Analysis of Competency After Hospital Pharmacy

Clerkship Modification During The COVID-19 Pandemic

Nurul Maziyyah1,*, Sri Tasminatun2, Wahyu Prastyo Aji3

Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, Indonesia

*
Corresponding author. Email: maziyyahnurul@umy.ac.id

ABSTRACT
Introduction - Pharmacist as one of the health care team is characterized with specific competencies which are mostly
achieved during formal education through knowledge transfer as well as various clerkship programs, one of which is the
hospital pharmacy. Direct experiences in conducting pharmacy works are the main activity in clerkship programs which was
then limited since COVID-19 pandemic.
Purpose - This study aims to analyze students’ competency outcome of modified hospital pharmacy clerkship program in the
Department of Pharmacist Profession Education, Universitas Muhammadiyah Yogyakarta (UMY) during the pandemic.
Methodology/Approach - A non-experimental design was conducted for this study. Students’ competency outcome was
analyzed from the comprehensive examination score obtained after students have finished their clerkship program. Data
collection was gained from three batches of students (a total of 163 students) who undertook the clerkship during the pandemic
from 2020 - 2021. Analysis of difference in competency outcome between the three batches was carried out using the Kruskal-
Wallis test.
Findings - The method of hospital pharmacy clerkship program in the three batches of students during pandemic were
different mostly related to the proportion of online and offline activities. There were no significant differences (p-value <0.05)
in competency outcome seen in all three area of competence which are drug management, pharmaceutical care and drug use, as
well as management support. This finding indicates that the modification of clerkship program was able to maintain the quality
of learning process compared to pre-pandemic situation.
Originality/Value/Implication - Modifying clerkship programs in pharmacy should be routinely evaluated to assure the
quality and result in competency achievement by the students.

Keywords: COVID-19 Pandemic, hospital pharmacy, clerkship, competency

1. INTRODUCTION online learning during the pandemic situation (Shawaqfeh et

The COVID-19 pandemic has led to major impact in
various aspects of life. The impact in the educational sector
has affect the way of teaching and learning from pre-
kindergarten level up to the university level, where the use
of information technology become the most occupied
innovation throughout the sector (Firman & Rahayu, 2020).
Educators, learners as well as parents or care givers have
been demanded to learn and use technology in order to
maintain the quality of the learning and teaching process.
The shifting process from face to face toward online classes
did not occur smoothly, especially in developing countries
such as Indonesia where information technology capacity
varies throughout the provinces. Obstacles mostly
mentioned in many studies were lack of connectivity, lack of
student engagement or feedback, and difficulty in
conducting practical experiments which for sure could affect
learning outcomes (Jayara, 2020; Al-Obaidi et al, 2020;
Rondonuwu et al, 2021). Although faced with many
challenges, study on online learning in pharmacy education
has revealed that students were mostly ready to conduct
al, 2020).
Pharmacist profession education as a learning
continuation after Bachelor of Pharmacy had also undergo
adaptation with the pandemic through various innovation in
learning and teaching process. As the nature of learning
process in the profession level was through real-life practice
in many pharmacies’ workplace such as in the community
pharmacy, primary healthcare centre, hospital pharmacy,
industrial pharmacy, etc., debate emerged whether using
online methods of learning would result in the expected
competence of a fresh graduate pharmacist. Achievement of
skill competencies were usually the main issue to overcome
due to the complexity of transferring skill through online
methods. Huang et al (2019) mentioned that student direct
practice in the workplace will develop their understanding
and cognitive skill. Knowledge and skill competencies in
healthcare education are important aspects which would
eventually affect the work quality and performance of
healthcare providers towards future patients (directly on
indirectly) (Taburnal, 2020). Therefore, continuous
evaluation of new programmes or method must be
conducted to confirm the effectiveness of the program.
Hospital pharmacy clerkship program is one of the main
clerkship programs in almost all pharmacy profession
education in Indonesia. Based on the Regulation of
Indonesian Ministry of Health No 72 (2016) regarding the
Standards of Pharmaceutical Care in Hospital, there are
three major aspect of pharmacy service in the hospital
settings: 1) Drug Management; 2) Pharmaceutical Care; 3)
Management Support. Pharmacist-to-be must be familiar
with all three aspects since their study in the pharmacist
profession education programme. The institution must make
sure to give the minimum requirement of competence for
their students to be able to work in the three areas of hospital
pharmacy. Good competency in these areas will contribute
to the goal and maintenance of patient safety in the hospital.
Universitas Muhammadiyah Yogyakarta (UMY) since
2017 have begun the pharmacist profession education
programme with a 2-month hospital clerkship programme as
one of the main clerkship programmes given to the students
(Esha, et al, 2020). A clerkship module has been used to
make sure the students get the expected learning outcomes
and competencies in several hospital around Special Region
of Yogyakarta collaborating with UMY. Continuous
evaluation and feedback from students and preceptors were
conducted routinely to improve the programme.
Due to the COVID-19 outbreak in March 2020,
pharmacist profession education programme in UMY had to
withdraw some of the students from several workplace based
on the regulation of the workplace in order to avoid virus
transmission. This was also strengthened by The Association
of Indonesian Pharmacy Higher Education (AIPHE) who
released an inform letter to all pharmacy schools to make
adjustments regarding clerkship programmes, especially in
hospitals where high transmission would probably occur.
Suggestion to maximise the use of online methods compared
to face-to-face method was also informed in the letter. UMY
responded this situation by conducting online clerkship
programmes and adjusting it periodically based on routine
evaluation and pandemic situation. The adjustment resulted
in a variety of clerkship method in each batch. In order to
evaluate competency achievement from three batches of
students attached in hospital clerkship during the pandemic
era, the authors conducted analysis of the knowledge
competency achievement to determine outcome difference
from each batch which eventually will relate to the
effectiveness of the clerkship programme adjusted
throughout the time.
2. RESEARCH METHOD
2.1. Study Design
This study was conducted using a non-experimental,
descriptive design in order to give a description about the
clerkship adjustment during the pandemic in UMY as well
as the difference in competency achievement from each
student batch. Quantitative method was occupied to collect
and analyze comprehension examination score of the
students, while a qualitative method was used to collect
clerkship perception from the students’ representatives.
2.2. Study Subjects
This study analyzed data from three batches of students
who conducted hospital clerkship program from March 2020
until July 2021, namely batch 6; batch 7; and batch 8 of
Pharmacist Profession Education Program UMY. Data of
comprehension examination score from a total of 107
students from the three batches was used for difference
analysis while 6 student representative (2 from each batch)
was used for qualitative analysis of perception.
2.3. Data Collection
There were 2 main data collected in this study. Firstly,
data of comprehension examination score of hospital
clerkship program from 107 students (from 3 batches) which
was obtained from the administrative staff of Pharmacist
Profession Education Program UMY. Each student will have
a pair of score from two examiners which consisted of three
scores based on the three major area of competence in
hospital pharmacy: 1) Drug Management; 2) Pharmaceutical
Care; 3) Management Support. The mean score from each
area will then be entered into Microsoft Excel data.
The second data was perception data which was collected
through in-depth interview to representatives of the students
form each batch. Representative students were recruited by
the help of the student batch coordinator to choose students
that have experience hospital clerkship program during
pandemic era. In-depth interview was conducted by two
methods, through direct or face-to-face interview and by
online platform for students who are not in Yogyakarta
during the study. An interview guideline and recording tools
were prepared to make sure full information required for
analysis was obtained. Informed consent was given by the
representative before the interview was conducted.
2.4. Data Analysis
2.4.1. Analysis of students’ perception
Students’ perception regarding the method used for the
hospital clerkship program was analysed descriptively from
what was mentioned by the respondents. Important points
were written down and combined for similar points to obtain
main perceptions on the clerkship program.
2.4.2. Analysis of competence achievement
Students’ knowledge competence on hospital pharmacy
was analysed from the score of comprehension examination
after the hospital clerkship program ended. The mean score
for each area of competence was then tested using Kruskal-
Wallis test to determine the difference between batch 6, 7
and 8 in order to see whether different method used in each
batch affected competency achievement (knowledge
competency).
3. RESULT AND DISCUSSION
3.1. Overview of Hospital Clerkship
Below is a scheme on the different methods of hospital
clerkship program conducted by the 3 batches during the
COVID-19 pandemic.
full offline
(before pandemic)
Batch 6
full online
(during pandemic)
Clerkship model
3 weeks online
Batch 7
1 week offline
1 month online
Batch 8
1 month offline
Figure 1. Hospital clerkship model from the three batches
3.1.1. Batch 6
Based on the results of interviews, there were two
groups of students in batch 6 who carried out hospital
clerkship with different methods, a full offline and full
online method. The group of students with the full offline
method was carried out in February-March 2020 where
the COVID-19 pandemic had not yet appeared in
Indonesia, while the full online method began in April-
May 2020. The implementation of online clerkship is
carried out for two months where the first month of online
activities was provided by UMY through regular tasks
using e-learning system. Clerkship program for the next
month was then conducted in the hospital. For the first
three days, the hospital provided orientation materials by
watching videos and competency achievements that must
be achieved during their offline clerkship. The hospital
also gave assignments every week, the tasks given are in
the form of individual tasks such as counseling,
The impact experienced by students is that they lack
mastery in practice because they only study theory.
However, students feel confident in answering questions
related to the theory given by the examiner during the
comprehensive exam. To support the achievement of
competence in hospitals, students ask other senior students
who carry out offline clerkship to get an overview of what
activities are carried out in the hospital.
The full online clerkship method is considered less
effective, because there are obstacles and challenges in its
implementation. Students do not get real picture of
pharmaceutical work in hospitals if clerkship is done fully
online. This is not in accordance with one of the goals of
clerkship in hospitals based on APTFI (2010), namely
students should get a real picture of the problems of
pharmacy work in hospitals.
3.1.2. Batch 7
clerkship at the hospital in batch 7 used a combination
of online and offline methods at PKU Gamping Hospital
for one month. In the first three weeks, students do an
online clerkship which is filled out by the hospital.
Students are given direction and introduction related to the
hospital. Then an explanation is given regarding what
competencies must be achieved during clerkship. Every
week students get assignments and conduct discussions
and presentations on these assignments.
One week later, students take clerkship offline with
strict health protocols where before implementation
students must quarantine for 14 days and show a rapid
letter. clerkship activities carried out in hospitals include
visits to inpatient, outpatient, and warehouse departments.
However, for inpatient stations it is very limited, only a
few wards can be visited, in outpatient care, students do
counseling to patients, while in warehouses they observe
the storage and distribution of drugs. During activities
students are required to use Personal Protective
Equipment (PPE). The experience gained is very little
because visits to the ward are limited so it is difficult to
meet with patients and the implementation time is very
short where in one week all stations must be completed.
The online offline combination method is still
considered less effective, because the implementation was
more dominant using the online method. Students prefer
hands-on learning in practice. This is in accordance with
Kharisma et al (2020), which stated that 93.5% of students
prefer face-to-face offline learning compared to online
learning. Hence, having a well standardized process
should be prepared when conducting a mixed method
(Maskar et al, 2020).
3.1.3. Batch 8
Based on the results of interviews with informants,
clerkship in hospitals in batch 8 was carried out using a
combination of online and offline methods. In the first
month, students are given briefing first, then delivery of
material and also given assignments. All coincided with
the implementation of the second wave of clerkship in
batch 6 so that the implementation of clerkship was
carried out fully online. In batch 7, clerkship was carried
out in a combination of online and offline for one month,
where in practice the online method was more dominant.
Offline activities are very limited with a short time so that
the achievement of competencies obtained is not maximal.
In batch 8, clerkship was carried out in a combination
online and offline for one month each. students consider
the method used is quite effective.
At the hospital, online activities are carried out at the
hospital which same that is RSPKU Gamping.
Then continued with offline clerkship for one month at
another hospital. Before implementing the offline
clerkship, students are required to do an antigen swab
first. Activities in the hospital are very limited because
they are only allowed to enter a few wards, so cases are
obtained from very few patients. The discussion process is
carried out directly with the preceptors at the end of the
session.
The method of implementing clerkship in hospitals in
batch 8 which is carried out in combination online offline
or known as the blended learning method. This method is
often used with a 50/50 pattern, in the available time
allocation 50% online and 50% offline (Abdullah, 2017).
In batch 8 the online and offline combination method has
been running quite effectively. This can increase interest
in learning compared to full online learning (Dziuban et
al., 2004).
Table 1. Inadequate experience of competency
Area of Competence Inadequate experience
Batch 6 Batch 7 Batch 8
Drug Management  
Pharmaceutical Care    pharmaceutical service standards in hospitals is to improve
Management Support
Based on Table 1, students of batch 6 and 7 consider
that experiences related to competence in drug
management and pharmaceutical care during their hospital
clerkship program were inadequate. Class 6 students
consider the implementation of online clerkship to lack
direct experience. Likewise, batch 7 only carried out
clerkship offline for one week, which was deemed not
optimal. Meanwhile, for batch 8 only pharmaceutical
services in the use of drugs are considered not optimal.
The components of competence above are considered not
optimal because according to Huriah (2018), to achieve
maximum competence, it should be through practical
experience in the field to achieve competence cognitively,
skills, and attitudes.
3.2. Analysis of Competence
In this study, the number of samples used was 107
because all data met the inclusion criteria and none met
the exclusion criteria. This hypothesis test was used to
determine differences in the achievement of clerkship
competencies in hospitals in batches 6, 7, and 8 based on
comprehensive exam scores. The number of samples in
the hospital clerkship was 107 because all data met the
inclusion criteria. The following are the test results using
the Kruskal Wallis method.
Table 2. Difference in Competency Score
Average Test Score
Area of Competence Batch Batch Batch p-value
6 7 8 discussions with preceptors, and Focus Group Discussions
Drug Management 79.34 80.25 80.59 0.926
Pharmaceutical Care 78.27 80.64 80.79 0.346
Management Support 78.12 79.33 80.91 0.198
Based on the table above, the results of the test using
Kruskal Wallis on the competence of the management of
pharmaceutical supplies obtained the Asymp.Sig value (p
> 0.05) so that there was no significant difference in the
average score for the comprehensive exam in batches 6, 7
and 8 in these competencies. However, in this competency
the highest average score is class 8 with an average score
of 80.59. The competence of pharmaceutical supply
management is important for prospective pharmacists to
know where pharmacists are responsible for and ensure all
pharmaceutical supply management activities are in
accordance with applicable regulations to ensure safety,
benefits and quality (PERMENKES, 2016).
The competence of pharmaceutical services in the use of
drugs also did not have a significant difference where the sig
value was 0.346 (p > 0.05). The highest average score on the
competence of pharmaceutical services in the use of drugs is
class 8 with an average score of 80.79. Pharmaceutical
services are services that are provided directly to patients
related to pharmaceutical preparations. The purpose of
the quality of pharmaceutical services, protect patients from
irrational use of pharmaceutical preparations
(PERMENKES, 2016).
Furthermore, for the third aspect of clerkship in
hospitals, namely supporting management, there is also no
significant difference in batches 6, 7 and 8 where the
Asymp.Sig value (p> 0.05). Just like the previous aspect, the
highest average score in this aspect is class 8 with a score of
80.91.
clerkship competence in hospitals in batch 8 has the
highest average score in all aspects of hospital competence
where the learning method used in batch 8 is a combination
of online and offline. In accordance with the statement of
respondents from batch 8 where the combination of online
and offline learning methods is quite effective. Batch 6
obtained the lowest average score among other batches
where the methods used by batch 6 were full offline and full
online.
There are several factors that can affect the
comprehensive test scores, namely blended learning,
clerkship location, self-study motivation. This is in line with
the results of research conducted by Rafiola et al., (2020),
which states that the blended learning method and learning
motivation have a significant influence on student learning
outcomes.
Efforts made by PSPPA FKIK UMY in increasing
achievement clerkship competencies during the pandemic,
namely internal lecturers providing intensive guidance by
discussing and assigning tasks to students, sharing and
(FGD) ahead of the comprehensive exam. All of these
efforts are carried out online.
CONCLUSION
There were no significant differences (p-value <0.05) in
competency outcome seen in all three area of competence
which are drug management, pharmaceutical care and drug
use, as well as management support. This finding indicates
that the modification of clerkship program was able to
maintain the quality of learning process compared to pre-
pandemic situation. Modifying clerkship programs in
pharmacy should be routinely evaluated to assure the quality
and result in competency achievement by the students.
ACKNOWLEDGMENTS
The authors would like to thank the Faculty of Medicine
and Health Sciences, Universitas Muhammadiyah
Yogyakarta who has given the research grant as well as
permission for conducting the study in the Pharmacist
Profession Education Program.
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