Abstract
OBJECTIVE
The objective of this study was to assess the impact of a pediatric pharmacy–focused skills laboratory on student pharmacist confidence and comfort with pediatric topics.
METHODS
This study compared student responses on a questionnaire completed both pre- and post-lab. The lab activities included pre-readings, a pre-lab lecture, and a 2-hour laboratory session. The questionnaire assessed perceptions related to counseling pediatric patients and confidence in communicating with children and caregivers. Wilcoxon rank sum tests compared the differences in the preand post-lab questionnaire results. The McNemar test was used to test for conversion.
RESULTS
A total of 187 of 221 pharmacy students completed the pre-lab questionnaire (85% response rate) and 116 completed the post-lab questionnaire (52% response rate). Significantly higher confidence levels were reported in the post-lab questionnaire for 5 of the 7 questionnaire items. Specifically, concerning level of confidence in measuring oral solutions, 17.5% of students' pre-lab, compared with 42.6% post-lab felt completely confident in being able to determine the appropriate measuring devices for liquid medications. No statistically significant differences were noted regarding comfort level or knowledge.
CONCLUSIONS
Although an increase in confidence was seen in several areas, some students still lacked confidence after the lab session, suggesting that more pediatric-focused activities may be needed in the curriculum to reinforce pediatric concepts.
Keywords: communication, confidence, curriculum, pediatrics, skills laboratory
Introduction
Pediatric patients encompass a very vulnerable population who require specialized care. Even though not every pharmacist will choose a career path specializing in pediatrics, it is important that student pharmacists be prepared to care for this population. Many pharmacists will encounter a prescription written for a pediatric patient at some point, given that millions of prescriptions are written for children every year.1 Although pediatrics is an important practice area in which student pharmacists should be instructed, it has been previously reported that pediatric curricula are inadequate.1 It is noteworthy that the Accreditation Council for Pharmacy Education (ACPE) 2016 accreditation standards and key elements do not explicitly mention the need for educating student pharmacists regarding pediatric topics, but rather emphasize the need for patient-centered and population-based care.2 Appendix 1 in the ACPE document lists a wide variety of recommended topics to be included in the pharmacy curricula and “across the lifespan” is listed in multiple categories.2 Therefore, this suggests that pediatrics is an expected area to be covered, although is not clearly stated. Additionally, the American College of Clinical Pharmacy Pharmacotherapy didactic curriculum toolkit serves as a guide for schools and colleges of pharmacy as to which topics should be covered in the curricula and classifies the topics into tiers one, two, and three.3 Tier one specifies the topics that should be covered to prepare students for patient care upon graduation or licensure.3 Pediatrics is included in the special populations section, and there are several topics within pediatrics listed that should be covered; these include growth and development and pediatric drug dosing and delivery.3
There is variation in the pediatric-related topics covered in pharmacy school curricula. Prescott et al4 conducted a study in which they surveyed doctor of pharmacy programs in the United States to evaluate the degree to which pediatric-related topics are covered in the curriculum. Of the 86 respondents for programs that participated, 81 (94%) noted that pediatrics was included in the required coursework.4 There was variability noted in the timing of the courses, the credit hours, and types of learning experiences available.4 Of note, 26 (35.6%) reported having pediatric instruction included in a required laboratory session.4
At our institution, faculty members thought it was key to implement a pediatric pharmacy lab into one of the skills labs based on the importance of this topic. During development of the lab session, it was discussed that it was unknown how students felt about pediatric-related topics and the lab authors decided to explore this issue. The purpose of this study was to determine how the implementation of a pediatric pharmacy–focused skills lab would influence the students' attitudes and perceptions regarding pediatric-related pharmacy topics.
Materials and Methods
Participants in this study were second-year doctor of pharmacy candidates enrolled in the required Pharmacy Practice Skills Laboratory sequence at the school of pharmacy in 2018 and 2019. Participation in weekly lab activities was a required element of the course at the time of the study. Our institution recently implemented a new curriculum where skills labs are incorporated into various courses. This study used a pre- and post-test study design with the use of a questionnaire before and after the implementation of the pediatric-focused lab. The study was completed over a 3-week period. Approximately 1 week prior to the scheduled activities, all students received the optional pre-lab questionnaire. Students completed their specific course requirements for this activity, which included a pre-reading, a pre-lab didactic lecture, and a 2-hour skills lab session. Students were then sent the post-lab questionnaire immediately following the lab and asked to complete the questionnaire within 1 week. This study was approved as exempt by the institution's institutional review board and participants consented to be part of the study through completion of the questionnaire.
Description of Lab Activities. Prior to the lab, students were required to listen to a pre-lab lecture and to read 3 articles related to measuring devices and strategies to engage children in medication counseling.5–7 During the lab session, the students participated in 3 different stations. The learning objectives for these activities were as follows: 1) Identify strategies for communicating with children and caregivers; 2) Interview a caregiver using the QuEST SCHOLAR-MAC method8; 3) Determine medications appropriate to use for the management of cough or cold and fever in children; 4) Identify dosing errors; 5) Recognize self-care exclusion criteria for patients with fever; and 6) Compare and contrast devices used to measure liquid medications.
In station one, students were given 1 of 6 clinical scenario cards for a pediatric patient presenting to the pharmacy with a prescription for an albuterol inhaler or an over-the-counter antihistamine. Students discussed different product formulations and counseling points based on the age of the patient. Students also reviewed helpful strategies for counseling pediatric patients based on Piaget Developmental Stages.9
In station two, students worked in groups of 2 to 3 and used the QuEST SCHOLAR-MAC8 technique to interview the facilitator, who was acting as a caregiver of a child with cough and cold symptoms. The students had a variety of over-the-counter cough and cold products available to choose from in order to select an appropriate product. At the conclusion of the activity, the facilitator reviewed each of the groups' selected products and discussed benefits and risks associated with each in pediatric patients. Students were also asked to think about different age groups with each of the products through addition of an older or younger sibling who was experiencing similar symptoms. In station three, students evaluated 3 prescriptions for appropriate weight-based dosing and volume of oral solutions. Students were then given different measuring devices (e.g., household teaspoon, medicine cup, dosing spoon, medication dropper, and dosing syringe). Students measured a dose with their assigned measuring device to compare and contrast accuracy and ease of use.
Description of Survey Instrument. Participation in the questionnaire was voluntary and anonymous. The pre-lab questionnaire and post-lab questionnaire were administered anonymously using Qualtrics (Provo, UT). On the pre-lab questionnaire, participants were asked several demographic questions related to their age, gender, prior work experience, and experiences with children. Both questionnaires included 5 questions on their perceptions related to counseling of pediatric patients. The answer choices were agree, disagree, or unsure/don't know. Students were then asked 7 questions ranking their confidence in communicating with children and their caregivers or making clinical recommendations for children on a Likert-type scale where 0 was not at all confident and 7 was completely confident. When evaluating the Likert-type scale regarding confidence, the authors grouped the numbers into the following categories: 0 (no confidence), 1 to 3 (less confident), 4 to 6 (more confident), and 7 (completely confident).
Data Analysis. Descriptive statistics were used to analyze student responses and for changes in confidence and perceptions. The disagree and unsure/don't know responses for the first group of questions were condensed into a single categorical response for comparison against the agree category by using the McNemar test for paired nominal data to test for statistical significance. Questionnaire items in the second group of questions assessing confidence using the 8-point Likert-type responses were analyzed using the Wilcoxon rank sum test for paired ordinal data to test for statistical significance. An alpha level of significance of 0.05 was used with no adjustments for repeated testing. IBM SPSS Statistics for Windows, version 26.0 (IBM Corp, Armonk, NY) was used to conduct the statistical analyses.
Results
Pre-Lab Questionnaire. Over 2 years, 187 of 221 second-year student pharmacists (85%) completed at least part of the questionnaire. Table 1 contains demographic information of the participants. Although most students (56.4%) reported having some pharmacy work experience, none of them had work experience in a children's hospital. Most students (88.4%) who reported having counseling experience at work stated they either never or rarely had the chance to counsel children regarding their medications.
Table 1.
Demographic Information
| Variable | n (%)* |
|---|---|
| Female, n = 180 | 126 (70.0) |
| Caregiver for children, n = 180 | 34 (18.9) |
| Pharmacy experience, overall, n = 181 | 102 (56.4) |
| Chain retail, n = 100 | 92 (92.0) |
| Children’s Hospital, n = 100 | 0 (0.0) |
| Compounding services offered at place of employment, n = 101 | 33 (32.7) |
| Opportunities to counsel patients at place of employment, n = 102 | 87 (85.3) |
| Frequency of counseling children regarding their medications, n = 86 | |
| Never | 42 (48.9) |
| Rarely | 34 (39.5) |
| Sometimes | 9 (10.5) |
| Often | 1 (1.1) |
| Frequency of counseling caregivers of children regarding their children’s medications (n = 86) | |
| Never | 3 (3.5) |
| Rarely | 17 (19.8) |
| Sometimes | 35 (40.7) |
| Often | 31 (36.0) |
* The survey instrument used skip logic, so some participants were not asked all of the questions. Additionally, participants were not required to answer a question if they did not want to, so the number of responses varied. The n for each item represents the total number of responses for that particular item and not the questionnaire as a whole.
Table 2 describes student responses regarding knowledge and comfort levels and confidence prior to the pediatrics skills lab. Approximately one-fifth of students did not feel comfortable counseling pediatric patients about medications. However, when looking at confidence regarding communication, approximately 10% of students reported being completely confident in communicating with children regarding medication-related topics. Regarding the level of confidence in clinical recommendations for children, there were very few students who answered completely confident for any of the questions. Only 10 students (5.8%) reported being completely confident in determining the appropriate milligram dose of medications for children.
Table 2.
Knowledge and Comfort Levels Pre- and Post-Lab
| Category | n (%) | ||
|---|---|---|---|
|
| |||
| Agree | Disagree | Unsure | |
| Knowledge, n = 177 | |||
| All pediatric patients should be counseled on their medications | |||
| Pre-lab results, n = 177 | 110 (62.2) | 40 (22.6) | 27 (15.2) |
| Post-lab results, n = 116 | 72 (62.1) | 39 (33.6) | 5 (4.3) |
| The level of medication counseling for pediatric patients is dependent on their age | |||
| Pre-lab results, n = 177 | 160 (90.4) | 11 (6.2) | 6 (3.4) |
| Post-lab results, n = 116 | 115 (99) | 1 (1) | 0 (0) |
| Caregivers should only be included in medication counseling for their children if their children are not present | |||
| Pre-lab results, n = 177 | 27 (15.3) | 146 (82.5) | 4 (2.2) |
| Post-lab results, n = 116 | 13 (11.2) | 101 (87.1) | 2 (1.7) |
|
| |||
| Comfort level, n = 177 | |||
| I do not feel comfortable providing medication counseling for pediatric patients | |||
| Pre-lab results, n = 177 | 38 (21.5) | 91 (51.4) | 48 (27.1) |
| Post-lab results, n = 116 | 12 (10.3) | 90 (77.6) | 14 (12.1) |
| I do not feel comfortable providing medication counseling for caregivers of pediatric patients | |||
| Pre-lab results, n = 177 | 9 (5.1) | 142 (80.2) | 26 (14.7) |
| Post-lab results, n = 116 | 8 (6.9) | 101 (87.1) | 7 (6.0) |
Post-Lab Questionnaire. A total of 116 students participated in the post-lab questionnaire over the 2 years. Table 2 describes student responses regarding knowledge and comfort levels or confidence after completion of the pediatrics skills lab. When surveyed regarding their level of comfort with medication counseling, approximately 10% of students still did not feel comfortable counseling pediatric patients. Regarding the level of confidence in clinical recommendations for children, overall more students answered completely confident compared with the pre-lab questionnaire. Thirty-three students (28.4%) reported being completely confident in determining the appropriate milligram dose of medications for children.
There was statistically significant improvement in 5 of the 7 confidence statements after the lab activities (Table 3). The items with the largest increase in score were related to determining the appropriate dose and volume of medications for children. Items that did not demonstrate a statistically significant improvement centered on communication with children on nonmedication related topics and communication with caregivers about medications. The respondents' confidence on these items were relatively high at baseline and remained high after the lab session.
Table 3.
Confidence Pre- and Post-Lab
| Category | n (%)* | Median (IQR) | p value | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
| ||||||||||
| 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | |||
| I can communicate with children regarding non-medication related topics | ||||||||||
| Pre-lab results, n = 171 | 0 (0.0) | 1 (0.6) | 3 (1.8) | 12 (7.0) | 24 (14.0) | 29 (17.0) | 35 (20.5) | 67 (39.2) | 6 (5–7) | 0.799 |
| Post-lab results, n = 116 | 0 (0.0) | 0 (0.0) | 3 (2.6) | 6 (5.2) | 9 (7.9) | 22 (19) | 37 (31.9) | 39 (33.6) | 6 (5–7) | |
| I can communicate with children regarding medication related topics at an appropriate level | ||||||||||
| Pre-lab results, n = 171 | 1 (0.6) | 1 (0.6) | 15 (8.8) | 33 (19.3) | 34 (19.9) | 45 (26.3) | 24 (14.0) | 18 (10.5) | 5 (3–6) | <0.001 |
| Post-lab results, n = 116 | 0 (0.0) | 1 (0.9) | 2 (1.7) | 9 (7.8) | 16 (13.8) | 44 (37.9) | 33 (28.4) | 11 (9.5) | 5 (5–6) | |
| I can communicate with caregivers regarding their child’s medications effectively | ||||||||||
| Pre-lab results, n = 172 | 1 (0.6) | 1 (0.6) | 2 (1.2) | 5 (2.9) | 26 (15.1) | 44 (25.6) | 52 (30.2) | 41 (23.8) | 6 (5–6) | 0.178 |
| Post-lab results, n = 116 | 0 (0.0) | 0 (0.0) | 0 (0.0) | 5 (4.3) | 7 (6.0) | 31 (26.7) | 49 (42.2) | 24 (20.7) | 6 (5–6) | |
| I can engage both the child and caregiver during medication counseling sessions at an appropriate level | ||||||||||
| Pre-lab results, n = 172 | 1 (0.6) | 3 (1.7) | 9 (5.2) | 22 (12.8) | 46 (26.7) | 42 (24.4) | 29 (16.9) | 20 (11.6) | 4 (3–6) | <0.001 |
| Post-lab results, n = 116 | 0 (0.0) | 1 (0.9) | 0 (0.0) | 8 (6.9) | 18 (15.5) | 35 (30.2) | 38 (32.8) | 16 (13.8) | 6 (5–6) | |
| I am able to determine the appropriate dose (in mg) of medications for children | ||||||||||
| Pre-lab results, n = 172 | 7 (4.1) | 5 (2.9) | 23 (13.4) | 29 (16.9) | 45 (26.2) | 33 (19.2) | 20 (11.6) | 10 (5.8) | 4 (3–5) | <0.001 |
| Post-lab results, n = 116 | 0 (0.0) | 1 (0.9) | 2 (1.7) | 10 (8.6) | 13 (11.2) | 19 (16.4) | 38 (32.8) | 33 (28.4) | 6 (5–7) | |
| I am able to determine the appropriate volume (in mL) of medications for children | ||||||||||
| Pre-lab results, n = 172 | 5 (2.9) | 7 (4.1) | 17 (9.9) | 30 (17.4) | 39 (22.7) | 29 (16.9) | 27 (15.7) | 18 (10.5) | 4 (3–6) | <0.001 |
| Post-lab results, n = 116 | 0 (0.0) | 1 (0.9) | 1 (0.9) | 9 (7.8) | 11 (9.5) | 18 (15.5) | 41 (35.3) | 35 (30.2) | 6 (5–7) | |
| I am able to determine the appropriate measuring device for liquid medications for children | ||||||||||
| Pre-lab results, n = 171 | 4 (2.3) | 2 (1.2) | 8 (4.7) | 19 (11.1) | 33 (19.3) | 40 (23.4) | 35 (20.5) | 30 (17.5) | 5 (4–6) | <0.001 |
| Post-lab results, n = 115 | 0 (0.0) | 1 (0.9) | 0 (0) | 6 (5.2) | 9 (7.8) | 18 (15.7) | 32 (27.8) | 49 (42.6) | 6 (5–7) | |
* 1, not confident at all; 7, completely confident
Students were also asked to rate their level of agreement with 5 statements related to certain pediatric topics and the conversion rate was determined (Table 4). The students' responses to these statements did not demonstrate statistically significant changes.
Table 4.
Perception Conversion Rates (n = 75)
| Questionnaire Item | Conversion Rate, %* | p value |
|---|---|---|
| All pediatric patients should be counseled on their medications | 16 | 0.0845 |
| The level of medication counseling for pediatric patients is dependent on their age | 12 | NA† |
| Caregivers should only be included in medication counseling sessions for their children if their children are not present | 9 | 1.0 |
| I do not feel comfortable providing medication counseling for pediatric patients | 4 | 0.508 |
| I do not feel comfortable providing medication counseling for caregivers of pediatric patients | 8 | 0.754 |
* Percentage of students converting to the intended (desired) perception.
† Not applicable; could not be calculated due to some cells having zeros.
Discussion
This is the first study to our knowledge specifically evaluating the perceptions and confidence of student pharmacists related to pediatric topics pre- and post-lab. However, Hutchison and Eiland10 conducted a study assessing the incorporation of age-related considerations (i.e., geriatrics, pediatrics) in a course sequence of pharmacy skills labs. The authors found over a 4-year study period that 89 of the 205 pharmacy skills lab sessions (43%) covered age-related concepts that included pediatric topics.10 Assessment items, including quiz, exam, and objective-structured clinical exam scores, were evaluated.10 Overall, the authors noted that the scores were satisfactory on these assessments with a mean ± SD difficulty index of 85.8% ± 12.8% on exams.10 Although the study examined the inclusion of pediatric considerations in a skills labs course sequence and found appropriate performance through assessment, it is unknown if the students felt confident and comfortable in their abilities related to pediatric topics.10
Johnson et al11 conducted a study in which they surveyed students who graduated from their college of pharmacy and completed their optional pediatric degree program, which included 16 required credit hours related to pediatric-focused content. Participants were sent a 30-item questionnaire, which included Likert-type questions regarding confidence in their abilities to complete a variety of tasks such as counseling children and caregivers and calculating doses.11 Nineteen of the 30 graduates (63.3%) who completed the optional program submitted the questionnaire.11 Approximately 74% of participants responded with high or very high confidence in counseling children.11 Furthermore, 100% of the participants responded with high or very high confidence regarding their ability to determine the dose in milligrams and volume in milliliters for children.11 Although there was a statistically significant improvement in students' confidence in all of these areas in our study, there were students who still reported a lack of confidence in these areas. This suggests the need for more than 1 lab session to practice these skills.
Work Experience. Although most students reported having work experience, none of them reported having worked in a children's hospital in this study. This is not surprising because there is only 1 children's hospital in our state, and it is located over 100 miles away from where the second-year student pharmacists are based. It is an important reminder that many of our students will not have the opportunity to gain experience in a pediatric environment as a student, so it is important to give students opportunities in the classroom to be exposed to a variety of pediatric topics.
Knowledge and Comfort. When students were asked questions regarding their knowledge of who should be included in medication counseling for a pediatric patient, the majority of students thought that all pediatric patients should be counseled on their medications and that the level of medication counseling for pediatric patients is dependent on their age before and after the lab session. Although the level of medication counseling is definitely dependent on the age of the patient, there would be some circumstances where pediatric patients should not be counseled on their medications. One example would be if the patient were classified in the sensory motor phase, which could be due to age, but also neurodevelopmental delay. When students were asked about their level of comfort providing medication counseling to pediatric patients and caregivers of pediatric patients, the majority of students before and after the lab session expressed being comfortable. It was surprising to the authors that the majority of students felt comfortable with counseling pediatric patients because the majority of students who have the opportunity to counsel patients during work reported minimal opportunities to counsel children regarding their medications. This is encouraging that students feel comfortable, but it is important to note that clinical performance was not assessed in this study, so it is not clear if comfort level matches with clinical competency.
Confidence: Medication Counseling. When evaluating students' level of confidence in ability to communicate with children regarding medications and to engage both the child and the caregiver during medication counseling sessions, there was a statistically significant improvement after the lab session. This result shows the benefit of the lab session; however, there were some students who reported being less confident in these areas, which suggests the need for additional activities.
Confidence: Dose Calculations. Overall, several students reported no confidence or being less confident in their abilities to determine the appropriate dose (milligrams) and volume (milliliters) for children prior to the lab session. This is important to note that some students are not confident in these areas and it is important not only to be able to determine the appropriate milligrams and milliliters based on a concentration as a pharmacist, but also to be able to help caregivers understand the appropriate amount to administer. It is encouraging to see that there was a large increase in confidence in these areas after the lab session; however, there were still some students who reported lower confidence in these areas based on the Likert scale used. This suggests the need for more hands-on experiences throughout the curriculum for students to practice these skills. Additionally, it is not clear if increased confidence correlates with change in skill performance.
Confidence: Dose Measurement. Similarly, there were several students who reported no confidence or being less confident in being able to determine the appropriate measuring device for liquid medications at baseline. This is important to recognize because student pharmacists who ultimately work in the community or a retail setting will be responsible for making sure the medication is dispensed with an appropriate measuring device, and there is variability in measuring devices available in retail pharmacies. Although, there was an overall increase in confidence after the lab session, there were still some students who reported lower confidence in this ability based on the Likert scale. The authors believe additional hands-on experiences throughout the curriculum using various measuring devices could be beneficial in further developing students' confidence in their abilities.
Limitations and Future Directions. There are a number of limitations. There was a limited sample size due to the number of students enrolled in the skills lab class each year. Additionally, because participation in the study was voluntary, not all eligible participants consented to participate. Furthermore, a fewer number of students participated in the post-lab questionnaire compared with the pre-lab questionnaire. Therefore, generalizability is limited given the sample size. Furthermore, schools and colleges of pharmacy have a variation in the breadth and depth of pediatric-related topics in the curricula that could limit applicability. In the absence of relevant, validated survey instruments, the questionnaires were developed de novo and this survey instrument was not tested before distributing to students. The authors recognize there could be some room for interpretation with some of the questions and some of the responses could vary based on certain situations. Additionally, the authors did not specifically assess knowledge, which could lead to a mismatch between comfort or confidence and competence. Gabbard and Romanelli12 wrote a review article evaluating the correlation between health professional students' self-reported confidence and competency. Twelve articles were summarized and several of the studies found that there was no correlation with self-confidence and competency.12 The authors of this review noted the importance in having competency as a primary outcome when having students report their confidence level.12 This suggests that in our study, although students' confidence increased in several areas, this may not have correlated with an increase in knowledge or mastery of content because competency was not assessed.
The authors believe that it is important to recognize that student pharmacists lack confidence in certain areas, including pediatric-related topics, and that there is variability in the degree of concepts introduced to pharmacy students. The results of this study are important in emphasizing that a skills lab can help improve students' perceptions of pediatric-related topics in some areas. However, the findings suggest that 1 skills lab will not improve confidence in all students. Therefore, this suggests the need for more opportunities for students to practice these skills and the need to further study students' comfort or confidence in more specialized areas, such as pediatrics. Of note, with our institution's new curriculum 1 of the required courses during the third professional year is a Pediatric/Geriatrics Pharmacotherapy Module. Through this course, there will be additional opportunities to explore these concepts. Additionally, it will be important to determine if there is a correlation with confidence and competency.
Conclusion
There has been a paucity of data on student pharmacists' comfort and confidence regarding pediatrics. Students demonstrated comfort in counseling pediatric patients before and after participation in the pediatric pharmacy–focused skills lab session. There was an increase in confidence in several areas after the lab session, including determining the appropriate dose, volume, and measuring device for medications. However, some students lacked confidence after the session in some areas, which suggests the need for more pediatric-focused activities throughout the pharmacy school curriculum. Future studies are needed to further explore students' perceptions of topics in specialty areas such as pediatrics and to determine if there is a correlation between confidence or comfort and performance on student assessment.
ABBREVIATIONS
- ACPE
Accreditation Council for Pharmacy Education
Footnotes
Disclosures. The authors declare no conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria. The authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Ethical Approval and Informed Consent. Given the nature of this study, the project was deemed as exempt by the institution review board, but student consent was obtained via a consent statement in the questionnaire.
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