Abstract
Objective. To implement and evaluate a laboratory simulation for teaching difficult patient encounter skills to pharmacy students to improve their self-assessed communication abilities and skills in the affective domain.
Methods. Twelve simulation scenarios that represented difficult patient encounters in a variety of practice settings were developed. All students completed a self-assessment of their ability to communicate during difficult patient encounters before and after the simulations, and wrote a guided reflection afterward. The impact of the simulation was evaluated using quantitative and qualitative methodology. Three student cohorts were analyzed to determine whether significant change occurred in students’ self-perceived communication abilities. Thematic analysis of the qualitative reflection responses was performed.
Results. Over three years, three student cohorts of third-year professional students participated in the simulations (n=236). Students self-rated their ability to communicate on a 0-100 scale. Mean self-rating of ability prior to the simulation was 57.7 (SD=15.9) and after was 79.2 (SD=15.2). This mean difference of 21.5 points equates to an approximate 20% increase in self-rated ability. Variability in self-ratings between the cohorts was not significant. Qualitative analysis revealed that the simulation identified for student areas needing further development which in turn promoted self-awareness. Students expressed that learning in the safe, formative environment provided by the simulation contributed to their professional growth and was relevant to their future practice of pharmacy.
Conclusion. This simulation fills a gap in skills-based education, addresses the affective domain of the Accreditation Council for Pharmacy Education (ACPE) Standards, transfers easily to schools and colleges of pharmacy. This supports a call to action for pharmacy educators to provide purposeful opportunities for students to practice communicating with patients during difficult encounters.
INTRODUCTION
Pharmacists in all practice settings face difficult patient encounters. Patients may be in a hurry, angry about prescription drug costs, embarrassed about a personal symptom, or disagree with the plan of care. The pharmacist’s response during these moments may influence the patient and their medication self-management.1-3 Responding effectively requires professionalism, active listening, focused communication, empathy, and attention to each patient’s unique needs.3-5 However, pharmacists tend to feel inadequately prepared to respond to difficult situations. In a survey administered by Drug Topics, only 2% of respondents indicated that they received training to support difficult patient encounters during pharmacy school.6
The guiding standards for professional pharmacy education mandate teaching and assessment of affective domain skills such as self-awareness, patient advocacy, cultural sensitivity, and professionalism, which are necessary for communicating with and educating patients in difficult situations.7-9 Despite the importance of these “soft skills” to pharmacy practice, many schools and colleges of pharmacy find it challenging to teach and to assess affective skills. Moreover, the pharmacy education literature provides limited examples of teaching activities that equip students to effectively handle difficult patient encounters. One study described an interdisciplinary simulation consisting of pharmacy, nursing, and medical learners and their ability to engage in difficult conversations with standardized patients and human simulators.10 Another study provided schools of pharmacy with a framework for student communication towards mental health.11
Provider and nurse educators have implemented training in how to manage difficult patient encounters through didactic lectures and assessed students’ ability to manage these situations using simulations.12,13 Experts in medical education emphasize the need for the development of students’ self-awareness, preparedness, and positive interpersonal communication skills while focusing on the patient relationship rather than the disease in the encounter.14-16
Based on results reported in and lessons learned from existing literature, faculty at North Dakota State University School of Pharmacy created, implemented, and evaluated the effectiveness of a skills laboratory simulation related to the management of difficult patient encounters. The simulation was developed to provide students an opportunity to practice communicating with patients in difficult situations in order to improve their affective domain skills (eg, self-awareness, patient advocacy, cultural sensitivity, professionalism). The objective of this research was to develop a series of simulated difficult patient encounters and investigate their impact on pharmacy students’ self-reported ability and affective skills.
METHODS
A learning experience was created that included modeling of appropriate behaviors by a pharmacy faculty member followed by a simulation in which pharmacy students could practice their affective domain skills for managing difficult patient encounters in diverse practice settings. This simulation was delivered in the third professional (P3) year in a two-credit skills laboratory course. The course included a 50-minute didactic lecture and a two-hour laboratory session each week, with the class divided into four sections of 22 students each. The simulation provided 3.2 hours of introduction pharmacy practice experience (IPPE) based on actual clock hours that students devoted to the activity.
To provide context for the simulation, prior to the laboratory session, the lead faculty member modeled techniques to address various scenarios in real-time during two 50-minute didactic lectures (Article Supplement 1). Following each modeling session, the faculty held a debriefing session in which students were asked to discuss which skills and key techniques the pharmacist had used and areas for improvement. Students were not assessed on their understanding of the concepts presented in the modeling sessions as the objective was to immerse and engage them and provide an example of situations which may arise in practice. Articles were assigned as pre-readings to prepare students for the difficult scenarios that would be modeled (Article Supplement 1). After the didactic lectures, students participated in pairs in the difficult patient encounters activity during their laboratory sections. Twelve simulation scenarios represented difficult patient encounters in a variety of settings, including the community pharmacy, ambulatory care, emergency department, institutional pharmacy setting, and while in transition between care locations. Appendix 1 includes the educational objectives of each scenario and the associated Accreditation Council for Pharmacy Education (ACPE) Standards.
Each scenario consisted of three participant roles: an actor, a student facilitator, and a student pharmacist. Actors included personal acquaintances of course faculty members, retired health care professionals, PGY-1 residents, and graduate students. Actors in each scenario portrayed unique attributes that required students to respond using specific communication techniques, to call upon pharmacotherapy skills, and to employ soft skills from the affective domain. Scripted actors who were role-playing patients or caregivers were angry, embarrassed, worried, in pain, or hurried. Some were resistant to the plan of care or unwilling to take prescription medications. Others were overwhelmed, confused, or doubtful. One scenario included a provider who was demeaning and unhelpful regarding a concern about medication cost. Another scenario included a patient who needed a language translator and addressed cultural competencies. In a final example, a patient was scared and worried that they might have been a victim of a medication error.
Acting guidelines were provided to hired actors one week in advance of the simulation and included demographic information, current medical history, tips for demonstrating the assigned difficult attribute, response suggestions, and questions to ask the student pharmacist. The lead faculty member followed up with each actor via telephone or email to answer questions about the assigned case and demonstrated examples of how to act out the assigned case.
The 22 students in each laboratory session were divided randomly into pairs. Student pairs rotated through the stations at their own pace. The time spent at each station varied by case and student, so we had one more station than number of student pairs to allow flexibility. The average amount of time that a student pair spent at each station was 10 minutes. Each student in each pair was alternately assigned to the role of student pharmacist or student facilitator at each station. The course faculty provided prompts for the student pharmacists to introduce the basin scenario and a comprehensive key including topics of discussion for use following the encounter for the student facilitator. At the end of each scenario, the student facilitator asked the actor structured questions to stimulate formative feedback for the pharmacy students. An example of the materials provided for all three roles for one scenario is provided in Figure 1. All simulation materials are available in Article Supplement 2. All students participated in a faculty-led debriefing following the simulation.
Example Materials for a Scenario Included in this Simulation
Over three years, three student cohorts participated in the simulation (n=236). Using the course learning management system (LMS), all students completed a faculty-developed self-assessment of their ability to communicate during difficult conversations. Students self-rated their ability to communicate during difficult conversations on a 0-100 scale (0=poor, 100=exceeds expectations for a professional pharmacist). This self-assessment was a required part of the course and was completed immediately before and after the laboratory simulation. This 0-100 self-evaluation is a common component of reflective learning in the skills laboratory course. Cohorts were analyzed for variability using analysis of variance (ANOVA) and the Kruskal-Wallis test. The effect size was calculated with a Cohen d and significance of change in self-perceived ability was measured with a paired t test.
Following the simulation and post self-assessment, students also completed a guided reflection exercise through the course LMS. Students responded to the following prompts: “Reflect on your thinking, learning, and work today. What was most surprising to you? What are you most proud of?”
Three researchers conducted thematic analysis of the qualitative reflection responses. The research team analyzed the data using conventional content analysis, including an initial inductive approach and then a deductive analysis.14 Researchers first conducted memos to bracket their assumptions. Each then independently read through all three cohort responses. Each member of the research team coded half of the first cohort’s reflections, labeling key concepts or thoughts expressed by participants. All three researchers met to discuss findings, and 37 codes were identified initially. Similar codes were then consolidated via development of a consensus codebook that included agreed upon definitions to clarify code meaning. The consensus codebook guided two researchers in the analysis of the remaining cohorts’ reflections. An iterative process of coding and peer debriefing occurred until all three cohort reflections were fully coded. As is common practice in qualitative descriptive research, multiple codes were applied to a single response in some cases.15 For example, three codes (thinking on my feet, realism, and relevance to practice) were assigned to the student response, “I was most surprised on how good the actresses were at staying in character. They were able to bring up issues that we will have to deal with in future, and they were very good at keeping us on our toes.” During peer debriefing sessions, researchers identified student responses that best embodied each code and noted the number of responses linked to each code. For example, approximately 75 students across the three cohorts referred to “empathizing” (theme: listening and empathizing), and 65 students felt that the activity helped “reveal what I don’t know” (theme: gauging knowledge, skills, and behaviors). Codes were eventually grouped into categorical themes with corresponding illustrative quotations. Because the self-assessments and guided reflections were a part of the typical course procedure, the North Dakota State University IRB office considered the project exempt from review.
RESULTS
Of the three cohorts of students, 232 (98.3%) students provided complete responses to the self-assessment quantitative survey. The variability of responses between cohorts was tested. While some variability existed between cohorts prior to and after the simulation, which can be expected when comparing various groups of students, ANOVA and Kruskal-Wallis did not identify significant differences between the cohorts. Therefore, all three cohorts were evaluated together to determine overall changes in students’ pre- and post-intervention abilities.
Mean self-rating of ability to communicate during difficult conversations for the entire population (n=232) prior to the simulation was 57.7 (SD=15.9) and after was 79.2 (SD=15.2). This mean difference of 21.5 points (p<.001) equates to an approximate 20% increase in self-rated ability to communicate during difficult conversations. The effect size, as measured by Cohen d, is 1.42. Since this value exceeds 0.8, our Cohen d measure indicated a very large effect size.
All 232 students completed the guided reflection exercise. Qualitative analysis revealed themes related to students’ internal responses to as well as external experiences during the simulation, as illustrated in Appendix 2. Most students commented about how they grew in the affective domain of learning, which is related to attitudes, emotional responses, and communication techniques. Multiple students indicated feeling nervous and uncertain prior to the simulation. Lacking relevant work experience affected the degree to which students felt prepared, ie, a lack of work experience created the expectation that they would struggle during the simulation. Most of these same students praised the value of practicing having difficult conversations in pharmacy settings. Students who felt confident going into the simulation often indicated that their prior work experiences helped them in feeling comfortable with and prepared to handle difficult conversations.
Overall, students appreciated the realism of the simulation, commenting on the complexity of the scenarios as well as the actors’ abilities to portray “real life.” Students often discussed the need to think on their feet as they attempted to listen to the patient, recall prior knowledge, think critically, use resources, and incorporate soft skills to obtain positive outcomes. Many commented that actors in the scenarios were rude, rushed, and/or inattentive, which left students feeling thrown off and flustered and caused them to forget key information. Nevertheless, some of these students and many others were proud that they remained calm, quickly adapted to the situation, and effectively carried out patient-centered plans. Rather than simply describing how they delivered education about medications to patients, students discussed how they had to respond empathetically to the actors. Student responses indicated that the activity not only reinforced the importance of effectively communicating accurate and relevant information to patients but also the need to use therapeutic communication skills. Students reflected that empathy facilitated effective communication and outcomes. In this way, the most valuable learning experiences seemed related to growth in the affective domain.
Students found that the simulation gauged current knowledge and skills and revealed areas needing further development. Working through the scenarios, observing classmates, and receiving feedback from the actors helped students to recognize strengths and improvement opportunities. In particular, areas noted for improvement included remembering specific information, speaking more clearly and loudly, and communicating more empathetically. Most students seemed to appreciate these revelations and thought that continued practice would increase confidence and abilities, especially when encountering difficult conversations. Several students discussed how the safe, formative environment contributed to their growth. Overall, students expressed increased confidence and comfort in their abilities both during and after the simulation. Students noted the simulation scenarios were relevant to future professional pharmacy practice.
DISCUSSION
Pharmacy practice requires a pharmacist to engage in a variety of patient encounters, some of which may be difficult to manage, especially if they have not undergone training in this area. Pharmacy education accrediting bodies mandate that students demonstrate affective-learning outcomes.3 However, the literature offers few examples of learning strategies to facilitate these outcomes. To address this gap in pharmacy education, this simulation focused on targeting the pharmacist-patient relationship using guided student learning.
The findings of this study align with other health professions literature related to difficult encounters simulations. A short training seminar for medical residents on how to handle difficult patients showed a positive learning experience noted by participants, emphasizing confidence, satisfaction, and acquisition of new knowledge.16 Pharmacy learners who have engaged in activities intended to prepare them to manage difficult patient encounters have noted that these activities were effective in preparing them for future practice.10 Other studies in health professions education have shown that simulations of difficult encounters resulted in student self-assessment scores similar to performance scores given by faculty or actors.16,17 As noted in our findings, qualitative collection of debriefing and reflective responses provides a valuable assessment of student readiness and perception.10,16
The learning format summarized in this study afforded students the opportunity to participate in 12 different difficult patient scenarios. Students’ quantitative and qualitative responses regarding the simulation support the usefulness of this learning method in improving student communication and patient education abilities as well as describe how the educational design supports student learning. Results from student self-assessments illustrate that this simulation was valuable in developing students’ affective domain and in increasing their ability to communicate during difficult conversations. Student reflections indicated a decrease in nervousness or hesitancy and growth in both self-awareness and confidence when presented with difficult patient encounters. Further, students acknowledged the authenticity provided by the actors in simulating real-life scenarios that necessitated students’ use of critical thinking and the affective domain to produce optimal outcomes. In summary, the methods used and results found in there were consistent with those of previously reported studies in the health sciences literature.
The simulation demands few faculty resources, transfers easily to other schools, and has the potential to meet accreditation expectations of pharmacy schools across the country. This simulation is easily transferrable to other institutions. The entire simulation, including acting scripts, facilitator guides, student pharmacist prompts, and patient case artifacts are available here for download as article supplements to encourage seamless transferability to all interested readers. Article Supplement 1 includes the didactic modeling cases in a PowerPoint file and Article Supplement 2 includes facilitator, actor, and student pharmacist materials for all 12 scenarios. One faculty facilitator is needed along with actors for each station. Out-of-laboratory grading time is not required as real-time formative feedback is provided by the actors.
This study has some limitations. Student reflections were part of the course curricula, and students knew they would be read by the faculty; thus, student responses may have been influenced by social desirability. Summative evaluations were not conducted, so gains in students’ skills and/or knowledge could not be measured quantitatively. The preliminary data of student self-efficacy supports the continuation of similar activities but does not necessarily demonstrate student competence or causality. Additionally, self-rating of soft skills does not always predict performance, though the provision of feedback and improvement strategies may support more accurate self-ratings.18
CONCLUSION
Pharmacists face unique challenges in responding to the needs of patients during difficult conversations; however, few pharmacists receive the necessary education, practice, and feedback to develop these skills. It is incumbent on pharmacy faculty to incorporate soft skills training in their curricula. The simulation described here fills a gap in skills-based education, addresses the affective domain as described in the ACPE Standards, transfers easily across schools, and demonstrates significant quantitative and qualitative findings. The results of this study showed a significant increase in student confidence to communicate during difficult conversations and suggested student gains in their ability to “think on their feet” and development of affective domain skills such as empathy to achieve positive patient outcomes.
ACKNOWLEDGMENTS
The authors acknowledge Drs. Amy Drummond, Jeanne Frenzel, and Elizabeth Skoy for their support of implementation of this learning activity within the laboratory course. Thanks to Ally Bakken, PharmD, for her contribution to the qualitative analysis of this study.
Appendix
Scenarios of Difficult Encounters in Various Pharmacy Settings Used to Prepare Pharmacy Students for Practice
Appendix
Qualitative Themes and Associated Illustrative Quotes
- Received August 2, 2020.
- Accepted January 8, 2021.
- © 2021 American Association of Colleges of Pharmacy
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