October 8, 2013

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.

1.  Mirsa R and McKean M.  College students' academic stress and its relation to their anxiety, time management, and leisure satisfactionAmerican 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.

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 | 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

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.