A novel approach to Introductory Pharmacy Practice Experiences: an integrated, longitudinal, residence-based program

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Currents in Pharmacy Teaching and Learning 3 (2011) 41–52 http://www.pharmacyteaching.com

Put it into Practice!: Experiential Tidbits

A novel approach to Introductory Pharmacy Practice Experiences: an integrated, longitudinal, residence-based program T. Lynn Stevenson, PharmDa,*, P. David Brackett, PharmDb a

Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, AL b Pharmaceutical Care Center, Harrison School of Pharmacy, Auburn University, AL

Abstract Objective: Introductory pharmacy practice experiences (IPPEs) became part of accreditation standards for schools of pharmacy in 2004. However, a novel practice experience program that places students in the community visiting patients began at Auburn University Harrison School of Pharmacy in 1997. This article will describe the structure and success of our IPPE program. Methods: This IPPE is a longitudinal program that spans the first three professional years and focuses on patient care in residential settings. Student pharmacists and faculty collaborate in managing a patient caseload. During patient visits, student pharmacists conduct interviews and assessments that are then presented at weekly team meetings. Faculty members provide supervision and guidance to students during these meetings. Students document patient interactions in an electronic record. Teams meet to discuss patient status and explore patient care issues. Student pharmacists, faculty mentors and the IPPE coordinator make interventions on behalf of the patient if needed. Results: Over the past four academic years, almost 97% of students have received grades of either satisfactory or excels. Student pharmacists’ success in the course has been high and positive student feedback has been expressed through course evaluations and student focus groups. Conclusion: This IPPE program is part of the culture of Harrison School of Pharmacy and provides student pharmacists with relevant, real-life pharmacy care responsibilities. The program teaches communication, patient and drug therapy assessment, health care issues, and promotes professional socialization. The program’s design is a unique method for providing introductory pharmacy practice experiences. © 2011 Elsevier Inc. All rights reserved. Keywords: Introductory pharmacy practice experiences; Experiential learning; Pharmacy care

Introduction The Accreditation Council for Pharmacy Education (ACPE) Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree (2007) focus on the “development of students who can contribute to the care of patients and to the profession by practicing with competence and confidence in collabo-

* Reprint requests: T. Lynn Stevenson, Assistant Clinical Professor, Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, 1202-B Walker Building, Auburn University, AL 36849. E-mail: [email protected].

ration with other health care providers.” In addition, the Standards emphasize “the importance of the development of the student as a professional and lifelong learner” and “the development of students’ professional knowledge, skills, attitudes, and values, as well as sound and reasoned judgment and the highest level of ethical behavior.”1 Several important factors were noted by ACPE as important in the update of accreditation standards that went into effect in July 2007. These factors included the Institute of Medicine report,2 American Association of Colleges of Pharmacy’s Center for the Advancement of Pharmaceutical Education outcomes,3 the 2003 Medicare Modernization Act, and the Joint Commission of Pharmacy Practitioner’s Vision of Pharmacy Practice 2015.4 Medication therapy management

1877-1297/11/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.cptl.2010.10.010

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T.L. Stevenson et al. / Currents in Pharmacy Teaching and Learning 3 (2011) 41–52

and collaborative practice agreements, now part of many state pharmacy practice acts, were also noted to have played a role in these revisions. Important concepts within these position pieces and initiatives include patient-centeredness, collaborative practice, evidenced-based approaches, teamwork, professional behavior, responsibility, and optimal medication therapy outcomes. Introductory and advanced pharmacy practice experiences (IPPEs and APPEs) are significant components of pharmacy curricula and offer opportunities for these concepts to be taught and applied. Our school has attempted to create an IPPE program that encompasses these concepts. A review of the literature of the past decade shows that schools/colleges of pharmacy have used many different methods of early or introductory practice experiences (e.g., shadowing, practice site visits, interdisciplinary experiences, vaccination administration, modules on specific topics/activities, patient visits/interviews and presentations, blocks of practice experiences, health screenings, and service learning).5-16 Early practice experiences were piloted at Auburn University School of Pharmacy in the fall of 1991. These practice experiences have been described by Thomas et al.17,18 and Beck et al.19 Thomas et al. described and assessed a Continuous Community Pharmacy Practice Experience (CPPE).17,18 In the CPPE, students cared for a “patient family” under the supervision of a community pharmacist preceptor and a faculty adviser. Students completed six learning modules during this two-year longitudinal program. These learning modules were developed to be integrated with other didactic coursework and stimulate student self-directed learning.17 Students and preceptors in this program reported that the learning experience was valuable. Although the assessment of this program did not show significant changes in student attitudes, motivation, and professionalization, the study likely lacked adequate power to detect such differences.18 Beck et al. have also described a concept of an introductory practice experience based around the goals of achieving “professional socialization and internalization of pharmaceutical care.”19 In this concept, students worked toward these goals in teams, taking care of individuals in a community setting. Using these two models as a guide, the faculty at Auburn University Harrison School of Pharmacy (HSOP) developed and implemented an IPPE program that has been a component of the curriculum in the first three professional years since 1997. This IPPE program at HSOP through its evolution has become more than just courses in the curriculum. It has contributed to the development of a culture of patient care within the school and now represents a component of the school’s institutional commitment to patient care. Recently, additional components in community and institutional pharmacy settings have been incorporated into our IPPE program to address accreditation requirements. The purpose of this paper is to describe the integrated, longitudinal, residence-based portion of our IPPE program.

Rationale/Objectives There are five primary goals of the IPPE sequence20: ● To involve student pharmacists in the provision of pharmacy care ● To promote professional socialization ● To develop reflective thinking skills ● To provide the community with meaningful assistance with health-related needs ● To provide outreach to the community as an additional resource for health information and advocacy Specific objectives of the IPPE program are outlined in Fig. 1. Our institution has established ability-based outcomes desired in graduates. Table 1 provides a description of the expansion of student pharmacists’ responsibilities across the IPPE program’s three professional years and shows the link between these responsibilities to programmatic goals and HSOP’s ability-based outcomes. The IPPE program is designed to prepare students for patient care responsibilities during the APPE.

Methods The HSOP is located in Auburn, AL, which is a small city situated in a rural area of east central Alabama. HSOP recently established a satellite campus located on the campus of the University of South Alabama in Mobile, AL. Enrollment has increased over the past few years to a current class size of 148 to 150, with approximately 16% of the student pharmacists on the Mobile campus. This project was reviewed and exempted by the Auburn University Institutional Review Board. Team structure First (P1)-, second (P2)-, and third (P3)-year student pharmacists are divided and placed as evenly as possible onto 26 teams, with approximately five to six students from each class. Eight teams include students from both the Auburn campus and the satellite campus, allowing for direct interaction between these students. Teams consist of students and faculty with varied characteristics, backgrounds, and experience in an effort to promote cultural diversity. Each team is precepted and mentored by two to three faculty members. All faculty, including department heads and Deans, serve as “attendings” to the teams. The faculty attendings review the status of patients, provide guidance on patient care activities, promote student learning, act as role models, serve as the final authority for patient care decisions, and provide student assessment and evaluations for the course. At least one of the faculty attendings for each team is located on the Auburn campus and at least one is a clinical faculty member in the Department of Pharmacy Practice. Student pharmacists (P4s) on APPE rotations with practice faculty may also be involved in the program and

T.L. Stevenson et al. / Currents in Pharmacy Teaching and Learning 3 (2011) 41–52

43

Figure 1. IPPE program objectives.

assist with patient care, as well as serve as role models for the other students. Patient enrollment/interactions Patient recruitment efforts include Office of Experiential Learning (OEL) faculty and staff attendance at health fairs and other local community events, promotion of the program to individuals at local independent and assisted living facilities, and communication via mass media (electronic newsletters and newspaper) to the university and local community. Referrals may also come from physicians and other health care providers, current patients, facility administrators, student pharmacists, faculty, and staff. Patients volunteer and provide consent for their participation in the program. All patients are screened and educated about the IPPE program by professional staff from the OEL. Criteria for enrollment include having at least one chronic disease state that requires medication therapy and a willingness to have students visit them regularly in their place of residence. Patients reside in individual homes, independent and assisted living facilities, and long-term care facilities. Patient demographic information is maintained in a database, which serves as a patient registry for administrative monitoring of

patient caseload statistics. This database is also used to manage contact information of individuals interested in the program and track information related to facilities (independent living, assisted living, and long-term care) participating in the program. All patients are enrolled in the Auburn University Pharmaceutical Care Center (AUPCC), the pharmacy clinic located within HSOP. Patient health records are maintained electronically within this clinic. The AUPCC is currently staffed by a clinical pharmacist and two to three pharmacy practice faculty. A medical director oversees patient care with all intervention recommendations communicated to and authorized by the individual patient’s medical provider. The goal for each team’s assigned caseload is at least 16 to 18 patients. Patients are generally maintained on the same team from year to year to allow for continuity of care and maintenance of established professional relationships between the student pharmacists and patients. Team members share a common responsibility for ensuring proper care for all assigned patients. Each team creates subteams consisting of one P3 leader plus two to four P1s and P2s to distribute the patient caseload. Student peer mentoring is an important component of the IPPE program because student pharma-

44

Table 1 Student pharmacists’ responsibilities within the IPPE Sequence and Relationship to Program Goals and Abilities-Based Outcomes* Year 1

Year 3

Program Goals

Curricular Outcomes

●

●

Assume leadership responsibility for all patients on the team Assist P1 and P2 students in identifying medication-related problems and developing care plans Maintain a database, documenting each patient’s medications, current problems, care plan, and times for follow-up Document patient care via SOAP/ progress notes

●

● 1, 3, 4, 6–8

●

Involve students in the provision of pharmacy care Provide the community with meaningful assistance with healthrelated needs

Mentor P1 and P2 students Assume team leadership roles

●

Promote professional socialization

● 5, 6, and 8

Demonstrate professional behavior as outlined in Performance Evaluation Rubric (Figure 2) Serve as role model for P1 and P2 students

●

Involve students in the provision of pharmacy care Promote professional socialization Provide the community with meaningful assistance with healthrelated needs Provide outreach to the community as an additional resource for health information and advocacy

● 5–8

Involve students in the provision of pharmacy care Develop reflective thinking skills

●4

●

● ●

Routinely perform the patient work up process (involves drug therapy assessments and identification of medication-related problems) Learn about the patient’s diseases and use this information to further expand the patient database Routinely update patient care plans Document care via SOAP/progress notes

●

●

●

Team Responsibilities ● Participate as an active team member and fulfill assigned responsibilities Professionalism ● Demonstrate professional behavior as outlined in Performance Evaluation Rubric (Figure 2)

● ●

●

●

Mentor P1 students Promote open discussion and problem-solving within the team

●

Demonstrate professional behavior as outlined in Performance Evaluation Rubric (Figure 2) Serve as role model for P1 students

●

●

●

● ●

●

Self-Learning Abilities ● Demonstrate ability to reflect and learn from service-learning experiences

● Demonstrate ability to perform self-directed learning about disease states and drug therapy as patient problems are encountered

1. Evaluate pharmacotherapy 2. Provide appropriate pharmacotherapy interventions 3. Ensure appropriate drug distribution 4. Maintain and enhance competence through self-initiated learning 5. Manage the pharmacy within the organization’s business plan 6. Develop practice and leadership 7. Participate in public health and professional initiatives and policies 8. Advance the profession * Adapted from Krueger JL, Beck DE.21

● Anticipate team learning needs and perform self-directed learning about those topics

● ●

T.L. Stevenson et al. / Currents in Pharmacy Teaching and Learning 3 (2011) 41–52

Patient Care Responsibilities ● Establish a student pharmacist- patient relationship ● Help an individual in the community by assisting with daily life needs ● Initiate development of a patient database ● Routinely perform basic assessment of patient’s vital signs ● By middle of year, document patient care via SOAP/progress note(s)

Year 2

T.L. Stevenson et al. / Currents in Pharmacy Teaching and Learning 3 (2011) 41–52

cists from all three classes work collaboratively to care for their patients. Subteams have primary responsibility for three to six patients and establish a schedule for visiting them. Individual students may visit a patient, but most visits involve two to three students. Visits occur at a frequency of the patient’s choosing or as dictated by their pharmacy care needs. The initial goal of the IPPE program is to develop patient-student pharmacist relationships. These relationships form the foundation for the provision of pharmacy care wherein student pharmacists, working with attending faculty, attempt to identify, solve, and prevent drugrelated problems and achieve optimal drug therapy outcomes. During the first year of the IPPE program, minimal expectations are for the student pharmacist to begin to use basic pharmacy practice skills (e.g., patient interviewing, obtaining vital signs, patient care documentation). As student pharmacists progress to the second year and into the third, they are expected to use new knowledge, skills, and abilities to become more involved in medication therapy assessments and solving drug-related problems. To assist in caring for patients, student pharmacists are expected to engage in self-directed learning beyond what they encounter in other coursework. In addition, student pharmacists are expected to assume increased leadership responsibilities as they progress. This culminates in the P3 year, where they will lead a subteam, provide feedback on Subjective/Objective/Assessment/Plan (SOAP) notes written by P1 and P2 student pharmacists, and alternate the role of chairing weekly team meetings. Leadership is one of the specific components assessed in the P3 year. All patient care activities provided in this program are undertaken through communication and guidance from clinical practice faculty. Faculty attendings monitor patient care through discussions in team meetings, electronic patient care records, personal patient care visits, or visits by the IPPE course coordinator. Faculty attendings are accessible to student pharmacists via phone and e-mail on an ongoing basis. Interventions are not communicated to patients or implemented without prior approval from a faculty attending. During patient visits, student pharmacists engage in patient interviewing and medical histories, physical assessment (e.g., blood pressure, pulse, weight, respiratory rate, blood glucose, assessing extremities for edema) and medication therapy review. Another important component of patient interactions is education on many topics, such as adherence, diet, exercise, wellness, and medications. Patient visits may also occur in the AUPCC on the Auburn Campus. Patient care is maintained through holiday breaks and summers for all patients identified as having significant pharmacy care needs. P4 student pharmacists and underclassmen in Special Topics elective courses may assist the course coordinator with this extended care.

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Program schedule and activities The IPPE program provides continuous, integrated practice experiences where patient and team interactions begin the first week of classes in the fall semester each year and continue for three full academic years. The program is administered as six 2-credit-hour courses. IPPE-related activities include patient visits, weekly team meetings, documentation (SOAP notes and reflections), patient care follow-up, presentations, research of learning issues, and health/wellness events. Throughout each semester, student pharmacists make 30- to 60-minute visits with patients and document their patient care interactions (SOAP notes) in a web-based, Health Insurance Portability and Accountability Act (HIPAA)-compliant electronic patient record. Student pharmacists are also required to write reflections on professionalism and patient care interactions. Each week of the academic calendar, student pharmacists attend their onehour team meeting to discuss patient care issues, disease states, and medications. Students are expected to research patient care issues or questions that arise during team meetings, prepare for patients’ questions, as well as develop presentations on patients and disease state topics. An endof-semester debriefing paper is also required of all students. Recently, student pharmacists have begun to document their time for IPPE-related activities in an electronic tracking system. Although patient care activities or team learning needs may dictate otherwise, there are minimum semester requirements for each student pharmacist. These minimum requirements are shown in Table 2. Student pharmacists are expected to go beyond these requirements to meet patient care needs. Documentation Documentation of patient visits is maintained in an electronic charting system, creating a permanent pharmacy care record within the AUPCC. All patient visits are documented by a student pharmacist in the electronic record using the SOAP format. First-year student pharmacists are expected to begin writing SOAP notes no later than the second half of their first semester after learning the process in other coursework (skills laboratory). Student pharmacists must also write reflections about their patient care experiences. A specific two-page reflective assignment, called a debriefing paper, is required at the end of each semester. In this paper, student pharmacists are asked to write about the benefits and meaning of their experiences as well as their personal/ professional accomplishments within the IPPE program. The topics are standardized for each semester of the program and call for progressively more sophisticated reflections. In addition to patient care reflections and debriefing paper topics, student pharmacists are also required to document reflections on professionalism and professional goals each semester. All reflections and debriefing papers are submitted and maintained in an electronic student portfolio.

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T.L. Stevenson et al. / Currents in Pharmacy Teaching and Learning 3 (2011) 41–52

Table 2 Minimum student pharmacist requirements for IPPE Documentations Rank

Sem

Visits*

SOAPs*

PCR*

PR*

Co*

DBP

P3

Fall Spring Fall Spring Fall Spring

10 10 10 10 10 10

4 4 2 3 1 2

0 0 2 1 3 2

1 1 1 1 1 1

1 1 1 1 1 1

1-Summer IPPE 1-End of semester 1-End of semester 1-Summer IPPE 1-End of semester 1-End of semester 1-End of semester 1-End of semester

P2 P1

FP* 1 1 1

Sem ⫽ semester; PCR ⫽ patient care reflections; PR ⫽ professionalism reflections; Co ⫽ coaching meetings with mentor; DBP ⫽ debriefing paper on assigned topics; FP ⫽ formal presentation. * These are MINIMUM requirements. Patient care and student/team learning needs may dictate need for additional visits, documentations (SOAP notes, reflections), coaching meetings, or need for additional formal/informal presentations during team meetings.

Team meetings Third-year student pharmacists direct (chair) weekly team meetings that are facilitated by the faculty attendings. The P3s rotate the role of chair throughout the semester. When serving as chair, the P3 sets the agenda and leads the meeting. Meetings usually begin with brief patient rounds where the student pharmacists report on their patient caseload and provide follow-up on learning issues that were generated at the last meeting. Most meetings also include a formal presentation (e.g., patient, disease state, other pertinent topic) by one student pharmacist. A schedule for presentations is set at the beginning of each semester by the team’s P3s and is approved by the faculty mentors. Student pharmacists rotate presentation responsibilities throughout the academic year. The remainder of the team meeting consists of a variety of activities as agreed upon by the team. Some examples include clinical topic discussions, coaching activities, team-building activities, practicing patient-care skills, discussions of current topics in health care, relevant issues in pharmacy practice, journal clubs, and professional development topics. Team meetings involving faculty and student pharmacists from both campuses and other off-campus practice sites are conducted through video conferencing. Patient care interventions During the course of working with a patient caseload, opportunities may present that allow the team to collaborate on definitive interventions on behalf of their patients. These interventions often consist of recommendations to the patient’s medical provider regarding medication therapy. Interventions may also include communication with medical providers and/or the community pharmacist for clarification of medication therapy, adherence assessment, or prevention of drug-related problems. Student pharmacists, led by a P3, are required to draft written communication to physicians with regard to recommendations for medication therapy. This document is then reviewed and approved by the team’s faculty attending. The written recommendation is then provided to the course coordinator who facilitates delivery (via

fax) of the document to the physician under the auspices of the AUPCC. Urgent recommendations are communicated via phone by the faculty attending or course coordinator. Student pharmacists may also help facilitate medical evaluation based on patient needs. Student pharmacists often assist in medication preparation, such as filling of pillboxes for patients with special needs. Student pharmacists have even initiated emergency care in some instances by contacting emergency medical services. In all cases, interventions are discussed with faculty attendings and team members. Coaching/mentoring An additional purpose of our IPPE program is its role in the professionalization of student pharmacists. Faculty attendings serve as coaches and conduct one-on-one sessions with the student pharmacists on their teams with the primary objectives being professionalization of students and monitoring of student pharmacist progress. This process allows faculty to check-in with the student pharmacists regarding personal well-being and overall academic progress. Faculty provide support and referral for supplemental assistance as deemed appropriate. Faculty attendings are notified by the student affairs office within the school of pharmacy if students on their team are having academic difficulty. The IPPE team is often the school’s best opportunity for early identification of students experiencing personal or academic difficulties or those with professionalism concerns. Faculty mentors review student reflections to facilitate discussions as part of the coaching/mentoring process in IPPE. Integration within the curriculum The IPPE program is fully integrated with other components of the curriculum. Student pharmacists are expected to practice skills learned in other courses (i.e., communication skills, motivational interviewing, patient assessment) and complete assignments from other courses based on issues identified during IPPE. Student pharmacists are also able to observe the effects of diseases and medications using real patient care scenarios as they learn about them in other

T.L. Stevenson et al. / Currents in Pharmacy Teaching and Learning 3 (2011) 41–52

47

Results

Figure 2. Components of rubric for evaluating IPPE student pharmacist performance.

The IPPE program at HSOP provides student pharmacists the opportunity to be involved in pharmacy care, develop professionally, reflect on practice experiences, assist individuals in the community with health care needs, and provide outreach to the community. One basic assessment of the IPPE program may be made by looking at student performance in the program. Faculty evaluations of students have been consistently high, with 96.6% of students receiving satisfactory or excels in the past four years. During that time, an average of 387 (362– 421) students participated in the IPPE program each semester. Student course grades for Fall 2005 through Spring 2009 are shown in Table 4. Course evaluations in 2008 and 2009 included responses from 352 (92.7%) and 278 (66.5%) students, respectively. Seventy-seven percent of student pharmacists responding to the course evaluation in 2008, and 82% of students responding in 2009, rated the “course as a whole” as good, very good, or excellent. In addition, “course content” was rated good, very good, or excellent by 80% of respondents in 2008 and 83% in 2009. Additional questions in the course evaluation regarding overall experiences asked student pharmacists to indicate their level of agreement with various statements. Data from eight of the 21 questions in the survey relating to IPPE course goals is provided in Table 5. Most students agreed or strongly agreed with these questions relating to course goals. Several comments offered in the 2008 and 2009 course evaluations include: “IPPE provided me with . . . valuable information regarding diseases and disease states relating to my IPPE patients, better allowing me to help them.”

courses. A problem-based learning approach is encouraged and reinforced in the IPPE program as student pharmacists address actual patient health care issues. Student assessment/evaluation Student pharmacists are assessed each semester using a rubric that includes the key components depicted in Fig. 2. One example of applying the grading criteria to a rubric component is shown in Table 3. Student pharmacists receive a final grade of either satisfactory or unsatisfactory on their university transcript. However, HSOP has elected to show degrees of a satisfactory grade with excels, satisfactory, or marginal. Student pharmacists receiving a grade of excels are eligible for IPPE awards that are given at the end of each academic year. Students receiving marginal grades are essentially on probation and must complete a plan of remediation the following semester. During remediation, students must improve on problem areas and receive a grade above marginal or receive an unsatisfactory grade for that current semester. Unsatisfactory grades are handled like any other failing grade within the curriculum and are reviewed by the school’s committee for academic performance. This committee develops a plan of remediation for these student pharmacists.

“I really enjoy seeing real patients. It actually feels like what I want to do in practice one day.” “I really enjoy PPE! It gives us, as students, a chance to use what we are learning in class and apply it to real-life situations.” “It is difficult to get schedules between different classes coordinated. It makes it almost impossible to see patients together.” “I dislike the high level of variability among groups . . .” “I absolutely love my mentors. They are definitely here for the students, both academically and personally. They expect a lot out of us students, but they do so to challenge us and never use our failures to embarrass us for our lack of knowledge. I really appreciate my Team!”

Student self-reported average weekly time spent on IPPE-related activities in 2008 was one to three hours (65.2%), four to six hours (27%), seven to nine hours (3.1%), more than 10 hours (0.6%), and not reported (4.2%). In 2009, students reported one to three hours (57.9%), four to six hours (36%), seven to nine hours (4%), and not reported (2.2%). Throughout the academic year, HSOP’s Office of Teaching, Learning and Assessment obtains immediate feedback

48

Table 3 Example grading criteria Accomplished

Developing excellence

Average/Satisfactory

Covenantal Patient Care and Relationship ● Conduct pt interviews and history ● Build a patient database ● Assess and update patient data ● Provide patient follow-up and evaluation ● Improve a patient’s quality of life

Patient Information Analysis After collecting information, the selfdirected student pharmacist will always objectively and thoughtfully analyze data using appropriate resources and subsequently develop clear action steps and a sound patient care plan. ----------------------Follow-up and Evaluation After implementation of a well-designed therapeutic pt care plan, the student pharmacist will continuously evaluate the plan by assessing objective and subjective findings to determine progress in meeting patient-specific goals. No details are overlooked in either the plan or continual reevaluation.

Patient Information Analysis After collecting information, the selfdirected student pharmacist will often objectively and thoughtfully analyze data using appropriate resources and subsequently often develop clear action steps and a sound patient care plan. ----------------------Follow-up and Evaluation After implementation of a well-designed therapeutic patient care plan, the student pharmacist will often evaluate the plan by assessing objective and subjective findings to determine progress in meeting patient-specific goals. Few details are overlooked in either the plan or continual reevaluation.

Patient Information Analysis After collecting information, the selfdirected student pharmacist will objectively analyze data using appropriate resources and subsequently develop action steps and a patient care plan. ----------------------Follow-up and Evaluation After implementation of a therapeutic pt care plan, the student pharmacist will evaluate the plan by assessing objective and subjective findings to determine progress in meeting patient-specific goals.

Below average/Needs significant development

Unsatisfactory/ remediation required

Patient Information Analysis After collecting information, the student pharmacist will occasionally analyze data using appropriate resources and subsequently develop action steps and a patient care plan. Student lacks some self-direction in terms of analyzing data, identifying appropriate resources and will often have an incomplete patient care plan. ----------------------Follow-up and Evaluation The student pharmacist may occasionally implement a therapeutic pt care plan and/or the plan may be of marginal quality. The student pharmacist does not regularly evaluate the plan by assessing objective and subjective findings to determine progress in meeting patient-specific goals.

Patient Information Analysis After collecting information, the student pharmacist does not or is unable to analyze data using appropriate resources and/ or is unable to develop subsequent action steps and a reasonable patient care plan. Self-direction is seriously lacking. May also lack the ability to determine appropriate resources and/or how to analyze them objectively. ----------------------Follow-up and Evaluation Student pharmacist does not or is unable to initiate a therapeutic pt care plan and/or does not evaluate the plan to determine progress in meeting patient-specific goals

T.L. Stevenson et al. / Currents in Pharmacy Teaching and Learning 3 (2011) 41–52

Grading criteria

T.L. Stevenson et al. / Currents in Pharmacy Teaching and Learning 3 (2011) 41–52

2008. It is likely this decrease is because before 2009, student grades were held if the student did not complete the course evaluation. This was not done in 2009 primarily because follow-up on outstanding evaluations and grades became too cumbersome and time-consuming. Overall student feedback has been positive. The two most common concerns verbalized by students have been the need for additional patients in the program and inconsistencies between IPPE teams as it relates to the structure of team meetings and student expectations between different faculty members. To sustain and expand the program, OEL staff members are continually trying to identify new patients who are willing to participate in the program. The overall goal is to have at least 16 to 18 patients per team to allow for sufficient variability of student experiences. Recruitment of patients is difficult because they are not compensated in any way, but rather volunteer to participate as a patient in this experiential program. Continuous faculty training and development is an ongoing process to ensure standardization and consistency between teams and faculty. Additional standardization through sharing of team activities, visits by the course coordinator to team meetings, and centralization of some course assignments with the course coordinator should allow for continued improvement in consistency. Students may visit patients individually but most choose to conduct these visits in groups of two to three. At times, students have expressed difficulty scheduling patient visits

Table 4 Student pharmacist IPPE course grades Fall 2005 to Spring 2009

Excels Satisfactory Marginal Unsatisfactory Incomplete

P1

P2

P3

296 762 19 10

269 748 27 18

399 518 18 10 2

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from students regarding IPPE through student focus groups. These interactive focus groups allow student pharmacists to provide feedback on all courses in the curriculum. Examples of this feedback of IPPE are depicted in Fig. 3. Discussion When we consider the specific skills, attitudes, and abilities evaluated in IPPE, student academic success is one indication that the program is achieving its goals. Overall student performance has resulted in satisfactory progress through the six-course sequence by almost all students. Course evaluations seem to support the achievement of programmatic goals with the ratings and comments made by the student pharmacists. The number of students responding to the course evaluation decreased in 2009 compared with

Table 5 Student pharmacist feedback from 2007–2008 (n ⫽ 352) and 2008-2009 (n ⫽ 278) course evaluations; values reported as percent Statement

Strongly Agree

Agree

Academic Year Ending

2008

2009

2008

2009

2008

27.6

25.9

56.8

57.9

25.3

23.0

56.0

13.6

16.9

18.9

Team meetings address issues that are relevant to real issues/problems. Team meetings address issues that are relevant to my learning/education as a student pharmacist. Questions posed during team meetings cause me to reflect more deeply about issues. Team meetings have been good outlets for learning and reinforcing knowledge and skills I learned in prior or concurrent coursework. Discussions during team meetings cause me to look up information for my own learning. I believe my patient caring skills have improved as a result of my IPPE experiences this year. My IPPE experience this year heightened my sensitivity and awareness regarding health care barriers (e.g., insurance, financial, education). This year, I feel I have grown personally and professionally as a result of my IPPE experiences. * Not answered.

Disagree

Strongly Disagree

NA*

2009

2008

2009

2008

2009

2008

2009

9.5

10.1

1.1

2.5

3.1

3.2

1.9

0.4

59.0

11.4

11.2

1.7

3.2

3.3

3.6

2.2

0.0

53.5

54.7

20.9

20.5

7.0

4.3

1.9

2.5

3.1

1.1

23.0

61.8

57.2

12.3

14.7

2.2

2.9

1.1

0.7

3.6

1.4

12.5

12.6

52.6

54.3

21.2

20.9

8.1

7.9

2.8

3.6

2.8

0.7

24.0

25.9

53.2

54.3

12.5

14.0

5.6

2.5

1.1

1.4

3.6

1.8

15.3

17.6

51.5

52.5

18.9

21.2

7.5

5.0

3.1

1.4

3.6

2.2

18.0

17.3

54.6

51.4

16.7

16.5

5.8

4.7

1.7

1.8

3.9

2.2

Neutral

50

T.L. Stevenson et al. / Currents in Pharmacy Teaching and Learning 3 (2011) 41–52

Figure 3. Topics of student feedback with selected quotes (listed in order of decreasing frequency or report). Student focus group reports (internal documents). Office of Teaching, Learning and Assessment (OTLA); Auburn University Harrison School of Pharmacy: September 2006-October 2007.

with students from other classes. The schedules of students at HSOP are very demanding and it is often a challenge for P3s, P2s, and P1s to find times to visit patients together. Students have stated they like the team approach and working with students from other classes, but often have difficulties with the logistics of scheduling visits. Most student pharmacists reported spending either one to three hours or four to six hours per week on IPPE

activities. Expectations are that students spend one hour per week in their team meeting, 30 minutes to one hour visiting patients and additional time in self-directed learning, follow-up of patient care issues, and development of presentations for their team meeting. Student pharmacists are now required to document their time throughout each semester in an electronic tracking system to quantify each individual student’s time for IPPE-related activities in this program.

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This continuous, longitudinal, residence-based program has evolved into a clinically oriented, direct patient care, practice experience for student pharmacists. The program has grown with regard to the number of student pharmacists and now involves two campuses. In addition, one could argue that the level of realism has evolved in that an electronic patient record is now used to document patient interactions, patient care is coordinated through the AUPCC within the school, and communication of recommendations to physicians is now centralized within the center. A February 2006 self-study identified several strengths and accomplishments of the program, including direct, evidence-based patient care, qualified faculty preceptors, diverse experiences, as well as the integration of IPPE with the rest of the curriculum.22 This assessment also identified the authenticity of the program as being a strength because student pharmacists are involved with actual patients beginning in their first year of professional education. In reflecting on the creation and refinement of the program over the years, several themes emerge that guide our understanding of the successes of the past and contribute to the ongoing improvement of the program.

OEL have recently increased efforts of collaboration with pharmacy practice faculty who practice in local institutions as a means of identifying and involving more patients.

School commitment

Important concepts, such as patient-centeredness, collaborative practice, evidenced-based practice, teamwork, professional behavior, responsibility, and efforts to optimize medication therapy outcomes are integral components of this IPPE program. This longitudinal, residence-based practice experience focuses on relevant aspects of patient care and plays an invaluable role in the development of student pharmacists at HSOP. Many successful IPPE programs have focused on the operational aspects of daily pharmacy practice. The priority at HSOP has been an IPPE program that immerses students in the principles of pharmacy care, including establishing professional caring relationships with patients, assessing medication therapy, solving drug-related problems, and coping with the difficulties of patient care (e.g., financial, cultural, motivational) regardless of the setting. It is important to note the relatively high demands on personnel, time, and physical space required to conduct a program of this type. The HSOP has built and refined this program into a vital element in the culture of this school for both student pharmacists and faculty. Because the main campus is not located on a health sciences campus or in a large metropolitan city, training sites in community and institutional settings are limited. Therefore, meeting the current requirements for IPPE within the academic year has been challenging and has required innovation. The structure of our IPPE program offers direct patient care activities for student pharmacists longitudinally while being integrated within the curriculum. Based on overall student success and positive feedback on the program, it is our belief that this IPPE model offers students a broad experience through engagement in patient-centered care using real-world scenarios, team building, and mentoring. Expanding IPPE activities within the AUPCC is the next step in the evolution of this program. Opportunities for future assessment of this

Since the inception of the IPPE program, HSOP has shown a strong commitment in personnel and resources for its operation and success. The educational component is delivered through a commitment from the entire faculty of the school and is considered in the workload of each faculty member. As stated previously, this program represents a portion of each pharmacy practice faculty’s clinical practice. The IPPE program is managed through the OEL. There are three full-time equivalents (FTEs). These FTEs include one faculty and two professional staff directly responsible for the IPPE program in addition to the director of OEL who oversees all IPPE and APPE processes and activities. For comparison, the results from the survey assessing IPPE programs across the nation conducted by Darbishire et al. reported an average of 2.90 FTEs (1.64 faculty, 0.62 professional staff, 0.64 clerical staff) based on data supplied by 46 schools of pharmacy.23 Clinical integration and oversight Over recent years, the establishment of the AUPCC for patient care located within the school has provided additional clinical relevance to the program. The AUPCC provides an infrastructure for students to readily request patient records, acquire patient monitoring supplies, conduct health screenings, and facilitate clinical faculty follow-up for patients when needed. In addition, the IPPE course coordinator serves as a liaison between student pharmacists, faculty, patients, and the local medical community, providing assistance with communications and formal interventions. A physician advisory council has provided input with respect to the program’s development and integration within the local health care communities. Faculty and staff from the

Documentation and technology In addition to the electronic patient record for documentation of visits and tracking of data, the IPPE program uses a web-based proprietary intervention tracking software to document clinical interventions made through the program. Data collected are being used to validate further the clinical significance of the IPPE program for the school and community. Video conferencing, wireless networking, and electronic presentation equipment exist in seven well-designed team rooms, providing a state-of-the-art setting for IPPE team meetings. Because all faculty are involved in the program, the use of video conferencing allows our offsite faculty to engage in IPPE from their practice sites in four regional clinical education centers across the state of Alabama and affiliated regional practice sites. Conclusion

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program include clinical impact, patient and physician satisfaction, faculty attending satisfaction, enhancement of interprofessional collaboration, and comparison of student performance in the IPPE sequence with performance in the APPE sequence within our curriculum. Acknowledgments The authors would like to acknowledge the following individuals for their contributions to the initiation, implementation, and management of the IPPE program at Harrison School of Pharmacy. Dean R. Lee Evans provided much of the initial impetus and has given his full administrative backing and support as the program has grown. HSOP faculty members contribute to the program’s direction and sustain the daily operations of the program. Dr. Diane Beck (now at the University of Florida) was the Director of Experiential Learning at the inception of the program and provided additional vision, direction, and staffing. Mrs. Janelle Krueger (now at the University of Wyoming) served as the first Coordinator of PPE and significantly contributed to growth and development of the program. Mrs. Tara Maple, Mrs. April Staton, and Mrs. Kathy Kyle provided assistance with data collection. References 1. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. The Accreditation Council for Pharmacy Education Inc. Available at: http://www.acpe-accredit.org/pdf/ACPE_Revised_PharmD_ Standards_Adopted_Jan152006.pdf. Accessed November 21, 2010. 2. Institute of Medicine of the National Academies. Committee on the Health Professions Education Summit; executive summary— health professions education: A bridge to quality. Available at: http://www.nap.edu/catalog/10681.html. Accessed November 21, 2010. 3. American Association of Colleges of Pharmacy. Center for the advancement of pharmaceutical education (CAPE)— educational outcomes 2004. Available at: http://www.aacp.org/ resources/education/Documents/CAPE2004.pdf. Accessed November 21, 2010. 4. The Joint Commission of Pharmacy Practitioners. JCPP future vision for pharmacy practice, 2015. Available at: http://www. ascp.com/advocacy/coalitions/upload/JCPP%20Future%20Vision% 20for%20Pharmacy%20Practice-2004.pdf. Accessed November 21, 2010. 5. Turner CJ, Jarvis C, Altiere R, Clark L. A Patient focused and outcomes-based experiential course for first year pharmacy students. Am J Pharm Educ 2000;64:312–9. 6. Doty RE, Latham KM, Stewart RB. Public health screenings as a component of introductory practice experiences. Am J Pharm Educ 2000;64:426 –30.

7. MacKinnon GE, McAllister DK, Anderson SC. Introductory practice experiences: an opportunity for early professionalization. Am J Pharm Educ 2001;65:247–53. 8. Brown MC, Lind PR, Sorensen TD. Early pharmacy education with Community Teachers (EPhECT): a longitudinal servicelearning experience. Am J Pharm Educ 2002;66:443–9. 9. Chisholm MA, DiPiro JT, Fagan SC. An innovative introductory pharmacy practice experience model. Am J Pharm Educ 2003;67:Article 22. 10. Rahman A, Tahir R, Brocavich J. Student attitudes and assessment of a first year pharmacy shadowing course. Am J Pharm Educ 2003;67:Article 40. 11. Turner CJ, Altiere R, Clark L, Dwinnell B, Barton AJ. An interdisciplinary introductory pharmacy practice experience course. Am J Pharm Educ 2004;68:Article 10. 12. Dennis VC. Longitudinal student self-assessment in an introductory pharmacy practice experience course. Am J Pharm Educ 2005;69:Article 1. 13. Turner CJ, Altiere R, Clark L, Maffeo C, Valdez C. Competencybased introductory pharmacy practice experiential course. Am J Pharm Educ 2005;69:Article 21. 14. Turner CJ, Ellis S, Giles J, Altiere R, Sintek C, Ulrich H, et al. An introductory pharmacy practice experience emphasizing student-administered vaccinations. Am J Pharm Educ 2007;71: Article 3. 15. Wuller WR, Luer MS. A sequence of introductory pharmacy practice experiences to address the new standards for experiential learning. Am J Pharm Educ 2008;72:Article 73. 16. Crill CM, Matlock MA, Pinner NA, Self TH. Integration of first- and second-year introductory pharmacy practice experiences. Am J Pharm Educ 2009;73:Article 50. 17. Thomas SG, Janer A, Beck DE. A continuous community pharmacy practice experience: design and evaluation of instructional materials. Am J Pharm Educ 1996;60:4 –12. 18. Thomas SG, Beck DE, Janer A. Effect of a continuous community pharmacy practice experience on student attitudes, motivation, and communication skills. Am J Pharm Educ 1997; 61:125–31. 19. Beck DE, Thomas SG, Janer AL. Introductory practice experiences: a conceptual framework. Am J Pharm Educ 1996;60: 122–31. 20. Auburn University, Harrison School of Pharmacy. Introductory pharmacy practice experience (IPPE) Manual, 2009. Available at: http://www.pharmacy.auburn.edu/oel/pdf/ppe_manual.pdf. Accessed November 21, 2010. 21. Krueger JL, Beck DE; Harrison School of Pharmacy, Auburn University. Instilling a patient care culture: engaging all students and faculty in the continuous care of community-based patients. Paper submitted at 2003 American Association of Colleges of Pharmacy Annual Meeting. Innovation in Teaching Competition, July 2003, Minneapolis, MN. 22. Auburn University Harrison School of Pharmacy. Accreditation Assessment Self-Study. Volume I of III, Standard 29, 169 –170. 2006. 23. Darbishire PL, Devine T, Holowatyj MR, Schmelz AN. National Survey of Introductory Pharmacy Practice Experience programs. Available at: http://www4.samford.edu/schools/ pharmacy/ijpe/208/ippe.pdf. Accessed November 21, 2010.