ff1 fs7 fc0 sc0 ls0 ws9">PHA 413 is a four-semester-hour required course offered to
almost 200 students in the second professional year. Engaging
such large classes in the application of knowledge from didactic
content is a challenge. One way the course instructors ad-
dressed this issue was by incorporating a “virtual pharmacy”
component into the examinations routinely given in this four-
credit-hour nonprescription therapeutics course. The term “vir-
tual pharmacy” refers to a computerized simulation of the non-
prescription products area of a community pharmacy. Students
in the combination campus and distance-based class in the
spring of 2011 were transitioning from being consumers of
nonprescription products to becoming professionals who rec-
ommend products to patients for a variety of health issues.
The multiple choice examination format does not provide
students with the same number of possible choices that they
would have in a pharmacy. To solve this problem, we devel-
oped a virtual pharmacy exam. The virtual pharmacy examina-
tion contains images of numerous products that one would en-
counter in an OTC aisle of the pharmacy. On the examination,
the student is given a self-care question or issue and they must
select an appropriate recommendation from numerous options.
Product images are separated into different sections similar to
the aisles one would find in a pharmacy, e.g. cough and cold
products, gastrointestinal products.
Although it would be possible to administer the virtual
pharmacy examination in a paper version, the combination of: 1)
students having laptop computers that allow them to take
on-line examinations; 2) examination software, such as Ques-
tion Mark®; and 3) a secure browser system provided an op-
portunity to create and use a virtual pharmacy examination
format. Creighton University pharmacy students have been
issued laptop computers since the fall of 2000. Examination
software is embedded in all the issued laptops. Examination
software allows students to take examinations in any location
with supervision by a proctor who oversees the student while
taking the examination; results are immediately available for
access by students and instructors. A secure browser allows
students to log into the examination while it blocks any other
computer use such as web surfing for answers.
Students look at images of product packaging and labels, and
then select what they conclude would be the best choice for a
patient in a given situation. The virtual pharmacy is set up as a
group of linked web pages. Examination web pages were au-
thored by creating two views of each product, one large, one
small with a third large view of the Drug Facts of each product.
Naming conventions for image files were standardized (exam-
ples VP01_ProductLarge_001.gif, VP01_ ProductSmall_001.
gif, VP01_ ProductLabel_001.gif) as were label page names
(VP01_Product001.html). Standardization of naming conven-
tions allowed for use of an Excel® spreadsheet to create neces-
sary names by changing the numerical portion of each file name
by an increment of one. The mail merge function of Microsoft
Word® was then used to create individual .txt files containing
appropriate html code. File extensions were then changed
to .html and pages copied to a web server. See Figure 1 for
examples of examination questions and pictures.
The main page represents shelves in a pharmacy and displays
small pictures of various product packages. Clicking the small
picture provides a larger picture of the front of the package.
This process can be thought of as taking a product off the shelf.
Clicking a larger image turns the package around to allow stu-
dents to view the back where Drug Facts are listed. Returning
to the main page can be thought of as putting a product back on
the shelf to once again view all products available in the virtual
pharmacy.
Objective
The objective of the study was to determine the impact of the
virtual pharmacy examination format on student perceptions of
confidence, competence, and comfort when recommending a
nonprescription product.
Null Hypotheses
1) There will be no change in the level of a student’s confi-
dence in making nonprescription product recommendations
after the virtual pharmacy examination experience;
2) Pharmacy work experience is not related to levels of con-
fidence;
3) There will be no change in the level of a student’s per-
ceived competence in making nonprescription product recom-
mendations after the virtual pharmacy examination experience;
4) Pharmacy work experience is not related to levels of per-
ceived competence;
5) There will be no change in the level of a student’s per-
ceived comfort in making nonprescription product recommen-
dations after the virtual pharmacy examination experience;
6) Pharmacy work experience is not related to levels of per-
ceived comfort.
Methods
Survey Instrument De sign, Adm i n istration, and
Validation
A survey instrument was designed for electronic administra-
tion. The instrument was composed of: 1) categorical demogra-
phic items; and 2) likert-scale items designed to assess students’
self-perceptions of confidence, competence and comfort when
making nonprescription product rcommendations (Figure 2). e
Copyright © 2012 SciRes. 589
W. R. HAMILTON ET AL.
Copyright © 2012 SciRes.
590
Figure 1.
Sample “virtual pharmacy” format. Note: The larger individual product picture below can be viewed by clicking the
thumbnail in the “virtual pharmacy aisle”. The student can click on this product and see the back of the box or the specific
information that the instructors wish to provide.
W. R. HAMILTON ET AL.
Q#13. Have you ever worked in a pharmacy as an intern
since you began pharmacy school?
1) Yes (If yes, please go to question 14)
2) No (If no, please go to question 16)
Q#14. Please indicate the type of pharmacy (s) you have
worked in as a pharmacy intern. Check all that apply.
a) Independent community pharmacy
b) Chain or other corporately owned pharmacy
c) Hospital pharmacy—inpatient
d) Nursing home or long term care pharmacy
e) Home infusion pharmacy
f) Nuclear pharmacy
g) Pharmaceutical industry
h) Pharmacy benefit manager
i) Other (please specify) _____________________
Q#15. About how many total hours have you worked as a
pharmacy intern since you began pharmacy school? ____
Q#16. Identify your pathway: Campus insert radio button
Distance insert radio button.
Q#17. Identify your gender: Male insert radio button Female
insert radio button.
Q#18. What was your age on your last birthday: ____
Pre-test and post-test survey instruments were administered
to 182 students at the beginning and end of the semester. Con-
firmatory factor analysis with Varimax rotation was used to
establish validity of subscale composition. Cronbach’s alpha
was calculated to determine subscale reliability. This study was
considered exempt by the Creighton University Institutional
Review Board.
Results
Of the 182 pre and post surveys administered, 168 students
completed both (106 by campus students and 62 by distance
students) for a usable response rate of 92.3%. Among these, for
those who chose to answer the gender item, gender distribution
was 107 females and 59 males. There were 122 respondents
with pharmacy work experience and 46 with none.
Paired sample t-tests and independent samples t-tests were
used for pre-post comparisons where appropriate. Analysis
showed a pre-post mean increase of 1.25 on a 5-point scale for
the 3-item subscale measuring perceived confidence in making
OTC recommendations (p < 0.001, Cronbach’s alpha = 0.91).
Confirmatory factor analyses with Varimax rotation and reli-
ability analyses were conducted on the three-item scale meas-
uring respondent confidence in making an OTC product rec-
ommendation. For the pre-confidence analysis, of three com-
ponents extracted, the primary component had an Eigen value
of 2.579 explaining 86.55% of the variance. Reliability analysis
for this subscale had a Cronbach’s Alpha of 0.92. For the
post-confidence analysis of three components extracted, the
primary component had an Eigen value of 2.722 explaining
90.72% of the variance. Reliability analysis for this subscale had
a Cronbach’s Alpha of 0.95. A single item for a pre-post com-
parison of perceived competence showed a mean increase of
1.45 on a 5-point scale (p < 0.001). A single item for a pre-post
Instructions: Please indicate the extent to which you agree or disagree with each statement using the answer
codes provided.
Survey Items:
Response Codes:
1 = Strongly Disagree
2 = Disagree
3 = Neither Agree nor Disagree
4 = Agree
5 = Strongly Agree
Q#01. I am confident in my ability to make a recommendation to a patient for use of a self-care product. 1 2 3 4 5
Q#02. I think I can do a good job when making a recommendation to a patient for use of a self-care product. 1 2 3 4 5
Q#03. I am confident that I can select an appropriate product in response to a patient’s request for a self-care
product recommendation. 1 2 3 4 5
Q#04. The virtual pharmacy examination format used in this course is a realistic simulation of the types of
problem solving a pharmacist engages in when making recommendations to a patient regarding self-care. 1 2 3 4 5
Q#05. The use of the virtual pharmacy examination in this course helped me to become more confident when
making a self-care recommendation to patients. 1 2 3 4 5
Q#06. The use of the virtual pharmacy examination in this course has helped me to become more confident
when making a self-care recommendation. Not used because it is a duplication of 5. 1 2 3 4 5
Q#07. I am currently competent to make self-care recommendation to patients. 1 2 3 4 5
Q#08. The use of the virtual pharmacy examination in this course helped me to become more competent to
make a self-care product recommendation to a patient. 1 2 3 4 5
Q#09. I feel nervous when I make a recommendation to a patient for use of a self-care product. 1 2 3 4 5
Q#10. The use of the virtual pharmacy examination in this course has helped me to become less anxious when
making a self-care recommendation. 1 2 3 4 5
Q#11. I like the virtual pharmacy examination format used in this course more than the traditional multiple
choice examination format. 1 2 3 4 5
Q#12. The virtual pharmacy examination format used in this course is harder than the traditional multiple
choice examination format. 1 2 3 4 5
Figure 2.
urvey instrument. S
Copyright © 2012 SciRes. 591
W. R. HAMILTON ET AL.
comparison of perceived comfort in making nonprescription
product recommendations showed a mean increase of 0.49 on a
5-point scale (p < 0.001). See Table 1 for comparisons by sub-
groups.
Comparisons based upon whether or not respondents had
pharmacy work experience, showed significant differences only
for comparisons of pre-test perceived competence (0.31 less for
the group with no work experience, p < 0.05) and for post-test
competence (0.43 less for the group with no work experience, p
< 0.05), see Table 2. The negligible differences seen between
responses of campus and distance pathway students were not
statistically significant.
Discussion
Overall and within subgroups with and without work ex-
perience, respondents’ levels of self-perceived confidence,
competence and comfort in making nonprescription product
recommendations increased significantly from pre-test to post-
test, thus refuting the Null Hypotheses 1, 3 and 5. Of interest is
that the presence or absence of work experience had no rela-
tionship to these pre-post increases, thus refuting Null Hy-
potheses 2, 4 and 6 vis-à-vis pre-post comparisons. Both groups
showed increases in their perceived levels of confidence, com-
petence and comfort in making nonprescription product rec-
ommendations. Table 3 summarizes support and lack of sup-
port for the null hypotheses.
The presence of work experience does play a statistically sig-
nificant role when contrasting pre-test levels of self-perceived
competence, with the experienced group having statistically
significant higher values of pre-test competence. Of note is
Table 1.
Pre-post comparisons.
Null Hypotheses
Addressed Comparisons via Paired Samples t-tests
Mean (SD) N Mean Scale
Difference Significance
(2-tailed)
1 Pre Confidence—All
2.95 (0.88) N = 168
Post Confidence—All
4.19 (0.50) N = 168 1.25 p < 0.001
1 Pre Confidence—Work
3.03 (0.84) N = 122
Post Confidence—Work
4.20 (0.53) N = 122 1.17 p < 0.001
1 Pre Confidence—No Work
2.74 (0.96) N = 46
Post Confidence—No Work
4.16 (0.44) N = 46 1.42 p < 0.001
3 Pre Competence—All
2.62 (0.91) N = 168
Post Competence—All
4.07 (0.68) N = 168 1.45 p < 0.001
3 Pre Competence—Work
2.75 (0.91) N = 122
Post Competence—Work
4.07 (0.71) N = 122 1.32 p < 0.001
3 Pre Competence—No Work
2.28 (0.86) N = 46
Post Competence—No Work
4.04 (0.60) N = 46 1.76 p < 0.001
5 Pre Comfort—All
2.65 (0.91) N = 167
Post Comfort—All
3.13 (0.68) N = 167 0.49 p < 0.01
5 Pre Comfort—Work
2.69 (0.96) N = 121
Post Comfort—Work
3.07 (1.13) N = 121 0.38 p < 0.01
5 Pre Comfort—No Work
2.54 (0.91) N = 46
Post Comfort—No Work
3.28 (0.68) N = 46 0.74 p < 0.01
Table 2.
Comparisons within subgroups: Work versus no work.
Null Hypotheses
Addressed Comparisons via Independent Sample s t-tests
Mean (SD) N Mean Scale
Difference Significance
(2-tailed)
2 Pre Confidence—Work
3.03 (0.84) N = 122
Pre Confidence—No Work
2.74 (0.95) N = 46 0.29 N.S.
2 Post Confidence—Work
4.20 (0.53) N = 122
Post Confidence—No Work
4.16 (0.43) N = 46 0.05 N.S.
2 Post Confidence Diff.—Work
1.18 (0.81) N = 122
Post Confidence Diff.—No Work
1.42 (0.97) N = 46 0.24 N.S.
4 Pre Competence—Work
2.75 (0.91) N = 122
Pre Competence—No Work
2.28 (0.86) N = 46 0.46 p < 0.01
4 Post Competence—Work
4.07 (0.71) N = 122
Post Competence—No Work
4.04 (0.60) N = 46 0.03 N.S.
4 Post Competence Diff.—Work
1.33 (0.83) N = 122
Post Competence Diff.—No Work
1.76 (0.85) N = 46 0.43 p < 0.01
6 Pre Comfort—Work
2.69 (0.96) N = 121
Pre Comfort—No Work
2.54 (0.94) N = 46 0.14 N.S.
6 Post Comfort—Work
3.07 (1.13) N = 122
Post Comfort—No Work
3.28 (0.68) N = 46 0.20 N.S.
6 Comfort Diff.—Work
0.39 (1.33) N = 121
Comfort Diff.—No Work
0.74 (0.93) N = 46 0.35 N.S.
Copyright © 2012 SciRes.
592
W. R. HAMILTON ET AL.
Table 3.
Summary of null hypothesis results.
Null Hypotheses Null Hypothesis Supported? Significance
1 There will be no change in the level of a student’s confidence in making OTC product
recommendations change after the virtual pharmacy exam experience. No p < 0.001
2 Pharmacy work experience is not related to the level of confidence in making OTC
product recommendations. Yes N.S.
3 There will be no change in the level of a student’s perceived competence in making
OTC product recommendations change after the virtual pharmacy exam experience. No p < 0.001
4 Pharmacy work experience is not related to the level of perceived competence in
making OTC product recommendations. Partially p < 0.01 N.S. p < 0.01
5 There will be no change in the level of a student’s perceived comfort in making OTC
product recommendations change after the virtual pharmacy exam experience. No p < 0.001
6 Pharmacy work experience is not related to the level of perceived comfort in making
OTC product recommendations. Yes N.S.
the statistically non-significant comparison of competence in
the post-test. Respondents with and without work experience
reported a virtually identical level of competence. This indi-
cates that respondents’ exposure to the virtual pharmacy ex-
amination format and course content brought both experienced
and inexperienced respondents up to the same level of post-test
competence. The statistical significance of the pre-post differ-
ence in competence between the work-experienced and work-
inexperienced groups is not attributable to the difference seen
in the pre-test, nor to the course or exam. Differences are sig-
nificant but are in the opposite direction. This significance is
attributable to the fact that work-inexperienced respondents had
a higher and statistically significant pre-post increase than those
with pharmacy work experience. Neither the presence nor ab-
sence of work experience had a statistically significant rela-
tionship with confidence and comfort levels compared within
the pre-test and post-test groups (Table 2).
Though not specifically addressed by the research questions,
possible relationships among age, gender and experience with
the outcome variables of confidence, competence and comfort
were examined in order to take into account possible alternative
explanations for the results. While respondent age correlated
significantly with work experience (r = 0.398, p < 0.001), gen-
der did not. Yet, when examining confidence, competence and
comfort among the work-experienced group by gender, males
had significantly higher levels of pre-confidence (p < 0.01) and
pre-competence (p < 0.05) with no significant difference by
gender in either of the comfort measures. Of interest is that
subsequent to exposure to the virtual pharmacy examination
and course content, there was no significant difference by gen-
der in the post-confidence and post-competence measures. Men
and women were virtually at the same level. These same com-
parisons by gender showed no significant differences in any
comparisons in the respondents with no work experience.
Limitations
There was no measure of actual or real world performance in
making nonprescription product recommendations by these
students. Exposure to course content likely contributed to
changes observed in respondents’ perceptions of confidence,
competence and comfort when making nonprescription product
recommendations.
Conclusion
The survey measured student self-perceptions of confidence,
competence and comfort in making nonprescription product
recommendations. The analysis indicates that exposure to the
course content and the more realistic simulation experiences of
the virtual pharmacy examination were strongly related to the
observed increases in confidence, competence, and comfort.
Despite differences in prior pharmacy work experience, the
data indicate that students arrived at the same levels of compe-
tence, confidence and comfort in making nonprescription
product recommendations.
Acknowledgements
The authors wish to express their gratitude to Ted A. Kasha,
B.S. for his assistance in the design and management of the
survey instrument.
REFERENCES
Accreditation Council for Pharmacy Education (2007). Accreditation
standards and guidelines for the professional program in pharmacy
leading to the doctor of pharmacy degree. Standard 14., v. adopted:
effective 1 July 2007.
Alexiou, A., Bouras, C., Giannaka, E. et al. (2004). The virtual radio-
pharmacy laboratory: A 3-D simulation for distance Learning. Jour-
nal of Educational Multimedia Hypermedia, 13, 307-322.
Bambini, D., Washburn, J., & Perkins, R. (2009). Outcomes of clinical
simulation for novice nursing students: Communication, confidence,
clinical judgement. Nursing Educatio n Perspectives, 30, 79-82.
Boje, K., Sauciunac, C., & Piper, T. (2005). A pharmaceutical biotech-
nology virtual laboratory. American Journal of Pharmaceutical Educa-
tion, 69, 157-168. doi:10.5688/aj690224
Brands, M. W., & Schumacher, L. (2009). Active learning strategies to
teach renal-cardiovascular integration with high student-to-teacher
ratios. Advances Physiology Education , 33, 282-285.
doi:10.1152/advan.00055.2009
Consumer Healthcare Products Association (2012). The value of OTC
medicine to the United States. URL (last checked 30 April 2012).
http://www.yourhealthathand.org/images/uploads/The_Value_of_OT
C_Medicine_to_the_United_States_BoozCo.pdf
Fuhrman, L. C., Buff, W. E., Eaddy, M. et al. (2001). Utilization of an
integrated interactive virtual patient database ina web-based envi-
ronment for teaching continuity of care. American Journal of Phar-
maceutical Education, 65 , 271-275.
Haworth, I. S., Bolger, M. B., & Eriksen, S. P. (1997). Use of com-
Copyright © 2012 SciRes. 593
W. R. HAMILTON ET AL.
puter-based case studies in a problem-solving curriculum. American
Journal of Pharmaceu tical Education, 61, 97-102.
Hedaya, M. A. (1998). Development and evaluation of an interactive
Internet-based pharmacokinetic teaching module. American Journal
of Pharmaceutical Educatio n, 62, 12-16.
Kameg, K., Howard, V. M., Clochesy, J. et al. (2010). The impact of
high fidelity human simulation on self-efficacy of communication
skills. Issues in Mental Health Nursing, 31, 315-323.
doi:10.3109/01612840903420331
Kiegaldie, D. (2006). “The virtual patient”—Development, implemen-
tation and evaluation of an innovative computer simulation for post-
graduate nursing students. Journal of Educational Multimedia and
Hypermedia, 15, 31-47.
Kinkade, R. E., Mathews, C. T., Draugalis, J. R. et al. (1995). Evalua-
tion of a computer simulation in a therapeutics case discussion.
American Journal of Pha r m a ce u t i c a l Education, 59, 147-150.
Kluge, M. A., Glick, L. K., & Engleman, L. L. (2007). Teaching nurs-
ing and allied health care students how to “communicate care” to
older adults. E d u c a t io n a l G e r o nt o logy, 33, 187-207.
doi:10.1080/03601270600864082
Li, R. C., Wong, S. L., & Chan, K. H. (1995). Microcomputer-based
programs for pharmacokinetic simulations. American Journal of
Pharmaceutical Education, 59, 143-147.
Liaw, S. Y., Chen, F. G., Klainin, P. et al. (2010). Developing clinical
competency in crisis event management: An integrated simulation
problem-based learning activity. Advances in Health Sciences Edu-
cation, 15, 403-413. doi:10.1007/s10459-009-9208-9
Orr, K. K. (2007). Integrating virtual patients into a self-care course.
American Journal of Pha r m a ce u t i c a l Education, 71, 1-9.
doi:10.5688/aj710230
Paige, J. T., Kozmenko, V., Yang, T. et al. (2009). Attitudinal changes
resulting from repetitive training of operating room personnel using
high-fidelity simulation at the point of care. The American Surgeon,
75, 584.
Schlicht, J. R., Livengood, B., & Shepard, J. (1997). Development of
multimedia computer applications for clinical pharmacy training.
American Journal of Pha r m a ce u t i c a l Education, 61, 287-292.
Sewell, R. D. E., Stevens, R. G., & Lewis, D. J. (1996). A pharmacol-
ogy experimental benefits from the use of computer-assisted learning.
American Journal of Pha r m a ce u t i c a l Education, 60, 303-307.
Sibbald, D. (2003). Virtual interactive case tool for asynchronous
learning and other self-directed learning formats. American Journal
of Pharmaceutical Educatio n, 67, 144-152.
Sibbald, D. (2004). A student assessment of virtual interactive case tool
for asynchronous learning: Develop online resources for non-pre-
scription drugs. American Journal of Pharmaceutical Education, 68,
1-7. doi:10.5688/aj680111
Srinivasan, M., Hwang, J. C., West, D. et al. (2006). Assessment of
clinical skills using simulator technologies. Academic Psychiatry, 30,
505-515. doi:10.1176/appi.ap.30.6.505
Tompson, G. H., & Dass, P. (2000). Improving students’ self-efficacy
in strategic management: The relative impact of cases and simula-
tions. Simulation Gaming, 31, 21-44.
doi:10.1177/104687810003100102
Tsai, S., Chai, S., Hsieh, L. et al. (2008). The use of virtual reality
computer simulation in learning port—A cath injection. Advances in
Health Sciences Education, 1 3 , 71-87.
doi:10.1007/s10459-006-9025-3
Copyright © 2012 SciRes.
594