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An active-learning laboratory on respiratory devices
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Currents in Pharmacy Teaching and Learning 7 (2015) 434–442
Research
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An active-learning laboratory on respiratory devices Krista L. Donohoe, PharmD, BCPS, CGPa,*, Nancy S. Yunker, PharmD, FCCP, BCPSa, Laura Morgan, PharmD, MEd, BCPSa, Yaena Min, PhDa, Punam H. Patel, PharmD, BCPSb a
Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA b Euclid Hospital, Cleveland Clinic, Euclid, OH
Abstract Objective: To implement and evaluate an active-learning laboratory activity designed to teach second-year pharmacy students about the appropriate use of various respiratory devices including proper inhalation technique, device maintenance, and counseling points. Methods: The laboratory session was divided into four small-group teaching stations: (1) nebulizers, (2) chronic obstructive pulmonary disease (COPD) exacerbation case and HandiHalers, (3) dry powder inhalers, and (4) metered dose inhalers and spacers. Students completed a pre-assessment and a post-assessment to measure changes in their respiratory device knowledge and confidence. McNemar’s test and a paired t-test were used to determine statistical significance. Results: Both the pre- and the post-assessments were completed by 131 of the 133 students enrolled (98.5%). The average score on pre-assessment knowledge-based questions was 52.7% (range: 10–90%). The post-assessment average score improved to 86.6% (range: 30–100%). Student’s confidence improved in all of the four areas. All knowledge and confidence improvements were statistically significant (p o 0.05). Conclusion: An active-learning approach facilitated students’ gain in knowledge, confidence, and experience with the various devices used to deliver respiratory medications. r 2015 Elsevier Inc. All rights reserved.
Keywords: Respiratory devices; Inhalers; Active learning; Laboratory; Pharmacy students
Introduction Pharmacists frequently receive their first exposure to inhaler devices and proper technique in pharmacy school. This education may be taught in any number of ways including didactic lectures on pertinent disease states or the devices themselves, demonstration by a teacher in a large lecture setting, student hands-on learning in a laboratory setting, or via internet-based modules. These devices are * Corresponding author: Krista L. Donohoe, PharmD, BCPS, CGP, Virginia Commonwealth University School of Pharmacy, 410 North 12th Street, P.O. Box 980533, Richmond, VA 23298-0533. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2015.04.014 1877-1297/r 2015 Elsevier Inc. All rights reserved.
most commonly used in the treatment of asthma and chronic obstructive pulmonary disease (COPD), and often the patient is required to use of multiple devices.1 In addition to medications commonly prescribed in a pressurized metered dose inhaler (pMDI), a patient may receive medication in one of several dry powder inhalers (DPIs) or in a nebulizer. Student pharmacist education on these devices may occur at any point in the pharmacy school curriculum. According to the Accreditation Council on Pharmacy Education (ACPE) updated 2011 Standards and Guidelines, students are required to complete Advanced Pharmacy Practice Experiences (APPEs) or experiential training.2 At the Virginia Commonwealth University School of
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Pharmacy and other schools in the United States, APPEs are completed during the fourth year of the pharmacy school curriculum. Students may be asked to educate patients with asthma and COPD on the use of their inhalers during the course of these APPEs both in the hospital and community settings. They may also be asked to provide inhaler education to other health care professionals during their experiential training. This suggests that students should receive preliminary training in their pharmacy curriculum earlier than APPEs. The proper use of these medications and devices is not intuitive and may require different inhalation techniques with multiple steps performed for correct use. While manufacturers do provide patient educational leaflets detailing the appropriate technique for a specific device, it has been estimated that fewer than one-half of adult patients use a pMDI effectively.3 In some patients who are unable to coordinate the actuation and inhalation of medication in pMDI, a valved holding chamber or “spacer” may be used to facilitate optimal delivery of medication, but this may not address all areas of incorrect use.4 Patients are also prone to use DPIs incorrectly. In 2008, Lavorini et al.5 conducted a systematic literature review of DPI use in patients with asthma or COPD and found that 4–94% of patients used their inhaler incorrectly. Incorrect use of inhalers may lead to a reduced proportion of drug reaching the lung, ultimately resulting in suboptimal control of a patient’s symptoms.6 In patients with asthma, optimizing patient inhaler use has been associated with a significant decrease in asthma exacerbation frequency and emergency department (ED) visits.7 In patients with COPD, incorrect use of inhalers has been associated with an increased risk of hospitalization, ED visits, courses of antimicrobials and oral steroids, and poor disease control, while patients receiving training on inhaler use have been reported to have a higher rate of adherence, a decrease in dyspnea, number of exacerbations, ED visits, and hospitalizations.8–10 An improved quality of life has been associated with inhaler instruction.9,10 Guidelines recognize that pharmacists can provide effective education to patients about these devices.4,11 Education by pharmacists has also been shown to improve inhaler technique in patients with asthma and COPD.12 For optimal education to occur, the pharmacist should know and be able to demonstrate the correct inhaler technique for each device. This is important, as patients who are educated on inhaler technique by pharmacists make errors similar to those who train them.1 Unfortunately, it has been documented that health care professionals, including pharmacists and student pharmacists, may not be able to appropriately use these devices or educate patients on proper device technique.13–17 In addition, not all pharmacists educate patients on the proper inhaler technique, which has been suggested is due in part to a lack of knowledge and skills, which affects their confidence and willingness to educate patients.14 Fortunately, improvement in pharmacists’ inhaler
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technique has been shown in community and hospital pharmacists who complete formalized educational training.14,18–20 Provision of inhaler technique training in pharmacy schools has been described in several articles, although specifics on the effectiveness of these methods was not described in all.21–24 Two studies described specific educational methods that improved the knowledge, skills, and confidence of pharmacy students with inhalers.23,24 Toumas et al.23 compared small-group versus internet-based training to improve 236 second-year pharmacy students’ knowledge of a single type of DPI (Turbuhalers) in a pre- and postintervention designed study. The small-group intervention consisted of watching a step-by-step demonstration of inhaler use by an asthma physician after which the students were paired, and they evaluated each other on correct inhaler technique using a checklist. The internet-based group each individually watched a pharmacist demonstrate the correct use of the Turbuhalers via a computer. A checklist of steps was provided that students used to practice with a placebo inhaler. Finally, the students in this group also observed a patient using an inhaler and were asked to identify any steps performed incorrectly according to a checklist. Both the types of interventions resulted in an increase in the number of students who were able to demonstrate correct technique with this single device. The authors concluded that the small-group training was as effective as self-directed internet-based training in improving the students’ inhaler technique.23 The authors also evaluated the students’ confidence in using the inhaler and increased student confidence was a predictor of correct inhaler technique.23 In a smaller number of students, Erickson et al. compared 42 third-year students’ acquired knowledge and ability to correctly use a single type of pMDI in a three-arm design. A total of 13 students received education on correct pMDI use via a classroom lecture by the instructor who normally provided this information to students in the Pathophysiology and Therapeutics course. A total of 14 students independently completed internet-based instruction developed by the College of Pharmacy.24 These two groups were compared to a control group of 15 students who did not receive any specific education on the topic before the post-evaluation assessment was conducted.24 All students had not yet had formal educational training on the pMDI technique in their curriculum before the study was conducted. Comparing pre- and post-intervention assessments, the baseline MDI technique knowledge test scores did not differ between the three groups.24 In the postintervention assessment, both the intervention groups scored significantly better than the control group, but there was no difference between the two intervention groups.24 Both of these studies indicate that educating students on inhaler technique is effective, albeit with a single device at a time. Due to the growth in the number of devices in the market (spacers; nebulizers; Diskuss, Twisthalers, Flexhalers, Pressair™, and Respimats inhalers; and many more), a
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method needs to be found to deliver education on all of these device types efficiently and effectively, as students may encounter all of these types of devices in practice. At Virginia Commonwealth University School of Pharmacy, during the second year of the curriculum, students receive a one-hour didactic lecture on inhalational devices as part of the pharmacotherapy respiratory module. However, they are not given an opportunity to practice using the devices or counsel patients using the devices at that time. The ACPE-updated 2011 Standards and Guidelines include the need for active-learning techniques and strategies to develop students’ critical thinking skills and problemsolving capabilities.2 When developing a method to provide additional respiratory device education and training, the course coordinators of the laboratory and respiratory pharmacotherapy module decided that the laboratory setting provides an excellent environment to incorporate activelearning strategies in a low-risk setting. Active-learning encourages students to process and understand information, which results in retention of information as opposed to learning solely by rote memorization.25 Ideally, successful active-learning engages students in the classroom and is assisted by the use of small groups of students participating with a more experienced facilitator. Therefore, a two-hour laboratory experience was designed to incorporate the use of internet-based instruction for various devices used to deliver respiratory medications and supplemented by small-group discussions about these devices that would be in concert with the pharmacotherapy
module. This type of laboratory experience was designed to ease the transition between the classroom and the direct patient care environment. The objective of this study was to implement and evaluate an active-learning laboratory activity to teach pharmacy students about appropriate use of various respiratory devices including proper inhalation technique, device maintenance, and counseling points. Methods The active-learning laboratory included 133 second-year pharmacy students enrolled in the pharmacy practice skills laboratory course (de-identified course title) during the spring semester. The skills laboratory is a one-credit course intended to provide second-year pharmacy students with opportunities to improve acquired skills and gain additional skills that are necessary to be a competent, caring pharmacist. It is the fourth course in a six-semester practice-based laboratory course sequence. The students were divided into two-hour laboratory sections offered four times per week on either Mondays or Wednesdays, with one common hour of lecture time once weekly on Fridays. Each of the laboratory sections had between 33 and 34 students. On the day of the active-learning laboratory session, approximately ten minutes were spent discussing the logistics of the lab, explaining the objectives for the activity, and answering logistical questions. Students were divided into groups of eight or nine and rotated through each of the four stations approximately every 25 minutes. The students
Table 1 Key objectives for each station Station 1: nebulizers Determine which patients should and should not use a nebulizer List which medications are available in nebulized forms Discuss the proper storage for various nebulizer treatments Explain proper procedures for mixing nebulizer medications Describe the steps on how to use a nebulizer and appropriate cleaning and care for the device Station 2: COPD exacerbation case and HandiHalers Categorize a patient into the correct COPD stage based on airflow limitation Identify signs and symptoms consistent with respiratory acidosis Recommend treatment for a patient with respiratory acidosis Recommend appropriate long-term maintenance treatment for a patient with COPD Identify errors and omissions with a simulated patient using a HandiHalers incorrectly Demonstrate how to appropriately use a HandiHalers Station 3: dry powder inhalers Demonstrate proper administration technique for Diskuss, Twishalers, Flexhalers, and Pressair™ inhalers Identify errors and omissions with a simulated patient using a Diskuss inhaler incorrectly Identify errors and omissions with a simulated patient using a Twisthalers inhaler incorrectly Describe various counseling points for cleaning, storage, dosing, expiration, and days’ supply for various DPIs Label parts of a Diskuss inhaler Station 4: metered dose inhalers and spacers Demonstrate proper administration for pMDI including cleaning and priming Identify errors and omissions with a simulated patient using a pMDI incorrectly Identify errors and omissions with a simulated patient using a pMDI with spacer incorrectly Describe when to use a spacer, how to use the AeroChambers, and how to clean it Describe the steps for using Respimats COPD ¼ chronic obstructive pulmonary disease; DPI ¼ dry powder inhaler; pMDI ¼ pressurized metered dose inhaler.
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were provided with a worksheet that corresponded to key learning points at each station (Table 1). They were instructed to fill out the worksheet; however, it was not collected or graded. The students were told to use the worksheet as a study guide for their final exam. A faculty member, pharmacy resident, or an APPE student working with a faculty member led each station. The faculty members who participated included the course coordinators, other lab faculty, and the course coordinator for the respiratory pharmacotherapy module. The facilitators were provided with specific instructions for their stations prior to the exercise via e-mail and had access to the course Blackboards site where instructional videos had been posted. The course coordinators met with the facilitators briefly prior to the start of the lab to ensure they had complete understanding of their roles and responsibilities. Facilitators were provided a hardcopy of the script to follow during the lab activity, which included discussion questions to ask students, when to show the videos posted on Blackboards, and answers to the key points on the worksheet. The instructor’s script helped to ensure that all facilitators at each station were consistent. The facilitators walked the students through the activities at each station and ensured the students felt comfortable using the respiratory devices. Blackboards is a web-based learning management system that is used to support courses. For this activity, students had access to instructional videos one week prior to the lab. The errors and omissions videos were made available after the active-learning lab in case students wanted to use the material to study for their final exam.
Respiratory stations The laboratory activity was divided into four respiratory stations: (1) nebulizers, (2) COPD exacerbation case and HandiHalers, (3) dry powder inhalers, and (4) metered dose inhalers and spacers. Each station was carefully designed to incorporate specific devices that pharmacy students may be faced with in practice. Table 1 describes the key objectives covered at each station. Students at the four stations were shown how to correctly use the respiratory devices by viewing videos from the National Jewish Healths website (http://www. nationaljewish.org/healthinfo/medications/lung-diseases/ devices/instructional-videos/). The National Jewish Healths videos were chosen as they provide short, demonstrative clips on how to properly use a respiratory device. At the three inhaler stations, students also viewed videos that were developed for this laboratory exercise, with errors and omissions for certain respiratory devices. Prior to the lab, the course coordinators created videos using volunteer fourth-year students portraying patients who use their respiratory devices incorrectly. Some examples in the student videos include swallowing a Spirivas capsule,
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spraying a metered dose inhaler on the neck, and holding the Diskuss inhaler in the wrong position. Students had the opportunity to practice with the devices at each station. Students were asked to either verbalize how to correctly use the inhaler to the group or counsel another student on the device. Facilitators observed student technique and made corrections as necessary. Students were allowed to practice inhaling on certain devices if they wished, but this was not required. Demonstration inhalers were donated by the manufacturers. The nebulizer station had nebulizers and tubing. The National Jewish Healths video was then shown to review correct technique. Students volunteered to assemble the nebulizer. At the COPD exacerbation case and HandiHalers station, the focus was on the pharmacotherapy of the COPD case and the use of the HandiHalers device. About twothirds of the time was spent on the case facilitated by the instructor and one-third of the time was spent on the device. Students watched how to correctly use the HandiHalers device from the National Jewish Healths website and then identified the errors and omissions from the student video. The dry powder inhaler station included the Diskuss, Twisthalers, Flexhalers, and Pressair™ demonstration inhalers. Students watched the National Jewish Healths videos and then identified errors and omissions for the Diskuss and Twisthalers in the student videos. Student volunteers demonstrated how quickly and deeply a patient needs to breathe in to change the control window for the Pressair™ device, as this is an important counseling point. At the metered dose inhalers and spacers station, the students could practice with Respimats and Ventolins HFA inhalers as well as AeroChamberss. Students volunteered to demonstrate the use of the devices, after which the group assessed the volunteer’s technique. Students viewed the correct use from the National Jewish Healths website for each of the devices and then identified errors and omissions for the metered dose inhaler and using a spacer in the student videos. For Respimats, a student volunteered to activate the device, as demonstrated by the manufacturer’s video in order to emphasize the strength needed to put the device together so that they could convey this information to patients, especially those with dexterity issues. At each of the stations, key points on inhalation technique, device maintenance, and counseling points were reviewed. The worksheet the students completed while rotating through each station helped make sure that the students had all of the key points after completing the laboratory activity. Student assessment methods The assessment questions were developed in conjunction with the course coordinator of the respiratory pharmacotherapy module and laboratory coordinators. A preassessment including knowledge-based multiple-choice
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questions, a confidence survey, questions regarding what types of counseling activities related to respiratory devices students have participated in, and the importance of pharmacists counseling a patient about a respiratory device when it is dispensed was administered on Blackboards. The students completed the pre-assessment during lab three weeks before the active-learning laboratory. The preassessment was completed prior to the students starting the respiratory module in their pharmacotherapy course sequence. Students had no advanced knowledge of this assessment and therefore answered questions solely based on their baseline knowledge. Students’ baseline knowledge at the time of the pre-assessment included a pharmaceutics lecture on respiratory dosage forms and small-group presentations on respiratory devices that was part of the pharmacy school curriculum one year previously, as well as their personal experiences. Completion of the preassessment was a requirement in the course but was not included as part of their course grade. The last week of the semester, two weeks after the active-learning laboratory, the students were asked to complete the confidence survey questions again as well as answer a question on how important they thought it was to counsel a patient on respiratory devices on Blackboards. The post-assessment confidence survey was left open for about a month so that all students would have the opportunity to complete it. Two and a half weeks after the active-learning laboratory session, students were given the same knowledge-based questions as a post-assessment on their final exam. This was included as part of their course grade for (de-identified course title). Data assessment methods The knowledge-based quiz consisted of ten multiplechoice questions directly related to the objectives of the station activities. Students’ knowledge on the devices was reported as the percentage of those who answered correctly on each item. The overall score for the knowledge-based questions was reported as mean and standard deviation (SD) (Table 2). The confidence survey consisted of four questions that allowed students to rate their level of confidence in their ability to counsel on four different respiratory devices. The students ranked their confidence level on a Likert scale with 5 ¼ completely confident, 4 ¼ very confident, 3 ¼ somewhat confident, 2 ¼ not very confident, and 1 ¼ not at all confident. Students’ confidence on the use of the devices was described as the percentage of those who answered “completely confident,” “very confident,” or “somewhat confident” (Table 3). Since the responses from the assessments can be linked by students’ names in Blackboards, data were only analyzed on matched pairs. A paired t-test was used based on the distribution of the data for the overall knowledge score to compare the score before and after the session.
McNemar’s test was used to examine each knowledgebased question. A similar approach was used for students’ confidence. McNemar’s test was used from a categorical perspective to assess the differences between the proportions of those who were confident in each item before and after the laboratory session. On both the pre- and post-assessments, students were asked how important they thought it was for a pharmacist to counsel on respiratory devices using a Likert scale with 4 ¼ very important, 3 ¼ important, 2 ¼ somewhat important, and 1 ¼ not important at all. Students’ opinion on the importance of counseling was reported as the percentage of those who answered “very important,” “important,” and “somewhat important.” On the pre-assessment, students were also asked to identify with which respiratory devices they had experience in counseling a patient. The frequency of students who had previous experience on each of the respiratory devices is reported in Table 4. All statistical analyses were performed using SAS software, version 9.4 (SAS Institute Inc, Cary, NC, USA). P o 0.05 were considered significant. The Institutional Review Board of Virginia Commonwealth University approved this study as exempt research. Results Of 133 students, 131 (98.5%) completed both the assessments and provided consent to use their data. Students’ knowledge data are reported in Table 2. The average score on the pre-assessment knowledge-based questions was 52.8% (SD: 15.5, range: 10–90%). The post-assessment average score improved to 86.6% (SD: 12.3, range: 30– 100%). The question with the greatest improvement in the percentage correct score was about the use of the HandiHalers device (þ61.6%). About 95% of students scored higher on their post-assessment, with four students scoring the same and three students scoring lower on the postassessment. The individual questions all had statistically significant improvements as well as the overall scores on the knowledge-based assessment. Students’ confidence data are reported in Table 3. Students’ confidence in all of the four areas improved and was statistically significant. The ability to counsel a patient on the use of DPIs had the greatest level of confidence (100%) on the post-assessment. The most significant improvement in confidence was in the ability to counsel a patient on the use of nebulizers (þ53.5%). For the question regarding the importance of a pharmacist providing counseling on a respiratory device, all of the students (100%) answered either “very important,” “important,” or “somewhat important” on both the pre- and postassessments. In order to assess the students’ prior experiences with different respiratory devices, the survey asked about the types of devices on which the students previously counseled. A number of students (44.3%) reported that they did
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Table 2 Students’ knowledge of respiratory devices before and after completing an active-learning laboratory session, N ¼ 131 Question
Pre-assessment, % correct
Post-assessment, % correct
89.3
96.2
0.0490
32.3
93.9
o0.0001
72.5
98.5
o0.0001
55.0
90.1
o0.0001
21.4
79.4
o0.0001
47.3
92.4
o0.0001
74.1
89.3
0.0029
84.0
93.9
0.0192
47.3
92.4
o0.0001
3.8
40.5
o0.0001
86.64 (12.32)
o0.0001
P-valuea
s
Q1: Which of the following is TRUE about the use of HandiHaler ? a. The capsules contain a dry powder b. The capsules should be stored in the inhaler c. The capsules should be stored in the refrigerator prior to use d. The capsules may be swallowed or used in the inhaler device Q2: When using the HandiHalers device you should a. Hold the inhaler in a vertical position b. Tilt your head back and look toward the ceiling c. Hear or feel the capsule vibrate/rattle when inhaling a dose d. Take multiple shallow breaths until your lungs are full Q3: When using a Diskuss inhaler you should a. Use until the manufacturer’s expiration date once the pouch is opened b. Use another dose if you do not feel or taste the powder c. Wash the Diskus every two weeks d. Keep the Diskus in a level, flat position Q4: Diskuss inhalers should be inhaled a. Quickly and deeply b. Slowly and deeply c. Slowly in multiple breaths d. Any of the above will administer the correct dose to the patient Q5: Which of the following is TRUE regarding Twisthalers? a. A dose is loaded when the cap is removed b. It should be held in the vertical/upright position when administering c. It should be inhaled slowly and deeply d. The patient should be able to feel or taste the powder if administered correctly Q6: Which of the following is FALSE regarding a metered dose Albuterol inhaler? a. It is considered a rescue inhaler b. Rinse mouth after use to avoid thrush c. It should be used prior to a steroid inhaler to maximize delivery of steroid d. It should be shaken well before each use Q7: Which of the following is a disadvantage of using a spacer with a pMDI? a. Higher dose of maintenance therapy is required b. If not used properly, dose availability can be reduced c. Requires hand–lung coordination d. Increases risk of dysphonia Q8: Certain brands of spacers “whistle” if you are breathing a. Appropriately b. Too quickly c. Too slowly Q9: All parts of a nebulizer should be cleaned in soap and water after each use EXCEPT a. Interrupter b. Mask c. Mouthpiece d. Tubing Q10: How frequently should the parts of a nebulizer be cleaned in vinegar and water? a. Every treatment day b. Every other treatment day c. Weekly d. Every other week Overall score [mean (SD)]
52.75 (15.54)
Q ¼ question; pMDI ¼ pressurized metered dose inhaler; SD ¼ standard deviation; IQR ¼ interquartile range. a McNemar’s test on each question. Paired t-test for mean overall score.
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Table 3 Students’ confidence on the use of respiratory devices before and after an active-learning laboratory session, N ¼131 Statement I I I I
am am am am a b
confident confident confident confident
in in in in
my my my my
ability ability ability ability
to to to to
counsel counsel counsel counsel
a a a a
patient patient patient patient
on on on on
the the the the
use use use use
of of of of
metered dose inhalers. nebulizers. spacers. dry powder inhalers.
Pre-assessment, % Confidenta
Post-assessment, % Confidenta
p-value
55.7 45.0 61.1 48.9
99.2 98.5 99.2 100
o0.0001 o0.0001 o0.0001 o0.0001
b
Confident: categorical responses either as “completely confident,” “very confident,” or “somewhat confident.” McNemar’s test.
not have any experience in counseling patients on any of the respiratory devices. Students had the most experience (36.6%) counseling patients on the use of a metered dose inhaler. There were fewer students (13.7%) who had experience in counseling patients on the use of nebulizer. Some students (28.2%) had previous experience in counseling patients on the use of more than one kind of respiratory device (Table 4).
Discussion Implementation of an active-learning laboratory that focused on inhalation devices significantly improved students’ knowledge and confidence on respiratory devices. The pre-assessment quiz showed that over half of students correctly answered questions related to the HandiHalers, Diskuss inhaler, metered dose inhalers, and spacers. More than 50% of students rated themselves as confident in their ability to counsel a patient on the use of a pMDI and the use of spacers based on the pre-activity confidence rating. While the pre-assessments were administered prior to the delivery of respiratory content in the pharmacotherapy course sequence during their second year, students had been exposed to the pMDI technique about one year prior during their pharmaceutics course. Students also created formal small-group presentations on respiratory devices during their first year in the skills lab to correspond with the pharmaceutics course, where they focused on the dosage form but also included counseling points. This may have led to performance that was higher than expected on the preassessment multiple-choice questions and the students’ Table 4 Students’ experiences on different respiratory devices, N ¼ 131 Experiences
Students, no. (%a)
Counseled patients on use of nebulizer Counseled patients on use of a spacer device Counseled patients on use of a metered dose inhaler Counseled patients on a dry power inhaler Personally used an asthma product No experience
18 25 48 23 32 58
(13.7) (19.1) (36.6) (17.6) (24.4) (44.3)
a Percentages do not sum up to 100, as some students have experience with more than one device.
relatively high confidence in counseling a patient on certain devices. All students felt it was important for pharmacists to counsel a patient about a respiratory device when it is dispensed both before and after the activity. The activity was created to increase the level of engagement between the facilitator and the students. Further, it was designed to assess students’ prior knowledge, expand current understanding, and reassess students’ knowledge after the activity. The pre-assessment was intentionally unannounced so that students were assessed on only their baseline knowledge. This gave students an opportunity for self-assessment prior to participating in the activity. The improvement in post-assessment performance compared to pre-assessment performance demonstrates that the smallgroup active-learning activity in conjunction with the internet-based instruction was an effective design strategy. It is clear, based on post-assessment confidence ratings approaching 100% in all areas, that the active-learning laboratory activity had a significant impact on the students’ confidence in their abilities. Significant improvement in knowledge was seen for all devices. The change in the percentage of students correctly answering the first question about HandiHalers was the smallest; however, it was still statistically significant. The question related to the frequency of cleaning the parts of a nebulizer had the lowest performance on the postassessment. This may indicate a need for improving the emphasis of this key point during the nebulizer station. A formal survey was not administered to facilitators, but general feedback was solicited via e-mail. Overall, the feedback was positive with minor suggestions for additional materials at the nebulizer station and sequencing of videos played at each station based on flow. Facilitators appreciated having the demonstration products available and the interaction with students. Facilitators at the COPD HandiHalers and nebulizer stations expressed a need for additional time to cover the materials, while the timing of the pMDI and DPI stations worked well. Additional time needed at the nebulizer station could have possibly contributed to low performance on the post-assessment related to how frequently a nebulizer should be cleaned. In the future, possibly having the students watch the videos on proper technique of using a nebulizer and HandiHalers prior to coming to lab could allow for more discussion time at those stations.
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Unlike the study by Toumas et al.,23 students were not evaluated on their ability to demonstrate the use of each device. This could be included as an additional measure of the activity in the future. In the study by Erickson et al.,24 students were tested on their ability to document steps conducted incorrectly by a mock patient. Our activelearning lab included showing videos of improper inhaler technique at the pMDI, DPI, and COPD stations, and students were asked to identify errors and omissions in the videos but were not formally evaluated. This additional assessment method would be another opportunity for students to demonstrate their mastery of the material. A limitation of this study is test-re-test bias, which is a concern with the pre- and post-assessments. The students knew they would be receiving a post-assessment five and a half weeks after the pre-assessment and the same questions were used on both the assessments. Long-term retention of this material may be an issue, and future studies should look at if the students retain learning gains from this laboratory activity. Use of the knowledge-based assessment questions as part of the course final exam could have served as additional motivation to master the material. Another limitation is that it was difficult to discern which part of the laboratory exercise the students felt most valuable: practicing with the devices, viewing the National Jewish Healths videos, identifying errors and omissions in the student videos, or the discussion on key points from the facilitator. This could be assessed using a student survey. In the future, formally assessing the students’ technique and comparing it with their self-reported confidence could help validate the assessments used. Another future direction might include looking at students’ prior respiratory device counseling experiences and seeing how it compares with their pre- and post-assessment scores for both knowledge and confidence.
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9.
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Conclusion An active-learning laboratory activity to teach pharmacy students about appropriate use of various respiratory devices including proper inhalation technique, device maintenance, and counseling points was designed to help ease the transition between the classroom and the direct patient care environment. This active-learning laboratory allowed students to gain first-hand experience with multiple devices used to deliver respiratory medications, unlike previous studies only evaluating the use of one respiratory device at a time. Students’ knowledge and confidence on respiratory devices improved after completing the laboratory activity.
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Guidelines Version 2.0. Accreditation Council for Pharmacy Education. 〈https://www.acpe-accredit.org/pdf/FinalS2007Gui delines2.0.pdf〉; 2011 Accessed May 15, 2015. Crompton GK. Problems patients have using pressurized aerosol inhalers. Eur J Respir Dis Suppl. 1982;119:101–104. National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma. 〈http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln. htm〉; 2007 Accessed May 15, 2015. Lavorini F, Magnan A, Dubus JC, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med. 2008;102(4):593–604. Kelly HW. Correct aerosol medication use and the health professions: who will teach the teachers? Chest. 1993;104(6): 1648–1649. Takemura M, Mitsui K, Ido M, et al. Impact of a network system for providing proper inhalation technique by community pharmacists. J Asthma. 2012;49(5):535–541. Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011;105(6):930–938. Takemura M, Mitsui K, Itotani R, et al. Relationships between repeated instruction on inhalation therapy, medication adherence, and health status in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2011;6:97–104. Göriş S, Taşci S, Elmali F. The effects of training on inhaler technique and quality of life in patients with COPD. J Aerosol Med Pulm Drug Deliv. 2013;26(6):336–344. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention 2014. 〈www.ginasthma.org〉; Accessed May 15, 2015. Hämmerlein A, Müller U, Schulz M. Pharmacist-led intervention study to improve inhalation technique in asthma and COPD patients. J Eval Clin Pract. 2011;17(1):61–70. Self TH, Arnold LB, Czosnowski LM, Swanson JM, Swanson H. Inadequate skill of healthcare professionals in using asthma inhalation devices. J Asthma. 2007;44(8):593–598. Basheti IA, Armour CL, Reddel HK, Bosnic-Anticevich SZ. Long-term maintenance of pharmacists’ inhaler technique demonstration skills. Am J Pharm Educ. 2009;73(2): Article 32. Asmus MJ, Milavetz G, Teresi ME. Multicenter survey of pharmacy faculty and student metered-dose inhaler knowledge. J Am Pharm Assoc. 2001;41(3):461–464. Gemicioglu B, Borekci S, Can G. Investigation of knowledge of asthma and inhaler devices in pharmacy workers. J Asthma. 2014;51(9):982–988. Casset A, Meunier-Spitz M, Rebotier P, et al. Asthma management and inhalation techniques among community pharmacists in 2009: a comparison with the 1999 survey. J Asthma. 2014;51(9):964–973. Erickson SR, Landino HM, Zarowitz BJ, Kirking DM. Pharmacists’ understanding of patient education on metereddose inhaler technique. Ann Pharmacother. 2000;34(11): 1249–1256. Cain WT, Cable G, Oppenheimer JJ. The ability of the community pharmacist to learn proper actuation techniques of inhaler devices. J Allergy Clin Immunol. 2001;108(6):918–920. Jackevicius CA, Chapman KR. Inhaler education for hospitalbased pharmacists: How much is required? Can Respir J. 1999;6(3):237–244.
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21. Thurmon TB, Schwartz LL, Jervis KP. Asthma education in the student laboratory. J Pharm Pract. 2013;26(22):29–31. 22. Tofil NM, Benner KW, Worthington MA, Zinkan L, White ML. Use of simulation to enhance learning in a pediatric elective. Am J Pharm Educ. 2010;74(2): Article 21. 23. Toumas M, Basheti IA, Bosnic-Antcevich SZ. Comparison of small-group training with self-directed internet-based training in inhaler techniques. Am J Pharm Educ. 2009;75(5): Article 85.
24. Erickson SR, Chang A, Johnson CE, Gruppen LD. Lecture versus web tutorial for pharmacy students’ learning of MDI technique. Ann Pharmacother. 2003;37(4): 500–505. 25. Gleason BL, Peeter MJ, Resman-Targoff BH, et al. An active learning strategies primer for achieving ability-based educational outcomes. Am J Pharm Educ. 2011;75(9): Article 186.
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Research
http://www.pharmacyteaching.com
An active-learning laboratory on respiratory devices Krista L. Donohoe, PharmD, BCPS, CGPa,*, Nancy S. Yunker, PharmD, FCCP, BCPSa, Laura Morgan, PharmD, MEd, BCPSa, Yaena Min, PhDa, Punam H. Patel, PharmD, BCPSb a
Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA b Euclid Hospital, Cleveland Clinic, Euclid, OH
Abstract Objective: To implement and evaluate an active-learning laboratory activity designed to teach second-year pharmacy students about the appropriate use of various respiratory devices including proper inhalation technique, device maintenance, and counseling points. Methods: The laboratory session was divided into four small-group teaching stations: (1) nebulizers, (2) chronic obstructive pulmonary disease (COPD) exacerbation case and HandiHalers, (3) dry powder inhalers, and (4) metered dose inhalers and spacers. Students completed a pre-assessment and a post-assessment to measure changes in their respiratory device knowledge and confidence. McNemar’s test and a paired t-test were used to determine statistical significance. Results: Both the pre- and the post-assessments were completed by 131 of the 133 students enrolled (98.5%). The average score on pre-assessment knowledge-based questions was 52.7% (range: 10–90%). The post-assessment average score improved to 86.6% (range: 30–100%). Student’s confidence improved in all of the four areas. All knowledge and confidence improvements were statistically significant (p o 0.05). Conclusion: An active-learning approach facilitated students’ gain in knowledge, confidence, and experience with the various devices used to deliver respiratory medications. r 2015 Elsevier Inc. All rights reserved.
Keywords: Respiratory devices; Inhalers; Active learning; Laboratory; Pharmacy students
Introduction Pharmacists frequently receive their first exposure to inhaler devices and proper technique in pharmacy school. This education may be taught in any number of ways including didactic lectures on pertinent disease states or the devices themselves, demonstration by a teacher in a large lecture setting, student hands-on learning in a laboratory setting, or via internet-based modules. These devices are * Corresponding author: Krista L. Donohoe, PharmD, BCPS, CGP, Virginia Commonwealth University School of Pharmacy, 410 North 12th Street, P.O. Box 980533, Richmond, VA 23298-0533. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2015.04.014 1877-1297/r 2015 Elsevier Inc. All rights reserved.
most commonly used in the treatment of asthma and chronic obstructive pulmonary disease (COPD), and often the patient is required to use of multiple devices.1 In addition to medications commonly prescribed in a pressurized metered dose inhaler (pMDI), a patient may receive medication in one of several dry powder inhalers (DPIs) or in a nebulizer. Student pharmacist education on these devices may occur at any point in the pharmacy school curriculum. According to the Accreditation Council on Pharmacy Education (ACPE) updated 2011 Standards and Guidelines, students are required to complete Advanced Pharmacy Practice Experiences (APPEs) or experiential training.2 At the Virginia Commonwealth University School of
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Pharmacy and other schools in the United States, APPEs are completed during the fourth year of the pharmacy school curriculum. Students may be asked to educate patients with asthma and COPD on the use of their inhalers during the course of these APPEs both in the hospital and community settings. They may also be asked to provide inhaler education to other health care professionals during their experiential training. This suggests that students should receive preliminary training in their pharmacy curriculum earlier than APPEs. The proper use of these medications and devices is not intuitive and may require different inhalation techniques with multiple steps performed for correct use. While manufacturers do provide patient educational leaflets detailing the appropriate technique for a specific device, it has been estimated that fewer than one-half of adult patients use a pMDI effectively.3 In some patients who are unable to coordinate the actuation and inhalation of medication in pMDI, a valved holding chamber or “spacer” may be used to facilitate optimal delivery of medication, but this may not address all areas of incorrect use.4 Patients are also prone to use DPIs incorrectly. In 2008, Lavorini et al.5 conducted a systematic literature review of DPI use in patients with asthma or COPD and found that 4–94% of patients used their inhaler incorrectly. Incorrect use of inhalers may lead to a reduced proportion of drug reaching the lung, ultimately resulting in suboptimal control of a patient’s symptoms.6 In patients with asthma, optimizing patient inhaler use has been associated with a significant decrease in asthma exacerbation frequency and emergency department (ED) visits.7 In patients with COPD, incorrect use of inhalers has been associated with an increased risk of hospitalization, ED visits, courses of antimicrobials and oral steroids, and poor disease control, while patients receiving training on inhaler use have been reported to have a higher rate of adherence, a decrease in dyspnea, number of exacerbations, ED visits, and hospitalizations.8–10 An improved quality of life has been associated with inhaler instruction.9,10 Guidelines recognize that pharmacists can provide effective education to patients about these devices.4,11 Education by pharmacists has also been shown to improve inhaler technique in patients with asthma and COPD.12 For optimal education to occur, the pharmacist should know and be able to demonstrate the correct inhaler technique for each device. This is important, as patients who are educated on inhaler technique by pharmacists make errors similar to those who train them.1 Unfortunately, it has been documented that health care professionals, including pharmacists and student pharmacists, may not be able to appropriately use these devices or educate patients on proper device technique.13–17 In addition, not all pharmacists educate patients on the proper inhaler technique, which has been suggested is due in part to a lack of knowledge and skills, which affects their confidence and willingness to educate patients.14 Fortunately, improvement in pharmacists’ inhaler
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technique has been shown in community and hospital pharmacists who complete formalized educational training.14,18–20 Provision of inhaler technique training in pharmacy schools has been described in several articles, although specifics on the effectiveness of these methods was not described in all.21–24 Two studies described specific educational methods that improved the knowledge, skills, and confidence of pharmacy students with inhalers.23,24 Toumas et al.23 compared small-group versus internet-based training to improve 236 second-year pharmacy students’ knowledge of a single type of DPI (Turbuhalers) in a pre- and postintervention designed study. The small-group intervention consisted of watching a step-by-step demonstration of inhaler use by an asthma physician after which the students were paired, and they evaluated each other on correct inhaler technique using a checklist. The internet-based group each individually watched a pharmacist demonstrate the correct use of the Turbuhalers via a computer. A checklist of steps was provided that students used to practice with a placebo inhaler. Finally, the students in this group also observed a patient using an inhaler and were asked to identify any steps performed incorrectly according to a checklist. Both the types of interventions resulted in an increase in the number of students who were able to demonstrate correct technique with this single device. The authors concluded that the small-group training was as effective as self-directed internet-based training in improving the students’ inhaler technique.23 The authors also evaluated the students’ confidence in using the inhaler and increased student confidence was a predictor of correct inhaler technique.23 In a smaller number of students, Erickson et al. compared 42 third-year students’ acquired knowledge and ability to correctly use a single type of pMDI in a three-arm design. A total of 13 students received education on correct pMDI use via a classroom lecture by the instructor who normally provided this information to students in the Pathophysiology and Therapeutics course. A total of 14 students independently completed internet-based instruction developed by the College of Pharmacy.24 These two groups were compared to a control group of 15 students who did not receive any specific education on the topic before the post-evaluation assessment was conducted.24 All students had not yet had formal educational training on the pMDI technique in their curriculum before the study was conducted. Comparing pre- and post-intervention assessments, the baseline MDI technique knowledge test scores did not differ between the three groups.24 In the postintervention assessment, both the intervention groups scored significantly better than the control group, but there was no difference between the two intervention groups.24 Both of these studies indicate that educating students on inhaler technique is effective, albeit with a single device at a time. Due to the growth in the number of devices in the market (spacers; nebulizers; Diskuss, Twisthalers, Flexhalers, Pressair™, and Respimats inhalers; and many more), a
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method needs to be found to deliver education on all of these device types efficiently and effectively, as students may encounter all of these types of devices in practice. At Virginia Commonwealth University School of Pharmacy, during the second year of the curriculum, students receive a one-hour didactic lecture on inhalational devices as part of the pharmacotherapy respiratory module. However, they are not given an opportunity to practice using the devices or counsel patients using the devices at that time. The ACPE-updated 2011 Standards and Guidelines include the need for active-learning techniques and strategies to develop students’ critical thinking skills and problemsolving capabilities.2 When developing a method to provide additional respiratory device education and training, the course coordinators of the laboratory and respiratory pharmacotherapy module decided that the laboratory setting provides an excellent environment to incorporate activelearning strategies in a low-risk setting. Active-learning encourages students to process and understand information, which results in retention of information as opposed to learning solely by rote memorization.25 Ideally, successful active-learning engages students in the classroom and is assisted by the use of small groups of students participating with a more experienced facilitator. Therefore, a two-hour laboratory experience was designed to incorporate the use of internet-based instruction for various devices used to deliver respiratory medications and supplemented by small-group discussions about these devices that would be in concert with the pharmacotherapy
module. This type of laboratory experience was designed to ease the transition between the classroom and the direct patient care environment. The objective of this study was to implement and evaluate an active-learning laboratory activity to teach pharmacy students about appropriate use of various respiratory devices including proper inhalation technique, device maintenance, and counseling points. Methods The active-learning laboratory included 133 second-year pharmacy students enrolled in the pharmacy practice skills laboratory course (de-identified course title) during the spring semester. The skills laboratory is a one-credit course intended to provide second-year pharmacy students with opportunities to improve acquired skills and gain additional skills that are necessary to be a competent, caring pharmacist. It is the fourth course in a six-semester practice-based laboratory course sequence. The students were divided into two-hour laboratory sections offered four times per week on either Mondays or Wednesdays, with one common hour of lecture time once weekly on Fridays. Each of the laboratory sections had between 33 and 34 students. On the day of the active-learning laboratory session, approximately ten minutes were spent discussing the logistics of the lab, explaining the objectives for the activity, and answering logistical questions. Students were divided into groups of eight or nine and rotated through each of the four stations approximately every 25 minutes. The students
Table 1 Key objectives for each station Station 1: nebulizers Determine which patients should and should not use a nebulizer List which medications are available in nebulized forms Discuss the proper storage for various nebulizer treatments Explain proper procedures for mixing nebulizer medications Describe the steps on how to use a nebulizer and appropriate cleaning and care for the device Station 2: COPD exacerbation case and HandiHalers Categorize a patient into the correct COPD stage based on airflow limitation Identify signs and symptoms consistent with respiratory acidosis Recommend treatment for a patient with respiratory acidosis Recommend appropriate long-term maintenance treatment for a patient with COPD Identify errors and omissions with a simulated patient using a HandiHalers incorrectly Demonstrate how to appropriately use a HandiHalers Station 3: dry powder inhalers Demonstrate proper administration technique for Diskuss, Twishalers, Flexhalers, and Pressair™ inhalers Identify errors and omissions with a simulated patient using a Diskuss inhaler incorrectly Identify errors and omissions with a simulated patient using a Twisthalers inhaler incorrectly Describe various counseling points for cleaning, storage, dosing, expiration, and days’ supply for various DPIs Label parts of a Diskuss inhaler Station 4: metered dose inhalers and spacers Demonstrate proper administration for pMDI including cleaning and priming Identify errors and omissions with a simulated patient using a pMDI incorrectly Identify errors and omissions with a simulated patient using a pMDI with spacer incorrectly Describe when to use a spacer, how to use the AeroChambers, and how to clean it Describe the steps for using Respimats COPD ¼ chronic obstructive pulmonary disease; DPI ¼ dry powder inhaler; pMDI ¼ pressurized metered dose inhaler.
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were provided with a worksheet that corresponded to key learning points at each station (Table 1). They were instructed to fill out the worksheet; however, it was not collected or graded. The students were told to use the worksheet as a study guide for their final exam. A faculty member, pharmacy resident, or an APPE student working with a faculty member led each station. The faculty members who participated included the course coordinators, other lab faculty, and the course coordinator for the respiratory pharmacotherapy module. The facilitators were provided with specific instructions for their stations prior to the exercise via e-mail and had access to the course Blackboards site where instructional videos had been posted. The course coordinators met with the facilitators briefly prior to the start of the lab to ensure they had complete understanding of their roles and responsibilities. Facilitators were provided a hardcopy of the script to follow during the lab activity, which included discussion questions to ask students, when to show the videos posted on Blackboards, and answers to the key points on the worksheet. The instructor’s script helped to ensure that all facilitators at each station were consistent. The facilitators walked the students through the activities at each station and ensured the students felt comfortable using the respiratory devices. Blackboards is a web-based learning management system that is used to support courses. For this activity, students had access to instructional videos one week prior to the lab. The errors and omissions videos were made available after the active-learning lab in case students wanted to use the material to study for their final exam.
Respiratory stations The laboratory activity was divided into four respiratory stations: (1) nebulizers, (2) COPD exacerbation case and HandiHalers, (3) dry powder inhalers, and (4) metered dose inhalers and spacers. Each station was carefully designed to incorporate specific devices that pharmacy students may be faced with in practice. Table 1 describes the key objectives covered at each station. Students at the four stations were shown how to correctly use the respiratory devices by viewing videos from the National Jewish Healths website (http://www. nationaljewish.org/healthinfo/medications/lung-diseases/ devices/instructional-videos/). The National Jewish Healths videos were chosen as they provide short, demonstrative clips on how to properly use a respiratory device. At the three inhaler stations, students also viewed videos that were developed for this laboratory exercise, with errors and omissions for certain respiratory devices. Prior to the lab, the course coordinators created videos using volunteer fourth-year students portraying patients who use their respiratory devices incorrectly. Some examples in the student videos include swallowing a Spirivas capsule,
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spraying a metered dose inhaler on the neck, and holding the Diskuss inhaler in the wrong position. Students had the opportunity to practice with the devices at each station. Students were asked to either verbalize how to correctly use the inhaler to the group or counsel another student on the device. Facilitators observed student technique and made corrections as necessary. Students were allowed to practice inhaling on certain devices if they wished, but this was not required. Demonstration inhalers were donated by the manufacturers. The nebulizer station had nebulizers and tubing. The National Jewish Healths video was then shown to review correct technique. Students volunteered to assemble the nebulizer. At the COPD exacerbation case and HandiHalers station, the focus was on the pharmacotherapy of the COPD case and the use of the HandiHalers device. About twothirds of the time was spent on the case facilitated by the instructor and one-third of the time was spent on the device. Students watched how to correctly use the HandiHalers device from the National Jewish Healths website and then identified the errors and omissions from the student video. The dry powder inhaler station included the Diskuss, Twisthalers, Flexhalers, and Pressair™ demonstration inhalers. Students watched the National Jewish Healths videos and then identified errors and omissions for the Diskuss and Twisthalers in the student videos. Student volunteers demonstrated how quickly and deeply a patient needs to breathe in to change the control window for the Pressair™ device, as this is an important counseling point. At the metered dose inhalers and spacers station, the students could practice with Respimats and Ventolins HFA inhalers as well as AeroChamberss. Students volunteered to demonstrate the use of the devices, after which the group assessed the volunteer’s technique. Students viewed the correct use from the National Jewish Healths website for each of the devices and then identified errors and omissions for the metered dose inhaler and using a spacer in the student videos. For Respimats, a student volunteered to activate the device, as demonstrated by the manufacturer’s video in order to emphasize the strength needed to put the device together so that they could convey this information to patients, especially those with dexterity issues. At each of the stations, key points on inhalation technique, device maintenance, and counseling points were reviewed. The worksheet the students completed while rotating through each station helped make sure that the students had all of the key points after completing the laboratory activity. Student assessment methods The assessment questions were developed in conjunction with the course coordinator of the respiratory pharmacotherapy module and laboratory coordinators. A preassessment including knowledge-based multiple-choice
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questions, a confidence survey, questions regarding what types of counseling activities related to respiratory devices students have participated in, and the importance of pharmacists counseling a patient about a respiratory device when it is dispensed was administered on Blackboards. The students completed the pre-assessment during lab three weeks before the active-learning laboratory. The preassessment was completed prior to the students starting the respiratory module in their pharmacotherapy course sequence. Students had no advanced knowledge of this assessment and therefore answered questions solely based on their baseline knowledge. Students’ baseline knowledge at the time of the pre-assessment included a pharmaceutics lecture on respiratory dosage forms and small-group presentations on respiratory devices that was part of the pharmacy school curriculum one year previously, as well as their personal experiences. Completion of the preassessment was a requirement in the course but was not included as part of their course grade. The last week of the semester, two weeks after the active-learning laboratory, the students were asked to complete the confidence survey questions again as well as answer a question on how important they thought it was to counsel a patient on respiratory devices on Blackboards. The post-assessment confidence survey was left open for about a month so that all students would have the opportunity to complete it. Two and a half weeks after the active-learning laboratory session, students were given the same knowledge-based questions as a post-assessment on their final exam. This was included as part of their course grade for (de-identified course title). Data assessment methods The knowledge-based quiz consisted of ten multiplechoice questions directly related to the objectives of the station activities. Students’ knowledge on the devices was reported as the percentage of those who answered correctly on each item. The overall score for the knowledge-based questions was reported as mean and standard deviation (SD) (Table 2). The confidence survey consisted of four questions that allowed students to rate their level of confidence in their ability to counsel on four different respiratory devices. The students ranked their confidence level on a Likert scale with 5 ¼ completely confident, 4 ¼ very confident, 3 ¼ somewhat confident, 2 ¼ not very confident, and 1 ¼ not at all confident. Students’ confidence on the use of the devices was described as the percentage of those who answered “completely confident,” “very confident,” or “somewhat confident” (Table 3). Since the responses from the assessments can be linked by students’ names in Blackboards, data were only analyzed on matched pairs. A paired t-test was used based on the distribution of the data for the overall knowledge score to compare the score before and after the session.
McNemar’s test was used to examine each knowledgebased question. A similar approach was used for students’ confidence. McNemar’s test was used from a categorical perspective to assess the differences between the proportions of those who were confident in each item before and after the laboratory session. On both the pre- and post-assessments, students were asked how important they thought it was for a pharmacist to counsel on respiratory devices using a Likert scale with 4 ¼ very important, 3 ¼ important, 2 ¼ somewhat important, and 1 ¼ not important at all. Students’ opinion on the importance of counseling was reported as the percentage of those who answered “very important,” “important,” and “somewhat important.” On the pre-assessment, students were also asked to identify with which respiratory devices they had experience in counseling a patient. The frequency of students who had previous experience on each of the respiratory devices is reported in Table 4. All statistical analyses were performed using SAS software, version 9.4 (SAS Institute Inc, Cary, NC, USA). P o 0.05 were considered significant. The Institutional Review Board of Virginia Commonwealth University approved this study as exempt research. Results Of 133 students, 131 (98.5%) completed both the assessments and provided consent to use their data. Students’ knowledge data are reported in Table 2. The average score on the pre-assessment knowledge-based questions was 52.8% (SD: 15.5, range: 10–90%). The post-assessment average score improved to 86.6% (SD: 12.3, range: 30– 100%). The question with the greatest improvement in the percentage correct score was about the use of the HandiHalers device (þ61.6%). About 95% of students scored higher on their post-assessment, with four students scoring the same and three students scoring lower on the postassessment. The individual questions all had statistically significant improvements as well as the overall scores on the knowledge-based assessment. Students’ confidence data are reported in Table 3. Students’ confidence in all of the four areas improved and was statistically significant. The ability to counsel a patient on the use of DPIs had the greatest level of confidence (100%) on the post-assessment. The most significant improvement in confidence was in the ability to counsel a patient on the use of nebulizers (þ53.5%). For the question regarding the importance of a pharmacist providing counseling on a respiratory device, all of the students (100%) answered either “very important,” “important,” or “somewhat important” on both the pre- and postassessments. In order to assess the students’ prior experiences with different respiratory devices, the survey asked about the types of devices on which the students previously counseled. A number of students (44.3%) reported that they did
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439
Table 2 Students’ knowledge of respiratory devices before and after completing an active-learning laboratory session, N ¼ 131 Question
Pre-assessment, % correct
Post-assessment, % correct
89.3
96.2
0.0490
32.3
93.9
o0.0001
72.5
98.5
o0.0001
55.0
90.1
o0.0001
21.4
79.4
o0.0001
47.3
92.4
o0.0001
74.1
89.3
0.0029
84.0
93.9
0.0192
47.3
92.4
o0.0001
3.8
40.5
o0.0001
86.64 (12.32)
o0.0001
P-valuea
s
Q1: Which of the following is TRUE about the use of HandiHaler ? a. The capsules contain a dry powder b. The capsules should be stored in the inhaler c. The capsules should be stored in the refrigerator prior to use d. The capsules may be swallowed or used in the inhaler device Q2: When using the HandiHalers device you should a. Hold the inhaler in a vertical position b. Tilt your head back and look toward the ceiling c. Hear or feel the capsule vibrate/rattle when inhaling a dose d. Take multiple shallow breaths until your lungs are full Q3: When using a Diskuss inhaler you should a. Use until the manufacturer’s expiration date once the pouch is opened b. Use another dose if you do not feel or taste the powder c. Wash the Diskus every two weeks d. Keep the Diskus in a level, flat position Q4: Diskuss inhalers should be inhaled a. Quickly and deeply b. Slowly and deeply c. Slowly in multiple breaths d. Any of the above will administer the correct dose to the patient Q5: Which of the following is TRUE regarding Twisthalers? a. A dose is loaded when the cap is removed b. It should be held in the vertical/upright position when administering c. It should be inhaled slowly and deeply d. The patient should be able to feel or taste the powder if administered correctly Q6: Which of the following is FALSE regarding a metered dose Albuterol inhaler? a. It is considered a rescue inhaler b. Rinse mouth after use to avoid thrush c. It should be used prior to a steroid inhaler to maximize delivery of steroid d. It should be shaken well before each use Q7: Which of the following is a disadvantage of using a spacer with a pMDI? a. Higher dose of maintenance therapy is required b. If not used properly, dose availability can be reduced c. Requires hand–lung coordination d. Increases risk of dysphonia Q8: Certain brands of spacers “whistle” if you are breathing a. Appropriately b. Too quickly c. Too slowly Q9: All parts of a nebulizer should be cleaned in soap and water after each use EXCEPT a. Interrupter b. Mask c. Mouthpiece d. Tubing Q10: How frequently should the parts of a nebulizer be cleaned in vinegar and water? a. Every treatment day b. Every other treatment day c. Weekly d. Every other week Overall score [mean (SD)]
52.75 (15.54)
Q ¼ question; pMDI ¼ pressurized metered dose inhaler; SD ¼ standard deviation; IQR ¼ interquartile range. a McNemar’s test on each question. Paired t-test for mean overall score.
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Table 3 Students’ confidence on the use of respiratory devices before and after an active-learning laboratory session, N ¼131 Statement I I I I
am am am am a b
confident confident confident confident
in in in in
my my my my
ability ability ability ability
to to to to
counsel counsel counsel counsel
a a a a
patient patient patient patient
on on on on
the the the the
use use use use
of of of of
metered dose inhalers. nebulizers. spacers. dry powder inhalers.
Pre-assessment, % Confidenta
Post-assessment, % Confidenta
p-value
55.7 45.0 61.1 48.9
99.2 98.5 99.2 100
o0.0001 o0.0001 o0.0001 o0.0001
b
Confident: categorical responses either as “completely confident,” “very confident,” or “somewhat confident.” McNemar’s test.
not have any experience in counseling patients on any of the respiratory devices. Students had the most experience (36.6%) counseling patients on the use of a metered dose inhaler. There were fewer students (13.7%) who had experience in counseling patients on the use of nebulizer. Some students (28.2%) had previous experience in counseling patients on the use of more than one kind of respiratory device (Table 4).
Discussion Implementation of an active-learning laboratory that focused on inhalation devices significantly improved students’ knowledge and confidence on respiratory devices. The pre-assessment quiz showed that over half of students correctly answered questions related to the HandiHalers, Diskuss inhaler, metered dose inhalers, and spacers. More than 50% of students rated themselves as confident in their ability to counsel a patient on the use of a pMDI and the use of spacers based on the pre-activity confidence rating. While the pre-assessments were administered prior to the delivery of respiratory content in the pharmacotherapy course sequence during their second year, students had been exposed to the pMDI technique about one year prior during their pharmaceutics course. Students also created formal small-group presentations on respiratory devices during their first year in the skills lab to correspond with the pharmaceutics course, where they focused on the dosage form but also included counseling points. This may have led to performance that was higher than expected on the preassessment multiple-choice questions and the students’ Table 4 Students’ experiences on different respiratory devices, N ¼ 131 Experiences
Students, no. (%a)
Counseled patients on use of nebulizer Counseled patients on use of a spacer device Counseled patients on use of a metered dose inhaler Counseled patients on a dry power inhaler Personally used an asthma product No experience
18 25 48 23 32 58
(13.7) (19.1) (36.6) (17.6) (24.4) (44.3)
a Percentages do not sum up to 100, as some students have experience with more than one device.
relatively high confidence in counseling a patient on certain devices. All students felt it was important for pharmacists to counsel a patient about a respiratory device when it is dispensed both before and after the activity. The activity was created to increase the level of engagement between the facilitator and the students. Further, it was designed to assess students’ prior knowledge, expand current understanding, and reassess students’ knowledge after the activity. The pre-assessment was intentionally unannounced so that students were assessed on only their baseline knowledge. This gave students an opportunity for self-assessment prior to participating in the activity. The improvement in post-assessment performance compared to pre-assessment performance demonstrates that the smallgroup active-learning activity in conjunction with the internet-based instruction was an effective design strategy. It is clear, based on post-assessment confidence ratings approaching 100% in all areas, that the active-learning laboratory activity had a significant impact on the students’ confidence in their abilities. Significant improvement in knowledge was seen for all devices. The change in the percentage of students correctly answering the first question about HandiHalers was the smallest; however, it was still statistically significant. The question related to the frequency of cleaning the parts of a nebulizer had the lowest performance on the postassessment. This may indicate a need for improving the emphasis of this key point during the nebulizer station. A formal survey was not administered to facilitators, but general feedback was solicited via e-mail. Overall, the feedback was positive with minor suggestions for additional materials at the nebulizer station and sequencing of videos played at each station based on flow. Facilitators appreciated having the demonstration products available and the interaction with students. Facilitators at the COPD HandiHalers and nebulizer stations expressed a need for additional time to cover the materials, while the timing of the pMDI and DPI stations worked well. Additional time needed at the nebulizer station could have possibly contributed to low performance on the post-assessment related to how frequently a nebulizer should be cleaned. In the future, possibly having the students watch the videos on proper technique of using a nebulizer and HandiHalers prior to coming to lab could allow for more discussion time at those stations.
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Unlike the study by Toumas et al.,23 students were not evaluated on their ability to demonstrate the use of each device. This could be included as an additional measure of the activity in the future. In the study by Erickson et al.,24 students were tested on their ability to document steps conducted incorrectly by a mock patient. Our activelearning lab included showing videos of improper inhaler technique at the pMDI, DPI, and COPD stations, and students were asked to identify errors and omissions in the videos but were not formally evaluated. This additional assessment method would be another opportunity for students to demonstrate their mastery of the material. A limitation of this study is test-re-test bias, which is a concern with the pre- and post-assessments. The students knew they would be receiving a post-assessment five and a half weeks after the pre-assessment and the same questions were used on both the assessments. Long-term retention of this material may be an issue, and future studies should look at if the students retain learning gains from this laboratory activity. Use of the knowledge-based assessment questions as part of the course final exam could have served as additional motivation to master the material. Another limitation is that it was difficult to discern which part of the laboratory exercise the students felt most valuable: practicing with the devices, viewing the National Jewish Healths videos, identifying errors and omissions in the student videos, or the discussion on key points from the facilitator. This could be assessed using a student survey. In the future, formally assessing the students’ technique and comparing it with their self-reported confidence could help validate the assessments used. Another future direction might include looking at students’ prior respiratory device counseling experiences and seeing how it compares with their pre- and post-assessment scores for both knowledge and confidence.
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Conclusion An active-learning laboratory activity to teach pharmacy students about appropriate use of various respiratory devices including proper inhalation technique, device maintenance, and counseling points was designed to help ease the transition between the classroom and the direct patient care environment. This active-learning laboratory allowed students to gain first-hand experience with multiple devices used to deliver respiratory medications, unlike previous studies only evaluating the use of one respiratory device at a time. Students’ knowledge and confidence on respiratory devices improved after completing the laboratory activity.
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