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Articles Development and Implementation of Critical Thinking Assignments Throughout a Pharmacy Curriculum1,2

Marilyn F. Harris, Marc W. Harrold, Raymond A Giudici, Riccardo L. Boni, Wenchen Wu3, J. Douglas Bricker, and Juan R. Avila School of Pharmacy, Duquesne University, 600 Forbes Avenue, Pittsburgh PA 15282

A summer workshop on critical thinking, spread over two months with follow-up implementation allowed an extended period of time for faculty to clarify teaching goals and provide group support for implementing change. Seven faculty, representative of several pharmacy disciplines, clarified critical thinking outcomes for their courses, practiced this approach in a faculty workshop, and piloted the approach in the following academic year. Written processes, visual models and class assignments were developed for Biochemistry— intermediary metabolism; Therapeutics—psychiatric case study; Pharmacy Management—inventory; Pharmaceutic—osmolality; Pathophysiology—congestive heart failure; Pharmaceutical Analysis—glucose monitoring test; and Pharmacy Administration—practice issues. The faculty workshop commenced with a one-day session with an outside consultant. This was followed by a series of sessions where workshop participants discussed and practiced the skills necessary to teach critical thinking, and two sessions where each participant prepared and presented a critical thinking process for a specific course. After feedback and discussion, each participant revised their critical thinking class assignments and briefly presented these at the final workshop session. The developed assignments were then pilot tested and evaluated throughout the following academic year. A full report of the results of the project was distributed to all schools of pharmacy which are members of AACP.

FACULTY WORKSHOP The Commission to Implement Change in Pharmaceutical Education has emphasized the essential curricular outcomes of thinking abilities in preparing entry-level practitioners to provide pharmaceutical care (1). Thinking abilities consist of several contributing abilities, including scientific compre-hension, mathematical competence, and critical thinking. Pharmaceutical education has traditionally focused on sci-entific comprehension and mathematical competence. How-ever, critical thinking, the rational, logical and coherent examination of issues, has not been identified as an outcome in most pharmaceutical curricula until recently. The Focus Group on Liberalization of the Professional Curriculum (2) has built on the Commission paper to reinforce the need for engaging the student in active learning. The development of critical thinking abilities requires a shift from the traditional lecture format to a process engaging the student in becom-ing an active learner. This project focused on developing the skills of faculty to enable them to teach critical thinking to their students.

The School of Pharmacy embarked on a major curricu-lum revision for the new entry-level Doctor of Pharmacy program that will admit its first class in the fall of 1996. The curriculum change process involved coordinated efforts of a series of committees. The Instructional Strategies Commit-tee focused on identifying strategies for active learning to enable students to acquire the outcome abilities (i e., critical

1Supported by a SmithKline Beecham Foundation Grant Award (GAPS) through the American Association of Colleges of Pharmacy.

2Presented as a poster at the Exhibit Program of the 95th AACP Annual Meeting, Albuquerque NM, July 19, 1994.

3Currently at St. John’s University, College of Pharmacy and Allied Health Professions, Grand Central and Utopia Parkways, Jamaica NY 11439.

thinking) of the new curriculum. Traditionally, faculty have been reluctant to engage in this type of teaching for a variety of reasons including: inability to articulate critical thinking outcomes for a course, inexperience with these instructional approaches, comfort with the old methods, lack of time to develop new methods, perceived necessity to teach all the content in a subject area and concern for an active learning process taking too much class time and lack of rewards for teaching innovation.

Overcoming barriers was the goal of this project. A core group of faculty received the opportunity to clarify critical thinking outcomes for their courses and to practice this approach in a supportive collegial atmosphere. The momen-tum already established for curricular change at our institu-tion made this an appropriate time to offer faculty assistance in changing their instructional strategies. By using a core group of faculty, representative of all pharmacy disciplines, seven written processes and visual models of critical think-ing were developed. As faculty developed skills in this instructional strategy, they acquired increased comfort with this new method as well as experience which should lessen the time necessary for implementation of further changes.

How the Project Was Conducted Traditionally, faculty have not received professional

instruction or mentoring in pedagogy. As graduate students, their focus has been on research with little or no emphasis on developing teaching skills. On joining faculties, many new instructors are usually left to their own resources to develop teaching methods. Oftentimes, they resort to modeling after their own teachers as well as by trial and error. The result is that instructors teach in isolation and infrequently share successes or ask for ideas from their peers. More recently, local and national programs on faculty development at

American Journal of Pharmaceutical Education Vol. 61, Spring 1997 1

Fig. 1. Project objectives.

professional conferences have provided information on teaching technologies. These have tended to be short defini-tive programs with little opportunity for active learning. When faculty members return to their home base enthusiastic about these new ideas, they are met with lack of support from their peers for implementing new teaching methods. In contrast, Meyers(3) reported success with an ongoing semi-nar on critical thinking that allowed an extended period of time for faculty to clarify teaching goals and provide group support for implementing change.

As a part of this project, a summer workshop for faculty with follow-up implementation and assessment was con-ducted. The project was supported by a SmithKline Beecham Foundation Grant Award (GAPS) through the American Association of Colleges of Pharmacy. The project objectives are listed in Figure 1. Seven faculty from a variety of disci-plines within the School of Pharmacy participated in the workshop process. They met the first week for a one day seminar with an outside consultant, and then for two, three hour sessions each week for four additional weeks during the summer. The faculty serving on the Instructional Strat-egies Committee were given the first opportunity to partici-pate and six of these faculty, who represent all the pharmacy disciplines, participated. One additional participant was selected based on interest and to assure discipline balance. The principal investigator served as group facilitator and as a participant. However, the workshop operated on the principle of peer leadership with individuals sharing equal responsibility for teaching minilessons.

Faculty participants received workshop goals, expecta-tions and background material on critical thinking before beginning the workshop. At the one day (six hour) work-shop during the first week, an outside consultant4 intro-duced critical thinking and the concept of disciplinary frame-works as an approach to conceptualize active learning. Workshop participants reviewed the work of Meyers(4) and Cheng et al.(5). Both authors distinguish among skills in critical thinking, problem solving and logic. Problem solving and logic skills learned in one discipline, according to these authors, are not fully transferable to another discipline and they both propose a discipline-related framework for criti-cal thinking. Both logical reasoning and problem solving take different forms in the context of different academic disciplines. This concept requires faculty to develop the discipline-related framework for teaching critical thinking in their discipline.

During the second workshop, a three hour session, participants shared specific examples of the problems or 4C.A. Weiss, PhD, Director of the Teaching and Learning Center, Philadel-phia College of Pharmacy and Science.

issues they wanted students to be able to analyze in their respective courses. They were asked to discuss the critical skills and analytical framework they wanted their students to learn. As predicted in the initial workshop sessions, several different analytical frameworks became apparent with some overlap between disciplines.

In preparation for workshop sessions three and four, each participant was asked to prepare a one-page descrip-tion of the critical thinking process and the analytical frame-work he or she wanted students to learn and practice within a specific course. Participants were asked to include in their one-page description, a concrete example of how this critical thinking process works within the framework of their re-spective disciplines. At these workshop sessions, faculty participants were asked to present a 10-15 minute minilesson which would simulate an abbreviated first class session. This lesson included the objectives for the class and the value to students of a disciplinary framework for critical thinking. Following fifteen minutes of feedback and clarification, each participant was asked to use the information from this discussion to develop a revised and improved description and visualization of his or her framework for critical think-ing. Two full sessions were required for all seven partici-pants to teach and discuss their lessons within the group.

In workshop sessions five and six, each participant presented (via minilessons) a written assignment that re-quired students to practice the critical analytical skills he or she had described in the previous workshops. The partici-pants were asked to incorporate the feedback from the discussion into a revised written assignment.

During workshop session seven, each participant dis-tributed to the group a revised one- page written description and visual model of his or her analytical framework for critical thinking and a revised critical thinking assignment, taking ten minutes to explain the revisions. The final hour was used to evaluate the entire workshop.

Faculty incorporated the descriptions, models and as-signments into course modules. The resultant seven mod-ules are discussed individually below. Periodic follow-up meetings during the year ensured peer support for the participants as each faculty member implemented the new critical thinking teaching strategy. These meetings also pro-vided a forum for faculty to discuss other teaching strategies. All the modules were developed and implemented for the current BS in Pharmacy (0-5) program. Although students in the BS program were used to test these modules, they were developed with the intent of incorporating them in the new entry-level PharmD program, which enrolled its first students in the professional phase of the program in the fall of 1996. BIOCHEMISTRY

The basic concepts of biochemistry are currently taught at Duquesne University in a one semester, four credit course offered during the fall semester of the third year. Of these four credits, three are used for lecture and one is used for a weekly laboratory. Since course time for each individual subject area is extremely limited, it is crucial that students learn how to apply basic concepts to situations not explicitly covered in the course lectures.

The body’s use of fuels—proteins, lipids, and carbohy-drates—to provide both energy and building blocks is taught over a period of three weeks (10 lectures). The primary focus of this lecture series is the body’s utilization of glucose;

2 American Journal of Pharmaceutical Education Vol. 61, Spring 1997

Fig. 2. Stepwise solution to initial biochemistry problem.

however, an emphasis is placed on the basic concepts of metabolism and their application to physiological and patho-logical conditions. Specifically, the lecture series begins with a discussion of basic metabolic concepts and then continues with discussions of glycolysis, aerobic versus anaerobic con-ditions, the pentose phosphate pathway, the Kreb’s Cycle, oxidative phosphorylation, and the biochemical changes which occur in a diabetic patient. In other words, the lectures impart an overview of how pathways are organized in the body. Most importantly, they include discussions of the efficiency of metabolic organizational schemes—those nor-mally used by the body as well as less efficient alternatives. Rote memorization of complete pathways is neither stressed nor encouraged. Instead, students are encouraged to de-velop a conceptual understanding of biochemical principles. Presentation to Students. During the first half of the first lecture (approximately 25 minutes) on metabolism, stu-dents were introduced to critical thinking and problem solving within the context of both course objectives and subject material. First, they were given a copy of the objec-tives for the metabolism section of the course. These objec-tives were divided into two areas: knowledge and applica-tion of knowledge. In the area of knowledge, students were expected to learn definitions of key terms (e.g., oxidation, cofactor, etc.), basic concepts in the design of metabolism (e.g., the role of ATP), and the specific biochemical path-ways that were presented in class. Students were instructed that after successful completion of the course they would not be expected to remember or reproduce all of the schematic details of a given pathway; however, they would be expected to gain a knowledge of starting points, ending points, key intermediates, interconnections, and the purpose of the various pathways discussed. In the area of application of knowledge, a higher order process requiring critical think-ing and problem solving skills, students were expected to be able to explain or predict (whichever is applicable) the physiological or biochemical effect which will occur as a result of a specific disease or other circumstance. Addition-ally, they were expected to extend ideas and concepts to analogous pathways and situations not directly presented in

lecture. A stepwise approach to critical thinking and problem

solving as well as a model depicting one possible approach to problem-solving were then presented during this initial lecture. The stepwise approach taught students to sequen-tially: (i) define the problem; (ii) identify all pertinent information which is given; (iii) determine which biochemi-cal concepts or facts are applicable to the problem; (iv) apply their knowledge to solve the problem; (v) arrive at a possible solution; and (vi) verify their solution. While the presenta-tion was slanted towards biochemistry, many features of the process are applicable to other disciplines. The problem-solving model instructed the students that they need to draw on their foundation from previous chemistry and biology courses in order to understand the body’s rationale for how and why various pathways function and are organized. During this presentation, students were instructed that they should strive for a thorough understanding of why meta-bolic pathways behave as they do, since this would help them to better understand biochemical processes. Students were instructed that the knowledge and experience gained by this step-wise process could be applied to questions pertaining to normal processes as well as specific diseases and abnor-malities. Obviously, all of the steps in this model were not necessary for every question or problem; however, the model provided a way in which to dissect a biochemistry problem into its components.

An example of how critical thinking and knowledge application is a much more efficient process than rote memo-rization closed out the initial critical thinking/problem-solving lecture. Being that this critical thinking presentation occurred during the initial lecture on metabolism, a simplis-tic example was used. In this example, students were shown a simple reaction in which Compound A and NAD+ are converted to Compound B and NADH + H+. They were then asked to determine whether the substrate is oxidized or reduced. The students were then lead through the thought process that should be used to solve this problem (see Figure 2). During this presentation, the instructor stressed that memorization of specific reactions was of minimal use in solving the problem and that only through the proper use and application of knowledge can the problem be solved. Assignment. Students were given a copy of eight problems which were organized into three areas: prediction of how alterations in biochemical processes would affect the body, application of metabolic processes and concepts to other pathways, and discussion of how the body adjusts to chang-ing circumstances. Each of these areas directly coincided with the course objectives that required students to apply the knowledge they gained from the course. During the metabolism lecture sequence, one question from each area was solved during lecture, and the remaining questions were assigned as homework. The solutions presented during class emphasized problem solving skills and the application of knowledge. The homework questions were graded, and the scores were used as a portion of the students’ final grade. Examples of questions solved in class and those assigned as homework can be found in Figure 3. Evaluation. Although formal evaluation of the effective-ness of this critical thinking/problem solving module was not performed, the overall feedback from the students was very positive. Most students said that the exercises helped them to think through problems and provided them an opportu-


Fig. 3. Sample questions from biochemistry critical thinking assign-ment.

nity to improve problem solving skills. Despite the students’ enthusiasm for the method, correction of their homework assignments revealed unimpressive results. While most stu-dents demonstrated that they could arrive at a correct answer, a much smaller percentage of students were able to provide a complete rationale for their answer. Additionally, a large percentage of students did not thoroughly answer the questions. That is, they correctly discussed only one aspect of the correct answer and stopped. From this instructor’s viewpoint, the critical thinking module described in this document is useful in introducing students to problem solv-ing skills in biochemistry.

BASIC PHARMACEUTICS LABORATORY At Duquesne University the Basic Pharmaceutics 301-302 is a required course taught in the third year and is the first professional undergraduate pharmacy course taken by stu-dents in the School of Pharmacy. The laboratory portion of this course is an integration of basic pharmaceutics experi-ments and dosage form preparation. It is designed to apply basic concepts taught in the didactic section of the course with contemporary pharmacy practice. The basic science courses which students took in pre-pharmacy are building blocks for Basic Pharmaceutics and this course is one addi-tional building block for their future pharmacy practice.

A weekly lecture of 50 minutes introduces the material to be covered in the laboratory and provides the student with a basic minimum understanding of the laboratory. Since the laboratory is competency based, the student must review the competencies for each laboratory to ensure a mastery of the material covered. At the conclusion of the laboratory the students participate in a group discussion which is an interactive dialogue between the students and their teaching assistant. After the completion of the discus-sion, the student should be thoroughly knowledgeable in pharmaceutical concepts and applications taught or experi-

enced in the laboratory. Although the laboratory provides the opportunity for

creative thinking and problem solving, the student often is trapped in believing that education is only the recall of information. To make the transition from a lower (memory) to higher level of thinking (critical thinking), requires a understanding of the teacher’s concept of the critical think-ing process and its application to every day problem solving in pharmacy practice. Presentation to Students. In the first recitation of the fall semester, the students were informed that critical thinking would be emphasized in the course. If the pharmacy student is confronted with a problem or a question, the student should first define the problem. This step is critical because it may be the only opportunity to ask question(s) of the patient, physician or allied health worker. The student must then isolate the pertinent data that relates to the problem. After this step, the student begins the analysis phase of the critical thinking process. In the analysis phase the pertinent data are compared to the student’s basic knowledge base and a solution is proposed. Finally, the student evaluates the solution to determine if this is a reasonable solution to the problem. The definition of the problem, isolation of data, analysis, solution and evaluation are the basic steps in the critical thinking process. Assignment. A clinical scenario exercise was designed to illustrate the importance of osmolarity in problem solving (see Figure 4). The exercise was to be presented as a case presentation to the students during the laboratory on osmo-larity/osmolality. The goal was to draw basic concepts from their pre-pharmacy courses, the laboratory and general reasoning to solve a problem that was new to the students. Although critical thinking was the focus, at this time in the students educational development, it was decided by the instructor to emphasize the analysis phase.

The exercise was presented to the students at the con-clusion of the laboratory. This session was the last labora-tory of the semester, immediately preceding their Thanks-giving break and also the longest of the fall term. These factors were important in evaluation of this exercise.

There were a 151 students enrolled in the Basic Pharmaceutics class which was divided into five laboratory sections. In order to maintain consistency and to determine, if this exercise would be successful in a large group (30 students), the author presented the exercise to each section. The author worked together with the students as a resource to facilitate the discussion of the assignment. After the exercise (which lasted an average of 45 minutes), the stu-dents completed the calculations at home and then returned the exercise for extra credit. Evaluation. The final two questions on the critical thinking exercise asked the students if the group exercise should replace the traditional group discussions and if the student had a greater understanding of the clinical applications of osmolarity. Eighty-seven percent of the class returned the completed exercise. Sixty percent of the class did not feel that the group exercise should replace the traditional group discussions. The most frequent reason was that smaller groups allow the opportunity for the individual student to participate in the discussion. In a large class of thirty to forty students, the students were less inclined to participate. Many students suggested that this type of exercise be in-cluded in small group discussions instead of a large group.


Fig. 4. Basic pharmaceutics special assignment.

Eighty percent of the students agreed that their understand-ing of the topic was increased. Many of the students ex-pressed the need for more educational experiences to relate concepts taught in the classroom to pharmacy practice.

The teaching staff reported that the students enjoyed the exercise and the staff requested that additional scenarios be developed for the class. Development of these cases requires time but are an instructional technique that should be considered in teaching basic sciences. Students desire a educational experience that allows them to develop skills applicable to pharmacy practice.

PHARMACEUTICAL CHEMISTRY Analysis of Drug Substances (Pharmaceutical Chemistry 310) offered in the spring semester of the third year was a comprehensive course covering the basic principles of ana-lytical chemistry, statistics as applied to measurement, the analytical process, problem solving and data interpretation. Examples used came from pharmaceutical manufacturing, clinical and biochemical analysis, pharmacokinetics, phar-macology and drug therapeutics. The major objective of the course was to provide students with an understanding of the principles, techniques and methods used in the identifica-tion, characterization and quantification of drug substances. In addition, relevant examples of the application of analyti-cal and statistical principles to the varied disciplines of the pharmaceutical sciences were presented.

A number of critical thinking processes were relevant to

this course. Students were expected to memorize and com-prehend a great deal of mathematical, statistical, chemical, physical, and biological information of which they may have varying degrees of prior knowledge. Students progressed to problem-solving through application and analysis. Finally, students were introduced to the evaluation process as ap-plied to the evaluation of analytical data as well as the evaluation of methodologies used. Presentation to Students. A workshop on critical thinking in pharmaceutical analysis was presented during the first labo-ratory period of the semester. Students were presented with a brief introduction to critical thinking and its usefulness in pharmaceutical analysis and other pharmaceutical disci-plines. Bloom’s “taxonomy” of levels of knowledge and thinking was presented and the types of “higher order” thinking processes described. Special emphasis was placed on analysis as this process is the most obviously relevant in any course on pharmaceutical analysis.

The central component of the analysis process is the question-answer unit. It is very important that we are sure that we are asking the correct question, one likely to satisfy our goals and objectives by: (i) defining or selecting a single question; (ii) dissecting the question itself to ensure we have not included any ambiguities or introduced sources of error; and (iii) constructing a revised question so as to be unam-biguous and most likely result in a clearly defined answer.

Once the question is defined we must determine the most appropriate technique, procedure or method to an-


Fig. 5. Critical thinking exercise #1.

swer it. Based on theoretical and practical information and principles, an analytical method may be selected by: (iv) selecting existing techniques or methods or combinations of existing methodologies; (v) modifying existing techniques or methods; or (vi) developing novel analytical techniques or methods. It is important to critically evaluate the selected method with respect to sensitivity and specificity, cost and general acceptability in the analytical community. The se-lected method must then be applied correctly and repeat-edly in order to obtain the highest quality results.

After the question has been answered we must evaluate the quality of the answer obtained. This evaluation may include: (vii) a statistical analysis to describe the accuracy and precision of our answer, a cost-benefit analysis to deter-mine the overall effects of carrying out this analysis or an even wider critical evaluation to determine whether we have achieved our initial goals and objectives. Often the answer obtained will lead to (viii) a new question or questions of increasing complexity initiating a new analysis cycle. Assignment. In the time remaining (approximately 20 min-utes) two sample problems were presented and students guided through a discussion applying the critical thinking model. Students were guided in a step-by-step manner through the first exercise (Figure 5) with particular empha-sis on the problem-solving process and little or no emphasis on “correct answers” for which the students may not yet have the necessary background information.

For the second exercise (Figure 6) students were given several minutes to analyze the problem and discuss it amongst themselves. The problem was then reviewed with sugges-tions and comments solicited and compiled. At the end of the laboratory period, students were asked to evaluate the critical thinking workshop. Finally, students were asked to evaluate the workshop in terms of their understanding of critical thinking processes and the potential benefits of applying critical thinking to this and other coursework as well as to their future pharmacy careers. Evaluation. In general, feedback from the students was positive. This was the first laboratory presentation for this course and they had been involved in a number of critical thinking modules in the prior semester. Scheduling and environmental conflicts led to low attendance, 86 out of 144, and may have resulted in a small degree of bias in the evaluation. From a practical standpoint, the large class size did not lend itself to guided discussion and cooperative learning. Nonetheless, many students felt that discussing critical thinking strategies, explicitly, was and would be helpful for not only pharmaceutical analysis but other phar-maceutical disciplines as well.

Fig. 6. Critical thinking exercise #2.

Student comments ranged from very negative to very positive, falling roughly into three main groups. A number of students felt that they have discussed critical thinking all through their schooling and further discussion in pharmacy school was unnecessary and confusing. A number of stu-dents felt that a critical thinking approach is useful but felt frustrated that it was not presented earlier or integrated throughout the curriculum. The third group of comments were very positive with students commenting that critical thinking helped them organize their answers and use these techniques in practical applications.

From the instructor’s point of view, this exercise was very useful. Presenting and demonstrating a critical thinking model at the beginning of the course gave the students a framework they can use throughout the semester. Emphasis was placed on developing the higher order thought pro-cesses and problem-solving skills that can be used to “ana-lyze” problems and “process” large amounts of information and move away from rote memorization without compre-hension. Practicing these skills will benefit students in phar-macy school and in their future pharmacy careers.

PHARMACY ADMINISTRATION Pharmacy Administration 326, second semester third year in the BS in Pharmacy program, includes pharmacy practice and the American health care system. Critical thinking, communication abilities, social interaction and citizenship, and life-long learning outcomes at Level 2 as defined by the Focus Group(2) were the BS in Pharmacy program compe-tencies addressed in this course. The overall instructional strategy was a cooperative learning group process to de-velop critical thinking skills involving all 163 students. Course objectives specific to pharmacy practice were to critically analyze an issue important to the current practice of phar-macy, make a coherent persuasive presentation of the issue, listen to other points of view on the issue, and incorporate any new aspects of the issue into a written paper.

The three classes per week consisted of two traditional lectures and a cooperative learning session covering the professional practice issues. For the professional practice issues segment, the class was divided into four sections of approximately 40 students. At the first meeting of the sec-tion, the students formed five-member groups and selected their group leader. As a semester long project, each group searched the literature on a professional issue, critically analyzed the literature, developed a presentation (40-50


Table I. Semester assignment: Pharmacy practice issues General topic (assigned) Specific topic (selected)

Pharmacy: A Profession AIDS issues relative to pharmacy practice

Chemical substance abuse by pharmacists

Technical assistant for the pharmacist

Automation in pharmacy Mail order pharmacy Pharmacy technicians

The patient’s right to choose Freedom of choice Physician dispensing Direct of consumer advertising

Selection of appropriate drug therapy

Pharmacist prescribing A third class of drugs The switch of prescription drugs

to nonprescription drugs Drug product interchange:

A pharmacist respon-sibility to choose

Generic substitution Therapeutic interchange Medication errors

Some legal/ethical issues in the profession

Discriminatory pricing Drug diversion Rationing of drug therapy

Monetary issues in pharmacy Third party reimbursement Cost of drugs Pharmacy issues in the health

care system The patient, the center of

practice Patient counseling Providing pharmaceutical care Contemporary pharmacy practice

(niche marketing/compound ing, etc.)

minutes), prepared a handout for the section including a bibliography, and completed a written paper. Each section met for two hours weekly with the course instructors (one full-time faculty and two graduate assistants). During the first section meeting, the faculty instructor introduced criti-cal thinking, the group process, and the role of the leader and recorder. Presentation to Students. The first step of the critical think-ing framework asked students to analyze the assignment and to explore different viewpoints using reference litera-ture. The second step was for the group to decide on a direction for their presentation and to agree on the impor-tance of the different aspects of the issue. In step three, the students prepared the topic for presentation to the other students in the section. Step four was a discussion of the issue(s) led by the group. The framework indicated that the student presenters must be open to hear the discussion and incorporate different viewpoints into the fifth and final step, the written paper. This framework, in addition to assisting the students in the overall critical thinking process, focused on the discussion and the incorporation of new ideas into their final product. Previous groups without the critical thinking framework did not incorporate new ideas from the discussion into the final paper.

After the introduction of the framework, the students participated in a one-hour workshop to practice using it. Groups were given four one or two-page articles on a current professional issue. They were asked to read and discuss the articles in their groups and to prepare a five-

minute group presentation on the most important aspect of the issue decided by group consensus. One of the groups was asked to make its presentation to the class, followed by a general discussion. As all groups had read and prepared a presentation on the same general issue but selected what they considered the most important aspect for presentation, the discussion brought forward several different aspects of the issue. The presenting group then attempted to build a class consensus on the most important aspect of the issue. For example, in one of the sections, the assignment was current economic issues in pharmacy. The student thinking was directed by the articles distributed. Short articles were chosen simply because of the limited time available for this in-class project. (The students were given one hour to read the articles and prepare their presentation.) The groups who did not present but had prepared a presentation were ready to discuss their viewpoint rather strongly. In several sec-tions, the presenting groups had difficulty bringing consen-sus among the class, but all were able to make progress toward consensus. Assignment. The students were asked to follow this frame-work in developing the semester-long assignment: the group presentation and paper. A series of related topics relative to a pharmacy practice issue were developed by the instructor (see Table I). The general topics with dates of presentation were assigned by a lottery. Each cooperative learning group selected a sub-topic from the general topics assigned. An in-depth literature search on the topic with a minimum of 15 journal references was required. Students were encouraged to use a variety of presentation formats. A number of the groups chose a panel format with slides or overheads. Oth-ers used a round table discussion, skits, talk show format, debates both formal and informal, audience participation with voting for the pro or con side, demonstrations, props, etc. Groups not presenting listened to the presentation, evaluated the presenters and prepared a question to ask the presenters in the discussion session. The questions asked by the groups were written on cards and collected by the instructor for assessment of quality. This question decided by group consensus was part of the group grade. This method was used to ensure involvement of all students in the presentation and to encourage discussion among students in the section. Evaluation. From the observation of the instructors, there was better structure to the process, and the student groups analyzed the issue in more depth than previously. The students were more involved, both presenters and listening groups, than they had been in previous years. The discussion part of the assignment was not as effective as the in-class workshop, as the non- presenting students in the section had not prepared specifically for the topic and often brought erroneous information into the discussion. However, the presenters were diligent in trying to sift out the suggestions by their colleagues and incorporating the important new ideas into their final written paper. Overall, more class enthusiasm and depth of coverage of the topic resulted.

The students gave their evaluation of the framework and its usefulness in the project. Using a rating scale of 1 (lowest) to 5 (highest) the students gave the overall process a 3.6 rating. They perceived the framework as most helpful in the specific course assignment and less helpful in other courses or their future career.


PHARMACY MANAGEMENT Pharmacy Management, Pharmacy 325, is designed to fa-miliarize pharmacy students with managerial aspects of pharmacy practice. The main focuses of this course are to prepare the students to best serve their patients within limited resources and to make an optimum profit in a competitive environment. To achieve that goal, it is essen-tial for pharmacy students to acquire necessary business background and management knowledge while they are still in school. This education experience will enable them to think critically and initiate managerial decisions in their future pharmacy practice. A key element in achieving that goal is through efficient inventory management because a major part of pharmacy resources is invested in inventory.

In this course, an inventory management module is given over a three-week period. After completing this mod-ule, students are expected to understand basic concepts pertaining to inventory control, make decisions on inven-tory investment and evaluate inventory management per-formance.

Since Pharmacy Management 325 is the only required management course in the pharmacy curriculum, it poses a great challenge to the instructor to have pharmacy students become active learners of management in an otherwise clinically-oriented education environment. To motivate stu-dents’ learning interest, a stepwise approach was under-taken to enhance their critical thinking skills in pharmacy management. The whole learning cycle was broken into small components according to the degree of complexity of cognitive skills. The instruction of this module was started with the introduction of simple inventory management con-cepts, followed by the application of the learned concepts to pharmacy financial information, and concluded with the evaluation of inventory control decisions. Assignments were also given to reinforce their learning process. Presentation to Students. Demonstrating an interesting prob-lem at the beginning of a class should bring students’ atten-tion to the lecture. In a typical fifty-minute class session, the instructor began the class with a pharmacy inventory ex-ample to engage student interests and challenge their think-ing process. A brief explanation and discussion of the ex-ample led to the didactic presentation of basic information and concepts. The first twenty-five minutes of each class session were used to explain the concept. In general, basic critical thinking skills such as memory, comprehension, application and analysis were exercised in this segment. For the next twenty minutes, we practiced inventory problems to reinforce the materials they just learned, and to apply higher levels of critical thinking skills if applicable. The remaining class time was used to summarize the concept or prepare a new topic for the next class. Cooperative learning process was used when the time permitted. Assignment. A comprehensive assignment was designed to guide students in developing a stepwise critical thinking approach to grapple with real life problems. This assignment was organized in accordance with the component skills of critical thinking at increasingly complex levels. Two issues were addressed in the assignment: to understand the impor-tance of inventory management and to assess the efficiency of inventory control. The assignment is presented in Figure 7. Evaluation. In this section, the instructor tried to assess to what degree a critical-thinking oriented assignment assists the student in solving inventory control problems. Due to

Fig. 7. Inventory management assignment set.


the time and resource constraints, the instructor was not able to design an experiment-control study to assess the results. A simplified version of pretest-posttest design was used for this evaluation. Question I in the assignment set was first given to students to practice. After students handed in the first assignment (Question I only), the complete assign-ment set (Question A through I) was given to them. The answer of Question I in the first assignment serves as the pretest; the answer of Question I in the second assignment serves as the posttest. In addition to completing the assign-ment set, students were also asked to respond to one addi-tional attitudinal question: to what degree the stepwise assignment set helps them answer “the first inventory con-trol assignment” (i.e., Question I)? Instead of directly com-paring the student’s grade on Question I in those two assignments, we only assessed the response of the attitudinal question. The results of this additional question were tabu-lated and summarized by a teaching assistant. The result is quite positive (see Table II). More than four-fifths of the students (83.9 percent) felt the stepwise type assignment was helpful.

PATHOPHYSIOLOGY AND PHARMACOLOGY Pharmacology and Mechanisms of Drug Action is a two semester course offered to fourth-year pharmacy students. The course is arranged by a combination of drug classes, organ systems, and disease states. This course is a link between the basic concepts of pathophysiology offered in the previous year of study and the applied knowledge pre-sented in the therapeutics course offered in the following year. In order to facilitate continuity and relevance of con-tent, students are presented the pathophysiology of some disease states just prior to the explanation and discussion of the drugs or drug classes which would be used in the treat-ment of that disease. The section of the course which was chosen for the critical thinking module was the pathophysi-ology and pharmacology of the cardiovascular system, spe-cifically congestive heart failure.

The concept of critical thinking was introduced to stu-dents during part of the regular lecture time. The idea of critical thinking was approached from the viewpoint of Bloom’s Taxonomy, involving six levels of learning; memory, comprehension, application, analysis, synthesis, and evalu-ation. Students were presented a one-page explanation with examples of each of the levels of learning, followed by two problem-solving exercises. In one exercise students were asked to answer the questions and determine what level of thinking was required to answer the questions. The results were compared to the instructors. Presentation to Students. Using Bloom’s taxonomy of edu-cational objectives, a pyramid-type visual model was chosen to represent the hierarchy of thinking processes and depict that the lower levels of thinking precede the higher levels. It was pointed out that certain principles (basic knowledge) need to be mastered before one can proceed to the analysis, synthesis, and evaluation levels of thinking. Students were told that these basic principles may have been taught to them previously and they would have to use them at this time, as well as incorporating new information that was being presented.

Students were given a handout which explained each level of thinking and examples of what kinds of questions may be asked within the context of each level. In presenting

Table II. Students’ evaluation of critical thinking assignment and their summarized responses

Response category

Number of students (percent)

Examples of summarized responses

Very helpful 12(7.7) An excellent review. Helped greatly. Were guided through the

concept by breaking into small components.

Understand more of the impact of too much inventory turnover rate on the pharmacy’s performance.

Increase the understanding of inventory turnover, profit, etc.

Make it clear and easy to do.

Helpful 118(76.1)

Gave me a clear idea of what kind of answer was desired.

A little easier in answering the first assignment.

Same assignment (to figure out more in-depth in the second assignment).

Somewhat helpful

15 (9.7)

Assisted to small degree. Don’t think it would have

helped to answer the previous assignment. It gave me a chance to review the material and make sure I understand that.

Not helpful 10 (6.5)

The order of assignments would not matter.

this model and examples, it was noted that students do not realize that they often use critical thinking patterns auto-matically. Consequently, one of the purposes of conducting this critical thinking exercise was to make students aware that they use this process frequently in answering questions and that they are only able to perform the higher levels of thinking because they have mastered the lower levels of thinking. The framework in which this model was used involved a discussion of the pathophysiology of congestive heart failure and the drugs and drug classes used to treat this disease. Critical Thinking Assignment. After students were pre-sented the basic concepts of critical thinking and were given sufficient time to reflect on the examples of the various levels of thinking, they were given a take-home assignment. The content material for this assignment had been given in lecture previously. This assignment involved seven ran-domly arranged questions concerning the pathophysiology and pharmacology related to congestive heart failure. Stu-dents were asked to answer each question without using reference material (textbooks or notes) and to indicate what level of thinking they thought was required to answer each question (Figure 8). Evaluation. Student responses were recorded and com-pared to that of the instructor. In general, the student’s


Fig. 8. Critical thinking assignment: Cardiovascular pathology and pharmacology

interpretation correlated well with the instructor’s. In Ques-tion #4, the student’s interpretation of the level of thinking required was an almost even split between application and analysis. Although the instructor felt that the question was asking students to apply how each of those factors would be related to alterations in cardiac output, it is understandable that an explanation of the significance of each probably requires more analysis. In Question #5, the majority of students (64.5 percent) indicated that this question only involved memory, whereas the instructor felt that this was a question involving comprehension beyond the basic knowl-edge of congestion. In Question #6, the greatest percentage of students (32 percent) agreed with the instructor, but it appeared that many students felt that this question involved comprehension or application, rather than analysis. A simi-lar situation exists for Question #7, but the percent re-sponses are closely spread among application, analysis, and synthesis.

THERAPEUTICS Therapeutics is offered in the fall semester of the fifth year. The course is designed to be a capstone course which covers the therapeutic management of various disease states. It is a team taught course in which various instructors teach in there specific area of expertise. The psychiatry module is covered over a two week period (12 hours). The major objective of the course is to have a basic understanding of the major psychiatric disorders such as schizophrenia, de-pression, bipolar disorder, anxiety disorders and substance abuse disorders. The therapeutic principles of the disease state and the management of the disease are taught daily in a lecture format; a recitation section meets weekly to discuss cases. The goal is to prepare students for their experiential clerkships, especially their clinical clerkship.

The problem solving and critical thinking models are essential to any therapeutics course. The process of identi-fying the problem, collecting essential data, analyzing the data and then recommending a course of action requires a

systematic approach in which critical thinking plays a major role. In order to provide pharmaceutical care, pharmacists must go beyond simple problem-solving approaches to more complex models in which an individual patient’s problems are analyzed and therapy is recommended based on indi-vidual problems and needs versus merely treating a disease. The students’ ability to tackle complex problems lies in their ability to critically think through the problems. Presentation to Students. In order to develop the problem-solving and critical thinking skills in the students taking therapeutics, a model was presented at the beginning of their psychiatric section of therapeutics. This model was also presented in one of the therapeutic recitation groups. The model consisted of identifying the problem, gathering the data related to the problem, assessing the data and develop-ing a plan to solve the problem and monitor outcomes. Cases were assigned in the first class period and students were told to workup cases according to the model presented and be prepared to discuss the cases in class. Student evaluation of the process was obtained for the recitation section but not for the large class.

At the beginning of the first therapeutic lecture on psychiatry, the students were presented with the model for developing problem-solving and critical thinking skills. It was explained that the model was developed as part of a study work group but that the model would not be part of their exam (Figure 9). Assignment. The model was explained in class and, in addition, a handout with the guidelines for a problem-oriented approach to cases was distributed. Handout and cases were distributed and students were told to be prepared to discuss cases at the end of the next class period. In the recitation session, the model was explained in detail and examples were done in class, then the students were told that the model should be used for the next session.

Discussion of the assigned cases occurred over the last fifteen minutes of the class period for the big class and


Fig. 9. Model for critical thinking in therapeutics.

throughout the class period in the recitation group. Both the lecture discussion and the recitation were moderated by the course instructor. Evaluation. Student participation was the main criterion by which the assignment was evaluated. Cases were turned in at the end of the class period and evaluated but not graded. Overall the discussion was much better in the smaller reci-tation group as expected. The discussion in the large class

was very poor, with very little participation by the students. When called upon the students could answer specific ques-tions but they could not elaborate when questioned further. The discussions in the recitation group were much better and the feedback was positive. The students liked having a model to follow when approaching cases and the explana-tion of a model had been lacking in the other recitation groups.

CONCLUSION During the summer workshop, faculty clarified critical think-ing outcomes for their courses, produced and revised a framework for teaching critical thinking and developed a module using this framework in a specific content area. All seven modules developed were tested and evaluated during the academic year. The workshop faculty continued to meet throughout the academic year to discuss both the progress in incorporating the critical thinking modules in their respec-tive courses as well as how to improve their modules. Addi-tionally, the workshop faculty discussed methods to incor-porate critical thinking more extensively into the curricu-lum. As a result of this project, critical thinking outcomes have been incorporated into a variety of pharmacy courses and disciplines. Plans are currently in place to adapt these outcomes in a new entry-level Doctor of Pharmacy pro-gram.

Am. J. Pharm. Educ., 61, 1-11(1997); received 8/7/96, accepted 12/16/96.

References (1) Commission to Implement Change in Pharmaceutical Education,

Background Paper II, Entry-Level, Curricular Outcomes, Curricular Content and Educational Process, AACP Special Report, Nov. 1991, p. 17.

(2) Chalmers, R.K., J.J. Grotpeter, R. G. Hollenbeck, N. A. Nickerman, M. Z. Wincor, G. C. Loacker and S. M. Meyer, “Ability-based outcome goals for the professional curriculum: A report of the Focus Group on Liberalization of the Professional Curriculum,” Am. J. Pharm. Educ., 56, 304-309(1992).

(3) Chet Meyers, Teaching Students to Think Critically, Jossey-Bass, San Francisco CA (1991) pp. 101-114.

(4) Ibid, pp. 17-25. (5) Cheng, P.W., K.J. Holyoak, K.J., Nisbett, and Oliver, L.M., “Prag

matic vrsus syntactic approaches to training deductive reasoning,” Cog. Psy., 11, 293-328(1986).

(6) Bloom, B., Taxonomy of Educational Objectives, McKay, New York NY (1956).


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