Backchannel Communication to Improve Instruction and Learning

by Claire Calcote, PharmD, PGY1 Pharmacy Practice Resident, St. Dominic Jackson Memorial Hospital

If you are unfamiliar with backchannel communication, it involves using secondary ways to communicate “behind the scenes” of the primary method of communication, like during a lecture presentation. Its use within higher education has grown exceptionally, even before the COVID-19 pandemic. Backchannels have always existed within the classroom - like passing notes or private conversations with a nearby classmate. Now, multiple platforms allow students to submit comments, ask questions, or share supplemental materials without interrupting the primary communication channel (e.g., the teacher’s presentation). Essentially, the discussions and thoughts already occurring within the classroom are given an open environment to foster dialog. These channels don’t cure all problems - like distracting outside conversations, disengaged students surfing non-educational websites, and reserved learners who hesitate to ask for clarification or further explanation. However, a backchannel can create an additional outlet for discussions, engage both introverted and extroverted students, and reveal gaps in learners’ comprehension, which ultimately enriches instruction and enhances learning.

Several benefits of secondary communication through backchannels have been documented.^2,3 By providing an additional outlet for discussions and participation, student engagement is enhanced.² Backchannels also provide opportunities to engage those who are less likely to speak up during lectures or ask questions. Group collaboration can be facilitated when a backchannel is used.³ Additionally, these platforms foster an open environment for exchanging resources. Students can comment and clarify misunderstandings regarding lecture content.  And faculty can respond if needed.² This ultimately builds teamwork and collaboration skills, which are important outside of the classroom. Lastly, from an instructor perspective, the backchannel can reveal gaps in student comprehension, so efforts can be made to review or refocus specific content.³

While it is unclear when backchannel communication using modern technology first occurred, its formal use was described in the early two-thousands.¹ In 2006, a paper described a backchannel communication method using online chatrooms during graduate courses at the University of California, Berkley over a period of two years. Authors analyzed over 200,000 chat room entries, plotting chatroom communication over time to assess utilization trends.¹ They concluded that participation increased over time, with a small number of students participating most frequently.¹

I recently had some experiences working with a backchannel communication method during a course where I was the teaching assistant.  I wondered — is there a relationship between course performance and backchannel engagement? During this four-week course for second-year Doctor of Pharmacy students, a backchannel communication was available using a tool called Discord which includes Voice over Internet Protocol (VoIP) messaging, instant messaging, and digital media distribution platform. The instructor created a separate sever within Discord and enrolled the entire class, including teaching assistants and other faculty who contributed to the instruction. Additionally, students were assigned to small groups in the Discord community for active learning activities and other assignments throughout the course. During each class session, students had required to complete assignments or assessments that involved communicating with their group members in Discord. Individuals often used the general chat feature to communicate with other members of their group, the teaching assistants, and the instructors. Discord possesses helpful features like private messaging and both audio and video calling; therefore, students can contact anyone in the community to get clarification.  The system also provides a mechanism for urgent notification if emergent situations arise. Since Discord is popular among the gaming community, a select number of students were eager to engage on Discord as they were familiar with the platform.

During the first few days a majority of the class seemed hesitant to engage on Discord outside of the required in-class activities. However, as the course progressed, open discussions about lecture content occurred, with some students exchanging graphics and primary literature articles. Additionally, encouraging reminders before exams and amusing captioned pictures were exchanged between students and faculty. Students took the initiative to create topic-specific threads within the platform to organize the discussions for exam preparation. The experience aligned with the University of California, Berkley’s findings – backchannel communication participation increases over time, with a select number of individuals engaging the most.

By the second week of the module, particularly following the first exam, students were more likely to directly contact and communicate with the lead instructor and other faculty members. Questions became more specific and targeted as students began to study the materials. From a class administration perspective, in the event of a student emergency, participants were able to notify the faculty through Discord and devise alternative ways for the student to receive the instruction materials. These direct communication features were appealing from a faculty point of view, as they served as a more immediate way to communicate (when compared to email) and messages could be sent without disclose personal information. Platform use persisted until the conclusion of the four-week course, with students continuing to discuss and clarify lecture content prior to their final exam. After grades were finalizing, it was noted by the lead instructor that those who engaged the most within the backchannel were the highest performers within the course.

My observations coincide with experiences reported in a 2020 case study at the University of Aizu in Aizuwakamatsu, Japan.⁴ Professors used external personal social networking systems (SNS) like Twitter, Facebook, and Line for backchannel communication, which allowed students to interact and collaborate on assignments. Participants included those in four Japanese undergraduate English as a Foreign Language (EFL) courses and they were observed over one academic year.⁴ Interaction via the backchannel could be in any language of the students’ choice.  Initially, participants were hesitant to use the various SNS options for backchannel communication; however, reluctance was overcome once students realized the privacy of the backchannel. The study ultimately concluded that backchannel communication provided a comfortable outlet to engage with other classmates who they most likely would not interact with face-to-face.⁴

Backchannel communication can be used to overcome various classroom obstacles. Although multiple platforms exist, a single backchannel would be easier for faculty to maintain, monitor, and respond to. Students will need to learn about backchannel communication etiquette and faculty will need to set expectations on when and how to use the system.  Ideally, the backchannel would be used during the main channel (e.g. the lecture time) to prompt student engagement. This should be continued through several lectures to overcome potential participation hesitancy. Additionally, instructors should routinely send prompts in the backchannel that requires student response or collaboration related to the learning objectives of the course.  Creating a backchannel communication channel can increase classroom discussions, heighten student participation, and reveal misunderstood content.  In so doing, instruction and learning are ultimately enhanced.

References:

1. Yardi S. The Role of the Backchannel in Collaborative Learning Environments. In Barab S A , Hay KE, & Hickey DT. (Eds.), The International Conference of the Learning Sciences: Indiana University. 2006;(2):852-858.
2. Bruff D. Active Learning in Hybrid and Physically Distanced Classroom. In: Vanderbilt University Center for Teaching [Internet]. 2020.
3. Bruff D. Backchannel in Education – Nine Uses. In: Agile Learning: Derek Bruff’s blog on teaching and learning [Internet]. 2010.
4. Ilic P. Exploring EFL Student Use of Digital Backchannels During Collaborative Learning Activities. JALT CALL Publications. 2021;64-74.

Benefits of “Near-Peer” Teaching

by Allison Graffeo, PharmD, PGY-1 Pharmacy Practice Resident, University of Mississippi Medical Center

Near-peer teaching involves students learning from more senior peers, individuals who are one or two years ahead of them in school or post-graduate training.¹ It is a well-established model used by medical education programs; however, not fully established in pharmacy education. Some educators criticize this method, stating that it would lower the quality of teaching, be difficult to implement and be unethical to use students as teachers. However, using near peers in the classroom, practice labs, and experiential learning environment allows pharmacy students to learn from a peer who has been through similar (and recent) experiences. In addition, it contributes to the more senior peers’ growth to teach and develop their professional skills.²

There are two distinct types of near-peer teaching models most commonly employed: classroom-based and experiential learning. The classroom-based model incorporates senior peers to lead lectures, discussion, and other activities in classes or practice labs serving as an assistant to the faculty member. This model engages students to learn from their senior peers who use a similar language. When using near peers in the experiential learning setting, the instructor integrates learners (often at multiple stages of development) to address real-world problems or to gain research experience. Over the last decade, many authors and researchers have investigated the applicability of these near-peer teaching models in pharmacy education.

At the University of Toronto, near-peer teaching was assessed in an experiential teaching model that was led by a clinical pharmacist/preceptor and assisted by a recent graduate PharmD student with 3 years of previous hospital experience.  The learners included a pharmacy resident who had been with the institution for 6 months, a third-year pharmacy (cooperative “Co-op”) student, and a fourth-year pharmacy (Structured Practical Experience Program “SPEP”) student. The recently graduated PharmD and resident were considered the senior peers to the third- and fourth-year students. These clinical experiences consisted of patient-care rounds on a hemodialysis unit with a medical team. The lead pharmacist would provide articles on specific topics to the students and residents to prepare for patient and therapeutic discussions. Senior learners led the discussions, and all members of the group were expected to be in attendance to bring various experiences to discussions. This allowed the senior peers to use concepts and language that the third- and fourth-year students could more easily understand and relate to while also having the preceptor available to explain concepts more deeply and fill in the gaps. These sessions occurred at least three times a week and included minimal direction from the pharmacist to allow the senior peers to take the lead.² Although the expected hierarchy was for the students to rely on the resident, it turned into a collaborative group with each member of the team contributing. This method provided a unique and positive approach, particularly with regard to collaboration with healthcare teams and the students reported that they greatly benefited from having a near-peer role model. They explained that they felt comfortable approaching the recently graduated pharmacist and resident and they developed a better understanding of pharmacy interventions.

The Oregon State University College of Pharmacy recently assessed the effectiveness of a classroom-based near-peer teaching model.  They measured third-year pharmacy students’ knowledge and confidence related to frequently prescribed medications. There was a total of 98 third-year pharmacy students involved in the “RxReady” near-peer teaching series which occurred immediately prior to their advanced pharmacy practice experiences (APPEs). Twenty-four students were randomly selected and were required to study a certain medication and present a 10-minute presentation to other students (with a faculty member present). Students who participated in the presentation had to complete pre- and post-quizzes (test of knowledge) as well as a survey to determine the effectiveness (change in student confidence) of this teaching style.³ Out of the 96 students who took part in the pre- and post-quizzes and surveys, there was a 15% increase (p<.001) in post-scores compared to the initial quiz and survey. Additionally, 96% of students achieved a higher score on the final knowledge assessment compared to the initial ones. Student confidence scores significantly improved after the presentations (IQR [(0-0.5) – 1]; p<.05).² Targeted questions on the surveys included recalling dosing and formulations, side effects, pharmacokinetics and pharmacodynamics, drug-drug interactions, and counseling points.³ This method may be a useful way to assist students with learning gaps and prepare students to give presentations and engage in patient education during the APPEs.

Lastly, a review article examined six educational research studies that assessed the various models for near-peer teaching. The paper examined near-peer teaching activities in pharmacy schools. Of the six studies included in the review, surveys and questionnaires were used to assess knowledge, problem-solving skills, attitudes, and values towards near-peer teaching methods. These studies revealed that near-peer teaching was accepted and had a positive impact on students’ experiences. Students strongly agreed that near-peer teaching promoted collaboration and that they were excellent role models.¹

The purpose of experiential learning is for students to see real-life situations which reinforce drug knowledge, help develop communication skills, and provide opportunities to practice problem-solving. Near-peer teaching enhances student experiences by providing mentorship and assistance from a senior peer. However, barriers remain within pharmacy programs to implement near-peer teaching as a structured teaching model. To be most effective, senior peers should be assigned a faculty preceptor to ensure all daily responsibilities are being met and are receiving adequate feedback. Additionally, senior peers could create “notebooks” including classroom-based and experiential learning activities which they can pass down and updated annually, aiding the transition from student “learner” to senior “near-peer” teacher. If pharmacy schools routinely had near-peer teachers throughout their curriculum, it would not only provide a unique learning environment for students and residents but help to increase the confidence and clinical skills of pharmacists.^1,2,3

 

References: 

1. Aburahma MH, Mohamed HM. Peer teaching as an educational tool in Pharmacy schools; fruitful or futile. Curr Pharm Teach Learn. 2017;9(6):1170-1179.
2. Leong C, Battistella M, Austin Z. Implementation of a Near-Peer Teaching Model in Pharmacy Education: Experiences and Challenges. Can J Hosp Pharm. 2012;65(5):394-398.
3. Tsai T, Vo K, Ostrogorsky TL, McGregor JC, McCracken CM, Singh H. A Peer-Teaching Model to Reinforce Pharmacy Students’ Clinical Knowledge of Commonly Prescribed Medications. Am J Pharm Educ. 2021;85(5): Article 8451.

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/