Laughter and Learning

by Jonathan Grant, Pharm.D., PGY1 Community Pharmacy Practice Resident, Johns Hopkins Home Care Group

Is there a role in the classroom for laughter that leads to learning?  Or is laughter merely a distraction caused by side conversations between students?  Educators are constantly looking for better ways to engage students to enhance the learning experience.  A few studies suggest that humor produces psychological and physiological benefits that help students learn.¹  While humor can be used during any of Gagne’s 9 Events of Instruction, it  is perhaps most effective as means to gain attention, present new the material, and assess performance. The use of humor can serve as an attention grabber, stimulate students’ multiple intelligences, and appeal to various learning styles.

Laughter can engage students. Studies have shown that students were more likely to recall information about a lecture when it was interjected with jokes relevant to the topic.¹ For example, Randy Garner, PhD, used the following during a lecture about statistics and research methods — a metaphorical joke about a planned escape from prison between two prisoners in a jail located in the middle of a desert.²  One prisoner tries to escape alone after an unsuccessful attempt to persuade the other to go with him. The prisoner escapes only to find miles and miles of sand.  He is captured and returned to his cell. Upon his return, the prisoner that escaped exclaimed, “You knew! Why didn’t you tell me!?” whereupon the other remarks, “Silly man, you should know no one reports negative results.”² Well planned, appropriate, and contextual humor help students associate concepts from various courses.  Humor can include the use of self-deprecating jokes, cartoons related to the material, and appropriate situational humor.

In one study comparing humor-enhanced sessions with “standard” online course delivery, students were more likely to log onto Blackboard and stated that they enjoyed classes that used humor effectively.³ In the study, students assigned to the humor-enhanced section used social/interactive features (such as lectures, features, course documents, etc., more than the standard section).  This was determined by monitoring the number of mouse clicks in each Blackboard course category throughout a ten week academic term. The humor-enhanced section registered a significantly higher average number of clicks when compared to the standard section (583 vs. 418; p < 0.05).³ Although there were no significant differences in final grades between the two groups, the humor-enhanced group earned a significantly higher class participation points than the standard group (98 vs. 92 points;  p < 0.05).³  One major limitation to this study was the relatively small sample size — each section included only 22 students.  I believe larger studies need to be conducted to further validate the results.

In addition to helping to enhance the learning experience, humor has been linked with other psychological and physiological benefits.  Humor is a helpful emotional response that can buffer and relieve stress.⁴ Laughter has been shown to stimulate a physiological effect that decreases stress hormones such as serum cortisol and epinephrine.¹ Humor has also been linked to reducing anxiety and tension.¹ From a teaching perspective, humor can facilitate increased attention span, information retention as well as improve performance, problem-solving, team work, collaborative relationships, and coping strategies of students.⁵

The use of humor as a teaching tool must be harmonious with the learning experience. The overuse of humor can be perceived as a distraction and take students’ focus off of the material as they try to anticipate the next joke.   The primary focus needs to remain on educating, not entertaining.  Students do not want a stand-up comedian!  They want appropriate humor that is relevant, lightens the mood, and, most importantly, makes the information memorable.  Humor should not be disrespectful, insulting, or obnoxious as this may make students feel defensive or insulted.⁵  If used improperly, laughter can be a source of hurt. The goal is to laugh with each other, not at one another. When using humor, appropriate boundaries must be set and strictly followed.

Zach Stambor in his article entitled “The ‘ham it up’ how to”, gives the following tips for interjecting humor into teaching.⁶

“Make your syllabus funny - insert jocular descriptions in various sections of syllabus to make students read the syllabus.

Use real or hypothetical humorous situations - use TV clips, YouTube, or cartoons to enliven abstract concepts.

Ask punch line questions during question and answer sessions - set up a joke after asking a question.

Make questions and examples outrageous, ridiculous, or exaggerated - use patient cases with exaggerated situations.

Dramatize your material - develop skits or demonstrations with music.”

I think that the inclusion of some humor can maximize the learners’ experience. As a teacher, it is imperative that you put yourself in the shoes of the student when developing or incorporating humor into your instruction.  Humor should not only relate to the subject matter but be relevant to the audience as well.  This requires some extra effort but the more a student can relate and connect abstract concepts with familiar ones, the more likely the student will recall, retain, and apply the new material.  Most importantly, be yourself and have fun teaching!  Use humor as your instructional defibrillator — it can have beneficial psychologically and physiologically effects!

References
1. Stambor Z. How laughing leads to learning. American Psychological Association. June 2006, 37 (6): 62.
2. Garner RL. Humor in Pedagogy: How ha-ha can lead to aha!  College Teaching 2006, Vol. 54 (1); 177-180.
3. LoSchiavo F & Shatz M. Enhancing Online Instruction With Humor. Teaching Psychology, Vol. 32, No. 4;246-248.
4. Smith M & Segal J. Laughter is the best medicine. May 2013. Accessed October 8, 2013.
5. Chauvet S & Hofmeyer A. Humor as a facilitative style in problem-based learning enviroments for nursing students. Nurse Education Today. May 2007. Vol. 27 No. 4; 286-292.
6. Stambor Z. The ‘ham it up’ how to. American Psychological Association. June 2006 Vol 37, No. 6; 64.

Rote vs. Meaningful Learning

by Merid Belayneh, Pharm.D., PGY1 Pharmacy Practice Resident, VA Maryland Health Care System

“The mind is not a vessel to be filled but a fire to be kindled.”
― Plutarch (46 – 120 AD)

Karaste J. Available from: http://commons.wikimedia.org/wiki/File:Midsummer_bonfire_closeup.jpg

In pharmacy school I was encouraged to understand the material and not merely memorize it.  My professors were likely referring to the difference between rote and meaningful learning. Today, faculty and preceptors are strongly encouraged to use and frequently employ active learning strategies throughout the pharmacy curriculum.^1,2  While active learning is often used to foster meaningful learning, it is important to recognize that active learning does not ensure that meaningful learning actually occurs.³  Rote learning is still important and often pre-requisite.

Rote learning frequently involves repeating information until it's remembered.  Learners often resort to rote memorization because they are unable to relate new information to prior knowledge.^3,4 Meaningful learning is characterized by relating new information to prior knowledge.  When one recalls prior knowledge, all related information is more easily recalled.^3,4  Rote and meaningful learning lie on a continuum — they are not two separate entities.  Novak et al. describe three required conditions for meaningful learning: (1) the learner needs to possess relevant prior knowledge; (2) the material to be learned must be conceptually clear and presented with language relatable to the learner’s prior knowledge; and (3) the learner must choose to learn meaningfully.³  The student’s willingness to learn in a meaningful manner is something that teachers have the least control.  It can be indirectly influenced by using instructional and evaluation strategies that foster meaningful learning such as using active learning and team-based activities and reducing the amount of verbatim facts tested on exams.³

In order to encourage meaningful learning many pharmacy schools have employed a variety of active learning techniques including: cooperative learning, problem-based learning, team-based learning, and case-based learning.⁵   These methods of teaching enable students to identify their knowledge deficits as they attempt to apply their amassed knowledge.^3,5  However, these methods assume that students are willing to engage and have sufficient knowledge to convert their rote learning into meaningful learning.³  Unfortunately, students who lack (or unable to access their) prior knowledge often get very little out of these active learning sessions.  As pharmacy curriculums increasingly rely on these active learning techniques, there should be continued discussion on how to cultivate students’ abilities to develop a strong knowledge base.  Often this requires students to memorize material via rote learning.

To examine the importance of rote learning, let’s review two studies that looked at how students learn two different subjects: language and math. The first study evaluated two groups of 4th-5th graders.  One group had students that memorized root words for 20 different sessions and the other group did not.^6,7 The group that had memorized root words learned new vocabulary and figured out the meaning of words in context easier than the other group.^6,7  The second study evaluated the reasons for why students were making errors on complex math problems.  It found that most errors were due to fact inaccuracies (e.g. memorizable facts) and not algorithm errors (e.g. processes or rules that are used to meaningfully learn).^6,8  These studies illustrate the need to know (memorize) the basics in order to use meaningful strategies for learning. Pharmacy can be seen as a subject matter that requires students to learn a new language (i.e. brand and generic names, acronyms, medical terminology) and math (i.e. dosing, compounding, converting).  These studies give us insight regarding the necessity of rote learning in pharmacy curricula.

According to the FDA, in 2011, there were 8969 molecular entities approved in the United States and each drug has indications, side effects, dosing, pharmacodynamics/pharmacokinetics profiles, and patient education requirements.⁹  Although health professionals have technology to assist in retrieving most of this information, it is essential that the pharmacists have a substantial breadth of this knowledge stored away in their long-term memory.  Active learning assumes that students have the relevant prior knowledge (Novak’s 2^nd requirement) and that materials are taught in a manner that is relatable to the learner’s prior knowledge (Novak’s 3^rd requirement).  Thus, it does not negate the need for students to learn in a rote manner because they must possess sufficient knowledge. Thus, curricula must also teach students the basic facts and develop techniques that enable them to efficiently acquire new information.  Some rote learning techniques that could be employed include: (1) using acronyms (i.e. MONAB, SAAB), (2) using mnemonics (i.e. Hot as a hare meaning hyperthermia), (3) using physical or electronic flash cards (i.e. Top 200 drug cards), and (4) creating and providing cheat sheets of the most important facts discussed in each class.

Rote and meaningful learning are both important. Plutarch’s famous quote suggests that the mind is “a fire to be kindled.”  What modern learning models tend to neglect is the fuel required.  Before meaningful learning can be achieved, students need to possess sufficient prior knowledge (kindling wood).  Only then can teachers ignite the fire through active learning techniques.

References

1.    Donohoe L, Mawyer M, Stevens T, Morgan A, Harpe E. An Active-Learning Laboratory on Immunizations. Am J Pharm Educ. 2012; 76 (10):198. 
2.    Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree (Guidelines Version 2.0). Accreditation Council for Pharmacy Education (ACPE).  2006 [Updated 2011, cited 2013 Sept. 21].
3.    Novak J, Cañas A. The Theory Underlying Concept Maps and How to Construct Them. Technical Report IHMC Cmap Tools. Florida Institute for Human and Machine Cognition. 2006 [Updated 2008].

4.    Firestone M. Rote Memorization in Education: Definition, Techniques & Quiz [internet].  Education Portal; [cited 2013 Sept. 21].

5.    Gleason B, Peeters M, Resman-Targoff B, Karr S, McBane S, Kelley K, Thomas T, Denetclaw T. An active-learning strategies primer for achieving ability-based educational outcomes. Am J Pharm Educ. 2011; 75(9):186. 

6.    Murphy A. Why Kids Should Learn Cursive (And Math Facts, and Word Roots). Yew Chung Parenting Resources. Times Ideas. 2012 [cited 2013 Sept. 21]. 

7.    Bowers P, Kirby J. Effects of Morphological Instruction on Vocabulary Acquisition. Reading and Writing: An Interdisciplinary Journal. 2010; 23 (5): 515-537. 

8.    Cumming J, Elkins J. Lack of automaticity in the basic addition facts as a characteristic of arithmetic learning problems and instructional needs. Mathematical Cognition. 1999; 5 (2): 149-180.
9.    Huang R, Southall N, Wang Y, Yasgar A, Shinn P, Jadhav A, Nguyen D, Austin C. The NCGC Pharmaceutical Collection: A Comprehensive Resource of Clinically Approved Drugs Enabling Repurposing and Chemical Genomics. Science Translational Medicine. 2011; 3 (80): 80.

Stress and Anxiety: Effects on Learning

By Funmi Agunbiade, Pharm.D. PGY1 Pharmacy Practice Resident, Union Memorial Hospital

Its 5am.  You wake up groggy, wanting so badly to snooze the alarm and take the day off, but suddenly you remember you have that exam at 7am.   You’ve had only 3 hours of sleep. Panic stricken, you abruptly become alert. You feel your heart racing as you do one last review of the material before the exam starts. This is it.  There’s no turning back now. Your palms are sweaty and shaky as you try hard to remember everything. As you turn in the exam, you feel certain that you could have done better if you weren’t so stressed out.

Stress is defined as a state of mental strain or emotional tension resulting from adverse or demanding circumstances.  Anxiety is a feeling of worry, nervousness, or uneasiness often brought on by an imminent event or something with an uncertain outcome. A lot of learners experience stress and/or anxiety before learning activities such as taking an exam, giving a presentation, answering questions in class, speaking during group activities, or turning in a paper.  Sometimes just going to class can be a source of stress and anxiety to a learner.

Stress in modest amounts can be helpful to learning by increasing awareness and being a necessary push to accomplish a task.  However, an excessive amount of stress and anxiety can have detrimental effects on learning.  Stressors can be categorized as academic, financial, time-related, health-related, and self-imposed.¹  Academic stressors include the student's perception of the knowledge or skill required to do well and the perception that there is an inadequate amount of time to develop it.²  A study done to assess the interrelationship between academic stress, anxiety, time management, and leisure satisfaction among university undergraduates found that students experienced academic stress at predictable times each semester.  The greatest sources of academic stress were during periods when students were taking and studying for exams, especially when there was a large amount of content to master in a short period of time.³  The study showed that emotional and cognitive reactions to stressors occur frequently. Females may experience higher self-imposed stress and more physiological reactions to stressors than males. For example, female subjects sweat, stuttered, and experienced headaches more often due to stress than males.¹

Ways to reduce stress includes effective time management, social support, positive re-appraisal, and engagement in leisure pursuits. Time management is a cluster of behaviors that facilitate productivity.¹  Managing one’s time wisely can help reduce stress.  By breaking down larger tasks into smaller ones and creating a schedule for achieving each small task, makes things more manageable.  By doing this, the learner feels more in control of their learning and therefore significantly reduces the level of stress or anxiety that may be present.  One study showed that females are better at managing their time than males and they felt in better control, set and prioritized goals, and used an organized approach to tasks and workspace. It is interesting to note though that even though females had a better approach to time management they still experienced more “self-imposed” stress than males.

Leisure satisfaction is the positive feeling of contentment that results from meeting personal needs through leisure activities. A way of relieving stress/anxiety is to participate in leisure activities outside of the formal learning environment. Engaging in a hobby, exercising, trying out new things just for the fun of it can help increase relaxation prior to tackling a particularly difficult task. Personally, I have found that stepping away from the task for a short while to read a book or watch an episode of one of my favorite TV shows, helps me to gain a new perspective. This is especially helpful when I have an essay to turn in and I’m experiencing writer’s block.  It is important to note that when engaging in a leisure activity, one should be fully engaged in the leisure activity so that you can experience the highest amount of leisure satisfaction. The purpose is defeated if the learner is still obsessing or stressing about the academic task while engaging in the leisure activity.

Other studies show that an effective way of combating stress and anxiety is by practicing mindfulness. This is simply another term used for meditation. Researchers were able to show that when learners practice mindfulness every day, even if it is just for a short period of time, they were able to better focus their attention and experience less stress and anxiety.⁴  Personally, I have used some form of this before giving a presentation or before a class where I might be called on and was afraid that I might not know the answer to the question.

Educators can help to reduce the learners’ stress and anxiety by thoroughly reviewing and correlating the course content and the learning assignments. Learners want to learn.  They don’t want to feel bogged down doing “busy work.”  When learners do busy-work in addition to the activities that are truly pertinent to the course content, it can be stressful and they can become disengaged.

Educators can also facilitate learning and reduce stress is by placing an emphasis on learning and understanding the material instead of memorizing it. One way to achieve this is by creating class activities with groups of learners and developing the means by which learners can reflect upon what they are learning. In this way, learners take a more active role in their learning and therefore may be motivated to focus on what is needed to complete the tasks.

Excessive stress and anxiety can have a negative impact on learning.  A few simple strategies implemented by learners and educators can go a long way to reducing and preventing it.

References

1.  Mirsa R and McKean M.  College students' academic stress and its relation to their anxiety, time management, and leisure satisfaction. American Journal of Health Studies 2000; 16 (1): 41-51.

2.  Carveth JA, Gesse T, Moss N. . Survival strategies for nurse-midwifery students. Journal of Nurse-Midwifery, 1996; 41(1), 50-54.

3.  Abouserie R. Sources and levels of stress in relation to locus of control and self-esteem in university students. Educational Psychology 1994; 14(3): 323-330.
4.  Parish KA.  Quieting the Cacophony of the Mind: The Role of Mindfulness in Adult Learning. ProQuest LLC, Ed.D. Dissertation, Edgewood College.

The Multitasking Myth: Technology Use and Instructional Outcomes

By Brent Reed, Pharm.D., BCPS, Assistant Professor, University of Maryland School of Pharmacy

As you read this blog, how many technologies are competing for your attention? Perhaps your phone is sitting nearby, buzzing intermittently with the arrival of a new text message. Or a popup has just alerted you to the 17 new emails anxiously awaiting you in your email inbox.  Indeed, the neverending competition for our attention has become almost ubiquitous.  You can set “push” notifications for everything from up-to-the-minute scores of your favorite football team to the dessert photos your friend just posted to Instagram. The ability to manage these interruptions—often termed media multitasking—is the only way to survive in an increasingly technologically advanced society.   Or is it?  A growing body of evidence now suggests that multitasking is detrimental in many ways.  Some researchers contend that humans are incapable of performing multiple cognitive tasks at one time.  What we perceive as multitasking is essentially rapid “task switching.”¹

For many young adults, especially those in the millennial generation, media multitasking is a way of life.  In a survey of undergraduate students published in 2010, Smith, et al. found that 4 out of every 5 owned a laptop computer and nearly two-thirds owned a mobile device capable of accessing the Internet.² The overwhelming majority of young adults consider themselves excellent multitaskers, but studies indicate that individuals who proclaim themselves to be the most capable are actually the worst at multitasking.³  So too are those who most frequently multitask.⁴  Nevertheless, the growing prevalence of technologies that enable media multitasking has had a significant impact in a variety of areas of our lives.   The classroom and other learning environments are no exceptions.

Impact of Multitasking on Cognitive Processing

Numerous studies have investigated the impact of multitasking on cognitive performance, with many of them being published long before the widespread use of mobile devices. Although investigations date back to the mid-20^th century, several studies in the 1990s demonstrated that divided attention impairs the process of encoding information, thereby reducing cognitive performance and the quality of information stored.⁵  In contrast, divided attention has only minimal impact on memory retrieval, although it comes at a significant cost in terms of reaction time and performance on secondary tasks.^6,7 In more practical terms, attending to multiple tasks at a time may overload the mind’s cognitive capacity, impairing awareness, decision-making skills, and overall performance. For health care professionals, these consequences are especially dire, as multitasking has been highlighted by the Agency for Healthcare Research and Quality (AHRQ) as being detrimental to work performance and posing a risk to patient safety.^8–10

Multitasking and Learning

In their cognitive theory of multimedia learning, Meyer et al. describe three assumptions about how the mind processes information: (1) auditory and visual processing occurs via two separate channels, (2) each channel has limited processing capacity, and (3) learning requires considerable cognitive processing.¹¹ They also propose that cognitive demands may be classified as essential processing (required for comprehension of the material to be learned), incidental processing (information unrelated to the material to be learned), and representational holding (auditory or visual representations retained in working memory).  One or more of these demands can overwhelm processing capacity, a phenomenon they term cognitive overload.  The most significant danger to learning is when the incidental processing (e.g., text messaging, browsing Facebook or Pinterest) outstrips the far more taxing capacities required for essential processing and representational holding of educational material.

A number of recent studies have investigated how media multitasking impacts educational outcomes. In a study of nearly 2000 undergraduate students at a public university, over two-thirds of respondents reported text messaging during class, while another one-third reported using Facebook.¹² Although the frequency of multitasking during class was negatively correlated with grade point average, this trend was driven primarily by multitasking for social activities (e.g., text messaging, Facebook).  In a smaller but randomized study of undergraduate students (n=38-40), multitasking on a laptop during class was associated with 11% lower test scores (p=0.003).  Worse still, students who were distracted by the multitaskers’ laptops were also negatively impacted, scoring 17% lower on tests (p=0.001).

Implications for Learners

Although technology can enrich the learning experience, the evidence suggests that its use for unrelated tasks can have a detrimental impact on educational outcomes. Since mobile devices and other communication technologies are here to stay (can we possibly imagine a world without them?), learners must develop strategies for their responsible use in instructional settings, such as:

• Understanding the impact that media multitasking can have on information processing. This is especially important for future health care professionals, as the knowledge and skills obtained in school are required for providing care to patients.
• Recognizing that the magnitude of its impact is related to both the frequency of use and specific media applications used. Learners should minimize social activities in instructional settings, as these appear to have the most detrimental impact on performance.  Educational activities (e.g., searching the web for a topic presented in class, viewing multimedia related to course material) appear to have minimal to no impact on academic performance.
• Be aware that media multitasking during class may impair the academic performance of fellow learners.

Implications for Educators

Educators are expected to create environments that cultivate learning, so efforts should be made to minimize the detrimental impact of media multitasking in the classroom.  Although a ban on devices has been implemented by some instructors,¹⁴ this is likely to be met with dismay—not to mention abysmal student evaluations.  A less heavy handed approach is perhaps needed.  In addition to making learners aware of how media multitasking can impair learning, the following strategies should be considered:

• Incorporating technology in a way that engages learners and overcomes the lure of unrelated media multitasking.
• Providing a diverse mixture of materials and interactive activities, some of which may include media multitasking, such as asking learners to search for online videos that help explain a complex topic.
• Developing policies for wireless access; a balanced strategy might include designating a period at the beginning of class for downloading notes or presentation slides, responding to emails, or engaging in social media activities, then limiting wireless access during periods of instruction.
• Creating “zones” for those individuals using laptops and other devices in order to minimize the impact of media multitasking on adjacent learners.

Conclusions

The use of laptops, mobile devices, and other communication technologies have become an integral part of everyday life, but their use in instructional settings appears to have a negative impact on learning outcomes, especially when multitasking is used for social purposes.  However, these challenges provide an opportunity for dialogue between educators and learners, so that a strategy for effectively and responsibly incorporating technology can be developed—one that engages students and improves the learning experience while minimizing its detrimental impact on educational outcomes.

For those who found it challenging to read this entire essay without multitasking…

tl;dr: media multitasking widespread, negatively impacts learning; learners, educators should identify strategies for appropriate use; examples provided.

References

1. Rubinstein JS, Meyer DE, Evans JE. Executive control of cognitive processes in task switching. J Exp Psychol Hum Percept Perform 2001;27(4):763–97.

2. ECAR Study of Undergraduate Students and Information Technology, 2010 | EDUCAUSE.edu [Internet]. [cited 2013 Sep 7];Available from: http://www.educause.edu/library/resources/ecar-study-undergraduate-students-and-information-technology-2010
3.  Sanbonmatsu DM, Strayer DL, Medeiros-Ward N, Watson JM. Who Multi-Tasks and Why? Multi-Tasking Ability, Perceived Multi-Tasking Ability, Impulsivity, and Sensation Seeking. PLoS ONE 2013;8(1):e54402.

4.  Ophir E, Nass C, Wagner AD. Cognitive control in media multitaskers. Proc Natl Acad Sci U S A 2009;106(37):15583–7.

5.  Naveh-Benjamin M, M I, Guez J, Dori H. Effects of divided attention on encoding and retrieval processes in human memory: Further support for an asymmetry. J Exp Psychol Learn Mem Cogn 1998;24(5):1091–104.

6.  Craik, M I, Govoni R, Naveh-Benjamin M, Anderson ND. The effects of divided attention on encoding and retrieval processes in human memory. J Exp Psychol Gen 1996;125(2):159–80.

7.  Naveh-Benjamin M, Craik FIM, Perretta JG, Tonev ST. The effects of divided attention on encoding and retrieval processes: The resiliency of retrieval processes. Q J Exp Psychol Sect 2000;53(3):609–25.

8.  Weigl M, Müller A, Sevdalis N, Angerer P. Relationships of multitasking, physicians’ strain, and performance: an observational study in ward physicians. J Patient Saf 2013;9(1):18–23.

9.   Kalisch BJ, Aebersold M. Interruptions and multitasking in nursing care. Jt Comm J Qual Patient Saf Jt Comm Resour 2010;36(3):126–32.

10.  Order Interrupted by Text: Multitasking Mishap. AORN J 2013;98(2):208–115.

11.  Mayer RE, Moreno R. Nine Ways to Reduce Cognitive Load in Multimedia Learning. Educ Psychol 2003;38(1):43–52.

12.  Junco R. In-class multitasking and academic performance. Comput Hum Behav 2012;28(6):2236–43.

13.  Fried CB. In-class laptop use and its effects on student learning. Comput Educ 2008;50(3):906–14.

14.  Ban laptops in class [Internet]. Duke Chron. [cited 2013 Aug 29];Available from: http://www.dukechronicle.com/article/ban-laptops-class