Cultivating a Culture of Reflection Among Pharmacy Students Through Storytelling

INTRODUCTION

Pharmacy educators and practitioners desire that students be thoughtful, self-aware, and invested in their own self-development. However, students may be resistant to engage in reflective exercises based on a lack of experience, fear of showing vulnerability, and uncertainty over whether reflective exercises are valuable for learning.¹ The Office of Experiential Programs at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences has incorporated the use of storytelling into the Doctor of Pharmacy (PharmD) curriculum in hopes of mitigating these barriers and supporting a culture of reflection for all students.

Storytelling is the interactive art of using words and actions to reveal the elements and images of a story while encouraging the listener’s imagination.² Stories provide a very familiar framework for individuals to communicate their personal perspectives across diverse audiences.³ Storytellers weave together knowledge and experience with creativity and perspective, as they reflect on the human condition.⁴ Storytelling is rooted in oral traditions, often providing entertainment to listeners while imparting moral lessons. As an educational modality, storytelling has been used in primary, secondary, and post-secondary education settings and has been successfully incorporated into professional education settings.³

As storytelling is a natural means of communication between two individuals, such as patient and practitioner, it is featured prominently in health care and health professions education. By listening to illness narratives, providers glean data and better understand the patient experience. Sharing stories is also a powerful tool for encouraging self-reflection while exploring personal skills, challenging personal beliefs, and developing new perspectives.^3,5 Various health professions training programs have incorporated narrative medicine, the curricular use of sharing and responding to experiences, to improve the practitioner’s communication and listening skills.^6-10 Schools of medicine have successfully combined the concepts of reflection and narrative medicine to develop programs by which learners share experiences of providing patient care, reflect on clinical decision-making, and strengthen ethical mindfulness.^11-13 Moreover, nursing educators have integrated storytelling into professional curricula for the purpose of professional development and strengthening patient care skills.^6,14

The ability to self-reflect and express one’s professional values are desirable attributes in today’s pharmacy practitioners.^15,16 However, examples of integrating storytelling into pharmacy curricula are difficult to find, perhaps indicating the underutilization of this educational modality. Nevertheless, many educators are advocating that faculty members share personal experiences that may inspire future pharmacists to be vulnerable and courageous as they confront the challenges of practice.^17-19 As the importance of cultivating the reflective capacity of pharmacy students continues to grow, new strategies, such as incorporating storytelling, may be needed to engage students in reflective practice.

Experiential education faculty members at the Skaggs School of Pharmacy and Pharmaceutical Sciences have chosen storytelling as a means of engaging students in self-reflection using a variety of strategies. Since 2014, the school has hosted an event each spring for first professional year (P1) pharmacy student called Story Slam. The event is a friendly competition of amateur storytelling, featuring short, personal, first-hand accounts of experiences that are meaningful to the storyteller.²⁰ Stories are less than five minutes in duration and are told from memory without the aid of notes or prompts, a format similar to community-based storytelling events featured on The Moth Radio Hour and USA Today Network’s Storytellers Project.^20,21 Story Slam serves as an introduction to the school’s Reflective Practitioner Program, which engages students, individually and in peer groups, in mentored self-reflection through various modalities over the four-year curriculum.²² As such, a formal assessment of student reflections presented during Story Slam is not conducted. Rather, the role of Story Slam is to reduce perceived barriers to engaging in meaningful reflection during future Reflective Practitioner Program activities. Thus, Story Slam is a low-stakes activity that presents all students with an opportunity to engage in peer reflection. Formal evaluation of students’ reflective capacity is conducted later in the Reflective Practitioner Program.²²

While Story Slam has been well received, a formal evaluation was needed to determine whether the event achieved its intended purpose of creating an environment supportive of reflection rather than simply providing students with a fun event. To our knowledge, storytelling of this nature has not been formally evaluated in health professions’ education literature. In this study, we detail the qualitative research process used for gathering student perceptions, feelings, and reactions to Story Slam before, during, and one week after the event.

METHODS

Prior to Story Slam, students were instructed to arrive to class prepared to tell a short story based on a provided theme. For the 2019 event, faculty members provided students with four possible themes for their story: an awkward professional experience, an experience that validated why the student chose to pursue pharmacy, an experience that led the student to the pharmacy profession, or an experience the student wishes could be changed. The event itself was structured as a four-hour event occurring in three parts: the Faculty Slam, the Semifinals, and the Grand Slam.

The faculty portion of the event featured several faculty members sharing stories in the same manner expected of students. A short debrief followed, focusing on elements that made the stories reflective. These elements aligned with the aspects of critical reflection expected in the reflective writing assignments submitted during the Reflective Practitioner Program.²³ During the Semifinals, the entire class was divided into four large groups of up to 40 students. Each group was assigned a separate breakout room and a faculty facilitator who was also a seasoned Reflective Practitioner Program mentor. Once in their respective rooms, students were subdivided into four groups of eight to 10 students in which each student shared his or her previously prepared story. After all group members had recounted their story, each group identified one storyteller to continue in the competition. The four storytellers selected by the small groups to advance then told their story to everyone in the breakout room. Of those four storytellers, one finalist was chosen from each breakout room to compete in the Grand Slam. For the Grand Slam, the full class reconvened to hear the four finalists and a fifth student storyteller chosen at random by the faculty. After all of the finalists’ stories were told, faculty members shared their impressions of the stories with the entire class and provided constructive feedback, reinforcing the importance of reflective practice. Ultimately, the students voted to determine the winning storyteller.

In addition to sharing their stories, students also submitted handwritten “tweets” throughout the event. The tweets, written in a manner similar to a very short social media post, responded to prompts provided on small slips of paper. The prompts used a fill-in-the-blank structure and included prompts of “Surprise! I didn’t expect to learn (blank) in pharmacy school.” “(Blank): Learned that the hard way!” and “Lessons for a P1 student: (Blank).” Prompts were submitted anonymously and read aloud by a faculty member serving as master of ceremonies. The “tweets” were intended to maintain engagement with the entire class, providing an avenue of reflective sharing for those students not selected to participate in the latter portions of the event.

To evaluate the success of the Story Slam, we determined that an inductive qualitative research approach rooted in grounded theory would be most appropriate.²⁴ We identified two primary research questions: “How does Story Slam affect students’ perspectives and attitudes toward reflection for professional growth?” and “How does Story Slam contribute to the culture of reflection at the school?” The qualitative evaluation protocol included an iterative approach to collecting data prior, during, and following the event, using a combination of audio- and text-based artifacts. Because of the depth of data desired, a cadre of volunteer students was recruited prior to the event and engaged with at three time points. Funding from departmental resources provided $50 gift cards as incentives for up to 15 students who chose to complete all elements of the qualitative study. Artifacts for analysis included a pre-intervention survey of eight open-ended response questions submitted immediately prior to Story Slam, a post-intervention survey of 14 open-ended questions that was due within 48 hours of the event’s completion, and audio recordings of two one-hour focus group meetings occurring one week later.

Items in the pre- and post-intervention surveys aligned to capture changes in student perspectives regarding the design and implementation of the event, content of stories told and heard, emotions anticipated and experienced, and comfort levels and perceived value of engaging in self-reflection. The surveys were distributed via eValue (MedHub Inc., Minneapolis, MN), an online learning management system. A subgroup of the authors reviewed all survey responses and identified themes for later exploration during the facilitated focus groups.

Four preliminary themes emerged from the pre- and post-intervention surveys, and with that information, a semi-structured interview protocol was developed. The four themes were: feelings and reactions to stories heard, attributes of good stories, preparation for the Story Slam, and the value of reflection in professional practice. An organizational psychologist familiar with qualitative research and experienced in leading focus groups served as the facilitator for each discussion. This facilitator did not attend Story Slam but was familiar with the overall structure. The facilitator reviewed all the findings from the surveys and collaborated on the development of the final interview protocol. Per the protocol, the facilitator was permitted to probe and explore responses within the context of the themes of inquiry using open-ended questions until saturation of responses was achieved. The two focus groups occurred one week following the event.

Textual data from the surveys and audio data from the two focus groups were uploaded into Dedoose, an online qualitative research platform (SocioCulural Research Consultants, LLC, Manhattan Beach, CA) and underwent an iterative open-coding process for thematic analysis. Audio recordings were reviewed and coded independently and in parallel by two blinded investigators. All codes and sub-codes were reviewed by a fourth investigator, merging all codes into a single code tree for analysis. This investigator ensured all excerpts from the textual or audio data were unique, deleting duplications as needed. Finally, codes were grouped into themes and subthemes, and the resulting proposed code tree was reviewed by all authors before data analysis and reporting. The Colorado Multi-Institute Review Board reviewed the study protocol. Use of data collected from students participating in the evaluation surveys and focus groups were considered non-human subject research.

RESULTS

One hundred thirty-six P1 students attended Story Slam in 2019, and 11 students participated in the evaluation study. This study produced a myriad of artifacts for review, including 426 lines (7358 words) of text from the online surveys, and 109 minutes, 24 seconds of recorded audio from the focus groups. Investigators identified 295 unique excerpts, including 74 from the pre-intervention survey, 115 from the post-intervention survey, and 106 from the focus groups. Ultimately, the open coding process resulted in 239 unique codes, with 524 applications leading to the emergence of nine primary themes and 24 subthemes. A complete list of themes and subthemes and their associated sources is provided in Table 1.

Students endorsed several changes in their perspectives regarding the role of self-reflection in professional practice. For example, within theme 3, “Students describe several reasons why self-reflection is important to practitioners,” three distinct sub-themes emerged, including how self-reflection can improve interpersonal skills, improve self-expression, and foster growth from professional experiences. This evidence was found in all three sources of data, including the pre-intervention survey responses. In post-intervention survey responses and the focus group data, theme 5, “Students expressed a change in perspective following the story slam,” emerged, indicating students were more willing to engage in self-reflection individually and within peer groups after the experience. Some students in the evaluation study endorsed having previous experience establishing habits of self-reflection only to discover a new appreciation for engaging in reflection in a social-professional environment with peers after the event. Representative quotes from excerpts supporting change in students’ perspective are provided in Table 2.

Evidence that Story Slam affected the reflective culture of the school also emerged from the three data sources, as evident by several themes: theme 2: “Students appreciated how the story slam created an environment for reflection and engagement,” sub-theme 4.1: “Stories caused students to feel positive emotions about themselves and their peers in response to stories shared,” and sub-theme 8.2: “Students want guidance for reflection and appreciate feedback and modeling by peers and faculty members.” The students’ active engagement during the event created an environment safe for demonstrating vulnerability and encouraging self-expression. In describing their engagement during the event, students often used words such as trust, camaraderie, and relationship-building. Students expressed genuine interest in learning about their peers through sharing experiences they would not likely have shared outside of Story Slam. Hearing others share, including the faculty members’ stories, encouraged students to engage more meaningfully and invest in the process of sharing their experiences. More than one student changed their prepared story because they realized others were sharing more deeply than expected, and they felt encouraged to engage in more meaningful ways. Students also perceived the event as a safe time and space to be expressive, sharing their thoughts and feelings as well as their experiences. They reported initiating discussions about Story Slam after the event with preceptors, fellow students, and upper-class members. Representative quotes from excerpts indicating Story Slam supported a culture of reflection are presented in Table 3.

DISCUSSION

It was clear from the data gathered about Story Slam that students had a positive impression of the event after participating in it. Furthermore, this evaluation study provides evidence of effective integration of the event into the Reflective Practitioner Program. Additionally, this study provides new insights for the faculty members who are responsible for the program and for developing Story Slam. The Reflective Practitioner Program faculty were surprised to learn the degree to which students endorsed the connection between reflection and professional practice. In the past, students at this institution were resistant to engage in reflection activities, and Story Slam was incorporated into the Reflective Practitioner Program with hopes of improving the reflective culture at the school. At first, we assumed (perhaps incorrectly) that this resistance was because students did not perceive the value of self-reflection or students viewing reflective activities as a “waste of time.” However, several students in the evaluation study fully endorsed the value of reflection and had previously established reflective habits. Following the event, students expressed a desire to be more thoughtful about their successes, engage with preceptors differently, and be mindful of the lessons they were learning in practice. However, even the most reflective students in the study stated that they were unlikely to protect the time to engage in reflection without prompting or guidance by the school. This supports the critical role faculty members have in modeling reflective behaviors, engaging in reflection with students, and coaching students to be more reflective. Perhaps by focusing more on creating the time and space for reflection, rather than convincing students that reflection is ultimately an important skill to develop, both faculty members and students will continue to see the value in reflection.

A surprising range of emotional expression was identified throughout Story Slam, both positive and negative. This may be a direct result of the prompts provided to students. In previous iterations of the event, students were only provided one prompt: discuss an awkward professional experience. This theme was chosen in an effort to create something engaging and relatable among students. However, with the addition of new prompts, students gravitated toward more meaningful and emotive stories, such as pivotal moments that led them to the pharmacy profession. In response to sharing and hearing stories, students described emotions ranging from cathartic, eg, “I felt liberated,” to feeling anxious and worried about not having a story worthy of being shared. Students also reported being inspired by their peers’ experiences. One student in the focus groups who had been selected for the second round of storytelling described her experience of telling her story to a larger audience of peers as empowering and affirming. These are welcomed findings, as tending to emotions is an essential element of critical reflection.²³ In previous evaluations of components of the Reflective Practitioner Program, there was little evidence of such depth of emotional awareness in students.²² As the students in this cohort seemed to be more willing to emote publicly compared to those in previous classes, we are interested to see if this trend continues as students engage in reflective assignments in later years of their training.

An unexpected yet welcomed finding of this study was evidence suggesting Story Slam promotes peer-to-peer engagement and relationship building within the pharmacy class. Fostering improved relationships was not an intended purpose of Story Slam, but sharing reflections with peers is an expectation of the Reflective Practitioner Program. Student feedback from this study suggests the slam is effective at building rapport and respect among peers and faculty members as indicated by students who stated they were inspired to share more deeply after hearing the stories of others. Students also appeared to genuinely praise others for the candor of their stories, thus creating a positive feedback loop of encouraging more meaningful sharing among students. As fear of vulnerability and being exposed is a recognized barrier to sharing authentic reflections, increasing group cohesion and cultivating a shared sense of support within the group may improve the quality of individual reflective work.¹ The Story Slam appears to provide an effective strategy for addressing this particular barrier, and additional evaluation should be conducted to determine its effect on downstream reflective work within the Reflective Practitioner Program. The role of peer-engagement within the program may merit additional investigation in future studies.

Even after five years of using Story Slam as a means of introducing students to the reflective process, we continue to refine and improve the event. It can be delivered in a single afternoon without any pre-work or introduction, which makes the logistics manageable and efficient. However, many students desire more explanation and guidance in reflective writing before the event; thus, various strategies to better prepare students for Story Slam have been tried. At a minimum, students should be given the prompts ahead of time and told to anticipate sharing a five-minute story with peers. Although students are told the slam is an informal activity, many students often incorrectly anticipate the use of rigorous evaluation through detailed rubrics commonly used in didactic course activities. As a result, some students may request additional guidance and rubrics in preparation of the assignment. During the event, it becomes clear to students that the expectations of engaging and being authentic are all that is necessary to achieve the intended purpose of the activity. These students, in retrospect, realize the guidance provided prior to the slam was sufficient.

The basic structure of the event could be easily incorporated into any program or classroom. While it serves as a fun and engaging introduction to reflection, it could easily be modified as a capstone reflective event as well. During Story Slam, faculty members must be highly engaged, encouraging, and willing to show their own vulnerabilities in front of students through their storytelling. It is feasible the faculty demonstration portion of the event could be separated from and precede the student slam, but it has been intentionally coupled with the afternoon event. Judging and scoring is common with community-based storytelling, but we have excluded this aspect from the event. While attempts at game-show style judging panels and scoring have been made, our experience is that these aspects are unnecessary and at times may undermine the culture of sharing. Faculty, however, are asked to make general comments about the stories heard, and in doing so, reinforce the expectations of the Reflective Practitioner Program. Faculty members and students are reminded that sharing personal stories publicly is not easy for most people; therefore, audience members should encourage and praise storytellers for their efforts.

Student engagement during Story Slam is of utmost importance because students are assigned the role of engaged audience members. As such, we require students to store all electronic devices away for the duration of the event. The reading of tweets is an effective method of maintaining class-wide engagement, especially as the event progresses and fewer and fewer students are sharing their reflections. The tweets have also been a successful way to give voice to those students who are more comfortable with sharing a shorter reflection. Despite their short length, the tweets themselves offer reflective glimpses into student perspectives and experiences, and the exercise could be easily adapted to gather reflective feedback on student experiences.²⁵ Student tweets covered a range of topics, including encouragement for peers, expressions of self-doubt, and humorous references to bad habits (Table 4). Having the master of ceremonies read and react to a variety of tweets appeared to captivate students and give voice to their varied perspectives.

This study has many limitations to consider when reviewing our findings. First, the findings may not represent the full cohort of students who participated in Story Slam for several reasons. Intentional sampling is a critical methodological consideration in qualitative research; however, we had no basis by which to select students of interest, as this was our first attempt at gathering student perspectives about Story Slam. As an exploratory, inductive, qualitative research approach, the findings of this study provide insight to inform the design of more rigorous qualitative and quantitative research in the future. The use of a financial incentive was an effort to encourage students with a wide range of perspectives to participated in the study with hopes of reducing self-selection based solely on a student’s interest in reflection. Ultimately, the sampling was self-selective; thus, students participating in the evaluation may have had a higher baseline appreciation or inclination toward reflection compared to their peers. A full cadre of 15 students was not recruited despite offering students financial compensation. The reasons for nonparticipation were not explored, although we assume the expected time commitment for the live focus group meetings may have been one possible deterrent. The requirement to complete all three phases of data collection also may have reduced participation, as two students were removed from the study prior to the focus group for failing to submit the required surveys in the appropriate sequence. Data gathered from these students were excluded from analysis. The participating students did express varying levels of comfort with reflection prior to the event and described different degrees of effort in preparing for the Story Slam. This may indicate that participants did not self-select into the study based solely on comfort with or interest in reflection. Nevertheless, the concern for possible selection-bias during recruitment cannot be disregarded.

The study design may have also been influenced by the authors’ biased perspective, based on years of experience working with students, that students entering pharmacy school are not interested in engaging in reflection. Despite these concerns, the study found that students’ perspectives and their willingness to engage in reflection in professional contexts changed because of participating in Story Slam. We feel each Story Slam has been successful. We also recognize that each event has been unique, which likely reflects the distinct personalities of each year’s participants as well as the interpersonal dynamics already established within each cohort of students. Finally, this qualitative study was limited by its design in that it evaluated only a single cohort of students, and the experiences of these students may not predict how future cohorts may respond to the Story Slam.

CONCLUSION

Story Slam, an event featuring faculty members and students sharing personal anecdotes, is a fun, effective way to introduce first-year pharmacy students to reflection. It may also strengthen relationships among student peers and contribute to developing a positive culture on campus that values self-reflection and reinforces the importance of being a reflective practitioner. Finally, the act of sharing stories can be an emotional and mental “release” for students who had been focused only on studying prior to the event, and can cultivate trust and respect between students and faculty members.