clinical problem solving skills in pharmacy

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Teaching clinical problem solving: A preceptor’s guide

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Kristin W. Weitzel, Erika A. Walters, James Taylor, Teaching clinical problem solving: A preceptor’s guide, American Journal of Health-System Pharmacy , Volume 69, Issue 18, 15 September 2012, Pages 1588–1599, https://doi.org/10.2146/ajhp110521

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Instructional methods to help pharmacists succeed in their growing role in practice-based teaching are discussed, with an emphasis on techniques for fulfilling the four key preceptor roles.

The American Society of Health-System Pharmacists (ASHP) and other organizations advocate ongoing efforts to develop the teaching skills of clinician–educators serving as preceptors to pharmacy students and residents. The broad model of teaching clinical problem solving recommended by ASHP emphasizes the creative and flexible application of the four major preceptor roles: (1) direct instruction, (2) modeling, (3) coaching, and (4) facilitating. A variety of teaching methods used in the fields of medicine and nursing that can also be adopted by practice-based pharmacy educators are presented; in particular, the advantages and disadvantages of various case-presentation formats (e.g., One-Minute Preceptor, SNAPPS, patient-witnessed teaching, “Aunt Minnie,” “think-aloud”) are reviewed. Other topics discussed include the appropriate use of questioning as an educational tool, strategies for providing constructive feedback, teaching learners to self-evaluate their skills and progress, and integrating residents into teaching activities.

The ASHP-recommended approach to teaching clinical problem-solving skills can be applied within the educational frameworks provided by schools of pharmacy as well as pharmacy residency programs. A wide range of validated teaching strategies can be used to tailor learning experiences to individual learner needs while meeting overall program goals and objectives.

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Clinical reasoning model for pharmacy students

Affiliation.

• 1 Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, Pennsylvania, USA.
• PMID: 30207071
• DOI: 10.1111/tct.12944

Background: Clinical reasoning is an essential health care professional skill. Typically, pharmacy students figure out how to reason clinically on their own through the observation of skilled clinicians in various patient care settings. The need to start developing clinical reasoning skills in the pre-clinical years has increased interest in classroom-based clinical reasoning instruction.

Context: The focus of the current clinical reasoning literature is on teaching and assessing medical student clinical reasoning skills. Some literature is available for other health care professions, but there is little information regarding pharmacy student clinical reasoning skills. The current accreditation standards for pharmacy education in the USA require the assessment of clinical reasoning skills, but do not provide guidance regarding content, depth or breadth of skill development.

Innovation: A 2-credit pharmacy elective clinical reasoning course and a new integrated clinical reasoning model were developed for first-, second- and third-year pre-clinical Doctor of Pharmacy students. The new integrated clinical reasoning model, designed to guide pharmacy students through the clinical reasoning processes for making patient-specific therapeutic recommendations, integrates standard Subjective-Objective-Assessment-Planning (SOAPing) processes with pharmacy-specific elements of clinical reasoning.

Implications: Student achievement on whole case-based exams, designed to assess clinical reasoning skills, and student satisfaction with the course were high; however, longitudinal experience with cohorts internal and external to this institution is necessary to determine whether this type of course and clinical reasoning model is scalable, and whether the model has a measurable impact on student performance in the clinical year of the curriculum.

© 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

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Students Practice Clinical Problem-Solving Skills

On October 30, nearly 450 pharmacy students, medical students, nursing students and physician assistant students convened as teams to apply their diverse skills in a medical scenario. This is one of a series of large-scale interprofessional skills training event for health sciences students at the UW.   ‘UW Today’ article.

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Evaluation of the effectiveness of educational medical informatics tutorial on improving pharmacy students’ knowledge and skills about the clinical problem-solving process

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Clinical problem-solving process, Pharmacy, Informatics, Online learning

Objective: To investigate the effectiveness of an online tutorial and its impact on improving knowledge and skills of pharmacy students in the clinical problem-solving process that is necessary to implement pharmaceutical care. Methods: This is a prospective interventional study conducted during the COVID-19 pandemic restrictions using four novel templates. The first two levels of Kirkpatrick’s Model (Reaction and Learning) were used. Results: 129 participants completed all of the online training parts. The findings indicated a significant improvement in the students’ knowledge and skills. The participants achieved higher score following the tutorial than the baseline, with a statistically significant difference (p < 0.001). There was a significant improvement in the number of detected treatment-related problems. The majority of students were satisfied with the overall training process and stated a high evaluation score out of 10 (mean = 7.93 ± 1.42, median = 8.00). Conclusion: The educational intervention achieved a substantial positive impact on decision-making skills of participating students and was considered effective in helping them attain basic skills such as teamwork, peer assessment, communication and critical evaluation. Healthcare providers must work together to ensure accurate medication use during care transitions. Pharmacists, as medication experts, play an important role in the implementation process. Pharmacy educators must prepare pharmacy student to use pharmaceutical care in their future practice.

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Developing Critical Thinking Skills in Pharmacy Students

• Melissa S. Medina, EdD Melissa S. Medina Correspondence Corresponding Author: Melissa S. Medina, Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, PO Box 26901, 1110 N. Stonewall, CPB 125, Oklahoma City, OK 73190. Tel: 405-271-6484. Fax: 405-271-3830. Contact Affiliations College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma Search for articles by this author
• Ashley N. Castleberry, PharmD, MAEd Ashley N. Castleberry Affiliations College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas Search for articles by this author
• critical thinking
• metacognition
• course design
• problem solving
• clinical decision making

INTRODUCTION

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W Erstad . Six critical thinking skills you need to master now. http://www.rasmussen.edu/student-life/blogs/college-life/critical-thinking-skills-to-master-now/ . Accessed February 21, 2018.

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D Hartman . Strategies for critical thinking and problem solving. http://smallbusiness.chron.com/strategies-critical-thinking-problem-solving-12709.html . Accessed February 21, 2018.

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Developing Critical Thinking Skills

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Curriculum.

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Joint Commission of Pharmacy Practitioners . The pharmacists’ patient care process. https://jcpp.net/patient-care-process . Accessed February 21, 2018.

Appendix 1. List of Biases That May Impact Critical Thinking 40. List of biases in judgment and decision making . http://psychology.wikia.com/wiki/List_of_biases_in_judgment_and_decision_making . Accessed February 23, 2018. Google Scholar

Appendix 2. Generating Thoughtful Questions to Engage Students in Critical Thinking 26. Beyer B.K. Improving Student Thinking: A Comprehensive Approach. Allyn and Bacon , Boston, MA 1997 Google Scholar

• a. Rich enough detail, depth of detail, implications and interconnections and relationships inside and outside of area.
• b. Open to diverse interpretation and methods of inquiry.
• c. Capable of being entered at any variety of points.
• d. Requires guidance of an instructor.
• e. Is one that instructors are likely to spend lots of time on instead of rushing through it.
• f. Contributes to the development of meaningful and significant key ideas, explanation, principles, concepts, and generalizations.
• g. Can be learned about in the context of realistic problems.
• h. Fits into the overall curriculum and course
• i. Focuses on big picture.
• j. Focuses on ill-defined rather than precisely delineated topics.
• k. Requires students to pose and then answer numerous subordinate questions as they seek to define and probe the initial question and implications.
• l. Helps invite student engagement; questions that present unusual, unanticipated, or unconventional points of view bother people, agitate thinking, spark curiosity, and demand response.
• m. Focus on the “non-present” – predicting or planning future conditions or events, reconstructing past events.
• n. Have students reflect about questions before they attempt to answer them or before examining the answers they generate.

Appendix 3. Critical Thinking/Making an Argument Worksheet

• 1. State your conclusion.
• 2. Give 3 reasons (or some other number) that support your conclusion. Rate each reason (weak, moderate, strong, very strong).
• 3. Give 3 counterarguments (or some other number) that weaken your conclusion. Rate how much each counterargument weakens the conclusion (little, moderate, much, very much).
• 4. List any qualifiers (limitations on the reasons for or against).
• 5. List any assumptions.
• 6. Are your reasons and counterarguments directly related to your conclusion?
• 7. What is the overall strength of your argument? Weak, moderate, strong, very strong

Appendix 4. University of Oklahoma College of Pharmacy Problem Solving Rubric

List of biases in judgment and decision making . http://psychology.wikia.com/wiki/List_of_biases_in_judgment_and_decision_making . Accessed February 23, 2018.

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DOI: https://doi.org/10.5688/ajpe7033

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Simulation-based training: applications in clinical pharmacy

The role of pharmacists in the uk has evolved substantially over recent years. simulation-based training (sbt) is a widely used educational technique that could support the development of the clinical skills and competencies required of pharmacists. however, while sbt is widely adopted in other healthcare areas, evidence supporting its use in pharmacy is limited in the uk., this article discusses how sbt can be applied to clinical pharmacy and describes the educational benefits of developing pharmacists’ technical and non-technical skills. the application of sbt in other industries and healthcare areas is discussed, with consideration of the types of simulation techniques used and design of the simulation sessions. evidence supporting the use of high-fidelity sbt for pharmacists is reviewed for both individual skill acquisition and development of multiprofessional team performance. applications of sbt to support both patient safety and development of the skills required for pharmacists are described with consideration of the challenges and barriers to its implementation., keywords:  clinical pharmacy; pharmacist; pharmacy; simulation; simulation-based training; sbt., original submitted: 1 march 2018;  revised submitted: 4 july 2018;  accepted for publication: 19 july 2018; published online: 4 september 2018.

• Simulation-based training (SBT) is an innovative training technique that has been increasingly used in healthcare over the past few decades.
• A variety of simulation technologies are available to support skill development, including patient simulations, computer-based simulations and virtual reality simulations.
• SBT can be used to provide a safe environment for pharmacists to develop their professional skills.
• SBT can help develop technical and non-technical skills, including communication, team working, decision making and task prioritisation.
• SBT can assist in individual or multiprofessional team training, with the potential to enhance team performance and patient safety.

Introduction

The role of the pharmacist in UK hospital settings has changed significantly over the past 15 years, from a medication-centred to a more patient-centred role. Examples of this evolution and development include enhanced roles in medicines reconciliation, attendance on ward rounds, leading outpatient clinics and development of clinical speciality and prescribing roles [1] .

With the evolving role of pharmacists and the growing complexity of healthcare, there is a need for interventions and innovations to enhance both individual task and team performance. Simulation-based training (SBT) is an educational platform with potential in this area. This article outlines its applications in pharmacy and how it can support the skill acquisition and development of pharmacists.

Sources and selection criteria

Cumulative Index to Nursing and Allied Health Literature and PubMed (National Library of Medicine) were used to review relevant publications for this article. A general internet search was also carried out to identify relevant non-indexed content. Searches were limited to English language articles with no restrictions on the age of the article. Search terms included pharmacist (OR pharmacy) and simulation (OR simulation-based training). Similar terms were used to find relevant articles for the use of SBT in healthcare, including nursing and medicine. Each reference was reviewed for relevance and quality by the authors for inclusion in this article.

Simulation-based training

Simulation has been defined as “a technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive manner” [2] . Here, a simulation technique is used, utilising a device, such as a ‘standardised’ patient or mannequin, to teach healthcare professionals a relevant skill or process, helping them improve competence and ensure a safe level of care [3] .

SBT allows learners the opportunity for deliberate practice in a safe environment where they can respond to high-risk situations, make mistakes and learn from any errors [3] , [4] , [5] . Using simulation avoids inconveniencing patients by repeatedly involving them in training scenarios, or putting them at risk from error [6] , [7] , [8] .

Situations that could be stressful, infrequent or dangerous can be replicated through SBT. The controlled scenario allows for exposure to specific learning outcomes that can be standardised across all participants, allowing a platform for both formative and summative assessment as part of further study or competency programmes. It can also be used to allow controlled exposure to clinical scenarios of increasing complexity, in order to support individuals in developing more advanced clinical skills. SBT can also provide a unique opportunity for teams to work together and develop the non-technical skills required for the successful execution of tasks in clinical environments.

Educational benefits

Didactic teaching is insufficient for dealing with crises or rare clinical conditions [9] , or for team-based training or activities that require retention of knowledge and skills beyond a year [10] . Lectures and tutorials have traditionally been the core methods used to teach pharmacy students and pharmacists [11] , although lectures can limit development of skills required for clinical practice [12] .

By contrast, SBT can offer a rich, learner-centred educational platform and provide meaningful experiences where participants can reflect on identified knowledge gaps [13] , [14] .Evidence demonstrates that profound educational experiences are emotionally charged and challenging, with optimally designed SBT stimulating meaningful reflection to influence behaviour. [13] , [14]

For any team-based SBT, a community of practice can be developed, which can have benefits that reach beyond the learning experience [15] . SBT can be used to enhance team performance [16] , [17] , supporting patient safety outcomes through increased collaboration, reduction of error, and development of teamwork and communication skills [3] , [18] , [19] .

SBT in healthcare involves adult learners and independent practitioners. Adult learners are often intrinsically, rather than externally, motivated [20] ; therefore, it is important that the learning outcome is practical, immediately usable and relevant. It has been proposed that adults learn best when they participate, are engaged, and experience teaching in a cognitive and emotional way [21] . Experiential learning is a process where experience is transformed into learning [22] . This is reflected in a four-stage learning cycle of learning (see Figure 1), familiar to pharmacists through continuing professional development, which includes experience, reflection and experimentation — key components of SBT [22] .

Figure 1: Kolb’s experiential learning cycle

Simulation-based training can provide a tangible experience and reflective observation, allowing learners to conceptualise new mental models that can be actively tested.

The cycle begins with an experience (the SBT) that offers the chance for learners to identify knowledge gaps and reflect on their performance. Here, SBT is catalysing the learning process by providing an opportunity for observation and reflection. Reflection can be facilitated by educators who debrief on the simulation [14] . This then allows for abstract conceptualisation, shaping the learner’s mental model through analogical reasoning, allowing consideration of outside information from the educator to make sense of the experience [14] . This can inform future behaviour and decisions and be actively tested in practice, allowing the cycle to begin again. Feedback is a critical process of SBT and, as an educational tool, can reduce the gap between perceived and actual performance of learners, supporting reflection on performance and guiding progression through the learning cycle [23] .

Application of SBT

SBT has been used extensively in the aviation and aeronautical space industries, as well as in the military, chemical and nuclear power sectors where its efficacy and safety have been demonstrated [24] . In healthcare education, where learning experiences can be limited, where it is unethical to practice on patients, and/or where it could compromise patient safety, there is potential for the application of SBT. It is often used to develop and assess technical and clinical skills for healthcare professionals [3] , [25] (e.g. blood pressure measurement, cannulation or catheter insertion). SBT is also used to develop and assess non-technical skills, defined as cognitive, social and personal resource skills [26] (e.g. communication, teamwork, task prioritisation and decision making).

Crew resource training

Several publications have raised awareness around potential sources of error and the need to reduce avoidable harm in healthcare [27] , [28] .’ Around 20 years ago, the need for crew resource management training in healthcare (initially called ‘cockpit resource management training’), similar to the aviation industry, was described to develop the non-technical skills of staff and improve patient safety [27] . Crew resource management training provides traditional didactic teaching on a subject, with hands-on experiential learning for the whole team through simulation, improving teamwork and non-technical skills [29] .

Non-technical skill development

In addition to developing technical proficiency, SBT has also been used to develop and enhance team performance and non-technical skills and behaviours for specific situations [16] . These are the cognitive, social and personal resource skills that complement technical skills, supporting safety and task performance [26] , [30] . Cognitive skills include decision making, planning and situational awareness, while social skills include teamwork and communication [30] . These skills are increasingly recognised as critical in optimising prescribing outcomes [31] , and a recent review reported that moderate-to-high quality evidence suggests team training can positively impact healthcare team processes and patient outcomes. In addition, bundled team training interventions and implementation strategies that embed effective teamwork as a foundation for other improvement efforts may offer the greatest impact on patient outcomes [32] .

The simulation session

Simulation sessions should be carefully designed to ensure they are aligned with relevant curricula, performance standards and learning outcomes. Educators should consider the purpose of the SBT and whether students will be prepared for the session to simulate dealing with the unknown, or if they will be provided with background information in the form of videos or lectures in advance. The introduction to learning material ahead of the session utilises a flipped classroom approach that can cognitively prepare learners for the simulation, promote interest in learning and allow them to build on existing knowledge, and focus on the SBT learning experiences [33] , [34] . However, this approach requires students who are self-motivated; when students do not engage with the pre-learning activities, the SBT may be ineffective [35] , [36] .

Planning of any simulation session should include the type of simulation and scenario design, including relevant materials, patient training, transcripts and potential responses to treatment. Any planning should also consider the facilitation and briefing on the scenario so that participants are clear on the objectives before commencing the simulation.

Simulations can vary in their technical complexity and psychological, environmental and technological fidelity (level of realism). The level of fidelity required should be considered when designing SBT, with the learning outcomes influencing the types of simulation used and resources required. 

Types of simulation used in healthcare

Each simulation technique has the potential to provide different learning and development opportunities for pharmacists, depending on the intended learning outcome and required fidelity (see Table 1).

Technological fidelity relates to how the simulation duplicates the appearance of the system or patient, whereas environmental fidelity is concerned with environmental cues and stimuli of the task environment. However, psychological fidelity concerns the degree to which the trainee or student perceives the simulation to be a believable task replacement. This is considered the most essential requirement to suspend disbelief, requiring high task fidelity and functional fidelity so that the SBT both resembles and responds like real life.

SBT can vary from low- to high-fidelity scenarios that are delivered in a simulated environment, or in situ in the clinical environment using patient simulations. The purpose of the SBT and intended learning outcomes will influence construction of the SBT event, including resource considerations such as the type of patient simulation.

Training can include patient simulations, computer-based learning simulations and virtual reality (VR) patients [37] . Patient simulations broadly include two large groups which can include sophisticated mannequins and various part-task trainers [38] , and standardised patients consisting of paid actors, faculty members or students [38] , [39] , [40] .

Various types of mannequins are available in healthcare simulation, although they all share the same characteristic of using technology to enhance learning. Modern SBT in healthcare can be traced to the use of the Resusci Anne mannequin for effective mouth-to-mouth ventilation and chest compressions in the 1960s; mannequins have since been developed to simulate various diseases, allowing learners to develop the skills to manage these conditions [38] , [41] .

With advancing computer software and technologies, more complex high-fidelity mannequins that can talk, breathe and have realistic heart and lung sounds are available in healthcare education. They can also be programmed with greater sophistication and learner interactions that replicate physiological parameters and responses to procedures and treatment, including medication administration with appropriate physiological responses. Examples include the SimMan ® 3G (Laerdal Medical; see Figure 2), Human Patient Simulator (METI) and Emergency Care Simulator (METI) that can be programmed for a wide range of scenarios.

Part-task trainers may also be used that allow learners to develop specific skills in isolation and provide low-to-medium fidelity experiences [42] . Examples include practising blood pressure measurement on an artificial arm, screening a prescription for errors and accuracy, or standardising documentation in patient notes.

Other technologies used in SBT can include computer-based learning programmes and VR simulators. Here, the learner follows a programmed sequence, interacting with the environment through the computer or VR headset [43] , [44] . Evidence shows that use of this technology supports clinical reasoning and communication skills, and increases healthcare professionals’ knowledge [45] , [46] . Simulated electronic patient records have also been used to assess and support development of the accuracy of documentation in medical notes [47] .

‘Standardised’ patients are where a lay person, actor, faculty member or student peer are used to simulate the scenario or clinical condition [40] , [48] , [49] . They were introduced in the 1960s to assist in the training and assessment of communication, physical assessment and examination, professionalism and clinical skills [38] , [41] , and are commonly used in the training and assessment of pharmacists in patient counselling or throughout objective structured clinical examinations [40] , [48] , [49] . The use of standardised patients allows learners the opportunity to practice clinical skills as necessary, with provision of targeted facilitator feedback in a safe and controlled environment. When used in assessments, the standardisation can ensure fairness and valid comparisons in performance [40] . In addition, standardised patients offer the advantage of removing risk to patients [7] , [40] , [50] and can increase the fidelity of the experience in comparison to a mannequin. However, use of standardised patients can be associated with significant costs for payment of actors or faculty [48] , while the time required to prepare scenarios and train the individual can be substantial [40] .

Figure 2: Mannequin-based simulation

An example of SimMan ® 3G (Laerdal Medical) in a simulation training suite used to optimise simulation training and support technical and nontechnical skill development.

Full environment simulation involves high-fidelity mannequins and standardised patients, an authentic clinical environment and healthcare professionals with relevant equipment. This environment could be a simulation suite or simulated exercise that is delivered in situ with authentic materials and equipment, increasing the level of fidelity and providing a highly immersive experience (see Figure 3).

Figure 3: Multiprofessional simulation team

A simulated clinical scenario using SimMan® 3G (Laerdal Medical) for multiprofessional team training, facilitated by a simulation tutor.

Participant debriefing is a critical component of simulation for effective learning and should be planned as part of the learning session [20] . The concept originates from the military sector where participants would describe what happened on a mission, with analysis used to develop strategy for future missions [20] . In healthcare, debriefing is used to promote improved performance in similar future situations [51] .

Debriefing allows the opportunity to explore the skills, knowledge and attitudes that influenced a participant’s actions [52] , and is critical to presenting the outcomes of the simulation and evaluating perceptions of participants’ own performance [9] . The debriefing process facilitates reflection on the simulated scenario through active participation in conversation between the educator and learner or participant [7] , [53] , typically immediately following the simulation [54] . The benefits of debriefing in supporting development of interprofessional teams has been described [55] and similar positive outcomes would be expected with pharmacist involvement.

In healthcare, this can often involve participants watching a video recording of the simulated event, with a facilitator guiding participants to reflect on their performance. This technique has been demonstrated to encourage reflection, identify performance gaps and improve future performance [56] .

Debriefing is considered one of the most challenging aspects of SBT [54] and requires skilled individuals to both assess and facilitate the process. These facilitators should be trained in the delivery of feedback to ensure successful outcomes are achieved [52] . To support the debriefing process, various frameworks are available to educators to support practice [53] , [57] . Debriefing requires a psychologically safe environment to explore meaning behind a learner’s actions. Facilitators share their observations and insights with the learner, which are then explored. This is a good judgement approach, valuing both learner and facilitator perspectives to illuminate and understand learner behaviour [51] .

This process can explore both positive and negative aspects of the simulation performance [53] , [57] . Here, as well as exploring any reasons for failure by focusing on ‘work as done’ (a ‘safety 1’ approach), there is opportunity for learners to reflect on and learn from what went well. The reasons and behaviours for performing ‘work as imagined’ (a ‘safety 2’ approach) is increasingly advocated for safety management to understand good performance in different contexts [58] . There is growing recognition for this approach in healthcare and SBT [59] , [60] , where individuals and teams can learn from success or exceptional performance, as well as failure [16] , [53] , [58] , [61] , [62] .

SBT in healthcare education

Increasing use of SBT in healthcare education has been observed in recent years [52] , with the main aim of optimising patient care and safety, while allowing standardisation of training and assessment, and practicing skills in a controlled environment [2] .

A wide range of simulation technologies are commonly used in healthcare education to support knowledge acquisition, critical thinking and clinical skills, such as medicines administration and management of emergency situations [63] , [64] , while also improving the confidence or trainees [65] . SBT is widely used in both undergraduate and postgraduate medical curricula in the UK to enhance performance [37] . It is becoming accepted as the industry standard for the education and training of nurses and doctors [66] , with the effectiveness of SBT as a replacement for nursing hours demonstrated [67] .

However, the use of SBT has not evolved to the same level within pharmacy education [7] , [48] and high-fidelity SBT is still in its relative infancy in the UK [68] , [69] . The remaining sections below describe the potential applications of SBT in developing the skills and enhancing the performance of pharmacists.

SBT for pharmacists

Potential applications of SBT to support development of pharmacists’ technical, cognitive and non-technical skills are outlined in Table 2.

The literature supporting the use of high-fidelity SBT for pharmacy in the UK is limited, with the majority of evidence emerging from the United States [68] , [69] , [70] . This could be influenced by the perceived traditional supply role of a pharmacist having less direct patient contact compared with nurses and doctors. The role of pharmacists in the UK has evolved considerably in recent years towards a greater patient-centred role and, therefore, demands enhanced clinical skills [1] . However, as undergraduate pharmacy is funded differently to medicine and nursing programmes, the opportunities for clinical placements for pharmacy students can be limited [71] . Such limited exposure to clinical practice can create a mismatch between student expectations and the reality of clinical practice, with pharmacists requiring skills of a different order than can currently be achieved at registration [72] . SBT could be used to both supplement these experiences and support development of clinical skills as part of any ongoing postgraduate training, helping to better prepare and support pharmacists in clinical practice.

High-fidelity SBT can provide a safe and controlled learning environment for pharmacists to apply their knowledge and develop their professional skills [73] , [74] . SBT is well received by pharmacy students and has been shown to improve confidence [75] , enhance learning and improve test scores in the management of clinical conditions, medication administration or drug calculations [42] , [68] , [76] , [77] . Recently, the use of a computer-based simulation was reported to support self-directed learning and develop decision-making skills of pharmacy students in an oncology pharmacotherapeutics programme [78] . Elsewhere, SBT has been shown to enhance pharmacy student performance in monitoring drug treatment [79] and clinical skills such as blood pressure measurement [75] . In emergency situations, SBT has been reported to enhance problem-solving skills [74] and understanding of the role of pharmacists in managing these conditions [8] , [77] , although benefits also extend to routine clinical scenarios [9] .

SBT has also been shown to enhance pharmacist communication, critical thinking and team-working skills [6] , [68] , [76] , [80] , with teams that work effectively providing higher quality care and patient safety [31] . Healthcare students, including pharmacy students, are trained in profession-specific ways, yet are required to work in clinical settings as members of interprofessional teams [81] . Pharmacists routinely need to collaborate with doctors to resolve and optimise prescribing outcomes. Effective communication skills are essential performance standards for UK pharmacists [82] , [83] , yet poor communication between healthcare professionals, including pharmacists and doctors, is considered a leading contributing factor of prescribing error [84] .

While SBT is used within schools of pharmacy for dispensing, patient counselling, teaching of therapeutics and assessments in objective structured clinical examination, there is wider potential for clinical pharmacy to meet the evolving needs of the workforce. It could be used as a modality for training and assessment of clinical skills, application of pharmaceutical care, identification of medication errors, medicines reconciliation and prescribing tasks. As a technology, SBT has enhanced medical students’ knowledge and comfort in obtaining a medication history [85] and similar benefits might be expected for pharmacists and pharmacy technicians who undertake this role in UK hospital settings.

This training can enhance the self-reported preparedness of pharmacists for high-stress clinical scenarios while on-call, including management of sepsis, stroke, epilepsy and bleeding [86] . This demonstrates its potential application for enhancing knowledge and awareness of both frequent and rare clinical situations, or even to support pharmacists as they rotate between clinical areas and pharmacy placements, such as dispensary and medicines information.

Impact on patient safety

Medication errors are a leading cause of patient harm and can occur at the prescribing, dispensing or administration stages. Around 7% of prescribed items [87] , 0.02–2.68% dispensed items [88] and 3–8% of administered medications contain an error in the hospital setting. It has been estimated that up to 9% of hospital inpatients experience medicine-related harm [89] , with many of these incidents being preventable. In addition, the cost of preventable harm from medicines has been estimated at more than £750m per year — a significant, avoidable expenditure [90] .

Medication error causation is complex, with non-technical skills often described as contributing factors in both prescribing [91] , [92] , [93] and administration errors [94] . Failings in these non-technical skills have been estimated to contribute to 70–80% of errors in healthcare [29] . The seminal report ‘To Err Is Human: Building a safer health system’, published in 1999, advocated simulation as a technique to educate on error management, reduce error and achieve a safer healthcare system [27] . A more recent systematic review of the effect of SBT on medication errors also concluded that it can be effective at reducing risk of medication error [9] .

As team training improves passenger safety in the aviation industry, multiprofessional team training can improve patient safety, with pharmacists actively involved in optimising medication outcomes. Here, SBT can be an effective tool at raising awareness of error and critical process [95] , while reductions in medication administration errors by nurses have also been reported in a pharmacist-led patient simulation [96] , with similar reductions in medication errors and improvements in patient outcomes reported from SBT elsewhere [31] . Use of team training scenarios could enhance the non-technical skills of pharmacists to effectively communicate, work in a team, and influence and challenge medication issues while enhancing their clinical skills. These are integral skills in both foundation- and advanced-level competency frameworks for pharmacists [82] , [83] and SBT could provide the opportunity for pharmacists to develop the skills and attitudes required to both learn from, and prevent, error [97] .

Challenges and limitations of SBT

SBT is not without limitations. It should be emphasised that it is a supplementary experience and not a replacement for clinical experience [5] . More complex simulators and mannequins require tailored simulation facilities, technologies and resources. The cost of more sophisticated high-fidelity simulators can be considerable, with further associated costs for ongoing maintenance and ancillary equipment or materials [44] , [73] . Space to house a simulation suite is required, while staff skilled in the programming and use of the simulator, and assessment and debriefing of participants is also required, presenting limitations that are likely to be problematic for many pharmacy departments and organisations. The place and role of SBT in any clinical pharmacy curricula needs defining and should be aligned with relevant competencies, while SBT programmes will need further research and validation of their impact on both educational and clinical outcomes.

Such challenges will need to be overcome to enable SBT to be fully utilised in clinical pharmacy training. However, many hospitals and institutions already have access to these resources, and engagement with the dedicated clinical skills or simulation teams could foster a collaboration to support a dedicated or interprofessional SBT programme for pharmacists. Such collaboration could allow pharmacy faculties to develop and lead independently on their own SBT, creating opportunities to both drive the research agenda and contribute to the evidence base supporting SBT as a technique to help develop the skills of the pharmacy workforce.

SBT is an innovative and flexible training modality that is being increasingly used within healthcare to enhance quality and support attainment of professional competence. Effective training is critical for acquisition of the diverse skills required of healthcare professionals to deliver safe, high-quality care, and SBT can help develop and assess performance. Its use within clinical pharmacy has not evolved to the same levels as in other areas of healthcare; however, it offers clear potential not only for pharmacy-specific training, but for crew resource management training for entire clinical teams — along with potential benefits for optimising both medication and patient safety. As clinical pharmacy evolves to include more patient-facing roles, educators need to embrace educational interventions and technologies that will support the acquisition and development of the skills of tomorrow’s workforce; SBT is one option that should be explored further.

Useful resources

Pharmacists interested in developing or participating in simulation-based training (SBT) should contact their local clinical skills and simulation leads to explore potential for learning opportunities.

The following links provide additional information and support for those interested in exploring developing SBT further:

• The Association for Simulated Practice in Healthcare
• The Society in Europe for Simulation Applied to Medicine
• The Society for Simulation in Healthcare
• Simulation in Healthcare

Financial and conflicts of interests disclosure

The authors have no relevant affiliations or financial involvement with any organisation or entity with a financial interest in or financial conflict with the subject matter or materials discussed in this manuscript. No writing assistance was used in the production of this manuscript.

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[56] Watmough S, Box H, Bennett N et al . Unexpected medical undergraduate simulation training (UMUST): can unexpected medical simulation scenarios help prepare medical students for the transition to foundation year doctor? BMC Med Educ 2016;16:110. doi: 10.1186/s12909-016-0629-x

[57] Kolbe M, Weiss M, Grote G et al . TeamGAINS: a tool for structured debriefings for simulation-based team trainings. BMJ Qual Saf 2013;22(7):541–553. doi: 10.1136/bmjqs-2012-000917

[58] Hollnagel E, Wears RL & Braithwaite J. From safety-I to safety-II: a white paper. National Library of Congress, Washington DC.  doi: 10.13140/RG.2.1.4051.5282

[59] Dieckmann P, Patterson M, Lahlou S et al . Variation and adaptation: learning from success in patient safety-oriented simulation training. Adv Simul (Lond) 2017;2:21. doi: 10.1186/s41077-017-0054-1

[60] Staender S. Safety-II and resilience: the way ahead in patient safety in anaesthesiology. Curr Opin Anaesthesiol 2015;28(6):735–739. doi: 10.1097/ACO.0000000000000252

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[63]   Pauly-O’Neill S. Beyond the five rights: Improving patient safety in pediatric medication administration through simulation. Clin Simul Nurs 2009;5(5):e181–e186.
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[64]  Cant RP & Cooper SJ. Simulation-based learning in nurse education: systematic review. J Adv Nurs 2010;66(1):3–15.
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[65] Norman J. Systematic review of the literature on simulation in nursing education. ABNF J . 2012;23(2):24–28. PMID: 75292183

[66] Aebersold M. The history of simulation and its impact on the future. AACN Adv Crit Care 2017;27(1):56–61. doi: 10.4037/aacnacc2016436

[67] Hayden JK, Smiley RA, Alexander M et al . The NCSBN National Simulation Study: a longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. J Nurs Regul 2014;5(2):S3–S40. doi: 10.1016/S2155-8256(15)30062-4

[68] Branch C. Pharmacy students’ learning and satisfaction with high-fidelity simulation to teach drug-induced dyspepsia. Am J Pharm Educ 2013;77(2):Article 30. doi: 10.5688/ajpe77230

[69] Reape A, Lips-Nassif C, Bailey L et al . The use of human patient simulators for teaching UK pharmacy students about critical care. Pharm Educ 2011;11(1):1–7. Available at: http://pharmacyeducation.fip.org/pharmacyeducation/article/view/340 (accessed September 2018)

[70] Regan K, Harney L, Goodhand K et al . Pharmacy simulation: a Scottish, student-led perspective with lessons for the UK and beyond. Pharmacy 2014;2(1):50–64. doi: 10.3390/pharmacy2010050

[71] Langley C, Jesson J & Wilson K. Learning with other health professions in the United Kingdom MPharm degree: multidisciplinary and placement education. Pharm Educ 2010;10(1):39–46.

[72] Smith A & Darracott R.  Modernising Pharmacy Careers Programme. Review of pharmacist undergraduate education and pre-registration training and proposals for reform. Report to Medical Education England Board. 2011.  Available at: http://docplayer.net/26553607-Modernising-pharmacy-careers-programme-review-of-pharmacist-undergraduate-education-and-pre-registration-training-and-proposals-for-reform.html (accessed September 2018)

[73] Seybert AL. Patient simulation in pharmacy education. Am J Pharm Educ 2011;75(9):Article 187.  doi: 10.5688/ajpe759187

[74] Vyas D, Ottis EJ & Caligiuri FJ. Teaching clinical reasoning and problem-solving skills using human patient simulation. Am J Pharm Educ 2011;75(9):Article 189. doi: 10.5688/ajpe759189

[75] Seybert AL & Barton CM. Simulation-based learning to teach blood pressure assessment to doctor of pharmacy students. Am J Pharm Educ 2007;71(3):Article 48. doi: 10.5688/aj710348

[76] Seybert AL & Kane-Gill SL. Elective course in acute care using online learning and patient simulation. Am J Pharm Educ 2011;75(3):Article 54. doi: 10.5688/ajpe75354

[77] Mieure KD, Vincent WR, Cox MR et al . A high-fidelity simulation mannequin to introduce pharmacy students to advanced cardiovascular life support. Am J Pharm Educ 2010;74(2):Article 22. doi: 10.5688/aj740222

[78] Bernaitis N, Baumann-Birkbeck L, Alcorn S et al. Simulated patient cases using DecisionSimâ„¢ improves student performance and satisfaction in pharmacotherapeutics education.  Curr Pharm Teach Learn 2018;10(6):730–735. doi: 10.1016/j.cptl.2018.03.020

[79] Tokunaga J, Takamura N, Ogata K et al . Vital sign monitoring using human patient simulators at pharmacy schools in Japan. Am J Pharm Educ 2010;74(7):Article 132. doi: 10.5688/aj7407132

[80]   Fernandez R, Parker D, Kalus JS et al . Using a human patient simulation mannequin to teach interdisciplinary team skills to pharmacy students. Am J Pharm Educ 2007;71(3):Article 51.
 doi: 10.5688/aj710351

[81] Thomson K, Outram S, Gilligan C & Levett-Jones T. Interprofessional experiences of recent healthcare graduates: a social psychology perspective on the barriers to effective communication, teamwork, and patient-centred care. J Interprof Care 2015;29(6):634–640. doi: 10.3109/13561820.2015.1040873

[82] Royal Pharmaceutical Society. The RPS foundation pharmacy framework. A framework for professional development in foundation practice across pharmacy. 2014. Available at: https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Frameworks/RPS%20Foundation%20Pharmacy%20Framework.pdf (accessed September 2018) 

[83] Royal Pharmaceutical Society. The RPS advanced pharmacy framework (APF). 2013. Available at: https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Frameworks/RPS%20Advanced%20Pharmacy%20Framework.pdf (accessed September 2018)

[84] Dornan T, Ashcroft D, Heathfield H et al . An in-depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education — EQUIP Study. 2009. Available at: http://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf (accessed September 2018)

[85] Lindquist LA, Gleason KM, McDaniel MR et al . Teaching medication reconciliation through simulation: a patient safety initiative for second year medical students. J Gen Intern Med 2008;23(7):998–1001. doi: 10.1007/s11606-008-0567-3

[86] Thomson Bastin ML, Cook AM & Flannery AH. Use of simulation training to prepare pharmacy residents for medical emergencies. Am J Health-Syst Pharm 2017;74(6):424–429. doi: 10.2146/ajhp160129

[87] Lewis PJ, Dornan T, Taylor D et al . Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review. Drug Safety 2009;32(5):379–389. doi: 10.2165/00002018-200932050-00002

[88] James KL. Barlow D, Mcartney R et al . Incidence, type and causes of dispensing errors: review of the literature. In J Phar Pract 2009;17(1):9–30. doi: 10.1211/ijpp.17.1.0004

[89] Davies EC, Green CF, Mottram DR & Pirmohamed M. Adverse drug reactions in hospital inpatients: a pilot study. J Clin Pharm Ther 2006;31(4):335–341. doi: 10.1111/j.1365-2710.2006.00744.x

[90] National Patient Safety Agency. Safety in doses: improving the use of medicines in the UK. 2007

[91] Ryan C, Ross S, Davey P et al . Prevalence and Causes of Prescribing Errors: The Prescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) Study. PLoS ONE 2014;9(1):e79802. doi: 10.1371/journal.pone.0079802

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16 Community Pharmacist Skills for Your Career and Resume

Learn about the most important Community Pharmacist skills, how you can utilize them in the workplace, and what to list on your resume.

Community pharmacists are responsible for providing medication and other health-related products to patients. They also offer advice on the use of these products and services. Community pharmacists need to have a wide range of skills to be successful in their jobs. These skills include customer service, communication, organization, and more.

Clinical Services

Problem solving, pharmacy operations, third party billing, patient education, inventory management, customer service, patient counseling, supervisory skills, medication therapy management, regulatory compliance, decision making, compounding, attention to detail, communication, organization.

Community pharmacists often provide clinical services to patients, including treatment for minor health conditions and advice on how to manage chronic illnesses. Clinical skills include the ability to assess patient needs and prescribe medications that can help them feel better. Community pharmacists also use clinical skills when they conduct research into new drugs or drug combinations.

Community pharmacists often solve problems for their patients. They may help them find the right medication or dosage, answer questions about how to take medications and suggest lifestyle changes that can improve a patient’s health. Community pharmacists also use problem-solving skills when they’re trying to identify an unknown substance someone has taken.

Pharmacists use their knowledge of pharmacy operations to ensure that they can operate a community pharmacy efficiently. This includes knowing how to manage inventory, track sales and maintain the pharmacy’s physical space. Community pharmacists also use their skills in pharmacy operations when interacting with insurance companies or other health care providers who send them prescriptions.

Community pharmacists often bill insurance companies on behalf of their patients. This is an important skill because it allows them to receive payment for the medications they dispense and ensures that their patients can afford their treatment. It’s also a necessary part of maintaining a successful business, as most community pharmacies rely on third-party billing to stay in operation.

Patient education is an important skill for community pharmacists to have because it allows them to educate patients on how to use medications properly and safely. Community pharmacists often provide information about the side effects of certain medications, what to do if a patient experiences those side effects and any other relevant information that may be helpful to their patients.

Community pharmacists often manage inventory for their store, which requires them to know how to track and organize the supplies they have. They also need to be able to identify when they’re running low on a product so they can order more before they run out. This is important because it ensures customers are able to get the medication they need.

Customer service skills are important for community pharmacists to have because they interact with patients and customers regularly. Customer service involves providing information, answering questions and resolving issues that customers may have. Community pharmacists should be friendly and welcoming when interacting with their patients so they can help them understand the medications they’re taking or any side effects they may experience.

Community pharmacists often work with patients to help them understand their medication and how it works. They may explain the side effects of a drug, what to do if they experience those side effects or if they have any questions about their treatment plan. Patient counseling skills allow community pharmacists to educate patients on how to use medications safely and effectively. This can also help patients feel more comfortable when taking prescription drugs.

Community pharmacists often supervise pharmacy technicians and other staff members. Supervisory skills include the ability to delegate tasks, provide feedback and manage time effectively. Community pharmacists also need to instruct patients on how to use their medications properly and safely. They may also train new employees or act as a mentor for current employees.

Medication therapy management is the ability to assess a patient’s medication needs and create an individualized treatment plan. Community pharmacists often work with patients who have complex medical conditions that require several medications to treat different symptoms. For example, a patient may need one medication for high blood pressure and another medication to control their diabetes. A pharmacist can help determine which medications are most effective for each condition and ensure the patient understands how to take all of their medications correctly.

Regulatory compliance is the ability to follow all laws and regulations regarding medication. Community pharmacists must be aware of any changes in laws or regulations that may affect their practice, as well as how to apply these laws and regulations when filling prescriptions for patients. For example, a pharmacist should know what information they need to collect from a patient before filling a prescription and how to store medications safely.

Community pharmacists often need to make decisions about the medications they dispense. They may decide which medication is most effective for a patient’s condition or whether a medication is safe for a certain age group. Pharmacists also use decision-making skills when deciding how to handle an emergency situation, such as if a customer has taken too much of a drug and needs medical attention.

Compounding is the process of mixing ingredients to create a medication. Community pharmacists often use compounding skills to prepare medications for patients who need unique dosages or forms of treatment. For example, some patients may require liquid medication while others may need pills. A pharmacist can compound these medications by combining different ingredients and adjusting their proportions.

Community pharmacists must be able to accurately measure and mix medications. They also need to ensure that they enter the correct information into a patient’s medical records, including dosage instructions, side effects and potential drug interactions. This ensures that patients receive safe treatment and helps pharmacists monitor their patients’ progress.

Community pharmacists often work with patients to explain the medications they provide. They also communicate with other medical professionals, such as doctors and nurses, about patient care. This requires strong written and verbal communication skills so community pharmacists can send emails and make phone calls effectively. It’s also important for them to be able to clearly explain medication instructions to patients so they understand how to use their prescriptions properly.

Organization is the ability to keep track of multiple tasks and responsibilities. Community pharmacists often have many duties, including filling prescriptions, answering customer questions about medications and providing advice on health topics. Having strong organizational skills can help them manage their workload and prioritize their time effectively. It’s also important for community pharmacists to be organized when handling medication so they can ensure patients receive the correct treatment.

How Can I Learn These Community Pharmacist Skills?

Community pharmacists typically gain their skills through on-the-job training. However, there are a few ways that you can learn these skills outside of the traditional work setting. One way is to take courses offered by your local community college or university. These courses will give you the opportunity to learn about the different aspects of community pharmacy and how to perform your duties in this type of setting. Another way to learn these skills is to shadow a community pharmacist in your area. This will allow you to see firsthand how community pharmacists interact with patients and perform their duties.

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Simulation-Based Education Implementation in Pharmacy Curriculum: A Review of the Current Status

Ghazwa b korayem.

1 Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia

Omar A Alshaya

2 Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

3 Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia

4 King Abdullah International Medical Research Center, Riyadh, Saudi Arabia

Sawsan M Kurdi

5 Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

Lina I Alnajjar

Aisha f badr.

6 Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia

Amjaad Alfahed

Ameera cluntun.

7 Curriculum and Training Department, Health Academy, Saudi Commission for Health Specialties, Riyadh, Saudi Arabia

Simulation-based education (SBE) is a fundamental teaching method that complements traditional teaching modalities. SBE has improved students’ knowledge, understanding, and numerous essential skills within undergraduate pharmacy education, similar to traditional teaching methods. However, SBE has become crucial for developing students’ teamwork, decision-making, and communication skills. Even though the Accreditation Council for Pharmacy Education (ACPE) has acknowledged the benefit of SBE in interprofessional education (IPE) and the introductory pharmacy practice experience (IPPE). This article provides evidence that SBE can be effective beyond that. This narrative review is focused on the literature related to SBE modalities and the assessment methods of student learning outcomes in the undergraduate pharmacy curriculum. The review illustrates that SBE is an effective teaching method that could be utilized within the pharmacy curriculum. The review also could help pharmacy educators decide on the best modality and placement of integrating patient simulation within the pharmacy curriculum. Combining multiple simulation techniques may be the best way to achieve the desired student learning outcomes.

Pharmacy education has evolved with the progression of the pharmacist role. 1 The emphasis on patient-centered care has become the core of the pharmacy curriculum. 1 As clinical pharmacy continues to develop, pharmacy students are expected to play a vital role in direct patient care. 2 Therefore, several innovative teaching approaches have been implemented to enhance students’ pharmaceutical knowledge and clinical skills. 2 There is a massive shift in pharmacy education from traditional teaching methods into active learning methods. 3 Active learning includes class discussions, project-based learning, problem-based learning, case studies, and simulation. 4

Simulation-based education (SBE) is one of the teaching strategies that has been widely used in health profession education. Simulation-based learning is defined as “An array of structured activities representing actual or potential situations in education and practice„. 5 , 6 These activities allow participants to develop or enhance their knowledge, skills, and attitudes or analyze and respond to realistic situations in a simulated environment. 7 Patient simulation has been shown to be an effective teaching and assessment approach that replicates a patient within a clinical scenario in an educational setting. 8 It offers a controlled teaching environment for learners that is equivalent to realistic experiences without compromising patients’ safety. 9 Simulation application in health education is never limited to utilizing technologies. Instead, it is a technique used to replicate the real experience. 10 , 11 Therefore, simulation techniques include all of the following: mannequins, part-task trainers, role-play (RP), standardized patients (SP), computer-based systems (CBS), virtual reality (VR), and gaming. 11 , 12

Medical patient simulations originated in ancient times but advanced during the 1900s. 13 Patient simulation was first presented in medical learning and then expanded to other health disciplines. 13 Modern simulation was initially started using patient actors to teach medical students prior to the development of high-fidelity simulation. 14 Medical and nursing schools mostly use manikins to help develop students’ clinical and communication skills. 6 The first documented human patient simulation utilization in the pharmacy curriculum was at the University of Pittsburgh in 2006. 15

In 2007, the Accreditation Council for Pharmacy Education (ACPE) revised its accreditation standards to recommend using a hybrid of didactic, simulation, and experiential methods in teaching the pharmacy curriculum. 16 However, they encouraged simulation specifically in interprofessional education (IPE) and introductory pharmacy practice experience (IPPE). 16 The ACPE limited the duration of simulated practice experience to no more than 20% of the total IPPE required hours. 16 It also presented the types of simulation that pharmacy schools need to consider for IPPE and IPE, including virtual reality software, low- or high-fidelity manikins, role play, virtual environments, and standardized or virtual patients. 17 Nonetheless, over the past decade, several pharmacy schools have implemented various SBE methodologies in advanced pharmacy practice experiences (APPE) courses and others in the pharmacy curriculum. 18–22 During the COVID-19 pandemic, SBE emerged as an effective alternative teaching strategy due to its flexibility and the ability to train large numbers of students at various levels while maintaining students’ and patients’ safety. 23–25 Nonetheless, SBE should not always be perceived as an alternative teaching strategy; instead, it is a fundamental teaching method that complements traditional teaching.

This article presents a review of the utilization of patient simulation, including the type of simulation utilized, location in the curriculum, topics, intended learning outcomes, and assessment methods. In addition, we reviewed the needed resources, opportunities,challenges, and the published articles in which patient simulations were performed. We also assessed the student learning outcomes within undergraduate pharmacy education between 2007 and May 2021. After the literature review, six experts in the field of pharmacy and simulation education gathered to summarize the current literature and provide recommendations about the best implementation of SBE technologies within the pharmacy curriculum based on the literature and their expertise.

Patients Simulation Implemented in Pharmacy Curriculum

Standardized patients (sps), description.

SPs refer to well-trained specialists who portray the case of a real-life patient in a consistent and replicable performance to different students and provide responses that vary based on the students’ performance. 7 , 26 The SP portrayal should involve all aspects of the presented patient case, including but not limited to medical history, signs and symptoms, physical findings, emotional and personal characteristics, and body language. SPs may also assess students and provide feedback on their performance. 7 , 26

Implementation in the Pharmacy Curriculum

Utilizing SPs in pharmacy education has been widely reported in the literature as an effective complementary teaching modality to advance clinical pharmacy education. 27–33 Many learning outcomes can be achieved using this modality, ranging from advancing patient interviewing and history-taking skills to the optimal implementation and monitoring of a pharmacotherapy plan. 34 The SP modality can be utilized in various courses throughout the pharmacy curriculum and at various student levels, especially when the learning objectives are aimed to boost students’ confidence and develop the students’ professional skills, such as patient interviews and communication skills, clinical knowledge, and practice, cultural and emotional competence, and team-based skills. Courses that focus on pharmacotherapy, immunization, medication therapy management, and psychiatry are some examples where SP could be utilized. In addition, the standardization in the SP modality makes it an excellent modality to use in high-stake assessments where the responses to students are standardized among all participating students.

Pharmacy schools could recruit paid or volunteer actors to play the role of the SP, train their faculty members to play this role, or utilize student peers. Each strategy carries some advantages and disadvantages that should be weighed when choosing between them for specific learning experiences. Paid or volunteer actors are mostly flexible and available when needed and unfamiliar with students; however, they require more training time and may be costly on some occasions. Faculty members are a great resource to play this role, as they need less training and provide high-quality assessments and feedback; however, their availability is not guaranteed all the time.

Using simulation through SPs has been proven to improve students’ knowledge, perception, 30–32 cultural skills, and communication skills. 27 , 28 Tailoring the SP experience to the student’s specific areas of improvement in communication skills showed better performance and satisfaction when compared to a non-tailored standardized patient group. 35 Although simulation through SPs did improve the attainment of various learning outcomes, it does hold some limitations, such as high cost, the need for well-structured training, and the scarcity of validated and reliable assessment tools, as shown in Table 1 . The process of recruiting, training, and preparing SPs is expensive, despite the literature showing its cost-effectiveness. 26 , 28 , 36

Summary of the Features of Various Types of Patient Simulation Utilized in the Pharmacy Curriculum

Abbreviations : APPE, Advanced Pharmacy Practice Experiences; IPPE, Introductory Pharmacy Practice Experience; Low levels, first year of pharmacy school; Advanced levels, second year of pharmacy school or above; DKA, Diabetic ketoacidosis; PBL, Problem based learning; OSCE, Objective Structured Clinical Evaluation; CSAF, Communication Skills Assessment Form; SOAP, Subjective, Objective, Assessment, Plan; SWOC, Strengths, Weaknesses, Opportunities, and Challenges; SG, serious gaming.

Recommendation

The SP modality should be incorporated throughout the pharmacy curriculum in courses that involve higher-level skills with the utilization of faculty members or student peers to perform the SP role, given the high cost associated with recruiting outside performers. Assessments of student encounters with SPs can be performed through immediate feedback, rubrics, pre and post surveys, SOAP notes, and quizzes.

Role-Play (RP)

Role-play (RP) is a well-known learning practice in which students perform various roles in a simulation of real-life situations. 37 During role-play, a peer student (co-learner) may impersonate a patient, caregiver, or health care provider within a clinical scenario. 38 If the role is played with an individual who is trained to act as a patient or a family member, this can fall under an SP, as discussed earlier in this review. 38 This allows students to practice realistic experiences while remaining in a controlled environment.

Many pharmacy programs have reported successfully using RP to teach a wide range of skills in several core or elective courses and laboratories. 9 , 39–48 Moreover, it can be used in all levels of the pharmacy curriculum, including APPE. 9 , 39–48 Despite the variations in the application method, several researchers have reported positive outcomes regarding students’ communication skills, 9 , 42–48 motivational interviewing skills 47 , 48 medication reconciliation, 46 patient presentation skills, 45 patient and self-care, 43 and patient counseling. 41 Furthermore, students have reported increased confidence, 41 knowledge, 44 and engagement. 48 All of these outcomes have been assessed using various methods, such as rubrics, checklists, immediate feedback, and exams. 41 , 43–46 , 48

RP is considered one of the simplest simulation methods due to the ease of its application. It does not require many resources other than sufficient space, human resources, and sometimes money. However, training the faculty, students, or paid actors to play the role needed is time consuming. Furthermore, finding enough instructors is sometimes challenging when there are many students. 45 Language barriers have also been reported to be a drawback of this method, as it can result in a lack of understanding and fear of expression. 46 More details are presented about the advantages and disadvantages in Table 1 .

Simulation using RP should be implemented at all levels within the pharmacy curriculum, especially when teaching and practicing patient-care skills. Most RP simulations can be assessed using rubrics and immediate feedback.

Manikin-Based Simulation (MBS)

Manikins are classified according to their levels of physiologic function; the simulation replicates real life with low-fidelity, medium-fidelity, and high-fidelity mannequins. 7 Low fidelity refers to part-task trainers, static mannequins, or dolls. 49 Medium fidelity utilizes manikins or task trainers with limited physiological functions. 31 In contrast, high-fidelity mannequin simulators present a full-body mannequin that physiologically reacts like a “real” patient and has a voice based on computer programs. 31 Manikin-based simulations (MBSs) combined with other simulation types, such as SPs or RP, have been widely implemented in the pharmacy curriculum, especially in experiential training. 9 , 21 , 50

Implementations in the Pharmacy Curriculum

Several pharmacy schools have utilized and assessed MBSs in pharmacy curriculum in core and elective pharmacotherapy courses, 18 , 31 pharmacotherapy practice laboratories, 26 and certification programs, 33 in addition to mannequin-based simulator integration in IPPE and APPE. 21 , 33 Overall, MBSs have more frequently been used for advanced level pharmacy students. 26 , 32 , 34 This is expected, as pharmacotherapy courses and parallel laboratories are usually delivered at high pharmacy student levels. Moreover, many elective and certificate programs were built on preexisting knowledge from fundamental courses offered early in the pharmacy curriculum.

Nonetheless, most pharmacy schools have implemented MBSs in managing acutely ill patients with arrhythmia, decompensated heart failure, hypertensive crisis, or coronary syndrome. 15 , 18 , 51 Only a few schools have used MBSs in ambulatory care or non-acute settings, 33 , 52 as shown in Table 1 . Evidence has shown that implementing SBE using MBSs within the pharmacy curriculum has improved students’ learning, critical thinking, problem-solving, communication, clinical skills, 18 , 26 , 33 , 34 and information retention. 21 , 32 The use of mannequins in SBE can expose the students to high-risk and rare medical diseases. The benefit of MBSs has been evaluated through exams and OSCEs. 15 , 18 , 53–55 MBS has been shown to significantly benefit pharmacy learners through connecting didactic coursework with actual experiences. 26 , 33 , 34 However, it still has several drawbacks, as presented in Table 1 . Some major disadvantages include the extensive resources needed to apply such a simulation, including equipment, facilities, and advanced technical skills. 18 , 52 , 56 Moreover, the costs for resource acquisition, implementation, maintenance, and training are high. 53 MBS also may require many facilitators for a small group of learners, 53 , 56 is labor-intensive and requires extensive logistics and time for arrangement and preparation. 19 , 55 , 57

• MBS should be implemented as an active teaching method for high-level students within the pharmacy curriculum for acute and primary care situations, and formative or summative assessment methods should be used.

Computer-Based Simulation (CBS)

Advancements in technology have allowed pharmacy students to experience patient care without stepping into an actual pharmacy. Computer-based simulation (CBS) software and applications bring the experience into the classroom setting in an innovative and engaging manner. 57 , 58 Virtual reality (VR), also known as augmented reality, is a type of CBS where simulation software is utilized to aid pharmacy students in learning specialized tasks or situations. 59 , 60 It combines multimedia elements, such as audio, graphics, and animation, with textual information. VR simulation software mimics reality by modeling a clinical setting, outpatient/community pharmacy, or how to deal with a virtual patient. 6 , 61 Some examples of these simulation programs include Mydispense ® , Pharmacy Simulator, 36 , 49 DecisionSim™, and virtual patients software. 54 , 55

Many pharmacy colleges have applied VR simulation as a teaching method in various courses at different points of the pharmacy curriculum. 62–64 For instance, software programs such as Cyber Patient and Virtual Organ Bath have been used in pharmacokinetics and pharmacodynamics lectures. 62 This has led to higher learning and understanding when compared to traditional lecture-based teaching. 62 MyDispense, developed at Monash University, Australia, is another popular software program that simulates an authentic community pharmacy. 63 MyDispense software has been integrated into IPPE and therapeutic courses. 64 , 65 The use of such software has had positive effects on exam scores. 64 However, a randomized, parallel-group design was conducted at a private college of pharmacy to compare problem-based learning (PBL) and virtual simulated patient cases and found that the post-experience PBL scores were higher. 66 This suggests that a varied approach to simulated patient cases in education may lead to greater learning outcomes. 66

CBS offers many advantages in providing an adaptable, flexible, and accessible virtual pharmacy environment that maximizes the realism of actual patient-centered care at a low level of risk and relatively low cost compared to SP or manikins simulation. 57 , 58 It allows a high level of interactivity 57 , 67 and immediate feedback 49 , 57 , 58 and simultaneously caters to a large number of students. 58 , 61 Virtual patients’ demographic characteristics and comorbidities can be easily changed in virtual scenarios to follow the curricula and achieve the intended learning outcomes, as presented in Table 1 . 68 These learning outcomes include critical thinking, decision making, problem solving, communication skills, and information retention. 55 , 68 However, CBS still has its limitations related to the management of hardware and software, technical support, and unreliable internet connections, as presented in Table 1 .

Generally, published reports exploring the application of CBS in the pharmacy school curriculum are limited. However, the previous applications have been mainly used for higher-level students in comprehensive courses, therapeutic courses, and preparation before IPPE. Moreover, further studies are needed to assess the achievement of intended learning outcomes and integration into the curriculum.

CBS should be implemented in combination with other simulation techniques at all levels of the pharmacy curriculum along with pre and post-examinations and performance tests to help assess whether the desired learning outcomes have been achieved.

Serious Gaming (SG)

Serious gaming (SG) is a relatively new concept of teaching that incorporates simulation. 69 Even though SG itself is not a simulation modality, it encompasses simulation activities using play for problem solving instead of entertainment. 69 SG is designed for educational purposes rather than entertainment. 7 Within SG, real-world events or processes are simulated to solve problems. 7

Implementation in Pharmacy Curriculum

The 2013–2014 Academic Affairs Committee of the American Association of Colleges of Pharmacy (AACP) recommended that SG be incorporated in pharmacy education. 70 Faculty and student innovation in designing and implementing SG can be used to prepare future health care leaders. 70 As a result, the use of SG in pharmacy education has gained popularity in the past decade, particularly in in-patient simulations. Although most published research on gamification has aimed to assess student perceptions of these games, some have also assessed pre-and post-knowledge gain. For instance, the use of escape rooms resulted in a significant difference in knowledge and cognitive learning outcomes. 71–81 Escape rooms are a popular simulated gamification tool utilized in the enhancement of pharmacy student learning outcomes. 74 , 81 The rooms are used for groups or individuals who work to resolve several clues to “escape” simulated scenarios in a designated time frame. 76

Most researchers have described the utilization of simulated SG in the early years of pharmacy education, including the first, second, and third years. Simulated gamification can be implemented to help students examine various pharmacotherapy topics, including diabetes, 75 , 81 heart failure, 80 cancer, 78 toxicology, 73 non-sterile compounding, 74 geriatrics, 82 and others, such as disaster preparedness, 79 skill-based leadership, 76 opioid medication safety, medication history taking, 71 and APPE readiness. 77 Moreover, in past experiences, SG has proven to be impactful on students’ knowledge and learning experiences. 73 , 74

The apparent advantage of using SG is that students find it fun and engaging, 73–83 but these games also aim to build leadership, communication, problem-solving, and teamwork skills. 76 More details about the advantages, disadvantages, and essential resources for SG are presented in Table 1 . Several studies have highlighted the great potential of IPE using SG 67,68,72,74,76, and the remarkable adaptability of the game to use for any subject and in classes of any size. 71 , 75 , 77 , 81 However, these published studies lacked validity and reliability of the methods used since they mainly were pilot studies. 71–81 One of the drawbacks with SG was the fluctuating costs reported in these studies, which ranged from $0 to $400, and its dependence on available resources and funds. 74 , 75 , 77 , 79

Although positive outcomes have been reported, SG is still considered a relatively new concept to pharmacy educators and may require further studies to assess its use in simulation practice in the pharmacy curriculum. 83 SG helps build extracurricular skills such as leadership, communication, problem-solving, and teamwork.

SG should be incorporated into various courses and within different levels of pharmacy education. The use of pre- and post-knowledge assessments is mandated to test the validity of the SG implemented.

Hybrid Simulation

This describes the use of two or more simulation modalities in the same scenario to enhance the reality of the experience. 7 Primarily, this involves the use of MBS with supporting techniques to mimic real-life scenarios. These supporting methods include RP (involving another member of the health team or a caregiver), SPs, or CBS. Even though each of the mentioned simulation modalities has its advantages and disadvantages, the choice of the best SBE fit within the course depends on the desired learning outcomes.

Implications in the Pharmacy Curriculum

Numerous previous experiences in pharmacy education have involved the use of MBS with RP or SP. 21 , 74 , 84 Using hybrid SBE methods may be the best way to achieve the intended student learning outcomes. Hybrid simulation has proven to help students improve their knowledge, understanding, communication, and psychomotor skills. 19 , 21 , 34 , 54 , 55 , 84 However, its implementation may require extra resources, time, and workforce members. Previous reports have indicated the use of hybrid simulation in advanced pharmacy levels, including APPE. Various assessment methods have been used to evaluate student achievement, including summative and formative assessments, depending on the simulation modalities used and the intended learning outcome of the scenario.

Hybrid simulation is the best method to implement simulation scenarios to mimic real-world experiences for high-level pharmacy students and can be assessed using either summative or formative methods.

Future Recommendations About Patients-Simulation Implementation in the Pharmacy Curriculum

• Further studies are needed to assess the use of MBS within the pharmacy curriculum in non-acute care settings.
• Cost-effectiveness studies about patient simulation implementation within the pharmacy curriculum are needed given the high cost of some simulation methods.
• The integration of RP, SP, SG, and CBS should be explored for advanced pharmacotherapy courses, disease management, and care implementation within pharmacy school curricula.

Simulation Implemented in Interprofessional Education

IPE is defined as an experience involving two or more health care professionals who work collaboratively and learn from, with, and about each other to improve patient care. 85 This educational strategy has improved communication and the learning experience between pharmacy students and other health care professionals. The ACPE accreditation standards were establish to enforce the implementation of IPE in pharmacy curricula so that students can learn to be an active members of an interprofessional team. 16 The ACPE also encourages pharmacy schools to implement interprofessional simulation (sim-IPE) experiences and the utilization of simulation into IPE so that students can understand the scope of practice of team members. 16

The researchers who have previously applied sim-IPE for pharmacy students have mostly used hybrid simulations using human patients and MBS with SPs and/or RP. 20 , 86 , 87 They have demonstrated the possibility of enhancing students’ attitudes, teamwork skills, confidence, and communication with other healthcare professionals. 87–90 Most IPE experiences have involved high-level pharmacy students or APPE. 85 , 88–90 IPE primarily uses high-fidelity simulation within its activities to help students better understand the pharmacist’s role on the interdisciplinary team.

The major challenge in applying IPE within the pharmacy curriculum is finding the best course that fits its implementation and the arrangement with other health discipline schools. 87 , 90 In addition, IPE activities usually include a limited number of students in each session to achieve the desired outcomes. 87 Sim-IPE also carries the drawbacks of the types of simulation it utilizes, such as the need for resources, logistic arrangements, and extra cost. Thus, we suggest incorporating IPE within the pharmacotherapy laboratories of high-level pharmacy students, and advanced experiential training may be the best fit for IPE in the pharmacy curriculum.

Similar to traditional teaching methods, SBE has improved students’ knowledge, understanding, and numerous essential skills within undergraduate pharmacy education. This review highlights various modalities of simulation and their incorporation into pharmacy curricula. It can help pharmacy educators identify the best type and placement of integrating patient simulation within the pharmacy curriculum to achieve the intended student learning outcomes. The SBE method is crucial for developing skills (eg, teamwork, decision making, and communication) that are difficult to achieve by conventional methods.

Even though the ACPE acknowledged SBE benefits in IPE and IPPE, this article provides evidence that they are effective within all pharmacy curricula. Combining multiple simulation techniques may be the best way to achieve the desired student learning outcomes. Some gaps in the literature involving the use of SBE in pharmacy education have been identified and need to be further investigated in future studies.

Abbreviations

ACPE, Accreditation Council for Pharmacy Education; APPE, Advanced pharmacy practice experience; CBS, Computer-based simulation; COVID-19, Coronavirus 2019; CSAF, Communication Skills Assessment Form; IPE, Interprofessional education; Sim-IPE, Interprofessional simulation; IPPE, Introductory pharmacy practice experience; MBS, Manikin based simulators; OSCE, Objective Structured Clinical Examination; RP, Role-play; SBE, Simulation-based education; SP, Standardized patient; SG, Serious Gaming; SOAP, Subjective, Objective, Assessment, Plan; SWOC, Strengths, Weaknesses, Opportunities, Challenges.

The authors report no conflicts of interest in relation to this work.

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