Twelve tips to virtually operationalize co-creation of educational design.

Co-creation is the active involvement of all stakeholders, including students, in educational design processes to improve the quality of education by embodying inclusivity, transparency and empowerment. Virtual co-creation has the potential to expand the utility of co-creation as an inclusive approach by overcoming challenges regarding the practicality and availability of stakeholders, typically experienced in face-to-face co-creation. Drawing from the literature and our experiences of virtual co-creation activities in different educational contexts, this twelve tips paper provides guidelines on how to effectively operationalize co-creation in a virtual setting. Our proposed three-phased approach (preparation, conduction, follow-up) might help those aiming to virtually co-create courses and programs by involving stakeholders beyond institutes and across borders.

Insights from healthcare academics on facilitating interprofessional education activities.

Facilitators are of paramount importance to the success of interprofessional education (IPE) activities; hence, it is crucial to explore their perspectives and experiences in delivering IPE in Qatar. Using an exploratory case study approach, semi-structured interviews were conducted, in 2018, among faculty members, who had facilitated at least one IPE activity in Qatar, from healthcare professional education programs at Qatar University Colleges of Pharmacy, Medicine, and Health Sciences, Weill Cornell Medicine in Qatar, the University of Calgary in Qatar, and the College of North Atlantic. Interviews were recorded and transcribed verbatim. Inductive thematic content analysis was implemented. Twenty-one interviews were conducted with the following professions represented: medicine (n = 6), pharmacy (n = 5), nursing (n = 4), biomedical science (n = 3), respiratory theory (n = 2) and public health (n = 1). Four main themes emerged from the interviews: drivers to facilitator involvement that included interest and commitment to IPE and awareness of collaborative practice benefits; facilitator participation which was based on facilitator attributes and preparedness and readiness for IPE facilitation; the organizational support in terms of dedicated structure for IPE and IPE design and delivery and; student participation in terms of group dynamics and student engagement. Some key recommendations include having a dedicated unit for IPE, scheduling protected time for IPE, and organizing facilitators' training and debriefing workshops. The facilitators valued and appreciated IPE in preparing students for future collaborative practice. These findings can inform the development of quality and sustainable IPE activities in the future.

A cost-effectiveness analysis for high versus standard (low) dose caffeine for the treatment of apnea in neonatal intensive care unit.

Objective: Preterm babies are prone to experiencing apnea of prematurity (AOP), mostly characterised by a pause in breathing lasting a minimum of 20 seconds. Recent literature supported higher maintenance doses of caffeine, indicating benefits. This study evaluated the cost-effectiveness of high maintenance dose (HD) versus low maintenance dose (LD) caffeine for AOP in neonates. Methods: From the hospital perspective of Hamad Medical Corporation (HMC), Qatar, a cost-effectiveness decision-analytic model was constructed to follow the use of a HD maintenance caffeine of 20 mg/kg/dose versus a LD maintenance caffeine of 10 mg/kg/dose, in a simulated cohort of AOP neonates, over a therapy follow-up duration of six weeks, until neonatal intensive care (NICU) discharge. The clinical inputs were primarily literature-based, while the resource cost and utilisation were locally extracted in HMC. The cost-effectiveness outcome measure was calculated per therapy success, defined as survival with no apnea and successful extubation removal within 72 hours, with or without adverse events. One-way and multivariate sensitivity analyses were performed to confirm the robustness of the results. Results: With 0.23 (95% CI, 0.23-0.23) enhancement in success rate, at United States dollar (US$) 3869 (95% CI, US$ 3823-3915) added infant cost, the HD caffeine was between dominant (34.8%) and cost-effective (63.7%), with an average incremental cost-effectiveness ratio of US $16,895 (95% CI, US$ 15,242-18,549) relative to LD caffeine per additional case of success. The hospitalisation contributed the most to the total infant cost, and the probability of patent ductus arteriosus was the model input that influenced the results most. Conclusion: This is the first literature economic evaluation of caffeine for AOP. Despite increasing the cost of therapy, HD maintenance caffeine seems to be a cost-effective alternative to LD caffeine in Qatar. Our results support the recent global trends of increased use of HD caffeine for AOP in NICU.

Facilitators and barriers to interprofessional collaboration among health professionals in primary healthcare centers in Qatar: a qualitative exploration using the "Gears" model.

BACKGROUND: The number of patients seeking medical care is increasing, necessitating more access to primary healthcare services. As several of these patients usually present with complex medical conditions, the need for interprofessional collaboration (IPC) among health professionals in primary care is necessary. IPC is essential for facing the increasing and challenging healthcare demands. Therefore, the facilitators of and the barriers to IPC should be studied in the hope that the results will be used to promote such endeavors. OBJECTIVES: This study aimed to explore the perspectives of different health professionals regarding the facilitators of and the barriers to IPC in the primary healthcare settings in Qatar. METHODS: A qualitative study using focus groups was conducted within the Primary Health Care Corporation (PHCC) in Qatar. Several health professionals were invited to participate in the focus groups. The focus groups were uniprofessional for general practitioners (GPs), nurses, and dentists, while they were interprofessional for the other health professionals. Focus groups were audio-recorded and transcribed verbatim and validated by the research team. The data were analyzed by deductive thematic analysis using the "Gears" Conceptual Model as a coding framework. RESULTS: Fourteen focus groups were conducted involving 58 participants (including 17 GPs, 12 nurses, 15 pharmacists, 3 dentists, and 11 allied health professionals) working in PHCC in Qatar. The findings revealed a spectrum of factors influencing IPC, categorized into four main domains: Macro, Meso, Micro, and individual levels, with each accompanied by relevant barriers and facilitators. Key challenges identified included a lack of communication skills, insufficient professional competencies, and power imbalances, among others. To address these challenges, recommendations were made to implement dedicated training sessions on IPC, reduce hierarchical barriers among different health professionals, and enhance the effectiveness of existing systems. Conversely, it was emphasized that projects and campaigns focused on IPC, alongside the development of enhanced communication skills and the presence of supportive leadership, as essential for facilitating effective IPC in PHCCs. CONCLUSION: The interplay between the meso, macro, micro, and individual levels highlight the significance of a multifaceted approach to interventions, aiming to enhance the successes of IPC. While initiatives like interprofessional education training are underway, numerous challenges persist before achieving improved collaboration and more efficient integration of IPC in the PHCC setting.

Correction: Using Assessment Design Decision Framework in understanding the impact of rapid transition to remote education on student assessment in health-related colleges: A qualitative study.

[This corrects the article DOI: 10.1371/journal.pone.0254444.].

Evaluation of Health Literacy Levels and Associated Factors Among Patients with Acute Coronary Syndrome and Heart Failure in Qatar.

Purpose: To determine the prevalence of inadequate health literacy and its associated risk factors among patients with acute coronary syndrome (ACS) and/or heart failure (HF) in Qatar. Patients and Methods: This cross-sectional observational study was conducted among patients with ACS and/or HF attending the national Heart Hospital in Qatar. Health literacy was assessed using the abbreviated version of the Test of Functional Health Literacy in Adults (S-TOFHLA) and the Three-item Brief Health Literacy Screen (3-item BHLS). Results: Three hundred patients with ACS and/or HF, majority male (88%) and non-Qatari (94%), participated in the study. The median (IQR) age of the participants was 55 (11) years. The prevalence of inadequate to marginal health literacy ranged between 36% and 54%. There were statistically significant differences in health literacy level between patients based on their marital status (p=0.010), education (p≤0.001), ability to speak any of Arabic, English, Hindi, Urdu, Malayalam, or other languages (p-values ≤0.001 to 0.035), country of origin (p≤0.001), occupation (p≤0.001), and receiving information from a pharmacist (p=0.008), a physiotherapist (p≤0.001), or a nurse (p=0.004). Conclusion: Inadequate health literacy is common among patients with ACS and/or HF. This study suggests a need for developing strategies to assist healthcare professionals in improving health literacy skills among patients with ACS and HF. A combination of interventions may be needed to improve patients' understanding of their disease and medications, and ultimately overall health outcomes.

The Academic Triathlete: Applying Triathlon Training Principles to Guide Academic Success.

INTRODUCTION: Academic faculty are evaluated on their service, teaching, and research performance with the reward of tenure, promotion, and self-fulfillment. Triathletes spend numerous hours building their swim, bike, and run endurance in aspiration of crossing the finish line on race day. Given the workload required for academic and triathlon success, effective time and task management is essential. In this commentary, the authors posit that academic faculty can effectively structure their day-to-day "training" to achieve their career ambitions similarly to how a triathlete structures their training plan in preparation for a race. PERSPECTIVE: Triathlon requires mastery of three disciplines - swimming, biking, and running - each of which requires specific training approaches, skills, and techniques. Likewise, the service, teaching, and research pillars of academia involve planning, development, and application of diverse knowledge, skills, and techniques. The authors apply the fundamental aspects and lessons learned of triathlon training to the planning and execution of faculty academic work. IMPLICATIONS: Through the adaptation of a triathlete training framework to an academic position, the reader will be prepared to cross the finish line and realize their career goals as an academic triathlete.

Association of pharmacy students' cultural beliefs with perceived knowledge, beliefs, confidence, and experience with complementary medicine.

BACKGROUND AND PURPOSE: Culture has been shown to inform patients' acceptance and use of complementary medicine (CM) treatment. It is unknown how a pharmacist or pharmacy student's culture may be associated with perceptions of CM relating to patient care. Gaining a better understanding of this concept within student populations may inform educational needs for programs situated within culturally diverse settings. The purpose of this study was to explore how pharmacy students' cultural beliefs influence perceived knowledge, confidence, and practice with respect to CM. EDUCATIONAL ACTIVITY AND SETTING: A cross-sectional survey was distributed to all undergraduate pharmacy (professional years 1-4) and postgraduate doctor of pharmacy students. Results from the item "CM is an important aspect of my culture" were correlated with all other items using Spearman's correlation coefficient. FINDINGS: Senior students who had completed a two-credit hour course appeared to be more confident in their practice skills relating to CM and showed positive correlations with culture and effectiveness of CM. Senior students acknowledged the importance of CM knowledge as a student and within pharmacy practice. Junior students showed a positive correlation with culture and past use. SUMMARY: Pharmacy students in the Ccollege of pharmacy were positive towards the use of CM, with culture playing an important role. Students who perceived CM as an important aspect of their culture were more confident in their practice skills relating to CM. Future research is required to assess impact of students' cultural beliefs on practice.

Using Assessment Design Decision Framework in understanding the impact of rapid transition to remote education on student assessment in health-related colleges: A qualitative study.

Maintaining integrity and validity with online assessment is a significant issue that is well documented. Overt policies encouraging educators to adopt e-Learning and implement digital services coupled with the dramatic change in the education system in response to the challenges posed by COVID-19, has furthered the demand for evidence-based approaches for the planning and delivery of assessments. This study employed the Assessment Design Decision Framework (ADDF), a theoretical model that considers key aspects of assessment design, to retrospectively investigate from a multi-stakeholder perspective the assessments implemented following the rapid transition to remote learning during the COVID-19 pandemic. One-to-one semi-structured interviews were conducted with faculty and students from the Colleges of Pharmacy, Medicine and Health Sciences. After inductive and deductive thematic analysis three major themes were identified. These reflected on the impact of sudden transition on assessment design and assessment plan; changing assessment environment; and faculty-student assessment related interactions which included feedback. The use of a comprehensive validated framework such as ADDF, to plan assessments can improve validity and credibility of assessments. The strengths of this study lie in the innovative adoption of the ADDF to evaluate assessment design decisions from both an educator and student perspective. Further, the data yielded from this study offers novel validation of the use of ADDF in circumstances necessitating rapid transition, and additionally identifies a need for greater emphasis to be attributed to the significance of timeliness of the various activities that are advocated within the framework.

Global comparison of professional positioning by pharmacy programs towards prospective students.

BACKGROUND: Enrolment of capable prospective students for pharmacy programs is a major priority for the profession. The way in which these students perceive a future career in pharmacy may be dependent on how programs position the profession using recruitment material. OBJECTIVES: Objectives were to determine how top ranked pharmacy programs across 5 countries position the profession to prospective students on website recruitment material and to compare similarities and differences in how programs use speech acts within positioning statements. METHODS: A qualitative, thematic analysis of publicly available online recruitment information extracted from the top 2 ranked English-speaking pharmacy programs (according to 2018 QS rankings) from each of Australia, Canada, New Zealand, United Kingdom, and the United States was completed. RESULTS: Three positioning themes were identified: Pharmacists as health professionals and medicines experts; Pharmacists evolving role as care providers; and Pharmacist diversity in careers. Programs used questions, statistics, and carefully selected words to engage readers, backup statements with evidence, and market positioning statements to younger generations. CONCLUSIONS: Pharmacy programs position the profession using similar themes but use different strategies to relay positioning messages to prospective students. These findings may have implications for fostering prospective student interest in pharmacy programs.

Reporting and methodological quality of systematic reviews and meta-analysis with protocols in Diabetes Mellitus Type II: A systematic review.

BACKGROUND: Systematic reviews with or without meta-analyses (SR/MAs) are strongly encouraged to work from a protocol to facilitate high quality, transparent methodology. The completeness of reporting of a protocol (PRISMA-P) and manuscript (PRISMA) is essential to the quality appraisal (AMSTAR-2) and appropriate use of SR/MAs in making treatment decisions. OBJECTIVES: The objectives of this study were to describe the completeness of reporting and quality of SR/MAs, assess the correlations between PRISMA-P, PRISMA, and AMSTAR-2, and to identify reporting characteristics between similar items of PRISMA-P and PRISMA. METHODS: We performed a systematic review of Type 2 Diabetes Mellitus SR/MAs of hypoglycemic agents with publicly available protocols. Cochrane reviews, guidelines, and specific types of MA were excluded. Two reviewers independently, (i) searched PubMed and Embase between 1/1/2015 to 20/3/2019; (ii) identified protocols of included studies by searching the manuscript bibliography, supplementary material, PROSPERO, and Google; (iii) completed PRISMA-P, PRISMA, and AMSTAR-2 tools. Data analysis included descriptive statistics, Pearson correlation, and multivariable linear regression. RESULTS: Of 357 relevant SR/MAs, 51 had available protocols and were included. The average score for PRISMA-P was 15.8±3.3 (66%; maximum 24) and 25.2±1.1 (93%; maximum 27) for PRISMA. The quality of SR/MAs assessed using the AMSTAR-2 tool identified an overall poor quality (63% critically low, 18% low, 8% moderate, 12% high). The correlation between the PRISMA-P and PRISMA was not significant (r = 0.264; p = 0.06). Correlation was significant between PRISMA-P and AMSTAR-2 (r = 0.333; p = 0.02) and PRISMA and AMSTAR-2 (r = 0.555; p<0.01). Discrepancies in reporting were common between similar PRISMA-P and PRISMA items. CONCLUSION: Adherence to protocol reporting guidance was poor while manuscript reporting was comprehensive. Protocol completeness is not associated with a completely reported manuscript. Independently, PRISMA-P and PRISMA scores were weakly associated with higher quality assessments but insufficient as a surrogate for quality. Critical areas for quality improvement include protocol description, investigating causes of heterogeneity, and the impact of risk of bias on the evidence synthesis.

Evaluating knowledge, skills, and practice change after an accredited evidence-based medicine course for community pharmacy preceptors.

INTRODUCTION: Incorporating evidence-based medicine skills into practice is vital for pharmacists to promote rational medication use while making optimal patient care decisions. The objective of this study was to evaluate the impact of an evidence-based medicine course on the knowledge and precepting skills of community pharmacy preceptors. METHODS: This was a longitudinal, multiphase, interventional study, which involved the development of an evidence-based medicine course based on results of an educational assessment. The course was delivered over five sessions and included didactic and active learning strategies. The impact was measured by the preceptor's ability to apply knowledge gained from the course while providing student feedback during a community practice experience using a journal club context. RESULTS: Ten preceptors completed the course with 50% and 70% passing the drug information and critical appraisal assessments, respectively. When measuring course impact, 44% of preceptors were able to provide feedback at a proficient level while 56% needed further development. Preceptors' confidence improved across pre-course, post-course, and after the observation phase in interpreting study results (p = 0.016), teaching the student evidence-based medicine skills (p = 0.008), and providing feedback to the student regarding journal clubs (p = 0.010). Students rated high improvement in the preceptor's ability to provide feedback related to critical appraisal skills. CONCLUSION: A course-based approach to increase preceptor's knowledge of critical appraisal and drug information skills may be effective.

Pass-Fail Decisions for Borderline Performers After a Summative Objective Structured Clinical Examination.

Objective. To determine what expert assessors value when making pass-fail decisions regarding pharmacy students based on summative data from objective structured clinical examinations (OSCE), and to determine the reliability of these judgments between multiple assessors. Methods. All assessment data from 10 exit-from-degree OSCE stations for seven borderline pharmacy students (determined by standard setting methods) and one control was given to three of eight assessors for review. Assessors determined an overall pass-fail decision based on their perception of graduate competency. Assessors were interviewed to determine their decision-making rationale. Intraclass correlation coefficients were used to calculate reliability between assessor judgments. Results. Expert consensus was achieved for three of the eight students, however, the assessors' decisions did not align with standard-setting results. The reliability of assessors' decisions was poor. Assessors focused on ability to make correct recommendations rather than on gathering information or providing follow-up advice. Global evaluations (including a student's communication skills) rarely influenced the assessors' decision-making. Conclusion. When faced with making pass-fail decisions for borderline students, the assessors focus on evaluating the same competencies in the students but differed in their expected performance levels of these competencies. Pass-fail decisions are primarily based on task-focused components instead of global components (eg, communication skills), despite that global components are weighted the same for scoring purposes.

Measurement of health literacy in patients with cardiovascular diseases: A systematic review.

BACKGROUND: While many instruments have been developed, validated, and used to assess health literacy skills, their use and appropriateness among patients with cardiovascular diseases (CVDs) are not widely studied. OBJECTIVE: To identify, appraise, and synthesize available health literacy assessment instruments used in patients with CVDs. METHODS: Electronic databases were searched for studies that used validated measures to assess health literacy in patients with CVDs. Included studies were assessed for risk of bias and the identified instruments were evaluated based on their psychometric properties. Data were synthesized using a narrative approach. RESULTS: Forty-three studies were included in the review, of which 20 were cross-sectional studies and 12 were randomized controlled trials. Eleven health literacy assessment instruments were identified, of which only one was disease-specific. The Abbreviated version of the Test of Functional Health Literacy in Adults (S-TOFHLA) (n = 19) and the Rapid Estimate of Adult Literacy in Medicine (REALM) (n = 13) were found to be the most commonly used instruments to assess health literacy in CVDs. CONCLUSIONS: The S-TOFHLA and the REALM are the most widely used instruments to evaluate health literacy in CVD population. More CVD-specific health literacy screening instruments are warranted. Assessment of health literacy should be a standard of care in patients with CVDs and effective interventions should be developed to improve the impact of limited health literacy on health outcomes in this population.

Comparing student self-assessments of global communication with trained faculty and standardized patient assessments.

BACKGROUND AND PURPOSE: Assess the reliability of first year pharmacy student assessments completed by faculty members in comparison with a standardized patient (SP), and student self-assessments during a structured educational module on communication. EDUCATIONAL ACTIVITY AND SETTING: Pharmacy students completed four stations focused on communication with an SP. During each encounter, students completed a self-assessment and were evaluated by a faculty member and a trained SP. A five point Likert scale was used to evaluate student performance. Faculty assessments were compared against all others. A Pearson correlation coefficient for total scores was used and a Cohen's kappa was used to compare inter-rater reliability. Agreement and correlation was performed with student results categorized into poor, adequate, and exceptional performance based on faculty evaluation. FINDINGS: Twenty-four students participated. In all stations, student self-assessments were graded higher than corresponding faculty and SP assessments. Agreement between faculty, SP, and self-assessment was fair to slight (k < 0.4) for all comparisons but only significant (p < 0.05) between the faculty and self-assessment. After categorization, there was a small, non-significant correlation between faculty and self-assessment (r = 0.13, p = 0.21) and moderate and significant correlation between faculty and SP (r = 0.32, p = 0.001). Categorized inter-rater agreement was fair for all comparisons (k < 0.2) and only significant (p < 0.05) between faculty and SP assessment. DISCUSSION: Pharmacy students in their first professional year assess their communication skills more positively than other evaluators. Further instruction for students and reflection may be required to build understanding of global assessment in communication. SUMMARY: There is high incongruity between student self-assessment and faculty appraisal.

Stigma associated with mental illness and its treatment in the Arab culture: A systematic review.

BACKGROUND: Mental health has not had the same public profile as physical health. This has contributed to the stigma associated with mental illness and to its treatments. Research investigating how the traditions and values amongst those with an Arab heritage contribute to stigmatizing beliefs, attitudes or actions in the provision of mental healthcare has not been widely reported. AIM: To systematically review the literature and summarize the findings of studies reporting stigmatizing beliefs, actions and attitudes toward treatment of people with mental illness in the Arab population. METHODS: PubMed, Ovid, Psycharticles and Embase were used to identify original studies of non-institutionalized Arab adults or children reporting findings relevant to stigma toward mental illness. A manual search of the bibliography of all selected original studies was also undertaken. Independent data extraction was performed by two reviewers, who then met to compare data and reach consensus. Findings were classified as stigmatizing beliefs, actions or attitudes toward mental health treatments. RESULTS: A total of 33 articles were retrieved for full review. Those utilizing qualitative methodology provided insight into the many ways mental illness is viewed and defined among those with an Arab heritage. Among the studies using quantitative methodology, most compared stigmatizing beliefs, attitudes toward mental health treatments or stigmatizing actions among different Arab populations, some also investigated correlations between characteristics of the Arab population tested with stigmatizing beliefs, actions and attitudes toward mental health treatments. Findings from studies undertaken in Qatar reported greater stigmatizing beliefs, actions or attitudes toward mental health treatments among Qatari versus non-Qatari Arabs. CONCLUSION: A large diversity in the stigmatizing beliefs, actions and attitudes toward treatment of mental illness within the Arab population were identified. The influence of cultural variations on stigma should be explored further and used to tailor anti-stigma interventions in this population.

Team-Based Decision-Making in an Objective Structured Clinical Examination (OSCE): Are Pre-Licensure Healthcare Students "Collaborative Practice-Ready"?

Evaluation of pre-licensure students' competency in team-based decision-making is lacking. The purposes of this study were to evaluate pre-licensure pharmacy students' competency in team-based decision-making in the context of an objective structured clinical examination (OSCE), and to determine whether performance correlated with reflective assignment scores. Students' self-assessment and conceptualization of team-based decision-making in practice was also evaluated. Twenty-three pre-licensure pharmacy students' competency in team-based decision-making was evaluated in an OSCE station and with a reflective journal assignment; rubric scores for both evaluations were compared using Spearman's rank order analysis. Students completed an 18-item questionnaire regarding attitudes, confidence, and perceptions related to team-based decision-making. Descriptive statistics and construct analysis with open coding were used to analyse questionnaire results. Mean OSCE station and reflective journal scores were 45% and 66.3%, respectively, and were not correlated. Students' attitudes toward team-based decision-making were positive, and they reported performing associated behaviours during experiential education rotations. Students appropriately defined 'team-based decision-making' and were highly confident in performing related activities. However, students' conceptualization of team-based decision-making did not align with the pharmacy program's competency framework. Three key themes were identified through the study analyses: 1) student performance is dependent on assessment context when evaluating collaborator-related competencies; 2) there is a mismatch between students' perceived competency and objectively measured competence when collaborator outcomes were assessed within an OSCE; and 3) students' perceptions of team-based decision-making do not align with the program's competency framework. Future research is necessary to assess competency and perceptions of team-based decision-making in students from other healthcare professions, and to further evaluate whether pre-licensure students are "collaborative practice ready".

A psychometric analysis of a newly developed summative, multiple choice question assessment adapted from Canada to a Middle Eastern context.

INTRODUCTION: Accreditation necessitates that assessment methods reflect the standards established by the accrediting body. The process of adapting assessments to a new context can present unique challenges with uncertainty around psychometric defensibility of the adapted exam. METHODS: A psychometric analysis of a summative multiple-choice-question (MCQ) assessment, adapted from Canada, for graduating pharmacy students from a Canadian accredited program in Qatar was conducted. Rates of difficult items, item discrimination measured by point biserial correlation (rpb), and non-functioning distractors (NFDs) were calculated to identify deficiencies and challenges with an adapted exam. Challenges encountered throughout the adaption process and recommendations were documented. RESULTS: Overall score of a 90-item, four option, MCQ exam ranged from 46.7% to 78.9% (mean of 61.9%). For difficulty, there were 17 items with less than 30% of students answering correctly, while 29 items had unacceptable or poor discrimination (rpb < 0.1). NFDs occurred in 78 items with 49 containing at least two NFDs. DISCUSSION AND CONCLUSIONS: Difficulty of the exam was deemed acceptable yet discriminator ability requires improvement. The high frequency of questions with NFDs suggests that faculty have difficulty developing plausible distractors for an adapted MCQ exam. This could be due to a lack of training or requirement for inclusion of too many distractor options. While it is feasible to implement an assessment adapted from a different learning environment, measures need to be taken to improve psychometric defensibility. The high number of questions with NFDs indicates that the current method of exam development does not encourage the incorporation of functional distractors.