In recent decades, studies have demonstrated that pharmacists have an important role to play in medication therapy management, whereby they can greatly enhance overall patient health outcomes (Buurma et al., 2004; Dyck et al., 2005; Vinks et al., 2006; Lyra Jr. et al., 2007; Balisa-Rocha et al., 2012). In response to these needs, pharmacy profession experienced a fundamental change in its philosophy of practice. The change in orientation is synthesized by the term “pharmaceutical care”, defined by Hepler and Strand (1990) as “the responsible provision of drug therapy for the purpose of achieving defined outcomes that improve a patient's quality of life”. Pharmaceutical care entails more clinical pharmacy practice, wherein pharmacists focus less on the distribution of drugs and more on patient care (Schneider and Sill, 1995; Li, 2003).

To move in the direction of a more patient-focused practice, pharmacists must first possess competencies that include extensive pharmacotherapy knowledge, written and verbal communication skills, greater problem-solving capabilities, decision-making skills, motivation, and the self-confidence necessary to provide pharmaceutical care (Fisher, 1994; Culbertson, 2008). Furthermore, pharmacists must possess clinical knowledge of medication and disease states so as effectively monitor a patient’s drug therapy, and to develop relationships with patients that can facilitate discussions about drug-related problems, disease, and other relevant information (Schneider and Sill, 1995; Kassam, 2006a). In response to these changes in the pharmacy profession, a reorientation in pharmaceutical education became necessary for faculties and in postgraduate learning (Kassam, 2006a).

In pharmaceutical care, education is important for students to practice and develop proficiency in the skills, knowledge, and attitudes relevant to achieving the desired performance (Zaremski et al., 2005; Kassam, 2006a; Kassam et al., 2008). Consequently, educational strategies are being developed and rigorously evaluated to facilitate the learning outcomes needed to practice pharmaceutical care (Fisher, 1994; Popa et al., 2002; Sefton, 2004). In this perspective, new teaching methods and/or learning strategies have been incorporated into pharmacy curricula, mainly with the aim of changing the current model of learning/teaching. These methods require a learner-focused approach, that is, an approach that seeks to value the student as an active subject in the teaching process, who is co-responsible for the construction of knowledge in different learning scenario (Venturelli, 2003; Silva and Delizoicov, 2008). Problem-based learning, role-play, the use of clinical cases, and simulated patients are examples of these methods.

In this sense, the purpose of this systematic review was to describe the type of methodologies used in the teaching of pharmaceutical care.

The present review was written in accordance with some of the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration of methodology (Moher et al., 2009).

Eligibility criteria

Studies that addressed teaching methods used in pharmaceutical care or medication therapy management course were considered eligible. The outcomes of interest were the types of methodology used and the outcomes achieved.

Information sources

The databases EMBASE, Education Resources Information Center (ERIC), LILACS, PubMed and SCOPUS, were reviewed for original articles published until January 2015. The descriptors used were “pharmaceutical services”, “pharmaceutical care”, “medication therapy management”, “learning”, “education”, and “teaching” in different combinations.

Search strategy

A preliminary search was conducted, wherein the descriptors in the titles or abstracts of papers found were examined. However, a preliminary reading of random abstracts identified many studies that were not related to the theme, which justified a restriction in search terms. Thus, articles were selected in which the descriptors "learning", "education" and "teaching" occurred in the title of the article and the other descriptors in either the title and/or abstract, which increased the likelihood of the articles being relevant. The following is an example of the strategy that was used to search a PubMed databases: (learning[ti] or education[ti] or teaching[ti]) and ("pharmaceutical care"[tiab] or “pharmaceutical services”[tiab] or “medication therapy management”[tiab]). In addition, a manual search of relevant references in all included studies was performed.

Study selection and data collection process

Two reviewers independently have made a manual sorting through titles, abstracts, and full text and selected the articles for inclusion in this review. The degree of concordance between the two reviewers was evaluated using the kappa statistic (k). The kappa-measured agreement was based on the specifications of the specialized literature: k < 0.10, no agreement; k < 0.40, weak agreement; k = 0.40 to 0.75, good agreement; and k > 0.75, excellent agreement (Hosmer and Lameshow, 1989). At the end, the disagreements were resolved by consensus.

Articles repeatedly indexed in two or more databases were taken into consideration only once. Reviews, meta-analyses, and editorials were excluded. Those that were not written in English, Spanish, or Portuguese were also excluded. If the abstract or the full text were not available, attempts to contact the authors to obtain the full text were made.

Data items

The articles satisfying the inclusion criteria for data extraction were carefully examined regarding the following variables: study location (setting/country); formation degree; sample size (number of students or pharmacists); school year; educational intervention; method used for participant assessment in course; and outcomes variable. Furthermore, articles conceptualized pharmaceutical care was analyzed; the responsibilities of pharmacist in the patient care process and limitations or biases of the study were described.

Figure 1 illustrates the progressive selection and the number of articles in each stage. The initial screening using the keywords identified 562 titles, 14 of them indexed in the same database and 250 of them indexed simultaneously in two or more databases. Twenty four articles were published in another language and 21 consisted of systematic reviews. 183 citations were excluded on the basis of the title because they did not focus on the teaching of pharmaceutical care. Screening of the abstracts of the articles reduced the number of studies to 44. The full-text versions of the remaining articles were obtained and carefully reviewed. Twenty-eight articles were dropped from the screening process, because the full text was unavailable or the study was not related to the work of teaching or education.

An analysis of the references of the 16 selected articles was performed and 5  studies  were  search  in  reference list, totaling at the end of the selection process 21 publications included in the systematic review (Kocla-Kimble and Batz, 1994; Wislande, 1994; Lee et al., 1998; Reutzel et al., 1999; Chambers et al., 2000; James et al., 2001; Ramam-Wilms, 2001; Bertolo et al., 2003; Lam, 2005; Kassam, 2006a, b; Ross et al., 2007; Culbertson, 2008; Kassam et al., 2008; Zolezzi and Blake, 2008; Benedict, 2010; Chiang et al., 2010; Strohfeldt and Grant, 2010; Cone et al., 2013; Limberger, 2013; Galal et al., 2014). The concordance between the two review authors was considered excellent (k = 0.9987, k = 0.9851, and k = 0.9893, respectively) in 3 steps of the selection process of articles.

In this review, most of the studies (n = 15, 71.4%) were conducted in North America (Kocla-Kimble and Batz, 1994; Wislande, 1994; Lee et al., 1998; Reutzel et al., 1999; Chambers et al., 2000; Ramam-Wilms, 2001; Lam, 2005; Kassam, 2006a, b; Ross et al., 2007; Culbertson, 2008; Kassam et al., 2008; Benedict, 2010; Cone et al., 2013; Galal et al., 2014). Only one study  was  conducted in Brazil (Limberger, 2013). All selected studies were published after 1990. Only one study was written in Spanish and only one in Portuguese, the others were in English.

Most of the studies were directed for undergraduate students of pharmacy (n =14, 66.7%) (Fisher, 1994; Wislande, 1994; Schneider and Sill, 1995; Culbertson, 2008; Chambers et al., 2000; Ramam-Wilms, 2001; Lam, 2005; Kassam, 2006a, b; Ross et al., 2007; Kassam et al., 2008; Martínez-Sánchez, 2009; Benedict, 2010), while only 19.0% were courses of continuing education to pharmacists (n = 4) (Kocla-Kimble and Batz, 1994; Lee et al., 1998; Reutzel et al., 1999; Chiang et al., 2010) and the others (n = 3, 14.3%) were education programs for postgraduate pharmacists (Lam, 2005; Zolezzi and Blake, 2008; Strohfeldt and Grant, 2010). Educational interventions were used in the pharmaceutical care courses from the first until fourth year of an undergraduate pharmacy degree program. Sample size in the analyzed papers varied from 15 to 574 students or pharmacists.

In the present study, only two studies discussed the pharmaceutical care concept (James et al., 2001; Kassam et al., 2008). Fourteen studies (66.7%) reported several responsibilities of the pharmacist in the process of patient care. Among them, the most frequently cited were: determination of patient's drug-related needs (indication, effectiveness, safety, adherence) and identifying drug therapy problems, in ten articles (Wislande, 1994; Reutzel et al., 1999; Chambers et al., 2000; Ramam-Wilms, 2001; Bertolo et al., 2003; Kassam, 2006a, b; Culbertson, 2008; Limberger, 2013; Galal et al., 2014), followed by obtaining of patient data as the reason for the encounter, demographics, medication experience, and other clinical information (Wislande, 1994; Galal et al., 2014) and development of  care plans (James et al., 2001; Cone et al., 2013).

Table 1 presents the educational interventions, methods of assessment and outcomes measured by the 21 selected studies. Regarding the teaching methods or learning strategies used in analyzed studies, simulation was the most used, in eight studies (30.0%) (Kocla-Kimble and Batz, 1994; Lee et al., 1998; Reutzel et al., 1999; Chambers et al., 2000; James et al., 2001; Benedict, 2010; Cone et al., 2013; Galal et al., 2014), followed by the use of problem-based learning (Wislande, 1994; Ramam-Wilms, 2001; Ross et al., 2007; Culbertson, 2008; Benedict, 2010; Strohfeldt and Grant, 2010) and case study (Ramam-Wilms, 2001; Lam, 2005; Culbertson, 2008; Zolezzi and Blake, 2008; Chiang et al., 2010; Limberger, 2013) in six articles each (28.5%).

The evaluation methods most utilized to assess the students or pharmacists were evaluation of performance in the course or practical assessment, in eight studies (Lee et al., 1998; Reutzel et al., 1999; Chambers et al., 2000; Kassam, 2006b; Ross et al., 2007; Culbertson, 2008; Cone et al., 2013; Limberger, 2013). Other methods worth mentioning were written examinations (Wislande, 1994; Lee et al., 1998; Reutzel et al., 1999; Ross et al., 2007) and questionnaires (James et al., 2001; Kassam et al., 2008; Chiang et al., 2010; Galal et al., 2014) in four studies each.

Regarding the outcomes of studies, this study was divided in evaluation of participant knowledge, participant performance and participant satisfaction with the course. Eleven studies showed outcomes in the knowledge (52.4%) (Kocla-Kimble and Batz, 1994; Wislande, 1994; Reutzel et al., 1999; Ramam-Wilms, 2001; Bertolo et al., 2003; Zolezzi and Blake, 2008; Benedict, 2010; Chiang et al., 2010; Strohfeldt and Grant, 2010; Limberger, 2013; Galal et al., 2014), and all these studies demonstrated positive outcomes in the improvement of knowledge of the participants.

Performance assessment of participants was conducted in 16 articles (76.2%) (Kocla-Kimble and Batz, 1994; Lee et al., 1998; Reutzel et al., 1999; Chambers et al., 2000; James et al., 2001; Bertolo et al., 2003; Lam, 2005; Kassam, 2006a; Ross et al., 2007; Culbertson, 2008; Kassam et al., 2008; Zolezzi and Blake, 2008; Chiang et al., 2010; Cone et al., 2013; Limberger, 2013; Galal et al., 2014). In these studies, only 1 presented negative outcomes in the performance of the participants (Kassam, 2006a), and 1 was neutral; in other words, student performance did not decline, but outcomes did not improve (Ross et al., 2007). The others showed positive outcomes.

Ten studies also reported the outcomes in terms of participant satisfaction with the course (Wislande, 1994; Chambers et al., 2000; Reutzel et al., 1999; Ramam-Wilms, 2001; Kassam, 2006b; Ross et al., 2007; Zolezzi and Blake, 2008; Benedict, 2010; Strohfeldt and Grant, 2010; Cone et al., 2013). Most studies reported that educational interventions had been well received by students. Details of achieved outcomes are as shown in Table 2.

Finally, it is also worth highlighting that 9 articles reported the limitations of the completed study (Wislande, 1994; Lee et al., 1998; Ramam-Wilms, 2001; Kassam, 2006a, b; Kassam et al., 2008; Zolezzi and Blake, 2008; Chiang et al., 2010; Galal et al., 2014).

Loss of function, social power, and status in pharmacy profession has resulted in a gradual shift in focus away from the technical roles of pure procurement, supply, and distribution of medications, toward disease and patient-oriented approaches to pharmaceutical decision-making and more clinically oriented roles (Edmunds and Calnan, 2001; Bissell and Morgall-Traulsen, 2005). In the broadest sense, in response to these professional needs (Breimer, 2001; Shah et al., 2010), pharmaceutical education  in  developed  countries,  such  as  the  United Kingdom, the United States, Australia, Canada, and New Zealand, has evolved over time. Pharmacy education has undergone major change over the past decade with the approval of new standards and guidelines designed to assist pharmacy education institutions develop and maintain academically strong, effective programs that are responsive to changing health care needs.

The National Guidelines for Undergraduate Education in Pharmacy (2002) was published in Brazil which have been included as key aspects in pharmacy education as: evaluation of knowledge/skills application to patient care; fostering of critical thinking/problem-solving skills; skills mastery, communication ability,  among others (CNE, 2002). Thus, the focus of pharmaceutical education has shifted from the basic sciences to include clinical and health sciences, including pharmaceutical care (Hassali et al., 2011; Babar et al., 2013).

In this review, all studies were published after 1990, which is consistent with the period of extensive discussion about the definition of the mission, role, and functions of the pharmacist in pharmaceutical care (Hepler and Strand, 1990; Hepler and Graiger-Rousseaux, 1995; Faus-Dáder and Martínez Martínez, 1999; Cipolle et al., 2000). Most of these studies were performed in the United States, thereby reflecting the historical process of the development of American Pharmacy; since it was there that the concept of the practice of pharmaceutical care was elaborated and systematized.

A bibliometric review of pharmaceutical education literature, performed by Babar et al. (2013) showed few studies from low- to middle-income countries. As a result, members of the International Pharmaceutical Federation (FIP) Pharmacy Education Taskforce, whose objective is to develop pharmaceutical education globally, recently affirmed that a strategy should be used that involves determining local needs, identifying the services required to meet those needs, and articulating the competencies to be achieved by all practitioners for the development of a comprehensive education (Anderson et al., 2008, 2009a, b; Whitmarsh et al., 2010).

Most of these studies did not define the concept of pharmaceutical care. The literature suggests that there is a need to conceptually define the practice in order to distinguish the clinical services offered by pharmacists. According to Hepler and Strand (1990), pharmaceutical care is based specifically on the ability of the pharmacist to assume new responsibilities related to patient care. The three major steps in the patient care process are the assessment of the patient, his/her medical problems, and any drug therapy problems that have occurred; development of a care plan; and conducting a follow-up evaluation (Cipolle et al., 2004).

Most of these studies in this review used learner-centered method as educational intervention. According to learning theories, the active methods fall into in cognitive or humanistic theories. These are, therefore, methods that value individual differences and allows for a more effective assessment of the actions of the student. In addition, it value the education contextualized, that is, teaching in a close in which knowledge is used, increasing the understanding, retention and learning in adults (Piaget, 1976). In recent years, several active learning methodologies have been based on constructivist and humanist theory and incorporated in health education in order to bridge the gap between theory and real patient experience (Tagawa and Imanaka, 2010; Shrivastava et al., 2013).

The learning strategy most used by reviewed studies was simulations. Most simulation approaches described in the literature involved interaction between the pharmacist (student) and a patient (peer, instructor, standardized patient, actor or virtual patient) for the purpose of acquiring knowledge or developing a particular skill  (Parkhurst,  1994;  Ellington et al.,  2002).  In pharmacy, the role-play technique has been used primarily as a means of helping students develop skills in communication, consultation, and medication history-taking (Ellington et al., 2002; Shah et al., 2004; Rao, 2011).

Other finding was the limited number of studies using virtual patients in teaching pharmaceutical care. Several studies demonstrated the effectiveness of methods using simulations with virtual patients in the promotion of necessary competencies for pharmaceutical care (Fuhrman et al., 2001; Hussein and Kawahara, 2006; Orr, 2007). Furthermore, a systematic review published in 2012 pointed out that the use of virtual patients has the potential to be an innovative and effective educational tool in pharmaceutical education, particularly for optimizing the teaching of pharmaceutical care (Jabbur-Lopes et al., 2012).

Problem based learning (PBL) also was widely used. PBL is a well-known instructional method that has gained popularity in health professional education during the past few decades (Culbertson et al., 1997; Catney and Currie, 1999). In pharmacy, a literature review realized by Cisneros et al. (2002) revealed that there were a substantial number of articles that discussed the implementation of PBL methods in the pharmacy curriculum. Self-directed learning is the central element of the PBL approach, in which small groups of five or six students work together with the support of a facilitator (Wood, 2003). Compared to traditional methods, such as lectures and discussion, PBL is an instructional method that permits a higher degree of inquiry, greater learner control, and active participation (Catney and Currie, 1999).

Evensen and Hmelo (2000) suggested that PBL students might be better problem-solvers and more able to integrate basic science into clinical problems. In this sense, Catney and Currie (1999) concluded that adopting PBL in a pharmaceutical care course would provide an appropriate context for students to begin to develop the skills needed to actively evaluate patient data, identify drug therapy problems, and apply a consistent strategy for clinical problem-solving and care planning. Despite the advantages mentioned earlier, there are also disadvantages connected to PBL as a need of curriculum reform in pharmacy coursework, high costs and staff workload (Strohfeldt and Grant, 2010).

Despite the specific advantages of each teaching method or learning strategy, and in view of the complexity of pharmaceutical care practice, the ideal would be to utilize a range of different teaching methods. According to Gil (2008), the teacher should make sure that the chosen teaching method is the most appropriate to the learning goals and for this a sequence of methods can be used. For example, simulation strategies can be used before the student goes into the real environment of practice, with actual patients. In addition, using different teaching methods has the advantage of  accommodating  students with different learning styles. Catholico (2009) affirms that students’ learning style, the characteristics and preferences of individual learners in the ways they receive or process information, may help explain, for example, why some teaching methods are more or less effective for certain groups of students.

It is important that the assessment methods should be consistent with the teaching method and with learning objectives. Assessment plays a key role in the learner-centered teaching approach and must be focused on desired learning outcomes (Harpe and Phipps, 2008). Since the objective in teaching pharmaceutical care is not only memorization of knowledge but also development of skills and attitudes, instructors can provide students with multiple methods of assessment and increase the number of opportunities to demonstrate application of course material. Walczyk and Ramsey (2003) argue that, although traditional testing such as written examinations and questionnaires (which were often used in studies of this review) may form a component of assessment in learner-centered courses, assessments should also include opportunities that represent how course content will actually be used in practice.

Regarding the participants' knowledge, all the studies that reported this issue showed positive outcomes with the educational intervention. Similar results are found in literature which found that students perceived the merits of using active learning as improved application of knowledge and critical thinking (Van Amburgh et al., 2007). An important responsibility in educating student pharmacists via active learning methodologies is instilling in them a commitment to lifelong learning so that as pharmacists they will be able to maintain and expand their knowledge and skills to better serve patients, the profession, and society as a whole (Barclay et al., 2011).

Finally, for the performance and satisfaction of participants, most studies presented increased of confidence and motivation levels of the students in the patient counseling; better communication skills, empathy, attitudes in the patient care, and satisfaction with course. According to Branch (2014), the students’ found in the educational intervention a good way in increasing their confidence and prepare them for future practice. It is advisable that pharmacists have appropriate communication skills in order to better serve their patients (Hasan, 2008). Some studies evaluating health professional skills demonstrated that pharmacists have significantly increased their knowledge and skills after receiving educational interventions, as corroborated by this study (Kim et al., 2009; Basheti et al., 2009).

This paper sets out to systematically review published literature in peer-reviewed journals of education in pharmaceutical  care.  Many  different  teaching  methods were described in this study, notably simulation, PBL and case study. Most studies showed positive outcomes with the educational intervention.

LIMITATIONS

The present study is not without limitations. First, although the search strategy used in this study was helpful in gathering information relevant to our subject, there are some limitations and bias inherent in using databases for primary source collection. Such limitations include difficulty in establishing the correlation between the descriptors and the reliability of search results, particularly regarding the specificity, selectivity, and sensitivity of the descriptors to retrieve references that are relevant to the subject. To circumvent this problem, the databases instituted the use of a standardized vocabulary of keywords in order to standardize and facilitate the search for references in the database. The problem is that the term "pharmaceutical care," is not contained as a descriptor in the vocabulary of these databases, at least according to the definition proposed by Hepler and Strand (1990). This, coupled with the misinterpretation of the meaning of the term or variations in how it is translated, tends to reduce the effectiveness of reference recovery. This problem had been detected in the work of Machuca et al. (2003) and Silva (2009), who chose to combine descriptors such as "pharmaceutical care" and "drug related problem." In addition, the use of others relevant keywords, such as ‘‘pharmacy practice" or “course” may have yielded a larger sample.

Secondly, due to lack of access in our country, the researchers did not search the International Pharmaceutical Abstracts (IPA) database, which indexes pharmacy-specific journals that are not included in any other database. Hence, some studies that would have met inclusion criteria could have been left out of the review. Furthermore, since this review used only keywords in English, important publications in other languages may have been omitted. Finally, during the analysis of the articles, it was not possible to estimate the risk of bias in each study, as advocated by PRISMA.

PRACTICE IMPLICATIONS

Through this review, a series of themes have emerged to address gaps in the current knowledge. First, practical research should be conducted into different programs at different pharmacy schools and universities, in several countries, in an effort to more fully understand the processes involved in planning and implementing new teaching methods, as well as the variables that contribute to successes and challenges in those processes. Furthermore, this additional research should use a combination of both quantitative and qualitative research methodologies   to  more  fully  understand  the  effects of teaching methods on students.

Second, there is a need for more long term and even longitudinal assessments of the outcomes of pharmaceutical care courses. Often, research is conducted for a length of time that is determined by the experimenter’s time and resources, not necessarily the amount of time necessary to provide a thorough investigation into the effects of teaching methods on student learning (Faus-Dáder and Martínez-Martínez, 2009). Thus, studies of continuing education should follow the pharmacist into the profession to fully understand the effects of courses on actual practice.

In response to these gaps, active learning methods will be the basis for implementing a pharmaceutical care course at the College of Pharmacy of the Federal University of Sergipe in Brazil. It is anticipate that the use of active methods as an educational tool will not only facilitate the development of competencies and skills of pharmacy students in pharmaceutical care but will also facilitate the transfer of these skills to the practice setting.

This study was supported by Fundação de Apoio à Pesquisa e à Inovação Tecnológica of Sergipe State (Foundation for the Support of Research and Innovation) and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Coordinating Agency for the Professional Development of Tertiary Qualified Personnel).

Authors have none to declare.