Accepted Manuscript Title: Evaluating an Online Pharmaceutical Education System for Pharmacy Interns in Critical Care Settings Author: Yu-Ting Yeh Hsiang-Yin Chen Kuei-Ju Cheng Su-An Hou Yu-Hsuan Yen Chien-Tsai Liuindicates equal contribution. PII: DOI: Reference:
S0169-2607(13)00378-7 http://dx.doi.org/doi:10.1016/j.cmpb.2013.11.006 COMM 3699
To appear in:
Computer Methods and Programs in Biomedicine
Received date: Revised date: Accepted date:
26-4-2013 11-11-2013 12-11-2013
Please cite this article as: Y.-T. Yeh, H.-Y. Chen, K.-J. Cheng, S.-A. Hou, Y.-H. Yen, C.T. Liu, Evaluating an Online Pharmaceutical Education System for Pharmacy Interns in Critical Care Settings, Computer Methods and Programs in Biomedicine (2013), http://dx.doi.org/10.1016/j.cmpb.2013.11.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
*Manuscript
Evaluating an Online Pharmaceutical Education System for Pharmacy Interns in Critical Care Settings
Yu-Hsuan Yen3,5, Chien-Tsai Liu4,*
Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical
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1
University, Taipei, Taiwan
Information Technology Office, Shuang Ho Hospital, Taipei Medical
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2
University, Taipei, Taiwan
Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei,
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3
Taiwan
Graduate Institute of Biomedical Informatics, College of Medical Science and
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Yu-Ting Yeh1,2,#, Hsiang-Yin Chen3,5,#, Kuei-Ju Cheng 3,5, Su-An Hou4,
Technology, Taipei Medical University, Taipei, Taiwan Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University,
Taipei, Taiwan
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*Corresponding author: Dr. Chien-Tsai Liu Mailing Address: 250 WuXing Street, Taipei, Taiwan 110 Telephones: +886-2-27361661 ext 3342 Fax: +886-2-27339049
E-mail: [email protected]
# indicates equal contribution. 1
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Abstract Incorporating electronic learning (eLearning) system into professional experimental programs such as pharmacy internships is a challenge. However, none of the current systems can fully support the unique needs of clinical pharmacy internship. In this study we enhanced a commercial eLearning
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system for clinical pharmacy internship (The clinical pharmacy Internship eLearning System, CPIES). The KAP questionnaire was used to evaluate the performance of group A with the traditional teaching
model and group B with the CPIES teaching model. The CPIES teaching model showed significant
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improvement in interns’ knowledge and practice (p=0.002 and 0.031, respectively). The traditional
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teaching model only demonstrated significant improvement in practice (p=0.011). Moreover, professionalism, such as attitudes on cooperating with other health professionals, is developed by
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learning from a good mentor. The on-line teaching and traditional teaching methods should undoubtedly be blended in a complete teaching model in order to improve learners’ professional
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knowledge, facilitate correct attitude, and influence good practice.
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Keywords eLearning; Clinical Pharmacy; KAP; System Evaluation; Internet Learning
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1. Introduction The fundamental aim of pharmacy education is to cultivate pharmacists with sufficient knowledge in pharmacy profession to enable them effectively to support health care and research development. Thus, pharmacy education embraces not only classroom knowledge but also professional skills and attitudes in pharmaceutical care practice. Pharmacy students develop their professional skills
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and attitudes mainly through a pharmacy internship program in which pharmacy students serve as
interns and senior pharmacists serve as site preceptors in a clinical care setting. The internship program
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is designed to assist interns in integrating their undergraduate learning into real-world practice and transition from student to independent competent pharmacist.
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The required pharmacy internship hours may vary by institutions/countries, depending on the level of care and the degree of specialization. In Taiwan pharmacy students are required to take a 640
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hour pharmacy internship program [1], including at least 120 hours in clinical pharmacy services at a hospital. The clinical pharmacy internship program mainly focuses on the modules of medication
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assessment and recommendations for patients, evaluation of pharmacokinetics and therapeutic drug monitoring (TDM), adverse drug reactions (ADR), pharmaceutical care in intensive care, infection
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control and antibiotic management, and evidence based pharmaceutical care [2]. In Taipei Medical University Wan Fang Hospital (TMUWFH), the clinical pharmacy internship program consists of four
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consecutive weeks (40 hours a week). The modules are organized and presented as the formats of case studies, lectures, discussions, site observations and team research reports on the issues of pharmaceutical care in ICU, ADR and TDM. During the period of the intership, interns usually interact closely with their preceptors to complete the designated learning units and document accomplishments and growth in their learning portfolios accordingly. It is very important for preceptors to review their students’ portfolios and give them responsive feedbacks along the course of internship. The nature of pharmacy student internship program in learning and teaching involves intensive
interactions among preceptors, students and learning resources. Although the students are closely supervised throughout the internship, they are strongly encouraged to develop independent learning. At present most internship programs are conducted largely by using traditional face-to-face lectures, group discussions and in person contacts. Based on a survey, most hospital clinical pharmacists’ workload is already too heavy [3]. They can hardly contribute to the quality of the program. In nowadays, online learning (or eLearning) technology has been widely adopted by most education programs
[4-7].
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However, most of the tools, such as online learning modules, search engines, social networks, and so on, are distributed and separated in different systems. It is not an easy task for pharmacy students to put the tools working together for specific learning objectives, particularly for pharmacy internship programs. Thus, we need a unified, integrated eLearning system to support the internship programs that can offer high quality of the internship, and reduce the preceptors’ teaching workload without
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compromising patient care.
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2. Background
Traditional healthcare applications are restricted for use at specific geographical locations [8].
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However, the Internet promises many advantages: Access from all over the world with a low-cost technical infrastructure; independence from proprietary solutions in hardware and software by means
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of a common browser as front-end; independence from time restrictions because the material is available 24 h a day, 7 days a week without any technical necessity for downtime [9]. Incorporating
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electronic learning (eLearning) systems into professional experimental programs such as pharmacy internships is a challenge. A well-designed eLearning system can engage learners in a learning process
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by allowing them to participate in activities to facilitate active learning [10]. Many researches have noted the merits of eLearning, such as flexibility and the ability to be individualized. A legitimate
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aspiration of e-learning is to make existing approaches to teaching and learning more effective and efficient [11]. The eLearning allows students to adjust their learning paces and efficiently achieve better results [12-16]. Zapantis et al. combined class teaching and eLearning to develop a web-based course management system for adult acute care medicine [17]. The results showed that the web-based courses could promote students’ experience in adult acute care medication management and acute care advanced pharmacy practice experiences (APPEs) [18,19]. Kofraneka et al. developed a new interactive web-based application that primarily designed for biomedical education. The results showed that interactive simulations met with visibly high student approval and
and the teachers' experience is
positive [20]. Furthermore, Lopez et al. developed a web-based e-portfolio system to document students’ curricular outcomes and performance in pharmacy practice experiences. The result showed eportfolio was able to facilitate students' reflection on their own learning, leading to more awareness of learning strategies and needs [21].
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The successful development of human resources depends on training and continuing skill development. Educational technology is allowing educators to restructure classroom time for something other than simple transmission of factual information and to adopt an evidence-based approach to instructional innovation and reform. Many educators advocate training for all faculty members to develop their skills as teachers in distance education environments. The most continually
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survey finding to those new to online is that a majority of Chief Academic Officers rated learning outcomes for online instruction as the same or superior to those for face-to-face instruction. As more
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schools utilize information technology and the computer becomes an integral part of all pharmacy
students’ education, many schools will begin to require that students either own or have ready access to
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a computer [4-7]. However, most of the tools, such as online learning modules, search engines, social networks, and so on, are distributed and separated in different systems. To our knowledge, there is no
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such a system that can effectively support the needs of clinical pharmacy internship programs, such as online tools for therapeutic drug monitoring, pharmacokinetic calculation and dose adjustment which
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requires flexible integration of diverse computational tools. The optimal system designs will have to be found numerically and algorithms will have to be implemented for practitioners. [22,23].
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In this study we enhanced a commercial eLearning system for clinical pharmacy internship and to evaluate the interns’ knowledge, attitudes and practice comparing with the traditional teaching model.
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3. An enhanced system supporting internship programs 3.1 System functionality Enhanced Clinical Pharmacy Internship eLearning System (CPIES)
The learning procedure of enhanced clinical pharmacy Internship eLearning System (CPIES) is
based on client-server architecture. The server that stores the data and control the communication (basic system functionalities), the client that is used by preceptors-interns in order to access data from the server (web interface accessible via web browsers), and the network though which they connect with the server. The protocol that defines the communication between client and server is the HTTP. The system database collects directly data from the interaction with the client. Apache, MySQL database, PHP language and Windows 2003 server have been used in order to implement the system based on
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Pharmacy Interns’ learning styles to present the appropriate subject matter, including the content, format and media type. These technologies were used because of their faster reaction for dynamic web application and because the communication between them tends to be perfect. The CPIES development model defined learning scenarios (requirement analysis), outline the system architecture (system analysis), provide system design and specifications (system design), develop required extensions and
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interfaces, configure and implement, run validation trials (testing) and compile a set of best practices on integrated learning systems development and deployment. The development model was listed in Figure
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1.
The CPIES consists of a number of different components: user management, material management,
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eLearning process management, personal learning e-portfolio modules, and an interactive learning platform (Fig. 2). The user management module provided for the creation, approval, and management
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functionality for individual users, managed access control, and assigned roles to each user. The material management module enabled preceptors to upload, edit, and manage teaching materials online, review
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and return reports, and design tests and questionnaire databases. The eLearning process management module helped preceptors develop paths and check points during the course of learning based on
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internship goals, and set the minimum reading time and passing criterions for each learning unit. All learning activities were recorded into logs (i.e., e-portfolio) and displayed for the individual, including the courses taken, the scores awarded, homework submissions, test results, questionnaire
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evaluations, and so on. The e-portfolio can demonstrate the accumulative reading hours, and keep students informed of their own learning processes and problems. The CPIES provides three different assesses including course administrator, clinical preceptor
and pharmacy intern. The course administrator assigns a role (teacher or student) to each user, manages courses/offerings, and keeps track of a student’s earned credits. Clinical preceptors are responsible for managing course materials, specifying learning process, developing of tests and evaluation questionnaires, and reviewing students’ reports, assignments and e-portfolios. Pharmacy interns can online take courses and use the materials, follow the specified course schedule or learning goals to conduct learning activities, such as course reading, tests and report/assignment submissions. They can also use the interactive learning platform to initiate a group discussion on a specific subject. The preceptor can invite medical professionals to join the system according to needs of internship program. In this study, the infection control nurse was invited to perform the use of personal protective equipment
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(PPE) via video display and initiate an interactive discussion on standard precautions on line. Clinical preceptors are encouraged to become involved in the discussions and offer guidance to interns whenever they are available. The interactive learning platform includes forums, bulletins, integrated internet resources and the clinical pharmacokinetic calculating tool. Forums and bulletins provide a free atmosphere for
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discussions on course matters and exchange of ideas. Such platform can freely facilitate effective communication to overcome limitations of time and space which usually occur in short, intensive, and
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busy clinical internships. We enhanced this system by providing integrated internet resources and a
clinical pharmacokinetic calculating tool for the clinical pharmacy internship program. Integrated
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internet resources are a collection of learning resources and links of useful websites required by pharmacy preceptors and interns, giving them easy access to information needed for making
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professional decisions. It also provides evidence-based resources for asisiting clinical decisions, such as Micromedex, MDconsult, medical dictionaries, Medline, Pubmed etc. online
clinical
pharmacokinetic
calculator
helps
pharmacy
interns
perform
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The
pharmacokinetics monitoring and make drug-dose adjustments based on an individual patient’s
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pharmacokinetics parameters. The calculations was built with Flash programming, and created a frame in the homepage of the original system (Fig. 3). The clinical pharmacokinetic equations and calculations assistant provides seven frequently used clinical pharmacokinetic equations: (1) Ideal body
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weight (IBW) (2) Adjusted body weight (AjBW) (3) Creatinine clearance (CrCl) (4) Glomerular filtration rate (GFR) (5) Adjusted total phenytoin concentration (6) Aminoglycoside therapeutic drug monitoring (TDM) and (7) Vancomycin TDM. For example, to compute corrected phenytoin concentration, the calculations assistant ask for two parameters: phenytoin concentration and albumin level (Fig. 4, left). The user can also review the equations by clicking “check formula” button (Fig. 4, right). With these tools pharmacy interns can develop abilities and skills for clnical pharmacy sevices and ensuring medication safety.
3.2 Instructional design and learning workflow The clinical pharmacy services internship is a 160 hours program within a sixteen weeks pharmacy internship curriculum. The clinical pharmacy internship program consisted of 12 courseworks in covering three main subjects: clinical pharmacy of critical care, adverse drug reactions and therapeutic
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drug monitoring. The program requires pharmacy interns to fulfill activities, including literature readings, tests, case studies, reports, group discussions, presentations, advance clinical skills and personal learning portfolios. Clinical preceptor had to complete evaluation forms and scoring to ensure interns’ performances. The CPIES is an important platform that meets the needs of clinical pharmacy internship, except
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group discussions and case study presentations that were conducted with a face-to-face teaching method. Besides, with an interactive platform available all the time, they can easily go online to have a
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discussion with peers or search a needed tool or some information, making learning and problemsolving more timely
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Clinical preceptors can base test content on a fixed selection or computerize random selection of questions. Automatic score calculation allows students to learn the result of each test right after
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completion and reflect on own mistakes. Students were able to select topics and complete as many practice quizzes as required to become proficient with the topic area. Each topic contained sets of
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randomly generated questions relating to that topic; upon completion of the question set immediate feedback on performance, including worked solutions were automatically provided.
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The CPIES can keep track of each intern’s reading lists, assignment delivery, questionnaire completion, and test results. If interns have not kept abreast of studies, the system will automatically send email to remind preceptor pay attention to interns’ learning progress. Each intern has an e-
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Portfolio, offering their teachers insight into their internship experience and results as well as demands and problem. It also helps interns to aware of their own thinking, to reflect their thinking and to direct their motivation toward the attainment of learning goals. Via e-portfolios, the teachers are able to assess their teaching materials and to encourage students to undertake self-directed learning for better learning motivations and effects. Giving students freedom to arrange their own study paces is beneficial for the learners and the teachers alike. Together both sides can work on a plan best suited for individual learning demands to promote professional knowledge, self-disciplining and active learning.
4. Evaluation Method The system was built for the clinical pharmacy services internship in a university-affiliate teaching hospital. The CPIES was developed and applied in August 2009. To evaluate the outcomes of
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using the system, we compared the learning performance of two groups of interns. All fourth year pharmacy interns included in the study hospital during the study period were enrolled. The interns were divided into two groups: group A in February 2009 and group B in September 2009. Group A received the traditional face-to-face teaching method for all coursework. Group B teaching activities were through the CPIES, except group discussions and case study presentations that were conducted with a
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face-to-face teaching method. The interns followed the designed sequence to take lectures and complete the coursework according to syllabus of the pharmacy internship program which was
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distributed on the first day. They could also review the lessons when they needed. The interns respectively took pre- and post-tests on knowledge, attitude, and practice (KAP) at the beginning and
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end of the program. The learning flow with CPIES is depicted in Fig. 5.
The knowledge, attitude and practice (KAP) model has been used in health behavior surveys
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with an underlying assumption that practice can be changed by increasing knowledge. The increase knowledge is proposed to affect attitudes so that an individual is more predisposed to perform the
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behavior [24,25]. The KAP Questionnaire (Knowledge, Attitudes and Practice) was developed to test the difference between the traditional teaching method and the CPIES [26,27].
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There are 2 parts in the knowledge category which developed by adapting the content of the lectures which delivered to the students (one question is worth one point; possible total score is from 0 to 10): knowledge of pharmacokinetics (5 questions) and therapeutic drug monitoring (5 questions).
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The attitude category was designed to measure students’ attitude toward the responsibilities of pharmacists (2 questions) and the cooperation with medical teams (3 questions). All the questions were scored on a 5-point Likert scale, with "strongly agree" as 5 and "strongly disagree" as 1. (The possible total score is from 5 to 25.) The practice was designed to identify if the lectures could influence the students to be self-motivating (2 questions) and be responsible (3 questions). A 5-point Likert scale was applied to test the students’ potential practice behavior. (The possible total score is from 5 to 25.) The expert of this KAP questionnaire was first evaluated by a panel of experts in pharmaceutical
care, pharmacokinetics, and survey questionnaire development. Twenty newly graduated pharmacists who were similar to the study population were involved in assessing the surveys’ face validity to make sure the questions were able to be understood by a similar population. Test-retest reliability was assessed using the same group of pharmacists without an intervention to test the stability of the
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measurement, resulting in Spearman correlation coefficients of 0.92 for the knowledge test, 0.73 for the attitude test and 0.86 for the practice test. Statistical analyses were performed using SPSS version 18.0 for Windows (SPSS, Chicago, Illinois, USA). All results were expressed as mean ± standard deviation (SD) unless indicated otherwise. The Wilcoxon signed-rank test and Mann-Whitney U-test were used to compare differences
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between groups. A p-value of less than 0.05 was considered statistically significant.
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5. Results
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There were 11 pharmacy interns in the group A who received the traditional teaching method and 12 in the group B who received the CPIES program. Their demographical data are shown in Table
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1. They were fourth year pharmacy students, and had similar background. The baseline KAP questionnaire scores were no statisitcally difference between two groups (Table 2.). The results of KAP questionnaire surveys of the two groups are shown in Table 3. In the group
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A, the average scores of the pre-test and post-test on knowledge, attitude and practice categories were 4.73±1.191 and 6.18±2.228, 20.36±2.157 and 21.36±1.748, 20.18±2.786 and 21.91±2.023, respectively.
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In the group B, the average scores of the pre-test and post-test on knowledge, attitudes and practice categories were 3.92±1.621 and 7.75±1.815, 21.33±1.557 and 20.83±1.992, 20.50±2.468 and
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21.75±2.221, respectively.
The results in Table 3 show none significant findings for the group A in knowledge and attitude
scores (p = 0.111 and 0.205, respectively) between the pre-test and post-test. However, there was a significant difference in practice score (p = 0.011). In the group B, the results show significant differences in knowledge and practice scores (p = 0.002 and 0.031, respectively) between the pre-test and post-test, but there was no statistical significance (p = 0.379) in attitude score. Interesting findings were revealed by an analysis of subcategories for the 2 groups. In the group A, the scores of cooperation of attitudes, the scores of responsibilities and self-motivation of practice had significant differences between pre and post tests (p = 0.023, 0.02 and 0.039). The group B presented the significant differences in the scores of pharmacokinetics and TDM of knowledge as well as the scores of responsibilities of practice (p = 0.007, 0.003 and 0.046).
6. Discussion 10
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Among twenty-three fourth year pharmacy interns with similiar baseline clinical pharmacy knowledge, the results suggest that the enhanced eLearning system (CPIES) can help interns significantly improve their professional knowledge and practice. The learners only have improvements on their practice with the traditional teaching method. Both methods can improve interns’ professional practice, the CPIES provides better learning structure resulting in great improvements in interns’
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professional knowledge. This finding is consistance with previous studies for pharmacy professions, nurses and physicians [28-30]. The effective designed of an eLearning system can deliver useful
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knowledge, motivate active learning in order to facilitate good professional practice [10,31].
The CPIES supports not only interactive and self-pace online learning with integrated internet
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resources but an on-line clinical pharmacokinetic calculating tool to support the important clinical pharmacokinetic subjects in this internship. The higher improved scores in knowledge with the CPIES
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group indicated that this eLearning system augmented interns learning on clinical pharmacokinetics and TDM. A simple and user friendly clinical pharmacokinetic calculating tool is important for interns
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to have hands-on experiences and like to practice continuely with clinical cases in order to extend their knowledge into practice [32]. In addition, the CPIES provides a complete collection of online
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pharmacy refereces, such as Micromedex, MDconsult, medical dictionaries, Medline, Pubmed, and electronic version of textbooks etc., to help the interns easy access the resources and utilize effectively in the same electronic platform. In study design, group A and B are with the same preceptors and
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teaching strategy in order to minimize the effect caused by confounding variable. The preceptors are using CPIES to review intern’s progress, answer the questions and join on-line discussion through behavioral observations. The preceptors have indicated a substantially positive perception of the system. The system can help them can to ease teaching workload and contribute to the quality of the program. Neither teaching method in this study showed significant progress on scores of overall attitudes,
with better scores only for cooperative attitudes in the traditional teaching group. The attitude post-test score is lower than the pre-test score after using this system. These trends reflect the indispensable role of face-to-face coaching in developing proper attitudes. Nurturing attitudes towards being professionals might require dedicated mentorship. Moreover, professionalism, such as attitudes on cooperating with other health professionals, is developed by learning from a good mentor. Interactions between interns and preceptors were shown to be more efficacious and essential for motivating students to achieve better learning outcomes by personal encouragement or side-by-side tutoring [33].
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According to guidelines for hospitals pharmacy internship, the number of interns should not exceed one-third of the full-time pharmacists in the hospital during at the same time. A limitation of the study was the relatively small sample size. However, all of the materials, clinical preceptors, and learning procedure are under the experimental condition to ensure the effectiveness of the system. The
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another limitation of this study was the content of CPIES designed mainly for the clinical pharmacy services internship. Therefore, the extent of the usefulness of this eLearning system maybe
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underestimated. This may also resulted in no improvements of interns’ attitudes scores in both traditional teaching method and the utiliztion of CPIES. To educate professional attitude successfully,
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the courses realted to paitent safety, communication skills or medical ethics should be considered for addition to the eLearning system to deliever the complete concepts and skills for deveoping interns’
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7. Conclusion
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attitudes towards outstanding profesionalisms.
The eLearning system designed for clinical pharmacy intership significantly improved the
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pharmacy interns’ knowledge and practice. Although attitude did not improve in this study. It is promising to invest and incorporate the eLearning system with adequate in-person tutoring by clinical
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preceptors in intensive care training with a pharmacy internship program. But nurturing attitudes towards being professionals might require dedicated mentorship. The online clinical pharmacokinetic calculating tool as an important aid enhancing learners’ knowledge and progressing practice skills, which then may encourage further utilize the eLearning system in pharmacy internship program by extending more various courses. The online clinical pharmacokinetic calculating tool as an important aid enhancing learners’ knowledge and progressing practice skills, which then may encourage further utilize the eLearning system in pharmacy internship program by extending more various courses. The on-line teaching and traditional teaching methods should undoubtedly be blended in a complete teaching model in order to improve learners’ professional knowledge, facilitate correct attitudes, and influence good practice [33,34].
Conflict of interest statement The authors declare that they have no conflict of interest.
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Acknowledgements We thank the colleagues of the Pharmacy Department of Taipei Medical University-Wan Fang Hospital for their assistance in making this study possible. This study was partially supported by Taipei Medical University-Wan Fang Hospital (grant no. 98TMU-WFH-04-2) and National Science Council,
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Taiwan (grant no. NSC 97-2221-E-038–010.)
References
Taiwan Society of Health-system Pharmacists, Guidelines for hospitals pharmacy internship,.
us
1.
Available at: http://www.tshp.twmail.net/ (accessed July 2012).
Taipei Medical University Wan Fang Hospital, pharmacy internship manual (2009).
3.
M.J. Armahizer, D. Johnson, C.M. Deusenberry, J.J. Foley, E.P. Krenzelok, T.L. Pummer,
an
2.
M
Evaluation of pharmacist utilization of a poison center as a resource for patient care, Journal of Pharmacy Practice (first published on July 25, 2012).
Z.T. Grapes, D. Johnson, H.W. Matthews, A survey of instructional technology assets and
d
4.
support services at US schools and colleges of pharmacy, American Journal of Pharmaceutical Education 62 (3) (1998) 266-270.
5.
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
E. Allen, J. Seaman, Making the grade: online education in the United States, The Sloan Consortium (2006). Available at: http://www.sloan-c.org/publications/survey/index.asp (accessed December 2012).
6.
J.M. LeBlanc, M.C. Pruchnicki, S.V. Rohdieck, A. Khurma, J.F. Dasta, An instructional seminar for online case-based discussions, American Journal of Pharmaceutical Education 71 (3) (2007) 42.
7.
M.S. Monaghan, J.J. Cain, P.M. Malone, T.A. Chapman, R.W. Walters, D.C. Thompson, S.T. Riedl, Educational technology use among US colleges and achools of pharmacy, American Journal of Pharmaceutical Education 75 (5) (2011) 87.
8.
R. R. Bond, D. D. Finlay, C. D. Nugent, G. Moore, D. Guldenring, A usability evaluation of medical software at an expert conference setting, Computer Methods and Programs in Biomedicine In Press, Corrected Proof, Available online 21 October 2013.
13
Page 13 of 21
9.
M. Geueke, J. Stausberg, A meta-data-based learning resource server for medicine, Computer Methods and Programs in Biomedicine, 72 (3) (2003), 197-208.
10.
H. Ernst, K. Colthorpe, Instructional voluntary active-learning opportunities for pharmacy students in a respiratory physiology module, American journal of pharmaceutical education, 72 (2) (2008) 28. M. Komenda, D. Schwarz, J. Feberová, S. Štípek, V. Mihál, L. Dušek, Medical faculties
ip t
11.
educational network: Multidimensional quality assessment, Computer Methods and Programs in
12.
cr
Biomedicine 108 (3) (2012) 900-479.
H.K. Chou ,I.C. Lin, L.C. Woung, M.T. Tsai, Engagement in e-Learning opportunities: An
us
empirical study on patient education using expectation confirmation Theory, Journal of Medical Systems 36 (3) (2012)1697-706.
T. Govindasamy, Successful implementation of e-Learning Pedagogical considerations, The
an
13.
Internet and Higher Education, 4 (3–4) (2001) 287–299.
T.I. Lee, Y.T. Yeh, C.T. Liu, P.L. Chen, Development and evaluation of a patient-oriented
M
14.
education system for diabetes management, International Journal of Medical Informtics 76(9)
15.
d
(2007) 655-63.
P.R. Lockman, J.A. Gaasch, Using WebCT to implement a basic science competency education course, American Journal of Pharmaceutical Education 72(2) (2008) 39.
16.
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
R.A. Elliott, J. McDowell, J.L. Marriott, A. Calandra, G. Duncan, A pharmacy preregistration course using online teaching and learning methods, American Journal of Pharmaceutical Education, 73 (5) (2009) 77.
17.
A. Zapantis, C. Machado, R. Nemire, S. Leung, An elective course in adult acute care medicine using a hybrid delivery system, American Journal of Pharmaceutical Education, 72(5) (2008) 105.
18.
L.L. Briceland, R.A. Hamilton, Electronic reflective student portfolios to demonstrate achievement of ability-based outcomes during advanced pharmacy practice experiences, American Journal of Pharmaceutical Education 74 (5) (2010) 79.
19.
L.D. Ried, R. Nemire, R. Doty, An automated competency-based student performance assessment program for advanced pharmacy practice experiential programs, American Journal of Pharmaceutical Education 71 (6) (2007) 128.
14
Page 14 of 21
20.
J. Kofranek, S. Matousek, J. Rusz, P. Stodulka, P. Privitzer, M. Matejak, M. Tribula, The Atlas of Physiology and Pathophysiology: Web-based multimedia enabled interactive simulations, Computer Methods and Programs in Biomedicine 104 (2) (2011) 143-153.
21.
T.C. Lopez, D.D. Trang, N.C. Farrell, M.A. DeLeon, C.C. Villarreal, D.F. Maize, Development and Implementation of a Curricular-wide Electronic Portfolio System in a School of Pharmacy,
22.
ip t
American Journal of Pharmaceutical Education 75 (5) (2011) 89. T. T. Bergsma, W. Knebel, J. Fisher, W. R. Gillespie, M.M. Riggs, L. Gibiansky, M. R.
Methods and Programs in Biomedicine 109 (1) (2013) 77-85.
W. K. Wong, Web-based tools for finding optimal designs in biomedical studies, Computer
us
23.
cr
Gastonguay, Facilitating pharmacometric workflow with the metrumrg package for R, Computer
Methods and Programs in Biomedicine 111 (3) (2013) 701-710.
L. Breslow, From disease prevention to health promotion, The Journal of the American Medical
an
24.
Association 281 (11) (1999) 1030-3.
Y.A. Buischi, P. Axelsson, L.B. Oliveira, M.P. Mayer, Gjermo, P. (1994). Effect of two
M
25.
preventive programs on oral health knowledge and habits among Brazilian schoolchildren.
26.
d
Community Dentistry and Oral Epidemiology, 22(1), 41-6. L.S. Eller, E. Kleber, S.L. Wang, Research knowledge, attitudes and practice of health professionals, Nursing Outlook 51 (2003) 165-70.
27.
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
S.M. Hubbard, S.W. Hayashi, Use of diffusion of innovations theory to drive a federal agency’s program evaluation, Evaluation and Program Planning 26 (1) (2003) 49-56.
28.
G. Ryan, Online CME: An effective alternative to face-to-face delivery. Medical Teacher, 29 (2007) 251-257.
29.
Y.H. Sung, I.G. Kwon, J.W. Hwang, J.Y. Kim, Development of an e-learning program about medication for new nurses, Taehan Kanho Hakhoe Chi 35(6) (2005) 1113-1124.
30.
M.F. Fung, M. Walker, K.F. Fung, L. Temple, F. Lajoie, G. Bellemare, S.C. Bryson, An internetbased learning portfolio in resident education: the KOAL multicenter programme, Medical Education 34 (6) (2000) 474-479.
31.
J. Chenkin, S. Lee, T. Huyn, G. Bandiera, Procedures can be learned on the web: a randomized study of ultrasound-guided vascular access training, Academic Emergency Medicine 15(10) (2008) 949-954.
15
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32.
R. Mehvar, On-line individualized and interactive pharmacokinetic scenarios with immediate grading and feedback and potential for use by mutiple instructors, American Journal of Pharmaceutical Education. 63 (1999) 348-353.
33.
L. Alonso Díaz, F.Blázquez Entonado, Are the Functions of Teachers in e-Learning and Face-toFace Learning Environments Really Different?. Educational Technology & Society 12 (4) (2009)
L. Wong, A. Tatnall, The Need to Balance the Blend: Online versus Face-to-Face Teaching in an
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Introductory Accounting Subject, Issues in Informing Science and Information Technology, 6
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an
us
(2009) 310-322.
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34.
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331–343.
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
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Table
Table 1 The demographical data of the two groups Group B**
11 21.1
12 21.6
8(73%) 3(27%)
9(75%) 3(25%)
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N Age average (years) Gender Female Male
Group A*
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* Group A: received the traditional teaching method. ** Group B: using the CPIES.
Pre-Test (mean SD)
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Table 2 The baseline score analysis of KAP questionnaire
Group A*
Group B**
(n=11)
(n=12)
Knowledge
4.731.191
3.921.621
0.184
Attitude
20.362.157
21.331.557
0.288
Practice
20.182.786
20.502.468
0.780
M
an
Sig.
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* Group A: received the traditional teaching method. ** Group B: received the CPIES program.
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Table 3 The KAP questionnaire pre-test and post-test score analysis Group A (n=11)
Group B (n=12)
Pre-Test
Post-Test
(mean SD)
(mean SD)
Pre-Test
Post-Test
(mean SD)
(mean SD)
4.731.191
6.182.228
.111
3.921.621
7.751.815
.002
Pharmacokinetics
2.910.539
3.641.027
.062
2.080.996
3.920.996
.007
TDM
1.820.874
2.551.368
.203
1.831.337
3.831.115
.003
20.362.157
21.361.748
.205
21.331.557
20.831.992
.379
Cooperation
11.731.348
11.821.662
.023
9.500.674
9.000.853
.835
Responsibilities
8.641.027
9.550.688
.798
11.831.467
11.831.528
.119
20.182.786
21.912.023
.011
20.502.468
21.752.221
.031
Responsibilities
12.361.567
13.361.362
.020
13.081.443
14.001.537
.046
Self-motivation
7.821.471
8.551.214
.039
7.421.443
7.751.357
.395
Knowledge*
Attitude*
Practice*
Sig**
Sig**
*The score is the total score of the questionnaire. **The bolded number indicates statistic significant. TDM = therapeutic drug monitoring
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Figure
1. Preceptor interview 2. Learning syllabus/ Process 3. Guidelines for hospitals pharmacy internship
Requirement Analysis
System Analysis
1. 2.
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System Design/ Prototyping Implementation
Integration and Testing
Architecture design Modules flow design
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Test Case Design (Preceptor/ Interns)
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Yes Modified
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No
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Release/ Installation
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Fig. 1 The Enhanced clinical pharmacy Internship eLearning System (CPIES) development model
Monitoring/ Measuring/ Calculation Tools
Material Management
Bulletins
Interactive Learning Platform
eLearning Process Management
Integrated Internet Resources
Personal Learning e-Portfolio
Forums
Goals/Learning Progress/Scores Awarded/ e-Portfolio Examination
Pharmacy Interns
User Management
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1. Materials 3. Tests 2. Reports 4. Questionnaires
System Administrator
Internet
Clinical Preceptors
Course Administrator
Fig. 2 The Enhanced clinical pharmacy Internship eLearning System (CPIES)
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Fig. 3 The homepage of the CPIES
Fig. 4 Calculation of corrected total phenytoin concentration (left) and formulas (right)
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K.A.P. Post-test
End
Yes KAP Pre-test
No
Finish all course units?
courseworks
Take one Take unit lectures
Yes
Pass? No
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Informed Instructors
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Test quizzes Take
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Start
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Fig. 5 The learning flow with CPIES
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*Conflicts of Interest
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Conflict of interest statement The authors declare that they have no conflict of interest.
Dr. Chien-Tsai Liu
ed
Professor and corresponding author
Graduate Institute of Biomedical Informatics, Taipei Medical University
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250 Wu-Hsing Street, Taipei City, Taiwan 110 Tel: 886-2-27361661 ext.3342, Fax: 886-2-27339049
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E-mail: [email protected]
Page 21 of 21
S0169-2607(13)00378-7 http://dx.doi.org/doi:10.1016/j.cmpb.2013.11.006 COMM 3699
To appear in:
Computer Methods and Programs in Biomedicine
Received date: Revised date: Accepted date:
26-4-2013 11-11-2013 12-11-2013
Please cite this article as: Y.-T. Yeh, H.-Y. Chen, K.-J. Cheng, S.-A. Hou, Y.-H. Yen, C.T. Liu, Evaluating an Online Pharmaceutical Education System for Pharmacy Interns in Critical Care Settings, Computer Methods and Programs in Biomedicine (2013), http://dx.doi.org/10.1016/j.cmpb.2013.11.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
*Manuscript
Evaluating an Online Pharmaceutical Education System for Pharmacy Interns in Critical Care Settings
Yu-Hsuan Yen3,5, Chien-Tsai Liu4,*
Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical
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1
University, Taipei, Taiwan
Information Technology Office, Shuang Ho Hospital, Taipei Medical
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2
University, Taipei, Taiwan
Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei,
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3
Taiwan
Graduate Institute of Biomedical Informatics, College of Medical Science and
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4
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Yu-Ting Yeh1,2,#, Hsiang-Yin Chen3,5,#, Kuei-Ju Cheng 3,5, Su-An Hou4,
Technology, Taipei Medical University, Taipei, Taiwan Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University,
Taipei, Taiwan
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5
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*Corresponding author: Dr. Chien-Tsai Liu Mailing Address: 250 WuXing Street, Taipei, Taiwan 110 Telephones: +886-2-27361661 ext 3342 Fax: +886-2-27339049
E-mail: [email protected]
# indicates equal contribution. 1
Page 1 of 21
Abstract Incorporating electronic learning (eLearning) system into professional experimental programs such as pharmacy internships is a challenge. However, none of the current systems can fully support the unique needs of clinical pharmacy internship. In this study we enhanced a commercial eLearning
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system for clinical pharmacy internship (The clinical pharmacy Internship eLearning System, CPIES). The KAP questionnaire was used to evaluate the performance of group A with the traditional teaching
model and group B with the CPIES teaching model. The CPIES teaching model showed significant
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improvement in interns’ knowledge and practice (p=0.002 and 0.031, respectively). The traditional
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teaching model only demonstrated significant improvement in practice (p=0.011). Moreover, professionalism, such as attitudes on cooperating with other health professionals, is developed by
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learning from a good mentor. The on-line teaching and traditional teaching methods should undoubtedly be blended in a complete teaching model in order to improve learners’ professional
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knowledge, facilitate correct attitude, and influence good practice.
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Keywords eLearning; Clinical Pharmacy; KAP; System Evaluation; Internet Learning
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1. Introduction The fundamental aim of pharmacy education is to cultivate pharmacists with sufficient knowledge in pharmacy profession to enable them effectively to support health care and research development. Thus, pharmacy education embraces not only classroom knowledge but also professional skills and attitudes in pharmaceutical care practice. Pharmacy students develop their professional skills
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and attitudes mainly through a pharmacy internship program in which pharmacy students serve as
interns and senior pharmacists serve as site preceptors in a clinical care setting. The internship program
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is designed to assist interns in integrating their undergraduate learning into real-world practice and transition from student to independent competent pharmacist.
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The required pharmacy internship hours may vary by institutions/countries, depending on the level of care and the degree of specialization. In Taiwan pharmacy students are required to take a 640
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hour pharmacy internship program [1], including at least 120 hours in clinical pharmacy services at a hospital. The clinical pharmacy internship program mainly focuses on the modules of medication
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assessment and recommendations for patients, evaluation of pharmacokinetics and therapeutic drug monitoring (TDM), adverse drug reactions (ADR), pharmaceutical care in intensive care, infection
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control and antibiotic management, and evidence based pharmaceutical care [2]. In Taipei Medical University Wan Fang Hospital (TMUWFH), the clinical pharmacy internship program consists of four
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consecutive weeks (40 hours a week). The modules are organized and presented as the formats of case studies, lectures, discussions, site observations and team research reports on the issues of pharmaceutical care in ICU, ADR and TDM. During the period of the intership, interns usually interact closely with their preceptors to complete the designated learning units and document accomplishments and growth in their learning portfolios accordingly. It is very important for preceptors to review their students’ portfolios and give them responsive feedbacks along the course of internship. The nature of pharmacy student internship program in learning and teaching involves intensive
interactions among preceptors, students and learning resources. Although the students are closely supervised throughout the internship, they are strongly encouraged to develop independent learning. At present most internship programs are conducted largely by using traditional face-to-face lectures, group discussions and in person contacts. Based on a survey, most hospital clinical pharmacists’ workload is already too heavy [3]. They can hardly contribute to the quality of the program. In nowadays, online learning (or eLearning) technology has been widely adopted by most education programs
[4-7].
3
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However, most of the tools, such as online learning modules, search engines, social networks, and so on, are distributed and separated in different systems. It is not an easy task for pharmacy students to put the tools working together for specific learning objectives, particularly for pharmacy internship programs. Thus, we need a unified, integrated eLearning system to support the internship programs that can offer high quality of the internship, and reduce the preceptors’ teaching workload without
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compromising patient care.
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2. Background
Traditional healthcare applications are restricted for use at specific geographical locations [8].
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However, the Internet promises many advantages: Access from all over the world with a low-cost technical infrastructure; independence from proprietary solutions in hardware and software by means
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of a common browser as front-end; independence from time restrictions because the material is available 24 h a day, 7 days a week without any technical necessity for downtime [9]. Incorporating
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electronic learning (eLearning) systems into professional experimental programs such as pharmacy internships is a challenge. A well-designed eLearning system can engage learners in a learning process
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by allowing them to participate in activities to facilitate active learning [10]. Many researches have noted the merits of eLearning, such as flexibility and the ability to be individualized. A legitimate
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aspiration of e-learning is to make existing approaches to teaching and learning more effective and efficient [11]. The eLearning allows students to adjust their learning paces and efficiently achieve better results [12-16]. Zapantis et al. combined class teaching and eLearning to develop a web-based course management system for adult acute care medicine [17]. The results showed that the web-based courses could promote students’ experience in adult acute care medication management and acute care advanced pharmacy practice experiences (APPEs) [18,19]. Kofraneka et al. developed a new interactive web-based application that primarily designed for biomedical education. The results showed that interactive simulations met with visibly high student approval and
and the teachers' experience is
positive [20]. Furthermore, Lopez et al. developed a web-based e-portfolio system to document students’ curricular outcomes and performance in pharmacy practice experiences. The result showed eportfolio was able to facilitate students' reflection on their own learning, leading to more awareness of learning strategies and needs [21].
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The successful development of human resources depends on training and continuing skill development. Educational technology is allowing educators to restructure classroom time for something other than simple transmission of factual information and to adopt an evidence-based approach to instructional innovation and reform. Many educators advocate training for all faculty members to develop their skills as teachers in distance education environments. The most continually
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survey finding to those new to online is that a majority of Chief Academic Officers rated learning outcomes for online instruction as the same or superior to those for face-to-face instruction. As more
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schools utilize information technology and the computer becomes an integral part of all pharmacy
students’ education, many schools will begin to require that students either own or have ready access to
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a computer [4-7]. However, most of the tools, such as online learning modules, search engines, social networks, and so on, are distributed and separated in different systems. To our knowledge, there is no
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such a system that can effectively support the needs of clinical pharmacy internship programs, such as online tools for therapeutic drug monitoring, pharmacokinetic calculation and dose adjustment which
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requires flexible integration of diverse computational tools. The optimal system designs will have to be found numerically and algorithms will have to be implemented for practitioners. [22,23].
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In this study we enhanced a commercial eLearning system for clinical pharmacy internship and to evaluate the interns’ knowledge, attitudes and practice comparing with the traditional teaching model.
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3. An enhanced system supporting internship programs 3.1 System functionality Enhanced Clinical Pharmacy Internship eLearning System (CPIES)
The learning procedure of enhanced clinical pharmacy Internship eLearning System (CPIES) is
based on client-server architecture. The server that stores the data and control the communication (basic system functionalities), the client that is used by preceptors-interns in order to access data from the server (web interface accessible via web browsers), and the network though which they connect with the server. The protocol that defines the communication between client and server is the HTTP. The system database collects directly data from the interaction with the client. Apache, MySQL database, PHP language and Windows 2003 server have been used in order to implement the system based on
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Pharmacy Interns’ learning styles to present the appropriate subject matter, including the content, format and media type. These technologies were used because of their faster reaction for dynamic web application and because the communication between them tends to be perfect. The CPIES development model defined learning scenarios (requirement analysis), outline the system architecture (system analysis), provide system design and specifications (system design), develop required extensions and
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interfaces, configure and implement, run validation trials (testing) and compile a set of best practices on integrated learning systems development and deployment. The development model was listed in Figure
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1.
The CPIES consists of a number of different components: user management, material management,
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eLearning process management, personal learning e-portfolio modules, and an interactive learning platform (Fig. 2). The user management module provided for the creation, approval, and management
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functionality for individual users, managed access control, and assigned roles to each user. The material management module enabled preceptors to upload, edit, and manage teaching materials online, review
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and return reports, and design tests and questionnaire databases. The eLearning process management module helped preceptors develop paths and check points during the course of learning based on
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internship goals, and set the minimum reading time and passing criterions for each learning unit. All learning activities were recorded into logs (i.e., e-portfolio) and displayed for the individual, including the courses taken, the scores awarded, homework submissions, test results, questionnaire
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evaluations, and so on. The e-portfolio can demonstrate the accumulative reading hours, and keep students informed of their own learning processes and problems. The CPIES provides three different assesses including course administrator, clinical preceptor
and pharmacy intern. The course administrator assigns a role (teacher or student) to each user, manages courses/offerings, and keeps track of a student’s earned credits. Clinical preceptors are responsible for managing course materials, specifying learning process, developing of tests and evaluation questionnaires, and reviewing students’ reports, assignments and e-portfolios. Pharmacy interns can online take courses and use the materials, follow the specified course schedule or learning goals to conduct learning activities, such as course reading, tests and report/assignment submissions. They can also use the interactive learning platform to initiate a group discussion on a specific subject. The preceptor can invite medical professionals to join the system according to needs of internship program. In this study, the infection control nurse was invited to perform the use of personal protective equipment
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(PPE) via video display and initiate an interactive discussion on standard precautions on line. Clinical preceptors are encouraged to become involved in the discussions and offer guidance to interns whenever they are available. The interactive learning platform includes forums, bulletins, integrated internet resources and the clinical pharmacokinetic calculating tool. Forums and bulletins provide a free atmosphere for
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discussions on course matters and exchange of ideas. Such platform can freely facilitate effective communication to overcome limitations of time and space which usually occur in short, intensive, and
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busy clinical internships. We enhanced this system by providing integrated internet resources and a
clinical pharmacokinetic calculating tool for the clinical pharmacy internship program. Integrated
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internet resources are a collection of learning resources and links of useful websites required by pharmacy preceptors and interns, giving them easy access to information needed for making
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professional decisions. It also provides evidence-based resources for asisiting clinical decisions, such as Micromedex, MDconsult, medical dictionaries, Medline, Pubmed etc. online
clinical
pharmacokinetic
calculator
helps
pharmacy
interns
perform
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The
pharmacokinetics monitoring and make drug-dose adjustments based on an individual patient’s
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pharmacokinetics parameters. The calculations was built with Flash programming, and created a frame in the homepage of the original system (Fig. 3). The clinical pharmacokinetic equations and calculations assistant provides seven frequently used clinical pharmacokinetic equations: (1) Ideal body
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weight (IBW) (2) Adjusted body weight (AjBW) (3) Creatinine clearance (CrCl) (4) Glomerular filtration rate (GFR) (5) Adjusted total phenytoin concentration (6) Aminoglycoside therapeutic drug monitoring (TDM) and (7) Vancomycin TDM. For example, to compute corrected phenytoin concentration, the calculations assistant ask for two parameters: phenytoin concentration and albumin level (Fig. 4, left). The user can also review the equations by clicking “check formula” button (Fig. 4, right). With these tools pharmacy interns can develop abilities and skills for clnical pharmacy sevices and ensuring medication safety.
3.2 Instructional design and learning workflow The clinical pharmacy services internship is a 160 hours program within a sixteen weeks pharmacy internship curriculum. The clinical pharmacy internship program consisted of 12 courseworks in covering three main subjects: clinical pharmacy of critical care, adverse drug reactions and therapeutic
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drug monitoring. The program requires pharmacy interns to fulfill activities, including literature readings, tests, case studies, reports, group discussions, presentations, advance clinical skills and personal learning portfolios. Clinical preceptor had to complete evaluation forms and scoring to ensure interns’ performances. The CPIES is an important platform that meets the needs of clinical pharmacy internship, except
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group discussions and case study presentations that were conducted with a face-to-face teaching method. Besides, with an interactive platform available all the time, they can easily go online to have a
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discussion with peers or search a needed tool or some information, making learning and problemsolving more timely
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Clinical preceptors can base test content on a fixed selection or computerize random selection of questions. Automatic score calculation allows students to learn the result of each test right after
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completion and reflect on own mistakes. Students were able to select topics and complete as many practice quizzes as required to become proficient with the topic area. Each topic contained sets of
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randomly generated questions relating to that topic; upon completion of the question set immediate feedback on performance, including worked solutions were automatically provided.
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The CPIES can keep track of each intern’s reading lists, assignment delivery, questionnaire completion, and test results. If interns have not kept abreast of studies, the system will automatically send email to remind preceptor pay attention to interns’ learning progress. Each intern has an e-
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Portfolio, offering their teachers insight into their internship experience and results as well as demands and problem. It also helps interns to aware of their own thinking, to reflect their thinking and to direct their motivation toward the attainment of learning goals. Via e-portfolios, the teachers are able to assess their teaching materials and to encourage students to undertake self-directed learning for better learning motivations and effects. Giving students freedom to arrange their own study paces is beneficial for the learners and the teachers alike. Together both sides can work on a plan best suited for individual learning demands to promote professional knowledge, self-disciplining and active learning.
4. Evaluation Method The system was built for the clinical pharmacy services internship in a university-affiliate teaching hospital. The CPIES was developed and applied in August 2009. To evaluate the outcomes of
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using the system, we compared the learning performance of two groups of interns. All fourth year pharmacy interns included in the study hospital during the study period were enrolled. The interns were divided into two groups: group A in February 2009 and group B in September 2009. Group A received the traditional face-to-face teaching method for all coursework. Group B teaching activities were through the CPIES, except group discussions and case study presentations that were conducted with a
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face-to-face teaching method. The interns followed the designed sequence to take lectures and complete the coursework according to syllabus of the pharmacy internship program which was
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distributed on the first day. They could also review the lessons when they needed. The interns respectively took pre- and post-tests on knowledge, attitude, and practice (KAP) at the beginning and
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end of the program. The learning flow with CPIES is depicted in Fig. 5.
The knowledge, attitude and practice (KAP) model has been used in health behavior surveys
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with an underlying assumption that practice can be changed by increasing knowledge. The increase knowledge is proposed to affect attitudes so that an individual is more predisposed to perform the
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behavior [24,25]. The KAP Questionnaire (Knowledge, Attitudes and Practice) was developed to test the difference between the traditional teaching method and the CPIES [26,27].
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There are 2 parts in the knowledge category which developed by adapting the content of the lectures which delivered to the students (one question is worth one point; possible total score is from 0 to 10): knowledge of pharmacokinetics (5 questions) and therapeutic drug monitoring (5 questions).
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The attitude category was designed to measure students’ attitude toward the responsibilities of pharmacists (2 questions) and the cooperation with medical teams (3 questions). All the questions were scored on a 5-point Likert scale, with "strongly agree" as 5 and "strongly disagree" as 1. (The possible total score is from 5 to 25.) The practice was designed to identify if the lectures could influence the students to be self-motivating (2 questions) and be responsible (3 questions). A 5-point Likert scale was applied to test the students’ potential practice behavior. (The possible total score is from 5 to 25.) The expert of this KAP questionnaire was first evaluated by a panel of experts in pharmaceutical
care, pharmacokinetics, and survey questionnaire development. Twenty newly graduated pharmacists who were similar to the study population were involved in assessing the surveys’ face validity to make sure the questions were able to be understood by a similar population. Test-retest reliability was assessed using the same group of pharmacists without an intervention to test the stability of the
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measurement, resulting in Spearman correlation coefficients of 0.92 for the knowledge test, 0.73 for the attitude test and 0.86 for the practice test. Statistical analyses were performed using SPSS version 18.0 for Windows (SPSS, Chicago, Illinois, USA). All results were expressed as mean ± standard deviation (SD) unless indicated otherwise. The Wilcoxon signed-rank test and Mann-Whitney U-test were used to compare differences
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between groups. A p-value of less than 0.05 was considered statistically significant.
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5. Results
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There were 11 pharmacy interns in the group A who received the traditional teaching method and 12 in the group B who received the CPIES program. Their demographical data are shown in Table
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1. They were fourth year pharmacy students, and had similar background. The baseline KAP questionnaire scores were no statisitcally difference between two groups (Table 2.). The results of KAP questionnaire surveys of the two groups are shown in Table 3. In the group
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A, the average scores of the pre-test and post-test on knowledge, attitude and practice categories were 4.73±1.191 and 6.18±2.228, 20.36±2.157 and 21.36±1.748, 20.18±2.786 and 21.91±2.023, respectively.
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In the group B, the average scores of the pre-test and post-test on knowledge, attitudes and practice categories were 3.92±1.621 and 7.75±1.815, 21.33±1.557 and 20.83±1.992, 20.50±2.468 and
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21.75±2.221, respectively.
The results in Table 3 show none significant findings for the group A in knowledge and attitude
scores (p = 0.111 and 0.205, respectively) between the pre-test and post-test. However, there was a significant difference in practice score (p = 0.011). In the group B, the results show significant differences in knowledge and practice scores (p = 0.002 and 0.031, respectively) between the pre-test and post-test, but there was no statistical significance (p = 0.379) in attitude score. Interesting findings were revealed by an analysis of subcategories for the 2 groups. In the group A, the scores of cooperation of attitudes, the scores of responsibilities and self-motivation of practice had significant differences between pre and post tests (p = 0.023, 0.02 and 0.039). The group B presented the significant differences in the scores of pharmacokinetics and TDM of knowledge as well as the scores of responsibilities of practice (p = 0.007, 0.003 and 0.046).
6. Discussion 10
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Among twenty-three fourth year pharmacy interns with similiar baseline clinical pharmacy knowledge, the results suggest that the enhanced eLearning system (CPIES) can help interns significantly improve their professional knowledge and practice. The learners only have improvements on their practice with the traditional teaching method. Both methods can improve interns’ professional practice, the CPIES provides better learning structure resulting in great improvements in interns’
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professional knowledge. This finding is consistance with previous studies for pharmacy professions, nurses and physicians [28-30]. The effective designed of an eLearning system can deliver useful
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knowledge, motivate active learning in order to facilitate good professional practice [10,31].
The CPIES supports not only interactive and self-pace online learning with integrated internet
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resources but an on-line clinical pharmacokinetic calculating tool to support the important clinical pharmacokinetic subjects in this internship. The higher improved scores in knowledge with the CPIES
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group indicated that this eLearning system augmented interns learning on clinical pharmacokinetics and TDM. A simple and user friendly clinical pharmacokinetic calculating tool is important for interns
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to have hands-on experiences and like to practice continuely with clinical cases in order to extend their knowledge into practice [32]. In addition, the CPIES provides a complete collection of online
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pharmacy refereces, such as Micromedex, MDconsult, medical dictionaries, Medline, Pubmed, and electronic version of textbooks etc., to help the interns easy access the resources and utilize effectively in the same electronic platform. In study design, group A and B are with the same preceptors and
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teaching strategy in order to minimize the effect caused by confounding variable. The preceptors are using CPIES to review intern’s progress, answer the questions and join on-line discussion through behavioral observations. The preceptors have indicated a substantially positive perception of the system. The system can help them can to ease teaching workload and contribute to the quality of the program. Neither teaching method in this study showed significant progress on scores of overall attitudes,
with better scores only for cooperative attitudes in the traditional teaching group. The attitude post-test score is lower than the pre-test score after using this system. These trends reflect the indispensable role of face-to-face coaching in developing proper attitudes. Nurturing attitudes towards being professionals might require dedicated mentorship. Moreover, professionalism, such as attitudes on cooperating with other health professionals, is developed by learning from a good mentor. Interactions between interns and preceptors were shown to be more efficacious and essential for motivating students to achieve better learning outcomes by personal encouragement or side-by-side tutoring [33].
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According to guidelines for hospitals pharmacy internship, the number of interns should not exceed one-third of the full-time pharmacists in the hospital during at the same time. A limitation of the study was the relatively small sample size. However, all of the materials, clinical preceptors, and learning procedure are under the experimental condition to ensure the effectiveness of the system. The
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another limitation of this study was the content of CPIES designed mainly for the clinical pharmacy services internship. Therefore, the extent of the usefulness of this eLearning system maybe
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underestimated. This may also resulted in no improvements of interns’ attitudes scores in both traditional teaching method and the utiliztion of CPIES. To educate professional attitude successfully,
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the courses realted to paitent safety, communication skills or medical ethics should be considered for addition to the eLearning system to deliever the complete concepts and skills for deveoping interns’
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7. Conclusion
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attitudes towards outstanding profesionalisms.
The eLearning system designed for clinical pharmacy intership significantly improved the
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pharmacy interns’ knowledge and practice. Although attitude did not improve in this study. It is promising to invest and incorporate the eLearning system with adequate in-person tutoring by clinical
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preceptors in intensive care training with a pharmacy internship program. But nurturing attitudes towards being professionals might require dedicated mentorship. The online clinical pharmacokinetic calculating tool as an important aid enhancing learners’ knowledge and progressing practice skills, which then may encourage further utilize the eLearning system in pharmacy internship program by extending more various courses. The online clinical pharmacokinetic calculating tool as an important aid enhancing learners’ knowledge and progressing practice skills, which then may encourage further utilize the eLearning system in pharmacy internship program by extending more various courses. The on-line teaching and traditional teaching methods should undoubtedly be blended in a complete teaching model in order to improve learners’ professional knowledge, facilitate correct attitudes, and influence good practice [33,34].
Conflict of interest statement The authors declare that they have no conflict of interest.
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Acknowledgements We thank the colleagues of the Pharmacy Department of Taipei Medical University-Wan Fang Hospital for their assistance in making this study possible. This study was partially supported by Taipei Medical University-Wan Fang Hospital (grant no. 98TMU-WFH-04-2) and National Science Council,
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Taiwan (grant no. NSC 97-2221-E-038–010.)
References
Taiwan Society of Health-system Pharmacists, Guidelines for hospitals pharmacy internship,.
us
1.
Available at: http://www.tshp.twmail.net/ (accessed July 2012).
Taipei Medical University Wan Fang Hospital, pharmacy internship manual (2009).
3.
M.J. Armahizer, D. Johnson, C.M. Deusenberry, J.J. Foley, E.P. Krenzelok, T.L. Pummer,
an
2.
M
Evaluation of pharmacist utilization of a poison center as a resource for patient care, Journal of Pharmacy Practice (first published on July 25, 2012).
Z.T. Grapes, D. Johnson, H.W. Matthews, A survey of instructional technology assets and
d
4.
support services at US schools and colleges of pharmacy, American Journal of Pharmaceutical Education 62 (3) (1998) 266-270.
5.
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
E. Allen, J. Seaman, Making the grade: online education in the United States, The Sloan Consortium (2006). Available at: http://www.sloan-c.org/publications/survey/index.asp (accessed December 2012).
6.
J.M. LeBlanc, M.C. Pruchnicki, S.V. Rohdieck, A. Khurma, J.F. Dasta, An instructional seminar for online case-based discussions, American Journal of Pharmaceutical Education 71 (3) (2007) 42.
7.
M.S. Monaghan, J.J. Cain, P.M. Malone, T.A. Chapman, R.W. Walters, D.C. Thompson, S.T. Riedl, Educational technology use among US colleges and achools of pharmacy, American Journal of Pharmaceutical Education 75 (5) (2011) 87.
8.
R. R. Bond, D. D. Finlay, C. D. Nugent, G. Moore, D. Guldenring, A usability evaluation of medical software at an expert conference setting, Computer Methods and Programs in Biomedicine In Press, Corrected Proof, Available online 21 October 2013.
13
Page 13 of 21
9.
M. Geueke, J. Stausberg, A meta-data-based learning resource server for medicine, Computer Methods and Programs in Biomedicine, 72 (3) (2003), 197-208.
10.
H. Ernst, K. Colthorpe, Instructional voluntary active-learning opportunities for pharmacy students in a respiratory physiology module, American journal of pharmaceutical education, 72 (2) (2008) 28. M. Komenda, D. Schwarz, J. Feberová, S. Štípek, V. Mihál, L. Dušek, Medical faculties
ip t
11.
educational network: Multidimensional quality assessment, Computer Methods and Programs in
12.
cr
Biomedicine 108 (3) (2012) 900-479.
H.K. Chou ,I.C. Lin, L.C. Woung, M.T. Tsai, Engagement in e-Learning opportunities: An
us
empirical study on patient education using expectation confirmation Theory, Journal of Medical Systems 36 (3) (2012)1697-706.
T. Govindasamy, Successful implementation of e-Learning Pedagogical considerations, The
an
13.
Internet and Higher Education, 4 (3–4) (2001) 287–299.
T.I. Lee, Y.T. Yeh, C.T. Liu, P.L. Chen, Development and evaluation of a patient-oriented
M
14.
education system for diabetes management, International Journal of Medical Informtics 76(9)
15.
d
(2007) 655-63.
P.R. Lockman, J.A. Gaasch, Using WebCT to implement a basic science competency education course, American Journal of Pharmaceutical Education 72(2) (2008) 39.
16.
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
R.A. Elliott, J. McDowell, J.L. Marriott, A. Calandra, G. Duncan, A pharmacy preregistration course using online teaching and learning methods, American Journal of Pharmaceutical Education, 73 (5) (2009) 77.
17.
A. Zapantis, C. Machado, R. Nemire, S. Leung, An elective course in adult acute care medicine using a hybrid delivery system, American Journal of Pharmaceutical Education, 72(5) (2008) 105.
18.
L.L. Briceland, R.A. Hamilton, Electronic reflective student portfolios to demonstrate achievement of ability-based outcomes during advanced pharmacy practice experiences, American Journal of Pharmaceutical Education 74 (5) (2010) 79.
19.
L.D. Ried, R. Nemire, R. Doty, An automated competency-based student performance assessment program for advanced pharmacy practice experiential programs, American Journal of Pharmaceutical Education 71 (6) (2007) 128.
14
Page 14 of 21
20.
J. Kofranek, S. Matousek, J. Rusz, P. Stodulka, P. Privitzer, M. Matejak, M. Tribula, The Atlas of Physiology and Pathophysiology: Web-based multimedia enabled interactive simulations, Computer Methods and Programs in Biomedicine 104 (2) (2011) 143-153.
21.
T.C. Lopez, D.D. Trang, N.C. Farrell, M.A. DeLeon, C.C. Villarreal, D.F. Maize, Development and Implementation of a Curricular-wide Electronic Portfolio System in a School of Pharmacy,
22.
ip t
American Journal of Pharmaceutical Education 75 (5) (2011) 89. T. T. Bergsma, W. Knebel, J. Fisher, W. R. Gillespie, M.M. Riggs, L. Gibiansky, M. R.
Methods and Programs in Biomedicine 109 (1) (2013) 77-85.
W. K. Wong, Web-based tools for finding optimal designs in biomedical studies, Computer
us
23.
cr
Gastonguay, Facilitating pharmacometric workflow with the metrumrg package for R, Computer
Methods and Programs in Biomedicine 111 (3) (2013) 701-710.
L. Breslow, From disease prevention to health promotion, The Journal of the American Medical
an
24.
Association 281 (11) (1999) 1030-3.
Y.A. Buischi, P. Axelsson, L.B. Oliveira, M.P. Mayer, Gjermo, P. (1994). Effect of two
M
25.
preventive programs on oral health knowledge and habits among Brazilian schoolchildren.
26.
d
Community Dentistry and Oral Epidemiology, 22(1), 41-6. L.S. Eller, E. Kleber, S.L. Wang, Research knowledge, attitudes and practice of health professionals, Nursing Outlook 51 (2003) 165-70.
27.
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
S.M. Hubbard, S.W. Hayashi, Use of diffusion of innovations theory to drive a federal agency’s program evaluation, Evaluation and Program Planning 26 (1) (2003) 49-56.
28.
G. Ryan, Online CME: An effective alternative to face-to-face delivery. Medical Teacher, 29 (2007) 251-257.
29.
Y.H. Sung, I.G. Kwon, J.W. Hwang, J.Y. Kim, Development of an e-learning program about medication for new nurses, Taehan Kanho Hakhoe Chi 35(6) (2005) 1113-1124.
30.
M.F. Fung, M. Walker, K.F. Fung, L. Temple, F. Lajoie, G. Bellemare, S.C. Bryson, An internetbased learning portfolio in resident education: the KOAL multicenter programme, Medical Education 34 (6) (2000) 474-479.
31.
J. Chenkin, S. Lee, T. Huyn, G. Bandiera, Procedures can be learned on the web: a randomized study of ultrasound-guided vascular access training, Academic Emergency Medicine 15(10) (2008) 949-954.
15
Page 15 of 21
32.
R. Mehvar, On-line individualized and interactive pharmacokinetic scenarios with immediate grading and feedback and potential for use by mutiple instructors, American Journal of Pharmaceutical Education. 63 (1999) 348-353.
33.
L. Alonso Díaz, F.Blázquez Entonado, Are the Functions of Teachers in e-Learning and Face-toFace Learning Environments Really Different?. Educational Technology & Society 12 (4) (2009)
L. Wong, A. Tatnall, The Need to Balance the Blend: Online versus Face-to-Face Teaching in an
cr
Introductory Accounting Subject, Issues in Informing Science and Information Technology, 6
M
an
us
(2009) 310-322.
d
34.
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331–343.
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
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Table
Table 1 The demographical data of the two groups Group B**
11 21.1
12 21.6
8(73%) 3(27%)
9(75%) 3(25%)
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N Age average (years) Gender Female Male
Group A*
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* Group A: received the traditional teaching method. ** Group B: using the CPIES.
Pre-Test (mean SD)
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Table 2 The baseline score analysis of KAP questionnaire
Group A*
Group B**
(n=11)
(n=12)
Knowledge
4.731.191
3.921.621
0.184
Attitude
20.362.157
21.331.557
0.288
Practice
20.182.786
20.502.468
0.780
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Sig.
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* Group A: received the traditional teaching method. ** Group B: received the CPIES program.
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Table 3 The KAP questionnaire pre-test and post-test score analysis Group A (n=11)
Group B (n=12)
Pre-Test
Post-Test
(mean SD)
(mean SD)
Pre-Test
Post-Test
(mean SD)
(mean SD)
4.731.191
6.182.228
.111
3.921.621
7.751.815
.002
Pharmacokinetics
2.910.539
3.641.027
.062
2.080.996
3.920.996
.007
TDM
1.820.874
2.551.368
.203
1.831.337
3.831.115
.003
20.362.157
21.361.748
.205
21.331.557
20.831.992
.379
Cooperation
11.731.348
11.821.662
.023
9.500.674
9.000.853
.835
Responsibilities
8.641.027
9.550.688
.798
11.831.467
11.831.528
.119
20.182.786
21.912.023
.011
20.502.468
21.752.221
.031
Responsibilities
12.361.567
13.361.362
.020
13.081.443
14.001.537
.046
Self-motivation
7.821.471
8.551.214
.039
7.421.443
7.751.357
.395
Knowledge*
Attitude*
Practice*
Sig**
Sig**
*The score is the total score of the questionnaire. **The bolded number indicates statistic significant. TDM = therapeutic drug monitoring
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Figure
1. Preceptor interview 2. Learning syllabus/ Process 3. Guidelines for hospitals pharmacy internship
Requirement Analysis
System Analysis
1. 2.
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System Design/ Prototyping Implementation
Integration and Testing
Architecture design Modules flow design
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Test Case Design (Preceptor/ Interns)
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Yes Modified
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No
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Release/ Installation
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Fig. 1 The Enhanced clinical pharmacy Internship eLearning System (CPIES) development model
Monitoring/ Measuring/ Calculation Tools
Material Management
Bulletins
Interactive Learning Platform
eLearning Process Management
Integrated Internet Resources
Personal Learning e-Portfolio
Forums
Goals/Learning Progress/Scores Awarded/ e-Portfolio Examination
Pharmacy Interns
User Management
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1. Materials 3. Tests 2. Reports 4. Questionnaires
System Administrator
Internet
Clinical Preceptors
Course Administrator
Fig. 2 The Enhanced clinical pharmacy Internship eLearning System (CPIES)
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Fig. 3 The homepage of the CPIES
Fig. 4 Calculation of corrected total phenytoin concentration (left) and formulas (right)
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K.A.P. Post-test
End
Yes KAP Pre-test
No
Finish all course units?
courseworks
Take one Take unit lectures
Yes
Pass? No
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Informed Instructors
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Test quizzes Take
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Start
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Fig. 5 The learning flow with CPIES
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*Conflicts of Interest
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Conflict of interest statement The authors declare that they have no conflict of interest.
Dr. Chien-Tsai Liu
ed
Professor and corresponding author
Graduate Institute of Biomedical Informatics, Taipei Medical University
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250 Wu-Hsing Street, Taipei City, Taiwan 110 Tel: 886-2-27361661 ext.3342, Fax: 886-2-27339049
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E-mail: [email protected]
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