Building Authentic, Meaningful, and High-Quality Team-Based Learning Activities

by Megan Harlow, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

In pharmacy school I participated in many team-based learning activities. As an introvert, I found it challenging to be thrown into a (seemingly) random group and try to work toward a common goal with people who may not care about the end result as much as I did. None-the-less, some team-based learning activities were satisfying learning experiences and I actually had fun working with others applying our knowledge to a (seemingly) real-life situation. Some of these experiences are by far my favorites in pharmacy school.

Team-based learning is a type of small-group learning that requires student preparation prior to class and devotes class time to application exercises. Before class starts, students complete a pre-class activity (reading, watching videos, etc.) to learn about the key concepts that will be needed during the in-class activity.¹ The class starts with each student taking a test to assess his/her readiness after which the same test is completed by students as a team. At some point, either during or after the group readiness test, the instructor reveals the answers. Depending on the testing procedures employed by the instructor, the groups may find out if their answers are correct during the testing process. For example, one of my classes used scratch-off answer cards. The correct answer had a star next to it to indicate that the answer was correct. Computer methods for scoring the group readiness test can also be used. Students have the opportunity to appeal the correctness of any answers with which they disagree. After the testing is finished, a short presentation may be given whereby the instructor hones in on concepts students struggled with on the test.

Image from: Sultan Qaboos University medical journal 12(3):336-43

After the readiness testing, students then work in small groups on application activities.  These activities present the student groups with a problem for which they are require to select a specific course of action.¹ All teams report their decisions at the same time.  This gives the students an opportunity to see how other teams have managed the problem differently. The teacher does not tell students the answer but rather guides the teams as they work through the problem toward their own solution.¹ The theoretical basis of this instructional method is grounded in constructivist learning theory, whereby the active involvement of the student is essential to the process. Students are encouraged to use their life experiences and knowledge while trying to solve the assigned problem.^1,2

While this instructional strategy sounds great, things don’t always live up to the ideal. Yes, when the activities are well-designed, students have the opportunity to acquire foundation knowledge and they get to apply those concepts to problems. Students are also learning how to work with others who may have different backgrounds and opinions from their own. However, some team-based learning activities aren’t well-designed and students don’t achieve the desired learning outcomes. This was a problem I faced several times during my undergraduate and pharmacy school years. Learning activities that are not well-designed lead to frustration among students and can cause group tension. One of the hardest parts of creating team-based learning activities is developing assignments that encourage deep thinking as well as engaged, content-focused small group discussion. The problems that the groups attempt to solve should be authentic and have clear application to their future roles.²

So, what makes a team-based learning activity effective? A recent study solicited the opinions of pharmacy educators who are experts on team-based learning to identify quality indicators for team-based learning activities. A two-rounded modified Delphi process was used whereby these experts were asked about the characteristics of strong team-based learning activities and how to create positive learning outcomes as well as enhance student satisfaction.² The first round of the Delphi process asked the experts a series of open-ended questions about team-based learning activities. These thoughts and opinions were then summarized and a series of best practice statements were formulated.  The investigators presented these statements back to the experts to measure their level of agreement.²

According to the expert panel, effective team-based learning activities must be focused and clear instructions must be provided to students.  Students should know what they are being asked to do and what they need to do to prepare for the in-class activity using the assigned pre-class background materials. The learning activity must be feasibly completed in the allotted in-class period but also appropriately challenging and complex. There also must be time allotted to providing effective feedback to each group. The content of the activity should be an authentic challenge in pharmacy practice and require the application of multiple domains of knowledge and/or skill.² The activity should encourage the group to pool their prior knowledge and life experiences together to solve a multifaceted problem. The activity should be clearly linked to an outcome or objective of the course but should also require students to apply their knowledge from other courses. In addition, a good team-based learning activity should prepare students for future assignments. Lastly, team-based activities should promote higher-level thinking, encourage group discussion, and require the involvement of every student in the group.²

Feedback is an essential component of team-based learning for both learning and long-term retention. Feedback should be included at each step of the process. The individual and group tests provide feedback on the students’ preparation for the activity. While working with their group, students receive peer feedback as well as feedback from the instructor on the group’s ability to prioritize, organize, and defend their approach to the problem.²

To illustrate these concepts, here’s a team-based activity I participated in during pharmacy school. The module was related to pain management. The syllabus provided explicit instructions on what should be done before coming to class. The class was assigned two presentations to review. We then took a quiz to assess our pre-class learning and the instructor gave a short lecture before beginning the team activity. The assignment was able to be feasibly completed in the class period and there were several facilitators to keep us on track. The subject matter included many new concepts for my classmates, so the problems were straight forward but challenging. We had access to evidence-based resources during the activity. During the assignment, each group was given feedback about their progress. We all understood how this activity was relevant to our future professional role as pharmacists and it required us to recall things we learned during pharmacotherapy courses earlier in the curriculum and apply them to a case. 

Some students may be resistant to this form of instruction at first. Over time student objections and concerns will likely subside. One study, which surveyed occupational therapy students about their perceptions of team-based learning, showed that students were significantly more satisfied with team-based instruction after the third trimester when compared to their opinions after the first trimester.  Moreover, students reported they were significantly more accountable for completing the pre-class assignments.³ These findings indicate that students need time to become accustomed to the team-based learning technique and must learn how to meaningfully engage in the in-class activity.

While team-based learning can promote higher-order thinking, problem-solving, and teamwork, these all depend on designing effective pre-class and in-class learning activities.  Students need clear instructions about what they need to do to prepare.  Feedback at each step of the process is important.  The instructional activities need to align with the course objectives.  And the in-class group activities should be relevant, sufficiently complex, but achievable in the allotted time.   By keeping these principles in mind, instructors can create authentic, meaningful, and high-quality team-based learning activities that have a lasting impact.

References

1. Brame C. Team-based learning. Vanderbilt University. 2020.
2. Janke K, Bechtol R, James S. Determining indicators of high-quality application activities for team-based learning. Am J Pharm Educ 2019;89(9): Article 7109. 
3. Carson R, Mennenga H. Team-based learning and the team-based learning student assessment instrument (TBL-SAI): a longitudinal study of master of occupational therapy students’ changing perceptions. Am J Occupational Ther 2019;73(4): 7304205010p1–7304205010p7.

Creating an Effective Feedback Environment to Enhance Students’ Field Experiences

by Clare Olin, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Many students in higher education learn through field experiences, like internships or clinical “rotations.” During these experiences, an assigned preceptor helps the student to gain “on the job” experience to better understand their chosen profession. Experimental education is important because it provides students with an opportunity to use skills they initially learning about during didactic instruction. The preceptor reinforces the knowledge the student initially gained in the classroom.  Students also receive feedback from the preceptor who evaluates their performance.  Ultimately, these experiences and the feedback from their preceptors prepare them for their career. 

Feedback given by preceptors is meaningful in guiding a student’s growth. It’s important to create what Steelman and colleagues an effective “feedback environment.”¹ This is how feedback is delivered in both words and actions. Learners are more likely to accept and act on feedback when it is given well. There are seven variables that contribute to the feedback environment and influence whether the recipient will perceive the feedback as useful:¹

• Source credibility
• Feedback quality
• Feedback delivery
• Frequency of favorable feedback
• Frequency of unfavorable feedback
• Source availability  

Source credibility refers to how students perceive their preceptors. Students are more likely to acknowledge and implement the comments provided by people they highly respect.  Thus, a preceptor should be, first and foremost, a good professional role model.  Feedback is considered high quality when it is consistent, relevant, specific, and useful to the learner. Feedback delivery refers to both verbal and non-verbal communication. The reception of both positive and negative comments can be influenced by the tone, volume, word inflection, eye contact, and even body language of the deliverer. The frequency of favorable feedback can influence a student’s behavior and keep them motivated. Thus, positive reinforcement techniques can help engage students throughout their practice experiences and build positive attitudes and relationships. Positive feedback also builds students confidence and helps them develop independence. The frequency of unfavorable feedback is also important.  Constructive feedback is intended to help students improve and, when delivered effectively, can also keep students motivated. When unfavorable feedback is given, it is more likely to be taken positively if preceptors describe specific ways that the students’ performance can improve. Source availability refers to the how accessible the preceptor is – both physically and psychologically. Students are more likely to approach an accessible preceptor with questions and concerns. This can then help build a relationship between the two, and in turn, it may allow the feedback received to be more meaningful. While these seven principles were determined by observing employee relationships with their direct supervisors, the concepts are equally applicable to clinical instruction. In clinical teaching environments, students are preparing for a job and feedback strategies should be similar.² 

One study looked at the feedback strategies of preceptors in relation to student’s perceived feedback value.³ Students (n=132) from multiple states and with a variety of clinical experiences were asked to complete a survey. The survey consisted of three sections: demographic data, feedback environment scale (FES), and the feedback orientation scale (FOS).  The students were asked to rank statements about FES and FOS using a 5-point scale.  The FES section of the survey examined the following aspects of the environment:

• Source credibility
• Feedback quality
• Feedback delivery
• Favorable feedback
• Unfavorable feedback
• Source availability
• Promotes feedback-seeking behaviors

The FES represented how well students respond to the feedback “environment” that the preceptor created. The FOS included the student’s self-reflection on how they best use feedback and included:

• Utility
• Accountability
• Social awareness
• Feedback self-efficacy

The results demonstrated a significant positive correlation between the FOS and FES scores (p = 0.01), meaning that as the student’s perception of the feedback environment improved so did the perceived usefulness of the feedback given. When focusing on each element of the feedback environment, feedback utility was most affected by feedback quality and delivery. There was a significant relationship between accountability and the frequency of favorable feedback (p = 0.05), suggesting that consistency of feedback promotes the application of the preceptor’s assessments to the student’s daily work. Although utility, social awareness, and self-efficacy did not achieve statistical significance, there were positive relationships between each and the FES scores.

In order to implement these principles in practice, preceptors should start by being accessible and available to students. This should include providing phone number(s), email address, and reliable office hours or meeting times.  In addition, it is important to create a psychologically safe environment so that students feel comfortable reaching out. Regularly scheduled times for feedback can help the preceptor and the student stay on track. Preceptors should plan what to say in advance of these meetings and be prepared to give specific examples of both positive and negative observations.⁴ Preceptors should also encourage students to engage in self-reflection by using open-ended questions.  Finally, preceptors should give feedback promptly after a practice experience while the student can recall specific details.⁴

Keeping the seven dimensions of an effective feedback environment in mind can help new preceptors create positive field experiences. Constructive feedback should be specific and provide actionable strategies the student can use to improve their performance. Positive reinforcement should be given whenever a student has shown improvement. Effective feedback enhances students’ confidence and will enhance their ability to their professional responsibilities in the future.

References

1. Steelman LA, Levy PE, Snell AF. The feedback environment scale: construct definition, measurement, and validation. Educ Psychol Meas. 2004;64(1):165-184. doi:10.1177/0013164403258440.
2. Jonsson A. Facilitating productive use of feedback in higher education. Active Learn High Educ. 2013;14(1):63-76. doi:10.1177/1469787412467125.
3. Nolan T, Loubier C. Relating Instructor Feedback and Student Reception in the Clinical Environment. Radiol Technol. 2018 Jan;89(3):238-256.
4. Hardavella G, Aamli-Gaagnat A, Saad N, et al. How to give and receive feedback effectively. Breathe 2017; 13: 327–333.

Situational Judgment Tests (SJTs) to Measure Beyond Recall

by Karmen McMinn, PGY1 Pharmacy Community Practice Resident, Mississippi State Department of Health

In order to become a pharmacist, a student must receive a Doctor of Pharmacy degree. This means that they receive several years of education, but does all of that knowledge mean they will be successful? In addition to having a wide range of factual knowledge, pharmacists must also be able to display empathy towards patients and caregivers, work well in teams, and many other qualities that do not rely on the recall of facts.^1,2 These qualities (empathy, team player, etc) are sometimes be referred to as “soft” skills while being able to recall factual knowledge is often referred to as academic or cognitive skills.³ Some have argued that strong academic skills are inversely related to soft skills.^1,2 Thus, someone who earned straight A’s in those early science classes may struggle during advanced practice experiences.

One common requirement for pharmacy school admission is the Pharmacy College Admission Test (PCAT). The PCAT was designed to measure general academic ability and scientific knowledge. This background knowledge is something all students must have in order to be successful in pharmacy school. The problem with a test like this is that it only looks at a student's general academic knowledge while neglecting to assess other important skills a successful pharmacist must possess. For example, the PCAT does not assess a person’s ethical decision-making ability. This is where situational judgment tests (SJTs) might be useful. They can be an effective tool for assessing soft skills.^2,4

Icons made by Smashicons from www.flaticon.com

SJTs are a type of psychometric test in which learners are presented with a realistic scenario or situation. Examinees are then presented with 4 or more actions they could take and instructed to pick the option they believe is the most appropriate – an action they would take in real life. The test taker is often asked to pick not only the most appropriate response but also the least appropriate response. In some SJTs, they are asked to rank the relative appropriateness of the responses from most appropriate to least appropriate.⁵ SJTs can measure traits not related to a person’s ability to recall factual knowledge.⁶ This can be done by making sure questions ask what the person “would do” instead of what someone “should do.”⁷ Skills that can be measured on an SJT include personality traits like conflict management, interpersonal skills, teamwork, and cultural awareness.^3,5 All of these skills can help identify people who would make amazing pharmacists that have the ability to interact with a wide range of people and work effectively as a part of a healthcare team.¹

In one study, investigators at Monash University in Australia developed an SJT. They used experts to evaluate the tool’s validity, reliability, fairness, and to determine the appropriateness of using an SJT as a formative assessment. This study appears to be the first to report on the development, implementation, and evaluation of SJT as a formative assessment for pharmacy students. They developed the test to help identify students that might need more training to develop the soft skills integral to becoming a successful pharmacist.³

Here is an example SJT scenario and directions³

Scenario
Nikhil, a pharmacy student, is working in a community pharmacy. A customer explains to Nikhil that she came to the pharmacy yesterday to collect some blood pressure tablets. However, when she arrived home, she realized that she had been given double the strength of the tablet that she required and has not taken any of the new medications. Nikhil arranges for the pharmacist to correct the medication and apologizes to the customer for the error. However, the customer looks angry and says, “sorry is not good enough.”

Response Instructions
How appropriate are each of the following responses by Nikhil in this situation?

Options: 
1 = a very appropriate thing to do; 2 = appropriate, but not ideal; 3 = inappropriate, but not awful; 4 = a very inappropriate thing to do

Responses

Inform the customer that he has already apologized to her and that there is nothing more that he can do

1. Tell the customer that he was not working yesterday
2. Tell the customer that she needs to calm down
3. Ask the customer whether she would like compensation
4. Ask the pharmacist to come and speak to the customer
5. Provide the customer with information on the pharmacy’s formal complaints procedure

The potential advantages of using SJTs in health professional curricula include building a student’s understanding of the concept “best” and “better” ways of performance and increases self-assessment skills. Self-assessment skills are an important part of continuing professional development. Providing students with feedback and the opportunity for reflection can help motivate further development of these soft skills. It can also be helpful to students by administering multiple SJTs so that they can see their improvement over time.^3,6

There are a few issues that educators should consider before implementing SJTs. First, it is important to make sure the scenario or situation is well described. There must be enough information for a student to be able to fully visualize the scenario. If a student cannot envision the scenario, it will be difficult for them to pick the “best” answer. Secondly, it is best to develop a scenario that does not force a student to choose an action that would go violate their personal beliefs and values.^3,7

Educators can use SJTs to help develop skills and traits, such as interprofessional skills and cultural sensitivity, that help students become better pharmacists. These tests can be used as a tool to assist with admission decisions but also deployed repeatedly throughout the curriculum in order to document change over time. By using SJTs for formative purposes, an institution can personalize the development of soft skills, focusing the student’s attention on weaknesses as well as uncovering strengths. In the end, every school wants to graduate well-rounded and well-educated pharmacists.^1,3


References:

1. Gilchrist A. Top 5 Pharmacist Personality Traits. Pharmacy Times. 2015 July 23.
2. Jones J, Krass I, Holder GM, Robinson RA. Selecting pharmacy students with appropriate communication skills. [Internet]. Am J Pharm Educ 2000; 64(1): 68-73.
3. Patterson F, Galbraith K, Flaxman C, Kirkpatrick CMJ. Evaluation of A Situational Judgement Test to Develop Non-Academic Skills in Pharmacy Students. Am J Pharm Educ 2019 [Ahead of Print]
4. About the PCAT. [Internet]. Pearson. 2019. Cited 2019 Nov 12.
5. Situational Judgement Test [Internet]. Psychometric Tests. 2019 Jan 9. [cited 2019 Nov 11].
6. Austin Z, Gregory PAM. Evaluating the accuracy of pharmacy students’ self-assessment skills. Am J Pharm Educ. 2007;71(5): Article 89.
7. Assessment & Selection. Other Assessment Methods. Situational Judgment Tests. United States Office of Personnel Management. 2019. Cited 2019 Nov 21.

Creating Meaningful International Pharmacy Experiences

by Katherine Baker, Pharm.D., PGY1 Pharmacy Practice Resident, North Mississippi Medical Center

International pharmacy experiences are increasingly popular. Today, students are eager to see the world and compare their learning environments to those of other students around the globe. In 2010, a survey of 114 pharmacy schools in the United States revealed that 40 had an active global/international program.¹ Having completed a global pharmacy experience during pharmacy school, I can speak to their value. I was fortunate to spend 5 weeks in Phitsanulok, Thailand at Naresuan University teaching hospital. What seemed like a distant dream soon became a reality when I found myself in rural Thailand with one of my best pharmacy school friends relying on the Google translator application to help us communicate. While international experiences have important benefits simply from “being there,” it is equally important to know how to design these experiences to maximize learning.

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First, it important to ensure that international experiences foster the development of the competencies required for graduation. Second, that there should be policies in place to ensure that the international site and faculty are qualified.² To address these requirements and the increasing demand for global health experiences, several initiatives have sought to improve the quality of international pharmacy rotations. Indeed, the American Association of Colleges of Pharmacy developed a special interest group that includes a dedicated team of individuals who discuss topics and ideas related to global healthcare.¹  

Prior to establishing an international experience and sending student pharmacists across the globe, great attention should be paid to ensuring that both the student and the host site are prepared for the visit. The planning period for my international rotation was stressful due to unknowns that come with living and learning in a foreign country. These stresses were alleviated when the host site sent me documents with helpful information about our living arrangements and coordinated everything before arrival. A number of articles have explored important considerations that must be taken into account before developing a Global/International Advanced Pharmacy Practice Experience (G/I APPE). These considerations include host country, home institution, host institution, faculty/preceptors, and student issues.² 

The host country is an important factor to consider before establishing an international rotation. While having a well-thought-out curriculum is necessary, ensuring a safe and functional learning environment in a foreign country is even more important. Pharmacy schools need to ensure that students are well informed about the country they will be traveling to.  Students should try to learn about the local culture(s) and basic parts of the native language. This will help them while navigating abroad as well as improving patient interactions during the experience. While in Thailand, I worked in an anticoagulation clinic and was asked to interview and counsel patients. I struggled to communicate and had to rely on my preceptor. This particular experience would have been much more meaningful had I learned the language ahead of time. Logistics of the rotation such as visas, living arrangements, transportation, and financial considerations should also be addressed well in advance. 

Equally important are the host institution and the curriculum. To justify an international experience, the host institution should be vetted and deemed an appropriate pharmacy experience. It is recommended that the host and home institutions have a designate representative. These designated faculty members will be responsible for communicating student educational needs, learning outcomes, and detecting any red flags.¹  In addition, a thorough and thoughtful syllabus must be drafted and approved. Just like any other course or experience in pharmacy school, the syllabus should lay out expectations, goals, objectives, and grading criteria.¹    

Student interaction while on rotation is another important consideration to create a meaningful experience abroad. For students to take full advantage of their international pharmacy experience, they should be meaningfully engaged and aware of what they are learning. One descriptive study discusses the importance of reflective writing while on rotation. Based on student reflections, the authors noted a pattern to student learning while on a G/I APPE. Students use “communication, problem-solving, and adaptability”³ skills while on rotation and then reflect on the major differences between their home and host country. There a couple of ways to get students to reflect about their experiences.  One method is to ask students to keep a personal journal and regularly writing entries.  Another way to encourage reflection is to require students to give a presentation to peers after completing the experience. My pharmacy school required each student to create a weekly travel blog reflecting on their experiences (check out our blog: Thailand Adventures - Two Pharmacy Students Finding Their Way Through Thailand). This exercise helped us to reflect and translate what we learned abroad and apply it to our lives in the United States. Our blog essays were also useful to future participants. Indeed, many of our weekend excursions were based on blog posts from previous students!

Global pharmacy experiences are not only an adventurous, once-in-a-lifetime experience, they also enhance a pharmacy student’s professional advancement. In a world that is becoming smaller and more connected through technology, a G/I APPE will give students an opportunity to grow their perspective and sensitivity towards people from other cultures.¹ Students who have participated in a global pharmacy rotation are more likely to be culturally aware and “demonstrate increased interest in volunteerism, humanitarianism, and public health.”² Moreover, international experiences often help students improve their communication skills, problem-solving skills, and adaptability.³  

Having participated in an international rotation myself, I can attest to many of these benefits. If I could give any piece of advice, I would encourage students heading into an international experience to learn some of the host country’s language and keep a travel journal or blog. It’s also important to give both the host and home sites feedback. The home institution often go to great lengths to ensure that the rotation will be maximally beneficial but the best information is feedback based on personal experience. The host institution that I completed my rotation at required students to complete an in-depth exit survey. The institution wanted an honest review of the experience and it was important to openly discuss any concerns to better serve students for the future.

International pharmacy experiences are a once-in-a-lifetime opportunity that I would recommend to all pharmacy students. If the experience is well planned and executed by both the host and home institutions and if the student approaches the experience with enthusiasm and an open mind, it will be a personal and professional growth experience the student will never forget.

References:

1. Steeb DR, Overman RA, Sleath BL, Joyner PU. Global Experiential and Didactic Education Opportunities at US Colleges and Schools of Pharmacy. Am J Pharm Educ. 2016;80(1): Article 7. doi:10.5688/ajpe8017
2. Alsharif NZ, Dakkuri A, Abrons JP, et al. Current Practices in Global/International Advanced Pharmacy Practice Experiences: Home/Host Country or Site/Institution Considerations. Am J Pharm Educ. 2016;80(3): Article 38. doi:10.5688/ajpe80338.
3. Steeb DR, Miller ML, Schellhase EM, et al. Assessment of Global Health Learning Outcomes on International Experiences. Am J Pharm Educ. 2019. doi: 10.5688/apje7586