Keywords: self-care, pharmacy education, non-prescription medications, flipped classroom, curriculum
Conflicts of Interest: The authors have no conflicts of interest to report.
Objective: The objective of this study was to compare student learning outcomes, behaviors, and attitudes in a non-prescription drug and self-care therapeutics course taught in the second professional (P2) year versus the first professional (P1) year at one pharmacy school.
Methods: Mean performance of students by class year on case consultations and exam scores were compared. Focus groups with student volunteers and course teaching assistants (TAs) and one-on-one interviews with a subset of instructors were conducted by an outside educational evaluation specialist to capture perceptions of student learning behaviors and attitudes.
Results: There was no difference in performance on graded case consultations (mean difference 0.16, p=0.74, 95% CI [-0.77 – 1.09]), mid-term examinations (mean difference 0.53, p=0.62, 95% CI [-1.59 – 2.65]), or final examinations (mean difference 0.73, p=0.57, 95% CI [-1.83 – 3.30]) between P1 and P2 students. P1 students reported being more consistent in completing pre-class readings and in feeling less distracted by other courses than did P2 students. Students, TAs, and instructors consistently spoke about advantages of the course in the P1 year (e.g., less stress, greater eagerness to learn and apply skills at work) and disadvantages in the P2 year (e.g., distraction from concurrent P2 integrated pharmacotherapeutics course, tension between real-world experience and constraints of grading rubric).
Conclusion: Despite taking the course one year earlier than P2 students, P1 students performed equally as well. All stakeholders agree that the advantages of teaching a self-care course on students’ learning behaviors and attitudes in the P1 year outweigh disadvantages.
Patient self-care education is fundamental to pharmacy practice and included in the core pedagogy in pharmacy education.1-2 In 2006, the Nonprescription Medicines Academy issued recommendations to include a minimum of 60 contact hours of self-care instruction within the pharmacy curriculum and stated that a majority of the instruction should occur within a standalone course.3 Despite these recommendations, there is substantial variability in self-care education delivered by colleges of pharmacy across the United States.4 Some colleges require a standalone self-care course and others integrate content into other courses, labs, or experiential education.4 A number of colleges that do not require a standalone course instead offer electives in this topic area.4 Data about timing of self-care courses within the pharmacy curriculum are limited. Recommendations from the Nonprescription Medicines Academy highlight arguments for teaching this content earlier versus later in the curriculum. They note that placing the course in the first professional (P1) year allows for earlier application of pharmacy content and enhances professional development whereas placing it in the third professional (P3) year allows for more in-depth discussion of the pharmacotherapeutics of non-prescription drug therapy.3 To our knowledge, no studies have been published that explicitly address issues related to optimal timing of self-care courses in the curriculum.
The University of Utah College of Pharmacy has included a standalone three credit hour non-prescription drug and self-care therapeutics course since 1989. The course currently utilizes a modified flipped classroom model involving numerous co-instructors and guest lecturers.5 Within this model, students complete a number of required readings related to a self-care topic prior to attending two class sessions per week (1.5 hours per class session). During each class session, the instructor utilizes a series of case vignettes. For each case vignette, the instructor randomly selects a student to perform a self-care consultation role play in which the student is expected to follow a structured framework such as QuEST/SCHOLAR-MAC to assess the patient (played by the instructor) and provide a self-care recommendation.6 Following completion of the simulated consultation, there is a class discussion about the case and key learning points. This discussion facilitates learning and formative assessment. Students are required to complete at least three self-care consultations over the course of the semester. Additional summative assessment tools utilized in this course include two individual written assignments, two multiple-choice exams, and an oral final exam.
This course was taught during the P3 year from 1989 until 2016 and during the second professional (P2) year from 2016 until 2019. Based on feedback from students, faculty, and staff, a need to more evenly distribute curriculum workload during the P1 and P2 years was identified. As a result, the decision was made to transition the Community Practice (non-prescription drug and self-care therapeutics) course from Spring semester of the P2 year to Spring semester of the P1 year. The Pharmacokinetics and Pharmacodynamics course was moved from the P1 year to the P2 year to allow for this transition. As a result, the course was simultaneously taught to 53 P1 and 58 P2 students (one P2 student withdrew midway through the semester) during the 2020 Spring semester, using the same instructors, pre-class readings, cases, and assessments for both professional years. Teaching assistants (TAs) were different for each course, but drawn from the same pool of P3 student volunteers. P1 students also received an additional 15 minutes each week practicing a self-care consultation case as part of their Recitation course. Other than these noted differences, the courses were the same for the P1 and P2 students (Table 1).
Three weeks after the first mid-term exam (about 40% through the course duration), the COVID-19 global pandemic required in-class learning to be replaced by asynchronous on-line lectures. While the course content covered in each online session remained the same as the content scheduled for the in-class session, the case consultations were moved to separately scheduled times for randomly selected students and were conducted telephonically. Given the unprecedented circumstances, assessment and grading required modification, which included reducing the number of required case consultations to two, making the final multiple-choice exam open-book/open-note, and cancelling the oral final exam.
In this study, we sought to answer the following questions:
- Will moving the Self-Care course to the P1 year, negatively impact student performance on graded self-care consultations or scores on multiple choice mid-term or final exams?
This question stems from our assumption that P2 students taking this course have completed an additional year of the pharmacy curriculum and participated in one semester of the integrated pharmacotherapeutics course series; and, as a result, P2 students may have acquired a stronger base of therapeutics knowledge and exposure to more clinical problem-solving than P1 students. This increased knowledge may positively impact their ability to acquire self-care therapeutics knowledge and confidently engage with a patient to provide advanced non-prescription consultations.
- Will moving the course to P1 year impact students’ learning behaviors, such as course preparation, and engagement in class?
This question stems from our assumption that P2 students have more experience in a professional program and therefore may have developed better study habits which could result in better preparation for class. On the other hand, P2 students may have less time to dedicate to this self-care course given the competing demands of other rigorous courses taken concurrently, particularly the integrated therapeutics course.
- Will moving the course to P1 year impact stakeholder (student, instructor, and TA) attitudes about the relative advantages and disadvantages of when the course is taught on students learning to be a competent pharmacist?
This question stems from our assumption that attitudes are different from performance and learning behaviors and may be differentially influenced by the placement of the course. A priori anecdotal feedback suggested that students would prefer the course in P1 year because the workload is lighter and because many students begin working in outpatient settings starting in the first year and would value having the formal training to work with patients in these settings.
Material and Methods
A mixed-methods approach was utilized to answer the three study questions. To answer question one, the mean and standard deviation of case consultation and exam scores were compared for P1 and P2 students using two-tailed t-tests. To answer questions two and three, an educational evaluation team from the University of Utah School of Medicine conducted virtual interviews with course instructors and led focus groups with students and course TAs. Responses to end-of-course evaluations were also compared to answer question three.
Case Consultation and Multiple-Choice Exam Scores
A total of 53 P1 students and 58 P2 students completed the mid-term exam, final exam, and at least two case consultations. The mid-term exam consisted of 54 multiple-choice questions and students were not permitted to utilize resources such as course handouts or reference materials. The final exam was open-book/open-note and consisted of 61 multiple-choice questions. Both exams were administered via ExamSoft. Each self-care consultation was graded by the coursemaster and at least two other graders, comprising faculty members or TAs, using the same grading rubric. The grade was calculated by averaging the grader assessments. Since the number of required self-care consultations was reduced to two, some students completed two and others completed three. The total self-care consultation grade was calculated by averaging the scores for the total number of consultations completed (2 or 3).
Student and TA Focus Groups
Separate in-person focus groups were held with P1 and P2 students a few days after the midterm exam. All students enrolled in the course were invited via communication through the electronic learning management system (LMS). Participation was optional and lunch was served as an incentive. Five P1 students and one P2 student participated and the same structured protocol of questions guided both groups (Table 2). After the final exam, separate virtual focus group were held via Zoom with P1 and P2 students who had not participated in the midterm focus group. Recruitment information was again sent through the electronic LMS and students were incentivized with a $10 gift certificate for participation. Six P1 students and five P2 students participated in the final focus group and a structured protocol of questions modified from the midterm focus group was utilized (Table 2). One face-to-face focus group was held with TAs from both the P1 and P2 course together, over lunch, shortly after the midterm student focus groups. Two TAs from the P1 course and three TAs from the P2 course participated and a structured protocol of questions was used to solicit the TA’s perspective of students’ learning behavior and attitudes across the two years (Table 2). The educational evaluators took detailed notes during each of the focus groups, which they analyzed and shared with other members of the study team. Their analysis consisted of deductive review of focus group notes, looking specifically for answers to study questions two and three.7
In the weeks following the mid-term exam, four 20-30-minute interviews were conducted with course instructors. This included 2 faculty members and 2 adjunct faculty members. A structured protocol of questions (Table 2) specifically designed to answer study questions two and three was utilized to conduct the interviews. Members of the educational evaluation team took detailed notes during the interviews analyzed the data utilizing a deductive review to look specifically for answers to study questions two and three.
The same anonymous end-of-course evaluation was assigned to P1 and P2 students and they were incentivized to complete it with 5 extra credit points towards their final course grade. Evaluations were completed by 90.6% (48/53) of P1 students and 79.3% (46/58) of P2 students. In addition to 15 closed questions using a 6-point Likert scale (e.g., strongly disagree=1, disagree=2, mildly disagree=3, mildly agree=4, agree=5, strongly agree=6), the evaluation also included two short-answer questions. Averages on the closed questions and type of and frequency of comments on open ended questions were compared between classes.
There was no difference in performance on graded case consultations or mid-term and final examinations between P1 and P2 students (Table 3).
Preparation. Notes from interviews and focus groups indicated that P1 students spent more time preparing for class than P2 students. One course instructor noted that preparation for the first year was higher as they are more ambitious whereas P2 students have other difficult classes to prepare for. P2 students also indicated that they often divided up pre-class readings and shared notes with one another to reduce the amount of time needed to prepare for class.
Class Engagement. P1 students were also noted to be more engaged during class than P2 students. One instructor noted that P1 students were more attentive and talkative during class whereas P2 students appeared to be more focused on obtaining points needed to achieve a desired grade than on actually learning and processing the material.
Analysis of focus group and interview notes revealed that students, instructors, and TAs consistently recommended the course be taught in the P1 year. Each stakeholder group identified numerous advantages to offering the course earlier in the curriculum.
More opportunity to apply content. It was noted that including the course in the P1 year provides students with more opportunity to apply course material at their internships and experiential education sites. P1 students expressed satisfaction with using information and skills they learned in this course at their job sites and in conversations with family members.
P1 students prioritized course. This course was prioritized higher than other concurrent classes by P1 students and therefore prompted them to dedicate a significant amount of time towards studying. One P1 student stated the course was the most important class in year 1 of pharmacy, so they dedicate a lot more time to preparation for the class. A TA also noted the course is the hardest thing P1 students will do and they will need to take time to study in order to achieve a high grade.
Disadvantages of course in year 2. Stakeholders also identified disadvantages to offering the course during the P2 year. They noted that many other competing demands, specifically the 8-credit hour integrated pharmacotherapeutics course, were prioritized higher than the self-care course. One P2 student stated that it is very good that the class was moved to the first year because having the course during the P2 year is incredibly difficult, and unfortunately, students did not get the most out of it because they were forced to dedicate most of their time to therapeutics.
Nature of Grading Rubric. P2 students felt the self-care consultation grading rubric was too rigid and not representative of what they had observed on their clinical experiences. Given this inconsistency, many P2 students shifted their focus to meeting the rubric criteria rather than learning the material.
End-of-course evaluations were overwhelmingly positive for both groups. Responses to closed questions were similar; however, the mean was higher for P1 students (Table 4). Responses to open-ended questions revealed a few consistent themes. Students from both groups felt that the flipped classroom model was beneficial for learning. P1 and P2 students similarly thought that the in-class case consultations were stressful but believed that the chance of being randomly called upon in front of their peers motivated them to adequately prepare for class.
Our study revealed that moving the non-prescription drug and self-care therapeutics course from the P2 year to the P1 year did not appear to negatively impact student performance. Although P2 students had more clinical experience and had already completed a full year of the professional curriculum, they did not perform better on graded self-care consultations or score higher on mid-term or final exams than P1 students. This is likely due to differences in learning behaviors that were observed between the two groups. P1 students appeared to spend more time preparing and were more engaged during class time. In addition, P1 students ranked the non-prescription drug and self-care therapeutics course as their highest academic priority, likely because it is the P1 course most directly relevant to clinical application. With more competing demands, P2 students likely had lower motivation and less time to dedicate towards studying for this course. The combination of decreased preparation and less engagement during class may have impacted P2 student performance. Had P2 students been equally as prepared and engaged as P1 students, they may have performed better on self-care consultations and exams given their additional exposure to the pharmacy curriculum and clinical experiences. Instructors, students, and TAs all preferred that the non-prescription drug and self-care therapeutics course be taught in the P1 year rather than the P2 year. These stakeholders based that preference on evidence of benefit for P1 students and evidence of harm for P2 students taking the course. Based on these results, the decision was made to continue to offer this course during the P1 year of the pharmacy curriculum at our institution.
Most literature related to this topic focuses on course content and instructional design methods.8-11 An article published by the Nonprescriptions Medicine Academy Steering Committee highlights the importance of fostering effective communication and patient assessment skills in the self-care curriculum.4 Interactive methods have been shown to improve student confidence in providing self-care recommendations and a few studies have described the use of case simulations for development of these skills. 3,8,10 Based on course feedback, P1 and P2 students similarly found the case consultations to be beneficial for learning and applying course content. It seems that a key benefit of offering this course in the P1 year is promoting development of communication and patient assessment skills earlier in the curriculum.
This study has several limitations. The number of instructors selected for interviews was small; therefore, findings from these interviews may be biased by the small sample size. In addition, the student focus groups may be impacted by self-selection bias as the opinions of those who volunteered may not be truly representative of the class as a whole. We held two separate focus groups with students at the midpoint and end of the course and included different students in each in attempt to ensure diversity in opinions; however, there was an uneven distribution of P1 and P2 students in the midpoint focus group. Our study also has several strengths. The course was administered to P1 and P2 students simultaneously with identical instructional designs, instructors, and evaluation methods. Despite the transition to online learning due to COVID-19, all course changes were identical for both groups of students.
Our analysis of literature on this topic highlights gaps in knowledge related to non-prescription drug and self-care therapeutics within pharmacy education. There is limited information to guide the optimal timing of self-care courses within pharmacy curriculum and it is unclear what impact the timing of delivering this content may have on long-term knowledge retention, application of self-care concepts on experiential rotations and performance on self-care related PCOA and NAPLEX questions. Further studies of these two cohorts of students could be conducted by interviewing preceptors to assess performance on experiential rotations and comparing PCOA and NAPLEX exam scores.
This study showed that P1 students performed equally well in a non-prescription and self-care therapeutics course as P2 students, despite completing the course one year sooner. Numerous advantages to teaching this content earlier in the curriculum were identified. Our study also highlights the value of simulated case consultations in P1 skill development.
We thank the University of Utah College of Pharmacy Dean’s Office for providing financial support for the student incentives.
1. Accreditation council for Pharmacy Education. Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctoral Pharmacy Degree. https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf. Accessed June 4, 2020.
2. National Association of Boards of pharmacy. NAPLEX Competency Statements and Sample Questions https://nabp.pharmacy/wp-content/uploads/2020/04/NAPLEX-Competency-Statement-Sample-Questions.pdf. Accessed July 4, 2020.
3. Zierler-Brown SL, VanAmburgh JA, Casper KA, et al. Status and recommendations for self-care instruction in US colleges and schools of pharmacy, 2006. Am J Pharm Educ. 2006;70(6):139. doi:10.5688/aj7006139.
4. Nonprescriptions Medicine Academy Steering C, Ambizas EM, Bastianelli KM, et al. Evolution of self-care education. Am J Pharm Educ. 2014;78(2):28. doi:10.5688/ajpe78228.
5. Hew KF, Lo CK. Flipped classroom improves student learning in health professions education: a meta-analysis. BMC Med Educ. 2018;18(1):38. doi:10.1186/s12909-018-1144-z.
6. Daniel L. Krinsky SPF, Brian Hemstreet, Anne L. Hume, Gail D. Newton, Carol J. Rollins and Karen J. Tietze. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 19th Edition. American Pharmacists Association; 2017.
7. Bhavsar VM, Bird E, Anderson HM. Pharmacy student focus groups for formative evaluation of the learning environment. Am J Pharm Educ. 2007;71(2):22. doi:10.5688/aj710222.
8. Frame TR, Gryka R, Kiersma ME, Todt AL, Cailor SM, Chen AM. Student Perceptions of and Confidence in Self-Care Course Concepts Using Team-based Learning. Am J Pharm Educ. 2016;80(3):46. doi:10.5688/ajpe80346.
9. Franks AS. Using course survey feedback to encourage learning and concept application in a self-care and nonprescription medications course. Am J Pharm Educ. 2009;73(8):153. doi:10.5688/aj7308153.
10. Hamilton WR, Padron VA, Turner PD, et al. An instructional model for a nonprescription therapeutics course. Am J Pharm Educ. 2009;73(7):131.
11. Krypel LL. Constructing a self-care curriculum. Am J Pharm Educ. 2006;70(6):140. doi:10.5688/aj7006140.
Return to Table of Contents:Comparison of a Self-Care Therapeutics Course Taught in the P1 versus the P2 Year by Elizabeth Bald, PharmD, Demetrius Kourtides, BS, Nicholas Cox, PharmD, Hanna Raber, PharmD, James H. Ruble, PharmD & Boyd F. Richards, PhD