Simulation Activities Improve Students’ Perceptions and Confidence

by Erica Claire Loden, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Ledbetter E, Lau S, Enterline A, Sibbitt B, and Chen AMH. A simulation activity to assess student pharmacists’ knowledge and perceptions of oncology pharmacy. Am J Pharm Educ 2019; 84: Article 7474.

I am a student pharmacist and very interested in pursuing a career as an oncology pharmacy specialist. This study grabbed my attention because many of my classmates are unaware that knowledge regarding oncological diseases and treatments is essential in all practice settings. The study analyzed students’ perceptions of the importance of pharmacists in the treatment of cancer and measured their confidence in answering oncology-related questions. This study is necessary because improving confidence and perceptions of oncology therapeutics may help fill the gaps in patient care needs across practice settings.

The instructional activity was implemented by faculty at Cedarville University College of Pharmacy.  The intervention was a two-hour class session during week 4 of a required 5-week oncology module. There were two cohorts of students: third-year pharmacy students in 2016 and 2017. The same activity was implemented in both years. The instructional activity involved four interactive stations involving simulations in a managed care, community pharmacy, a hospital that does not have a clinical pharmacy oncology specialist, and a hospital that does have a clinical pharmacy oncology specialist. Students were placed in pre-assigned groups and given 75 minutes to complete all four stations and a 30 minute debrief followed. At the first station, students used information from a cost-minimization research abstract to examine the cost and efficacy of an oncology medication to be considered for the formulary. At the second station, students made non-pharmacological recommendations to help a patient presenting with chemotherapy-related adverse effects. At the third station, students determined when to discontinue medications and when to restart them for a patient enrolled in an oncology clinical drug trial who presented for cancer-related surgery. Students also developed a communication plan for the surgical team for this patient. At the fourth station, students utilized compounding and calculation skills to verify four prescriptions. The same faculty member facilitated the activity each year for both cohorts and led the debrief sessions. A pre-activity and post-activity survey assessed perceptions and knowledge of oncology-related topics. The same 17 item survey instrument was administered on day 1 of the oncology module (pre-activity survey) and again after students completed the activity in week 4 (post-activity survey). The survey rated items on a seven-point Likert-type scale. The survey measured two concepts: the first nine items assessed students’ confidence in answering oncology-related questions. The remaining eight items evaluated the student’s perceptions based on their level of agreement with pharmacists’ involvement in oncology patient care.

The results show that students in both cohorts had significantly greater confidence answering all nine oncology-related questions following the instructional activity than they did at baseline (p<0.001). Student pharmacists’ perceptions of pharmacists’ roles improved post-activity for all questions except one regarding hospital pharmacists’ ability to answer oncology-related questions at institutions with a clinical oncology pharmacist. Increases in knowledge between the pre-survey and post-survey were similar in both cohorts.

Overall, this educational activity adheres to some of the best practices in instructional design. The pre- and post-activity assessments were created carefully by the module coordinator and by a faculty member with experience developing surveys. Additionally, the instructional activities were kept constant between both cohorts. The study found no difference in responses based on differences in ages, ethnicity, past oncology experience, or gender. However, there are several weaknesses and limitations to this study. The instructional design was incomplete. Learning objectives were unclear and difficult to measure. Students were all from the same school; therefore, the results are less likely to be generalizable to other institutions. There are also other variables that researchers failed to consider. The increase in confidence and perceptions could be due to students completing the other instructional activities during the course before taking the post-survey, rather than the two-hour activity. Future studies could give the survey immediately before and after the instructional activity to alleviate this attribution problem. This study only addressed perceptions and not knowledge or outcomes. Responder bias is a concern because students may have given favorable ratings based on a belief that favorable survey responses could have positively influenced grades. Future studies could include administering knowledge assessments before the activity and administering longitudinal assessments to determine the long-term impact on students’ knowledge and perceptions following the course.

In a similar study which surveyed students from five pharmacy schools in Florida, the investigators found that the majority of the pharmacy students surveyed (75%) were only moderately or not at all comfortable with the field of oncology¹. They concluded maximizing experiential opportunities for students could potentially close knowledge gaps and improve confidence levels. In both studies, researchers found a desire from students to increase experiential learning opportunities related to oncology pharmacy practice. A separate study conducted at the University of South Florida showed participation in an ovarian-cancer simulation improved students' oncology-related knowledge and their perceived understanding of the roles of oncology pharmacists.² This study used a similar study design in that it utilized pre-assessment and post-assessment surveys to assess students’ perceptions.

I believe further studies are needed to produce higher quality, generalizable results. I am unsure if this educational intervention would increase students’ desire to become an oncology pharmacist. The study did show that instruction about oncology pharmacotherapy increases students’ confidence in oncology but it’s not surprising that perceptions about pharmacists' roles in oncology practice would increase after these learning activities. Insights from the science of learning indicate that the brain is malleable and that learning is an experience-dependent process.³ In that way, the 4-stations were well-designed and offered students a range of simulated experiences that illustrate what pharmacists can do across several practice settings. Another study showed experiential learning is capable of improving students’ confidence and perceptions and that students desire more experiential learning opportunities.⁴  The implications are that the best instructional activities immerse students in rich, engaging tasks that can help them achieve a conceptual understanding. Therefore, it is my recommendation that educators balance lectures with a number of simulation and experiential activities to facilitate comprehension and skills development. These activities would be more successful if done multiple times during a module. Providing oncology pharmacy experiences across all pharmacy schools and developing awareness on the importance of knowledge and training in oncology practice will better prepare students to deliver high-quality patient care.

References

1. May P, Ladd J. Florida Pharmacy Students’ Perspectives on Careers in Oncology. J Hema Onc Pharm 2017; 7 (2): 69-75.
2. Serag-Bolos ES, Chudow M, Perkins J, Patel RV. Enhancing Student Knowledge Through a Comprehensive Oncology Simulation. Am J Pharm Educ. 2018; 82(3): Article 6245.
3. Cantor P, Osher D, Berg J, Steyer L, Rose T. Malleability, plasticity, and individuality: How children learn and develop in context. App Developmental Sci. 2018; 23 (4): 307-337
4. Darling-Hammond L, Flook L, Cook-Harvey C, Barron B, Osher D.Implications for educational practice of the science of learning and development. Appl Development Sci 2019; 24 (2): 97-140.

Group-based Education for Self-Management of Type 2 Diabetes Mellitus

by Olivia Husband, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Rygg LØ, Rise MB, Grønning K, Steinsbekk A. Efficacy of ongoing group based diabetes self-management education for patients with type 2 diabetes mellitus. A randomised controlled trial. Patient Education and Counseling. 2012 Jan;86(1):98–105.

Type 2 Diabetes Mellitus (T2DM) is one of the most prevalent disease states worldwide, and it is projected that the number of people diagnosed with T2DM will continue to increase over the next decade.¹ As a student pharmacist, T2DM is something I am interested in, not only because of its high prevalence but the impact a pharmacist can have on the management of people with T2DM. An integral component of T2DM treatment is patient self-care and management, including self-monitoring blood glucose and self-administering insulin injections. Patient education is crucial in ensuring that patients are getting the greatest benefit out of their diabetes treatment regimen. The authors of this study state there was very little evidence regarding the efficacy of local, group-based T2DM education.¹

This randomized controlled trial was conducted from May 2006 to November 2008 in central Norway. Participants were patients age 18 or older with a physician confirmed diagnosis of type 2 diabetes mellitus who had at least one general practitioner consultation within the previous three years.¹ There was no specific A1C requirement to enter the trial; however, patients who previously attended a diabetes education program in the past 12 months were excluded from the study.¹ Twenty general practitioners in the local area were asked to evaluate their patients to identify those who met the inclusion criteria for T2DM group education and then to mail out an invitation to participate in the diabetes management course.  Patients who accepted the invitation were then interviewed and randomized into one of two groups: the intervention group, which consisted of two cohorts, hospital 1 and hospital 2, and a control group.¹ The intervention group cohorts attended 15 hours of T2DM education delivered over three class sessions. The members of the control group were told they would be placed on a waiting list and would be offered the education program after one year.  Control group patients were instructed to continue their self-management practices.¹ The intervention received education about T2DM as well as nutrition taught by a diabetes nurse educator who had several years of experience. The education methods used included lectures, interactive skills training with activities, including blood glucose monitoring and problem-solving activities, and group discussion.¹ The primary outcomes of the study were changes in A1C (a measure of long-term blood glucose control) as well as patient response to a questionnaire that assessed their knowledge.  The outcomes were measured at baseline, at 6 months after the education program, and again at 1-year post-program.¹ The results were analyzed using both per protocol and intention to treat analysis.¹

There were no statistically significant differences between the intervention and control groups in regards to primary outcomes at 6 months.¹ But, after 1 year, the control group had a worsening of their A1C level from baseline of 0.3% while the intervention group maintained their baseline A1C (p=0.032).¹ All groups improved their diabetes knowledge after 12 months, but the patients in the intervention group significantly greater improvements in diabetes knowledge when compared to the control group.¹ The intervention group also had a higher level of treatment satisfaction at 6 months, but not at 12 months.¹ There was also a significant increase in the number of participants who avoided fatty foods and regularly self-monitored their blood glucose (p=0.027) among members of the intervention group.¹ Although the intervention group improved their knowledge of self-management of T2DM, their quality of life decreased from baseline over the course of 12 months (p=0.005).¹ This was not the case for the control group, as their quality of life scores remained unchanged when compared to baseline.¹ I think the decline in quality of life in the intervention group might be due to the more intensive monitoring and, ironically, with greater knowledge, more anxiety about the negative effects of diabetes.

Many of the participants in the study had a baseline A1C that was below the recommended treatment goal, and this is a major limitation of this study. To offset this limitation, a sub-group was performed for the subset of patients with an A1C greater than 7.7% at baseline.¹ These participants had poorer glycemic control at baseline, so they reaped the most benefit from the T2DM education program. One way the investigators could have prevented this limitation is to have a baseline A1C requirement for participants to enter the study. I think it is important to note the general decline in patient quality of life within the year following the education program perhaps due to more stress and anxiety related to the management of their T2DM. The program consisted of 15 hours of education across 3 sessions which are very long sessions and it’s hard to absorb that much information. This could have been avoided if the 15 hours was separated into more sessions. The sessions themselves seemed to use an effective combination of lectures, activities, and discussions, with breaks provided for participants.¹ I think overall, the methods of this study were appropriate because the investigators measured both glycemic control as well as patient knowledge after attending the classes.  However, I think they should have scheduled shorter sessions and perhaps included sessions about stress reduction strategies.

Several studies have analyzed the benefits of providing group-based type 2 diabetes management education and most have produced positive results. Participants saw an improvement in their glycemic control.  In one analysis patients were more likely to see improvement when the program was taught by a pharmacist rather than a different healthcare professional.² In most other studies, participants also saw an improvement in their overall quality of life, which was not seen in this study.^1-3 

This study shows that patient education about type 2 diabetes mellitus and self-care is an essential element of its management. This study reinforces the importance of patient education while providing insight on how to structure it. Learning how to manage a disease can be overwhelming, so it is important to address the stress and anxiety that can occur.

References

1. Rygg LØ, Rise MB, Grønning K, Steinsbekk A. Efficacy of ongoing group based diabetes self-management education for patients with type 2 diabetes mellitus. A randomised controlled trial. Patient Education and Counseling. 2012;86:98–105.
2. Mikhael EM, Hassali MA, Hussain SA. Effectiveness of diabetes self-management education programs for type 2 diabetes mellitus patients In middle east countries: A systematic review. Diabetes Metab Syndr Obes. 2020;13:117-138.
3. Kumah E, Sciolli G, Toraldo ML, Murante AM. The diabetes self-management education programs and their integration in the usual care: A systematic literature review. Health Policy 2018;122:866–77.