Discussion
After integrating an aging simulation game into a pharmacy practice laboratory, first professional year pharmacy students reported significant improvement in their empathy and attitude toward older adults and perceptions of older adults' experiences in the health care system. Researchers have found similar success among other health care professionals when incorporating aging simulation games into curricula.
Pharmacy students had fairly high levels of empathy toward older adults before the simulation, but even these levels improved significantly, as evidenced by scores on the KCES and the JSE-HPS. All individual items on the KCES either significantly improved or were maintained after the simulation. Since there is no published research evaluating empathy in pharmacy students using the KCES, the comparability of empathy scores to other research is not possible. However, the scale does correspond to the JSE-HPS, and similar empathy scores have been documented by Fjortoft and colleagues using the JSE-HPS to examine overall patient empathy in first-year pharmacy students (110.7(12.1)). Many students in our study indicated that they had a close relationship with an older adult, which may explain why they had high empathy levels before the intervention. However, simulation experiences may be able to assist students in reinforcing and improving their empathy, as previously seen among nursing students and as was demonstrated in our study.
The aging simulation game was incorporated into the first professional year to modify or reinforce students' empathy, attitudes, and perceptions prior to or at the beginning of clinical experiences and appeared to successfully do so. Once students engage in clinical practice, negative attitudes from other health care providers could be adopted, or students may create their own misperceptions of patient attitudes. For example, a patient who visits the pharmacy at the end of the long day of laboratories and doctor appointments may seem "cranky." Students in health professions schools are typically younger and may not have experienced the health care system as much as their patients, so they may misunderstand a patient's perspective or interpret a patient's attitude incorrectly and, over time, assign those attitudinal characteristics to all similar patients (ie, stereotype). The literature yields similar findings, as researchers report students further in their professional program have less empathy for patients. Thus, the timing of curricular interventions may be crucial in the development of empathy, attitudes, and perceptions. Adopting early experiences, such as the GMG, can be useful to positively impact students. Indeed, students in the GMG experienced patient emotions, such as frustration and impatience after a long "day" of health care visits.
The GMG provided an opportunity for students to experience a "health care system," such as visiting multiple providers, waiting in line, paying for services, and remembering complicated medication directions. Students' understanding of the experiences of patients improved significantly or remained the same on 11 of 13 items, which may ultimately help students provide better care and gain more empathy for patients. The only 2 items that declined were negatively-worded and indicated improvement of student understanding. Past research shows that aging simulation games improve student understanding of the experience of older adults in the health care system. The ASES, designed from years of qualitative data and experiences with the GMG, can be a useful tool to assess the impact of this curricular integration.
Given the final scores regarding student empathy, attitudes, and perceptions, there is still room for improvement. While incorporation of a single activity has immediate impact and potentially has long-term impact, curricular items should be incorporated to reinforce these concepts and prevent students from losing empathy for patients as they engage in IPPEs and advanced pharmacy practice experiences (APPEs). For example, preceptors can incorporate experiences related to patient populations being studied at that time in the didactic curriculum. Practice experiences also could be directed at improving student empathy, attitudes, and perceptions. These aspects should be assessed longitudinally to determine what is impactful and how empathy, attitudes, and perceptions change over time.
Incorporation of the age simulation game, while in a fairly large class size (N=156), has limited generalizability as it was only incorporated and assessed at a single university with a single student cohort. These results should be validated at other universities with multiple cohorts. It also was a single curricular integration targeted at students' understanding of older adults with assessments before and after the simulation; therefore, evaluations of students' empathy, attitudes, and perceptions may not reflect long-term changes and may not be maintained when engaging in patient care. Additional coursework, activities, and experiences should be integrated and assessed. The goal of incorporating the GMG into the curriculum was to improve empathy toward older adults prior to the majority of clinical experiences, so that positive attitudes and understanding could be reinforced in IPPEs and APPEs. While the assessments in this study could not assess long-term impact, Galanos and Cohen did find that an aging simulation game had a long-term impact on medical students.
The ASES underwent peer and expert review prior to administration, but it is not a validated instrument. Thus, it may not accurately measure student understanding and perceptions. The ASES should undergo psychometric validation in order to determine its utility with the GMG. As these were self-report measures, there is a risk of social desirability bias. This potential impact was minimized as much as possible with the anonymous survey. However, these results also may not reflect reality, as students may have believed they were empathetic but may not have displayed empathetic behavior in patient care. Results from this study are consistent with other research, but future studies should validate our results using other methods of measuring empathy, such as patient perceptions or faculty evaluations.