The Airplane Mode Classroom

by E. Ashton Smith, PharmD, PGY1 Pharmacy Practice Resident, Mississippi State Department of Health 

With today’s technology, people spend hours upon hours consumed with a screen every day. Whether it is scrolling on social media, shopping online, texting with friends, playing games, or watching the next episode of a favorite Netflix series, we are rarely disconnected from the internet. We can enjoy this media from our phones, laptops, tablets, televisions, and now even smartwatches. It can be a pleasant distraction.

Icons made by Freepik from www.flaticon.com

But let’s talk about distractions. Media available on the Internet and through our devices can be a good thing; for example, to pass the time during periods of boredom or to partake in a few enjoyable laughs from a friend’s text message. However, the distraction of constant notifications and the temptation to while away hours of time online can be harmful when there are other things at hand that are currently more important.

Devices in the classroom have become second nature to today’s college students. Laptops, cell phones, and tablets are brought into the classroom each day and can be beneficial for things such as note-taking and other class-related activities. These devices, however, can be a major distraction from learning and participation. In a recent study, the investigators surveyed college students in 26 states in the United States.¹ Their sample included college freshmen all the way up to graduate students. The survey focused on the use of digital devices for non-class purposes in the classroom and the effects that usage may have on learning. Almost 97 percent of the participants admitted to using a digital device on a typical school day in the classroom for non-class related activities. The top two reasons (which were both reported by more than 50% of students) for using a device in the classroom were to stay connected and fight boredom. Although the students were choosing to use those devices during class time, it was not without realizing that it could hinder their learning. Nearly 90% of students admitted that the biggest disadvantage of using devices in the classroom was that it causes them to not pay attention.¹ These results are from a survey conducted in 2016.  It seems likely device use would be even greater now in 2020, as the availability of social and video media online continues to skyrocket.

A study published in 2012 found that students who used their laptops during class scored an average of 11 percentage points lower in the course than the students who did not use their laptops.² That is a whole letter grade! Not only does the laptop user become affected by non-class related internet usage during class, but the surrounding peers are also hindered by this distraction. In an experiment conducted in an undergraduate psychology class at McMaster University, half of the participants were instructed to use paper and pencil only to take notes during a lecture.³ The other participants were asked to use a laptop during the class session and were given tasks to complete on their computers during the lecture that was not related to the instruction. The students were given assigned seats and placed strategically around the room such that some students would have a view of other students using laptops, and others would have a distraction-free view. At the conclusion of the lecture, all participants completed a multiple-choice comprehension test with questions evaluating simple knowledge and application of the information presented during the lecture. Not only did the participants using the laptops perform significantly worse on the comprehension test but also the participants who had a view of a student with a laptop scored significantly lower than participants in the distraction-free zones.³ 

Students know the negative consequence and yet still continue to use their devices during class. So, what is the solution? Some schools have explored the idea of disabling WiFi access in classrooms. Cornell University in Ithaca, New York has implemented the use of software to block access to WiFi while inside classrooms. This doesn’t, however, stop cellular signals, but it likely reduces media usage during class. Purdue University in West Lafayette, Indiana has restricted WiFi access throughout campus during class time hours. Streaming sites were completely banned in March 2019. Feedback from faculty has been positive, with one professor saying it has helped students who were previously distracted by other students streaming during class. The ban also challenged teachers at the university to develop class activities that engage students since more were actually paying attention in class!⁴ 

Some classrooms have gone “tech-free.” Teachers in schools throughout the country have experimented with policies that prohibit students from bringing laptops, phones, and tablets into the classroom. A professor in the Department of Psychology and Neuroscience at Duke University tested this policy. She stated that the results were positive and students really loved it. Indeed, students in the tech-free class scored five percent higher on exams than previous semesters.⁵ 

Another way to ease the students into using devices less frequently is to include “tech breaks” during class time. These five-minute breaks are sandwich between lecture segments during which students are allowed to pull out their phones and check social media, text messages, and emails. Students must pay close attention during lecture time to receive this privilege, however. For example, an hour-long class might have 30 minutes of lecturing, then five minutes for a tech break, before the second half of the class begins. This is a good way to not look like the bad guy, eliminating technology completely, and acknowledging how important students’ devices are to them.

Strategies to limit electronic device use in classrooms will continue to rise as the next generation of learners who are even more addicted to their devices enter college. While eliminating WiFI access and banding electronic devices continue to gain traction in schools, more pressure will be placed on teachers to use more engaging instructional strategies during class. Teachers need to explore ways to restructure class time. Ideas include more in-class small group activities, pop quizzes at the end of presentations, and inviting and interacting with guest experts. One of the most useful techniques is to chunk class time into brief activities, each focused on different learning objectives. These brief activities keep the students engaged and involved. Clearly, we need more research about the harms of technology addiction, how it hinders learning, and strategies to address it. 

References

1. McCoy B. Digital distractions in the classroom phase II: student classroom use of digital devices for non-class related purposes. Journal of Media Education [Internet]. 2016; 7: 5-32. [cited 2020 February 10].
2. Duncan D, Hoekstra A, Wilcox B. Digital devices, distraction, and student performance: does in-class cell phone use reduce learning? Astronomy Education Review [Internet] 2012; 11: DOI: 10.3847/AER2012011 [cited 2020 February 10].
3. Sana F, Weston T, Cepeda NJ. Laptop multitasking hinders classroom learning for both users and nearby peers. Computers & Education [Internet]. 2013; 62: 24-31. [cited 2020 February 18].
4. Smith M. Purdue University bans Netflix, other streaming services for students in academic buildings. The Washington Post [Internet]. 2019 March 15. [cited 2020 February 18].
5. Gaither S. Why you should consider a tech-free classroom. Psychology Today [Internet]. 2019 September 23. [cited 2020 February 18].

Games in Healthcare

by Melissa Weaver, Pharm.D., PGY1 Pharmacy Practice Resident, Carroll Hospital Center

I love Angry Birds. Fire the slingshot to send the single-minded birds on their mission!  Victory comes when the evil pigs die! Getting engaged in the game is so easy.  On level 1-1, the player gets three angry birds to kill one evil pig in a wooden and ice structure.  Usually, the player needs only one angry bird to succeed at the mission and feels like a “rock star” after the victory. The story and feelings build with each episode and level.¹

But how do suicidal birds relate to healthcare and education?  Think of the last time you sat in a class and were captivated by the topic.  Compare that to the last time you played a video or computer game and were completely engrossed. In which situation were you more engaged and involved?  I’ll admit, I often feel more involved when I play Angry Birds than when I listen to a lecture.

So what exactly is a game?  The definition seems to be evolving, but Roger Caillois, the French sociologist, said that games have six elements: (1) non-obligatory (2) separate in time and place (3) uncertain course (4) unproductive (5) governed by rules and (6) make-believe.²  Games are designed with multiple ways of keeping the player participating and involved.  Most presentations I have seen lack that level of engagement. The lecture is thought by some to be an inefficient, stifling, and clunky means of delivering instruction; a blunt tool in an age of laser precision.³

Why do games make a difference now?  Games are not new to healthcare education.  In 1995, one of my preceptors played Jeopardy! during her pharmacy residency at the University of Illinois, Chicago.  But technology has improved significantly since 1995.  The proliferation of mobile devices such as tablets and smart phone pave the way for using these devices to teach.  These devices are the first to overcome the limitations of handsets as learning tools.³ The technology also allows the speed and scope of information to be more current than is typically seen in academic courses.⁴ 

How are games being used in healthcare?  Currently, there are more than 300 health-related games on the market aimed at patients in two general themes – physical exercise and brain fitness games.⁵  But disease-specific games are also available such as Re-Mission, a video game for young people with cancer.  The lead characters for Re-Mission include Roxxi, a microscopic robot that fights infections and cancer at the cellular level; Smitty, a retired nanobot who provides holographic guidance to Roxxi; and Dr. West, creator of the self-aware artificial intelligence nanobots and the nanotech chronic illness treatment program.⁶  From a patient education standpoint, the game addresses the importance of taking oral chemotherapy regimens, prompt reporting of symptoms and side effects, proper nutrition, as well as anxiety, nausea, and pain management.⁷ A randomized controlled trial compared adolescents and young adults who played a standard commercial video game versus Re-Mission.  Participants were asked to play the game at least one hour per week for the three-month study period. The conclusion of the trial is that treatment adherence and indicators of cancer-related self-efficacy and knowledge were significantly improved in those who played Re-Mission.⁸

Games are engaging.  They can be used to teach by allowing the learner to apply newfound knowledge to new situations.  Game scenarios can be easily modified to reflect the continuous influx of healthcare information updates.  While playing the game, the learner has the opportunity to make decisions and instantly see the results of those decisions.  The ability to recreate the scenario allows the learner to practice this decision-making skill. Better decisions in healthcare result in better healthcare.

References

1  Angry Birds [Internet]. Finland: Rovio Entertainment Ltd. Accessed 2012 Oct. 16. 

2  Caillois R. Man, Play and Games. University of Illinois Press: 2001. pp. 9-10. Accessed on 2012 Nov 26. 

3  Galagan P. From Pie in the Sky to the Palm of Your Hand: The Proliferation of Devices Spurs More Mobile Learning. T+D [serial online]. March 2012;66(3):29-31. Accessed 2012 Oct 11.

4  Kalman F. Social Media: Learning's New Ecosystem. Chief Learning Officer [serial online]. August 2012;11(8):42-45. Accessed 2012 Oct 11.

5  Gaming in Healthcare. Digitome Corporation. Accessed on 2012 Nov 26.

6  Re-Mission Characters. HopeLab, A Part of the Omidyar Group. Accessed on 2012 Nov 26.

7  Re-Mission For Clinicians. HopeLab, A Part of the Omidyar Group. Accessed on 2012 Nov 26.

8  Kato PM, Cole SW, Bradlyn AS, Pollock BH. A Video Game Improves Behavioral Outcomes in Adolescents and Young Adults WithCancer: A Randomized Trial. Pediatrics 2008; 122:2 e305-e317.

Simulating Experiences in Pharmacy Education

By Xiaoxue Nehrbass, Pharm.D., PGY1 Pharmacy Resident, Johns Hopkins Bayview Medical Center

What is simulation? According to the Accreditation Council for Pharmacy Education (ACPE), simulation is an activity or event replicating pharmacy practice.¹ Simulation experiences may include the use of high- or medium-fidelity manikins, standardized patients, standardized colleagues, role play, and computer-based exercises.¹  Benefits of these experiences may include enhancements in student knowledge and clinical performance, improvements in critical thinking and student confidence, as well as reductions in medication errors.² In the latest version of its Accreditation Standards and Guidelines, ACPE states that colleges and schools of pharmacy may choose to incorporate simulation into introductory pharmacy practice experiences (IPPEs) but it can not exceed 20% (60 hours) of the total IPPE requirement (300 hours).¹

In April of 2011, watching the first Inter-professional Critical Care Simulation that took place at Universities at Shady Grove, I was impressed by how high-fidelity simulation technology brought the health professional disciplines on our campus together.  I learned first-hand the importance of interdisciplinary collaboration in a healthcare setting to optimize patient care. High-fidelity simulation has been widely used in other health professional schools, such as medical and nursing education. The high-fidelity manikin mimics a real patient with computerized programmable physiological responses to disease states and medication treatments.² Similar to a real patient, the manikin can talk and breathe, has heart sounds and palpable pulses.  Simulations can include cardiac and pulmonary arrest, anaphylactic reactions, myocardial infarction, stroke and other scenarios.² In one recent study, a group of fourth-year pharmacy students (in a five year program) used high-fidelity simulation in a series of courses.³ The scenarios included various exercises such as drug-drug interactions, intravenous drip rate calculations, medication recommendation, physiological changes, as well as patient education.³ In addition to the patient (manikin) and pharmacy students, these scenarios also included role plays with physicians, nurses, and family members. Interestingly, the role of family member was played by a standardized patient, who displayed certain emotional responses during the simulation in response to the care provided to patient (manikin). The study showed that when compared to students who did not participate in the simulations, students who experienced the simulations felt more confident in making recommendations to other healthcare providers.³ Additionally, over ninety percent of students reported that simulation enhanced their learning compared to didactic lecture alone.³ As this study has shown, high-fidelity simulations can help to enhance clinical knowledge in various acute care scenarios, improve communication skills and build confidence.  But high-fidelity manikins aren’t cheap!  The cost can range from $16,000 to $90,000 depending on the model.²

Computer-based virtual patient technology offers another type of simulation experience. At the end of the ACLS/BLS training program I completed a few months ago, online simulation technology allowed me to practice the skills and knowledge I had learned, and to make assessments and decisions in a virtual environment. I valued the simulation component of the program because it allowed me to use newly acquired knowledge to create solutions during plausible situations. Throughout each simulation scenario, I learned quickly what I did wrong and the potential (positive or negative) consequences my decisions may have had on my virtual patient. According Jabbur-Lopes and colleagues, one advantage of using virtual patients in patient counseling is that a virtual patient can exhibit various psychological states, such as angry, anxiety, ambivalence, passivity, assertiveness, and persuasiveness.⁴ Through the use of virtual patient technology, students can practice counseling skills with a wide range of patients. Despite these benefits, Jabbur-Lopes and colleagues found that this type of simulation is underutilized in pharmacy education.⁴

For me, the most realistic patient counseling simulation experiences were my encounters with standardized patients. As actors who have been trained to play the role of real patients in specific scenarios, standardized patients not only perform, but in many cases, evaluate the student’s interviewing skills during the counseling session. My personal encounter with standardized patients came during the University of Maryland’s required Objective Structure Clinical Exam (OSCE), a comprehensive assessment that required students to use a wide range of knowledge and skills learned throughout pharmacy school. The counseling sessions were taped and standardized patients evaluated our performance.

To best serve students, programs must evaluate each type of simulation for its strengths and weaknesses. High-fidelity simulation may be an effective teaching tool in an urgent care scenario occurring in the acute care setting. It allows participants to enhance interpersonal skills through team building exercises. The high costs of this simulation tool may, however, be a barrier at some institutions. In addition, it may not be appropriate or efficient to use high-fidelity simulation in less acute situations which do not require close monitoring of the patient, such as counseling on management of chronic disease states. On the other hand, virtual patient technology offers an advantage of accessibility and convenience. It also provides hands-on experience students may need when learning a complicated concept or procedure. Finally, standardized patients may be most beneficial when used in assessing students’ interviewing skills and clinical knowledge. This experience will also prepare them to enter the profession and face real world situations.

With the continued expansion of pharmacy schools and ACPE’s increased acceptance of simulation has part of the IPPEs, simulation experiences should play a larger role in pharmacy education.  Using these types of teaching tools helps students gain the skills and confidence to enter advance pharmacy practice experiences.  Simulations are an innovative and effective way of providing training in an evolving academic landscape.

References:

1.  Accreditation Council for Pharmacy Education. Accreditationstandards and guidelines for the professional program in pharmacy leading tothe doctor of pharmacy degree. Chicago: Accreditation Council for Pharmacy Education; 2011. [cited 2012 Oct 29]

2.  Seybert AL. Patient simulation in pharmacy education. Am J Pharm Educ 2011; 75(9): Article 187. [cited 2012 Oct 29]

3.  Vyas D, Wombwell E, Russell E et al. High-fidelitypatient simulation series to supplement introductory pharmacy practice experiences. Am J Pharm Educ 2010; 74(9): Article 169. [cited 2012 Oct 29]

4.    Jabbur-Lopes MO, Mesquita AR, Silva LM et al. Virtual patientsin pharmacy education. Am J Pharm Educ 2012; 76(5): Article 92. [cited 2012 Oct 29]

Using Audience Response Systems

by Adrian Hui, Pharm.D., PGY1 Pharmacy Resident, MedStar Union Memorial Hospital

How many of you have used an audience response system? Please use your devices to select an answer. 

A.    Yes

B.    No

C.   Not sure

D.   What is an audience response system?

Many of you may be familiar with this scenario, commonly seen in classroom settings today.  With their increasingly widespread use, audience response systems have made their way into television game shows such as “Who Wants to be a Millionaire” where the audience can be polled to help the contestant answer a question.  If you are not familiar with the term “audience response system,” perhaps one of the following alternatives may ring a bell: personal response system, electronic voting system, or student response system.¹

What exactly are “audience response systems (ARS)?”  ARS are tools used to quickly gather data from people participating in a poll.  ARS made their first appearance in the 1960s at Cornell and Stanford Universities² but were costly, cumbersome, and frequently malfunctioned.¹  Eventually, ARS became commercially available in the 1990s, and with several technological improvements (e.g. infrared capability, portability), it soon became widely used in various educational settings in the early 21^st century.¹  Nowadays, ARS are simple and easy to use.  They only require the following components:³

• Presentation software (i.e., PowerPoint with Turning Point)
• Hardware to transmit information (i.e., “clickers”, mobile computers, mobile phones)
• Wireless receiver or Internet connection to a computer to receive the data

I first experienced ARS as an undergraduate student when I was required to purchase my first “clicker” for an introductory genetics class.  The device was about the size of a small TV remote and had buttons for the numbers 0-9, the letters A-J, and a few other miscellaneous functions.  We were required to bring the “clickers” to every class and use them to answer multiple choice quiz questions interspersed throughout the lectures.  Our answers on these “quizzes” counted towards 10% of our final grade.  This mode of learning was unlike anything I had ever experienced before, and although I initially felt apprehensive about ARS, I eventually came to appreciate its utility. 

There are several benefits to using ARS.  Once a question is posed, responses are anonymous and summarized graphically for the audience.  However, the instructor has the flexibility to track each individual response and can collect the data for a grade or to give credit for attendance.  Anonymity can have a positive impact on learning, often enhancing participation, engaging the students, and promoting greater interactions between the students and their peers/teachers.¹  In fact, a study by Clauson et al.⁴ showed that 93.2% of pharmacy students appreciated the anonymity of ARS.  To gauge how well the students understand the material being covered in class, the instructor can use ARS intermittently throughout a lecture.  Based on the results, the instructor can determine whether it's appropriate to re-explain concepts more in-depth if the class seems to be struggling or continue on to the next topic.  Thus, ARS, if used effectively, can improve the quality of learning and provide both the instructor and students valuable feedback.  ARS may help improve test results as well.  In a study by Cain et al., final grades for a Physiological Chemistry and Molecular Biology (PCMB) II course in 2008 (using ARS) were significantly higher than those in previous years without ARS (p < 0.05 for 2008 vs 2007 and p < 0.001 for 2008 vs 2006).  Also, students taking PCMB II with ARS in 2008 had significantly higher final grades compared to when they took PCMB I the previous semester without ARS (p < 0.001).  Although this study has some limitations, the findings suggest that ARS may be a useful tool to improve student performance on exams.³  See Table 1 for a summary of the benefits of ARS.¹

Table 1: Summary of ARS Benefits

Classroom environment benefits

Attendance: Students go to class more

Attention: Students are more focused in class

Anonymity: All students participate anonymously

Participation: Students participate with peers more in class to solve problems

Engagement: Students are more engaged in class

Learning benefits

Interaction: Students interact more with peers to discuss ideas

Discussion: Students actively discuss misconceptions to build knowledge

Contingent teaching: Instruction can be modified based on feedback

Learning performance: Learning performance increases as a result of using ARS

Quality of learning: Qualitative difference when learning with ARS (e.g., better explanations, thinking about important concepts, resolving misconceptions)

Assessment benefits

Feedback: Students and teachers like getting regular feedback on understanding

Formative: Assessment is done that improves student understanding and quality of teaching

Compare: Students compare their ARS responses to class responses

 Adapted from Kay et al (2009)¹

Although ARS has some benefits, there are some challenges too.  From my experience, the “clickers” were a source of stress when students lost/forgot them or had technical difficulties.  This was especially the case when the “clickers” were used to answer quiz questions that counted toward a student’s grade or attendance.  Cain et al.³ found that the most common complaint about ARS (shared by 82% of pharmacy students) was the cost of the devices.  It should be noted, however, that some schools “cover” the cost of the devices and recirculate them to students in different classes.  But let’s face it, even when the school buys the devices to be shared by students, the cost of this technology is, in the end, bore by students in the form of tuition and fees.  Technical problems with ARS can also be frustrating for instructors that have integrated ARS questions into their lectures.  Furthermore, ARS may be a challenge for relatively inexperienced instructors unable to adapt their teaching to address unexpected responses from the students.  Developing ARS questions can be time consuming and takes skill and experience in order to create truly effective ones.  Effective questioning should not target simple recall of the material being presented but rather should cultivate conceptual, analytical, and problem solving skills.⁵  Such thoughtful questions are more likely to lead to enriching discussions and stimulate higher-level cognitive processes instead of serving as one-dimensional questions simply used to keep the student awake.  For a summary of the challenges with ARS, see Table 2.¹

Table 2: Summary of ARS Challenges

Technology-based challenges

Bringing remotes: Students forgot/lost remotes and could not participate in class

ARS did not work: Remote devices did not function properly

Teacher-based challenges

Responding to student feedback: Less experienced teachers cannot adjust to student feedback

Coverage: Cover less course content if ARS is used

Developing questions: Time consuming to create ARS questions

Student-based challenges

New method: Students find it difficult to shift to a new way of learning

Discussion: Discussion leads to confusion or wasting time

Effort: Too much effort is required by students when using ARS

Summative assessment: Using ARS for tests may not be popular with students

Attendance for grades: Students do not like ARS used for monitoring attendance

Identifying students: Students want to remain anonymous

Negative feedback: Students feel bad when receiving negative feedback

 Adapted from Kay et al (2009)¹

How can we optimize the use of ARS in the classroom?  Since our attention span often fades after about 20 minutes,¹ one strategy is to provide ARS questions every 20 minutes to break up a lecture.  Along with using effective questions, a small incentive to increase participation and attendance may be helpful.  Using ARS responses for 5% of a student’s grade is sufficient to increase motivation and attendance.¹  Lastly, although ARS may take away time to cover material, I would argue that ARS enables the instructor to explore concepts in greater depth and thus provides greater value in terms of student learning.  Overall, the benefits of ARS seem to outweigh its challenges, and several studies have shown that the majority of students favor its use in the classroom.  Yet, more research is needed to better understand the utility of ARS and to hone best practices.¹ 

References:

1. Kay RH and LeSage A. Examining the benefits and challenges of using audience response systems: a review of the literature. Computers and Education. 2009; 53:819-27.

2. Nelson C, Hartling L, Campbell S et al. The effects of audience response systems on learning outcomes in health professions education. A BEME systematic review: BEME Guide No. 21. Med Teach. 2012;34(6):e386-405.

3. Cain J, Black EP, Rohr J. An audience response system strategy to improve student motivation, attention, and feedback. Am J Pharm Educ. 2009; 73(2): Article 21.

4. Clauson KA, Alkhateeb FM, Singh-Franco D. Concurrent use of anaudience response system at a multi-campus college of pharmacy. Am J Pharm Educ. 2012;76(1): Article 6.

5. Dangel HL and Wang CX. Student response systems in higher education: Moving beyond linear teaching and surface learning. Journal of Educational Technology Development and Exchange 2008; 1(1): 93-104.