Hello Operator? A Pharmacy Practice Simulation to Increase Student Confidence in Telephone Communication Skills

Abstract

Background: Communicating interprofessionally using the telephone is an essential skill within pharmacy practice. Student pharmacists’ ability to perform this task effectively and efficiently may be hindered by generational changes, social anxiety, and very few opportunities to practice these skills. Objective: The purpose of this study was to develop and implement a simulation allowing students to practice interprofessional communication and assess the simulation’s impact on students’ confidence in providing pharmacy-related interventions to another health care professional via telephone. Methods: Faculty developed a simulation focused on interprofessional telephone communication. Baseline student information was collected to quantify pharmacy work experience in terms of practice setting, duration of employment, and skills. Presimulation and postsimulation surveys evaluated self-assessed telephone-related skills, attitudes, and confidence. Quantitative data were analyzed with descriptive statistics. Qualitative data were evaluated through a thematic analysis of students’ reflective responses to 2 open-ended questions. Results: Of the 53 pharmacy students that participated in the simulation, 44 (83%) and 43 (81%) completed the anonymous presimulation and postsimulation surveys. Students significantly improved as reflected in the following response: “I have confidence in my ability to provide pharmacy-related interventions to another health care professional in a logical and concise manner via telephone call.” Significant improvement also occurred in the ability to work independently, communicate an order change to another health care professional, justify recommendations, answer a drug information question, and discuss recommendations in a logical and concise manner. Conclusion: The simulation discussed in this article provided students an opportunity to practice interprofessional telephone communication in a low-risk environment and resulted in significant growth in confidence and skills.

Introduction

Effective communication is vital to pharmacy practice. Pharmacists may need to communicate with prescribers to clarify prescriptions, improve the effectiveness of therapy, address safety concerns, and decrease the cost of medications.^{1 -4} In addition, pharmacists communicate with a variety of other health care professionals regarding drug information questions and transitions of care.^5,6 Common methods of communication utilized in pharmacy practice include fax, telephone, face-to-face communication, electronic health record messaging, and written documents.^{2 -7} The telephone is a common and preferred method of communication between pharmacists and other health care professionals in pharmacy practice.^{2 -4,8}

Although important to pharmacy practice, telephone communication can be hindered in many ways, one of which may be the communicator’s ability and confidence to communicate via telephone. Speaking on the phone to an unfamiliar person is a social interaction that may be anxiety provoking, as it requires real-time, spontaneous verbal output. ⁹ Several studies have found that individuals with social anxiety prefer text messaging over telephone calls or face-to-face interactions.^{10 -12} Additionally, the technology used for interpersonal communication has evolved over the years. Social media, email, and instant messaging are preferred methods of communication, especially for individuals born after the year 1980. ¹³ These changes in personal communication technology further indicate a need for telephone communication exposure in Doctor of Pharmacy (PharmD) curricula.

The Accreditation Council for Pharmacy Education (ACPE) requires PharmD programs to teach and assess communication skills. ¹⁴ Multiple instructional methods exist to enhance the learning of communication skills by pharmacy students, including in-person and virtual simulations, interdisciplinary activities, lectures, and pharmacy practice experiences.^{15 -18} Among these instructional methods, role-play is a popular approach.^{18 -20}

Learning activities that enhance general communication skills using a telephone have been studied in the recent past.^16,17,19 One study described a telephone simulation consisting of pharmacy student learners and their ability to communicate pharmacotherapy recommendations using the SBAR (situation, background, assessment, recommendation) technique. ¹⁶ Another study used a telephone simulation to assess pharmacy students’ ability to answer a drug information question and to improve communication and professionalism skills. ¹⁹ This study differs from previous research as it focuses specifically on improving telephone communication skills within pharmacy practice, focusing on interprofessional scenarios.

The objectives of this study were to (1) design and implement a multistation telephone call simulation focusing on various pharmacy practice scenarios requiring interprofessional communication; (2) assess the impact of the simulation on students’ confidence in providing pharmacy-related interventions to another health care professional via telephone call; and (3) identify themes in student learners’ perceptions about the simulation.

Methods

Simulation Logistics and Flow

First-year pharmacy students at a single institution completed a 16-week skills laboratory course the semester prior to their community-based Introductory Pharmacy Practice Experience (IPPE). The skills course consisted of a weekly 1-hour didactic lecture followed by a 2-hour laboratory session for students in groups of 18-20. The School of Pharmacy faculty received informal feedback from preceptors that students’ ability and confidence to communicate via telephone has dramatically decreased, likely due to changes in the technology used for personal communication on a daily basis. To further enhance phone call communication skills and confidence, the faculty developed a simulation to expose all students to various scenarios that require telephone communication in interprofessional topics.

Students completed 5 different case stations simulating various telephone interactions commonly encountered in community pharmacy practice. These cases were mapped to the 2016 ACPE Standards and are described in Table 1. The phone call simulation was designed to accommodate up to 10 students for a time period of over 40 minutes. While completing the simulation, groups were divided into subgroups A and B. Group A started off by rotating through each of the 5 stations, serving the role of a pharmacist. Group B students were assigned to a single role-play station for the length of the other group’s rotation. Group B students were separated from those completing the activity and given a script with suggested responses and prompts to help guide them through their assigned role-play scenario. After all students rotated through the stations, the 2 groups switched roles. Phone calls were completed using closed-loop handheld telephone systems. Figure 1 shows a schematic of the simulation.

Table 1.

Phone Call Speed Dating Simulation Cases Mapped to ACPE Standards and Appendix 1.

Case	Case description	ACPE standards/Appendix 1
Receive a call  Case 1: A pleasant and appreciative physical therapist calls with questions about a patient’s medications	Requires student to provide information about pharmacy operations and extrapolate how long it will take for a medication to work based on half-life and absorption information	Standards  1.1, 3.6, 4.4 Appendix 1  Pharmacokinetics  Professional communication
Make a call  Case 2: A student calls an annoyed and dismissive provider for a medication change	Provider answers the phone very abruptly, continuously interrupts and asks the student to hurry, and dismisses the student’s concerns	Standards  2.1, 3.3, 3.4, 3.6, 4.4 Appendix 1  Professional communication
Make a call  Case 3: A student calls to obtain a verbal prescription from a new nurse with little experience	The nurse asks the student pharmacist for guidance on what information to provide for a verbal order and forgets certain aspects, requiring the student to request information	Standards  3.4, 3.6, 4.4 Appendix 1  Professional communication  Professional development/social and behavioral aspects of practice
Receive a call  Case 4: A home health nurse calls to ask for help educating a patient on using their inhaler	The nurse asks for guidance on how to administer the Spiriva inhaler for a home care patient, prompting the student pharmacist to counsel on medication use	Standards  1.1, 3.2, 3.4, 3.6, 4.4 Appendix 1  Professional communication
Make a call  Case 5: Students asks for a medication change from a very skeptical, experienced nurse	Students ask for a change in the antibiotic due to the patient’s allergy The nurse states “Is Augmentin not safe if the patient is allergic to penicillin? I thought these were 2 different medications?”	Standards  2.1, 3.3, 3.4, 3.6, 4.4 Appendix 1  Professional communication Professional development/social and behavioral aspects of practice

Standards: 1.1, foundational knowledge; 2.1, patient-centered care; 3.2, education; 3.3, patient advocacy; 3.4, interprofessional collaboration; 3.6, communication; 4.4, professionalism.

Abbreviation: ACPE, Accreditation Council for Pharmacy Education.

Figure 1.

Telephone simulation schematic. A schematic representation of the telephone call simulation showing group A (outside circle) and group B (inside circle). Students in group A rotated through each pharmacist station for 5 cases while students in group B role-played members of the interprofessional team.

Didactic content was delivered in the 1-hour prelab lecture and included topics such as the professional way to answer the telephone and to make a telephone call, how to justify changes to therapy recommendations, the use of nonaccusatory language, and concise yet efficient telephonic communication techniques. Modeling of appropriate telephone communication was also conducted by the faculty. Students were given approximately 3 to 4 minutes to complete each station. Simulation materials included acting scripts, and information and case worksheets for students playing the pharmacist role can be accessed here: https://tinyurl.com/4dn8xy42

Case worksheets included all the information needed for the call, including who they were calling, what they were calling about, and pertinent drug information resources that may be needed for some scenarios. Students were required to document outcomes of the call in the case worksheets in accordance with legal requirements. Students were not graded on this work as it was designed to be an immersive, formative experience.

Students either made a call or received a call from another health care professional such as a nurse, provider, physical therapist, etc. Case scenarios included increased communication skill application, such as justification of medication recommendation, explanation of complex medical information in understandable terms, dealing with dismissive and abrupt behavior, and complex medication device training via telephone. A 10-minute debrief session was conducted with each small group upon completion of the simulation to assess students’ opinions and answer immediate questions. Due to time constraints, a longer, more in-depth rundown of each scenario and how a pharmacist may appropriately handle the situation was emailed out to students following the simulation.

Assessment Data Collection

In the week leading up to the lab session, the research team sent the students a presimulation survey via Qualtrics to gather self-assessed baseline information to quantify pharmacy work experience in terms of practice setting, duration of employment, previous experience related to making medication-related recommendations to another health care professional, and telephone calls made at work as well as for personal use. In both the presimulation and postsimulation surveys, a list of questions was included based on the SBAR grading tool utilized in previous work by Brust-Sisti et al. ¹⁶ The SBAR technique, and its associated grading tool, is a method that can be incorporated into a professional health care curriculum to enhance students’ ability to communicate information logically and concisely. An additional question used in both surveys, related to a pharmacist’s telephone communication skills, was drawn from a questionnaire used by Jin et al. ¹⁸ Lastly, 2 open-ended questions were used on the postsimulation survey. These questions asked students to provide comments addressing what they enjoyed most about the simulation and how they will apply learned skills in their future IPPE, advanced pharmacy practice experiences, and in practice at their places of employment. Both the presimulation and postsimulation survey were answered anonymously by the students.

Data Analysis

Quantitative data from the presimulation and postsimulation surveys were analyzed with descriptive statistics. The analysis of variance, single-factor, test for unmatched samples was used to analyze the differences between the mean scores of the students’ self-assessed communication skills, attitude, and confidence level. A P value < 0.05 was considered statistically significant for all analyses. All statistical analyses were performed using Microsoft Excel 2019. Qualitative data were collected through a thematic analysis of students’ reflective responses to the 2 open-ended questions. Reflections were analyzed using a conventional content analysis through memoing, brief coding, labeling key thoughts, and code identification. A consensus codebook was created to guide the analysis of the reflections. The North Dakota State University Institutional Review Board approved this study.

Results

Of the 53 pharmacy students that participated in the simulation, 44 (83%) and 43 (81%) completed the anonymous presimulation and postsimulation surveys, respectively, and consented to allow the researchers to use their responses. Of the 44 students, 24 worked as community pharmacy interns, 8 as hospital/institutional interns, 9 worked in both settings, and 3 did not work. The mean amount of time worked as a pharmacy intern to date was 20 months (standard deviation [SD] 12.3 months). Fourteen of the 44 (32%) students had previous experience in making medication-related recommendations to another health care professional at work via any of the following routes: telephone, fax, email, face-to-face talk, direct message. The mean number of recommendations made through any of these methods was 2.3 (SD 8.1). In the past 2 weeks prior to the simulation, this cohort reported that they made approximately 5 (SD 1.5) phone calls for personal (nonwork) reasons on their own phone.

According to the presurvey and postsurvey responses to the questions listed in Table 2, students significantly improved as reflected in the following response: “I have confidence in my ability to provide pharmacy-related interventions to another health care professional in a logical and concise manner via telephone call.” Students experienced significant improvement across all 5 questions outlined in Table 3. These questions highlighted telephone communication skills such as communicating a change in an order to another health care professional, justifying a recommendation for a change in order, answering a drug information question, and discussing recommendations in a logical and concise manner. Additional questions in Table 3 are anchored around a situation where it is imperative for the student to call the provider to change the dose of a medication to treat the patient most effectively. Students significantly improved in abilities to explain their reason for the call, provide pertinent information regarding the reason for the call, summarize facts to support their recommendation, and explicitly state the new recommendation. One last question not included in the tables asked the students which method of communication is most effective and efficient for communication with another health care professional. The answers were similar before and after the simulation. Telephone call and face-to-face verbal communication were rated the highest, 19 and 17 responses, respectively. Followed by direct message (7 responses), email (1 response), and fax (no responses).

Table 2.

Students’ Perspectives Before and After Completing a Telephone Communication Simulation.

Question	Presimulation, mean (SD)	Postsimulation, mean (SD)	P value
Telephone is an effective and efficient method of communicating with another health care professional.	3.75 (1.42)	4.08 (1.23)	0.231
I have confidence in my ability to provide pharmacy-related interventions to another health care professional in a logical and concise manner via telephone call.	3.61 (0.92)	4.11 (0.90)	0.006
Telephone communication with other health care professionals is part of a pharmacist’s job.	4.45 (1.17)	4.70 (0.79)	0.181
In order to be a good pharmacist, I must have good telephone communication skills.	4.34 (1.22)	4.57 (0.72)	0.187
Learning telephone communication skills applicable to the pharmacy profession is interesting.	3.98 (1.15)	4.24 (0.96)	0.188

1= Strongly disagree, 2 = somewhat disagree, 3 = neutral, 4 = somewhat agree, 5 = strongly agree.

Abbreviation: SD, standard deviation.

Table 3.

Students’ Self-Rated Ability to Perform Telephone Communication in a Health Care Setting.

Question	Presimulation, mean (SD)*	Postsimulation, mean (SD)*	P value
In the pharmacy setting, I can independently answer the telephone and answer questions for the caller.	62.09 (19.09)	80.97 (14.94)	<0.001
In the pharmacy setting, I can communicate a change to a medication order to another health care professional via telephone call.	50.45 (28.18)	84.19 (15.93)	<0.001
In the pharmacy setting, I can justify my reasoning for a change to a prescription to another health care provider via telephone call.	49.00 (27.65)	78.70 (17.63)	<0.001
In the pharmacy setting, I can answer a drug information question for another health care provider via telephone call.	37.64 (23.60)	69.92 (20.66)	<0.001
In the pharmacy setting, I can discuss a recommendation with another member of the health care team in a logical and concise manner via telephone call.	47.95 (25.11)	80.35 (16.86)	<0.001
Imagine you must call the provider to change the dose of a medication to most effectively treat the patient. Rate your ability to do the following: Introduce yourself to the health care professional’s office	90.27 (12.69)	93.65 (8.66)	0.095
Explain in brief the reason for the call	82.43 (15.91)	91.22 (9.20)	0.001
Provide pertinent information regarding the reason for the call	80.30 (18.90)	88.03 (11.13)	0.011
Summarize the facts to support your new recommendation	63.50 (21.90)	82.08 (16.90)	<0.001
Explicitly state your recommendation for the new/changed therapy	65.82 (22.68)	85.51 (13.81)	<0.001

^*Student response scale: 0 = poor to 100 = can perform the skill at the level of a licensed pharmacist.

Abbreviation: SD, standard deviation.

Analysis of the reflective responses to the 2 open-ended questions resulted in emerging themes. The 3 main themes included (1) safe environment to receive repetitive practice, (2) practice-readiness, and (3) increased confidence.

Theme 1: Students noted the activity was a positive learning experience as it afforded repetition and provided an opportunity to practice in a safe environment. One student commented “I enjoyed experiencing the various scenarios we could encounter to get practice with different types of conversations that we will have.” Another student commented that they enjoyed “Getting experience with making phone calls since this isn’t something I have had to do.”

Theme 2: Students noted the scenarios were authentic and created a sense of practice-readiness. Additionally, application of prior knowledge was a noted valuable component of the simulation. “The unexpected really allowed me the opportunity to let my need for preparation go down, and just rely on my knowledge.”

Theme 3: When asked how the students will use what they learned during the simulation in the future, the primary finding was that the simulation increased confidence to afford readiness to perform. A student commented that “I won’t be afraid to answer the phone and can confidently fulfill duties that involve communication via telephone.” Students noted they will be comfortable answering the phone on their community IPPEs and effectively communicating with interprofessional and intraprofessional health teams. Another student noted “I will be more comfortable answering phone calls and making phone calls to a provider.”

Discussion

This study utilized a multistation simulation to foster confidence and growth in telephone communication skills for first-year professional pharmacy students. Although a majority of the cohort (91%) had pharmacy intern experience, only about one-third reported previous experience with making medication-related recommendations to another health care professional, supporting the need for integration of this topic into pharmacy education. As a result of completing the simulation, students reported a significant growth in multiple areas of survey responses, aligning with previous studies finding increased student confidence and skills after simulations.^16,19,20 Although beyond the scope of this study, based on what was learned about the cohort’s background and the results of the data analysis, the researchers hypothesize that the timing of this simulation was ideal in the curriculum. The confidence and skills learned early within the professional curriculum perhaps will serve as a catalyst for further development in their places of employment, as well as in their community IPPE directly following the end of the semester.

Even with constant technological advancements including the implementation of electronic prescribing, interprofessional communication is imperative to provide safe patient-centered care. Pharmacists, and student pharmacists, have an important role in fulfilling accurate and appropriate prescriptions by clarifying medication dosing, directions, and any other vital prescription information. ² Literature shows that providers prefer when recommendations are well communicated and to the point due to their demanding schedules. ¹ The activity was designed to be fast-paced, and students were given a time limit of 3 to 4 minutes to intentionally reinforce the idea that interprofessional phone calls should be thorough but efficient.

Advances in technology-based communication (eg, instant messaging) have led to a decrease in face-to-face or telephone interactions, especially for more recent generations.ٰ ¹³ Those born post 1980 are highly dependent on communication through digital tools, and while some may have experience with face-to-face communication, a majority still prefer digital methods. Additionally, studies have shown a connection between social anxiety and a higher dependence on digital messaging.^9,10,11,12 Individuals with social anxiety may prefer digital messaging due to the lack of spontaneity compared with interactions involving verbal output. ⁹ Lack of experience with verbal communication may also lead to higher occurrence of social anxiety due to fear of the unknown associated with these interactions. Despite continued advancements in technology and a shift in generational preferences, there will likely remain the need for pharmacists to communicate directly by telephone. Continued practice of these skills, especially in low-stake environments such as simulations, may help mitigate the anxiety surrounding interpersonal communication and help future professionals develop necessary skills such as confidence and composure. ¹³

An identified limitation was that students who completed the acting portion of the activity first became aware of the station that they would later participate in as the learner. A way to mitigate students becoming privy to any of the stations prior to going through them would be to use nonstudent actors; however, obtaining volunteers who are willing and able to give their time during the week is often a difficult task. The researchers also hypothesize that the acting students gained valuable skills by hearing their peers communicate in varying strategies. Additionally, a potential limitation could be the scales used in the surveys. A rating of 0 to 100 could be difficult for a student to determine as a lot of subjectivity exists within this range.

Conclusion

Evolution of personal communication technology, including text messaging, social media, and instant messaging, can lead to social anxieties and decreases confidence in the ability to communicate with the interprofessional team via telephone. However, the telephone remains the common and preferred method of communication within community pharmacy practice.^{2 -4,8} The phone call speed dating simulation provided students an opportunity to practice telephone communication with the interprofessional team in a low-risk environment and resulted in significant growth in self-assessed confidence and skills. This simulation topic could be an important addition to the PharmD curricula at schools of pharmacy.