Nurse Education Today 38 (2016) 2–4
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Nurse Education Today journal homepage: www.elsevier.com/nedt
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Learning how to learn: Meta-learning strategies for the challenges of learning pharmacology Suzanne Alton ⁎ School of Nursing, University of Texas, Medical Branch, Galveston, TX 77555-1029, USA
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Article history: Accepted 5 January 2016 Keywords: Learning Active learning Problem-based learning Memory Pharmacology Students Students, nursing Education
a b s t r a c t Background: Nursing students have difficulty with pharmacology courses because of the complicated nomenclature and the difficulty of applying drug information to actual patient care. Objectives: As part of a new pharmacology course being created, meta-learning strategies designed to diminish the difficulties of learning this difficult content were part of the course pedagogy. Design: Strategies were demonstrated, reviewed in class, and implemented through homework assignments. Setting: The setting was an Academic Health Center's School of Nursing in the southern United States. Participants: Participants were third-year nursing students in an undergraduate nursing program. Methods: Surveys of students' opinions of learning gains were conducted at the end of the course over several semesters. In addition, pharmacology scores on a standardized exit exam were compared prior to implementing the course and after. Results: Students reported learning dry material more easily, having greater confidence, and finding substantial value in the learning strategies. Students indicated the most helpful strategies, in descending order, as follows: making charts to compare and contrast drugs and drug classes, writing out drug flash cards, making or reviewing creative projects, prioritizing information, making or using visual study aids, and using time and repetition to space learning. Implementation of the new course improved pharmacology scores on a standardized exit exam from 67.0% to 74.3%. Conclusions: Overall response to learning strategies was positive, and the increase in the pharmacology standardized exit exam scores demonstrated the effectiveness of this instructional approach. © 2016 Elsevier Ltd. All rights reserved.
Introduction
Background
Pharmacology is difficult for nursing students to learn because it is dry and complex, but students need to know information about medications and how to apply this information in clinical situations. An integrated pharmacology and pathophysiology course resulted in poor student performance on standardized tests and reports of insufficient knowledge of pharmacology by faculty teaching more advanced clinical courses. A simultaneous increase in pharmacology content of the National Council Licensure Examination (NCLEX) along with this gap in students' understanding of medications resulted in the development of a stand-alone pharmacology course. The pharmacology course was for third-year nursing students, to be completed after pathophysiology and concurrent with the medical-surgical clinical course.
The stated purpose of the course was to develop the students' ability to “clinically reason through information in order to choose the best action for the nurse to take, given a specific scenario involving a patient and medication.” Each module covered specific clinical application learning outcomes that contributed toward the overall course objective. Because faculty recognized that students must memorize a large volume of complex material in order to achieve the clinical application goals of the course, active and meta-learning strategies were incorporated to facilitate student comprehension. The intended learning outcome for including meta-learning strategies into the course curriculum was to produce more effective student learning combined with better clinical application of the course content. The learning strategies were introduced from the first class meeting, and other specific learning topics were interspersed throughout the course as determined by pedagogical objectives. Students received coaching on how to apply their knowledge of pertinent physiology and pathophysiology to clinical situations using medications. The course was taught using a face-to-face format in three to four hour-long
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http://dx.doi.org/10.1016/j.nedt.2016.01.003 0260-6917/© 2016 Elsevier Ltd. All rights reserved.
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sessions over 12 to 13 weeks, with class sizes ranging from 95 to 120 students. Methods Students were provided with a personal goal sheet as they arrived to the first class meeting and asked to indicate which goals out of those provided they would like to achieve during the course. Goals incorporated the need to pass the standardized exit exam and the NCLEX licensing exam and ultimately achieve clinical competence. Additionally, the goals represented development of personal and professional strengths that could be of benefit to potential future employers. For example, the goal “Be accountable for putting time and effort into learning several times a week, which demonstrates a strong work ethic, as well as an effective learning strategy” was underscored by the statement, “If you master the above, you can tell your employer that you have the skills to be a life-long learner and are self-directed; these are top skills that employers request!” The purpose of the goal sheet was to shift focus away from extrinsic motivation for learning the course material (e.g., I must pass this required course) toward more intrinsic rewards (Pink, 2011), like competent nursing practice. The goal sheet was collected at the end of the first class. After the final exam, students were encouraged to pick up their goal sheets in order to reflect on what they had accomplished over the semester. Evidence-based learning methods were taught at the beginning of the course using PowerPoint presentations and included the following: the need for movement to increase neurotransmitters and circulation during the long class period as well as with regular exercise (Jensen, 2008; Meier, 2000); how incorporating emotions and humor increase retention (Jensen, 2008); and the superiority of using multiple modes or senses to deeply learn information (Meier, 2000; Wagner, 2014). The sources of the research presented were credited, modeling the use of evidence in practice. The instructor also led students in singing and kinesthetic routines in order to demonstrate the effectiveness of the recommended strategies in achieving more rapid and comprehensive learning (Medina, 2008; Wagner, 2014). Another strategy presented at the beginning of the course was chunking information into logical units for easier recall. A pictorial analogy of a mountain of clothes being organized slowly into a designer closet illustrated how scaffolding information logically, like clothes, serves to make later retrieval easier. For example, students were encouraged to write out flash cards by class characteristics and at the bottom of the card outline the differentiating features of specific drugs. Concept-based learning was taught in chunks as well, i.e., recognizing the signs and symptoms of dehydration as a side effect of medication as well as a primary condition. Other meta-learning strategies covered later in the course included better note taking, easier ways to memorize, and the process of clinical reasoning. Nurses must constantly prioritize competing issues and this was illustrated by organizing the course content according to the Pareto Principle, or the 80/20 rule (Reh, 2014). The most important 20% of course information was presented in class as a foundation, with the intent that students would add more pharmacological knowledge as they progressed through the nursing program. Students were provided with a document that included essential information about the drug classes and individual drugs they were expected to learn. This approach allowed the students to process a smaller volume of material in their working memory, which facilitated more effective learning (Kaylor, 2014). Students were required work in small groups to complete a creative project which incorporated the essential drug or drug class knowledge that was outlined in the essential information document. The creative project involved students creating a picture, song, or skit representing a drug, drug class, or pharmacological concept for presentation and discussion in class. As the students worked on these projects, strategies for effective collaboration and group conflict resolution were discussed.
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The projects were shared among the students who were encouraged to use them for study. At the end of the course students voted on the most helpful, funny, and creative project. Winners were announced before the final exam, and each student in a winning group received a certificate of peer acknowledgement, which they appeared to value. A modified Student Assessment of Their Learning Gains (Wisconsin Center for Educational Research, WCER at the University of WisconsinMadison, 2014) was conducted using Survey Monkey® to determine the perceived effectiveness of the meta-learning strategies. Approval was obtained from the institutional review board for the use of human research subjects prior to gathering information from students. Four cohorts of students were analyzed in this paper. A great majority of students indicated they learned a lot or some about how to more easily learn dry material (80%), felt greater confidence in their ability to learn dry material (93%), and that spending class time on learning methods was very or somewhat helpful (77%). Results The question “How has this class changed the way you learn or study?” required write-in responses, which were analyzed based on frequency of responses. The most frequent responses, in descending order, were • • • • • •
making charts to compare and contrast drugs and drug classes, writing out drug flash cards, making or reviewing creative projects, prioritizing information (80/20 rule), making or using visual study aids, and using time and repetition to space learning.
In addition to positive subjective student responses about metalearning strategies, pharmacology scores on the standardized exit exam increased for the cohorts who completed the new course. The pharmacology score averaged 67% among the 187 students who completed the integrated pharmacology and pathophysiology course, whereas the average scores among the 196 students completing the new stand-alone course were 74.3%. Discussion Course evaluations included many unsolicited student comments about the helpfulness of making charts and the 80/20 rule. Of note, the chart-making activity required revision after the first semester. Although presented with instructions of how to create a chart in order to compare, contrast, and sort information, most students were not able to fill in the headings at the top and left side of the chart on their own. The activity was revised to include examples of titles for the chart headings, and students produced more useful charts after this. Conclusions Pharmacology is difficult for nursing students in terms of knowledge and application. Student data supported the effectiveness of metalearning strategies in increasing retention and improving application of pharmacology concepts. A student remarked, “This class caused me more stress and swollen eyes from crying than I would have ever thought, but it also gave me confidence that I can do this and that I can learn this information because of the new study tips that I have implemented.” Incorporation of learning strategies requires careful balance to ensure that the strategies are relevant to nursing and lead to improved student performance. Continued attention to student feedback is recommended when incorporating this approach to ensure maximized benefit.
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References Jensen, E., 2008. Brain-Based Learning: The New Paradigm of Teaching. Corwin Press Sage, Thousand Oaks, CA. Kaylor, S., 2014. Preventing information overload: cognitive load theory as an instructional framework for teaching pharmacology. J. Nurs. Educ. 53 (2), 108–111. http://dx. doi.org/10.3928/01484834–20140122-03 (Retrieved 11/28/15 from http://search. proquest.com/openview/a7a62332c4ef028defcf971295f18c0e/1?pq-origsite= gscholar). Medina, J., 2008. Brain rules: 12 principles for surviving and thriving at work, home, and school. Pear Press, Seattle, WA. Meier, D., 2000. The Accelerated Learning Handbook. McGraw-Hill, New York, NY. Pink, D.H., 2011. Drive: The Surprising Truth about What Motivates Us. Penguin, New York, NY.
Reh, J., 2014. Pareto's Principle—The 80–20 Rule: How the 80/20 Rule Can Help You to be More Effective. (Retrieved 11/28/15 from) http://management.about.com/cs/ generalmanagement /a/Pareto081202.htm. Wagner, E.A., 2014. Using a kinesthetic learning strategy to engage nursing student thinking, enhance retention, and improve critical thinking. J. Nurs. Educ. 53 (6), 348–351. http://dx.doi.org/10.3928/01484834–20140512-02 (Retrieved 11/28/15 from http:// search.proquest.com/openview/5acce4ed447dca074593f0b001306c52/1?pqorigsite=gscholar). Wisconsin Center for Educational Research (WCER) at the University of WisconsinMadison, 2014v. Student assessment of their learning gains. (Retrieved 11/28/15 from) http://www.salgsite.org/about.
