances in their education, the stressors can really add up.  Or it can be due to unresolved testing anxiety carried from childhood.

According to a study evaluating health professional students, there was a significantly positive correlation between test anxiety and procrastination on school-related work.² Not surprisingly, students with test anxiety tend to have lower scores on standardized tests and lower GPAs.³ Unfortunately, many decisions such as college admission, scholarships, and career opportunities are influenced by test scores.³ Thus, those with test anxiety are the ones who suffer the most because there is no way to adjust for test anxiety. Until we move past standardized testing, we need to help students address and overcome test anxiety so they can achieve their full potential.  It’s true that academic performance is influenced by many factors, but teachers should always strive to identify and address the obstacles that hinder their performance. Address text anxiety may not only lead to improvement in the students’ test performance but it may also to improvements in the student’s sense of wellbeing and life satisfaction.

So how can you help students who are struggling with test anxiety? Here are some things that students and educators can do:

Advice for Students:	Advice for Educators:
·  Preparation ·  Develop a routine ·  Adequate sleep and rest ·  Decrease caffeine ·  Eat balanced meals ·  Exercise ·  Talk to the instructor ·  Learn relaxation techniques ·  Get a tutor ·  Seek counseling and support ·  Ask for accommodations	·  Teach and provide opportunities to engage in breathing exercises ·  Provide practice exams ·  Offer comprehensive review ·  Set clear expectations ·  Stagger test schedules ·  Refrain from time limits (when possible) ·  Try different exam formats and styles ·  Provide accommodations if necessary ·  Offer encouragement

The first step in helping students with test anxiety is recognizing its validity and legitimacy. Helping them realize their triggers and what induces anxiety can help a student learn how to address anxious thoughts. One way this can be done is by having the counselors come to do a general presentation about anxiety (including test anxiety) — that way every student gets the information but no student is singled out. This opens the door for a student to come forward in private. Every teacher should destigmatize anxiety and encourage students to seek counseling, engage in some form of cognitive therapy, and (when needed) take medication. This is not to say that even when a student receives therapy that anxiety will never be there. But therapy can help students take positive action, rather than letting anxiety have a hold and control over them.

Helen Keller once said “Be of good cheer. Do not think of today’s failures, but of the success that may come tomorrow. You have set yourself a difficult task, but you will succeed if you persevere, and you will find a joy in overcoming obstacles.” Addressing and overcoming anxiety is difficult to do. No one wakes up each day and chooses to have anxiety. However, addressing test anxiety can arm a student with new coping skills that can help in many other life situations.  It can really improve a student’s academic performance and quality of life.

 

References:

1. Pate AN, Neely S, Malcolm DR, et al. Multisite study assessing the effect of cognitive test anxiety on academic and standardized test performance. Am J Pharm Educ. 2021; 85(1): Article 8041.
2. Sarvenaz R, Seyyed MA, and Alireza K. Investigating the relationship of test anxiety and time management with academic procrastination in students of health professions. Education Research International 2021; Article 1378774
3. Myers S, Davis S, and Chan JCK. Does expressive writing or an instructional intervention reduce the impacts of test anxiety in a college classroom? Research 2021; 6:44.
4. Harris H and Coy D. Helping students cope with test anxiety. ERIC Digest 2003.

The Importance of Self-Assessment

by Taylor Hayes, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital – Golden Triangle

Self-assessment is a practice that encourages students to reflect on their learning or performance so that they can identify strengths and weaknesses and make improvements. Teaching a student to effectively engage in self-assessment brings to mind the parable “If you give a man a fish, you can feed him for a day. However if you teach a man to fish, you feed him for a lifetime”.¹Teaching self-assessment helps students to become more autonomous in their learning by being able to self-identify what went right or wrong. From this, students can tailor their learning habits, strategies, and materials so that have a positive effect on their performance.

Self-assessment can come in many forms – from students scoring their own projects using a rubric, reflective assignments, and exam wrappers. Exam wrappers are designed to make students look beyond their score of the exam and take a deeper dive.  An exam wrapper asks students probing questions about the exam and the student’s preparation. Some example questions of the exam wrapper include how much time the student spent preparing for the exam, the part of the exam that the student believes they did not perform the best on, and what the student believes the teachers can do to help in their preparation for the next exam.² Having students ponder on these questions prompts self-reflection and gets them to consider ways they might better prepare for the next exam.

Self-assessment is a key element of metacognition, the mental processes where one develops awareness of the processes one uses when learning new material or problem-solving. Metacognition makes students more conscious of their thinking and how their cognitive strategies help them succeed. Being self-aware of one’s performance helps students take ownership of their learning.^3,4

However, self-assessment is often subjective and students often struggle with identifying the areas where they need to make improvements. These students are unconscious in their shortcomings and may not realize the need for adjustments (or how to make adjustments). A preceptor once asked for me to place myself into a category – unconsciously incompetent, consciously incompetent, consciously competent, or unconsciously competent. These categories are known as the four stages of competency. When you are unconsciously incompetent, you are unaware of a knowledge gap. When you are consciously incompetent, you are aware of a knowledge gap and recognize the importance of filling this gap. For those who are consciously competent, they know the information but they need to put forth conscious effort to recall the information or perform the task. Finally, unconsciously competent refers to knowing the information and being able to easily perform the skill without much conscious effort or thought.⁶ It is hard for students that are unconsciously incompetent to be aware of what they do not know.  Thus, continually practicing self-assessment can help the learner develop the skills needed to identify areas that need improvement. Self-assessment can, at first, be facilitated by teachers giving students feedback on their performance and then asking the students to reflect on how they think they performed (or vice versa). This helps students gain a sense of direction on the things they can improve, while also prompting them to independently think about how they can improve.

Source: The Four Stages of Competence [Internet]. Timothy S. Bates. 2014. Available from: https://tsbates.com/blog/four-stages-competence/

One study looked at the impact of self-assessment on academic performance in students. Eighty-nine students took a test and then self-assessed their performance by grading their exams under the supervision of a teacher. Following this, the teachers also graded the test and provided feedback to the students. A second test was given on the same topic and was graded solely by the teachers. From this, the two scores from both the student-graded test and the teacher-graded test were then calculated. The study found that 74% of students scored higher on the second test. This helped to show that after the students had self-assessed their own performance, they were able to identify the areas of shortcomings in order to improve on them for the next exam.

This same study, however, also showed some of the pitfalls that may occur with self-assessments. An analysis of the first student-graded test was performed to assess the difference in scoring between the student’s score versus the teacher’s score.  The majority of the students (74%) gave themselves significantly higher scores than what the teacher had given them. This highlights that self-assessment is subjective, and that being able to accurately assess one’s performance is difficult for some students. Ways to combat this include giving students a rubric to follow, showing an example of good performance and comparing it to a not-so-good performance, or grading a paper together as a group. In the study, the student’s and teachers’ perceptions about the self-assessment process were gathered using questionnaires. The teachers believed that having the students perform the self-assessment was effective in promoting student self-learning. The students found the process beneficial but time-consuming. While as teachers we can never give back time, we can reiterate the importance of the task as a worthwhile investment of time. Reminding the students that self-assessment will help them in future learning and performances will help the student understand why the self-assessment activity is being done. The authors of the study concluded that self-assessment can serve to increase the motivation for students to both want to perform better and help develop self-directed learning skills.⁶

It might be beneficial for students to develop a list of their “successes” and “failures” in order to reflect on them. When were times they were disappointed in their performance, and how could they avoid these same disappointments from happening in the future? When was a time they were proud of their work, and what were the steps they took in order for this to happen? If other people have provided feedback on the student’s performance, it might be beneficial for them to reflect on this in their self-assessment as well. The student needs to really reflect and narrate on their experience to improve from it, rather than just regurgitate a list. Of course, it’s important to remember when writing a self-assessment that there is always room for improvement. Self-assessment isn’t remediation, only for those who are performing poorly.  Even when a student is performing well, there are still things to learn from that experience that can benefit the student in future exams and experiences.^7,8

References:

1. Loveless B. Helping students thrive by using self-assessment [Internet]. Education Corner.
2. Lovett M. Exam Wrappers [Internet]. Eberly Center - Carnegie Mellon University.
3. Mcdaniel R. Metacognition [Internet]. Vanderbilt University. 1970.
4. Burch N. The Four Stages of Competence [Internet]. Mercer County Community College.
5. Assessment Resource Centre [Internet]. Centre of Enhancement for Teaching and Learning.
6. Hertzberg K. How to Write a Self-Evaluation [Internet]. Grammarly; 2020.
7. How to write a performance evaluation self-assessment [Internet]. Business News Daily.

Cameras on! Requiring Cameras “on” in the Virtual Classroom

by Sydney Kennedy, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

The Covid-19 pandemic forced employees of many industries into remote work, most often from home. Likewise, students were forced to rapidly transition to remote learning.  The rapid transition from in-person to remote instruction posed challenges to both learners and educators. From an educator’s standpoint, requiring the use of cameras during remote instruction most closely approximates the face-to-face interaction that occurs in an in-person classroom.  The assumption is that interacting “face-to-face” will increase student participation, but is this true? There is controversy about whether requiring cameras to be “on” during meetings and classes improves the quality of the meeting or the instruction. The lay press reports how students and workers are feeling drained after attending face-to-face virtual meetings.  Some call this phenomenon “Zoom fatigue.” The impact on students who have been, by necessity, forced to learn in a virtual environment has not been studied. There may be consequences of the virtual environment caused by prolonged video conferencing.  Just because you ‘can’ use video cameras does not necessarily mean that using video leads to better outcomes.

A recent study entitled “The Fatiguing Effects of Camera Use in Virtual Meetings: A Within-Person Field Experiment” reveals the negative impact that a “camera’s on” policy might have. This was a four-week field experiment.  The authors hypothesized that virtual meetings would be more fatiguing for women and those who were newer members of the organization.  The study was performed to gather insights about best practices for virtual meetings. The study involved 103 employees that were largely female (56.3%) who had been with the organization, on average, for about three years. The participants were randomly assigned to the camera study condition, “on” or “off.” The camera “on” or “off” condition was the independent variable, and all participants were given a survey instrument that included questions about how they felt during the meeting. Fatigue was significantly greater in the camera “on” group (p < 0.001). Camera use also negatively effected engagement (p < 0.001). This was assessed by participant ratings on the survey after each meeting to the question, “in meetings today, when I had something to say, I felt like I had a voice.” The association between camera use and fatigue was stronger for women than men (p < 0.001). Additionally, there was a positive relationship between camera use and fatigue among those employees with the shortest tenure with the organization (p < 0.001). Overall, these results suggest that camera use is particularly fatiguing for women and newer employees.

The results of this study align with the theory that virtual meeting participants feel that they need to actively manage impressions when their cameras are on.  When the participants’ are on camera, they experience a “self-presentation” effect that causes fatigue. Thus, encouraging (or requiring) employees or students to turn cameras on may be harmful and actually hinder engagement. 

To date, there are no studies that have evaluated whether different camera angles would be less fatiguing by being able to give the learner the ability to minimize the self-presentation effects. Self-presentation may be fatiguing due to pressure to “look” competent while maintaining societal appearance standards. There are limitations to these findings, however, such as not being able to evaluate the long-term effects of virtual meetings over time and whether the size of the virtual meetings contributes to these effects.

While this study evaluated people in an employment context, I believe the results can be extrapolated to the virtual classroom. Similar to students, employees are being evaluated on performance and engagement in discussions. There may be additional reasons contributing to fatigue in the virtual classroom. The amount of close-up eye contact with the instructor and other students is not a natural distance when compared to in-person classrooms. Furthermore, students may be spending a lot of time acknowledging self (e.g., looking at themselves) rather than the educator — a phenomenon that does not occur during in-person classes. Additionally, the frame of the camera is small and limits normal mobility.  This can be physically straining. Lastly, the cognitive load is higher in a video environment because it’s more challenging to pick up on nonverbal cues and therefore work much harder to send and receive signals. 

There have been several proposed solutions to these problems. It may be beneficial to reduce the size of the window on the monitor to reduce the student’s face size. For those who use laptop computers, external keyboards can increase the distance between the learner and the video monitor. It has also could be suggested to build in camera “off” time spaced throughout the day to give the students nonverbal rest. 

Admittedly, this topic is controversial.  But the results of this study provide some evidence that requiring “cameras on” during video conferencing may not always be beneficial and may contribute to a negative learning environment. Clearly, we need to learn more about the effects of cameras on student learning and performance! However, educators should be cognizant of some of the negative consequences of “cameras on” in their virtual classrooms.

References

1. Shockley KM, Gabriel AS, Robertson D, et al. The fatiguing effects of camera use in virtual meetings: A within-person field experiment. J Appl Psychol. 2021 Aug;106(8):1137-1155.
2. Ramachandran V. Stanford researchers identify four causes for ‘Zoom fatigue’ and their simple fixes.. Stanford News 2021. Accessed November 2021.

Creating Psychological Safety in Learning Environments

by Emily Keveryn, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital - North Mississippi

Student engagement is often something teachers and educators strive to achieve for lots of reasons — to have students actively thinking about the material and responding to questions, to validate that what is being taught is being understood, and to promote positive attitudes toward the material. But why is there a lack of engagement so common in many learning environments? As a teacher, it may be easy to forget how stressful or daunting the feeling of speaking up in front of a group of peers or instructors is.  For students, this is one of the most common barriers to active engagement in group learning settings. Having an environment where students feel comfortable enough to interact without concerns of sounding silly or being embarrassed is challenging to achieve, especially in very large groups and, conversely, in very small groups too. 

Amy Edmondson, an American scholar of leadership, teaming, and organizational learning, coined the term "psychological safety” to describe “the feeling that one is comfortable expressing and being themselves, and sharing concerns and mistakes without fear of embarrassment, ridicule, shame, or retribution.”^1,2 While Edmondson’s research focuses on psychological safety in teams in business and healthcare settings, many of the ideas and behaviors she observed are relevant to the classroom and other learning environments. It is human nature to want to be accepted, heard, and understood.  And, perhaps more importantly, to avoid rejection, embarrassment, or punishment.  Therefore, fostering a psychologically safe learning environment is critically important and it creates a climate where the material and learning process is engaging, exciting, and lively!

Whether it is in a large classroom, during medical rounds, interacting with an intern on a job site, or in any situation where an educator is teaching something, psychological safety must be present for many reasons.  It encourages learning by making the learner comfortable asking questions when they may not understand the material. It stimulates innovation by encouraging higher-level thinking and understanding.  And it provides a sense of belonging whereby learners feel they can express their thoughts on a subject without being ridiculed or feeling rejected. In one study that addressed psychological safety in a simulation with medical residents in a trauma scenario, researchers found that increased stress impaired knowledge recall and decreased clinical performance.  The medical resident’s performance was measured using a standardized assessment form and a global rating checklist.³ In another study, researchers found that feeling psychologically safe reduced anxiety in nursing students who were participated in simulation activities.  Anxiety was measured by pre- and post-surveys completed by the students.⁴ While these studies looked at psychological safety during simulation activities, the results strongly suggest that the environment, psychologically speaking, has a significant impact on learners' ability to perform activities, recall information, and feel confident.

Timothy Clark writes that there are four stages of psychological safety that individuals go through that reflect basic human needs: inclusion safety, learner safety, contributor safety, and challenger safety.⁵ Inclusion safety is the feeling of belonging and being accepted. One way to provide this type of safety is to learn and use students' names, welcome them to the classroom, and include the learner, and listen to their input. This can be challenging when educating multiple learners, balancing the time between each. Learner safety, which may arguably be the most important stage for educators, occurs when individuals feel comfortable asking questions, receiving feedback, asking for help, and even making mistakes. By actively listening and offering gentle, clear guidance, educators can increase learner safety. This stage is especially important when trying to encourage the learner to speak up and not fear retribution. Contributor safety satisfies the need to feel like we are contributing in a meaningful way and making a difference. When a learner feels included and safe to make mistakes, they feel more inclined to contribute and use the knowledge that they possess to make a difference. This builds off of learner safety, which bolsters confidence in asking questions, and encourages the learner to contribute ideas without fear. Lastly, challenger safety encourages individuals to use what they have learned and strive to make things better in the learning environment and beyond. Challenger safety occurs when students feel they can directly challenge the status quo, recommend an idea or a process, without feeling like the suggestion or comment may damage their reputation.

The Do’s and Don’ts of Psychological Safety:

DO	DON’T
Stay attentive to what is happening and if things seem to be feeling unsafe for some students, listen carefully to understand what may be causing others to feel this way, and ask questions to clarify how they feel.	Don't let uneasiness stop you from discussing what needs to be discussed - if you are feeling uncomfortable, it is likely they are too!
Offer encouragement and support to ensure that each learner knows they are heard and will not be subject to ridicule or embarrassment.	Don’t use sarcasm or emotive language, it can cause others to feel as though we may not be taking them seriously.
Reinforce a conversational culture by making it safe for anyone to talk about anything.	Don’t be defensive or apathetic; it will likely result in the situation continuing and the learner being afraid to speak up again

Psychological safety in learning environments is often something that educators struggle to achieve but is one of the best ways to increase student engagement, interaction, and learning. By role modeling an open and comfortable environment, we are also are fostering the skills within our learners as they learn how to interact with patients and colleagues … and students in the future! Educators need to understand the stages and the ways to create a psychologically safe learning environment to ensure learners get the greatest benefit from the learning process. 

References:

1. Edmondson A. Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly 1999; 44: 350–383.
2. Edmondson A. The Fearless Organization: Creating Psychological Safety in the workplace for learning, Innovation and Growth. Hoboken, NJ: Wiley; 2018.
3. Harve A, Bandiera G, Nathens AB, and LeBlanc VR. Impact of stress on resident performance in simulated trauma scenarios. Journal of Trauma and Acute Care Surgery 2012; 72: 497–503.
4. Ignacio J, Dolmans D, Scherpbier A, et. al. Comparison of standardized patients with high-fidelity simulators for managing stress and improving performance in clinical deterioration: A mixed methods study. Nurse Education Today 2015; 35: 1161–1168.
5. Clark TR. The 4 stages of psychological safety: Defining the path to inclusion and Innovation. Oakland, CA: Berrett-Koehler Publishers, Inc.; 2020.