November 24, 2020

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.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.


  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.

No comments: