Japanese Journal of Pharmaceutical Education
Online ISSN : 2433-4774
Print ISSN : 2432-4124
ISSN-L : 2433-4774
Current issue
Displaying 1-26 of 26 articles from this issue
Series | Promoting an international perspective based on the needs of Japanese pharmacy education
Review Article
  • Mayumi Asahina
    Article type: Review Article
    2025Volume 9 Article ID: e09024
    Published: 2025
    Released on J-STAGE: September 17, 2025
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    Medical professionalism is a process of acquiring a professional identity, and it should be taught in parallel with Interprofessional Education (IPE). IPE’s purpose is to practice collaborative patient-centered medicine among medical departments successfully. IPE is a process of interprofessional socialization and a positive educational strategy that allows students to develop a professional identity. The pre-clinical IPE and the clinical practice IPE programs at Chiba University involve the School of Medicine, the Faculty of Pharmaceutical Sciences, the School of Nursing, and the Faculty of Engineering. This study aims to introduce, recommend, and encourage participation in IPE at other universities.

  • Hiroko Kawara
    Article type: Review Article
    2025Volume 9 Article ID: e09030
    Published: 2025
    Released on J-STAGE: October 15, 2025
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    At present, pharmacists are required to have a high level of expertise in multidisciplinary team care, and the number of pharmacists who are generalists and specialists in particular fields is increasing. In this situation, various organizations have established certified pharmacy specialist and certified pharmacist systems. “Emergency medical care” is a field in which certified pharmacy specialist and certified pharmacist systems have been established. However, the number of certified pharmacists in this field remains lower than that in the field of infectious diseases and oncology. In “emergency medical care,” which varies greatly depending on the region and facility, pharmacists currently provide services based on their knowledge and experience accumulated at each facility. On February 1, 2025, the Japanese Society of Hospital Pharmacists and the Japanese Society for Emergency Medicine published the “Guidelines on Emergency Outpatient Pharmacist Services,” which is expected to promote pharmacist services in the future. This paper reports on the efforts of Kyoto Okamoto Memorial Hospital and the Kinki Emergency Pharmacist Study Group regarding pharmacist services related to “emergency medicine” and the educational system for such services.

Special Topics | Recommendations to the pharmaceutical education from social needs by specialists in various fields
  • Sayo Suzuki, Kayoko Takeda, Yoshiyuki Hari, Takanori Kanazawa, Takao I ...
    Article type: Review Article
    2025Volume 9 Article ID: e09015
    Published: 2025
    Released on J-STAGE: June 21, 2025
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    The next revision of the Model Core Curriculum for Pharmacy Education is planned for 2030. In formulating and revising the core curriculum, we should consider what is needed for pharmacy education, not only in terms of outcomes but also in terms of long-term impact (impact on society and contribution to society after graduation). Pharmacy education in itself is a discipline based on pedagogical theory, and its mission is to contribute to the development and improvement of curricula to produce excellent human resources that will contribute to society, looking at all specializations and curricula from basic science to clinical settings. In this symposium, we present the current research and work of specialists who are impacting the real world beyond the C to F domains of the Core Curriculum (as of 2024), as well as their opinions on what they ask for pharmacy education.

  • —An example from nucleic acid chemistry research—
    Yoshiyuki Hari
    Article type: Review Article
    2025Volume 9 Article ID: e09009
    Published: 2025
    Released on J-STAGE: June 21, 2025
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    A six-year pharmaceutical training program, the major purpose of which was to cultivate practical clinical abilities, admitted its inaugural class in 2006. Thereafter, education programs in clinical pharmacies have become well-established. As the array of drug modalities is being expanded, the importance of basic pharmaceutical science is also increasing. Niches for pharmacists’ skills are now wide-ranging, including hospitals, pharmacies, pharmaceutical companies, and administrative offices. To date, I have taught a basic pharmaceutical science education and conducted basic pharmaceutical research on nucleic acid chemistry in a six-year pharmaceutical training program. In this review, using recent research results contributable to oligonucleotide therapeutics as examples, I describe the skills necessary to play a central role in basic pharmaceutical research and express my opinion on the preferred education for skill development. These skills are essential not only for basic pharmaceutical sciences but also for various fields, including clinical settings.

Special Topics | Professionalism and emotional labor of pharmacists
  • Sayo Suzuki, Itsuko Ishii, Miho Utsumi, Yoshinori Takata, Manako Hanya
    Article type: Review Article
    2025Volume 9 Article ID: e09016
    Published: 2025
    Released on J-STAGE: July 17, 2025
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    A social contract based on “mutual trust” between professionals and society constitutes a fundamental concept of professionalism. Altruism and empathy are the essential elements of medical professionalism. It is necessary for healthcare professionals to manage their emotions and perform emotional labor to demonstrate professionalism in clinical settings that are uncertain and challenging and where many factors, such as human relationships with patients, patients’ families, and other professionals, the work environment, and social and legal factors, are intricately intertwined. I believe that the ability to recognize such harsh situations and manage emotions in response is also an essential aspect of the professionalism that pharmacists must possess. Numerous initiatives have focused on the emotional labor of doctors, particularly nurses; however, very little attention has been devoted to the emotional labor of pharmacists. In this symposium, we will examine pharmacists’ professionalism through the lens of emotional labor a perspective not yet explored in the field of pharmacy, and offer suggestions for pharmacy education.

  • Miho Utsumi
    Article type: Review Article
    2025Volume 9 Article ID: e09010
    Published: 2025
    Released on J-STAGE: July 17, 2025
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    As pharmacists perform emotional labor in clinical settings, they are prone to mental stress and burnout due to staff shortages, long working hours, and a lack of support from colleagues. In addition, Japan’s current medical laws impede cooperation and collaboration between pharmacists and other professionals. Despite this, in order to fulfill their professional responsibilities, pharmacists must strive for professional autonomy to provide a certain level of care and services. In order to maintain professionalism and achieve sustainable medical care, it is necessary to alleviate the suffering and conflict of health professionals by disseminating knowledge about emotional labor and creating systems to protect and support professionals, rather than expecting individuals to solve their own issues. It is also considered necessary to harmonize the legal system such that all professionals involved in welfare or the medical field are not legally hindered.

  • Yoshinori Takata
    Article type: Review Article
    2025Volume 9 Article ID: e09018
    Published: 2025
    Released on J-STAGE: July 17, 2025
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    Everyone manages their emotions according to societal rules, especially at work, which is referred to as “emotional labor.” This concept has attracted great interest in the medical field for nurses, doctors, and pharmacists because of the necessity of interpersonal relationships. In medical education programs, emotional socialization is a hidden curriculum, but with an emphasis on suppressing emotions and neglecting the presence of strong emotions in medical care. This paper will raise some issues regarding the position of emotions in future medical education programs from the perspective of new healthcare professionals.

Special Topics | Reform of educational support for pharmacy students: Sharing case studies, identifying challenges, and proposing new initiatives
  • Rie Yamauchi, Shou Nakadate, Harumi Hata, Hiroshi Saimaru, Nobuhiro In ...
    Article type: Review Article
    2025Volume 9 Article ID: e09026
    Published: 2025
    Released on J-STAGE: October 15, 2025
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    For decades, the declining 18-year-old population has led to increased college enrollment rates, admitting a broader range of students with varying levels of academic abilities. Therefore, the Faculty of Pharmacy is modernizing and personalizing learning support to strengthen student proficiency in specialized subjects. For example, at the Faculty of Pharmacy, we are strengthening our academic portfolio by integrating Institutional Research (IR), leveraging IT to enhance analytical capabilities in academic affairs, applying Instructional Design (ID) to improve the learning environment, and providing academic counseling tailored to each student’s cognitive style and motivation. These initiatives have started to yield positive outcomes. However, as we remain in a transitional phase, fundamental reforms in learning support are still needed. These include assessing and supporting students’ proficiency levels in their early years and improving the overall quality of learning. To address these issues, in August 2024, we organized a symposium on “Academic Support Reform for Pharmacy Students” at the 9th Annual Conference of the Japanese Society for Pharmaceutical Education. During the symposium, we discussed findings from case studies conducted at four pharmaceutical universities, highlighting key insights and challenges. We hope this report offers valuable insights for enhancing educational support for pharmacy students facing learning difficulties.

Special Topics | How pharmacy education should use generative AI
  • Hiroyuki Nihei
    Article type: Review Article
    2025Volume 9 Article ID: e09019
    Published: 2025
    Released on J-STAGE: November 06, 2025
    Advance online publication: July 16, 2025
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    We report on “learning in collaboration with generative AI,” which is practiced in the literacy-level courses of the Mathematics, Data science and AI Smart Higher education (MDASH) program, and which is advanced through verification by the students themselves. The purpose of incorporating generative AI is to improve students’ communication skills (ability to discuss, argue, and present). The feature of this system is that it provides a learning environment in which students can coexist with a generative AI that prompts them to role-play, i.e., the generative AI plays the roles of a student, a teacher, and a master painter, and the students themselves verify the generative AI’s creativity and expressive power. The results of a questionnaire survey of students showed that while the use of AI was highly evaluated as beneficial, some students pointed out that the feedback from the AI contained errors and was not sufficient. However, students also have high expectations for the advancement of AI technology, and further technological innovation and promotion of its use are expected in the future.

  • Chikusa Muraoka, Atsushi Kinoshita
    Article type: Review Article
    2025Volume 9 Article ID: e09042
    Published: 2025
    Released on J-STAGE: November 06, 2025
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    GPT (Generative Pre-trained Transformer) is a type of generative AI that uses machine learning, a core technology of artificial intelligence (AI), and is one of the language models that represent deep learning models in natural language processing (NLP), a series of technologies for processing natural language on computers. Generative AI powered by GPT is developing rapidly. Meanwhile, the Ministry of Education, Culture, Sports, Science and Technology has also issued guidelines on the educational use of generative AI at universities and technical colleges, calling for the use of generative AI with appropriate literacy, such as responding to hallucinations where generative AI outputs information that differs from the facts. With this background, it is expected that the use of generative AI will increase in pharmaceutical education in the future. This paper summarizes the results of a survey on how universities with pharmaceutical schools are responding to AI and discusses how pharmaceutical education should utilize generative AI.

Original Article
  • Masahiro Ueda, Mai Aoe, Kanae Nishimura, Masaki Nakazawa, Noriaki Naga ...
    Article type: Original Article
    2025Volume 9 Article ID: e09005
    Published: 2025
    Released on J-STAGE: April 03, 2025
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    Few pharmacists reportedly utilize their knowledge of organic chemistry in clinical practice, so this study aimed to identify the factors that prevent pharmacists from applying this knowledge. Three authors performed a secondary KJ method on the descriptive labels obtained in two chemical structural formula workshops in 2018. The results generated 16 islands of possible factors, further classified into five groups, that prevented 55 pharmacy students and pharmacists from using the chemical structures in clinical practice. The five groups were named “environmental problems,” “individual problems,” “educational problems,” “lack of social demand,” and “limited data for clinical application of chemical structure formulas.” In conclusion, two main factors were identified: “social demand and environmental external factors” and “individual internal factors attributable to education.” These results provided helpful information for the clinical application of organic chemistry in pharmaceutical education.

  • Michiko Goromaru-Shinkai, Maki Shimizu, Jun Kuroda, Shigeki Mizuochi, ...
    Article type: Original Article
    2025Volume 9 Article ID: e09006
    Published: 2025
    Released on J-STAGE: April 03, 2025
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    The guidelines for handling radiopharmaceuticals in hospitals state that pharmacists must be designated for their preparation. Few pharmacy colleges in Japan, other than Toho University School of Pharmacy, provide practical training on handling unsealed radioactive materials. In the fall semester of the third year of pharmacy study, students learn to master radiation protection and handle unsealed radioactive materials. In this study, an analysis of student questionnaires conducted from 2014 to 2023 identified differences in the awareness of radiopharmaceutical handling among students who completed and those who did not complete the practical training course.

  • Shugo Yamashita, Shunsuke Kimura, Akiko Kiriyama
    Article type: Original Article
    2025Volume 9 Article ID: e09008
    Published: 2025
    Released on J-STAGE: April 12, 2025
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    The over-enrollment in pharmacy schools has led to concern over the quality of pharmacy education and an oversupply of pharmacists. A review of educational management focused on learning outcomes visualization as a learning methodology with short tests and search queries. “Search queries” were used in Internet search engines to answer these small tests. The aggregated text data was mined and processed into a co-occurrence network diagram that revealed the “unlearned knowledge” of the learning population. Additionally, multivariate analysis based on the question categories was performed on the text-mined data. The results indicated that search targets differed by question type, and there were variations in the relationship between search frequency and correct response rate. These findings suggested that this search query system and its visualized learning outcomes could be used to identify areas for improvement in lecture contents and the quality of pharmacy education.

  • Mai Ikemura, Satoru Esumi, Sari Nakagawa, Yui Takezawa, Miho Harada, M ...
    Article type: Original Article
    2025Volume 9 Article ID: e09047
    Published: 2025
    Released on J-STAGE: November 06, 2025
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    Supplementary material

    Objective: This study aimed to verify the educational usefulness of a “dispensing experience virtual reality (VR) training tool” in preparatory clinical education for pharmacy students in a large-scale group learning environment. Methods: The study involved fourth-year pharmacy students with no experience in dispensing medication, except for learning about measured dispensing of liquid medicines from a textbook. The respondents received a VR training session and completed a questionnaire afterward to evaluate their learning. Results: The survey revealed that 167 students (90.8%) “agreed” or “somewhat agreed” VR increased their motivation to learn beyond textbooks, and resulted in positive responses to the VR training. Regarding the reasons for this, students cited that VR made learning fun, allowed them to gain practical experience, and encouraged active participation. Discussion: The results proved that universities can implement this VR tool smoothly in group learning of more than 150 students and improve student motivation to learn. It will also be an effective means of employing Information and Communication Technologies (ICT) in future pharmaceutical education.

Short Communication
  • Chiharu Matsunobu, Tomonori Shiratani, Toshio Kubota
    Article type: Short Communication
    2025Volume 9 Article ID: e09001
    Published: 2025
    Released on J-STAGE: February 15, 2025
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    Some private Japanese universities have recently faced low student pass rates on the National Pharmacist Examination within the standard six-year pharmacy program. As a result, this study employed data on first- to third-year students’ academic performances to identify the students requiring learning support and apply a model Random Forest algorithm to predict whether the students would pass the National Pharmacist Examination. The average decrease in the Gini coefficient of the model using Grade Point Average (GPA) revealed that grades in the second semester of the third year were most significant for prediction. The receiver operating characteristic area under the curve (ROC_AUC) for the model using the GPA of first to third year of students enrolled in 2015 to predict the pass or fail rates of the National Pharmacist Examination for students enrolled in 2016 and 2017 was 0.86 and 0.75, respectively. Similarly, for the model employing specialized subject regular examination scores in the second semester of the third year, ROC_AUC was 0.80 and 0.74, respectively. The ROC_AUC of the model using specialized subject regular examination scores for the first semester of the second year was 0.69 and 0.67. These findings suggest that constructing a model to predict a pass or fail on the National Pharmacist Examination using GPA data from the first to third-year academic performance may help identify the students who require learning support early on in the program.

  • Chikusa Muraoka
    Article type: Short Communication
    2025Volume 9 Article ID: e09021
    Published: 2025
    Released on J-STAGE: July 16, 2025
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    Generative Artificial Intelligence (AI) technologies in education are spreading rapidly. In February 2024, this study investigated the publication status, content, and characteristics of “Notices on generative AI” from the websites of 79 pharmacy schools. In addition, the relationship between the presence or absence of AI notices and the Mathematics, Data Science, and AI Smart Higher Education (MDASH) accreditation was studied. A survey of publicly available information on the school websites revealed that 64.5% of universities have published notices on generative AI. These notices were classified into three types: warnings, assumptions of use, and restrictions/prohibitions. The adverse effects on education were more frequently referenced in the restrictions/prohibitions than in the other types. Furthermore, 56.9% of the universities were MDASH-accredited and published generative AI notices, whereas 20.2% were not and had not published. The ethical use of generative AI and its integration into education requires further research, with a continuous need to share information and guidelines among faculty members.

  • Yumiko Nishimura, Norihito Kanai, Noriko Kohyama, Takahiro Motegi, Tom ...
    Article type: Short Communication
    2025Volume 9 Article ID: e09031
    Published: 2025
    Released on J-STAGE: October 16, 2025
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    Supplementary material

    Since lifelong training assesses an individual’s attitude toward continued learning, the attitude toward education often remains passive. We hypothesized that understanding current competencies and the study needed to achieve attainment goals could foster an active attitude toward learning. This study aimed to develop a self-assessment rubric for competencies reflecting practical performance and to verify its validity. A self-assessment rubric was created with input from a certified instructor for a workshop focused on pharmacotherapy assessment and literature review. Sixteen workshop participants used the rubric to evaluate their competencies and understanding of its descriptions. These evaluations and learning behaviors were analyzed. Self-assessments indicated positive changes from before to after the study. Although characteristics differed between the courses, more than half of the participants showed moderate to high correlations between self-assessment and post-assessment growth rates in understanding content and completing pre-assignments. The results suggest the rubric’s validity and its potential to promote active lifelong learning behaviors.

Practical Article
  • Tokunori Ikeda, Ryosuke Imai, Keishi Yamasaki, Kazumi Shimono, Noriaki ...
    Article type: Practical Article
    2025Volume 9 Article ID: e09002
    Published: 2025
    Released on J-STAGE: March 15, 2025
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    Supplementary material

    In recent years, the need to establish educational management at universities has been recognized. The most important part of the management of teaching and learning is the embodiment of learning goals through three policies: Diploma Policy (DP), Curriculum Policy (CP), and Admission Policy (AP). AP has two required aspects: the growth of students after admission on the basis of DP and CP, and the qualities and abilities that prospective students should possess. Furthermore, it is recommended that the AP is organized and presented in relation to “three elements of academic ability.” The Department of Pharmacy at Sojo University’s Faculty of Pharmaceutical Sciences reviewed the three policies from 2022 to 2023 and revised them in April 2024. The revision of our AP is based on the three pillars of qualities and abilities (“knowledge and skills,” “ability to think/make decisions/express oneself and so on,” and “ability geared toward learning/human nature”) to be cultivated in the new Courses of Study, which is related to “three elements of academic ability” and is familiar to high school students. In this paper, we report our new AP with DP and CP.

  • Naoko Takenaga, Yumiko Komori, Koji Ueda, Kohta Kurohane, Shinsuke His ...
    Article type: Practical Article
    2025Volume 9 Article ID: e09003
    Published: 2025
    Released on J-STAGE: March 15, 2025
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    Supplementary material

    There were changes in the format of chemistry-related laboratory courses at Meijo University’s Faculty of Pharmacy from face-to-face lectures in 2019 to distance learning with on-demand video distribution in 2020. From 2021, online summary tests and skill and attitude evaluation lists were included to supplement distance learning. Additionally, face-to-face lectures were reintroduced to support experimental techniques in 2023. A program analysis examined the experimental methods of students in 2022 and 2023 and the effects of these initiatives at various evaluation points, revealing several differences between the two years. While the 2022 students achieved higher results in crude rutin yield, the 2023 students performed smoothly in recrystallization. It was considered appropriate to continue delivering remote and face-to-face lectures while addressing any new issues that may develop throughout the program.

  • Naoko Takenaga, Koji Ueda, Kohta Kurohane, Yumiko Komori
    Article type: Practical Article
    2025Volume 9 Article ID: e09007
    Published: 2025
    Released on J-STAGE: April 03, 2025
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    Supplementary material

    Laboratory training courses in post-secondary education essentially build a foundation for creative activities and enable students to acquire data interpretation and critical thinking skills. In pharmaceutical sciences, these practical courses cultivate the scientific thinking required of pharmacists. At Meijo University, the Instrumental Analysis Practicum, introduced in 2023, allowed students to engage in spectroscopic analysis, including nuclear magnetic resonance (NMR) and infrared absorption spectrometry (IR). Tests were administered before and after the practical program in 2024 to measure increased student understanding of NMR and IR after classroom lectures. The effectiveness of this approach was assessed by analyzing pre-test and post-test scores and conducting text-mining and a customer satisfaction (CS) analysis on student surveys. The results indicated a distinct level of educational effectiveness in aligning classroom lectures with practical training, thereby contributing to the development of pharmacists with a robust scientific mindset.

  • Ryo Konno, Fumitake Okabe, Daiki Nagakubo
    Article type: Practical Article
    2025Volume 9 Article ID: e09012
    Published: 2025
    Released on J-STAGE: April 15, 2025
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    This study aimed to evaluate a newly developed physical education class designed to reduce pharmacy students’ dislike of physical education and enhance their communication skills (CS). It also sought to explore the relationship between aversion to physical education and CS. Participants were surveyed about their likes and dislikes and CS before and after attending the class and encouraged to freely describe any reasons for changes following their participation. The findings indicated that an effective physical education class fosters an environment where failure in sports is acceptable, emphasizing enjoyment over motor skill proficiency. This is particularly important because many pharmacy students are thought to harbor a dislike for sports. Additionally, incorporating group activities and strategy sessions that require collaboration and communication with peers proved beneficial. Therefore, the newly developed physical education class shows promise in mitigating students’ aversion to physical education while simultaneously improving their CS.

  • Yuki Yasutaka, Nanako Tone, Kenichi Mishima, Hidetoshi Kamimura
    Article type: Practical Article
    2025Volume 9 Article ID: e09036
    Published: 2025
    Released on J-STAGE: September 11, 2025
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    In Japan, a super-aged society, the number of patients with dementia is increasing, highlighting the importance of pharmacists’ roles in dementia care. However, opportunities for pharmacy students to learn about dementia care during long-term practical training are limited. To address this, Fukuoka University Hospital introduced a new practical training program in 2024 to help pharmacy students gain a deeper understanding of pharmacists’ roles in dementia care. This study evaluated the program’s educational effectiveness through self-assessment questionnaires and report analysis conducted before and after the training. The results showed a significant improvement in students’ self-assessments across all items, particularly in their understanding of delirium pharmacotherapy, its risk factors, and the roles of pharmacists and other healthcare professionals within dementia care teams. Furthermore, participation in dementia care rounds provided students with concrete opportunities to learn about interprofessional collaboration and the specific roles of pharmacists. The introduction of this dementia care training program was found to be beneficial in enhancing pharmacy students’ practical knowledge and understanding of dementia care, contributing to the development of their professional competencies as future pharmacists.

  • Mai Aoe, Tadashi Shimizu, Sumio Matsuno, Hidekazu Ouchi, Noriaki Nagai ...
    Article type: Practical Article
    2025Volume 9 Article ID: e09033
    Published: 2025
    Released on J-STAGE: October 18, 2025
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    Supplementary material

    Organic chemistry is a challenging subject for many pharmacy students. To address this issue, a mobile app called Chemical Structural Formula Karuta (hereafter referred to as the Karuta Application) incorporated gamification elements to assist learning. This study aimed to clarify the educational usefulness and areas for improvement of the Karuta Application and identify the characteristics of students well-suited to its use. First- to fourth-year pharmacy students answered questionnaires and knowledge acquisition tests and were then classified by cluster analysis based on their responses to the pre-questionnaire. The results found that the group exhibiting a high affinity for gaming, even among students who disliked organic chemistry, demonstrated high app utilization. However, student engagement did not translate into a statistically significant improvement in examination performance. These findings suggested that while the Karuta Application had the potential to enhance learning motivation, sustained learning with regular classes and periodic encouragement from educators was necessary to improve learning outcomes.

  • Hiroko Sakurai, Daiya Kato, Takeshi Honma, Atsuo Inomata
    Article type: Practical Article
    2025Volume 9 Article ID: e09043
    Published: 2025
    Released on J-STAGE: November 11, 2025
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    This study examined the implementation and educational impact of information ethics instruction in the early years of pharmacy education. Tokyo University’s Faculty of Pharmacy and Life Sciences offered an elective course titled “Information Society and Ethics” to first- and second-year students. The course included eight 90-minute weekly sessions that covered topics such as information security, cryptographic technologies, real-world cyberattacks, personal data protection, electronic prescriptions, and information and communication technology (ICT) in healthcare. At the conclusion of the course, 110 students completed a self-assessment survey. The survey results indicated that 97.3% of the students recognized the importance of information ethics in pharmacy practice. Students also reported a heightened awareness of information-related risks in daily life, particularly those associated with social media and email. However, several students also expressed difficulty in understanding the technical content and uncertainty regarding their ICT competencies. These findings suggested a need for additional support through repeated instruction, quizzes, and knowledge-check activities, as well as a medical-themed incident response board game for experiential and collaborative learning. Overall, this instructional model yielded positive results, demonstrating that the early integration of information ethics and literacy, through both lectures and interactive methods, effectively strengthened the pharmacy students’ understanding of data security, ethical responsibilities, and practical risk management. The inclusion of information ethics in pharmacy curricula will prepare future pharmacists to manage sensitive data in ICT-dependent healthcare systems.

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