Climbing the Ladder of Scaffolded Practice

By:  Kristine M. Cline, PharmD, MS, Brianne L. Porter, PharmD, MS and Marje M. Winhoven, PharmD, BCACP

Picture it: Summer 2021. Two integrated pharmacotherapy course coordination teams sit down for a summer retreat, ready to review the courses with an ever-earnest emphasis on improvement. Reflecting on the evolution of the courses over the years, we are struck by the volume of practice added; yet, a primary theme of student feedback remains, ‘more practice!’ How could that possibly be? 

With the pace and complexity of learning in integrated pharmacotherapy courses delivered by interdisciplinary teams, the limited time to digest, understand, and make connections to and across material is enough to make any student feel defeated before they begin. As we reviewed, it became clear to us that practice was key. 

Designing Practice

Retrieving and predicting practice builds foundational knowledge, interleaving practice builds long-term retention and discernment, and practice with connecting concepts assists with problem-solving.^1,2 Our course included these types of practice activities so why did students request more? Upon further reflection, we recognized that the practice lacked scaffolding.

Scaffolding is a learning theory which can be described as a strategy for assisting students in the learning process by breaking down complex information and skills into smaller learning chunks and removing instructor support as students approach mastery.^2,3

For the purposes of this post, we’ll consider scaffolding the building of practice in the course with increasing complexity and instructor support decreasing as students approach mastery.

Following COVID, we adopted a flipped learning model. The flipped learning model allows students to engage in knowledge transfer independently before class so that class time is spent practicing application of concepts with the content expert present to answer questions.⁴ What this looks like for us is that lectures are pre-recorded for students to view prior to class (low complexity), and class time is used for practice activities like science and clinical application (high complexity).  With a focus on increasing complexity, we repurposed existing practice intentionally to build foundational knowledge independently before class. Students can make connections and practice critical thinking with the instructor during class, and progress toward mastery with a comprehensive final exam. These practice activities look like this… 

Practice Activities

Asynchronous Knowledge Checks	Active Learning Sessions	Topic Exams
foundational knowledge, low stakes, independent, before class	foundational knowledge and critical thinking, medium stakes, team-based, during class	foundational knowledge and critical thinking, high stakes, independent, after class
Following the completion of asynchronous learning activities (e.g. readings, lectures, etc.), students complete a brief knowledge check quiz, including foundational concepts and key take-aways from the content. This retrieval practice gives students feedback on the foundational knowledge they’ve begun to build and identify specific questions to bring to class before they can dive deeper in their understanding.	For application-based practice in-person, we implement Team-Based Learning (TBL). In TBL, students complete a readiness assurance test (RAT), focused on knowledge recall, individually and then collaboratively with teammates. RATs reinforce knowledge check practice as well as interleave previous, relevant knowledge. RATs offer a final opportunity to identify foundational knowledge gaps and ask questions.  Once foundational concepts are clarified, students work through application-based activities in teams and with the instructor present. These activities give students a chance to apply their foundational knowledge and practice utilizing information to make clinical decisions. This practice provides students with feedback on the nuances of clinical decision-making with the instructor present to dissect confusion and guide students through the complexity of developing critical thinking in real-time.	To prepare for the final exam, topic exams, while higher stakes and graded for accuracy, are another level of practice for our students, though of higher complexity. Topic exams practice basic recall and critical thinking, simultaneously. As summative assessments that capture their knowledge at the end of a content module, topic exams provide students with insight on areas that are clear and those that are still confusing. This information allows for students to reflect on areas of focus for future assessments and rotations. Ultimately this reflection process prepares students to become lifelong learners.

So… how do we feel about it? Learning models have changed post-COVID, but one thing remains the same – students’ desire for practice. Designing a consistent structure for practice activities seems to decrease cognitive load by allowing students to anticipate how they will engage.⁵ The results of practice at each step provide students and instructors, both, with feedback on knowledge gaps or points of confusion before increasing practice complexity. This allows instructors to better understand “pinch points” in their content and provides students with direction for how to focus their study efforts.  This structure for practice activities outlines a plan for students to use a step-wise approach to learning, a skill that is necessary to triumph over the volume of content and the pace of integrated courses. 

Have you considered how you are designing your practice ladder to support progressive learning?

References:

1. Ambrose, SA, Bridges, MW, DiPietro, M, Lovett, MC, & Norman, MK. How learning works: Seven research-based principles for smart teaching. Jossey-Bass; 2010. 
2. Lang, JM. Small teaching: Everyday lessons from the science of learning. Jossey-Bass; 2016. 
3. Wood D, Bruner JS, Ross G. The role of tutoring in problem solving. J Child Psychol Psychiat. 1976;17(2):89-100. doi.org/10.1111/j.1469-7610.1976.tb00381.x 
4. Roehling PV. Introduction to Flipped Learning. Flipping the College Classroom. Palgrave Pivot, Charm; 2018:1-2. Accessed July 29, 2024. https://doi.org/10.1007/978-3-319-69392-7_1
5. Paas F, Renkl A, Sweller J. Cognitive load theory and instructional design: Recent developments. Educational Psychologist. 2003;38(1):1-4. doi:10.1207/s15326985ep3801_1

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Author Bio(s):

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Pulses is a scholarly blog supported by a team of pharmacy education scholars.