Virtual Patient Case Sharing Across Two Schools of Pharmacy

A meta-narrative review of choose-your-own-adventure style patient case activities in pharmacy education

BACKGROUND

The objective of this review was to characterize the methods of delivery and assessment of Choose Your Own Adventure (CYOA)-style activities in pharmacy education. A secondary objective was to utilize available data to determine best practices for educators interested in developing similar activities.

METHODS

A meta-narrative approach according to the guidance of the RAMESES standards was used for this review. A broad literature search was conducted using PubMed and Embase. Studies published on the use of a CYOA-style patient case format in pharmacy education were identified and appraised individually for their relevance.

RESULTS

Thirteen studies from the pharmacy education literature were included in the review. Activities were delivered for 25 unique topics, largely in small groups during class via patient simulation or interactive data collection software. Overall, students have a positive perception of CYOA-style activities, with positive results regarding knowledge development and student engagement. The most commonly reported challenge to implementing CYOA-style patient case activities was the up-front time commitment to develop activities.

IMPLICATIONS

This review provides a snapshot of the small but expanding body of literature on CYOA-style patient case activities in pharmacy education. CYOA-style activities are recommended for expanded use in pharmacy education as the preponderance of studies that assessed knowledge development showed significant improvement in knowledge after participation in CYOA-style activities. Additionally, students have a positive perception of CYOA-style activities and reported that they were enjoyable, improved their confidence, and helped them learn course material.

Potential Barriers to the Implementation of Computer-Based Simulation in Pharmacy Education: A Systematic Review

Computer-based simulation (CBS) is an interactive pedagogical training method that has seen increased interest, especially in recent years. There is some evidence that CBS in pharmacy education is not as widely adopted compared to other healthcare disciplines. Pharmacy education literature to date has not specifically discussed the potential barriers which may cause this uptake challenge. In this systematic narrative review, we attempted to explore and discuss potential barriers that may impact the integration of CBS in pharmacy practice education and provide our suggestions to overcome them. We searched five major databases and used the AACODS checklist for grey literature assessment. We identified 42 studies and four grey literature reports, published between 1 January 2000 and 31 August 2022, which met the inclusion criteria. Then, the specific approach of Braun and Clarke for thematic analysis was followed. The majority of the included articles were from Europe, North America, and Australasia. Although none of the included articles had a specific focus on barriers to implementation, thematic analysis was used to extract and discuss several potential barriers, such as resistance to change, cost, time, usability of software, meeting accreditation standards, motivating and engaging students, faculty experience, and curriculum constraints. Ad- dressing academic, process, and cultural barriers can be considered the first step in providing guidance for future implementation research for CBS in pharmacy education. The analysis suggests that to effectively overcome any possible barriers to implementing CBS, different stakeholders must engage in careful planning, collaboration, and investment in resources and training. The review indicates that additional research is required to offer evidence-based approach and strategies to prevent overwhelming or disengaging users from either learning or teaching process. It also guides further research into exploring potential barriers in different institutional cultures and regions.

Implementing a choose your own adventure activity to improve insulin decision making

INTRODUCTION

The objective of this educational activity was to evaluate the impact of a virtually simulated Choose Your Own Adventure (CYOA) activity on pharmacy student knowledge and confidence of insulin management.

METHODS

An online CYOA activity was created using TypeForm, version 2 (TypeForm SL) for a third-year pharmacy school diabetes elective with 16 enrollees over two course offerings. Through use of interactive storytelling, students used critical thinking skills to make decisions in six simulated patient's care including initiation, counseling, conversions, and titration of multiple types of insulin. Instructor-created surveys were administered to students before and after the activity to assess satisfaction, confidence, and knowledge.

RESULTS

Ten students (62.5%) completed the activity and both pre- and post-surveys. Average total scores on the five-question insulin knowledge quiz improved significantly from 46% to 68% (P = .02). High satisfaction scores were recorded for each item in the post-survey. Student confidence improved in all aspects related to insulin management (P < .001). No differences in knowledge, confidence, or satisfaction were found between students who completed the activity in an in-person vs. virtual classroom.

CONCLUSIONS

CYOA activities can be successfully implemented in an in-person and virtual pharmacy classroom using a digital platform. Students viewed the CYOA activity as an enjoyable, low-stakes learning tool to increase confidence in their decision making. This small study did find knowledge improvements, but further research is needed to fully establish the validity of the knowledge assessments and ensure knowledge gains are sustainable.

Computer-Based Simulators in Pharmacy Practice Education: A Systematic Narrative Review

Computer-based simulations may represent an innovative, flexible, and cost-efficient training approach that has been underutilised in pharmacy practice education. This may need to change, with increasing pressure on clinical placement availability, COVID-19 restrictions, and economic pressures to improve teaching efficiency. This systematic narrative review summarises various computer-based simulations described in the pharmacy practice education literature, identifies the currently available products, and highlights key characteristics. Five major databases were searched (Medline, CINAHL, ERIC, Education Source and Embase). Authors also manually reviewed the publication section of major pharmacy simulator websites and performed a citation analysis. We identified 49 studies describing 29 unique simulators, which met the inclusion criteria. Only eight of these simulators were found to be currently available. The characteristics of these eight simulators were examined through the lens of eight main criteria (feedback type, grading, user play mode, cost, operational requirement, community/hospital setting, scenario sharing option, and interaction elements). Although a number of systems have been developed and trialled, relatively few are available on the market, and each comes with benefits and drawbacks. Educators are encouraged to consider their own institutional, professional and curriculum needs, and determine which product best aligns with their teaching goals.

Using Interactive Fiction to Teach Clinical Decision-Making in a PharmD Curriculum

Teaching of clinical decision-making is an important component of health professions education. Patient case examples are widely used in didactic coursework to teach this material, but engaging all learners in large, lecture-based courses remains a challenge. Interactive fiction (IF), a digital choose-your-own-adventure media, provides an accessible way for students to individually explore the narrative of a patient-case in a safe environment. Here, we report the development of interactive, digital patient-cases (eCases) using Twine, a free IF development platform. Fourteen eCases were developed in collaboration with 11 faculty members and were used in seven different PharmD courses over three semesters. eCase content was developed by faculty members for their respective instructional topics and accessed via Web browsers on students' personal electronic devices. eCases were received positively by students, with > 90% of students reporting that eCases were easy to use, helped them learn the material at their own pace, and gave them an opportunity to learn from mistakes. Student self-perceived confidence also increased significantly after eCase use. Faculty reported that eCases took more time to develop than conventional cases, but were easier to deliver and provided better student engagement. IF is an accessible media for creating and delivering low-fidelity interactive patient cases that can engage all students in a large class. eCases allow students to apply their knowledge, practice clinical decision-making, and safely learn from their mistakes. eCases are versatile and well suited for both in-person and virtual teaching across a variety of health professions programs to teach clinical decision-making.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-021-01245-7.

Interactive Clinical Avatar Use in Pharmacist Preregistration Training: Design and Review

BACKGROUND

Virtual patients are interactive computer-based simulations that are being increasingly used in modern health care education. They have been identified as tools that can provide experiential learning and assessment in a standardized and safe environment. However, the study of high-fidelity virtual patients such as interactive clinical avatars within pharmacy is limited.

OBJECTIVE

The aim of this paper is to describe the design and review of three interactive clinical avatar simulations as part of pharmacist preregistration training.

METHODS

A multistep design approach was taken to create interactive clinical avatar simulations on the topics of emergency hormonal contraception (EHC), calculation of renal function, and childhood illnesses. All case studies were reviewed by registered pharmacists to establish content and face validity. The EHC case study and data collection questionnaire were also reviewed by a purposive sample of preregistration trainees and newly qualified pharmacists. The questionnaire used Likert ranking statements and open-ended questions to obtain users' feedback on the design, usability, and usefulness of the interactive clinical avatars as learning tools. Descriptive statistics and content analysis were undertaken on the data.

RESULTS

Ten preregistration trainees and newly qualified pharmacists reviewed the EHC interactive clinical avatars and data collection questionnaire. The data collection questionnaire was associated with a Cronbach alpha=.95, demonstrating good reliability. All three interactive clinical avatar simulations were reported as usable and appropriately designed for preregistration training. Users perceived they were developing skills and knowledge from the simulations. The high-fidelity nature of the avatars and relevance of the simulations to real-life practice were reported as aspects that encouraged the application of theory to practice. Improvements were suggested to ensure the simulations were more user-friendly.

CONCLUSIONS

The design and creation of the interactive clinical avatar simulations was successful. The multistep review process ensured validity and reliability of the simulations and data collection questionnaire. The in-depth explanation of the design process and provision of a questionnaire may help widen the use and evaluation of interactive clinical avatars or other simulation tools in pharmacy education. The interactive clinical avatars were reported as novel learning tools that promoted experiential learning and allowed users to feel like they were engaging in real-life scenarios, thus developing transferable knowledge and skills. This may be potentially beneficial for many health care training courses as a way to provide standardized experiences promoting active learning and reflection.

Virtual Versus Paper-based Cases in Reinforcing the Collect and Assess Elements of the Pharmacists' Patient Care Process

Objective. To compare pharmacy students' perceptions about and performance when using paper-based versus virtual patient cases to reinforce knowledge of the collect and assess elements of the Pharmacists' Patient Care Process (PPCP). Methods. Twenty-seven pharmacy students enrolled in an ambulatory care elective course were randomized to receive either paper-based cases or virtual patient cases for three weeks. They then crossed over to receive the alternative case format for the next three weeks. Each student received a score for their performance on questions related to the collect and assess elements of the PPCP. Students completed a survey and participated in a focus group to evaluate their perceptions of each learning method. Statistical analyses were performed on all data collected. Results. Students' performance (n=27) was better on the assess questions of the PPCP when they used paper-based patient cases than when they used virtual patient cases. The only difference in students' perceptions was related to the collect element, as students favored using paper-based patient cases over virtual patient cases when collecting subjective and objective information. Students who participated in the focus groups believed that the virtual patient cases provided a more realistic and engaging experience in addition to promoting critical thinking. Conclusion. While paper-based patient cases allowed pharmacy students to quickly identify and "collect" relevant information, increased use of virtual patient cases may enhance students' comfort level with and ability to "assess" actual patients.

Use of a virtual patient simulation program to enhance the physical assessment and medical history taking skills of doctor of pharmacy students

INTRODUCTION

To evaluate if utilizing a virtual simulated patient program in a required pharmacy course improves the health history taking and physical assessment skills of first-year professional pharmacy students.

METHODS

During a 14-week course students registered for a web-based virtual patient simulation program. Students were assigned a virtual patient case to complete during weeks one and 13 of the course. Scores from the pre- and post-interventions were compared focusing on the students' ability to perform a physical exam, take a medical history, provide patient education, and display empathy. Students were also asked to self-assess their skills after having been exposed to the virtual simulation program throughout the semester.

RESULTS

The total number of paired observations used in the final analysis of the pre- and post-virtual patient test case was 171 students. The overall student performance index, which includes the scoring of subjective/objective data and patient education/empathy, improved from 52% at week one to 78.42% at week 14. The individual scoring of subjective/objective data and patient education/empathy significantly improved from week one to week 13. Approximately 76.54% of the class strongly agreed or agreed that the virtual simulation program made them feel more confident in their ability to obtain a medical history from patients.

CONCLUSIONS

Virtual patient simulation programs are effective teaching methods for students to develop and improve upon their medical history taking and physical assessment skills.

Curriculum integration of virtual patients

BACKGROUND AND PURPOSE

Virtual patients (VP) offer an enhanced learning experience for students to assume the role of health professional and make therapeutic decisions in a simulated environment. While VPs are valued by students and offer benefits to the learner, little is known about how best to implement them in pharmacy education curricula. The purpose of our study was to investigate students' perceptions of VPs and build understanding about how to optimally implement them in the future.

EDUCATIONAL ACTIVITY AND SETTING

Four VP cases were implemented over the first three years of the entry to practice doctor of pharmacy program. Each case was focused on a different condition and implemented in one of three settings (i.e. integration activities, large lecture setting, or independent review). Students were invited to complete a survey and participate in a focus group after completing the patient case.

FINDINGS

One-hundred eighty students completed the survey and six students participated in a focus group. Ninety-four percent of respondents strongly agreed/agreed that VPs were valuable for their learning. Students preferred the VP cases be implemented in small-group settings and be relevantly timed with course material. Students found helpful that cases were realistic, clear, comprehensive, engaging, and incorporated feedback. Perceived benefits included enhanced learning about medical conditions, development of clinical reasoning skills and processes for working through cases.

SUMMARY

VPs continue to be identified as a valuable learning experience. When implemented it is important to consider the learner setting in order to get the greatest value from their use.

Interprofessional education through a telehealth team based learning exercise focused on pharmacogenomics

BACKGROUND

Traditional interprofessional educational (IPE) exercises are those where learning exists "about, from, and with" trainees in two or more professions in order to prepare health sciences professionals to work on interprofessional teams. One emerging difficulty with IPE is the paucity of health profession students at single institutions, and the geographic and financial constraints of multi-institutional collaboration.

INTERPROFESSIONAL EDUCATION ACTIVITY

To circumvent these barriers, we developed a multi-institution telehealth team-based learning (TBL) event between medical and pharmacy students on the topic of pharmacogenomics (PGx). Using a validated pre-post survey design, student attitudes and perceptions were measured before and after an educational intervention designed to simulate interprofessional telehealth collaboration. The survey results showed significant improvement across all areas of student attitudes toward interprofessional collaboration. Also, medical student PGx confidence increased substantially during the exercise even though the only PGx instruction they received was from pharmacy students.

DISCUSSION

These data demonstrate that learning exists "about, from, and with" trainees in other professions, even if they do not physically train in the same location. Free tools are available to create virtual interactions between students on different campuses, and telehealth exercises using these tools are a valid way to conduct IPE across different campuses. The instructional experience does not need to be identical for all participants in the IPE event; rather, tailoring the educational experience to each group of students provides opportunities for inter-student teaching.