key: cord-0865173-2zg2kd2x
authors: Strawbridge, Judith; Hayden, John C.; Robson, Tracy; Flood, Michelle; Cullinan, Shane; Lynch, Matthew; Morgan, Anne Teresa; O'Brien, Fiona; Reynolds, Róisín; Kerrigan, Steven W.; Cavalleri, Gianpiero; Kirby, Brian P.; Tighe, Orna; Maher, Anthony; Barlow, James W.
title: Educating pharmacy students through a pandemic: Reflecting on our COVID-19 experience
date: 2021-08-17
journal: Res Social Adm Pharm
DOI: 10.1016/j.sapharm.2021.08.007
sha: 038f36dc102e179343fc03b86429667e7d372413
doc_id: 865173
cord_uid: 2zg2kd2x

The impact of the COVID-19 pandemic on pharmacy education worldwide has been immense, affecting students, educators and regulatory agencies. Pharmacy programmes have had to rapidly adapt in their delivery of education, maintaining standards while also ensuring the safety of all stakeholders. In this commentary, we describe the challenges, compromises and solutions adopted by our institution throughout the pandemic, the lessons learnt, adaptive measures taken, and strategies to develop and future-proof our curricula.

The World Health Organisation declared the SARS-CoV-2 outbreak, known as COVID- 19 , a pandemic on March 11, 2020. On the following day, March 12, 2020, the Irish Government announced that all universities were to close campuses. Since then, Ireland has had three waves of cases: April 2020 (end of Semester 2 2019/2020), October 2020 (mid Semester 1 2020/2021), and January 2021 (start of Semester 2 2020/2021). For most of this time, Ireland has been in some form of lockdown, although the Irish Government deemed higher education an essential service that could continue under specific guidance. 1 The Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences is based in Dublin, Ireland. It offers degree programmes in Medicine, Physiotherapy and Pharmacy, alongside diverse postgraduate programmes, and operates as a not-for-profit university. Most programmes have a high proportion of international students. Its 5-year integrated Master of Pharmacy (M.Pharm.) programme has an intake of approximately 60 students annually. The driving mission in response to was that students continued their education, that health and wellbeing were protected, that the profession was adequately served, the national effort supported, and that research continued and contributed to the scholarly response to the pandemic. Similar challenges were encountered globally, with much deliberation on the impact on J o u r n a l P r e -p r o o f education from the outset of the pandemic. 2- 6 The aim of this paper is to provide a relatively detailed description of the extent of the challenges faced in our institution, and with 15 months experience accrued, to reflect on the lessons for pharmacy educators.

Continuity of education has been achieved in different ways since the onset of the pandemic. Campus closure in March 2020 resulted in an overnight pivot to online teaching for the remaining 6 weeks of the 2019/2020 academic year. A blended learning approach, using a combination of remote teaching using online platforms, which was predominantly used for lectures, and on-site attendance for laboratory classes and workshops that were deemed to be optimally delivered face-to-face, was implemented in September 2020 for the new academic year, aiming to retain meaningful on-campus experience. Students were advised to stay in Ireland between semesters, but some travelled overseas in December 2020 and were unable to return during the ensuing third wave. This necessitated re-calibration, with the option of continued delivery of blended learning for those in Ireland and a fully online programme for those electing to attend solely online. Of our students in Years 1-4 of the programme during Semester 2 of 2021, 55% elected to attend on-site and 45% online, with 17% connecting from overseas.

The curriculum was revised on three occasions. The first revision prioritised content and reimagined delivery for fully online delivery for the end of Semester 2 2019/2020. The second revision, during summer 2020 and implementing institutional direction, planned for three half-day sessions per week on-campus for years 1-3. Content of these sessions was designed to afford maximum benefit to students through in-person delivery. Others have reported similar, sustainable approaches. 3 Online content was streamed live, employing efforts to enhance digital engagement. In line with best practice, streamed content was recorded and made available to all students for later review, to facilitate those unwell due to COVID-19, having connection problems, or caring responsibilities. 7 Synchronous live sessions were scheduled to help students feel part of a community rather than communicating with a computer in isolation. 8 Enablers of engagement with online learning included the flipped classroom approach, small group tutorials, online breakout rooms, working on shared documents, use of an electronic whiteboard, and live polling. Breakout rooms also provided opportunities for peer-to-peer contact, which helped in building relationships and confidence. 9 Use of electronic whiteboards provided for anonymised student questions and comments, which enhanced student engagement, and was endorsed in student feedback. This was facilitated through use of Blackboard Collaborate ® software, which all staff had been trained in prior to campus closure, as part of pre-emptive planning. A central Digitally Engaged Learning Hub was created, to provide ongoing help and support for staff designing online learning.

It featured weekly themes, a help forum, practice space and a series of live and recorded practical workshops. The use of additional tools, such as Turning Technologies ® , allowed for more seamless use of polling questions to sense-check student understanding in realtime. Student feedback indicated that the majority of staff used such methods, including polls, which encouraged engagement. Additionally, students commented that there had been significant efforts to engage them; that the use of the whiteboard encouraged students to ask questions, breakout rooms made the class interactive and that polls were both fun and engaging. The use of such software, alongside the case-based approach used within the University, has been shown to enhance student engagement. 10 Provision of both online learning and blended delivery in 2021 necessitated the use of HyFlex technology, whereby staff engaged with some students on-campus, with simultaneous live-streaming to others. These approaches have been associated with similar student satisfaction and performance in both multiple choice and written exams, regardless of whether engaging in person or online. 11 Significant challenges were encountered adapting practical classes to facilitate on-campus learning and remote delivery. Time dedicated to practical skills was reduced, with those attending online-only periods risking lower proficiency. These risks were mitigated through HyFlex delivery alongside video-recordings of laboratory experiments. Experimental data was provided to online students, with a shift to data interpretation skills over practical skill acquisition.

For example, in semester 2 of 2020, remote students were emailed prescriptions for patient-centred care laboratories in advance, mirroring national developments in practice J o u r n a l P r e -p r o o f where prescriptions were being securely transferred to pharmacies electronically. 12, 13 They could then engage in interventions and practice consultations via video call, but would not use any dispensing software. As a pilot initiative, we also trialled MyDispense ® among our Year 3 students, which offered them further opportunity to practice their dispensing skills, including navigating dispensing software in a virtual environment.

Online laboratories have not been found to be a full substitute for in-class skills laboratories but are a useful complement and have some unique advantages. 14 Additionally, some laboratory classes cancelled in 2019/2020 were offered as a catch up in the following years' modules. APPEL worked with the PSI to make provisions for remote experiential learning in environments where the providers were all working from home in accordance with Government guidelines. Students in the incoming Year 5 were only due to be on campus for the first semester of 2020/2021, for 12 weeks between September and December 2020, prior to their eight-month block of experiential learning. As these postgraduate students have learned to work together and have developed independent learning skills, it was envisaged that they could take responsibility for learning, similar to the requirements of mandatory continuing professional education. 16 A decision was taken to deliver their learning online. Modules were redesigned, incorporating small group work and simulation to promote self-directed learning and optimise clinical reasoning and complex consultation skills. Timetabling was mindful of the small number of students in different time zones.

A smooth transition to online and blended learning was achieved, as all students receive a laptop on registration, which meant that concerns about access to appropriate J o u r n a l P r e -p r o o f hardware were not relevant. 2,17 An early decision to use Blackboard Collaborate proved an enabler and completing the initial training of staff in advance of university closure was advantageous. Despite initial anxiety, students appreciated continuity of experiential learning. Those who undertook remote experiential learning were positive about the experience. Year 5 students engaged well with online learning, but it was a challenge to facilitate diverse time zones. The decision to facilitate both blended and fully online learning in 2021 resulted in a significant increase in staff workload. 18 Interprofessional learning was also logistically challenging 3 but was facilitated by the willingness of simulated patients to embrace the online format. Real patients also continued to contribute to teaching and assessment online.

Ongoing research, and the return of students to campus in September 2020, necessitated planning for a safe environment. The campus was prepared by controlling access, increased cleaning, installation of sanitizer dispensing stations, signage indicating traffic flow, installation of plexiglass shielding, increasing the supply of personal protective equipment, and introducing clean in, clean out protocols. Physical distancing of 2m was implemented in all venues. A COVID-19 response plan was prepared. Both institutional and departmental COVID-19 risk assessments were developed. Mandatory COVID-19 'Return to Campus' induction training was required for everyone, alongside daily electronic sign-in and health check. A work from home directive for staff was introduced, along with division of staff into two "pods", to allow for attendance on alternate days. An office space booking system accommodated staff with on-campus teaching responsibilities outside of "pod" days.

Physical distancing had the immediate effect of reducing the capacity of all teaching facilities. The University invested in a new satellite campus to increase available teaching space, yet class size reduction across all programmes was necessary. Pharmacy classes were divided into two "learning communities". 19 Students were allocated to these communities based on personal contacts within the class, e.g., shared accommodation or transport. This was intended to help minimize the impact of any outbreaks. Students were timetabled to attend campus three times weekly within their communities, and were also limited in accessing the library, including to expanded J o u r n a l P r e -p r o o f study spaces, to their scheduled on-campus times. The creation of learning communities increased operational workload and necessitated teaching the same material twice.

The University's Medical Centre managed the care of all students with suspected or positive COVID-19. A university-specific contact tracing system was established to quickly identify and manage close contacts. This was important to alleviate pressure on the National contact tracing system. COVID-19 screening tests were provided for students 48 hours before embarking on experiential learning placements and every 14 days thereafter. Swabs were initially processed at an off-site public testing laboratory. 

Students' lives have been altered by the pandemic. Increased remote learning meant reduced connections with staff and fellow students. Some faced additional challenges: caring responsibilities, home-schooling, isolation, loss of income, illness, and grief.

Formal strategies to support students to counteract possible burnout have been described in the literature. 22 At RCSI, all academic members of staff additionally take a mentoring role through acting as a personal tutor for a number of students, and through this mechanism, increased their contacts with tutees. Students with difficulties were referred to Student Welfare for further support. Academic Year Leads sent weekly update emails, which helped students keep connected with RCSI, especially during the initial shutdown.

Full class on-line meetings were convened when issues required discussion. Engagement with online material was monitored and clear lack of engagement followed up on. This was not from a disciplinary standpoint, but rather to identify those struggling and to provide support.

Staff were especially mindful that incoming first year students would not have the 'typical' experience they would have envisaged at the beginning of their college life.

The transition from second to third level education can be challenging under normal circumstances 23 , and staff recognised this would be complicated by COVID-19 restrictions. 24 A two-week, fully online, 'arrival and integration programme' was developed for first year students. This consisted of activities in four categories; academic, social, health and well-being, and 'Passport for Success' (a formal RCSI induction programme). Examples of these activities are presented in Table 1 : First years met with their personal tutor weekly for the first two weeks, and at regular intervals thereafter. One emergent issue was that some of these students had not covered the expected breadth of material due to school closures and cancellation of state exams.

Extra tutorials were delivered by academic module coordinators to address any gaps in student knowledge. At the end of each week, consolidation sessions were held online, with all staff that had taught that week attending to answer any student queries. A group project was reconfigured to promote student interaction in small groups, working together on a shared task and getting to know each other. Mid-semester student feedback indicated that first year students were settling in, were positive about their time on-campus, but missed the opportunity to interact with each other and staff.

Despite limited permitted interactions, a physically distanced Christmas Lunch successfully allowed first years and staff to meet each other outside the classroom. The winter holiday was a challenging time for all students, particularly those from overseas who stayed in Ireland. RCSI partnered with the Students Union to support these students. Staff and alumni funded 1,500 Christmas gift stockings and takeaway dinners.

A guide of things to do and see in Dublin at Christmas was prepared, and opportunities provided to get involved in outreach activities within the local community.

Intensive student engagement was a global phenomenon during COVID-19. 2 Not all engagement was successful. Reassurances about campus safety led to fully on-line students feeling that they were missing a campus experience. Students missed the social aspects of College life prohibited due to public health guidance, including in-person gym access, indoor catering, social activities, graduations, and events. Library access, when available, was restricted to designated time slots. Campus life was also curtailed by wider closures of non-essential businesses and entertainment venues in the city.

The assessment strategy for the M.Pharm. programme was designed pre-pandemic to (Table 2) . were offered on two occasions, one more opportunity than would normally be given.

Under these conditions all students successfully progressed to the following year.

As restrictions continued into the academic year 2020/2021, many continuous and summative assessments were adapted to online formats, including simulated clinical teaching, group project presentations, and OSCEs. The relative proportion of marks awarded to continuous assessments was increased, typically to 30% for most modules. Reassuringly, performance in these examinations broadly aligned with overall performance over the preceding three academic years.

Authors have reflected on the challenges and opportunities for assessment, and how these should act as a catalyst for future innovation. 2,25 Technological innovations in the delivery of examinations have been widely adopted, and have met with varied degrees of student acceptance. 26, 27 Changes to assessment procedures, both proctored and unproctored, increase student-reported stress. 28 Students found it difficult to answer calculations questions without access to rough work paper and their own calculator, which were restricted by proctoring requirements. This was addressed by separating the calculations into stand-alone papers which were proctored by watching the videos rather than using inbuilt proctoring software. Another limitation of online examinations was that free-text drawing, for example of chemical structures, was not possible with the software used. Additional reading time was provided for each format to account for student concerns about typing speed. The benefits of the more diverse question constructs in improving reliability were evident to faculty. The use of online assessment has advantages in ease of marking and maintaining data integrity. There are however limitations to online proctoring that need to be considered. 25, 29 It is likely that some J o u r n a l P r e -p r o o f elements of the changes to assessment will be retained; namely use of online assessment, diverse question constructs, and open book assessments. the additional work on staff is unknown, but there must be a risk of burnout. 35 There has also been a significant impact on students. 36 Although their education has been maintained, it has not been the university experience that they expected. Again, the full impact is unknown. There is a focus on skill development within the programme, and it was a challenge to convert skills-based learning to remote delivery. 3 It remains to be seen what the impact will be on students being practice-ready in the future.

Similarly, assessment processes were fair, but the reliability of these approaches remains unconfirmed. 2

There have been positive outcomes. Staff have upskilled in providing digitally engaged online learning. This has potential to enhance teaching and learning when implemented judiciously and has a particular role in blended learning Masters programmes. 5 Newfound creativity and flexibility in delivering pharmacy programmes, born out of need, will likely continue. 37 There is a role for online patient and public involvement in education, with patients reporting that they found that they could contribute without the associated concerns about travel and available facilities to meet their needs. There are other wider implications, in that it may provide scope for supporting recognition of prior learning and therefore widening diversity in pharmacy. The interest in pharmacy as a career may have been enhanced by recognition of the important role for pharmacists providing healthcare during the pandemic. Curricula should and must evolve to incorporate necessary knowledge and skills regarding topics such as infection control and vaccine hesitancy. 38 The need to strengthen the workforce has prompted further reflection on determining competency, and a full review of workplace-based assessment and the PRE has been instigated by the board of APPEL. Pharmacy students have been embedded in the wider pharmacy team, and their role has been extended to include vaccination. This has wider benefits for the profession in concretising the full scope of practice for pharmacists.

J o u r n a l P r e -p r o o f 

Guidance for Further and Higher Education for returning to on-site activity in 2020: Roadmap and COVID-19 Adaptation Framework, Department of Education

COVID-19 pandemic challenges and lessons learned by pharmacy educators around the globe

Sustainable pharmacy education in the time of COVID-19

Lessons Learned and Brighter Opportunities for Pharmacy Education Amid COVID-19

A paradigm shift in us experiential pharmacy education accelerated by the COVID-19 pandemic

An update on developments in medical education in response to the COVID-19 pandemic: A BEME scoping review: BEME Guide No. 64

The use of streamlined lecture recordings: patterns of use, student experience and effects on learning outcomes

Design exemplars for synchronous elearning: A design theory approach

Using breakout rooms in synchronous online tutorials

A comparative study: do "clickers" increase student engagement in multidisciplinary clinical microbiology teaching

Academic students' satisfaction and learning outcomes in a HyFlex course: Do delivery modes matter?

The challenges of COVID-19 for community pharmacists and opportunities for the future

COVID-19 related regulatory change for pharmacists-The case for its retention post the pandemic

Virtual laboratories during coronavirus (COVID-19) pandemic

Adult learners' perceptions of selfdirected learning and digital technology usage in continuing professional education: An update for the digital age

Institutional drivers and barriers to faculty adoption of blended learning in higher education

Examining workload models in online and blended teaching

Learning communities engage medical students: a COVID-19 virtual conversation series

Psychological effects of the COVID-19 outbreak and lockdown among students and workers of a Spanish university

Lockdown, emotional intelligence, academic engagement and burnout in pharmacy students during the quarantine

Factors affecting international students' transition to higher education institutions in the United States

The impact of COVID-19 pandemic on international students in Canada

Reflections on assessment in the wake of change from the COVID-19 pandemic

Remote E-exams during Covid-19 pandemic: A cross-sectional study of students' preferences and academic dishonesty in faculties of medical sciences

Moving assessment online: experiences within a school of pharmacy

Government of Ireland. Pharmaceutical Society of Ireland (Education & Training) (Integrated Course) (Amendment) Rules. In. Dublin: Government Publication Office; 2020. 31. Government of Ireland

Transitioning competency-based communication assessments to the online platform: examples and student outcomes

Conducting a high-stakes OSCE in a COVID-19 environment

Medicinal Products (Prescription and Control of Supply) (Amendment) (No. 7) Regulations 2021. In. Dublin: Government Publication Office

Pharmacy faculty burnout: cause for concern that requires our support and use of best evidence

What just happened? Impact of oncampus activities suspension on pharmacy education during COVID-19 lockdown-A students' perspective

Pharmacy education crosses the rubicon

Pharmacy education in the time of COVID-19: in chaos, there is opportunity

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