September 10, 2013

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-20th 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.
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.

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 | [Internet]. [cited 2013 Sep 7];Available from:
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:

July 11, 2013

Leadership Education for Pharmacists

by Ryan Costantino, Pharm.D., PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

In sports, business, politics, or healthcare, leadership is a highly sought after character trait. Over the past several years I have repeatedly heard “Pharmacy needs to train more leaders.”  Interest in training and developing leaders has been mentioned by Harvey A.K. Whitney Award recipients1, in a Rho Chi Lecture2, and it appears several times in the current ACPE accreditation standards.3 While the need for leadership education and training is clear, the best method to train leaders in pharmacy is not.

Articles or reports published in scholarly journals that specifically address leadership education for pharmacy students are sparse.4,5  Boyle and colleagues describe an elective course implemented to develop pharmacy students’ leadership and political advocacy. Course evaluations from the elective identified benefits including building public-speaking skills, debating skills, increasing confidence at business functions, and networking.  The authors also report that students sought leadership positions after completing the course and felt a sense of empowerment with increased confidence to become more involved in organizations as leaders and advocates.

From an instructional design standpoint, Boyle and colleagues designed their course well. It had clearly stated objectives and used a variety of assessment methods that required students to verbally discuss and debate issues as well as summarize their course experience in a written reflective paper. The course also had an experiential component that required students to participate in various professional organizations or activities. I believe an experiential component is essential for any leadership education program because leadership is more than having knowledge or skills. It’s also the ability to act at the appropriate time and in the appropriate way to exert influence.

Another manuscript that described leadership education was published by Sorensen and colleagues from the University of Minnesota.  The course included didactic, experiential, and self directed learning activities. It focused on developing core leadership skills, self-awareness, and awareness of the process for leading change. The authors used activities such as StengthsFinder®, and reputable books such as Our Iceberg is Melting to augment the classroom-based activities. Course evaluations by the students were generally positive and students rated the activities in the course moderately to very useful. The authors also stated that evaluations from both students and practicing pharmacists suggested that the course could serve as an effective tool in preparing students to lead change when they enter the profession.

Both of these courses appear to have been constructed with sound principles of instructional design in mind.  They incorporated a variety of didactic classes and experiential experiences to convey knowledge regarding leadership.  However, on the negative side, both courses relied heavily on course evaluations from student to evaluate course effectiveness.

After searching the literature regarding leadership education, it’s clear that there is a lack of evidence about how best to teach someone to be a leader. It is unclear if either of these courses have had a long-term impact on students. Evaluating additional outcomes is needed. For example, it would be useful to survey the entire pharmacy class and see if students who took the course were more involved in leadership roles or professional organizations than students who did not enroll in the course. Or perhaps surveying employers of these graduates to assess whether the employer thought the student possessed leadership skills or traits at a higher level than what would be expected for an entry-level pharmacist.

Leadership courses for pharmacy students have approached leadership development in a very appropriate manner using a variety of instructional activities and tools. What we don’t seem to do well is critically evaluate and assess whether these courses actually produce the desired results.  Leadership education would be well served to apply the same rigorous standards we apply to other disciplines by examining long-term outcomes.

Leadership will continue to be a desired character trait in pharmacy and healthcare.  All pharmacists should possess fundamental leadership skills regardless of whether they hold a formal leadership position because all pharmacists influence people.  Pharmacy schools would be prudent to continue to encourage faculty to develop innovative programs and courses that work to mentor and develop future leaders and equip all graduates with the skills they need to lead at all levels in an organization. Leadership courses and programs should continue to be created using the principles of instructional design but must employ more rigorous evaluations if we want to critically assess whether they are effective.

1. White SJ. Leadership: successful alchemy. Am J Health Syst Pharm 2006; 63:1497-1503.
2. Grabenstein, JD. 2011 Rho Chi Lecture: Mortars & Pestles, Maps & Compasses, Vaccines & Syringes. Am J Pharm Educ 2011: 75: Article 79.
3. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree [Internet]. Chicago: Accreditation Council for Pharmacy Education; 2011.  97 p.  [cited 2012 Oct 8]
4. Boyle, CJ, Beardsley, RS, Hayes, M.  Effective leadership and advocacy: amplifying professional citizenship. Am J Pharm Educ 2004;68:Article 63.
5. Sorensen, TD, Traynor, AP, Janke, KK.  A pharmacy course on leadership and leading change.  Am J Pharm Educ 2009;73:Article 23.

May 12, 2013

Reducing Test Anxiety

by Jesse Foster, Pharm.D., PGY1 Pharmacy Practice Resident, Medstar Georgetown University Hospital

When I was a pharmacy student, I had a friend who seemed to understand the course content very well. When my friend took the final exam — an exam that weighed a lot toward our final grade — he failed the exam.  It was a classic case of test anxiety. Test anxiety can be a serious problem for some students.  An estimated 15-20% of students feel impaired by exam stress.2

The impact of test anxiety can lead to several negative outcomes.  Students with test anxiety can have a good understanding of the material but may be unable to recall what they know.  Anxiety can also impair problem solving and lead to poor decisions on exams. Some learners may develop avoidance behaviors and pass up learning opportunities. Avoidance behavior develops after past poor performance.  Understandably, students don't want to repeat the negative experience. 4  Further, test anxiety shifts the focus toward performance and outcomes rather than on learning the subject matter.  Lastly, poor performance due to test anxiety can lead to lost educational and job opportunities.2

At the heart of test anxiety is stress. In a study by Yusoff, the impact of stress on exam scores was examined in first year Malaysian medical students. This study looked at students' mental status immediately after taking a final exam. The results show that students with severe stress were 2.43 times more likely to fail the exam compared to students with normal to mild stress.5

Cognitive interference is a possible cause for exam anxiety. This model postulates that cognitive processes are occupied by negative and irrelevant thoughts resulting in poor exam performance.2  Test anxiety has been correlated to feelings of unpreparedness when students are unfamiliar with the exam style and content. Students can also feel unprepared when there is a large amount of content and limited amount of time to review what will be covered on the exam.5 Poor study habits add to test anxiety as well. Studies have shown that students with high test anxiety are more likely to procrastinate and use less effective studying strategies.1

The perception by the student that the exam or assessment has significant implications can also increase anxiety and stress.  Students become overly concerned that poor performance on an exam will result in major negative consequences.  If a student has an unrealistic expectation that he/she will achieve a perfect score on an exam, then stress and anxiety can increase when he/she is unable to answer an exam question.6

To help with cognitive interference, cognitive behavioral therapy can be used to help reduce stress. Expressive writing is a technique to help with these disruptive thoughts. Using this technique, the student writes out his/her negative thoughts for 10 minutes before the exam. This allows the student to vent and express their concerns on paper before the exam. Expressing their concerns will clear their mind so they can better focus on the exam. Another approach to help reduce test anxiety is relaxation techniques. These techniques have the student focus on deep breathing along with muscle relaxation of the arms, legs and stomach. Similar to expressive writing, this helps the person clear their mind of negative thoughts and anxiety.4

Reducing the perceived significance of the exam can help to alleviate the stress and anxiety that a student may feel.  Both the learner and teacher can help minimize this type of stressor.  Its important not to overemphasize the importance of an exam and its potential impact. Multiple exams in a course can help reduce anxiety by minimizing the impact any one exam might have on the overall outcome.2

Providing more realistic expectations for the exam will help students who panic when they don’t know or understand questions. Answering questions where the answers are known and understood first can improve test anxiety. This helps to improve confidence and in turn, reduce anxiety during the exam as well as diminishes the sensation that time is running out.3, 4

For students who feel unprepared, teachers can provide insight into the exam content and style to help reduce the fear of the unknown. Study habits can be improved by providing a clear, regimented course schedule. Study groups can also be beneficial by helping keep students focused. Having more frequent exams can also improve study habits since students will need to review material more frequently.1, 2

Test anxiety is a major concern for some students. It can prevent students from advancing academically and professionally. Test anxiety also causes students to avoid other educational experiences and to focus more on passing exams instead of learning the content. However, test anxiety can be minimized if both the student and teacher employ some proven strategies.


1. Sansgiry SS, Sail K. Effect of Students’ Perceptions of Course Load on Test Anxiety. Am J Pharm Edu. 2006; 70(2): Article 26.
2. Neuderth S, Jabs B, Schmidtke A. Strategies for reducing test anxiety and optimizing exam preparation in German university students: a prevention-oriented pilot project of the University of Wurzburg. J Neural Transm. 2009; 116: 785–90.
3. Abolafia J, Lumpkins A, Malandro T. High Stakes Testing: Managing Test Anxiety. [Internet]. Accessed April 27, 2013.
4.  Paul A. Relax, It's Only A Test. Time 2013;181(5):42-5.
5. Yusof M, Associations of Pass-Fail Outcomes with Psychological Health of First-Year Medical Students in a Malaysian Medical School. Sultan Qaboos University Med. 2013; 13(1): 107-14.
6. Chinta R. Exam Anxiety Effect on Exam Performance: An Empirical Replication in the Middle East. Aryan Hellas Limited, IRBC Athens, 2005. Accessed 5 May 2013.