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Concept mapping, reflective writing, and patchwork text assessment in a first-year pharmaceutical care course
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Currents in Pharmacy Teaching and Learning 8 (2016) 492–500
Teaching and Learning Matters
http://www.pharmacyteaching.com
Concept mapping, reflective writing, and patchwork text assessment in a first-year pharmaceutical care course Keri D. Hager, PharmD, BCACPa,*, Claire Kolar, PharmDb, Kristin K. Janke, PhDb a
Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota College of Pharmacy, Duluth, MN b Pharmaceutical Care & Health Systems, University of Minnesota College of Pharmacy, Minneapolis, MN
Abstract Background: The aim of this work was to aid learner's understanding and application of the complexities of pharmaceutical care practice. Specifically, this initiative sought to design, implement, and evaluate student perceptions of and performance on a longitudinal sequence of concept mapping (CM), reflective writing (RW), and patchwork text (PT) activities in a first-year Foundations of Pharmaceutical Care (FPC) course. Educational activity: To encourage examination of the complexities of pharmaceutical care practice, three iterations of combined CM and RW (or PT) occurred throughout the semester, along with peer sharing. The sequence was evaluated by examining student work and student documentation of peer sharing, as well as a survey. The sequence was completed by 163 (99.4%) students. Satisfactory ratings were achieved on final concept mapping assignments by 97% of participants and 80% of students agreed/ strongly agreed that, through re-review of work they could see that their understanding of the topic had improved over time. Critical analysis: The deliberate pairing, sequencing, and repeating of CM, RW, and critical appraisal (CA), provided instructors with a more thorough and precise understanding of student knowledge and the ability to monitor, acknowledge, and respond to student learning as it occurred over the course of a semester. r 2016 Elsevier Inc. All rights reserved.
Keywords: Concept mapping; Reflection; Assessment; Patchwork text
Background Ensuring the ability to provide patient care is a major focal point of Doctor of Pharmacy curricula. The Center for Advancement of Pharmacy Education (CAPE) 2013 Educational Outcomes set the expectation that “the graduate is able to provide patient-centered care as the medication expert (collect and interpret evidence, prioritize, formulate assessments and recommendations, implement, monitor and adjust plans, and document activities)” in outcome 2.1.1
* Corresponding author: Keri D. Hager, PharmD, BCACP, Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota College of Pharmacy, Duluth, 232 Life Science, 1110 Kirby Dr, Duluth, MN 55812. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2016.03.006 1877-1297/r 2016 Elsevier Inc. All rights reserved.
This desired outcome was affirmed in Standard 2 of the Accreditation Council for Pharmacy Education's Standards 2016.2 The pharmaceutical care practice model creates a foundation for the pharmacist's contributions to the rational use of drugs in patient care.3 As with any professional practice, the pharmaceutical care practice (PCP) includes three core components: the philosophy of practice, the patient care process, and the practice management system. Adopting the philosophy of pharmaceutical care practice is critical, as it acts as a compass and provides the practitioner guidance in prioritizing and decision-making in patient care. The patient care process includes assessment, care plan, and follow-up evaluation to ensure a patient's medications are properly indicated, effective, and safe, and the patient is able to take them as intended. Practice management systems include all
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the support required to provide pharmaceutical care. All three combine to form the professional practice of the pharmacist. Medication therapy management (MTM) focuses on the patient care process component of PCP. A number of reports have discussed the development of MTM-related skills through core courses,4–7 electives,8 or early9 or advanced10,11 experiential education. However, these reports on MTM skill development do not include a clear and comprehensive approach to teaching the philosophy of practice and practice management systems. Teaching students all three components of pharmaceutical care practice, as opposed to only the patient care process, provides a more complete framework for development into a practitioner. The philosophy of practice and practice management systems are also needed to provide the foundation (i.e., values and responsibilities) and context for delivering MTM services. Helping students to understand the complexities and interrelationships of the three components presents an instructional challenge. Historically, students have been able to describe each component separately as they have matriculated through the semester. In subsequent coursework students could apply the patient care process but struggled to articulate the philosophy of practice, the elements of a practice management system or explain the relationship between the three components. In order to aid deeper understanding of PCP, this initiative aimed to design, implement, and evaluate student perceptions of and performance on a longitudinal sequence of activities. This sequence was designed to help students draw connections between components of PCP, consider application of the model to future practice, and reflect on their own development into a pharmaceutical care practitioner. This article will review the design of these activities, as well as student performance and student perceptions of the activities. Educational activity Design considerations Foundations of Pharmaceutical Care (FPC) is a required, 1.5-credit fall first-year pharmacy course. In this course, students work individually and in groups to learn about pharmaceutical care practice, focusing on the three major components of the practice: philosophy of practice, patient care process, and practice management system.3 Various iterations of this course have existed for over 20 years. As the name suggests, the Foundations of Pharmaceutical Care course lays the foundation for professional practice and the pharmacy curriculum. A primary course goal is to provide the scaffolding and structure upon which future course content can be hung. The course meets for 90 minutes twice weekly, and the bulk of in-class activities are active learning (e.g., role play). Course content progresses from philosophy of practice to the patient care process to practice
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management systems throughout the semester. Student performance is based on a philosophy of practice writing assignment (8%), four patient care process assessment activities (48%), a midterm examination (20%), and an assignment requiring students to teach pharmaceutical care practice to a non-pharmacist clinician (16%). The longitudinal sequence of activities described in this article accounts for 8% of the total course grade. When first introduced, PCP can be difficult for students to understand, particularly if their experience in pharmacy has not allowed them to see this model of practice in action. For example, if students have experience working as a pharmacy technician, they may have participated in dispensing functions more than comprehensive patient care. In the past, students have been successful in learning and applying the individual components of the patient care process. However, students have struggled with making practical connections between the philosophy of practice, the patient care process, and the practice management system. Students have also had difficulty envisioning this model's use outside of the controlled classroom environment. To further enhance student learning, a combination of learning methods were employed with the goals of: (1) supporting learning of the PCP, (2) fostering critical thinking, particularly about the connections between concepts in the course, (3) encouraging reflection on learning, and its impact on future practice, and (4) aiding in the development of reflective practitioners. Concept mapping (CM) was introduced to aid learners in creating the scaffolding/structure for current learning and future curricular content. Concept maps represent relationships between ideas through a hierarchical structure and connective terms (usually prepositional phrases) referred to as links and cross-links.12 The meaning of any concept for the learner is represented by these linkages.13 In discussing the implementation of the Accreditation Council for Pharmacy Education's 1997 standards, Brandt14 identified CM as an example of effective teaching and learning strategies. CM has also been used to encourage connections between theory and practice,15 which was one of our goals. Concept maps have been used in a pharmaceutics course to explain the interrelationships of physicochemical properties, formulation factors, and excipient requirements of a specific dosage form.16 Concept maps have also been used in a pharmacy communications course to demonstrate student understanding of the concepts taught and their interrelationships.17 In a previous offering of a pharmaceutical care course, mind mapping (i.e., a representation of connected and related concepts emphasizing free-form, spontaneous thinking in order to find creative associations between ideas12) had been employed as a tool for this same purpose. Instructors described many mind map submissions as looking like “spaghetti” with no apparent order. In addition, the means by which the various concepts connected in students' minds was often unclear to instructors. Thus, the new CM activity was designed to encourage a graphic
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representation of the course concepts that required a hierarchy to be developed and relationships between concepts to be better defined. Concept mapping was paired with reflective writing (RW). Should students struggle to express their thoughts graphically, the reflective writing might assist in explaining their learning and vice versa. In addition, the combination of RW and CM may provide instructors with a clearer picture of the students' learning by providing insight into the students' thinking. The reflective writing asked students to use an information processing model adapted to learning, namely the “What? So What? Now What?” model.18–20 Using this model, students are encouraged to describe their learning (What?), evaluating it and giving it meaning (So What?) and considering possible actions (Now What?). In particular, RW was seen to aid students in processing the meaning and implications of their learning. A patchwork text (PT) approach was used to facilitate students' ability to pull together course content and consider how course content applies to practice. In PT, students are guided through a series of tasks (patches) over the course of their learning, which are shared with colleagues for discussion. The “patches” are then “stitched” together at the end of the course when students review the body of their work and produce a critical commentary demonstrating their learning and interpreting what the material means to them.21 In this way, the patches document particular parts of the student's learning journey,22 as well as providing source material in creating a coherent account of personal development, when the patches are stitched together. It has been argued that patchwork text can improve students' holistic grasp of a field of knowledge and its practical application.23 It can also assist in their development as autonomous, reflective practitioners.24 In our use, the patches were the concept maps and reflective writing and the “stitching together” occurred during an end-of-semester critical appraisal (CA). Peer sharing was used to provide students with an opportunity to present their work and learn from the work of others. A combination of these techniques was used to assist students in their learning of PCP. The CM provided a way for students to visually represent how the components of PCP relate to one another. Based on previous experiences with mind mapping, the visual representation alone was not enough to demonstrate their understanding, so RW was incorporated. Finally, the PT approach and CA activity were incorporated for students to review their work over time. Each component of PCP builds on what came before, so a longitudinal approach was sought for students to document their learning. There were three iterations of the CM/RW/CA work throughout the semester (Fig. 1). For each submission, students built off their initial work and incorporated peer and instructor feedback. Multiple submissions allowed faculty to assess students' understanding at strategic points and to reinforce concepts and connections during subsequent class periods when gaps in understanding emerged.
Fig. 1. Outline of semester activities.
All students were supplied paper and were loaned colored pencils for completion of their initial concept maps, and by request for subsequent maps. Some students chose to use online tools to create their concept maps (e.g., Cacoo: https://cacoo.com/diagrams/; SimpleMindþ: http://www. simpleapps.eu/simplemind/; and Mental iOS App; Xmind: http://www.xmind.net/). Moodle 2.4 (Moodle Pty Ltd., Perth, Australia), the online course management system, was used for uploading electronic or scanned assignments, grading rubrics, and links to surveys. Expectations of students For their initial CM submission, students were asked to create a concept map demonstrating their understanding of pharmaceutical care (Supplementary information, Appendix A; Fig. 2). For their initial RW submission, students were asked
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Fig. 2. Example first submission concept map.
to write a one-page reflection following a “What? So What? Now What?” format18–20 about what they learned (What?), why the learning matters (So What?), and what implications the learning has for their future (Now What?). Prior to submitting the initial concept map, students were given an opportunity (15 minutes) for peer sharing/review and feedback on their maps during class. Students were asked to compare and contrast the concepts that were included in maps, as well as the links and cross-links. Following the peer sharing session, students submitted documentation about the peer work. This documentation asked them to report any added concepts or connections made or that their colleagues made as a result of the consultation. A concluding question asked: “After seeing several examples, how would you describe your work relative to others?” Mid-semester, students updated their concept maps and completed peer sharing, answering the same questions for the peer consultation. At the end of the semester, students updated and submitted their concept maps, and also completed the CA (Supplementary information, Appendix B). At this time, students also completed an end-of-semester survey designed to capture their perceptions of these activities. The survey addressed students' perceptions of the combined CM and RW process, in addition to their perceptions about the individual components (i.e., CM, RW, and CA) and their growth over time. The survey also asked about their perceptions of the
work they did with their peers and the feedback they received from both their peers and the instructors. Students received individual feedback via a rubric for all submissions (Supplementary information, Appendix C). General, global feedback was also provided to the whole class on the concept maps and reflective writing after the initial and mid-semester submissions. Literature on the assessment of concept maps in medical education25,26 was consulted to identify variables for the creation of a rubric assessing pharmaceutical care knowledge, concept mapping, and reflection/critical appraisal (Supplementary information, Appendix C). Ratings were used as feedback to show students their progress and also to assign points toward the course grade. Qualtricss (Qualtricss Labs Inc., Provo, UT) was used for the student survey and for the documentation of the peer consultation. Descriptive statistics of student performance and perception ratings were calculated. In addition, thematic analysis was used to analyze the peer sharing comments made by students. First instructor coded student responses using the In Vivo Coding method.27 In Vivo Coding captures the actual language of the respondent.27 Once the initial codes were established, they were collapsed into more broad focus codes and grouped into overarching categories by the same instructor.27 A second instructor reviewed and verified the analysis at each step: coding,
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development of focus codes, and categorization. This project was reviewed and determined exempt by the University of Minnesota Institutional Review Board (IRB). Student performance and evaluative results A total of 165 students participated in the course. The three instructors with pharmaceutical care content expertise (one course faculty and two graduate teaching assistants) divided the review of student work and provided individualized feedback on each submission. The instructors did not receive training prior to evaluating student work, but applied the rubric to a subset of student assignments and discussed interpretation of the criteria to help ensure they were applied consistently. The time required to review, rate and provide feedback on individual concept maps was estimated to be five minutes per student or about 14 hours for the class for each submission. Table 1 provides rubric ratings for pharmaceutical care knowledge, concept mapping skills, and reflective writing. Submissions received ratings of needs improvement or satisfactory (Supplementary information, Appendix C). If submissions achieved any exemplary ratings, students were awarded an additional bonus point for the submission for a maximum of a bonus point per submission, regardless of number of exemplary ratings. The overall survey response rates for peer sharing activities were 96% (157 of 164 students) for Submission 1, and 95% (156 of 164 students) for Submission 2. The results of the thematic analysis for Submission 1, grouped by category, are presented in Table 2. The overall response rate to the survey was 95.7% (157 out of 164 students), but the response rate for the Submission 1 question, “After seeing several examples, how would you describe your
Table 1 Number of students receiving needs improvement or satisfactory rubric ratingsa Needs improvement (%)
Satisfactoryb (%)
Pharmaceutical care knowledge (PK) PK submission 1 28 (17.2) 135 (82.8) PK submission 3 22 (13.5) 141 (86.5) Concept mapping (CM) skill CM submission 1 18 (11) 145 (89) CM submission 3 5 (3.1) 158 (96.9) Reflective writing (RW) and critical appraisal (CA) RW submission 1 12 (7.4) 151 (92.6) CA submission 3 18 (11) 145 (89) a One student did not complete the initial concept map and reflective writing submission; her data were excluded. b 11 Students received an exemplary rating for submission 1 and 29 students received an exemplary rating for submission 3.
Table 2 Categories and codes of student responses to submission 1 peer sharing (number) My concept map compared to my peers' was … (108) Better than in some way (32) In need of some improvement (17) Average/satisfactory (16) Different, but comparable (14) Similar (12) Similar ideas, different organization (9) Different/unique (8) My peers' concept maps were … (27) Different (11) More detailed (6) Better organized (4) Difficult to follow (4) More creative/appealing (2) I am going to make changes to my concept map by … (15) Revising/reorganizing (6) Adding concepts (5) Being more creative (2) Adding links/cross-links/connections (2) I learned from my peers … (8) Additional concepts (3) Ideas for linking and organization (3) Better understanding (2)
work relative to others?” was 61.6% (101 of 164 students). Results of thematic analysis for Submission 2 were similar to Submission 1. Via Qualtricss, students completed an online survey of their perceptions of the sequence including the value of CM, RW, and CA and working with peers. The survey response rate was 94.5% (155 of 164 students). A total of 38 (25%) had used concept mapping prior to pharmacy school. The number of students who chose to submit their concept maps using an online tool increased from 69 students (44.5%) on Submission 1 to 81 students (52.2%) on Submission 3. Only 42.6% (66 of 155) of respondents agreed/strongly agreed that concept mapping was easy and only 50.3% (78 of 155) of respondents agreed/strongly agreed the reflective writing was easy (Table 3). However, 67% (105 of 155) agreed/strongly agreed “listening to my colleagues present their work helped me to improve my own.” Additionally, 80% (124 of 155) agreed/strongly agreed with the statement, “As I re-reviewed my work, I could see that my understanding of the topic had improved over time.” Respondents agreed/strongly agreed that the CM/RW process helped them to: learn the pharmaceutical care framework (65%), reflect on what they were learning (68%), and understand how the course concepts apply to future practice (60%) (Table 4). Fewer students agreed/ strongly agreed the process helped them think critically (40%) or develop as a reflective practitioner (45%).
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Table 3 Student perceptions of concept mapping (CM) and reflective writing (RW) components Survey question
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Perceptions of concept mapping and reflective writing Concept mapping was easy I enjoyed concept mapping The written reflections were easy I enjoyed the written reflections
7 8 12 5
59 27 66 28
41 40 40 43
35 33 28 36
13 47 9 43
Perceptions of peer interactions Presenting my work to my colleagues helped me to understand my own work better Listening to my colleagues present their work helped me to improve my own Feedback I received from fellow students was helpful in creating my concept maps Feedback I received from fellow students was helpful in writing my reflections The feedback I received was helpful in guiding improvement Perceptions of growth over time As I re-reviewed my work, I could see that my understanding of the topic had improved over time As I re-reviewed my work, I could see that my ability to use concept mapping had improved over time
(4.5%) (5.2%) (7.7%) (3.2%)
(38.1%) (17.4%) (42.6%) (18.1%)
(26.5%) (25.8%) (25.8%) (27.7%)
(22.6%) (21.3%) (18.1%) (23.2%)
(8.4%) (30.3%) (5.8%) (27.7%)
13 (8.3%)
65 (41.7%)
43 (27.6%)
25 (16%)
17 (10.9%)
88 (56.4%)
26 (16.7%)
17 (10.9%)
8 (5.1%)
12 (7.7%)
62 (39.7%)
41 (26.3%)
29 (18.6%)
12 (7.7%)
7 (4.5%)
48 (30.8%)
46 (29.5%)
39 (25%)
16 (10.3%)
9 (5.8%)
77 (49.4%)
34 (21.8%)
24 (15.4%)
12 (7.7%)
32 (20.6%)
92 (59.4%)
19 (12.3%)
6 (3.9%)
6 (3.9%)
18 (11.6%)
70 (45.2%)
31 (20%)
26 (16.8%)
10 (6.5%)
Critical analysis The goal of this initiative was to use a combination of concept mapping, reflective writing, and a patchwork text approach to assessment to help students learn about Pharmaceutical Care Practice and reflect on their own development over the course of the semester. Student performance was rated at each submission using a rubric to assess concept mapping skills, pharmaceutical care knowledge, and reflective writing/critical appraisal. In addition, students engaged in peer sharing and their reported responses were analyzed. Finally, a survey was used to measure student perceptions after the final submission. In evaluating concept mapping and reflective writing, a sizeable proportion of students reported being neutral (12.3–29.5%). Concept mapping was used three times and reflective writing and critical analysis were each used once over the course of a 15-week term. Students may have felt
10 (6.4%)
this was insufficient exposure to form an opinion. While the amount of practice needed is not known, a previous study of concept mapping with diet therapy students has recommended that a “one-shot approach” to concept mapping be avoided and that repeated practice increases student satisfaction.28 Only a small percentage of participants agreed/strongly agreed that concept mapping was easy (42.6%) or enjoyable (22.6%) and that reflective writing was easy (50.3%) or enjoyable (21.3%). Similarly, a study of the use of concept mapping with fifth semester pharmacy students in a cardiovascular care therapeutics course reported that “students were generally resistant to this process” and that feedback following the first two assignments via course liaisons was that the majority of students did not like the concept maps.29 It is understandable that techniques that require effort to master may not be rated highly by students.
Table 4 Student perceptions of concept mapping (CM) and reflective writing (RW) process Survey question The process of concept mapping and reflection helped me to Learn the pharmaceutical care framework Reflect on what I was learning Understand how the concepts in this course apply to my future practice as a pharmacist Think critically Develop as a reflective practitioner
Strongly agree
Disagree
Strongly disagree
25 (16%) 77 (49.4%) 22 (14.1%) 16 (10.3%) 76 (48.7%) 29 (18.6%) 12 (7.7%) 71 (45.5%) 31 (19.9%)
21 (13.5%) 25 (16%) 27 (17.3%)
11 (7%) 10 (6.4%) 15 (9.6%)
15 (9.6%) 11 (7.1%)
37 (23.72%) 21 (13.5%) 33 (21.2%) 13 (8.3%)
Agree
Neither agree nor disagree
48 (30.8%) 35 (22.4%) 58 (37.2%) 41 (26.3%)
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Instructors electing to implement these techniques may find that response from students is divided, particularly as they are working to develop their skills. Specifically, frustration with mastering the technique may get in the way of students perceiving the benefits of use. To assist students in developing their first concept map, detailed instructions and examples are helpful. Instructors will want to carefully consider the training or guidance provided to students, when using concept mapping for the first time. While perceived value to students and student response is important, there is also value to instructors when concept mapping is used as a Classroom Assessment Technique (CAT). A CAT is a tool used by instructors to gauge how well students are learning the course material and to provide students a chance to self-assess their own learning.30 In this course, instructor review of concept maps helped to reveal areas of confusion. Instructors could clarify in the next class session and/or provide additional learning opportunities. For example, when reviewing concept maps early on, many students struggled with the relationship between medication dispensing and the practice of pharmaceutical care. As a result, additional time was spent clarifying this relationship in class and there was improvement in student understanding on the next concept map submission. A recent study demonstrated a significant association between preferred learning approach and self-reported attitudes to concept maps.31 In our initiative, concept mapping and reflective writing were deliberately paired. Instructors reasoned that some students would prefer concept mapping, while others would favor reflective writing. In this way, the pairing appealed to a broader array of learning preferences. In addition, it was thought that the two activities would be synergistic. The concept maps allowed students to document their knowledge, while reflective writing allowed them to explain and expound on it. The techniques were also used repeatedly over the course of the semester with the CA assisting students in identifying the growth of their knowledge over time. Indeed, 80% of students agreed/strongly agreed that “as I re-reviewed my work, I could see that my understanding of the topic had improved over time.” This response was particularly important in a course that emphasized conceptual understanding over knowledge acquisition. A total of 97% of students achieved a satisfactory rating on their last concept map. As described in the rubric, this rating indicated that the student was able to demonstrate their understanding of the intricacies of pharmaceutical care and provide evidence that materials from class has been processed and examined carefully. In addition, the majority of students had satisfactory performance on the initial RW activity (92.6%) and the end-of-semester CA (89%) (Table 1). Students who did not have satisfactory performance were given individual feedback and encouraged to contact course instructors with remaining questions or for clarification. Given that the CA required students to reflect more deeply across their own learning over the semester and that it was the first
opportunity that students had to engage in this type of activity formally in the curriculum, this level of satisfactory performance is noteworthy. The patchwork text approach to assessment has been argued to promote integration of theory and practice 32 and merits more investigation in pharmacy. Students found peer sharing helpful, but most did not find the actual feedback from their fellow students helpful. Specifically, 67.3% of students agreed or strongly agreed that listening to colleagues present their maps helped improve their own work, while only 47.7% agreed or strongly agreed the feedback they received from their peers was helpful in creating their own concept maps. Other studies have reported slightly different results. Theising et al.33 examined the impact of peer assessment activities throughout the curriculum on third year pharmacy students. Their study reported that 78% of students agreed that the peer assessments were accurate and 85% agreed that positive peer assessments increased their confidence in their abilities. The specific feedback task may matter. In another study using a process of self-directed learning, followed by peer teaching and peer/self-assessment, only 57% of firstyear student respondents indicated that peer feedback facilitated their ability to write SOAP notes.34 However, preparation for the feedback task may also be important. Miesner et al.35 prepared APPE students with a lecture/discussion on meaningful feedback prior to assessments of peers in journal clubs. Participants reported that the learning impact of being evaluated in journal club by peers was 4.12 of 5. In addition, the influence in their ability to evaluate/give feedback was 4.35 of 5. In our study, explicit preparation for delivering or receiving/ incorporating peer feedback was not provided, however, this training is now being considered within the professional development portions of the curriculum. Summary of analysis Concept mapping, reflective writing, and a patchwork text approach to assessment were deliberately paired, sequenced, and repeated. This design encouraged students to examine their learning and demonstrate their mastery to instructors as the course progressed, allowing instructors to respond to areas of confusion. Although students did not find the activities to be easy, performance was strong, with ratings indicating that students had achieved the key goals of the assignments. In addition, upon re-review of their work over the semester, students reported seeing that their understanding of the topic had improved over time. There were several rewards to developing and implementing this sequence. First, the combination of CM and RW/CA provided a more thorough and precise understanding of student's knowledge. We were more informed and in-tune with where students were at in their thinking of PCP. Second, the timing and nature of the activities helped us to be responsive and agile. We were able to modify course content and delivery quickly as we identified areas of confusion and content connections that had not been made. Finally, the PT approach allowed us to better appreciate the
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development that students were experiencing and students' thoughts on that development. While much has been written on these teaching and learning methods individually, the combination, sequencing and repeating of these activities allowed us to monitor, acknowledge, and appreciate student learning as it was occurring over the course of a semester. In an effort to address challenges and continually improve, several changes were made for the next offering of the course. When asked to complete the first submission, some students experienced frustration due to a lack of information on PCP. As a result, the initial submission is now due mid-semester to allow more time to acquire content and context. Students also struggled with where to start. Students are now asked to begin their concept maps with the three key components of PCP: philosophy of practice, patient care process, and practice management systems. In addition, graders struggled to implement the concept mapping rubric given the interconnectedness of the concepts, links, cross-links, and linking phrases with the content knowledge itself. The scoring process was refined for the second offering and now distributes CM points evenly across four criteria: concepts, organization/hierarchy, links/ linking phrases, and cross-links/phrases and includes an option to deduct points for lack of coherence, grammar, and spelling (Supplementary information, Appendix D). Graders found the updated process easier to use and better for providing feedback to learners. A longitudinal sequence of concept mapping, reflective writing, and patchwork text can be used to help students understand the inter-connectedness and complexities of the key components of pharmaceutical care practice. Students can also use this activity to reflect on what they are learning, how they are progressing in their knowledge and understanding, and how PCP content ties to their future practice. Conflicts of interest None.
Supplementary information Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/ j.cptl.2016.03.006.
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3. Cipolle RJ, Strand LM, Morley PC. Pharmaceutical Care Practice: The Patient-Centered Approach to Medication Management Services3rd ed, New York, NY: McGraw Hill Professional; 2012. 4. Begley KJ, Coover KL, Tilleman JA, Haddad AMR, Augustine SC. Medication therapy management training using case studies and the MirixaPro platform. Am J Pharm Educ. 2011;75(3): Article 49. 5. Eukel HN, Skoy ET, Frenzel JE. Provision of medication therapy management to university faculty and staff members by third-year pharmacy students. Am J Pharm Educ. 2010;74(10): Article 182. 6. Battaglia JN, Kieser Ma, Bruskiewitz RH, Pitterle ME, Thorpe JM. An online virtual-patient program to teach pharmacists and pharmacy students how to provide diabetes-specific medication therapy management. Am J Pharm Educ. 2012;76(7): Article 131. 7. Gallimore CE, Thorpe JM, Trapskin K. Simulated medication therapy management activities in a pharmacotherapy laboratory course. Am J Pharm Educ. 2011;75(5): Article 95. 8. Kuhn C, Powell PH, Sterrett JJ. Elective course on medication therapy management services. Am J Pharm Educ. 2010;74(3): Article 40. 9. Agness CF, Huynh D, Brandt N. An introductory pharmacy practice experience based on a medication therapy management service model. Am J Pharm Educ. 2011;75(5): Article 82. 10. Hardin HC, Hall AM, Roane TE, Mistry R. An advanced pharmacy practice experience in a student-staffed medication therapy management call center. Am J Pharm Educ. 2012;76 (6): Article 110. 11. Hata M, Klotz R, Sylvies R, et al. Medication therapy management services provided by student pharmacists. Am J Pharm Educ. 2012;76(3): Article 51. 12. Davies M. Concept mapping, mind mapping and argument mapping: what are the differences and do they matter? J High Educ. 2010;62(3):279–301. 13. Novak JD. Concept maps and Vee diagrams: two metacognitive tools to facilitate meaningful learning. Instr Sci. 1990;19 (1):29–52. 14. Brandt BF. Effective teaching and learning strategies. Pharmacotherapy. 2000;20(10 Pt 2):307S–316S. 15. Smith BE. Linking theory and practice in teaching basic nursing skills. J Nurs Educ. 1992;31(1):16–23. 16. Vadlapatla R, Kaur S, Zhao Y. Evaluation of student perceptions of concept mapping activity in a didactic pharmaceutics course. Curr Pharm Teach Learn. 2014;6(4):543–549. 17. Hill LH. Concept mapping in a pharmacy communications course to encourage meaningful student learning. Am J Pharm Educ. 2004;68(5): Article 109. 18. Borton T. Process concerns. Reach, Touch and Teach. New York, NY: McGraw-Hill Book Company; 75–91. 19. Rolfe G, Freshwater D, Jasper M. Models of Critical Reflection. Critical Reflection for Nursing and the Helping Professions, 1st ed, New York, NY: Palgrave; 22–40. 20. Rolfe G. Reach touch and teach: Terry Borton. Nurse Educ Today. 2014;34(4):488–489. 21. Leigh JA, Rutherford J, Wild J, Cappleman J, Hynes C. Use of the patchwork text assessment as a vehicle for evaluating students' perceptions of their clinical leadership development. Nurs Educ Pract. 2012;12(1):46–51. 22. Mabbett GM, Jenkins ER, Surridge AG, Warring J, Gwynn ED. Supporting and supervising district nurse students
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K.D. Hager et al. / Currents in Pharmacy Teaching and Learning 8 (2016) 492–500 through patchwork text writing. Nurse Educ Pract. 2011;11(1): 6–13. Ovens P. Using the patchwork text to develop a critical understanding of science. Innov Educ Teach Int. 2003;40(2): 133–143. Ovens P. A patchwork text approach to assessment in teacher education. Teach High Educ. 2003;8(4):545–562. West DC, Park JK, Pomeroy JR, Sandoval J. Concept mapping assessment in medical education: a comparison of two scoring systems. Med Educ. 2002;36(9):820–826. West DC, Pomeroy JR, Park JK, Gerstenberger EA. Critical thinking in graduate medical education. J Am Med Assoc. 2013;284(9):1105–1110. Saldana J. The Coding Manual for Qualitative Researchers 2nd ed, Los Angeles, CA: Sage Publications, Inc.; 2013. Roberts CM, Sucher K, Perrin DG, Rodriguez S. Concept mapping: an effective instructional strategy for diet therapy. J Am Diet Assoc. 1995;95(8):908–911. Carr-lopez SM, Galal SM, Vyas D, Patel RA, Gnesa Eh. The utility of concept maps to facilitate higher-level learning in a large classroom setting. Am J Pharm Educ. 2014;78(9): Article 170.
30. Angelo TA, Cross KP. Classroom Assessment Techniques: A Handbook for College Teachers 2nd ed, San Francisco, CA: Jossey-Bass; 1993. 31. Laight DW. Attitudes to concept maps as a teaching/learning activity in undergraduate health professional education: influence of preferred approach to learning. Med Teach. 2006;28(2): e64–e67. 32. Dalrymple R, Smith P. The patchwork text: enabling discursive writing and reflective practice on a foundation module in workbased learning. Innov Educ Teach Int. 2008;45(1):47–54. 33. Theising K, Wu K, Sheehan AH. Impact of peer assessment on student pharmacists' behaviors and self-confidence. Curr Pharm Teach Learn. 2014;6(1):10–14. 34. Valdez C, Shea L, Knutsen R, Hoody D. Facilitating skill development using student-directed activities and personalized formative feedback. Curr Pharm Teach Learn. 2014;6(6): 826–833. 35. Miesner AR, Grady S, Trewet CB. Use of student pharmacist peer feedback during journal club in an advanced pharmacy practice experience. Curr Pharm Teach Learn. 2012;4(3): 165–173.
Currents in Pharmacy Teaching and Learning 8 (2016) 492–500
Teaching and Learning Matters
http://www.pharmacyteaching.com
Concept mapping, reflective writing, and patchwork text assessment in a first-year pharmaceutical care course Keri D. Hager, PharmD, BCACPa,*, Claire Kolar, PharmDb, Kristin K. Janke, PhDb a
Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota College of Pharmacy, Duluth, MN b Pharmaceutical Care & Health Systems, University of Minnesota College of Pharmacy, Minneapolis, MN
Abstract Background: The aim of this work was to aid learner's understanding and application of the complexities of pharmaceutical care practice. Specifically, this initiative sought to design, implement, and evaluate student perceptions of and performance on a longitudinal sequence of concept mapping (CM), reflective writing (RW), and patchwork text (PT) activities in a first-year Foundations of Pharmaceutical Care (FPC) course. Educational activity: To encourage examination of the complexities of pharmaceutical care practice, three iterations of combined CM and RW (or PT) occurred throughout the semester, along with peer sharing. The sequence was evaluated by examining student work and student documentation of peer sharing, as well as a survey. The sequence was completed by 163 (99.4%) students. Satisfactory ratings were achieved on final concept mapping assignments by 97% of participants and 80% of students agreed/ strongly agreed that, through re-review of work they could see that their understanding of the topic had improved over time. Critical analysis: The deliberate pairing, sequencing, and repeating of CM, RW, and critical appraisal (CA), provided instructors with a more thorough and precise understanding of student knowledge and the ability to monitor, acknowledge, and respond to student learning as it occurred over the course of a semester. r 2016 Elsevier Inc. All rights reserved.
Keywords: Concept mapping; Reflection; Assessment; Patchwork text
Background Ensuring the ability to provide patient care is a major focal point of Doctor of Pharmacy curricula. The Center for Advancement of Pharmacy Education (CAPE) 2013 Educational Outcomes set the expectation that “the graduate is able to provide patient-centered care as the medication expert (collect and interpret evidence, prioritize, formulate assessments and recommendations, implement, monitor and adjust plans, and document activities)” in outcome 2.1.1
* Corresponding author: Keri D. Hager, PharmD, BCACP, Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota College of Pharmacy, Duluth, 232 Life Science, 1110 Kirby Dr, Duluth, MN 55812. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2016.03.006 1877-1297/r 2016 Elsevier Inc. All rights reserved.
This desired outcome was affirmed in Standard 2 of the Accreditation Council for Pharmacy Education's Standards 2016.2 The pharmaceutical care practice model creates a foundation for the pharmacist's contributions to the rational use of drugs in patient care.3 As with any professional practice, the pharmaceutical care practice (PCP) includes three core components: the philosophy of practice, the patient care process, and the practice management system. Adopting the philosophy of pharmaceutical care practice is critical, as it acts as a compass and provides the practitioner guidance in prioritizing and decision-making in patient care. The patient care process includes assessment, care plan, and follow-up evaluation to ensure a patient's medications are properly indicated, effective, and safe, and the patient is able to take them as intended. Practice management systems include all
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the support required to provide pharmaceutical care. All three combine to form the professional practice of the pharmacist. Medication therapy management (MTM) focuses on the patient care process component of PCP. A number of reports have discussed the development of MTM-related skills through core courses,4–7 electives,8 or early9 or advanced10,11 experiential education. However, these reports on MTM skill development do not include a clear and comprehensive approach to teaching the philosophy of practice and practice management systems. Teaching students all three components of pharmaceutical care practice, as opposed to only the patient care process, provides a more complete framework for development into a practitioner. The philosophy of practice and practice management systems are also needed to provide the foundation (i.e., values and responsibilities) and context for delivering MTM services. Helping students to understand the complexities and interrelationships of the three components presents an instructional challenge. Historically, students have been able to describe each component separately as they have matriculated through the semester. In subsequent coursework students could apply the patient care process but struggled to articulate the philosophy of practice, the elements of a practice management system or explain the relationship between the three components. In order to aid deeper understanding of PCP, this initiative aimed to design, implement, and evaluate student perceptions of and performance on a longitudinal sequence of activities. This sequence was designed to help students draw connections between components of PCP, consider application of the model to future practice, and reflect on their own development into a pharmaceutical care practitioner. This article will review the design of these activities, as well as student performance and student perceptions of the activities. Educational activity Design considerations Foundations of Pharmaceutical Care (FPC) is a required, 1.5-credit fall first-year pharmacy course. In this course, students work individually and in groups to learn about pharmaceutical care practice, focusing on the three major components of the practice: philosophy of practice, patient care process, and practice management system.3 Various iterations of this course have existed for over 20 years. As the name suggests, the Foundations of Pharmaceutical Care course lays the foundation for professional practice and the pharmacy curriculum. A primary course goal is to provide the scaffolding and structure upon which future course content can be hung. The course meets for 90 minutes twice weekly, and the bulk of in-class activities are active learning (e.g., role play). Course content progresses from philosophy of practice to the patient care process to practice
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management systems throughout the semester. Student performance is based on a philosophy of practice writing assignment (8%), four patient care process assessment activities (48%), a midterm examination (20%), and an assignment requiring students to teach pharmaceutical care practice to a non-pharmacist clinician (16%). The longitudinal sequence of activities described in this article accounts for 8% of the total course grade. When first introduced, PCP can be difficult for students to understand, particularly if their experience in pharmacy has not allowed them to see this model of practice in action. For example, if students have experience working as a pharmacy technician, they may have participated in dispensing functions more than comprehensive patient care. In the past, students have been successful in learning and applying the individual components of the patient care process. However, students have struggled with making practical connections between the philosophy of practice, the patient care process, and the practice management system. Students have also had difficulty envisioning this model's use outside of the controlled classroom environment. To further enhance student learning, a combination of learning methods were employed with the goals of: (1) supporting learning of the PCP, (2) fostering critical thinking, particularly about the connections between concepts in the course, (3) encouraging reflection on learning, and its impact on future practice, and (4) aiding in the development of reflective practitioners. Concept mapping (CM) was introduced to aid learners in creating the scaffolding/structure for current learning and future curricular content. Concept maps represent relationships between ideas through a hierarchical structure and connective terms (usually prepositional phrases) referred to as links and cross-links.12 The meaning of any concept for the learner is represented by these linkages.13 In discussing the implementation of the Accreditation Council for Pharmacy Education's 1997 standards, Brandt14 identified CM as an example of effective teaching and learning strategies. CM has also been used to encourage connections between theory and practice,15 which was one of our goals. Concept maps have been used in a pharmaceutics course to explain the interrelationships of physicochemical properties, formulation factors, and excipient requirements of a specific dosage form.16 Concept maps have also been used in a pharmacy communications course to demonstrate student understanding of the concepts taught and their interrelationships.17 In a previous offering of a pharmaceutical care course, mind mapping (i.e., a representation of connected and related concepts emphasizing free-form, spontaneous thinking in order to find creative associations between ideas12) had been employed as a tool for this same purpose. Instructors described many mind map submissions as looking like “spaghetti” with no apparent order. In addition, the means by which the various concepts connected in students' minds was often unclear to instructors. Thus, the new CM activity was designed to encourage a graphic
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representation of the course concepts that required a hierarchy to be developed and relationships between concepts to be better defined. Concept mapping was paired with reflective writing (RW). Should students struggle to express their thoughts graphically, the reflective writing might assist in explaining their learning and vice versa. In addition, the combination of RW and CM may provide instructors with a clearer picture of the students' learning by providing insight into the students' thinking. The reflective writing asked students to use an information processing model adapted to learning, namely the “What? So What? Now What?” model.18–20 Using this model, students are encouraged to describe their learning (What?), evaluating it and giving it meaning (So What?) and considering possible actions (Now What?). In particular, RW was seen to aid students in processing the meaning and implications of their learning. A patchwork text (PT) approach was used to facilitate students' ability to pull together course content and consider how course content applies to practice. In PT, students are guided through a series of tasks (patches) over the course of their learning, which are shared with colleagues for discussion. The “patches” are then “stitched” together at the end of the course when students review the body of their work and produce a critical commentary demonstrating their learning and interpreting what the material means to them.21 In this way, the patches document particular parts of the student's learning journey,22 as well as providing source material in creating a coherent account of personal development, when the patches are stitched together. It has been argued that patchwork text can improve students' holistic grasp of a field of knowledge and its practical application.23 It can also assist in their development as autonomous, reflective practitioners.24 In our use, the patches were the concept maps and reflective writing and the “stitching together” occurred during an end-of-semester critical appraisal (CA). Peer sharing was used to provide students with an opportunity to present their work and learn from the work of others. A combination of these techniques was used to assist students in their learning of PCP. The CM provided a way for students to visually represent how the components of PCP relate to one another. Based on previous experiences with mind mapping, the visual representation alone was not enough to demonstrate their understanding, so RW was incorporated. Finally, the PT approach and CA activity were incorporated for students to review their work over time. Each component of PCP builds on what came before, so a longitudinal approach was sought for students to document their learning. There were three iterations of the CM/RW/CA work throughout the semester (Fig. 1). For each submission, students built off their initial work and incorporated peer and instructor feedback. Multiple submissions allowed faculty to assess students' understanding at strategic points and to reinforce concepts and connections during subsequent class periods when gaps in understanding emerged.
Fig. 1. Outline of semester activities.
All students were supplied paper and were loaned colored pencils for completion of their initial concept maps, and by request for subsequent maps. Some students chose to use online tools to create their concept maps (e.g., Cacoo: https://cacoo.com/diagrams/; SimpleMindþ: http://www. simpleapps.eu/simplemind/; and Mental iOS App; Xmind: http://www.xmind.net/). Moodle 2.4 (Moodle Pty Ltd., Perth, Australia), the online course management system, was used for uploading electronic or scanned assignments, grading rubrics, and links to surveys. Expectations of students For their initial CM submission, students were asked to create a concept map demonstrating their understanding of pharmaceutical care (Supplementary information, Appendix A; Fig. 2). For their initial RW submission, students were asked
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Fig. 2. Example first submission concept map.
to write a one-page reflection following a “What? So What? Now What?” format18–20 about what they learned (What?), why the learning matters (So What?), and what implications the learning has for their future (Now What?). Prior to submitting the initial concept map, students were given an opportunity (15 minutes) for peer sharing/review and feedback on their maps during class. Students were asked to compare and contrast the concepts that were included in maps, as well as the links and cross-links. Following the peer sharing session, students submitted documentation about the peer work. This documentation asked them to report any added concepts or connections made or that their colleagues made as a result of the consultation. A concluding question asked: “After seeing several examples, how would you describe your work relative to others?” Mid-semester, students updated their concept maps and completed peer sharing, answering the same questions for the peer consultation. At the end of the semester, students updated and submitted their concept maps, and also completed the CA (Supplementary information, Appendix B). At this time, students also completed an end-of-semester survey designed to capture their perceptions of these activities. The survey addressed students' perceptions of the combined CM and RW process, in addition to their perceptions about the individual components (i.e., CM, RW, and CA) and their growth over time. The survey also asked about their perceptions of the
work they did with their peers and the feedback they received from both their peers and the instructors. Students received individual feedback via a rubric for all submissions (Supplementary information, Appendix C). General, global feedback was also provided to the whole class on the concept maps and reflective writing after the initial and mid-semester submissions. Literature on the assessment of concept maps in medical education25,26 was consulted to identify variables for the creation of a rubric assessing pharmaceutical care knowledge, concept mapping, and reflection/critical appraisal (Supplementary information, Appendix C). Ratings were used as feedback to show students their progress and also to assign points toward the course grade. Qualtricss (Qualtricss Labs Inc., Provo, UT) was used for the student survey and for the documentation of the peer consultation. Descriptive statistics of student performance and perception ratings were calculated. In addition, thematic analysis was used to analyze the peer sharing comments made by students. First instructor coded student responses using the In Vivo Coding method.27 In Vivo Coding captures the actual language of the respondent.27 Once the initial codes were established, they were collapsed into more broad focus codes and grouped into overarching categories by the same instructor.27 A second instructor reviewed and verified the analysis at each step: coding,
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development of focus codes, and categorization. This project was reviewed and determined exempt by the University of Minnesota Institutional Review Board (IRB). Student performance and evaluative results A total of 165 students participated in the course. The three instructors with pharmaceutical care content expertise (one course faculty and two graduate teaching assistants) divided the review of student work and provided individualized feedback on each submission. The instructors did not receive training prior to evaluating student work, but applied the rubric to a subset of student assignments and discussed interpretation of the criteria to help ensure they were applied consistently. The time required to review, rate and provide feedback on individual concept maps was estimated to be five minutes per student or about 14 hours for the class for each submission. Table 1 provides rubric ratings for pharmaceutical care knowledge, concept mapping skills, and reflective writing. Submissions received ratings of needs improvement or satisfactory (Supplementary information, Appendix C). If submissions achieved any exemplary ratings, students were awarded an additional bonus point for the submission for a maximum of a bonus point per submission, regardless of number of exemplary ratings. The overall survey response rates for peer sharing activities were 96% (157 of 164 students) for Submission 1, and 95% (156 of 164 students) for Submission 2. The results of the thematic analysis for Submission 1, grouped by category, are presented in Table 2. The overall response rate to the survey was 95.7% (157 out of 164 students), but the response rate for the Submission 1 question, “After seeing several examples, how would you describe your
Table 1 Number of students receiving needs improvement or satisfactory rubric ratingsa Needs improvement (%)
Satisfactoryb (%)
Pharmaceutical care knowledge (PK) PK submission 1 28 (17.2) 135 (82.8) PK submission 3 22 (13.5) 141 (86.5) Concept mapping (CM) skill CM submission 1 18 (11) 145 (89) CM submission 3 5 (3.1) 158 (96.9) Reflective writing (RW) and critical appraisal (CA) RW submission 1 12 (7.4) 151 (92.6) CA submission 3 18 (11) 145 (89) a One student did not complete the initial concept map and reflective writing submission; her data were excluded. b 11 Students received an exemplary rating for submission 1 and 29 students received an exemplary rating for submission 3.
Table 2 Categories and codes of student responses to submission 1 peer sharing (number) My concept map compared to my peers' was … (108) Better than in some way (32) In need of some improvement (17) Average/satisfactory (16) Different, but comparable (14) Similar (12) Similar ideas, different organization (9) Different/unique (8) My peers' concept maps were … (27) Different (11) More detailed (6) Better organized (4) Difficult to follow (4) More creative/appealing (2) I am going to make changes to my concept map by … (15) Revising/reorganizing (6) Adding concepts (5) Being more creative (2) Adding links/cross-links/connections (2) I learned from my peers … (8) Additional concepts (3) Ideas for linking and organization (3) Better understanding (2)
work relative to others?” was 61.6% (101 of 164 students). Results of thematic analysis for Submission 2 were similar to Submission 1. Via Qualtricss, students completed an online survey of their perceptions of the sequence including the value of CM, RW, and CA and working with peers. The survey response rate was 94.5% (155 of 164 students). A total of 38 (25%) had used concept mapping prior to pharmacy school. The number of students who chose to submit their concept maps using an online tool increased from 69 students (44.5%) on Submission 1 to 81 students (52.2%) on Submission 3. Only 42.6% (66 of 155) of respondents agreed/strongly agreed that concept mapping was easy and only 50.3% (78 of 155) of respondents agreed/strongly agreed the reflective writing was easy (Table 3). However, 67% (105 of 155) agreed/strongly agreed “listening to my colleagues present their work helped me to improve my own.” Additionally, 80% (124 of 155) agreed/strongly agreed with the statement, “As I re-reviewed my work, I could see that my understanding of the topic had improved over time.” Respondents agreed/strongly agreed that the CM/RW process helped them to: learn the pharmaceutical care framework (65%), reflect on what they were learning (68%), and understand how the course concepts apply to future practice (60%) (Table 4). Fewer students agreed/ strongly agreed the process helped them think critically (40%) or develop as a reflective practitioner (45%).
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Table 3 Student perceptions of concept mapping (CM) and reflective writing (RW) components Survey question
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Perceptions of concept mapping and reflective writing Concept mapping was easy I enjoyed concept mapping The written reflections were easy I enjoyed the written reflections
7 8 12 5
59 27 66 28
41 40 40 43
35 33 28 36
13 47 9 43
Perceptions of peer interactions Presenting my work to my colleagues helped me to understand my own work better Listening to my colleagues present their work helped me to improve my own Feedback I received from fellow students was helpful in creating my concept maps Feedback I received from fellow students was helpful in writing my reflections The feedback I received was helpful in guiding improvement Perceptions of growth over time As I re-reviewed my work, I could see that my understanding of the topic had improved over time As I re-reviewed my work, I could see that my ability to use concept mapping had improved over time
(4.5%) (5.2%) (7.7%) (3.2%)
(38.1%) (17.4%) (42.6%) (18.1%)
(26.5%) (25.8%) (25.8%) (27.7%)
(22.6%) (21.3%) (18.1%) (23.2%)
(8.4%) (30.3%) (5.8%) (27.7%)
13 (8.3%)
65 (41.7%)
43 (27.6%)
25 (16%)
17 (10.9%)
88 (56.4%)
26 (16.7%)
17 (10.9%)
8 (5.1%)
12 (7.7%)
62 (39.7%)
41 (26.3%)
29 (18.6%)
12 (7.7%)
7 (4.5%)
48 (30.8%)
46 (29.5%)
39 (25%)
16 (10.3%)
9 (5.8%)
77 (49.4%)
34 (21.8%)
24 (15.4%)
12 (7.7%)
32 (20.6%)
92 (59.4%)
19 (12.3%)
6 (3.9%)
6 (3.9%)
18 (11.6%)
70 (45.2%)
31 (20%)
26 (16.8%)
10 (6.5%)
Critical analysis The goal of this initiative was to use a combination of concept mapping, reflective writing, and a patchwork text approach to assessment to help students learn about Pharmaceutical Care Practice and reflect on their own development over the course of the semester. Student performance was rated at each submission using a rubric to assess concept mapping skills, pharmaceutical care knowledge, and reflective writing/critical appraisal. In addition, students engaged in peer sharing and their reported responses were analyzed. Finally, a survey was used to measure student perceptions after the final submission. In evaluating concept mapping and reflective writing, a sizeable proportion of students reported being neutral (12.3–29.5%). Concept mapping was used three times and reflective writing and critical analysis were each used once over the course of a 15-week term. Students may have felt
10 (6.4%)
this was insufficient exposure to form an opinion. While the amount of practice needed is not known, a previous study of concept mapping with diet therapy students has recommended that a “one-shot approach” to concept mapping be avoided and that repeated practice increases student satisfaction.28 Only a small percentage of participants agreed/strongly agreed that concept mapping was easy (42.6%) or enjoyable (22.6%) and that reflective writing was easy (50.3%) or enjoyable (21.3%). Similarly, a study of the use of concept mapping with fifth semester pharmacy students in a cardiovascular care therapeutics course reported that “students were generally resistant to this process” and that feedback following the first two assignments via course liaisons was that the majority of students did not like the concept maps.29 It is understandable that techniques that require effort to master may not be rated highly by students.
Table 4 Student perceptions of concept mapping (CM) and reflective writing (RW) process Survey question The process of concept mapping and reflection helped me to Learn the pharmaceutical care framework Reflect on what I was learning Understand how the concepts in this course apply to my future practice as a pharmacist Think critically Develop as a reflective practitioner
Strongly agree
Disagree
Strongly disagree
25 (16%) 77 (49.4%) 22 (14.1%) 16 (10.3%) 76 (48.7%) 29 (18.6%) 12 (7.7%) 71 (45.5%) 31 (19.9%)
21 (13.5%) 25 (16%) 27 (17.3%)
11 (7%) 10 (6.4%) 15 (9.6%)
15 (9.6%) 11 (7.1%)
37 (23.72%) 21 (13.5%) 33 (21.2%) 13 (8.3%)
Agree
Neither agree nor disagree
48 (30.8%) 35 (22.4%) 58 (37.2%) 41 (26.3%)
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Instructors electing to implement these techniques may find that response from students is divided, particularly as they are working to develop their skills. Specifically, frustration with mastering the technique may get in the way of students perceiving the benefits of use. To assist students in developing their first concept map, detailed instructions and examples are helpful. Instructors will want to carefully consider the training or guidance provided to students, when using concept mapping for the first time. While perceived value to students and student response is important, there is also value to instructors when concept mapping is used as a Classroom Assessment Technique (CAT). A CAT is a tool used by instructors to gauge how well students are learning the course material and to provide students a chance to self-assess their own learning.30 In this course, instructor review of concept maps helped to reveal areas of confusion. Instructors could clarify in the next class session and/or provide additional learning opportunities. For example, when reviewing concept maps early on, many students struggled with the relationship between medication dispensing and the practice of pharmaceutical care. As a result, additional time was spent clarifying this relationship in class and there was improvement in student understanding on the next concept map submission. A recent study demonstrated a significant association between preferred learning approach and self-reported attitudes to concept maps.31 In our initiative, concept mapping and reflective writing were deliberately paired. Instructors reasoned that some students would prefer concept mapping, while others would favor reflective writing. In this way, the pairing appealed to a broader array of learning preferences. In addition, it was thought that the two activities would be synergistic. The concept maps allowed students to document their knowledge, while reflective writing allowed them to explain and expound on it. The techniques were also used repeatedly over the course of the semester with the CA assisting students in identifying the growth of their knowledge over time. Indeed, 80% of students agreed/strongly agreed that “as I re-reviewed my work, I could see that my understanding of the topic had improved over time.” This response was particularly important in a course that emphasized conceptual understanding over knowledge acquisition. A total of 97% of students achieved a satisfactory rating on their last concept map. As described in the rubric, this rating indicated that the student was able to demonstrate their understanding of the intricacies of pharmaceutical care and provide evidence that materials from class has been processed and examined carefully. In addition, the majority of students had satisfactory performance on the initial RW activity (92.6%) and the end-of-semester CA (89%) (Table 1). Students who did not have satisfactory performance were given individual feedback and encouraged to contact course instructors with remaining questions or for clarification. Given that the CA required students to reflect more deeply across their own learning over the semester and that it was the first
opportunity that students had to engage in this type of activity formally in the curriculum, this level of satisfactory performance is noteworthy. The patchwork text approach to assessment has been argued to promote integration of theory and practice 32 and merits more investigation in pharmacy. Students found peer sharing helpful, but most did not find the actual feedback from their fellow students helpful. Specifically, 67.3% of students agreed or strongly agreed that listening to colleagues present their maps helped improve their own work, while only 47.7% agreed or strongly agreed the feedback they received from their peers was helpful in creating their own concept maps. Other studies have reported slightly different results. Theising et al.33 examined the impact of peer assessment activities throughout the curriculum on third year pharmacy students. Their study reported that 78% of students agreed that the peer assessments were accurate and 85% agreed that positive peer assessments increased their confidence in their abilities. The specific feedback task may matter. In another study using a process of self-directed learning, followed by peer teaching and peer/self-assessment, only 57% of firstyear student respondents indicated that peer feedback facilitated their ability to write SOAP notes.34 However, preparation for the feedback task may also be important. Miesner et al.35 prepared APPE students with a lecture/discussion on meaningful feedback prior to assessments of peers in journal clubs. Participants reported that the learning impact of being evaluated in journal club by peers was 4.12 of 5. In addition, the influence in their ability to evaluate/give feedback was 4.35 of 5. In our study, explicit preparation for delivering or receiving/ incorporating peer feedback was not provided, however, this training is now being considered within the professional development portions of the curriculum. Summary of analysis Concept mapping, reflective writing, and a patchwork text approach to assessment were deliberately paired, sequenced, and repeated. This design encouraged students to examine their learning and demonstrate their mastery to instructors as the course progressed, allowing instructors to respond to areas of confusion. Although students did not find the activities to be easy, performance was strong, with ratings indicating that students had achieved the key goals of the assignments. In addition, upon re-review of their work over the semester, students reported seeing that their understanding of the topic had improved over time. There were several rewards to developing and implementing this sequence. First, the combination of CM and RW/CA provided a more thorough and precise understanding of student's knowledge. We were more informed and in-tune with where students were at in their thinking of PCP. Second, the timing and nature of the activities helped us to be responsive and agile. We were able to modify course content and delivery quickly as we identified areas of confusion and content connections that had not been made. Finally, the PT approach allowed us to better appreciate the
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development that students were experiencing and students' thoughts on that development. While much has been written on these teaching and learning methods individually, the combination, sequencing and repeating of these activities allowed us to monitor, acknowledge, and appreciate student learning as it was occurring over the course of a semester. In an effort to address challenges and continually improve, several changes were made for the next offering of the course. When asked to complete the first submission, some students experienced frustration due to a lack of information on PCP. As a result, the initial submission is now due mid-semester to allow more time to acquire content and context. Students also struggled with where to start. Students are now asked to begin their concept maps with the three key components of PCP: philosophy of practice, patient care process, and practice management systems. In addition, graders struggled to implement the concept mapping rubric given the interconnectedness of the concepts, links, cross-links, and linking phrases with the content knowledge itself. The scoring process was refined for the second offering and now distributes CM points evenly across four criteria: concepts, organization/hierarchy, links/ linking phrases, and cross-links/phrases and includes an option to deduct points for lack of coherence, grammar, and spelling (Supplementary information, Appendix D). Graders found the updated process easier to use and better for providing feedback to learners. A longitudinal sequence of concept mapping, reflective writing, and patchwork text can be used to help students understand the inter-connectedness and complexities of the key components of pharmaceutical care practice. Students can also use this activity to reflect on what they are learning, how they are progressing in their knowledge and understanding, and how PCP content ties to their future practice. Conflicts of interest None.
Supplementary information Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/ j.cptl.2016.03.006.
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