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Nursing students' experiences of service- learning at community and hospital pharmacies in Belize: Pedagogical implications for nursing pharmacology

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Abstract

Objectives Many students seem to find pharmacology learning very challenging due to the complexity and variety of drugs they have to study. The number of drugs the students have to learn, the duration of time to learn the medications, and the evolving nature of diseases demanded learning beyond the classroom walls. This study explored and described nursing students' experiences in community and hospital-based pharmacy practice sites during their service-learning and its implications for pharmacology pedagogical practices. Methods Kolb's learning theory provided the framework to explore nursing students' 48-hour service-learning experiences at community/hospital-based pharmacies in Belize and its implications for pharmacology pedagogy. The study utilized two qualitative approaches, reflective journals and focus group interviews, to collect data from 46 second-year nursing students. NVivo software and coding schemes were employed to analyze the data from the interviews and reflective journals.
RESEARCH ARTICLE
Nursing students’ experiences of service-
learning at community and hospital
pharmacies in Belize: Pedagogical
implications for nursing pharmacology
Danladi Chiroma HusainiID
1
*, David D. Mphuthi
2
, Jane A. Chiroma
3
,
Yusuf Abubakar
1
, Adeniyi O. AdeleyeID
4
1Faculty of Health Sciences, Allied Health Department, University of Belize, Central America, Belmopan,
Belize, 2Faculty of Health Studies, College of Human Sciences, University of South Africa, Pretoria, South
Africa, 3Department of Leadership and Curriculum Development, Pan Africa Christian University, Nairobi,
Kenya, 4Central Queensland University, College of Nursing and Midwifery, Rockhampton, Queensland,
Australia
These authors contributed equally to this work.
*hchiroma@ub.edu.bz
Abstract
Objectives
Many students seem to find pharmacology learning very challenging due to the complexity
and variety of drugs they have to study. The number of drugs the students have to learn, the
duration of time to learn the medications, and the evolving nature of diseases demanded
learning beyond the classroom walls. This study explored and described nursing students’
experiences in community and hospital-based pharmacy practice sites during their service-
learning and its implications for pharmacology pedagogical practices.
Methods
Kolb’s learning theory provided the framework to explore nursing students’ 48-hour service-
learning experiences at community/hospital-based pharmacies in Belize and its implications
for pharmacology pedagogy. The study utilized two qualitative approaches, reflective jour-
nals and focus group interviews, to collect data from 46 second-year nursing students.
NVivo software and coding schemes were employed to analyze the data from the interviews
and reflective journals.
Results
Students reported learning medications, integrating classroom pharmacological knowledge
at pharmacy practice sites, acquiring and enhancing communication skills, interpreting pre-
scriptions, dispensing medications, drug calculations, taking inventory, doing vital signs,
and patient education. In addition, students reported experiencing inter-professional rela-
tionships as healthcare team members. Anxiety was a major challenge experienced by
many students at the beginning of the service-learning experience.
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Citation: Husaini DC, Mphuthi DD, Chiroma JA,
Abubakar Y, Adeleye AO (2022) Nursing students’
experiences of service-learning at community and
hospital pharmacies in Belize: Pedagogical
implications for nursing pharmacology. PLoS ONE
17(11): e0276656. https://doi.org/10.1371/journal.
pone.0276656
Editor: Dana M. Hansen, Kent State University,
UNITED STATES
Received: May 14, 2021
Accepted: October 11, 2022
Published: November 3, 2022
Copyright: ©2022 Husaini et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
files.
Funding: The author(s) received no specific
funding for this work.
Competing interests: The authors have declared
that no competing interests exist.
Conclusions
This study highlights the importance of experiential learning of pharmacology amongst sec-
ond year nursing students, offering the opportunity to inform and support pharmacothera-
peutics educators in designing strategies for more effective teaching of medications to
nursing students. It also supports the addition of pharmacy placements to the nursing curric-
ulum’ as it shows that nursing students can learn medications, skills, and teamwork from
experiential pharmacy site posting. Combining classroom instruction with pharmacy experi-
ential service learning might be an effective complement for teaching nursing
pharmacology.
Introduction
Pharmacotherapeutics is the study of medications and their clinical use in disease manage-
ment. It comprises pharmacokinetics, pharmacodynamics, and therapeutics. In nursing prac-
tice, pharmacotherapeutics is a crucial component of drug administration that embraces
assessment, planning, implementation, and evaluation. The nurse’s role involves prescription
interpretation, dosage calculation, drug administration, and monitoring of the effects of the
administered drug [1]. Many students find pharmacology difficult because of the complexity
of drugs, the number of drugs the students have to learn, the duration of time to learn the
drugs, and the evolving nature of diseases the students are required to understand [2]. Few
studies have reported the dissatisfaction of nursing students with pharmacology teaching in
their training, resulting in anxiety and uncertainty in medication management and decision-
making [3,4]. Another concern for pharmacotherapeutics teaching and knowledge develop-
ment is the minimization or elimination of medication errors during practice [2]. Even though
other healthcare professionals can cause medication errors, nursing medication errors have
been the most common because nurses administer most drug orders and spend a considerable
amount of time with their patients [5]. Medication errors can occur during the preparation,
distribution, or administration of drugs. Research has shown that approximately one-third of
medication errors occur during the nurse administration phase and contribute to the adverse
effects that compromise patient safety [6]. Medication errors have been reported to prolong
patient hospitalization, leading to increased financial costs and therapy burden [5,6].
Some pharmacology teaching methods and strategies have been described to undergraduate
students. Such strategies include traditional lectures, simulation, autobiography of drugs, con-
cept maps, flipped classrooms, collage making, animations, cooperative learning, and integrat-
ing theory with clinical exposure [2,79]. Traditional nursing classroom lectures are mainly
effective for cognitive content delivery and do not provide sufficient experiential learning [10].
With the expanding scope of diseases and the number and complexity of medications, the
need to urgently explore innovative strategies in enhancing both the cognitive and experiential
learning in nursing pharmacology is paramount. This will ensure effective theoretical, cogni-
tive and experiential learning opportunities for enhance holistic nursing training that leads to
high quality and safe patient care.
Service-learning, as the experiential learning component, is an innovative teaching method
designed to integrate educational objectives with community needs to enhance students’ learn-
ing during community participation [1114]. Furthermore, service-learning connects students
to the realities of practice and comprises reciprocal learning, reflection, and experiential learn-
ing as essential elements that distinguish service-learning from other learning experiences
[11,13].
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Currently, few studies have explored and described nursing education in Central America
and the Caribbean, to which Belize is a member [1518]. Formal nursing education in Belize
was established in 1894, approximately 21 years after the establishment of the first nursing
schools in the United States of America [15]. Since then, the training of nurses in Belize has
transitioned from awarding diplomas to baccalaureate degree training.
To provide students with a holistic model of care learning experience, we explored innova-
tive service-learning teaching strategies to help students gain sufficient interest and knowledge
in pharmacology [13,19,20]. This study’s pedagogical approach allowed nursing students to
spend time at community and hospital pharmacies with licensed pharmacists to facilitate
enhanced learning of pharmacology. The purpose of this study is to introduce second-year
baccalaureate nursing students to experiential pharmacotherapeutics. To the best of our
knowledge, this is the first study in Belize, Central America, and the Caribbean.
Theoretical foundation
The experiential learning theory developed by Kolb and Kolb [21] was adopted in this study.
For over three decades, Kolb’s model of experiential learning has been used by educators to
support pedagogical practices [21]. Concrete experience, reflective observation, abstract
conceptualization, and active experimentation formed the key phases of Kolb’s experiential
learning cycle [21]. The nursing undergraduate learner can start the experience (cognitive
and/or experiential) at any phase of the learning cycle, thereby giving the student the prospect
of applying the knowledge learned to develop the skills and competencies necessary for prac-
tice (Fig 1). Experiential learning inspires student nurses to relate to theoretical content while
learning the skills that will help them make meaningful contributions to global healthcare.
Fig 1. Service-learning framework.
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Problem statement
The enormous content of the nursing pharmacotherapeutics at the university of Belize (UB)
and the short duration of time allotted for teaching have resulted in information overload to
the students, creating a lack of interest in learning and increased student anxiety due to the
inability to adequately retain pharmacological knowledge. This study explored the experiences
of student nurses at pharmacy practice sites as part of an innovative service-learning teaching
strategy to help students gain meaningful knowledge in pharmacotherapeutics.
Primary question
1. How do volunteer service-learning-related activities at community/hospital-based pharma-
cies help nursing students learn pharmacotherapeutics?
Secondary questions
1. In what ways do students’ pharmacy service-learning experiences expand their knowledge
of pharmacotherapeutics?
2. As a pedagogical approach, what role does service-learning in community/hospital-based
pharmacies practice sites play in developing nursing practices that count in nursing phar-
macotherapeutics undergraduate education?
Methodology
Method
Kolb’s learning theory provided the framework to explore nursing students’ service-learning
experiences in community/hospital-based pharmacies in Belize and its implications for phar-
macology pedagogy [22,23]. Two qualitative approaches, reflective journals and focus groups
were used in this study.
Sampling
Students enrolled in the nursing pharmacotherapeutics course and who provided written con-
sent to participate were included in the study. Any student who did not provide consent was
excluded from the study. Fifty students enrolled in the course that started in January 2020 and
ended in the first week of May 2020. Forty-six students completed all aspects of the study.
Setting
The students volunteered for a minimum of 48 hours of service-learning at approved phar-
macy practice sites within Belize. The approved pharmacy practice sites are mostly sites used
by the University of Belize’s pharmacy program for the training of pharmacy students. A letter
of introduction containing the volunteer service-learning objectives was given to the students
to present to the preceptor pharmacist.
Instruments for data collection
Two qualitative data, reflective journals and focus groups were obtained in this study. Kolb’s [23]
experiential cycle was utilized along with concepts garnered from the literature review to formu-
late questions that guided students’ reflections and focus group discussions. The coding schemes
proposed by Kember et al. [24] were employed for evaluating students’ reflective journals.
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Data collection
Nursing students enrolled in the pharmacotherapeutics course were informed about the
research protocols, and for the 46 students interested, consent was obtained. Qualitative data
were collected from reflective journals and focus-group interviews (Fig 2).
Reflective journals. For the reflective journals, the students kept one paragraph of hand-
written reflection daily for the duration of the experiential learning. The prompts for their
daily journals were based on the service-learning objectives. Students submitted unnamed
reflective journals weekly or at the end of every 8-hour service-learning duration. Approxi-
mately every student submitted six reflective journals throughout the service-learning period.
Copies of the reflective journals were made for one of the reviewers. To enhance credibility of
the study we reviewed the journal entries with students for clarity and to reduce the likelihood
of investigators’ mistaken meanings in students’ writings. The discussion with the students
helped the investigators better understand the students’ values, feelings, and thoughts
expressed in the reflective journal entries. The reflective journal included the students’ experi-
ences, the drugs they came across at the pharmacy, and information about the drug. The
review allowed the investigators to guide the students and encouraged the reflective process
while promoting pharmacologic learning.
Focus groups. For the focus group data collection, two instructors conducted the focus
group interviews with student nurses. Because of the large class size, the 46 students were
divided into nine groups of five students each with one overflow to facilitate robust discus-
sions. The focus group interviews were conducted over a round table in comfortable class-
rooms at the University of Belize. Two of the study investigators conducted the focus group
interviews using a semi-structured questionnaire. The main question asked was share with us
your experience during the pharmacy volunteer service” (S1 File). Thereafter, other follow-up
questions were asked to understand how students experienced pharmacotherapy service-
learning in community/hospital-based pharmacies. Each focus group session lasted for
approximately one and half hours. Questions were presented to the students by the investiga-
tors, and responses were recorded based on group responses rather than on individual
responses. Students’ responses were recorded using notes and digital recorders.
Data analysis
Reflective journals. Two investigators analyzed the reflective journals to determine the
student’s level of introspection based on whether the journal entry characterizes non-reflec-
tion, understanding, reflection, and critical thinking, as Kember et al. [24] coding schemes
Fig 2. Approach for data collection and analysis.
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proposed. The approach was employed to identify students’ analytical and reflective insights
and the ability to merge process, introspection, and analysis eventually.
Focus groups. For the data analysis, two investigators analyzed the focus group interviews.
The audio-recorded interviews were first transcribed verbatim and analyzed thematically. The the-
matic analysis procedure summarized by Moseholm et al. [25] was employed as the general strat-
egy for the focus groups. In order to obtain a sense of the whole, the interview transcripts were
read several times. We then identified emergent themes, patterns, and uniqueness within the
scripts. After that, similarities and differences within the narratives were compared to create coher-
ent themes. Microsoft software was used to organize the data, while Nvivo 11 software aided the
analysis. The coding of themes was based on group respondents’ views and levels of data saturation
from both sources. The integrated themes and sub-themes from the focus group summarized the
students’ service-learning experiences. Four main themes and seven subthemes were identified in
the analysis. The main themes and sub-themes identified in the analysis are presented in Table 2
and discussed below. The consolidated criteria for reporting qualitative research, as reported by
Tong et al. [26] and Holloway [27], guided the data analysis and reporting of our findings.
Trustworthiness
Peer debriefing and member checks were employed to ensure trustworthiness during the qual-
itative data analysis. Peer debriefings facilitated an in-depth understanding of the students’
experiences within the pharmacy practice sites, and member checks were utilized to ensure
credibility and accuracy of the results. In addition, transcripts and field notes were studied and
discussed by the research team to ensure accurate interpretation and presentation of the data.
Finally, the collaborative review of students’ unnamed reflective journals provided clarity and
reduced the likelihood of investigators’ mistaken meanings in students’ writings, thereby
strengthening the interpretation process.
Ethics approval
This study was performed in accordance with the principles of the Declaration of Helsinki.
The study was approved by the Health Sciences Faculty of the University of Belize as part of
the faculty experiential learning project (UBP-ELP-1).
Results
Demographics
A total of 46 students comprised of male n = 11 (23.91%) and female n = 35 (76.09%) with a
mean age of n = 22.06±5.76 participated in the study. The majority of the participants, n = 29
(63.04%), held a high school diploma, while n = 16 (34.78%) had associate degrees, with one
(2.17%) rural health nurse. Approximately 83% (n = 38) volunteered at community pharma-
cies, 13% (n = 6) at hospital-based pharmacies, and 4% (n = 2) volunteered at community and
hospital-based pharmacies. The mean hours of volunteer service reported were 50.43±5.37.
Reflective journals
Most students expressed that collaborative discussions with the lecturers concerning the reflec-
tive journals enriched the service-learning experience. The collaborative reviews allowed stu-
dents to discuss their experiences with the lecturers and receive timely feedback, helping the
students gain insights, understanding, and better knowledge of medications. Many students
indicated that the experience fostered a better relationship with the preceptors and the lectur-
ers and encouraged pharmacologic learning.
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The reflective journal analysis indicated that most students’ learning was enhanced as they
reflectively journaled their daily experiences, as indicated by a student’s entry.
Today, I learned the mechanism of action, dosage, and dispensing information of few medi-
cations, notably omeprazole, lisinopril, and atorvastatin.
Overall, the analysis of the reflective journals showed a pattern based on the coding schemes
described by Kember et al. [24]. The reflective journal entries made by most students were at
the understanding and reflective levels; only a few provided entries that indicated critical
reflection levels, as evidenced by a student’s reflective journal entry.
A patient came with a prescription to buy Ardosons. First, I was curious about the name
because it was unusual and did not seem to follow a pattern, and when I checked the medi-
cation, I discovered it was a combination of indomethacin, betamethasone, and methocar-
bamol. I knew the mechanism of action of 2 of the meds, but I had not heard of the last one.
After researching the third drug, I knew combining NSAIDs, corticosteroids, and muscle
relaxants would help someone in pain. I then searched for the drug and discovered I was
right. I shared the information of my discovery with some of my coursemates.
The students did not record many critical reviews in their reflective journals. Nevertheless,
the course lecturers were satisfied with the student’s ability to demonstrate comprehension of
basic pharmacologic knowledge through the reflective journals, achieving the intended learn-
ing objective.
Focus groups
Themes and sub-themes identified during analysis of focus group transcripts (Table 1).
1. Students’ perceptions of pharmacy service-learning
In this study, 46 students in focus group discussions shared their experiences and perceptions
after a 48- hour pharmacy voluntary service indicated that the experience was interesting and
helped them learn and remember medications differently. A student from group A indicated
that the experience was satisfying, as expressed by the following quote:
Table 1. Themes and sub-themes identified during analysis of focus group.
Focus Group Themes and Sub-themes
1. Student’s perceptions of pharmacy service-learning
2. Students integration of theoretical pharmacologic knowledge
3. Students acquisition of skills from pharmacy service learning
3.1 Pharmacy environment for learning drugs
3.2 Prescription interpretation
3.3 Calculating and dispensing medications
3.4 Taking drug inventory
3.5 Taking patients vital signs
3.6 Patient education
3.7 Communication skills in healthcare setting
4. Inter-professional relationship in healthcare
5. Challenges and suggestions to pharmacy service learning experience
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I knew that I had to learn medications to succeed in my career. . ...in the end,it turned out to
be a great experience.I realized that I could learn from other medical professionals while serv-
ing.In the end,I benefitted more than the pharmacist because I achieved my goals of going
there.In all,I had a very satisfying experience and would not mind volunteering again. (Stu-
dent 3 from Group A)
Some students reported that at first, they were not very enthusiastic about going to the
pharmacy because in their opinions it was not a nursing setting and they were not sure how
they will fit in a pharmacy setting. However, at the end of their volunteer service, they reported
that they had learned several medications differently and in a different setting. Some students
mentioned that they enjoyed their experiences as they were actively involved in learning and
dispensing medications, communicating with clients, and attending to patients. Most of the
students were of the view that this experience was beneficial and was an eye-opener to the
demands of the nursing profession, especially when it comes to medications.
I enjoyed my experience and felt I gained a lot of knowledge from it since.The experience
helped me throughout my pharmacotherapy class. . .I really did enjoy the time of packing the
medications,documenting,learning,and dispensing medication.All the knowledge gained at
the pharmacy is now permanent and is helping me; it was worth the volunteer. (Student 1
from Group B)
2. Students integration of theoretical pharmacogic knowledge
Students shared that volunteering at the pharmacy helped them to integrate the theoretical
knowledge learned in class with the drugs encountered at the pharmacy. Pharmacologic con-
cepts taught in the class were reinforced at the pharmacy practice sites. They reported that
they had first-hand experiences with many medications in a way that was not taught in the
class. Some students recounted that the volunteering initiative was very helpful in affirming
what they learned in class. The students recounted that they learned the drug names, indica-
tions, mechanisms of action, side effects, and pregnancy categories. Students further indicated
that the experience broadened their knowledge of medications and helped them learn. Inte-
grating theory into practice is important for training nurses. The students described that the
pharmacy experience helped them recall and remember some of the drugs taught in the class-
room. They view that what they learned in class was reinforced in the pharmacy, or vice versa.
The quotes from students are shown below:
Much medication information is provided during the class lecture, but when I go to the
pharmacy, I see the drugs, read the information on the packaging, and sometimes dispense
them. That helps me a lot with what was taught in the class and sometimes much more.
(Student 4 from Group C).
"The combination of the class and the pharmacy volunteer allowed me to quickly grasp the
information on medications, such as the mechanism of action, the drug side effects, uses,
and even the pregnancy categories. I learned a lot." (Student 1 from Group I)
3. Student’s acquisition of skills from pharmacy service-learning
The majority of the students reported that they appreciated the volunteer experience because it
helped them practically learn the medications. The students reported learning several skills
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that are useful for medication safety and nursing practice as summarized on Table 2. They also
testified that they now understand part of their roles as members of the healthcare team. This
helped to strengthen their previous knowledge and make learning memorable, as reported in
the following quotes:
The volunteer was more like a practical component of the pharmaco class as it blended so well
with my learning methodology since I learned easily by seeing. (Student 5 from Group E)
Table 2. Student’s acquisition of skills from pharmacy service-learning at community/hospital pharmacies in Belize.
Sub-themes Comments Student’s quotes
Pharmacy environment
for learning drugs
Students appreciated pharmacy environment through cleaning
shelves that provided the opportunity for learning medications and
knowing how they are arranged.
We were asked to clean cabinets and shelves in the prescription area
of the pharmacy.While doing so,I had to remove the stacks of
medications and cleaned them one by one.We also had to look for
expiration dates of all the medications available in that section and
had to tag the ones that would expire within six months.I got to know
that the reason for doing this is for the pharmacist to dispense the
ones that expire sooner than those that had a longer shelf life.
Cleaning the shelves and arranging the medications was a special skill
that I learned during the volunteer.Apart from cleaning,we were
asked to help count medication tablets that the customers needed.
(Student 2 from group F)
Prescription
interpretation
Students reported being taught to read and interpret prescriptions
accurately so that the patient could be given the correct drug dosage.
During class sessions,we were taught the rights of medication
administration.I practically experienced that,as I learned to dispense
medications to a few patients during the volunteer.I first had to learn
to interpret the prescription correctly,find the medication,and come
back to dispense to the patient.Interpretation of the prescription was
a very important skill that I learned during volunteering. (Student 4
from the group G)
Calculating and
dispensing medications
During the volunteer service-learning experience, the students
reported that they had the opportunity to learn drug calculations and
dispense medications to the patients
I progressed from first learning to interpret prescriptions to
dispense medications, and finally to compounding medications
under the guidance of the pharmacist (Student 3 from Group H)
Taking drug inventory Part of the nursing process involves observation, planning,
implementation, and evaluation. Nurses are required to maintain a
proper inventory of medications and items they use in the ward for
their patients. Although the setting for the volunteer was pharmacy-
based, students reported learning to take an inventory of
medications.
In addition to checking expiration dates,I also learned to take
inventory of the drugs.I only performed this task when asked by the
pharmacist.(Student 6 from Group I)
Taking patients vital
signs
One fundamental responsibility of nursing care is the accurate
measurement of vital signs. Most pharmacy outlets in Belize measure
blood glucose levels and hypertension in patients. Many students
reported learning to measure blood glucose levels and blood pressure
during volunteer service.
The pharmacy where I volunteered test patients for diabetes and
checked their blood pressure.As soon as I got there,I was taught to
perform these measurements and it became part of my daily
routine. . . . I can now check blood glucose and BP accurately and
with confidence. (Student 1 from Group I)
Patient education The students reported that they could counsel the patients about
medication dosages, frequency of medication intake, and other
useful information about the medication. A few students reported
that they could discuss the etiology and pathophysiology of some
diseases with customers.
I learned to do patient counseling when I dispense medication to the
patient.I was told that even if the customer did not ask for
information on the medication,such as side effects,I should tell them,
so they are made aware. . . (Student 3 from Group B)
Communication skills in
healthcare
Students reported gaining new communication skills or improved
their communication skills as they interacted with the pharmacist
and customers.
. . .. . ..even though I am somehow shy,I made deliberate efforts to
improve my communication with the pharmacist and also with the
customers.I watched and listened when the pharmacist discussed
with the patient.Overall,the experience helped build my confidence
to listen and be more expressive. (Student 5 from Group A)
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4. Inter-professional relationship in healthcare
In addition to interacting with patients, nurses regularly interact with other healthcare professionals
in the line of duty. The students reported that the volunteer provided them with an opportunity to
interact with other healthcare professionals, especially pharmacists and pharmacy assistants.
This entire experience was an eye-opener from the start to the end.I felt like I grew as much as
a person,nurse,and patient educator.Even though I had previous experience in the hospital
setting,I think it is a good idea to get a little insight into other professions related to yours.I
noticed that we get to learn much more and understand things better when we are placed in
different environments,but somehow still related to our field. (Student 2 from Group C)
5. Challenges and suggestions to pharmacy service-learning
Most of the students reported that volunteer experience was a helpful experience, even though
several of them experienced a few challenges. The most common challenge reported by the
participants was anxiety due to lack of experience. Other students reported that they were not
sure how the preceptors would respond to them because they were nursing students. A few
mentioned challenges such as how to manage school work and volunteer service, and whether
they will be able to communicate effectively or learn the medications at the pharmacy. Some of
the quotes expressed students’ views:
First I was nervous.Then,I was also unfamiliar with all the drugs and their presentations.
Sometimes I felt a bit embarrassed about not being familiar with a certain drug,so I would go
in the pharmacy when am free and search for the drugs I was not familiar with in order for
me to familiarize myself with the various unfamiliar drugs.Eventually,the pharmacist was
really nice,made me comfortable,and took time to teach me the drugs.I ended up liking my
experiences. (Student 1 from group H)
The students also recommended that the experience should be ongoing.
My friend who took this course last year told me it was very challenging,so I enrolled with
some anxiety.However,with the pharmacy volunteer,and my interactions with the pharma-
cists and the teachers,I had a great experience.I will recommend this to be ongoing for future
students.It was a rewarding experience for me.(Student 1 from Group C).
Discussion
The second-year baccalaureate nursing students were assigned 48-hours voluntary commu-
nity/hospital pharmacy service-learning to help familiarize them with different medications
used in clinical practice. Deficiencies in nursing students’ pharmacological knowledge bases
have been previously reported [2830]. Iranian nursing students have reported the challenge
of effectively teaching pharmacology and medication management as the weakest performance
of nursing pharmacology instructors [31]. Although this study targeted pharmacy practice
sites in contrast to hospital clinical practice sites reported by most studies, the results of the
present study corroborated the studies that reported positive outcomes as a result of exposing
students’ nurses to practical clinical experiences [3234]. However, the results of this study are
in contrast to the research by Sharif and Masoumi [35], who reported that nursing students in
Iran were not satisfied with the clinical component of their training.
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Results from the students’ reflective journals and focus group interviews supported each
other and showed that the students learned the different classes of drugs, their indications,
adverse effects, pregnancy categories, and contraindications of the medications they encoun-
tered at the pharmacy, an indication of the effectiveness of the teaching approach. Recent
reviews enumerated learning strategies for training nurses to include simulation, technology,
collaborative learning, peer learning, and research-based strategies [2,36,37]. The success of
the teaching strategy employed in this study may have been a result of motivation and interest
stimulated by the lecturers and the desire for students to explore new learning methods. Partic-
ipation in extracurricular activities, students’ interests, and motivation have been reported as
student-related factors that could play essential roles in undergraduate nursing students’ aca-
demic engagement [38]. The findings of this study further support the need for nursing phar-
macology instructors to explore unconventional strategies such as pharmacy service-learning
in engaging students with activities that will facilitate the learning of medications.
In addition to learning medications, most nursing students reported that they learned a few
skills that are useful to medication safety and the overall nursing profession (Table 2). This
study corroborated some reports in which students learned skills during clinical posting
[39,40]. For instance, healthcare workers’ communication is an essential tool that fosters inter-
actions and satisfaction between healthcare personnel and patients. In nursing, communica-
tion is a crucial tool for the interaction between the healthcare team, patients, and all aspects of
nursing management [41,42]. Therefore, learning practical communication skills is relevant to
nursing students because ineffective communication can lead to errors in diagnoses, anxiety,
lack of patient satisfaction, and poor treatment outcomes. Ineffective communication among
healthcare teams has been reported as a common cause of medical errors [42,43]. Training
that will improve communication among nursing students is therefore significant in reducing
therapeutic errors [43].
The opportunity to learn to interpret prescriptions and dispense medications was another
notable finding of this study. Accurate interpretation of prescriptions, dispensing medications,
and administering medications are vital roles of nurses that ensure their patients’ safety.
Therefore, proper medication safety is critical in preventing medication errors, and nursing
students must have mastery of this skill for better therapeutic outcomes [44]. In Indonesia, stu-
dents reported a lack of knowledge, skills, supervision, and good role models as significant
causes of medication errors [44]. Therefore, this study indicated that nursing students had the
opportunity to gain skills in prescription interpretation and dispensing, which play vital roles
in medication safety.
Another notable skill reported by the students was their ability to learn the basics of patient
education. One key role of nurses is patient education. This dynamic skill starts from admis-
sion and continues throughout therapy until the patient is discharged. Effective patient educa-
tion helps reduce the incidence of complications, improve patient quality of life and
satisfaction, increase patient participation in healthcare activities, and reinforce positive
patient behaviors while reducing admission rate and cost [39,45]. Poor quality of education
and communication skills have been attributed to unsatisfactory patient education, leading to
patients’ perception that good counseling or information was not provided [39,46]. A recent
study in Iran reported barriers to patient education, including lack of self-confidence, lack of
willingness and motivation, and insufficient academic knowledge expression in a simple way
for the patient to understand [47]. Although this study was not conducted in a clinical setting,
nursing students’ opportunities to interact with patients and provide primary patient educa-
tion were considered a crucial input to their learning. Confidence in nursing students will sup-
port classroom learning and a foundation for future interaction with their patients, making
the initiative a beneficial experience.
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Learning to work with preceptor pharmacists as members of the healthcare team was
reported by most nursing students in this study. In previous studies, student nurses reported
learning from registered nurses and other professionals during ward round discussions or
observations [37,48,49]. Wang et al. [50] assessed nurse-pharmacy collaboration in Wuhan,
China, and reported positive attitudes toward nurse-pharmacist collaboration. With emerging
global health problems such as COVID-19 and related diseases, health professionals need to
work as teams to tackle global crises effectively. Teamwork among health professionals can be
achieved by a clear definition of responsibilities and roles, respect and trust, effective open
communication lines, and the establishment of common goals [51,52]. Moreover, when
healthcare professionals work as a team, there is an improvement in the implementation of
responsibilities and competencies, integration of values, accountability, and synergies [52].
Personal attributes, willingness, and professionalism were some of the characteristics reported
by clinical supervisors that were important for students’ preparedness for clinical learning
[53]. The report by nursing students on learning to work as members of the healthcare team is
consequently significant. Belize as a country is multicultural and multi-ethnic; as such, nursing
students’ opportunity to work with diverse healthcare professionals at the pharmacy practice
sites was an advantage to the students since it was introduced early in their training.
Finally, even though most students reported positive responses to the service-learning expe-
riences, a few students reported challenges they faced either before or during the experience.
Anxiety is the most reported challenge among students. Nursing students’ challenges during
clinical practice have been reported in several studies [34,54,55]. In a recent review, Panda
et al. [55] reported that the attitudes of instructors, clinical staff, and significant others have
substantial influences on students’ learning during clinical postings. The perceived fear of
making errors, lack of self-motivation, and a lack of a sense of belonging, theory and practice
inconsistencies, and workload were some of the daunting aspects among nursing students dur-
ing clinical practice [55]. The challenges reported in this study were sufficiently overcome by
the students to achieve the objectives of the volunteer service. The students were highly moti-
vated to learn hence, the challenges did not become daunting. In addition, the lecturers and
preceptors provided support and commitment to the students to assuage their fears and anxi-
eties. Overall, the volunteer experience provided opportunities for second-year baccalaureate
nursing students to integrate theory with practice, learn skills, and work as part of the health-
care team.
Therefore, the present study’s findings are significant because they suggested that combin-
ing classroom instructions with pharmacy experiential learning effectively complements teach-
ing nursing pharmacology. The service-learning provided the students the opportunity to
learn pharmacologic knowledge through direct interactions with medications, pharmacists,
and lecturers and to apply introspection to reflect on the pharmacologic learning experience,
thereby bridging the gap between conventional classroom instruction with experiential ser-
vice-learning [21]. Because pharmacology is a challenging subject for many nursing students,
applying Kolb’s [21] experiential theory of learning in this study positively facilitated learning
through service-learning and reflective journals. Based on Kolb’s [21] experiential learning
theory, the results of this study indicated that nursing students passed through a concrete
learning experience, reflective observation, abstract conceptualization, and active experimen-
tation to learn pharmacologic knowledge during the pharmacy volunteer service. The avail-
ability and accessibility of training facilities, inadequate training for preceptors, students’
perceptions and preparedness, and finances could be barriers to implementing this teaching
strategy. Effective planning and training could help implement innovative teaching methods
reported in this study.
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Conclusions
This study highlights the importance of experiential learning of pharmacology amongst second
year nursing students, offering the opportunity to inform and support pharmacotherapeutics
educators in designing strategies for more effective teaching of medications to nursing stu-
dents. It also supports the addition of pharmacy placements to the nursing curriculum’ as it
shows that nursing students can learn medications, skills, and teamwork from experiential
pharmacy site posting. Combining classroom instruction with pharmacy experiential service-
learning might be an effective complement for teaching nursing pharmacology.
Limitations
The present study has some limitations, and the results should be interpreted with caution.
Although two qualitative data collection approaches were utilized, the results were still self-
reported, and the possibility of recall bias may not be ruled out. The study did not compare dif-
ferent teaching strategies to assess the best approach for a unique learning environment. The
qualitative data generated were extensive due to the large number of students in the study, and
not all analysed data were presented. Furthermore, caution needs to be exercised in utilizing
this teaching approach to not confuse the students in their training to become professional
nurses, primarily as this study was only conducted in one institution and only in the country
of Belize. The study needs to be replicated in different settings using a larger sample size to
ensure generalizability. Finally, although the students reported positive experiences, possible
bias could have been introduced during the interviews as the students may be tempted to
report what the instructors want to hear. Despite these limitations, this study is unique. The
methodological approaches and the fact that this study has not been conducted in Belize, the
Caribbean, and the entire Central America, make the study unique. It provides baseline data
for the design and further exploration of this teaching strategy, overall, giving the study valu-
able and encouraging strengths.
Supporting information
S1 File. Tool focus group interview guide.
(DOCX)
Acknowledgments
The authors acknowledge the administrative support of the Dean Faculty of Health Sciences
Dr. Lisa Johnson and the Chair nursing department, Ms. Isidora Espadas. The authors are
grateful to the second-year nursing students (academic year 2019–2) for willingly participating
in the study and the pharmacy preceptors for partnering with faculty to give students a reward-
ing learning experience.
Author Contributions
Conceptualization: Danladi Chiroma Husaini, David D. Mphuthi, Jane A. Chiroma, Yusuf
Abubakar, Adeniyi O. Adeleye.
Data curation: Danladi Chiroma Husaini, Yusuf Abubakar.
Formal analysis: David D. Mphuthi, Jane A. Chiroma, Yusuf Abubakar, Adeniyi O. Adeleye.
Investigation: Danladi Chiroma Husaini, Yusuf Abubakar.
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Methodology: Danladi Chiroma Husaini, David D. Mphuthi, Jane A. Chiroma, Yusuf Abuba-
kar, Adeniyi O. Adeleye.
Project administration: Danladi Chiroma Husaini, David D. Mphuthi, Jane A. Chiroma.
Supervision: Danladi Chiroma Husaini, David D. Mphuthi, Jane A. Chiroma.
Validation: Danladi Chiroma Husaini, Jane A. Chiroma, Adeniyi O. Adeleye.
Writing original draft: Danladi Chiroma Husaini.
Writing review & editing: Danladi Chiroma Husaini, David D. Mphuthi, Jane A. Chiroma,
Yusuf Abubakar, Adeniyi O. Adeleye.
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Article
Full-text available
Objectives This systematic review aimed to offer insight and understanding, through synthesis of findings from studies that report on perspectives of student nurses/midwives, clinical instructors, clinical nurses/midwives on the challenges faced by student nurses/midwives in the clinical learning environment (CLE). Design All primary qualitative research studies published in the English language that reported on the views of student nurses/midwives, clinical instructors and clinical nurses/midwives on the challenges faced by student nurses/midwives in the CLE were included. Data sources The electronic databases of Medline EBSCO (1946-), CINAHL (1970), Embase Ovid (1974-), ScielO, WHOLIS (2002-), ASSIA (1985-), Web of Science (1956-), PsycINFO (1800s-) and Maternal and Infant Care (1970-) were searched in November 2019. Review methods Retrieved papers were reviewed independently by two authors for selection by title, abstract and full text, and two authors agreed for inclusion of the papers. The COREQ criteria checklist was used for assessment of methodological quality of the included studies. Results The review included 32 studies published over 22 years between 1997 and 2019 involving 853 nursing/midwifery students, clinical instructors, and clinical nurses/midwives from 14 countries. Three key themes emerged: ‘The support structure’, ‘Personal factors’, and ‘Planning and organisation – influence of extrinsic factors’. Conclusion Three key themes emerged: ‘The support structure’, ‘Personal factors’, and ‘Planning and organisation – influence of extrinsic factors’. Attitude of clinical staff, instructors, and significant others had a major influence on students' clinical learning. Lack of a sense of belongingness and self-motivation to learn, and perceived fear of doing errors were some of the demotivating factors. Lack of resources to facilitate need-based training, staff shortages, workload and inconsistencies between theory and practice were other key challenges in the CLE. Understanding the challenges faced by students in clinical practice can help overcome the barriers leading to development of competent and confident nurses and midwives.
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