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Basic Pharmacokinetics PHA 443

Course Content available @ http://pharmacy.creighton.edu

Schedule Spring 1999

Week of TextChapters

Content Comments

March 15 1 –2 Introduction,Basic Math Skills

March 22 3 PharmacologicalResponse

March 29 4 – 5 IV Bolus,IV Infusion

End of Materialfor Exam # 1

April 5 Exam #1 40% To Be Scheduled

April 12 7 – 8 Oral Dosing,Bioavailability

April 19 9 Clearance

April 26 10 DosageRegimens

May 3 Exam #2 60% To Be Scheduled

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Teaching Philosophy

Teaching is the number one priority of my Creighton mission. This is why I went to graduate school. Thisis what I wanted to do all of my life. After I had graduated from pharmacy school and been a practicingpharmacist, I applied to and was accepted into pharmacy graduate school and medical school. I chose theformer, without hesitation and without a second thought.

Availability

My students come first. I am available to students at any time. I do not have office hours. Instead, I havea two-week running schedule on my door which tells the student when I am not available through previouscommitments. A student may see me whenever I’m available in the office or sign up for a futureappointment on that schedule if I’m not available. When in my office, the student has my entire attentioneven to the point of ignoring phone calls. I have voice mail and can return calls but a student ignored is lostforever. Obviously, this process is only a problem when more than one student needs attention at the sametime. Thus the need for future appointments.

My vision - what I do.

When asked, “What do you do?” I am reminded of a story in which the prince of a nation came upon aconstruction site whereupon he asked several people what they were doing. They answered according totheir job description: “I’m cutting stone.” or “I’m mixing mortar.” The prince happened on an old stonecarver cutting a gargoyle. He asked, “What are you doing?” To which the old stone cutter replied, ”I’mbuilding a cathedral!” Well, I’m building competent health professionals. I teach them Creighton values. Iteach them teamwork. I teach them to be self motivated. I teach them to be self learners. We discussethics; the professional, intellectual, social aspects of what it means to be a health professional graduate ofCreighton University. I tell my students that I used to teach Pharmacokinetics and Pharmacy Calculations.Now, I use this same course content to teach Creighton values and to build competent health professionals.It took ten years and major trauma to recognize who I am and prioritize what I do. This is what I do.!Every morning, I get up and think, “I get to go to school today.” It’s exciting! When we talk in class aboutcareers, I tell the students that they will have a professional life of about 40 years. For five days a week,fifty weeks a year, they will go to work. It had better be what they want to do! It had better be fun!

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Teaching Style – Excerpted from Presentation to American Association ofColleges of Pharmacy – July 1997

Evolution of style - Where did it come from?

I have over the years attempted to emulate several different styles of pedagogy in an attempt to be a betterteacher. Most of us have been trained to do research, but have we been trained to teach? Most of us teachas we were taught. Whether that is good or bad, it’s the best we can do because it's all we know how to do.We use the tools that we learned to pass on the skills that we learned to the next generation of healthprofessionals. Many of us, (Pharmacy professors) come to the AACP meeting and attend the Teacher'sSeminar. We spend one day a year attempting to perfect our craft. I say craft, for craft, it really is. Itreally is a learned skill and it doesn't come on conferral of a degree. We don't know how to teach contentjust because we know content. I have searched for a better way to do this. What I have found,interestingly, comes from coaching techniques as well as pedagogical literature. Several years ago, I tookcourses to become an ACEP (American Coaching Effectiveness Program) certified Judo coach. Moststates recognize this program in lieu of a teaching certificate. After taking this course, I felt that thetechniques utilized in the psycho-motor domain should have counterparts in the cognitive domain and Ibegan to search the literature as well as attending workshops on pedagogy. I began to apply what I learnedwith a gradual improvement of the outcomes of my teaching as evidenced by an improvement of overallperformance by the students and improvement of student perceptions of what was being taught asevidenced by my teaching evaluations and student letters. A major breakthrough in my teaching style cameas a result of a one week workshop hosted by AACP in the use of case studies in teaching. What I saw wasthe basics of group dynamics and the beginnings of the process described below. This seminarsignificantly altered my teaching style from a professor-centered, passive-learning lecture format to anstudent-centered, active-learning problem solving format.

Student Centered, Active Learning Process

What I will describe is a student-centered, active learning process applied to teaching a basic sciencecourse. Results of this process over multi-year longitudinal retrospective study with respect to studentperceptions and performance are evaluated.

Objective: Describe (II) the role of objectives in evaluation process

I submit that we make competent health professionals. We don't have a guild system of apprenticeship toaccomplish this, like pharmacy of a hundred and fifty years ago nor do we have a completely didacticsystem, but a combination of both with a didactic system designed to impart the scientific background andbasis for the rotational “apprenticeship” experience. If, in fact, our job is to make competent healthprofessionals, it would be reasonable to define a competent health professional. The profession ofPharmacy has determined that there are minimum, entry level abilities or competencies necessary forpharmacists. It is important to understand that these are not the result of some faculty member who sits inhis ivory tower saying what he thinks is important, these are what pharmacists do. These have beenpromulgated as a set competency statements. The NABPLEX competency statements are one such set.These competency statements should be the basis for the NABLPEX part of the state board exam as well assome of the pharmacy curriculum. They are a subset of the Creighton outcomes statements which havebeen promulgated by and for the faculty. These competency statements are broken down into five generalareas and further subdivided into specific activities. These should be considered goals of the educational

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process, these measurable competencies. From these, should come the course objectives, broken down asfinely as necessary to give the student the tools to do the competencies. These objectives should consist ofthree parts, information necessary to do something, (Given....), an action verb (student does something)with a level of difficulty (Bloom's taxonomy of higher educational objectives), and what is it that is to bedone. For example:

Connect course objectives to desired outcomes

Competence statement 2.00.00 Assessing prescriptions / medication orders and the drugs used indispensing them.

Specific activity 2.02.00 The candidate shall assess the physicochemical equivalency or non-equivalency ofmulti-source drugs

Course objectives for Bioavailability:

i. Given sufficient data to compare an oral product with another oral product or an IV product, the studentwill estimate (III) the bioavailability (compare AUCs) and judge (VI) professional acceptance of the productwith regard to bioequivalence (evaluate (VI) AUC, Tp, and Cpmax).

ii. The student will write (V) a professional consult using the above calculations.

Connect course exams to course objectives.

It follows, then, that the practice problems and the examinations or course evaluations should bemeasurement of how well the student mastered the course objectives and nothing else. If it's not anobjective, it shouldn't be graded. Conversely, if you think that it should be graded, then it should be anobjective. The exam questions and problem sets should be linked to the course objectives and the courseobjectives should be linked to the competency statements. Chaining this process back one more step, itshould be obvious that the prerequisites necessary to complete the objectives also can be determined by thisprocess and clearly stated.

The concept is reasonably straight forward:

1. tell them what you expect from them in detail,2. give them practice at doing it, and3. have them show you that they can do it.

My accountability to stick to the objectives.

I add a fourth part: If I don't follow the above three parts and put a question on an exam which doesn't meetthe requirements, the class votes and if it is agreed that the question did not meet the requirements, it isthrown out. Note: not that it was hard, not that you got it wrong, not that you didn't think that it should beon the exam, but did I tell them that they needed to know how to do it?; was it an objective?; and werethere practice problems? Not all possibilities can be explored in problem sets, but general problem solvingprocedures can be taught. In ten years of student suffrage, not one question has ever been voted out. I donot believe that teaching is the hauling out of voluminous amounts of facts to be sorted out and prioritizedby the neophyte student, nor is it the spoon-feeding of predigested pabulum.

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Clearly, tell the students what they are to do.

Objective: Compare (III) various levels of expectations

The expectations that you should have for the student performance would be in three arenas:

Expectations for the course

1. Level of Complexity - how much do you want them to know? (Table 2)2. Level of Mastery - how well do you want them to know it? (Table 3)3. Level of Instructional Demand- what student resources are required? (Table4)

These levels are really a continuum, arbitrarily partitioned into six levels with some landmarks defined. Itshould be apparent that the levels should be commensurate with the student's abilities. Students should nomore be expected to perform in a previously unpracticed level than they should be able to swim whenthrown into the water for the first time. They need demonstration, practice, encouragement, practice,evaluation, practice and then more practice.

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TABLE 2. Level of Complexity (Evans’ Taxonomy of Complexity (Modified))Cognitive Domain Psycho-motor Domain

1 Overview - Highlights of the areaSimple Motor Skills: easy repetitive motions

2 Introduction: Some perspectives andprinciples

Compound Motor Skills: Multiple motions notnecessarily repetitive

3 Perspectives and some essential principles Applied Motor Skills: care and beginnings ofdexterity required

4 Intermediate : Most essential principles and fewtopics in depth

Involved Motor skills: coordinated, multiplemanipulations

5 Advanced: All principles and majority of topics in depth Complex Motor Skills: high degree of dexterity required

6 Most Advanced: Great depth in virtually all subjects Most Complex Motor Skills: strength, endurance,dexterity needed

TABLE 3. Level of Mastery (Bloom’s Taxonomy of Higher Educational Objectives)Cognitive Domain Psycho-motor Domain

1 To Know, Recognize information / material Slow and awkward2 To Comprehend, Recall information /

materialNot as slow with moderate precision and accuracy

3 To Apply information, do calculationsSpeed, accuracy and precision improving

technical skills but still substandard for entry level

4 To Analyze a body of knowledge identifyrelationships

Methodical and meeting all minimum standards ofprecision and accuracy

5 To Synthesize put together information in new waysMethodical processing declining and finesseincreasing as well as accuracy and precision

6 To evaluate judge the worth of an idea Good speed, with precisionaccuracy and finesse

TABLE 4. Level of Instructional Demand (Evans’ Taxonomy of Instructional Demand (Modified))1

Little or no initiative required, virtually no outside class time needed

2 Moderate initiative and concentration, outside class time approaches in-class time3 Increased level of initiative and concentration required; begin independent learning; outside class time begins

to exceed in-class time4 Average level of initiative and concentration independent learning required; outside class time about twice in-

class time5 Substantial initiative, concentration, independent learning as well as outside class time required6

Intense initiative and concentration required, in-class time minimal

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Getting the student to buy into your expectations is critical for his/her success.

Level one in complexity, mastery and demand might be boring to a first year pharmacy student and beconsidered a “nothing” course, but if your objective is to simply expose the students to the jobopportunities available to a pharmacist, for example, level one is appropriate. Setting appropriateexpectation levels is essential and making the students aware of the expectations is critical. This latterprocess is most difficult. Students have a learning process which has served them well in the first twoyears of undergraduate courses. In these courses the mastery level was wrote memorization (Bloom's levelI), a little essay (level II), maybe some application (Level III), and occasionally, very rarely, some analysis(level IV). They have gotten good grades by cramming the night before the exam, which works well withlevel I and decreases in effectiveness as the cognitive expectations increase. Now, in professional school,the mastery level expectations are Level IV for many of the courses and by the time they are on rotations,level V. Interestingly, even when these expectations are discussed in detail, the students memorize the factthat they need to operate at level IV and are quite good at regurgitating the taxonomy, and the definitions (aLevel I cognitive skill), but complain bitterly when asked to perform at that level (do one on an exam.)“You never showed us how to do that variation!” That’s right. If I had showed them that variation, itwouldn’t be a Level IV. It would be a Level III.

They are not prepared to operate at these levels. They are, for the most part, devoid of experience in theselevels. They are comfortable being passive learners in which the faculty lecture and they take notes andmemorize the notes for the exam. Getting them to understand that, if they continue on this course of action,they are doomed to failure is difficult and in many cases takes a “wake up call” of poor performance whichgalvanizes them to change behavior. Those that can not, or will not because they cling to old behaviors, areeliminated. Each year, we lose several bright, young students who can't or won’t make the transition.Thinking is hard. Thinking is painful. To quote Tom Hanks from “A League of Their Own,” “Of courseit's hard! If it were easy, everybody could do it!”

Why might students fail?

I believe that there could be four reasons for failure:

Student is not intelligent or prepared enough to do his/her job.

In the first reason/excuse, I would offer that our student pool is such that we take the best of the best. AtCreighton School of Pharmacy and Allied Health Professions, we routinely have 9 applicants for everyseat. Our incoming classes GPA is > 3.2 with many having attained a Bachelor’s degree. These folks areeducable. I've found that they are neither stupid nor lazy. Content ignorant, yes, but that is why they arehere and that is fixable. Give them the tools, point them in the right direction, and get out of their way.

Faculty refuses to do his/her job.

In the second reason/excuse, I would also offer that I routinely get students who have failed a comparablecourse at other universities in my summer session. These students not only pass, but learn with enthusiasmand get A's in a course that they hated before. And before you chalk it off to “a nothing course,” take alook at the exams. One student from another university called me to tell me of her experience uponreturning to her home college. Her instructor asked her how she did and when she told him that she earnedan A, his response was that it must have been an easy course. What does that tell the student about hisopinion of her abilities? She whipped out the final exam and said, “Here, you do it!” His response, upon

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looking at the final was, “Oh, S---! - You've got to be kidding.” This faculty member routinely fails 20% ofthe class. I wonder.

Student refuses to do his/her job.

In this third instance, I believe the students have motivation to perform well. They, after all, have chosenpharmacy as their profession. In most cases, no one holds a gun to their head (although I can remembertwo cases in which this was not true. Once, I had a young lady who dearly wanted to be a dancer and herparents would pay for college only if she would become a pharmacist. She's now a dancer. A secondstudent didn't want to be a pharmacist but again, parental pressure. He's now a happy, professionallysatisfied pharmacist in Oregon.) If they don't want to work, we have failed to motivate them, interest them,or show them the relevance of what we teach. In a recalcitrant few whom I am unable to motivate, evenwhen they complain, they recognize what is happening and complain all the way down to failure. Onestudent's evaluation stated, “I hated this course. I had to do it all by myself.” Right on! All learning isactive. If the only active part of the course is the night before the exam, how much can you learn,particularly at the higher mastery levels. It has been said that people remember 10% of what they hear (Iwonder if it's that high if you are the sixth lecture of the day or right after lunch). I submit that they retaingreater than 90% of what they do, actively do, in concert with their peers.

Students experience problem outside their control.

In a few cases, students who perform poorly, do so as a result of some psychological emotional, monetaryor physical problem which must be solved before and meaningful learning can take place.

Whose education is it anyway?

Objective: Assess (IV) differences between traditional passive and active group-based learning

The crux of the matter is responsibility. The main difference, I believe, between active and passivelearning is shifting the responsibility for the education from the professor to the student. In the professorcentered, passive process, it's the professor's responsibility to set and adhere to a time-line. It's his/herresponsibility to “cover” the material. It becomes a game by the student to get the faculty “off-track” so asnot to cover so much for the exam. When the students are successful, the faculty, either covers less or moreoften covers the same amount, only faster. The professor assigns readings with the inevitable question, “Isthat going to be on the exam?” If you tell them it is, and it isn't, they'll never read the book again. If it is,then you're too picky and you didn't explain it in class. Another part of the game is to ask “Is this relevant?I don’t do this at Walgreen’s”. It's the professor's responsibility to make up the exam and the students'game to find out what's on the exam and to argue for points after the fact. Its the professor's responsibilityto come to class prepared, give an organized, coherent lecture, and possibly answer questions. It's thestudents' responsibility to take (or get from someone who came to class) a few notes which are ignoreduntil the night before the exam.

When students take responsibility, students win.

In the student-centered, active learning approach, it's the student's responsibility to set and adhere to a time-line. It's the student's responsibility to cover the material. It's the student's responsibility to come to classprepared. (You might argue that these have always been student responsibilities. I submit that in thisactive learning process, they accept them and run with it and, if they don't, the members of their groupdrag them kicking and screaming into compliance.) Last year's class voted for unannounced quizzes

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because they felt that there were members of the class who were not coming to class prepared. It passedunanimously! They are given the opportunity to the set the exam schedule. From these, the faculty setsthe content and the weights. The student is given the detailed objectives, reading materials, references, andpractice problem sets. They set their own time lines to attain mastery of the objectives. From theobjectives, the faculty create the exams. This obviates the eternal question, “Will this be on the exam?”What ever they have to do, where ever they have to go to get competent in an objective is theirresponsibility. If they have to read the book, if they have to go to the reference material, if they have towork a hundred problems, so be it. A second year student retold a first year's conversation that sheoverheard, in which the first year was complaining that I had given out 90 problems to review by thefollowing week, to which she replied, “and you had better do them, too.”

This is a competency based educational experience.

Competence must be reached by the end of the course. I personally don't particularly care if that occursearly or late in the course. If, for example, the class decides on two exams, then in my course, competenceof the first exam material can be shown in a special version of the second exam whereby students who havefailed to show mastery in the obtaining of the pharmacokinetic parameters from data sets must do so inorder to proceed whereas those who have shown mastery at the appropriate level are given thoseparameters for their use in developing a dosage regime. If they, then, have gained competence in the firstsection material, taking this exam replaces the previously unsatisfactory grade with the grade earned onthis section of the exam. If they haven't gained competence on the first section, they can not do the secondsection as answers from the first section are used as input for the second section. This special exam isrequired for the students who previously failed to show competence (D or F) and optional for anyone else.

Pharmacy is a lock step curriculum. What that means is that all the students take the core courses at thesame time. The corollary is also true. The whole class is off at the same time. An interesting phenomenonhas arisen in my classes. Second year students are off and in the building when the first year students are inPharmacy Calculations. The second year students voluntarily come into the class and work with the P1groups and don’t need to look at the book to assist the P1s in problem solving! The third year class is offwhen the second year class is in Pharmacokinetics and the same thing is happening. Competence is not thatyou could do it on an exam but when you can explain it a year later!

To recap:

1. Expectations: tell them what is expected - in detail, with specific objectives and appropriate discussionof mastery required.

2. Employ skills: Give them resources to complete the objectives (reading materials, references, problemsets with answers.)

3. Evaluate Mastery: of those specific skills learned and objectives met.

How does a faculty do this? Group Based Learning is the key! In medicine, the era of the mad scientist,locked up in his tower laboratory discovering the cure for Cancer or some other dreaded disease is goneforever. Almost all significant scientific advances come as a result of teamwork. Why not teaching?

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Teaching Process - Group Based Problem Solving

Objective: Describe (II) the process of initiation of group based learning

Establishing the Process

In this changing world of health care, pharmacists are being challenged to enhance their clinical andproblem solving skills. Students of pharmacy must develop these skills so that they may help fulfill theprofession's emerging role in pharmaceutical care. At Creighton University students are introduced togroup-based learning in their first professional year in Calculations and in their second year inPharmacokinetics in my courses and several faculty are beginning to apply this pedagogy in their courses.Being able to work in a team, being an active, contributing member of a team is a Creighton value. It isone of the other than content things that is stressed at Creighton University. The transformation fromtraditional, didactic, professor-centered passive learning to student centered active, group based learning isoften dramatic and always traumatic - for both the student and professor! It will not go well for the firstfour weeks if the student has never experienced this process. Don't give up. It will be worth every secondof agony that you go through. (I have found ways to shorten the first, troubled stages of group growth.Constant communication and defining expectations is the key.) The first time I decided to do this, Iconsulted with my chairman and told him that I was going to try a new teaching style and to be ready for alot of complaints and possibly bad evaluations at the end of the semester. Then I told the class how it wasto go, I held the first introduction, gave over the keys to the kingdom, and promptly when into thebathroom and threw up! How could I turn over the responsibility for their education to children who arealways looking for the easy way out? Well, I tell you that it succeeded beyond my wildest dreams.Seriously, it’s not for the faint hearted. It requires major shifting of paradigms on everybody’s part, but it’sworth it if you don’t give up.

“Toto, I've a feeling we're not in Kansas anymore!” - Dorothy, Wizard of Oz.

Objective: Describe (II) the responsibilities of the various players

Who are the Players?

Facilitator: Person coordinating the course. (Read Professor in other style.) Person who assists thestudents upon request. S/he would direct students to references and help them organize and connect upwhat they read.

Quality Team Leader (QTL): Student group leader / ombudsman to facilitator from group. (See QTLResponsibilities at the end of this section on Teaching.)

Group: Collection of four students assigned to work together by the facilitator. Once a level ofperformance is reached, they become a team.

Team: A well organized group who can work together outside of class to meet common goals.

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First day of class

Facilitator introduces the course, outlines his expectations (of both the students and the Quality TeamLeader, QTL), hands out course materials and detailed objectives. He outlines the ground rules, whichare: the groups have majority control governing number of exams to be given, exam dates, and if theywant quizzes. Items that are not negotiable are overall course time table, overall course content, number ofquestions on exams, weight of exams or exchanging group members. Attendance is not optional - it'smandatory. The group needs to be together to function.

Students are randomly assigned to groups of four by a deck of cards. Each group is a card value and eachstudent is a suit. e.g. the Aces are a group and each student is permanently assigned a suit. The studentsare given an “icebreaker” exercise to get them to learn more about each other. Each group selects a qualityleader to serve as a direct liaison between the group and facilitator.

The students are expected to read the book and references, come to class prepared and bring the toolsnecessary to work the problems; i.e. ruler, log paper, pencils, etc. They meet within their groups, discussthe required reading, correlate the specific objectives and the reading material and begin working onproblem sets. In addition to the problem sets each individual student is responsible for several libraryassignments in which they are required to calculate the pharmacokinetic parameters from the data using thetools learned in class. The student is then required to communicate in writing the results of suchcalculations with a suitable commentary regarding differences and interpretations. Each of the abovesections is designed to bring the student an understanding of the information and the processesnecessary to operate as a competent professional in the area of pharmacokinetic evaluation andconsulting. Consequently, the course evolves from a quantitative, manipulative mathematics course toa course which stresses communication skills. Consults will be graded not only on content (the properdosage regimen for the patient) but also grammar, punctuation, spelling, organization and neatness. Thestudent may have the best medical information in the world, but if it is poorly executed, it will beignored.

Weekly, the students are asked to provide a one minute summary of the topic consisting answering thefollowing questions:

Weekly Status Report

1. What was the main thrust of the study section?2. What was clear about the study section? What was done well?3. What was unclear? How could it be done better?

This provides a running monitor of effectiveness as well as a framework of what to stress in the referencematerials. This feedback is essential to get the mood of the groups and to address major concerns.Furthermore it serves to provide a continuous quality improvement aspect of the course - it is constantlyevolving and refined each time it's offered. (See Weekly Status Report at the end of this section onteaching.)

What does the facilitator do?

The facilitator roams around the groups to answer questions, guides groups to resources to clarify conceptsand start them on derivations of equations if needed. After each section, the facilitator will give anexecutive summary of the essential material the student needs to process for the exam, if requested. It is ashort lecture (overview) designed to tie in key concepts in order to enable the student to visualize the bigpicture - how small pieces fit into the larger whole. An important piece in the scenario is timing. The

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executive summary is not done at the beginning. It is not a lecture. If done before the student reads thematerial, it becomes a replacement for reading the material and since it is not designed as such but designedonly to tie together the reading and emphasize salient points, the process fails. In this case, the operativethought is: “No question is answered before it's asked.” The facilitator must wait until the student getsstuck and needs to seek assistance. When the same question shows up in several groups, the facilitatorhalts the group activity and gives the executive summary. At that point, an interesting phenomenon occurs.As the facilitator ties things together, students are listening, the facilitator gets positive feedback by facialexpressions and head bobbing and nobody is taking notes! They are ready to hear what you have to say.They have already created the storage space in their mind. They are not stenographers who blindly takeevery word down in hopes of understanding it later. They understand it now!

Facilitator responsibilities include training the QTLs, initiating regular meetings with QTLs, helpingidentify and solve problems within groups. He focuses on process, not content during the meetings. Hemight intervene to clarify/correct/teach if discussion deviates too much from what is reasonable. He mayalso institute changes in the course if a particular issue seems to be a major problem.

The facilitator should only intervene in a group if and only if the following conditions exist: the group isdysfunctional; clarification, feedback, summarization, or encouragement is needed; the group needs aformula/tool that the facilitator knows and can suggest where it can be found. Don't just give the answer.Show them how to find it. OTHERWISE HE IS TO SIT STILL AND BE QUIET!!!!!!

The facilitator attitude must be (and perceived to be) honest, genuine, respectful, humble (here to serve, notdominate). He must remain patient and detached, always attentive (listens to everything said, and watcheswhat goes on). Studies body language and gives careful attention to quiet members. He must stay at ahigh energy level (groups will tend to set pace with the facilitator). He must communicate on a one-to-onebasis as well as to the whole class. These must perceive that the facilitator is listening! Most students’perceptions were favorable about the facilitator. Most students recognize that this is not an easy task:(Student Quotes from evaluations are added in italics.)“Dr. Makoid is an outstanding educator, he takes a tremendous amount of pride in what he does. His availability to the studentsamazes me, I have never seen this.”“I think you were very fair and extremely generous with your time.”“I hope to get a C, but whatever my grade turns out to be I am proud of it because I know that I earned it.”“You made a very difficult subject very easy to understand.”“My first really relevant course and my best at Creighton so far.”“I think he is a great teacher. Always answered my questions and encouraged the students to do their best. He also respects thestudents as tomorrow’s professionals.”

However, there are some students who get very hostile about this type of learning. For example:“This is a worthless approach - by the end of the first class I knew if I was going to get anything from it, it would come from self-teaching.!! (Isn’t this what I was trying to do?)“We pay him to teach us, not to teach ourselves! Maybe we should of been paid, instead of him.”“I think this is an easy way for professor’s to get out of teaching!!”

I might suggest that this is definitely not a teaching cop out. It takes considerably more effort than thetraditional didactic process. In the professor-centered, passive-learning lecture format, I would, for a 2credit course of 100 students, give two lectures of 50 minutes each. In the student-centered, active learningprocess the students are broken into four sections of 24 each (six groups of four.) I am with those sixgroups for two and a half hours each section plus an extra two hours every week that is an open section foranyone to come and ask questions. In a session, each group of four has my entire attention for an averageof about 20 to 30 minutes. Some groups who are doing well don’t need the entire time, while other groupsneed more than the average. I do, however, sit with each group for every session, listening to thediscussion and giving direction if necessary. I will also offer that active learning is not some weird processthat I thought up. There is over fifty years of competent research in the educational field proving

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conclusively that this method is substantially better for the student with significant improvement ofcomprehension as well as retention. This is also apparent in data from this class at Creighton University.

What do the QTLs do? Kizen.

The Quality Team Leaders (QTL) and the facilitator begin meeting on a regularly scheduled date and time.They meet throughout the semester to resolve group issues and problems. The Japanese term for this is“Kizen.” It means to continuously improve. What better way to improve than to ask the people involved,the students, what is a barrier to your learning? Lets remove it. Last year the students voted to haveunannounced quizzes because they felt some members of the teams were not coming prepared to work. (IfI had instituted that, I’d be persona non grata. Go figure.) This year, the students suggested that we meetin a room with tables rather than desks -- done. They suggested blackboard for the groups would be useful-- a little harder, but we got it done. Westerners tend to make giant leaps and sit back on their laurels,whereas the Japanese constantly work, constantly make things better. We want to constantly make thelearning experience better. It’s kind of like the tortoise and the hare and you know who won that race. Thequality team leaders are given instruction and reading materials regarding their responsibilities. It is theirjob to make the group work. It is important to note another cultural difference at this point. It iscommonplace for Westerners to place blame when something doesn't work. Eastern philosophy is not theleast bit concerned with blame; the focus is problem solution.

Problem solving, not placing blame, is important.

It shifts from a person problem to a process problem which is completely non-judgmental. The QTLmembers bring suggestions which are discussed and voted on by the entire QTL team. If passed, it isbrought before the class and voted. If passed, it is implemented immediately. Personally, I have alwaysthought that student evaluations at the end of the semester have only served to allow the student to venthis/her spleen about some thing that didn't go right in the course that the teacher doesn't know about untilit's too late to do anything about it for this class. This process allows the student to remove the barriersfrom his/her learning when it will do her/him some good. Students feel that the faculty has listened and aremore responsive to listen to the faculty.

Quality Team Leader's responsibilities are to attend all the quality meetings with the facilitator or makearrangements to have another of their group take their place if they cannot make it. They are to participateas a group member as well as ensure that the group is functioning. The quality leader must exchangeinformation with the facilitator concerning problems encountered within the group so that they can beaddressed and corrected. They are responsible for the timeline between learning the material and examdates. They help establish and abide by guidelines given at beginning of course.

Quality Team Leader attributes include an outgoing friendly nature and a willingness to support the processas well as a sense of personal responsibility to ensure the process is working. They must be able tocommunicate verbally within the group and with facilitator and serve as a role model.

What do the students do?

Students are to participate as a group member and teach one quarter of each exam material to their groupmembers. This forces each member to be an active participant or risk the wrath of their peers. Obviously,they are to read the material, be prepared to ask and answer questions and help solve the problems. Theyare to seek assistance from the facilitator when the group gets stuck.

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It is interesting to note that some students secretly, resolutely hold on to their paradigm of the professor-centered, passive-learning process. Upon poor performance in the class, they lash out against thefacilitator, QTL, and the group even after reporting weekly to the QTL that everything is going well, thegroup experience is positive and that they have no complaints. I believe that it is simply a sign ofimmaturity to seek to place blame for your failures rather than to accept the consequences of your actions.They will learn that this behavior is counter productive to their goal of becoming a competent healthprofessional.

“You can observe a lot just by watching” Yogi Berra

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Teaching Process - Group Growth Stages

Objective: Describe (II) the stages of group growth

Group Dynamics: Learning to work together.

In group-based learning, the members must work out personal differences, find strengths on which to build,balance commitments of this class against the demands of other classes and work, and learn how toproblem solve. Pharmacy students are competitive by nature, and in traditional didactic learning they haverelied solely on themselves. A major obstacle to overcome is to change their thinking of “me” to thinkingof “us” and to take the responsibility of teaching a portion of the material to their peers. This is animportant step in realizing that someday they may become part of a team in which they must educate otherhealth-care professionals in order to improve patient care. As the team matures, members gradually learnto cope with the emotional and group pressures they face. As a result, the group goes through fairlypredictable stages.

Stage 1: Forming

This is a stage of transition from individual to member status - like hesitant swimmers; they stand by thepool, dabbling their toes in the water. They don't believe that this is for real. They demand a lecturer,someone to read the book for them and tell them what to do. Their feelings may include excitement,suspicion, fear, and anxiety about the course ahead. Student comments regarding this stage include:“In the beginning I was apprehensive, but at the end of the class comfortable.”“I felt very defensive at the beginning but better now.”“In the beginning I felt intimidated, at the end of the course I felt like I could be an asset to my group.”

Because there is so much going on to distract member's attention in the beginning, the group accomplisheslittle, if anything.

Stage 2: Storming

Storming is probably the most difficult stage for the group and the facilitator. It is as if the group membersjump in the water, and, thinking they are about to drown, start thrashing about. They begin to realize theclass is different and more difficult than they imagined, becoming testy, and blameful. “It's all Dr.Makoid’s fault. If he would only teach us like he's supposed to, it would be OK!” At this stage they areimpatient about their lack of progress, but too inexperienced to know what to expect or what action thegroup should be taking. At this point they resist the need to collaborate with their group and because testtime is rapidly approaching, panic and revert back to their norm - I can do this by myself - and I can waituntil two days before the exam to do it!!!!! This phase unfortunately takes place before the first exam. Donot give in to the desire to revert back to spoon feeding the poor dears. Remember “Knowledge maketh abloody entrance!”

Stage 3: Norming

This stage forms rapidly after the first exam results are posted. During this stage, members reconcilecompeting loyalties between themselves and their group and their responsibilities. They accept the group,

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the ground rules, their roles in the group, and the individuality of fellow members. Emotional conflict isreduced as previously competitive relationships become more cooperative. Group members begin to settledown and start helping each other. The change is significant to an observer - they become more relaxed,enjoy themselves, and begin to work together. As one insightful student wrote, “I wasn’t giving all I couldon the first exam, thinking I could pick it up days before, but I was sadly mistaken. Groups are a goodthing. I don’t think I was fully taking advantage of them, but I hope to improve in that aspect.”

Stage 4: Performing

By this stage, the group has settled its relationship and expectations. The team is now an effective, cohesiveunit. You can tell when the students reach this stage because they get a lot of work done. Complaints arerarely made. In fact, when asked to give their group mates a percentage score based on their group activity- everyone unanimously gives their group members a 100%!!! They have moved from passive to activelearning. One student's response to the facilitator's question of “How are you doing?” was “We’re busy.We’ll call you if we have any questions.” You can tell when you are there. No questions!

At this stage they may also have insights into personal and group processes, and a better understanding ofeach other's strengths and weaknesses. For instance, when surveyed, a majority of students stated that theirgreatest individual weakness was that they felt they were slow to understand/learn. They perceived that thegroup’s major weakness was that they could not meet as much as they wanted to outside of class.COMMUNICATION“I know you believe that you understand what I said, but I'm not sure you realize that what you heard is not what I meant”1. “In the beginning I was apprehensive, but at the end of the class comfortable.”2. “I wasn’t giving all I could on the first exam, thinking I could pick it up days before, but I was sadly mistaken. Groups are a goodthing. I don’t think I was fully taking advantage of them, but I hope to improve in that aspect.”3. “I felt very defensive at the beginning but better now.”4. “I'm busy. I'll call you if I have any questions.”5. “In the beginning I felt intimidated, at the end of the course I felt like I could be an asset to my group.”6. “It's all Dr. Makoid’s fault. If he would only teach us like he's supposed to, it would be OK!”7. “I was very skeptical concerning the teaching method, especially at the beginning.”8. “Working in groups was definitely beneficial. I think I learned a lot more than I would have learned on my own.”9. “I felt the course taught me to think more on my own.”10. “We pay him to teach us! Not us teaching ourselves! Maybe we should have been paid instead of him!”11. “Working in groups helped me get a better understanding for it because when I talked about it, I found I really knew what I wasdoing. I think it was good just the way we did it.”12. “Our group has hard time going at the same pace. Some members are ready to jump into the problems with no idea about theconcept while others try to read up on it because they don’t understand.”13. “The group thing needs a lot of work.”

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Barriers to Overcome

1. Physical

A. This method of instruction will not work well in lecture amphitheaters. Even in rooms with separateddesks, this does not work well. Students complain there is not enough desk top space, and they aredistracted by other groups talking. The ideal atmosphere includes a room divided into discrete sections foreach group with a large table and blackboard for each section.

B. In retrospect, a common complaint of spring/fall semester students is that they don’t have enough timeto work together. This method of teaching is not well suited to 50 minute periods. The ideal scenarioseems to be blocks of time - for instance, summer groups seem to coalesce faster because they meet for 3hours per day. They have time to accomplish problem sets without running out of time.

2. Mental (Refer to Appendix E)

A. Student Attitude - What I call the John Wayne attitude: I can do it all the night before and teacher willtell me everything I need to know for the test among others.

B. Facilitator Attitude - You just got to believe and exude confidence in this style of learning. If youdon’t, it will crash and burn.

3. Materials

A. Objectives must be and perceived to be clearly stated and detailed. Approximately 95% of studentssurveyed agreed that they felt the course objectives were clearly stated. In addition, 98% agreed that theexaminations given reflected the course objectives.

B. Content of the class must be organized in a step-by-step fashion so that the student is always buildinghis knowledge base.

“Paradigms are significant problems that cannot be solved with the same level of thinking with which wecreated them” EINSTEIN

It is possible to facilitate the group growth into stage four if the students are told what to expect about theprocess as well as monitored and behavior corrected as it develops.

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Teaching - Student Perceptions of the Process

Objective: Discuss (III) the student perceptions and corresponding supportive data derived fromgroup based learning experience

Student perceptions of group-based learning:

“This is the first course that I've been given credit for being able to read.” “Wonderful feeling to have an understanding rather than memorizing for a course.” “I feel more driven and challenged.” “This teaching style makes you think and learn for yourself. This is the real world.” “I thought the new style of class instruction helped me learn more effectively.” “I have never felt this good about a class and so confident.” “Overall it has prepared me to think more on an individual level, which in some cases in the profession you will have to do that.”

What to expect:

Expect variability in the classroom. In traditional didactic lecturing, the classroom remains a staticenvironment, however in group based learning each class becomes a new adventure in teaching. Eachgroup progresses at a different rate and has unique characteristics.

Expect that the groups may fail in the beginning and be ready to accept their failure. It is extremely gut-wrenching to watch this, but a valuable lesson is learned after the exam: “Let's start working together!”

Expect that the groups will no longer need you when they approach Stage 4. It can be very disconcertingfor a facilitator who wants to be needed!

Expect that other faculty may consider group based learning after they come to observe the process.However, expect also that some may run away as fast as they can!

With respect to the students expect better performance, higher grades, greater retention, improved attitudetoward field, improved attitude toward facilitator.

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Teaching - Supportive data - Student Performance

Does this process work?

Group work outside class increases prior to the night before exam. This can be readily observed andsubstantiated by the fact that the students who do not work within a group environment or groups that donot meet outside of class time do not perform well on exams. This is supported by student comments andself-evaluations.

TABLE 5. Supportive data - Exam ScoresPassive Learning Group1991 – 1993(n =273)

Active Learning Group1994 - 1996(n = 255)

Exam 1 78.6 85.3

Exam 2 82.2 92.7

On the average, exam means increased one letter grade without any change in content, complexity ormastery requirements.

“This was the first time that I went to bed at 9:00 P.M. the night before an exam.”

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Teaching - Supportive Data - Student PerceptionsTABLE 6. Student Perceptions of their performance

Exam 1 Exam 2Higher 27% 57%

Same 14% 11%

Lower 21% 11%

No Reply 38% 21%

Do the students think it works?

Since most students do not have a comparison between how they would have performed in a traditionalpharmacokinetics course in comparison the group-based course, they have difficulty in perceiving how thegroup has affected their grade. There are, however, a few students from other universities who have hadthe “opportunity” to experience similar courses differing only in active v passive style. At first, they areapprehensive and try to do it the passive way. They even tell me that at _____ university, we did it bypassive teaching style (my translation). I tell them that the operative definition of insanity is to do the samething over again and expect a different result. I ask them to give this process a chance and to try somethingnew.

It was interesting to compare IDEA evaluation responses for traditional (passive) students versus groupbased (active) students. In both subject matter mastery and the development of general skills, students whotook the traditional course in the summer mirrored group based learning responses. It has long been myperception that the summer classes performed better than the regular semester. Everything I did was thesame in both classes, so the differences were not something that I did. In 1991 through 1993, I observedthat in the summer, students came to me in groups to answer questions while in the regular semester, theycame singly. Voluntary group learning was the only difference! Thus, in the subsequent tables, PassiveSummer is separated from Passive Semester. It can be seen that Passive Summer Session more closelyresembles the active groups because they, in fact, voluntarily formed active study groups.

TABLE 7. Student Perceptions from IDEA Evaluations Regarding Development of General Skills1StronglyDisagree

2Disagree

3Neutral

4Agree

5Strongly Agree

Passive Groups Active GroupsSemester Summer Both

Thinking andProblem Solving

4.0 4.3 4.2

Creative Capacities 2.4 3.5 3.7

EffectiveCommunication

2.0 3.0 3.0

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TABLE 8. Student Perception from IDEA Evaluations of Questions regarding Subject MatterMastery

1StronglyDisagree

2Disagree

3Neutral

4Agree

5Strongly Agree

Passive Groups Active GroupsSemester Summer Both

Factual Knowledge 3.7 4.1 4.0

Principles and theories 3.8 4.1 4.0

Professional Skills andviewpoints

4.0 4.2 4.1

Discipline’s Methods 3.2 4.0 4.0

Some student perceptions:

“This course required a lot of hard work and thinking. Initially it was frustrating, but after working hard the concepts fell into placeand soon I was surprised at how much I learned. I became self-motivated to work even harder and found the concepts fascinating andalmost fun.”“Excellent class and instructor. It challenged my level of thinking and problem solving.”“This course involved a lot of time and effort, which made it very challenging. But in the end, it pays off.”

TABLE 9. Student Perceptions from IDEA Evaluations Regarding Development of Personal Skills1StronglyDisagree

2Disagree

3Neutral

4Agree

5Strongly Agree

Passive Groups Active GroupsSemester Summer Both

Personal Responsibility 3.3 4.0 4.1

It is not surprising that the students perceive an increase in personal responsibility in group based learning.When asked if the group experience made them a more responsible and knowledgeable group member,>95% agreed. In reply to the question of what was your group’s greatest strength, a majority of studentsreplied that their group worked well together - members were willing to help each other, communicationwas good, and they worked hard to accomplish the given objectives. When asked what strengths theygained through the group experience, the students replied: understanding, confidence, communicationskills, time management, listening to others.

TABLE 10. Student Perceptions from IDEA Evaluations Regarding Student’s Self Rating1StronglyDisagree

2Disagree

3Neutral

4Agree

5Strongly Agree

Passive Groups Active GroupsSemester Summer Both

Improved Attitudetoward Field

3.6 4.0 3.9

Student comments:

“After taking this Pharmacokinetics course, I have a more confident feeling about going into the pharmacy profession. I feel that I amcompetent and secure in deciding what's best for a patient in regards to dosing regimens.”“Would like to take advanced kinetics class - am very interested in the field.”“I was not looking forward to taking this course, however, I have gotten more from this class than I ever thought I could have. Iactually enjoyed kinetics, the method in which the course was taught, and then being able to solve the problems. I now have a verypositive attitude toward kinetics and look forward to taking another class.”

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Teaching - Appendix A - QTL ResponsibilitiesCongratulations! You have volunteered (or have been coerced) to assume the role of a Quality TeamLeader (QTL). This is a position of leadership within your group and with it comes some addedresponsibility. The purpose of this handout is to outline your role as QTL - your duties, and theexpectations I have for you. Do not panic. I realize that for most of you this process is new and different.Group based learning is rapidly becoming the teaching method of choice for several important reasons -students understand better and retain longer knowledge that they have actively learned, and they usuallyperform at a higher grade level. The main difficulty students have with this type of education is that theyhave never been responsible for learning or teaching each other within a group environment. Manystudents resist group learning and rebel or they may not know how or where to begin. Another obstacle isestablishing and maintaining a timetable in order to get through the material before the exams. A majordilemma you face will be focusing the group’s energy and attention to work through concepts and problemsin time for the exams.

QTL Responsibilities:1. Attend all quality meetings or make arrangements to have another group member take your place ifyou cannot make it. This is important to keep lines of communication open between each group and me.You can voice your group’s concerns, bring suggestions to discuss and vote for changes. You will beresponsible to take back meeting information to your group.

2. You are to participate as a group member - being a QTL does not excuse you from taking on yourshare of group responsibility. Set an example to come to class with the required materials and be ready towork.

3. Be a role model - be willing to support the process. Your fellow group members will take their cuesfrom you. We all know attitudes can be as infectious as the common cold - Keep yours positive! If youhave concerns or feel yourself down, talk with me.

4. Communicate with me about any problems or concerns within your group. This is not “ratting” onyour peers. Our (mine and yours) major concern is to ensure that the groups are functioning to the best oftheir abilities, that they are meshing together, learning the material, and working on the problem sets. Ifyour group (or a particular member) is not functioning well, everyone loses time and knowledge. My jobas facilitator is to help get the group working - BUT this can only happen if I know that a problem exists.This information will remain between us and confidential.

5. You will be responsible for creating your group’s timeline for learning each portion of materialbefore the exam. Your class determines the date and time of exams but the content is not negotiable. Youneed to work within your group to establish how much time you need to devote to each portion so that yourgroup will be done with the material before each section exam. You will have to monitor your group’sprogress and keep them focused. Tell them what is to be covered next, assign problems to members, andkeep moving forward. Not all groups will work at the same speed. What is important that all thedesignated material is covered well before the exam - Do not wait to learn it all the last 2 days before theexam! It won’t happen!

6. You are responsible for turning in a weekly status report. It is important for us to communicate bothverbally and in writing. I need to know how everyone is progressing through the course material andwithin the group. If you have any concerns/problems that you feel cannot be addressed in the qualitymeetings, write them down on this report.

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Teaching - Appendix B - QTL Weekly Status Report

GROUP:___________________ LEADER NAME:_____________________

MEMBERS PRESENT:_________________________________________________

MEMBERS ABSENT:__________________________________________________

DATE:__________________ LAB SECTION (circle one) A B

The purpose of this weekly status report is to keep the lines of communication open between you, the QTLand me, the course facilitator. Honest, open and constructive dialogue (written or verbal) between us willresult in a class which is continuously improving.

GROUP PROCESS - COMMENTS/CONCERNS/SUGGESTIONS:What can be done to help your group accomplish the course objectives? Please list any suggestions orconstructive changes that you or your group members may have to improve in this area. Is your groupworking together? If not, what can we do to make things better?

COURSE CONTENT - COMMENTS/CONCERNS/SUGGESTIONS:Is the course running smoothly? Are there any problems with course materials or objectives? If yes, list anychanges/suggestions that you or your group members have to make the course better. What area needsimprovement and how do you suggest that it be done?

LIST PROBLEMS WORKED ON/CONCEPTS COVERED:

DID GROUP WORK OUTSIDE OF CLASS THIS WEEK:if yes, list # of hours______if no, what can be done to help the group meet outside of class?

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Teaching - Appendix C - Examples of QTL Communications:QTL Meeting 1I. Introductions:II. Importance of Group Based Learning(GBL): Pharmacy classes currently using some form of GBLare: OTC, Toxicology, Therapeutics, Pharmacokinetics, Pharmacology, Chemical Basis for Drug Action,Parenterals and the list keeps growing… .. However, the main difference between the above classes andthis class is that we teach and monitor the group process along with the content. Past experience has foundthat in group based learning, the content cannot be mastered if the group process is failing - courseperformance is directly tied to group performance. Therefore, it is imperative that you learn principles ofgroup dynamics along with the course content. These skills will last you a lifetime and work in any groupsituation you may find yourself. Remember as a future pharmacist, you will be a member of the healthcare team - and it is necessary to work effectively with others (physicians, nurses, lab, x-ray, etc.) to solvepatient problems. III. Peer assessment: In group based learning, you have an opportunity to observe your peers in a closeproblem-solving environment. You will have more detailed insight and knowledge of their work than theinstructor. In order to honestly and effectively evaluate everyone’s performance within the group, peerassessment is necessary. In your future as a pharmacist, you may be asked to fill out a performanceappraisal on a co-worker. Many pharmacists find this upsetting since they have had no prior experience atdoing this. We must get comfortable with the process of receiving and giving assessment feedback. In thisclass, peer assessment will be worth 10% of your final exam grade. You will assess yourself and beassessed by your peers at midterm and at the end of the course. Only the final peer and self assessment willcount towards your final grade. The mid-term assessment is for practice and your own personal growth.See attached sample copy.IV. Group dynamics - problems?V. Decision making: Any group’s goal should be to reach a decision that best reflects the thinking of allgroup members. This is called reaching a consensus. A consensus is finding a proposal acceptable enoughso that all members can support it and no member opposes it. A consensus is neither a unanimous vote - aconsensus may not represent everyone’s first priorities nor a majority vote - (in a majority vote, only themajority gets something they are happy with; people in the minority get something they don’t want at all).A consensus requires time, active participation of all group members, skills in communication (such aslistening, conflict resolution, and discussion), creative thinking and open-mindedness.Rules for Decision by Consensus:• Look for acceptable alternatives• State your opinion - it doesn’t matter that others do not share it. Conflict spawns creativity.• Look for win-win situations• Remember that difference of opinion is healthyAiming for consensus requires a much different strategy than does unanimous or majority vote. To reach aconsensus, the group must let each member voice their concerns/opinions. It may be hard to tell when youhave reached consensus - a good rule of thumb is when no one is completely satisfied, but the decision isone that you all can live with. Complete unanimity is not the goal - it is rarely achieved, but acceptance is.VI. Time-lines:How to deal with “floundering” (a lack of direction):• Review the timeline within the group. Hopefully by this point you have set dates for exams and know

the topics to be covered for each. Draw the timeline out on paper. Give each member a copy. Assignproblems to individuals and keep track.

• State “Let’s review our timeline and make sure it is clear to everyone.”• “What do we have to do next?”• “What do we need to do/ask so we can move on? What is holding us up?”• Finish up every class by giving everyone duties for the next meeting. There should not be any

confusion at that point as to who is responsible for what.

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Teaching Appendix D –

MID-SEMESTER PEER/SELF GROUP INTERACTION ASSESSMENTPlease evaluate each member of your calculations group and yourself. Evaluate performance over the firsthalf of the semester. You are expected to evaluate each member/self honestly. Please record yourevaluation responses below their names. Hand-written comments are encouraged. Turn in this sheet onceyou have completed the evaluations. Be assured that your confidentiality will be maintained. You will geta copy of these results along with any constructive hand-written comments.Please indicate your response on the score sheet using the following rating guide.The rating scale:5 = Student is consistent and provides excellent contributions4 = Student is generally consistent and provides very good contributions3 = Student is somewhat consistent and provides satisfactory contributions2 = Student is somewhat inconsistent and provides unsatisfactory contributions1 = Student is inconsistent and provides inappropriate contributions (or doesn’t contribute at all)Your name:_______________________ Section: _________ Group:__________List group members below next to their suit:Club:___________________________________Diamond:________________________________Heart:__________________________________Spade:_________________________________Extra:__________________________________Supply written comments on back: General Group and Individual Group Members:

Assessment items Club Diamond Heart Spade extra

1. This person actively contributes to group discussions.

2. This person comes prepared for class each week.

3. This person helps to redirect discussions/problem-solving whenthe group gets “off track.”4. This person listens to the opinions and contributions of others.

5. This person exercises mutual respect for others in the group.

6. This person helps keep the group focused on the timeline.

7. This person works well with the other group members.

8. This person does not monopolize group discussions.

9. This person is available outside of class for group work.

10. This person shares their knowledge within the group.

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Teaching Appendix E - MANAGING DIFFICULT PEOPLEJust about everyone has felt the pulse-pounding, face-flushing, word-sputtering frustration caused by trying to reason withdifficult people. We find them to be uncooperative, uncompromising, and stubborn. Each encounter with them leaves usfeeling increasingly frustrated and angry. No matter what we do, it isn't effective. While it may seem easier to ignoredifficult people rather than face a confrontation, team morale and productivity greatly decrease when difficult people aretolerated, even reluctantly. The following five strategies allow you to take control of situations involving difficult people andbuild more cohesive teams as a result.Question: can you find yourself - what type are you?

STRATEGY 1: De-personalize the situation

No matter how challenging, belligerent, or negative the difficult person behaves, do not take it personally. Difficultpeople are often acting out their personal problems, and their behavior is a cry for help. You can more easily control youremotional reactions to them and defuse any anger you feel if you do not take their behavior personally. When youencounter a difficult person, observe how he or she behaves with others, especially other team members. You will findthat the behavior is consistently difficult. This awareness helps put things in perspective; you can see that you are not toblame for the difficulty.

STRATEGY 2: Learn to identify difficult personalitiesGenerally, there are seven types of difficult personalities. As each type is presented, strategies for coaching, motivating,and communicating with them will be presented. It takes some planning and practice, but as we learn to manage thesedifficult types, the effectiveness of the entire team will increase.

ATTACKERS: Attackers are hostile, aggressive, abusive, and intimidating. They need to be right and will charge likeangry bulls if they think they have been challenged or crossed. The best coping strategy is to let them blow off steam andexpress their anger in a safe environment. But you can't let them run on. To maintain control, address them by name:“David, I hear what you are saying. Let's sit down and talk about it.” Getting attackers to sit will have a calming effect onthem; and, once calmed, attackers become more reasonable. Take what attackers say seriously. Hear them out, let themknow you have heard them, and then state your position clearly and avoid the temptation to argue.

EGOTISTS: Egotists are often experts and know more than others on the team about a particular subject. They believefacts are power; and, since they know the facts, they act in a superior way that often demeans the knowledge of others.Plan meetings so the egotists on the team speak first and allow time for them to “bask” in their knowledge. This strategyminimizes their tendency to interrupt later in the meeting. You must be prepared with facts and information, because youcannot “fake it” with egotists. But you can capitalize on what they know by asking questions. Egotists love to show off andhave their knowledge appreciated. If you approach them from this perspective, their abusive attitudes and behaviors canbe tempered so you can more effectively use their knowledge and expertise to support your efforts.

SNEAKS: Sneaks take potshots. They undercut your authority in devious ways by using sarcasm, which is oftendisguised as a joke. Never ignore the sneak's snide comments. That just gives them power to continue Instead, exposethem. When they snipe at someone, be direct and ask them for their opinions or solutions. Force them into the open andyou will weaken their ability to cause problems. Try to turn their attention and comments to the issues, not thepersonalities involved. Once they realize you won't put up with their sniping, they will stop.

VICTIMS: Victims see everything negatively. They complain, whine, seem to be powerless, and act defeated. Victims alsoshift blame and refuse to take responsibility for situations or decisions, especially unpopular ones. They act as if they arepassing on orders from above and blame the boss for that “dumb” new policy. Such behavior hurts morale and erodes thesupport of your team. Since victims often believe no one thinks they are important or takes them seriously, start yourinteractions by listening to what they say. Steer them toward the facts, which are usually much less negative than theirinterpretations. When you ask for suggestions to improve the situation, maintain control by bringing up the negativesyourself, then dismiss each logically. Direct their attention to the more positive aspects of the situation.

NEGATORS: Victims seem pale compared to true negators. Negators aren’t just negative, they distrust anyone in power.They believe that their way is the only right way, and their motto is “I told you so.” Stay positive, but realistic. Delaydiscussing solutions, since negators will dismiss every solution as soon as it is spoken. Refuse to argue with them andstick with the facts. Anticipate any objections they may raise and prepare facts and information to refute them.

SUPERAGREEABLE PEOPLE: While super-agreeable people are easy to like, they are one of the most difficultpersonalities to deal with. Super-agreeables are outgoing and friendly; but, because they have such a strong need to beliked, they frequently become whatever others need them to be at the expense of their own needs and desires. They areusually terrified of making mistakes. Superagreeable people can’t say “No” and, thus, overcommit themselves and theirstaffs. They disappoint and frustrate the very people from whom they so desperately need to receive approval— theirmanagers, staff, co-workers and, in personal matters, their family and friends. Carefully limit how much you ask of them toeliminate the disappointments caused by missed deadlines.Teach them to see things in greater perspective to help themovercome their fear of making mistakes.

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UNRESPONSIVE PEOPLE: Unresponsive people are the ''clams'' of humankind. They are the most difficult personalitiesto deal with. They don't reveal their true motives, and you play a guessing game trying to find out what makes them tick.They are hard to understand and seemingly impossible to draw out. Yet that is the most effective strategy: draw them out.Always ask open-ended questions that require more than “Yes” or “No” answers, then wait for them to respond. Typically,they respond more slowly than other kinds of personalities and rely on others to take over so they can maintain their clam-like reserves. Even if the silence between you and an unresponsive person grows chasmlike, wait for a response. If theyrefuse to open up, agree to meet again later and ask them to think about specific topics you will discuss at that time. Thisstrategy will eventually draw them out-and, once they begin to trust you, they will become less clamlike.

STRATEGY 3: Characterize the difficult people in your lifeNo one demonstrates one of these personality traits to the exclusion of all the others. But most difficult peopledemonstrate one so strongly, you can predict how they are going to respond. It is that predictability that gives you theedge in any situation involving them because you can thoroughly prepare and practice how you will respond to theirbehavior. And, as with anything else, practice makes perfect.

List the difficult people you work with and identify which personality most closely fits their dominant behaviors. Jot thetechniques for each personality on a 3 x 5 index card and review the cards before meeting with them. Take time to reviewthe strategies for dealing with a particular personality, and then recall a past unsatisfactory confrontation with him or her.Imagine how much more successful it would have been if you had used the techniques for dealing with that personality.Now, visualize your next confrontation with that person and see yourself Using these techniques. Rehearse until you feelcomfortable with the techniques and are well prepared to deal with the person who manifests this difficult personality trait.

STRATEGY 4: Encourage people to changeBy becoming skillful in using these techniques, you will not only learn how to handle difficult people, you will be reinforcingteamwork behaviors. When we ignore difficult people, they don't change. But when we insist they change, when we refuseto indulge their behaviors, we require them to learn new coping skills. This can strengthen the entire team.

STRATEGY 5: Know when to give upThese strategies work with people who have grating personality traits, but you must be careful when working with peoplefor whom the strategies don't work. Keep in mind that some people may suffer from more than just difficult personalitytraits. Some may have personal problems they cannot leave at home. If the strategies don't work, seek feedback fromsomeone who can recognize the existence of serious problems that need professional help. Always document facts aboutincidents that occur and strategies you try with difficult employees. If leaders cannot control negative behavior, teammembers lose respect for them. A highly cohesive team can soon become one with little cohesiveness and lowerproductivity.Dealing with difficult people doesn't have to lead to confrontation. It takes effort, time, and attention to turn a challengingperson into a productive and satisfying one. But when we are successful, our effectiveness and the effectiveness of theteams we manage will improve and we will create win-win situations for everyone involved.

(Manning, Marilyn Ph.D. and P.A. Haddock. “Managing Difficult People,” SKY, November 1988, pp. 128-135)