A Systematic Review of Immunization Administration Training for African Pharmacists and Student Pharmacists.

OBJECTIVES: Recent calls to action have encouraged African pharmacists to become trained to administer immunizations with the goals of developing a strong pharmacy vaccination workforce, addressing a shortage of vaccinators, and improving vaccination access. However limited availability of training programs for pharmacists and student pharmacists to learn to administer immunizations may restrict the ability of African pharmacists and student pharmacists to meet these goals. This work sought to systematically identify literature published regarding immunization administration training for pharmacists and student pharmacists in Africa. FINDINGS: In total, 940 articles were identified from 6 databases and gray literature. After eligibility criteria were applied, a total of 8 studies from 7 African countries were included, representing Democratic Republic of Congo, Ethiopia, Nigeria, Senegal, South Africa, Uganda, and Zimbabwe. Three studies described immunization administration training programs for pharmacists and 1 described training for student pharmacists. SUMMARY: This literature review identified that there are limited publications describing immunization training for pharmacists and student pharmacists in Africa. Training pharmacists to immunize could make a meaningful impact in increasing immunization access and reducing the spread of vaccine-preventable diseases in Africa. Expansion of available immunization administration training is needed for African pharmacists and student pharmacists if calls to action are to be met.

Training Student Pharmacists in Microaggressions and Gender Inclusive Communication.

OBJECTIVE: The objectives of this study were to describe the implementation of a microaggression and gender inclusive communication (MGIC) module in a required course in a Doctor of Pharmacy curriculum; and to evaluate the impact on student pharmacist knowledge, comfort, and confidence using gender inclusive communication and addressing microaggressions. METHODS: Students participated in MGIC module, which included training on microaggressions, and terminology related to gender. The module implementation was evaluated through a pre and post training knowledge assessment and survey of student confidence, comfort, and perceived importance of gender inclusive care. Additional evaluation included qualitative review of the graphics depicting the terminology and rephrasing statement with a microaggression to inclusive language. Survey responses were analyzed using Mann-Whitney U test and knowledge responses were analyzed using the Fisher exact test in SPSS. RESULTS: A total of 106 students completed the module, 105 completed presurvey and knowledge assessment, and 92 completed the postsurvey and knowledge assessment. Results demonstrated a statistically significant increase from pre to post on the comfort and importance domain questions. A statistically significant increase in the student confidence was seen on all questions except for 2. The pre and postknowledge assessment results on all questions showed improvement from pre to post, although not all changes were statistically significant. CONCLUSION: The MGIC module was effective in increasing to evaluate the impact on student pharmacist knowledge, comfort, and confidence using gender inclusive communication and addressing microaggressions. Reflections echoed the value and need for this training.

A Pharmacist's Role in a Case of Allergy Labeling and Acute Bacterial Rhinosinusitis Treatment.

This case report describes a pharmacist's intervention with a 58-year-old female who presented with recurrent rhinosinusitis symptoms and limited treatment options due to a complicated allergy history. Using guidelines for treatment of acute bacterial rhinosinusitis coupled with a thorough antibiotic allergy assessment, the pharmacist developed a treatment plan that was acceptable to both the patient and the provider. Pharmacists can play an essential role in verification of allergies to both medications and non-pharmaceutical products, which further ensures patient safety as well as optimization of appropriate treatment methods.

Role of the pharmacist in the management of postmenopausal breast cancer treatment with vasomotor symptoms: A case report.

This case report describes the pharmacist intervention with a 62-year-old woman who had postmenopausal breast cancer. The patient was experiencing severe vasomotor symptoms from her cancer therapy and wanted to discontinue her treatment despite her risk of cancer returning. Using guidelines for treatment of postmenopausal breast cancer and medication options to mitigate vasomotor symptoms, the pharmacist developed a treatment plan that was acceptable to the patient and approved by the oncologist. Following implementation, the patient was satisfied to experience minimal hot flashes and relayed full compliance with her breast cancer treatment regimen. Pharmacists can play an important role in the management of postmenopausal breast cancer and vasomotor symptoms by providing patient education and recommending medications based on treatment guidelines with consideration to side effects and drug interactions.

A Case of Clostridioides difficile: Update on Practice Guidelines.

This report describes a case of recurrent Clostridioides difficile infection (CDI) and illustrates that pharmacist's role in selecting appropriate treatment. The report discusses CDI risk factors and reviews the guidelines for the pharmacological management of CDI.

Implementing Mental Health First Aid Training in a Doctor of Pharmacy Program.

OBJECTIVE: In this study, we aimed to describe the implementation of Mental Health First Aid (MHFA) training as a required curricular component in a Doctor of Pharmacy (PharmD) program; and analyze the impact of MHFA training on student pharmacist's perceptions of stigma, comfort, confidence, and willingness to intervene when someone is experiencing a mental health issue. METHODS: Student pharmacists completed an all-day MHFA training as a required element of the PharmD curriculum during the spring of 2022. Pre- and post-survey was completed by students during the in-person training. Questions included items from the Opening Minds to Stigma Scale for Healthcare Providers; question, persuade, refer gatekeeper training for suicide prevention; and questions developed by the authors to assess the impact of the training on participant-reported stigma, confidence, and willingness to provide care to those potentially experiencing a mental issue. RESULTS: A total of 235 student pharmacists completed the MHFA training. A statistically significant reduction of stigma was seen for 9 of the 15 statements from Opening Minds to Stigma Scale for Healthcare Providers. Additionally, all responses related to comfort and willingness to provide care and confidence improved significantly after completing MHFA. CONCLUSION: MHFA training was implemented as a mandatory requirement for all student pharmacists in the didactic portion of a PharmD program. This training led to reduced stigma around mental illness and improved confidence, comfort, and willingness to intervene among student pharmacists.

Hypothermia as a Possible Symptom of Serotonin Toxicity: A Case Report.

Background There are three commonly used sets of criteria to diagnose serotonin syndrome and all three diagnostic tools have all been shown to have shortcomings that do not fully encompass the possible symptoms of serotonin toxicity. Objective To describe a case of an atypical presentation of possible drug-induced serotonin syndrome, characterized by hypothermia, night sweats, muscle tremors, and confusion. Setting A rural and medically underserved area in eastern Washington State. Practice Description This patient case was identified as a part of a project to identify and intervene with complex and high-risk patients from local rural and underserved populations. The pharmacist identified the symptoms of possible drug-induced serotonin syndrome during a comprehensive medication review with the patient. Results The pharmacist identified a possible case of drug-induced serotonin syndrome and made a recommendation to the patient's physician that led to discontinuation of both fluoxetine and trazodone. At the follow-up visit, the patient reported that his symptoms had resolved completely. Discussion The three sets of diagnostic criteria for serotonin syndrome all include fever as a symptom, but do not list hypothermia. Effects at various 5-HT receptors and receptor subtypes have been linked to symptoms often seen in serotonin syndrome, but there are gaps in the currently used diagnostic criteria. Conclusion Pharmacists' comprehensive review of medications can allow identification of symptoms, such as hypothermia to identify possible serotonin syndrome.

A qualitative evaluation of pharmacy technician opinions about administering immunizations.

Introduction: Pharmacy technicians began administering immunizations in Idaho State as part of a new administrative rule in 2017. Rapid expansion of pharmacy technicians as immunizers occurred during the COVID-19 pandemic. Previous studies demonstrate the success of having technicians as immunizers but, the opinions of technicians themselves about immunizing have not been explored. Methods: Key informant interviews were conducted to evaluate the opinions of certified and immunization-trained pharmacy technicians in the State of Idaho. A key informant interview script was utilized and included questions regarding satisfaction with current position, feelings about responsibility in the pharmacy, confidence administering immunizations to patients, changes patient interactions after becoming immunization-trained, support in the pharmacy, and opinion about expansion of immunization training for technicians to other states. The aim of this research was to gather the opinions of pharmacy technicians regarding the impact of administering immunizations on job satisfaction and career outlook. Results: Fifteen pharmacy technicians were interviewed. All participants believed their role as immunizers improved job satisfaction and feelings of being a valuable part of the pharmacy team. Technicians also believed being able to immunize aided in pharmacy workflow, decreased wait time for immunizations at their respective pharmacies, and increased the number of immunizations being administered. Respondents also believed technicians should be allowed to administer immunizations nation-wide but also felt strongly that the decision to immunize should be up to each individual pharmacy technician. Conclusion: Immunizing technicians in this study believe that this advanced role has had a positive impact on their job satisfaction, feeling valued in the workplace, and likelihood of staying in their current position. Immunizing has also led to positive engagement with patients and beliefs that they are providing an impactful service to their communities.

The role of community pharmacies in the HIV and HCV care continuum.

Introduction: In 2019, there were over 1.1 million people living with human immunodeficiency virus (HIV) and 2.4 million people living with hepatitis C virus (HCV) in the United States. One in seven (14%) are unaware of their HIV infection and almost half of all HCV infections are undiagnosed. People with unstable housing are disproportionately affected by HIV and HCV. The present study will evaluate interventions by community pharmacists that may reduce HIV and HCV transmission and promote linkage to care. Methods: This study was conducted in an independent community pharmacy in Spokane, Washington. Eligible study participants were walk-in patients of the pharmacy, over the age of 18, and experiencing homelessness. Pharmacy patients were excluded if they had a history of HIV or HCV diagnosis, received a screening for HIV or HCV in the last six months or were unable to give informed consent. The intervention included administration of HIV and HCV point-of-care testing (POCT) using a blood sample, risk determination interview, comprehensive HIV and HCV education, and personalized post-test and risk mitigation counseling followed by referral to partnering health clinics. Results: Fifty participants were included in the final data analysis. Twenty-two participants (44%) had a reactive HCV POCT, and one participant had a reactive HIV POCT. Of the 94% of participants who reported illicit drug use, 74% reported injection drug use. Seventy-six percent (n = 38) qualified for PrEP. Pharmacist referrals were made for 28 participants and 71% were confirmed to have established care. Conclusion: Individuals experiencing homelessness are at an increased risk for acquiring HIV and HCV due to risky sexual behaviors and substance misuse. PrEP is underutilized in the U.S. and pharmacist involvement in the HIV and HCV care continuum may have a significant impact in improving linkage and retention in care of difficult to treat populations.

Design, Implementation, and Assessment Approaches Within an Advanced Human Immunodeficiency Virus (HIV) Elective Course.

Introduction: An estimated 38 million people are living with human immunodeficiency virus (HIV) worldwide. Pharmacists are well positioned to provide care to patients with HIV, but gaps in HIV education among pharmacists exist. Recognizing the need to educate and prepare future pharmacists, a 2-credit advanced HIV elective course was created for Doctor of Pharmacy students at Washington State University College of Pharmacy and Pharmaceutical Sciences in the United States, and Masters of Clinical Pharmacy students from University of Western Cape School of Pharmacy in South Africa. Methods: Course topics included diagnosis and treatment of HIV in children and adults, management of common comorbidities, pre-exposure prophylaxis, pharmacogenetic applications, and antiretroviral drug-drug interactions. Course effectiveness was evaluated using student examination results. Student perceptions were evaluated using pre- and post-course self-assessments involving abilities, confidence, and attitudes toward caring for people living with HIV. Results: Student pharmacists demonstrated competency in HIV knowledge, demonstrated skills in application to clinical-based scenarios, and reported significantly improved confidence and abilities as well as positive changes in attitudes toward people with HIV. Conclusion: This course contributed to student learning across different student cohorts in an institutional program in the United States including successful execution of distance learning and clinical application for students at a program in South Africa.

Cultures of support and resilience are associated with certified pharmacy technicians embracing new roles.

BACKGROUND: Various technological, economic, and regulatory factors are creating opportunities for pharmacy technicians to take on additional responsibilities. Technicians in the broader sense have indicated a preference for expanded scope of duties; however, it is not known what drives technicians' greater inclinations to accept these new roles. OBJECTIVE: The purpose of this study was to determine the association of various work-related factors, such as co-worker support, pharmacist-leadership style, future uncertainty, their own organizational commitment, and personal characteristics of technicians, including their resilience, on pharmacy technicians' willingness to take on emerging responsibilities in pharmacy. METHODS: A self-administered questionnaire survey was disseminated through email to a national, randomized sample of 3000 technicians certified through the National Healthcareer Association (NHA). The questionnaire solicited data on willingness to participate in either of 13 emerging responsibilities as well as resilience, perceived transformative leadership behaviors of supervising pharmacists, future uncertainty, coworker support, organizational commitment, and various personal and practice-related variables. Following the use of principal component analyses for item purification and summation of various scale responses, inferential analyses were conducted via independent sample t-tests, one way analyses of variance, and Pearson's product moment correlation, as appropriate. RESULTS: From 2906 surveys delivered, 878 were returned, with 745 of them providing completed responses on willingness to participate in emerging responsibilities. Willingness on most items/responsibilities was highly rated, with many means being at least 4 on a 5-point scale, though some were lower and perhaps a reflection of less exposure to these by way of their personal experience orpractice setting. Technicians' resilience, their coworker support, organizational commitment, and perceived transformative behaviors undertaken by their supervising pharmacists were all highly associated with willingness to engage. CONCLUSIONS: Pharmacists, pharmacy technician peers, and organizations can contribute to a culture that is supportive for pharmacy technicians and may serve to encourage commitment, resilience, and willingness to embrace new, or emerging responsibilities.

Correlations to and potential implications of resilience among certified pharmacy technicians.

OBJECTIVES: To assess resilience among a sample of certified pharmacy technicians in the United States and evaluate associations between resilience and various personal and work-related characteristics and conditions, including coworker support and pharmacist leadership behaviors, and to assess the relationship between technicians' resilience and support from coworkers and commitment to their organization. METHODS: This study employed the use of a self-administered questionnaire survey electronically in a cross-sectional design. The questionnaire was delivered with a response portal open for approximately 6 weeks during the spring of 2022 to a sample of 3000 technicians certified through the National Healthcareer Association. The questionnaire consisted of items comprising the Brief Resilience Scale, an adapted version of the Multifactorial Leadership Questionnaire (A-MLQ), and items measuring aspects of coworker support, future uncertainty, commitment, and turnover, in addition to demographic and practice site-related questions. RESULTS: Usable responses were acquired from 822 respondents, who reported relatively high levels of resilience. Resilience was observed to be positively correlated with pharmacy transformative leadership behaviors measured on the A-MLQ and with coworker support and negatively correlated with future uncertainty. Respondents indicating the highest level of profession commitment reported a statistically higher level of resilience than did others. There were very few relationships observed between resilience and technicians' personal characteristics. CONCLUSIONS: Immutable characteristics (e.g., race/ethnicity, sex, and age) played a very small role in describing resilience among pharmacy technicians. Instead, organizational characteristics of the workplace were shown to be highly associative with resilience of technicians, adding further evidence that organizations and the profession can help facilitate resilience among these important pharmacy support personnel.

The Role of the Pharmacist in Patient Self-Advocacy for Osteoporosis Screening.

Background Osteoporosis is a common bone disease affecting more than 200 million people worldwide. Commonly prescribed medications have the potential to contribute to bone loss and fracture risk. Providers may be unaware of effects of other commonly used medication classes, which can lead to inadequate prevention or a lack of screening. Objective To describe a case of drug-induced bone density loss, characterized by long-term use of proton pump inhibitors (PPIs) in a postmenopausal woman; to describe the pharmacist's role in encouraging patient self-advocacy. Setting A rural and medically underserved area in eastern Washington State. Practice Description This patient case was part of a grant-funded project to identify and intervene with complex and high-risk patients from local rural and underserved populations. Practice Innovation A pharmacist met with a 61-year-old female patient to complete a comprehensive medication review and subsequently identified a risk of osteoporosis secondary to long-term PPI and hormone replacement therapy use. Empowered by the knowledge of risk of development of low bone density, the patient approached her provider twice with a request for bone density measurement. Results Despite initial hesitancy from her physician, the patient advocated for herself with concerns about developing osteoporosis. Following obtaining a dual energy X-ray absorptiometry scan, the patient received a diagnosis of osteoporosis. Discussion Education from the pharmacist prompted the patient to advocate for osteoporosis screening and ultimately led to a diagnosis. Conclusion Pharmacists play a critical role in identifying medication-induced conditions in patients with complex medications and multiple chronic disease states.

Technicians' perception of pharmacist leadership behaviors on their own commitment and turnover intention.

PURPOSE: To evaluate technicians' perceptions of how they are supported and supervised by pharmacists through assessment of various components of pharmacists' leadership behaviors in developing the technician workforce. Additional objectives included evaluating levels of pharmacy technician uncertainty about their future, job commitment, and turnover intention in relation to perceived pharmacist leadership behaviors. METHODS: This study employed a cross-sectional design involving administration of an online questionnaire survey. The target population was technicians certified through the National Healthcareer Association. The questionnaire was disseminated to a random, nationwide sample of 3,000 technicians. It solicited responses to an adapted version of the Multifactorial Leadership Questionnaire (MLQ), a 29-item instrument for measuring the frequency of observed pharmacist supervisory behaviors, which are categorized as transactional, transformative, or both. The questionnaire also inquired as to respondents' levels of future uncertainty, profession commitment, organization commitment, and turnover intentions. RESULTS: Responses were acquired from 882 certified pharmacy technicians, who reported their observance of pharmacy supervisory behaviors, as measured by the adapted MLQ, with moderate frequency. Higher technician-reported levels of transformative leadership behavior by pharmacists were associated with lower levels of future uncertainty, greater profession and organization commitment, and diminished turnover intentions. CONCLUSION: Pharmacists' supervisory behaviors, namely transformative leadership behaviors, may be impactful to pharmacy technicians' attitudes and work-related outcomes. The pharmacy profession's leaders and educators might consider these results in educating current and future pharmacists so as to improve the workplace and, potentially, organizational and profession-wide outcomes in the delivery of care.

Utilizing an optional cumulative examination in a skills-based lab course series to assess student performance and knowledge retention.

INTRODUCTION: In the doctor of pharmacy curriculum, students are subjected to scenarios where success is contingent upon accurate retention of information learned during class. To provide incentive to students and simultaneously gauge student retention of course material, an optional honors examination was created for a skills laboratory course. The objectives of this research were to determine student pharmacist performance on the examination and to assess student pharmacist interest and motivation for taking (or not taking) the optional examination. METHODS: An optional comprehensive honors examination was implemented simultaneously within a laboratory course series. Student performance was analyzed across cohorts and students were given a web-based survey prior to the examination to gauge initial interest and engagement. A second survey was conducted after the examination to identify motivation for taking the optional examination. Surveys were analyzed using quantitative and qualitative methods. RESULTS: There were 238 responses to the initial survey (47%) and 183 (96%) responses to the post-examination survey. Common topics of motivation for taking the examination included enhancing transcripts, gauging their own retention, and assessing readiness for experiential activities. One hundred sixty-one students participated in the optional examination, and 65 achieved a score of 90% and the honors designation. The majority (96%) of students who chose to take the examination thought the activity was valuable to their education. CONCLUSIONS: An optional comprehensive honors examination is one method of evaluating student retention of course material and provides an opportunity for students to set themselves apart from colleagues with an honors designation.

Training student pharmacists to administer pediatric immunizations.

BACKGROUND AND PURPOSE: To describe the implementation of a pediatric vaccination training for student pharmacists and to assess student confidence in providing pediatric vaccinations after taking part in a mixed media, traditional lecture, and active learning, formatted training course. EDUCATIONAL ACTIVITY AND SETTING: Student pharmacists were trained with a two-hour pediatric immunization training module which consisted of materials to detail administration techniques. Students were assessed using a live skills assessment and a multiple-choice knowledge examination. To assess student confidence in these skills, the students were given a pre- and post-instruction survey which was analyzed using the Mann-Whitney U test. FINDINGS: All 170 students enrolled successfully completed the knowledge assessment with an average score of 87% (SD 10%). The skills assessment items most commonly needing remediation were verifying that caregivers received the Vaccine Information Sheet (24%) and reviewing comfort measures and after care instructions with the caregiver (24%). The pre-course survey was completed by 169 out of 170 student pharmacists (99.4%) while the post-course survey was completed by 164 student pharmacists (96.4%) with each item showing a statistically significant increase in perceived confidence in vaccine administration. SUMMARY: Pediatric vaccination training was integrated into a doctor of pharmacy curriculum with the goals of increasing student knowledge and confidence in giving pediatric immunizations. Upon course completion, there was a statistically significant increase in student-perceived knowledge and confidence when administering pediatric immunizations. By expanding access to pediatric immunizers, pharmacists can aid in increasing immunization rates improving public health in their communities.

The physician perspective on pharmacist-physician collaboration and trust.

BACKGROUND: Health care has shifted to focus less on individual practitioners and more on providing interprofessional and collaborative patient care. A strong working relationship among pharmacists and physicians is imperative for patient care and safety. OBJECTIVES: The objective of this research was to examine physician perspectives of the relationship between physicians and pharmacists, specifically evaluating the qualities and actions necessary for pharmacists to establish trust to provide the best quality of patient care. METHODS: Semistructured qualitative key informant interviews were conducted with 11 physicians. Questions were designed to gather information about the physicians' experiences with pharmacists and perceived barriers and opportunities for building trust and collaboration. The Unified Theory of Trust and Collaboration was used as a theoretical framework. RESULTS: The ability to cooperate was the most important aspect identified by all 11 physicians in creating effective collaboration along with respect, knowledge, communication, and trust. Common barriers identified with the pharmacist-physician relationship were the lack of identity, rapport, knowledge, positive attitude, and communication. CONCLUSION: Building trust and narrowing the gaps of communication are crucial in achieving effective collaborative practice among health professionals. Pharmacists and physicians must have the capability to cooperate with one another, understand the common moral responsibility they share, recognize the implications of their personal behavior on their professional relationships, and focus on their scope of practice without crossing boundaries. Through positive behaviors of civility, communication, adaption, and mutual respect in their individual roles, pharmacists and physicians can enhance their relationship and practice collaboratively.

Respecting the Patient's Choice: A Case of Possible Drug-Induced Parkinsonism.

This report describes a case of likely drug-induced Parkinsonism (DIP) identified by the pharmacist. A 54-year-old female patient was referred by a physician to the pharmacist in a rural, integrated care team for a comprehensive medication review (CMR) to address the patient's concerns of possible Parkinson's disease (PD). While PD may occur over the progression of age, medications that affect dopamine transport can also cause DIP, a secondary form of Parkinson's disease. Although PD and DIP may be clinically indistinguishable, differentiation may be possible by reviewing a patient's medication history for any potential causative drugs correlating to the timeline of the onset of symptoms. In this case, the pharmacist reviewed the medication profile and identified medications that could be responsible for causing DIP, specifically bupropion. The pharmacist suggested discontinuing bupropion and identifying another option for treating depression. The patient appreciated the suggestion and education, but ultimately preferred continuing her bupropion therapy instead of discontinuing therapy or changing to an alternative agent. At a follow-up meeting with the pharmacist, not only was the patient still experiencing tremors despite taking carbidopa/levodopa, but additional medications known to be potential inducers of tremors were added to her regimen. Although the pharmacist repeatedly discussed DIP with the patient and believed stopping bupropion would determine whether her Parkinsonism was PD or DIP, ultimately the patient continued taking bupropion because of concerns related to depression severity and the impact on her well-being. The patient's wishes were respected.

Evaluating a Skills Laboratory Curriculum to Determine the Essential Skills for Pharmacy Students to Learn.

The profession of pharmacy is complex and diverse, encompassing a wide range of necessary practice skills. Decisions regarding which skills are essential for students are made by faculty of skills-based laboratory courses, who also determine how these skills are taught and assessed. This commentary aims to further the discussion regarding how the essential skills taught and assessed in skills laboratory curricula are identified, with the intention of preparing student pharmacists for both current and future pharmacy practice. Guidance on essential skills is provided by various organizations and documents, but ultimately each institution has the autonomy to decide what to teach. As such, this piece discusses the importance of frequent curriculum evaluation to determine how to train pharmacists of the future so they will practice at the top of their license rather than simply meet competency with historical skills.

A Mixed-Methods Exploration of the Effect of Disabling Backward Navigation on Calculations-Focused Computerized Examinations.

Objective. The aim of this mixed-methods study was to examine the effect of disabled backward navigation on computerized calculation examinations in multiple courses.Methods. Student performance on comprehensive pharmacy calculation examinations before and after implementation of disabled backward navigation were compared. Deidentified data from ExamSoft were used to determine median examination scores, passing rates, and time to completion for all three attempts given on comprehensive calculation exams held in a pharmacy calculations course (PharDSci 504) and in three applied patient care laboratory courses (Pharm 531, 541, and 551). An anonymous, voluntary student survey gathered student perceptions of disabled backward navigation. Qualitative data were evaluated for thematic findings.Results. The impact of disabled backward navigation on test scores and passing rates varied by course and test attempt. Students in Pharm 541 and 551 performed significantly worse on the initial test attempt after backward navigation was disabled compared to the previous year, with no significant differences in student performance seen on the retakes. Performance in PharDSci 504 and Pharm 531 followed the opposite pattern, with no significant difference in performance for the initial tests but significantly increased performance on the retakes. The amount of time spent on examinations either significantly decreased or remained the same. Student perceptions were generally consistent across all cohorts, with at least 74% agreeing that disabling backward navigation increased examination difficulty.Conclusion. Disabling backward navigation had a mixed effect on student examination performance. This may highlight how student behaviors change as backward navigation is disabled.