Abstract
Objective. To determine pharmacy students’ impressions of their faculty’s interactions with diverse student and patient populations.
Methods. Three student focus groups were convened. Eighty-four page transcripts were coded, and emergent themes were identified by qualitative analysis.
Results. Students defined diversity as multidimensional beyond traditional categories. Emergent themes were faculty awareness or lack of awareness of cultural diversity, disparate cultural perspectives and preferences within student groups, teaching/learning approaches to prepare students to be more culturally competent, and student group dynamics. First- and second-year students emphasized student-to-student interactions, while third- and fourth-year students emphasized a lack of preparation for the realities of contemporary practice based on instructional methods.
Conclusion. Students perceived the majority of their pharmacy faculty to be culturally sensitive and aware, but microaggression and discrimination from faculty and student peers were experienced. Study implications can potentially improve curricular offerings, cultural awareness of faculty and students, and care to diverse patient populations.
INTRODUCTION
Improving the cultural competence of pharmacists and pharmacy students is an important necessity to help overcome health care disparities. Reports of health disparities among racial, ethnic, and socioeconomic sectors of the US population have hastened the development of educational strategies to address this issue. The Accreditation Council for Pharmacy Education (ACPE) 2016 Standards 3.5 and 13.2 call for cultural sensitivity, ie, professional attitudes and behavior development, and student exposure to diverse populations in doctor of pharmacy (PharmD) education.1
Murray-Garcia and Garcia suggested that informal messages experienced by medical students about cultural competence in clinical contexts can differ from that in the formal, didactic curriculum.2 While efforts have begun to study these differences, little has been investigated about clinical educators’ cultural competence. Similarly, in pharmacy education, there has been no known investigation about PharmD students’ perceptions of their basic science, applied science and clinical faculty as it relates to perceptions of cultural competence. Faculty members serve as role models for students, and ideally, student-faculty relationships are characterized by mutual respect, flexibility, collaboration, emotional investment, and interdependence and support for one’s identity (ie, reciprocal influence).3 However, it is important to learn how our students perceive their faculty’s attitudes and behaviors regarding cultural awareness. Hagan and colleagues encouraged pharmacy schools to conduct cultural assessments of their faculty, staff, and students to determine individuals’ attitudes toward other groups.4
The University of Illinois College of Pharmacy (COP) engaged in a series of programmatic initiatives to foster a community of diversity and inclusiveness. Efforts have included curricular assessment to address gaps, faculty interviews, and quantitative survey analysis.5 The purpose of this study was to determine pharmacy students’ impressions of their faculty’s interactions with diverse student and patient populations. The Diversity Strategic Thinking and Planning (DSTP) Teaching and Learning (T&L) Subcommittee at the University of Illinois COP decided the optimal way to gauge student perceptions of the interactions of faculty with diverse groups was to seek student volunteers to participate in focus groups. This approach is useful when the researcher is interested in obtaining detailed information in response to open-ended questions about attitudes, values, and beliefs that might not be apparent in observations of behavior or individual interviews.6 It was anticipated that study findings would help the college institute quality improvements to assist its current faculty members and incoming faculty/staff during orientation programs, move the COP toward enhanced achievement of its urban and rural missions, and serve as a basis to provide insights and recommendations that could be helpful to other pharmacy schools.
METHODS
In recruiting focus group participants, an important consideration is whether to target heterogeneous (ie, mixed characteristics) or homogeneous (people as similar as possible in terms of individual demographics, knowledge, background, experiences) samples.7 Strengths and weaknesses have been noted about the quality of group interactions, dynamics, and output with both methods.8 Participants should also be made to feel comfortable with each other as familiarity among group members could affect discussions.9 Because of the variation of student experiences with faculty, three homogeneous pharmacy student focus groups were assembled based on academic status, ie, fourth professional year (P4), third professional year (P3), first and second professional year (P1 and P2). The P1s and P2s constituted one focus group because these two student groups had the least exposure to faculty compared to the P3s and P4s. Focus groups were conducted in the 2016 spring semester.
Several recruitment approaches were used to recruit volunteers (eg, announcements on the main college campus’ large screen monitors in the lobby, announcements at pharmacy student council and individual student organization meetings, handouts, and email announcements). An email was forwarded to all COP students explaining the study purpose and inviting their voluntary participation on a focus group. A volunteer recruitment form was forwarded electronically to all enrolled PharmD students. Those volunteering at the Chicago campus were instructed to place the completed printed form in a plain envelope addressed to the associate dean for professional development (study principal investigator [PI]) by the specified date. Students volunteering from the Rockford campus submitted their form in the vice dean’s office at the branch campus, and these were forwarded to the PI via courier in a sealed envelope. The PI then collected the sealed envelopes and provided them in person to the focus group facilitator, who contacted the student volunteers and informed them of the meeting date, time, and place (away from the COP).
Focus groups should be facilitated by an experienced moderator/facilitator who can manage discussion of diverse opinions in a constructive and trustworthy manner.10 An external faculty facilitator from another Chicago campus college was used as a facilitator in consideration of the investigators’ positionality – such as personal identities, assumptions and perceived biases, status and influence relative to the participants – and effects it might have on the student participants and data collection.11,12 At the beginning of each focus group session, participants were informed of their rights as research subjects and provided an informed consent form to read and sign. The signed forms were collected by the focus group facilitator and remain stored securely in his care. No other research team members are aware of the identities of focus group participants. The focus groups were intended to last no more than 90 minutes, and participants needed to agree to maintain confidentiality after the session concluded and not to discuss individual responses in session outcomes with anyone.
Using the interpretivist framework as a guide, the focus group interview questions were designed by faculty members of the DSTP T&L Subcommittee. The questions were developed to allow for any social or cultural student phenomena to emerge from the narratives on how students construct meaning. Qualitative research and thematic analysis can help glean nuanced, in-depth information for complicated issues.13 Appendix 1 shows the focus group facilitation guide. This guide contained an introduction for the facilitator to use and a series of questions that were used as a framework for the session. The experienced facilitator asked follow-up questions to seek more detailed information or explanations from the participants. As extensive extemporaneous comments were offered about peer-to-peer student interactions during the first session, the facilitator incorporated a question about students’ cultural sensitivity in each of the other two focus groups. The facilitator frequently gave prompts for subsequent data analysis to indicate when different students were speaking, eg, “Anyone else?” He also asked for clarifications when responses were unclear, eg, if students were describing situations with faculty or with fellow students. The audiotaped recordings were forwarded to an external vendor service in California for transcription. The facilitator reviewed the transcripts to verify accuracy and remove identifying information before forwarding to the three analytic research team members.
Thematic analysis was used to identify, analyze and report recurring themes relevant to the study results.14-17 A general inductive approach in our analytic strategies and interpretations was utilized.18 Three faculty investigators read through the transcript printouts independently, line-by-line to identify, arrange, and systematize the ideas, concepts, and categories found in the transcripts. Eighty-four pages of focus group interview transcripts were manually scrutinized for open coding by each of the three researchers, who each noted distinct concepts in their initial code categories. Percent agreement calculations were made of the initial codes. To perform the axial/thematic analysis, the investigators met together for approximately three hours each for six weeks, reading through the raw data of the students’ responses to compare individual coding, develop, and refine themes per recommended technique.19
Once recurrent themes were identified, to uncover nuances and the less obvious contextual or latent content, the researchers asked themselves, eg, what is the intent of a particular student in his/her responses? What feelings or thoughts are the students trying to communicate? There was further refinement/reconceptualization of the initial topics and ideas generated from the raw data into broader emergent themes and subthemes by the researchers. Guiding this research was the constructivist epistemology viewed from a social science framework that sees knowledge as socially constructed and fluid, and recognizes that individuals reflect on their own experiences to construct an understanding of the world in which they live.18 To establish rigor for our qualitative focus group data analysis, the researchers used several strategies appropriate to ensure the trustworthiness, credibility, and replicability.20-22 The three analytic team members used bracketing, multiple coders, and peer debriefing.20 By bracketing, they recognized the potential of bringing personal preconceptions, prejudices, or beliefs about the study being investigated, and bracketing allowed each analytic team member to guard against personal biases and presuppositions during data coding and interpretation.23,24 This approach was important because one analytic team member’s scholarship focuses broadly on the utility of Critical Race Theory and its application to undergraduate, professional and graduate student experiences in higher education, issues of equity, cultural competence, and cultural reproduction – especially in higher education where non-minority students, faculty, and staff make up higher percentages of the population. Use of bracketing enabled the analytic team members to be more mindful of Sipe and Ghiso’s narrative about coding dilemmas as a judgment call, and the potential for researchers to bring their subjectivities, personalities, predispositions, and quirks to the process.19 Credibility, dependability, and confirmation are germane to satisfying the validity and reliability of qualitative research.22,25-27 To help establish validity or trustworthiness,28-30 the three analytic researchers met to assess the consistency of the data reduction methods (in initial independent codes) and guard against methodological issues that could influence and affect coding decisions.14,15,17 When there were disagreements among the analytic team, the guiding principle was to identify the intent of the student and the theme being communicated, and then reach consensus agreement.
The analytic researchers made sure that the derived themes were exhaustive, capturing all important data relevant for this study and conceptually congruent with the level of abstraction and characterizations of the themes making sense together.30 Additional refinement and consolidation of the themes was done by consensus and therefore was not included in the qualitative reliability assessment. For accuracy, the researchers double-checked and reviewed the themes weeks after the initial determination and agreed on final theme labels. The final four emergent themes were identified following the guidance of Lincoln and Guba, ie, when researchers come to the point of saturation when there are no more unassigned data items, and researchers agreed that there are no more perceived ambiguities of classification.21
Institutional review board approval for this study was obtained from the campus Office for the Protection of Research Subjects.
RESULTS
Seven P4 students volunteered for the focus group, and all attended the session. Twelve P3 students volunteered for the focus group, and seven attended the session. Twelve P1 and P2 students volunteered for the focus group, and seven attended the session. There were 21 total participants, 13 women and eight men. Ten participants were African-American, six Caucasian, four Asian/Pacific Islander, and one Hispanic. In qualitative educational research, an inter-rater agreement reliability coefficient of 0.80 (ie, 80% agreement among different coders) is considered acceptable.31,32 In this study, the observed percent agreement among the three independent analytic researchers in initial coding was 96.5%.
At the beginning of two focus group interview sessions, students were asked to respond to how they defined diversity. The P4 and P3 student groups defined diversity as multifaceted. For example, some students perceived diversity as a variety of backgrounds including culture, gender, and things which make an individual unique. Others commented that besides cultural background and race, sexuality and gender diversity should be included. Other student responses included religion, sexual orientation, disability, socioeconomic status and class, intellectual background, and geographical location. Further, some participants identified two additional dimensions of diversity through their lens, ie, those working while attending school and the varying amount of practice experience among the student body. Some participants thought the college’s perspective was the students’ academic work should be their first priority, but was not practical for some students who had to work to pay for their tuition. In terms of type of work and practice experience, some students commented that some faculty may look down upon the work experience if the student does not practice as a pharmacy technician.
Below we explore each of the themes that emerged from the focus group interviews. We considered themes to be emergent if responses were unanticipated and could not have been precoded.30,33 Table 1 includes example quotes for the four emergent themes.
Example Student Quotes for Emergent Themes
Emergent Themes
Participants described their experiences and observations on whether faculty respected all students, if students were singled out based on their cultural backgrounds, and faculty’s day-to-day interactions with students that showed cultural awareness. The first theme that emerged was awareness or lack of awareness of cultural diversity among faculty. In general, respondents expressed that faculty treated all students the same way and with respect. Focus group participants appreciated that their faculty were aware of and respectful of certain holidays, certain observances, and/or specific groups of students. Participants noted faculty members followed university policy about religious holidays, accommodations for students with disabilities, and support for cultural holidays and events. While the overall response to faculty’s cultural sensitivity was generally positive, students were probed on any negative examples experienced or observed. When the focus groups were asked if they have ever felt singled out by faculty because of their culture or background, the students shared thoughts about some faculty’s infrequent, and possibly unintentional slights/subconscious stereotypes due to limited exposure to diverse views. Examples given by students were in sporadic faculty members’ references to Asian students as “Orientals” or “quiet Asians.” Some faculty demonstrated a perceived lack of trust in certain minority students’ integrity by lurking close to them during written examinations and in laboratory activities. The students shared how this was “weird.” Perceived stereotyping was evident in another student’s observation about being the only African-American in a recitation section. The student indicated while the professors were talking with the group, (s)he would not get addressed personally. The student felt the professor intentionally looked at the other students and wanted them to answer instead of the African-American student. The student translated this behavior of the faculty person as believing the student would not know the answer anyway. Another student who had participated in research for a number of years in the student’s home country gained this impression because the research was not performed in the USA. That is his/her research abilities would be degraded based on where (s)he was from. There was general agreement that these types of biases and stereotypes of students who are not from the USA still exist for very few faculty members.
Student comments indicated faculty cultural awareness and sensitivity to diversity may differ by faculty age and career stage, particularly older faculty who have not been exposed to as many diverse opinions and experiences. Another P4 student, however, thought this was more likely demonstrated by faculty in the middle of their career. In response to the question on students’ observation of faculty exhibiting cultural awareness toward students in day-to-day interactions, a P4 student implied the curriculum is heavily anchored toward drug knowledge while indicating a lack of faculty awareness of the complex patients our students deal with, ie, a lack of understanding of the relevance of cultural awareness. Further, some students shared their disappointment that some of their fellow classmates failed to realize the relevance of the need for cultural awareness and skill development.
The second emergent theme was disparate cultural perspectives and preferences within groups. Participants shared concerns of how students from different races and ethnicities are lumped together as one. An example by this P4 student captured the essence of unintentional mistakes people make when categorizing races/ethnicities as monolithic. The example shared was when studying a specific race and a specific disease from a pharmacotherapeutic or contextual perspective. For example, the faculty described patient race as “blacks,” which is not the way some African-American students prefer to be addressed. Students indicated not all cultural groups define themselves similarly, eg, African-Americans vs Blacks, American-born Asians vs Asian immigrants, Latino cultures, people of Middle Eastern backgrounds, and different subcultures within White races. Table 1 lists additional examples.
The third emergent theme focused upon teaching and learning approaches to prepare students to become culturally competent. Students expressed a desire for increased exposure to various cultures, eg, “immersion into actual patient situations beyond simulations.” The students thought they were taught the basics about cultural diversity, but frequently there was too much redundancy on the basics in subsequent courses in the curriculum. Participants also believed they were not prepared to apply concepts in the “real world.” One participant felt the faculty focused more on the academic side of things rather than on the practical. Participants stated the social theory was not always connected to practical application. In particular, upperclassmen (ie, P3 and P4 focus group participants) believed the instructional methods did not adequately prepare students with desired skills and exposure to serve a diverse, multicultural society. One P1-P2 focus group member, however, felt the curriculum has changed to focus more on diversity and patient care in our his (her) culture.
Across all three focus groups, students wanted more interactive student participation, ie, not just the lecture knowledge base, but more on the “how” of cultural competency demonstration. More reinforcement was desired (eg, more small group discussion as opposed to large group, teaching appropriate language to use, more experiential exposures, and bringing in real patients and applications). There was perception of cultural competence/diversity topics as “hit or miss,” but participants shared valuable insights. Some students spoke of the social and behavioral pharmacy course faculty inviting patients into class to share their stories and have an open discussion. Some clinical faculty were known to share stories of their patients given the rich diversity of the academic health center’s diverse patient population. The students appreciated the diverse clinical faculty, and these faculty members were perceived to be better attuned to issues of diversity than the basic science faculty. The students desired more opportunities to work with and learn from interpreters/translators (including adequate orientation to use of computer-based translation systems and tools). Participants felt more students should be encouraged to go beyond being “book smart” and develop their interpersonal skills. All focus groups encouraged student participation in co-curricular service-learning activities and opportunities within and outside the college, eg, health fairs, fundraisers for charities.
The fourth emergent theme involved student group dynamics. Especially among P1-P2 participants, peer-to-peer student group dynamics were seen as challenges in fostering diversity awareness and professional interactions. Responses showed that “exclusive student cliques” were viewed as potentially leaving out certain groups in student-to-student interactions. The student example related to student organization elections where students were more apt to vote for a friend rather than deciding on the merits of all the students’ leadership skills and vision for the organization. To further explain how cliques are formed one group member indicated that when a student first comes into the pharmacy program, he/she would be more likely to gravitate toward those fellow students of similar appearance.
Some participants felt there was a culture of intellectual aggression from student competition. They also said that certain students were singled out. One focus group participants shared how Asian students were expected to take on bigger burden in group projects. Students identified perceived stereotyping from their peers, eg, a stated perception that African-American students were viewed (even subconsciously) as less intelligent. One black student commented upon a situation of being assigned to work in a group during a recitation case study. As this student shared, the other group members would not accept/consider his/her answer. The student went on to indicate it was only after the teaching assistant or the professor leading the session affirmed that the student was “on the right track” that the other group members would accept it. Gender equity issues were also identified, eg, a few commented that women’s statements or views were seemingly dismissed more often. Lastly, participants identified the benefits afforded by being a member of a professional pharmacy fraternity and certain student associations, eg, access to old examinations, which sometimes revealed cultural divides via group memberships. Study participants perceived that some student leaders occasionally displayed cultural insensitivity. One student shared his/her concern about some of these top pharmacy students going out into the real world and actually enforcing policies or maybe even being some of the policy makers because of their lack of consideration to certain groups of people, eg, African-Americans, Muslims, Indians, Chinese.
Lastly, the focus groups provided many student recommendations. They expressed the need for a more diverse faculty (eg, more underrepresented minority faculty members) to encourage dialogue and an understanding of issues. The students believed the college could do more in recruiting and providing more social and financial support to enhance college diversity. This suggested students gauged cultural climate by structural elements, eg, programs/policies, of the College’s commitment to diversity, and also by the processes, eg, recruitment efforts, social support, and outcomes of that commitment.34 The participants recommended the integration and incorporation of cultural awareness considerations within therapeutics coursework series and experiential learning. In addition, periodic development workshops were proposed, eg, enhancing one’s cultural competence, gender equity, classroom strategies, to increase engagement of culturally diverse students and working with non-native English speakers.
Faculty members were encouraged to be creative by designing instruction and identifying issues that engage students in class. Having “real patients” during class sessions, for example, also exposes students to different patient populations, eg, transgender, HIV/AIDS, sickle-cell. The students encouraged faculty development of coursework with embedded demonstrations, vignettes, and assessments, eg, more targeted reflective opportunities to demonstrate cultural and interpersonal skill development.35 One student said, if (s)he “could make a recommendation for the school, it would be to incorporate some of the dialogue and some of the personal stories of students into the class. It would be very engaging because it is students presenting to other students about themselves and their culture.”
The P4 students suggested better use of “class days” held immediately following a completed Advanced Pharmacy Practice Experience (APPE) module featuring breakout sessions. For example, the “breakout sessions could illustrate observed examples of sexism, racism, a low-income patient’s inability to pay for medication, or prejudicial behaviors.” Students also recommended service-based learning to be a component of the curriculum. Lastly, students recommended the introduction of cultural diversity during the orientation program for the incoming classes preceding the P1 fall semester.
DISCUSSION
An advantage of using focus groups for this study was that students responded spontaneously, reflected on their personal experiences, verbalized their opinions, and heard the experiences of their peers.7-9 The students’ broad definition of how they perceived diversity is consistent along the domains of how most educational literature on diversity-related topics conceptualize diversity. However, students working while in school and students’ pharmacist practice experience were also described by some respondents as a diversity issue that faculty members do not consider. Since many of our students work while in school, this addition to the definition of diversity may warrant further exploration at a later time. Oftentimes, individuals think of diversity demographically, eg, ethnicity, race, gender, age, education. However, diversity could be based upon a person’s experience and personality type. Diversity could also be based upon the person’s values and goals. An important finding is that students from different racial/ethnic and other cultural backgrounds want faculty members to be cognizant of within-group cultural differences and not make assumptions that all students within certain cultural groups are monolithic.
One of the positive outcomes of this study was the students’ feeling that their faculty was overall culturally aware, with most well-intentioned faculty members trying hard not to offend students. The authors used examples where this did not occur to educate faculty how their words and actions resonate with students, both positively and negatively. The clinical faculty were thought to be more familiar with issues of diversity than the basic science faculty. This finding aligns with the institution’s mission because of the patients served at the University of Illinois Hospital & Health Sciences System represent a diverse patient population. In addition, several faculty members (especially faculty in social and administrative sciences, SAS) work with physicians, nurses, and allied health practitioners in interprofessional research projects and gain valuable insights from patient interactions. These experiences then are integrated into core coursework in the professional curriculum. Some clinical and SAS faculty members also invite community health practitioners into course sessions and few patients, as well.
Students felt they were provided theoretical knowledge but need more practical applications, including having actual patients participate in instruction. This need for more practical experience was similar to findings in a longitudinal survey by Green and colleagues who reported that second-year (77.5%), third-year (74.8%), and fourth-year (68.8%) Harvard medical students perceived a problematic lack of experience in caring for culturally diverse patient populations despite the school’s curricular emphasis on culturally-competent care.36 Health profession students desire and need greater exposure and more real-life experiences (eg, case narratives, simulations, actual patient encounters) to bolster their preparation and skills to serve diverse patients.37-39 In our study, participants suggested that incorporation of cultural awareness elements into patient cases would be a welcomed approach. Results suggested the need for course coordination planning with specific course coordinators and experiential directors to create an environment for positive student growth using a scaffolding approach in cultural awareness with periodic, assessment mechanisms to capture that growth.40,41 This necessitates a linking of coursework horizontally (across courses within a given year) and vertically (over different curricular years) in the curriculum, where simplified lessons to be learned are followed by lessons gradually increasing in complexity, difficulty, and sophistication as students progress through the curriculum. Hopefully, this will be consistent with the outcome of a comparative analysis of cultural competence in beginning and graduating nursing students.42 Nursing students perceived that they became culturally competent during their nursing education beginning with the first course and continuing throughout the curriculum leading to the conclusion for continued education relating to cultural competence. To enhance cohesiveness and continuity, a domain leader/dedicated faculty member with demonstrated cultural competence expertise could oversee this process. An outcome of our study has been the interactive dialogue with college faculty and senior leadership in the information technology group to determine ways to incorporate more actual and simulated student exposure to diverse patient populations.
As cultural awareness is an ongoing journey, there is a continued need for faculty development on cultural diversity. This could be accomplished, in part, during the annual faculty retreat. Administrative leadership will be necessary to ensure that faculty members receive the requisite training to be more culturally competent. Otherwise, only interested faculty will attend. To be successful, all faculty members must be on board. The authors presented recommendations at meetings of COP administrative officers and the college faculty. As a new professional curriculum was implemented during the 2016-2017 academic year at the study institution, faculty and students will have more opportunities to engage with one another to learn about each other’s backgrounds and cultures. Faculty members should incorporate more personal stories or experiences from students into their course, helping them to get to know and better relate to one another. Particularly at this college, students from inner-city, suburban, and rural communities may have very different pictures of health compared to one another. Sharing of personal stories by students and faculty through facilitated critical dialogue can help dispel traditional pseudo-adversarial stereotypes, creating a more positive, enlightening and engaging environment. Additionally, faculty must foster learning and student development of important outcome abilities, including interpersonal, communication, problem solving, and critical thinking skills.
High quality student-teacher relationships are associated with students’ motivation to learn.18,43 The importance of faculty demonstrating cultural competence cannot be overemphasized as faculty are the students’ prime role models in the classroom and in practice areas. Students observe their faculty’s behaviors, and these behaviors help shape students’ behaviors. A flippant comment or nonverbal behavior, even if only on occasion, will be picked up by the students and helps to fashion their behavior. While some students viewed these faculty behaviors as unintentional and without malicious intent, over time students might come to view such behaviors or comments as slights and verbal microaggressions.44 Microaggressions manifest frequently as casual comments regarding appearance, language, or country of origin that occur in classrooms, causing a student to have self-doubt, anger, stress, poor academic performance, and poor health outcomes.45 Microaggressions are insidious and implicit slights regardless of whether such actions are unintentional or blatant.46 If students observe that faculty members do not demonstrate respect and cultural awareness, students might learn from that behavior not to respect their peers or others by modeling the inappropriate behaviors. Health care practitioners will interact with diverse patient populations. If health profession schools and colleges fail to teach students about cultural heritage, beliefs, and values of their potential patients, then the health care provider-patient relationship will result in poorer outcomes, resulting in the widening of the national health-related disparities for some groups.47 This study helped to illuminate students’ perceptions of both microaggressive and discriminatory behaviors and words from their peers and faculty. The college DSTP T&L subcommittee will recommend faculty development programs to facilitate introspection efforts by faculty to identify unconscious bias that could potentially influence faculty-student interactions and/or patient care in a negative manner.48-50
Students also have a reciprocal responsibility to educate their faculty and fellow students about cultural norms, biases and unintentional cues of stereotyping and how they could be avoided. A P1-P2 focus group observation was that several student organization officers or top students failed to demonstrate respect for fellow students. Behavior like this must be corrected or addressed as a teachable moment whenever possible by faculty advisors and fellow students. In the curriculum, whenever possible (eg, recitations) student group work should be encouraged but with assigned student groups demonstrating diversity. This will challenge students to communicate with others outside of their comfort zone and learn to work together.
The focus groups also offered recommendations to benefit student development. Introducing cultural sensitivity training during the incoming class orientation program preceding the P1 fall semester was recommended and has already been implemented for the Class of 2020. Further, concepts and activities from the elective Critical Dialogue course were suggested to be integrated into sessions throughout the core curriculum. That highly interactive course engages pharmacy students in a broad conceptualization of pharmacy practice in a multicultural society. Students also expressed the need for more diversity among the faculty. A 2013 American College of Clinical Pharmacy (ACCP) white paper concluded that broader diversity is needed in academia and its student body to foster better understanding, accommodation, and appreciation of diversity, which can lead to better patient and educational outcomes.51
Recommendations were made to integrate cultural awareness learning into the experiential component of the curriculum, eg, student portfolio reflections and discussion groups. The P4 focus group recommended that the last day of the APPE module should feature breakout sessions on cultural awareness topics and encountered experiences. The authors shared findings with course directors involved with APPE and Introductory Pharmacy Practice Experiences to encourage student use of reflective diaries/portfolios to demonstrate professional growth and interpersonal skills with emphasis on cultural diversity and sensitivity. This will allow evidence to be collected demonstrating the students’ analytic processes of learning and achievement of the performance-based outcome goals of the curriculum.31 For this to succeed, however, the students must be convinced of the value of taking time to develop and maintain a portfolio demonstrating evidence of their growth, and faculty must educate students and reinforce the importance of doing so for their professional growth and effectiveness.
The College’s Office of Student Affairs and the Office for Diversity and Inclusion will help lead the charge to continue informing students of co-curricular learning opportunities, including activities to foster growth in cultural awareness and sensitivity. Coupled with this would be weaving of assessment strategies throughout the curriculum and co-curriculum via leadership efforts of the curriculum committee, curriculum assessment committee, and the Office of Academic Affairs. The DSTP T&L Subcommittee will take leadership in advocating for change and education through faculty workshops to advance teaching and learning methods that will focus on diverse patient cultural framework instead of monolithic instructional delivery. Study findings also demonstrated the need for consideration of two additional competencies and outcomes for the doctor of pharmacy curriculum. Specifically, under professionalism outcomes, a proposed statement was put forth for inclusion, ie, “demonstrate basic cross/multicultural understanding, empathy, and communication.” Specifically, under technology outcomes, a proposed addition to the original statement was put forth to include service delivery, ie, “Apply current and emerging technology to assist with analytical thinking, problem-solving, and the synthesis of information and service delivery.”
It will be important for all faculty to nurture students when opportunities are present to engage students from other cultures. It is vital that our faculty and students take advantage of the diverse patient populations and diverse clinical faculty at our college within coursework to help students develop their cultural competence. Creative course planning and execution will help to encourage and nurture cross-cultural growth of the student body. Faculty must seek opportunities to forge positive relationships with students through advising, mentoring, organizational involvement, and special programming. Lastly, faculty should strive for core course coordination and planning to build upon prior cultural competency learning as students progress through the curriculum.
While the results of this qualitative study provided rich, detailed insights about the cultural awareness of the faculty, findings may not be representative of all UIC COP students. Focus group sample sizes are small by design. Further, these results might not be generalizable to all pharmacy schools. While a call for volunteers to participate used numerous methods to make students aware of this project, it is possible that those students who did not volunteer could not because of work schedules, inclement weather, course conflicts, or other reasons. Students who participated were self-selected and may reflect students with stronger views on the topic. The authors believe, however, that the results highlighted previously unknown experiences of pharmacy students. Findings from the emergent themes are being used as a basis for programmatic improvement recommendations for the study institution and could be used by other colleges of pharmacy.
CONCLUSION
Results of this study suggest students view the majority of their pharmacy faculty as culturally sensitive and aware. Nevertheless, students experienced microaggressions and discrimination from both faculty and peers. College faculty and administrators will address reasons why some students perceive the problems and ways to help students and faculty increase cultural competence in educational and clinical encounters. This study resulted in insights and student recommendations to improve the curriculum and the cultural competence of faculty and students, eg, more practical experiences and avoidance of monolithic conceptions of cultures with intragroup differences. As our society becomes more culturally diverse, it is obvious that culture will continue to play an important role in health, disease, and treatment success. Pharmacy students must be culturally competent in order to help address health care disparities.
ACKNOWLEDGMENTS
The authors are grateful for the input of April Quarles, UIC COP Class of 2018, PharmD student, who as a student member contributed to the development and implementation of this project through service on the DSTP T& L subcommittee. The authors acknowledge Tina Griffin, visiting assistant professor and information services & liaison librarian, who initiated literature searches for the DSTP T&L subcommittee.
Appendix 1. Focus Group Facilitation Guide
Assessing the students’ impressions of the cultural awareness of the UIC College of Pharmacy Faculty
Introduction of Facilitator: The purpose of this focus group is to get feedback from students for a College of Pharmacy subcommittee on teaching and learning. Specifically, we need your thoughts about your faculty’s interactions with diverse student populations. As a reminder, you are to answer questions about the faculty in general terms without identifying any specific faculty members.
In addition, although we ask everyone in the group to respect everyone’s privacy and confidentiality, and not to identify anyone in the group or repeat what is said during the group discussion, please remember that other participants in the group may accidently disclose what was said.
As the session facilitator, I will begin by going around the room and asking your personal definition of diversity.
What is the first thing that comes to your mind in defining diversity?
(Moderator will note what is included in diversity and share a piece of paper which reads, “All of your ideas could represent diversity. In answering questions during this session, we would like you to take a broad view of diversity and diverse groups.”)
1. Do you feel faculty treat all students with respect regardless of background (eg, race/ethnicity, gender, sexual orientation, socio-economic status, age, disabilities)? Please explain.
2. Have you ever felt singled out by faculty because of your culture or background? Please explain.
3. How have you observed faculty exhibiting cultural awareness during day-to-day interactions with students?
4. Have you observed faculty exhibiting a lack of cultural awareness toward students? Describe how they handled the situation.
5. At times, have you been upset or made uncomfortable by your faculty’s comments in your learning environment? Please explain.
6. At times, do your faculty members seem uncomfortable through verbal or non-verbal behavior with certain diverse groups?
7. From your experience, how well does the faculty demonstrate cultural awareness in their teaching?
8. Based on your observations, how well does the faculty prepare you for practicing pharmacy in a multicultural environment? Please explain.
9. Do you have any final comments to share?
- Received November 7, 2016.
- Accepted May 19, 2017.
- © 2018 American Association of Colleges of Pharmacy
