Pharmacists are health professionals responsible for preparing, dispensing, and re-viewing therapy, providing pharmaceutical consultations, advising patients, and developing new medicines or implementing and validating clinical or genetic analyses, among other functions ^[1][2][1,2]. Both the World Health Organization (WHO) and International Pharmaceutical Federation (FIP) advocate that pharmacy students need to be prepared to address future digital health patients’ needs, such as the provision of telehealth consultations with patients. Consequently, healthcare students need to develop new skills to use online health tools or to orientate patients on the use and comprehension of digital technologies, with e-learning methodologies facilitating the teaching and acquisition of these skills ^[3][4][3,4].

E-learning commenced long ago, with one of the first reports about online education at the University of Illinois, USA, in 1960 [5]. Before the COVID-19 pandemic, online pharmacy education was already successfully and routinely applied to provide continuing education, with high rates of pharmacy students’ acceptance [6]. The COVID-19 pandemic was declared by the World Health Organization on 11 March 2020, with a global outbreak of coronavirus, an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [7]. Because of the COVID-19 outbreak, there was a shift from face-to-face teaching to online teaching, due to the successive lockdowns imposed by the health authorities at a global level. Healthcare teachers, such as pharmacists, nurses, or physicians, were also forced to cancel face-to-face classes and adopt online teaching [8].

Several benefits and/or problems related to teaching pharmaceutical sciences have been identified during the COVID-19 pandemic. The benefits of online teaching were as follows: being more comfortable, spending less time in transport, and having more time for family, among others ^[9][10][9,10]. However, several problems related to online teaching were also identified, such as spending too much time on screens, less communication/interaction with colleagues and teachers, more anxiety and mental problems, less knowledge acquisition, more difficulty in consulting/understanding study materials, less acquisition of new practical/laboratorial skills, and more distractions at home ^[11][12][11,12].

Laboratorial and practical classes are common in pharmacy studies. However, the provision of online lab classes is complex to implement and operate ^[1][2][1,2]. Practical and laboratory classes were canceled or adapted for online teaching in health courses during the COVID-19 pandemic, with a likely reduction in the acquisition of new laboratory skills by students [9].

Overall, students pointed out diverse strengths regarding the internal environment of pharmacy schools. These strengths were organized into five topics: (1) students; (2) materials and teachers; (3) technologies; (4) classes/training; and (5) faculty/school of pharmacy and other variables.

In general, pharmacy students declared improved feelings, such as self-confidence, acceptance, engagement, satisfaction, motivation (e.g., hedonic motivation), intellectual development, and security in relation to patient interactions (e.g., virtual patients) or a positive general perception about online education ^{[8][13][14][15][16][17]}[8,13,21,39,43,57]. Students declared being satisfied with the possibility of applying previous computer or other technological skills (e.g., “I have satisfactory computer skills for dealing with online course/assignments”) ^[18][48], and students recognized the usefulness of e-learning (e.g., “My attention to the class tasks during e-learning session was greater in comparison to the traditional face-to-face class meetings”) ^[19][24].

Visual aids, videos, and interactive materials were shown to be attractive materials/documents for pharmacy students. For instance, audiovisual enhanced illustrations encouraged students to interact with the lecture material prior to the virtual class ^[19][20][21][24,44,46]. Additionally, it was possible to have access to information in different formats, such as patient digital health records or digital biomarkers, which may lead to the study of new relevant topics in pharmacy practice ^[22][56]. Students’ satisfaction with the quality of developed materials (e.g., type of covered topics—more or less interesting or too challenging e-learning materials) and/or teachers’ performance was evaluated and reported in a limited number of studies ^[18][21][23][38,46,48].

Considering that digital health education is widely used at a global level, disruptive teachers capable of using innovative technologies and e-learning methodologies are needed in the future of pharmacy education ^[24][47]. For instance, flipped e-learning activities could draw pharmacy students’ attention, motivate students, increase fun, encourage students to prepare lectures, improve concentration, raise the level of interactions, and provide more time for activities and exercises during the class ^[21][46].

Besides the internet, IT infrastructures, laptops, tablets, and mobile phones, other devices may be required (e.g., for augmented reality) [3]. Many students prefer smartphones for online access, but tablets and laptops were also satisfactorily used ^[25][26][22,30].

The gradual translational rotation to a new technological environment at pharmacy schools, necessarily, implies the development of innovative study methodologies and students’ adaptation. Examples regarding clinical pharmacy and telemedicine include active learning sessions or digitally adapted games, virtual patient software, augmented reality, chronic disease management, and medication review through software applications ^[27][28][32,33].

Online education offers the opportunity of introducing new technologies, which in general positively impact students’ perceptions and satisfaction, such as the perceived ease of use of e-learning platforms by students (e.g., “I find the e-learning system easy to use”) ^[19][24]. Artificial intelligence (AI), bots, big data, blockchain, robotics, barcode dispensing, management of patient health records, and computer-based support systems for decision making, among other innovations, are being introduced to pharmacy education ^{[3][22][24][29]}[3,47,55,56]. Students are required to learn how to use these innovations during online education, which can also be applied to clinical settings. Overall, technological innovations are expected to revolutionize the future of pharmacy education, healthcare professions, and patient care [3].

E-learning can be used to provide online theoretical, practical, or other types of classes (e.g., storytelling classes), to record classes, to give access to documents and other materials, to publish grades, to provide exams, or to ensure communication between students, between students and professors, or between professors, among others. Thus, e-learning offers the opportunity of implementing more flexible programs ^{[26][29][30][31][32][33]}[26,29,30,42,52,55]. Online classes and training sessions should be designed to ensure students’ knowledge acquisition and improve students’ skills and competencies, such as the use of technologies to help patients in managing their therapeutic regimen (safety and efficacy issues) [3].

During online training, pharmacy students have the opportunity to participate in virtual teleconsultations, real online practices, or consultations involving simulated patients, with the incorporation into patient care and the teaching–learning process ^[24][34][40,47]. Online pharmaceutical consultations may benefit from access to patients’ clinical data, which can raise confidentiality or data security issues ^[22][35][51,56]. For instance, virtual objective structured clinical examinations (OSCEs) promoted the acquisition of knowledge and competencies through real-life situations, with positive student opinions ^[36][45]. The positive aspects of OSCEs included schedule flexibility, decreased levels of anxiety, a higher sense of security, improved knowledge, satisfaction, communication, and better patient counseling (e.g., diabetes management, dispensation of over-the-counter medicines, warfarin initiation, or self-care aspects) ^{[25][34][36][37][38]}[22,28,36,40,45].

Positively, online classes were classified by students as more flexible and versatile and less time-consuming since students could set their own pace (better time management) or spent less time traveling ^[10][33][10,52]. Many pharmacy students manifested a positive opinion about the diversity of online resources, such as forums, quizzes, videos, or games ^[27][28][32,33]. Students’ acquisition enforcement was also pointed out as an advantage since pharmacy students can choose when to see recorded classes: lectures or workshops ^[29][30][26,55]. Practice readiness was also classified as a positive issue, regarding the easy implementation of digitizing scoring systems or the facility of contacting teachers or colleagues or receiving scores and tasks through different applications ^[29][39][40][37,50,55].

The availability of technical support by schools (e.g., hardware/software assistance); the possibility to receive interprofessional training, join in internships or postgraduation courses, and participate in continuing education during e-learning classes; and the chance to be involved in the development, evaluation, or validation of e-learning (e.g., team debates, focus groups) were among the variables related to pharmacy undergraduates’ positive perceptions ^{[17][18][24][31][33][41][42][43]}[23,29,35,41,47,48,52,57].

The weaknesses related to the internal environment were grouped into four groups: (1) students—human interactions and communication; (2) students—other; (3) online classes; and (4) technologies.

In general, students reported dissatisfaction regarding the lack of communication, networking, and human interactions with their teachers, colleagues, patients, experts, and others ^{[18][29][30][44]}[26,48,54,55]. Absent or decreased interactions contributed to students’ social isolation, missing colleagues, limited development of social skills, students’ negative emotional responses (e.g., less positive attitudes), and possible communication barriers during virtual learning (e.g., lower predisposition to clarify doubts or to ask/reply to questions) ^[20][30][26,44]. Thus, the acquisition of new communication skills (e.g., eye contact or talking slowly) seems to be essential to communicate online (e-communication) with peers or patients. Specific communication competencies are needed in the healthcare professions, such as promoting students’ consciousness, empathy, culture of care, or humanity, while respecting patients’ rights, for instance, during digital pharmaceutical consultations ^[24][47].

Some pharmacy students classified e-learning as not effective or helpful ^{[8][13][14][15][16][17]}[8,13,21,39,43,57], which confirms that online education can present some constraints/limitations. For instance, less knowledge acquisition was reported with e-learning in comparison to in-person sessions in some studies ^[11][12][11,12]. These findings confirm the need to regularly check the quality and effectiveness of online education in all schools of pharmacy.

The risk of cheating in online assessments was an underreported issue ^[29][41][23,55] which should be carefully evaluated in future studies. In particular, assessments based on closed-ended questions (i.e., when students can choose one (or more) correct options from a group of statements/predetermined answers) should be carried out in person to avoid the possibility of cheating. Additionally, students can be required to declare the non-use of artificial intelligence (AI) tools when elaborating monographs, theses, or other written works.

The worst e-learning experiences were reported by students with a lack of past experience in using online tools or limited digital literacy. The students’ difficulties in using digital technologies can be justified by poor digital literacy, a lack of active participation in the digital society, or living in a developing country (digital divide) ^{[16][20][24][44]}[43,44,47,54]. Ideally, students’ digital skills should be evaluated before the provision of online education to ensure that digital tools are effectively used.

There was an eventual degradation of the quality of education, with some students declaring being unsatisfied and less motivated. For instance, students’ acquisition of knowledge, skills, and competencies was negatively affected in some studies (e.g., practical and laboratorial classes) ^[15][29][45][39,53,55]. In general, the provision of lab classes was recognized as more difficult/complex online than in-person, although some strategies can be adopted, such as the use of recorded videos to demonstrate key practices, submission of videos, role-plays, or using the MyDispense software ^[41][46][23,27].

Pharmacy students have identified diverse issues related to e-learning methodologies, such as complex e-learning materials, the inexistence of instructions/norms, unfair or complex assessments, and impractical evaluation platforms, among others ^[18][29][48,55]. Thus, specific training to optimize the administration or reception of online courses/classes may be necessary ^[24][47]. Teachers should clearly explain, through oral and written instructions, the access to materials and how classes and assessments will be carried out online. Additionally, the usability and intelligibility of online platforms should be pretested by students and teachers (e.g., simulated students’ assessments). These procedures are expected to increase students’ comprehension of online assessment methodologies, regarding the quality of online assessments seems to have an impact on students’ satisfaction.

Students reported dissatisfaction with low speed and instability of the internet or other connection issues, besides the need for appropriate hardware, software, and internet, which implies monetary investments ^[46][27]. Thus, the provision of technical support by faculties is essential to ensure the appropriate implementation of e-learning sessions ^[17][57].

Additionally, some pharmacy undergraduates manifested e-learning disapproval if social networking tools were not used (e.g., “avoiding commonly used online tools such as YouTube and Facebook by instructors”), if the used e-learning tools were too complex, or if electronic devices such as smartphones or tablets were not used ^[18][47][48,58]. Students perceived the usefulness or awareness of online platforms as essential to their acceptance of e-learning ^[14][21]. The use of advanced and usable computer-based platforms, with the offer of an e-learning environment similar to face-to-face teaching, was preferred (e.g., ZOOM) ^{[16][20][25][29]}[22,43,44,55]. Preferably, usability testing of online education systems should regularly be evaluated and monitored by students and teachers.

The opportunities related to the external environment were grouped into two groups: (1) students and (2) classes.

Students pointed out as advantages that they could access classes anywhere or living away from educational institutions, with saved time and reduced costs ^[18][29][48,55]. E-learning is more economical and sustainable than in-person classes (e.g., digitization of materials or an ecological footprint). In general, students felt improved family conviviality and comfort, with a likely better quality of life at home ^[20][28][33,44].

E-learning seems to be a more immediate educational methodology. For instance, it ensures quicker contact with teachers or other academic staff through proper communication online channels (e.g., chats) or permanent access to online materials everywhere (24 h days) ^[28][29][33,55]. Additionally, online education offers the chance to receive external training from private or public health authorities, community or hospital pharmacies, regulators, the pharmaceutical industry, or other organizations, with a likely higher diversity of courses and content. These courses can cover wide audiences without space constraints, if necessary.

The threats related to the external environment were grouped into three groups: (1) students’ well-being, (2) classes, and (3) technologies.

There is an increased risk of pharmacy students’ psychological problems (e.g., online exam phobia, frustration, anxiety, worries, or stress) or physical disorders/well-being compromise (e.g., posture and vision issues due to long-time screen use) ^{[14][29][48][49][50]}[21,31,34,49,55]. Stress can be justified by students’ psychological distress, inexperience, and unpreparedness, regarding online education ^[14][21]. Academic uncertainty, job insecurity, and dissatisfaction with e-learning activities can negatively affect students’ mental health. Fewer social interactions with colleagues outside of classes may also justify students’ dissatisfaction, social isolation, and frustration ^[48][31].

Students are more likely to be distracted at home, which may be due to the presence of family members (or other persons) or a higher opportunity for leisure activities ^[8][13][8,13]. There is low resistance to tobacco or unhealthy foods because students can become more anxious at home ^[48][31]. The obligatory acquisition of a laptop/tablet or the internet bill increases costs, which may explain pharmacy students’ dissatisfaction in some cases ^[25][22].

The presence of other family members at home may raise confidentiality issues (e.g., pharmaceutical teleconsultations) and/or interfere with students’ concentration and activities during classes. Internet connectivity issues may lead to the interruption of classes (e.g., disconnection, poor audio and/or video quality, or power cuts) ^[14][20][21,44], which reinforces the importance of technical assistance by schools/faculties.

Barriers to access to online education, especially for economically and socially vulnerable students or students with low digital literacy, were identified. For instance, restrictions in access to electricity, the internet, or digital technologies are more prevalent in developing countries (digital divide) ^[24][44][46][27,47,54]. One risk/threat of using digital technologies is cybercrime or cybersecurity issues. Thus, students should install proper antivirus software, which also increase costs.

Strengths and weaknesses should be carefully evaluated and optimized since they are directly (or indirectly) related to pharmacy students’ satisfaction, self-confidence, engagement, and/or motivation. Both strengths and weaknesses can be integrated into the strategic planning of faculties. For instance, more online classes may be created, with the use of visual aids, interactive materials, and/or new disruptive technologies (e.g., use of AI during pharmaceutical consultations or the access to online patient data/databases), regarding strengths ^{[19][20][21][22][24][34]}[24,40,44,46,47,56]. Additionally, potential weaknesses should be carefully addressed. For instance, interactive tasks and group activities can be introduced during online classes to bridge the lack of human interactions and/or potential social isolation, the quality of e-communication and students’ knowledge acquisition or culture of care should be supervised since virtual interactions can be more problematic/limited than in-person interactions ^[11][12][24][11,12,47], technological issues (e.g., internet speed) should be solved, students with limited digital literacy should be identified and supported ^{[16][17][20][24][44][46]}[27,43,44,47,54,57], and the needs of unsatisfied pharmacy students’ with online education should be carefully identified and addressed, for instance, through using regular quality queries.

Opportunities and threats should be individually analyzed by each faculty/school of pharmacy. If necessary, opportunities as well as the solutions for threats should be integrated into the strategic planning of faculties, since opportunities need to be strengthened (e.g., tailoring the number and type of online classes according to the needs of students) and threats need to be avoided (e.g., ensuring regular supervision of students’ well-being or the availability of adequate technological means for the less favored students).