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.

References

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].

Developing Residents into Preceptors Using the Layered Learning Practice Model

by Brianna F. Waller, PharmD, PGY-1 Pharmacy Practice Resident, Baptist Memorial Hospital – North Mississippi

During their year-long commitment toward becoming a competent practitioner, many pharmacy residents (and other post-graduate trainees) will suddenly find themselves partially or fully responsible for someone else’s learning as a “preceptor." Although assuming this role may make some residents uneasy, the positive benefits of “near-peer” teachers and layered learning have been repeatedly discussed in secondary and higher education literature. Indeed, medical school students report they value and respond well to learning from near-peers due to their recent experience and relatability.  Near-peer teachers are not too far removed from the students’ “struggles” and experiences.¹ Let’s take a closer look at how this can be applied within pharmacy education.

Layered-Learning Practice Model
Senior educators work with advanced learners to teach junior leaners

A survey sent to all residency program directors (RPDs) of ASHP-accredited programs determined precepting opportunities for residents, identified barriers to developing precepting skills, and discovered opportunities to optimize programming. Among the 538 responses, the researcher found that 71% of residency programs did not offer a formal precepting rotation despite the fact that 59% of RPDs admitted their graduates frequently accepted positions that involved teaching / precepting.² Just as importantly, there is a serious shortage of pharmacy preceptors!  In another survey (n= 4,396) of pharmacists, 73% accepted an invitation to precept two or more students in the past year but almost half turned students away.³ This gap is a glaring opportunity for the layered learning practice model.  One of the benefits of this model is the fact that it increases the amount of time that attending pharmacists (aka senior preceptors) can spend focusing on their practice while allowing the resident to spend the most time supervising students and thereby gaining valuable precepting experience. Engaging residents in this role increases the number of people available to precept the growing number of student pharmacists without causing the workflow to suffer. Providing structured experiences for residents to precept students not only helps fill the gap, but they get feedback about their precepting skills before accepting post-residency positions that require them to teaching/precepting.

The layered learning practice model (LLPM) is a teaching strategy designed to train residents to precept students and, in some cases, more junior residents with oversight from a more experienced pharmacist. The four recommended steps to help all parties get the most out of the LLPM are orientation, pre-experience planning, implementation, and post-experience evaluation.⁴ I will use my own experiences with the Teaching & Learning Program during my PGY-1 program through the University of Mississippi School of Pharmacy (UMSOP) to illustrate concepts of the LLPM.

Let’s start by breaking down each component of the LLPM. Orientation to the LLPM is vital not only for the resident but also for the attending pharmacist. This helps outline goals, expectations, and responsibilities for each party, thus reducing the potential for overlap and confusion.⁴ In my own experience, this was extremely beneficial given the chaotic effect that COVID-19 seemed to have on nearly everything at the School of Pharmacy and the Medical Center. I had several meetings with faculty and staff regarding my role, a list of things I needed to accomplish, and, most importantly, how to use the tools to host virtual seminar meetings and IPPE rotation experiences. Typically, during the orientation the resident gets some feedback regarding his/her performance which can help build their confidence and independence.

Table 1: Typical Roles and Responsibilities in the LLPM

Primary Preceptor	Orient resident & student to layered learning practice model, practice site, and staff Create or obtain resident and student syllabus Outline trainee responsibilities Define the expectations of all learners Assist resident performance for clinical and teaching activities Evaluate resident performance for clinical and teaching activities Oversee all patient care activities and pharmacy education
Resident Preceptor	Discuss learning experience with preceptor prior to the first day Assist in the development of student calendar and rotation activities Orient student to practice site and establish goals Integrate student into patient care activities Supervise student during patient care activities Obtain any resources students need to perform required activities Provide regular feedback to students Lead topic discussions and other educational activities Evaluate the performance of the student and provide regular feedback
Student Learner	Report directly to the resident preceptor Actively participate in patient care and rotation activities Provide feedback on the layered learning practice model and resident performance as an experiential educator

Once everyone's roles (see Table 1) are established, pre-experience planning begins. The resident is involved by developing activities and materials for students to uses. Examples include developing calendars, rubrics, and activity descriptions.⁴ For me, I develop presentations and getting a once-in-a-lifetime opportunity to create a 4-hour IPPE experience on chart review & labs.  Because students were no longer allowed at our practice site due to the risk of COVID-19 exposure, I had to deliver this instruction using a videoconference tool. The LLPM process allowed enough structure for me to develop these activities independently, while also having the support of my preceptor when needed.

The implementation stage is relatively self-explanatory. The material prepared by the resident is delivered. The resident is considered the primary preceptor for the student(s), and depending on the activity, they are responsible for assigning them specific patient care duties, evaluating student performance, or providing feedback. The senior preceptor continues to be available and provides guidance to the resident. In longitudinal settings, such as precepting over the course of the month, the preceptor directly observes the resident periodically in order to assess progression.⁴ In situations such as delivering a presentation, it is important that the senior preceptor observe the session in order to provide constructive feedback to the resident, as was done in my case.

Finally, post-experience evaluation occurs whereby the primary preceptor solicits and provides feedback to resident(s) and student(s).⁴ An additional benefit is the identification of potential improvements that can be made within the LLPM at the institution, as well as the opportunity to solicit feedback from both layers of learners regarding their experiences and suggestions for improvement. One of the most helpful ways this was achieved in my own experience was by surveying the students in an effort to measure the effectiveness of my presentation, as well as obtain recommendations for improvement.  Afterward, I discussed this feedback in great detail with my preceptor.

More residency programs should adopt the layered learning practice model, as it appears to not only address the need for more preceptors but also affords the resident meaningful teaching experiences, and provides a more relatable role model for students. 

References

1. Lockspeiser T, O’Sullivan P, Teherani A, and Muller J. Understanding the experience of being taught by peers: the value of social and cognitive congruence. Adv Health Sci Educ 2006;13(3):361-372.
2. Dipaula BA, Mohammad RA, Ayers P, et al. Residents as preceptors and educators: What we can learn from a national survey to improve our residency programs. Curr Pharm Teach Learn 2018;10(1):21–7.
3. Skrabal MZ, Jones RM, Nemire RE, et al. National Survey of Volunteer Pharmacy Preceptors. Am J Pharm Educ 2008;72(5): Article 112.
4. Loy BM, Yang S, Moss JM et al. Application of the Layered Learning Practice Model in an Academic Medical Center. Hospital Pharm 2017; 52 (4): 266-272.