1016484

research-article2021
MDE0010.1177/23821205211016484Journal of Medical Education and Curricular DevelopmentFarahani et al.

Training Pharmacy Students in Self-Medication Journal of Medical Education and

Curricular Development

Counseling Using an Objective Structured Volume 8: 1–9

© The Author(s) 2021

Clinical Examination–Based Approach DOI: 10.1177/23821205211016484

https://doi.org/10.1177/23821205211016484

Imaneh Farahani1 , Samieh Farahani1 , Maira Anna Deters1,

Holger Schwender2 and Stephanie Laeer1
1Institute
of Clinical Pharmacy and Pharmacotherapy, Heinrich Heine University Duesseldorf,
Duesseldorf, North Rhine-Westphalia, Germany. 2Mathematical Institute, Heinrich Heine
University Duesseldorf, Duesseldorf, North Rhine-Westphalia, Germany.

ABSTRACT

Introduction: Pharmacists play an important role in ensuring the safe, effective, and rational use of drugs in self-medication. Given the
potential risks of self-medication, adequate training on self-medication counseling should be provided to pharmacy students during their
academic education. Objective structured clinical examinations (OSCEs) could be used to train pharmacy students in these skills. This study
evaluated the efficacy of an OSCE-based approach for training pharmacy students in self-medication counseling and communication skills.

Methods: This randomized controlled study was conducted among pharmacy students using a pre-post design. The intervention group
completed OSCE-based self-medication training, while the control group collected counseling-relevant information from summaries of prod-
uct characteristics of over-the-counter drugs. The counseling and communication skills of both groups before and after training were
assessed by completing OSCEs. The participants completed a self-assessment questionnaire on self-confidence and self-perceived profi-
ciency before each OSCE encounter and a satisfaction survey at the end of the seminar.

Results: Students were generally satisfied with the seminar. While the OSCE-trained group demonstrated significantly greater increases in coun-
seling skills and self-confidence and self-perceived proficiency than the control group, both groups had similar increases in communication skills.

Conclusion: The present study suggests that applying OSCEs as a learning tool for self-medication counseling is beneficial for improv-
ing students’ counseling skills as well as self-confidence and self-perceived proficiency. These results support the inclusion of OSCEs in
pharmacy education and highlight its potential to bridge gaps between knowledge and practice.

Keywords: Pharmacy education, pharmacy students, OSCE, self-medication, counseling

RECEIVED: January 26, 2021. ACCEPTED: April 16, 2021. Declaration Of Conflicting Interests :The author(s) declared no potential
conflicts of interest with respect to the research, authorship, and/or publication of this
Type: Original Research article.

Funding: The author(s) disclosed receipt of the following financial support for the CORRESPONDING AUTHOR: Imaneh Farahani, Institute of Clinical Pharmacy and
research, authorship, and/or publication of this article: We acknowledge that the Pharmacotherapy, Heinrich Heine University Duesseldorf, Universitaetsstrasse 1,
publication fees were funded by the Heinrich Heine University Duesseldorf. The funding Duesseldorf, North Rhine-Westphalia 40225, Germany. Email: [email protected]
institution had no role in the design of the study, in the collection, analyses, or
interpretation of data or in the writing of the manuscript.

Introduction expenditure.”2 Self-medication can also delay the diagnosis

Self-medication, defined as “the selection and use of medicines and treatment of serious medical conditions or mask the symp-
by individuals to treat self-recognized illnesses or symptoms,”1 toms of a serious condition.6 Nevertheless, patients are not
plays an important role in health care by providing patients always aware of the potential risks of NMPs.7 To ensure the
direct and rapid access to treatment.2 It offers patients an active safe, appropriate, and effective application of self-medication,
role in their health care, allowing them to personally manage pharmacists play an important role.8
non-critical conditions with non-prescription medicines Pharmacists are experts in drug therapy9 and can provide
(NPMs).2,3 Access to NPMs, often called over-the-counter adequate counseling to ensure self-medication is performed
(OTC) medications,3 varies by country, and, for example, may appropriately by educating patients about a healthy lifestyle, rec-
be available at pharmacies as well as retail stores in some coun- ommending and advising about NPM-treatments, and referring
tries.4,5 Proper self-medication practices might provide eco- patients to physicians when symptoms indicate a potentially
nomic benefits, such as reducing the need for medical serious condition.10 Ample research supports the beneficial
consultations and the costs of community-funded healthcare impact of pharmacist intervention in NPM therapy.8,11,12 For
programs.2 Unfortunately, self-medication comes with poten- example, Eickhoff et al8 reported that community pharmacists
tial risks, including, but not limited to, incorrect self-diagnosis found drug-related problems (DRPs) in 17.6% out of 12 567
or choice of therapy, inadequate administration, inappropriate self-medication requests (ie, approximately 1 out of 5 encoun-
dosages, excessively prolonged use, dependence, abuse, and ters), with “inappropriate self-medication, inappropriate
contraindications or interactions, which could lead to “an requested drug, duration of drug use too long (including abuse),
increase in drug-induced disease and wasteful public and the wrong dosage” the most frequently reported. In addition,

Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License
(https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission
provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
2 Journal of Medical Education and Curricular Development 

they outlined that according to the pharmacists participating in 2018-246-ProspDEuA). The study was conducted between
the study approximately 90% of DRPs could partially or com- October 2018 and January 2019 during a clinical pharmacy
pletely be solved, highlighting pharmacists’ important role in course at Heinrich Heine University Duesseldorf. The clinical
detecting DRPs and advising patients on the proper and safe use pharmacy course and investigation were conducted in the
of medicines during self-medication. Nevertheless, several stud- German language.
ies indicate that community pharmacy staff ’s (including phar- Fifty-eight students in the eighth and final semester of
macists) counseling skills regarding self-medication could be their pharmacy studies were invited to participate in the study
improved.13-16 For example, Watson et al16 indicate poor consul- in October 2018. Students were eligible if they signed volun-
tation performance in community pharmacies mostly due to tarily the informed consent form. It was necessary to limit the
inadequate information gathering or advice provision. It is vital sample size to 20 participants per group as the study was con-
to gather pertinent details from patients and disclose relevant ducted as part of a self-medication seminar during the clinical
information to them to address their conditions and therapy pharmacy course in which the time and staff available were
appropriately.1,17 When counseling patients on NPMs, a phar- limited. Thus, of the students who signed the informed con-
macist is responsible for assessing whether a patient can be self- sent form, 40 students were randomly selected, with 20 rand-
treated within the pharmacists’ scope of practice or a referral to a omized into the intervention group and 20 into the control
physician is necessary.18 group using the statistical software R.23 Non-participating
Given the potential risk of self-medication2,6 and the room students served as support staff digitizing collected data from
for improvement in pharmacists’ counseling skills,13-15 phar- self-assessment questionnaires or as timekeepers during sum-
macy students should receive appropriate training during their mative OSCEs.
academic education. One strategic teaching approach could be
the incorporation of objective structured clinical examinations Study procedure
(OSCEs) in training pharmacy students. OSCEs have the
The study (Figure 1) began with recruitment, during which
potential to bridge the gap between academic knowledge and
students were informed about and invited to the study. After
practical application.18 OSCEs can be formative or summative,
collecting the informed consent forms, the lots were drawn
with formative OSCEs functioning as learning tools and sum-
for determining 40 participants who were randomized into
mative OSCEs used for evaluating clinical skills or knowl-
the intervention group or control group. All the students lis-
edge.19 Although, OSCEs are meanwhile widely implemented
tened to a lecture on self-medication, covering definitions,
in pharmacy education, there is a lack of investigations evaluat-
relevance, legal basis, and clinical aspects focused on head-
ing improvements in NPM counseling skills from formative
ache, heartburn, and diarrhea, to establish comparable basic
OSCEs, particularly those with peer-based training, with most
knowledge. For each indication, the following aspects were
studies focusing on the use of OSCEs as an assessment tool.18,20
addressed:
To address this need, this study employed a randomized
controlled design to evaluate the effect of an OSCE-based • an overview of the limits of self-medication
training approach on self-medication counseling skills of phar- • examples of medicines used for self-medication, for
macy students, focusing on conditions frequently treated by which contraindication, interactions, adverse drug reac-
self-medication: headache, heartburn, and diarrhea.8,21 The tions, and a table with (1) information on dosage, (2)
application of OSCEs to teach self-medication counseling in duration of intake, and (3) additional important infor-
pharmacy students was based on promising results from a prior mation about the respective medicine (eg, in the case of
study at the institution involving diabetes mellitus counseling, headache: “prolonged use of any type of pain reliever for
however, without a control group.22
headaches can make them worse”) based on the Laven24
counseling trio were stated
Methods • additional recommendations
Operational definitions
On the same day of the lecture, the participants completed a
For the purpose of this article, the term “formative OSCEs”
summative pre-training OSCE evaluating their baseline
describes OSCEs used for training the intervention group
counseling performance. Five weeks after the summative
(OSCE-based training). For the purpose of this article, the
pre-training OSCE, the participants underwent their
term “summative OSCEs” refers to OSCEs for measuring the
assigned training. The intervention group completed forma-
participants’ skills at baseline (summative pre-training OSCE)
tive OSCEs on self-medication, while the control group
and after training (summative post-training OSCE).
collected counseling-relevant information from summaries
of product characteristics (SmPCs) of OTC drugs (see sec-
Study design and participants
tion Training for further details). Immediately following
This randomized controlled trial with a pre-post design was training, participants completed the summative post-train-
approved by the responsible ethics committee (Number ing OSCE evaluating the change in their counseling and
Farahani et al. 3

Figure 1.  Overview of the study procedure.

Abbreviation: OSCE, objective structured clinical examination.

communication skills (see section Summative OSCEs for OSCE encounter. Each OSCE comprised a 1-minute pre-
further details on pre- and post-training OSCEs). Finally, encounter phase, during which the participant had the possibil-
the participants completed an anonymous satisfaction ity to read the instruction and the SmPCs, and a 7-minute
survey. patient-encounter phase during which the participant assumed
the role of the pharmacist and had the task to counsel the simu-
lated patient. The simulated patient initiated each case by
Summative OSCEs
directly requesting a product from the participant. The observer
The participants completed summative OSCEs before (sum- evaluated the participant’s performance using a case-specific
mative pre-training OSCEs) and after (summative post-train- analytical checklist and global rating scale. To reduce the risk of
ing OSCEs) training. Summative pre-training OSCEs assessed inter-observer variability due to 2 different observers, the same
the participants’ baseline skills, while summative post-training observer was allocated to each participant for both the summa-
OSCEs evaluated changes in their OSCE performance after tive pre- and post-training OSCEs. Participants received indi-
the respective training. Participants filled out a self-assessment vidual feedback from their respective observer immediately
questionnaire before each summative OSCE encounter. A after the summative post-training OSCE. The simulated
pharmacist with experience in community pharmacy developed patients and observers were portrayed by 4 faculty members
20 cases focused on self-medication for headache, heartburn, or (pharmacists) who were instructed specifically on their tasks.
diarrhea, 10 each for the summative pre- and post-training An additional faculty member (pharmacist) coordinated the
OSCEs. All cases were reviewed by another pharmacist. A sim- pre- and post-training OSCEs. OSCEs were completed by 2
ulated patient, 1 observer, and 1 participant attended each participants simultaneously in a single lecture hall.
4 Journal of Medical Education and Curricular Development 

Training Instruments
The intervention group was divided into 5 groups, each of Analytical checklist.  A global analytical checklist modified from
which trained for 1 hour on 2 summative pre-training OSCE previous studies22,25 was used to assess the participants’ coun-
cases concerning the indication completed in the pre-training seling skills. The modifications were based on the federal phar-
OSCEs. One case focused on counseling about a drug new to macy chamber’s national guidelines for self-medication26-28 to
the patient (initiation) and the other about a drug known to account for self-medication counseling requirements and were
the patient (implementation). Each group was provided for the adapted on a case-specific basis (an example of a case-specific
2 respective cases the following material: the actor description checklist applied for an “initiation” case is depicted in Supple-
(including patient characteristics), respective SmPCs, the case- mental Material 1), such that the maximum achievable scores
specific analytical checklist, and global rating scale. Within in case-specific checklists varied. The analytical checklist
these groups, each study participant was instructed to portray encompassed the sections “greeting,” “medical history,” “drug
the pharmacist. In each group, non-participating students information” (initiation or implementation), “additional rec-
played the role of the simulated patient and/or observer, pro- ommendations,” “risk communication,” “goal setting,” “patient
viding feedback using the case-specific analytical checklist and involvement,” and where necessary, “additional questions that
global rating scale. The intention of involving the non-partici- are necessary in the specific case.” Each section was comprised
pating students as simulated patients and/or observers in the of 1 or more items. For every correctly performed item in the
formative OSCEs was to let them experience OSCEs as well case-specific analytical checklist 1 point was awarded, if the
since the study participants of both groups at least experienced item was not performed correctly, zero points were awarded.
summative OSCEs. Moreover, the participating students had
the chance to listen focused to each other’s counseling and pro- Global rating scale. A global rating scale modified from
vide feedback without simultaneously performing the role of literature25 and previously applied in another study22 was used
simulated patient. Two instructors were present during training to evaluate participants’ communication skills employing a
and moved from group to group to answer questions and give 6-point Likert scale ranging from 0 (poor behavior) to 5
feedback. (optimal behavior). The global rating scale comprised 3 items
The control group trained for 1 hour on handling SmPCs covering “verbal communication skills,” “non-verbal commu-
for OTC drugs indicated for the treatment of conditions not nication skills,” and “patient-centered communication.”22
covered in the OSCEs (obstipation, athlete’s foot, cough, and Both the analytical checklist and global rating scale were
sore throat). Different indications were used for the control completed by the observers during the summative OSCEs.
group’s training than in the intervention group’s training
because those handled by the intervention group during their Self-assessment questionnaire.  Each participant filled out a self-
training and by both groups in the pre-training OSCEs were assessment questionnaire immediately preceding the summative
already presented in the lecture to both groups and thus, had pre- and post-training OSCEs. The questionnaire comprised 7
already been discussed. Participants were required to process items intending to rate students’ self-confidence and self-
the information in the SmPCs in a structured approach by col- perceived proficiency using a 6-point Likert scale ranging from
lecting information on each drug, including active ingredients, 0 (“very bad”) to 5 (“very good”) and was based on a self-assess-
contraindications, patient situations requiring prior consulta- ment questionnaire used in studies prior22,25 (Supplemental
tion or monitoring by a physician, examples of interactions and Material 2). The questionnaire for the post-training OSCE also
adverse drug reactions, dosage and maximal duration of appli- surveyed demographic characteristics, including age, gender,
cation in the scope of self-medication, important administer- additional education as a pharmaceutical technical assistant, and
ing information, approved age groups, and examples of working in a community pharmacy, counseling patients.
additional recommendations the pharmacist could provide for
the assigned condition. The content-related aspects to be con- Satisfaction survey.  Upon completion of the seminar, the par-
sidered in self-medication counseling regarding the tested ticipants completed a satisfaction survey comprising 8 items
indications were already presented to both groups prior to the rated on a 6-point Likert scale from “strongly disagree” to
pre-training OSCEs in the above-mentioned lecture. The con- “strongly agree” and 2 open-ended questions (free-text items)
trol group’s activity on handling SmPCs intended first to facili- concerning what they particularly liked about the seminar and
tate students’ ability to filter out autonomously relevant what they would suggest changing. For analysis, the comments
information on OTC-drugs from the SmPCs as a preparation on the free-text items were categorized into topics.
for the summative post-training OSCEs in which the SmPCs
were provided as supporting materials. Second, it purposed to
Data analyses and statistical methods
raise the awareness for important elements of self-medication
counseling such as contraindications or dosage which need to This study analyzed the effects of OSCE training on the ana-
be considered during counseling by the pharmacist. lytical checklist, global rating scale, and self-assessment
Farahani et al. 5

Table 1.  Demographic characteristics.

Intervention group Control group

Age in years n = 16 n = 12*

  Mean (SD) 25.75 (2.84) 24.08 (1.73)

  Median (IQR) 25 (4.5) 24 (3)

 Range 22-32 22-27

Gender n = 16 n = 14

  Female, n (%) 13 (81.25) 10 (71.43)

  Male, n (%) 3 (18.75) 4 (28.57)

Additional education as a pharmaceutical technician assistant n = 16 n = 14

  Yes, n (%) 4 (25) 5 (35.71)

  No, n (%) 12 (75) 9 (64.29)

Working in a community pharmacy (counseling patients) n = 16 n = 13**

  Yes, n (%) 3 (18.75) 3 (23.08)

  No, n (%) 13 (81.25) 10 (76.92)

Abbreviations: IQR, interquartile range; SD, standard deviation.

*Two participants did not provide information about their age.
**One participant did not provide information about his/her work in a community pharmacy.

questionnaire scores and surveyed students’ satisfaction with Additionally, 1 participant was excluded due to non-standardized
this training method. Point-based scores were converted into conditions during the summative post-training OSCE but
percentages or percentage points (p.p.) to enable comparison could not be excluded from the satisfaction survey due to its
between the different OSCE cases. A 2-sided Mann-Whitney anonymous character. Finally, 16 participants in the interven-
test was applied for a baseline comparison of the scores between tion group and 14 in the control group were included in the
the 2 groups. A 1-sided Wilcoxon signed-rank test applied to analyses of OSCE performance and the self-assessment ques-
the differences between pre- and post-training scores was used tionnaire. The demographic characteristics of the participants
to evaluate whether the respective scores increased significantly are depicted in Table 1.
from pre- to post-training. A 1-sided Mann-Whitney test was
used to determine whether score increases from pre- to post-
Analytical checklist
training in the respective scores were significantly greater in
the intervention group as compared to the control group. In all The analytical checklist score reflects the participants’ coun-
statistical tests, the significance level was considered to be seling skills, particularly regarding content and structure (Table
alpha = 0.05. Asymptotic P-values are stated which were not 2). At baseline, there was no significant difference in the ana-
adjusted for multiple testing. All data were collected in pseu- lytical checklist scores between the 2 groups (P = .884).
donymous form, except the anonymous satisfaction survey. Following the respective training, significantly higher scores
After analysis, all data were rendered anonymous. The statisti- were observed for both groups in the summative post-training
cal software R23 was used for randomization, Microsoft Excel OSCE as compared to the pre-training OSCE (intervention
201929 was used for data entry, and Microsoft Excel 201929 and group: P < .001; control group: P = .007). The intervention
OriginPro 201930 were used for data analyses. group showed significantly greater improvement than the con-
trol group (P = .007) (Figure 2).
Results
Participants Global rating scale
Of the 58 students in the semester, 46 signed the informed The global rating scale score represents the participants’ com-
consent form and 40 of them were randomly selected for the munication skills (Table 2). At baseline, there was no signifi-
study. All the 40 participants attended the summative pre- cant difference in the global rating scale scores between the 2
training OSCE. Participants who did not attend the summa- groups (P = .342). These scores significantly increased for both
tive pre-training OSCE, and/or training and/or summative the intervention group (P  = 
.002) and the control group
post-training OSCE were excluded from the analyses. (P = .015) in the summative post-training OSCE as compared
6 Journal of Medical Education and Curricular Development 

Table 2.  Intervention and control group scores from the analytical checklist, global rating scale, and self-assessment questionnaire.

Group Summative pre-training Summative post-training Score difference in P-

score in % score in % percentage points value*

Mean (SD) Median (IQR) Mean (SD) Median (IQR) Mean (SD) Median (IQR)

Analytical checklist

  Intervention group 33.47 (7.00) 32.74 (8.47) 53.46 (7.49) 50 (10.73) 19.98 (10.93) 20.19 (15.10) P = .007

  Control group 34.16 (10.95) 33.91 (16.93) 43.66 (11.36) 44.51 (21.43) 9.51 (11.16) 9.88 (8.34)

Global rating scale

  Intervention group 58.33 (14.50) 56.67 (26.67) 79.17 (14.58) 80 (23.33) 20.83 (23.08) 20 (40) P = .157

  Control group 63.33 (14.02) 66.67 (6.67) 75.24 (9.58) 73.33 (13.33) 11.90 (17.77) 13.33 (26.67)

Self-assessment questionnaire

  Intervention group 49.11 (20.05) 47.14 (34.29) 67.86 (13.98) 68.57 (20) 18.75 (14.00) 18.57 (24.29) P = .022

  Control group 49.18 (19.51) 50 (40) 57.35 (15.47) 55.71 (22.86) 8.16 (9.43) 10 (14.29)

N = 16 (intervention group) and n = 14 (control group).

*A 1-sided Mann-Whitney test with a significance level of alpha = 0.05 was applied to the score difference (from pre- to post-training) of both groups in the respective
scores.
Abbreviations: IQR, interquartile range; SD, standard deviation.

self-assessment questionnaire scores between the 2 groups

(P = 0.787). While both groups showed a significant increase in
the self-assessment questionnaire scores from the summative
pre- to post-training OSCEs (intervention group: P < .001;
control group: P = .007), this was significantly higher for the
intervention group as compared to the control group (P = .022)
(Figure 2).

Satisfaction survey
A total of 22, who attended both summative OSCEs and the
respective training, completed the satisfaction survey, which
did not distinguish between the 2 groups (Tables 3 and 4). The
majority of participants approved of the OSCE seminar, with
Figure 2.  Score differences in percentage points (p.p.).
White boxes = intervention group; gray boxes = control group; black squares 72.73% agreeing (slightly agree, agree, and strongly agree sum-
(■) = mean; horizontal lines = median; black diamonds (♦) = outliers. A 1-sided marized) that OSCEs should be implemented in the clinical
Mann-Whitney test with a significance level of alpha = 0.05 was used. N = 16
(intervention group) and n = 14 (control group). pharmacy course.

to the pre-training OSCE. The intervention group tended to Discussion

have a greater score increase in communication skills (interven- This randomized controlled study showed that our OSCE-
tion group: mean change = 20.83 p.p. (SD = 23.08 p.p.) and based training approach was well accepted by pharmacy stu-
median = 20 p.p. (IQR = 40 p.p.); control group: mean dents and provides an effective approach for teaching
change = 11.90 p.p. (SD = 17.77 p.p.) and median = 13.33 p.p. self-medication counseling. OSCE-based training improved
(IQR = 26.67 p.p.)), although the increase was not significantly students’ self-confidence and self-perceived proficiency, as well
greater in the intervention group as compared to the control as their counseling skills, compared to a non-OSCE-trained
group (P = .157) (Figure 2). control group. However, OSCE-based training did not result
in a significantly greater increase of communication skills in
the intervention group as compared to the control group.
Self-assessment questionnaire Our findings support the use of OSCEs as a method for
The self-assessment questionnaire score reflects the partici- training self-medication counseling skills to pharmacy stu-
pants’ self-confidence and self-perceived proficiency (Table 2). dents, with our OSCE-based training resulting in significantly
At baseline, there was no significant difference in the greater improvements in counseling performance in the
Farahani et al. 7

Table 3.  Results of the satisfaction survey.

Proportions of responses in %

  Strongly Disagree Slightly Slightly Agree Strongly

disagree disagree agree agree

I enjoyed the OSCE seminar. 4.55 13.64 4.55 27.27 45.45 4.55

During the OSCEs, I was able to determine my 0 4.55 31.82 22.73 31.82 9.09
strengths and weaknesses.

The OSCE seminar conveyed safety in dealing with 4.55 18.18 22.73 22.73 18.18 13.64
patients in the community pharmacy.

The OSCE cases were practice-oriented. 0 4.55 18.18 31.82 40.91 4.55

The OSCE cases were too easy. 0 9.09 27.27 27.27 22.73 13.64

The OSCE cases were too difficult. 36.36 31.82 27.27 4.55 0 0

Two days for the OSCE seminar were sufficient. 4.55 13.64 27.27 18.18 13.64 22.73

OSCEs should be implemented in future clinical 4.55 9.09 13.64 13.64 40.91 18.18
pharmacy course to train counseling skills.

N = 22.
Abbreviation: OSCE, objective structured clinical examination

Table 4.  Example topics of comments from free-text items of the satisfaction survey.

Free-text item Topic of comments*

I particularly liked the •  Patient counseling

following at the OSCE
seminar: •  Receiving feedback after summative post-training OSCE

•  Friendly faculty members

I would change the •  Long waiting times for the summative OSCEs
following:
•  Training on the summary of product characteristics was unnecessary (control group’s training)

•  OSCE cases were too easy

*The 3 most frequent topics of comments per item are shown.

Abbreviation: OSCE, objective structured clinical examination

intervention group compared to the control group. However, in the analytical checklist: 53.46% (SD = 7.49%), median post-
there is still controversy regarding the efficacy of formative training score: 50% (IQR = 10.73%) for the intervention group).
OSCES in the literature.19,31 Moreover, few investigations In contrast to that, Hastings et al18 reported an average grade
focus on the use of NPM-related OSCEs. For example, of 78% in the 3-case OSCE final, where students completed
Hastings et  al18 investigated the effect of summative NPM 2-hour credit courses for 2 semesters. We hypothesize that
OSCEs on students’ final grades. They refined the NPM elec- longer or more frequent training will lead to higher OSCE
tive course for pharmacy students by including case-based scores.
small group periods, which incorporated role-playing (similar The use of formative OSCEs in this study did not lead to a
to the formative OSCEs in our study) and other tasks, and significantly greater improvement of the communication skills
added a final summative OSCE. They found similar overall in the intervention group as compared to the control group,
grades compared to previous years where OSCEs were not part although both groups displayed significant improvement from
of the overall grade. However, they did not report further the summative pre- to post-training OSCEs. It might be pos-
results regarding the efficacy of their refined elective course on sible that longer and more frequent OSCE training sessions
their summative OSCEs. Our research evaluated the efficacy would result in a significantly higher increase in the interven-
of a peer interaction–based OSCE training approach in a ran- tion group’s global rating scale score as compared to the control
domized controlled design and found a greater improvement in group. This assumption is also indicated by findings in the lit-
the summative post-training OSCE for the OSCE-trained erature.18,32 For example, a randomized controlled study by
intervention group compared to the control group, although Cannick et  al32 investigating a brief 2-hour communication
there is still room for improvement (mean post-training score skills training for dental students assessed by OSCEs found no
8 Journal of Medical Education and Curricular Development 

significant differences from baseline to post-test between the in participation rate at the post-training OSCE, which was the
intervention and control group. They concluded that the brief final clinical pharmacy seminar day in the semester, might be
training was insufficient and that comprehensive training with due to competing demands in their time at the end of the
frequent reinforcements might be more beneficial. However, it semester because of pending exams. Moreover, in educational
should be considered that in the study at hand, the final scores research “contamination” can occur, such as students randomly
of the global rating scale (post-training scores) show only little assigned to different groups share information.39 To mitigate
room for further improvement in both groups. this possible bias, the post-training OSCEs were conducted
Increases in self-assessment questionnaire scores reflect immediately after the training on the same day. Moreover, due
increases in participants’ self-confidence and self-perceived to the lack of staff, only 2 OSCE encounters could take place
proficiency. This study found significant increases in self-con- at 1 time. Thus, some students had long waiting times for the
fidence through the application of OSCEs, in agreement with OSCEs which was criticized in the satisfaction survey.
findings in the literature.22,33-35 Moreover, the majority of stu- This might have negatively influenced the results of the
dents in this study agreed that OSCEs should be implemented satisfaction survey.
in future clinical pharmacy courses for training their counseling Despite these limitations, the results show a valuable benefit
skills. These findings support students’ acceptance of OSCEs, of applying an OSCE-based training approach in improving
which is in line with findings of other studies.22,33,36 Although pharmacy students’ self-medication counseling skills. As phar-
the control group’s training with the SmPCs was rather dis- macists play an important role to ensure the safe, appropriate,
liked by the students, the positive results, including the signifi- and effective application of self-medication,8 and literature
cant increase in the analytical checklist score, global rating indicates room for improvement of pharmacists’ self-medica-
scale score, and self-assessment questionnaire score from pre- tion counseling skills,13-16 we suggest that an OSCE-based
to post-training OSCEs, indicate a beneficial contribution on training approach has the potential to contribute to the future
students’ counseling skills. Nevertheless, regarding the analyti- pharmacists’ education.
cal checklist and self-assessment questionnaire, the OSCE-
trained group was superior. Conclusion
We assume that using a pre-test/post-test design might This study found that our OSCE-based training was widely
have led to underestimating the effect of the intervention accepted by pharmacy students and provides an effective
(OSCE-based training). The pre-training OSCE might have method for training self-medication counseling. Applying
caused a learning effect as the students might be faced with OSCEs as a learning tool in pharmacy education is benefi-
their weaknesses as previously assumed by other researchers.37 cial, improving both the students’ counseling skills as well as
As such, it is possible that removing the pre-training OSCE self-confidence and self-perceived proficiency. These find-
from this study would better reveal the effects of the interven- ings support the inclusion of this strategic educational
tion, including in the participants’ communication skills. approach throughout pharmacy education and highlight its
We are aware of some limitations. The analytical checklists potential for bridging gaps between knowledge and
and global rating scale were only available to the intervention practice.
group during their training to enable the students to provide
each other adequate feedback and were collected again after the Author’s Note
1-hour training. The checklists were not provided to the control A conference abstract on a part of this work was presented and
group. Although we cannot completely exclude a potential published previously.40
impact of the provision of the checklists, we assume that knowl-
edge of the checklists would probably not substantially affect Acknowledgements
the performance of the intervention group compared to the The authors thank the faculty members Martin Feickert and
control group during the summative post-training OSCEs. Fabian Konstantin Suessenbach for acting the simulated
This assumption is supported by the findings of Cole et al.38 In patients and Anna Laven for the support in drafting the initial
particular, they compared the OSCE scores of students who concept of the study.
attended a peer-taught training session to the scores of students
who did not attend the session. Both groups were provided with Author Contributions
scoring rubrics during the semester. Although differences in IF, SF and SL designed the study. IF, SF and MAD were active
student scores for each skill were not statistically significant in data gathering. The analyses were done by IF and HS. The
between both groups, they found a significant difference in the visualization as well as the writing of the original draft were
overall OSCE score favoring the group which attended the done by IF. Moreover, IF, SF, HS and SL edited the manuscript
training session. The rationale of providing the checklists to the and IF, SF, MAD, HS and SL reviewed the manuscript. All
intervention group was to set a framework for adequate peer authors have read and approved to the final version of the
feedback while coping with limited staff available. The decrease manuscript.
Farahani et al. 9

ORCID iDs 19. Chisnall B, Vince T, Hall S, Tribe R. Evaluation of outcomes of a formative
objective structured clinical examination for second-year UK medical students.
Imaneh Farahani https://orcid.org/0000-0001-5335-4580 Int J Med Educ. 2015;6:76-83.
2 0. Galato D, Alano GM, Trauthman SC, França TF. Pharmacy practice simula-
Samieh Farahani https://orcid.org/0000-0003-1009-4824 tions: performance of senior pharmacy students at a University in southern Bra-
zil. Pharm Pract (Granada). 2011;9:136-140.
Supplemental Material 21. Limaye D, Limaye V, Krause G, Fortwengel G. A systematic review of the litera-
ture to assess self-medication practices. Ann Med Health Sci Res. 2017;7:1-15.
Supplemental material for this article is available online. 22. Farahani I, Laeer S, Farahani S, Schwender H, Laven A. Blended learning:
improving the diabetes mellitus counseling skills of German pharmacy students.
Curr Pharm Teach Learn. 2020;12:963-974.
23. R: A Language and Environment for Statistical Computing. 2018. Vienna, Austria:
References R Foundation for Statistical Computing; 2018. https://www.R-project.org
1. World Health Organization. The role of the pharmacist in self-care and self- 24. Laven A. ‘Was geht Sie das an?’. Die PTA in der Apotheke. 2013. Published 06
medication: report of the 4th WHO consultative group on the role of the phar- 2013. Accessed March 30, 2021. https://www.diepta.de/news/praxis/
macist. The Hague, the Netherlands, 26–28 August 1998. World Health kommunikation-was-geht-sie-das-an-538044/
Organization. 1998. Accessed March 30, 2021. https://apps.who.int/iris/ 25. Laven A, Deters MA, Rose O, et al. PharmAdhere: training German commu-
handle/10665/65860 nity pharmacists with objective structured clinical examinations. Int J Clin
2. World Health Organization. Guidelines for the regulatory assessment of medici- Pharm. 2018;40:1317-1327.
nal products for use in self-medication. World Health Organization. 2000. 26. Bundesapothekerkammer. Arbeitshilfe der Bundesapothekerkammer zur Qualitätssi-
Accessed March 30, 2021. https://apps.who.int/iris/handle/10665/66154 cherung: Anwendungsbeispiel zu den Leitlinien: Information und Beratung im Rahmen
3. Hughes CM, McElnay JC, Fleming GF. Benefits and risks of self medication. der Selbstmedikation am Beispiel Magenbeschwerden. Version November 23, 2016.
Drug Saf. 2001;24:1027-1037. Bundesapothekerkammer. Accessed October 9, 2018. https://www.abda.de/fuer-
4. GIRP - European Healthcare Distribution Association. Access to non-prescrip- apotheker/qualitaetssicherung/leitlinien/leitlinien-und-arbeitshilfen/
tion medicines – the key role of pharmacy in self-care: GIRP position paper. 27. Bundesapothekerkammer. Arbeitshilfe der Bundesapothekerkammer zur Qual-
GIRP - European Healthcare Distribution Association. 2016. Accessed March itätssicherung: Anwendungsbeispiel zu den Leitlinien: Information und Beratung im
30, 2021. https://girp.eu/sites/default/files/documents/girp_position_paper_ Rahmen der Selbstmedikation am Beispiel Kopfschmerzen. Version November 23,
on_non_prescription_medicines.pdf 2016. Bundesapothekerkammer. Accessed October 9, 2018. https://www.abda.
5. Van Eikenhorst L, Salema NE, Anderson C. A systematic review in select coun- de/fuer-apotheker/qualitaetssicherung/leitlinien/leitlinien-und-arbeitshilfen/
tries of the role of the pharmacist in consultations and sales of non-prescription 28. Bundesapothekerkammer. Arbeitshilfe der Bundesapothekerkammer zur Qual-
medicines in community pharmacy. Res Social Adm Pharm. 2017;13:17-38. itätssicherung: Anwendungsbeispiel zu den Leitlinien: Information und Beratung im
6. Bradley CP, Bond C. Increasing the number of drugs available over the counter: Rahmen der Selbstmedikation am Beispiel Durchfall. Version November 23, 2016.
arguments for and against. Br J Gen Pract. 1995;45:553-556. Bundesapothekerkammer. Accessed October 9, 2018. https://www.abda.de/
7. Barrenberg E, Garbe E. Use of over-the-counter (OTC) drugs and perceptions of fuer-apotheker/qualitaetssicherung/leitlinien/leitlinien-und-arbeitshilfen/
OTC drug safety among German adults. Eur J Clin Pharmacol. 2015;71: 29. Microsoft Excel 2019 (for Windows). Redmond, WA, USA: Microsoft Corporation;
1389-1396. 2019.
8. Eickhoff C, Hämmerlein A, Griese N, Schulz M. Nature and frequency of drug- 30. OriginPro 2019. Northampton, MA, USA: OriginLab Corporation; 2019.
related problems in self-medication (over-the-counter drugs) in daily community 31. Alkhateeb NE, Al-Dabbagh A, Ibrahim M, Al-Tawil NG. Effect of a formative
pharmacy practice in Germany. Pharmacoepidemiol Drug Saf. 2012;21:254-260. objective structured clinical examination on the clinical performance of under-
9. Kehrer JP, Eberhart G, Wing M, Horon K. Pharmacy’s role in a modern health graduate medical students in a summative examination: a randomized controlled
continuum. Can Pharm J (Ott). 2013;146:321-324. trial. Indian Pediatr. 2019;56:745-748.
10. Bell J, Dziekan G, Pollack C, Mahachai V. Self-care in the twenty first century: 32. Cannick GF, Horowitz AM, Garr DR, et al. Use of the OSCE to evaluate brief
a vital role for the pharmacist. Adv Ther. 2016;33:1691-1703. communication skills training for dental students. J Dent Educ. 2007;71:
11. Ylä-Rautio H, Siissalo S, Leikola S. Drug-related problems and pharmacy inter- 1203-1209.
ventions in non-prescription medication, with a focus on high-risk over-the- 33. Farahani I, Farahani S, Deters MA, Schwender H, Laeer S. Efficacy of an objec-
counter medications. Int J Clin Pharm. 2020;42:786-795. tive structured clinical examination training approach for training pharmacy
12. Bosse N, Machado M, Mistry A. Efficacy of an over-the-counter intervention students in diabetes mellitus counseling: a randomized controlled trial. Pharmacy
follow-up program in community pharmacies. J Am Pharm Assoc (2003). (Basel). 2020;8:229.
2012;52:535-540. 34. Bevan J, Russell B, Marshall B. A new approach to OSCE preparation - PrO-
13. Langer B, Bull E, Burgsthaler T, Glawe J, Schwobeda M, Simon K. Die Bera- SCEs. BMC Med Educ. 2019;19:126.
tungsqualität von Apotheken bei akutem Durchfall - Eine Analyse unter Ver- 35. McClimens A, Ibbotson R, Kenyon C, McLean S, Soltani H. Confidence and
wendung der “Simulated Patient”-Methode. [Using the simulated patient performance in objective structured clinical examination. Br J Midwifery.
methodology to assess counselling for acute diarrhoea - evidence from Germany]. 2012;20:746-751.
Article in German. Z Evid Fortbild Qual Gesundhwes. 2016;112:19-26. 36. Awaisu A, Mohamed MHN, Al-Efan QAM. Perception of pharmacy students
14. Horvat N, Koder M, Kos M. Using the simulated patient methodology to assess in Malaysia on the use of objective structured clinical examinations to evaluate
paracetamol-related counselling for headache. PLoS One. 2012;7:e52510. competence. Am J Pharm Educ. 2007;71:118.
15. Rutter PM, Horsley E, Brown DT. Evaluation of community pharmacists’ rec- 37. Nielsen AM, Henriksen MJV, Isbye DL, Lippert FK, Rasmussen LS. Acquisi-
ommendations to standardized patient scenarios. Ann Pharmacother. tion and retention of basic life support skills in an untrained population using a
2004;38:1080-1085. personal resuscitation manikin and video self-instruction (VSI). Resuscitation.
16. Watson MC, Bond CM, Johnston M, Mearns K. Using human error theory to 2010;81:1156-1160.
explore the supply of non-prescription medicines from community pharmacies. 38. Cole JD, Ruble MJ, Donnelly J, Groves B. Peer-assisted learning: clinical skills
Qual Saf Health Care. 2006;15:244-250. training for pharmacy students. Am J Pharm Educ. 2018;82:6511.
17. Taylor J, Rocchi M. The art and science of counselling patients on minor ail- 39. Collins J. Medical education research: challenges and opportunities. Radiology.
ments/OTC medicines. SelfCare. 2018;9:3-22. 2006;240:639-647.
18. Hastings JK, Flowers SK, Pace AC, Spadaro D. An objective standardized clini- 4 0. Farahani I, Laven A, Farahani S, et al. P33 Effectiveness of OSCEs in training
cal examination (OSCE) in an advanced nonprescription medicines course. Am J German pharmacy students in consultation on self-medication – a randomised
Pharm Educ. 2010;74:98. controlled investigation. [abstract P33]. Arch Dis Child. 2019;104:e30.2–e31.