Stop, collaborate, and listen: Encouraging interprofessional education through critical care simulations for pharmacy students

The ability to work effectively on an interprofessional team is a key skill for pharmacy students, especially in the critical care setting. Successful interprofessional teamwork between pharmacists and the health care team has been shown to improve patient outcomes. Subsequently, early exposure to interprofessionalism in the critical care setting may benefit student pharmacist confidence and performance prior to advanced hospital rotations. Simulation training offers an ideal, low‐risk educational methodology for student pharmacists to practice key skills. To describe changes in student pharmacist confidence in pharmacotherapy interventions and interprofessional skills using team‐based critical care simulations. Teams of two student pharmacists and six student physicians executed two simulated cases of myocardial infarction and emergent hypertension under the auspices of a physician resident or senior student physician. After diagnosis by the student physicians, student pharmacists consulted on treatment decisions including drug selection, dose, and frequency. Confidence in clinical skills and interprofessionalism were assessed via an unvalidated, pre‐ and post‐simulation survey unique to each profession. Questions were a combination of free responses and a five‐point Likert scale. A total of 105 students participated in the simulations with 26 student pharmacists and 79 student physicians. After the simulations, student pharmacist confidence in their pharmacotherapy knowledge of emergent hypertension and myocardial infarctions (p < 0.02) improved; however, their confidence in effectively communicating with their physician counterparts did not increase significantly (p = 0.06). Student physician confidence in the pharmacist's role during codes increased (p < 0.001), which coincided with student pharmacists' feeling respected and included by the physician team. Interprofessional simulations can supplement critical care exposure and pharmacotherapy education for student pharmacists and student physicians. The simulation design discussed in this report can provide pharmacy educators with a model for implementing team‐based critical care scenarios within pharmacotherapy or foundational professional skills curricula.


| INTRODUCTION
The impact of pharmacists on patient outcomes in the critical care setting has been well-documented for decades. [1][2][3] Pharmacists play a key role in the treatment of critically ill patients through multiprofessional health care teams, 4 so it is important to expose pharmacy students to both the critical care setting and the interprofessional framework required of this setting.
Student pharmacists may have critical care experiential opportunities through hospital introductory pharmacy practice experiences (IPPE) and elective advanced pharmacy practice experiences (APPE), but critical care knowledge is often limited to the didactic curriculum due to limited availability of critical care IPPEs and APPEs. The American College of Clinical Pharmacy Pharmacotherapy Toolkit indicates that all pharmacy students should receive education and training on critical care topics. 5 However, the critical care environment and necessary interprofessional collaboration are not easily translated into a classroom setting. 6 Accordingly, there can be gaps in critical care exposure for student pharmacists who are interested in the field or would like to learn more about it during required coursework. Through the development of additional educational techniques for kinesthetic learners, simulations have demonstrated remarkable improvement in student satisfaction and confidence before apprenticeship-type training. 7 For optimal performance in the critical care setting, student pharmacists must be able to effectively contribute to and interact within an interprofessional, team-based care model of physicians and other prescribers, nurses, dieticians, respiratory therapists, social workers, and more. 8,9 In alignment with the Texas Interprofessional Education Consortium and the American Association of Colleges of Pharmacy Curriculum Outcomes and Entrustable Professional Activities (COEPA) Educational Outcome 2.7 on interprofessional collaboration, the University of North Texas Health Science Center at Fort Worth (UNTHSC) routinely bolsters interprofessional education by hosting multi-institutional educational events with the previously listed professions. 10 These events primarily focus on role awareness and effective communication to improve health outcomes, as in alignment with the Interprofessional Education Collaborative 11 four core competencies, and the Health Professions Accreditors Collaborative, specifically competencies 3 and 4, which are interprofessional communication and teamwork respectively. [12][13][14] In part to further interprofessional opportunities for students and community partners, the institution recently opened the Health Science Center (HSC) Regional Simulation Center. This new addition to the university provides students a chance to participate in various interprofessional activities with the resources they may need to develop team-based skills that would be required in practice after graduation. 15 Student leaders from the UNTHSC College of Pharmacy (HSCCP) and UNTHSC Texas College of Osteopathic Medicine (TCOM) identified an opportunity for an interprofessional critical care simulation that emphasized exposure to both the fast-paced environment of critical illness and the necessary pharmacist-physician relationship to provide optimal patient care as well as an opportunity to help generate critical care-competent pharmacists. In this report, we describe the development and execution of a student-led, interprofessional, critical care simulation. Through exposure to realistic, high-stress, teambased simulation training of critically ill patients, student pharmacists, and student physicians experienced a health care team of diverse professionals that used each profession's specialized knowledge for the mutual benefit of their patients prior to joining the workforce. The objective of this simulation was to provide student pharmacists and student physicians exposure to simulated realistic scenarios of critically ill patients. Ideally, these experiences would foster mutual respect for each profession and their role on a health care team. Student participants were split into a 3:1 ratio of student physicians to student pharmacists with a resident physician or senior student physician (third-or fourth-year student) moderating the simulation. Most teams were comprised of six student physicians and two student pharmacists. First-year student pharmacists were intentionally paired with second-or third-year student pharmacists to encourage student pharmacist teamwork and provide support from students who have entered or completed their cardiovascular pharmacotherapy curriculum. To facilitate role development and awareness, student physicians were responsible for providing a diagnosis and an initial pharmacologic recommendation following consultation with the student pharmacists. Student pharmacists were then responsible for verifying the appropriateness of the pharmacologic regimen and consulting on therapeutic treatment order, dose, administration, frequency, and duration. Throughout the simulation, senior student physicians and resident physicians, who were alumni of the college and practiced at hospitals within the community, interjected changes in patient status in response to or independent of pharmacotherapy, challenging both cohorts to communicate effectively and modify treatment plans accordingly.
Following the completion of the simulation (simulated survival or death), all participants engaged in a verbal debrief consisting of self and team evaluations. Topics prompted by student leaders and resident physicians included diagnosis and intervention timing, appropriateness of recommendations, and communication effectiveness of the interprofessional team. Prior to the simulation and immediately after the simulation, an unvalidated pre-and post-survey was administered to evaluate outcomes in the two professions. Participation in the student survey included providing informed consent. Each profession received a different survey tailored to their outcomes. Survey questions were adapted from studies including interprofessional events between pharmacy and nursing students. 16

| Outcome measures
The primary outcome for student pharmacists was describing the effect of an interprofessional critical care simulation on student pharmacist confidence in interprofessional communication and confidence in providing relevant pharmacotherapy recommendations. Secondary outcomes included the ability to appropriately interpret an electrocardiogram (EKG), awareness of provider roles in a medical code, student physician confidence in the necessity of a pharmacist during a medical code, and quality improvement suggestions for the next simulation.
All outcomes were assessed via free response or a 5-point Likert Scale using Google Forms (Google Workspace, 2022, Mountain View, CA). Survey questions differed between student pharmacists and student physicians. Table 1 summarizes key questions asked of each cohort. Student pharmacists received their pre-survey 48 h prior to the simulation via email while student physicians received their presurvey in-person immediately prior to the simulation event briefing as their survey was shorter and it was easier to ensure each student was able to participate. Both cohorts were asked to complete their respective post-survey within 24 h following the simulation.

| RESULTS
A total of 26 student pharmacists and 79 student physicians participated (N = 105). Three student pharmacists, four student physicians, and six resident physicians operated as event moderators. The overall pre-survey response rate was 97%, and the post-survey response rate was 78%. Twenty-three student pharmacists completed the presurvey, and 19 of these students completed the post-survey (83% retention). Seventy-nine student physicians completed the pre-survey, and 63 student physicians completed the post-survey (80% retention).
Participation across all graduation cohorts of eligible student pharmacists and student physicians were similar (Table 1).
On the pre-survey, 38% of student pharmacists reported having previous inpatient or emergency department exposure through shadowing, employment, or a hospital IPPE, with most reporting less than 6 months of experience in this setting. The majority of these student pharmacists were in their third year of coursework, which requires successful completion of a hospital IPPE and advanced cardiovascular life support (ACLS) certification. As previously discussed, successful completion of a hospital IPPE does not require exposure to the critical care setting, as indicated by the four third-year students who did not report previous inpatient or emergency department exposure in Table 1. First-year students were the most likely to not report previous inpatient or emergency department experience. Data was obtained from the student pharmacist pre-survey. % of participants was measured using the total student pharmacist cohort from the pre-survey (n = 23).
Confidence in communicating recommendations to student physician counterparts did not have a statistically significant change (premean = 3.3, post-mean = 3.6, p = 0.06) ( Table 2). In the post-survey, student pharmacists also reported feeling respected and included by the physician team (post-mean = 4.7). A total of 20 free responses to optional questions regarding the "scariest" and "most exciting" parts of the simulation were collected, resulting in the following quotes: • "I wasn't sure what to dose the patient's epinephrine, so I was scared to overdose." • "The scariest part was everyone talking over each other." • "It was amazing to see the second-year med students go through their roles." • "The most exciting part was being part of a collaborative team to learn something outside of the classroom."
Following the simulation, student physician participants were more Note: A list of profession-specific questions asked before and after the simulation to student pharmacist and student physician participants. A 5-point Likert scale was utilized with 1 being not confident at all to 5 being extremely confident. Confidence was reported used pre-and post-survey means. Abbreviation: EKG, electrocardiogram. *p-value <0.05.
likely to strongly agree that pharmacists play an impactful role within a medical team (pre-mean = 3.9, post-mean = 4.7, p < 0.001).

| DISCUSSION
Student pharmacists and student physicians collaboratively completed two critical care simulations and debriefed on performance immediately after. Simulation provides low-risk learning opportunities for high-stress environments, such like the critical care setting. It also provides innovative training opportunities for health professional students to practice their clinical roles interprofessionally, as is often required in the critical care setting. Our study supports the advantages of providing exposure to both the critical care setting and interprofessional teamwork through simulation.
There are multiple reports of integrating simulation into pharmacy curricula within the United States, including critical care simulation. 17,18 Second-year pharmacy student satisfaction with interactive myocardial infarction 19 and emergent hypertension 18 simulations after corresponding didactic curricula have been reported. 19,20 Similarly, both studies required that student pharmacists complete an immediate debrief, with Seybert and colleagues requiring the additional step of writing a SOAP (subjective, objective, assessment, and plan) note following the simulation. 19 Though a pre-survey was not reported in either study, 59%-90% of participants reported that patient simulation allowed them to use the knowledge gained in their critical care curriculum. 18,19 This parallels the results found in our study of improved student confidence in pharmacotherapy knowledge for the treatment of myocardial infarctions.
Bolesta and Chmil reported an interprofessional simulation on acute heart failure exacerbation involving nursing and pharmacy students in a required interprofessional laboratory session in both professions' curricula. 16 Similar to our simulation design, student pharmacists prepared through a review of various cardiovascular topics. Students were also exposed to simulation technology a week prior to the event, which we did not do. Study outcomes focused on the validated Readiness for Interprofessional Learning Scale rather than the impact of the simulation on student confidence of clinical knowledge. The authors reported improvement in the overall attitudes toward interprofessional education, 16 which was reflected in our data for student pharmacists.
Though our study assessed interprofessional skills through an unvalidated survey, we also assessed students' self-confidence in the ability to select appropriate pharmacotherapy and to perform effectively in a medical code. The survey was modeled after the interprofessional event hosting nursing and pharmacy students mentioned previously. 16 Our study is unique in multiple aspects. To our knowledge, this study is the first to report an interprofessional critical care simulation specific to student pharmacists and student physicians. Many studies in pharmacy education literature reported interprofessional simulations occurring with student nurses. 16,18 Second, our simulation included different years of professional students more closely representing the layered learning model present in educational institutions where additional critical care training might occur. For third-year student pharmacists, this simulation provided exposure to critical care following hospital IPPEs and provided the opportunity for students to consider pursuing an APPE elective rotation in critical care, as similarly expressed by colleagues. 17 Student participants were also provided with the opportunity to prepare for APPEs and improve performance with these simulations. 17 Additionally, student participants in our study were voluntary as part of a student organization collaboration rather than required within their respective programs' curricula. This lends itself well to the increasing need for interprofessional practice opportunities and is consistent with the COEPA outcomes 10 for pharmacy curricula. Using standardized, simulated cases from the student physician curriculum is another strength of this study because it enhances the generalizability of their application at other institutions.
The authors hope that the positive experience at our institution can be shared by various health professions to encourage multidisciplinary exposure to the critical care setting.
While it is clear that student participants found this simulation to be beneficial, there are limitations to this study and notable improvements for future simulation designs. As the inaugural event, student participants were recruited through convenience as most event marketing occurred through HSCCP and TCOM student organizations focused on health-system pharmacy and medical simulation. This could have created a biased sample of participants as students who were not involved within those organizations may have missed the opportunity to participate, and students that did choose to participate may have been the type of student to be more likely to gain confidence through the experience.
Another limitation was that most participants were early in their didactic curriculum, so simulation moderators assisted teams through these codes as needed. Additionally, because the reported simulation was a single event, we are unable to report the long-term impact on pharmacist-physician relationships or on student performance in the critical care setting. Anecdotal evidence from numerous verbal reports suggest that the simulation was an eye-opening experience for both student pharmacists and student physicians. Lastly, the administered survey was an unvalidated survey of student confidence specific to this event and responses were collected anonymously on Google Forms without accompanying randomized survey identifiers to track paired responses.
While it was a convenient method to collect data from students, we had no way of knowing if every participant completed both the pre-and post-surveys or if a participant completed the surveys multiple times.
Considerations for replication of this study should include the availability of a simulation center and proximity to other health professional schools. UNTHSC houses a medical school, a pharmacy school, and a physician assistant school, which provides access to a variety of health profession students. The recent construction of the simulation center provided technology and resources to make the event execution possible. Without these resources, replication may be challenging and require additional considerations. An additional consideration is the timing of distribution of pharmacotherapy algorithms prior to the event.
For this event, we distributed the pharmacotherapy algorithms 48 h prior, however, we understand there may be scenarios in which this may not be enough time for students to refresh their knowledge prior to the event.
Suggestions for future simulations include simplified ACLS and pharmacotherapy algorithms to accommodate all learning levels, implementation of a unique survey identifier to allow for paired analysis, consideration of a validated survey instrument, and aggregate results from multiple years of the event. This could also allow for further research on the association between this simulation exposure and future APPE or career selections in critical care. Future iterations of this simulation may also benefit from the involvement of additional health care professional programs, such as nursing and dietician students.

| CONCLUSION
This report demonstrates the benefit of an interprofessional layeredlearning clinical simulation in a critical care setting on student pharmacist and student physician confidence. With positive reflections from both student physicians and pharmacists, this educational event allowed students to practice both interprofessionalism and high-stakes pharmacotherapy skills in a low-stakes setting. Critical care simulations also offer the opportunity for student pharmacists to improve their confidence in critical care knowledge prior to APPEs and graduation.
The simulation design discussed in this report can provide pharmacy educators and other student organizations with a model for implementing multidisciplinary team-based critical care scenarios.

AUTHOR CONTRIBUTIONS
Kaanan R Shah and Haley JM McKeefer were responsible for simulation design, study recruitment, data collection, and manuscript writing.
Matthew D Wieters directly contributed to simulation design, study recruitment, data collection, and manuscript writing. R. Oluwafunmito Babalola and Crystal K Hodge served as advisors in providing event guidance and manuscript writing. also thank the HSC Regional Simulation Center staff for their support and simulation resources.

FUNDING INFORMATION
There was no external funding for this research.