Bridging the Gap: From the Classroom to Practice

Cody Taylor, PharmD, PGY2 Critical Care Pharmacy Practice Resident, University of Mississippi Medical Center

It’s 06:00 and a nervous pharmacy student anxiously waits to begin his first Advanced Pharmacy Practice Experience (APPE) in the cardiac intensive care unit. He takes a moment to look around the unit hoping to calm his nerves but to no avail. The scene unfolding before him consists of nurses running from room to room, a patient in critical condition, and medical residents asking for drugs he only vaguely remembers from his second year in pharmacy school. It’s day 1 of his final year of pharmacy school and he already feels defeated. This is my story and one that is similar to that of many pharmacy students across the nation.

APPEs are designed to provide students with daily opportunities to assess and monitor patients, interact with other healthcare professionals, improve literature evaluation, and enhance many other skills including giving presentations and educating patients.  These experiences often provoke stress and anxiety for students. For me, it was a combination of my first experience with critically ill patients, a lack of knowledge regarding critical care practice, the pressure to remember everything from the previous three years of pharmacy school, navigating an unfamiliar electronic medical record, and learning to cope with difficult situations.

Student pharmacists are expected to master various core competencies during their final year of APPEs. While each college of pharmacy has their own set of competency statements, they generally revolve around: developing and applying foundational knowledge, promoting safe and evidence-based patient care, contributing to interprofessional teams, and engaging in professional development. Some colleges of pharmacy have begun assessing their students’ preparedness to meet these competencies. Student pharmacists have reported less preparedness in areas such as recommending medications and doses, evaluating laboratory test results, assessing medication appropriateness, and discussing pharmacotherapy recommendations during interprofessional team rounds.¹  Preceptors have also weighed in.  Students do not seem to be able to integrate foundational knowledge from all academic disciplines when discussing a patient problem.  Moreover, students have difficulty performing pharmaceutical calculations and critiquing primary and tertiary literature.² These topics are discussed throughout the pharmacy curriculum, but many factors can influence why pharmacy students may feel unprepared and anxious. In addition to the fact that these topics were often covered in class two or three years ago, some students are innately prone, based on their personality and previous experiences, to anxiety, fear, or low self-esteem.

So, what can we do to help prepare pharmacy students to transition from the classroom to clinical practice? The Accreditation Council for Pharmacy Education (ACPE) accreditation standards now require colleges to assess student readiness to enter APPEs.³ Since the release of these standards, colleges/schools of pharmacy have increasingly implemented objective structured clinical examinations (OSCEs), simulations, and authentic patient cases in their curriculum.

Tchen and colleagues at the University of British Columbia took a different approach to prepare their students for APPEs.⁴ They received feedback from both students and preceptors that students were not adequately ready for their inpatient APPEs. To address this problem, they developed a series of online, self-paced modules.  They used focus groups consisting of preceptors, faculty, pharmacy residents, and recent alumni to develop these modules. Modules focused on common terminology, processes, and procedures in the inpatient setting; how to effectively use a patient’s chart to identify pertinent information; and how to perform a patient workup and assessment. Post-module survey results indicated just under 70% of students felt the modules improved their performance during their inpatient APPEs. However, only 25% of students believed it helped reduce their anxiety. This is not surprising as many people experience anxiety when experiencing new, unfamiliar circumstances and this feeling likely cannot be completely mitigated through didactic instruction. Preceptors also perceived a benefit to the modules, stating that there was more time to focus on student-centered learning versus orienting the student to the practice environment.

This is an interesting approach to increasing APPE readiness among pharmacy students. Gathering feedback from faculty, preceptors, and alumni to create these modules enabled a multidimensional approach to fill the gaps between the classroom and practice. Allowing students to progress through the modules at their own pace is also helpful as this allows each student to review the material at a time when they are most motivated to learn and immediately before starting the rotation.  This is a great example of “just in time” learning.

It is difficult to change curriculums based on one college of pharmacy’s experience, but I believe Tchen and his colleagues at the University of British Columbia describe an effective way to increase pharmacy students’ readiness for their APPEs.

References:

1. Scott DM, Friesner DL, Miller DR. Pharmacy students’ perceptions of their preparedness to provide pharmaceutical care. American Journal of Pharmaceutical Education.74(1) Article 8.
2. Lundquist LM, Hogan S. Evaluating preceptors’ perceptions of student preparedness for advanced pharmacy practice experiences. Journal of Pharmacy Teaching. 14(1);19-32.
3. Accreditation Council for Pharmacy Education. Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree (Standards 2016). 2015.
4. Tchen P, Leung L, Simpson F, et. al. Bridging the gap: An evaluation of self-paced online transition modules for advanced pharmacy practice experience students. Currents in Pharmacy Teaching and Learning 2018; 10:1375-1383.

Peer-to-Peer Teaching/Mentoring and Application for Educators

by Kathy Lee Barrack PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Mentoring, guidance provided by an experienced person, can lead to professional growth and development.^1.2 In post-graduate training, mentors impact the careers of health care practitioners and studies have shown that individuals with mentors are more likely to be successful.^1,2  They are more likely to become published and be more rapidly promoted.

https://chicago-woman.com/career/network/mentoring-day-importance-having-mentor/

Traditionally, the mentoring relationship is characterized as a partnership between a more experienced and an inexperienced person.¹ While those seeking mentorship often strive to find someone more advanced in their career, the mentee should keep in mind that more than one mentor is often needed at a variety of stages within a long career.¹ Peer mentors can be valuable too.

In professional healthcare curricula (e.g. medicine, nursing, pharmacy, and physical therapy) peer-to-peer mentoring can provide social and academic support, professional development, and tutoring services.^1,4 Peer-to-peer mentoring consists of two people who are roughly the same age with similar experience. As burn-out becomes more commonplace and problematic, peer-to-peer mentoring may be a part of the solution.^1,4 Peer-to-peer mentoring may help prepare for the transition into professional school or post-graduate training.^1,4

The Ohio State University College of Pharmacy implemented a student peer-mentoring program for a drug information assignment in an introductory pharmacy practice course.³ This exercise was intended to ensure students were adequately prepared for future courses. During the experience, first-year pharmacy students were paired with a peer (second-year pharmacy students) who completed the same assignment.  Students practiced effective communication, organizational, and time-management skills.³ A faculty member provided mentors with training on how to serve as a resource and facilitated oversight of the mentorship program.³

To evaluate the success of this program, the investigators measured the impacted on first-year pharmacy students’ performance on the drug information question, and second, how the student peer-mentoring program impacted the mentors’ (second-year students’) perceptions of their ability to write future drug information questions.³ A strong majority of first-year pharmacy (76%) and second-year pharmacy mentors (100%) agreed that participation improved their ability to prepare a drug information response.³ Additionally, 65% of first-year pharmacy student and 91% of second-year pharmacy students agreed that the peer-to-peer program improved the first-year pharmacy students’ grade.³   In addition, the peer mentors believed the training sessions were constructive, and a majority of the student mentors would participate in the program again. Course faculty also felt the peer-mentoring program was beneficial for first-year and second-year pharmacy students. While this program improved perceptions, it is worth noting the investigators believe the peer-mentoring program will have a positive impact on the mentor’s likelihood to engage in future teaching opportunities and provide constructive feedback.³ See study here: https://bit.ly/2LKVmmS.

There are examples in the Nursing literature as well.  The University of Northern Kentucky implemented a peer-based mentor tutoring program for at-risk students to improve retention and academic outcomes.⁴ While the program had a positive impact on academic performance, as measured by higher final grades, investigators also found that peer-mentors were more likely to pursue a career in academia.⁴ Implementing the program was not without difficulties or barriers including documentation and communication.⁴ See article here https://bit.ly/2F41HcA.

In other studies, peer mentoring has been shown to improve professional development, research productivity, and career transition.^2,3 The University of Kansas and UNC Eshelman School of Pharmacy have both implemented peer mentoring programs with significant success. See https://unc.live/2VpHEuq and https://bit.ly/2s5V4y9.

The goals of peer-mentoring programs are to foster and develop students by providing additional guidance and support.^1,5 Recommendations for implementing peer mentoring programs include:^1,3

• Establish mentor eligibility requirements – such as GPA and/or leadership qualities
• Develop student commitment - allow students to volunteer or could implement this program as a part of a professional development elective
• Orchestrate meaningful meetings or events – such as professional development opportunities
• Institute faculty oversight - to provide mentors with adequate training
• Evaluate the program –create surveys to obtain feedback and learn about areas of improvement

More tips provided by student pharmacists can be found in an article published in the Pharmacy Times (https://bit.ly/2TlIGFA).⁵

References

1. Raub JN, Thurston TM, Fiovento AD, et al. Implementation and Outcomes of a Pharmacy Residency Mentorship Program. Am J Health-Syst Pharm 2015; 72 (11) Suppl 1: S1-S5.
2. Sambunjak D, Straus SE, Marusic A. Mentoring in Academic Medicine: A Systematic Review. JAMA. 2006;296(9):1103-15.
3. Rodis J, Backo J, Schmidt B, and Pruchnicki MC. Student-Peer Mentoring on a Drug Information Response. Am J Pharm Educ 2014; 78(2): Article 38.
4. Robinson E, Niemer L. A Peer Mentor Tutor Program for Academic Success in Nursing. Nurs Educ Perspect. 2010;31(5):286-9.
5. Nguyen H, Hoang P. 3 Tips for Launching a Peer Mentoring Program. Pharmacy Times. 2016 Oct.

Escape Classroom Monotony: Creating “Escape Room” Activities to Engage Learners

by Natalie Kern, PharmD, PGY1 Community Pharmacy Practice Resident, Walgreens Pharmacy

In my experience as a student, educational games merely included flash cards for memorizing drug names and the ever-famous Jeopardy test review before a big exam. A recent publication caught my eye. The instructors were using an “escape room” for teaching and learning purposes.  The notion of participating in an escape room in an academic setting seemed exhilarating but, frankly, unfathomable. An escape room is a “live-action team-based game where players discover clues, solve puzzles, and accomplish tasks in one or more rooms in order to accomplish specific goals in a limited amount of time.”¹ On any given Saturday night, you can find friends lining up to embark on an escape room adventure. No matter the age, people seem to love the interactive mystery of the escape room. Escape rooms are a team-building adventure game, where players are locked in a room to gather clues, discover hidden objects, and solve riddles in order to escape. Could such a collaborative, task-centered, time-based activity be used to promote student engagement in the classroom?

Many educators struggle to effectively maintain the attention and interest of millennial students in traditional classrooms. Teaching methods such as problem-based learning, flipped classrooms, case-based learning, and gaming seek to promote engagement. “Escape room”- like activities are a new form of instructional gaming or gamification. Clues and puzzles provided in the activity relate to the specific learning objectives of the course. While health professional programs in medicine, nursing, and pharmacy have documented adaptations of educational escape rooms, all describe their success in small groups of students.

The University of Kentucky College of Pharmacy adapted the popular phenomenon into its five-credit required Pharmacy Management course when third-year student pharmacists expressed disinterest in the course.² Students felt that the course was irrelevant to their future careers. The course instructors decided to adapt by providing students with engaging real-life applications. They developed a blended online/ offline escape room activity to help students review basic human resource laws and the hiring process. The course designers built an educational escape room for a class of over 100 student pharmacists. Students were not required to escape an actual room; instead, they completed paper and electronic puzzles and riddles that lead to a series of clues that would help them unlock a box with a combination lock.

One week before participating in the educational escape room, the instructors gave a two-hour lecture on employment law and explained the hiring process. The students were given all the information that they needed to successfully complete the “escape room.” Therefore, the objective of the activity was to reinforce the fundamentals of human resource principles discussed in the lecture. The “escape room” was designed to be completed in a one-hour class period, allowing 5 minutes for instruction, 45-minutes for the students to solve the escape puzzles, and 10 minutes for debriefing.  Using an online learning management system, students were organized into twenty-four groups consisting of five to six learners. On the day of the activity, groups met face-to-face in the classroom auditorium. Two-course instructors and a PGY1 resident facilitated the activity by reviewing the rules and directions of the game and a timer was set for 45 minutes. Each team was required to complete 10 puzzles that would enable them to select the best candidate for a new pharmacist’s position. A four-digit number was embedded within the best candidate's resume; this would be used to unlock a box at the front of the auditorium.  If any team was unable to advance to the next puzzle, they could ask for a hint from an instructor. However, the team would be given a one-minute penalty. The three teams who finished the fastest received bonus points for the management course. All participants were asked to complete an anonymous survey about their experience. One hundred and thirty-nine responses were recorded.

Overall, the students' perceptions of the escape room activity were positive. Ninety-one percent of students reported more engagement in the material compared to the typical classroom lecture. Over 80% of participants felt more involved in the subject matter when compared to the lecture. The students also agreed that teamwork played an important part in successfully completing the activity. From the instructors’ perspective, logistics were complex and a lot of planning was required for the success of this large-scale escaped room.

Thinking of implementing an educational escape room in your course? While creating puzzles and clues are not difficult, ensuring that students are engaged in the material rather than merely playing a game is a key to the instructional design. This challenges educators to develop clear objectives. Does Bloom’s Taxonomy ring a bell? It is important to identify the cognitive domains the escape room is intended to achieve when writing the objectives.³ In reflecting on the potential educational outcomes of an escape room, students are challenged to think critically, transitioning from understanding lecture material to applying and analyzing the information. A course designer needs to consider the class and room size as well as logistics when planning the escape room. Students can be placed into small groups in class or online based on the preference of the course designer and space limitations. The instructor will need to create a set of activities that encourage the students to problem solve together and to arrive at a specific answer. A correct answer reveals a new clue and a new activity or challenge. When facilitating an escape room for a large group of students, online problem-solving activities are not limited by space and can save money on supplies. Be mindful of the time needed for the instructor to create and the students to participate in the escape room. According to Cain, it took 20 hours to design the puzzles and clues for the activity. Lastly, consider pilot testing the activity on a small group of students to estimate the time needed to complete the escape room. This will also help identify potential problems.¹

After listening to more than my fair share of lectures, the classroom feels more like a room that I’d like to escape rather than an engaging space for intellectual growth. New methods for gamification create an innovative spin on the beloved “group project” by facilitating collaborative efforts of all team members to reach the finish line. Escape room-like activities require effective communication, teamwork, and delegation. These are skills needed to be an effective member of a healthcare team. Escape rooms are a great way to challenge students to be collaborative problem-solvers.

References

1. Peeking behind the locked door: A survey of escape room facilities. Self-published 2015.  White Paper available online at:http://scottnicholson.com/pubs/erfacwhite.pdf.
2. Cain J. Exploratory implementation of a blended format escape room in a large enrollment pharmacy management class. Currents in Pharmacy Teaching and Learning. 2019 Jan;11(1):44-50. doi: 10.1016/j.cptl.2018.09.010. Epub 2018 Oct 3.
3. Poirier T, Crouch M, MacKinnon G, Mehvar R, Monk-Tutor M; American Association of Colleges of Pharmacy.. Updated guidelines for manuscripts describing instructional design and assessment: the IDEAS format. Am J Pharm Educ. 2009 May 27;73(3): Article 55. 

Edutainment: Is There a Place for it in Higher Education?

by Anna Kathryn Ward, PharmD, PGY1 Community/Public Health Pharmacy Resident, Mississippi State Department of Health Pharmacy

Whether you are known as a mentor, teacher, preceptor, and/or facilitator, all forms of teaching are moving toward an innovative and creative way of presenting instructional material. “Edutainment”  is growing in popularity, mostly due to the growing number of students that have grown up with ubiquitous technology and entertainment venues. Edutainment is the “presentation of informative or educational material in an entertaining style.”¹ An entertaining style encompasses four different processes known as signaling (e.g., highlighting keywords, changing font color), segmenting (e.g., short videos, short chapters within videos as well as question prompts), weeding (e.g., eliminating extraneous information), and matching modalities (e.g., auditory and visual channels to convey information).² There are many examples of edutainment including the use of short television and movie clips to introduce a concept, the use of board and computer games to learn and/or apply a concept, as entertaining videos that explain topics (e.g., YouTube; Kahn-Academy).

As educators have come to a greater understanding on how people learn and that “one size does not fit all,” edutainment is one potential solution that’s creative and has been used successfully. Edutainment is widely used by preschool and elementary educators, due to popular children’s programming such as Sesame Street that provides educational topics with an entertaining delivery. With new advancements in technology, teachers can now create their own videos and games. The need for a large budget and staff to produce edutainment elements has become unnecessary. But is there a place for edutainment in higher education?

While I am a recent graduate from a professional program, in my current role I now have the responsibility to teach and help millennial students gain knowledge and grow as future pharmacists. This generation seemingly has the expectation, need, and wish to be entertained throughout their learning experiences.³ Because of this expectation, multimedia presentations and the integration of edutainment is gaining momentum and popularity in many college classrooms.³ Strategies, reasoning, and rationales for integrating edutainment elements into the college classroom have received attention in the educational literature in recent years.

One study investigated the use of instructional YouTube videos by faculty to augment instruction in college classes. An online survey was distributed to health and human performance faculty at a southeastern university in the United States. Information about the course levels taught, number of courses taught, and instructional setting (online or in-class) were gathered in the survey. The results showed that slightly more than 40% of the faculty reported the use of YouTube in their courses, with almost all of the participants (>90%) stating an interest in learning how to use of YouTube as a learning resource. The study found that the faculty who use YouTube in their courses consider it to be an effective teaching resource and enhances their course material.³

Another study investigated how online content (e.g., YouTube) could be used as a means to reach today’s students and capture their attention and interest, with the goal of increasing the long-term retention of the course content. The study evaluated 284 college students exposed to two types of videos. The students were introduced to a lesson’s concept either through an emotionally charged video (humorous stimuli) or a neutral video (utilitarian stimuli). Five months later, the students were asked to complete a survey testing their long-term recall of the content. Results indicated that humorous videos shown at the beginning of a class increased the positive mood of students, increasing active learning and attention. Moreover, humorous videos that were congruent with the educational objectives more effectively reinforce the material and significantly increased short and long-term recall when compared to the utilitarian videos.⁴

There has also been research looking at entertaining approaches to training pharmacy preceptors. A training program was developed consisting of 12 online video episodes providing innovative, entertaining, and flexible continuing education programs for pharmacy preceptors. The 12 episodes combine to form a mini-series that form a professionally produced movie. Each episode is five to eight minutes in length and designed to include entertaining elements, practical scenarios, commentary, and teaching pearls. The mini-series follows a pharmacist and student storyline. Participants in the program completed questions and evaluations after each episode, and three months following completion of the training a survey was distributed to analyze their long-term impact on precepting skills. The 202 participants stated significant increases in their confidence level as an educator when comparing the pre- and post-program survey results. Questions about the entertainment value were included on the post-program survey with 99% of the participants indicating they would recommend the program to others and would complete a program of similar format again.⁵

Given the conclusions from these studies, the evidence provides positive reasons for using edutainment in higher education. It can be concluded that teaching with entertaining elements can enhance student attention and results in greater recall of the material. Entertaining materials may also increase curiosity and motivate students to learn more on their own. Simple ways to start incorporating these elements into teaching include using short pre-made videos found on the Internet, using a role-playing game for students to apply the concepts taught, and/or simply changing color and contrast of important information in PowerPoint slides. Teachers can easily adjust the use of these elements throughout their lessons. There is some controversy about how often edutainment elements should be used. Finding the right balance and learning what works to teach certain concepts requires careful consideration. Some topics might work well with videos, where others might work better with in-class games. It’s all about trial and error to find what works best for the teacher and their students. Nonetheless, the use of edutainment in higher education is here to stay and, when used appropriately, will enhance students learning.

References

1. Collins English Dictionary. Definition of ‘edutainment.’ [Cited 2019 Jan 18]
2. Brame CJ. Effective educational videos. Vanderbilt University Center for Teaching. 2015 [Cited 2019 Jan 18].
3. Burke S, Snyder S, Rager RC. An Assessment of Faculty Usage of YouTube as a Teaching Resource. IJAHSP. 2009;7(1): Article 8.
4. Steffes EM, Duverger P. Edutainment with Videos and its Positive Effect on Long Term Memory. JAME. 2012;20(1):1-10.
5. Cox CD, Cheon J, Crooks SM, Lee J, Curtis JD. Use of Entertainment Elements in an Online Video Mini-Series to Train Pharmacy Preceptors. Am J Pharm Educ. 2017;81(1): Article 12. 

Burnout in Health Professions Education

by Karli Kurwicki, Pharm.D., PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Burnout among healthcare students and professionals has been studied for many years. Burnout is typically caused by stress that builds over time and can cause students to have damaging thoughts about themselves, anger, frustration, and even depression. A student experiencing burnout might also develop paranoia and skepticism about their future, and this may lead to distrust in colleagues or mentors. Burnout contributes to poor mental health.

There are three dimensions of burnout: emotional exhaustion; depersonalization and cynicism; and a lost sense of personal accomplishment. Emotional exhaustion occurs when a student feels indifferent towards the outcome of school work. Students may feel apathy toward studying so they perform poorly on tests and other assignments. Depersonalization and cynicism typically occur after the student has developed emotional exhaustion. Cynicism causes the student to have negative feelings towards school work and their profession. A decreased sense of personal accomplishment causes the student to feel incompetent. These feelings can ultimately lead to depression and impact the student’s emotional well-being. Many healthcare professionals and students feel a stigma with admitting they are depressed because there are negative connotations towards mental illness, even among those who work in the medical field. Students often see depression or anxiety as a weakness.¹

Marshall et al² investigated stress, quality of life, and burnout among pharmacy students attending a US pharmacy school. Third-year pharmacy students filled out a questionnaire that asked about stressors, how the students handle stress, and health-related quality of life over the previous four weeks. Female students had higher perceived levels of stress than males and the mean mental health score was significantly lower for the female students. A majority (56.9%) of the students admitted to feeling nervous or anxious, ranging from fairly often to very often, over the previous four weeks. The investigators also compared perceived stress levels between the graduate students and undergraduate students. The graduate students were significantly more stressed than the undergraduate students. The most common stress trigger for students was not examinations and tests (23.9%) but family and relationships (36.7%). They also asked students to suggest ways the college could help address their stress. The most common recommendation was to move Monday examinations to another day (67.9%) so that they could enjoy their weekends with family and friends. These results remind faculty that school is not the only stressor students face and that to have better learning outcomes and reduce the risk burnout, asking student opinions is important.

A survey of medical students at 7 medical schools across the United States examined the correlation between burnout and suicidal ideation. The authors report that 49.6% of students experienced symptoms of burnout and 11.2% experienced suicidal ideation. Burnout and low mental quality of life were strong predictors of suicide ideation. They also noted that students who recovered from burnout later were less likely to report suicidal ideation.³ This study serves as a good reminder that burnout can be so mentally taxing that it may cause a student to have suicidal thoughts.

Another study done in Portugal compared stress and burnout between students in the first two years of pharmacy school to students in the last two years.⁴ The results of this study are similar to the study done in the United States. Female students were significantly more likely to report emotional exhaustion compared to male students (p=0.017). Students in the last two years of pharmacy school experienced more depersonalization (p=0.006) meaning that they felt less connected to those around them. They found that students with more anxiety and higher personal accomplishment had higher scores on the Maslach Burnout Inventory. Burnout was associated with higher rates of dissatisfaction with school.

Lastly, a study performed in Australia aimed to measure burnout and engagement of nursing, occupational therapy, social work, and psychology students.⁵ The students were sent a survey to fill out. The investigators assessed burnout using the Maslach Burnout Inventory. The majority of the students who completed the survey were nursing students (53.5%). They found that burnout increased and engagement decreased as students progressed through the curriculum. However, they did not find a difference in burnout rates among the different health profession students. The authors speculated that improving student resources to help with exhaustion and burnout may be beneficial.

Burnout among students in health profession programs is higher in female students, high achievers, and increases as students progress through the curriculum. Faculty at all health profession schools must consider the negative effects stress has on students. Faculty should be able to recognize signs of burnout and should be prepared to help students by talking about burnout. Providing resources to students so that they can recognize the signs of burnout is a must. Faculty should encourage students to reach out to school counselors, mentors, and faculty if they are experiencing these symptoms, and they should help the students to understand that burnout is something that happens to many students. They should not be ashamed. It is also important to provide mental health counseling to those who are experiencing burnout. Offering free services to help students such as free tutoring could potentially decrease student stress and ultimately burnout. Lastly, schools should perform annual student opinion surveys to try to find ways to help students in terms of mental health and adding more resources to help students.

References

1. Bridgeman PJ, Bridgeman MB, Barone J. Burnout syndrome among healthcare professionals. Am J Health-Syst Pharm. 2018;75:147-52.
2. Marshall LL, Allison A, Nykamp D, et al. Perceived stress and quality of life among doctor of pharmacy students. Am J Pharm Educ. 2008;72(6): Article 137.
3. Dyrbye LN, Thomas MR, Massie MF, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334-341.
4. Silva RG, Figueiredo-Braga M. The roles of empathy, attachment style, and burnout in pharmacy student’s academic satisfaction. Am J Pharm Educ. 2018: in press. DOI 10.5688.
5. Robins TG, Roberts RM, Sarris A. Burnout and engagement in health profession students: the relationships between study demands, study resources and personal resources. Australian Journal of Organisational Psychology. 2015;8(e1):1-13.