December 7, 2013

Patients Counseling: Applying Gagne’s Nine Events of Instruction

by Chris Dobroth, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

“Excuse me. Where are the paper towels? Oh, and I have a prescription to pick up.” Or "Really? We have to talk to another person before we can be discharged?” Not an auspicious start to a conversation, much less one regarding someone’s health. This indifference by many patients combined with the many demands for the pharmacist’s time calls for counseling sessions that are quick and efficient. What makes these sessions both quick and efficient as opposed to just quick?

The American Society of Health System Pharmacists (ASHP) in Guidelines on Pharmacist-Conducted Patient Education and Counseling states that patient counseling and education should be approached by pharmacists as “interrelated activities.”1  According to the American psychologist Robert Gagne, there are nine events that should be included in every instructional activity to maximize its effectiveness.2  These events are the “why” behind the “how” of ASHP’s four steps to patient interaction.  Examining them more closely will help us develop a more complete understanding of what needs to happen during a patient counseling session. After all, at its core, effective patient counseling is a form of instruction.

Here are AHSP’s four step of patient counseling and how Gagne’s nine events of instruction related to each:1,2

Step 1. Establish caring relationship, explain pharmacist role, and ask for permission to counsel. Gagne’s first and second event of instruction are to gain the learner’s attention and inform them of the objectives.

Step 2. Assess the patient’s knowledge and capabilities. Gagne’s third event is to stimulate recall of prior learning.

Step 3. Provide information to fill in the gaps in the patient’s knowledge. Gagne’s fourth and fifth events are to present content and provide learning guidance.

Step 4. Verify patient’s knowledge and understanding. Here Gagne’s sixth through ninth events are to elicit performance, provide feedback, assess performance, and enhance retention and transfer.

Notice how efficiently ASHP’s four steps contain all of Gagne’s nine events of instruction?

Let’s consider the Indian Health Services Three-Prime Questions:3 
  1. What did the doctor tell you this medication was for?
  2. How did the doctor tell you to take this medication?
  3. What did the doctor tell you to expect?

Gagne’s nine events show that these questions are an integral part of the learning process.2 Here the use of opened questions serve to grab learners’ attention and engage them in conversation.  Now that you’ve got their brain running and you’re stimulating prior learning through the three questions, it’s your turn to assess their “knowledge and capabilities” as Gagne suggests and then to present the content and provide guidance.  You have already elicited the patient’s understanding, so now the holes can be filled in based on their level of health literacy. While the Indian Health Service’s Three-Prime questions lay the groundwork for an effective counseling session, they do not offer guidance from start to finish the way ASHP’s Four-Steps do.  Understanding Gagne’s nine events of instruction allows for an effective closer to the counseling session by utilizing the sixth through ninth steps: eliciting performance, providing feedback, assess performance, and enhance retention, and finally transfer to future situations.  Without these final steps, the patient will have endured a deluge of information but you won’t know if they really understood. While your intentions were good and the information thorough, the “teach back” technique is the only way to ensure the patient is truly ready to use their medication in an appropriate manner.

As the demands on our time increase, we must seek ways to be more efficient. By reminding ourselves that patient counseling sessions are a form of instruction, we can use Gagne’s nine events of instruction to master these techniques. Effective patient counseling leads to better outcomes and may decrease the amount of time spent re-answering the same questions at a later encounter.  So before your next patient encounter, take a few minutes to reflect on how you would approach it and remember Gagne’s nine events of instruction.

1.  American Society of Health Systems Pharmacists. ASHP Guidelines on pharmacist-conducted patient education and counseling. Am J Health-Sys Pharm. 1997; 54:431-434. [accessed 2013 Sept 22].
2.  Buscombe, C. Using Gagne’s theory to teach procedural skills. The Clinical Teacher. 2013; 10: 302-307. [Accessed 2013 Nov 16th].
3.  Indian Health Services: The Federal Program for American Indians and Alaska Natives [Internet]. Patient-Provider Communication Toolkit. Tool 9.  Pharmacist Consultation.  Rockville: Indian Health Services. [accessed 2013 Nov 16th].

Can You Use Games to Train Your Brain?

by Allison Holllis, Pharm.D., PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

Ever have trouble recalling the location of objects, remembering people’s names soon after they’ve introduced themselves, maintaining focus on important tasks all day, calculating figures in your head, or determining the best course of action?  Of course you have.  We all have!  We’ve spent years cramming entirely too much information into our heads and will spend the rest of our lives digging through the trenches of our brains trying to pull out stored information. If only there was a fun app to help keep our minds sharp, recall important information at the drop of a hat, improve our attention span, and increase our problem solving ability. Maybe there is!

LumosityTM is a web-based application that presents a variety of game-like exercises with the intent of improving your cognitive abilities. According to the Lumosity website, setting aside a few minutes each day to complete the tasks provided on their app can make you "smarter, sharper, and brighter."1  The exercises designed by the folks a Lumosity are intended to improve specific brain functions such as sustaining attention, thinking before acting, visual and auditory processing, listening and reading.  Can playing games improve your brain power?  Sounds too good to be true!  Does brain training really work? The evidence is controversial.

A 2008 study by the psychologist Susanne Jaeggi found that memory training increased intelligence and implied that a person could boost their IQ by a full point per hour of training.2 However, when a group of psychologists working at Georgia Tech tried to replicate the findings, with tougher controls, there was no evidence that it increased intelligence.3

A group of researchers in San Francisco examined whether Lumosity led to improvements in visual attention and working memory.  Participants were given initial cognitive assessments, randomly assigned to a training intervention group or waitlist control group, and then cognitive assessments where performed again following the intervention periods.4  The training intervention consisted of cognitive exercise sessions (20 minutes per day) using the Lumosity app. They found that the trained group improved significantly over the control group in the areas of visual acuity and working memory.

Could these brain games be useful in people with dementia and other cognitive impairments?  A 2013 study of brain training exercises in older adults with mild cognitive deficits found no statistically significant difference in the treatment and control groups.  But there was a trend toward better performance in the treatment group in those with the least impairment at baseline.5

The largest study ever conducted on brain training involved 11,430 participants who trained several times each week on cognitive tasks designed to improve reasoning, memory, planning, visuospatial skills, and attention.6  Although improvements were observed performing each of the cognitive tasks that participants were trained to do, there was no evidence of transfer to tasks they were not trained to do — even tasks that are cognitively related. The researchers found that regular players of brain games got better at the games themselves but did not experience marked improvement in fluid intelligence (the ability to solve novel problems and adapt to new situations). Researchers attributed the improvements not to increasing memory and skills but rather to learning how to play the games better and memorizing the answers.

Is there a role for brain training and apps like Lumosity in our classrooms? Applications such as Lumosity can be a fun way for students to engage in the learning process without even realizing they are learning! Lessons like math, spelling, and vocabulary can be taught via brain apps that quiz students and they can reinforce topics discussed in class.  Educators can also teach specific skills by playing games.  If these games present realistic cognitive tasks that are reasonably similar those needed in the “real world,” it can perhaps help students develop the necessary skills to be better practitioners.  Even if lessons aren’t targeted toward specific skills that might be used in practice, brain-training apps may be a useful way to help students build memory, perform calculations, and remain focused.

So the next time you are having trouble remembering where you left your keys or want to get better at Sudoku, consider Lumosity (and similar cognitive training tools) to help train your brain.  While it may or may not help you analyze clinical trial data or make important life decisions, it’s a fun way to keep you entertained during your next road trip!

1.   Lumosity [Internet]. [cited 2013 Sept 25]
2.   Jaeggi S, Buschkuehl M, Jonides J, Perrig W. Improving fluid intelligence with training on working memory. PNAS Early Edition. 2008:10:1-5.
3.   Redick TS, Shipstead Z, Harrison TL, Hicks KL, Fried DR, Hambrick DZ, Kane MJ, Engle RW. No evidence of intelligence improvement after working memory training: a randomized, placebo-controlled study. J Exp Phychol Gen 2013:142:359-79.
4.   Hardy J, Drescher D, Sarkar K, Kellett G, Scanlon M. Enhancing visual attention and working memory with a web-based cognitive training program. Mensa Research Journal 2007: 42:13-20.
5.   Zhuang JP, Fang R, Feng X, Xu XH, Liu LH, Bai QK, Tang HD, Zhao ZG, Chen SD. The impact of human-computer interaction-based comprehensive training on the cognitive functions of cognitive impairment elderly individuals in a nursing home. J Alzheimers Dis. 2013:1:36:245-51.
6.   Owen AM, Hampshire A, Grahn JA, Stenton R, Dajani S, Burns AS, Howard RJ, Ballard CG. Putting brain training to the test. Naure 2010:456:775-8.