NMA: Nonprescription Medicines Academy

ABSTRACT

Objective: To evaluate pharmacy students in an elective nonprescription medication course using the Objective Standardized Clinical Exam (OSCE).

Methods: The students’ average grades in the current course were compared to previous grades. Also, student performances between the OSCE cases were compared and student evaluations of the course were examined.

Assessment: The course revisions provided students with an enhanced mechanism for evaluation of their self-care education and skill development for students. This had no effect on students’ overall grade in the elective compared to previous years and the overall student evaluations of the course were similar. Conclusion: The addition of the OSCE to the elective course allowed the student a more realistic experience in dealing with nonprescription medicine patients.

INTRODUCTION

Nonprescription medicine and self-care are important aspects of pharmacy practice. Yet due to curricular constraints in many US Colleges of Pharmacy, nonprescription medicine training is dispersed throughout a curriculum and students may not have a chance to adequately practice the application of self-care prior to beginning their experiential coursework.

COURSE BACKGROUND

In addition to a required nonprescription medication course, students at the University of Arkansas for Medical Sciences COP have the opportunity to take an elective advanced nonprescription course during the third year (P3). This course is divided into a lecture format and recitation. The lecture –based materials are tested at the mid-point using a multiple-choice exam. Students are tested on the didactic material plus what they learned in recitation using one OSCE at the end of the course. In recitation, the students are given basic information about a patient and their chief complaint. The students ask the recitation leader questions using the QuEST SCHOLAR method to obtain the information they need to triage and treat appropriately. The students then document the encounter via a SOAP note and present their recommendations.

The OSCE was created based on cases in the areas of constipation, smoking cessation and headache and takes place in the University’s Center for Clinical Skills Education (CCSE). The encounters are graded by standardized participants (SP) who are recruited from a database of community participants who are paid for their time. The OSCE is graded by the SPs using detailed rubrics developed for the cases. The encounters between the students and SPs are graded in real time but the encounters are digitally recorded and available to faculty for viewing. Prior to the exam the SPs were provided detailed training in the CCSE on their respective cases and instructed on how to interact with the students. The training included a practice experience on the case where facultymembers role-played examples of how an excellent student might perform as well as how a poor student might perform. SPs graded the practice role-plays and discussed grading as a group in order to ensure standardization of grades.

The grading rubric is a checklist of specific items on which the student is marked pass or fail. Each rubric contains 8-15 clinical knowledge items and nine communication checklist items. SPs also provided their “overall impression of student performance” by choosing a designation of outstanding, clear pass, borderline or clear failure. Each of these categories of overall performance are discussed and agreed upon with the SPs grading each case. This question allowed the results to be normalized if needed. In addition, the SPs indicated whether they would return to the student based on the encounter. However, neither of these global impressions counted towards the student grade on the case.

RESULTS

Thirty-four students in their P3 year took the elective. The average grade on the OSCE final was 78% with scores ranging from 61% - 91%. However, all students made a final letter grade of either an ‘A’ or a ‘B’ in the course.

Student performance on each case was similar. The average scores were 79%, 80% and 77% for the constipation, smoking cessation and headache cases, respectively. However, there was a difference in the SPs overall impression between the cases. The SPs rated the student performance as “clear pass” or “outstanding” in 74%, 62.5%, and 35.3% of the students for the constipation, smoking cessation, and headache cases respectively. Approximately 56% of students were rated by the SP at a “borderline” level for the headache case, compared to 20% of students for the constipation and smoking cessation cases. The smoking cessation case had the highest percentage of student performance (19%) being rated as “clear fail”.

Overall, student assessments of the course were good. Items were rated on a 5 point Likert scale where 1 represented “strongly disagree” and 5 represented “strongly agree.” The overall course evaluation median score was 4.0. Student comments were that the course overall was beneficial and that they appreciated the OSCE , despite apprehension in taking this type of exam.

DISCUSSION

Nonprescription medication counseling differs from prescription counseling in that diagnosis must be made by the pharmacist prior to making a recommendation for a patient. Using an OSCE for the final exam in the elective demonstrated that for the constipation and smoking cessation cases, the students made a correct diagnostic decision prior to making a recommendation. However, based upon the overall impressions of the SPs, in the headache case students had difficulty recognizing when to refer a patient who was not a candidate for self-care.

In the case the patient presented with a headache of more than 12 hours duration and symptoms that indicated a migraine. If asked the SP informed the student that they had never been diagnosed with migraines and the pain was ‘the worst headache they had ever experienced’. Thisshould have led the student to immediately refer the patient to her physician or an emergency room, rather than offer a recommendation for treatment. However, only 27% of the class referred the patient for immediate medical attention. Of note, more than 80% of the SPs gave the students credit for referring them to the primary care provider. This contrasted to what faculty observers witnessed while watching students’ live performances. Upon review of the encounters, faculty were able to determine that SPs had interpreted ‘referral’ as any reference to follow-up with their primary care provider.

SUMMARY

The data presented from the elective nonprescription medicines course demonstrates that students learning and application was occurring. It also reveals that more emphasis needs to be placed on determining when it is appropriate to refer patients seeking nonprescription medications. Faculty in all nonprescription courses at the College will try to ensure that students understand that not making a recommendation for a product may be the most appropriate recommendation. In addition, students found value in the OSCE assessment, even though at times they felt uncomfortable during the process. Also, faculty take steps to ensure that the SP’s and faculty are defining technical terms identically to improve the experience for future students.