Values Affirmation: Reducing the Gender Gap in STEM Disciplines

by Samantha McBryde, Pharm.D., PGY1 Pharmacy Practice Resident, Magnolia Regional Health Center

Policy makers and the educational community have debated for decades ways to address the underrepresentation of women in science, technology, engineering, and mathematics (STEM) disciplines. In high school, male and female students enroll in advanced science courses at about the same rates. Indeed, females are slightly more likely to enroll in some STEM courses than males.¹ However, the rates of women taking science and engineering courses drop in college and significant disparities begin to emerge in the workplace, especially for minority women.¹

The gender disparity in the STEM fields in the United States is wide! In 2016, women made up half of the total college-educated workforce, but only 29% of the science and engineering workforce.¹ While women receive over half of the bachelor’s degrees awarded in the biological sciences, they receive far fewer in the computer sciences (17.9%), engineering (19.3%), physical sciences (39%), and mathematics (43.1%).¹

One issue of concern that could jeopardize women’s decisions to go into these fields is that in some STEM disciplines men outperform women on in-class exams and standardized tests.^2,3 Numerous interventions, such as tutorials, peer instruction, and context-rich problems have been used to address the gender gap in STEM courses. While these approaches likely work, a novel approach known as values affirmation was recently studied in a college-level introductory physics class.²

Values affirmation is a psychological intervention whereby students engage in structured reflection on self-defining values. In this study, 399 students (283 men and 116 women) were randomly assigned to either a values affirmation group or a control group. Students in the values affirmation group were asked to select their most important values from a list and write an essay about why these values were important to them. This group would write about things such as friends and family in response to a series of structured prompts. The control group selected their least important values from the same list and were instructed to write an essay about why these values might be important to other people. Therefore, both groups wrote about values and their importance, but the exercise was self-relevant only for the values affirmation group.²

This assignment was completed twice during the semester, in the first week of the course and shortly before the first midterm exam. Both groups were given 15 minutes for this writing exercise during the physics class. Students were assigned to the same group for both essays. The course instructor and teaching assistants were unaware of students’ group assignments. Moreover, the teaching assistants and students were blinded to the purpose of the writing exercises.¹

To assess the effect of values affirmation on learning, the researchers examined scores on three in-class exams, the in-class final, and a nationally-normed standardized test [the Force and Motion Conceptual Evaluation (FMCE)].²

 Previously, men substantially outperformed women on the exams in this course and the FMCE.³ Specifically, 58% of females versus 35% of males fell into the lowest two pretest quintiles on a FMCE pretest, while 22% of females and 44% of males scored in the highest two quintiles.³ After taking the course, the post-test scores for males and females increased, on average, 10.7 points. Moreover, 64% of the males and 49% of the females scored above 60% on the post-test.³ If the difference in the FMCE scores after this intervention shrank, values affirmation might prove to be a promising way to address the STEM gender gap.²

The FMCE exam was administered twice during the introductory physics course, once during week 1 of the semester and once at the end of the semester. In the control group, men improved their FMCE scores more than women. However, in the values affirmation group, the gender performance gap disappeared.²

Stereotype beliefs also appear to impact student performance. In the first weeks of the introductory physics course, students were asked to indicate their endorsement of the stereotype: men perform better than women in physics.² Women in this study, as a whole, did not strongly endorse the stereotype; however, even a moderate level of stereotype endorsement was costly for women in the control group. Their FMCE exam scores were significantly lower as a function of stereotype endorsement.² The values affirmation activity buffered women against this identity threat.² The intervention eliminated the negative relationship between the exam scores and stereotype endorsement.² On the other hand, men’s FMCE exam scores were not impacted regardless of whether they endorsed the gender stereotype or not.²

The results suggest that female students positively benefited from the values affirmation activity. Among women in the control group, there was a negative relationship between stereotype endorsement and end-of-semester FMCE scores.²  In other words, as stereotype endorsement went up, FMCE scores went down. Among women in the values affirmation group, this relationship was not found.²

Looking at the average of the four exams in the course, men substantially outperformed women. However, the difference in the average scores between men and women was much smaller in the values affirmation group. The improvements in performance was also evident in the distribution of final letter grades. More women earned B’s in the values affirmation group than in the control group. Conversely, more women in the control group earned C’s than women assigned to the values affirmation group.²

The results of this study suggest that the values affirmation activity reduces the gender gap and women who endorsed the gender stereotype benefitted the most.² Values affirmation is an intervention that could be used in an effort to lessen evaluative stress and also improve the performance of stereotype-threatened students.² Values affirmation activities offer a promising intervention to reduce the gender achievement gap in STEM courses.

References:

1. Britsch B, Carter G, Gustafson J, et al. “Statistics.” National Girls Collaborative Project. 2016. Available from: https://ngcproject.org/statistics. Accessed April 6, 2019.
2. Miyake A, Kost-Smith LE, Finkelstein ND, et al. “Reducing the Gender Achievement Gap in College Science: A Classroom Study of Values Affirmation.” Science 2010; 330: 1234-37.
3. Kost LE, Pollock SJ, Finkelstein ND. “Characterizing the gender gap in introductory physics.” Physics Review Special Topics - Physics Education Research. January 2009. Available from: https://doi.org/10.1103/PhysRevSTPER.5.010101. Accessed April 8, 2019. 

The Connection Between Confidence, Knowledge, and Experience

by Madalyn Van Valkenburg, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

During my first hospital pharmacy experience, I remember being awe-struck by the confidence exuding from the pharmacist when she gave her recommendations to the attending physicians and other members of the interprofessional team. She seemed at ease discussing the evidence supporting the recommendations. And when there was uncertainty about the next steps, she asked explicit questions to develop a more accurate assessment. I wanted to have this level of confidence in my clinical decision-making, but I was unsure about how to achieve it. I think every student (and resident) seeks to gain a high level of confidence but how can educators assess and cultivate it?

Before measuring confidence, we need to define it. Therein lies the initial problem. Confidence is tricky to define because it is not concrete – you can’t actually see it. It is a belief the action taken is right, proper, and effective.¹ Clinical confidence is the certainty that a decision or action undertaken in the clinical setting is correct and will lead to the best outcome.

One of the interesting aspects of confidence is that it doesn’t always match with knowledge. This mismatch is known as the Dunning–Kruger effect whereby, based on our perceived knowledge, we overestimate our ability. In other words, some knowledge of the subject matter leads us to conclude we are more competent than we actually are when measured using objective tests.²

In a 2006 study, Valdez and colleagues compared second-year pharmacy students’ self-confidence scores regarding the treatment of dyslipidemia and hypertension to their scores on a multiple-choice exam. Confidence was measured using a 12-item questionnaire and rated on a 5-point Likert scale (1=low confidence and 5=high confidence). Each confidence question was linked to a critical concept on the 21-item multiple-choice test. For example, students were asked to rank their confidence “identifying causes of resistant HTN” and this concept was evaluated on one or more items on the multiple-choice test. The confidence assessment (administered first) and multiple-choice test (administered second) were given immediately after students had received didactic instruction about the treatment of patients with dyslipidemia and hypertension. For most items on the test, there was little or no correlation between the students’ level of confidence (mean scores typically = 3.5 to 4.2) and whether (or not) they correctly answered the question. In other words, students who incorrectly answered questions about a concept were just a likely to rate their confidence as a 4 or 5 (moderate-high or high) as students who correctly answered the question. The same confidence and knowledge assessments were administered 4 months later. Interestingly, student confidence remained relatively high (despite the passage of time); however, their retention of the knowledge decreased significantly, by about one letter grade.³ Since the multiple-choice exam was administered after the confidence assessment, it seems clear that students were not able to accurately judge their knowledge. Moreover, as we all know, in the absence of use, knowledge diminishes over time as the “use it or lose it” phrase implies. And yet, students continued to be quite confident in their knowledge even after doing poorly on an exam and with the passage of time.

While learners may over-estimate their knowledge and skill, is it possible to increase their confidence using novel teaching techniques? In a pharmacotherapy laboratory course, teachers at the University of Wisconsin-Madison School of Pharmacy compared the use of paper-based patient-case narratives to the same cases deployed in a simulated Case Scenario/Critical Reader (CSCR) Builder program. The hypothesis was that the simulated environment would increase student engagement, knowledge, and confidence. Each group – paper-based and simulation— completed a 13-item pre-experience confidence survey (0-39 score) regarding their self-perceived ability to manage a patient with osteoarthritis. The simulated-case students had access to an electronic medical record (EMR), could navigate through a series of multiple-choice questions, and could gather information from the simulated patient and physician. The simulation group reported significantly increased confidence in their ability to assess the medication regimen and document the encounter (p < 0.05) when compared to the paper-based group. However, the mean SOAP scores were not significantly different. So, the instructor’s effort (> 20 hours) put into creating a simulated patient case may have increase student confidence but its impact on skill appears to be marginal.⁴

Similarly, instructors at the University of North Carolina at Chapel Hill School of Pharmacy designed a rigorous third-year pharmacy elective where students gained experience with exercise counseling. The students created pamphlets and monitored a patient over a 4-week period. Students who took the elective were more confident counseling patients about exercise and remained more confident 6 months later when compared to students who did not enroll in the course.⁵ Thus, engaging students in practical, hands-on experiences appear to be an important aspect of developing confidence.⁶

Developing one’s confidence is an important step in becoming an effective clinician. Students may be misled by high exam scores into believing their clinical abilities are well developed. This can be problematic because overestimation may result in students inadvertently practicing beyond their level of competence, resulting in patient harm. However, providing students with opportunities to simultaneously employ their knowledge through concrete, real-life experiences improve their clinical confidence and competence.⁶

Recommendations to help students more accurately assess their confidence and competence:

• Measure confidence before administering knowledge and/or skill assessments
• Provide students with engaging ways to learn and test their skills
• If students overestimate their knowledge or skill, challenge them to identify where their knowledge or skill is lacking
• Personal experience, providing students autonomous practice, can help students grow their confidence and competence

Questions yet to be answered:

• What factors influence students’ perception of confidence?
• What is the relationship between clinical experience and confidence?
• What effect does problem-based learning (and other forms of classroom-based problem-solving) have on clinical confidence?

References

1. Confidence. Merriam-Webster's dictionary. 2019.
2. Kruger J1, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999; 77: 1121-34.
3. Valdez CA, Thompson D, Ulrich H, Bi H, Paulsen S. A Comparison of Pharmacy Students’ Confidence and Test Performance. Am J Pharm Ed. 2006; 70 (4) Article 76.
4. Barnett SG, Gallimore CE, Pitterle M, Morrill J. Impact of a Paper vs Virtual Simulated Patient Case on Student-Perceived Confidence and Engagement. Am J Pharm Ed 2016; 80: Article 16.
5. Persky AM. An Exercise Prescription Course to Improve Pharmacy Students’ Confidence in Patient Counseling. Am J Pharm Ed 2009; 73: Article 118.
6. Jih JS, Shrewsbury RP. Student Self-Analysis of Their Nonsterile Preparations and its Effect on Compounding Confidence. Am J Pharm Ed 2018; 82: Article 6473.

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Problem-Based Learning: Is It A Better Way To Learn?

by Brandon Hawkins, Pharm.D., PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Howard Barrows, one of the earliest champions of problem-based learning (PBL), once defined it as “the learning that results from the process of working toward the understanding or resolution of a problem.”¹ Since its first use at McMaster University School of Medicine in the 1960s, PBL has been used by many other health disciplines including nursing and pharmacy.^2,3 PBL really took off in pharmacy education in the early 2000’s when the Accreditation Council for Pharmacy Education (ACPE) standards proclaimed that the Doctor of Pharmacy curriculum should promote “lifelong learning through the emphasis on active, self-directed learning and … teaching strategies to ensure the adeptness of critical thinking and problem-solving.”⁴ This theme continues today in the 2016 ACPE accreditation standards.⁵

As an instructional method, PBL is primarily designed to empower learners to solve a problem through the application of knowledge. Given its wide range of implementations, there is no universally agreed definition of problem-based learning. Traditionally, PBL usually involves a small group of students with an elected (or appointed) leader and scribe. A faculty member serves as the facilitator whose primary role is to observe the group dynamics and ensure the intended learning objectives are achieved but does not provide any direct instruction. The groups review “trigger material,” such as a patient case or clinical scenario with no prior exposure and without instruction by the facilitator.⁶ Some institutions like the University of Southern California implemented “assisted” PBL, whereby didactic lectures are used to enhance the students’ background knowledge, but the technique still contains elements common to a traditional PBL experience.⁷ However, despite some differences in their implementation in pharmacy education, there are several common themes: discussions in small groups; hypothetical or real case scenarios; facilitation focused on group progress; and self-direction combined with collaborative learning. PBL uses problems in order to develop problem-solving skills as well as reinforce existing and acquire new knowledge.^8,9 Thus, PBL was an obvious choice for many schools and colleges of pharmacy to meet their need for a self-directed form of active learning. However, despite the level of “deep learning” provided by PBL, a common concern is that it may not lead to the same level of performance on standardized exams, which often focus on knowledge recall and memorization.⁶

Various disciplines and institutions have been experimenting with how best to implement PBL and to what degree this teaching strategy should be used throughout the curriculum. Should it be implemented in a single year as preparation for advanced practice experiences? Or used exclusively throughout the entire curriculum? Or sporadically as a substitute for case-based learning? Several investigators have now published about their experiences with PBL. In pharmacy education, feedback from students and educational performance data provide some insight into the methodology’s successes.

In a comparative study conducted at the University of Southern California, student rotation performance was compared after students participated in either PBL (Class of 1995) or received traditional didactic lectures (Class of 1994) during their third year of the pharmacy curriculum.¹⁰  Both groups received the same instruction in the first year of the curriculum and had similar mean GPAs (2.88 vs. 2.9, p=0.1). However, when comparing the graduating classes of 1994 and 1995’s mean GPA during experiential rotations, the PBL group was had significantly higher GPAs for both elective and required rotations (3.29 and 3.38 vs. 3.09 and 3.11, respectively). The authors concluded that PBL produced positive outcomes during fourth-year advanced practice experiences because it increased students’ ability to engage in self-directed learning, increased their independence, and enhanced their decision-making skills. The authors felt these results were important given that the functions, responsibility, and skillsets required during the fourth year of the curriculum are similar to that of pharmacists providing pharmaceutical care.

A relatively recent meta-analysis analyzed 5 studies conducted in Canada, the US, and UK comparing the outcomes of PBL to conventional didactic instruction in pharmacy courses.¹¹ The primary endpoints were midterm and final grades, as well as subjective evaluations. While both the midterm (OR = 1.46; 1.16–1.89) and final (OR = 1.60; 1.06–2.43) grades were significantly higher in the PBL groups, subjective evaluations between the two did not differ. The authors concluded that PBL yielded superior student performance on assessments, while also promoting clinical reasoning and self-directed learning. However, the authors did note that the relatively small sample size may not be large enough to ensure the generalizability to other pharmacy programs.

Student assessment of PBL seems largely positive as well. In one survey, graduates from the University of Mississippi School of Pharmacy were surveyed regarding PBL and the adequacy of their preparation for Advanced Pharmacy Practice Experiences (APPEs).¹²  In disease state/drug therapy discussions, efficient retrieval of current medical literature, and patient-specific evaluation of drug regimens, 50% or more of graduates believed PBL had provided them with above average preparation in these areas. The authors point out that the success of PBL shouldn’t be solely measured by student success on licensing exams, but also students’ perceptions and self-confidence to enter practice.

Though the impetus for many colleges and schools of pharmacy to move toward PBL may have been, in part, to satisfy accreditation standards, it would seem that the results, at least in pharmacy education, suggest this instructional technique is effective. There are multiple sources of data that suggest the PBL is as good as, or possibly superior to, more passive learning strategies such as didactic instruction. However, while assessments and correlations with academic performance are helpful in gauging its efficacy and benefits, it can difficult to truly assess the student experience.

I recently had my first experiences as a PBL facilitator. When I begin a PBL session, I always ask the students what their expectations of the facilitator are. They frequently asked for clinical pearls. While I believe that PBL provides more robust, “real world” examples and deeper learning as a whole, I do think it is valuable for teachers to share “clinical pearls” with students. Traditional PBL offers little opportunity for teachers to share “pro tips,” instead emphasizing how to learn, apply, and approach a complex problem. Though assessments and surveys may indicate that students are more prepared for practice and are generally satisfied with PBL as a learning method, it does leave me wondering if learners are missing out on “fact-based learning” that more traditional methods of instruction afford.


References

1. Barrows H. A taxonomy of problem-based learning methods. Med Educ. 1986;20(6):481-486.
2. Creating Lifelong Learners. London: English National Board; 1994.
3. Ross L, Crabtree B, Theilman G, Ross B, Cleary J, Byrd H. Implementation and Refinement of a Problem-based Learning Model: A Ten-Year Experience. Am J Pharm Educ. 2007;71: Article 17.
4. American Council on Pharmaceutical Education. Chicago; 2000:52-53.
5. Accreditation Council for Pharmacy Education. 2016. Accreditation standards and key elements for the professional program in pharmacy leading to the Doctor of Pharmacy degree. Available at https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf.
6. Wood D. Problem based learning. BMJ. 2003;326(7384):328–30.
7. Romero R, Eriksen S, Haworth I. Quantitative Assessment of Assisted Problem-based Learning in a Pharmaceutics Course. Am J Pharm Educ. 2010;74(4):Article 66.
8. Savery J. Overview of Problem-based Learning: Definitions and Distinctions. Interdisciplinary Journal of Problem-Based Learning. 2006;1(1):9-20.
9. Barrows H. Problem-based learning in medicine and beyond: A brief overview. New Directions for Teaching and Learning. 1996;Winter 1996(68):3-12
10. Nii L, Chin A. Notes Comparative Trial of Problem-Based Learning Versus Didactic Lectures on Clerkship Performance. Am J Pharm Educ. 1996;60: 162-164.
11. Galvao T, Silva M, Neiva C, Ribeiro L, Pereira M. Problem-Based Learning in Pharmaceutical Education: A Systematic Review and Meta-Analysis. The Scientific World Journal. 2014; Feb:1-7.
12. Hogan S, Lundquist L. The Impact of Problem-based Learning on Students' Perceptions of Preparedness for Advanced Pharmacy Practice Experiences. Am J Pharm Educ. 2006;70:Article 82.

Using Nostalgia to Increase Motivation and Counteract Threats

by Andrew Watkins, Pharm.D., PGY1 Pharmacy Practice Resident, St. Dominic Memorial Hospital

Nostalgia, “a sentimental longing or wistful affection for the past,” has become a topic of active research in recent years.¹ It is a unique emotion that is anchored in social interactions and past experiences that invoke both positive feelings of support but also feelings of longing. Despite its bittersweet nature, it tends to be a positive emotion that people of all ages and cultures experience. Evidence now suggestions that nostalgia has a role as a psychological balancer, maintaining homeostasis and comforting people in times of stress or adversity. Nostalgia can be prompted by a number of stimuli such as smells, tastes, or visual information. In addition to these stimuli, nostalgia can also be prompted by feelings of loneliness, angst, or unrest. It is in these situations that nostalgia works to counteract these negative experiences and rebalance one’s emotional state. For example, it is not uncommon during times of stress or hardship to reminisce or nostalgize about good times experienced in the past. While these feelings are bittersweet and emphasize the dichotomy between the past and present, they promote positive emotions that can act as a buffer to help one progress through current situations.

One of the fascinating things about nostalgia is that the event being remembered need not be positive for the nostalgic feelings to be positive. There are many times when remembering a “bad” or negative past event or time period can still invoke positive feelings. One example, many people reminiscing about early times in a relationship or creating a business when there were hardships or financial struggles. The experience was probably not enjoyable at the time, but reminiscing about it will likely invoke positive feelings of happiness and pride in your ability to navigate those difficult times and grow. The role of nostalgia as a tool in education is relatively unexplored. As educational environments often elicit feelings of stress or anxiety, the use of nostalgia to mitigate these feelings is a very intriguing area of research.

When pursuing goals, people typically appraise tasks as threats or challenges. Threats are seen as negative experiences in which one may experience loss or may not be able to meet demands. On the other hand, challenges are seen as positive experiences that provide opportunities for growth. Threat appraisals in an educational context have been associated with procrastination, higher anxiety, lower performance, and decreased intrinsic motivation.^2-5 These effects are very detrimental because a decrease in intrinsic motivation arguably has the greatest negative effect on performance.⁶ If using the homeostatic model of nostalgia, one might expect a negative stimulus to prompt nostalgic feelings, which then help offset the negative stimulus. Numerous studies have found this to be the case; threats against self-esteem, meaning in life, and social connectedness have all been found to be reversed by nostalgia.^7-10 As an example, one of these studies involved researchers prompting one group of participants to think of a nostalgic experience. In a questionnaire given after this experience, these participants reported stronger feelings of support and self-regard than those who were not prompted to think of a nostalgic experience. Using this homeostatic model in the context of threat/challenge appraisals, one could hypothesize that the negative stimulus of a threat appraisal would stimulate nostalgia, which would counteract the negative feelings and increase intrinsic motivation. Challenge appraisals, because of their positive connotations, would theoretically not prompt nostalgic feelings. Knowing this, a group of researchers recently set out to explore whether nostalgia could restore the intrinsic motivation prompted by threat appraisals.¹¹

In their study, the authors deployed a number of specifically timed questionnaires to students (n = 382, age 18 to 27 years) who attended at a university in Northeastern United States. The experiment began with a baseline nostalgia inventory (T0 nostalgia) that where participants indicated how nostalgic they felt in the preceding days. The scores from this questionnaire were averaged to create a nostalgia index score. Two months later (around the middle of the semester), participants answered questionnaires to assess their threat and challenge appraisals (T1 threat and T1 challenge). The scores were averaged to give each participant both a threat and a challenge index score. Lastly, the participants were asked one month later (toward the end of the semester) to answer the same nostalgia inventory (T2 nostalgia) as well as an intrinsic motivation scale (T2 intrinsic motivation). The relationships among these variables were then analyzed.

The results suggest that perceived threats may promote nostalgia. Threat appraisals were negatively associated with intrinsic motivation and positively associated with the T2 nostalgia score, even when controlling for baseline T0 nostalgia in a regression analysis. Moreover, the authors found that T2 nostalgia was positively associated with intrinsic motivation. These results align with the idea that threat appraisals decrease intrinsic motivation but also increase nostalgia. This nostalgia then acts to balance the negative effects by increasing intrinsic motivation. Next, the authors found that challenge appraisals were associated with higher intrinsic motivation. Challenge appraisals were also associated with higher T2 nostalgia, but this relationship was no longer significant when T0 baseline nostalgia was taken into account. This implies that challenge appraisals do not predict a change in nostalgia over time like threat appraisals do. This nostalgia indirectly increases intrinsic motivation in response to threat appraisals but are unaffected by challenge appraisals.

This evidence opens the door for future research into nostalgia as a tool to overcome a variety of perceived threats in educational settings. I personally think that nostalgia is a promising tool to help students experiencing stress or feelings of being overwhelmed. I could see it playing a role in individual student counseling sessions, which could involve the educator prompting the student to reflect on past experiences and how he or she handled those situations. These sessions could also be as simple as a student just talking through a past experience(s) while the educator listens, prompting internal feelings of reassurance and promoting the student’s self-esteem.

One could also imagine brief nostalgic writing assignments, perhaps weekly, during a course. An instructor could ask students to briefly write about a time in their past when certain feelings or events happened (e.g. time of difficulty, a prideful experience) and how the situation was resolved or handled. The writing prompts could change each week to avoid assignment burnout. These types of brief written assignments would give students the opportunities to express themselves and would force them to reflect on past events. Or perhaps simply making brief cultural references to the past (i.e. music, TV shows) during class sessions could subconsciously promote nostalgic feelings in students, which might promote positive feelings and improve intrinsic motivation. Nostalgia appears to be a promising tool. We need more research in order to optimize its use in education.

References

1. Pearsall J, Hanks P. New Oxford Dictionary of English. 1^st ed. Oxford (UK): Oxford University Press;1998.
2. McGregor HA, Elliot AJ. Achievement goals as predictors of achievement-relevant processes prior to task engagement. J Educ Psychol. 2002;94(2):381-95.
3. Putwain D, Remedios R. The scare tactic: do fear appeals predict motivation and exam scores? School Psychol Quart. 2014;29(4):503-16.
4. Putwain D, Symes W. Perceived fear appeals and examination performance: facilitating or debilitating outcomes? Learn Individ Differ. 2011;21(2):227-32.
5. Putwain D, Symes W. Teachers' use of fear appeals in the mathematics classroom: worrying or motivating students? Br J Educ Psychol. 2011 Sep;81(Pt 3):456-74.
6. Cerasoli CP, Nicklin JM, Ford MT. Intrinsic motivation and extrinsic incentives jointly predict performance: a 40 year meta-analysis. Psychol Bull. 2014;140(4):980–1008.
7. Sedikides C, Wildschut T, Routledge C et al. To nostalgize: mixing memory with affect and desire. Adv Exp Soc Psychol. 2015;51:189–273.
8. Wildschut T, Sedikides C, Arndt J et al. Nostalgia: content, triggers, functions. J Pers Soc Psychol. 2006;91(5):975–93.
9. Routledge C, Wildschut T, Sedikides C et al. The power of the past: nostalgia as a meaning-making resource. Memory. 2012;20(5):452–60.
10. Zhou X, Sedikides C, Routledge C et al. Counteracting loneliness: on the restorative function of nostalgia. Psychol Sci. 2008;19(10):1023-9.
11. Bialobrzeska O, Elliot AJ, Wildschut T et al (2019). Nostalgia counteracts the negative relation between threat appraisals and intrinsic motivation in an educational context. Learn Individ Differ. 2019;69:219–24.

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.