February 14, 2022

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.


  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].