2024/07/13 by Samantha Smith, Scott McColgan-Smith, Emma Claire Phillips +1 · 1 voice
Medicine · Psychology · Social Sciences · #Education and Critical Thinking Development #Human Resource Development and Performance Evaluation #Simulation-Based Education in Healthcare
paper · pdf · doi:10.1093/ijpp/riae034
openalex publication_date 2024/07/13 · openalex created_date 2025/10/10 · openalex updated_date 2026/08/01
“The measure of intelligence is the ability to change”—Albert Einstein Given the ever-changing requirements of clinical roles, adaptability is one of the most important attributes of health professions educators. Pharmacy has seen one of the largest role expansions of all health professions over the last few years. There is a growing drive for pharmacists to provide high quality-services utilizing their skills as autonomous clinicians. Pharmacy work also increasingly incorporates clinical duties such as history-taking, examination skills, and prescribing. Newly qualified pharmacists are not always ready to face all aspects of these clinical roles [1]. The authors observe that newly qualified pharmacists are particularly risk-averse and unwilling to make definitive decisions, and this is borne out in the pharmacy literature [2, 3]. Navigating decisions that involve risk is a skill required by all clinicians, particularly those who prescribe. Clinicians who find risk-taking challenging may find themselves paralyzed by anxiety and unable to care for patients due to indecision. Clinicians who are more neurotic (which is associated with lower risk tolerance [4]) are also more prone to burnout [5]. The authors propose a solution, already incorporated into some pharmacy curricula: simulation-based education (SBE). Simulation is an imitation of a situation or process. In health care, it is utilized to teach and learn skills with the goal of transferring these to the clinical environment to ensure a high standard of patient care. Although the exact origins of SBE are unknown, evidence dates back to the 1600s when dolls were used to teach midwives safe delivery techniques [6]. In recent years, advances in technology and a growing body of evidence mean that SBE has become more popular and is now endorsed in many under and postgraduate curricula. For example, in the USA, The Accreditation Council for Pharmacy Education recommends simulation for addressing interprofessional education and introductory pharmacy practice experience. Similar recommendations have been made by the General Pharmaceutical Council in the UK, who advocate using simulated environments and simulated patients (for skills such as history-taking and prescribing). There is a vast breadth in the nature of simulation activity in terms of the resources used. Simulators include part-task trainers, full-body mannequins, simulated patients, simulated environments, and even virtual reality, and these can be used with varying levels of realism and immersion. A popular model of SBE is a scenario followed by a structured facilitated debriefing. The debriefing is a critical reflection of actions taken within a scenario, with discussion identifying learning points, and is considered by many as the most important component of learning in SBE. While appreciating the modern developments and innovations that have occurred in SBE, it is important to remember that ‘simulation is a technique, not a technology’ [7], and therefore, activity should be tailored according to the specific context and learning outcomes, being responsible with the use of resources such as equipment and faculty. Traditionally focussed on the development and improvement of procedural skills, SBE has grown to encompass a wide range of aims and contexts. It has been shown to help with the development of consultation skills, prescribing, behavioural skills, inter-professional working, workforce integration, and identity formation. The role of SBE in developing these aspects is discussed in turn, and the crucial relevance to improving pharmacists’ tolerance of risk is explained. Given that many pharmacists undertake independent consultations, there is a need for them to master consultation skills, including clinical examination skills. SBE offers an opportunity for both those training to be pharmacists, and qualified pharmacists, to learn and practice these skills in an environment in which mistakes can be readily reflected upon and learned from. SBE has been shown to be effective in improving the confidence and competence of pharmacists when learning such skills [8]. SBE can also help educators to reframe error as an unavoidable part of patient care, thus reducing the fear and stigma associated with mistakes, and allowing learners to move towards the adoption of a growth mindset [9]. Such a mindset helps learners to frame error as an essential part of the learning process, and therefore reflect on their mistakes to improve their consultation skills. As well as aiding consultation skills acquisition, simulation may also enhance prescribing education. In some countries, pharmacists undertake further training to gain their independent prescribing qualification. Despite this, there is evidence that a significant proportion of pharmacist prescribers do not use their independent prescribing skills on a regular basis. The reasons for this are thought to be multifactorial, however, lack of confidence and historical approaches to training are implicated [2]. Some countries now mandate that pharmacy training incorporates prescribing education. For example, in the UK, newly qualified pharmacists will take on the role of a prescriber on registration with the General Pharmaceutical Council in 2026. This change makes the need for appropriate educational intervention even more important. SBE can strengthen the ability to make autonomous clinical decisions more effectively, through rehearsal for performance. SBE can empower prescribers to meet their full potential while increasing standardization in education and ensuring safe and effective patient management. For prescribing skills, as with other clinical skills, SBE can normalize mistake-making and therefore reduce fear of risk. A foundational principle of SBE, which helps to normalize and explore mistake-making, is that of psychological safety. In order for the simulation to feel psychologically safe for participants, explicit and implicit strategies are used to make them comfortable with the concept of learning from mistakes. This psychological safety within simulation may also be used to increase pharmacists’ comfort with the idea that even without any mistake, there may be a poor outcome for the patient. Poor outcomes are, of course, unfortunately, a part of clinical practice, regardless of how meticulous clinicians are. SBE is crucial in exposing pharmacists to the negative emotions associated with mistake-making and poor outcomes, and, through active reflection, allowing them to recognize these emotions and process them in a safe space [10]. SBE for the purposes of emotion-regulation training is underutilized in pharmacy education and may prove especially important for those training to be pharmacists. For example, one study found that pharmacy residents felt underprepared to deal with the emotional challenges of patient care [1]. SBE might therefore be used to fulfil this important unmet need in pharmacy education. SBE has an important role to play in technical skills acquisition and emotional regulation, but with its emphasis on postevent debriefing, SBE is particularly well-suited to the development of behavioural (also known as nontechnical) skills. Behavioural skills are traditionally defined as the skills that complement technical skills to improve safety and enhance performance. Such skills include decision-making, teamwork, and communication. The development of behavioural skills can be enhanced by the use of behavioural marker systems, such as PhaBS, which was developed specifically for pharmacists [11]. These systems facilitate the provision of individualized and meaningful feedback on concepts that can otherwise feel nebulous. Systems such as PhaBS may also highlight the key behavioural skills required of pharmacists (and those training to become pharmacists) and may be used to guide learning objectives and scenario design. As the remit of pharmacy roles expands, tolerance of ambiguity, or ‘operating in the grey’, is a behavioural skill that has been identified as particularly important for pharmacists of the future. Interprofessional SBE has been shown to increase pharmacists’ tolerance of ambiguity, perhaps through reframing the concept of safety towards a more nuanced understanding of balancing risks [12]. Beyond individual technical and behavioural skill acquisition, SBE may be used to facilitate team training, allowing clinicians to learn with, from and about each other, often in interprofessional groups. Such training can challenge stereotypes and enhance cohesion, by providing the opportunity for pharmacists to engage in joint decision-making and genuine collaboration with other healthcare professionals. The experiences of interprofessional SBE can lead to significant reconceptualization of pharmacists’ roles and relationships, and increased reciprocity between different groups of healthcare professionals [13]. In addition, it can improve recognition of the skills that pharmacists bring to the multidisciplinary team. As the roles of pharmacists change and expand, how pharmacists of the future optimally integrate into the workplace also presents a challenge to the profession. Contemporary discourse in SBE has highlighted its potential role in promoting workplace integration, through the exploration of professional hierarchies and power dynamics inherent within healthcare teams and practice. The opportunity that SBE offers to recreate and reinforce social norms and values allows them to become tangible, explicit, and thereby open to challenge. This may empower pharmacists, in particular newly qualified pharmacists, to challenge the decision-making and prescribing of others. It also allows clear articulation of prevailing social practices to new members of the team in ways that can promote integration and a sense of belonging [14]. The professional identities of pharmacists must adapt to the changes expected of the pharmacist role. Pharmacists must now identify first and foremost as clinicians, and they must be able to act both as independent clinicians and prescribers and as key members of a multidisciplinary healthcare team. Through improving technical and behavioural competence, and working with other healthcare professionals, SBE has the potential to help pharmacists embody this new identity. Despite its many benefits, SBE is not currently available to all pharmacists and those training to be pharmacists, due to the expense of simulation centres and the complexity involved in educating faculty in the art of simulation facilitation. This is, in part, due to a misunderstanding that simulation must involve expensive equipment. On the contrary, many of the attributes described above can be taught in normal classrooms. The authors believe that well-trained facilitators can help pharmacists to develop many of the skills outlined above without the need for high-fidelity mannequins. For example, some simulations may simply require a desk, chair, pen, and paper, with some form of basic audio-visual equipment to live stream to an alternative room (e.g. using Microsoft Teams or Zoom). This fits well with a patient consultation-based scenario, and with the right approach, this can still achieve a high level of immersion for the participants. Appropriate training for faculty is the most important investment for those incorporating simulation into their curricula, as inadequate training may result in psychological harm to participants, and be detrimental to their education. While SBE should be accessible to all, the authors do not subscribe to the idea that SBE can replace workplace learning. Just like other healthcare professionals, pharmacy students need to contribute to the care of real patients to fully develop their identities as clinical professionals [15]. However, some of the benefits of workplace learning can be brought into the simulation space when pharmacists and pharmacy students are able to interact with other professionals, in the same way that they do in the clinical environment [16]. SBE can complement workplace learning, by helping to develop skills that prepare learners for the clinical workplace, but is most effective when delivered as part of a curriculum alongside other forms of learning, to achieve the desired learning outcomes. When considering the future of SBE within pharmacy education, the authors purport that it is currently under-researched. SBE offers the opportunity for educators to better understand which skills pharmacists (and those training to be pharmacists) excel in, and which areas require further development. Future research might usefully focus on these aspects. In summary, the landscape of clinical pharmacy is changing, and pharmacy educators and training programmes must be adaptable to help their learners thrive. The current pharmacy workforce must develop risk mitigation and management strategies as part of clinical decision-making. SBE is a crucial part of the solution and can help not only with skill development, but also with workplace relationships, workforce integration, and identity formation. Together, these changes can improve pharmacists’ tolerance of risk and abilities to cope with error, therefore enabling them to better meet the needs of patients. None. S.E.S. drafted the outline of the document, and each of the authors wrote a section of the document. S.E.S. collated the draft of the article and all authors reviewed and amended the drafts. The authors declare that there are no conflicts of interest. This work was supported by a grant from NHS Education for Scotland. The funding sources had no involvement in the article, and there were no restrictions regarding publication. Not applicable.