Teaching Emotional Competence through Simulation

by Matt Newman, PharmD, PGY1 Pharmacy Practice Resident, The Johns Hopkins Hospital

Recent graduates of Doctor of Pharmacy programs are likely familiar with the role of simulation in education. Activities like patient counseling laboratories and clinical skills practicums are common, even if the formats may vary. While these instructional methods are useful and are aimed at providing a true-to-life experience, one aspect of pharmacy practice in the “real world” is not easily taught: social and emotional compassion and competence.

As a pharmacy student, I participated in a somewhat dreaded patient counseling lab during “angry week.”  In this session, rather than being presented with a calm and cooperative patient needing advice about smoking cessation or seeking help with the high cost of co-payments, the patient was irate about a perceived medication error that had occurred with her prescription. Sitting in the counseling room, I remember a distinct feeling of uneasiness as I pondered the best way to manage the patient’s emotional state and formulate an appropriate response to her concerns.  I have found that the best way to improve this skill set is through experience.

You may have had a similar lab in pharmacy school.   And you probably already have some idea of what social emotional competence means and how you might demonstrate it in practice.  Exact definitions vary, but emotional intelligence is considered “the overlap between emotion and intelligence,” or, “the intelligent use of emotions.”¹ It is a set of skills used to read, understand, and react effectively to emotional signals sent by others and oneself.²  While this sounds obvious, assessing one’s ability to utilize this skill set can be difficult. There is, however, an increasing body of literature regarding social emotional intelligence, which demonstrates an expanding awareness of its importance.

While the need for emotional intelligence in healthcare has been thoroughly described, there has been little research about how to best teach and measurement it, especially among pharmacy students.¹ A group of instructors at one pharmacy school sought to measure the development of social emotional competence in students before and after a series of simulated patient counseling activities. To do so, a group of first-year students were asked to complete the Social Emotional Development Index (SED-I) before and after participation in mock patient consultations. Students were also graded on a scale of 0-3 for social emotional competence.

The SED-I is a self-assessment tool in which participants respond to questions such as “I take the lead role,” “People know that I care about them,” and “I act without considering another person’s perspective” with the goal of assessing the respondents SED in four domains: connection, influence, consideration, and awareness. In this study, students took the SED-I at baseline and after performing two mock counseling sessions on topics such as smoking cessation, nonprescription medications, blood pressure, and blood glucose monitoring. Statistical analysis demonstrated a significant positive correlation between students’ patient counseling assessment scores (as judged by the instructors) and their self-assessment using the SED-I.¹ In other words, students who performed better in the lab also scored higher on the SED-I.

These results indicate the potential utility of the SED-I as a tool to evaluate the development of social emotional intelligence. While not surprising, it is useful to note that the students who performed better on the lab activities were the ones who had more developed social emotional intelligence.  This reinforces the current understanding that this type of intelligence is important during patient interactions. The authors noted that pharmacy curricula are effective at teaching core knowledge and technical skills, but social skills may be more important in order to influence patient behavior.¹  A possible limitation of the study is the use of second-year pharmacy students as the “patients” in the counseling sessions; the use of professional actors would have made the counseling sessions more realistic.

Another group of pharmacy faculty studied students’ perceptions of emotional intelligence material used in a communications course.³ Objectives for this course included “Define an emotional concept,” “Relate how self-confidence would be beneficial to the Director of Pharmacy in a large hospital,” and “Describe the characteristics of people who are competent in communication skills and relate how these characteristics would benefit the pharmacist who manages a staff of 20.”  In addition to traditional didactic content, a patient counseling activity similar to the previous study was used to teach the core principles. Instructors reviewed a video recording of the counseling activity with the students, and noted the empathic responses used. They also role-modeled for the students. Additionally, students were asked to answer two reflective questions and course content was assessed on a formal examination. Student responses were mostly positive: they recognized the importance of these skills and the need to apply them to practice. It is interesting to note that the authors mention the lack of standardized tools available to assess the students. Perhaps the SED-I could have been used to assess student performance in this type of educational activity.

I wonder how my patient counseling lab experience may have been different if the SED-I, or another measure of social emotional intelligence, had been used. While most may not think about social emotional intelligence in day-to-day interactions, awareness of the concept is important. The same skills needed for effective patient counseling would also be useful in ensuring productive interactions with many others, including peers, family, and members of the medical team.

Using simulation to teach social skills is useful but it is not without caveats. Using students or actors as “patients” during patient counseling labs is a great way for students to gain experience and confidence in their interactions. However, it is difficult to emulate real emotions and personalities as they will be experienced in the clinical setting.  Finding the best method of evaluating student’s social and emotional development is a work in progress. Regardless, including instruction regarding social emotional intelligence into pharmacy curriculums is important and simulated patient interactions serve as a reasonable substitute for real-life experience.

References

1.  Galal S, Carr-Lopez S, Seal CR, et al. Development and assessment of social and emotional competence through simulated patient consultations. Am J Pharm Educ. 2012;76: Article 132.
2.  Romanelli F, Cain J, Smith KM. Emotional intelligence as a predictor of academic and/or professional success. Am J Pharm Educ. 2006;70: Article 69.
3.  Lust E, Moore FC. Emotional intelligence instruction in a pharmacy communications course. Am J Pharm Educ. 2006;70: Article 06.

Internships – Employers As Educators

by Holly L. Tumlin, Pharm.D., PGY1 Pharmacy Practice Resident, The Johns Hopkins Hospital

Over the past several decades, internships have become increasingly popular for college students and young professionals.  As students complete their final stages of training and prepare to enter an extremely competitive work force, internships have been marketed as a way for students to distinguish themselves from their peers.  Internships.com recently reported that in 2012 an estimated two-thirds of all college graduates completed some form of internship and 69% of companies offered full time positions to their interns.¹ The National Association for College and Employers (NACE) defines an internship as:

“…a form of experiential learning that integrates knowledge and theory learned in the classroom with practical application and skills development in a professional setting.  Internships give students the opportunity to gain valuable applied experience and make connections in professional fields they are considering for career paths; and give employers the opportunity to guide and evaluate talent.” ²

It is important to remember that internships are a form of experiential learning.  Other experiential learning experiences recognized by the NACE include volunteering, student organization leadership, campus involvement, faculty-led research projects, study abroad programs, student employment/work-study, and service learning.² The internship is unique in that it is often run by professionals who have not been formally trained to be educators.  My goal is to provide current and future internship programs with a few tools and resources to expand and improve this important method of education.

It is not by happenstance that the pursuit of experiential learning experiences has increased among students.  Internships offer a variety of opportunities that are essentially impossible to replicate in the classroom.  A few examples include direct experience in an area of interest, working under the supervision of professionals or experts in the field, building on classroom knowledge through application, and learning through problem solving and creative thinking.²  Employers should remember that interns are adult learners and benefit from learning techniques and strategies that capitalize on these assumptions:³

1.    They are independent and self-directed

2.    They have accumulated experience, which is a rich resource for learning

3.    They value learning that integrates with the demands of their everyday life

4.    They are more interested in immediate, problem-centered approaches to learning than in subject-centered ones

5.    They are more motivated to learn by internal drives than by external ones

Interns benefit from projects and experiences that allow them to test their independence.  As with any other employee, interns still need to be held accountable for their work but be allowed to develop their own path to achieve the final goal.  Through this type of learning environment, the company will benefit from the innovative ideas that interns can bring from their past experiences.

When starting an internship, it is often difficult to know where to begin.  Organizations such as the National Association of Colleges and Employers (NACE) provide programs with guidelines to help facilitate a quality experience for the intern.  Some of the recommended standards by NACE include:²

·       The experience must be an extension of the classroom: a learning experience that provides for applying the knowledge gained in the classroom.  It must not be simply to advance the operations of the employer or be the work that a regular employee would routinely perform.

·       The skills or knowledge learned must be transferable to other employment settings.

·       The experience has a defined beginning and end, and a job description with desired qualifications.

·       There are clearly defined learning objectives/goals related to the professional goals of the student’s academic coursework.

·       There is supervision by a professional with expertise and education and/or professional background in the field of the experience.

·       There is routine feedback by an experienced supervisor.

·       There are resources, equipment, and facilities provided by the host employer that support learning objectives/goals.

For the learner to achieve the full benefit from completing an internship there needs to be a process of self-evaluation and feedback.   During these assessments, the employer should access the intern’s progress as well as make necessary changes to the program to help the intern meet the program’s objectives.  A great model for this practice would be the ADDIE Model.  This model is a frame work that consists of five phases: Analysis, Design, Development, Implementation, and Evaluation.⁴  Through these steps, the educator is able to constantly assess the learner and make necessary changes to improve outcomes.

Especially in this climate of economic uncertainty, graduates and qualified professionals need to expand their educational experience through programs like internships.  As more employers step into the educator role, it is important to provide these individuals with the tools to provide students with quality educational experiences that enable them to reach their full potential as well-qualified members in their field.

References:

1.  Internships Survey Reveals the Increasing Importance of Internships for Both Students and Employers.  Internships.com. 06 Dec 2012. Accessed on 1 Mar 2013.

2.  NACE Position Statement on U.S. Internships - A Definition and Criteria to Assess Opportunities and Determine the Implications for Compensation. National Association of Colleges and Employers.  June 2012. Accessed on 1 Mar 2013.

3.  Kaufman DM. Applying educational theory in practice. BMJ 2003; 326: 213-216.

4.  Allen WC.  Overview and Evolution of the ADDIE Training System.  Advances in Developing Human Resources 2006; 8: 430-41.

Gender Differences in Learning Preferences?

by Rachel Flurie, PGY1 Pharmacotherapy Resident, University of Maryland School of Pharmacy

Extensive research has documented that people learn in different ways and there are a variety of surveys and analytical schema to categorize these different learning preferences. This allows a person to understand how they learn best and also allows the teacher/learner to select teaching/learning methods that compliment these preferences. For example, I took the VARK (Visual, Aural, Read/Write, Kinesthetic) survey and found out that I am mostly a Read/Write learner.¹ Now that I have insight as to how I learn best, I can optimize my learning by picking materials that capitalize on my strengths. It’s always fun to take these questionnaires because they give you insights that you might not have been able to figure out on your own. In these learning descriptors, the emphasis is on the individual, irrespective of any other attributes or classifications we may have. But I began to wonder if fundamental genetic characteristics might influence our learning style.  For example, do males and females have learning preferences that are inherent to their gender?

In a broad sense, several stereotypes already exist about males and females when it comes to learning.  Men gravitate towards the sciences while women are attracted to the arts.  Men learn better by doing and women learning better by pondering. These stereotypes were perhaps relevant back when there was a distinctive division between males and females in terms of gender roles.  But do these stereotypes still apply today?  Or are learning styles truly based on individual preferences?

In my search for answers, I found several reviews and studies that focused on gender differences in learning preferences.^2,3  One review and meta-analysis explained the differences it found by relating them to Curry’s onion model.²  In this model there are three layers that explain learning preferences.   Learning preferences that fall in the inner most layer are considered fixed; those that fall in the middle layer are pretty stable but they are still subject to change; and those preferences that fall in the outer layer can be easily modified.  The meta-analysis found only one study out of 19 that showed a difference between men and women in an “inner layer” learning preference – certainly not enough to warrant a change in educational methods.  In the middle layer of the onion, a few studies that assessed learning preferences using Kolb’s Learning Style Inventory showed the following²:

• Women prefer concrete experiences while men prefer abstract concepts
• Women are more socially oriented than men
• Men are more grade-oriented and more competitive than women

In thinking back to all of my experiences, I would generally nod in agreement with these conclusions. The fact that they fall into the middle layer of the onion is a key point because these preferences might be linked to gender, but they’re certainly not permanent. As an educator, I would be mindful about these preferences when teaching. In circumstances where the learners are predominantly one gender, altering your teaching style based on these preferences might be helpful. For example, you might plan for more group discussions over individual assignments in an all-female classroom. But in mixed gender classrooms, other issues should influence your teaching more (e.g. the material being taught, the setting, the prerequisite knowledge of the learners).

Authors in another review noted that their literature search revealed a lot of variability in learning preference based on gender (and in some cases they were even contradictory!). For example, two studies used the same VARK survey to explore gender-associated learning differences.^4,5 One study, done in undergraduate physiology students, found that the males preferred multimodal instruction whereas the females were more likely to have single-mode preferences. The other study, done in first year medical students, found that the females tended to be more multimodal in learning style compared to their male counterparts. Perhaps the preferred learning style is also based on the material being taught? Personally, I think I have different learning preferences when I’m learning to cook a meal versus learning how to treat a patient’s hypertension. In the end, I’ve concluded, apart from a few generalizations that have been made, learning preferences are not significantly influenced by gender.

Suffice it to say, as a current learner and educator, I will not be relying on stereotypes when it comes to men versus women in education. Instead, I will consider learning preferences on an individual basis and will select the most appropriate methods based on the material being taught. While some preferences in life might be heavily influenced by gender, learning style is not one of them.

References:

1. Fleming N. VARK^® A guide to learning styles [Internet]. 2001 [cited 2013 March 11]. Available from: http://www.vark-learn.com/english/index.asp.

2. Severiens SE and Ten Dam GTM. Gender differences in learning styles: a narrative review and quantitative meta-analysis. High Educ. 1994;27:487-501.

3. Severiens SE and Ten Dam GTM. Gender and gender identity differences in learning styles. Edu Psychol. 1997;17:79-93.

4. Wehrwein EA, Lujan HL, DiCarlo SE. Gender differences in learning style preferences among undergraduate physiology students. Adv Physiol Educ. 2007;31:153-157.

5. Slater JA, Lujan HL, DiCarlo SE. Does gender influence style preferences of first-year medical students? Adv Physiol Educ. 2007;31:336-342.

Helping Students with ADHD Stay Focused

by Gary Flowers, Pharm.D., PGY1 Pharmacy Practice Resident, Suburban Hospital

According to the Centers for Disease Control and Prevention (CDC), 9.5% of school children between the ages 4 and 17 have been diagnosed with ADHD, and this number is rising.¹  Undiagnosed, untreated ADHD can wreak havoc in an individual’s life and in the lives of loved ones.²  I’ve watched my brother’s daily struggles as they tried to improve his son’s grades at school.  My brother tried many methods at home to help his son but to no avail.  After much frustration, my brother sought help.  My nephew was diagnosed with ADHD.

ADHD is commonly treated with psychostimulant medications.  Psychostimulants have shown to be beneficial in the majority of people with ADHD by helping to diminish hyperactivity as well as improve attention problems which cause many of the behavioral symptoms.  Long-term studies have shown that these medications have protective effects against later psychopathology and reduced the chances of substance abuse in adolescents with ADHD.³

After evaluation of the individual’s needs, a teacher can devise a lesson plan built around the student’s needs and strengths.  These accommodations are incorporated in educational activities with other students in the class. These lesson plans are best constructed with the input of a multidisciplinary team and the parents of the child.  Teachers can often use assessment tools, such as learning style inventories, to better understand how to instruct the student and enhance his or her learning.  For consistency, there should be one designated teacher that is used as an advisor or coordinator for the student to rely on and report.

Short-term and long-term goals should be set for the student with ADHD and reassessed periodically over time (i.e. quarterly) and edited as needed to adjust for advancements or emerging deficits.  The goals should be written in the SMART format: specific, measurable, attainable, realistic, and timely.

Students with ADHD benefit from the teaching best practices we’ve all learned.  For example, teachers should explicitly explain learning objectives at the beginning of the lesson so students know what is expected.  At the beginning of each class the teacher should review previous topics and then connect that information with the information being covered that day or week.  Using a variety of audiovisual materials can help reinforce concepts.

Simplifying and breaking work into smaller units makes information easier and more palatable for students with ADHD to digest.  Time limits during tests may need to be relaxed or eliminated in order for the student with ADHD to successfully demonstrate what he or she has learned and retained.⁴  

Although the media typically focuses on children, many adults have ADHD too.  Adults tend to have similar challenges as children, such as, disorganization and staying attentive for long periods of time.  Unfortunately, it is more difficult to diagnose ADHD in adults due to the variability and vagueness of their symptoms.  Moreover, the symptoms must have began in childhood and persisted into adulthood in order to make the diagnosis of ADHD.⁵ 

Combination treatment, medications plus behavioral interventions, work best for the majority of people with ADHD.  Adjustments may need to be made throughout life to control one’s actions and minimize the urge to take unnecessary risks.  Teachers (and parents) need to remember that it’s important to be patient, experiment with different strategies, and seek support.

Fortunately, my brother sought help early and my nephew received the help he needed.  They tried medication but focused on behavioral modification using positive and negative feedback.  Teachers at his school and my brother set short and long term goals for my nephew.  He is now seventeen and has plans to join the military after graduation!

References

1.  Centers for Disease Control and Prevention (US). Attention-deficit/hyperactivity disorder (ADHD). [Internet]. 2011 Dec 12 [cited 2013 Mar 10].

2.  Pliszka S. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/ hyperactivity disorder. J. Am. Acad. Child Adolesc. Psychiatry  2007 46(7):894-921.

3.  Albert P. Drugs for kids: Good or bad? J Psychiatry Neurosci 2012; 37(5):293-5.

4.  U.S. Department of Education. Teaching children with attention deficit hyperactivity disorder: Instructional strategies and practices. [Internet]. 2004 Feb [cited 2013 Mar 10].

5.  National Institute of Mental Health. Attention Deficit Hyperactivity Disorder (ADHD). [Internet]. 2009 Jan 23 [cited 2013 Mar 10].