- Email: [email protected]
Impact of virtual simulation in self-care therapeutics course on introductory pharmacy practice experience self-care encounters
Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx
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Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Experiences in Teaching and Learning
Impact of virtual simulation in self-care therapeutics course on introductory pharmacy practice experience self-care encounters Ming-Hei Taia, Nada Ridaa, Kristin C. Kleina, Heidi Dieza, Trisha Wellsa, ⁎ Kellie Kippesa, Paul C. Walkera, Sarah E. Vordenbergb, a b
University of Michigan College of Pharmacy, Ann Arbor, MI, United States University of Michigan College of Pharmacy, 428 Church St, Suite 3563 NUB, Ann Arbor, MI, United States
A R T IC LE I N F O
ABS TRA CT
Keywords: MyDispense Simulated learning environment Self-care Over-the-counter medications Introductory pharmacy practice experience
Background and purpose: Pharmacy education programs use simulation to provide a realistic and safe environment for student learning. We studied whether incorporation of virtual simulation into a required first year self-care therapeutics course impacted frequency of interactions, selfreported student confidence, and preceptor-reported student performance during second-year community pharmacy introductory pharmacy practice experiences (IPPEs). Educational activity and setting: Virtual simulation cases using MyDispense were incorporated into a self-care therapeutics course in winter 2017. Students and preceptors were surveyed at the end of the fall semester community pharmacy IPPE. Data from IPPE experiences was compared with students who took the self-care therapeutics course in winter 2016 (control). Findings: Students completed 30 virtual simulation cases and three cases as part of the final examination (n = 33). Students in the intervention group reported more patient care interactions during their IPPEs than students who did not complete virtual simulation cases, but there was no difference in self-reported confidence. Preceptors did not report any differences in the ability of students to complete over-the-counter medication interactions during IPPEs. Summary: Cases were well received by students although they took longer to complete than initially anticipated. Students in the intervention group reported significantly more patient care interactions during IPPEs than those in the control group; however, there were no differences in self-reported confidence. Incorporation of virtual simulation was a sustainable change as the cases were able to be re-used the following year with minimal edits.
Background and purpose Pharmacy education programs are increasingly using virtual simulation in order to provide a realistic and safe environment for student learning.1–10 A literature review found that students enjoyed patient simulation and virtual patient studies and the amount of learning from use of these tools was significant.11 While the number of studies reviewed was small, virtual patient simulation was associated with improved knowledge and problem-solving, communication, and professional skills according to student self-assessments and either no change or improvements in examination scores.11 One virtual simulation tool that is increasingly being used is MyDispense, a customizable open access outpatient pharmacy web application developed by Monash University in Australia.7–10,12 Community pharmacy preceptors and students at our institution had provided informal feedback that students had difficulty
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Corresponding author. E-mail address: [email protected] (S.E. Vordenberg).
https://doi.org/10.1016/j.cptl.2019.10.015
1877-1297/ © 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Ming-Hei Tai, et al., Currents in Pharmacy Teaching and Learning, https://doi.org/10.1016/j.cptl.2019.10.015
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applying knowledge learned in the classroom setting to the introductory pharmacy practice experiences (IPPEs). As a result, we aimed to determine whether incorporation of virtual simulation using MyDispense into a required first-year (P1) self-care therapeutics course impacted the frequency of interactions, self-reported student confidence, and preceptor-reported student performance of students during their second-year (P2) community pharmacy IPPE. Educational activity and setting Curriculum This study was completed at a public university with a four-year pharmacy program containing approximately 85 students per class. Student pharmacists take a required, four-credit hour self-care therapeutics course in the P1 winter semester. This is the first in a five-semester sequence of courses that focus on therapeutic problem solving and emphasizes over-the-counter (OTC) therapies for the self-treating patient. Students learn a systematic approach to assess, triage, and appropriately use OTC medications for selftreatable conditions. The course consists of recitation sessions (1.5 hours twice weekly) taught using team-based learning (TBL) and laboratory sessions (three hours once weekly) where students further practice applying their knowledge and pharmacy practice skills.13 Traditionally, the laboratory component of the course included a wide variety of activities ranging from knowledge-based activities using the physical packages of OTC medications provided in class to application-based activities that included interviewing patients (as played by peers or simulated patients). Students also watched the recorded encounters in order to reflect on their performances. However, opportunities to practice interviewing and counseling patients were limited, primarily due to time constraints and logistic difficulties in setting up these complex activities during classroom times. P2 students completed a two-credit hour IPPE in which they spent eight hours per week in a community pharmacy during either fall or winter semester (104 hours over 13 weeks). This course provided students the opportunity to enhance their pharmacy knowledge and skills learned in the classroom through hands-on experiences, including counseling patients about prescription and OTC medications. Each student worked with one primary preceptor who is a pharmacist that meets the requirements of being an adjunct clinical assistant, associate, or full professor at the university. Intervention This study involved replacement of most of the knowledge-based activities in the laboratory component of the self-care therapeutics course (class of 2019) with virtual simulation activities that allowed students more opportunities to practice applying the course content and skills related to patient interviewing and making recommendations (class of 2020). Case development Cases were developed to align with topics taught in the self-care therapeutics course and commonly observed patient care interactions in the community pharmacy setting. Two students working on this project in exchange for independent study credit (independent study students) who previously completed both the self-care therapeutics and IPPE courses drafted the initial cases in collaboration with the principle investigator. Subsequently, faculty members teaching the corresponding topics reviewed the cases and worked with the independent study students to edit the cases until the desired result was achieved. A total of 30 cases were developed for use during the semester and three cases with topics that were previously covered in the semester were incorporated into the final examination. Case development consisted of creating the patient's demographics, past medical history, information about the reason for the visit to the community pharmacy, and questions for the student pharmacist. The virtual patient would present with a chief complaint or question, either with or without a specific product that they were interested in purchasing. Students were expected to further investigate the patient's condition by asking appropriate triage questions from a predetermined list of questions, which created a virtual dialogue between the student and the patient. Students needed to use their clinical judgement to determine which questions were appropriate to ask (e.g., symptoms, location, pregnancy, other medications). The instructor identified in advance if each question was required, optional, or inappropriate to ask the patient. Each case required that students either make a medication recommendation or refer the patient to another health care professional for further management, in which case a justification was required. Immediately after submitting the case, students received feedback regarding whether the student asked appropriate questions, whether the patient was a candidate for self-treatment, and if so, if the selected medication was appropriate. Students were able to repeat each case as many times as desired before submitting the cases for the entire module for a grade. Implementation Students were provided a guide to navigating MyDispense, three short videos that showed how to complete and submit the cases, and instructions regarding expectations. Key points regarding how to complete MyDispense cases and expectations were also discussed with the students in class at the beginning of the semester. Importantly, all students had used the prescription medication dispensing feature of MyDispense in a different course the previous semester and were familiar with this functionality of the application. 2
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Fig. 1. Study timeline. IPPE = Introductory pharmacy practice experience.
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The course material was taught in four modules with an examination at the end of each. Students were provided access to the cases at the beginning of each module and were instructed to complete the cases individually before the examination covering that material (Appendix 1). Students were given time during the laboratory to complete the cases; however, nearly all students worked on the cases outside of class. The final examination included three cases that covered topics taught earlier in the semester and they could only be attempted once. Grading rubrics that were designed to assess key points or unique aspects of each case were utilized. Short debriefs that covered commonly missed points were discussed in class. The four modules accounted for 1.7% of the course grade (divided equally among each module) and the MyDispense component of the final exam accounted for 2.25% of the total course grade. Data collection and analysis A summary of the study timeline, including data collection time points is available (Fig. 1). Scores on virtual simulation cases for each module, as well as the virtual simulation component of the final examination, were collected from students in the class of 2020 (intervention group). At the end of the semester, these students also completed an online Qualtrics survey (Qualtrics, Provo, UT). Students were asked three questions about their perceptions regarding learning using virtual simulation (5-point Likert scale, strongly agree to strongly disagree), and six questions regarding their perceived confidence and ability to provide appropriate self-care recommendations (4-point Likert scale, very confident to not confident at all). The specific skills were selected to align with the steps in an OTC interaction. Students were also asked frequency of using class notes or the textbook when completing the cases (4-point Likert scale, never to always), average time to complete the case (< 10 min to 71 min or more in 10-min increments), and questions regarding demographics and pharmacy experience. The last set of questions were included as it was hypothesized that students with prior community pharmacy work experience may have higher levels of self-reported confidence with OTC patient encounters. Students were instructed to complete the survey within one week of the distribution date. Two reminders were electronically sent to students. All students were required to complete this survey as it was considered a reflective exercise as part of the course. Students were given the option to have their data excluded from the research study. Data were also collected at the end of the IPPE for the class of 2019 (control group) and 2020 (intervention group). Students were asked to complete an online Qualtrics survey regarding their perceptions of their ability to and confidence in making recommendations related to self-treatable conditions. These questions were the same as those at the end of the self-care therapeutics course with the addition of an option to indicate that the student never completed a specific skill during their IPPE. In addition, students indicated how many times they participated in the self-care/OTC process. Preceptors were asked to complete an online Qualtrics survey that focused on student ability and confidence in making recommendations related to self-treatable conditions (4point Likert scale, the student was able to consistently perform this skill with limited/no assistance to the student was never able to perform this skill, even with the assistance from the preceptor). These skills were selected to align with the steps of OTC interactions and the rating system aligned with the scale used by preceptors to assess other skills during community pharmacy rotations. Preceptors were sent the survey via email and a reminder was sent after one week. Preceptors had a total of two weeks to complete the survey. Completion of these surveys was voluntary with the goal of obtaining information about consequences of this curricular change. All surveys consisted of closed-ended and Likert-type questions (Appendix 2). t-Tests were used for all comparisons, except a X2 test was used to analyze the number of interactions reported by students during their IPPE. MedCalc Statistical Software version 18.6 was used.14 This study was reviewed and approved by the University of Michigan Health Sciences and Behavioral Sciences Institutional Review Board. Findings Post self-care course survey All students from the class of 2020 (n = 85, 100%) completed the post-course survey during winter 2017 (intervention group). Sixty percent of students reported having community pharmacy experience (Table 1). Regardless of prior community pharmacy work experience, students generally reported that they were either somewhat or very confident in their ability to complete all aspects of Table 1 Student work experience prior to self-care therapeutics course. Students n = 85 (%) Pharmacy work experience prior to winter P1 semester Community/outpatient only Hospital/inpatient only Community/outpatient plus one additional setting No work experience
P1 = first-year. 4
51 (60.0) 3 (3.5) 6 (7.1) 25 (29.4)
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Table 2 Student self-reported confidence in ability to perform self-care encounters at end of self-care course by community pharmacy work experiencea.
Collect data Assess data Triage to correct level of care Select medication regimen Provide patient education Create follow-up plan a
Community pharmacy work experience (n = 57)
No community pharmacy work experience (n = 28)
Mean
Standard deviation
Mean
Standard deviation
1.5 1.6 1.7 1.8 1.8 1.7
0.6 0.6 0.6 0.5 0.6 0.7
1.8 1.9 1.9 2.2 2.0 2.0
0.8 0.5 0.5 0.8 0.6 0.6
p-Value
0.02 0.02 0.18 0.01 0.07 0.11
1 = Very confident; 2 = Somewhat confident; 3 = Not very confident; 4 = Not confident at all.-.
self-care interactions at the end of the self-care course. Students with community pharmacy experience expressed a significantly higher confidence level in their abilities to collect (p = .02) and assess (p = .02) data and select a medication regimen (p = .01) (Table 2). Students agreed that MyDispense was a valuable tool for learning self-care (2.8 ± 1.1; 1 = strongly agree, 5 = strongly disagree) and that the cases emphasized key learning points (2.6 ± 1.0). Students agreed that the self-care cases aligned with course material (1.9 ± 0.8) and students needed to reference class notes or the textbook most of the time when completing the self-care cases (1.4 ± 0.6; 1 = always, 4 = never). There was no significant difference when comparing student perceptions of MyDispense as a learning tool for students with and without community pharmacy work experience (p > .05). The majority of students (58.8%) reported needing 31–60 min to complete each simulation. Twenty percent of students reported only needing 1–30 min for the simulations, while 21.2% of students needed 61 min or longer for case completion. There was no significant difference when calculating the amount of time it took to complete a case for students with and without community pharmacy work experience (p = .9). The average and range for student scores were: module 1 80.7% (8%–100%); module 2 89.2% (64%–100%); module 3 92.6% (72%–100%); module 4 99.4% (80%–100%); and final 96.5% (60%–100%).
Student post-IPPE survey Approximately 70% (n = 26/37) of students who completed their community pharmacy IPPEs in fall 2016 (control group) responded to the survey, while only 55% (n = 22/40) of students who completed their community pharmacy IPPEs in fall 2017 (intervention group) responded to the survey. When comparing students completing their IPPEs in fall 2016 (control group) with fall 2017 (intervention group), there were no significant differences in self-reported levels of confidence when comparing specific skills (Table 3). Student confidence in fall 2016 ranged from 1.6 ± 0.6 for assess to 2.1 ± 0.6 for follow-up plan creation whereas student confidence in fall 2017 ranged from 1.7 ± 0.5 for collect to 2.1 ± 0.7 for selecting a medication regimen as well as counseling (1 = very confident, 4 = not confident at all). There was no significant difference when comparing confidence levels of students with or without community pharmacy work experience (p > .05). Students in the intervention group (fall IPPE 2017) reported statistically significantly more patient interactions during their community pharmacy IPPEs than those in the control group (fall IPPE 2016; p < .007; Fig. 2). Students from the intervention group (Fall 2017 IPPE) felt very confident collecting data at the end of the self-care course; however, they reported statistically significant less confidence with this skill at the completion of their IPPE (p = .03). Students reported high confidence both at the end of the self-care course and IPPE as it related to assessment, triaging based on level of care, medication selection, patient education, and creation of a follow-up plan.
Table 3 Student self-reported confidence during self-care encounters at end of introductory pharmacy practice experience by virtual simulation exposure.a,b
Collect data Assess data Triage to correct level of care Select medication regimen Provide patient education Create follow-up plan a b
Virtual simulation exposure during self-care course fall 2017 (n = 22)
No virtual simulation exposure during self-care course fall 2016 (n = 26)
Mean
Standard deviation
Mean
Standard deviation
1.7 1.9 1.9 2.1 2.1 2.1
0.5 0.6 0.6 0.7 0.7 0.8
1.8 1.9 2.0 2.0 1.8 2.1
0.5 0.6 0.5 0.7 0.6 0.6
1 = Very confident; 4 = Not confident at all. No statistically significant difference between groups. 5
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Fig. 2. Number of interactions reported by students during introductory pharmacy practice experience (IPPE)a. a The chi-square statistic is 9.8868, p-value = .007.
Preceptor survey In 2016, there were 24 preceptors for 37 students. Preceptors completed surveys for seven students (18.9%). In 2017, there were 39 preceptors for 40 students, and 12 preceptors responded to the survey (31%). Preceptors consistently rated students highly in all skills performed. Students in the intervention group (fall IPPE 2017) had slightly higher scores overall; however, this difference was not significant (Table 4). Discussion Virtual simulation was successfully incorporated into a self-care therapeutics course. Students agreed that the simulations were a valuable tool for learning self-care and that the cases aligned with course material and emphasized key learning points. Use of virtual simulation was associated with students engaging in more patient care interactions during their IPPE than students who did not complete virtual simulation cases. This suggests that students who completed the simulations may have felt more comfortable engaging with patients regarding self-care encounters. We hypothesize that the opportunity to practice more encounters in a safe environment while receiving immediate feedback may have led to this improvement; however, there have been mixed findings in the literature regarding the impact of simulation on confidence.15,16 Importantly, previous literature has identified the need to establish a link between simulation and changes in practice and this study begins to address that gap in the area of community pharmacy practice.17 Preceptors did not report any differences in the ability of students to complete OTC medication interactions during IPPEs. Use of application-based simulation cases was determined by course faculty to be more appropriate for student learning compared to prior knowledge-based activities and, therefore, the decision was made to continue to use virtual simulation even though significant improvements were not seen during the community IPPE, aside from the number of patient care interactions. Interestingly, students who completed the virtual simulation cases reported feeling less confident in medication selection, patient education, and follow-up plan creation at the end of their IPPEs compared to the end of the self-care course. This suggests that interacting with patients in a simulated environment does not fully replicate the interaction with real patients that occurs in the community pharmacy. For example, the student may feel time pressure from the patient, feel uncertainty about the wide variety of products that are available, and face communication barriers. Due to limitations in this study, it was not possible to determine if students in the control group experienced similar decreases in confidence when transitioning from the classroom to experiential Table 4 Preceptor perceptions of student ability to perform self-care encounters at end of introductory pharmacy practice experience by virtual simulation exposurea,b.
Collect data Assess data Triage to correct level of care Select medication regimen Provide patient education Create follow-up plan
Virtual simulation exposure during self-care course fall 2017 (n = 12)
No virtual simulation exposure during self-care course fall 2016 (n = 7)
Mean
Standard deviation
Mean
Standard deviation
1.50 1.58 1.75 1.67 1.50 1.67
0.52 0.67 0.62 0.49 0.52 0.65
1.71 1.71 1.71 2.00 1.71 1.67
0.76 0.76 0.49 0.58 0.76 0.52
a
1 = Consistently able, limited to no assistance, entry level performance; 2 = Sometimes able, preceptor provided some assistance; 3 = Infrequently unable even with assistance from preceptor; 4 = Never able even with assistance. b No statistically significant difference between groups. 6
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settings. Time was a significant concern when embarking on this intervention. Specifically, course faculty were concerned about the amount of time to create and test cases, how much time it would take for students to complete cases, and the time required to grade the cases. By working with two independent study students, the amount of time faculty spent developing and testing the cases was minimized. Furthermore, the cases were used the subsequent academic year with very minimal modifications. Cases took significantly longer for students to complete than originally anticipated by course faculty (31–60 min compared to an anticipated 15 min). As a result, the number of cases was decreased from 30 plus three for the final examination (n = 33) to 26 plus two for the final examination (n = 28), which provided one simulation per topic the following year. More significantly, expectations for the cases were modified to focus on the most relevant points when providing counseling in patient care interactions. For example, the specificity of dosing information varied by case. Students were expected to provide the number of tablets and milligrams per dose and per day when providing dosing information regarding acetaminophen for an adult with a headache but they were only expected to provide the number of drops per dose and frequency of administration when making a recommendation regarding an ophthalmic product. The key points were designed to align with the information patients most often need in practice. Finally, grading rubrics were developed with standardized feedback in order to ensure efficient and consistent grading of cases and facilitate feedback. In the future, details of the cases may be modified in order to preserve the integrity of the cases. Additionally, a portion of the final examination grade comes from the completion of cases without notes or other resources which serves as an incentive for students to independently practice the material throughout the semester. There were several key limitations to this study. First, it was completed at one academic institution and the number of students was relatively small. Furthermore, data were not available from the control group regarding their previous pharmacy work experience or self-reported confidence at the end of the self-care therapeutics course. A variety of pharmacies provide IPPEs and the opportunities to provide self-care counseling may have varied by site and year. Additionally, data was only collected at the end of the IPPE, therefore it is possible that internship experiences or other courses during the fall semester influenced student confidence. Data collection was limited to the fall semester as it was thought that the courses and additional experiences that students complete during the winter semester may confound the study results. As part of the standard IPPE at this university, students were supposed to track how many OTC patient interactions they completed; however, students may have estimated this number. Finally, IPPE-related data were provided by a small number of students and preceptors. Additional research regarding the use of virtual simulation in a self-care therapeutics course and its impact on community pharmacy IPPEs is warranted. Summary Virtual simulation was incorporated into a required self-care therapeutics course as a way to increase the amount of applicationbased exercises completed by students. Students who completed the cases reported significantly more patient care interactions during their IPPEs than those in the control group; however, there were no differences in self-reported confidence. Incorporation of virtual simulation was a sustainable change as the cases were able to be re-used the following year with minimal edits. Declaration of competing interest None. Acknowledgements We appreciate the technical assistance provided by Mr. Keith Sewell and Mr. Keenan Beaumont at Monash University. Appendix 1. Summary of virtual simulation cases by module in order of content taught in course1
Module 1
Module 2
Module 3
Module 4
Dietary supplements 1 Dietary supplements 2 Tobacco cessation Obesity Constipation Diarrhea Nausea/vomiting
Heartburn Intestinal gas Pinworms Fungal skin infections 1 Fungal skin infections 2 Pediculosis 1 Pediculosis 2 Headache Musculoskeletal pain Colds
Fever Cough Allergic rhinitis Diaper dermatitis Atopic dermatitis Contact dermatitis Bug bites 1 Bug bites 2
Contraception Ophthalmic health Oral health Otic health Acne
1 Two cases were used where one case required a referral and the second case required over-the-counter medication treatment or if there were two distinct issues that needed to be treated (e.g., two different types of bug bites).
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Appendix 2. Surveys Post self-care course survey 1. How confident did you feel with the following skills? Very confident Somewhat confident Not very confident Not confident at all I never did this skill. a. b. c. d. e. f.
Collecting necessary subjective and objective information about the patient Assessing the information that was collected in order to identify and prioritize problems Triaging patients appropriately to self-care, medical care, or emergency care Selecting an appropriate self-care regimen Providing self-care counseling/education Developing a plan for following up with the patient as needed
2. Please answer the following questions, considering only your personal experience with the virtual simulation program, MyDispense, in the P512 Self-Care Course. Strongly agree Agree Neural Disagree Strongly disagree a. MyDispense was a valuable tool for learning self-care. b. MyDispense cases aligned with P512 course material. c. MyDispense cases emphasized key learning points from the course. 3. How often did you use class notes or the textbook when you completed the cases? a. Never b. Occasionally c. Frequently d. Always 4. On average, how long did it take you to complete each MyDispense case? Think about how long it took for completing ONE case that required providing counseling (i.e. not an exclusion to self-treatment). a. < 10 min b. 11–20 min c. 21–30 min d. 31–40 min e. 41–50 min f. 51–60 min g. 61–70 min h. 71 or more minutes 5. What is your age? a. 18–19 b. 20–24 c. 25–29 d. 30–34 e. 35 and older 6. What is your gender? a. Male b. Female c. Prefer not to say 7. What is your ethnicity? (Select all that apply) a. African American b. Asian c. Hispanic 8
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d. Pacific Islander e. White f. Other g. Prefer not to say 8. In what setting have you worked as a pharmacy technician or intern? (Select all that apply) a. Community/outpatient pharmacy practice b. Hospital/inpatient pharmacy practice c. Other pharmacy practice d. I have not worked in a pharmacy practice setting 9. IF 8a selected… a. How many times have you provided self-care recommendations while working in a community pharmacy? i. Never ii. 1 to 5 times iii. 6 to 10 times iv. 11 to 15 times v. > 20 times b. How long have you worked in a community pharmacy setting? i. < 6 months ii. > 6 months, but < 1 year iii. 1 to 2 years iv. > 2 years Student Post-IPPE Survey 10. How many times during your community pharmacy IPPE did you do any of the following: triage patients appropriately to selfcare, medical care, or emergency care; help patients select OTC products; and/or provide counseling/education? a. 0 times b. 1–5 times c. 6–10 times d. 11–15 times e. 16–20 times f. > 20 times 11. How confident did you feel with the following skills? Very confident. Somewhat confident. Not very confident. Not confident at all. I never did this skill. a. b. c. d. e. f.
Collecting necessary subjective and objective information about the patient Assessing the information that was collected in order to identify and prioritize problems Triaging patients appropriately to self-care, medical care, or emergency care Selecting an appropriate self-care regimen Providing self-care counseling/education Developing a plan for following up with the patient as needed Preceptor Survey
1. What is your name? 2. What is the name of the student you are completing the evaluation regarding? 3. Estimate how many times during the community pharmacy IPPE the student interacted with patients regarding self-care/OTC medications. a. 0 times b. 1–5 times c. 6–10 times d. 11–15 times e. 16–20 times f. > 20 times 4. How well was the student able to complete the following skills The student was consistently able to perform this skill with limited/no assistance (entry level performance, far beyond expectation 9
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for P2 student). The student was sometimes able to perform this skill and the preceptor provided some assistance. The student was infrequently able to perform this skill, even with assistance from the preceptor. The student was never able to perform this skill, even with the assistance of the preceptor. a. b. c. d. e. f.
Collecting necessary subjective and objective information about the patient Assessing the information that was collected in order to identify and prioritize problems Triaging patients appropriately to self-care, medical care, or emergency care Selecting an appropriate self-care regimen Providing self-care counseling/education Developing a plan for following up with the patient as needed IPPE = Introductory pharmacy practice experience; OTC = Over-the-counter; P2 = Second-year.
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Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Experiences in Teaching and Learning
Impact of virtual simulation in self-care therapeutics course on introductory pharmacy practice experience self-care encounters Ming-Hei Taia, Nada Ridaa, Kristin C. Kleina, Heidi Dieza, Trisha Wellsa, ⁎ Kellie Kippesa, Paul C. Walkera, Sarah E. Vordenbergb, a b
University of Michigan College of Pharmacy, Ann Arbor, MI, United States University of Michigan College of Pharmacy, 428 Church St, Suite 3563 NUB, Ann Arbor, MI, United States
A R T IC LE I N F O
ABS TRA CT
Keywords: MyDispense Simulated learning environment Self-care Over-the-counter medications Introductory pharmacy practice experience
Background and purpose: Pharmacy education programs use simulation to provide a realistic and safe environment for student learning. We studied whether incorporation of virtual simulation into a required first year self-care therapeutics course impacted frequency of interactions, selfreported student confidence, and preceptor-reported student performance during second-year community pharmacy introductory pharmacy practice experiences (IPPEs). Educational activity and setting: Virtual simulation cases using MyDispense were incorporated into a self-care therapeutics course in winter 2017. Students and preceptors were surveyed at the end of the fall semester community pharmacy IPPE. Data from IPPE experiences was compared with students who took the self-care therapeutics course in winter 2016 (control). Findings: Students completed 30 virtual simulation cases and three cases as part of the final examination (n = 33). Students in the intervention group reported more patient care interactions during their IPPEs than students who did not complete virtual simulation cases, but there was no difference in self-reported confidence. Preceptors did not report any differences in the ability of students to complete over-the-counter medication interactions during IPPEs. Summary: Cases were well received by students although they took longer to complete than initially anticipated. Students in the intervention group reported significantly more patient care interactions during IPPEs than those in the control group; however, there were no differences in self-reported confidence. Incorporation of virtual simulation was a sustainable change as the cases were able to be re-used the following year with minimal edits.
Background and purpose Pharmacy education programs are increasingly using virtual simulation in order to provide a realistic and safe environment for student learning.1–10 A literature review found that students enjoyed patient simulation and virtual patient studies and the amount of learning from use of these tools was significant.11 While the number of studies reviewed was small, virtual patient simulation was associated with improved knowledge and problem-solving, communication, and professional skills according to student self-assessments and either no change or improvements in examination scores.11 One virtual simulation tool that is increasingly being used is MyDispense, a customizable open access outpatient pharmacy web application developed by Monash University in Australia.7–10,12 Community pharmacy preceptors and students at our institution had provided informal feedback that students had difficulty
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Corresponding author. E-mail address: [email protected] (S.E. Vordenberg).
https://doi.org/10.1016/j.cptl.2019.10.015
1877-1297/ © 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Ming-Hei Tai, et al., Currents in Pharmacy Teaching and Learning, https://doi.org/10.1016/j.cptl.2019.10.015
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applying knowledge learned in the classroom setting to the introductory pharmacy practice experiences (IPPEs). As a result, we aimed to determine whether incorporation of virtual simulation using MyDispense into a required first-year (P1) self-care therapeutics course impacted the frequency of interactions, self-reported student confidence, and preceptor-reported student performance of students during their second-year (P2) community pharmacy IPPE. Educational activity and setting Curriculum This study was completed at a public university with a four-year pharmacy program containing approximately 85 students per class. Student pharmacists take a required, four-credit hour self-care therapeutics course in the P1 winter semester. This is the first in a five-semester sequence of courses that focus on therapeutic problem solving and emphasizes over-the-counter (OTC) therapies for the self-treating patient. Students learn a systematic approach to assess, triage, and appropriately use OTC medications for selftreatable conditions. The course consists of recitation sessions (1.5 hours twice weekly) taught using team-based learning (TBL) and laboratory sessions (three hours once weekly) where students further practice applying their knowledge and pharmacy practice skills.13 Traditionally, the laboratory component of the course included a wide variety of activities ranging from knowledge-based activities using the physical packages of OTC medications provided in class to application-based activities that included interviewing patients (as played by peers or simulated patients). Students also watched the recorded encounters in order to reflect on their performances. However, opportunities to practice interviewing and counseling patients were limited, primarily due to time constraints and logistic difficulties in setting up these complex activities during classroom times. P2 students completed a two-credit hour IPPE in which they spent eight hours per week in a community pharmacy during either fall or winter semester (104 hours over 13 weeks). This course provided students the opportunity to enhance their pharmacy knowledge and skills learned in the classroom through hands-on experiences, including counseling patients about prescription and OTC medications. Each student worked with one primary preceptor who is a pharmacist that meets the requirements of being an adjunct clinical assistant, associate, or full professor at the university. Intervention This study involved replacement of most of the knowledge-based activities in the laboratory component of the self-care therapeutics course (class of 2019) with virtual simulation activities that allowed students more opportunities to practice applying the course content and skills related to patient interviewing and making recommendations (class of 2020). Case development Cases were developed to align with topics taught in the self-care therapeutics course and commonly observed patient care interactions in the community pharmacy setting. Two students working on this project in exchange for independent study credit (independent study students) who previously completed both the self-care therapeutics and IPPE courses drafted the initial cases in collaboration with the principle investigator. Subsequently, faculty members teaching the corresponding topics reviewed the cases and worked with the independent study students to edit the cases until the desired result was achieved. A total of 30 cases were developed for use during the semester and three cases with topics that were previously covered in the semester were incorporated into the final examination. Case development consisted of creating the patient's demographics, past medical history, information about the reason for the visit to the community pharmacy, and questions for the student pharmacist. The virtual patient would present with a chief complaint or question, either with or without a specific product that they were interested in purchasing. Students were expected to further investigate the patient's condition by asking appropriate triage questions from a predetermined list of questions, which created a virtual dialogue between the student and the patient. Students needed to use their clinical judgement to determine which questions were appropriate to ask (e.g., symptoms, location, pregnancy, other medications). The instructor identified in advance if each question was required, optional, or inappropriate to ask the patient. Each case required that students either make a medication recommendation or refer the patient to another health care professional for further management, in which case a justification was required. Immediately after submitting the case, students received feedback regarding whether the student asked appropriate questions, whether the patient was a candidate for self-treatment, and if so, if the selected medication was appropriate. Students were able to repeat each case as many times as desired before submitting the cases for the entire module for a grade. Implementation Students were provided a guide to navigating MyDispense, three short videos that showed how to complete and submit the cases, and instructions regarding expectations. Key points regarding how to complete MyDispense cases and expectations were also discussed with the students in class at the beginning of the semester. Importantly, all students had used the prescription medication dispensing feature of MyDispense in a different course the previous semester and were familiar with this functionality of the application. 2
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Fig. 1. Study timeline. IPPE = Introductory pharmacy practice experience.
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The course material was taught in four modules with an examination at the end of each. Students were provided access to the cases at the beginning of each module and were instructed to complete the cases individually before the examination covering that material (Appendix 1). Students were given time during the laboratory to complete the cases; however, nearly all students worked on the cases outside of class. The final examination included three cases that covered topics taught earlier in the semester and they could only be attempted once. Grading rubrics that were designed to assess key points or unique aspects of each case were utilized. Short debriefs that covered commonly missed points were discussed in class. The four modules accounted for 1.7% of the course grade (divided equally among each module) and the MyDispense component of the final exam accounted for 2.25% of the total course grade. Data collection and analysis A summary of the study timeline, including data collection time points is available (Fig. 1). Scores on virtual simulation cases for each module, as well as the virtual simulation component of the final examination, were collected from students in the class of 2020 (intervention group). At the end of the semester, these students also completed an online Qualtrics survey (Qualtrics, Provo, UT). Students were asked three questions about their perceptions regarding learning using virtual simulation (5-point Likert scale, strongly agree to strongly disagree), and six questions regarding their perceived confidence and ability to provide appropriate self-care recommendations (4-point Likert scale, very confident to not confident at all). The specific skills were selected to align with the steps in an OTC interaction. Students were also asked frequency of using class notes or the textbook when completing the cases (4-point Likert scale, never to always), average time to complete the case (< 10 min to 71 min or more in 10-min increments), and questions regarding demographics and pharmacy experience. The last set of questions were included as it was hypothesized that students with prior community pharmacy work experience may have higher levels of self-reported confidence with OTC patient encounters. Students were instructed to complete the survey within one week of the distribution date. Two reminders were electronically sent to students. All students were required to complete this survey as it was considered a reflective exercise as part of the course. Students were given the option to have their data excluded from the research study. Data were also collected at the end of the IPPE for the class of 2019 (control group) and 2020 (intervention group). Students were asked to complete an online Qualtrics survey regarding their perceptions of their ability to and confidence in making recommendations related to self-treatable conditions. These questions were the same as those at the end of the self-care therapeutics course with the addition of an option to indicate that the student never completed a specific skill during their IPPE. In addition, students indicated how many times they participated in the self-care/OTC process. Preceptors were asked to complete an online Qualtrics survey that focused on student ability and confidence in making recommendations related to self-treatable conditions (4point Likert scale, the student was able to consistently perform this skill with limited/no assistance to the student was never able to perform this skill, even with the assistance from the preceptor). These skills were selected to align with the steps of OTC interactions and the rating system aligned with the scale used by preceptors to assess other skills during community pharmacy rotations. Preceptors were sent the survey via email and a reminder was sent after one week. Preceptors had a total of two weeks to complete the survey. Completion of these surveys was voluntary with the goal of obtaining information about consequences of this curricular change. All surveys consisted of closed-ended and Likert-type questions (Appendix 2). t-Tests were used for all comparisons, except a X2 test was used to analyze the number of interactions reported by students during their IPPE. MedCalc Statistical Software version 18.6 was used.14 This study was reviewed and approved by the University of Michigan Health Sciences and Behavioral Sciences Institutional Review Board. Findings Post self-care course survey All students from the class of 2020 (n = 85, 100%) completed the post-course survey during winter 2017 (intervention group). Sixty percent of students reported having community pharmacy experience (Table 1). Regardless of prior community pharmacy work experience, students generally reported that they were either somewhat or very confident in their ability to complete all aspects of Table 1 Student work experience prior to self-care therapeutics course. Students n = 85 (%) Pharmacy work experience prior to winter P1 semester Community/outpatient only Hospital/inpatient only Community/outpatient plus one additional setting No work experience
P1 = first-year. 4
51 (60.0) 3 (3.5) 6 (7.1) 25 (29.4)
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Table 2 Student self-reported confidence in ability to perform self-care encounters at end of self-care course by community pharmacy work experiencea.
Collect data Assess data Triage to correct level of care Select medication regimen Provide patient education Create follow-up plan a
Community pharmacy work experience (n = 57)
No community pharmacy work experience (n = 28)
Mean
Standard deviation
Mean
Standard deviation
1.5 1.6 1.7 1.8 1.8 1.7
0.6 0.6 0.6 0.5 0.6 0.7
1.8 1.9 1.9 2.2 2.0 2.0
0.8 0.5 0.5 0.8 0.6 0.6
p-Value
0.02 0.02 0.18 0.01 0.07 0.11
1 = Very confident; 2 = Somewhat confident; 3 = Not very confident; 4 = Not confident at all.-.
self-care interactions at the end of the self-care course. Students with community pharmacy experience expressed a significantly higher confidence level in their abilities to collect (p = .02) and assess (p = .02) data and select a medication regimen (p = .01) (Table 2). Students agreed that MyDispense was a valuable tool for learning self-care (2.8 ± 1.1; 1 = strongly agree, 5 = strongly disagree) and that the cases emphasized key learning points (2.6 ± 1.0). Students agreed that the self-care cases aligned with course material (1.9 ± 0.8) and students needed to reference class notes or the textbook most of the time when completing the self-care cases (1.4 ± 0.6; 1 = always, 4 = never). There was no significant difference when comparing student perceptions of MyDispense as a learning tool for students with and without community pharmacy work experience (p > .05). The majority of students (58.8%) reported needing 31–60 min to complete each simulation. Twenty percent of students reported only needing 1–30 min for the simulations, while 21.2% of students needed 61 min or longer for case completion. There was no significant difference when calculating the amount of time it took to complete a case for students with and without community pharmacy work experience (p = .9). The average and range for student scores were: module 1 80.7% (8%–100%); module 2 89.2% (64%–100%); module 3 92.6% (72%–100%); module 4 99.4% (80%–100%); and final 96.5% (60%–100%).
Student post-IPPE survey Approximately 70% (n = 26/37) of students who completed their community pharmacy IPPEs in fall 2016 (control group) responded to the survey, while only 55% (n = 22/40) of students who completed their community pharmacy IPPEs in fall 2017 (intervention group) responded to the survey. When comparing students completing their IPPEs in fall 2016 (control group) with fall 2017 (intervention group), there were no significant differences in self-reported levels of confidence when comparing specific skills (Table 3). Student confidence in fall 2016 ranged from 1.6 ± 0.6 for assess to 2.1 ± 0.6 for follow-up plan creation whereas student confidence in fall 2017 ranged from 1.7 ± 0.5 for collect to 2.1 ± 0.7 for selecting a medication regimen as well as counseling (1 = very confident, 4 = not confident at all). There was no significant difference when comparing confidence levels of students with or without community pharmacy work experience (p > .05). Students in the intervention group (fall IPPE 2017) reported statistically significantly more patient interactions during their community pharmacy IPPEs than those in the control group (fall IPPE 2016; p < .007; Fig. 2). Students from the intervention group (Fall 2017 IPPE) felt very confident collecting data at the end of the self-care course; however, they reported statistically significant less confidence with this skill at the completion of their IPPE (p = .03). Students reported high confidence both at the end of the self-care course and IPPE as it related to assessment, triaging based on level of care, medication selection, patient education, and creation of a follow-up plan.
Table 3 Student self-reported confidence during self-care encounters at end of introductory pharmacy practice experience by virtual simulation exposure.a,b
Collect data Assess data Triage to correct level of care Select medication regimen Provide patient education Create follow-up plan a b
Virtual simulation exposure during self-care course fall 2017 (n = 22)
No virtual simulation exposure during self-care course fall 2016 (n = 26)
Mean
Standard deviation
Mean
Standard deviation
1.7 1.9 1.9 2.1 2.1 2.1
0.5 0.6 0.6 0.7 0.7 0.8
1.8 1.9 2.0 2.0 1.8 2.1
0.5 0.6 0.5 0.7 0.6 0.6
1 = Very confident; 4 = Not confident at all. No statistically significant difference between groups. 5
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Fig. 2. Number of interactions reported by students during introductory pharmacy practice experience (IPPE)a. a The chi-square statistic is 9.8868, p-value = .007.
Preceptor survey In 2016, there were 24 preceptors for 37 students. Preceptors completed surveys for seven students (18.9%). In 2017, there were 39 preceptors for 40 students, and 12 preceptors responded to the survey (31%). Preceptors consistently rated students highly in all skills performed. Students in the intervention group (fall IPPE 2017) had slightly higher scores overall; however, this difference was not significant (Table 4). Discussion Virtual simulation was successfully incorporated into a self-care therapeutics course. Students agreed that the simulations were a valuable tool for learning self-care and that the cases aligned with course material and emphasized key learning points. Use of virtual simulation was associated with students engaging in more patient care interactions during their IPPE than students who did not complete virtual simulation cases. This suggests that students who completed the simulations may have felt more comfortable engaging with patients regarding self-care encounters. We hypothesize that the opportunity to practice more encounters in a safe environment while receiving immediate feedback may have led to this improvement; however, there have been mixed findings in the literature regarding the impact of simulation on confidence.15,16 Importantly, previous literature has identified the need to establish a link between simulation and changes in practice and this study begins to address that gap in the area of community pharmacy practice.17 Preceptors did not report any differences in the ability of students to complete OTC medication interactions during IPPEs. Use of application-based simulation cases was determined by course faculty to be more appropriate for student learning compared to prior knowledge-based activities and, therefore, the decision was made to continue to use virtual simulation even though significant improvements were not seen during the community IPPE, aside from the number of patient care interactions. Interestingly, students who completed the virtual simulation cases reported feeling less confident in medication selection, patient education, and follow-up plan creation at the end of their IPPEs compared to the end of the self-care course. This suggests that interacting with patients in a simulated environment does not fully replicate the interaction with real patients that occurs in the community pharmacy. For example, the student may feel time pressure from the patient, feel uncertainty about the wide variety of products that are available, and face communication barriers. Due to limitations in this study, it was not possible to determine if students in the control group experienced similar decreases in confidence when transitioning from the classroom to experiential Table 4 Preceptor perceptions of student ability to perform self-care encounters at end of introductory pharmacy practice experience by virtual simulation exposurea,b.
Collect data Assess data Triage to correct level of care Select medication regimen Provide patient education Create follow-up plan
Virtual simulation exposure during self-care course fall 2017 (n = 12)
No virtual simulation exposure during self-care course fall 2016 (n = 7)
Mean
Standard deviation
Mean
Standard deviation
1.50 1.58 1.75 1.67 1.50 1.67
0.52 0.67 0.62 0.49 0.52 0.65
1.71 1.71 1.71 2.00 1.71 1.67
0.76 0.76 0.49 0.58 0.76 0.52
a
1 = Consistently able, limited to no assistance, entry level performance; 2 = Sometimes able, preceptor provided some assistance; 3 = Infrequently unable even with assistance from preceptor; 4 = Never able even with assistance. b No statistically significant difference between groups. 6
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settings. Time was a significant concern when embarking on this intervention. Specifically, course faculty were concerned about the amount of time to create and test cases, how much time it would take for students to complete cases, and the time required to grade the cases. By working with two independent study students, the amount of time faculty spent developing and testing the cases was minimized. Furthermore, the cases were used the subsequent academic year with very minimal modifications. Cases took significantly longer for students to complete than originally anticipated by course faculty (31–60 min compared to an anticipated 15 min). As a result, the number of cases was decreased from 30 plus three for the final examination (n = 33) to 26 plus two for the final examination (n = 28), which provided one simulation per topic the following year. More significantly, expectations for the cases were modified to focus on the most relevant points when providing counseling in patient care interactions. For example, the specificity of dosing information varied by case. Students were expected to provide the number of tablets and milligrams per dose and per day when providing dosing information regarding acetaminophen for an adult with a headache but they were only expected to provide the number of drops per dose and frequency of administration when making a recommendation regarding an ophthalmic product. The key points were designed to align with the information patients most often need in practice. Finally, grading rubrics were developed with standardized feedback in order to ensure efficient and consistent grading of cases and facilitate feedback. In the future, details of the cases may be modified in order to preserve the integrity of the cases. Additionally, a portion of the final examination grade comes from the completion of cases without notes or other resources which serves as an incentive for students to independently practice the material throughout the semester. There were several key limitations to this study. First, it was completed at one academic institution and the number of students was relatively small. Furthermore, data were not available from the control group regarding their previous pharmacy work experience or self-reported confidence at the end of the self-care therapeutics course. A variety of pharmacies provide IPPEs and the opportunities to provide self-care counseling may have varied by site and year. Additionally, data was only collected at the end of the IPPE, therefore it is possible that internship experiences or other courses during the fall semester influenced student confidence. Data collection was limited to the fall semester as it was thought that the courses and additional experiences that students complete during the winter semester may confound the study results. As part of the standard IPPE at this university, students were supposed to track how many OTC patient interactions they completed; however, students may have estimated this number. Finally, IPPE-related data were provided by a small number of students and preceptors. Additional research regarding the use of virtual simulation in a self-care therapeutics course and its impact on community pharmacy IPPEs is warranted. Summary Virtual simulation was incorporated into a required self-care therapeutics course as a way to increase the amount of applicationbased exercises completed by students. Students who completed the cases reported significantly more patient care interactions during their IPPEs than those in the control group; however, there were no differences in self-reported confidence. Incorporation of virtual simulation was a sustainable change as the cases were able to be re-used the following year with minimal edits. Declaration of competing interest None. Acknowledgements We appreciate the technical assistance provided by Mr. Keith Sewell and Mr. Keenan Beaumont at Monash University. Appendix 1. Summary of virtual simulation cases by module in order of content taught in course1
Module 1
Module 2
Module 3
Module 4
Dietary supplements 1 Dietary supplements 2 Tobacco cessation Obesity Constipation Diarrhea Nausea/vomiting
Heartburn Intestinal gas Pinworms Fungal skin infections 1 Fungal skin infections 2 Pediculosis 1 Pediculosis 2 Headache Musculoskeletal pain Colds
Fever Cough Allergic rhinitis Diaper dermatitis Atopic dermatitis Contact dermatitis Bug bites 1 Bug bites 2
Contraception Ophthalmic health Oral health Otic health Acne
1 Two cases were used where one case required a referral and the second case required over-the-counter medication treatment or if there were two distinct issues that needed to be treated (e.g., two different types of bug bites).
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Appendix 2. Surveys Post self-care course survey 1. How confident did you feel with the following skills? Very confident Somewhat confident Not very confident Not confident at all I never did this skill. a. b. c. d. e. f.
Collecting necessary subjective and objective information about the patient Assessing the information that was collected in order to identify and prioritize problems Triaging patients appropriately to self-care, medical care, or emergency care Selecting an appropriate self-care regimen Providing self-care counseling/education Developing a plan for following up with the patient as needed
2. Please answer the following questions, considering only your personal experience with the virtual simulation program, MyDispense, in the P512 Self-Care Course. Strongly agree Agree Neural Disagree Strongly disagree a. MyDispense was a valuable tool for learning self-care. b. MyDispense cases aligned with P512 course material. c. MyDispense cases emphasized key learning points from the course. 3. How often did you use class notes or the textbook when you completed the cases? a. Never b. Occasionally c. Frequently d. Always 4. On average, how long did it take you to complete each MyDispense case? Think about how long it took for completing ONE case that required providing counseling (i.e. not an exclusion to self-treatment). a. < 10 min b. 11–20 min c. 21–30 min d. 31–40 min e. 41–50 min f. 51–60 min g. 61–70 min h. 71 or more minutes 5. What is your age? a. 18–19 b. 20–24 c. 25–29 d. 30–34 e. 35 and older 6. What is your gender? a. Male b. Female c. Prefer not to say 7. What is your ethnicity? (Select all that apply) a. African American b. Asian c. Hispanic 8
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d. Pacific Islander e. White f. Other g. Prefer not to say 8. In what setting have you worked as a pharmacy technician or intern? (Select all that apply) a. Community/outpatient pharmacy practice b. Hospital/inpatient pharmacy practice c. Other pharmacy practice d. I have not worked in a pharmacy practice setting 9. IF 8a selected… a. How many times have you provided self-care recommendations while working in a community pharmacy? i. Never ii. 1 to 5 times iii. 6 to 10 times iv. 11 to 15 times v. > 20 times b. How long have you worked in a community pharmacy setting? i. < 6 months ii. > 6 months, but < 1 year iii. 1 to 2 years iv. > 2 years Student Post-IPPE Survey 10. How many times during your community pharmacy IPPE did you do any of the following: triage patients appropriately to selfcare, medical care, or emergency care; help patients select OTC products; and/or provide counseling/education? a. 0 times b. 1–5 times c. 6–10 times d. 11–15 times e. 16–20 times f. > 20 times 11. How confident did you feel with the following skills? Very confident. Somewhat confident. Not very confident. Not confident at all. I never did this skill. a. b. c. d. e. f.
Collecting necessary subjective and objective information about the patient Assessing the information that was collected in order to identify and prioritize problems Triaging patients appropriately to self-care, medical care, or emergency care Selecting an appropriate self-care regimen Providing self-care counseling/education Developing a plan for following up with the patient as needed Preceptor Survey
1. What is your name? 2. What is the name of the student you are completing the evaluation regarding? 3. Estimate how many times during the community pharmacy IPPE the student interacted with patients regarding self-care/OTC medications. a. 0 times b. 1–5 times c. 6–10 times d. 11–15 times e. 16–20 times f. > 20 times 4. How well was the student able to complete the following skills The student was consistently able to perform this skill with limited/no assistance (entry level performance, far beyond expectation 9
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for P2 student). The student was sometimes able to perform this skill and the preceptor provided some assistance. The student was infrequently able to perform this skill, even with assistance from the preceptor. The student was never able to perform this skill, even with the assistance of the preceptor. a. b. c. d. e. f.
Collecting necessary subjective and objective information about the patient Assessing the information that was collected in order to identify and prioritize problems Triaging patients appropriately to self-care, medical care, or emergency care Selecting an appropriate self-care regimen Providing self-care counseling/education Developing a plan for following up with the patient as needed IPPE = Introductory pharmacy practice experience; OTC = Over-the-counter; P2 = Second-year.
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