- Email: [email protected]
Pharmacy students’ perception of learning and satisfaction with various active learning exercises
Available online at www.sciencedirect.com
Currents in Pharmacy Teaching and Learning ] (]]]]) ]]]–]]]
Short communication
http://www.pharmacyteaching.com
Pharmacy students’ perception of learning and satisfaction with various active learning exercises Amulya Tatachar, PharmD, BCACPa,*, Feiming Li, PhDb, Caitlin M. Gibson, PharmD, BCPSa, Carol Kominski, PhDb a
Department of Pharmacotherapy, University of North Texas Health Science Center, Fort Worth, TX Center for Innovative Learning, University of North Texas Health Science Center, Fort Worth, TX
b
Abstract Objective: To evaluate pharmacy studentsʼ perceptions of learning and satisfaction related to eight active learning exercises. Methods: Eight active learning exercises were implemented in class recitation sessions. Students completed anonymous surveys in an introductory session to identify interests, goals, strengths, and weaknesses, as well as at the courseʼs end to assess perceptions of learning and satisfaction with each active learning exercise. Results: All students (n ¼ 76) responded to both surveys. Students consistently ranked exercises, in which they created, answered, rated, and commented on multiple-choice questions (PeerWise) or answered factual questions in a Jeopardy™-like format highest both for accomplishment of their learning goals and for satisfaction or enjoyment. Comments supported data from the rankings. Conclusions: Students, overall, enjoyed the variety of active learning exercises. Active learning exercises such as PeerWiseTM and Jeopardy™ appeared to be particularly effective in fostering student learning, satisfaction, and interest in further engagement. r 2016 Elsevier Inc. All rights reserved.
Keywords: Pharmacy education; Active learning; Student perception
Introduction The Accreditation Council for Pharmacy Education (ACPE) recommends that curricula emphasize active learning pedagogy, skill development, and the application of knowledge and skills to therapeutic decision-making.1 Active learning techniques have been encouraged and embraced in pharmacy education to engage students in their learning processes.2–13 However, fostering active learning exercises in a relatively large classroom setting poses several challenges to
* Corresponding author: Amulya Tatachar, PharmD, BCACP, Department of Pharmacotherapy, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, Texas 76107. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2016.03.019 1877-1297/r 2016 Elsevier Inc. All rights reserved.
pharmacy educators. Active learning exercises need to be carefully structured to capture studentsʼ interest and engage them sufficiently to promote acquisition as well as application of knowledge to problems and issues likely to be encountered in the profession. Exercises must be presented in a meaningful context to empower students to perform as health care professionals and enhance their interest in a learning environment.12,13 Therefore, understanding student perceptions of learning and satisfaction is integral to selection and implementation of exercises that promote student engagement and performance. The University of North Texas System College of Pharmacy implemented a 12-week recitation course with the purpose of integrating pharmacotherapy concepts into active learning application exercises. This pilot study evaluates pharmacy studentsʼ perceptions of learning and satisfaction with eight active learning exercises.
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A. Tatachar et al. / Currents in Pharmacy Teaching and Learning ] (]]]]) ]]]–]]]
Methods Participants included 76 second-year pharmacy students enrolled in PHAR 7136 in the fall 2014 semester. Students met once a week for two hours for a total of 12 sessions. Each of the seven faculty members facilitated at least one recitation session related to the topic or disease state he/she covered in the didactic portion of the pharmacotherapy module. Class design Students were assigned reading and provided with learning objectives at least one week prior to the active learning sessions. The pre-class reading assignments often included literature articles, textbook sections, and/or instructor-prepared handouts. The learning objectives were clear and concise objectives written by the lead instructor to prepare students for the recitation session. The learning objectives and reading assignments aligned or were the same as the learning objectives and reading assignments of the respective didactic lecture. At the start of each class, students completed a five question individual readiness assessment test (iRAT) to assess their preparation for class. iRATs were collected and then the same test was distributed to the teams and each team was given time to discuss and select the best answers for the group readiness assessment test (gRAT). After completion, gRATs were collected and the instructor transitioned into a discussion of the assessment tests. The two readiness assessment tests and discussion took approximately 30 minutes to complete. Both iRATs and gRATs were given on scantron and graded. Students then worked in an assigned team on an active learning exercise related to a certain topic or disease state for the remainder of the class. Each of 11 teams consisting of six to seven students worked together in all sessions. Table describes each active learning exercise, the topic(s) covered, and hours dedicated to each topic in didactic lectures. The educational games were based on available evidence on active learning strategies.14 Each active learning exercise took place either immediately or at least a day after completion of the didactic lecture on the respective topic. Each type of exercise was used in only one class session with the exception of case-based exercises, which were used in four class sessions. Each active learning exercise took approximately 90 minutes to complete. All active learning exercises were completed in class. No outside classroom activities were assigned to the students with the exception of preparatory learning objectives and reading assignments. Educational games, teach-back method, counseling, and PeerWise were graded based on completion and participation. Case-based exercises and clinical protocol were graded on appropriateness and/or correctness. Faculty spent five hours on average preparing for the readiness assessment tests, discussion, and active
learning exercise. Students completed pre- and postassessment surveys at the initial session and final session of the course, respectively. Pre-assessment Students completed a pencil-and-paper, free-form survey in the first class session. The survey identified studentsʼ short-term and long-term career goals, semester goals, specific interests in the pharmacy field, and areas of weakness and strength. The course director and faculty then created and adapted active learning exercises based on self-reported student interests and goals. To encourage survey completion, students were given bonus points that comprised o1% of the total course points. Post-assessment A post-assessment survey consisted of open- and closeended questions on studentsʼ perception of the active learning exercises and solicited suggestions for future classes. The post-assessment survey was administered via an e-mailed internet link (QualtricsTM, Provo, UT, version 5/2015). The following three variables were constructed from the post-assessment survey items: student learning, student satisfaction, and interest in continuing participation. Student learning Three survey questions assessed student learning by asking students to assign each exercise scores on a scale of 1–100 based on their perceived (a) level of competence, (b) extent of increased understanding, and (c) effort expended with each exercise. Student satisfaction Three survey questions assessed student satisfaction by asking students to assign each exercise a score on a scale of 1–100 based on (a) level of enjoyment experienced and (b) level of contribution to their semester goals. For the third question, students rated each exercise on the extent to which they felt very tense (rating ¼ 1) up to very relaxed (rating ¼ 5). Interest in continuing participation On one item, students also ranked each exercise based on the likelihood that they would participate in the exercise in future courses, which provided an overall perception of learning and satisfaction for each active learning exercise. Students were asked to comment on exercises they preferred to see continued or discontinued in future courses and to offer any suggestions to improve the exercises. After student learning and student satisfaction sub-scores were calculated, all eight activities were ranked on each variable. In other words, each activity received a ranking of one to eight on learning and another ranking of one to eight on satisfaction.
A. Tatachar et al. / Currents in Pharmacy Teaching and Learning ] (]]]]) ]]]–]]]
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Table Description of active learning exercises, topic(s) covered, and hours spent on topic in pharmacotherapy module
Games Jeopardy™-like game
Taboo™-like game
UNO™-like game
Hours spent on topic in pharmacotherapy module
Description
Topic
This game features a quiz competition in which teams are presented with general knowledge clues in forms of answers, and the representative from each team must phrase their responses in form of questions. A team picks a category and monetary value. The host reads the clue and a representative from the team can buzz into answer the question. Points are given for correct answers. Points are not deducted for incorrect answers. If a team answers incorrectly, the opponent team has ten seconds to answer the question. If both teams answer incorrectly, the host will provide both teams with the correct answer. This is a word-guessing game and its main objective is for a player to have their team members guess the word on the player's card without using the word itself. All members from each team draw card from stack. As soon as timer starts, member gives clues to help teammates state the word on the card. This is a card game which is played with a printed deck. The cards contain words and/or pictures that describe the basic metabolic panel or complications of electrolyte disorders. Two team representatives draw seven cards from a stack and take turns manipulating a basic metabolic panel to normalize (Team 1) or “sabotage” (Team 2) electrolyte levels. For example, one team plays an “ACE inhibitor” card to raise potassium levels, and another team plays “Vomiting” card to lower potassium levels. The first team to get rid of all their cards wins the game.
Acute kidney injury/druginduced kidney disease
2
Top 200 drugs/ enzyme activity
1
Electrolyte disorders
2
Receptors and drug activity
2
End-stage renal disease
2
Drug allergies
2
Glaucoma Pharmacokinetics Chronic kidney disease Anemia Acid–base disorders
2 2 2
Non-Game Exercises Teach back Students are randomly assigned a concept, which they must teach back to all their classmates. Students are given 20 minutes to prepare their presentation and five minutes to present. PeerWise This is a web-based application that allows students to collaboratively author multiple-choice questions and provide explanations for correct and incorrect alternatives, and answer, rate, and comment on other students' questions. Clinical protocol Students apply primary literature examples to create a drug desensitization protocol. Students are given one hour to complete a mock drug desensitization protocol and five minutes to present the protocol to their peers and instructors. Counseling Students counsel their peers on eye drop administration. Case based Students answer questions related to vignettes or scenarios on specific disease states. Questions are open-ended or close-ended.
To incentivize completion of surveys, students were given points toward their course grade for survey completion and were required to complete the survey to receive full credit. The points to complete the survey comprised 7% of their total course points. Although respondents who completed the survey were tracked, only collective data were analyzed and the respondent for each set of responses was
3 2
anonymous. Approval for this study was obtained from the Institutional Review Board. Results All 76 students completed the pre-assessment and postassessment surveys (100% response rate).
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Pre-assessment survey The pre-assessment survey identified following three common goals: gaining confidence, gaining competence, and developing organizational and interpersonal skills. Students were most interested in improving skills related to counseling techniques, public speaking, and time management. Post-assessment survey Figure 1 illustrates how the active learning exercises rank on the self-reported variables of student learning and student satisfaction. PeerWise and the Jeopardy™-like game ranked one and two, respectively, for both learning and satisfaction. Four activities received the same ranking in learning and satisfaction. The teach-back method and UNO™-like game ranked seven and eight, respectively, in both learning and satisfaction. Open-ended comments on other activities were helpful in furthering understanding of student thinking. For example, students noted that the teach-back method was not effective in reinforcement and retention of material because students felt pressured to present a creative script more than to focus on the topic content. Students also noted that the UNO™-like game required more organization and student engagement. The Taboo™-like game received conflicting responses. Students ranked the Taboo™-like game as the active learning exercise that made students feel most tense. Although students noted that the game improved their knowledge, they also noted feelings of unease with public speaking. Students ranked the clinical protocol exercise higher in satisfaction than learning and the counseling exercise higher in learning than satisfaction.
Case-based questions were ranked higher in learning than in satisfaction (Fig. 1). Several themes emerging in open-ended responses helped explain what students were thinking explicitly. Some said written case-based questions were difficult to complete in the allotted time. Others said they preferred to submit cases electronically to improve quality of answers and time management. Others noted that they lacked the foundational knowledge of the subject to effectively and efficiently answer the case-based questions in the allotted time. PeerWise rated highest in likelihood that students would still participate if given a choice (Fig. 2). Discussion Consideration of studentsʼ goals, strengths, and weaknesses is essential when designing educational exercises because students learn and engage best in an environment that satisfies their existing needs.15,16 The active learning exercises in this recitation course were tailored to address studentsʼ needs and interests as indicated in the preassessment survey. Particularly, the interactive games were designed to help students build confidence, interpersonal skills, and develop public speaking skills in addition to increasing pharmacotherapy knowledge. As a means to develop time management and organization skills, students also worked in teams and managed their time to complete the exercises in the timeframe of a class session. Numerous studies describing educational health care games found student enjoyment of these active learning activities.17–19 The Jeopardy™-like game in this course received the most positive feedback of the interactive games. Students appreciated the competitiveness, collaboration, and reinforcement of material. Initially, students
Fig. 1. Ranking of learning and satisfaction for active learning exercises.
A. Tatachar et al. / Currents in Pharmacy Teaching and Learning ] (]]]]) ]]]–]]]
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Fig. 2. Rating of interest in continuing participation for each active learning exercise.
were confused about the rules and logistics. During the second and third round, students felt more at ease with the structure of the game. Overall, students noted increased understanding of the material and enjoyment of the Jeopardy™-like game. Studies conducted in nursing education showed similar results of increased student satisfaction and improved learning with a Jeopardy™-like game.20,21 Although Jeopardy was clearly a success with most students, a few voiced concerns of incomplete engagement of the entire class during the game. While two teams were playing a round, the remaining students could not hear their peersʼ responses to the questions. Two other interactive games in the course received mixed feedback. The Taboo™-like game was the first interactive game introduced to the students, but its requirements for public speaking made students feel relatively tense. Students suggested playing within the teams instead in front of all students to reduce anxiety related to public speaking. It is also possible that placement of this game at the end of the course rather than at its beginning might produce more positive reactions from students. Tasdelen et al., for example, studied the perception and effectiveness of a Taboo™-like game in a group of prospective chemistry teachers completing their last year in a five-year Teacher Education Program. The authors concluded that a Taboo™like game was helpful to enhance and evaluate studentsʼ views on concepts learned throughout the course. The game also created a context through which the content of the course could be summarized.22 While the study population and results from Tasdelen et al. may not be generalizable to this study, the study does demonstrate the potential in utilizing the Taboo™-like game later rather than earlier in the curriculum as a means to summarize concepts. The UNO™-like game ranked the lowest in competence, enjoyment, and relatedness. A potential reason for student dissatisfaction was using one set of cards for the entire class leading to disengagement and frustration.
In addition to interactive games, PeerWise (Denny) software supporting the generation and exchange of multiplechoice questions, was implemented as an active learning exercise in the course for one session. Students particularly enjoyed the collaboration with team members as well as the challenge and excitement of creating questions. In addition, they appreciated having access to peer-written questions for exam preparation. Student satisfaction, engagement, and increased understanding of material have been mirrored in other studies.23,24 Rhind et al. demonstrated that students either agreed or strongly agreed that both authoring and answering questions was helpful for their studies and wanted to use the system again in future courses. In the study, students described an increased breadth and depth of knowledge and understanding while engaging with PeerWise.23 Students overall noted enjoyment of case-based questions because of the collaboration, application skills, and applicability to pharmacy practice. However, students preferred more guidance from faculty members on casebased questions. Since students have yet to appreciate the fundamentals of the material as applied to a patient case, a combination of recall, application, and higher-order thinking case-based questions to reinforce the newly taught material is desirable. Other active learning exercises received both positive and constructive comments. While students enjoyed the creativity and interactivity of the teach-back method, this exercise did not reinforce the material adequately and made several students feel intimidated when performing in front of the class. Although students enjoyed the counseling exercise as a practical experience and reinforcement of what was learned, the exercise unexpectedly ranked lower in relatedness. A potential reason could be that grades were awarded based on completion of the exercise, rather than by an assessment of the quality of the counseling. Several students noted appreciation of the practicality of the clinical
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protocol exercise, but also commented that the exercise needed more instruction and would be more beneficial for assessing the quality of an established protocol. Implementing active learning exercises is not without challenges. Confirming the findings of Ofstad and colleagues, faculty members found that changes to familiar styles of learning present a difficult adjustment for many students. Many students have spent a great part of their education passively acquiring knowledge. Utilizing active learning exercises mandates students to apply their knowledge and master the content.25 The students initially had a difficult time adjusting to a different teaching method because the active learning exercises required students to collaborate in teams, speak publicly, and develop interpersonal skills in addition to reinforcing and applying concepts. However, by the middle of the semester, students voiced enthusiasm to participate in the active learning exercises because they appreciated the uniqueness and variety of the teaching strategies. In addition, organizing and implementing active learning exercises—particularly interactive games—in a relatively large class created a pragmatic challenge for faculty members. Due to the large classroom setting, unexpected technical and logistical difficulties arose despite faculty preparation. These challenges justifiably frustrate students, which can impact their learning, satisfaction, and perception of the faculty member. Subsequent courses have used student feedback to improve the active learning exercises and improve student experiences. For example, since some students noted that the peer-written questions in PeerWise were redundant, students are now assigned different topics within each disease state to provide a greater variety of questions. The Jeopardy™-like game is now structured to have all students participate in each round to promote engagement. Cases are now posted on the learning management system to be completed and submitted electronically. In addition, both recall and higherorder thinking questions are provided to students for case vignettes. For future UNO™-like games, faculty will provide students with multiple sets of cards, more clear rules, and verbal reinforcement of electrolyte concepts. There were several limitations to the study. While the study measured studentsʼ perceptions of active learning exercises, direct measures of student learning were not associated with each exercise. Due to the nature of active learning exercises, students were mostly graded on completing or participating in the active learning exercise rather than on the content of studentsʼ responses. The variety of strategies and varying levels of difficulty within the subject matter made this assessment a little more challenging. The assessment of activities mainly derived from student perceptionsʼ of learning. A correlation between performance and active learning exercise were not examined. In future courses, studentsʼ responses will be graded to provide an objective assessment of the active learning methods. In addition, student performance in pharmacotherapy modules will be assessed and analyzed to determine impact of active
learning exercises on student performance. Furthermore, concise, constructive feedback will be provided to students for each active learning exercise. Another limitation in the study is the small sample size of one class. This is a newly implemented course and concurrent classes did not follow this similar class design. Future studies will include multiple classes and comparators to increase sample size. Students were also asked to provide feedback at the end of the course rather than immediately after each exercise because of the fear of “survey fatigue” if surveys were administered immediately after each exercise. However, immediate feedback has the potential of eliciting more specific comments about each exercise. Furthermore, faculty members were not surveyed in this study. Faculty perspectives, feedback, and experiences with active learning methods can impact the studentsʼ perceptions of their learning and satisfaction. Overall, the results indicate students enjoyed the variety of active learning exercises, but that students prefer some methods to others. Student perception and feedback is crucial to improving strategies that increase student learning and satisfaction. Thus, it is beneficial for faculty to engage with students on the types of exercises they prefer in order to design more effective learning exercises. Faculty who invest in students will more likely receive positive and constructive feedback and students will be more amenable to providing feedback to improve future courses. Additional investigation is planned to evaluate the impact of learning exercises on student learning, retention, and other important outcomes. Conclusion Students favor active learning exercises that require collaboration and application of knowledge. Active learning exercises where in a team setting students create, answer, and comment on their own questions (PeerWise) or respond competitively to factual questions in a Jeopardy-like format have been shown to engage students and increase their selfreported learning, satisfaction, and willingness to continue to participate in these activities given a choice. References 1. Accreditation Council for Pharmacy Education. Accreditation Standards and Key Elements for the professional Program in Pharmacy Leading to the Doctor of Pharmacy (“Standards 2016”). Chicago IL: Accreditation Council for Pharmacy Education. Available at: 〈https://www.acpe-accredit. org/pdf/Standards2016FINAL.pdf〉; 2015 Accessed May 7, 2016. 2. Conway SE, Johnson JL, Ripley TL. Integration of team-based learning strategies into a cardiovascular module. Am J Pharm Educ. 2010;74(2): Article 35. 3. Gallegos PJ, Peeters MJ. A measure of teamwork perceptions for team-based learning. Curr Pharm Teach Learn. 2011;3(1): 30–35.
A. Tatachar et al. / Currents in Pharmacy Teaching and Learning ] (]]]]) ]]]–]]] 4. Kolluru S, Roesch DM, Akhtar de la Fuente A. A multi-instructor, team-based, active learning exercise to integrate basic and clinical sciences content. Am J Pharm Educ. 2012;76(2): Article 33. 5. Letassy NA, Fugate SE, Medina MS, Stroup JS, Britton ML. Using team-based learning in an endocrine module taught across two campuses. Am J Pharm Educ. 2008;72(5): Article 103. 6. Persky AM, Pollack GM. A modified team-based learning physiology course. Am J Pharm Educ. 2011;75(10): Article 204. 7. Walters DE. Team-based learning applied to a medicinal chemistry course. Med Princ Pract. 2013;22(1):2–3. 8. Redwanski J. Incorporating team-based learning in a drug information course covering tertiary literature. Curr Pharm Teach Learn. 2012;4(3):202–206. 9. Zingone MM, Franks AS, Guirguis AB, George CM, HowardThompson A, Heidel RE. Comparing team-based and mixed active-learning methods in an ambulatory care elective course. Am J Pharm Educ. 2010;74(9): Article 160. 10. Strohfeldt K, Grant DT. A model for self-directed problembased learning for renal therapeutics. Am J Pharm Educ. 2010;74(9): Article 173. 11. Medina MS, Conway SE, Davis-Maxwell TS, Webb R. The impact of problem-solving feedback on team-based learning case responses. Am J Pharm Educ. 2013;77(9): Article 189. 12. Subramaniam P. Motivational effects of interest on student engagement and learning in physical education: a review. Int J Phys Educ. 2009;46(2):11–19. 13. Brookfield S. Chapter 1: Adult Learners: Motives for Learning and Implications for Practice. Understanding and Facilitating Adult Learning: A Comprehensive Analysis of Principles and Effective Practices. Bury St Edmunds, Suffolk: Open University Press; 1986:1–24. 14. Gleason BL, Peeters MJ, Resman-Targoff BH, et al. An activelearning strategies primer for achieving ability-based educational outcomes. Am J Pharm Educ. 2011;75(9): Article 186.
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15. Davis BG. Tools for Teaching. San Francisco, California: Jossey-Bass; 1993. 16. Knowles MS. Chapter 4: What is Androgogy? In: The Modern Practice of Adult Education. Andragogy versus Pedagogy. Englewood Cliffs, NJ: Cambridge Adult Education; 1980: 40–59. 17. Persky AM. Multi-faceted approach to improve learning in pharmacokinetics. Am J Pharm Educ. 2008;72(2): Article 36. 18. Beylefeld AA, Struwig MC. A gaming approach to learning medical microbiology: studentsʼ experiences of flow. Med Teach. 2007;29(9):933–940. 19. Tietze KJ. A bingo game motivates students to interact with course material. Am J Pharm Educ. 2007;71(4): Article 79. 20. Aljezawi M, Albashtawy M. Quiz game teaching format versus didactic lectures. Br J Nurs. 2015;24(2):86–92. 21. Boctor L. Active-learning strategies: the use of a game to reinforce learning in nursing education. A case study. Nurse Educ Pract. 2013;13(2):96–100. 22. Tasdelen U, Koseoglu F, Ozdem A Search engines for the World Wide Web: interactive evaluation of nature of science: a taboo-like game as a final semester activity. Paper presented at 3rd International Conference of Education, Research, and Innovation, Madrid, Spain. Available at: 〈http://library.iated. org/view/TASDELEN2010INT〉; November 15–17, 2010 Accessed May 7, 2016. 23. Rhind SM, Pettigrew GW. Peer generation of multiple-choice questions: student engagement and experiences. J Vet Med Educ. 2012;39(4):375–379. 24. Bottomley S, Denny P. A participatory learning approach to biochemistry using student authored and evaluated multiplechoice questions. Biochem Mol Biol Educ. 2011;39(5): 352–361. 25. Ofstad W, Brunner LJ. Team-based learning in pharmacy education. Am J Pharm Educ. 2013;77(4): Article 70.
Currents in Pharmacy Teaching and Learning ] (]]]]) ]]]–]]]
Short communication
http://www.pharmacyteaching.com
Pharmacy students’ perception of learning and satisfaction with various active learning exercises Amulya Tatachar, PharmD, BCACPa,*, Feiming Li, PhDb, Caitlin M. Gibson, PharmD, BCPSa, Carol Kominski, PhDb a
Department of Pharmacotherapy, University of North Texas Health Science Center, Fort Worth, TX Center for Innovative Learning, University of North Texas Health Science Center, Fort Worth, TX
b
Abstract Objective: To evaluate pharmacy studentsʼ perceptions of learning and satisfaction related to eight active learning exercises. Methods: Eight active learning exercises were implemented in class recitation sessions. Students completed anonymous surveys in an introductory session to identify interests, goals, strengths, and weaknesses, as well as at the courseʼs end to assess perceptions of learning and satisfaction with each active learning exercise. Results: All students (n ¼ 76) responded to both surveys. Students consistently ranked exercises, in which they created, answered, rated, and commented on multiple-choice questions (PeerWise) or answered factual questions in a Jeopardy™-like format highest both for accomplishment of their learning goals and for satisfaction or enjoyment. Comments supported data from the rankings. Conclusions: Students, overall, enjoyed the variety of active learning exercises. Active learning exercises such as PeerWiseTM and Jeopardy™ appeared to be particularly effective in fostering student learning, satisfaction, and interest in further engagement. r 2016 Elsevier Inc. All rights reserved.
Keywords: Pharmacy education; Active learning; Student perception
Introduction The Accreditation Council for Pharmacy Education (ACPE) recommends that curricula emphasize active learning pedagogy, skill development, and the application of knowledge and skills to therapeutic decision-making.1 Active learning techniques have been encouraged and embraced in pharmacy education to engage students in their learning processes.2–13 However, fostering active learning exercises in a relatively large classroom setting poses several challenges to
* Corresponding author: Amulya Tatachar, PharmD, BCACP, Department of Pharmacotherapy, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, Texas 76107. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2016.03.019 1877-1297/r 2016 Elsevier Inc. All rights reserved.
pharmacy educators. Active learning exercises need to be carefully structured to capture studentsʼ interest and engage them sufficiently to promote acquisition as well as application of knowledge to problems and issues likely to be encountered in the profession. Exercises must be presented in a meaningful context to empower students to perform as health care professionals and enhance their interest in a learning environment.12,13 Therefore, understanding student perceptions of learning and satisfaction is integral to selection and implementation of exercises that promote student engagement and performance. The University of North Texas System College of Pharmacy implemented a 12-week recitation course with the purpose of integrating pharmacotherapy concepts into active learning application exercises. This pilot study evaluates pharmacy studentsʼ perceptions of learning and satisfaction with eight active learning exercises.
2
A. Tatachar et al. / Currents in Pharmacy Teaching and Learning ] (]]]]) ]]]–]]]
Methods Participants included 76 second-year pharmacy students enrolled in PHAR 7136 in the fall 2014 semester. Students met once a week for two hours for a total of 12 sessions. Each of the seven faculty members facilitated at least one recitation session related to the topic or disease state he/she covered in the didactic portion of the pharmacotherapy module. Class design Students were assigned reading and provided with learning objectives at least one week prior to the active learning sessions. The pre-class reading assignments often included literature articles, textbook sections, and/or instructor-prepared handouts. The learning objectives were clear and concise objectives written by the lead instructor to prepare students for the recitation session. The learning objectives and reading assignments aligned or were the same as the learning objectives and reading assignments of the respective didactic lecture. At the start of each class, students completed a five question individual readiness assessment test (iRAT) to assess their preparation for class. iRATs were collected and then the same test was distributed to the teams and each team was given time to discuss and select the best answers for the group readiness assessment test (gRAT). After completion, gRATs were collected and the instructor transitioned into a discussion of the assessment tests. The two readiness assessment tests and discussion took approximately 30 minutes to complete. Both iRATs and gRATs were given on scantron and graded. Students then worked in an assigned team on an active learning exercise related to a certain topic or disease state for the remainder of the class. Each of 11 teams consisting of six to seven students worked together in all sessions. Table describes each active learning exercise, the topic(s) covered, and hours dedicated to each topic in didactic lectures. The educational games were based on available evidence on active learning strategies.14 Each active learning exercise took place either immediately or at least a day after completion of the didactic lecture on the respective topic. Each type of exercise was used in only one class session with the exception of case-based exercises, which were used in four class sessions. Each active learning exercise took approximately 90 minutes to complete. All active learning exercises were completed in class. No outside classroom activities were assigned to the students with the exception of preparatory learning objectives and reading assignments. Educational games, teach-back method, counseling, and PeerWise were graded based on completion and participation. Case-based exercises and clinical protocol were graded on appropriateness and/or correctness. Faculty spent five hours on average preparing for the readiness assessment tests, discussion, and active
learning exercise. Students completed pre- and postassessment surveys at the initial session and final session of the course, respectively. Pre-assessment Students completed a pencil-and-paper, free-form survey in the first class session. The survey identified studentsʼ short-term and long-term career goals, semester goals, specific interests in the pharmacy field, and areas of weakness and strength. The course director and faculty then created and adapted active learning exercises based on self-reported student interests and goals. To encourage survey completion, students were given bonus points that comprised o1% of the total course points. Post-assessment A post-assessment survey consisted of open- and closeended questions on studentsʼ perception of the active learning exercises and solicited suggestions for future classes. The post-assessment survey was administered via an e-mailed internet link (QualtricsTM, Provo, UT, version 5/2015). The following three variables were constructed from the post-assessment survey items: student learning, student satisfaction, and interest in continuing participation. Student learning Three survey questions assessed student learning by asking students to assign each exercise scores on a scale of 1–100 based on their perceived (a) level of competence, (b) extent of increased understanding, and (c) effort expended with each exercise. Student satisfaction Three survey questions assessed student satisfaction by asking students to assign each exercise a score on a scale of 1–100 based on (a) level of enjoyment experienced and (b) level of contribution to their semester goals. For the third question, students rated each exercise on the extent to which they felt very tense (rating ¼ 1) up to very relaxed (rating ¼ 5). Interest in continuing participation On one item, students also ranked each exercise based on the likelihood that they would participate in the exercise in future courses, which provided an overall perception of learning and satisfaction for each active learning exercise. Students were asked to comment on exercises they preferred to see continued or discontinued in future courses and to offer any suggestions to improve the exercises. After student learning and student satisfaction sub-scores were calculated, all eight activities were ranked on each variable. In other words, each activity received a ranking of one to eight on learning and another ranking of one to eight on satisfaction.
A. Tatachar et al. / Currents in Pharmacy Teaching and Learning ] (]]]]) ]]]–]]]
3
Table Description of active learning exercises, topic(s) covered, and hours spent on topic in pharmacotherapy module
Games Jeopardy™-like game
Taboo™-like game
UNO™-like game
Hours spent on topic in pharmacotherapy module
Description
Topic
This game features a quiz competition in which teams are presented with general knowledge clues in forms of answers, and the representative from each team must phrase their responses in form of questions. A team picks a category and monetary value. The host reads the clue and a representative from the team can buzz into answer the question. Points are given for correct answers. Points are not deducted for incorrect answers. If a team answers incorrectly, the opponent team has ten seconds to answer the question. If both teams answer incorrectly, the host will provide both teams with the correct answer. This is a word-guessing game and its main objective is for a player to have their team members guess the word on the player's card without using the word itself. All members from each team draw card from stack. As soon as timer starts, member gives clues to help teammates state the word on the card. This is a card game which is played with a printed deck. The cards contain words and/or pictures that describe the basic metabolic panel or complications of electrolyte disorders. Two team representatives draw seven cards from a stack and take turns manipulating a basic metabolic panel to normalize (Team 1) or “sabotage” (Team 2) electrolyte levels. For example, one team plays an “ACE inhibitor” card to raise potassium levels, and another team plays “Vomiting” card to lower potassium levels. The first team to get rid of all their cards wins the game.
Acute kidney injury/druginduced kidney disease
2
Top 200 drugs/ enzyme activity
1
Electrolyte disorders
2
Receptors and drug activity
2
End-stage renal disease
2
Drug allergies
2
Glaucoma Pharmacokinetics Chronic kidney disease Anemia Acid–base disorders
2 2 2
Non-Game Exercises Teach back Students are randomly assigned a concept, which they must teach back to all their classmates. Students are given 20 minutes to prepare their presentation and five minutes to present. PeerWise This is a web-based application that allows students to collaboratively author multiple-choice questions and provide explanations for correct and incorrect alternatives, and answer, rate, and comment on other students' questions. Clinical protocol Students apply primary literature examples to create a drug desensitization protocol. Students are given one hour to complete a mock drug desensitization protocol and five minutes to present the protocol to their peers and instructors. Counseling Students counsel their peers on eye drop administration. Case based Students answer questions related to vignettes or scenarios on specific disease states. Questions are open-ended or close-ended.
To incentivize completion of surveys, students were given points toward their course grade for survey completion and were required to complete the survey to receive full credit. The points to complete the survey comprised 7% of their total course points. Although respondents who completed the survey were tracked, only collective data were analyzed and the respondent for each set of responses was
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anonymous. Approval for this study was obtained from the Institutional Review Board. Results All 76 students completed the pre-assessment and postassessment surveys (100% response rate).
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Pre-assessment survey The pre-assessment survey identified following three common goals: gaining confidence, gaining competence, and developing organizational and interpersonal skills. Students were most interested in improving skills related to counseling techniques, public speaking, and time management. Post-assessment survey Figure 1 illustrates how the active learning exercises rank on the self-reported variables of student learning and student satisfaction. PeerWise and the Jeopardy™-like game ranked one and two, respectively, for both learning and satisfaction. Four activities received the same ranking in learning and satisfaction. The teach-back method and UNO™-like game ranked seven and eight, respectively, in both learning and satisfaction. Open-ended comments on other activities were helpful in furthering understanding of student thinking. For example, students noted that the teach-back method was not effective in reinforcement and retention of material because students felt pressured to present a creative script more than to focus on the topic content. Students also noted that the UNO™-like game required more organization and student engagement. The Taboo™-like game received conflicting responses. Students ranked the Taboo™-like game as the active learning exercise that made students feel most tense. Although students noted that the game improved their knowledge, they also noted feelings of unease with public speaking. Students ranked the clinical protocol exercise higher in satisfaction than learning and the counseling exercise higher in learning than satisfaction.
Case-based questions were ranked higher in learning than in satisfaction (Fig. 1). Several themes emerging in open-ended responses helped explain what students were thinking explicitly. Some said written case-based questions were difficult to complete in the allotted time. Others said they preferred to submit cases electronically to improve quality of answers and time management. Others noted that they lacked the foundational knowledge of the subject to effectively and efficiently answer the case-based questions in the allotted time. PeerWise rated highest in likelihood that students would still participate if given a choice (Fig. 2). Discussion Consideration of studentsʼ goals, strengths, and weaknesses is essential when designing educational exercises because students learn and engage best in an environment that satisfies their existing needs.15,16 The active learning exercises in this recitation course were tailored to address studentsʼ needs and interests as indicated in the preassessment survey. Particularly, the interactive games were designed to help students build confidence, interpersonal skills, and develop public speaking skills in addition to increasing pharmacotherapy knowledge. As a means to develop time management and organization skills, students also worked in teams and managed their time to complete the exercises in the timeframe of a class session. Numerous studies describing educational health care games found student enjoyment of these active learning activities.17–19 The Jeopardy™-like game in this course received the most positive feedback of the interactive games. Students appreciated the competitiveness, collaboration, and reinforcement of material. Initially, students
Fig. 1. Ranking of learning and satisfaction for active learning exercises.
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Fig. 2. Rating of interest in continuing participation for each active learning exercise.
were confused about the rules and logistics. During the second and third round, students felt more at ease with the structure of the game. Overall, students noted increased understanding of the material and enjoyment of the Jeopardy™-like game. Studies conducted in nursing education showed similar results of increased student satisfaction and improved learning with a Jeopardy™-like game.20,21 Although Jeopardy was clearly a success with most students, a few voiced concerns of incomplete engagement of the entire class during the game. While two teams were playing a round, the remaining students could not hear their peersʼ responses to the questions. Two other interactive games in the course received mixed feedback. The Taboo™-like game was the first interactive game introduced to the students, but its requirements for public speaking made students feel relatively tense. Students suggested playing within the teams instead in front of all students to reduce anxiety related to public speaking. It is also possible that placement of this game at the end of the course rather than at its beginning might produce more positive reactions from students. Tasdelen et al., for example, studied the perception and effectiveness of a Taboo™-like game in a group of prospective chemistry teachers completing their last year in a five-year Teacher Education Program. The authors concluded that a Taboo™like game was helpful to enhance and evaluate studentsʼ views on concepts learned throughout the course. The game also created a context through which the content of the course could be summarized.22 While the study population and results from Tasdelen et al. may not be generalizable to this study, the study does demonstrate the potential in utilizing the Taboo™-like game later rather than earlier in the curriculum as a means to summarize concepts. The UNO™-like game ranked the lowest in competence, enjoyment, and relatedness. A potential reason for student dissatisfaction was using one set of cards for the entire class leading to disengagement and frustration.
In addition to interactive games, PeerWise (Denny) software supporting the generation and exchange of multiplechoice questions, was implemented as an active learning exercise in the course for one session. Students particularly enjoyed the collaboration with team members as well as the challenge and excitement of creating questions. In addition, they appreciated having access to peer-written questions for exam preparation. Student satisfaction, engagement, and increased understanding of material have been mirrored in other studies.23,24 Rhind et al. demonstrated that students either agreed or strongly agreed that both authoring and answering questions was helpful for their studies and wanted to use the system again in future courses. In the study, students described an increased breadth and depth of knowledge and understanding while engaging with PeerWise.23 Students overall noted enjoyment of case-based questions because of the collaboration, application skills, and applicability to pharmacy practice. However, students preferred more guidance from faculty members on casebased questions. Since students have yet to appreciate the fundamentals of the material as applied to a patient case, a combination of recall, application, and higher-order thinking case-based questions to reinforce the newly taught material is desirable. Other active learning exercises received both positive and constructive comments. While students enjoyed the creativity and interactivity of the teach-back method, this exercise did not reinforce the material adequately and made several students feel intimidated when performing in front of the class. Although students enjoyed the counseling exercise as a practical experience and reinforcement of what was learned, the exercise unexpectedly ranked lower in relatedness. A potential reason could be that grades were awarded based on completion of the exercise, rather than by an assessment of the quality of the counseling. Several students noted appreciation of the practicality of the clinical
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protocol exercise, but also commented that the exercise needed more instruction and would be more beneficial for assessing the quality of an established protocol. Implementing active learning exercises is not without challenges. Confirming the findings of Ofstad and colleagues, faculty members found that changes to familiar styles of learning present a difficult adjustment for many students. Many students have spent a great part of their education passively acquiring knowledge. Utilizing active learning exercises mandates students to apply their knowledge and master the content.25 The students initially had a difficult time adjusting to a different teaching method because the active learning exercises required students to collaborate in teams, speak publicly, and develop interpersonal skills in addition to reinforcing and applying concepts. However, by the middle of the semester, students voiced enthusiasm to participate in the active learning exercises because they appreciated the uniqueness and variety of the teaching strategies. In addition, organizing and implementing active learning exercises—particularly interactive games—in a relatively large class created a pragmatic challenge for faculty members. Due to the large classroom setting, unexpected technical and logistical difficulties arose despite faculty preparation. These challenges justifiably frustrate students, which can impact their learning, satisfaction, and perception of the faculty member. Subsequent courses have used student feedback to improve the active learning exercises and improve student experiences. For example, since some students noted that the peer-written questions in PeerWise were redundant, students are now assigned different topics within each disease state to provide a greater variety of questions. The Jeopardy™-like game is now structured to have all students participate in each round to promote engagement. Cases are now posted on the learning management system to be completed and submitted electronically. In addition, both recall and higherorder thinking questions are provided to students for case vignettes. For future UNO™-like games, faculty will provide students with multiple sets of cards, more clear rules, and verbal reinforcement of electrolyte concepts. There were several limitations to the study. While the study measured studentsʼ perceptions of active learning exercises, direct measures of student learning were not associated with each exercise. Due to the nature of active learning exercises, students were mostly graded on completing or participating in the active learning exercise rather than on the content of studentsʼ responses. The variety of strategies and varying levels of difficulty within the subject matter made this assessment a little more challenging. The assessment of activities mainly derived from student perceptionsʼ of learning. A correlation between performance and active learning exercise were not examined. In future courses, studentsʼ responses will be graded to provide an objective assessment of the active learning methods. In addition, student performance in pharmacotherapy modules will be assessed and analyzed to determine impact of active
learning exercises on student performance. Furthermore, concise, constructive feedback will be provided to students for each active learning exercise. Another limitation in the study is the small sample size of one class. This is a newly implemented course and concurrent classes did not follow this similar class design. Future studies will include multiple classes and comparators to increase sample size. Students were also asked to provide feedback at the end of the course rather than immediately after each exercise because of the fear of “survey fatigue” if surveys were administered immediately after each exercise. However, immediate feedback has the potential of eliciting more specific comments about each exercise. Furthermore, faculty members were not surveyed in this study. Faculty perspectives, feedback, and experiences with active learning methods can impact the studentsʼ perceptions of their learning and satisfaction. Overall, the results indicate students enjoyed the variety of active learning exercises, but that students prefer some methods to others. Student perception and feedback is crucial to improving strategies that increase student learning and satisfaction. Thus, it is beneficial for faculty to engage with students on the types of exercises they prefer in order to design more effective learning exercises. Faculty who invest in students will more likely receive positive and constructive feedback and students will be more amenable to providing feedback to improve future courses. Additional investigation is planned to evaluate the impact of learning exercises on student learning, retention, and other important outcomes. Conclusion Students favor active learning exercises that require collaboration and application of knowledge. Active learning exercises where in a team setting students create, answer, and comment on their own questions (PeerWise) or respond competitively to factual questions in a Jeopardy-like format have been shown to engage students and increase their selfreported learning, satisfaction, and willingness to continue to participate in these activities given a choice. References 1. Accreditation Council for Pharmacy Education. Accreditation Standards and Key Elements for the professional Program in Pharmacy Leading to the Doctor of Pharmacy (“Standards 2016”). Chicago IL: Accreditation Council for Pharmacy Education. Available at: 〈https://www.acpe-accredit. org/pdf/Standards2016FINAL.pdf〉; 2015 Accessed May 7, 2016. 2. Conway SE, Johnson JL, Ripley TL. Integration of team-based learning strategies into a cardiovascular module. Am J Pharm Educ. 2010;74(2): Article 35. 3. Gallegos PJ, Peeters MJ. A measure of teamwork perceptions for team-based learning. Curr Pharm Teach Learn. 2011;3(1): 30–35.
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15. Davis BG. Tools for Teaching. San Francisco, California: Jossey-Bass; 1993. 16. Knowles MS. Chapter 4: What is Androgogy? In: The Modern Practice of Adult Education. Andragogy versus Pedagogy. Englewood Cliffs, NJ: Cambridge Adult Education; 1980: 40–59. 17. Persky AM. Multi-faceted approach to improve learning in pharmacokinetics. Am J Pharm Educ. 2008;72(2): Article 36. 18. Beylefeld AA, Struwig MC. A gaming approach to learning medical microbiology: studentsʼ experiences of flow. Med Teach. 2007;29(9):933–940. 19. Tietze KJ. A bingo game motivates students to interact with course material. Am J Pharm Educ. 2007;71(4): Article 79. 20. Aljezawi M, Albashtawy M. Quiz game teaching format versus didactic lectures. Br J Nurs. 2015;24(2):86–92. 21. Boctor L. Active-learning strategies: the use of a game to reinforce learning in nursing education. A case study. Nurse Educ Pract. 2013;13(2):96–100. 22. Tasdelen U, Koseoglu F, Ozdem A Search engines for the World Wide Web: interactive evaluation of nature of science: a taboo-like game as a final semester activity. Paper presented at 3rd International Conference of Education, Research, and Innovation, Madrid, Spain. Available at: 〈http://library.iated. org/view/TASDELEN2010INT〉; November 15–17, 2010 Accessed May 7, 2016. 23. Rhind SM, Pettigrew GW. Peer generation of multiple-choice questions: student engagement and experiences. J Vet Med Educ. 2012;39(4):375–379. 24. Bottomley S, Denny P. A participatory learning approach to biochemistry using student authored and evaluated multiplechoice questions. Biochem Mol Biol Educ. 2011;39(5): 352–361. 25. Ofstad W, Brunner LJ. Team-based learning in pharmacy education. Am J Pharm Educ. 2013;77(4): Article 70.