PGY-1 Pharmacy Resident
Suburban Hospital Johns Hopkins Medicine
Pharmacists across the country are increasingly transitioning from a traditional role of dispensing medications from behind the counter to a more patient-focused clinical role. Clinical pharmacists are progressively serving as part of a team that provides bed side and emergency care to patients in hospitals and other clinical facilities. The nature of this clinical work is dynamic and stressful, and typically involves techniques and pharmacotherapy not widely covered by students in PharmD and Bachelor of Pharmacy curriculums.1 Simulation-based Learning (SBL) is a proven, innovative learning technique that mimics real-world scenarios allowing students to not only practice and improve their clinical knowledge and skills with no risk to a patient, but to also improve critical thinking and decision-making in high stakes environments. Simulation has been defined as: “an event or situation made to resemble clinical practice as closely as possible”.2 This method of teaching will enable pharmacy students across the country to improve both rudimentary and advanced skillsets and their own confidence in wide variety of clinical situations.
Currently, multiple forms of SBL are being utilized around the country in pharmacy education.3 These forms vary in technological complexity and differ mainly on the focus of which skill(s) are being emphasized by the specific training. One of the most advanced forms of SBL currently is the high-fidelity patient simulator mannequin.4 This form is most associated with simulation-based training in healthcare. These simulator mannequins are software-driven and load data to mimic human actions and physiology and respond accordingly to physiological and pharmacological interventions of students. Some mannequins are advanced enough to be disease specific (such as a cardiopulmonary simulator), while some are designed to simulate a variety of disease states.4 More, less-technically complex forms of SBL include the use of standardized patients. Standardized patients are live people who are portraying patients and all the associated medical history, emotions, and personality associated with medical patients in a clinical setting. Standardized patients are a very widely utilized form of simulation-based learning and are commonly used to develop students’ communication and intervention skills.2 The most complex and immersive form of SBL is the full environment simulation.4 It is the incorporation of high-fidelity mannequins, standardized patients, healthcare professionals, and other ancillary equipment to re-create a real-life clinical environment. This type of SBL is expensive and requires extensive planning to execute correctly. Therefore, full environment simulation is less common and is typically shared between multiple different healthcare education programs (i.e., nursing/PharmD/MD students) when implemented.5
Multiple pharmacy schools across the country have successfully implemented SBL into their core curriculum.2 At both the University of Pittsburgh and Rhode Island College of Pharmacy, simulation has been integrated into the pharmacology, therapeutic, and medicinal chemistry coursework. In both programs, PharmD students participate in the SBL laboratories alongside both nursing and medical students.5 Furthermore, University of Minnesota holds a yearly professional workshop for medical, nursing, public health, and pharmacy students called “Disaster-10” that reproduces a mass-casualty event at an office building using standardized patients and high-fidelity mannequins. The program’s objective is to assess the effectiveness of live simulations for teaching emergency response skills to students and professionals.6 This form of instructional design forces students to “think outside the box” and induces further knowledge recall by the learners based upon their experiences within the simulation. As technology progresses, these forms of instructional design become more feasible to implement into pharmacy school and medical professional programs.
A pilot study in nursing students assessed the outcomes of simulation on the clinical skills of the students and suggested that simulation-based teaching coupled with clinical experience led to an overall improvement in their clinical knowledge and recollection.7 Another study of found that the use of SBL in PharmD curriculum showed significant improvement of students’ clinical skills performance and increased their knowledge of the pharmacotherapy of hypertension. The students involved in the study also expressed high levels of satisfaction with this SBL type of learning experience.5
Unfortunately, some colleges and universities are experiencing pushback when inquiring about the possibility of substituting simulation for some aspects of Introductory Pharmacy Practice Experiences (IPPEs). This standard has precluded use of any simulation experience, regardless of the quality and nature of the simulation, as acceptable for IPPE credit. Some administrators of colleges and schools of pharmacy have argued that simulation should be considered an alternative for some portion of the required IPPEs, and most educators would agree that a student’s ability to learn and retain how to treat a patient with is best served by being involved with actual patients or via high-fidelity simulation versus shadowing a clinical preceptor.2
There are many clear advantages to SBL in pharmacy education: patient safety/quality, the ability to directly address gaps in clinical conditions and settings, a completely safe learning environment that poses no risk to patients or the learner, the ability to practice difficult skills and build confidence about complex procedures or pharmacotherapy. However, there are some disadvantages that critics of SBL have voiced as well. The most obvious being, simulation is not real life. Real human factors are not portrayed well in simulations as they are in the real world. Because of this, students’ take away from the simulation is dependent on how engaged they are and how willing they are to take the simulation seriously.7 From an instructional design perspective, it may be difficult to predict the students’ level of engagement. If a student is fully committed, they are likely to benefit from the simulation, but if the student thinks the simulation is unrealistic and are unengaged, their learning will be hampered, and the learning will be sub-optimal. Another key disadvantage to simulation-based learning is the large focus on specific skills or competencies. An SBL exercise using a blood pressure task trainer vastly improved PharmD students’ abilities to measure blood pressure but did little to none to develop their communication and assessment skills.5
Another key drawback to SBL is the cost of the equipment. High-fidelity simulators typically cost around $30,000 a piece, and require maintenance, training for educators, and technical support for the software inside them.4 The ability to provide real-time immediate feedback to the students based on their medical interventions is a great advantage of teaching using SBL, but to do so requires faculty resources to conduct simulations and assess the students.1 Much of the published literature in support of teaching via SBL is subjective. However, some studies have demonstrated that students who receive simulation training in combination with clinical experiential education exhibit better assessment and management skills than students who receive only one form of training.
Furthermore, the implementation of instructional design using simulation-based learning allows pharmacy school students to learn/retain the skills necessary to excel as pharmacists in clinical settings and has evidence to support this evolutionary form of teaching.
References:
1. Lavelle BA, McLaughlin JJ. Simulation-based education improves patient safety in Ambulatory Care. Agency for Healthcare Research and Quality. (Dr. LaVelle, formerly); HealthPartners Medical Groups and Clinics (Ms. McLaughlin). https://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-Lavelle_33.pdf. Accessed October 15, 2021.
2. Vyas D, Bray BS, Wilson MN. Use of simulation-based teaching methodologies in US colleges and Schools of Pharmacy. American Journal of Pharmaceutical Education. https://www.ajpe.org/content/77/3/53. Published April 12, 2013. Accessed October 14, 2021.
3. Cheema E. The need to introduce simulation-based teaching in pharmacy education in Saudi Arabia. Pharmacy (Basel, Switzerland). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163641/#:~:text=The%20use%20of%20simulation%20in,in%20sound%20clinical%20decision%2Dmaking. Published July 3, 2018. Accessed October 16, 2021.
4. Sarfati L, Ranchon F, Vantard N, et al. Human‐simulation‐based learning to prevent medication error: A systematic review. Wiley OnlineLibrary.https://onlinelibrary.wiley.com/doi/abs/10.1111/jep.12883. Published January 31, 2018. Accessed October 13, 2021.
5. Seybert AL, Barton CM. Simulation-based learning to teach blood pressure assessment to Doctor of Pharmacy Students. American journal of pharmaceutical education. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1913304/. Published June 15, 2007. Accessed October 15, 2021.
6. A simulation center for all of Minnesota and beyond! M Simulation. https://msimulation.umn.edu/. Published 2021. Accessed October 13, 2021.
7. Seybert AL, Kobulinsky LR, Mckaveney TP. Human patient simulation in a pharmacotherapy course. American journal of pharmaceutical education. https://pubmed.ncbi.nlm.nih.gov/18483603/. Published April 2008. Accessed October 13, 2021.
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