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]

Using Audience Response Systems

by Adrian Hui, Pharm.D., PGY1 Pharmacy Resident, MedStar Union Memorial Hospital

How many of you have used an audience response system? Please use your devices to select an answer. 
A.    Yes
B.    No
C.   Not sure
D.   What is an audience response system?

Many of you may be familiar with this scenario, commonly seen in classroom settings today.  With their increasingly widespread use, audience response systems have made their way into television game shows such as “Who Wants to be a Millionaire” where the audience can be polled to help the contestant answer a question.  If you are not familiar with the term “audience response system,” perhaps one of the following alternatives may ring a bell: personal response system, electronic voting system, or student response system.1

What exactly are “audience response systems (ARS)?”  ARS are tools used to quickly gather data from people participating in a poll.  ARS made their first appearance in the 1960s at Cornell and Stanford Universities2 but were costly, cumbersome, and frequently malfunctioned.1  Eventually, ARS became commercially available in the 1990s, and with several technological improvements (e.g. infrared capability, portability), it soon became widely used in various educational settings in the early 21st century.1  Nowadays, ARS are simple and easy to use.  They only require the following components:3
  • Presentation software (i.e., PowerPoint with Turning Point)
  • Hardware to transmit information (i.e., “clickers”, mobile computers, mobile phones)
  • Wireless receiver or Internet connection to a computer to receive the data

I first experienced ARS as an undergraduate student when I was required to purchase my first “clicker” for an introductory genetics class.  The device was about the size of a small TV remote and had buttons for the numbers 0-9, the letters A-J, and a few other miscellaneous functions.  We were required to bring the “clickers” to every class and use them to answer multiple choice quiz questions interspersed throughout the lectures.  Our answers on these “quizzes” counted towards 10% of our final grade.  This mode of learning was unlike anything I had ever experienced before, and although I initially felt apprehensive about ARS, I eventually came to appreciate its utility. 

There are several benefits to using ARS.  Once a question is posed, responses are anonymous and summarized graphically for the audience.  However, the instructor has the flexibility to track each individual response and can collect the data for a grade or to give credit for attendance.  Anonymity can have a positive impact on learning, often enhancing participation, engaging the students, and promoting greater interactions between the students and their peers/teachers.1  In fact, a study by Clauson et al.4 showed that 93.2% of pharmacy students appreciated the anonymity of ARS.  To gauge how well the students understand the material being covered in class, the instructor can use ARS intermittently throughout a lecture.  Based on the results, the instructor can determine whether it's appropriate to re-explain concepts more in-depth if the class seems to be struggling or continue on to the next topic.  Thus, ARS, if used effectively, can improve the quality of learning and provide both the instructor and students valuable feedback.  ARS may help improve test results as well.  In a study by Cain et al., final grades for a Physiological Chemistry and Molecular Biology (PCMB) II course in 2008 (using ARS) were significantly higher than those in previous years without ARS (p < 0.05 for 2008 vs 2007 and p < 0.001 for 2008 vs 2006).  Also, students taking PCMB II with ARS in 2008 had significantly higher final grades compared to when they took PCMB I the previous semester without ARS (p < 0.001).  Although this study has some limitations, the findings suggest that ARS may be a useful tool to improve student performance on exams.3  See Table 1 for a summary of the benefits of ARS.1

Table 1: Summary of ARS Benefits

Classroom environment benefits
Attendance: Students go to class more
Attention: Students are more focused in class
Anonymity: All students participate anonymously
Participation: Students participate with peers more in class to solve problems
Engagement: Students are more engaged in class
Learning benefits
Interaction: Students interact more with peers to discuss ideas
Discussion: Students actively discuss misconceptions to build knowledge
Contingent teaching: Instruction can be modified based on feedback
Learning performance: Learning performance increases as a result of using ARS
Quality of learning: Qualitative difference when learning with ARS (e.g., better explanations, thinking about important concepts, resolving misconceptions)
Assessment benefits
Feedback: Students and teachers like getting regular feedback on understanding
Formative: Assessment is done that improves student understanding and quality of teaching
Compare: Students compare their ARS responses to class responses
 Adapted from Kay et al (2009)1

Although ARS has some benefits, there are some challenges too.  From my experience, the “clickers” were a source of stress when students lost/forgot them or had technical difficulties.  This was especially the case when the “clickers” were used to answer quiz questions that counted toward a student’s grade or attendance.  Cain et al.3 found that the most common complaint about ARS (shared by 82% of pharmacy students) was the cost of the devices.  It should be noted, however, that some schools “cover” the cost of the devices and recirculate them to students in different classes.  But let’s face it, even when the school buys the devices to be shared by students, the cost of this technology is, in the end, bore by students in the form of tuition and fees.  Technical problems with ARS can also be frustrating for instructors that have integrated ARS questions into their lectures.  Furthermore, ARS may be a challenge for relatively inexperienced instructors unable to adapt their teaching to address unexpected responses from the students.  Developing ARS questions can be time consuming and takes skill and experience in order to create truly effective ones.  Effective questioning should not target simple recall of the material being presented but rather should cultivate conceptual, analytical, and problem solving skills.5  Such thoughtful questions are more likely to lead to enriching discussions and stimulate higher-level cognitive processes instead of serving as one-dimensional questions simply used to keep the student awake.  For a summary of the challenges with ARS, see Table 2.1

Table 2: Summary of ARS Challenges

Technology-based challenges
Bringing remotes: Students forgot/lost remotes and could not participate in class
ARS did not work: Remote devices did not function properly
Teacher-based challenges
Responding to student feedback: Less experienced teachers cannot adjust to student feedback
Coverage: Cover less course content if ARS is used
Developing questions: Time consuming to create ARS questions
Student-based challenges
New method: Students find it difficult to shift to a new way of learning
Discussion: Discussion leads to confusion or wasting time
Effort: Too much effort is required by students when using ARS
Summative assessment: Using ARS for tests may not be popular with students
Attendance for grades: Students do not like ARS used for monitoring attendance
Identifying students: Students want to remain anonymous
Negative feedback: Students feel bad when receiving negative feedback
 Adapted from Kay et al (2009)1

How can we optimize the use of ARS in the classroom?  Since our attention span often fades after about 20 minutes,1 one strategy is to provide ARS questions every 20 minutes to break up a lecture.  Along with using effective questions, a small incentive to increase participation and attendance may be helpful.  Using ARS responses for 5% of a student’s grade is sufficient to increase motivation and attendance.1  Lastly, although ARS may take away time to cover material, I would argue that ARS enables the instructor to explore concepts in greater depth and thus provides greater value in terms of student learning.  Overall, the benefits of ARS seem to outweigh its challenges, and several studies have shown that the majority of students favor its use in the classroom.  Yet, more research is needed to better understand the utility of ARS and to hone best practices.1 


1. Kay RH and LeSage A. Examining the benefits and challenges of using audience response systems: a review of the literature. Computers and Education. 2009; 53:819-27.

3. Cain J, Black EP, Rohr J. An audience response system strategy to improve student motivation, attention, and feedback. Am J Pharm Educ. 2009; 73(2): Article 21.

4. Clauson KA, Alkhateeb FM, Singh-Franco D. Concurrent use of anaudience response system at a multi-campus college of pharmacy. Am J Pharm Educ. 2012;76(1): Article 6.

5. Dangel HL and Wang CX. Student response systems in higher education: Moving beyond linear teaching and surface learning. Journal of Educational Technology Development and Exchange 2008; 1(1): 93-104.