Using Positive Psychology to Enhance Well-being

By Arthur Graber, Pharm.D., PGY1 Pharmacy Practice Resident, Medstar Georgetown University Hospital

Do we really want our students to merely learn how to be successful in their work environments … or do we want them to thrive and have a high sense of well-being?  Recently, the study of “positive” psychology (PP) has taken flight. This is a new type of psychology that focuses on the achievement of well-being. In traditional psychology, there is a focus on solving a problem and correcting weaknesses.  However, the positive psychology perspective states that if you focus on your strengths and talents, you will indirectly address your weaknesses and achieve success.¹ PP is an exciting area of focus that can help people discover meaning in their lives and build resilience in tough times.

Residency training and medical education are some of the psychologically hardest times for young professionals.  Not exactly the best time to learn how to flourish into well rounded, patient-centered practitioner.  Indeed, the rate of emotional exhaustion and depersonalization among medical residents and students has been estimated to be between 40% and 70%.² Burnout adversely affects judgment and clinical decision-making as well as undermines satisfaction.¹ In order to prevent burnout, it is important for educators, preceptors, and (most importantly) students to understand how they can improve their experience, develop a sense of

well-being, and make the most of the educational experience.

Well-being encompasses a wide range of factors including the following components: Positive emotion, engagement, meaning, positive relationships, and accomplishment.³ Put into play, these elements create an environment that allows students to flourish.

Positive emotion or as Dr. Seligman, one of the founders of PP, likes to describe it, living the pleasant life, is the component that encompasses happiness and life satisfaction.  Engagement is also pleasurable but we realize it only in retrospect. “Wow, I got lost in what I was doing!”  Engagement occurs when a person uses their personal strengths and virtues in a manner that causing them to experience “flow.”³  For a teacher, the use of “strength-based education” is a shift in paradigm from focusing on the clinical expertise of the instructor to one of cooperative management and exploration of the skills, knowledge, and resources of each student.¹ Students can be coached to determine what their strengths are and evaluate if potential projects, work settings, and other life pursuits provide opportunities for the student to use their strengths.⁴  Meaning, belonging to and serving something greater than yourself, is another measure of well-being.  Positive relationships add significantly to a person’s well-being. Relationships allow us to perform acts of kindness for others.  It is through acts of kindness that we can produce the most reliable increase in our sense of well-being.³  And finally, Accomplishment can be objectively measured and describes what people pursue in order to increase their well-being.³

Activities that allow us to build our positive emotions, engagement, meaning, positive relationships, and accomplishment substantially increase our sense of well-being.   Those who have a sense of well-being are in a better position to learn and to perform well in their responsibilities.  The following exercises can be applied by teachers to increase student well-being:⁵

Reflective Learning Exercises

Three Good Things

• Activity: Write down three positive events that happened during the work day every night for one week and answer the question of why the positive outcome occurred.
• Benefit: Provides changes in perspective, a cognitive-behavioral strategy, to improve stress management and self-care. It can also be used as a reflection strategy to understand how to approach future endeavors in order to get more positive results. These lessons can be shared with group members.

Not Always, Not Everything

• Activity: Reflect on negative outcomes and attribute them to factors that are not innate to the student and are temporary and specific.
• Benefit: This allows students to see that failure may be situational instead of innate and allow them to perform better in subsequent attempts.

Satisfice more

• Activity: Choose to purposely do what is good enough as opposed to maximize, a.k.a. obtain the best possible outcome by default. Determine what features are desired and pick the first option that meets those criteria.
• Benefit: Teaching this skill to students builds efficiency. It can teach students the importance of prioritizing effort for for major projects, while doing less for minor ones and still obtaining positive outcomes while lowering stress levels.

Team-Building Exercises

Capitalization

• Activity: Spend time sharing positive news and events that occurred such as the events stated in the above activity.
• Benefit: For residency programs, the development of a structured support group that meet regularly in order to share positive events and accomplishments instead of just problems may improve and enhance the quality of the work/education setting.

Personal Development Exercises

Signature Strengths

• Activity: Identify your top strengths by visiting www.authentichappiness.org. Aim to use these strengths intentionally every day or choose one to develop.
• Benefit: This is one of the best methods of developing skills and overcoming weaknesses while increasing active learning. Using these strengths purposely for one week has been associated with increased happiness and less depression up to 3 months into the future.

Since fit between academic interest and career reduce the risk of burnout, using activities aimed at cultivating positive behaviors and the development of personal strengths will benefit students and teachers. These benefits are related to achieving greater student engagement as well as promoting mindful empathy, critical thinking, professionalism, and stress management.¹

References

1.  Pedrals NG, et al. Applying positive psychology to medical education. Rev Med 2011; 139: 941-9.

2.  Thomas NK. Resident burnout. JAMA 2004; 292: 2880-9.

3.  Seligman MEP. Flourish.  New York: Free Press, 2011.

4.  Skerrett K. Extending family nursing: concepts from positive psychology.  Journal of Family Nursing 2010; 16: 487-502.

5.  Hershberger PJ. Prescribing happiness: positive psychology and family medicine.  Family Medicine 2005; 37: 630-4.

What Do Elvis Presley and Aristotle Have in Common? Metaphor!

by Peggy Kraus, Pharm.D., Clinical Pharmacy Specialist, the Johns Hopkins Hospital

Aristotle once observed that “Those words are most pleasant which give us new knowledge.  Strange words have no meaning for us; common terms we know already. It is metaphor which gives us most of this pleasure.”

The word metaphor comes from the Greek words meta or “over, across” and pherein or “to carry.”¹  They are often used in education to help “bridge the distance” (a metaphor) between what students already know and what they need to know.¹  Every metaphor highlights one aspect of the concept, just as it hides another.¹  George Lakoff, Professor of Linguistics at University of California, Berkeley and Mark Johnson, Knight Professor of Liberal Arts and Sciences at University of Oregon, called this “metaphorical systematicity.”¹ Are we not “bridging the distance” through distance learning (yep a metaphor) thanks to the power of technology in our own class?

Metaphors can be used to create a pattern and expectations, shape the way we think, and influence the decisions or thoughts of others. ^1,2,3  In education, are we not trying to do these very things?  We need to relay complex, often abstract concepts.  Metaphors can help students understand the concepts.⁴

Using “the web” as a metaphor for the Internet highlights some of its essential characteristics while making other, non-web-like qualities less apparent.¹   Information is education (another metaphor).¹ Some assume information transmission is the main purpose of education, or that the content of education is synonymous with information.¹  But if this were the case, the internet would do away with the need for schools and colleges.¹ What is lost or hidden in this metaphor is that attending too closely to information overlooks the social context that helps people understand what the information means and why it matters.¹ This information needs to assimilated, understood and made sense of, and that understanding is different depending on the learner.¹

We use metaphors as a bridge to understand educational contexts.  Researchers and participants often draw on pre-existing knowledge to explain current experiences.³ Metaphors accomplish this by enabling the connection of information about a familiar concept to another familiar concept.³ That can lead to a new understanding in which the comparison between the two concepts acts as generators for new meaning(another metaphor).³  They can be used to take knowledge that is already held and build the scaffold (another one) to teach or learn a newer concept.⁴

In order to examine the use of metaphor, Devon Jensen classified metaphors into four categories: active, inactive, dead, and foundational.³  Active metaphors carry saliency between the topic and vehicle terms.  For example, “This school is a real melting pot.”³  Inactive metaphors, the optic term must be interpreted through the vehicle term just as “The car race ended in a massacre.”³  Dead metaphors , the saliency between the topic and the vehicle terms are not apparent to due a lack of knowledge or experience with the characteristics of the vehicle term.  For example, “working downtown is a real rat race” is only understandable to modern man when the concept of a “rat race” is explained; few of us today have had experience or witnessed rats in a frenzy. ³  The last category, foundational, the metaphor defines the centrally important features of the concept.  Example: “ organization as machine.”³

Jensen then used these classifications and searched for studies that used metaphors and metaphor analysis as their central method.³  He found 1,128 studies, which surprised me.  He then classified the studies into five major themes. Studies in theme one attempted to raise awareness of modern metaphors that legitimized social process with regard to power and politics.³ In the second theme, these studies examined the metaphoric usage within an educational setting and led to change in education practice, policy and/or roles.³ The third theme was a group of studies that examined techniques and procedures for measuring, understanding, and interpreting metaphors in educational and literary writing.³ Theme four examined the usages, implementation, and/or analysis of metaphor in student, school, and institutional writing.³ And the last theme was on qualitative education research characterized by studies that look at how participants use metaphor to describe existing educational states.³  Metaphors can be myths that limit growth or new ideas that expand possibilities.³

One must be careful about the use of metaphors because it can lead to confusion or misunderstanding.⁴ This is particularly true when there are culture differences between students and instructors or when the metaphor is too old for a younger audience to understand.  Metaphors mean different things to people of different cultures and ages.

James Geary, a writer and the former European Editor of Time, during his TED talk entitled "Metaphorically Speaking" claims that we use six metaphors a minute.²  I really did not spend much time thinking about metaphors until I started working on this blog, but I now recognize that I use them a lot without even realizing it.  Geary starts his presentation by analyzing the many metaphors found in Elvis Presley’s song, “I’m All Shook Up.”  It might sound a little weird but its an interesting analysis.  Later in his presentation, he draws parallels between  René Descartes famous philosophical declaration and Elvis’ song.  “I think therefore I am” was translated into English from the Latin “cogito ergo sum.”   But according to Geary, the literal translation should be “I shake things up, therefore I am.”  So perhaps Elvis was trying to tell us something really deep through the use of metaphor!

References:

1.  Meyer, K.A. Common Metaphors and Their Impact on Distance Education: What They Tell Us and What They Hide. Teachers College Record. 2005; 107 (8):1601-1625.

2.  Geary J.  Metaphorically speaking. TED.com.   Accessed February 20, 2013.

3.  Jensen, D.F.N. Metaphors as a bridge to understanding educational and social contexts. International Journal of Qualitative Methods 2006, 5(1), Article 4. Accessed March 30, 2013.

4.  Ritcher, R. The use of metaphors in teaching and learning. The teaching tomtom. Accessed March 30, 2013.

Computerized Adaptive Testing

by David Cannon, Pharm.D., Clinical Instructor, University of Maryland School of Pharmacy

Unique assessment tools have always been fascinating to me.  Once, when I was taking a practice exam consisting of 25 questions on pharmacy law the following message appeared:  “You scored a 56%, you passed!” How could that be, I thought?  Surely the minimum passing score for a state law exam could not be that low! But, as it turned out, this exam was an adaptive test. While the computer was reporting the percentage of questions I scored correctly, behind the scenes it was doing calculations based on the difficulty and weight of the questions.  Once I began to peel back the surface of these complicated algorithms, I wanted to learn more.  But first, let’s review some basics about assessment …

The purpose of an exam, including high stakes exams to make state licensure decisions, is to use the assessment data (answers to test items) to make inferences about the learner.  Assessment is best approached by first considering what the end requirements of the learner are. Then think about what actions, jobs, or thoughts would illustrate mastery of the desired requirements. By deciding what the goals of assessment are makes the process of actually creating it much easier.¹

Evidence-Centered Design utilizes a series of key questions to analyze the assessment design. Table 1 is good example of a set of questions recommended by Mislevy, et. al.:¹

Table 1: a. Why are we assessing? b. What will be said, done, or predicted on the basis of the assessment results? c. What portions of a field of study or practice does the assessment serve? d. Which knowledge and proficiencies are relevant to the field of study or practice? e. Which knowledge or proficiencies will be assessed? f. What behaviors would indicate levels of proficiency? g. How can assessment tasks be contrived to elicit behavior that discriminates among levels of knowledge and proficiency? h. How will the assessment be conducted and at what point will sufficient evidence be obtained? i. What will the assessment look like? j. How will the assessment be implemented? Taken from Automated Scoring of Complex Tasks in Computer-based Testing1

ECD draws parallels to instructional design in that these questions do not necessarily need to be asked in order, the outputs to each question should be considered when examining the others, and these questions should be repeated as necessary.¹ To understand how evidence-centered design is utilized in creating assessments, the assessment tool must be broken down its individual components.

When designing assessments used for licensing examinations, many domains of knowledge are tested. A domain is a complex of knowledge or skills that is valued, where features of good performance or situations during which proficiency can be exhibited, and where there are relationships between knowledge and performance.¹   In a high stakes examination, like a state board licensure exam, it is not sufficient for an examinee to be competent in only one domain but not the others. To test proficiency in each of the domains, smaller subunits of the assessment called “testlets” are used. Testlets typically contain a group of assessment items that are related to each other that would elicit the behaviors associated with the domain.³  It is vital to understand how these examinations are designed from an evidence based perspective in order to evaluate the validity of computerized adaptive testing.

So what is a computerized adaptive test anyways?  CAT is an assessment tool that utilizes a iterative algorithm with the following steps:²

1) Search the available items in the testlet domain for an optimal item based on the student’s ability

2) Present the chosen item to the student

3) The student either gets the item right or wrong

4) Using this information as well as the responses on all prior items, an updated ability estimate of the student is determined

5) Repeat steps 1-4 until some termination criteria is met

CAT is utilized in many high-stakes licensing examinations such as the National Council Licensure Examination (NCLEX), which is required by most states for nurses before they can practice. In the case of NCLEX, after each item is answered by the examinee a calculation is done in the background that determines an estimate of the persons competency based on the difficulty of the item answered. The computer then subsequently asks a slightly more difficult question to apply the algorithm again, creating a new estimate of the candidates competency. This is repeated until the computer reaches a predetermined cutoff (with a confidence interval 95% in the case of the NACLEX³) for minimum competency or until the number of test items has been exhausted. Put another way, the exam will cease when the algorithm has determined with 95% certainty that the student’s ability falls above or below a minimum competency standard. Check out this VIDEO of how the algorithm works behind the NACLEX.³

Now you might be wondering how you create an adaptive test.  It’s a pretty complicated process that would involve breaking down the different subject areas you want to test into different domains.  Then you’d need to develop an item bank for each domain. Content experts would come together and decide what items should be included while at the same time evaluating their appropriateness and difficulty/weight.  A great free resource for creating your own adaptive test can be found here.⁴  The NCLEX is a great example of how computerized adaptive testing brings together the ideas of evidence centered design and instructional design by helping educators assess their students with greater accuracy.

References:

1.  Mislevy RJ, Steinberg LS, Almond RG, Lukas JF.  Concepts, Terminology, and Basic Models of Evidence-Centered Design.  In:  Williamson, D, Mislevy, R, Bejar, I (eds). Automated Scoring of Complex Tasks in Computer-based Testing (1^st ed). Mahwah, NJ.: Lawrence Erlbaum Associates, 2006 (pp 15-47).

2. Thissen, D., Mislevy, R.J.. Testing Algorithms. In Wainer, H. (eds.) Computerized Adaptive Testing: A Primer. Mahwah, NJ: Lawrence Erlbaum Associates, 2000.

3.  Computerized Adaptive Testing (CAT). National Council of State Boards of Nursing. Accessed on: March 11, 2013.

4.  Software for developing computer-adaptive tests. Assessment Focus. Accessed on: March 26, 2013.

Teaching Emotional Competence through Simulation

by Matt Newman, PharmD, PGY1 Pharmacy Practice Resident, The Johns Hopkins Hospital

Recent graduates of Doctor of Pharmacy programs are likely familiar with the role of simulation in education. Activities like patient counseling laboratories and clinical skills practicums are common, even if the formats may vary. While these instructional methods are useful and are aimed at providing a true-to-life experience, one aspect of pharmacy practice in the “real world” is not easily taught: social and emotional compassion and competence.

As a pharmacy student, I participated in a somewhat dreaded patient counseling lab during “angry week.”  In this session, rather than being presented with a calm and cooperative patient needing advice about smoking cessation or seeking help with the high cost of co-payments, the patient was irate about a perceived medication error that had occurred with her prescription. Sitting in the counseling room, I remember a distinct feeling of uneasiness as I pondered the best way to manage the patient’s emotional state and formulate an appropriate response to her concerns.  I have found that the best way to improve this skill set is through experience.

You may have had a similar lab in pharmacy school.   And you probably already have some idea of what social emotional competence means and how you might demonstrate it in practice.  Exact definitions vary, but emotional intelligence is considered “the overlap between emotion and intelligence,” or, “the intelligent use of emotions.”¹ It is a set of skills used to read, understand, and react effectively to emotional signals sent by others and oneself.²  While this sounds obvious, assessing one’s ability to utilize this skill set can be difficult. There is, however, an increasing body of literature regarding social emotional intelligence, which demonstrates an expanding awareness of its importance.

While the need for emotional intelligence in healthcare has been thoroughly described, there has been little research about how to best teach and measurement it, especially among pharmacy students.¹ A group of instructors at one pharmacy school sought to measure the development of social emotional competence in students before and after a series of simulated patient counseling activities. To do so, a group of first-year students were asked to complete the Social Emotional Development Index (SED-I) before and after participation in mock patient consultations. Students were also graded on a scale of 0-3 for social emotional competence.

The SED-I is a self-assessment tool in which participants respond to questions such as “I take the lead role,” “People know that I care about them,” and “I act without considering another person’s perspective” with the goal of assessing the respondents SED in four domains: connection, influence, consideration, and awareness. In this study, students took the SED-I at baseline and after performing two mock counseling sessions on topics such as smoking cessation, nonprescription medications, blood pressure, and blood glucose monitoring. Statistical analysis demonstrated a significant positive correlation between students’ patient counseling assessment scores (as judged by the instructors) and their self-assessment using the SED-I.¹ In other words, students who performed better in the lab also scored higher on the SED-I.

These results indicate the potential utility of the SED-I as a tool to evaluate the development of social emotional intelligence. While not surprising, it is useful to note that the students who performed better on the lab activities were the ones who had more developed social emotional intelligence.  This reinforces the current understanding that this type of intelligence is important during patient interactions. The authors noted that pharmacy curricula are effective at teaching core knowledge and technical skills, but social skills may be more important in order to influence patient behavior.¹  A possible limitation of the study is the use of second-year pharmacy students as the “patients” in the counseling sessions; the use of professional actors would have made the counseling sessions more realistic.

Another group of pharmacy faculty studied students’ perceptions of emotional intelligence material used in a communications course.³ Objectives for this course included “Define an emotional concept,” “Relate how self-confidence would be beneficial to the Director of Pharmacy in a large hospital,” and “Describe the characteristics of people who are competent in communication skills and relate how these characteristics would benefit the pharmacist who manages a staff of 20.”  In addition to traditional didactic content, a patient counseling activity similar to the previous study was used to teach the core principles. Instructors reviewed a video recording of the counseling activity with the students, and noted the empathic responses used. They also role-modeled for the students. Additionally, students were asked to answer two reflective questions and course content was assessed on a formal examination. Student responses were mostly positive: they recognized the importance of these skills and the need to apply them to practice. It is interesting to note that the authors mention the lack of standardized tools available to assess the students. Perhaps the SED-I could have been used to assess student performance in this type of educational activity.

I wonder how my patient counseling lab experience may have been different if the SED-I, or another measure of social emotional intelligence, had been used. While most may not think about social emotional intelligence in day-to-day interactions, awareness of the concept is important. The same skills needed for effective patient counseling would also be useful in ensuring productive interactions with many others, including peers, family, and members of the medical team.

Using simulation to teach social skills is useful but it is not without caveats. Using students or actors as “patients” during patient counseling labs is a great way for students to gain experience and confidence in their interactions. However, it is difficult to emulate real emotions and personalities as they will be experienced in the clinical setting.  Finding the best method of evaluating student’s social and emotional development is a work in progress. Regardless, including instruction regarding social emotional intelligence into pharmacy curriculums is important and simulated patient interactions serve as a reasonable substitute for real-life experience.

References

1.  Galal S, Carr-Lopez S, Seal CR, et al. Development and assessment of social and emotional competence through simulated patient consultations. Am J Pharm Educ. 2012;76: Article 132.
2.  Romanelli F, Cain J, Smith KM. Emotional intelligence as a predictor of academic and/or professional success. Am J Pharm Educ. 2006;70: Article 69.
3.  Lust E, Moore FC. Emotional intelligence instruction in a pharmacy communications course. Am J Pharm Educ. 2006;70: Article 06.