Psychological Safety - A Key Component to Students’ Motivation

by Kimberly Still, Pharm.D., PGY1 Pharmacy Practice Resident, Baltimore VA Medical Center

Have you ever had a truly stellar professor? The kind who made you feel like no question was a dumb question?  Who made you energized about the subject and confident that you would succeed? Ever had the complete opposite? A professor so intimidating and negative you’d rather bite your tongue (literally) than ask a question for fear of looking stupid? What’s the main difference between these two extreme cases? The answer: the presence/absence of psychological safety.

So what does this term mean exactly? Psychological safety basically endorses the concept that students learn better when they feel safe. Embracing this idea means creating an environment where students feel comfortable enough to acknowledge their own weaknesses, voice their gaps in knowledge, and ask for help when they need it.  The importance of this concept lies in its link to student motivation. However, in order to understand how the two are related, we must first take a look at what creates motivation.
Though there are many theories surrounding student motivation, it is pretty well summarized by the following equation from Barron and Hulleman:¹

motivation = expectancy x value

“Expectancy” in this case means the extent to which a student believes that he/she can perform a particular task. “Value” means the level of interest and degree of importance the student places on a task. Psychological safety ties into this equation in a number of ways. Creating a positive and safe learning environment can be empowering for students, giving them the confidence to take on the challenge presented to them, which translates to a high level of expectancy. Furthermore, allowing students to feel safe asking questions prevents the suppression of any innate interest they might already have for a particular topic, which helps preserve perceived value.

While most instructors are unlikely to fall into the extreme category of the negative and demeaning persona presented at the beginning of this discussion, evidence suggests that many teachers have lost sight of the importance of psychological safety, specifically as it relates to student-teacher rapport. One survey of teachers and undergraduates revealed only 7% of professors ranked rapport in the list of top 10 master teaching qualities, compared to 42% of students.² Another student survey by Benson, et al, examined the association of rapport with student attitudes and motivation. They found a positive relationship between rapport and many proacademic behaviors such as “attending class, paying attention during class, and studying.” When asked to identify the characteristics needed to establish rapport, among the most common responses included open-mindedness, accessibility, approachability, and concern for students.³

So how does one go about establishing a rapport and promoting psychological safety in the classroom? The possibilities are numerous. Here are just a few suggestions:⁴

• Address students by name. With a large class size this can be an arduous task, but it can go a long way with letting your students know that you care about them.
• Set your students up for early success. Start off easy and gradually increase the level of difficulty in content. Such a strategy will help build their confidence and their comfort level with the subject.
• Provide positive feedback early and often.
• Avoid demeaning comments.
• Don’t be afraid to admit “I don’t know.”  This will help increase your students’ comfort level in voicing their own gaps in knowledge.
• Never underestimate the utility of the compliment sandwich!
• When providing individualized negative feedback, identify with your student if possible.  At a minimum encourage him/her by expressing a sincere belief that he/she can improve (Ex. “I noticed you had some difficulty putting things into layman’s terms for the patient. I had trouble with that as well when I was first starting out. Here are some tips that I find handy… Don’t stress, I know you’ll get the hang of it, it just takes practice.”)

These suggestions may sound fairly simple, but attempting to utilize such strategies while still maintaining focus on the successful implementation of the course/rotation can be quite challenging. Nonetheless, adhering to these principles is vital in order to maintain a positive learning experience and cultivate each student’s motivation to succeed.

References:

1. Barron KE and Hulleman CS. Is there a formula to help understand and improve student motivation? Essays from e-xcellence in teaching. 2006 ;8:33-8.  [cited 2010 Oct 18]

2. Buskist W, Sikorski J, Buckley T, & Saville BK. The teaching of psychology: Essays in honor of Wilbert J. McKeachie and Charles L. Brewer. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2002. Elements of master teaching; p. 27-39.

3. Benson TA and Cohen AL. Rapport: its relation to student abilities and behaviors toward teachers and classes. Teach Psychol 2005;32:237-9. [cited 2010 Oct 18]

4. Davis BG. Tools for teaching. 2^nd ed. San Francisco: Jossey-Bass; 2009. Chapter 31, Motivating Students; p. 278-87.

Embracing Social Media in Teaching

by Leah Sera, Pharm.D., PGY1 Pharmacy Practice Resident, Suburban Hospital

OK, I admit it – I’ve been suckered into social media. Not at the crest of the wave, mind you. In my case it’s more like being pulled in by the undertow.  But the end result is the same: I have a Twitter account, I spend lots of time on Facebook, I’m an occasional contributor to various discussion boards and listservs.  And I’m really, truly, going to start a blog as soon as I have the time to do so. We’ve been using social media from the beginning in this class as a teaching and learning tool – this blog, for instance, and our discussion board. I think these techniques have been useful in our online class, but are they being used elsewhere? How successful are they?

Media consultant Fred Cavazza breaks the term “social media” into ten categories: publication tools, sharing tools, discussion tools, social networks, micropublication, social aggregation, platforms for livecast hosting, virtual worlds, social gaming platforms, and massively multiplayer online games. ¹ Most of what has been written about higher education and social media addresses recruitment efforts, but there is some information available about its use in the classroom – and I found most of the information on discussion boards and in blogs!

Social media is apparently a more widely used instructional technique than I might have guessed from my own experience. A survey of about a thousand professors conducted by the Babson Survey Research Group reported that over half of those surveyed used video, podcasts, blogs, and wikis as part of their classes (online videos and podcasts were most commonly used), and about a third used social networks to communicate with students.²

It’s intriguing to imagine what things might be like if classroom techniques moved beyond BlackBoard and online lecture tools. How about creating a virtual classroom using a tool like Second Life? Using Facebook groups to increase communication between classmates, and between faculty and students? One educator has stopped using physical textbooks completely; instead she uses a social bookmarking tool to share current articles, websites, and other online content. She also requires the students to use the bookmarking tool to collect and share materials relevant to their field, as well as keep a blog. She even created a synchronous chat (e.g. instant messaging board) which allowed students to anonymously pass virtual notes during her class sessions so that they could “add their own voice to the lecture, as well as…have the agency to multitask while listening.”³

The use of social media may be a way to mitigate some of the problems with traditional education in today’s tech saavy society. Often traditional lectures fail to capture students’ attention, especially when there are so many distractions. Teachers who inadequately attempt to bridge the gap between traditional classroom teaching and modern technology often seem to end up reading lecture notes verbatim from a set of PowerPoint slides. As a student, that experience is supremely boring, and a bit of an insult to student capabilities. I’ve been known to remark to my classmates that it doesn’t seem likely that I would have been accepted into a doctoral program if I wasn’t capable of reading the slides on my own. I can be snarky like that sometimes.

In the case of Educational Theory and Practice [the course for which this blog essay was written], social media makes the class much more accessible.  Since one of the instructors lives in Florida, I’d say social media makes this course possible. For those of us who also live outside the Baltimore area [this course is offered through the University of Maryland School of Pharmacy Baltimore campus], online discussions cut down on travel time (and gas money).  Indeed, it seems likely there are a few participants taking advantage of this class who otherwise would not have been able to do so. It takes some adjustment, particularly with regard to student participation. It’s much easier to be distracted when you’re not sitting in a classroom, and there isn’t as much pressure to participate because you can easily avoid eye contact with the professor (indeed, there is no eye contact!). However, my mother once told me that when she was in grad school, before Gmail and Facebook, and lectures were primarily accompanied by a set of slides, that the lights would go down and so would student eyelids. So maybe student participation is more about student attitude and engagement than the mode of delivery. As someone interested in a career in academia, I think social media has a lot to offer and represents a new and creative way to engage students in the learning process.

¹ Cavazza F. Social Media Landscape [internet]. Accessed 2010 Sept 27. Available from http://www.fredcavazza.net/2008/06/09/social-media-landscape/

² Pearson Social Media Survey 2010 (online presentation). 2010. Accessed 2010 Sept 27. Available from http://www.slideshare.net/PearsonLearningSolutions/pearson-socialmediasurvey2010

³ Manfield L. Effectively using media in social education: a college educator on the advantage of Web 2.0 Classroom [internet]. Published 2008 Dec 30. Accessed 2010 Oct 5. Available from http://www.suite101.com/content/using-social-media-in-education-a87365

You Can’t Teach an Old Dog New Tricks. Or Can You?

by Brian Timberlake, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

We all know the age old adage “You can’t teach an old dog new tricks.”  You’ve probably heard this phrase so often you might think its true.  However, research today shows that this is an outdated notion.  Until recently, many people, including scientists, believed that the brain deteriorated over time through loss of neurotransmitters, decreased blood flow, and a diminishing oxygen supply.  However, now, it seems these “facts” are not true, and that learning occurs throughout one’s life.

People can learn at any age.  Prior to the 1960's, it was considered nonsensical for people to seek education in midlife.  Not only was the brain slowly starting to “shut down,” but the working years left in one’s life were slowly coming to an end.  With the baby boomer generation and longer life spans, middle aged people seeking education has gained wide spread acceptance. 

Even though acceptance has been gained for adult education, there is still that small problem of the deteriorating brain.  Science has come to show that as we age, the possibility of learning does not deteriorate.  While the middle-aged brain is slower at recalling facts, it gets much better at other tasks.  As people age, their brain actually gets sharper, due to myelination.  Myelination basically protects brain cells and increases conductivity in the brain.  Improved interconnections in the brain leads to improved reasoning skills.  Science has shown us that “life and learning doesn’t end at 50.”

Of course, disease is more prevalent in older people and diseases of the brain can change the brain drastically.  The most notable brain disease is Alzheimer’s, which is a form of dementia.  It is estimated that by 2050, 1 in 85 persons will suffer from Alzheimer’s Disease. The disease causes a significant loss of memory and the ability to learn.  Alzheimer’s disease usually presents around sixty-five, but can have early onset in some people.  It usually presents as difficulty in acquiring new memory or trouble recalling facts.  Since these symptoms are common as we age, it is hard to diagnose, and can lead into intense mood swings, extreme forgetfulness, and episodes of rage.

Even though the physiological aspect plays a huge role in learning, there is still the aspect of outside influences.  The differences in learning between children and adults has been a hot topic for the past few decades, and those differences are discussed in theory in the book, “The Modern Practice of Adult Education: Andragogy vs. Pedagogy,” written by the American educator Malcolm Knowles.  Knowles’ theory claims that there are five key differences in the learning processes between adults and children.  The theory describes key differences in the learner, experience, readiness, orientation to learning, and motivation.

The theory postulates that adults are independent and evaluate themselves and their surroundings while children need instruction from a teacher and must be told what to focus on.  Adults bring the experience factor to the table and can incorporate life lessons into what they learn, while children have very little or no experience.  In terms of readiness, adults usually learn based on their current needs and often with a sense of urgency and necessity, while children are guided by a teacher and only advance when they are told they are ready.  In the last part of the theory, Knowles described differences in motivation.  Adults are driven by emotions and personal goals, whereas children are usually affected by factors such as rewards and peer pressure.

The true mystery behind all of this research is the brain itself.  Nothing can unlock the intricacies and depth of this most fragile organ.  In the end, it all comes down to the individual.  Just like no two people are alike, no two brains are the same.  The best we can do as individuals is to keep using our brains and presenting ourselves with the new challenges.  Because of life’s uncertainties, you can’t teach every old dog a new trick, but age does bring new opportunities and possibilities.

References

Crawford, David.  The Role of Aging in Adult Learning: Implications for Instructors in Higher Education.  New Horizons for Learning [Internet].  December 2004.  [cited 2010 September 28].  Available at  http://www.newhorizons.org/lifelong/higher_ed/crawford.htm

Flatlow, Ira and Strauch, Barbara.  Brains, like Red Wine, Gets Better with Age.  NPR radio broadcast.  2010.  [cited September 28, 2010].  Available at  http://www.npr.org/templates/story/story.php?storyId=127771662

Trudeau, Michelle.  The Aging Brain Is Less Quick, But More Shrewd.  NPR radio broadcast, morning edition.  2010.  [cited September 28, 2010].  Available at http://www.npr.org/templates/story/story.php?storyId=124118077

Knowles, M. S. The Modern Practice of Adult Education. Andragogy versus pedagogy, Englewood Cliffs: Prentice Hall/Cambridge. 1970, 1980.

Interprofessional Education: An Argument for Starting Early

by Kimberly A. Toussaint, Pharm.D., PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

When was your first professional encounter with a physician? What about a nurse? For me, it was during my fourth year of pharmacy school, on my first clinical rotation. Prior to that time, my collaborative experience with other health care professionals was merely theoretical – as abstract as the patient cases that we were given to write SOAP notes about during my therapeutics labs.  During pharmacy school, there are numerous opportunities to gain teamwork experiences.  Many schools require group journal club presentations, SOAP note write-ups, and case presentations.  However, this group experience typically involves only other student pharmacists.  Although many health professionals are educated on universities located on a academic health center that include pharmacy, medical, nursing and dental schools (within walking distance of one another), integration of the education of these various disciplines is rare.

Although health professional disciplines work together on a daily basis, at the beginning of their professional experiences they are often unsure of the extent of the other disciplines’ training and knowledge. This is likely due to the fact that health professionals have little exposure to the curriculum, knowledge base, and perspectives of other disciplines during school.  Familiarity with other disciplines typically improves after health professionals are licensed and begin practicing (and even then, misperceptions are common).  When I started my first clinical rotation, I had no frame of reference for how much instruction regarding pharmacology or pharmacokinetics the medical interns on my team had during their classes. For this reason, I was unsure of how to phrase my recommendations. Often, I was concerned that I was regurgitating information they’d heard numerous times. As it turned out, I probably wasn’t explaining things well enough because my knowledge and perspectives were different.

The “Seamless Care” model addresses the need for interprofessional practice experience during training, and has been studied in Canada and Australia.  This model prepares students in health professional schools to become collaborative practitioners by forming teams of students from different health disciplines (medicine, nursing, pharmacy, dentistry, and dental hygiene) and having them work together for eight weeks to plan one patient’s transition from acute care to home.  The primary purpose of this model is to create a unifying task and facilitate a real-life collaboration between health professionals.  The model also serves to address a disparity in the continuity of care between hospital discharge and home. The students work under the guidance of experienced preceptors that helped to facilitate the care of the patient as well as helping the student develop team work skills by serving as a role model and mentor.^1,2

This model is built on several educational theories.  It is an example of social learning theory because the students are able to observe the ways that their preceptors work collaboratively with other disciplines, and model that behavior.  Constructivist learning theory is exhibited by the students working collaboratively to share past experiences and to increase their understanding of the patients’ care and their respective roles on the team.

A study done by Coster et. al published in the International Journal of Nursing Medicine in 2008 measured the readiness of health professional students to learn together, using a survey.  This study showed that students’ readiness for interprofessional education was high at the beginning of their professional education, but declined over time. These results support the notion that interprofessional education should start from very early in health professional students’ education.³

By integrating this interdisciplinary practice model early in the advanced pharmacy school curriculum, collaborative work habits, trust, and rapport would be facilitated between various health disciplines. Additionally, each discipline would enhance the knowledgebase of the others by contributing a new perspective. This would enhance experiential learning across all disciplines, and would benefit everyone on the team, especially our patients.  Interprofessional education involving pharmacists, physicians, and nurses providing continuity of care for patients will have long term benefits - increasing the quality for years to come.

Carlisle, Cooper, and Watkins summed it up best:

Teams have a collective responsibility that necessitates even closer interprofessional working relationships.  Complementary action is not enough.  It is essential to cultivate this working relationship, beginning in school.⁴

The future of healthcare relies on increased collaboration between health care professionals.  Collaboration is frequently limited by preconceived beliefs about other disciplines, and this is exacerbated by our limited exposure during our education.  This leads to a lack of understanding and trust among health care professionals.  Incorporating interprofessional learning into the curriculum of health professional students would increase trust and enhance collaboration between disciplines, and ultimately optimize patient care.

References

Mann K, McFetridge-Durdle J, Martin-Misener R. Interprofessional education for students of the health professions: The “Seamless Care” model. Journal of Interprofessional Care. 2009 May;23(3):224-233.

Nisbet G, Hendry G, Rolls G. Interprofessional learning for pre-qualified health care students: An outcomes-based evaluation. Journal of Interprofessional Care. 2008 January;22(1):57-68.

Coster S, Normal I, Murrells T. Interprofessional attitudes amongst undergraduate students in the health professions: A longitudinal questionnaire survey. International Journal of Nursing Studies. 2008;45:1667-1681.

Carlisle C, Cooper H, Watkins C. “Do none of you talk to each other?”: the challenges facing the implementation of interprofessional education. Medical Teacher. 2004;26(6);545-552.


[Editor's Commentary:  There has been increased interest in interprofessional education at most health professional schools over the past decade - but, unfortunately, there has been limited progress despite calls by many professional organizations and the Institute of Medicine to introduce interprofessional education early (and more often) within our curricula.  Deep in our hearts, we believe patients would gain from increased interprofessional collaboration.  The data to support this belief is accumulating.  Intuitively it makes sense to harness the power of people of various knowledge and skills into a cohesive unit.   But getting people to play in the same sand box isn't always easy - particularly when everyone has had their own sandbox in the past.  The patient-centered medical home or accountable care team model is emerging under health care reform as THE health care delivery model.  Under such models of care, payment structures reward interprofessional team work and meeting quality standards.  But how to get from here (silo care) to there (interprofessional care).  Its not going to be easy and its not going to happen over night.  Certain teaching our students in an interprofessional, collaborative manner will go along way toward breakdown barriers.  Dobson and colleagues at the University of Saskatchewan describe the work of interprofessional student teams including pharmacists, nurses, dietitians, and physical therapists in a paper entitled "A Quality Improvement Activity to Promote Interprofessional Collaboration Among Health Professions Students."  During this activity, small groups of students participated in a quality improvement project following the Plan-Do-Study-Act (PDSA) model.  Through this work, the students increased their understanding of their respective roles as well as the value that each member of the team brought to the project.  It is not difficult to imagine that these kinds of "hands on" projects could be implemented at various times throughout the curricula of health professional schools.  Moreover, guided by experienced practitioners from each discipline, the groups would design and implement projects that meaningfully contribute to the care of patients in a variety of settings.  The American College of Clinical Pharmacy has a strong policy statement regarding interprofessional education and recently published a white paper on this topic that I encourage everyone to read. - S.H.]

Simulation in Health Professional Education

By Chris Shaw, Pharm.D., PGY2 Emergency Medicine Pharmacy Resident, Johns Hopkins Hospital

Passive versus active. “Chalk and talk” versus hands-on.  Educators and theorists have suggested that active learning and learner participation produce better educational outcomes than traditional, lecture-based teaching methods. Lecture, and other forms of simple information dispersion, may still be required depending on the content area and students’ prior knowledge. However, it is not until the learner is able to apply that information to a given situation, thereby linking the theory with practice that true understanding materializes. One method that can be used to achieve this linking is through the use of simulation.

Simulation training has been used for decades in military and aeronautics training with positive results. In the realm of healthcare, surgery simulation has been well described and simulation has been used extensively to train cardiopulmonary resuscitative techniques and emergency preparedness. A simple PubMed search will retrieve thousands of results for ‘simulation training.’ Formal simulation labs as well as medical and surgical simulation fellowships have been created at some of the top medical centers around the country, including The Johns Hopkins Hospital, Duke University Medical Center, Harvard, and The Mayo Clinic. The recently formed Society for Simulation in Healthcare, which publishes a peer-reviewed journal, is a forum for scholars interested in simulation technology and techniques. Simulation in the training of health professionals seems to have cemented itself in the culture of health professional education. Why is that? I believe the answer is that as health care professionals, we are always looking for ways to continually improve our knowledge and skills, with the ultimate goal of improving patient care and outcomes.

The initial and continual training of health professionals is an important factor that contributes to this goal. Human patient simulation (HPS), or “a technique to replace or amplify real patient experiences … which evoke or replicate substantial aspects of the real world in a fully interactive manner,” is one method of active learning to help build and maintain skills. HPS is able to offer a method for putting theory into practice, while maintaining a non-threatening, safe environment for students to achieve competence through repetition.  HPS can be use to reproduce a variety of clinical scenarios. This is done with a wide margin for error as real patients are not put in harm’s way, illustrating the principle of risk minimization. For a list of additional pros and cons related to the use of medical simulation training, I refer you to a previous post on this blog.

HPS has been adopted by a number of pharmacy educators at schools and colleges of pharmacy in United States. There have been publications regarding the use of patient-simulation technology such as mannequins or computer programs to teach pharmacotherapeutics, pharmacokinetics, interdisciplinary team skills, advanced cardiac life support, and other topics in the pharmacy curriculum. The benefits of these simulations vary based upon the topic and simulation.

Does effective simulation require the use of expensive technologies? Why not use real people to simulate clinical situations? HPS can and often does utilize real humans. This may be one way for pharmacy programs to incorporate simulation into their curriculum if access to the simulation technologies is not an option.

In 1997, the World Health Organization published a report entitled “Preparing the Pharmacist of the Future: curricular development.” In this report, it was stated that as a communicator, the pharmacist “must be knowledgeable and confident while interacting with other health professionals and the public… communication skills involve verbal, non-verbal, listening, and writing skills.” How does this relate to simulation? The enhancement of communication skills through simulation is commonplace in pharmacy education.

HPS using humans in lieu of available technologies is a technique that has been adopted by many schools of pharmacy, including where I graduated, Northeastern University (NU), where we frequently use simulation for patient counseling. Actors would be brought in to serve as standardized patients, and different scenarios were put forth during class sessions. Students would be required to develop and deliver educational material, counsel the patients about their diagnoses and medication regimens, and answer questions. The questions posed were a combination of what had been prepared by the facilitators of the course and provided to the actors, as well as questions the actors improvised.  This added another level of complexity to the interaction. Simulation exposed us to different scenarios, enhanced our critical thinking, and provided an opportunity to practice the management of a patient encounter.  An advanced understanding of and ability to apply all the material involved in real-time was required. But most importantly, it was a way for us to link our didactic education with practice, prior to actually stepping foot in a real practice environment during clinical rotations.

Further exploration of a variety of simulation techniques should be promoted in pharmacy education. The study of both technology and human-based simulations should evolve, with the ultimate goal of producing and identifying methods to most effectively prepare tomorrow’s pharmacy professionals. Although I’ve had only  limited personal experience with simulation training, I felt much more comfortable and confident going into the “real” clinical setting. It was still a scary prospect going in out on rotations, but it was made exponentially easier as I had my prior experiences built through simulation to fall back on.

McGahie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research. Med Educ. 2010; 44: 50-63.

Schiavenato M. Reevaluating simulation in nursing education: beyond the human patient simulator. J Nurs Educ. 2009; 48(7): 388-394.

Mesquita AR, Lyra Jr DP, Brito GC, Balisa-Rocha BJ, Aguiar PM, Neto ACA. Developing communication skills in pharmacy: a systematic review of the use of simulated patient methods. Patient Educ Couns. 2010; 78: 143-148.

Haidar E. Clinical simulation: a better way of learning? Nurs Manag. 2009; 16(5): 22-23.