Beyond “You Can Do It!” — Supporting Learner Autonomy

by Jessica Biggs, Pharm.D., PGY2 Pediatric Pharmacy Practice Resident, University of Maryland School of Pharmacy

If you are a teacher reading this blog now, I’m sure you would agree that some students seem more motivated than others. While this may be the case, not all students respond the same way to motivators. In other words, motivation is not fully explained by HOW motivated students are, but also by WHAT is motivating them. Are they studying diligently for that pharmacology test with the hopes of getting an A to please their parent? Are they studying because they have a genuine interest in the topic? Or is it a combination of these factors? Autonomous motivation, or a desire to learn due to a genuine interest, has been associated with greater effort and higher academic performance.^1,2 Unfortunately, many educators fail to create an environment that fosters learner autonomy.

According to the self-determination theory (SDT), some learners are motivated primarily by controlled motivation.  Others are motivated more by autonomous motivation.  Controlled motivation refers to a student learning something due to external pressures (such as a parent or teacher), internal pressures (such as guilt or stress), or to gain a reward (such as a passing grade or screen time).³ This form of motivation can be seen in B.F. Skinner’s behaviorism studies.  Behaviorists often use a system of rewards (and punishments) to motivate learner participation. On the opposite end of the spectrum, autonomous motivation refers to learning that resulted from a genuine, internally perceived personal value or interest.³ Simply put, controlled factors are not the primary, or sole, source of motivation. In reality, for most students, the source of motivation is not so black and white.  Motivators often overlap.

What exactly does the term “autonomy” refer to? Autonomy is synonymous with volition. When students are autonomous, they act on their internal desire to align the learning activities with their sense of self.³ It is important to note that autonomous learning does NOT require students to work alone or without assistance.

At this point you may be thinking: How is it possible for students to be autonomously motivated?  There’s no way that they will be interested in absolutely everything I teach?  Autonomous motivation is still possible even if the student is not truly interested in the subject matter because autonomous learners are able to identify the value and personal importance of what they are learning.³ For example, as a pharmacy resident, I am not genuinely interested in learning how to perform open-heart surgery.  I do not wish to be a surgeon. On the other hand, I would gladly accept the opportunity to shadow a cardiac surgeon performing open-heart surgery because I see the value in understanding the complexity of the heart and the cardiac anatomy.  This kind of knowledge would be relevant so that I better understand the cardiac medications that I work with and would be useful during my patient education sessions. I am able to see the value in this learning experience.

Even though I am early in my career, I already see the importance of fostering a sense of learner autonomy. In medical education, autonomous learning has been associated with enhanced learner effort, superior performance academically, as well as reduced learner exhaustion.^1,2  Since I was given opportunities to act autonomously both as a pharmacy student and as a first-year resident, I can attest that I have more energy to take on learning tasks that align with my goals and my performance is better.

So how can we support this type of learning? Small group teaching, problem or case-based learning, and a gradual escalation in learner responsibility and tasks are all appropriate methods.³ Asking students to lead patient case discussions in a small group environment (with other students or pharmacy residents) is an effective tactic. With increased autonomy however, it is also essential to provide constructive feedback, acknowledge students’ perspectives, and ask for learner goals and preferences.⁶ All of these learning opportunities should be done in a structured manner with an appropriate level of learner challenge because allowing a student to “run wild” with their own learning is not what is meant by autonomous learning.

Admittedly, it is often a struggle to achieve a balance between fostering learner autonomy and providing adequate supervision. How can a resident (or pharmacy student) gain real-life experience, including the opportunity to take care of patients autonomously, while also being appropriately supervised to ensure patient safety?⁵  Many teachers struggle with this balance and some micro-manage student activities when it comes to patient care. In these situations learners may feel their ability to make their own choices and decisions, one of the important aspects of autonomy, is compromised.¹

As a second-year pharmacy resident I have witnessed the progression of learner autonomy, both as a learner and now as a supporter of students who seek greater autonomy. Personal experience has proven to me that practicing in an environment that fosters autonomy will give a learner the best chance to shine and demonstrate their intrinsic motivation. It is the job of educators to support learner autonomy – to help students view the materials they are studying or the tasks that they are completing as opportunities that will pave the way to the future goals that they hope to achieve.

References

1. Kusurkar RA, Croiset G, Galindo-Garre F, Ten Cate TJ. Motivational profiles of medical students: association with study effort, academic performance and exhaustion. BMC Med Educ. 2013; 13: 87.
2. Kusurkar RA, Ten Cate, TJ, Vos CM, Westers P, Croiset G. How motivation affects academic performance: a structural equation modelling analysis. Adv Health Sci Educ. 2013; 18: 57-69.
3. Kusurkar RA and Croiset G. Autonomy support for autonomous motivation in medical education. Med Educ Online. 2015; 20: 27591.
4. Deci EL, Ryan RM. The “what” and “why” of goal pursuits: human needs and the self-determination of behavior. Psychol Inq. 2000; 11: 227-68.
5. Hoffman BD. Using self-determination theory to improve residency training: learning how to make omelets without breaking eggs. Acad Med. 2015; 90: 408-410.
6. Cate TJ, Kusurkar RA, Williams GC. How self-determination theory can assist our understanding of the teaching and learning processes in medical education. AMEE Guide. 2011; 33: 961-973.

Maximizing Learner Attention

By Virginia Nguyen, Pharm.D., PGY1 Community Pharmacy Practice Resident, Johns Hopkins Outpatient Pharmacy

We’ve all heard it before. There’s a right time for everything — and learning is no exception. Research has shown that there are some physiologic reasons why some people are ‘morning people’ and some are ‘evening/night people.’  Our individual circadian rhythms affect our attention, executive functioning, and memory.^1,2 Some studies have shown that those who are left brain-dominant perform better in the morning while those who are more right brain-dominant perform better in the afternoon.^3,4

While it is interesting to note how some may perform better in the morning compared to others, it is impossible for an instructor to optimally time a presentation or lecture to coincide with every learner’s physiological predilection. What is more important for educators to focus on are the factors that they can control that will maximize learning. Below are a few tips and tools for educators to make the most of their learner’s time and attention.

Keeping it short and sweet

In the day and age of social media, texting, and email alerts going off on a smartphone, laptop, and/or tablet, chances are instructors are perpetually competing for their learner’s attention. A recent Microsoft study found that the human attention span has decreased from 12 seconds in 2000 to 8 seconds in 2015.⁶ In order to make every second count, be sure to start your educational activity with a hook to gain the audience’s attention. If you aren’t able to gain their attention off the bat, there’s small chance you’ll be able to sustain it for the entirety of your instructional activity.

Breaking it up

Studies have shown that adults can only sustain attention for about 20 minutes at a time.  Experiencing multiple stimuli during those 20 minutes help to maximize and maintain attention.⁷ Think about movies or the NFL RedZone- both of these sources are able to grab the audience’s attention by producing multiple stimuli (different angles and clips) every few seconds or 1-2 minutes at the most. The effect multiple stimuli enables the learner to stay focused longer than if a single stimuli is used for minutes on end.

For most lesson plans, showing multiple movie or football clips isn’t feasible; however, breaking up the lesson plan by creating different stimuli related to the instructional objectives can help the audience recharge and stay engaged. Consider for every 4-5 minutes of instruction, there should be a change.  Perhaps interrupting the lecture with a discussion question, active learning technique, or different way to present the material. Use media clips or pictures to break up the monotony of your PowerPoint presentation. Using different stimuli not only maximizes the audience’s attention but also their ability to learn.

Get up and move

Taking physical and mental breaks are just as important. There’s a reason why the MLB created the 7^th inning stretch, and it’s not just so we can sing ‘Take me out to the ballgame.’ Studies have shown that physical activity can help to boost energy levels, attention, and academic performance.⁵ Although recess has been phased out of schools across the country, consider giving the audience a physical recess or break from the material to digest and recharge. The audience doesn’t necessarily need to run laps around a track or do jumping jacks, but simply getting up to walk around will help your audience get back on track (no pun intended).

Timing it right

You, as the instructor, are not the only one accountable for maximizing audience attention (spoiler alert: the audience member is also responsible for this). While it’s impossible to sync instructional activities to account for all left and right brain-dominant audience members, what is possible is encouraging each audience member to identify times during the day they are most attentive and to use that time to enhance their learning. Depending on the audience member’s ‘peak’ time for being most awake and attentive, recommend they use this time to focus on tasks that require his or her full attention and problem-solving skills. For the avid coffee drinker, it’s best to think of it this way: save the tasks that require a high level of thinking once your cup of coffee has kicked in.

Summary

While we can’t teach a lecture or activity to match the physiologic and biochemical changes of each student, we can make sure that what we teach captures their attention and energy- no matter what time that is. Depending on the length of your instructional activity, consider the impact of grabbing your audience’s attention, interjecting active learning strategies every few minutes, and incorporating breaks to maintain it.  Encourage your audience members to identify times that they are most awake and attentive and to use that to their advantage in completing learning tasks.

References

1. Schmidt C, Collette F, Cajochen C, et al. A time to think: Circadian rhythms in human cognition. Cogn Neuropsychol 2007;24(7):755-89.
2. Wile AJ, Shouppe GA. Does Time-of-Day of Instruction Impact Class Achievement? Perspectives in Learning: A Journal of the College of Education & Health Professions, Columbus State University 2011;12(1):21-25.
3. Klein, J. Attention, scholastic achievement and timing of lessons. Scandinavian Journal of Educational Research 2001;45(3):301-309.
4. Millar K, Styles B, Wastell D. Time of day and retrieval from longterm memory. British Journal of Psychology 1980;71:407-414.
5. Singh A, Ulijtdewilligen L, Twisk JW, et al. Physical activity and performance at school: a systematic review of the literature including a methodological quality assessment. Arch Pediatr Adolesc Med 2012;166(1):49-55
6. Watson L. Humans have shorter attention span than goldfish, thanks to smartphones [Internet]. London (UK): The Telegraph, Telegraph Media Group Limited. 2015 May 15 [cited 2015 Oct 23].
7. Islam K. Attention Span and Performance Improvement [Internet]. Cary (NC): Training Industry, Training Industry, Inc. 2013 1 Mar [cited 2015 Oct 24].

Incorporating OSCEs into the Curriculum

by Jueli Li, PharmD, PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

The objective structured clinical examination (OSCE) is an authentic assessment, where learners are evaluated in a realistic, simulated real-world setting that requires the student to apply their knowledge and skills in a problem-based learning environment.^1-3 Although OSCEs are implemented differently at different health professional schools, they all include a series of stations in which standardized patients portray a part in an interactive clinical case scenarios. Students are graded based on a set of items on a checklist that are intended to assess students’ ability to problem-solve.^2,3  An overall impression rating is also given to the students and knowledge is indirectly measured based on the response to the case scenario.^2,3 At my pharmacy school, students were evaluated using OSCE each spring semester as a part of our pharmacy practice laboratory course. During the first year, students were assessed on one OSCE case and by the time they complete their third year, students are assessed on a series of five case scenarios. Each scenario focused on a different aspect of patient care, including medication reconciliation, patient counseling, documentation, and other pharmacy-related tasks.



The OSCE was initially described in the 1970s as an objective evaluation of clinical competency and has since then been used in the United States Medical Licensing Examination, the Medical Council of Canada Qualifying Examination, as well as the Canadian Pharmacist Qualifying Examination.^4,5 OSCEs are used during the professional education of many health professions including dentistry, optometry, nursing, and more. Starting in 2007, the United States pharmacy school accreditation board, Accreditation Council for Pharmacy Education (ACPE), included OSCE as an option for schools to provide simulated clinical experiences.⁶ Since then, there has been a surge in the number of pharmacy schools who have implemented them.

OSCEs are a valid method to evaluate pharmacy students’ performance. In an observational single-cohort study conducted in the United Kingdom which compared multiple-choice exams to OSCEs, the investigators found that student performance on the multiple-choice exam was only moderately correlated with the outcome of an OSCE (r=0.6). The study showed that OSCE assessed a student’s knowledge and skill, while multiple choice examinations are only able to assess a student’s knowledge.² These results were further corroborated by another observational study in the United States, where the authors found a very weak relationship between OSCE scores and written examination scores (r=0.15; p=0.24).

A survey of students and faculty have found that the OSCE method was view favorably, particularly in terms of realism. Furthermore, more than 75% of students rated OSCEs as an appropriate way to measure their knowledge, communication, and clinical skills. The results showcased the value of utilizing OSCEs to provide a more comprehensive assessment for problem-based learning as well as building critical thinking, communication abilities, and clinical judgment.³

In 2010, a study sampled 108 pharmacy schools in the United States and found a great deal of variability with regard to how pharmacy schools implemented OSCEs. Many schools indicated that cost and increased faculty time commitment were barriers to implement OSCEs. In order to create valid exams, a consortium of faculty are needed to develop authentic case scenarios and validate checklists. It is also important to provide training for standardized patients and examiners, and to have an adequate amount of space or stations.⁵

Fortunately, there is a wealth of information on how to implement OSCEs. The Association of Standardized Patient Educators (ASPE) has an OSCE toolkit.⁷  A paper by the Medical University of Vienna in Austria provides detailed guidance document on how to develop and implement OSCEs.⁸ Both documents recommend adequate planning in the pre-assessment phase to determine available resources, resource allocation, test logistics, and an “examination blueprint” or a test plan that includes the objectives, goals, and competencies that the OSCE cases will assess. Once those points have been discussed, realistic cases and grading checklists need to be developed. Additionally, it is important to provide detailed instructions – not only to the students, but also the standardized patients.  This includes the grading checklists and embedded instructions in the written cases scenarios. To decrease inter-rater variable, the Medical University of Vienna suggests providing standardized patients and graders a frame of reference for a “gold standard” student and identifying standards for pass and fail. The ASPE OSCE toolkit contains a to-do list for developing the cases, instructions on how to implement the OSCEs, how to set the grading checklists, as well as an actual case example, which could be very helpful for any institution.⁷

The integration of OSCEs into the curriculum allows students an opportunity to develop their critical thinking abilities, communication skills, and knowledge base in a more realistic setting. Current literature suggests that OSCEs evaluate more than just knowledge and complement traditional assessment methods. Schools interested in improving or initiating the use of OSCEs at their institution can find ample resources for guidance.

References:

1. Mueller J. The authentic assessment toolbox: Enhancing student learning through online faculty development. J Online Learning and Teaching. 2005 Jul:1(1):1-7.
2. Kirton SB and Kravitz L. Objective structured clinical examinations (OSCEs) compared with traditional assessment methods. Am J Pharm educ. 2011 Aug 10: 75(6): Article 111.
3. Salinitri FD, O’Connell MB, Garwood CL, et al. An objective structured clinical examination to assess problem-based learning. Am J Pharm Educ. 2012 Apr 10: 76(3): Article 44.
4. Harden RM, Stevenson M, Downie WW, et al. Assessment of clinical competence using objective structured examination. Br Med J. 1975; 1: 447-451.
5. Sturpe DA. Objective structured clinical examinations in doctor of pharmacy programs in the United States. Am J Pharm Educ. 2010 Oct 11: 74(8): Article 148.
6. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. 2007 Jul 1.
7. Association of Standardized Patient Educators. Pharmacy OSCE toolkit. [Internet]. (cited 2015 Oct 29).
8. Preusche I, Schmidts M, Wagner-Menghin M. Twelve tips for designing and implementing a structured rater training in OSCEs. Med Teacher. 2012; 34: 368.