- Email: [email protected]
Development and evaluation of an elective course designed to prepare pharmacy students for advanced pharmacy practice experiences
Available online at www.sciencedirect.com
Currents in Pharmacy Teaching and Learning 6 (2014) 871–876
Research
http://www.pharmacyteaching.com
Development and evaluation of an elective course designed to prepare pharmacy students for advanced pharmacy practice experiences Jasmine D. Gonzalvo, PharmDa,c,*, Andrew N. Schmelz, PharmDb, Brian M. Shepler, PharmDc b
a Eskenazi Health, Indianapolis, IN IU Health Physicians Family Medicine Center, Indianapolis, IN c College of Pharmacy, Purdue University, West Lafayette, IN
Abstract Colleges of pharmacy have used a number of strategies to assess student readiness and facilitate the transition into Advanced Pharmacy Practice Experiences (APPE). However, previous documented strategies have revealed important limitations. In this article, we describe the Introduction to Advanced Pharmacy Practice Experiences course that helps students transition to APPE, a course that could easily be replicated at other colleges of pharmacy. This course has provided third professional year pharmacy students with a strong foundation of practical and useful knowledge to help better prepare them for the rotational year. r 2014 Elsevier Inc. All rights reserved.
Keywords: Advanced Pharmacy Practice Experiences (APPE); Clerkship rotations; Preparation for rotations
Introduction The Accreditation Council for Pharmacy Education (ACPE) requires colleges of pharmacy to provide pharmacy practice experiences to support the achievement of professional competencies.1 These experiences include Introductory Pharmacy Practice Experiences (IPPE) and Advanced Pharmacy Practice Experiences (APPE) and are designed to “integrate, apply, reinforce, and advance the knowledge, skills, attitudes, and values developed through other components of the curriculum” that support the Center for Advancement of Pharmaceutical Education (CAPE) outcomes.2 Additionally, the ACPE guidelines state that IPPE continue in a progressive manner, leading to entry into APPE. The ACPE guidelines also now provide guidance on * Corresponding author at: Jasmine D. Gonzalvo, Eskenazi Health, 640 Eskenazi Avenue, Indianapolis, IN. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2014.07.016 1877-1297/r 2014 Elsevier Inc. All rights reserved.
core abilities and competencies that pharmacy students should have before beginning APPE. These competency domains are mapped to specific CAPE outcomes. Colleges of pharmacy have used a number of strategies to assess student readiness and facilitate the transition into APPE. Curricular changes such as integration, problembased learning, situational counseling, and professionalism preparation have been used, though specific examples of the efficacy of these individual approaches in improving APPE performance have not been evaluated. However, previous documented strategies have revealed important limitations. In 2008, Culbertson3 used problem-based learning exams to assess student readiness for APPE from a knowledge standpoint and designed a method that was highly specific for identifying students likely to underperform during APPE. Using another approach, Meszaros et al.4 designed a series of exams (offered at the end of each semester), including written closed-book, written openbook, and objective structured clinical exams (OSCE) that
872
J.D. Gonzalvo et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 871–876
were correlated with APPE evaluations. While these studies helped colleges identify students who were likely to underperform during rotations, they did not employ strategies to facilitate pharmacy students in transitioning from classroom-based learning to APPE. More recently, colleges of pharmacy have begun developing methods to aid students in transitioning from IPPE and classroom-based learning to APPE. In 2010, Mort et al.5 evaluated an IPPE course called “First-steps” that focused on pharmacy practice skills and communication, and uses reference material to prepare students for APPE. The course was experiential in nature and supplemented their college’s previous IPPE curriculum. The course resulted in increased frequency of desired clinical behaviors on a subsequent APPE. While this approach proved to be effective, the course required a high volume of time and resources, including 14 faculty and 14 non-faculty preceptors working daily with student groups (56 students completed this experience each year over a four-week rotation block). For larger programs, this approach may likely become unmanageable. To account for the additional time students spent in IPPE, the duration of their APPE experience was shortened from 44 weeks to 40 weeks. Using a classroom-based approach, Bookstaver et al.6 designed an evidence-based medicine elective course to determine if students on rotations who took the elective performed superior to those who did not. Most APPE preceptors who were surveyed reported they felt that students completing the course performed better on their rotation than those who did not. While an important part of success on rotations involved student preparedness to evaluate and use evidence-based medicine, other abilities and competencies identified in the ACPE guidelines were not assessed. Vyas et al.7 designed an IPPE simulation class (using standardized patient actors) to evaluate students in 10 of the 11 domains in the pre-APPE core domain abilities described in the ACPE guidelines.1, Students completing the course performed better on practical examinations compared to those who did not. This approach was described as costly and highly resource intensive, the authors noting each simulation experience required eight hours of direct faculty time, three hours of preparation, and the direct and indirect costs of the experience were $7500 (to deliver the experience to 28 students). Ragan et al.8 also utilized simulation in the form of standardized clients and didactic components, and they were able to predict students who underperform during APPEs. It also was described as resource-intensive and highly costly, and it also was only a measurement of student preparedness and did not provide students with tools or strategies to transition from IPPE to APPE. Rationale and objectives While supplemental IPPE and simulation-based courses have demonstrated success in helping students transition to
APPE, multiple factors, including a lack of resources, may prevent colleges of pharmacy from developing standardized courses. While actual costs and utilization of resources were not available for most of the programs described in the literature, most could be assumed to be intensive, since programs were designed to address more of the pre-APPE competences that require higher costs and more resources. An elective course designed around evidence-based medicine did demonstrate success in improving APPE performance, however, did not provide students with further resources for self-assessment and supplementation of their clinical knowledge.6 In this article, we describe the Introduction to Advanced Pharmacy Practice Experiences course that helps students transition to APPE. Materials and methods The Introduction to Advanced Pharmacy Practice Experiences course was conceptualized and designed to have more time in the curriculum devoted to preparing students for the APPE year. Currently, the course is coordinated by two faculty members and taught by an additional five faculty members and five volunteer preceptors. Before this course existed, third professional (P3) year students were required to attend a two-hour meeting during the spring semester of the P3 year. This meeting occurred in April prior to the first rotation of the P4 year that would begin in May. It was designed as a lecture during which the experiential learning program director would deliver all of the information concerning APPE rotations to the students and consisted of a thorough review of the APPE policies that appeared in the APPE manual. Topics reviewed with students included evaluation of students’ and preceptors’ performances, professional behavior, documenting hours of experience, collecting immunization documentation, and review of required assignments. It was essentially the “nuts and bolts” of how the APPE program worked and presentation of student requirements for successful completion of the program. The two-hour meeting often did not allow for a thorough explanation of the APPE requirements in sufficient depth so as to ensure student understanding. This resulted in students having many questions once APPE rotations began and some missing evaluations as well as missing-hour certification forms. It also did not provide any supplemental material to support students’ abilities to accomplish the core competencies outlined in the ACPE guidelines.1 The Experiential Learning Advisory Council (ELAC), a group of faculty and experienced preceptors from each region who assist the APPE director in oversight of the experiential program, discussed ways for improving the delivery of this material to the P3 students and recommended changing the two-hour meeting to a one-credit-hour course. The course would not only cover the basic policies and procedures of APPE rotations but would also incorporate other material designed to prepare students for rotations.
J.D. Gonzalvo et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 871–876
873
Table 1 Course goals and objectives Goals The Introduction to Advanced Pharmacy Practice Experiences (APPE) course is intended to: 1. Provide professional students with the basic introductory practice information needed to succeed during clerkship. 2. Enable professional students to avoid common rotation mistakes. 3. Remove confusion surrounding the clerkship experience by alleviating anxiety and building student confidence. 4. Standardize pre-rotation training. Objectives By the end of the course, professional students are expected to be able to: 1. Explain how to register for rotations. 2. Recall clerkship policies and procedures. 3. List the forms that should be submitted to the Office of Experiential Learning after each rotation. 4. Critique preceptors and rotations constructively and assess peer performance on oral and written work. 5. Apply strategies to maximize the clerkship experience to each assigned rotation. 6. Cite the rotation portfolio requirements. 7. List handy drug information resources to use during rotations. 8. Explain ways to handle “tough situations” during rotations. 9. Document complete clinical interventions using Clinical Measures software. 10. Provide pharmacokinetic recommendations using provided equations and tools. 11. List ways to succeed on non-patient-care rotations. 12. List ways to prepare for post-graduate training during rotations. 13. Recall important information from common disease states encountered while on rotation.
Basic introductory experiential activities were already covered in the Introductory Pharmacy Practice Experiences (IPPEs) and were not repeated here. Course goals and objectives are listed in Table 1. All P3 students were told about the course and were strongly encouraged to participate as individual schedules permitted. All of the course lectures were recorded so that students who were unable to take the course due to schedule conflicts with other courses could watch the lectures and still obtain the information. BlackboardTM, an online course management system, was utilized to post all course-related information and to administer course evaluations. Upon completion of the course, students should possess knowledge of the college’s specific APPE policies and procedures, as well as meet all of the core competencies outlined in the ACPE guidelines. Although this course did not specifically cover material related to each of these competencies, the rest of the pharmacy curriculum supported students’ achievement of this objective after their completion of the course. Didactic lectures were utilized as the primary mode of instruction. Once the course was conceptualized, content topics were suggested by the ELAC. A current course schedule is presented in Table 2 and illustrates all topics covered in each hour of the course. During class period 2, for example, both hours were devoted to providing more information to the students about community pharmacy and ambulatory care rotations and post-graduate opportunities in those fields. The ELAC felt that students were already receiving a lot of information and guidance regarding hospital and inpatient specialty practice and could benefit from some additional information about outpatient practice settings. In class period 3, the second hour was devoted to unique
situations and focused primarily on pharmacy robberies, but also included some discussion on work place issues and personnel interactions. The last class period was devoted to hosting a preceptor and current APPE student (P4) question and answer panel. The course was scheduled as eight, two-hour lectures beginning the second half of the spring semester of the P3 year. These eight weeks directly preceded the APPE rotations. The course was offered as a Pass/Not Pass course with attendance being the only criteria for successful completion, initially. Students completed a brief reflection at the end of each class to provide course feedback and record attendance. Feedback from course evaluations contributed to minor modifications in the course. Additionally, the ELAC continued to provide suggestions and guidance on which topics were most relevant. After the first three years, the course was modified to incorporate the clinical topic modules. Successful completion of the clinical topic modules became an additional requirement for passing the course. Clinical topic modules In Summer 2011, a planning meeting was held to discuss the potential incorporation of web-based clinical topic modules into the course. The modules would be designed as a concise review that focused on disease state topics initially taught in the Therapeutics courses. A focus group first met to outline an appropriate approach for the development of the modules. An initial survey to P4s ascertained which topics students felt were most important to target prior to development of the modules. Survey topics ranked highest by the P4 students were selected for development.
874
J.D. Gonzalvo et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 871–876
Table 2 Introduction to Advanced Pharmacy Practice Experiences (APPE) course schedule Class Description
Assignments
1
Topic 1: Registration Topic 2: Policies & procedures Registering for rotations, patient care modules, and rotation policies and procedures Spring break—No class
In-class reflection
2
Topic 1: Community pharmacy Topic 2 : Ambulatory care How to succeed in community pharmacy and amb care rotations, Post grad training opportunities in amb care and community pharmacy
In-class reflection Week 2 module
3
Topic 1: Clinical documentation Topic 2: Unique situations Using clinical documentation software on rotations and handling tough situations on rotations and in the real world
In-class reflection Week 3 module
4
Topic 1: DI resources Topic 2: Portfolios Requirements for rotation portfolios and drug information resources to use on rotations (hand-held devices applications, useful pocket guides, Purdue library resources, etc.)
In-class reflection Week 4 module
5
Topic 1: Required documentation and evaluation of Topic 2: Professionalism in the workplace APPEs Required forms to submit at the end of each rotation, skill-based competencies/operations 2 modules, clinical skills competition information, and professionalism
In-class reflection
6
Topic 1: Pharmacokinetics booster Pharmacokinetics in the “real world”
Topic 2: Pharmacokinetics booster
Kinetics problems Week 6 module
7
Topic 1: Student panel Student and preceptor panels Q & A
Topic 2: Preceptor panel
PRE reflection Course evaluation Week 7 module
Module topics were divided into three categories: outpatient, inpatient, and extra (Table 3). Clinical pharmacy specialists, some of whom were faculty members, were solicited to aid in the development of the web-based modules. Adobe PresenterTM and VoiceThreadTM technologies were utilized to develop the 30-minute modules. These volunteers were provided several months to develop each module. Following Table 3 Clinical topic modules Outpatient Diabetes Hyperlipidemia Hypertension Over-the-counter (OTC) and herbal medications Asthma and chronic obstructive pulmonary disease (COPD) Anticoagulation Inpatient Heart failure Arrhythmias Infectious disease Fluid/electrolytes/nutrition (FEN) Clinical pearls Acid–base Venous thromboembolism (VTE) Extra Medication therapy management (MTM) Coronary artery disease (CAD) Chemotherapy-induced nausea and vomiting (CINV) Febrile neutropenia Pediatrics
Week 5 module
development, web links to the modules were posted on BlackBoardTM. Students enrolled in the course were required to pass a total of six module quizzes, outside of scheduled class time, over the eight-week course with a minimum score of 80% on each quiz. Each quiz was comprised of ten, multiple-choice questions and was available electronically on BlackboardTM. The modules were not only offered to the P3 students preparing for rotations enrolled in the course, but also to P4 students as an educational resource while on rotation. The majority of the course utilized didactic instructional methods, particularly the clinical topic modules. In-class sessions employed didactic instruction, as well as active discussions and participation from the students. No outside class time was required for students to prepare for in-class sessions; however, the clinical topic modules were completed online, outside of regular class time. On average, the duration of the didactic portion for each module was approximately 30 minutes. No textbooks were required for this course. No formal assessments or examinations were administered outside of the 10-point quizzes associated with the clinical topic modules. Course evaluations included 11 assessment statements with a score of 5 ¼ Strongly Agree, 4 ¼ Agree, 3 ¼ Neutral, 2 ¼ Disagree, and 1 ¼ Strongly Disagree. A Student’s t-test was used to compare data sets from 2009 and 2011. Results Every year, only two to three students opted not to participate in the elective course due to class scheduling
J.D. Gonzalvo et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 871–876
875
Table 4 Assessment statements and mean student scores Assessment statements
2009, n ¼ 135
2010, n ¼ 146
2011, n ¼ 127
p Value 2009 vs. 2011
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
4.33 4.29 4.26 4.16 4.28 4.12 3.98 4.36 4.21 4.12 4.13
4.28 4.36 4.36 4.17 4.26 4.23 4.21 4.30 4.00 4.29 4.19
4.46 4.56 4.54 4.28 4.39 4.40 4.30 4.52 4.19 4.38 4.35
0.02 NS 0.0003 NS NS 0.003 0.004 0.009 NS 0.001 0.002
The objectives of this course were clearly explained to me. Practical applications of course material are discussed. This course material is pertinent to my professional training. In this course, many methods are used to involve me in learning. Team teaching is used effectively in this course. There is an appropriate mix of lecture and discussion in this class. Class sessions were interesting and engaging. My instructors make effective use of classroom technology. Assignments are related to the goals of the course. As a result of this course, I feel more prepared to begin rotations. Overall, I would rate this course as excellent.
5 ¼ Strongly Agree, 4 ¼ Agree, 3 ¼ Neutral, 2 ¼ Disagree, 1 ¼ Strongly Disagree, NS ¼ not statistically significant.
conflicts. The course evaluation assessment statements with their correlating average scores are included in Table 4. The mean student rating for each assessment statement was between Strongly Agree and Agree with the exception of “Class sessions were interesting and engaging,” which scored a 3.98 initially but improved to 4.21 the subsequent year and again to 4.30 in the third year. Statistical analysis indicated a significant improvement in the course scores on 7 of the 11 items between 2009 and 2011. Four items remained unchanged. In addition, during the first year that the course was offered (2009), the students provided some reflective feedback at the end of each class period. This information was used to modify the class in the subsequent years. Although the majority of students had either no comments for improvement or said everything was “good,” some students indicated there was redundancy in the presented material and that certain class periods could be more efficient. There were also some negative comments regarding specific instructors and presentation styles. Most statements improved from the first year the course was offered to the third year. This improvement was likely due to the course coordinators incorporating different presenters into the course based on feedback from the students. For example in 2009, statement 7, “Class sessions were interesting and engaging,” scored a 3.98 but increased to 4.30 the third year. In this particular instance, the presenter giving the professionalism talk used a PowerPointTM lecture style the first year. In the following years, a new presenter was identified who used interactive teaching and role-played different professionalism scenarios that were entertaining to the class. Statements 6 and 7 relate to class format and engagement of students. From 2009 to 2011, more emphasis was placed on discussing topics with students and making them a part of the class as opposed to the typical lecture format. In the third class period, during the Unique Situations presentation, students are shown a video produced by the Federal Bureau of Investigation (FBI) on pharmacy robberies and how to react if this
happens during rotations. In 2011, after the video was shown, one of the students in the class who had already been robbed in her pharmacy where she worked in the summer talked to the class about her personal experience. This was a very effective way of connecting the class to the topic in a meaningful way. Both statements 6 and 7 improved significantly from 2009 to 2011 (p ¼ 0.003 and 0.004, respectively). Implementing the clinical topic modules was another major advancement in the course and could explain the significant increase in students’ perceptions that the material was more pertinent to their professional training (statement 3;, p ¼ 0.0003) and their feeling more prepared to begin rotations (statement 10, p ¼ 0.002). At the end of the Spring 2011 semester, third-year students who were enrolled in the course completed a survey to assess their perceptions of the clinical modules. At the end of the 2012 rotation year, the same students were surveyed to assess their perceptions of the utility of the clinical modules while on rotations. Both the surveys revealed that the students perceived the modules to be helpful. The average pass rate on the P3 module quizzes was 79.2%, with a range from 32.0% (Venous Thromboembolism) to 99.1% (Inpatient Clinical Pearls). A more detailed description of the survey methods and results has been previously published.9
Discussion In 2011, this course was accepted for full integration into the professional curriculum. In 2013, along with significant curricular changes, the Introduction to APPE course became a required course. The requirement of this course largely stems from our consistent assessment data that have reflected positive student perceptions of the course and the clinical topic modules. Course coordinators have implemented strategies to improve the course based on initial student feedback, which has resulted in improved scores since the inception of the course. These strengths of the
876
J.D. Gonzalvo et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 871–876
course support the decision to continue to offer the course, incorporating revisions from ELAC and student feedback. One current limitation is the lack of subsequent assessment of P4 students’ performance while on rotation following participation in this course. A subsequent survey to P4 students and preceptors while on rotation would allow for evaluation of achievement of course goals and objectives. Results from a survey of this nature would also inform decisions related to the need for modifications to the course. At this time, specific modifications to the course are not planned. A paucity of literature exists with regard to how colleges of pharmacy can feasibly prepare students for the APPE year. Colleges of pharmacy may consider implementing a similar course to better prepare P3 students for rotations. Implementation of a comparable course supports the core domains outlined in the ACPE accreditation standards and provides an opportunity to assess student readiness to enter APPEs.1 The Director of experiential learning would ideally play a key role in the development and implementation of the course; although, additional support from faculty and preceptors is necessary to effectively offer the varied aspects of the course. Development and coordination of the clinical topic modules requires a significant amount of time and effort. Ideally, an additional course coordinator would be available to solicit expert instructors, manage the technology related to accessing the modules, and answer topic-related questions. The decision to offer the course as Pass/Not Pass or for a letter grade may be individualized to the institution and coordinator preferences. Schools wishing to implement a similar course will require commitment from multiple faculty, content experts, and basic technological support. Colleges of pharmacy with limited resources may consider reaching out to residents or preceptors to help design the course and deliver lectures. As with the course described here, colleges may consider initially offering the course without the online review modules to decrease the time and effort to offer a course of this nature. Additionally, the possibility of offering this course exclusively online may be more feasible to some institutions. Conclusions The Introduction to Advanced Pharmacy Practice Experiences course has provided P3 students with a strong foundation of practical and useful knowledge to help better prepare them for the rotational year. To date, the majority of each class of students has elected to participate in this course. This course has received positive feedback from
students since its inception in 2009.The course has grown to involve online, didactic clinical topic modules to provide a therapeutic review of commonly encountered disease states. Course coordinators expect this elective course to continue to garner significant participation. This course could be replicated at other colleges of pharmacy and will likely require less time and resources than other similar courses described in the literature. Colleges of Pharmacy may wish to consider incorporating similar courses to help prepare P3 students prior to beginning APPE rotations.
References 1. Accreditation Council for Pharmaceutical Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. S2007, Guidelines 2.0, Preamble Addendum, Appendix D. Chicago, IL: 2011. 〈http://www.acpe-accredit.org/pdf/FinalS2007Guidelines 2.0.pdf/〉 Accessed July 28, 2014. 2. Medina M, Plaza C, Stowe C, Robinson ET, DeLander G, Beck DE, et al. Center for the Advancement of Pharmacy Education (CAPE) Educational Outcomes 2013. Am J Pharm Educ. 2013;77(8): Article 162. 3. Culbertson VL. Pharmaceutical care plan examinations to identify students at risk for poor performance in advanced pharmacy practice experiences. Am J Pharm Educ. 2008;72 (5): Article 111. 4. Meszaros K, Barnett MJ, McDonald K, Wehring H, Evans DJ, Sasaki-Hill D, et al. Progress examination for assessing students’ readiness for advanced pharmacy practice experiences. Am J Pharm Educ. 2009;73(6): Article 109. 5. Mort JR, Johnson TJ, Hedge DD. Impact of an introductory pharmacy practice experience on students’ performance in an advanced practice experience. Am J Pharm Educ. 2010;74(1): Article 11. 6. Bookstaver PB, Rudisill CN, Bickley AR, McAbee C, Miller AD, Piro CC, et al. An evidence-based medicine elective course to improve student performance in advanced pharmacy experiences. Am J Pharm Educ. 2011;75(1): Article 9. 7. Vyas D, Bhutada NS, Feng X. Patient simulation to demonstrate students’ competency in core domain abilities prior to beginning advanced pharmacy practice experiences. Am J Pharm Educ. 2012;76(9): Article 176. 8. Ragan RE, Virtue DW, Chi SJ. An assessment program using standardized clients to determine student readiness for clinical practice. Am J Pharm Educ. 2013;77(1): Article 14. 9. Gonzalvo JD, Chomicki J, Chu M, Frail C. Incorporation of online clinical topic modules in an introduction to advanced pharmacy practice experience course. Curr Pharm Teach Learn. 2013;5(5):438–443.
Currents in Pharmacy Teaching and Learning 6 (2014) 871–876
Research
http://www.pharmacyteaching.com
Development and evaluation of an elective course designed to prepare pharmacy students for advanced pharmacy practice experiences Jasmine D. Gonzalvo, PharmDa,c,*, Andrew N. Schmelz, PharmDb, Brian M. Shepler, PharmDc b
a Eskenazi Health, Indianapolis, IN IU Health Physicians Family Medicine Center, Indianapolis, IN c College of Pharmacy, Purdue University, West Lafayette, IN
Abstract Colleges of pharmacy have used a number of strategies to assess student readiness and facilitate the transition into Advanced Pharmacy Practice Experiences (APPE). However, previous documented strategies have revealed important limitations. In this article, we describe the Introduction to Advanced Pharmacy Practice Experiences course that helps students transition to APPE, a course that could easily be replicated at other colleges of pharmacy. This course has provided third professional year pharmacy students with a strong foundation of practical and useful knowledge to help better prepare them for the rotational year. r 2014 Elsevier Inc. All rights reserved.
Keywords: Advanced Pharmacy Practice Experiences (APPE); Clerkship rotations; Preparation for rotations
Introduction The Accreditation Council for Pharmacy Education (ACPE) requires colleges of pharmacy to provide pharmacy practice experiences to support the achievement of professional competencies.1 These experiences include Introductory Pharmacy Practice Experiences (IPPE) and Advanced Pharmacy Practice Experiences (APPE) and are designed to “integrate, apply, reinforce, and advance the knowledge, skills, attitudes, and values developed through other components of the curriculum” that support the Center for Advancement of Pharmaceutical Education (CAPE) outcomes.2 Additionally, the ACPE guidelines state that IPPE continue in a progressive manner, leading to entry into APPE. The ACPE guidelines also now provide guidance on * Corresponding author at: Jasmine D. Gonzalvo, Eskenazi Health, 640 Eskenazi Avenue, Indianapolis, IN. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2014.07.016 1877-1297/r 2014 Elsevier Inc. All rights reserved.
core abilities and competencies that pharmacy students should have before beginning APPE. These competency domains are mapped to specific CAPE outcomes. Colleges of pharmacy have used a number of strategies to assess student readiness and facilitate the transition into APPE. Curricular changes such as integration, problembased learning, situational counseling, and professionalism preparation have been used, though specific examples of the efficacy of these individual approaches in improving APPE performance have not been evaluated. However, previous documented strategies have revealed important limitations. In 2008, Culbertson3 used problem-based learning exams to assess student readiness for APPE from a knowledge standpoint and designed a method that was highly specific for identifying students likely to underperform during APPE. Using another approach, Meszaros et al.4 designed a series of exams (offered at the end of each semester), including written closed-book, written openbook, and objective structured clinical exams (OSCE) that
872
J.D. Gonzalvo et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 871–876
were correlated with APPE evaluations. While these studies helped colleges identify students who were likely to underperform during rotations, they did not employ strategies to facilitate pharmacy students in transitioning from classroom-based learning to APPE. More recently, colleges of pharmacy have begun developing methods to aid students in transitioning from IPPE and classroom-based learning to APPE. In 2010, Mort et al.5 evaluated an IPPE course called “First-steps” that focused on pharmacy practice skills and communication, and uses reference material to prepare students for APPE. The course was experiential in nature and supplemented their college’s previous IPPE curriculum. The course resulted in increased frequency of desired clinical behaviors on a subsequent APPE. While this approach proved to be effective, the course required a high volume of time and resources, including 14 faculty and 14 non-faculty preceptors working daily with student groups (56 students completed this experience each year over a four-week rotation block). For larger programs, this approach may likely become unmanageable. To account for the additional time students spent in IPPE, the duration of their APPE experience was shortened from 44 weeks to 40 weeks. Using a classroom-based approach, Bookstaver et al.6 designed an evidence-based medicine elective course to determine if students on rotations who took the elective performed superior to those who did not. Most APPE preceptors who were surveyed reported they felt that students completing the course performed better on their rotation than those who did not. While an important part of success on rotations involved student preparedness to evaluate and use evidence-based medicine, other abilities and competencies identified in the ACPE guidelines were not assessed. Vyas et al.7 designed an IPPE simulation class (using standardized patient actors) to evaluate students in 10 of the 11 domains in the pre-APPE core domain abilities described in the ACPE guidelines.1, Students completing the course performed better on practical examinations compared to those who did not. This approach was described as costly and highly resource intensive, the authors noting each simulation experience required eight hours of direct faculty time, three hours of preparation, and the direct and indirect costs of the experience were $7500 (to deliver the experience to 28 students). Ragan et al.8 also utilized simulation in the form of standardized clients and didactic components, and they were able to predict students who underperform during APPEs. It also was described as resource-intensive and highly costly, and it also was only a measurement of student preparedness and did not provide students with tools or strategies to transition from IPPE to APPE. Rationale and objectives While supplemental IPPE and simulation-based courses have demonstrated success in helping students transition to
APPE, multiple factors, including a lack of resources, may prevent colleges of pharmacy from developing standardized courses. While actual costs and utilization of resources were not available for most of the programs described in the literature, most could be assumed to be intensive, since programs were designed to address more of the pre-APPE competences that require higher costs and more resources. An elective course designed around evidence-based medicine did demonstrate success in improving APPE performance, however, did not provide students with further resources for self-assessment and supplementation of their clinical knowledge.6 In this article, we describe the Introduction to Advanced Pharmacy Practice Experiences course that helps students transition to APPE. Materials and methods The Introduction to Advanced Pharmacy Practice Experiences course was conceptualized and designed to have more time in the curriculum devoted to preparing students for the APPE year. Currently, the course is coordinated by two faculty members and taught by an additional five faculty members and five volunteer preceptors. Before this course existed, third professional (P3) year students were required to attend a two-hour meeting during the spring semester of the P3 year. This meeting occurred in April prior to the first rotation of the P4 year that would begin in May. It was designed as a lecture during which the experiential learning program director would deliver all of the information concerning APPE rotations to the students and consisted of a thorough review of the APPE policies that appeared in the APPE manual. Topics reviewed with students included evaluation of students’ and preceptors’ performances, professional behavior, documenting hours of experience, collecting immunization documentation, and review of required assignments. It was essentially the “nuts and bolts” of how the APPE program worked and presentation of student requirements for successful completion of the program. The two-hour meeting often did not allow for a thorough explanation of the APPE requirements in sufficient depth so as to ensure student understanding. This resulted in students having many questions once APPE rotations began and some missing evaluations as well as missing-hour certification forms. It also did not provide any supplemental material to support students’ abilities to accomplish the core competencies outlined in the ACPE guidelines.1 The Experiential Learning Advisory Council (ELAC), a group of faculty and experienced preceptors from each region who assist the APPE director in oversight of the experiential program, discussed ways for improving the delivery of this material to the P3 students and recommended changing the two-hour meeting to a one-credit-hour course. The course would not only cover the basic policies and procedures of APPE rotations but would also incorporate other material designed to prepare students for rotations.
J.D. Gonzalvo et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 871–876
873
Table 1 Course goals and objectives Goals The Introduction to Advanced Pharmacy Practice Experiences (APPE) course is intended to: 1. Provide professional students with the basic introductory practice information needed to succeed during clerkship. 2. Enable professional students to avoid common rotation mistakes. 3. Remove confusion surrounding the clerkship experience by alleviating anxiety and building student confidence. 4. Standardize pre-rotation training. Objectives By the end of the course, professional students are expected to be able to: 1. Explain how to register for rotations. 2. Recall clerkship policies and procedures. 3. List the forms that should be submitted to the Office of Experiential Learning after each rotation. 4. Critique preceptors and rotations constructively and assess peer performance on oral and written work. 5. Apply strategies to maximize the clerkship experience to each assigned rotation. 6. Cite the rotation portfolio requirements. 7. List handy drug information resources to use during rotations. 8. Explain ways to handle “tough situations” during rotations. 9. Document complete clinical interventions using Clinical Measures software. 10. Provide pharmacokinetic recommendations using provided equations and tools. 11. List ways to succeed on non-patient-care rotations. 12. List ways to prepare for post-graduate training during rotations. 13. Recall important information from common disease states encountered while on rotation.
Basic introductory experiential activities were already covered in the Introductory Pharmacy Practice Experiences (IPPEs) and were not repeated here. Course goals and objectives are listed in Table 1. All P3 students were told about the course and were strongly encouraged to participate as individual schedules permitted. All of the course lectures were recorded so that students who were unable to take the course due to schedule conflicts with other courses could watch the lectures and still obtain the information. BlackboardTM, an online course management system, was utilized to post all course-related information and to administer course evaluations. Upon completion of the course, students should possess knowledge of the college’s specific APPE policies and procedures, as well as meet all of the core competencies outlined in the ACPE guidelines. Although this course did not specifically cover material related to each of these competencies, the rest of the pharmacy curriculum supported students’ achievement of this objective after their completion of the course. Didactic lectures were utilized as the primary mode of instruction. Once the course was conceptualized, content topics were suggested by the ELAC. A current course schedule is presented in Table 2 and illustrates all topics covered in each hour of the course. During class period 2, for example, both hours were devoted to providing more information to the students about community pharmacy and ambulatory care rotations and post-graduate opportunities in those fields. The ELAC felt that students were already receiving a lot of information and guidance regarding hospital and inpatient specialty practice and could benefit from some additional information about outpatient practice settings. In class period 3, the second hour was devoted to unique
situations and focused primarily on pharmacy robberies, but also included some discussion on work place issues and personnel interactions. The last class period was devoted to hosting a preceptor and current APPE student (P4) question and answer panel. The course was scheduled as eight, two-hour lectures beginning the second half of the spring semester of the P3 year. These eight weeks directly preceded the APPE rotations. The course was offered as a Pass/Not Pass course with attendance being the only criteria for successful completion, initially. Students completed a brief reflection at the end of each class to provide course feedback and record attendance. Feedback from course evaluations contributed to minor modifications in the course. Additionally, the ELAC continued to provide suggestions and guidance on which topics were most relevant. After the first three years, the course was modified to incorporate the clinical topic modules. Successful completion of the clinical topic modules became an additional requirement for passing the course. Clinical topic modules In Summer 2011, a planning meeting was held to discuss the potential incorporation of web-based clinical topic modules into the course. The modules would be designed as a concise review that focused on disease state topics initially taught in the Therapeutics courses. A focus group first met to outline an appropriate approach for the development of the modules. An initial survey to P4s ascertained which topics students felt were most important to target prior to development of the modules. Survey topics ranked highest by the P4 students were selected for development.
874
J.D. Gonzalvo et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 871–876
Table 2 Introduction to Advanced Pharmacy Practice Experiences (APPE) course schedule Class Description
Assignments
1
Topic 1: Registration Topic 2: Policies & procedures Registering for rotations, patient care modules, and rotation policies and procedures Spring break—No class
In-class reflection
2
Topic 1: Community pharmacy Topic 2 : Ambulatory care How to succeed in community pharmacy and amb care rotations, Post grad training opportunities in amb care and community pharmacy
In-class reflection Week 2 module
3
Topic 1: Clinical documentation Topic 2: Unique situations Using clinical documentation software on rotations and handling tough situations on rotations and in the real world
In-class reflection Week 3 module
4
Topic 1: DI resources Topic 2: Portfolios Requirements for rotation portfolios and drug information resources to use on rotations (hand-held devices applications, useful pocket guides, Purdue library resources, etc.)
In-class reflection Week 4 module
5
Topic 1: Required documentation and evaluation of Topic 2: Professionalism in the workplace APPEs Required forms to submit at the end of each rotation, skill-based competencies/operations 2 modules, clinical skills competition information, and professionalism
In-class reflection
6
Topic 1: Pharmacokinetics booster Pharmacokinetics in the “real world”
Topic 2: Pharmacokinetics booster
Kinetics problems Week 6 module
7
Topic 1: Student panel Student and preceptor panels Q & A
Topic 2: Preceptor panel
PRE reflection Course evaluation Week 7 module
Module topics were divided into three categories: outpatient, inpatient, and extra (Table 3). Clinical pharmacy specialists, some of whom were faculty members, were solicited to aid in the development of the web-based modules. Adobe PresenterTM and VoiceThreadTM technologies were utilized to develop the 30-minute modules. These volunteers were provided several months to develop each module. Following Table 3 Clinical topic modules Outpatient Diabetes Hyperlipidemia Hypertension Over-the-counter (OTC) and herbal medications Asthma and chronic obstructive pulmonary disease (COPD) Anticoagulation Inpatient Heart failure Arrhythmias Infectious disease Fluid/electrolytes/nutrition (FEN) Clinical pearls Acid–base Venous thromboembolism (VTE) Extra Medication therapy management (MTM) Coronary artery disease (CAD) Chemotherapy-induced nausea and vomiting (CINV) Febrile neutropenia Pediatrics
Week 5 module
development, web links to the modules were posted on BlackBoardTM. Students enrolled in the course were required to pass a total of six module quizzes, outside of scheduled class time, over the eight-week course with a minimum score of 80% on each quiz. Each quiz was comprised of ten, multiple-choice questions and was available electronically on BlackboardTM. The modules were not only offered to the P3 students preparing for rotations enrolled in the course, but also to P4 students as an educational resource while on rotation. The majority of the course utilized didactic instructional methods, particularly the clinical topic modules. In-class sessions employed didactic instruction, as well as active discussions and participation from the students. No outside class time was required for students to prepare for in-class sessions; however, the clinical topic modules were completed online, outside of regular class time. On average, the duration of the didactic portion for each module was approximately 30 minutes. No textbooks were required for this course. No formal assessments or examinations were administered outside of the 10-point quizzes associated with the clinical topic modules. Course evaluations included 11 assessment statements with a score of 5 ¼ Strongly Agree, 4 ¼ Agree, 3 ¼ Neutral, 2 ¼ Disagree, and 1 ¼ Strongly Disagree. A Student’s t-test was used to compare data sets from 2009 and 2011. Results Every year, only two to three students opted not to participate in the elective course due to class scheduling
J.D. Gonzalvo et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 871–876
875
Table 4 Assessment statements and mean student scores Assessment statements
2009, n ¼ 135
2010, n ¼ 146
2011, n ¼ 127
p Value 2009 vs. 2011
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
4.33 4.29 4.26 4.16 4.28 4.12 3.98 4.36 4.21 4.12 4.13
4.28 4.36 4.36 4.17 4.26 4.23 4.21 4.30 4.00 4.29 4.19
4.46 4.56 4.54 4.28 4.39 4.40 4.30 4.52 4.19 4.38 4.35
0.02 NS 0.0003 NS NS 0.003 0.004 0.009 NS 0.001 0.002
The objectives of this course were clearly explained to me. Practical applications of course material are discussed. This course material is pertinent to my professional training. In this course, many methods are used to involve me in learning. Team teaching is used effectively in this course. There is an appropriate mix of lecture and discussion in this class. Class sessions were interesting and engaging. My instructors make effective use of classroom technology. Assignments are related to the goals of the course. As a result of this course, I feel more prepared to begin rotations. Overall, I would rate this course as excellent.
5 ¼ Strongly Agree, 4 ¼ Agree, 3 ¼ Neutral, 2 ¼ Disagree, 1 ¼ Strongly Disagree, NS ¼ not statistically significant.
conflicts. The course evaluation assessment statements with their correlating average scores are included in Table 4. The mean student rating for each assessment statement was between Strongly Agree and Agree with the exception of “Class sessions were interesting and engaging,” which scored a 3.98 initially but improved to 4.21 the subsequent year and again to 4.30 in the third year. Statistical analysis indicated a significant improvement in the course scores on 7 of the 11 items between 2009 and 2011. Four items remained unchanged. In addition, during the first year that the course was offered (2009), the students provided some reflective feedback at the end of each class period. This information was used to modify the class in the subsequent years. Although the majority of students had either no comments for improvement or said everything was “good,” some students indicated there was redundancy in the presented material and that certain class periods could be more efficient. There were also some negative comments regarding specific instructors and presentation styles. Most statements improved from the first year the course was offered to the third year. This improvement was likely due to the course coordinators incorporating different presenters into the course based on feedback from the students. For example in 2009, statement 7, “Class sessions were interesting and engaging,” scored a 3.98 but increased to 4.30 the third year. In this particular instance, the presenter giving the professionalism talk used a PowerPointTM lecture style the first year. In the following years, a new presenter was identified who used interactive teaching and role-played different professionalism scenarios that were entertaining to the class. Statements 6 and 7 relate to class format and engagement of students. From 2009 to 2011, more emphasis was placed on discussing topics with students and making them a part of the class as opposed to the typical lecture format. In the third class period, during the Unique Situations presentation, students are shown a video produced by the Federal Bureau of Investigation (FBI) on pharmacy robberies and how to react if this
happens during rotations. In 2011, after the video was shown, one of the students in the class who had already been robbed in her pharmacy where she worked in the summer talked to the class about her personal experience. This was a very effective way of connecting the class to the topic in a meaningful way. Both statements 6 and 7 improved significantly from 2009 to 2011 (p ¼ 0.003 and 0.004, respectively). Implementing the clinical topic modules was another major advancement in the course and could explain the significant increase in students’ perceptions that the material was more pertinent to their professional training (statement 3;, p ¼ 0.0003) and their feeling more prepared to begin rotations (statement 10, p ¼ 0.002). At the end of the Spring 2011 semester, third-year students who were enrolled in the course completed a survey to assess their perceptions of the clinical modules. At the end of the 2012 rotation year, the same students were surveyed to assess their perceptions of the utility of the clinical modules while on rotations. Both the surveys revealed that the students perceived the modules to be helpful. The average pass rate on the P3 module quizzes was 79.2%, with a range from 32.0% (Venous Thromboembolism) to 99.1% (Inpatient Clinical Pearls). A more detailed description of the survey methods and results has been previously published.9
Discussion In 2011, this course was accepted for full integration into the professional curriculum. In 2013, along with significant curricular changes, the Introduction to APPE course became a required course. The requirement of this course largely stems from our consistent assessment data that have reflected positive student perceptions of the course and the clinical topic modules. Course coordinators have implemented strategies to improve the course based on initial student feedback, which has resulted in improved scores since the inception of the course. These strengths of the
876
J.D. Gonzalvo et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 871–876
course support the decision to continue to offer the course, incorporating revisions from ELAC and student feedback. One current limitation is the lack of subsequent assessment of P4 students’ performance while on rotation following participation in this course. A subsequent survey to P4 students and preceptors while on rotation would allow for evaluation of achievement of course goals and objectives. Results from a survey of this nature would also inform decisions related to the need for modifications to the course. At this time, specific modifications to the course are not planned. A paucity of literature exists with regard to how colleges of pharmacy can feasibly prepare students for the APPE year. Colleges of pharmacy may consider implementing a similar course to better prepare P3 students for rotations. Implementation of a comparable course supports the core domains outlined in the ACPE accreditation standards and provides an opportunity to assess student readiness to enter APPEs.1 The Director of experiential learning would ideally play a key role in the development and implementation of the course; although, additional support from faculty and preceptors is necessary to effectively offer the varied aspects of the course. Development and coordination of the clinical topic modules requires a significant amount of time and effort. Ideally, an additional course coordinator would be available to solicit expert instructors, manage the technology related to accessing the modules, and answer topic-related questions. The decision to offer the course as Pass/Not Pass or for a letter grade may be individualized to the institution and coordinator preferences. Schools wishing to implement a similar course will require commitment from multiple faculty, content experts, and basic technological support. Colleges of pharmacy with limited resources may consider reaching out to residents or preceptors to help design the course and deliver lectures. As with the course described here, colleges may consider initially offering the course without the online review modules to decrease the time and effort to offer a course of this nature. Additionally, the possibility of offering this course exclusively online may be more feasible to some institutions. Conclusions The Introduction to Advanced Pharmacy Practice Experiences course has provided P3 students with a strong foundation of practical and useful knowledge to help better prepare them for the rotational year. To date, the majority of each class of students has elected to participate in this course. This course has received positive feedback from
students since its inception in 2009.The course has grown to involve online, didactic clinical topic modules to provide a therapeutic review of commonly encountered disease states. Course coordinators expect this elective course to continue to garner significant participation. This course could be replicated at other colleges of pharmacy and will likely require less time and resources than other similar courses described in the literature. Colleges of Pharmacy may wish to consider incorporating similar courses to help prepare P3 students prior to beginning APPE rotations.
References 1. Accreditation Council for Pharmaceutical Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. S2007, Guidelines 2.0, Preamble Addendum, Appendix D. Chicago, IL: 2011. 〈http://www.acpe-accredit.org/pdf/FinalS2007Guidelines 2.0.pdf/〉 Accessed July 28, 2014. 2. Medina M, Plaza C, Stowe C, Robinson ET, DeLander G, Beck DE, et al. Center for the Advancement of Pharmacy Education (CAPE) Educational Outcomes 2013. Am J Pharm Educ. 2013;77(8): Article 162. 3. Culbertson VL. Pharmaceutical care plan examinations to identify students at risk for poor performance in advanced pharmacy practice experiences. Am J Pharm Educ. 2008;72 (5): Article 111. 4. Meszaros K, Barnett MJ, McDonald K, Wehring H, Evans DJ, Sasaki-Hill D, et al. Progress examination for assessing students’ readiness for advanced pharmacy practice experiences. Am J Pharm Educ. 2009;73(6): Article 109. 5. Mort JR, Johnson TJ, Hedge DD. Impact of an introductory pharmacy practice experience on students’ performance in an advanced practice experience. Am J Pharm Educ. 2010;74(1): Article 11. 6. Bookstaver PB, Rudisill CN, Bickley AR, McAbee C, Miller AD, Piro CC, et al. An evidence-based medicine elective course to improve student performance in advanced pharmacy experiences. Am J Pharm Educ. 2011;75(1): Article 9. 7. Vyas D, Bhutada NS, Feng X. Patient simulation to demonstrate students’ competency in core domain abilities prior to beginning advanced pharmacy practice experiences. Am J Pharm Educ. 2012;76(9): Article 176. 8. Ragan RE, Virtue DW, Chi SJ. An assessment program using standardized clients to determine student readiness for clinical practice. Am J Pharm Educ. 2013;77(1): Article 14. 9. Gonzalvo JD, Chomicki J, Chu M, Frail C. Incorporation of online clinical topic modules in an introduction to advanced pharmacy practice experience course. Curr Pharm Teach Learn. 2013;5(5):438–443.