Feedback of 5th-Year Pharmacy Students About Objective Structured Practical Examination (OSPE) After the Pharmaceutical Care Course in Poland.

An important part of the pharmaceutical study program is a thorough assessment of students' practical skills. The new form of assessing skills in pharmacy teaching is the Objective Structured Practical Examination (OSPE). Methods The study was conducted in the winter semesters in the academic years 2018–2019 and 2019–2020. The study was attended by students of the 5th -year of pharmacy who rst time taking the OSPE. After the exam, students lled in an anonymous questionnaire about their general approach to OSPE. They assessed each station and the self-assessment. The results were analyzed by performing statistical analyses and compared between years.


Results
A total of 183 5th -year pharmacy students participated in the study, including 108 students in the 2018-2019 academic year and 75 students in the 2019-2020 academic year. Pharmacy students rated OSPE as a reliable tool for assessing their practical skills. Half of the students had a positive attitude towards OSPE, but the vast majority stated that OSPE was stressful for them. Over 70% of students assessed that stations with simulated patients create real situations in pharmacy. Students found that OSPE is a better form of the exam than the written exam.

Conclusion
Pharmacy students rated the OSPE exam as a reliable tool for assessing their practical skills. The results of the survey indicate that the students accepted the new form of the examination. As well, they evaluated the OSPEs well in terms of testing their skills.

Background
In teaching in pharmacy, today's challenge is to provide graduates with a portion of knowledge and provide them tools to acquire this knowledge throughout their future professional life. In addition to knowledge, it is important that graduates also acquire appropriate practical skills that will allow them to provide pharmaceutical services in a pharmacy in the right way of life in the future. Curricula at universities that prepare graduates to provide pharmaceutical services in a pharmacy should be organized in such a way as to allow students not only to acquire knowledge but also to develop practical skills. One of the pharmacist's necessary skills is engaging patient care, monitoring the patient's pharmacotherapy's safety and effectiveness. 1 Assessment of practical skills is a crucial element of assessment in study programs at medical and pharmaceutical universities worldwide. Pharmacy curricula are still changing, and more and more emphasis is being placed on teaching students the practical skills necessary to provide services according to the national standards. National standards describe learning outcomes that are gained by students while studying pharmacy. Knowledge should be balanced by practical skills in curricula, as both prepare students for their working lives. 2 Usually, knowledge is veri ed in a traditional way (e.g., multiple, single choice tests, descriptive reports, etc.). Unfortunately, assessing knowledge methods allows assessing does not practical skills acquired by students during their studies. 3 Practical skills in the pharmacy profession are fundamental aspects.
Therefore some universities have implemented in their assessment systems appropriate tools to test speci c skills. For some time in pharmaceutical education so-called Objective Structured Practical Exam (OSPE) is being used to assess practical skills (including manual, interpersonal, and communication skills). Some studies indicate that 37% of US universities that educate future pharmacists use OSPE extensively to assess students' practical skills. 4 OSPE has become a good assessment tool and has been marked as a gold standard tool to assess students' practical skills around the world. 5-7 A wellconstructed and implemented OSPE is the key to achieve the correct and reliable assessment of practical skills. [8][9][10][11] OSPE is conducted with simulated patients' participation in standardized conditions. 12 OSPE requires that each student demonstrates speci c skills and attitudes in simulated conditions. It consists of several stations where students' practical competencies are assessed. Students during OSPE have a de ned time to perform all procedures. The duration of the station ranges from several to several dozen minutes. An objective grading system is used to assess students. 2 Examiners play a key role in running OSPE. Research indicates that the examiners participating in the OSPE and student assessment agree that OSPE assesses practical skills, while <50% believe that it also tests knowledge. The authors of other publications, based on their experience, believe that OSPE is a crucial tool for assessing skills in patient care, interpersonal and communication skills. 13,14 In Poland, medical teaching was rst implemented and conducted at the Faculty of Medicine of the Jagiellonian University Medical College. 15 For the rst time in pharmacy education in Poland, this challenge was faced by the Department of Social Pharmacy at the faculty of pharmacy of the Jagiellonian University Medical College, which conducted the OSPE exam at the end of the Pharmaceutical Care course (PCc). The exam consisted of stations that checked acquired knowledge and skills following the learning outcomes contained in the syllabus for this course. The exam organizers analyzed the learning outcomes skills and separated pharmaceutical services. They created six stations: pharmaceutical interview, advice for self-medication, education about medicines, medical device education, identi cation, and solving of drug-related problems (DRPs). 16 The purpose of our study was to evaluate feedback from students who are taking the OSPE exam for the rst time about the preparation, organization, and conduct of the exam. The study aimed to assess and analyze students' suggestions to improve future OSPE exams' quality and improve the Pharmaceutical Care course's teaching method (PCc).

Methods
The study was conducted at the Faculty of Pharmacy of the Jagiellonian University Medical College in the winter semesters in the academic years 2018-2019 and 2019-2020. The 5th year of pharmacy students took part in the study, taking the rst OSPE for the rst time. This exam completed the PCc.
Exams in 2018-2019 and 2019-2020 were carried out in the same way. The number and type of stations and scenarios did not change. The same assessment questionnaires, the same academic teachers, were the examiners. Instructions describing the course and rules of the exam and instructions at individual stations have not changed. Some classes in pharmaceutical care in 2019-2020 were conducted using the PBL (Problem-Based Learning) method. The difference in the teaching method used during the PCc is the only element that may affect the survey results.

Tools of data collection
The tool for collecting data was a questionnaire allowing to express opinions and assess students' rst OSPE. The survey was voluntary and anonymous. The questionnaire consisted of two parts. The rst part concerned the general feelings related to the exam, e.g., whether the student had a positive attitude to the exam, how the exam was organized and whether it was run as per student's expectations, whether the instructions at the stations were clear and understandable. Students answered questions about whether the exam allowed them to assess their practical skills, whether there are still areas that the student should complete and whether the OSPE was better than other traditional forms of assessment (e.g., written form).
Part I of the questionnaire was prepared based on the Likert 5-point scale. The respondents de ned their attitude to the statements presented in the following way: strongly disagree (SD), disagree (D), neutral (N), agree (A), strongly agree (SA). Table 1 includes all questions from part I of the survey.
Part II of the survey concerned the students' self-assessment and their feelings related to individual stations. The respondents responded to the statements and indicated all stations (one or more), which information concerned, e.g., whether I expect I was rated high / low at a given station, which station was the most / least stressful for me. Table 2 includes all questions from part II of the survey. After completing the study, students were able to describe additional comments related to OSPE.

Statistical analysis
The data were analyzed by using the Statistica (version 12) package. The independent samples T-test were used for statistical analyses. Statistical signi cance was set at p < 0.05.

Results
In the study participated 108 5th-year pharmacy students in the 2018-2019 academic year and 75 students in the 2019-2020 academic year. Researchers analyzed the signi cance of differences for structural indicators (percentages) of the rst part of the questionnaire in the speci c years (Table 1). Table 1 includes the questions included in the survey in Part I, together with information on how many students agreed with the declaration (agree / strongly agree). Over 80% of students indicated that the exam and instructions for individual stations were clear and understandable. The course of the exam was as expected by over 70% of students. In the 2018-2019 academic year, about 56% of students had a positive attitude towards OSPE before it began, and in the 2019/2020 academic year, only 43% of students had a similar opinion (p = 0.044). Over 86% of students from 2019-2020 admitted that the exam was stressful, but at the same time, students declared that OSPE helped them assess their skills (80%) and recognize issues for further study (84%).
For students from the 2018-2019 academic year, signi cantly fewer students agreed with these statements (68%, 66%, 30%, respectively). Table 2 contains the questions included in the second part of the study and information on what percentage of students agreed with each station's statement. Over 60% of students from the 2018/2019 academic year and over 50% from 2019/2020 expected that they would be highly rated at station 1 and indicated that the PCc prepared them the most to pass this station. Simultaneously, students showed this station as the least stressful for them (over 50% of respondents). Over 60% of students chosen station 5 where they expect to be rated the least and as the most stressful station (over 40%).

Discussion
The study was conducted among 5 th -year pharmacy students who took the OSPE for the rst time. An anonymous survey on the preparation, organization, and conduct of OSPE was chosen as a tool to learn students' opinions about the exam.
The literature indicates the usefulness of such a tool for modi cation and quality improvement of OSPE. It gives opportunities to improve and develop OSPE. Student feedback after the exam may contribute to changes in the manner and form of teaching. [17][18][19] . In our study, most students (67.2% of all students surveyed) recognized OSPE as a better form of the exam than other traditional assessment methods, including a written form. A similar opinion was noticed in other studies, which may be related to the documented objectivity and credibility of OSPE. [20][21][22] Our study also con rmed that pharmacy students accept this form of the exam in assessing practical skills. Positive opinions have already appeared in the literature on this acceptability of OSPE among medical students. 23,24 Seventy-ve percent of students in our study agreed that OSPE, due to its form, allows them to assess their practical skills and identify areas that require them to supplement their knowledge. Similar results were obtained by Yaqinuddin et al. 25 in a study, where 74% of students admitted that the exam allowed them to verify what they should supplement and improve in terms of their knowledge and skills in the eld of anatomy. Other articles in the literature con rm that OSPE, due to its form, is considered a good, valuable tool for assessing students' practical skills. 22 Wadde et al. made quite the opposite conclusions in a study in which students participating in the OSPE found that the exam was not stressful for them, while the examiners were experiencing stress. 26 In our study, some students admitted that the time allocated to perform tasks at stations 5 and 6 was insu cient for them, with no comments related to the exam duration at the other four stations. Similar feelings of students appear in the study of Manjula et al., where for 60% of students, the exam time could be longer. In the Chandelkar study, only 0.69% of students were unhappy with the time allocated for OSPE. In the Deshpande study, every student (100%) admitted that su cient time was given to each student. 20,24 The issues related to time at individual stations in our study are not so obvious. While students scored the lowest average number of points at station 5, they scored 70% on average at station 6 (2nd best result). This may be since students taking our exam do not have time management experience in this form of assessment. Wadde et al. also pointed to this problem in their observations. 26

Conclusions
Fifth-year pharmacy students positively evaluated OSPE as a method of assessing practical skills, re ecting real situations in the pharmacy. They also found that OSPE was better than other traditional assessment methods, but most students said that the OSPE form was stressful for them. In their comments on the quality of OSPE, students referred primarily to the time provided for individual stations' solution.