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☆Financial Dipart of an existin* Correspondi

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E-mail: bagg

Currents in Pharmacy Teaching and Learning 5 (2013) 499–507

Research

Student self-assessment of knowledge and application of legalconcepts in a community pharmacy simulation$

Roxie Stewart, PharmD, Scott Baggarly, PhD, MBA, BS Pharm*,Candace Chelette, PharmD

Department of Clinical and Administrative Sciences, University of Louisiana at Monroe College of Pharmacy, Monroe, LA

http://www.pharmacyteaching.com

Abstract

Background: The Accreditation Council for Pharmacy Education (ACPE) lists the topic of pharmacists’ responsibilities andlimits under the law as an area essential to the development of pharmacists. The use of active learning techniques such as role-play and simulation in pharmacy education is encouraged; however, these have rarely been used to reinforce students’knowledge and application of legal concepts.Objectives: To assess students’ confidence in knowledge and application of pharmacy laws; their ability to properly supervisesupport staff and to evaluate the influence of inattentive behavior upon pharmacy practice responsibilities.Methods: Students role-played as pharmacists, technicians, and interns in a series of ten-minute community pharmacysimulations. Pharmacists oversaw typical operations and were presented with situations that challenged their knowledge ofpharmacy law while background activities competed for their attention. Students completed pre- and post-assessments on theirconfidence in knowledge of legal requirements and their ability to recognize violations. Students in the pharmacist rolecompleted an additional questionnaire concerning simulation events. All students completed a reflective writing assignment.Faculty observers evaluated student performance.Results: Positive and negative changes from baseline occurred in students’ confidence of knowledge and recognizingviolations. Students’ awareness of the impact of inattentive behavior upon pharmacy practice increased. Students’ ratings oftheir attention to detail and ability to multi-task decreased.Conclusion: The assessment methods in this study provided students insight into their strengths and weaknesses regardingknowledge and application of legal concepts in pharmacy. This information gives students an opportunity to address deficientknowledge areas before entering pharmacy practice.r 2013 Elsevier Inc. All rights reserved.

Keywords: Laboratory exercise; Simulation; Inattentional blindness; Self-assessment; Pharmacy law

Introduction

In all aspects of community pharmacy practice, pharmacistsare guided by legal requirements. These legal requirements,

– see front matter r 2013 Elsevier Inc. All rights reserv/10.1016/j.cptl.2013.07.016

sclosure Statement: This study was performed as ag course, and no additional funding was received.ng author: Scott Baggarly, PhD, MBA, BS Pharm,linical and Administrative Sciences, University ofonroe College of Pharmacy, 1800 Bienville Dr.,201.arly@ulm.edu

along with practice standards, serve a necessary purpose.When laws and regulations are violated, the health, safety,and welfare of the public may be at risk. Students areexpected to accurately dispense medications and complywith all federal, state, and local laws related to pharmacypractice prior to entering an Advanced Pharmacy PracticeExperience (APPE). Guidance for the assessment of studentcapabilities in the areas of Patient Safety and Ethical,Professional, and Legal Behavior are provided in theAccreditation Council for Pharmacy Education (ACPE)Accreditation Standards and Guidelines 2.0.1

ed.

R. Stewart et al. / Currents in Pharmacy Teaching and Learning 5 (2013) 499–507500

Pharmacists believe that the workplace environmentcontributes heavily to the occurrence of errors.2 Highprescription volume, overwork, interruptions, distractions,and insufficient time to counsel are factors that have beenperceived by pharmacists as underlying causes for errors.2–6

Interruptions and distractions are common for pharmacistsin the community pharmacy practice setting. Pharmacistsare expected to be able to divide attention among multipletasks, while paying critical attention to the details of eachtask. For instance, while focusing on a primary task, such asfilling a prescription, the pharmacist is often interrupted byone or more peripheral tasks such as answering the phone.When peripheral tasks interrupt the execution of primarytasks, more time is required to complete the primary tasks,more errors are committed across tasks, and more annoy-ance and anxiety is experienced than when those sameperipheral tasks are presented between the primary tasks.7

Previous studies have investigated the effects occurringwhen a person’s attention is diverted. With rare exceptions,observers generally do not see what they are directlylooking at when they are attending to something else. Thisis a phenomenon known as inattentional blindness.8,9 Whilesome tasks can be performed simultaneously, others cannotand require one’s full attention. Both inattentional blindnessand insufficient attention due to interruptions, distractions,and high volume, may lead to undesired outcomes in thepharmacy department.10

Rationale and objectives

Simulation training in healthcare has been used as aneffective assessment tool, and has been shown to improveeducation and to increase skill retention up to one year aftertraining.11 Role-playing is an active learning technique thathas been used in a variety of situations in pharmacyeducation.12–16 In this active learning exercise, studentswere required to role-play as pharmacists, student interns,and technicians in a simulation of a high-paced communitypharmacy setting in which interruptions and distractionsmay negatively affect the application of previously learnedknowledge, skills, and attitudes related to pharmacy law.Students were required to use their foundational knowledgeof laws and regulations and to employ higher-order thinkingskills, aligned with Bloom’s17 and Fink’s18 taxonomies oflearning, as they responded to challenges during thesimulation. The simulation activities were built aroundethical, professional, and legal behavior and included thesupervision of pharmacy staff, an activity suggested in theACPE Guidelines, which may be included in communitypharmacy APPEs.1

In the first professional year at the University ofLouisiana at Monroe College of Pharmacy, students enrollin the first of two law classes in the curriculum. Thisdidactic class introduces students to state laws and regu-lations that apply to pharmacists and pharmacy staffmembers, prescriptions, controlled drugs, and pharmacy

practice in community, hospital, and institutional settings.Students also participate in laboratory exercises in whichthey learn to use dispensing software, fill prescriptions, andcheck previously filled prescriptions for errors and omis-sions. In the summer following the first professional year,the students work in a community pharmacy setting duringa four-week Introductory Pharmacy Practice Experience. Inthe first semester of the second professional year, thestudents enroll in a one-credit-hour course in which materialfrom didactic courses is reinforced through laboratoryexercises. The active learning laboratory exercise describedherein was planned to reinforce the information andexperiences from the first professional year in a session oftwo hours and 50 minutes in which 43 students wereenrolled.

The primary objectives of this exercise were for studentsto (1) assess their confidence level in knowledge ofpharmacy laws/regulations and their confidence level inrecognizing when laws/regulations are violated and (2) torecognize when laws/regulations are violated during acommunity pharmacy simulation. Secondary objectiveswere (1) for students in the role of pharmacists to managetheir support staff within their legal scope of practice and(2) for students to evaluate the influence of inattentivebehavior upon pharmacy practice responsibilities.

In this exercise, students were required to perform self-assessments before and after a community pharmacysimulation. Students rated their confidence in knowledgeof pharmacy law and in their ability to recognize violations.In addition, students were required to self-assess theirability to multi-task and pay attention to detail, two highlydesired skills for pharmacists in community practice set-tings. Following the exercise, students completed a reflec-tive writing assignment in which they evaluated theirperformance and attitudes during the simulation.

To our knowledge, no previous studies measuringstudent confidence in knowledge and application of phar-macy laws, recognition of law violations, or the impact ofinattentive behavior have been conducted in a simulatedcommunity pharmacy setting. This exercise exposed stu-dents to an environment much like a busy communitypharmacy. In order to introduce the concept of inattentionalblindness, interruptions and distractions occurred often andstudents’ abilities to multi-task and pay attention to detailwere challenged. Students had the opportunity to gain anincreased awareness of the negative effects these challengesmay have on patient safety and employee well-being.Through self-assessment, students also had the opportunityto identify areas of strengths and weaknesses prior toentering advanced pharmacy practice experiences.

Materials and methods

The simulation included state laws and regulationsregarding the scope of practice of pharmacy staff members;regulations regarding staffing ratios; prescription validation

R. Stewart et al. / Currents in Pharmacy Teaching and Learning 5 (2013) 499–507 501

and processing; required elements of patient counseling;and certification of practical experience for techniciancandidates. Table 1 presents a description of the pharmacystaff members, their scope of practice, and maximum legalstaffing ratios. State law requires the following points to beincluded during patient counseling sessions: (1) name anddescription of the medication; (2) dosage form, dosage,route of administration, and duration of therapy; (3) specialdirections and precautions for preparation, administration,and use by the patient; (4) common severe side effects oradverse effects or interactions and therapeutic contraindica-tions that may be encountered, including their avoidanceand the action required in the event of their occurrence; (5)techniques for self-monitoring drug therapy; (6) properstorage of the medication; (7) prescription refill information,if any; and (8) the action to be taken in the event of a misseddose. Certification of technician candidate hours requires aproperly executed preceptor affidavit that verifies that thecandidate has completed at least 600 hours of practicalexperience under the supervision of a pharmacist preceptor.The candidate may receive credit for no more than 50 hoursweekly. The pharmacist preceptor must sign the form in thepresence of a notary in order for the form to be properlyexecuted.19

Students in the role of pharmacist were expected to usethe intern and technicians within their scope of practice toaccomplish tasks during the simulation. For example,pharmacy interns may counsel patients, but techniciansare not legally authorized to do so. During the simulation,students in the role of pharmacist were challenged withseveral violations that they should have recognized: thetechnician candidate claimed hours of practical experiencein excess of the weekly limit on the affidavit that thepharmacist was asked to certify; two required points,storage requirements and refill information, were omittedby the student interns during the patient counseling session;and the staffing ratios were in excess of the legal limit whenanother pharmacist left for a lunch break.

Table 1Pharmacy staff members

Staff member Description and scope of practice related to si

Pharmacist (Preceptor) A person licensed to practice pharmacy in thecandidates; may supervise a maximum of oncandidate) at a time

Pharmacy Intern A pharmacy student registered with the Boardshe is supervised by a pharmacist

Pharmacy Technician A person who is licensed to practice in the stprescriptions; may enter orders into a compucannot counsel patients

Pharmacy TechnicianCandidate

A person who is registered with the Board ofpractical experience required for licensure;perform other duties of technicians; may reweek

*Definitions for the state of Louisiana.19

Simulations

The laboratory exercise consisted of a series of identicalten-minute simulations, held in the Pharmacy Care Labo-ratory that has a section with a secured dispensing area set upas a typical community pharmacy. There are work areas, acounseling room, and legend drugs stocked on standardpharmacy shelves. Three pharmacist workstations, eachequipped with a computer, printer, and telephone, are locatedat the front counter to enable interaction with patients.Directly in front of the pharmacy counter is a section withthree aisles of display shelves stocked with over-the-counter(OTC) products. The setting was described to students as alarge community pharmacy in which three pharmacists workat the same time. In each simulation, three students playingthe role of pharmacists were placed in a busy communitypharmacy environment, where they were responsible forfilling and checking prescriptions, accepting call-in prescrip-tions, counseling patients, and supervising staff members.Each pharmacist was assigned to one of the workstationsalong with a support staff, which included one pharmacyintern, two technicians, and one technician candidate.

Roles/Responsibilities of participants

Simulation participants included students in the roles ofpharmacists, student interns, technicians, and techniciancandidates; three persons acting as patients; one facultymember posing as a physician; and one janitor. Threefaculty observers and one facilitator were also required. Theintern worked at the counter with the pharmacist, and thetechnicians and technician candidates worked behind themto fill prescriptions and conduct inventory. Persons in theroles of interns, technicians, technician candidates, andpatients were used as accomplices and presented thepharmacists with a series of tasks to handle during thesimulations. A detailed description of each role isgiven below.

mulation activities*

state and certified to act as a preceptor to train interns and techniciane intern and three technicians (or two technicians and one technician

of Pharmacy; may perform any duty of a pharmacist as long as he/

ate as a certified pharmacy technician; may receive telephonedter system; may prepare prescriptions for final check by pharmacists;

Pharmacy as a pharmacy technician candidate and is obtainingcannot receive telephoned prescriptions or counsel patients but mayceive credit for a maximum of 50 hours of practical experience per

R. Stewart et al. / Currents in Pharmacy Teaching and Learning 5 (2013) 499–507502

PharmacistsStudents in this role were told to do everything that a

pharmacist would do in a real community pharmacy setting,such as order entry, checking prescriptions, managing staff,and speaking with patients and physicians. They were toldthat the scenario begins with two prescriptions to be filled,and as they fill prescriptions, other normal pharmacyactivities will take place. They were told to manage thetasks properly from a legal perspective and to use theirsupport staff as needed to manage the pharmacy workflow.

Student internsOne intern was placed at each station and was told to

perform tasks during the simulation as instructed by thepharmacist. In their role as accomplices, the student internswere to intentionally omit two required counseling points(storage information and refill information) when counsel-ing a patient who was picking up a prescription. They weretold to act as if the omission was unintentional if thepharmacists noticed the error and to include the omittedcounseling points.

Technicians/Technician candidatesTwo technicians and one technician candidate were

placed at each station and told to do whatever tasks thepharmacist asked them to do. If the pharmacist did not askthem to perform a task, they were to appear busy by takinginventory of the pharmacy stock. In their role as accom-plices, each of them had specific tasks. The technicians wereto interrupt the pharmacist at designated times to have afilled prescription checked. The technician candidate was topresent the pharmacist with an affidavit for certifying hoursof practical experience in order to obtain the pharmacist’ssignature. If the pharmacist signed it, the techniciancandidate was to take the affidavit and thank the pharmacist;if the pharmacist said they would have to handle it later, thetechnician candidate was to leave the affidavit with thepharmacist.

PatientsOne patient was assigned to each workstation. At the

beginning of the simulation, they were to approach theworkstation to pick up a filled prescription. They wereinstructed not to ask the intern about storage requirementsfor the medicine or about refill information during thecounseling session. After being counseled, the patient wasto approach the pharmacist and ask for a recommendationof an over-the-counter product. After receiving a recom-mendation, the patients left the pharmacy.

Faculty physicianOne faculty member posed as a physician and tele-

phoned one prescription to each of the three stations duringeach simulation.

JanitorA person posing as a janitor was responsible for entering

the pharmacy and moving through as he chatted withpeople, emptied trash, and “stole” a bottle of medicinebefore he exited.

Faculty observersA faculty member was placed at each station to observe

the scenarios. The faculty observers were responsible fornoting general comments about each scenario and recordingif the pharmacists violated the legal scope of practice forany of their staff members, erroneously signed the affidavitof experiential hours from the technician candidate,recorded the telephoned prescription properly, or noticedthe janitor’s theft.

FacilitatorOne person was assigned to regulate the flow of students

in the role of pharmacists from a holding room to the mockcommunity pharmacy for the simulation and then to aclassroom where the students remained until all the simu-lations were completed.

Assessment methods included faculty observation, pre-and post-laboratory assessments for all students, a post-simulation questionnaire for students in the role of pharmacist,and a reflective writing assignment for all students.

Procedures

This project was approved by the University InstitutionalReview Board. Participation in the exercise was required as apart of the course; however, students voluntarily completed aconsent form to allow the use of their responses for thisresearch. At the beginning of the laboratory session, thestudents were given a brief description of the exercise andall students (n ¼ 42) completed a pre-laboratory assessmentfrom the perspective of a pharmacist. Students were randomlyassigned to the following roles for the laboratory simulation:pharmacists (n ¼ 29), certified technicians (n ¼ 6), techniciancandidates (n ¼ 3), student interns (n ¼ 3), and patient (n ¼1). Two additional patients were required. These roles werefilled by one faculty member and one graduate teachingassistant. Participants then received instructions about theirroles in the simulations. The students in the role of pharmacistwere taken to a holding room while those in other roles weretaken to the mock pharmacy.

Each simulation began by bringing in three pharmacistsand placing each of them with their support staff at one ofthe workstations. The ten-minute simulation began with thepharmacists being told to fill the two new prescriptions thatwere waiting on the counter. When the pharmacists andinterns began to fill the first prescription, a patientapproached each pharmacist to pick up a previously filledprescription. The intern retrieved the prescription, gave it tothe pharmacist to be checked, and proceeded to counsel thepatient, purposely leaving out two required components of

R. Stewart et al. / Currents in Pharmacy Teaching and Learning 5 (2013) 499–507 503

patient counseling. While the intern counseled the patient,the pharmacist resumed filling the new prescriptions. Whenthe intern finished counseling the patient, the patient askedthe pharmacist a scripted question for a recommendation ofan OTC medication. Each of the pharmacists was free todecide how the question was handled, either by personallyescorting the patient to the OTC area to retrieve themedication or by delegating the task to a staff member.

As the pharmacists were working, they were randomlyinterrupted several times. After the pharmacists handled thepatient questions, they were interrupted by the first technician,who asked them to check a filled prescription. Next, thetechnician candidate asked them to sign an affidavit forcertifying hours of practical experience. The form claimedhours in excess of the weekly limit for some weeks and plainlyindicated that a notarized signature was required. At randompoints during the simulation, the faculty physician telephonedeach station to give the pharmacist a new prescription.

At the midpoint of the simulation, the middle pharmacistwas removed for two minutes to simulate a lunch break, andan announcement was made to everyone that the pharmacistwas leaving for lunch. This caused the staffing ratios to exceedthe legal limits that pharmacists are allowed to supervise.Shortly after the pharmacist returned from the lunch break, thejanitor entered the pharmacy, moved through as he emptiedtrash and “stole” a bottle of medicine before leaving thepharmacy. Approximately two minutes before the simulationended, the last technician asked the pharmacist to checkanother filled prescription. At the ten-minute point, thesimulation ended and the three pharmacists left the mockpharmacy, completed the pharmacists’ post-simulation ques-tionnaire, and were moved to a classroom.

The support staff members acting as accomplicesremained present for all simulations and were responsiblefor re-setting the mock pharmacy in preparation for the nextsimulation. This required placing two new prescriptions ateach station for the pharmacists to fill and placing the filledprescriptions in the back of the pharmacy. When thepharmacy was reset, a group of three new pharmacistsentered and the simulation was repeated. At the end of thelaboratory period, students moved to a classroom, where allstudents completed the post-laboratory assessment from theperspective of a pharmacist. A follow-up discussion washeld to debrief the students and a video was shown toreinforce the concept of inattentional blindness.20

Evaluation and assessment

The laboratory exercise was evaluated by the use of pre-and post-assessments, faculty observation, and by a post-simulation questionnaire completed by students in the roleof pharmacist.

Pre-assessmentThe pre-assessment was completed by the students at the

beginning of the laboratory period. The confidence portion

of the instrument was divided into two sections related tothe primary objectives of the study. The first sectionincluded eight items for which students rated their level ofconfidence in their knowledge of pharmacy laws andregulations. In the second section, for the same eight items,students rated their level of confidence in their ability torecognize when the laws or regulations are violated. Each ofthese sections used an 11-point scale (0 ¼ not confident;10 ¼ very confident). In order to prevent students frombeing aware of all the laws actually used in the simulation,an additional item was included in the instrument. The itemwas not included in the simulation and was not included inthe analysis. Students also rated their agreement with twostatements, “I pay attention to detail,” and “I am able tomulti-task” using 5-point scales (1 ¼ strongly disagree; 5 ¼strongly agree), and estimated the number of prescriptionsthey could accurately complete as a pharmacist duringone hour.

Post-assessmentThe post-assessment was completed by the students at

the end of the laboratory period. It was identical to the pre-assessment except for the addition of one item to indicatethe students’ awareness of inattentive behavior and fouritems for students in the role of pharmacist. These itemsasked the students to rate the influence of inattentivebehavior and lack of knowledge on errors and omissions.

Faculty observationsComments from faculty observers were employed to

evaluate the activities of pharmacists and their support staffduring the scenarios. The faculty observers noted if thepharmacists properly used staff members within their legalscope of practice, erroneously signed the affidavit ofexperiential hours from the technician candidate, recordedthe telephoned prescription properly, or noticed thejanitor’s theft.

Pharmacists’ post-simulation questionnaireThis questionnaire was completed by students in the role

of pharmacists immediately after their turn in the simu-lations. This allowed the instructors to evaluate the designof the exercise by having the students indicate the taskswhich they were able to complete, counseling pointscovered by the intern, their awareness of the staffing ratios,and their awareness of the janitor’s actions during thesimulation. The students were asked to respond honestly toquestions about their awareness, as their answers had noimpact upon their grade.

Results

SAS version 9.2 (SAS Institute Inc., Cary, NC) was usedfor data analysis. An a priori alpha level of 0.05 was set forall analyses. The primary objectives of the study were for

R. Stewart et al. / Currents in Pharmacy Teaching and Learning 5 (2013) 499–507504

students to rate their confidence level in knowledge ofpharmacy laws and regulations and their confidence level inrecognizing violations. Pre- to post-assessment changes inconfidence levels are presented descriptively in Table 2. Forconfidence in knowledge of laws and confidence in recog-nizing violations, the two items for which the most studentsreported increased confidence levels were requirements fora pharmacist in charge, and regulations regarding theabsence of a pharmacist. The item for which the moststudents reported decreased confidence in their knowledgewas the minimum requirements for patient counseling. Thetwo items for which the most students reported decreasedconfidence in recognizing violations were licensing, regis-tration, and certification of persons and the minimumrequirements for patient counseling.

Pre- and post-assessment confidence ratings were com-pared with paired t-tests. Table 3 presents the meanconfidence levels and p-values from the analysis. For thestudents’ ratings of their confidence in knowledge of lawsand regulations, the greatest increase occurred for standardsregarding the absence of a pharmacist; the greatest decreaseoccurred for the practical experience required of pharmacyinterns and technicians. For the students’ ratings of con-fidence in recognizing violations, the greatest increaseoccurred for standards regarding the absence of a pharmacist;the greatest decrease occurred for licensing, registration, andcertification of persons. No statistically significant changefrom pre- to post-assessment confidence ratings was present.

The second primary objective of the study was forstudents to recognize when laws or regulations were violatedduring the simulation. This objective was evaluated throughfaculty observation and items on the pharmacists’ post-simulation questionnaire. The first violation the studentswere expected to recognize was the omission of storageinformation and refill information by the intern during thecounseling session. The majority of students realized that

Table 2Pre-lab to post-lab confidence level changes in knowledge of pharmacy l

Item

KnowleNumber

Decreasconfiden

Licensing, registration, and certification of persons includingqualification for licensure and renewal of licenses

15 (36%

Minimum requirements for patient counseling 18 (43%Scope of practice for pharmacy interns 17 (40%Scope of practice for pharmacy technicians 12 (29%Practical experience required of pharmacy interns and pharmacytechnicians

17 (40%

Requirements for a pharmacist in charge 14 (33%Professional and occupational standards regarding the absence ortemporary absence of a pharmacist

13 (31%

a Measured on an 11-point scale (0 ¼ Not confident; 10 ¼ Very confident).b Percentages may not total to 100% due to rounding.

medication storage was not covered but only 52% wereaware that refill information was not provided. Facultyobservations concurred with this finding and noted that thepharmacists who corrected the interns addressed medicationstorage more frequently than refill information. Otherviolations involved the decision to sign the affidavit certify-ing the hours of practical experience for the techniciancandidate and recognizing the improper staffing levels whileone pharmacist left the pharmacy for a lunch break. Therewere 59% of the pharmacists who incorrectly signed theaffidavit, and only 10.3% of the pharmacists who wereaware that the legal staffing limits were violated.

A secondary objective of the study was for students inthe role of pharmacist to manage their support staff withintheir legal scope of practice. This objective was evaluatedthrough faculty observation during the scenarios. Thepharmacists properly used the interns to assist in fillingprescriptions, counseling patients, and advising the patienton the OTC product. The technicians and techniciancandidates also performed acceptable duties during thesimulation. Some pharmacists chose to have the techniciansenter prescription information in the computer, while otherpharmacists chose to perform the task themselves. Obser-vations indicated that students followed proper legalrequirements with regard to dispensing during the simula-tion, including proper documentation of the telephonedprescriptions. No violations were noted in the use of thesupport staff by the pharmacists; however, observationsindicate that the pharmacists who delegated more tasks tothe technicians were more successful in completing tasksefficiently during the simulations.

Another secondary objective was to evaluate the influ-ence of inattentive behavior upon pharmacy practiceresponsibilities. One of the most obvious examples ofinattentive behavior was that only twelve of the twenty-nine pharmacists noticed that the janitor came through the

aws and recognizing violationsa

dge of laws Recognizing violations(%) of studentsb (n ¼ 42) Number (%) of studentsb (n ¼ 42)

edce

Nochange

Increasedconfidence

Decreasedconfidence

Nochange

Increasedconfidence

) 15 (36%) 12 (29%) 17 (40%) 11 (26%) 14 (33%)

) 10 (24%) 14 (33%) 17 (40%) 11 (26%) 14 (33%)) 15 (36%) 10 (24%) 11 (26%) 17 (40%) 14 (33%)) 17 (40%) 13 (31%) 13 (31%) 15 (36%) 14 (33%)) 16 (38%) 9 (21%) 16 (38%) 15 (36%) 11 (26%)

) 10 (24%) 18 (43%) 11 (26%) 12 (29%) 19 (45%)) 8 (19%) 21 (50%) 13 (31%) 8 (19%) 21 (50%)

Table 3Mean confidence ratings and p-values for knowledge of laws and recognizing violationsa

Item

Knowledge of laws Recognizing violations

Pre-lab Post-lab p-valueb Pre-lab Post-lab p-valueb

Licensing, registration, and certification of persons including qualification forlicensure and renewal of licenses

6.76 6.57 0.4890 6.64 6.29 0.2931

Minimum requirements for patient counseling 7.21 6.93 0.4400 7.00 6.76 0.4387Scope of practice for pharmacy interns 7.71 7.29 0.1316 7.21 7.19 0.9331Scope of practice for pharmacy technicians 7.07 6.98 0.7390 6.69 6.71 0.9336Practical experience required of pharmacy interns and pharmacy technicians 7.45 6.93 0.0729 7.10 6.81 0.3299Requirements for a pharmacist in charge 5.86 6.12 0.4828 5.52 6.10 0.0782Professional and occupational standards regarding the absence or temporaryabsence of a pharmacist

6.24 6.93 0.0571 6.02 6.71 0.0688

a Measured on an 11-point scale (0 ¼ Not confident; 10 ¼ Very confident).b Compared with paired t-tests.

R. Stewart et al. / Currents in Pharmacy Teaching and Learning 5 (2013) 499–507 505

pharmacy to empty trash. Of these twelve, none of themnoticed the janitor stealing the bottle of medicine. Althoughstudents in the roles of interns and technicians were used asaccomplices during the scenarios, they were not told aboutthe janitor. None of these support staff members noticed thetheft until the third iteration of the scenario. Students used a5-point Likert scale (1 ¼ no influence; 5 ¼ strong influence)to rate the influence of inattentive behavior and lack ofknowledge on errors and omissions. Insufficient attentionhad a greater influence upon the students’ ability torecognize non-dispensing-related errors or omissions(median ¼ 4) than upon dispensing-related errors or omissions(median¼ 3). Lack of knowledge had an equal influence uponthe students’ ability to recognize dispensing- and non-dispensing-related errors or omissions (median ¼ 3).

Several other items were included in the assessments andwere used as discussion points during the debriefing periodfollowing the simulations and for general assessments of theexercise. The students’ rating of their ability to multi-tasksignificantly decreased following the simulation (p ¼0.007), as did the rating of their attention to detail (p ¼0.005). Prior to the exercise, students estimated that theycould fill 16–20 prescriptions per hour as a pharmacist. Thisestimate changed to 11–15 prescriptions per hour followingthe exercise. As a formative assessment of the exercise,students in the role of pharmacist were asked to indicate thetasks they completed during the simulation. All but one ofthe pharmacists checked the three previously filled pre-scriptions and answered the OTC question from the patient.Only 38% of the pharmacists successfully filled the twonew written prescriptions and only 31% filled the tele-phoned prescription. As an overall evaluation of theexercise, a 5-point Likert scale (1 ¼ strongly disagree;5 ¼ strongly agree) was used to rate the level that students’awareness of inattentive behavior increased because of thelaboratory exercise (median ¼ 4). The students also ratedtheir level of awareness that medication errors may resultdue to inattentive behavior (median ¼ 4.5).

Discussion

Community pharmacists are frequently bombarded withmultiple primary and peripheral tasks. This may result ininsufficient attention to detail and inattentional blindness,that can ultimately lead to dispensing errors or pharmacylaw violations. As educators, it is important to expose ourstudents to this type of environment to prepare them to becompetent pharmacists and potentially decrease pharmacyerrors as a result. This simulated exercise gave students theopportunity to apply their knowledge of pharmacy law in acommunity practice setting, identify areas of strengths andweaknesses in a challenging environment, and gain aware-ness of the potential effects resulting from inattentionalbehavior. The detailed responsibilities with which pharma-cists and support staff were presented are consistent with thepractice of pharmacy and the didactic material studentsreceived in their law class, taking into account our statepharmacy practice laws. Using the same types of simulationexercises and personnel, another institution wishing toincorporate hands-on learning could easily use this as atemplate to create their own simulation exercise by sub-stituting the appropriate pharmacy practice laws and regu-lations regarding staff ratios, technician training hours, andpatient counseling requirements.

The primary goals of this study were to assess students’confidence levels with regard to knowledge of communitypharmacy laws and regulations and confidence levels inrecognition of violations. As indicated in the pre- to post-assessment changes in confidence levels presented inTable 2, the percentage of students who reported increasedconfidence in their knowledge of laws was similar to thepercentage of students who reported decreased confidence.This finding helps explain the lack of a significant differ-ence in the mean pre- and post-assessment confidence levelspresented in Table 3. This phenomenon was also true for theconfidence levels in recognizing violations. Although nostatistically significant differences were found in the mean

R. Stewart et al. / Currents in Pharmacy Teaching and Learning 5 (2013) 499–507506

confidence ratings for knowledge of laws or recognition ofviolations, we found that some students were initiallyoverconfident in these areas. This is consistent withprevious literature evaluating the accuracy of student self-assessment.21,22 One student commented: “When I firstheard what we were going to be doing in lab, I was quiteconfident that I had the knowledge and skills necessary tocomplete the scenario. Having worked in a retail pharmacyfor almost four years, I thought I had a good understandingof the pharmacist role. I quickly learned that my perceptionof the pharmacist’s daily duties was very wrong. The mostdifficult part was paying attention to everything going onaround me and noticing when laws are being broken. As aresult of the lab exercise, I feel more confident in handlingoverwhelming situations that may occur in the pharmacy,and it has opened my eyes to know how easily mistakes canoccur and how important it is to know the laws. I need toreview some of the laws again in order to become moreconfident in this area. I certainly think this lab will help mebe a better pharmacist.”

In addition to assessing the students’ confidence withregard to knowledge and recognition of pharmacy laws andviolations, secondary objectives were for students in the roleof pharmacists to manage their staff within their legal scopeof practice and for all students to evaluate the influence ofinattentive behavior toward pharmacy practice responsibil-ities. When students were exposed to a busy environmentduring the simulation, many of the pharmacists did notrecognize violations such as inappropriate certification ofthe technician candidate’s hours or the disproportionatestaffing ratios. Additionally, several of the pharmacists wereunsure of duties that technicians were legally allowed toperform. Application of pharmacy practice laws is muchdifferent from answering multiple-choice questions on anexam, and it forces the student to utilize higher taxonomiesof learning, which equates to improved student learning andhigher retention.17,18 One student commented, “After thisexercise, I realized I would have been fined by the Board ofPharmacy and possibly placed on suspension for all thethings I did wrong and failed to notice. Today’s exercisewas an eye-opener because in the real world there willprobably not be any redo’s. I will remember the things I didwrong, and not make the same mistakes as a pharmacist.”

By nature of the profession, the ability to multi-task is anextremely important component to the success of commun-ity pharmacists. Prior to and following the simulationexercise, the students completed a self-assessment of theirattention to detail and ability to multi-task. In the pre-laboratory assessment, students felt confident they would beable to complete more prescriptions per hour than reportedon the post-laboratory assessment. This could be due to thevarious other tasks the pharmacists were given while tryingto complete their dispensing duties. The students’ rating oftheir ability to multi-task and pay attention to detailsignificantly decreased following the simulation. It was alsoevident from faculty observations that multi-tasking was the

biggest challenge for the majority of the pharmacists. Manycomments from students participating in support staff roleswere about their observations of the pharmacist. Onestudent commented, “I learned some important things fromobserving my classmates. The best pharmacists were theones who immediately started delegating tasks to the techsand intern and remained calm.” Another student com-mented: “the greatest lessons I learned today in lab werethat attention to detail is key and use of the pharmacy teammembers is essential for the pharmacist to multi-task.”

The design strategy fulfilled our goals for the exerciseand was effective in assessing students’ confidence andawareness of their actions. These concepts are often difficultto teach in the classroom. With high volume, constantinterruptions, and distractions being underlying causes ofdispensing errors, it is important for our students to learn tofocus their attention appropriately.2–4 It is imperative thatstudents recognize that the primary focus should be uponthe patient’s safety and well-being. One student stated itperfectly, “When pharmacists are pulled in multiple direc-tions, it can be a little overwhelming. I realized I need totake a couple [of] seconds to step back and reassess thesituation. By doing this, mistakes can be avoided, errorscaught, and more attention could be given to the mostimportant person in the pharmacy: the patient.”

As with any study, there are limitations that require someattention. The study sample was relatively small and waslimited to second-year professional students enrolled in thislaboratory course. Therefore, the results may not be represen-tative of all student pharmacists. Logistical constraints pre-vented every student from playing the pharmacist role. Thismay have influenced their reported confidence levels on thepost-lab assessment. One question on the post-lab assessmentstated: “Because of the exercise, I am now more aware thatmedication errors may result due to inattentive behavior.”After completion of the exercise, the authors noted that thisquestion could be a leading question and should be changedfor future labs using this exercise. Faculty members were ableto observe student performance; however, the number ofmedication-related errors made by pharmacists and supportstaff was not investigated. Future studies could investigate thenumber of medication errors made by pharmacists and supportstaff within this environment to compare their knowledge andaccuracy of pharmacy practice.

It should be well noted that the simulation exerciseswere developed based on pharmacy practice laws andregulations in our state. While this exercise could be easilyduplicated by another school or college of pharmacy,certain tasks may require modifications to be consistentwith the state pharmacy practice laws and didactic coursework. Activities during this simulation provided evidence ofstudents’ achievement of abilities and competencies withinthe core domains of Patient Safety and Ethical, Professional,and Legal Behavior. Competency in these and other ACPEcore performance domains reflects student readiness to enterAPPEs.1

R. Stewart et al. / Currents in Pharmacy Teaching and Learning 5 (2013) 499–507 507

Conclusions

Demanding and distracting work conditions may con-tribute to a lack of concentration, possibly resulting inerrors. This exercise was designed to simulate a realisticcommunity pharmacy environment in which practitionersare forced to multi-task. By participating in this laboratoryexercise, students had the opportunity to apply their knowl-edge of pharmacy law, test their ability to recognizeviolations, and evaluate the influence of inattentive behavioron job performance. Insight gained from the self-assessments of their confidence in knowledge of laws/regulations and recognizing violations that were providedin this activity will allow them the opportunity to correctdeficits prior to entering professional practice experiences.

Acknowledgments

The authors wish to acknowledge Dr. Michelle Zagar forher review of the manuscript and would also like to expressspecial thanks to the faculty and staff members at ourinstitution who assisted in facilitating this exercise.

References

1. Accreditation Council for Pharmacy Education Website:Accreditation Standards and Guidelines Version 2.0. February14, 2011. Available at: http://www.acpe-accredit.org/standards/default.asp; Accessed July 27, 2013.

2. Gianutsos G. Identifying factors that cause pharmacy errors.US Pharm. 2008;12(44):[Epub].

3. Peterson GM, Wu H, Bergin JK. Pharmacists’ attitudes towardsdispensing errors: their causes and prevention. J Clin PharmTher. 1999;24:57–71.

4. Flynn EA, Barker KN, Gibson JT, et al. Impact of interruptionsand distractions on dispensing errors in an ambulatory carepharmacy. Am J Health Syst Pharm. 1999;56:1319–1325.

5. Massachusetts Board of Registration in Pharmacy. Medicationerror study. Massachusetts Office of Health and Human Services.Available at: http://www.mass.gov/eohhs/docs/dph/quality/boards/pharmacy-newsletter-072005.pdf; Accessed July 27, 2013.

6. Holden RJ, Patel NR, Scanlon MC, et al. Effects of mentaldemands during dispensing on perceived medication safety andemployee well-being: a study of workload in pediatric hospitalpharmacies. Res Social Adm Pharm. 2010;6:293–306.

7. Bailey BP, Konstan JA. On the need for attention-awaresystems; measuring effects of interruption on task performance,

error rate, and affective state. Comput Hum Behav. 2006;22:685–708.

8. Mack A. Inattentional blindness: looking without seeing. CurrDir Psychol Sci. 2003;12:180–184.

9. Mack A, Rock I. Inattentional blindness: an overview. In:Mack A, Rock I, eds. Inattentional Blindness. Cambridge, MA:MIT Press; 1998.

10. Institute for safe medication practices website: ISMP medica-tion safety alert! Inattentional blindness: what captures yourattention? February 26, 2009. Available at: http://www.ismp.org/newsletters/acutecare/articles/20090226.asp; Accessed July27, 2013.

11. Lupu AM, Stewart AL, O’Neil C. Comparison of active-learning strategies for motivational interviewing skills, knowl-edge, and confidence in first-year pharmacy students. Am JPharm Educ. 2012;76(2):Article 28.

12. Orledge J, Phillips WJ, Murray WB, Lerant A. The use ofsimulation in healthcare: from systems issues, to team building,to task training, to education and high stakes examinations.Curr Opin Crit Care. 2012;18(00):1–7.

13. Garwood CL, Bishja M, Smythe MA. An innovative electivecourse in anticoagulation management. Am J Pharm Educ.2010;74(10):Article 187.

14. Darbishire PL, Plake KS, Nash CL, Shepler BM. Active-learning laboratory session to teach the four M’s of diabetescare. Am J Pharm Educ. 2009;73(2):Article 22.

15. Kimberlin CL. Communicating with patients: skills assessmentin US Colleges of Pharmacy. Am J Pharm Educ. 2006;70(3):Article 67.

16. Rao D. Skills development using role-play in a first-yearpharmacy practice course. Am J Pharm Educ. 2011;75(5):Article 84.

17. Bloom BS, ed. Taxonomy of Educational Objectives. TheClassification of Educational Goals. Handbook I: CognitiveDomain. New York: McKay; 1956.

18. Fink LD. Creating Significant Learning Experiences. AnIntegrated Approach to Designing College Courses. SanFrancisco, CA: Jossey-Bass; 2003.

19. Louisiana Board of Pharmacy. Laws and Regulations. BatonRouge, LA: Louisiana Board of Pharmacy; 2012.

20. Brown D. Person Swap [Video]. YouTube. Available at http://www.youtube.com/watch?v=vBPG_OBgTWg. PublishedAugust 26, 2007; Accessed July 27, 2013.

21. Zubin A, Gregory PA. Evaluating the accuracy of pharmacystudents’ self-assessment skills. Am J Pharm Educ. 2007;71(5):Article 89.

22. Valdez CA, Thompson D, Ulrich H, Bi H, Paulsen S. Acomparison of pharmacy students’ confidence and test perform-ance. Am J Pharm Educ. 2006;70(4):Article 76.