January 29, 2014

Danger Zone: Failure Ahead

by Elaine Yip, Pharm.D., PGY1 Pharmacy Practice Resident, Kaiser Permanente Mid-Atlantic

John is a student in your class.  He has several unexplained absences, is unable to follow along during topic discussions, and has not turned in several assignments.  The end of the semester is approaching.  What should you do?  Wait for John to approach you for help? Give him a grade that is just enough to pass at the end of the year?  Fail him?

Luckily, I have not yet been confronted with this situation. However, as I engage in more teaching and supervise students during advanced practice experiences, I know that, sooner or later, I will be faced with this unfortunate and uncomfortable situation.  I am afraid that when that moment comes, I will not be prepared to handle it appropriately and will ultimately end up doing a great disservice to the student. I know that I am not alone in this fear.  In a survey of nursing student preceptors, approximately 18% reported a lack of confidence when dealing with and failing a student who was not performing well.1  I have often wondered, what is the best course of action when it seems that a student is headed in the wrong direction or faces a real danger of failing?

In order to appropriately address the situation, we must differentiate between the types of failing students we may encounter. There are “actively” failing students who usually attend class, take notes, complete assignments, and participate in learning activities.2 Despite this, they are still having a difficult time with the material. Thankfully, these are the students you tend to proactively seek assistance. The story can be quite different when dealing with “passively” failing students, like John. These are the students who skip class, don’t turn in assignments, and are not engaged in the learning process.  Most often, these are the more difficult students to work with as they may not be as receptive towards efforts to help.

Once you have identified which category the student falls into, it is important to understand the specifics about why that student is struggling. Whether it may be poor study habits, difficulty juggling multiple priorities, test anxiety, or other extenuating circumstances (such a learning disability or a mental health problem), each student should be evaluated on a case by case basis. In her study looking at nursing students who failed their clinical experiences, Duffy identifies common reasons including poor communication, lack of interest in the learning experience, persistent lateness, and lack of insight into professional boundaries.3

What strategies may be helpful in preventing students from falling into that danger zone in the first place2,3,4? Course design, clarity of communication, and including more active learning in a course seems to be helpful. One study looking at failure rates in introductory science courses showed that highly structured course a that incorporated active learning activities had lower failure rates when compared to a less structured course that was taught primarily by lecturing.4  The failure rate dropped from 18.2% in the low-structure course to 6.3% in the high-structure course.  Here are some things you can do:
  • Create a syllabus and set clear objectives: This conveys expectations and helps students understand exactly what they are held accountable for.
  • Perform an audience analysis: Identify the needs of the students. Take into consideration how far along they are in their training.  Is your level of expectations consistent with what they should reasonably be expected to do?
  • Use the Socratic Method:  Students are regularly engaged in answering questions and learn from the resulting discussion rather than simply being handed the information.
  • Use ungraded, active learning exercises: Ungraded sample exam questions, case studies and in-class demonstrations can help students digest and discuss what they have just learned. It allows room for error and the discovery of weaknesses without the pressure of a grade.
  • Use clicker/polling questions: These provide a helpful way to gauge audience understanding throughout the learning process. It enables the teacher to identify knowledge gaps early on that need extra review rather than wait until exam time.
  • Implement a weekly class summary assignment: Have students write down what they think was the most important concept introduced that week and at least one question they have about the material.
  • Provide frequent quizzes: This forces students to pace themselves and keep up with course content over the course of the semester rather than falling victim to procrastination.  Start quizzing early to identify students who are struggling and at risk for failing.
What if a student is already heading into the danger zone, like John? What can be done to get them back on track2,5,6
  • Talk to the student and do it early! Note your concerns and ask them if there is anything that can be done to help.
  • Develop an action plan. Include the student’s input. The plan should include the instructor and the student’s roles to resolve the situation. Together, decide what reasonable and measurable outcomes would represent improvement.
  • Schedule times for regular and constructive feedback.  The “sandwich method” can be used to help deliver negative feedback by first highlighting something the student has done well, then moving on to areas of improvement, and then ending with more positive feedback.  Feedback should not only occur when something is wrong.  Positive feedback will improve the student’s confidence and encourage continuation of that specific behavior.
  • Perform regular self-assessments. This can be done formally in writing or as a discussion. The student should be asked to evaluate themselves on their performance and progress.
  • Document, document, document. Make note of all of these interactions with the student and efforts made so far to resolve the situation.
Unfortunately, there will be some students who will not make any effort to acknowledge and act on your feedback. In these circumstances, you will need to make that difficult decision to fail a student.  Hopefully, by implementing these strategies, failures will be a rare occurrence.  If I’m ever faced with that decision, I will know that I have given it my best effort.


1.  Heaslip V, Scammell JM. Failing underperforming students: the role of grading in practice assessment. Nurse Educ Pract. 2012 Mar;12(2):95-100.
2.  Buskist, W., & Howard, C. Helping Failing Students: Part 1. Association for Psychological Science RSS.  Accessed on January 24, 2014.
4.  Freeman, S, Haak D, Wenderoth M.  Increased Course Structure Improves Performance in Introductory Biology. CBE-Life Sciences Education. 2001:10:175-186.
5.  Buskist, W., & Howard, C.  Helping Failing Students: Part 2. Association for Psychological Science RSS.  Accessed on January 25, 2014.
6.  Ideas When a Student Has Difficulty: Understanding the Failing or Weak Student. Philadelphia University. Accessed on January 24, 2014.

January 17, 2014

Less is More: Learning in Small Groups

by: Yevgeniya Kogan, Pharm.D., PGY-2 Health-System and Administration Resident, University of Maryland Medical Center

College. Freshman year.  Day one.  First class. If those factors weren’t intimidating enough, imagine hurrying through a huge college campus, and locating the tucked away lecture hall.  When you enter it, before you unfold a sea of stadium-like seats occupied by about 300 hundred unfamiliar faces. You make your way all the way up to the top of the hall looking for an empty seat. Your professor is about the size of a fly from your birds-eye perspective and you are grateful for his annoyingly loud voice and 10 foot tall power point presentation.  Now, fast-forward almost 10 years and, in stark contrast, you find yourself in front of a computer (maybe in your pajamas), on your own, with faceless participants, and an unfamiliar voice permeating from the telephone leading a discussion. You are in your very first online class. Questions come to mind; which is better? What environment provides the most opportunity for growth?  Which set up will I benefit from the most? The answer might seem obvious. After all, who doesn’t love the comfort of their own pajamas over a humongous lecture hall crammed next to students, some of whom have obviously given up showering in favor of long nights of partying. Are these two extremes the only way?

Hamann1 and colleagues took on the challenge of assessing just that question in a study where they compared discussions conducted in large face-to-face classes, online classes, and (the alternative) small face-to-face classes. Based on a survey of students who were exposed to all three environments, they found (no surprise) large class discussions were rated least favorable by the majority of students. The interesting findings emerged when they compared online and small-group discussions. While online- classes tend to yield the most satisfaction when it comes to participation and the ability to express one’s thoughts, the small-group face-to-face discussions out-perform the online environment in terms of getting to know your classmates, stimulating interest, and overall satisfaction.

The authors explore participation, which is known to enhance learning and stimulate creativity, even further by looking at gender differences. It is common knowledge that male participants tend to dominate discussions. When Hamann1 and colleagues explored this phenomenon they saw the following. As expected, in the face-to-face classes, both large and small, males tended to participate more frequently than their female counterparts. However, in the online environment, this difference is virtually eliminated and equal participation emerged. The increased participation from the female students might be attributable to a less intimidating environment.  There is also evidence to support that smaller groups tend to level the playing field for students of different ethnic backgrounds.2

During my undergraduate years I was in many large-classrooms in a science-focused school for most of my science and math courses.  Indeed, most colleges and universities teach the  introductory science, technology, engineering and math (STEM) courses in large, stadium-like lecture halls. According to Jason Koebler3, the large classroom is a way higher-education uses a “weed-them-out” process that teaches students to sink or swim.  Luckily, I swam. During graduate school I was in both the traditional large classroom and the smaller group setting where discussions were mandated and you were held accountable for the taught content. As I reflect back, one thing stands out the most are the many faces engrossed in their laptops – such a studious bunch!   But on closer inspection, the sea of brightly lit screens were displaying social media, news, movies, and online chats.  Very few screens projected the course material.  Perhaps the large-classroom wasn’t as studious as I thought.  In contrast, my experience in small groups, while sometimes forced, yielded greater interaction, discussion, and exchange of ideas.  True, some small groups were more effective in generating discussions than others.  In larger small-groups (more than 15 people), more people took the back seat while in smaller small-groups (8 students or less) everyone was engaged. When does a small group become too large?

Class size has been a hot topic for many years.  The US Federal government allocated $12 billion (over a seven-year period) to reduce class size and states like California spent another $3.6 billion.4  There are some conflicting results when it comes to class size.  Maasoumi4 and colleagues’ analysis indicates that a reduction in class size from 20 or more students down to less than 20 students generally increases test scores for those students who initially scored below the median test score but decreases test scores for those who scored above the median.  Conversely, Konstantopoulos5  found that all students reap the benefit from being in small classes when they examined Stanford Achievement Test scores in  mathematics, reading, and science.  The greatest benefit was seen in students who were low achievers and those who spent the longest duration of time in a small class setting. Nye6 reported that when students transitioned from small classes to large ones, the academic benefits persists for two full years.

As the pressures on academia increases to produce competent and confident students, it is important to consider the benefits of small groups and the impact they have on student satisfaction, understanding of concepts, and ability to work together.  Learning in small, face-to-face groups seems to have many advantages over large, content driven, sink or swim classrooms and independent, self-directed, lonely cyberspace classes.

1. Hamann K, Pollock P, Wilson B. Assessing Student Perceptions of the Benefits of Discussion in Small-Group, Large-Class, and Online Learning Contexts. College Teaching [serial online]. Spring 2012; 60(2):65-75. Accessed December 15, 2013.
2. Pollock P, Hamann K, Wilson B. Learning through Discussions: Comparing the Benefits of Small-Group and Large-Class Settings. Journal of Political Science Education [serial online]. January 1, 2011;7(1):48-64. Available from: ERIC, Ipswitch, MA. Accessed December 17, 2013.
3. Koebler J. Experts: 'Weed Out' Classes Are Killing STEM Achievement. US News & World Report.  April 19, 2012. Online. Accessed December 14, 2013.
4. Maasoumi E, Milliment D, Rangaprasad V. Class Size and Educational Policy: Who Benefits from Smaller Classes? Econometric Review [serial online]. November 2005;24(4):33-68. Accessed December 17, 2013.
5. Konstantopoulos S, Chung V. What are the Long-Term Effects of Small Classes on the Achievement Gap? Evidence from the Lasting Beneftis Study. American Journal of Education [serial online]. November 1, 2009;116(1):125-54. Accessed December 14, 2013.
6. Nye B, Tennessee State Univ.  Small is Far Better. A Report on Three Class-Size Initiatives: Tennessee’s Student Teacher Achievement Ration (STAR) Project (8/85-8/89), Lasting Benefits Study (LBS:9/89-7/92) and Project CHALLENGE (7-89-7/29) as a Policy Application (Perliminary Results). Pager No. 5. [serial online]. November 13, 1992.  Accessed December 14, 2013.

Tips for Teaching Non-Native English Speakers

By Ittiporn Chuatrisorn, PGY-1 Pharmacy Practice Resident at the University of Maryland Medical Center

The non-native English speaking adult population in the United States is large and diverse.  Educational programs serve learners from very different backgrounds and with very different needs.1,2  From my experience as an international student, I have found some teachers to be more understandable and have more effective techniques for teaching non-native English speakers (NNES) than others. This blog essay has been assembled as a resource for you - the instructors and preceptors who are encountering more and more NNES students.  I hope to provide you with some ideas on how to teach lectures and lead small groups in a manner that improves listening comprehension for NNES and ways to get your non-native speakers more involved in class discussions.

Monitor how you speak and what you say.2-6  Pause for a couple of extra beats between sentences.  By reducing the speed of your speaking, even just alittle, you are giving the audience (NNES and English speakers alike) a chance to absorb what you say.  You do not have to cut your rate of speech in half; simply become aware of your speech and slow down! When a professor speaks slowly and clearly this helps NNES understand the concepts and, later, they do not have spent extra hours trying to find the concept in the textbooks or other resources.

Avoid idiomatic expressions and slang.3-6 If you use idioms, slang, or long series of adjectives, define them and repeat the concept in more formal terms.  For example, one professor, when explaining how to approach a job interview, said “Do not shake hands like a wet fish when you greet the interviewer.” I had absolutely no idea what the professor meant until the idiomatic expression was explained to me!

Clarify examples that refer to cultural events or norms that may be unfamiliar to people from another country.6-7 Some professors use “Ameri-centric” examples to explain concepts (e.g. references to U.S. history or popular culture). NNES who are unfamiliar with the examples may not understand the concept. You should take a few minutes to provide brief background information.  During one lecture regarding drug therapy reimbursement, for example, a professor talked about Blue Cross and Blue Shield, Aetna, and Humana. I had no idea that these were health insurance companies! At the end of that lecture, I did not understand anything. What may seem everyday and commonplace to the lecturer may be alien to the NNES student.  Of course, this is not unique to NNES students.  English speakers who are not from the US would have similar difficulties – but NNES students likely face even greater challenges when Ameri-centric examples are used.

Use visual aids.  Write key words on the board, slides, or otherwise provide visual cues to help NNES process meaning more readily.  This can include gestures, pictures, and concrete objects.2-4 I think it is better to start early with visual cues in the class.  When the professor repeated key terms, wrote key terms on the board, and prepared a handouts in advance, this really helped me follow the lecture.  One of my pharmacy professors had a section of the blackboard site set aside for key terms and an outline of the day’s lesson plan.  He posted this information on board prior class. This gave me a refer to if I lost the thread of the discussion.

Provide written instructions about homework assignments and examinations.2,6  Asking if everyone understands the assignment or knows when it is due may not be enough. NNES may be too embarrassed to speak up or may not even understand that you are discussing an assignment.7-8 When I studied in pharmacy school, the professor asked if everyone understood the assignment, no one said a word. However, a Chinese colleague, who had only been in the country for 2 months, did not understand.  She misunderstood and presented a wrong topic. As you can imagine, she was very embarrassed!  Thus, oral explanations, without written support, could create problems for NNES.

Allow NNES students to record lectures.2 They can listen as often as necessary to fill in their notes. Moreover, they can concentrate solely on trying to understand what the professor is saying during class, knowing that they can make notes later from the recording. In my first semester of school, I was shocked to discover that the professor did not begin at chapter one and continued through the textbook in a step-wise manner, chapter by chapter.  And they use a lot of materials outside the textbook. This can create confusion and obstacles for NNESstudents. Access to notes, class recordings, and a list of helpful outside sources helps NNES keep up the class.

Provide NNES students more opportunities to talk about the material.  Give NNES time to reflect before asking them to speak.7-8 Many Americans think aloud, but people from many other cultures do not. What this means is that NNES rarely have time to reflect and respond before a native English speaking student (or, worse, the professor) has answered the question and taken over the conversation.  In some parts of the world, students are taught to be deferential, never challenging the teacher’s point of view or offering innovative ideas.8 For example, many Asian student would prefer to conform to tradition without trying to present novel ideas. Furthermore, you may experience difficulty-eliciting opinions from Korean, Japanese, Chinese, Thailand, and other students who come from educational systems where rote learning is the rule. Thus, you should give NNES a few minutes to write in response to a question before asking students to participate in the discussion.

Some NNES are very self-conscious about their imperfect English.7,8 They may be frustrated by not being able to accurately articulate their complex thoughts. They may be concerned that their native English-speaking peers will think less highly of them. If the response is slightly off, try to do something positive with it. You should rephrase the response but don’t point out grammatical errors.2  Ask clarifying questions and elaborate on their response.

To summarize, NNES students are just as smart as native English speakers and will learn from you if you employ a few simple techniques. These students face many challenges navigating a new academic setting with different expectations, studying in a new language, and adapting to a new culture.  These techniques will help you to make your lectures and small group discussions more accessible to them, improve their listening comprehension, and enhance the learning experience for everyone.

Check out these additional resources:
1)   Responding to non-native speakers of English (University of Minnesota)
2)   Teaching Nonnative Speakers (Baruch College)
3)   ESL Instructional Resources (University of Washington)

1.   National Center for Education Statistics. Participation of adults in English as a second language classes: 1994-1995. Washington DC. Assessed 1 December 2013.
2.   Stevens LP, Jefferies J, Brisk ME, Kaczmarek S. Linguistics and Science Learning for Diverse Population: An Agenda for Teacher Education. In: Bruna KR and Gomez K, editors. The Work of Language in Multicultural Classrooms – Talking Science, Writing Science. 2nd ed. New York: Taylor and Francis Publishers; 2009. p291.
3.   Wright WE. Foundations for Teaching English Language Learners: Research, Theory, Policy, and Practice. 1st ed. Philadelphia. Caslon Inc. Publisher; 2010.
4.   Common Classroom Practices for All English Language Learner Educators. In: Wagner S, King T. Implementing Effective Instruction for English Language Learners: 12 Key Practices for Administrators, Teachers, and Leadership Teams. Philadelphia. 1st ed. Caslon Inc. Publisher; 2012. p107.
5.   Tapia AT. Non-Native English Speakers Setting New Standard. New America Media Commentary. Assessed 1 December 2013.
6.   Lee DS. What Teachers Can Do to Relieve Problems Identified by International Students. New Directions for Teaching and Learning. 1997; 70: 40-51.
7. Nelson GL. How Culture Differences affect Written and Oral Communication; The Case of Peer Response Groups. New Directions for Teaching and Learning. 1997; 70: 77-84.
8. Hodne BD. Please Speak Up: Asian Immigrant Students in American College Classrooms. New Directions for Teaching and Learning. 1997; 70: 85-92.