Study design and Participants
A cross-sectional pre-post and self-administrated questionnaire survey was conducted to collect data of the participants before and after their clerkship schemes.
The participants were fifth-year undergraduate students majoring in clinical pharmacy of three continuous years at China Pharmaceutical University (CPU), a pharmaceutical-science-focused university affiliated with the Chinese Ministry of Education. CPU is one of the top pharmaceutical universities and the first institution to offer a program in clinical pharmacy among China’s pharmaceutical higher educational programs[43]. It is a five-year program in which the last year is a clerkship period, during which the students are provided with basic training in clinical pharmacy practical and scientific research skills by teaching hospitals or facilities, and the arrangements and contents of this clerkship scheme are typical among clerkship schemes for pharmacy students in China[44]. Most clerkship schemes of other clinical pharmacy programs in China were mostly design based on it[36-39].
The inclusion criteria for respondents were as follows:
- Registered as undergraduate fifth-year clinical pharmacy students in September 2014, September 2015 or September 2016 (All three groups shared almost the identical admission requirements, curriculum settings, teaching staff, clerkship arrangements and graduation requirements).
- Had completed all the courses and passed all examinations or assessments before the clerkship (to eliminate the effect of quality issues related to the course education).
- Had signed up for the clerkship schemes.
- (For the post-part of the survey) had passed the final examination of the clerkship scheme.
Each respondent was assign with a distinct ID number to ensure the consistency of the pre-part and the post-part of the survey. Written consent forms were received from all the students who voluntarily participated in this study after they were informed about the aim and processes of the study orally and in writing and orally confirmed their willingness to participate.
Instruments
A three-section questionnaire in Chinese was developed (Annex 1).
Section 1 of the questionnaire concerns sociodemographic characteristics and records of study and training of clinical pharmacy, including the respondents’ gender, age, admission year, GPA, clerkship grades, grade of teaching hospital, and internship or work experience involving PC before the clerkship.
Section 2 contained 12 true-or-false questions about the definitions and goals of PC and the role and responsibility of pharmacists in providing PC, aiming to measure the correctness of the respondents’ understanding of PC. The questionnaire was designed according to the standardized definition and contents of PC1, the guidelines regarding the standardized method for providing PC issued by American Society of Health-System Pharmacists and American College of Clinical Pharmacy[45, 46], and other studies concerning the understanding of PC[47, 4, 5]. Correct response to statement 3, 4, 10 and 12 was false.
Section 3 is 14-item 5-point Likert scale from 1 (strongly agree) to 5 (strongly disagree) concerning the respondents’ degree of acceptance of the goals, standard contents, modes and outcomes of PC and their PC workloads, targeting at the attitudes of pharmacy students toward PC and was built based on the Pharmaceutical Care Attitude Survey, which is a validated instrument that measures pharmacy students’ attitude toward PC[48], and was adapted in reference to other studies adopting or adapting this instrument[1, 9, 4, 5, 11, 14, 15] and context of China. Higher response scores indicate more positive attitudes, and statements 6 and 13 were reverse coded.
Two English-proficient native Chinese speakers and two native English speakers fluent in Chinese were recruited to translate the English reference. Then, under their assist, the draft questionnaire was reviewed and modified by experienced clinical pharmacists serving in hospitals for descriptive accuracy and readability in the social and linguistic context of China. In August 2014, 50 pharmacy students who had graduated in June 2014 were recruited for the pilot survey by e-mail. Researchers collected comments and suggestions regarding the readability and understandability of the questionnaire provided by 10 of those students and, again, modified the questionnaire. Then, the pilot survey data were collected from the other 40 students using the modified questionnaire. With the data above, the reliability of section 2 and 3 was separately assessed with Cronbach’s alpha, and the validity was assessed with the Kaiser-Meyer-Olkin measurement of sampling adequacy and Barlett’s Test of Sphericity The test results showed acceptable reliability (standardized Cronbach’s alpha: section 2 = 0.955, section 3 =0.948) and validity (KMO measurement of sampling adequacy: section 2 = 0.595, section 3 = 0.609; Barlett’s Test of Sphericity: p = 0.000 for section 2, psection3 = 0.000 for section 3) of both instruments used in this study.
Data collection
In August 2014, 10 first-year PhD students at CPU with clinical pharmacy backgrounds were recruited as the assistants of the researchers in data collection.
Data were collected through two rounds of self-administrated survey using paper questionnaires. Each respondent was required to complete the first round of the survey within one week before the clerkship and the second round of the survey within one week of after the clerkship by convenience of their time. To avoid interference from environmental factors, the students were required to finish the questionnaires in an undisturbed and quiet room provided by the researchers. The study was single blinded that the participants’ identification information was collected previous to the survey and kept by one researcher that didn’t contribute in data collection, and the assistants and the researchers contributed in data collection were blinded. Incomplete data were excluded.
Data analysis
Descriptive statistics were used to display and analyze differences in the pharmacy students’ understanding of and attitudes toward PC before and after clerkship.
Kruskal-Wallis one-way analysis of variance test and the Mann-Whitney U test were used to examine whether there were significant differences in the pre-clerkship and post-clerkship understanding of and attitudes toward PC of respondents who differed by gender, registration year, clerkship hospital level (under current hierarchical health system of China, hospitals are divided into three levels, and hospitals with different levels have distinct functions and roles in the health system[49], and this may lead to differences in clerkship schemes for pharmacy students), internship or work experience involving PC, age, mean GPA before clerkship and mean clerkship grades.
Wilcoxon Signed Rank test were applied to examine the significance of the data regarding the differences in students’ understanding of PC before and after clerkship. McNemar’s test was used to examine the significance of the difference in the data between the students’ attitudes toward PC before and after clerkship. The difference was considered significant when the p-value was < 0.05.
All survey data were back-to-back cross-input into the computer by two of the authors using EpiData3.1 and analyzed using SPSS 24 (IBM Corporation, Armonk, NY, USA).