Best Practices in Preceptor Training and Development

by Natasha Lewis, PharmD,  PGY1 Pharmacy Practice Resident, Mississippi State Department of Health Pharmacy

A preceptor is a teacher who facilitates practice-based learning. They serve as an instructor or coach for students and residents, providing them with support as well as direct instruction that facilitates their professional development. Preceptors practice in a variety of settings and have different teaching styles and expectations. New and experienced preceptors may inquire about ways to start or improve their teaching skills as a preceptor. Others may feel that they lack time or resources to be an effective preceptor. Successful preceptor development and training should include educational activities and resources to meet the diverse needs of all students. Many of these qualities, such as assessing a learner’s clinical skills, developing relationships with other healthcare professionals, and being a positive role model should all be part of the preceptor’s professional development. Since preceptors play a vital role in a student/resident’s clinical learning, preceptor training programs are essential to keep them up to date on learning theories and practices to prepare future health professionals with the knowledge and critical thinking skills to be successful. The purpose of this article is to evaluate the literature pertaining to pharmacy preceptor development activities.

A recently published article entitled “A Scoping Review of Pharmacy Preceptor Training” identified and evaluated the literature pertaining to preceptor training programs. This article provided evidence-based options for colleges and schools to use in their preceptor training program.¹ Many of the preceptor training programs were face-to-face sessions and web-based modules, combined with written materials such as a preceptor manual, pre-session assignments, and self-study readings.¹ The responses to these programs were generally positive and described as beneficial.  The participants indicated that easy access to the training was important.  They also found that preceptor training was a great opportunity to share ideas, could illicit positive changes in behavior and attitudes, and a great way to gain insight into learning science.¹

In the scoping review, the authors suggested using online preceptor self-reflection/self-assessment tools as part of their training programs.¹ One program provided preceptors with a computer-mediated support network following a development workshop.^1,4 This workshop covered ways to provide feedback and teaching skills in patient care settings, and rotation design.⁴ After several of these programs, preceptors reported feeling adequately trained to be effective educators while still meeting their employment responsibilities.⁴

The University of Iowa College of Pharmacy’s constellation of preceptor development and training programs is a great example of a comprehensive program that follows best practices.² Their program includes four development tools: live events, printed documents, one-on-one experiences, and web-based programs.²

 

Preceptor Development and Training Programs
Live	Print	One-on-One	Web
Regional events On-campus programs State association educational seminars	Preceptor manual Preceptor newsletter National organization resources	Practice site visits Student feedback Available experiential faculty and staff	On-demand CPE webinars On-the-fly training videos Monthly journal club

Web-based programs were developed to provide preceptors with the convenience of learning and developing skills at their own pace. The program created a web-based development tool with four 30-minute modules for initial preceptor development.² They were made available online to be completed at the preceptors’ convenience. Periodically, new modules were added to the website with content relating to learning strategies, ethics, generational learning, continuing professional development, and mentoring.² Several other opportunities were created to complement these program elements, such as clinical topics, monthly journal club, and a preceptor discussion guide to facilitate dialogue with students.² At the end of the modules, preceptors were asked to complete an anonymous evaluation of the program. Preceptors highly rated several of these modules, stating that it helped improve their clinical practice, enhanced their knowledge, skills, attitudes, and values.

Printed documents included newsletters and manuals with guidance on educational philosophies, resources, policies, and curriculum.² The guides were created by faculty and staff members of the professional experience program.² Preceptors were also provided with links to websites with helpful resources.

Live educational events provide preceptors with networking opportunities, discussions, and continuing education credit on specific practice-based teaching skills.² Examples of these events include dinners, annual events, and workshops held for professionals within the field. These events afforded preceptors with a safe space to interact with other preceptors and gain knowledge, or “preceptor pearls” based on successful experiences of others.²

One-on-one training provide preceptors with the opportunity to open their practice site to students and provide quality practice experience while also increasing students’ communication skills with other professionals.² Students gain actual experience on site, while also building a relationship with their preceptors. This type of training provides students/residents with the opportunity to provide an assessment before and after the experience.² Students/residents interact with patients, as well as the staff at these practice sites, to gain a better understanding of what the preceptor does every day and learn more about the preceptor’s role.² After engaging in several of these activities, students rated their preceptors as “good” and “excellent”.^2,4 Several instructors reported that they felt more confident in guiding student learners.

Dental preceptors are encouraged to use the iCARE method for precepting, which stands for Inquire, Cultivate, Advise, Reinforce, and Empower.³ It is used to assist students with gathering and analyzing important information, assessing the patient’s condition, coming to a diagnosis, and developing a treatment plan and course of action.³ This process has been successful in providing students room to reflect on their knowledge and thought process while also providing time for preceptors to assess the learners’ understanding of key concepts and the scientific literature.

1. Inquire: Ask the student about the patient’s history, condition, diagnosis, and treatment plan options
2. Cultivate: What evidence does the student use to support the diagnosis and treatment?
3. Advise: Preceptor discusses information that student did not bring forth or perhaps overlooked. This helps build upon the student’s knowledge for future cases.
4. Reinforce: Preceptor discusses with the student what was completed well and areas for improvement
5. Empower: Students evaluate and reflect on the process. They propose changes they would like to make.

Medical preceptors often use the One-Minute Preceptor method to teach their students.³ This provides open communication between the preceptor and students while also providing time to teach clinical topics.³ When discussing a clinical case, the preceptor and student completed five tasks:

1. Get a commitment: The student is encouraged to commit to the next steps in a patient case. This can range from forming a diagnosis to creating a treatment plan. The student’s knowledge of the subject is applied to formulate a plan for the patient.
2. Probe for supporting evidence: The preceptor asks for evidence that supports the student’s plan. This provides the student an opportunity to explain how they at their plan.
3. Teach general rules: After listening to the student’s thought process and ideas, the preceptor then provides information to address general concepts.
4. Reinforce what was done right: The preceptor reinforces what the student completed correctly when analyzing the case. This creates a positive relationship between the preceptor and student, increasing the student’s confidence.
5. Correct mistakes: The preceptor corrects any mistakes and provides an explanation on anything missed. They can also prompt the student to critique their own process.

Both of these teaching approaches provide a great communication framework.³  Training preceptors to routinely use these communication and questioning strategies can enhance the student’s learning, problem-solving skills, and confidence.

Preceptor development and training programs provide resources and instruction to improve field-based teaching. By offering a variety of methods, preceptors have options to choose from for self-directed learning. Preceptor training and development programs are especially beneficial for new practitioners. With the guidance and assistance from these programs, preceptors can become comfortable and confident, adding their own personal touches to these experiences, demonstrating interest and enthusiasm for teaching, and with a caring attitude. Regardless of the profession, it is important to continuously improve our skills as healthcare practitioners and teachers to prepare the future members of our profession for the benefit of patients. 

References:

1. Knott GJ, Mylrea MF, and Glass BD. A Scoping Review of Pharmacy Preceptor Training Programs. Am J Pharm Educ 2020; 84(10): Article 8039.
2. Vos SS, Trewet CB. A comprehensive approach to preceptor development. Am J Pharm Educ. 2012 Apr 10;76(3): Article 47.
3. Sakaguchi, Ronald L. Facilitating Preceptor and Student Communication in a Dental School Teaching Clinic. Journal of Dental Education 2010; 74(1): 36-42.
4. Bolt J, Baranski B, Bell A, Semchuk WM. Assessment of Preceptor Development Strategies across Canadian Pharmacy Residency Programs. Can J Hosp Pharm 2016;69(2):144-8.

Finding Direction With Layered Learning

by Anna Rhett, PharmD, PGY1 Community Pharmacy Resident, the University of Mississippi School of Pharmacy

If you cannot see where you are going,
ask someone who has been there before.
-J Loren Norris, an international speaker on leadership

As a learner, sometimes you might feel like a tourist in a foreign city, trying to understand the map. You want to reach the city’s biggest attractions, but you’re stuck going in circles. A great way to solve this problem is to find a tour guide — someone who can help you reach your destination. Not only will you find what you’ve been looking for more quickly, but you often will gain insight along the journey you would have never otherwise obtained.

While formal education is often more complex than looking for exciting landmarks, well-designed instruction can model these behaviors in more ways than you would expect. Like pursuing a popular destination, students today pursue degrees. Rather than booking a tour with a helpful guide, students seek out guidance from teachers. Like stepping off of a tour bus and waving goodbye to the tour guide who has led you through a new city, students must “wave goodbye” to their teachers when completing the curriculum of study.

But what about the pseudo-teachers who are not paid to teach but still teach? These “stand-in” teachers are often learners themselves who have progressed further in their curriculum and thus have acquired slightly more knowledge. Whether it’s a more senior student, resident, fellow, or graduate student, these more advanced learners help less advanced students gain an understanding of expectations of the learning environment. In academic circles, when there are learners at different levels learning together, this model of instruction is known as “layered learning.”

Healthcare education, specifically, is no stranger to the layered learning practice model (LLPM). For many years, aspiring physicians have presented patient cases to attending physicians and reported to chief residents for daily assignments. The LLPM also reframes traditional clinical services by creating a team of learning to deliver care. The LLPM team includes a healthcare provider, or preceptor, at the “top of the totem pole” and individuals of varying levels of clinical skill, ranging from first-professional-year students to third-postgraduate-year fellows.

In pharmacy, the LLPM has been used successfully to expand services and meet the needs of learners.¹  At the University of Oklahoma Health Sciences Center, introductory pharmacy practice experience (IPPE) students were integrated into advanced pharmacy practice experience (APPE) adult medicine rotations. During these experiences, IPPE students reported significant improvement in their ability to describe the role of a clinical pharmacist, identify information in a patient’s medical record, find answers to drug information questions, critically evaluate primary literature surrounding medications, and successfully educate patients about their medication regimens.²

Not only has the LLPM had a positive impact from a clinical perspective, but learners report having a positive experience.¹ While reflecting on their time spent with more experienced learners, IPPE students reported experiencing a foreshadowing of what was to come in their APPE year.² Another benefit of the LLPM is increased student comfort. Preceptors can sometimes (unintentionally) intimidate students.  In an LLPM, students may feel more comfortable asking questions and learning with someone who isn’t far removed from their present circumstances.

The LLPM also serves as a beneficial experience for the more advanced team members. “Teaching is the highest form of understanding,” Aristotle once said. The LLPM allows the more advanced individuals to step into a teaching role. By serving as an educator, they can become more confident talking about and demonstrating their clinical knowledge. Explaining various principles and practices can aid in mastering their craft.

On the surface the LLPM may appear to be a simple way to teach, some challenges come with implementing this model. It may be difficult for preceptors to differentiate between the abilities and needs of individual learners. While some students may need more supervision and explanation, a more advanced student may be able to quickly jump into projects and patient care assignments. Adding in residents, fellows, and other post-graduate trainees can be challenging to balance, as those individuals function at a higher level. It may be difficult to create an effective learning environment that challenges residents and fellows while not overwhelming a first-year student.¹ 

Another hurdle of incorporating more advanced individuals is that while they can offer a level of expertise beyond that of a student, preceptors must not lose sight of the fact that residents and fellows are still learners themselves. While it’s great to integrate residents and fellows into academic experiences whenever possible, these individuals will have varying competency levels, especially when it comes to areas of practice where they may not have much prior experience. Another concern is the receptiveness of the more advanced learners when it comes to serving as a teacher. While some will be eager to step into the role, others may not have an interest in teaching. Students may be put at a disadvantage if an uninterested resident or fellow is left on their own to manage a group of learners, essentially serving as their primary preceptor.¹

Some teachers may be hesitant to implement a layered learning model in their practice setting; however, layered learning can be a success with thoughtful planning and strategic thinking. Some strategies for effectively teaching a group who varying levels of knowledge, skills, and abilities include using differentiation, making use of intentional grouping, and promoting an environment that celebrates collaboration.

In the academic setting, “differentiation” refers to a personalized approach to instruction that recognizes the specific learning needs of individuals rather than using a one-size-fits-all method. For example, when it comes to layered learning, a teacher might use an educational video to build on first-year students’ knowledge of foundational principles and then ask thought-provoking questions that require a higher level of expertise to the residents. Another helpful tool is intentional grouping. Intentional grouping is when teachers organize students based upon similar interests or backgrounds. For example, a preceptor might form smaller groups within the layered learning team. These smaller groups may consist of a first-year student, a fourth-year student, and a resident, all of whom have an interest in cardiology. This intentional grouping with shared interests can keep all parties engaged and provide the less experienced learners with mentorship. Lastly, collaboration is key to making the most of layered learning. It is crucial to keep everyone communicating and working alongside each other toward common goals. Teachers should promote conversation by having students self-reflect on strengths and weaknesses within the group. Hearing peers articulate their ideas and experiences builds community and increases empathy, while also helping less-advanced individuals develop the shared language needed to work on healthcare teams.³ 

Henry Ford said it best: “If everyone is moving forward together, then success takes care of itself.” Whether it be through serving as a mentor for those who are standing where you’ve stood or receiving advice from those who have reached the destinations you are seeking, the layered learning practice model has all of the necessary ingredients to create opportunities for learners of all levels. Any milestone can be reached more easily when working together, whether it be finding that historic landmark in a foreign city or mastering a key concept needed to deliver optimal patient care. Through the LLPM, students, residents, post-graduate trainees, and students alike can venture out into their careers without their eyes glued to maps, but rather looking outward at what lies new on the horizon.

References

1. Loy BM, Yang S, Moss JM, Kemp DW, & Brown JN. Application of the Layered Learning Practice Model in an Academic Medical Center. Hospital Pharmacy. 2017; 52(4):266–272.
2. Smith WJ, Bird ML, Vesta KS, Harrison DL, & Dennis VC. Integration of an Introductory Pharmacy Practice Experience With an Advanced Pharmacy Practice Experience in Adult Internal Medicine. American Journal of Pharmaceutical Education. 2012; 76(3):Article 52.
3. Soika B. USC Rossier School of Education: How to Address a Wide Range of Skills and Abilities in Your Classroom [Internet]. Los Angeles: Brian Soika. 2020 Jul- [cited 2021 Nov 30].

The Vicious Cycle of Sleep Deprivation, Decreased Academic Performance, and Poor Mental and Physical Health

by Kendall Kara, PharmD, PGY1 Pharmacy Practice Resident, G.V. Sonny Montgomery VA Medical Center

Inadequate amounts of sleep can have detrimental effects on test scores, GPA, mental health, and physical health.1,2,3 Adequate sleep is essential to physical and mental wellbeing. A lack of sleep leading to poor outcomes in all aspects of students’ lives can lead to a “vicious” cycle.2 According to the CDC, 1 in 3 adults do not get enough sleep per night. The suggested number of hours of sleep per night varies based on age. For adults 18-60 years old, at least 7 hours of sleep is recommended.¹ If you ask any college or graduate student if they consistently get 7 hours of sleep every night the answer is probably “no”.

A lack of sleep and a lack of daytime alertness has negative impacts on cognitive function and learning by disrupting the prefrontal cortex that helps control language, creativity, consolidation of memory, and reasoning skills. Studies have shown that slow-wave sleep can help consolidate fact-based learning whereas REM sleep can help consolidate procedural memory.⁶ Lack of sleep not only affects test performance and GPA but also causes daytime sleepiness, impaired concentration in class, and decreased memory capacity.3 The amount of time we have each day is finite.  So the longer students stay up to study, the less time they have for sleep. Thus “pulling all-nighters” and late-night study sessions can be detrimental to their success in school.

A lack of sleep has been shown to have a negative impact on academic performance in multiple clinical trials. Having recently graduated from pharmacy school, I found the study entitled “Sleep Duration and Academic Performance Among Student Pharmacists'' was very relatable.³ Professional school is very demanding, but it is a time when students get the least amount of sleep. In this study, students were asked to complete a questionnaire about their sleep patterns during a typical school week and the night before an examination, as well as the frequency of daytime sleepiness. More than half of the 364 students surveyed reported they do not get the recommended 7 hours of sleep per night (54.7%), went to bed later (52.2%) the night before, and woke up earlier (67.5%) the morning of an exam, and reported feeling tired almost every morning when waking up (54.4%). Students who reported shorter sleep durations the night prior to an exam had significantly lower test scores and lower semester GPAs.³  An increase in sleep by one hour was associated with an 11% increase in the course grade. This cycle of studying, lack of sleep, decreased concentration in class, daytime sleepiness, and poor test performance is a vicious cycle many students experience.

Another study titled “Test Anxiety and Poor Sleep: A Vicious Cycle” was designed to examine if test anxiety affects sleep quality and duration among undergraduate students taking a statistics class.² It is already well established that test anxiety has a negative impact on test performance but adding the element of poor sleep to this equation has not been well tested. The researchers used multiple tests to measure students' baseline sleep quality and quantity, depression, anxiety, and insomnia. The students were also sent a Sleep Mood Study Diary that they were asked to fill out every day for 6 days leading up to the exam. The questions from this diary assessed sleep onset latency, total sleep time, and sleep efficiency. Students were assessed for test anxiety the mornings before and after the exam. Study results revealed that students who had even minor amounts of anxiety had worse test scores. Anxiety was also associated with poor sleep quality. Poor sleep quality resulted in increased anxiety and caused further sleep disruption, again leading to a vicious cycle that ultimately had negative academic consequences. The combination of text anxiety and poor sleep resulted in lower test scores (up to 4.96 points) in many students.²  In this study it is unclear what starts the beginning of the cycle. Do anxious people sleep less, which causes anxiety and decreased test performance? Or, does sleep deprivation cause poor test performance that ultimately causes anxiety?

Inadequate sleep not only affects academic performance but also impacts mental and physical health.^3,4 Lack of sleep is associated with mental health issues such as irritability, hyperactivity, poor impulse control, impaired memory, depression, anxiety, mood swings, and increased perceived stress. Physically, lack of sleep is associated with an increased risk of infection, slowed metabolism, heart disease, high blood pressure, obesity, diabetes, and all-cause mortality.⁴

So how can we break these vicious cycles? It is important that teachers and faculty are aware of that many of their students are sleep deprived. Teachers and administrators have the opportunity to positively impact the overall well-being of students starting from the very beginning of their program.3 Educating students about healthy sleep habits, self-care, doing regular wellness checks, and scheduling tests at appropriate hours are ways teachers can positively impact the overall well-being of students.^3,5

There are many recommendations to ensure students (and their teachers!) are getting high-quality sleep, but here are 6 important “counseling points” to help students develop healthy sleep habits:⁵

1. Limit caffeine intake and other stimulants. I know this is hard for many students because they can become dependent on caffeine to get through the day and stay awake at night to study. Cutting back on caffeine intake, and not consuming caffeine 8 hours before bedtime can help students fall asleep easier.⁵
2. Reduce screen time. Putting away the phone, computer, and TV an hour or so before bedtime can help with falling asleep faster. Lights from devices can disrupt the secretion of melatonin which can make it harder to fall asleep.⁵
3. Plan ahead and create a study schedule in advance. Setting specific and regular times to study before tests rather than cramming the night before can help improve overall sleep quality and test performance.
4. Diet and exercise. It’s very easy to tell people about the importance of diet and exercise but it’s difficult to actually practice what you preach. Maintaining a healthy lifestyle can help with overall well-being including improved sleep.⁵
5. Prioritize your sleep just as much as you prioritize school and studying. Setting a bedtime that allows you to get 7 hours of sleep every night. Tracking your sleep can help increase accountability to yourself.⁵
6. Finally, know when to seek help. If sleep deprivation is negatively impacting academic performance or mental/physical health, it is important that students feel comfortable talking to teachers about their struggles. Teachers, faculty, and staff should be judgment-free resources for finding students the help they need to succeed.⁵

References

1. 1 in 3 adults don't get enough sleep [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2016 [cited 2021Oct27].
2. Hamilton N, Freche R, Zhang Y, Zeller G, Carroll I. Test anxiety and poor sleep: A vicious cycle. Int J Behav Med 2021;28(2):250–8.
3. Zeek ML, Savoie MJ, Song M, Kennemur LM, Qian J, Jungnickel PW, et al. Sleep duration and academic performance among student pharmacists. Am J Pharm Educ. 2015;79(5): Article 63.
4. Sleep health [Internet]. Sleep Health | Healthy People 2020. [cited 2021Oct27]. Available from: https://www.healthypeople.gov/2020/topics-objectives/topic/sleep-health?topicid=38
5. Sleeping to succeed [Internet]. Learning Center. 2020 [cited 2021Oct27].
6. Sleep clinic Seattle: Sleep doctor Kirkland, Washington (n.d.). Retrieved January 25, 2022, from https://www.soundsleephealth.com/

Using Team-Based Learning in Health Professions Education

by Carlos Logan Magana, PharmD, PGY1 Pharmacy Practice Resident, North Mississippi Medical Center

Team-based learning (TBL) has been around since the 1980s.  This strategy has been used in academic settings to supplement education through peer collaboration whereby students work in smaller groups when in large classroom settings.  This teaching strategy has been used widely in health professions education. TBL helps student develop their communication skills while making the learning environment stimulating.  I believe TBL should be used in combination with other teaching methods to help augment student learning.  This can benefit students both academically and professionally.

TBL has four key components.  The instructor must carefully form and manage groups, give frequent feedback, create problem-solving activities, and engage students in a peer evaluation process.  TBL sessions are conducted during class time and but the precise sequence of activities can vary depending on the course topic. When entering the classroom, students take an individual knowledge assessment where they are quizzed on pre-readings.  This is followed by a team-based assessment where teams work together to establish a consensus on answers. The group test is followed by facilitator feedback where the questions are discussed, and the answers explained.  Following these assessments, the instructor provides problems or activities that students worked on for the majority of the in-class time.  Groups work together using their pooled knowledge. There is a final debriefing about these activities.  Finally, the instructor has some closing messages and summarizes the key concepts addressed in the activity.

A method that is similar to TBL, but has some important differences, is called problem-based learning (PBL).  PBL also involves small student groups but the sessions are led by a facilitator who guides the students through a case from beginning to end. The team aspect is similar to TBL but PBL is more resource-intensive because it requires a greater number of facilitators and the pace of the activity is driven by the facilitator.  This differs with TBL does not (typically) require multiple facilitators and gives the learners more control over the learning environment and pace. Thus TBL is a hybrid teaching and learning method that blends aspects of small group activities with large group presentations.

TBL has gained traction in health professions education perhaps because it enables students to develop their team interaction skills.  It is also a great way for learners to spend time with facilitators who are experts in their field which allows for current information to be taught. TBL is more structured than PBL. In TBL, students must be prepared for the class content. This method also allows learners to learn from their peers – to get different points of view.  This constant influx of new thoughts and viewpoints is helpful for the learner to grow outside of their own personal bubble and implement new ideas into their own knowledge.  Finally, facilitators learn from each other based on their experiences and from learners that they have worked with throughout the year.

A few studies have explored the impact of TBL on learning outcomes. One study evaluated the TBL method in the second year of the curriculum at the Boonshoft School of Medicine.  The study was conducted over two consecutive academic years (2003-2004) and (2004-2005).  This study looked at the exam scores of 2nd-year medical students which included courses consisting of topics that emphasized foundational knowledge such as physiology, pathology, and pharmacology.  Teaching methods of these courses included lectures, lab exercises, clinical case discussions, independent study modules, and TBL modules.  All courses determined the overall course grade using multiple-choice question examinations.  There were a total of 28 examinations, and the investigators divided scores into two subgroups as follows: designated TBL-related pathology-based questions (TR PBQs) and designated TBL-unrelated questions (TU PBQs).  Once data was collected data showed that student scores in the TR area had overall improved mean scores on examination questions compared to the TU scores.  Indeed, not only did the highest quartile students in the TR group perform better (89.3% and 85.5%), so did the lowest quartile students (77.5% and 69.6%).  This kind of analysis is important because it documents that the lower quartile of the class also had a significant improvement in their scores (not just the high-performing students).  Thus, TBL can benefit students who may be struggling in their classes. The study concluded that TBL helps enhance mastery of content.

Another study published in 2017 surveyed first-year medical students in the Sydney Medical Program.  In total 144 out of 169 students completed a questionnaire regarding both TBL and PBL methods in their courses.  Overall students preferred TBL, with 85% agreeing it helped to enhance peer learning experiences compared to 37% in the PBL group.  It is also noted that 93% agreed that their team members made adequate efforts in team discussions compared to 46% with PBL.  While these are just some examples of student satisfaction of TBL there are others regarding their fondness of the facilitators and team feedback in TBL over PBL as well as other perceived benefits such as knowledge gained and examination preparedness. 

Most literature supports the use of the TBL method in health professions education. While there are many teaching methods that could be used in any curriculum, some will be more effective than others depending on course content and the audience. TBL is helpful but it is not all-encompassing. Learning is complex and teaching should involve a variety of methods. It is also crucial to use subjective data such as learner feedback and satisfaction along with performance data such as examination scores.  TBL is a truly welcomed addition to the teaching methods available to faculty and should be considered when teaching clinical decision-making and problem-solving skills.

References

1. Burgess A, van Diggele C, Roberts C, and Mellis C. Team-Based Learning: Design, Facilitation and Participation. BMC Medical Educ 2020; 20: Article 461.
2. Koles P, Stolfi A, Borges N, Nelson S, and Parmelee D. The Impact of Team-Based Learning on Medical Studentsʼ Academic Performance. Academic Medicine 2010; 85(11): 1739-1745.
3. Burgess A, Bleasel J, Haq I, Roberts C, Garsia R, Robertson T, and Mellis, C. Team-based learning (TBL) in the medical curriculum: better than PBL?BMC Medical Educ 2017; 17(1): Article 243.

The Influence of Emotions on Learning

by Jonathan Newbaker, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

In ‘The Righteous Mind’ by Jonathan Haidt, the author introduces the concept of the elephant and the rider.¹ In this analogy, the rider is our logical, reasoning self and the elephant is our reactive, emotional self. His point is that the rider, our reasoning, seems to guide our emotions and decision; however, the reality appears to be the opposite. Haidt argues that our intuition and emotions have a much larger subliminal impact on our decision-making than we are consciously aware. Emotion management, other than perhaps recommendations to seek counseling when needed, is not commonly discussed in the academic setting. Given the impact that emotions can have on logic and reason, it’s a topic worth exploring as recent studies are showing emotions are a driving force in information collection and strongly influences memory. In this essay, I will explore a definition of emotions, the correlation of emotions to learning, and some data on how the two intersect. In addition, the application of these findings will be discussed for health profession educators to consider when teaching.

Emotions can be considered a distinct form of cognition in that they are often the first process to occur in a situation before logical reasoning.² These feelings can be defined in terms of their valence and arousal.³ The valence of emotions, a term borrowed from the fields of physics and chemistry, describes them as positive or negative.³ The term arousal refers to how activating or deactivating the emotions are.³ Activating emotions energize us, whereas deactivating emotions lead to a loss of energy.³ These various combinations of valence and arousal are displayed in the table below. 

	Valence – Positive	Valence – Negative
Arousal – Activating	Excitement, joy	Anxiety, fear
Arousal - Deactivating	Contentment, calmness	Depression, shame

Activated and deactivated states as well as positive and negative emotions can predispose students to particular methods of processing and applying information.³  One study compared emotions (positive or negative) to the students’ information processing method (global processing or local processing).⁴ To induce the emotional state, the researchers had the students watch either a positive or negative emotionally evocative video or an emotionally neutral video (control). After viewing the video, students were asked to compare three geometric figures. The control figure was a triangular-shaped arrangement of three circles. This was to be contrasted to comparison item 1, a triangular assortment of three cubes, and to comparison item 2, a rectangular assortment of circles. When a student uses global processing, they will pick up on the triangular assortment of the differing shapes (i.e., triangular circles to triangular squares), whereas when a student uses local processing they will pick up on the presence of the same shapes in a different arrangement (i.e., triangular circles to rectangular circles).⁴ The results showed that students with positive emotional states were more likely to employ global processing than students who were shown the negative or neutral videos. The latter two groups had a stronger tendency to focus on specific details using local processing. Using two emotionally positive videos, one emotionally neutral video, and two emotionally negative videos, the researchers then tested for group differences in global bias scores using a 5 × 2 × 2 ANOVA (Video Group × Sex × Ethnicity). The video type was the only factor that had a significant effect (p = 0.042).⁴ The two positive emotion videos produced significantly greater global bias scores than the two negative emotion films (p = 0.035).⁴ In contrast, the global bias scores for the two negative clips did not differ from each other.⁴ The results suggest that various emotionally-charged delivery methods may change the way learners perceive and process information.

Unfortunately, the conclusion is not so straight forward and we cannot conclude that “positive emotions lead to improved processing and recall”. For example, some research shows that negative events are more likely to be spontaneously remembered than positive events.⁵ Researchers of one study analyzed involuntary memories in groups of traumatized subjects and contrasted these with involuntary memories among subjects who had an overwhelmingly happy experience. They found that the vividness of trauma-related memories was more significant than non-trauma memories (p < 0.005).⁵ Of note, the mean number of trauma flashbacks was lower than the mean number of non-traumatic flashbacks (p < 0.01), with happy memories being the most abundant.⁵ This data indicates that, although trauma is not a prerequisite for memory recall, it does play an important role in the amount of detail that one is able to recall. To tie this into learning, some negative experiences may have beneficial long-term effects and prompt behavior changes.  Therefore, mistakes which provoke negative emotions can be beneficial but students need to be taught how to view these events as opportunities for improvement rather than solely negative events.

The difficulty in providing standardized emotional experiences for students is that they are unique individuals and their emotional response to situations are different. It is possible that one student may feel positive emotions during an encounter with a professor and another student is offput by the same encounter. Therefore, feedback from both the educator and the learner should be incorporated at multiple points throughout a given semester to assess the students’ perspective and emotional state. In addition, this would afford the educator an opportunity to encourage the student to identify and manage any deactivating emotions.

It is clear that emotions play a significant role in how students perceive and remember information.  Thus, instruction techniques and methods for questioning students should consider the emotions they might evoke and the desired educational outcome. For example, playing a video that evokes excitement or joy might be great when global processing is preferred. However, when attention to detail is ideal, the educator could consider creating an environment that fosters a negative emotional state such as providing a grave clinical situation (or simulation) that drives the students towards local processing. Moreover, the educator should emphasize the importance of learning from mistakes which evoke negative, activating emotions. Negative events such getting a “bad grade” or making an ill-conceived recommendation during patient care rounds can leave a last impression on a student but, if managed by the teacher well, they can be “teachable moments” that motivate learning and behavior change. However, if handled poorly, these negative events can be demotivating, causing students to withdraw and avoid.

Lastly, it is important to gather feedback (either formally or informally) at regular intervals to assess the learners’ emotional states. Watch for non-verbal clues!  This should be considered along with formal assessments of student performance. Individuals will process the same experience in different ways, so it is critically important for health professions educators to pay attention to emotional clues and “check in” with students.

 

Resources:

1. Haidt J. The Righteous Mind. New York City, NY: Vintage; 2012.
2. Zajonc, R. B. Emotions. The handbook of social psychology. McGraw-Hill. 1998. P. 591–632.
3. McConnell MM, Eva KW. The Role of Emotion in the Learning and Transfer of Clinical Skills and Knowledge. Academic Medicine 2012; 87 (10): 1316–1322.
4. Fredrickson BL, Branigan C. Positive emotions broaden the scope of attention and thought-action repertoires. Cogn Emot 2005;19(3):313-332.
5. Berntsen D. Involuntary Memories of Emotional Events: Do Memories of Traumas and Extremely Happy Events Differ? Appl Cognit Psychol 2001;15(7): P. S135–S158.