November 12, 2012

Simulating Experiences in Pharmacy Education

By Xiaoxue Nehrbass, Pharm.D., PGY1 Pharmacy Resident, Johns Hopkins Bayview Medical Center

What is simulation? According to the Accreditation Council for Pharmacy Education (ACPE), simulation is an activity or event replicating pharmacy practice.1 Simulation experiences may include the use of high- or medium-fidelity manikins, standardized patients, standardized colleagues, role play, and computer-based exercises.1  Benefits of these experiences may include enhancements in student knowledge and clinical performance, improvements in critical thinking and student confidence, as well as reductions in medication errors.2 In the latest version of its Accreditation Standards and Guidelines, ACPE states that colleges and schools of pharmacy may choose to incorporate simulation into introductory pharmacy practice experiences (IPPEs) but it can not exceed 20% (60 hours) of the total IPPE requirement (300 hours).1

In April of 2011, watching the first Inter-professional Critical Care Simulation that took place at Universities at Shady Grove, I was impressed by how high-fidelity simulation technology brought the health professional disciplines on our campus together.  I learned first-hand the importance of interdisciplinary collaboration in a healthcare setting to optimize patient care. High-fidelity simulation has been widely used in other health professional schools, such as medical and nursing education. The high-fidelity manikin mimics a real patient with computerized programmable physiological responses to disease states and medication treatments.2 Similar to a real patient, the manikin can talk and breathe, has heart sounds and palpable pulses.  Simulations can include cardiac and pulmonary arrest, anaphylactic reactions, myocardial infarction, stroke and other scenarios.2 In one recent study, a group of fourth-year pharmacy students (in a five year program) used high-fidelity simulation in a series of courses.3 The scenarios included various exercises such as drug-drug interactions, intravenous drip rate calculations, medication recommendation, physiological changes, as well as patient education.3 In addition to the patient (manikin) and pharmacy students, these scenarios also included role plays with physicians, nurses, and family members. Interestingly, the role of family member was played by a standardized patient, who displayed certain emotional responses during the simulation in response to the care provided to patient (manikin). The study showed that when compared to students who did not participate in the simulations, students who experienced the simulations felt more confident in making recommendations to other healthcare providers.3 Additionally, over ninety percent of students reported that simulation enhanced their learning compared to didactic lecture alone.3 As this study has shown, high-fidelity simulations can help to enhance clinical knowledge in various acute care scenarios, improve communication skills and build confidence.  But high-fidelity manikins aren’t cheap!  The cost can range from $16,000 to $90,000 depending on the model.2

Computer-based virtual patient technology offers another type of simulation experience. At the end of the ACLS/BLS training program I completed a few months ago, online simulation technology allowed me to practice the skills and knowledge I had learned, and to make assessments and decisions in a virtual environment. I valued the simulation component of the program because it allowed me to use newly acquired knowledge to create solutions during plausible situations. Throughout each simulation scenario, I learned quickly what I did wrong and the potential (positive or negative) consequences my decisions may have had on my virtual patient. According Jabbur-Lopes and colleagues, one advantage of using virtual patients in patient counseling is that a virtual patient can exhibit various psychological states, such as angry, anxiety, ambivalence, passivity, assertiveness, and persuasiveness.4 Through the use of virtual patient technology, students can practice counseling skills with a wide range of patients. Despite these benefits, Jabbur-Lopes and colleagues found that this type of simulation is underutilized in pharmacy education.4

For me, the most realistic patient counseling simulation experiences were my encounters with standardized patients. As actors who have been trained to play the role of real patients in specific scenarios, standardized patients not only perform, but in many cases, evaluate the student’s interviewing skills during the counseling session. My personal encounter with standardized patients came during the University of Maryland’s required Objective Structure Clinical Exam (OSCE), a comprehensive assessment that required students to use a wide range of knowledge and skills learned throughout pharmacy school. The counseling sessions were taped and standardized patients evaluated our performance.

To best serve students, programs must evaluate each type of simulation for its strengths and weaknesses. High-fidelity simulation may be an effective teaching tool in an urgent care scenario occurring in the acute care setting. It allows participants to enhance interpersonal skills through team building exercises. The high costs of this simulation tool may, however, be a barrier at some institutions. In addition, it may not be appropriate or efficient to use high-fidelity simulation in less acute situations which do not require close monitoring of the patient, such as counseling on management of chronic disease states. On the other hand, virtual patient technology offers an advantage of accessibility and convenience. It also provides hands-on experience students may need when learning a complicated concept or procedure. Finally, standardized patients may be most beneficial when used in assessing students’ interviewing skills and clinical knowledge. This experience will also prepare them to enter the profession and face real world situations.

With the continued expansion of pharmacy schools and ACPE’s increased acceptance of simulation has part of the IPPEs, simulation experiences should play a larger role in pharmacy education.  Using these types of teaching tools helps students gain the skills and confidence to enter advance pharmacy practice experiences.  Simulations are an innovative and effective way of providing training in an evolving academic landscape.

1.  Accreditation Council for Pharmacy Education. Accreditationstandards and guidelines for the professional program in pharmacy leading tothe doctor of pharmacy degree. Chicago: Accreditation Council for Pharmacy Education; 2011. [cited 2012 Oct 29]
2.  Seybert AL. Patient simulation in pharmacy education. Am J Pharm Educ 2011; 75(9): Article 187. [cited 2012 Oct 29]
3.  Vyas D, Wombwell E, Russell E et al. High-fidelitypatient simulation series to supplement introductory pharmacy practice experiences. Am J Pharm Educ 2010; 74(9): Article 169. [cited 2012 Oct 29]
4.    Jabbur-Lopes MO, Mesquita AR, Silva LM et al. Virtual patientsin pharmacy education. Am J Pharm Educ 2012; 76(5): Article 92. [cited 2012 Oct 29]

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