Practice Reinforces Knowledge and Builds Confidence

by Shannon Buehler, Doctor of Pharmacy student, University of Mississippi School of Pharmacy

Summary and Analysis of: Manigault KR, Augustine JM, and Thurston MM. Impact of Student Pharmacists Teaching a Diabetes Self-Management Education and Support Class. Am J Pharm Educ 2020; 84 (3): Article 7621.

This article caught my attention because it involved student pharmacists implementing a diabetes self-management class for patients.¹ As a student pharmacist, diabetes is an interest of mine – something I think that will be important in my future career. This study attempted to demonstrate that students learn best by practicing in a real-life, authentic setting. The authors of this study compared two groups, one group received traditional instruction and experiences working with people with diabetes, the control group, and the other group, the intervention group, had an opportunity to apply what they learned by teaching a diabetes management class to patients. A study like this is needed to help determine what ways are most effective in teaching health professional students.

This study took place at Wellstar Atlanta Medical Center outpatient clinic. The investigators precept Doctor of Pharmacy students from the Mercer University College of Pharmacy during their fourth-year ambulatory care advanced pharmacy practice experience (APPE). This investigation took place from June 2016 to April 2018 and there were one to two student pharmacists participating in the experience each month. The control and intervention alternated each month so that there was an equal distribution of participants in the two groups. During the first week of the APPE, both groups completed two assessments: one on knowledge of diabetes and the other about their perceived aptitude and confidence. Both groups engaged in traditional patient care activities throughout the five-week APPE. The intervention group conducted a single diabetes self-management education and support (DSMES) class during their fourth or fifth week. Students in the control group did not.  During this investigation period, a total of 15 DSMES classes were taught. The DSMES classes typically had three to five patients participate.  The patients had been previously seen in the clinic by the student. These classes were in-person and lasted approximately two hours.  The students used the US Diabetes Conversations Map Kit provided by the American Diabetes Association (ADA) to help guide the class.² Immediately after conducting the class, the intervention group completed two post-intervention assessments – the same assessments that were administered during the first week of the APPE. Similarly, the control group received the post-intervention assessments in the 4^th or 5^th week.

The results showed that the intervention group substantially increased their level of knowledge and confidence. The intervention group students had a significant improvement in their knowledge (increased from 68.4% at baseline to 81.8%) while the control group did not (increased from 70.0% to 74.1%). Both groups showed significant improvement in aptitude and confidence from baseline. However, the change in mean aptitude/confidence scores was greater in the intervention group (11.9 point increase) when compared to the control group (6.7 point increase, p=.0026).

Measuring knowledge and confidence are two important constructs to assess. Both contribute to what makes a good healthcare provider, thus making this study relevant to APPE preceptors for student pharmacists. It is important to note that students in the intervention group put forth more time and effort and this likely explains why their knowledge gains were greater. Although the post-assessment confidence levels improved in both groups, a confidence boost might come from simply getting real-world experience when completing an APPE rotation. Both groups provided one-on-one counseling about diabetes to patients. This might explain the increased confidence in both groups. The intervention group had greater improvement in confidence which can be explained by their additional experience leading the DSMES class. 

The strengths of this study include using alternating months to enroll participants in the control vs. intervention groups and using consistent pre- and post-assessments. Although they were not randomly assigned by the investigators, students were not “selected” to participate in the intervention or control groups. However, there are some weaknesses including the fact that all participants (students, patients, and preceptors) were from the same clinic and the same school of pharmacy. Moreover, we don’t know if all students had similar experiences and patients may have had different issues or complications. Lastly, some students (20%) had previously participated in a diabetes management elective course offered during their curriculum.  Slightly more students in the control group had taken the elective course but it is unclear if this difference impacted the study results.

A similar study was previously conducted by Shrader and colleagues. Similarly, student pharmacists were engaged in teaching DSMES, but the study did not include a control group. Moreover, the investigators did not perform a comprehensive assessment – they only measured changes in student confidence.³ Another small study evaluated student pharmacists who participated in an interprofessional elective.  Again, the investigators only measured improvements in student confidence when providing DSMES to patients.⁴ In both of these studies, there were positive effects on student confidence levels.  It is perhaps not surprising that student confidence consistently improved in all of these studies as one would hope an educational intervention would improve how students perceive their ability to perform these tasks.

I believe this study provides solid evidence that practice, applying one’s knowledge, improves both knowledge and confidence. From my own experience, I know that putting my knowledge into action in “real” life truly solidifies my knowledge. Every preceptor should provide opportunities for hands-on, authentic practice. This article is a good example that could be applied during any ambulatory care APPE but it can be modified for experiences in other settings too. The key is to provide students with opportunities for more practice.  And this will increase their knowledge and confidence as they transition to independent practitioners. 

References:

1. Manigault K, Augustine J, Thurston M. Impact of Student Pharmacists Teaching a Diabetes Self-Management Education and Support Class. Am J Pharm Educ. 2020;84(3): Article 7621.
2. Diabetes Care. American Diabetes Association Standards of Medical Care in Diabetes – 2020 [Internet]. Diabetes Care 2020;43(1): S1-S212
3. Shrader S, Kavanagh K, Thompson A. A Diabetes Self-Management Education Class Taught by Pharmacy Students. Am J Pharm Educ 2012 Feb 10;76(1): Article 13.
4. Fazel M, Cooley J, Kurdi S, Fazel M. A co-curricular diabetes-specific elective with interprofessional students and faculty. Curr Pharm Teach Learn 2019 Feb;11(2):172-177.

Forming One’s Professional Identity

by Alex Craig, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Making the transition from pharmacy student to practicing pharmacist is challenging.¹ New pharmacists are tasked with actively applying learned materials in their everyday practice as well as problem-solving when areas of practice are often more gray than black and white. During this transition, a pharmacist’s professional identity plays a crucial role. Professional identity has been defined as “a representation of self, achieved in stages over time during which the characteristics, values, and norms” of the profession are “internalized, resulting in an individual thinking, acting, and feeling” like a health professional.² Those with strong professional identities tend to be confident, driven, and adaptive when faced with uncertainty.³ I believe professional identity can and must be actively developed through thoughtfully designed student experiences.

Over the last two decades, there has been an explicit effort to teach “professionalism” in health professions education. In recent years this has evolved and helping students form their “professional identity” during their journey to become healthcare professionals has become the educational objective.⁴ In 2014, the American College of Clinical Pharmacy formed a task force on how to help foster professional identity formation. The task force made recommendations for best practices, created a framework for educational methods to support the formation of professional identity within interprofessional contexts, and generated recommendations to support faculty in helping students develop their professional identities.⁵

Facilitating professional identity formation requires consideration of many factors: What kind of pharmacist (generalist, specialist, practice setting) does the student pharmacist want to become? What are the hallmark characteristics society needs in a pharmacist now and into the foreseeable future? What processes are in place to support and promote identity formation?¹ Forming a professional identity is a dynamic process with many influences.  It is influenced not only by the student’s personal identity, but also factors such as clinical/non-clinical experiences, role models/mentors, formal instruction, self-assessment, reflection, and socialization. Among these, role models/mentors and experiences appear to have the biggest impact. In professional identity formation, a positive mentor/mentee relationship is facilitated by constructive feedback. Feedback serves as a reinforcement of learning and it assists in the confirmation of the learner’s self-perception.⁴ Preceptors and mentors can aid in identity development by sharing personal experiences and encouraging the student to shift into an independent mindset. For example, when encountering a situation where the best decision is unclear, the preceptor should encourage the student to express their thoughts and suggest potential solutions. Encouraging students to combine foundational knowledge with recent literature and applying that to a patient case or practice management scenario can facilitate this independent thinking.  Indeed, students should be encouraged to be responsible for making choices and this should align with who they want to become as a healthcare professional. Exposure to increasing complex scenarios can also help prepare students for their future practice. There also needs to be opportunities for students to share and reflect on their experiences and what was gained or learned. This may be facilitated through debriefing sessions that are student-led.⁴

A 2019 scoping review investigated pharmacy student professional identity formation.¹ The paper pointed out important aspects to be considered when developing curricula to foster professional identity formation. First, it's important to examine how pharmacy students see themselves. Pharmacy students often lack an understanding of their professional selves and are unable to articulate what it means to be a pharmacist. Pharmacy students tended to focus on traditional pharmacist roles (dispensing and counseling) and this understanding was reinforced by experiential learning and part-time work experiences. Pharmacy students also found it challenging when engaging with patients when they were met with disinterest or anger. Experiences gained within the pharmacy curriculum often led to unresolved identity dissonance because students’ practice experiences did not align with the idealist view taught in the classroom about the pharmacist role.¹ This includes ambiguity about the definition of “clinical” pharmacy. For example, the definition of “clinical” often vary by practice setting, and students perceive big differences in the role and responsibilities of pharmacists in community, ambulatory care, and hospital settings. Some educators suggest that role-play activities can help encourage students to merge the gap between the “ideal” professional role and their lived experiences. Students should be given opportunities to discuss their experiences with a trust role model and re-enact how they responded to the experience.  This enables students to envision their professional identity but also critically examine their personal identity.⁶

To facilitate professional identity formation, faculty will likely need to be educated about the construct. It is important that faculty understand that students must participate in developing their own professional identities and maintaining a welcoming environment for open dialog is critical.  The curriculum should address known factors that affect identity formation and there should be a mechanism to assess student progress. Some schools engage students in the development of professional identity by using reflective strategies.³ This strategy can consist of some foundational instruction about professional identity formation and periodically asking student pharmacists to reflect on their stage of development. These reflections can help gauge the student’s understanding, track their progress, and identify gaps. A tiered approach is needed and activities should be appropriate for the learner’s stage of development.

I challenge you to think about your own transition into practice and your understanding of your role. What experiences did you have that fostered the development of your professional identity? What experiences or role models do you wish you could have had during your training?

The aim is not to homogenize all personal identities into a standard; rather, the student maintains his or her ‘self-identity’ while building a professional identity through exposure to diverse experiences while upholding the key virtues of a … professional including competence, kindness, honesty, and integrity.⁷

References:

1. Noble C, McKauge L, Clavarino A. Pharmacy student professional identity formation: a scoping review. Integr Pharm Res Pract. 2019; 8: 15-34.
2. Cruess R, Cruess S, Boudreau J, et al. Reframing medical education to support professional identity formation. Acad Med. 2014;89(11):1446–1451.
3. Scanlon L. “Becoming” a professional. Dordrecht: Springer; 2011. 
4. Cruess S, Cruess R, Steinhert Y. Supporting the development of a professional identity: General principles. Medical Teacher. 2019; 41(6): 641-649.
5. American Association of Colleges of Pharmacy. Taskforce on professional identity formation – final report. 
6. Monrouxe LV, Rees CE, Endacott R, et al. “Even now it makes me angry”: health care students’ professionalism dilemma narratives. Med Educ. 2014; 48(5): 502–517.
7. Forouzadeh M, Kiani M, Bazmi S. Professionalism and its role in the formation of medical professional identity. Med J Islam Repub Iran. 2018; 32: 130.

Using Twitter to Augment Student Learning

by Emily Ware, PharmD, PGY1 Pharmacy Practice Resident, St. Dominic Hospital 

The use of social media across the educational landscape has considerably increased over the past few years and especially in the past few months during the COVID-19 pandemic. Social media was not designed for the purpose of education and other learning activities; however, the ease of networking and sharing content has allowed social media platforms to gain popularity in higher education.¹ Twitter has been used as a communication tool for formal and informal learning by allowing students and scholars to engage with their peers and discuss emerging information.¹

In one study that investigated the use of Twitter as part of a face-to-face class, undergraduate students taking a teacher education course reported that Twitter enabled communication and interaction between classmates as well as with the broader educational community.² Students stated that Twitter also facilitated connectedness and resource sharing. This encouraged a more collaborative approach to learning.² Another study looked at the perceptions of first-year biomedical students who completed a course in which Twitter-related activities were incorporated into the course design.³ The study found that the students who most actively engaging in the Twitter activities had higher end-of-semester grades compared with those who did not.³ The authors also reported that the use of Twitter was a useful method of promoting public health, along with facilitating collaboration among peers.³

While there are potential benefits using Twitter for educational purposes, there are some drawbacks that should be mentioned.  One study that explored the perceptions of high school students found that students were overwhelmed with the volume of information on Twitter.⁴ Moreover, first-time users had difficulty using the platform and questioned the appropriateness of using Twitter in the educational setting.⁴ In another study conducted at a school of pharmacy, students who completed an optional survey about the use of Twitter in a management course, 71% stated Twitter was distracting and 69% believed it prevented note-taking.⁵ Although these are valid points, these are issues that could be solved if students are taught how to use Twitter effectively as a tool to support their educational endeavors.

There are many ways to use Twitter as an instructional tool. Since some students will not be familiar with Twitter, it’s important to start out small with a brief activity that intended to get students accustomed to the platform.  For example, an instructor could tweet a poll for students to respond to during class. Next, teachers could create an assignment requiring students to formulate a tweet. As students become more comfortable with the tool, the instructor could ask students to create concise writing exercises (like a tweetorial), take Twitter quizzes, use it to research a topic, and engage “backchannel” discussions.  Backchannel discussions are digital conversations that run concurrently with a face-to-face activity and they enable more students to participate and ask questions.  Twitter can also be used for professional development. For example, there are many health professionals across the world who regularly use Twitter to discuss interesting cases they have seen, analyze recently published research manuscripts, or share experiences during their day-to-day work.  Students may find it beneficial to follow a few people on Twitter who work in a potential career path to get a glimpse of what that field or specialty might be like.  Students could then be asked to complete an assignment summarizing their findings and opinions about their potential career choice.

During my third year of my doctor of pharmacy curriculum, we had days in which we completed a “Twitter consult” and were “on call”. During these simulated on call activities (similar to being on call in real life), it was imperative to be readily available and not engage in any activities during the day that required us to be away from our phone.  The consult request was delivered in the form of a tweet, and we never knew when the consult request was going to arrive.  It was the student’s responsibility to respond to the consult within an hour and formulate a verbal response. Typically, the verbal response could not be longer than two minutes. The concept of Twitter consults was to provide a very interactive way for us to glimpse what our future careers may look like – concisely answering difficult questions from health professionals (and patients) in a timely manner. 

Now, as a pharmacy resident, Twitter has helped me to stay current on the latest research and therapeutic recommendations. I have found it to be a great networking tool. I “follow” other pharmacy residents and practitioners who are located all around the US. It is insightful to learn from other pharmacists about their ideas and perspectives on pharmacy and medication-related issues.

I believe that there are many benefits to using Twitter as a teaching tool and I hope it is used more frequently in the classroom and experiential learning settings.  Students need to develop the skills to collaborate and network with their peers and Twitter (and similar social media platforms) go beyond what could be achieved in face-to-face settings.  Twitter can also help build a student’s confidence by encouraging them to formulate their own ideas and opinions. I believe Twitter can augment learning and can be used by teachers and students to facilitate collaboration, networking, and interaction.

References:

1. Malik A, Heyman-Schrum C, Johri A. Use of Twitter Across Educational Settings: A Review of the Literature. Int J Educ Technol High Educ. 2019;16:1-22.
2. Carpenter JP. Twitter’s Capacity to Support Collaborative Learning. Int. J. of Social Media and Interactive Learning Environments. 2014;2:103
3. Diug B, Kendal E, Ilic D. Evaluating the Use of Twitter as a Tool to Increase Engagement in Medical Education. Educ Health (Abingdon). 2016;29(3):223-230.
4. Bull P, Adams S, et al. Learning Technologies: Tweeting in a High School Social Studies Class. Journal of Educational Technology. 2012;8:26–33.
5. Fox BI, Varadarajan R. Use of Twitter to Encourage Interaction in a Multi-Campus Pharmacy Management Course. Am J Pharm Educ. 2011;75:Article 88.