Chapter 1: Introduction and background 1
2.3 Pharmacy education 16
2.4.3 Experiential learning and integration 25
Pharmacy education in the USA evolved from an apprenticeship model to a professional curriculum and encompasses both theoretical and experiential learning.
The duration and sequencing of experiential learning or clinical professional practice in the undergraduate curricula varies between and within countries, along with its execution (Appendix 2).
Karimi et al. (2010) described these two major components of pharmacy education as didactic and experiential components. Depending on the context, the former is referred to in the literature as coursework or theory and the latter as clinical training, internship or practical training. While Sosabowski and Gard (2008) focus on the debate of science versus practice and whether science skills currently taught are a requirement for effective pharmacy practice, other studies focus on how best to integrate both components (Husband et al., 2014; Karimi et al., 2010; Pearson &
Hubball, 2012).
Curricula integration is described as being composed of horizontal and vertical components. In pharmacy programmes horizontal integration refers to integration across science disciplines such as medicinal chemistry, pharmacology and pharmaceutics (Pearson & Hubball, 2012). In South Africa, NMMU exhibits horizontal integration as they have adopted an integrated B. Pharm curriculum which incorporates the four major disciplines (pharmacology19, pharmaceutics, pharmaceutical chemistry and pharmaceutical care) into three streams (Clinical Pharmacy, The Molecule and Pharmacy, People and Systems) during first year (Boschmans, 2014). At Rhodes University the four major disciplines are also taught in a more horizontally integrated manner but this occurs later in the curriculum (in third year) (Walker, 2014).
19 Pharmacology and other majors are capitalised, as these refer to modules in the analysis chapters, where the module code 301 or 401 does not always feature.
Vertical integration, on the other hand, refers to the integration of basic sciences and clinical science disciplines (Pearson & Hubball, 2012) where the basic sciences continue into the later years of the curriculum. The Muhimbili University of Health and Allied Sciences School of Pharmacy (MUHAS) in Tanzania, moved to an integrated curriculum, aligning an antibiotic course with a clinical microbiology course. These modules were redesigned and re-sequenced allowing for reinforcement of content and concepts without duplication (Youmans, et al., 2012).
However confusion could arise as the term horizontal in pharmacy education is also used to describe the combination of basic and clinical sciences within a year of study or period of study. Vertical integration is also used to refer to spiral curricula where the structure allows for a topic to be revisited as content becomes increasingly complex with subsequent years (Pearson & Hubball, 2012). The use of vertical integration to link a topic between academic years is also believed to foster the transition from novice learner to master of the topic (Nelson et al., 2013).
“Integration” takes on yet another meaning when described by Summers et al. (2001), who use it to refer to the way in which course material is arranged and presented in thematic modules. Integration in pharmacy education can also see the content between different disciplines integrated into theme-based teaching. According to Enslin (2008), the theme-based, integrated, problem based, (PBL), experiential teaching and learning methodology adopted in South Africa in response to professional and educational demands has been successful and is more patient focused. NMMU uses thematic integration of disease states and associated management in the later years of the curriculum (Boschmans, 2014).
From the literature there appear to be different types of functional models of pharmacy curricula based on the link between the content driven syllabus and the experiential learning component. Zlatic’s (2000, p. 10) view on the construction of knowledge within the professional curriculum is based on the belief that “abilities are developed gradually, in an incremental fashion, over the years of a curriculum”.
Modules that appear earlier in the curriculum operates at a more basic level, whereas later modules require students to perform at a professional entry level. Pearson and Hubball, (2012) shared a similar view, stating that the traditional structure of
pharmacy curricula resembles a front-loaded curriculum, with basic sciences covered in earlier years and clinical experiences featuring towards the end of the curriculum.
An alternate approach to the traditional structure is described by Pearson and Hubball (2012, p. 2) as “inverted triangles” and this is an approach where clinical experience is introduced at the beginning of the curriculum and becomes increasingly prevalent with the basic sciences throughout the programme. This approach is believed to foster a greater link between theory and practice. In the integrated approach, experiential learning is introduced as early as year one or two into the curriculum and is threaded throughout the curriculum; it is referred to as “sandwiched within the curriculum”.
The Pacific University School of Pharmacy20 is an example of this approach, where they even use a block curriculum system, where one block is taught at a time (Karimi et al., 2010, p. 2). Students are assigned to pharmacies in their first year and engage in a learning bridge process. This approach is believed to allow students to apply a didactic curriculum with practice throughout the first year. In South Africa, pharmacy students at the University of Western Cape are also exposed to experiential learning from first year and work in a variety of community (pharmacies, old age homes and schools) and clinical environments with the aim of developing social responsiveness and producing socially accountable practitioners (Malan, 2014).
Yanchick (2008) stated that students taught in discipline silos, even operating in the best practical sites, are faced with not truly experiencing training in an interprofessional environment, highlighting the need for integration. Integration into the curriculum, however, requires carefully consideration by educators (Karimi et al., 2010) and they should avoid the “danger for integration for integration’s sake rather than for sound educational purposes” as pointed out by Pearson and Hubball (2012, p.
1). Decisions regarding where and how experiential learning takes place are also influenced by regulatory bodies. For example in the United States, the ACPE calls for practical experiences to start early in the curriculum and be interfaced with didactic coursework (Karimi et al., 2010). Williams et al. (2013) shared a similar view, believing that early placement and exposure will develop person-centered skills and help produce a well-balanced graduate. It is believed that this approach will expose
20 The Pacific University School of Pharmacy is located in the United States of America.
students to the profession and will continue throughout the degree, resulting in a smooth transition into pharmacy practice in work settings.
In other countries, circumstances and context-related issues may impact on when and how experiential learning features in the curriculum. For example in India, the lack of site training (or experiential training) occurs because most of the universities or institutions (colleges) offering pharmacy in India are located far from practice sites and there is no compulsory training in a practice sites. Pharmacists in India are also unique compared to other countries as they are not required to undergo further development - either in terms of education or training to maintain their license to practice once they have been obtained. In South African institutions offering the B.
Pharm degree, experiential learning is threaded throughout the curriculum. At UKZN, experiential learning usually takes place early in the curriculum, combined with an intensive training programme in fourth year which includes ward-rounds at various public hospitals, community pharmacies, rural clinics and the commercial and industrial pharmaceutical sectors (Anon, 2008). Pharmacy students at other South African institutions such as NMMU also gain experiential training in fourth year through their institute’s links with the Pharmaceutical industry (Aspen Pharmacare) and the Academic Hospital complex, located in the same area of Port Elizabeth (Anon, 2008).
2.5 Pedagogy in pharmacy education
Higher education is confronted with issues of knowledge explosion and knowledge complexity. The rapid increase of information and ease of accessibility has implications for the role universities and other learning institutions play and the pedagogical practices that academics employ (Frenk et al., 2010). Debates around pedagogy and the impact of instructional guidance have ensued for decades (Kirschner, Sweller & Clark, 2006). Placing the debates on pedagogical practices on a continuum, on one side are those who argue for direct instructional guidance (lectures and didactic teaching fall into this category) and on the other are those who advocate that people learn best in an unguided or minimally guided space. The approach with minimal guidance has been called by many names including discovery learning, inquiry-based learning (Aditomo, Goodyear, Bliuc & Ellis, 2013), problem-based learning, experiential learning or constructivist learning (Kirschner et al., 2006).
Along the spaces in between is room for hybrid models (Azer, 2009), broken lectures (Nayak, 2006) and technologically driven innovative practices (Cain & Fox, 2009).
While Savery (2006) argued against a hybrid curriculum, stating that problem-based learning should not be part of a didactic curriculum but rather the pedagogic base in the curriculum, Carter, Wesley and Larson (2006) and Azer (2009) concluded that strategically timed lectures have the potential to enforce educational values of other teaching activities. Lectures featuring in a PBL course should focus on integrating knowledge, developing critical skills, encouraging students to pursue further research and stimulating deeper understanding (Azer, 2009).
The purpose here is not to cover all the pedagogical debates as they are both expansive and extensive, but rather to highlight some of the pedagogical practices in pharmacy education, the rationale behind their implementation or some of the underlying learning theories upon which they are based.
2.5.1 Direct instructional guidance
Blouin et al. (2008) raised the issue of increasing frustration with pedagogy in pharmacy education occurring from the perspectives of student and academics.
Students view traditional lecture-based approaches or didactic teaching as a waste of valuable time, considering the potential of technology to offer a multitude of efficient options. Academics also experience frustration due to the confines of large class sizes, complex lecture dynamics and the large amount of factual content that needs to be covered. Covering large amounts of content is seen as an opportunity cost of engaging students in meaningful discussions and higher order learning (Blouin et al., 2008).
Oblinger (2003) argued that the lecture tradition of universities may not meet the expectations of students growing up with the internet.
The question of whether lectures have a place in higher education or not still exists.
The term “lectures”, however, are often used loosely in pedagogic studies and is sometimes misconstrued or taken to mean didactic teaching. Penson (2012) argued that there is still a place and purpose for lecturing in university education. His view is that lecturing promotes learning when incorporated as an overall strategy and that the predominant style should be aligned to learning objectives rather than compared to
other approaches. Lecturing has long been viewed as a deficit in light of newer or more innovative approaches, but there still remains a place for lecturing in pharmacy education (Penson, 2012). He also raised the point that not all traditional lecture-based learning is bad, but rather that bad lecturing does occur. So the argument for an approach that lends itself to the objective and purpose of the lecture remains most important and that a mixture of approaches can be used to address the menu of subjects in the pharmacy curriculum (Penson, 2012).
Blouin et al. (2008), on the other hand, felt that pedagogy in higher education, especially for modules dominated with highly factual knowledge and which forms the basis for further knowledge, has not been altered for decades. The so-called
‘traditional’ approach is described as focusing on transmission and repetition of factual content and has been accused of being insufficient in terms of fostering critical thought and assessing information for the purpose of solving problems (Blouin et al., 2008). Blouin et al. (2008) argued that content to be mastered in a professional qualification should be covered outside lecture time, given the time constraints of lectures and the high volume of factual knowledge that needs to be covered. Yet Penson (2012) disagreed, believing that lectures are effective for teaching in science and clinical degree programmes based on the volume and content that has to be covered. Stewart, Brown, Clavier and Wyatt (2011), however, presented the increased use of active learning techniques, which can be used in lectures, to address the increasing knowledge issue by preparing students to drive their learning in locating, processing and applying new information to clinical settings and patient care.
Blouin et al. (2008) argued that lectures should be dedicated to higher thought processes, problem-solving and critical skills instead of merely communicating factual content. Yet supporters of guided lectures, however argue that self-directed learning is not an innate characteristic and that our thinking will be distorted, biased, or prejudiced if we are left to our own devices and that learning how to think critically is something that can be taught (Pearson & Huball, 2012). If critical thinking is viewed as a set of tools that can be used to guide the student, then thinking and problem solving can be improved by instruction.
Charlton (2006) attributed the negative view of lectures to be based on a lack of theoretical rationale underpinning lectures. Kirschner et al. (2006) provided some theoretical rationale for why minimal guidance is likely to be ineffective based on human cognitive architecture saying that the purpose of all instruction is to change long-term memory and minimal guidance does not achieve this (Kirschner et al., 2006). Research on chess experts by Chase and Simon (1973) indicated that expert problem solvers access their extensive stored skills from long-term memory and use this to select and apply the best procedure for problem-solving. Kirschner et al. (2006) also distinguished between novice and expert learners and the impact pedagogical approaches have on them. They stated that while minimal instruction and guidance may benefit expert learners, its value diminishes with novice students who lack a sufficiently high prior knowledge to provide the internal guidance required for self- directed and enquiry learning strategies.
Gallagher (2011) offered a similar argument on using lectures to teach modules such as Pharmacy Law, where students are required to have knowledge of the law prior to achieving the outcomes designed for the module. Studies conducted by McKeachie (1990) highlighted the effectiveness of the lecture method and didactic teaching to assist students to acquire a foundational knowledge. This approach can be enhanced and reinforced by law seminars which operate at higher levels of Bloom’s taxonomy.
Gleason et al. (2011) made the point that active learning should not be viewed as a single teaching method but rather as an approach with multiple possible methods, where they can feature in lectures as well. Stewart’s et al. (2011) work on active learning in pharmacy education in the USA also changed the way traditional lectures are viewed. Their work revealed the use of active learning techniques in the majority of pharmacy schools’ lecture rooms, with higher active learning techniques being implemented in modules with heavier teaching loads. Perhaps this can be linked to the increasing knowledge base in the health care professions, where it is not possible to increase semester length or class time proportionately to accommodate all that is required.
In Nigeria, where lecture or didactic teaching is common, Osinubi and Ailjoe-Ibru (2014) discussed the advantages and attractiveness of using the lecture method,
especially in poor countries with limited economic resources. They do, however, believe that lectures are inadequate to prepare students for the professional situations that await them in the various complex and dynamic pharmacy practices. There is thus an urgent need to search and include complementary pedagogical approaches to those currently in use (Osinubi & Ailjoe-Ibru, 2014).