Original Article Factors affecting the learning outcomes

Japanese Journal of Pharmaceutical Education Volume 5 (2021)doi: 10.24489/jjphe.2020-049© 2021 Japan Society for Pharamaceutical Education

Original Article

Factors affecting the learning outcomes of early clinical exposure—An effective experience in hospital settings—

Taro Kushihata, Masahide Sumiyama, Misa Nagata, Masahiro Ueda, Wasako Kurio,Tomohisa Yasuhara and Tomomichi Sone

Faculty of Pharmaceutical Sciences, Setsunan University

Based on the revised edition of the Pharmaceutical Education Model Core Curriculum, participating in clinical practice andimplementing results based on experience are important for early clinical exposure. Nevertheless, there have been only a few reports onearly clinical exposure subsequent to the implementation of the revised core curriculum. Moreover, studies verifying the componentsof observations and experiences at clinical sites are limited. In this study, we investigated the components of observations andexperiences at the visited facilities from early clinical exposure in hospitals and conducted a questionnaire-based survey to assessstudent learning before and after visiting the facility. We also conducted a factor analysis of the questionnaire data and grouped thestudents based on cluster analysis to verify the influence of experiences on learning outcomes in each group. We found that regardlessof students’ perception of hospital pharmacists and their understanding of pharmacists’ job, the greater the number of observationsand experiences the students had at the visiting facility, the better the learning they gained. It was also observed that specific work doneby hospital pharmacists was recognized and clarified. However, we found that the effects of early clinical exposure are limited infacilities where there are few opportunities for observations and experiences.

Key words: early clinical exposure in hospital settings, first-year experience, factor analysis, cluster analysis

(Received September 5, 2020. Accepted February 8, 2021)

Introduction

The 6-year pharmaceutical education course, initiated in 2006,aimed at training high-quality pharmacists and requires students tocultivate practical abilities related to clinical practice1). The Phar‐maceutical Education Model Core Curriculum–Revised Edition(core curriculum) focused on learning outcome-based educationwas implemented from the 2015 fiscal year. This curriculum detailsthe basic qualities required in a pharmacist. Moreover, it advocatesthe development of a “ Patient-oriented attitude. ” This impliesrespecting the rights of individuals and promoting the health andwelfare of patients and consumers2).

“Early clinical exposure” was initially known as “early experien‐tial learning” in the conventional curriculum, and many reportshave been made to document the tours of medical facilities3–8), suchas hospitals and insurance pharmacies, pharmaceutical companies,

Corresponding auther: Taro KushihataFaculty of Pharmaceutical Sciences, Setsunan University, 45-1 Nagaotoge-cho, Hirakata City, Osaka 573-0101, JapanTEL: 072-807-6037, E-mail: [email protected]

and welfare facilities. In the core curriculum, early clinical exposureis integrated into the “F. Pharmacy Practice Experiences” item,and its goal is to observe and discuss the role of pharmacists andinteract with them in various pharmacy practice settings to gainan understanding of the patient ’ s/consumer ’ s perspective2). Inother words, the core curriculum describes the requirements fora shift from the conventional “ observation-based learning ” to“participation/experience-based learning” and emphasizes “legiti‐mate peripheral participation”9–12) as the first step in clinical prac‐tice. In early clinical exposure, students enrolled in the faculty ofpharmaceutical sciences will encounter pharmacists in the clinicalsetting; these are the initial role models. It has been shown thatsuch encounters are important for recognizing the importance ofthe training program, improving motivation for studying, anddeveloping professionalism as medical personnel13–15). Such en‐counters have been incorporated into the curriculum of other med‐ical professionals, such as those for physicians16) and nurses17).Students’ motivation to learn, an educational effect of early clinicalexposure, assessed using pre- and post-exposure questionnaires,was reported to increase18–24). However, there are only a few reportson early clinical exposure subsequent to the implementation of the

JJPhE　Vol. 5 (2021)

core curriculum in the field of pharmacy25), and there are no studiesinvestigating the components of participation/experiential learningrequired in early clinical exposure26). In addition, only a few studieshave examined the impact of differences in observations and expe‐riences, that depend on the facilities visited, on learning effective‐ness27). Therefore, in this study, we investigated each group thatvisited the hospital facility by interviewing them about what theyobserved and experienced during their early clinical exposure, afterthe implementation of the core curriculum. Based on the results ofthe interviews, the study examined how the different experiencesgained from visiting different facilities affect the learning outcomesof early clinical exposure.

Method

This early clinical exposure study was conducted among 249first-year students in 25 hospitals (54 groups) from April 25 to May2, 2017. Fig. 1 shows the flow of early clinical exposure at our uni‐versity. In addition, we requested for facilities to provide 2 to 3hours of early clinical exposure. The investigation on the observa‐tions and experiences at the visited facilities was conducted byinterviewing the visiting group, with verbal confirmation of theimplementation of the 26 items that might be implemented in earlyclinical exposure at the hospital. These were done during the Post-SGD conducted after the visit, with all the group members whovisited the facility. In the pre-exposure questionnaire, we queriedstudents regarding their perception of pharmacists and theirinterests in pharmacists’ roles. In the post-exposure questionnaire,we questioned students on their perception of pharmacists, their

interest in pharmacists’ roles, and their impressions of the visitedfacilities.

Based on the responses in the questionnaires, students weredivided into groups according to their tendencies. Factor and clus‐ter analyses were performed to examine the learning effects in eachgroup. Before the questionnaires were administered, students wereinformed that they could be answered freely. We explained to thestudents that they could choose whether or not to fill their namesin the questionnaire. In addition, students were made to under‐stand that the quality of their responses would not affect theirgrades. We explained to the students verbally and in writing thatthe results of the survey were to be used in research to improveeducation and that no individual’s identity would be comprised fol‐lowing the publication of research results in academic conferencesand papers. This study was approved by the Research Ethics ReviewBoard to include Setsunan University students (approval number:2016–002).

All unanswered questionnaires and those with missing itemswere excluded from the multivariate analysis. Finally, the analysiswas performed using the responses of 247 students. JMP® Pro 15(SAS Institute Inc., Cary, NC, USA) was used for the statisticalanalysis of the questionnaire data.

Results

Table 1 shows a simple tabulation of the pre-exposure question‐naire data. Factor analysis was performed using 10 items from thepre-exposure questionnaire. In the exploratory factor analysis, aneigenvalue of 1 or more was used as index. Following the applica‐

Fig. 1 Overview of early clinical exposure

The learning from early clinical exposure in hospital settings

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tion of the maximum likelihood estimation, squared multiple cor‐relation of diagonal elements, and quartimin rotation, the finalcommonality was measured to be 0.45 or more for all items; thus,all items were included in the analysis. Finally, the three factorsshown in Table 2 were extracted from the 10 items. The extractedfactors were selected from among items with a factor load of 0.4 ormore. The description of each factor, along with its componentitems and contribution rates were as follows; factor 1: specific rec‐ognition of hospital pharmacists’ roles (3 items, 26.4%), factor 2:impression of hospital pharmacists (4 items, 31.3%), and factor 3:interest in hospital pharmacists ’ roles (3 items, 32.0%). Subse‐quently, hierarchical cluster analysis (Ward’s method) was per‐formed using each factor score, and the students were classifiedinto three groups: A to C (Fig. 2). These three groups consideredtogether were named ‘pre-clusters’. Table 3 shows the average fac‐tor scores for each group. The characteristics of each group wereexpressed using factor scores. Group A (104 students, 42.1%) hadthe highest scores for all factors, especially “recognition of hospitalpharmacists’ roles”. Group B (98 students, 39.7%) had an averageimpression of hospital pharmacists and interest in pharmacists ’work but could not recognize the roles of a hospital pharmacist.

Table 2 Results of factor analysis of the pre-exposure questionnaire data

Question Commonality Factor 1 Factor 2 Factor 3

Q04 0.719 0.825 0.115 –0.046Q08 0.710 0.824 0.136 –0.079Q06 0.587 0.727 –0.167 0.188

Q09 0.523 0.067 0.689 0.017Q02 0.451 0.003 0.688 –0.031Q10 0.488 0.051 0.631 0.081Q03 0.732 –0.043 0.612 0.364

Q05 0.765 0.097 –0.082 0.877Q01 0.537 –0.090 0.169 0.656Q07 0.604 0.125 0.172 0.606

Contribution rate 26.4 31.3 32.0Cumulative contribution ratio 26.4 57.7 89.7

Group C (45 students, 18.2%) scored below average for all factor,showing the least interest in hospital pharmacists’ roles.

Table 4 shows a simple tabulation of the post-exposure question‐naire data. Factor analysis was performed using 14 items from thepost-exposure questionnaire. Exploratory factor analysis was per‐formed using the same criteria as those used in the analysis of the

Fig. 2 Dendrogram of hierarchical cluster analysis (Ward’s method) ofpre-exposure questionnaire data

Table 3 Factor scores of pre-exposure for each group

Number % Factor 1 Factor 2 Factor 3

A 104 42.1 0.85 ± 0.43 0.39 ± 0.77 0.45 ± 0.60B 98 39.7 –0.58 ± 0.60 0.17 ± 0.57 0.10 ± 0.71C 45 18.2 –0.68 ± 0.78 –1.27 ± 0.63 –1.28 ± 0.80

Mean ± standard deviation

Table 1 Simple tabulation of the pre-exposure questionnaire data

Questionnaire items1 2 3 4 5 6 7

Negative ~ Positive

Q01 Do you want to visit the hospital facility? Strongly disagree 1–7 Strongly agree 4 1 7 28 55 87 65Q02 What is your impression of a hospital pharmacist? Very bad 1–7 Very good 0 0 2 63 54 86 42Q03 What is your interest in the occupational category of hospital pharmacist? Not interested at all 1–7 Very interested 3 6 10 23 59 83 63Q04 What is your specific understanding of the duties and roles of the hospital pharmacist? I don’t know at all 1–7 I know very much 21 39 52 52 69 11 3Q05 What is your interest in team medical care at hospitals? Not interested at all 1–7 Very interested 9 6 12 37 82 61 40Q06 What is your specific understanding of team medical care at the hospital? I don’t know at all 1–7 I know very much 32 35 52 55 61 9 3Q07 What is your interest in hospital pharmacist ward work? Not interested at all 1–7 Very interested 9 6 23 32 96 48 33Q08 What is your specific understanding of hospital pharmacist ward work? I don’t know at all 1–7 I know very much 30 38 52 58 54 13 2Q09 Do you think that hospital pharmacist is a very rewarding occupation? Strongly disagree 1–7 Strongly agree 0 3 8 39 64 75 58Q10 Do you want to be a hospital pharmacist in the future? Strongly disagree 1–7 Strongly agree 7 12 23 54 43 50 58

Taro Kushihata et al.

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pre-questionnaire data. The two factors shown in Table 5 wereextracted from these 14 items. The extracted factors were selectedfrom among items with a factor load of 0.4 or more. The descrip‐tion of each factor, along with its component items and contribu‐tion rates were as follows: factor 1: impression gained after visitingthe facility (10 items, 54.3%), factor 2: specific recognition of hospi‐tal pharmacists’ roles (4 items, 44.0%). In addition, hierarchicalcluster analysis (Ward’s method) was performed using each factor

Table 5 Results of the factor analysis of the post-exposure questionnairedata

Question Commonality Factor 1 Factor 2

Q14 0.627 0.909 –0.169Q12 0.698 0.900 –0.090Q03 0.682 0.819 0.010Q02 0.644 0.751 0.068Q13 0.486 0.692 0.008Q10 0.629 0.670 0.157Q01 0.598 0.619 0.193Q07 0.605 0.600 0.220Q11 0.503 0.574 0.170Q09 0.593 0.538 0.282

Q04 0.748 –0.070 0.915Q06 0.560 0.120 0.655Q08 0.642 0.240 0.607Q05 0.559 0.298 0.500

Contribution rate 54.3 44.0Cumulative contribution ratio 54.3 98.4

score, and the students were classified into three groups: D to F(Fig. 3). These three groups considered together were named ‘post-clusters’. Table 6 shows the average factor scores for each group.Group D (116 students, 47.0%) had a good impression of the facili‐ties visited and gained knowledge regarding the work carried out at

Fig. 3 Dendrogram of hierarchical cluster analysis (Ward’s method) ofpost-exposure questionnaire data

Table 4 Simple tabulation of the post-exposure questionnaire data

Questionnaire items1 2 3 4 5 6 7

Negative ~ Positive

Q01 How was the early clinical exposure at the hospital? Very boring 1–7 Very enjoyable 7 13 21 58 64 67 17Q02 What was the impression of the hospital pharmacist during your early clinical exposure? Very bad 1–7 Very good 1 4 19 64 82 55 22Q03 How did your interest in the occupational category of hospital pharmacist change

following your early clinical exposure?Very degraded 1–7 Very Increased 3 9 22 56 74 51 32

Q04 Did your early clinical exposure give you a specific understanding of the duties and rolesof hospital pharmacist?

I couldn’t do it at all 1–7 I did very well 6 8 23 32 93 66 19

Q05 How did your interest in team medical care at the hospital change following your earlyclinical exposure?

Very degraded 1–7 Very Increased 4 6 17 91 71 44 14

Q06 Did your early clinical exposure give you a specific understanding of team medical care atthe hospital?


Q07 How did your interest in hospital pharmacist ward work change following your earlyclinical exposure?

Very degraded 1–7 Very Increased 3 12 21 73 78 44 16

Q08 Did your early clinical exposure give you a specific understanding of hospital pharmacistward work?


Q09 Following your early clinical exposure, do you think that hospital pharmacist is a veryrewarding occupation?

Strongly disagree 1–7 Strongly agree 4 8 13 35 59 79 49

Q10 How did your motivation to learn change following your early clinical exposure? Very degraded 1–7 Very Increased 3 6 18 61 61 70 28Q11 How did your early clinical exposure of the hospital help you to become aware of the

medical staff?Not useful at all 1–7 Very helpful 6 4 15 31 75 73 43

Q12 Do you want to become a pharmacist at the hospital you visited? Strongly disagree 1–7 Strongly agree 12 11 29 64 55 51 25Q13 Do you or your family want to avail services at the hospital you visited as a patient? Strongly disagree 1–7 Strongly agree 11 7 23 69 75 47 15Q14 Do you want to work as a pharmacist in the future at the hospital you visited? Strongly disagree 1–7 Strongly agree 14 18 38 86 46 25 20


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the hospital. Group E (115, 46.6%) had little knowledge regardingpharmacists’ roles at the hospital, and group F (16 students, 6.5%)had extremely poor impressions of the visited facilities.

The average number of observations and experiences for allgroups that conducted early clinical exposure in the hospitals was27.5 ± 10.1 (mean ± standard deviation). Table 7 shows the cross-tabulation with the average number of observations and experi‐ences for each group that moved from pre- to post-clusters. Inaddition, Table 8 shows a heat map of the percentage of implemen‐tation of each item of observations and experiences for each groupthat moved from pre- to post-cluster. The percentage of implemen‐tation was calculated by dividing the number of implementationsin each group by the number of group members. Concerning itemsrelated to prescriptions, various drugs and other objective work ofthe pharmacist (e.g., no. 1 to no. 7), the groups that migrated intogroups D and E tended to have fewer observations and experiencesrelated to No. 4 (liquid medicines) and No. 5 (medical ointments),but generally, had some kind of observations and experiencesrelated to pharmacists’ objective work. In contrast, the groups thatmigrated into group F tended to have fewer opportunities to view areal prescription or to handle drugs; thus, the overall observationsand experiences regarding pharmacists’ objective work were insuf‐ficient in this group. Regarding items related to observations andexperiences related to patient information records, medical recordsand laboratory values (e.g., no. 8 to no. 10); use of information; andpharmacists ’ interpersonal work involving patients and othermedical staff such as medication instructions and team medicalcare (e.g., no. 11 to no. 18), group E tended to have fewer itemsthan groups D, whereas group F had the least number of itemsperformed.

Table 6 Factor scores of post-exposure for each group

Number % Factor 1 Factor 2

D 116 47.0 0.45 ± 0.82 0.51 ± 0.64E 115 46.6 –0.55 ± 0.51 –0.32 ± 0.59F 16 6.5 –1.95 ± 0.66 –2.34 ± 0.34


Table 7 Cross-tabulation of the number of experiences in each group thatmigrated from pre- to post-clusters

A n B n C n Overall n

D 31.1 ± 11.5 63 30.1 ± 11.0 41 31.4 ± 12.7 12 30.8 ± 11.3 116E 24.7 ± 4.3 34 25.2 ± 7.6 54 28.1 ± 8.5 27 25.9 ± 7.1 115F 12.0 ± 8.3 7 22.3 ± 0.6 3 17.0 ± 8.4 6 15.8 ± 8.2 16


Discussion

From the pre-exposure questionnaire analysis results, we foundthat approximately 80% of the students were interested in hospitalpharmacy as a profession and the role of hospital pharmacists(Table 3). Some students, such as those in group A, had concreteawareness regarding the role of hospital pharmacists, whichshowed their high motivation.

In contrast, there were students who were less interested in hos‐pital pharmacy, such as those in group C. Young individuals are lesslikely to receive medical treatment involving a hospital pharmacistthan individuals of other age groups. Therefore, it was assumed thata certain number of students, including a few students who wereenrolled in the 6-year pharmaceutical education course at the Fac‐ulty of Pharmaceutical Science, had low awareness regarding therole of hospital pharmacists.

The factor analysis of post-exposure questionnaire data revealedthat 10 out of 14 items were categorized as factor 1 (Table 5). Thiswas likely because the responders comprehensively evaluated, theirexperience at the facility, the aspirations they built from interactingwith the pharmacist and increased learning motivation, as theimpressions they had at the visited facility.

Based on cross-tabulation of each group that migrated from pre-to post-clusters (Table 7), the number of observations and experi‐ences in group D, which had a good impression of the facilitiesvisited and obtained higher knowledge about pharmacists’ work atthe hospital, was 30.8 ± 11.3 (mean ± standard deviation), andtended to be higher than the overall average, indicating good earlyclinical exposure. For first-year students who have little specializedknowledge regarding medicine and pharmacy, being able to experi‐ence multiple aspects even within a limited time period mayenhance the learning effects of early clinical exposure. In contrast,the number of observations and experiences in group F, which hada poor impression of the facilities visited, was about half of theoverall average i.e., 15.8 ± 8.2 (mean ± standard deviation). Partic‐ularly, the number of observations and experiences of the studentswho migrated from group A, where all factor scores were aboveaverage in the pre-clusters, to group F was the lowest i.e., 12.0 ± 8.3(mean ± standard deviation). These results suggest that a smallnumber of observations and experiences reduce students’ interestin hospital pharmacy and their future learning motivation.

From the heat map showing the percentage of implementation ofeach of the “observations and experiences” items (Table 8), it wasfound that the groups that migrated into group D tended to have ahigher percentage of observations and experiences on items relatedto pharmacists ’ interpersonal work than the other groups. Thegroups that migrated into group E tended to have the same per‐centage of observations and experiences on items related to phar‐macists’ objective work as group D, but had a lower percentage of


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Table 8 Heat map of the percentage of experiences that were implemented for each group that migrated from pre- to post-clusters


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Table 8 (Continued)


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observations and experiences on items related to pharmacists ’interpersonal work than group D. Concerning early clinical expo‐sure at the hospital, it is believed that the number of observationsand experiences related to these series of interpersonal work per‐formed by the pharmacist affected the learning outcomes of eachgroup. Furthermore, group D tended to have more observationsand experiences with inpatients (no. 20 and 22: inpatients; no. 23:physicians; and no. 26: non-medical staff [e.g., office workers]). It isconsidered that group D experienced pharmacists ’ activitiesbeyond the hospital dispensing room and got a concrete picture ofthe situations in which medical care was provided. For the groupsthat migrated into group F, it was suggested that the lack of expo‐sure to the pharmacists’ interpersonal work, in addition to fewergeneral observations and experiences, may significantly impairlearning outcomes in early clinical exposure at the hospital. How‐ever, the investigation of observations and experiences used in thisstudy is based on interviews with visiting groups on predetermineditems, and there are limitations in accurately measuring the level ofimplementation of early clinical exposure at the visited facilitiesand the level of awareness of individual students.

In a similar trend to that the reports on early experiential learn‐ing in the conventional curriculum18–24), it was confirmed that theearly clinical exposure with a high level of satisfaction increased thelearning motivation of first-year students even early clinical expo‐sure subsequent to the implementation of the core curriculum. Inaddition, while previous studies have reported the effect of on-campus efforts, such as prior learning before visiting a facility20) andpresentations after visiting a facility18), on increasing satisfaction inearly experiential learning, this study revealed that differences inthe content of the implementation of observations and experiencesat each hospital facility visited had an impact on learningoutcomes.

Experiences in clinical settings, concrete experiences gainedthrough “legitimate peripheral participation,” and future impres‐sions about pharmacy cannot be learned only at the university.Early clinical exposure in hospitals helped recognize the impor‐tance of pharmacists and imparted a sense of responsibility as med‐ical personnel, regardless of the first-year students’ understandingof hospital pharmacists ’ roles. We believe that this exposureincreased students ’ professional interest in pharmacy and theirtrust in pharmacists from the patient’s perspective.

To ensure awareness as a medical professional right from thelower grades and future learning motivation, it is important todirectly experience the roles of pharmacists’ at a visiting facility.Such pharmacists act as initial role models. Although such earlyclinical exposure takes place within a limited time period, theextent to which students gain observations and experiences fromsuch exposures greatly affects learning outcomes.

Conflicts of interest

There is no conflict of interest to disclose in relation to thecontents of this paper.

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早期臨床体験の学習成果に影響を与える因子の検証―病院早期臨床体験での効果的な見聞・体験―

串畑　太郎，住山　昌英，永田　実沙，上田　昌宏，栗尾　和佐子，安原　智久，曽根　知道

摂南大学薬学部

改訂薬学教育モデル・コアカリキュラムの適用下で実施される早期臨床体験は，臨床現場への参加・体験型での実施が重要視されている．しかし，改訂コアカリ適用後の早期臨床体験に関する報告は少なく，臨床現場での見聞・体験内容の検証はごく限られている．本研究では，病院での早期臨床体験における見聞・体験内容を調査した．また，学生に対する施設訪問前後でのアンケートを用いて因子分析，クラスター分析による群分けを行い，各群での訪問施設での見聞・体験が学習成果に与える影響を検証した．その結果，学生が持つ事前の病院薬剤師に対するイメージや業務内容の理解によらず，訪問施設での見聞・体験数が多いほど，施設で受けた印象がよく，具体的な業務への認識が明確化されることが明らかとなった．その一方で，見聞・体験の機会が少ない施設に関して，施設見学の効果は限定的であることが示唆された．

キーワード：病院早期臨床体験，初年次教育，因子分析，クラスター分析


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Documents

Original Article Factors affecting the learning outcomes