Reducing Black and White Thinking: Constructing Partial Credit Multiple Choice Exams

by Lauryn Easley, PharmD, PGY1 Pharmacy Practice Resident, North Mississippi Medical Center

During my many years in school, exams were given primarily in the classic, multiple-choice question format. The form of assessment has been the gold standard for many years.¹ While multiple-choice question examinations aren’t perfect, many would argue that “if it’s not broken, don’t fix it”. However, I would argue there is one significant shortcoming for the single best answer, multiple-choice tests —students begin to assume there is only one correct answer. This has led generations of students to view concepts with a “black or white” mentality. You are either right or you are wrong.  This kind of thinking is not helpful. Life is more nuanced. We need to help students understand that the world and our knowledge is actually rather grey.

In a world full of possibilities, leading our students to develop black and white thinking causes them to misunderstand situations. They only see the two extremes and not the in-betweens.¹ Traditional multiple-choice examinations potentially stifle students’ creativity, as well as enable them to put forth minimal effort, thus producing lazy learners.^1,2 If students were made to explain their reasoning or defend their choices, we could move away from simplistic answers and move towards students better able to stand by their viewpoints and use evidence to support them.^1,2 Furthermore, multiple-choice exams inhibit the instructor’s ability to truly know whether the students fully grasp the concepts being taught. With traditional multiple-choice exams, students can guess the answers to most questions and still pass. A savvy test-taker might not actually comprehend the material.

Traditional multiple-choice tests can lead to “over-thinking” because the student assumes there is only one correct answer, even though other answer choices seem appropriate.² As a type-A, over-thinker, I would find myself reading a question and looking for additional details to help make a complex decision.  But sometimes I was making the question far more complicated than the teacher intended. Because of this, I would sometimes pick an “incorrect” answer simply because I misunderstood what the teacher was asking me. In traditional multiple-choice exams, I had no way of explaining my reasoning.  I was forced to choose one answer over another. For this reason, I rarely reviewed questions I answered incorrectly on a test because I did not like to rehash my errors. Looking back, this was not a healthy mindset. None-the-less, I think it’s an important question. Should we move away from traditional multiple-choice exams, and if so, what are some suitable alternatives?

There are, in fact, a few different options, including awarding partial credit for answers that are okay but less than ideal, utilizing select all that apply questions, and short-answer questions.^1,2,3

Partial credit focuses on awarding the most points to students picking the “most correct” or “best” answer but not fully penalizing students for picking an answer that may not have been the best option among the choices offered but is a reasonable option in some circumstances. Scoring questions in this manner can also help instructors move away from factual, straightforward, there is only one “right” answer to questions and move toward conceptual questions that require deeper thinking.^1,2  For example, a question might ask about various treatment options for a disease or problem. While the “best” or “preferred” option might be among the choices, the student might be awarded partial credit for an option that is effective and unlikely to cause patient harm. In this case, the answer choice the student picked could be awarded partial credit, rather than full credit. The instills the idea that some answers are better than others but there is a range of “acceptable” choices. Other advantages of awarding partial credit – it may be easier for instructors to create distractors for the question and there may be fewer post-exam arguments from students seeking credit for their selected answers.

 Duckor and Holmberg give the example below to illustrate the benefits of organizing answer choices into bins, where certain bins are worth partial credit and other bins are considered incorrect.³

When the time is taken to organize and categorize each answer choice, instructors will have a better grasp of how well their students understand the topic, where common misconceptions lie, and where clarification with additional instruction may be beneficial. 

Select all that apply questions always discouraged me as a student because they were treated as all-or-nothing questions at my school.  You had to select ONLY the correct options and not select the incorrect options in order to get credit.  If you selected (or didn’t select) 5 out of the 6 options correctly, you go NO points. In other words, a student who got 5 out of 6 options correctly received the same number of points as a student who got 0 out of the 6 options correct.  It seemly likely the two students' understanding of the material is VERY different, but in terms of performance on the exam, they both received the same score. While some national certification examinations score select all that apply questions as all-or-nothing, this is not conducive to learning and doesn’t acknowledge what students DO know about the subject matter. To encourage students, they should be granted partial credit for each correct response option chosen and, conversely, points should be deducted for each incorrect option chosen. So, for example, if a student was correct on 5 out of 6 options, the student would receive +5 – 1 = 4 points.  If a student had 3 out of 6 options correct, the student would receive +3 – 3 = 0.  Awarding partial credit while also subtracting points for incorrect answers prevents students from gaming the system and simply selecting all options just to get some points.

As a student, I’ll admit that I didn’t like short-answer questions. However, in employing this testing format, we allow students to show us how much they understand and we can get a glimpse of each student’s thinking.¹ Short-answer essay questions really require students to thoroughly prepare. The student is forced to formulate a response – they can’t rely on recall to select from a list of possible responses.  Short-answer essays can be combined with the multiple-choice format whereby the student must provide a rationale for the response they selected.  In this way, students must know the correct or “best” answers but also must defend their choice.¹  Points could be independently awarded for selecting the correct answer and for the rationale.  Or points might be awarded only when the correct rationale is provided.  This would prevent “guessing” the correct answer.

I think these testing formats would encourage more students to review their responses to questions on an exam and encourage them to fully grasp the concepts being tested. It could lead more students to dig deeper into the materials to assess why they missed certain questions and why the best answer was, in fact, better than the other choices.

While a majority of these testing options may require more time and effort for either preparing or grading examinations, they give us a much clearer picture of how our students are doing and how well they grasp the material.^1,2 More importantly, rather than reinforcing black and white thinking, these alternative exam formats promote critical thinking, encouraging students to weigh the merits of different options.

References: 

1. Harrnstadt D. Pivot away from multiple-choice testing [Internet]. Bethesda (MD): Walt Whitman High School, The Black & White; 2019 Mar 23 [cited 2021 Jan 28].
2. Berwick C. What Does the Research Say About Testing? [Internet]. San Rafael (CA): George Lucas Educational Foundation, Edutopia; 2019 Oct 25 [cited 2021 Jan 28].
3. Duckor B, Holmberg C. Two Strategies for Assessing for Learning: The Partial Credit Scoring Key and the Scoring Guide [Internet]. Alexandria (VA): Association for Supervision and Curriculum Development, Inservice; 2018 Jul 23 [cited 2021 Jan 28].

Mastery- vs Performance-Oriented Goals and Their influence on Motivation and Success

by Michelle Ha, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital-North Mississippi

Many of us are familiar with setting goals: short-term, long-term, professional, and personal. But do ever think about your goal orientation? The concept of goal orientation was developed by psychologists in the 1980s and explains the mindset that an individual has when developing and achieving goals. There are two primary ways one can approach goals: mastery or performance.

Learners who have a mastery-orientation focus on learning to perform better in the real world – for example, learning in order to become more skillful at taking care of patients. Learners who have a performance orientation focus on demonstrating competence relative to others – for example, performing well on exams, getting high marks on performance evaluations, and (in general) looking smart in front of others. In other words, those who set mastery-oriented goals tend to compete with themselves, and satisfaction is based on internal factors. Those who have performance-oriented goals are primarily motivated by external feedback and validation.^1,2

Summary of Mastery vs Performance-Oriented Goals.³

Mastery-Oriented	Performance-Oriented
More likely to be intrinsically motivated	More likely to be extrinsically motivated
Seek feedback that accurately describes their abilities and helps them improve	Seek feedback that flatters them
Choose tasks that maximize opportunities for learning and seek out challenges	Choose tasks that maximize opportunities for demonstrating competence and avoid tasks that make them look incompetent
Views errors as a normal part of learning and uses errors to improve	Views errors as a sign of failure and incompetence
Satisfied with performance as long as they make progress	Satisfied only if they succeed
Views teacher as a resource	Views teacher as a judge, rewarder, or punisher

Goal orientation is important because it influences one's motivation and selection of learning strategies. Goal setting starts at a young age - regardless if you were aware of it or not. Thus, many people are unaware of the impact that their goal orientation has on their performance in school and life.

Imagine you have two students in your class: Marcus and Marilyn.

Marcus wants to perform well in school. He studies hard and would like to earn an “A” in pharmacology. He pushes himself hard to make his parents proud. However, he sometimes worries about whether he'll get an "A", failing to live up to his parents' expectations, and looking incompetent in front of the teacher/preceptor. He knows what learning methods work best for him and does not want to try other studying strategies. When he performs poorly on an exam, he submits challenges to the instructor in order to “get” points, even if he really didn’t understand the concepts that well. Although Marcus nearly always meets his goals, he beats himself up when he falls a bit short.

On the other hand, Marilyn enjoys the process of learning. She goes beyond the expectations set by the instructor in her pharmacology course and seeks out outside opportunities to learn more about the topic. While getting an “A” in the course would be great, she’s not too worried about the grade, so long as she’s learning new things she feels are important to her future career. She is most happy when she meets her personal goals and continues to strive to do better each day. When she struggles to learn about a concept, she seeks help and tries new strategies, and uses new resources.  When she performs poorly on an exam, she seeks help from the instructor and signs up for tutoring help. Although Marilyn nearly always meets her goals, she knows that stretching herself and falling short is part of the process.

A person can have both mastery and performance-orientations.  Indeed, most people don’t fall exclusively in one camp or the other and their orientation can be different in different circumstances and courses. However, researchers have found that mastery-oriented goals are more effective in terms of student motivation. Satisfaction is not related to external factors. Performance goals are often helpful in the short-term; however, they may stifle a student growing to their full potential.

Back to our example, Marcus' goal was to make an A in pharmacology. Once he believes he’s achieved this goal in the class, he may be less motivated and prefer to “coast” through the rest of the course. "I've made As on the last three exams and as long as I get at least 67 points on the final, I’ll still get an A." In his mind, his success is determined by his grades. If Marcus ends up with a B in the course, he’ll probably avoid taking the pharmacology elective for fear he won’t do well and his GPA will be negatively impacted.  In contrast, for Marilyn, if she gets an A on the first 3 exams in pharmacology, she will continue to study hard and may even continue to seek out opportunities to learn more after the course has ended. If she falls short of a good grade in her pharmacology course, Marilyn might sign up for the pharmacology elective in order “to get better” at something she feels is critical to her success. The factors that move her forward are internal and within her control. Thus, it is easier for Marilyn to stay resilient and adapt during times of struggle. Marilyn experiences less anxiety and stress when she falls short.

To examine the influence of goal orientation on motivation, one study evaluated how students responded to negative feedback. The investigators used a simulation game. Prior to participating in the simulation, each student’s orientation was measured using a multi-item scale adapted from Ames and Archer (1998). Students then completed a Marketing Management Experience, where they manage a simulated company and competed against other groups. Learning implies a change in behavior which was measured by comparing the survey results over time. While both mastery and performance-oriented students performed well during this simulation, those in the mastery-oriented goal group tended to take negative feedback better. In the performance-oriented goal group, some of the students develop a learned behavior known as "learned helplessness". This is a term that describes the reaction to failure that reduces the desire to place oneself in that circumstance again. 

In another study, researchers surveyed medical, pharmacy, and veterinary students. The students completed a series of surveys at the beginning of 5 consecutive semesters that measured their mastery orientation, performance orientation, and self-efficacy. While most students were stable in terms of their goal orientation, there were some differences between students based on their gender, grades, and self-efficacy. Self-efficacy was the biggest predictor of those who adopted mastery-oriented goals. Self-efficacy is the strength of a student's belief in their ability to complete a task.⁵

Self-efficacy in itself is another important concept!  In brief, it is a good predictor of motivation and learning, especially in health professional students and practitioners. Someone with a high level of self-efficacy can visualize a positive outcome and is more likely to perform well in their daily duties such as delivering patient care. The ability to adapt and remain resilient in times of unexpected setbacks is also more easily managed among those with a high level of self-efficacy.⁶

Marilyn, our student who is focused on learning and improvement, is the ideal student. However, it is not an innate trait. Mastery-orientation to learning can be taught and cultivated! As educators, we must encourage students to approach their learning with mastery-oriented goals in mind. Because self-efficacy and mastery-oriented goals go hand in hand, it is important to give students a choice when assigning learning activities.  Asking students to think about how their learning activities link to their careers will increase the likelihood of students developing mastery-oriented goals.^1,7 Allowing students to make choices and linking those choices to career aspirations will help students feel autonomous and motivated to learn.⁷ Below is a list of other things that you may wish to try in the classroom to foster a mastery-oriented mindset.⁷ 

1. Be a role model for students. Show them that you have made mistakes but have learned from them instead of hiding them or avoiding them.
2. Give positive, constructive feedback that focuses on personal improvement. Focus less on grades and more on mastering the skill or concept.
3. Don’t compare the student’s performance to peers. Emphasize growth.  Compare the student's performance to previous performance.
4. Foster a community of trust within the classroom so that students are more likely to seek help from peers and you.

While students with performance-oriented goals are no less likely to get good grades, they may be less likely to develop life-long learning habits. Mastery-oriented goal-setters strive for improvement daily and want to become better even if that means venturing through unknown challenges. Students who approach their goals as an opportunity to master something will be the ones who love what they do and are motivated to learn more. Instilling a mastery-oriented mindset in your students will groom them for a future of success.

References:

1. Donald B. Stanford psychologist: Achievement goals can be shaped by environment [Internet]. Stanford University. 2012 [cited 2021 Jan 11].
2. Bråten I, Strømsø HI. Epistemological beliefs and implicit theories of intelligence as predictors of achievement goals. Contemporary Educational Psychology. 2004 Oct;29(4):371–88.

3. Mastery Vs Performance Goals. [Internet] Western Oregon University. [cited 11 January 2021].

4. Gentry JW, Dickinson JR, Burns AC, Mcginnis L, Park JY. The role of learning versus performance orientations when reacting to negative outcomes in simulation games. Association for Business Simulation and Experiential Learning. 2006;33.

5. Kool A, Mainhard T, Brekelmans M, van Beukelen P, Jaarsma D. Goal orientations of health profession students throughout the undergraduate program: a multilevel study. BMC Med Educ. 2016 Dec;16(1):100.

6. Zamani-Alavijeh F, Araban M, Harandy TF, Bastami F, Almasian M. Sources of health care providers’ Self-efficacy to deliver Health Education: a qualitative study. BMC Med Educ. Jan 2019;19(1):16.
7. Svinicki M. Fostering a Mastery Goal Orientation in the Classroom [Internet]. Austin; 2010 [cited 2021 Jan 23]. p. 25-28.

Team-Based Learning Promotes Self-Reflection and Creates Lifelong Learners

by Austin Simmons, PharmD, PGY1 Pharmacy Practice Resident, Magnolia Regional Health Center

During the first two years of any healthcare provider’s schooling, students often find themselves navigating their curriculum and trying to remember all of the little details that are thrown their way. Most students don’t engage in much self-reflection during this period due to workload demands. Then comes the third and fourth years of school. This is when students try to piece it all together and decipher what they know and what they will need to work on as they transition from student to independent practitioner. I believe team-based learning prepares students to transition from dependent learners to lifelong learners and promotes self-reflection.

Team-based learning is built on the constructivist theory which states that learners process new material and integrate it with existing understandings in order to form a new cognitive structure that is unique to them.¹ Hrynchak and Batty wrote about team-based learning and provide an analysis of how constructivist theory plays a role in student development. Essentially, the professor is a facilitator for learning.  The students encounter inconsistencies between their preconceptions and new experiences.  In team-based learning, the focus is on relevant problems and accompanied by group interactions, and this often leads to reflection.² They go on to explain that team-based learning can be used in large classes that are divided into smaller groups.  The goal should be to maximize the diversity within the teams.² Let’s take a look at the framework team-based learning uses to promote self-reflection and build lifelong learners.

Classically, the design of team-based learning is a three-step process that involves student preparation, readiness testing, and application-focused exercises.³ Now, how does this framework promote learning and increase student self-awareness? Let me draw from my own experience.  At my pharmacy school, we had a class called case studies. The intent of this class was for the students to prepare before the class session and use prior knowledge.  We would then engage in collaborative work discussing a patient case in our assigned small group. Then after our small group discussion, the classroom as a whole would come together and the professor would facilitate a conversation by asking each small group questions related to the patient case. The instructor would also encourage the entire class to openly respond to these questions. It was during these interactions, in our teams and the entire class, that we’d encounter inconsistencies between our preconceptions and the perspectives of our instructor as well as other students.² Doing so, in theory, prompts each student to reflect on his/her own understanding of the material. But what are the individual processes or parts that make team-based learning work and what are the important takeaways for a student and instructor?

From my own experience, I found that the immediate feedback from my classmates and the instructor allowed me a way to rapidly assess how well I understood the material. Our class was a 3-hour session which included the time for our small group discussion. If we discussing a case about a patient with diabetes, I might ask myself: what do the blood glucose data mean?  What are the blood glucose goals for the patient? I would rapidly assess and begin self-reflection by asking myself if I needed to review more about the treatment of diabetes. The immediate feedback is a big part of what makes team-based learning work and vital to increasing self-reflection.⁴

I believe it is important to keep in mind that all aspects of the team-based learning framework must be implemented and the intentional guidance provided by an instructor is essential.⁵ Martirosov and Moser found that a student’s understanding and performance were significantly reduced in the absence of appropriate guidance.⁵  To maximize learning, the instructor must ask probing questions. For example, a patient case about diabetes helped promote self-reflection by getting students to think through the data and recommend starting a medication, perhaps an angiotensin receptor blocker (ARB). Then the instructor would ask questions about why they think the patient should receive an ARB instead of an ACE inhibitor. By prodding the students to explain their choices, it forces them to reflect on that choice and critically examine the thought process. An instructor is the glue that prompts high-level cognitive processing and pulls forth the student’s previous knowledge.  In this way, team-based learning helps students put the pieces together.

Team-based learning is an excellent instructional strategy that many curriculums have used. Team-based learning requires students to engage in reflection because it frequently challenges their preconceived understanding of the material and, in turn, promotes life-long learning.  With guidance from the instructor, students must defend their choices, and this helps them “put it all together.” I firmly believe team-based learning helps students develop lifelong learning skills and helps them become excellent healthcare practitioners.

References:

1. Moon J. A Handbook of Reflective and Experiential Learning. 1st ed. Hoboken: Taylor and Francis; 2004.
2. Hrynchak P, Batty H. The educational theory basis of team-based learning. Medical Teacher [Internet]. 2012 [cited 2020 Nov 3];34(10):796-801.
3. Overview - Team-Based Learning Collaborative [Internet]. Team-Based Learning Collaborative. 2020 [cited 2020 Nov 3].
4. Whittaker A. Effects of Team-Based Learning on Self-Regulated Online Learning. International Journal of Nursing Education Scholarship [Internet]. 2015 [cited 2020 Nov 4];12(1):45-54.
5. Martirosov A, Moser L. How Team-Based Learning Can Promote the Development of Metacognitive Awareness and Monitoring. American Journal of Pharmaceutical Education [Internet]. 2020;84(11): Article 848112.

Teaching Health Profession Students the Skills Needed to Maintain Wellbeing

by Anna Carroll Harris, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Numerous studies have been published exploring burnout among healthcare workers. Health profession students are also prone to burnout due to the vigorous course load required to obtain their degrees. The WHO defines burnout as a syndrome that is directly correlated with an environment that exposes workers or students to chronic stress and where the stressors are not successfully handled. It is characterized by feelings of emotional exhaustion, amplified feelings of negativism towards one’s job, and decreased professional worth.

The occurrence of burnout not only affects those working and learning in the healthcare industry, but also the patients to whom they provide care. For example, pharmacists who are experiencing increased levels of stress and emotional exhaustion may feel a sense of depersonalization towards patients they are caring for. This in turn can lead to medication errors and harmful events for patients.¹ It is imperative that schools and colleges of pharmacy, and other health professional degree programs, help students develop the skillset and positive behavior practices that needed to maintain their wellbeing and prevent burnout throughout their careers.²

Many professional organizations have noted the need to provide health profession students and healthcare practitioners with resources to encourage a state of well-being and prevent burnout. The American Association of Colleges of Pharmacy has published two policies, a 2017 and 2018 statement, in response to the increasing realization that burnout is prevalent. Both statements encourage and hold schools and colleges of pharmacies accountable for effectively promoting wellness and implementing management methods directed to students, faculty, preceptors, and staff.³ In reaction to these statements, schools and colleges of pharmacy across the country are putting programs into place that foster an environment for creating and maintaining well-being. For example, the Ohio State University College of Pharmacy has a “Wellness Corner” dedicated to providing faculty, staff, and students an environment that promotes and protects well-being. They have been recognized across their campus as having a strong culture of wellness by implementing evidence-based wellness strategies and providing tools to achieve a sense of wellbeing.⁴

The University of Kentucky College of Pharmacy completed a study where they “nudged” pharmacy students to adopt well-being behaviors. Over a span of 4 months, a series of optional well-being challenges were embedded in their pharmacy management course. These challenges included limiting smartphone use, emphasizing feelings of gratitude, good sleep hygiene, and engaging in regular exercise. Participants completed a reflection at the end of the course that explored reasons for participation, prior behaviors, and if participants planned to continue to implement the new behaviors after completion of the challenges. The majority of participants indicated that they planned on maintaining the positive behaviors moving forward.⁵

The specific stressors that lead to burnout have been identified in many studies. A study that included pharmacy students in an urban Midwestern region identified strategies that pharmacy students utilized to protect their wellbeing and prevent burnout. Students participating in a social and administrative science course were to write a reflection on factors that they believed had the greatest impact, either positively, negatively or mixed, on their wellbeing during pharmacy school. Four specific themes emerged as strategies that students use to cope with stressors during pharmacy school:⁶

1. Availability and accessibility of institutional resources
2. Personal time management and organizational strategies
3. Personal, mental, and physical health strategies
4. Activities that maintain social relationships

These results provide schools and colleges of pharmacy specific ways they can augment their campuses' attempts to foster wellbeing. Ensuring that institutional resources, such as the medical library and faculty, are readily available to students can help reduce stress and maintain wellbeing. Offering counseling and health services to those who needed them is supportive of students’ wellbeing. A few of the wellness activities mentioned in the Ohio State University College of Pharmacy “Wellness Corner” were a take five-station, a mental timeout area where students could play a game or create a craft, as well as monthly wellness walks. Ensuring that students maintain a healthy balance between schoolwork and leisure activities can reduce stress. Emphasizing the need for students to take time for themselves to socialize with friends and family and maintain hobbies is important.

In the unprecedented times of a pandemic, providing students with resources and teaching them skills to protect their well-being is more essential than ever. With COVID-19 disrupting the lives and wellbeing of so many, health profession students are dealing with the added stressors of helping take care of family members and serving on the frontlines of healthcare, in addition to their demanding coursework.⁷ The loss of person-to-person contact and being isolated away from one’s family has taken a toll on many students. What once provided a means for students to reset and take a break from the rigors of academic coursework is now discouraged.  Schools and colleges need to find creative ways to provide ongoing support to their students, faculty, and staff.  See Table 1.

Table 1: Examples of support during a pandemic

Virtual group exercise	Email check-ins	Virtual mentorships programs
Virtual game nights	Virtual group meditations	PPE drives/mask-making
Virtual book clubs	Virtual dinner dates	Virtual tutoring

As health profession students graduate, they will continue to experience stressful times and emotional exhaustion that can lead down the path of burnout. Health profession programs should work to implement programming and strategies early in their curricula that can provide students with a skillset to prevent burnout. General professional development courses, which are often part of the curriculum, would be a great place to embed lectures about managing stress and including periodic wellbeing challenges for students. These longitudinal courses should be pass/fail due to the nature of the content and should encourage students to adopt and execute tactics that best fit their personal circumstances and needs. Learning about and implementing these healthy habits while in school can help students cope with the stressors they will face throughout their careers.

References

1. World Health Organization. Burn-out an "occupational phenomenon": International Classification of Diseases. Accessed November 18, 2020.
2. Hagemann TM, Reed BN, Bradley BA, et al. Burnout among clinical pharmacists: Causes, interventions, and a call to action. J Am Coll Clin Pharm 2020; 3:832–842.
3. American Association of Colleges of Pharmacy. AACP Statement on Commitment to Clinician Well-being and Resilience. Accessed November 18, 2020. https://accpjournals.onlinelibrary.wiley.com/doi/full/10.1002/jac5.1256
4. The Ohio State University College of Pharmacy. Wellness Corner. https://pharmacy.osu.edu/wellness-corner. Access November 18, 2020.
5. Cain J. Effectiveness of Issuing Well-being Challenges to Nudge Pharmacy Students to Adopt Well-being Protective Behaviors. Am J Pharm Educ 2020; 84(8) Article 7875.
6. Abraham O, Babal, JC, Brasel KV, Gay S. Strategies first year doctor of pharmacy students use to promote well-being. Currents in Pharmacy Teaching and Learning. 2021; 13:29–35.
7. Schlesselman LS, Cain J, DiVall M. THE COVID-19 PANDEMIC ACROSS THE ACADEMY: Improving and Restoring the Well-being and Resilience of Pharmacy Students during a Pandemic. Am J Pharm Educ 2020; 84 (6) Article 8144.

Community Baby Showers: An Innovative Approach to Teaching New Mothers Sleep Safety

by Megan Carter, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Ahlers-Schmidt C R, Schunn C, Hervey A M, et al. Redesigned community baby showers to promote infant safe sleep. Health Education Journal 2020; 79(8): 888-900.

When looking through the Health Education Journal, this article piqued my interest because I was aware of the importance of safe sleeping habits for infants.  My mom works for the Alabama Department of Public Health and has been reviewing infant death cases for about 15 years.  Although she doesn't reveal details about the cases she reviews, she has shared a couple of particularly heart-wrenching stories regarding babies who died.  Unfortunately, these stories are not rare, as nearly 3500 infant deaths in the USA are due to sleep-related causes. Unfortunately, although we know much more about sleep safety during infancy, this number has not declined in recent years.¹ These kinds of deaths are preventable if parents are properly educated about how to create a safe sleeping environment.  This study aimed to provide sleep safety education to mothers, specifically mothers from low-income communities, in a relaxed environment. The authors assessed a novel approach that could increase knowledge and health-promoting behaviors.

The authors of this study designed their educational intervention — including recruitment, lesson plans, materials, and assessments — around constructs from the Health Beliefs Model.  The intervention was delivered at community "baby showers" conducted in Sedgwick County, Kansas, and targeted women who were pregnant or who had recently delivered.  Upon arrival at the shower, participants were asked to complete a pre-assessment and information card.  Organizers divided the women into tour groups of 3-5 participants with a volunteer guide who led the women around the various vendor and educational booths for brief presentations.  The last stop for each tour group was the Safe Sleep Crib Demonstration.  Certified nurses or safe sleep instructors used a demonstration crib with safety-approved items to demonstrate their effectiveness as well as examples of unsafe items that are a hazard to infants.  Instructors provided tips for removing hazardous items from the infant's sleep environment.  The sessions were not time-constrained, allowing time for participants to ask questions.  After the shower, participants took home a safety-approved portable crib, blanket, and educational handouts/materials.

These events were held twice yearly (March and October) from Spring 2015 to Spring 2019 and recruited women using a variety of means including fliers at churches and clinics, maternal and child health programs, social media posts, and through partner organizations.  The program specifically targeted locations that served low-income communities, as this was the population that was most at-risk for sleep-related infant deaths.  During the study period, nine “community baby shower” events were conducted. The participants came from a range of racial and ethnic backgrounds: Non-Hispanic Black (30.4%), Non-Hispanic White (30.4%), and Hispanics (25.1%).  Greater than 70% of participants had only a high school education or less and greater than 70% were on Medicaid or uninsured.  It is also notable that less than half of participants received prenatal care from a private provider and about 20% received care from a county health department, community center, or received no routine care. The pre-assessment consisted of true/false statements developed around the Health Belief Model constructs on infant sleep safety and were compared to the responses to the same questions given as a post-assessment.  McNemar's test for paired dichotomous variables was used to analyze differences in pre- and post-assessment responses along with the McNemar odds ratio statistic.  The following true/false questions were included on the pre- and post-assessments:

• My baby is at risk of dying of SIDS
• Loose blankets in the crib can cause infant death
• Sleeping with my baby can cause infant death
• Putting my baby alone, on the back in a crib will help protect her
• My baby will choke on his back
• People tell me different things about how my baby should sleep and I don't know what to do.
• I can't keep my baby warm without blankets.
• I don't have room for a crib in my room.

The results of the study demonstrated statistically significance (p<0.001) improvements in the participants' responses in all but two of the assessment questions.  Responses to questions about knowledge and intentions showed changes in sleep positions, sleep locations, crib items, and plans to discuss safe sleep with others.  Overall, these results appear promising and events such as the community baby shower provide an excellent opportunity to teach sleep safety to mothers.

The results look promising, but as with any study, statistically significant results don't always equate to an improvement in outcomes.  This study did have several strengths, as the participants are representative of the target population and the assessment questions were based on the Health Belief Model and evaluated by the Medical Society of Sedgwick County's Safe Sleep Taskforce.  On the flip side, this study was conducted in one community, so may not be generalizable to other communities.  The study also targeted individuals from low-income areas with lower education, so the results may not apply to mothers in higher-income neighborhoods with greater levels of education.  The recruiting methods did yield a diverse participant population but relatively few dates that the event was held likely limited many women from attending.  Another potential issue was the true/false statements included in the assessment.  Several of the statements are subjective and others are potentially confusing, which may have contributed to some of the nonsignificant results.  Improving the clarity of these statements could improve the accuracy and validity of this study.  While the results were promising, I would be interested to see if the participants put their new knowledge into practice.  Are mothers able to identify hazardous materials in their home? Do they remove or replace these items?  Have the rates of infant death or hospital visits due to unsafe sleeping habits improved in this county as a result of the educational intervention?  Additionally, the results could have been biased as the group who developed the program assessed the results.  Moreover, there was no control group who received instruction in a more “traditional” manner.

Overall, this study proves that educational programs that structure their lesson plans around the Health Belief Model and offered in non-traditional environments can lead to changes in behavioral intentions.  It is important to recognize that instructional programs can be implemented outside of the traditional classroom settings and that informal community events can a venue where patients can learn about important health topics in a fun and engaging way.

References

1. About 3,500 babies in the US are lost to sleep-related deaths each year. (2018, January 09). Retrieved November 30, 2020, from https://www.cdc.gov/media/releases/2018/p0109-sleep-related-deaths.html
2. Ahlers-Schmidt C R, Schunn C, Hervey A M, et al. Redesigned community baby showers to promote infant safe sleep. Health Education Journal 2020; 79(8): 888-900.