Continuing Education and Performance Evaluation: Essential Elements of Community Pharmacy Success

by Dewansia Sutton, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Grant M, Remines J, Nadpara P, Goode J. Impact of Live Training on Medication Errors in a Community-Based Pharmacy Setting. Innov Pharm. 2020;11(3): Article 11. https://doi.org/10.24926/iip.v11i3.3291

The Academy of Managed Care Pharmacy reports that medication errors affect at least 1.5 million people every year resulting in direct medical costs of at least $3.5 billion and result in significant morbidity and mortality.¹ I know that medication errors are a widespread problem, so I chose this study² because I was curious about the influence of training programs on the practice and whether they would be a beneficial addition to my future practice as a community pharmacist. This study assessed the benefit of live interactive training and also analyzed the impact of pharmacy prescription volume and the ratio of pharmacists to pharmacy technicians on the incidence of medication errors.

The study analyzed the incidence of medication errors at several Kroger pharmacies in one district before and after a live training program that addressed the most common types of medication errors reported in the previous six months. These errors occurred at reception, product dispensing, and during the final verification step. The topics of physical and mental fatigue, workplace cohesiveness, ways in which medication errors occur, strategies for mitigating errors, best practices for pharmacy workflow, and company policies and procedures were also addressed during a series of mini (8-minute) lectures. Following the lectures, teams of four consisting of both pharmacists and pharmacy technicians discussed examples of how they could improve their practice to reduce the occurrence of medication errors. These sessions were led by the same team of pharmacists on six occasions. Eighty pharmacists and 150 technicians from 20 different Kroger pharmacies completed the program. The pharmacies were classified as low, medium, or high volume based on their average number of prescriptions filled per week.

Comparisons of medication error occurrences before and after training and differences between the pharmacy categories were made. The ratios of pharmacists to certified pharmacy technicians and other demographic information was recorded. The results of the study are summarized in the tables below. There was a decrease in the number of errors overall and between the pharmacy classifications from pre and post-training but these differences were not statistically significant. The number of pharmacists and technicians based on pharmacy volume (low, medium, or high volume) was significantly different.  The authors concluded that the implementation of these live training programs helped streamline best practices and reiterate patient safety by focusing on medication error reduction.

Table 1: Pharmacy Characteristics

*Differences between groups p <0.01

Table 2:  Medication Error Rates at Baseline vs. Post-Training

This study is valuable because it highlights the fact that even in the most structured pharmacy practice systems, there is always room for improvement. It is also valuable because it shows the potential benefit of continuing education and analyzing medication error trends. I think more pharmacies should design programs similar to this one where pharmacists educate pharmacy technicians and other pharmacists on methods to decrease workplace fatigue and increase cohesiveness to decrease medication errors. The mean number of full-time pharmacists to certified technicians was 2:1 in low volume pharmacies and 2:2 in medium volume pharmacies. The mean number of errors in the medium volume pharmacies pre-live training was just over double the mean number of errors in the low volume pharmacies pre-training.  These results were interesting to me because they show that the number of pharmacists relative to pharmacy technicians may be an important factor in mitigating medication errors. It would be beneficial to employees and patients if the work environment was less stressful and had a smooth, structured workflow with a balanced workload. It is also valuable because it shows what difference can be made when the focus is put towards fixing systematic problems in the pharmacy instead of placing blame on individual employees.

A limitation of this study is the fact that it relied on the pharmacies to self-report the number of medication errors. Recall bias and underreporting of medication by pharmacies could give false confidence that the pharmacy made fewer errors after the training. It also failed to report a breakdown of the number of reported errors in each category before and after the training. This data would have been helpful to determine if the training is effective in minimizing a specific type of medication error. Another limitation is the fact that the pharmacies included in the study were all Kroger pharmacies and have similar policies and procedures.  Moreover, the pharmacists and technicians may not have had the freedom to make significant changes in the workflow or environment if it violated corporate policies. A sample including multiple chains and independent pharmacies would have provided a more accurate assessment of whether this training program leads to a reduction in medication errors and which kinds of practices benefit the most. A larger sample may have produced statistically significant results and more generalizable data. A longer observation period for data collection before and after the training would have increased the amount of data available to analyze and perhaps draw more precise conclusions. 

A similar study analyzed the impact of pharmacist-led training on the incidence of medication errors in an intensive care unit and post-surgical care unit.³ The educators in that program included a clinical pharmacist and a nurse.  The incidence of medication errors before and after the program, which included a lecture and ward-based hands-on instruction, remained high.  But the authors concluded that the program was effective because it changed the work environment to promote a safety culture. Another study published in the Journal of Pharmacy Technology evaluated the incidence of medication errors in the community pharmacy setting but collected data retrospectively.⁴ It attributed the number of reported medication errors to high prescription volumes and lack of adequate pharmacist coverage.  The authors concluded that increasing the number of pharmacists to accommodate the workload may help to minimize errors. The results of this study lead to a revision of pharmacy technician training requirements and certification in the state of New Hampshire. The results of these studies suggest that more work is needed to minimize medication errors and well-constructed training programs may be part of the solution.

Medication errors are expensive, harmful, and potentially deadly.  Live interactive training programs are a great method for delivering information.  I believe people are more likely to remember things when given the opportunity to interact with other participants and the instructor compared to when participants only hear or read about the material. More studies regarding the impact of live interactive training in community pharmacy are needed but the available data suggests they can make a difference in medication errors in pharmacy. Trial and error will be needed to figure out what elements are needed in the training sessions and whether periodic follow-up training should be implemented. Training sessions will also need to be adapted to fit different types and sizes of community pharmacies. Pharmacists should be aware of this study and similar studies so they can make informed decisions about employee training and different approaches to reduce medication errors. 

References:

1. Medication Errors. AMCP.org. https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/medication-errors. Published 2019.
2. Grant M, Remines J, Nadpara P, Goode J. Impact of Live Training on Medication Errors in a Community-Based Pharmacy Setting. Innov Pharm. 2020;11(3):11. doi:10.24926/iip.v11i3.3291
3. Nguyen H, Pham H, Vo D et al. The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study. BMJ Qual Saf. 2013;23(4):319-324. doi:10.1136/bmjqs-2013-002357
4. Pervanas H, Revell N, Alotaibi A. Evaluation of Medication Errors in Community Pharmacy Settings. Journal of Pharmacy Technology. 2015;32(2):71-74. doi:10.1177/8755122515617199

An Escape Room Activity for Preceptor Development

by Elizabeth Akers, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Richter LM, Frenzel JE. Design and Assessment of a Preceptor Development Escape Room. Am J Pharm Educ. Published online July 28, 2020: ajpe8073. doi:10.5688/ajpe8073

Learning is often informative but boring.  Or it can be entertaining.  But I think the best learning is both informative and fun! When learning is fun, it helps grab my attention and engages me in the topic.  That’s why a recent article published in the American Journal of Pharmaceutical Education got my attention. The investigators created an escape room activity for preceptor development. Escape rooms are a form of amusement where a group of participants works together to actively solve puzzles in order to “escape” confinement from a room. Applying escape room principles to health professions education allows learners to participate in life-like scenarios but in a low-stakes environment. They offer an opportunity to learn and change perspectives based on experience in a practice scenario. While this instructional strategy was initially used to provide instruction to student pharmacists, this study looked at changes in preceptor knowledge following participation in an escape room game.

When structuring this game, the investigator wanted to create an interactive, fast-paced, hands-on preceptor development program.¹ The intent of this hands-on experience was for participants to use the school’s preceptor handbook, locate and understand the School of Pharmacy’s mission and vision statement, use the pharmacist's patient care process (PPCP), and problem-solve a patient case. The escape room activity was offered on two separate occasions, one to preceptors at a district meeting of the North Dakota (ND) Pharmacists Association and at the ND annual pharmacy convention. Facilitators created a virtual escape room which consisted of five rooms, each with a puzzle.  The participants were given a total of 45 minutes to escape. To move from one puzzle to the next, the participants had to submit their answers using a Google Form. The Google Form would “unlock” the next puzzle when the correct answer was submitted and this directed them to move on to the next station in the room. Teams also received a PPCP passport to document their progression through the PPCP wheel. If a puzzle was solved incorrectly or the team ran into a roadblock, teams could write a preceptor pearl in exchange for a hint. Teams were instructed to be efficient.  The team that solved all of the puzzles in the shortest amount of time was considered the “winner.” After all of the teams had completed the game, the faculty facilitators debriefed to enforce the core concepts that were encountered during the experience.

To document the impact of the escape room method, the investigators asked participants to complete an electronic survey via Qualtrics immediately before and after the experience.  They collected demographic information about the preceptor’s practice experiences and administered a knowledge-based multiple-choice test about the PPCP and the school’s mission, and asked questions about the preceptor’s perceptions of the game. They analyzed the perception and knowledge questions using a paired t-test to determine if participation in the escape room lead to statistically significant improvements when compared to the baseline responses.

Preceptors (n=15) who participated in the escape room experience had statistically significant increases in their perceived abilities to locate and access the preceptor handbook and to describe and use the PPCP. Before the experience, only nine preceptors could correctly order the 5 steps of the PPCP.  Following the escape room activity, 13 preceptors were able to do so. On the other hand, preceptors were less likely to correctly answer the type of approach the PPCP uses. Of the preceptors participating, ten had previously participated in an escape room and all 15 participants stated they would recommend the experience to another preceptor. Preceptors indicated they were open to the gaming format and their preference for using various resources remained unchanged.¹

The methods used to perform and evaluate this study were appropriate. A strength of the study was the diverse group of preceptors (from different practice environments) and it was offered on two different occasions in different locations. The weaknesses of this study included a very small sample size and previous exposure to escape rooms. Some participants felt less inclined to contribute compared to others. This could be due to the size of the team or their attitudes towards other team members. The time constraint and pace of the game could have caused participants to miss information needed to answer the post-game questions. The post-survey was also completed with a limited amount of time; therefore, they could have rushed through and not provided errant responses. Participants who had no experience with escape rooms would likely be less efficient at solving the puzzles and this may have reduced their motivation to participate in gameplay. Based on previous work, the investigators also discovered many preceptors prefer online preceptor development programs over face-to-face programs.² This led researchers to believe an online escape room may be more appealing and draw in a larger number of participants.

Previous studies have examined the impact of escape rooms on educating student pharmacists.^3-5  The previous studies showed mixed effects on learning but participants generally had positive perceptions of the escape room format.^3-5 In one study, students performed poorly on the post-assessment test but reported a positive perception of the game.⁴ Another study found that while the escape room was an effective method for reinforcing course content, knowledge retention was poor.⁶ Similarly, the participants stated they had positive experiences and believed they would use institution-specific tools more often.

This study demonstrates that an escape room is an interesting and fun way to learn. An escape room might not be the most efficient way to learn and didactic instruction might still be needed.  Moreover, learners might miss some of the key concepts if the activity isn’t reinforced by debriefing afterward with the facilitator. Using game-like scenarios in an escape room provides an opportunity for learners to practice teamwork which is an important skill in health care today. 

References

1. Richter LM, Frenzel JE. Design and Assessment of a Preceptor Development Escape Room. Am J Pharm Educ. Published online July 28, 2020: ajpe8073. doi:10.5688/ajpe8073
2. Davison M, Medina MS, Ray NE. Preceptor preferences for participating in electronic preceptor development. Pharm Pract 2009;7(1):47-53.
3. Eukel HN, Frenzel JE, Cernusca D. Educational gaming for pharmacy students – design and evaluation of a diabetes- themed escape room. Am J Pharm Educ. 2017;81(7):6265.
4. Clauson A, Hahn L, Frame T, et al. An innovative escape room activity to assess student readiness for advanced pharmacy practice experiences (APPEs). Curr Pharm Teach Learn. 2019;11(7):723-728.
5. Kavanaugh R, George S, Lamberton N, Frenzel JE, Cernusca D, Eukel HN. Transferability of a diabetes escape room into an accelerated pharmacy program. Curr Pharm Teach Learn. 2020;12(6):709-715.
6. Nybo SE, Klepser SA, Klepser M. Design of a disaster preparedness escape room for first and second-year pharmacy students. Curr Pharm Teach Learn. 2020;12(6):716-723.

The Positive Effects of Promoting Mental Illness Stigma Awareness

by Amber Forsman, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Bamgbade BA, Ford KH, Barner JC. Impact of a Mental Illness Stigma Awareness Intervention on Pharmacy Student Attitudes and Knowledge. Am J Pharm Educ. 2016; 80(5): Article 80.

Mental illness has been part of recorded history dating back to 400 B.C. in Ancient Greece and described by the physician Hippocrates.¹  The societal stigma that frames the diagnosis of mental illness has varied over time and culture. Pharmacy students, just like other members of society, have been exposed to and influenced by such stigmas. But unlike other members of society, pharmacy students (indeed, all health professions in general) have a special obligation to provide patient-centered care to all individuals, including those with mental illness. Thus, programs that are intended to address misconceptions about and stigma related to mental illness are a critical component of health professions education.  The Impact of a Mental Illness Stigma Awareness Intervention on Pharmacy Student Attitudes and Knowledge is a study conducted at the University of Texas at Austin that provides evidence that a course on mental illness stigma awareness can make a difference by reducing mental health stigma and increasing mental health knowledge.²

In this pre-post study, a stigma awareness program was provided to Doctor of Pharmacy students on select mental illnesses — specifically depression and schizophrenia —over two class periods (2.5 hours total). Participants (n=120) were third-year student pharmacists who had previously completed the mental health pharmacotherapy module in the school’s curriculum.² The mental illness stigma awareness program was provided as part of a required pharmacoeconomics course, but the activity did not count toward the students’ grades in the course.² The stigma awareness program included videos on schizophrenia stereotypes, patient and provider testimony on the impact of stigma in healthcare practices, patient testimony on experiencing depression and schizophrenia, and a documentary of a patient refusing to be treated for schizophrenia.² After students watch each video, the instructors facilitated reflective discussions.² In addition, there were active learning exercises such as schizophrenic hallucination simulations and “Fact or Fiction” exercises. The videos, discussions, and active learning exercises were designed to target specific domains of mental health stigma (MHS): safety, social distance, separation, comfort, disclosure, and recovery. Participants completed anonymous surveys immediately before and after the program using identical instruments.² The pre and post-surveys included questions related to MHS subdomains: recovery, safety, disclosure, separation, and comfort.² Responses to most survey questions were based on a 5-point Likert scale [strongly disagree (1) to strongly agree (5)].² However, the MHS separation subdomain was measured using an 8-item Social Distance Scale and two additional questions derived from the primary literature.^2,3-5 The pre and post-survey also included ten true/false questions to determine the students’ mental health knowledge (MHK).² The MHS data were analyzed using paired t-tests to compare mean scores before and after the program.² The MHK true/false question data (based on answer correctness) was analyzed using McNemar’s tests to compare the accuracy of student’s answers before and after the program.² 

The pre-program survey revealed significant knowledge deficits among students who had already taken a pharmacotherapy module regarding the treatment of various mental illnesses (pre-test MHK mean score = 5.9/10).  Moreover, the MHS subdomain mean scores range of 1.8 to 3.4 suggested that many students have some level of stigma toward individuals with mental illness.²  After completing the program, post-program survey results found the MHK improved significantly and there was diminished stigma towards mental illness.²  See a summary of the study results in Table 1.

Table 1:  Summary of Study Results²

MHS	Overall stigma toward depression and schizophrenia decreased after the mental illness stigma awareness program
	Significant improvements in the (p<0.01) mental illness stigma occurred in the following subdomains: recovery, safety, separation, and comfort stigma.
	There was a significantly greater decrease in stigma subdomains: recovery and separation for schizophrenia when compared to the changes in the recovery and separate subdomains for depression
MHK	MHK significantly increased after the program, with the mean score improving from 5.9 to 6.8 (<0.01).
	Improvements in student knowledge related to pharmacy counseling, outcomes associated with mental illness, and symptomology of mental illness significantly increased (P<0.05)

One strength of this study was the data collection about the students’ personal (including family members) experience with mental illness. This data was valuable because personal experience could impact a student’s responses to the survey. Conversely, a weakness is the limited diversity of the population.  The intervention was conducted and assessed in only one group of students at a single pharmacy school, with only 88 participants completing both the pre and post-survey. In order to get a more precise picture of the benefits of this intervention, it will be necessary to repeat the program in multiple groups of pharmacy students at several schools across the nation, or even internationally. I believe that the methods used in this study were appropriate, especially because the program included several elements (videos, reflective discussion, and active learning exercises), and the survey instruments included validated questions that measure the intended constructs related to MHS.

Similar studies have been conducted at other pharmacy schools.   Consumer- led Mental Health Educations for Pharmacy Student⁶, A Mental Health Elective to Improve Pharmacy Students’ Perspectives on Mental Illness ⁷, and An Elective Psychiatric Course to Reduce Pharmacy Student’s Social Distance Toward People with Severe Mental Illness⁸ all came to a similar conclusion -  that stigma toward individuals with mental illness can be reduced when student pharmacists interact with patients with mental illness and provided instruction regarding mental health.^2,6-8

The fact that student’s biases and knowledge can be positively impacted through an educational program seems like common sense. However, instruction can take many forms and some strategies may be more effective than others.  What I have found in the components of this study and the comparable studies is that the instructional materials used attempt to humanize mental illness in contrast to the textbook-type (detached and unemotional) way pharmacy students most often learn about diseases. Additionally, this study provides evidence that using diverse and engaging materials such as videos, discussions, and active learning exercises can have a positive impact. Moreover, this study provides some helpful insight into how programs intended to address highly stigmatized disease states could be designed and implemented. I sincerely hope that the positive effects observed in this short intervention will positively impact the way these students communicate with and care for their future patients with mental illness.

References

1. WGBH Educational Foundation. Treatments for Mental Illness [Internet]. PBS. Public Broadcasting Service; [cited 2020Sep29].
2. Bamgbade BA, Ford KH, Barner JC. Impact of a Mental Illness Stigma Awareness Intervention on Pharmacy Student Attitudes and Knowledge. Am J Pharm Educ. 2016; 80(5):Article 80.
3. Corrigan PW, Green A, Lundin R, Kubiak MA, Penn DL. Familiarity With and Social Distance From People Who Have Serious Mental Illness. Psychiatric Services. 2001; 52(7): Pages 953–8. [Pub Med]
4. Penn DL, Guynan K, Daily T, Spaulding WD, Garbin CP, Sullivan M. Dispelling the Stigma of Schizophrenia: What Sort of Information Is Best? Schizophrenia Bulletin. 1994; 20(3): Pages 567–78.
5. Link BG, Cullen FT, Frank J, Wozniak JF. The Social Rejection of Former Mental Patients: Understanding Why Labels Matter. American Journal of Sociology. 1987; 92(6): Pages 1461–500.
6. O'Reilly CL, Bell JS, Chen TF. Consumer-led Mental Health Education for Pharmacy Students. Am J Pharm Educ. 2010; 74(9): Article 167.
7. Gable KN, Muhlstadt KL, Celio MA. A Mental Health Elective to Improve Pharmacy Students' Perspectives on Mental Illness. Am J Pharm Educ. 2011;75(2): Article 34.
8. Di Paula BA, Qian J, Mehdizadegan N, Simoni-Wastila L. An Elective Psychiatric Course to Reduce Pharmacy Students’ Social Distance Toward People With Severe Mental Illness. Am J Pharm Educ 2011;75(4): Article 72.

Engaging Students in a Videoconference Classroom

by Kassidy Voinche, PharmD, PGY-1 Community Pharmacy Resident, University of Mississippi School of Pharmacy

Teaching and learning have looked different over the past six months. Due to the need for social distancing during the COVID-19 pandemic, many schools have turned to virtual classrooms. Using video teleconferencing for live educational seminars is a great solution to keep everyone safe and to keep learning on track. Indeed, there are many technologies available that can help bridge the distance between students and teachers. However, teaching at a distance, either synchronously or asynchronously, presents several challenges for both the instructor and the learner. It can be difficult to engage students in discussions, group work, and in-class assignments when they are home with lots of potential distractions. Although there are inherent obstacles, with some extra tools, creative thinking, and problem-solving, the online classroom can become a place for engaged learning.

According to an article in Teach for America (TFA), creativity, clarity, and self-reflection are key to being a great teacher in the virtual classroom.¹ It’s essential, particularly in an online environment, to establish clear learning goals and objectives. With so much digital communication to keep up with, expectations need to be well-defined to ensure everyone is on the same page. Instructor feedback on assignments should be more thorough. It's helpful to reflect on student engagement, both in and out of class-time, using these questions from the TFA article, 7 Tips for Being a Great Virtual Teacher:

• What trends do I see in student participation? Possible causes?
• What am I learning about my students as participants in my virtual classroom?
• What could I do to make learning more accessible, inclusive, and meaningful?
• How are we, as a class, doing physically, mentally, and emotionally? ¹

Checking in with yourself and the students allows for adaptation. Investigate what works and what does not, listening to and recognizing what the students seem to be responding to well.

Combining offline, asynchronous activities with synchronous videoconferencing can improve participation.²  Create brief recorded videos or other learning activities for students to complete before class. Then, use class-time to summarize this content. Students can divide into breakout rooms for problem-based learning.  Ask students to create a Google doc to keep them accountable. Allow students some autonomy over assignments and encourage them to experiment.  This can lead to richer discussions. ² Asynchronous participation could include allowing students to view other students’ work and asking them to give feedback with guiding questions. This method promotes peer-to-peer accountability. 

Incorporating personality with a little humor and fun goes a long way when capturing student’s attention. The article Don't Turn into a Bot Online: Three Easy Strategies to Let Your Personality Shine in Your Online Course provides several tips on how to add a personal touch to your virtual classroom.³ Let some of your personality shine through! This can be done using humor or relatable stories. Humor can be tricky, but in small doses, effective. Searching online for a popular meme or gif to throw into a PowerPoint presentation can provide a light-hearted visual. ³ An Inside Higher Ed article suggests allowing students to create various fun content in the forms of memes or tweets to summarize the discoveries made in the session. Instructors can then open the next class meeting with some of their favorites to recap.⁴

Teaching to a virtual classroom where no student has their camera on can seem like talking to a wall. However, students with their camera off could be more engaged than you think.⁵ Indeed, engagement may even be enhanced when the teacher allows students to turn off cameras. Students can record their break-out group sessions with cameras off and turn in the recording.⁵ Providing a choice of camera usage enhances student agency. Another option is to build in ‘camera-off’ time during a class session for students to reflect independently. Without the camera’s constant gaze, students are not rushing to the next step to prevent the awkward silence.⁵ This method provides a specified amount of time for students to work and develop an answer, then share when everyone regroups.  It is always a good idea to check in with students to assess their personal needs and preferences, asking them how they can most effectively interact with the class and material.

The impact of widely used virtual classrooms on student progression and success is unknown at this time, but a study done in 2019 found that the impact may be minimal. Based on eight years’ worth of data from Wingate University School of Pharmacy, investigators found that distance learning via synchronous videoconferencing did not impact performance in a basic biological sciences course among professional degree pharmacy students.⁶ These findings are consistent with several similar studies conducted with various student populations. While using video conferencing for a majority of classes may seem daunting, with the right mindset, support, and tools, students can perform as well as when classes are conducted in-person.

There a few tools built into many videoconferencing applications to improve student engagement, like polls and whiteboards.  But you can combine these tools with countless other online tools. Kahoot, Flipgrid, and Poll Everywhere are a few examples of other applications that can be used to increase student participation. When choosing a platform or method, always consider accessibility. Reach out to students to determine which technologies they’ve had previous experience using and are most accessible. Inviting students to provide input about technologies that will be used in a course can build a connection between teacher and learner. Periodic reflection, by teachers and students, can improve the virtual classroom and generate new ideas on ways to engage. With some thought and resourcefulness, teaching can work just as well and, in some cases, even better in the virtual environment.

In summary, here are six tips for enhancing student engagement through distance learning:

1. Communicate clear, detailed learning objectives and expectations.
2. Combine asynchronous and synchronous learning methods.
3. Allow students to create fun content to summarize what they learned.
4. Survey students about how they best engage with the content and their preferences.
5. Reflect on which strategies are working and how to continue improving.
6. Use tools such as polling and collaboration platforms.

 

References:

1. The TFA Editorial Team. 7 Tips for Being a Great Virtual Teacher. Teach For America [Internet]. 2020 Mar 24.
2. Minero E. 8 Strategies to Improve Participation in Your Virtual Classroom. Edutopia [Internet]. 2020 Aug 21.
3. Evans J. Don't Turn into a Bot Online: Three Easy Strategies to Let Your Personality Shine in Your Online Course. Faculty Focus [Internet]. 2020 Sep 08.
4. Crook A, Crook T. 6 Tips for Teaching Online and In Person Simultaneously. Inside Higher Ed [Internet]. 2020 August 26.
5. Seltzer K. Engaging Students in Virtual Instruction With the Camera Off. Edutopia [Internet]. 2020 Sep 14.
6. Dirks-Naylor AJ, Baucom E. Impact of distance learning via synchronous videoconferencing on pharmacy student performance in a biological science course sequence: an 8-yr analysis. Adv Physiol Educ. 2019;43(4):534-536.