The current complex and evolving health care environment is creating challenges for health care educators tasked with ensuring that students and health care professionals have sufficient skills and knowledge to undertake pharmacotherapy and medication management safely. Drug administration is the final step in the “medication process.” The multidisciplinary team shares responsibility of ensuring that medicines are safely administered to patients1; however, medication administration is extremely vulnerable to error, for example, wrong drug, dose, route, patient, or timing2 as well as inappropriate coadministration with food or interacting medicines. Retrospective record reviews indicate that adverse events affect 9.2% [interquartile range (IQR), 4.6%–12.4%] of those admitted to hospital, 15.1% (IQR, 11.9%–20.4%) are drug related, and 43% (IQR, 39.4%–49.6%) are preventable (n = 74,485 patients, 8 studies in the United States, Canada, UK, Australia, and New Zealand).3 When all health care settings are considered, estimates of the incidence of adverse events range from 0.1% to 65.4%, with little difference between countries, settings, or specialties (23,696,252 patients, 156 studies).4 A higher incidence is reported among elderly patients.5 Administration of intravenous medicines is particularly vulnerable to error, with 50% to 70% of doses affected,6,7 and there are reports of nurses failing to administer medicines.8,9 Hence, new and effective teaching methods for promoting safe pharmacotherapy are needed.10,11 One possibility is simulation-based teaching, which may afford appropriate and effective experiential learning for health care students and professionals.12
Previous systematic reviews (Table 1) have examined patient simulation as a teaching tool across a range of disciplines,14 its educational effectiveness,13 and its impact on attitudes toward patient safety outcomes.15 These reviews have focused on teaching perspectives. The main interest of this review is to consider pharmacotherapy and medicines’ management from the perspective of learning outcomes. We use the term patient simulation to mean full-scale high-fidelity simulation (HFS) with a patient simulator or standardized patient and pharmacotherapy to mean the medication process (prescription, administration, and monitoring of medicines) in the treatment of patients or service users by health care professionals, with main interest in administration phase.1,16 The aims of this integrative review were to identify evidence of the use of patient simulation teaching method in pharmacotherapy education and to explore the learning outcomes. We addressed the question “What are health care students’ or professionals’ learning outcomes when high-fidelity patient simulation is used for teaching pharmacotherapy?”
Integrative review methods summarize previous empirical studies with different research designs to provide a comprehensive understanding of a particular phenomenon. This present review is based on the framework reported by Whittemore and Knalf.17 A literature search was conducted in consultation with a librarian, searching databases PubMed, CINAHL, SCOPUS, ERIC, MEDIC (Finnish Medicine and Health Sciences Database), and Cochrane Library to obtain comprehensive search results. Broad search terms (MeSH, Medical Subject Headings) patient simulation and drug therapy were used where available. The key words used were as follows: patient simulation or high-fidelity simulation and drug therapy or drug administration or medication administration or pharmacotherapy. The search was limited to the decade 2003–2013 because of the rapid development in both simulation technology18 and medication competency requirements.19 The inclusion criteria were (1) evaluation of high-fidelity patient simulation; (2) focus on pharmacotherapy; (3) a learning or teaching perspective; (4) published 2003–2013; (5) written in English; and (6) publication in a peer-reviewed journal.17,20 Professional journal publications that were not peer reviewed, theses, opinion articles, and books were excluded.
Retrieval and selection (Fig. 1) were performed in 4 stages by 2 independent researchers. At each stage, discussions between researchers were conducted to reach a consensus over inclusion.
- Duplicates were removed, and the titles of studies were screened according to the inclusion criteria.
- Abstracts were read.
- Studies were read in their entirety.
- Reference lists were scrutinized. This identified one additional article. Altogether, 18 articles were included in the final review.
The methodological quality of each selected study was evaluated by 2 independent researchers, using the assessment form developed by Hawker et al.21 This assessment form comprises 9 sections: abstract and title, introduction and aims, methods and data analysis, sampling, data analysis, ethics and bias, results, transferability or generalizability, as well as implications and usefulness. Each of the sections was graded on a 1- to 4-point scale, where 4 indicated good quality and 1 indicated poor. Therefore, the maximum number of points available in the quality assessment was 36, and the minimum was 9. If the evaluations of the independent researchers differed, consensus was reached by discussion.
The 18 selected research articles were analyzed using qualitative content analysis17,22 tailored to the specific research question. In the first step, combinations of words or meaningful statements such as “opportunity to apply learning” and “knowledge of medication side effects increased” were chosen. Second, data were reduced to codes. Third, similarities and dissimilarities between codes were identified, and similar codes were grouped into classes. Finally, classes were further conceptualized into categories (Fig. 2).
From key word searches, 108 articles were identified; 18 articles met the inclusion criteria and were reviewed (Fig. 1). All selected studies achieved a total quality score of between 23 and 32 points (mean (SD) value, 28.1 (2.9) points) and were accepted for further analysis. The mean (SD) scores of quality for the different sections ranged from 2.2 (0.9) (ethics and bias) to 3.6 (0.5) (method and data). Differences in study methods, quality, and professions (nursing, medical, dental, and pharmacy) precluded combining studies.
Description of Included Studies
In the 18 articles, high-fidelity patient simulation was used in teaching pharmacotherapy or medication administration to nurses, nursing students, medical students or residents, pharmacy students or dental residents, and assistants (Table 2). Two of the studies were conducted in the UK, 1 in Germany, 1 in Canada, and 14 in the United States. All studies were published between 2005 and 2013 (Table 3). The sample sizes ranged from 13 to 222: in 1 study, the sample of 24 participants corresponded to 880 observations. Three participation randomized controlled trials were identified, and 1 study used cluster randomization. One study used qualitative methods, and 17 used quantitative methods; none seemed to be triangulated or mixed methods. The included articles’ designs, tests used, and learning outcomes are presented in Table 4.
Several positive learning outcomes of patient simulation in pharmacotherapy education were identified as follows: (1) commitment to pharmacotherapy learning, (2) development of pharmacotherapy evaluation skills, (3) improvement in pharmacotherapy application, and (4) knowledge and understanding of pharmacotherapy.
Commitment to Pharmacotherapy Learning
Overall, learners seemed to be satisfied with the use of patient simulation in pharmacotherapy teaching. Patient simulation was described as a motivating, a positive learning experience, and a good method for pharmacotherapy learning from the perspective of nursing students,37 dental residents and assistants,40 as well as medical24,38 and pharmacy students.34,36 Medical students reported enhanced commitment to learning when the patient simulation was used,30 and 22 (76%) of 29 of pharmacy students preferred simulation to problem-based learning (PBL) or didactic lectures.26
Development of Pharmacotherapy Evaluation Skills
The development of diagnostic and therapeutic accuracy was reported in 7 studies. Simulations enhanced nursing, medical, and pharmacy students’ and residents’ responses to patients’ needs in simulated clinical situations because of opportunity to practice problem-solving skills, including medication reconciliation, ventricular tachycardia, and overdose of sedatives in dental practice.23,24,26,35,37,38,40 Confidence was enhanced in nursing students’ pediatric medication administration33 and in pharmacy students’ abilities in recognizing, preventing, communicating, and reporting medication errors.32 Improved critical thinking was reported in pharmacy students’ management of critically ill patients34 and acute care pharmacotherapy.26
Improvement in Pharmacotherapy Application
Seven studies reported improvement in medication administration skills.23,25,27,28,30,33,37 Improvement in skills was evidenced by nursing students making fewer medication errors in clinical placements25 and calculating more doses and dilutions for pediatric medication administration safely33; nurses’ performance during cardiac arrest28; and a significant decrease in nurses’ medication administration errors.27 Obstetrics and gynecology residents training for eclampsia and magnesium toxicity management by simulation showed a 75% improvement in potentially harmful actions, including magnesium overdose, compared with lectures alone.23 Similarly, medical students’ medication administration skills improved after an online module and patient simulation teaching compared with lectures alone or lectures plus online module. These skills were retained for 9 months.33
Knowledge and Understanding of Pharmacotherapy
Increased knowledge was reported in several studies, for example, concerning medication safety and medicines’ adverse effects,31,32,36,37 correct dosages and dilutions,33 as well as acute care29 and cardiovascular pharmacotherapy.34,35 Pretest/posttest knowledge scores increased significantly in all studies,29,32–34 including those with active comparators26; however, in study of Ford et al,27 there were no differences between improvement in pretests/posttests of simulation and lecture groups. Wheeler et al30 observed that students who received teaching including simulation were significantly (P = 0.03) more likely to pass the final examination 9 months later.
Because all medicines, however necessary and appropriate, can have adverse effects, sometimes independent of dose administered,41,42 health care professionals’ knowledge remains a cornerstone of safe pharmacotherapy19 and features as a key “individual factor” in all patient safety frameworks and models.43–45 Patient simulation enhances important learning outcomes including commitment to pharmacotherapy learning, evaluation, application, knowledge, and understanding of pharmacotherapy and may decrease medication errors.15,23,25,27 There were no reports of dissatisfaction with simulation teaching methods, and comparisons against other teaching methods were generally favorable.
The Strength of the Evidence
The limitations of the research designs in many of these studies should be considered. Three studies used individual randomization. Two studies randomized students into simulation and lecture23 or PBL arms,26 and in 1 study, students were randomly allocated to simulation and clinical training arms.25 One study was cluster randomized and allocated groups into simulation and lecture arms.24 Three studies had no comparator data (Table 4).
Most studies (n = 10) used pretest/posttest designs, but only 4 had comparator groups.27–30 In 3 of these, medication administration skills were enhanced. In addition, there were improvements in nurses’ medication administration error rates,27 nurses’ medication administration in code blue (cardiac arrest) situations,28 and medical students’ medication administration skills.30 Two of these comparison group studies reported greater and more sustained improvement in knowl edge gain for HFS arms than for lecture arms.29,30 This consistency across settings, professions, and research designs strengthens the evidence for the efficacy of HFS teaching but does not discount either the Hawthorne effect—both teachers and students were aware of being observed46—or the Rosenthal expectancy effect.47 We identified little work on the potential bias in these reports, and further work is needed to explore volunteer bias, response bias, and generalizability.
In all 6 of the 1-group pretest and posttest studies, scores in knowledge-based tests improved.31–36 Studies without comparator groups also reported enhancement of understanding and self-confidence.32,37–40
Educators of health care professionals need to identify best practice in relation to pharmacotherapy and patient safety48 and develop a taxonomy of learning.49 Learning outcomes identified in this review correspond mainly to cognitive learning—knowledge and its application. However, some psychomotor skills, in medication administration, and affective learning (commitment and motivation) domains were evident.50,51
Limitations and Strengths
There are several issues to consider when evaluating this review. In integrative reviews, the complexity of combining diverse methods and multiple research designs can reduce rigor. Systematic methods for comprehensive literature searching and data analysis aim to maintain validity and reduce bias.17 This review focused entirely on HFSs; hence, studies using low- or medium-fidelity simulations were excluded.
The strength of this review is the synthesis of evidence across professions, settings, and study designs. Structured, integrative reviews are an essential component of evaluation of the educational and clinical effectiveness of new teaching methods in areas of the professional curriculum that underpin patient safety.
Wider Implications: An Evidence-Based Curriculum
If health care educators are to move toward an “evidence-based curriculum,” some restructuring of courses may be needed. Priorities should be set and decisions should be made, based on the results of reliable and valid research into the clinical outcomes of education initiatives. To evaluate courses and demonstrate educational effectiveness solely in terms of student satisfaction is not enough; to survive in the world of evidence-based care, educators must also demonstrate their contribution to clinical effectiveness.52 Some of the studies evaluated here adopted rigorous methods and evaluated clinical outcomes. Nonetheless, many studies were small, and most were single site. Resources are needed to ensure that all curriculum components are subjected to adequate scrutiny. However, the scale5,6 and seriousness of medication mismanagement8,9,41 suggest that investment in this area of the curriculum should be prioritized.53 Although further research is needed, the results of this review are encouraging to teachers using simulation methods for pharmacotherapy learning. More research is needed to determine and clarify the precise clinical impact of simulation, and at present, available evidence is too weak54 and insufficient to mandate curriculum reorganization. Health care professionals, particularly doctors, are unlikely to accept change without evidence from clinical trials.55,56 Accordingly, we propose to undertake randomized controlled trials and studies using comparator groups with before, after, and long-term follow-up measurements to test the hypothesis that simulation learning improves knowledge, performance, and clinical outcomes when compared with the “usual education.” In addition, mixed methods-research will enhance the comprehensive development of best practice and the theoretical basis of simulation learning in pharmacotherapy because these methods allow hypothesis testing and theory generation in a single study.57
Adverse events affect 9.2% of inpatients, and 15.1% are drug related.3 Higher incidence among elderly patients and administration of intravenous medicines are also reported.5–7 Thus “medication error and drug incident” problem is a major threat to patient safety,58 and it is extremely important to identify higher risks prone to error among patients, clinical settings, or phase of medication process.2,5–7 In addition, knowledge deficit is recognized as an etiologic factor.44,45 Hence, for the promotion of safe pharmacotherapy and to decrease adverse events, for example, these sectors should be addressed and effective teaching methods should be developed to ensure medication competence for health care students and professionals. On the basis of this study, high-fidelity patient simulation seems to increase cognitive learning, skills, motivation, and commitment to learning, all of which are important in promoting medication and patient safety. The number and size of studies focusing on the use of simulation in pharmacotherapy education is still limited; thus, there is a need for further research in the health disciplines.
We found no evidence of large-scale, multisite research to develop evidence-based learning strategies to remedy the situation. Rather, the field was characterized by local, small-scale initiatives led by dedicated, but underresourced, teachers.
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