A multistep design approach was taken.

Of 30 invited, 10 participants responded and reviewed the EHC interactive clinical avatar and data collection questionnaire: 4 were Keele University alumni and 6 studied at other universities and were members of the British Pharmaceutical Students Association. Four of the participants were preregistration trainees, and 6 were first-year qualified pharmacists; 7 of the participants were female and 3 were male. All participants were aged 20 to 25 years. Participants were of White British (7/10), Indian (1/10) and Chinese (2/10) ethnicities. An equal number of participants were from hospital and community practice. A greater proportion of participants (6/10) reported no previous experience with interactive clinical avatar simulations.

Initial reliability testing of the instrument consisted of establishing content and face validity. The research team as pharmacists had first-hand knowledge of the construct of interest from practice, and they could advise on the questionnaire content and language. The review of the questionnaire by three qualified pharmacists contributed to addressing the content validity of the instrument. This resulted in minor typographical changes, but the questionnaire was otherwise reported as appropriate to measure user views on interactive clinical avatar simulations.

All preregistration pharmacists and newly qualified pharmacists reported the questions and Likert statements to be clearly written and unambiguous, further confirming internal validity of the data collection tool. Cronbach α=.95, which demonstrated a high level of internal consistency suggesting that the Likert scales were reliable to be used in a bigger study [44].

The statements from the Likert ranking scales, their descriptions, and the associated median agreement scores are shown in Table 1. For all Likert ranking statements, participant median agreement scores were in the agree or strongly agree categories. Fewer participants ranked themselves as undecided, and only on 5 occasions did participants disagree with a statement. No participants ranked themselves as a 1 (strongly disagree) for any statement.

The fidelity of the simulation was reported as realistic by 80% (8/10) of participants, with it making them feel as if they were the pharmacist and were making the same decisions as in real practice (70% [7/10] and 90% [9/10] agreement, respectively). The simulation was reported as enjoyable (9/10, 90%), interesting (10/10, 100%), and set at the right level for preregistration training (9/10, 90%). The majority of participants reported that the simulation was easy to access (9/10, 90%) and the intended learning outcomes were easy to understand (7/10, 70%), indicating high usability as a learning tool.

The level and specificity of the feedback was reported as adequate for participants’ learning needs (10/10, 100%). The development of skills for future practice from the simulation was reported by 80% (8/10) of participants, with clinical reasoning skills being developed to a greater extent than problem-solving or decision-making skills (90% [9/10] vs 80% [8/10]). There was high agreement regarding the development of and application of knowledge from using the simulation (100% [10/10] and 80% [8/10], respectively). Participants reported feeling more confident in caring for patients (9/10, 90%), collaborating with other health care professionals (8/10, 80%) and practicing as a pharmacist (8/10, 80%) after completing the simulation.

There were some differences between data received from preregistration trainees and newly qualified pharmacists. Preregistration trainees agreed or strongly agreed with the majority of Likert statements; one participant (25%) was undecided with statements 2 and 3 relating to really feeling like the pharmacist in the simulation. Two newly qualified pharmacists (33%) also ranked themselves as undecided on statement 2. Newly qualified pharmacists were reportedly more undecided as to the simulation aiding the development of skills for practice (2/6, 33%) and allowing the application of theory to practice (2/6, 33%). There were a few statements on which newly qualified pharmacists disagreed: aiding the development of problem-solving and decision-making skills (1/6, 17%), individual responsibility to learning (1/6, 17%), collaborating with patients (1/6, 17%) and health care professionals and increasing confidence for practice (2/6, 33%).

Key themes emerged from content analysis of the open-ended questions on the questionnaire regarding use of the case studies as learning tools, use of the case studies in the preregistration training year, limitations of the case studies, and suggestions for improvements of the case studies. Themes and frequencies from the content analysis can be found in Multimedia Appendix 2.

Participants reported the interactive clinical avatar simulation as enjoyable and easy to use as a learning tool. It was described as providing a different format of learning, and the realism and relevance to practice of the simulation promoted experiential learning.

One participant specifically commented that the level of feedback was helpful to identify what they did well and how they could improve, while drawing on the repeatable aspect of the simulation.

Participants reported that the interactive clinical avatar could be a useful learning tool in preregistration training; it was primarily thought of as an individual revision aid or a group learning tool. A small number of participants commented on the use of interactive clinical avatar as a tool to help prepare for an Objective Structured Clinical Examination (OSCE).

Participants reported some limitations of the interactive clinical avatar. The most frequent concern related to the free-text part of the simulation.

The free-text entry was also associated with software recognition problems.

Four improvements were suggested: providing an example simulation, including a help button or email address for technical issues, including key learning points at the end of the case study, and increasing the size of the question bank (most commonly suggested).

The aim of the study was to describe the design and review of three interactive clinical avatar simulations as part of pharmacist preregistration training. Creating the interactive clinical avatar simulations involved multiple reviews and subsequent amendments to ensure content and face validity of the cases. Further measures of concurrent or construct validity were considered and dismissed as not appropriate because of the lack of validated instruments and, therefore, the inability for findings to be correlated with those from another instrument. A sample of preregistration trainees and newly qualified pharmacists reviewed the EHC simulation and reported it to be an effective learning tool, suggesting improvements to increase its usability. The wording, relevance, and difficulty of the interactive clinical avatar were reported as being appropriate with no changes required. The data collection questionnaire was found to be reliable, as indicated by the high Cronbach alpha score.

There has been only one previous study evaluating interactive clinical avatars in preregistration pharmacy training [10], which focused on improving users’ knowledge and confidence of a single community pharmacy service. In contrast to our study, there were few specifics on the simulation design process or validity of the self-rating scale. Previous literature reviews [2,6,7,59,60] concluded the need for further research to be undertaken on the role of virtual patients in postgraduate and continuing pharmacy education. The design of the interactive clinical avatars in this paper goes some way to filling this gap in current research and provides a rationale for a combination of input styles to determine the range of skills and knowledge that can be developed from these simulations [35,44].

This study indicated a high level of satisfaction by preregistration trainees and newly qualified pharmacists with the use of interactive clinical avatars as a learning tool, mirroring the wider literature [12,13,61-65]. Providing engaging and enjoyable learning environments are key components of the learning process [66]. Participants in this study enjoyed completing the EHC simulation, describing it as a novel learning tool that had not been widely used in participants’ undergraduate education. The increasingly digitally native generation of students justifies the creation and evaluation of these more interactive learning tools that may promote self-directed and distance learning, potentially increasing the scope of students who can use them [67].

Participants commented on the realistic design and relevance of the scenarios to real practice, implying high levels of cognitive realism [68]. The interactivity and fidelity of the interactive clinical avatar may have added to users’ immersion in the simulation and their experiential, situated learning; such learning has previously been proposed to occur only with real-life or concrete experiences [69]. Participants reported that the interactive clinical avatar provided them with a means to explore higher order skills such as clinical reasoning. In contrast, the development of more simple skills (such as problem solving or decision making) were not reported as freely, especially by newly qualified pharmacists. This is not necessarily an issue, as previous studies have found that lower order skills can be acquired through straightforward rote learning, but it remains essential to ensure that any learning tool is created with the level of learners and intended learning outcomes in mind [70]. Although virtual patients have been established as tools to develop health care professionals’ clinical reasoning skills [2,8,28,71,72], little work has been conducted within the pharmacy profession or evaluating interactive clinical avatars specifically. Findings from this study also mirror the wider literature regarding knowledge development post virtual patient use, with preregistration trainees and newly qualified pharmacists reporting the development of knowledge required for future practice after completing the interactive clinical avatar simulation [10,13,73-79]. Resources that allow users to immerse themselves in a scenario and behave as they would in real practice are extremely beneficial in aiding the development of knowledge, skills, and confidence and may bridge the gap between theory and practice in preregistration training [80].

Learning tools must reflect the level of education that individuals are at and allow a spirality of content to ensure new learning is linked to previous learning and students’ competence can develop in line with the difficulty of task [81]. Interactive clinical avatars may add little value when learners are at the lower levels of Bloom’s taxonomy [82]; they should instead be used when knowledge is combined with skills and applied in problem-solving scenarios or when direct patient contact is not possible. This may explain why preregistration trainees were more agreeable to the simulations allowing an opportunity to put theory into practice, developing skills, improving confidence for real-life practice, and collaborating with patients and health care professionals; newly qualified pharmacists may have had this experience in real-life practice. This demonstrates that interactive clinical avatars are able to help promote progression through the levels of Miller’s triangle, as per other simulation-based learning [83].

The integration of a decision tree into simulation design allows users to dynamically control the case study and assures outcomes are directly determined by user input to encourage a greater sense of realism and responsibility. Interactive clinical avatar simulations provide a safe environment for users to repeatedly practice, change the simulation outcome, receive the appropriate feedback, and reflectively learn. This was noted as being particularly beneficial in preregistration training, as it would allow individuals to learn from experiences they may not otherwise have.

All interactive clinical avatar case studies were reviewed by the research team and qualified pharmacists to increase their validity. The EHC simulation was also reviewed by a sample of preregistration trainees and newly qualified pharmacists. The sample size of 10 may be considered small and findings due to chance, but the purpose was to review the design of the interactive clinical avatar simulation and data collection tool, for which data saturation was reached. All comments received were useful regarding the interactive clinical avatar design—in particular, improvements suggested related to features consistent for all three case studies (eg, providing an example interactive clinical avatar simulation, signposting for help, and listing key points relating to the topic). The improvements regarding the question bank and recognition of the avatar can also be translated across the interactive clinical avatar simulations where free-text input is used.

Perceptions of the interactive clinical avatar were obtained via a questionnaire. The self-reporting aspect did not show whether participants’ knowledge or skills related to completing an EHC consultation did actually improve, only their thoughts of such. The primary focus of the questionnaire was to obtain participant perceptions relating to the avatar simulation rather than evaluating its ability to promote knowledge or skill development; this will be part of a larger study.

The design and creation of the interactive clinical avatar simulations was successful. The multistep review process ensured validity and reliability of the simulations and data collection questionnaire. The in-depth explanation of the design process and provision of a questionnaire may help widen the use and evaluation of interactive clinical avatars or other simulation tools.

The interactive clinical avatars were received favorably as a novel learning tool that was reported to promote experiential learning and allow individuals to feel like they were making real-life decisions, developing transferable knowledge and skills. Improvements were suggested to increase the use of the interactive clinical avatars, and amendments will be made for further, larger scale evaluations. The use of interactive clinical avatars as learning tools can provide potential benefits to many health care training courses because they provide standardized simulations that allow active learning and reflection.