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Incorporating the Pharmacists' Patient Care Process Into An Interprofessional Second Year Capstone
Currents in Pharmacy Teaching and Learning 12 (2020) 41–48
Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Research Note
Incorporating the Pharmacists' Patient Care Process Into An Interprofessional Second Year Capstone
T
Kathryn J. Smith University of Florida College of Pharmacy, P.O. Box 100486, Gainesville, FL 32610, United States
ARTICLE INFO
ABSTRACT
Keywords: Pharmacists' Patient Care Process Assessment Capstone Interprofessional collaboration Standardized patient
Objective: To describe elements of an interprofessional second year capstone experience designed to incorporate each step of the Pharmacists' Patient Care Process (PPCP) and to evaluate changes in attitudes towards interprofessional collaboration. Methods: Second year pharmacy students collaborated with dental students to collect information from a standardized patient (SP), assess dental and pharmacy-related problems, and develop a plan resolving the problems identified. Students documented via a SOAP note (subjective, objective, assessment, and plan) and followed up with the SP after an emergency room visit, developing a new plan for implementation. Pharmacy students followed up in the inpatient setting when the SP was preparing for discharge, collecting information from the electronic health record (EHR), assessing the patient's medical conditions, and planning for treatment. Multiple assessment methods were used including extended multiple-choice questions (eMCQs) to assess clinical reasoning skills and a rubric for SOAP note grading. Results: Students performed well on the assessments especially communicating with the SP during medication history and discharge counseling and documenting their care in a SOAP note. Students stated value was added to their education through this experience. Conclusions: This capstone allowed students the opportunity to practice each step of the PPCP and to collaborate as a member of an interprofessional team As the PPCP is integrated into pharmacy curricula, assessments such as this will be essential for determining practice-readiness and team-readiness of graduates.
Introduction The Pharmacists' Patient Care Process (PPCP) was developed to provide a framework for consistent delivery of pharmacy services across the continuum of care wherever patients might interact with a pharmacist.1 Standard 10.8 of the Accreditation Council for Pharmacy Education (ACPE) Accreditation Standards 2016 requires teaching of the PPCP as described by the Joint Commission of Pharmacy Practitioners (JCPP) and opportunities for interprofessional education.2 There are five steps of the PPCP (collect, assess, plan, implement, and follow up), which is an essential tool to help pharmacy students make sense of large amounts of patient information.3 While several colleges of pharmacy have begun to implement the PPCP into their curriculum, questions remain about the most effective way to assess the PPCP.4–6 The University of Florida College of Pharmacy introduces students to the PPCP in the first week of the first year of didactic courses, asks students to practice skills related to the PPCP in the six-semester skills lab course sequence, and models the PPCP with patients throughout the integrated Patient Care course sequence in years two and three of the curriculum.7 As a summative assessment in years one and three
E-mail address: [email protected]. https://doi.org/10.1016/j.cptl.2019.10.006
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Currents in Pharmacy Teaching and Learning 12 (2020) 41–48
K.J. Smith
Table 1 Summary of activities in capstone and step of PPCP assessed.
Part 1. Interprofessional (IP) introductions Part 2. IP outpatient visit with standardized patient (SP)
Part 3. IP follow up with SP (2018 only)
Part 4. Individual inpatient visit with SP
Learning activities
Associated step(s) of PPCP
Create a short video to introduce self and profession to IP teammates Team interview of SP Assess information collected from the patient, identify and prioritize medication related problems Collaborate interprofessionally to develop a care plan for SP Document care plan (individual SOAP note) Collect/assess information collected from patient/EHR (pharmacy students only) Communicate recommendation to dental students (pharmacy students only) Write prescriptions for SP (dental students only) Collect/assess information collected from EHR Document a patient discharge medication list Conduct discharge counseling with SP
Collaborate, communicate Collect Assess Plan, implement, collaborate Document Follow up, collect, assess Follow up, plan, communicate Implement Collect, assess Documentation Implement
PPCP = Pharmacists' Patient Care Process; SOAP = subjective, objective, assessment, plan; EHR = electronic health record.
of the didactic curriculum, students complete objective structured clinical exams (OSCEs). As an alternative summative assessment in year two of the curriculum, faculty designed an Interprofessional Second Year Capstone (the Capstone). Skills developed in the second year of skills lab include navigating an educational electronic health record (EHR), discharge counseling, and documenting patient care plans. Second year pharmacy students also complete didactic course work related to infectious diseases, cardiovascular and respiratory diseases, renal function, and endocrinology. The second year of the curriculum prepares the students for Hospital Introductory Pharmacy Practice Experience (HIPPEs), which, for many students, may be the first exposure to an EHR and working in interprofessional healthcare teams. The objectives of the Capstone were for students to utilize each step of the PPCP while collaborating as a member of an interprofessional team, and to assess the student attitudes of interprofessional team-based care. Methods The Capstone serves as a summative assessment at the end of the second year of the four-year doctor of pharmacy (PharmD) curriculum and interprofessional students were recruited for the interprofessional parts of the experience. Dental students were chosen for this experience due to mutual interest of the faculty in developing a learning experience and availability of the students who would participate. The Capstone was first offered in May 2017 (all parts) and again in March (Parts 1, 2, and 3) and May (Part 4) 2018. The schedule was adjusted during the second year due to changes in the availabilities of the dental students involved. During both 2017 and 2018, pharmacy and dental students were placed in interprofessional (IP) teams of approximately six pharmacy students and two dental students. In 2017, participating dental students had already started the fourth year of their course work (D4), while in 2018, they were completing the third year of their coursework (D3). The Capstone included four parts as outlined in Table 1. Part 1 Prior to beginning active learning activities, all students completed the Jefferson Scale of Attitudes Toward Interprofessional Collaboration (JeffSATIC) and a roles and responsibilities quiz (RR quiz) to assess attitudes towards interprofessional collaboration and knowledge related to the other profession involved.8 The RR quizzes were adapted from a survey on pharmacists' roles and responsibilities developed by Vrontos et al.9 Then students were required to create a short video to introduce themselves and their profession to their IP teammates. Part 2 All students received a brief written introduction to the standardized patient (SP) approximately 24 hours prior to attending a two-hour IP active learning session. The SP was a 47-year-old white male patient who presented to an IP free clinic complaining of a toothache. A current smoker, the SP had a past medical history of diabetes, hypertension, an artificial heart valve, and a history of substance abuse. Once students arrived at the active learning session, they sat with their IP teams and interviewed the SP. The goal of this activity was to collect additional information from the SP about his current complaint and other medical conditions. Then, the IP teams collaborated to develop a list of the SP's medication therapy problems and a patient care plan. Once the plan was agreed upon, the dental students wrote prescriptions for the patient and handed the prescriptions to the pharmacy students. The pharmacy students verified the prescriptions as if they were filling the prescription order for the patient in a community pharmacy setting. At the conclusion of the IP active learning session, pharmacy students documented their interaction with the patient, their assessment of the patient's medication therapy problems, and plans for the patient's care going forward. This documentation took the form of a SOAP note, which included subjective and objective information as well as the pharmacy student's assessment and plan. Dental students submitted a written care plan for the SP's dental care. 42
Currents in Pharmacy Teaching and Learning 12 (2020) 41–48
K.J. Smith
Part 3 After the 2017 offering of the Capstone, faculty felt the students needed an additional opportunity to interact as an IP team, so Part 3 of the Capstone was added in 2018. Approximately one week after Part 2, the dental students received a message from the SP on the learning management system's (LMS) discussion board. Dental students consulted the pharmacy students about the patient's new problem. Pharmacy students had access to the SP's EHR in EHRGo (Archetype Innovations, LLC, Duluth, MN), an educational EHR used throughout the PharmD curriculum. The pharmacy students provided a summary of the new problem and made a recommendation about continued care to the dental students. The dental students then wrote prescriptions for the SP based on the information provided by the pharmacy student. The accuracy of the medication(s) recommended for the SP by the dental students was not assessed. Part 4 Approximately one month later, the SP was being discharged from an inpatient visit. He had presented to the emergency room with complaints of chest pain and palpitations, diagnosed with atrial fibrillation and started on some new medications. In 2017, the pharmacy students started Part 4 by individually collecting a medication history from the SP. After the interview, pharmacy students accessed the SP's updated EHR and completed a 10-question extended multiple choice question (eMCQ) quiz in the LMS. The eMCQ quiz was designed to assess the student's ability to collect information from the EHR, develop a medication therapy problem list, and document a discharge medication list for the patient based on information found in the EHR, with several questions written specifically to link to a step in the PPCP. The skill of taking a medication history was added to the Professional Practice Skills Lab course in 2018, so the faculty decided to adjust the Capstone assessment to include discharge counseling instead of taking a medication history. Therefore in 2018, the pharmacy students started Part 4 of the Capstone with the eMCQ quiz before they individually conducted discharge counseling with the SP. Assessments used throughout the Capstone are outlined in Table 2. After the conclusion of the Capstone learning experiences, students completed the JeffSATIC and RR quiz. The results of the pre- and post-experience JeffSATIC (2017 offering only) and postRR quizzes were compared using paired t-tests to assess any change in attitudes towards IP collaboration or knowledge about the other professions that may have resulted from participation in the Capstone. In 2018, a five-question survey related to IP team dynamics was also completed.10 Pharmacy student SOAP notes were assessed using a rubric, with students earning one of four grades (excellent, competent, needs improvement, or not acceptable) on six components of the note (subjective, objective, assessment of medical conditions, treatment plan, structure (including spelling and unsafe abbreviations), and global assessment (including consistency, appropriate level of detail included)). In 2018 only, the rubric had a check mark (no point value) to assess if pharmacy students mentioned IP collaboration with the dental student in their note or not. The eMCQs, written by the faculty and designed to assess clinical thinking, linked to specific steps in the PPCP.11 SPs used a scoring rubric for grading the medication history interview (2017 only) and discharge counseling (2018 only). Students were also asked to provide feedback on the Capstone through open ended-questions. The JeffSATIC, pre-and post-RR quizzes, SOAP note and discharge counseling scores were summarized using means. The pre- and post-scores for JeffSATIC and RR quizzes were compared using paired t-tests. An asymptotic Wald test was used to evaluate responses to the teamwork dynamics questions, comparing the percentages of students with positive vs. negative feedback. Open-ended comments were summarized by theme. p-Values < 0.05 were considered statistically significant. All analyses were performed using SAS version 9.4 or R version 3.2.3.12,13 This study was submitted to the institutional review board (IRB) at The University of Florida who designated the study as exempt research.
Table 2 Summary of assessments used in the capstone.
Part 1. Interprofessional (IP) introductions Part 2. IP outpatient visit with standardized patient (SP) Part 4. Inpatient visit with SP Feedback
Knowledge/skill/attitude assessed
Assessment tool
Pre-experience knowledge of other profession Pre-experience attitude towards IP collaboration (2017 only) Documentation of care plan (SOAP note) Collection/assessment of information in EHR Medication history interview with SP (2017 only) Discharge counseling with SP (2018 only) Post-experience knowledge of other profession Post-experience attitude towards IP collaboration (2017 only) IP teamwork (2018 only)
Pre-RR quiz JeffSATIC SOAP note rubric eMCQ quiz Medication history interview rubric Discharge counseling rubric Post-RR quiz JeffSATIC Assessing teamwork: a reliable fivequestion survey
RR quiz = roles and responsibilities quiz; JeffSATIC = The Jefferson Scale of Attitudes Toward Interprofessional Collaboration; SOAP = subjective, objective, assessment, plan; EHR = electronic health record; eMCQ = extended multiple-choice questions. 43
Currents in Pharmacy Teaching and Learning 12 (2020) 41–48
K.J. Smith
Results In 2017, 230 second year pharmacy students and 68 D4 students participated in the Capstone. In 2018, 265 second year pharmacy students and 90 D3 students participated in the Capstone. The overall mean score for the pre-JeffSATIC for dental students was 83.6% (raw mean score 117, standard deviation (SD) 12, maximum possible score 140, higher scores indicate more positive attitudes towards IP collaboration). The overall mean score for the post-JeffSATIC for dental students was 83.6% (raw mean score 117, SD 13). The overall mean score for the pre-JeffSATIC for pharmacy students was 87.9% (raw mean score 123, SD 11). The overall mean score for the post-JeffSATIC for pharmacy students was 88.6% (raw mean score 124, SD 13). For students who completed both the pre- and post-JeffSATIC (n = 68 dental, n = 226 pharmacy), there was a mean difference in score of −0.5 (95% CI −1.84, 0.84, p = 0.46) and there was no statistically significant change in attitudes towards IP collaboration observed in dental or pharmacy students. In 2017, the overall mean score for the pre-RR quiz for dental students was 82% (raw mean score 82, SD 9, maximum possible score 100). The overall mean score for the post-RR quiz for dental students was 80% (raw mean score 80, SD 7). A paired t-test was done for dental students who completed both the pre- and post-RR quizzes with a mean difference in score of 2.15 (95% CI −0.66, 4.97, p = 0.13). The overall mean score for the pre-RR quiz for pharmacy students was 65% (raw mean score 65, SD 9). The overall mean score for the post-RR quiz for pharmacy students was 64% (raw mean score 64, SD 10). For students who completed both the pre- and post-RR quizzes, there was a mean difference in score of 1.31 (95% CI −0.32, 2.95, p = 0.11). In summary, there was no statistically significant change in the knowledge about the roles and responsibilities of the other profession before and after the Capstone. In 2018, the RR quizzes were built as surveys in the LMS instead of as quizzes so scores were not available for comparison. The results of the five-question survey related to teamwork conducted after the IP portions of the Capstone in 2018 are shown in Table 3. The overall mean score for the SOAP note in 2017 was 84% (raw mean score 50.2, SD 6.5, maximum possible score 60). The overall mean score for the SOAP note in 2018 was 83% (raw mean score 49.8, SD 4.9). In 2018, only 29% (n = 77) of pharmacy student notes included information about consulting the dental student prior to developing the patient care plan. Further breakdown of the SOAP note scores is shown in Table 4. Table 5 shows the results of the eMCQs asked during Part 4 of the Capstone including to which step of the PPCP each question related. Patient case details were changed from 2017 to 2018 and not all questions were asked both years. Because of the changes to the case and the changes made in content and skills taught to students prior to the Capstone from 2017 to 2018, there were several confounding variables that prevented statistical analysis from being useful for comparing 2017 to 2018 eMCQ results. In 2017, the overall mean score for the medication history rubric was 93% (raw mean score 14.9, SD 1.2, range 10–16, maximum possible score 16). In 2018, the overall mean score for the discharge counseling rubric was 96% (raw mean score 48.2, SD 2.4, range 39–50, maximum possible score 50). Results of the feedback questions asked of both pharmacy and dental students in both years of the Capstone can be found in Table 6. Open-ended comments in both years identified a student desire for additional time to collaborate face-to-face with the IP team and fewer activities requiring electronic communication. Discussion The results from the pre- and post-Capstone JeffSATIC and RR quizzes lead us to believe that this Capstone did not have a statistically significant impact on either pharmacy or dental students' attitudes towards IP collaboration or their knowledge about the other profession. While this was disappointing, there may be several reasons for these results. The Capstone provided an opportunity for dental and pharmacy students to communicate and collaborate on a medically complex patient case. Communication and collaboration are stated outcomes of other didactic and simulation-based IP experiences.14 Students who participated in this Capstone scored comparably to other health professions students on the JeffSATIC leading us to believe the participants likely had a positive baseline attitude towards IP collaboration and this activity did not negatively affect that.11 It is likely a single opportunity to collaborate with another profession would not have a significant impact on one's attitudes towards IP collaboration.15,16 Because of this, the faculty decided not to conduct the JeffSATIC in the 2018 offering of the Capstone. Others have shown longitudinal IP experiences throughout the curriculum can help students meet Interprofessional Education Collaborative (IPEC) Competencies.17–19 The students who participated in the Capstone do participate in other IP learning experiences during their education. Therefore, future studies could include assessing the impact of the complete IP curriculum at this institution on the students' attitudes towards IP collaboration and knowledge of other professions. Pharmacy student members of the IP teams had worked together in team-based learning (TBL) courses throughout the academic year and the dental students were added for the IP parts of this Capstone. While it was not clear exactly how the addition of this new team member would impact team dynamics, the five-question survey related to teamwork showed teams worked well together (Table 3).8 Overall, the pharmacy students performed well on their SOAP note documentation. In 2018, the most common error leading to a rating of “not acceptable” on the subjective portion of the note was neglecting to mention the patient's anaphylactic allergy to penicillin in the note (Table 4). Because this patient was being prescribed an antibiotic, this omission was considered potentially harmful to the patient, resulting in a “not acceptable” rating. The patient case was designed in a way so expertise from both pharmacy and dental students was needed to develop a treatment plan. Only 29% of pharmacy students mentioned IP collaboration in their SOAP note, leading us to believe additional opportunities to document IP encounters would be beneficial. 44
45
c
b
9
6 10 17 11
Not very positive frequency (team rating < 3)
80.43
86.96 78.26 63.04 76.09
Very positive percentage (%)
< 0.001
< 0.001 < 0.001 0.038 0.0002
p-Valuec
1 = strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree. n = 46/46 teams, n = 313/355 individual students. Asymptotic Wald test was used to compare the percentages of teams with very positive vs. not very positive feedback about their team dynamics, with significance defined as p < 0.05.
37
3.2
a
40 36 29 35
3.3 3.2 3.1 3.2
This team encouraged everyone to share ideas. Leadership in this team created an environment where things could be accomplished. People in this team had the information that they need to do their jobs well. When people in this team experienced a problem, they made a serious effort to figure out what's really going on. Everyone in the team felt able to act on the team vision.
Very positive frequency (team rating ≥ 3)
Response (mean value)a,b
Question
Table 3 Results of teamwork survey conducted after interprofessional activities in the capstone in 2018.
K.J. Smith
Currents in Pharmacy Teaching and Learning 12 (2020) 41–48
Currents in Pharmacy Teaching and Learning 12 (2020) 41–48
K.J. Smith
Table 4 Results of documentation of patient care with SOAP note rubric in the capstone. Criteria
% of students receiving each rating Excellent
Subjective Objective Assessment Treatment plan Structure Global assessment
Competent
Needs improvement
Not acceptable
2017
2018
2017
2018
2017
2018
2017
2018
83 77 31 19 49 31
61 77 10 11 87 26
16 22 48 62 44 58
14 23 79 87 13 72
1 <1 20 15 6 10
10 0 11 2 0 2
0 0 1 4 <1 1
15 0 <1 0 0 0
SOAP = subjective, objective, assessment, plan. Table 5 Results of eMCQ on electronic health record (EHR) part 4 of capstone. “According to the information found in the EHR and your clinical judgement…”
…which of the following medications are on SP's home medication list? …which of the following medical conditions should appear on SP's “current problems” list? …what is SP's INR goal? …what is SP's blood pressure goal? …what is SP's A1C goal? …which of the following medications should be on SP's discharge medication list? …when should SP have a follow up appointment for INR monitoring? …when should SP have a follow up appointment for diabetes management?
Step of PPCP
Collect Assess Assess Assess Assess Plan Plan Plan
% correct 2017
2018
85 32 89 75 –a 0 –a –a
98 52 80 –a 88 92 97 99
PPCP = Pharmacists' Patient Care Process; SP = standardized patient; INR = international normalized ratio; A1C = glycosylated hemoglobin. a Question was not asked. Table 6 Dental and pharmacy student feedback on interprofessional capstone learning activities.
Rate the following activities in terms of their value to your learning: Learning about roles/responsibilities of other profession Collaborating interprofessionally to interview the standardized patient (SP) Collaborating interprofessionally to develop a care plan Prescription writing/verifying Written follow up consultation and collaboration on the SP (2018 only) To what extent do you agree or disagree with the following statements? This learning experience prepares students to collaborate with a dentist/pharmacist in future practice when a patient presents with a complex medical/dental program. This learning experience enhanced my understanding of how a patient's care can be improved when both a pharmacist and a dentist provide input into the care. The patient case allowed both the pharmacy students and dental students to contribute to developing a plan. Input from both pharmacy students and dental students was necessary in order to develop the best care plan. The care plan would not have been complete had students from only my profession contributed to development of the plan. Overall, I recommend this learning experience for other dental/pharmacy students.
2017
2018
% V/EV 89 82 88 81 – % A/SA 91
% V/EV 72 76 78 75 67 % A/SA 71
91
74
93 90 81 89
80 78 70 63
V = valuable; EV = extremely valuable; SP = standardized patient; A = agree; SA = strongly agree.
eMCQs have been shown to assess clinical reasoning which is why they were selected for assessing steps in the PPCP during the Capstone.9 Students most often struggled with steps related to the assessment step. This included questions about developing a list of health conditions for the patient. The students had previous exposure applying the PPCP to patients with all health conditions experienced by the Capstone SP. In 2017, the most often missed medical condition was seasonal allergies while in 2018, the most often missed medical condition was a history of opioid dependence. Since this patient was in the hospital for chest pain, shortness of breath, and new onset atrial fibrillation, it could be argued that a history of seasonal allergies is not clinically significant. However, a history of opioid dependence is important to note in any patient presenting with pain, so additional training may be beneficial to our students in this content area. While the assessment step is potentially the most difficult step of the PPCP, it is the most critical step, wherein the pharmacist uses a combination of drug knowledge and critical thinking to consider how current therapies are helping or failing to meet the patient's therapeutic goals. When developing a plan for SP, it was surprising that not a single student was able to compile a discharge medication list that matched what faculty had developed. After debriefing with students about the case, it 46
Currents in Pharmacy Teaching and Learning 12 (2020) 41–48
K.J. Smith
seemed there was some confusion about the definition of “sliding scale insulin” and its use in the hospital setting. The Institute for Safe Medication Practices (ISMP) Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults outline the errors and poor outcomes associated with the use of sliding scale insulin as the only strategy for managing hyperglycemia in the inpatient setting.20 A safer and more appropriate term to use as an answer choice would have been “scheduled subcutaneous insulin doses that includes basal, nutritional, and correctional components”.20 Since the Comprehensive Medication Management in Primary Care Research Team released the operational definitions of each step of the PPCP, it will be easier to communicate to students what is expected in each step of the PPCP.21 With a clearer and most consistent definition of each step in the PPCP and their growing drug and disease state knowledge, students will improve their ability to demonstrate competence with each step of the PPCP. During the medication history interview and discharge counseling, students most commonly left out verification of both the patient name and date of birth, potentially leading to gathering information from or providing information to the wrong patient. These results point to patient safety as a topic which could be emphasized more often in the pharmacy curriculum. The student feedback reflected a decreased perception of the value of the Capstone activities from 2017 to 2018 (Table 6). While this result was not expected by the faculty, it did prompt additional reflection when considering future years of the activity. Different classes of students have different “personalities” and experience the same activities differently. From 2017 to 2018, the number of opportunities to collaborate interprofessionally on the SP increased from one to two, but only 67% of students rated the second collaboration activity as valuable or very valuable (Table 6). After reflecting on the specifics of the second collaboration activity, faculty decided they would need to clarify the directions and the clinical problem students were being asked to solve during this step of the Capstone. Additionally, pharmacy students were required to travel from distance campus sites to the main campus location for the IP part of the Capstone. This almost certainly affected the percentage of pharmacy students who would recommend this activity in the future as distance campus students dislike adding travel time and expense to their already busy schedule. As previously stated, the Capstone takes place at the end of the second year of the PharmD curriculum. Future studies could include assessing the impact of this Capstone on performance of the steps of the PPCP during the third year OSCE, on written clinical documentation, or on IP collaboration opportunities that occur in the third year of the curriculum. Limitations include only conducting the activity at one institution and only including two professions in the study. However, this type of activity could be conducted at institutions of various sizes with multiple health professions students if the patient case was written to require input from various members of the health care team. The Capstone activities did provide pharmacy students an opportunity to demonstrate ability to complete each step of the PPCP. Further research may include helping pharmacy and dental students develop a process for collaboration by comparing patient care processes between the two professions and adding more opportunities for these groups of students to work together to collaborate on patient care during their education. Conclusions The learning activities in Interprofessional Second Year Capstone were designed to assess the pharmacy students' ability to carry out the PPCP and to give them practice with IP collaboration. While the activities may not have had a significant impact on the students' attitudes towards IP collaboration, the Capstone did allow students the opportunity to practice each step of the PPCP. As the PPCP is integrated into pharmacy curriculum around the country, assessments such as this will be essential for determining practicereadiness and team-readiness of our graduates. Financial disclosures None. Declaration of competing interest None. Acknowledgments The author wishes to thank the pharmacy faculty who helped with case development and logistics support, Lori Dupree, Bethany Shoulders, and Lisa Vandervoort; the collaborating dental faculty, Gail Childs and Venita Sposetti; and Yan Gong and Yiqing Chen, who provided statistical support. References 1. Pharmacists’ patient care process. Joint Commission of Pharmacy Practitioners; 2014 https://jcpp.net/wp-content/uploads/2016/03/PatientCareProcess-withsupporting-organizations.pdf Published 29 May. Accessed 15 October 2019. 2. Accreditation Standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree (“standards 2016”). Accreditation Council for Pharmacy Education; 2015 https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf Published February. Accessed 15 September 2019. 3. Smith KJ. The pharmacists’ patient care process as sensemaking. Pulses; 2018 https://cptlpulses.com/2018/01/16/ppcp-sensemaking/ Published 16 January. Accessed 15 October 2019. 4. Cooley J, Lee J. Implementing the pharmacists’ patient care process at a public pharmacy school. Am J Pharm Educ. 2018;82(2) https://doi.org/10.5688/ ajpe6301.
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5. Kolar C, Hager KD, Losinski V. Beyond the pharmacists’ patient care process: cultivating patient care practitioners by uyilizing the pharmaceutical care framework. Innov Pharm. 2017;8(3) https://doi.org/10.24926/iip.v8i3.532. 6. Gonyeau MJ, DiVall M, Conley MP, Lancaster J. Integration of the Pharmacist’s Patient Care Process (PPCP) into a comprehensive disease management course series. Am J Pharm Educ. 2018;82(6) https://doi.org/10.5688/ajpe6311. 7. 2015–2019 PharmD Curriculum. University of Florida College of Pharmacy; 2019 https://curriculum.pharmacy.ufl.edu/curriculum-courses/about-the-curriculum/ 2015-2017-pharmd-curriculum/ Updated 1 September. Accessed 15 October 2019. 8. Hojat M, Ward J, Spandorfer J, Arenson C, Van Winkle LJ, Williams B. The Jefferson Scale of Attitudes Toward Interprofessional Collaboration (JeffSATIC): development and multi-institution psychometric data. J Interprof Care. 2015;29(3):238–244. 9. Vrontos EB, Kuhn CH, Brittain KL. Impact of interprofessional activities on health professions students’ knowledge of community pharmacists’ role and services. Am J Pharm Educ. 2011;75(8) https://doi.org/10.5688/ajpe758152. 10. Lurie SJ, Schultz SH, Lamanna G. Assessing teamwork: a reliable five-question survey. Fam Med. 2011;43(10):731–734. 11. Beullens J, Struyf E, Van Damme B. Do extended matching multiple-choice questions measure clinical reasoning? Med Educ. 2005;39(4):410–417. 12. SAS [computer program]. Version 9.4. Cary, NC: SAS Institute; 2014. 13. R [computer program]. Version 3.2.3. Vienna, Austria: R Foundation for Statistical Computing; 2019. 14. Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional education. Med Educ Online. 2011;16(1) https://doi.org/10.3402/meo.v16i0.6035. 15. Van Winkle LJ, Bjork BC, Chandar N, et al. Interprofessional workshop to improve mutual understanding between pharmacy and medical students. Am J Pharm Educ. 2012;76(8) https://doi.org/10.5688/ajpe768150. 16. Grice GR, McCorkle NA. Difference in student pharmacist attitudes and readiness for interprofessional learning after an activity with student nurses. J Interprofessional Educ Pract. 2016;3:29–33. 17. Woltenberg L, Taylor S. Successes, challenges, and impact of a large-cohort preclinical interprofessional curriculum: a four-year reflection. Curr Pharm Teach Learn. 2018;10(5):662–668. 18. Poling D, Kiersma M. A unique interprofessional and multi-institutional education series. J Nurs Educ. 2014;53(7):415–420. 19. Core competencies for interprofessional collaborative practice: 2016 update. Interprofessional Education Collaborative; 2016 https://nebula.wsimg.com/ 2f68a39520b03336b41038c370497473?AccessKeyId=DC06780E69ED19E2B3A5&disposition=0&alloworigin=1 Accessed 15 October 2019. 20. ISMP guidelines for optimizing safe subcutaneous insulin use in adults. Institute for Safe Medication Practices; 2018 https://www.ismp.org/sites/default/files/ attachments/2018-09/ISMP138D-Insulin%20Guideline-090718.pdf Accessed 15 October 2019. 21. The patient care process for delivering Comprehensive Medication Management (CMM): optimizing medication use in patient-centered, team-based care settings. CMM in Primary Care Research Team; 2018 http://www.accp.com/cmm_care_process Accessed 15 October 2019.
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Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Research Note
Incorporating the Pharmacists' Patient Care Process Into An Interprofessional Second Year Capstone
T
Kathryn J. Smith University of Florida College of Pharmacy, P.O. Box 100486, Gainesville, FL 32610, United States
ARTICLE INFO
ABSTRACT
Keywords: Pharmacists' Patient Care Process Assessment Capstone Interprofessional collaboration Standardized patient
Objective: To describe elements of an interprofessional second year capstone experience designed to incorporate each step of the Pharmacists' Patient Care Process (PPCP) and to evaluate changes in attitudes towards interprofessional collaboration. Methods: Second year pharmacy students collaborated with dental students to collect information from a standardized patient (SP), assess dental and pharmacy-related problems, and develop a plan resolving the problems identified. Students documented via a SOAP note (subjective, objective, assessment, and plan) and followed up with the SP after an emergency room visit, developing a new plan for implementation. Pharmacy students followed up in the inpatient setting when the SP was preparing for discharge, collecting information from the electronic health record (EHR), assessing the patient's medical conditions, and planning for treatment. Multiple assessment methods were used including extended multiple-choice questions (eMCQs) to assess clinical reasoning skills and a rubric for SOAP note grading. Results: Students performed well on the assessments especially communicating with the SP during medication history and discharge counseling and documenting their care in a SOAP note. Students stated value was added to their education through this experience. Conclusions: This capstone allowed students the opportunity to practice each step of the PPCP and to collaborate as a member of an interprofessional team As the PPCP is integrated into pharmacy curricula, assessments such as this will be essential for determining practice-readiness and team-readiness of graduates.
Introduction The Pharmacists' Patient Care Process (PPCP) was developed to provide a framework for consistent delivery of pharmacy services across the continuum of care wherever patients might interact with a pharmacist.1 Standard 10.8 of the Accreditation Council for Pharmacy Education (ACPE) Accreditation Standards 2016 requires teaching of the PPCP as described by the Joint Commission of Pharmacy Practitioners (JCPP) and opportunities for interprofessional education.2 There are five steps of the PPCP (collect, assess, plan, implement, and follow up), which is an essential tool to help pharmacy students make sense of large amounts of patient information.3 While several colleges of pharmacy have begun to implement the PPCP into their curriculum, questions remain about the most effective way to assess the PPCP.4–6 The University of Florida College of Pharmacy introduces students to the PPCP in the first week of the first year of didactic courses, asks students to practice skills related to the PPCP in the six-semester skills lab course sequence, and models the PPCP with patients throughout the integrated Patient Care course sequence in years two and three of the curriculum.7 As a summative assessment in years one and three
E-mail address: [email protected]. https://doi.org/10.1016/j.cptl.2019.10.006
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Currents in Pharmacy Teaching and Learning 12 (2020) 41–48
K.J. Smith
Table 1 Summary of activities in capstone and step of PPCP assessed.
Part 1. Interprofessional (IP) introductions Part 2. IP outpatient visit with standardized patient (SP)
Part 3. IP follow up with SP (2018 only)
Part 4. Individual inpatient visit with SP
Learning activities
Associated step(s) of PPCP
Create a short video to introduce self and profession to IP teammates Team interview of SP Assess information collected from the patient, identify and prioritize medication related problems Collaborate interprofessionally to develop a care plan for SP Document care plan (individual SOAP note) Collect/assess information collected from patient/EHR (pharmacy students only) Communicate recommendation to dental students (pharmacy students only) Write prescriptions for SP (dental students only) Collect/assess information collected from EHR Document a patient discharge medication list Conduct discharge counseling with SP
Collaborate, communicate Collect Assess Plan, implement, collaborate Document Follow up, collect, assess Follow up, plan, communicate Implement Collect, assess Documentation Implement
PPCP = Pharmacists' Patient Care Process; SOAP = subjective, objective, assessment, plan; EHR = electronic health record.
of the didactic curriculum, students complete objective structured clinical exams (OSCEs). As an alternative summative assessment in year two of the curriculum, faculty designed an Interprofessional Second Year Capstone (the Capstone). Skills developed in the second year of skills lab include navigating an educational electronic health record (EHR), discharge counseling, and documenting patient care plans. Second year pharmacy students also complete didactic course work related to infectious diseases, cardiovascular and respiratory diseases, renal function, and endocrinology. The second year of the curriculum prepares the students for Hospital Introductory Pharmacy Practice Experience (HIPPEs), which, for many students, may be the first exposure to an EHR and working in interprofessional healthcare teams. The objectives of the Capstone were for students to utilize each step of the PPCP while collaborating as a member of an interprofessional team, and to assess the student attitudes of interprofessional team-based care. Methods The Capstone serves as a summative assessment at the end of the second year of the four-year doctor of pharmacy (PharmD) curriculum and interprofessional students were recruited for the interprofessional parts of the experience. Dental students were chosen for this experience due to mutual interest of the faculty in developing a learning experience and availability of the students who would participate. The Capstone was first offered in May 2017 (all parts) and again in March (Parts 1, 2, and 3) and May (Part 4) 2018. The schedule was adjusted during the second year due to changes in the availabilities of the dental students involved. During both 2017 and 2018, pharmacy and dental students were placed in interprofessional (IP) teams of approximately six pharmacy students and two dental students. In 2017, participating dental students had already started the fourth year of their course work (D4), while in 2018, they were completing the third year of their coursework (D3). The Capstone included four parts as outlined in Table 1. Part 1 Prior to beginning active learning activities, all students completed the Jefferson Scale of Attitudes Toward Interprofessional Collaboration (JeffSATIC) and a roles and responsibilities quiz (RR quiz) to assess attitudes towards interprofessional collaboration and knowledge related to the other profession involved.8 The RR quizzes were adapted from a survey on pharmacists' roles and responsibilities developed by Vrontos et al.9 Then students were required to create a short video to introduce themselves and their profession to their IP teammates. Part 2 All students received a brief written introduction to the standardized patient (SP) approximately 24 hours prior to attending a two-hour IP active learning session. The SP was a 47-year-old white male patient who presented to an IP free clinic complaining of a toothache. A current smoker, the SP had a past medical history of diabetes, hypertension, an artificial heart valve, and a history of substance abuse. Once students arrived at the active learning session, they sat with their IP teams and interviewed the SP. The goal of this activity was to collect additional information from the SP about his current complaint and other medical conditions. Then, the IP teams collaborated to develop a list of the SP's medication therapy problems and a patient care plan. Once the plan was agreed upon, the dental students wrote prescriptions for the patient and handed the prescriptions to the pharmacy students. The pharmacy students verified the prescriptions as if they were filling the prescription order for the patient in a community pharmacy setting. At the conclusion of the IP active learning session, pharmacy students documented their interaction with the patient, their assessment of the patient's medication therapy problems, and plans for the patient's care going forward. This documentation took the form of a SOAP note, which included subjective and objective information as well as the pharmacy student's assessment and plan. Dental students submitted a written care plan for the SP's dental care. 42
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K.J. Smith
Part 3 After the 2017 offering of the Capstone, faculty felt the students needed an additional opportunity to interact as an IP team, so Part 3 of the Capstone was added in 2018. Approximately one week after Part 2, the dental students received a message from the SP on the learning management system's (LMS) discussion board. Dental students consulted the pharmacy students about the patient's new problem. Pharmacy students had access to the SP's EHR in EHRGo (Archetype Innovations, LLC, Duluth, MN), an educational EHR used throughout the PharmD curriculum. The pharmacy students provided a summary of the new problem and made a recommendation about continued care to the dental students. The dental students then wrote prescriptions for the SP based on the information provided by the pharmacy student. The accuracy of the medication(s) recommended for the SP by the dental students was not assessed. Part 4 Approximately one month later, the SP was being discharged from an inpatient visit. He had presented to the emergency room with complaints of chest pain and palpitations, diagnosed with atrial fibrillation and started on some new medications. In 2017, the pharmacy students started Part 4 by individually collecting a medication history from the SP. After the interview, pharmacy students accessed the SP's updated EHR and completed a 10-question extended multiple choice question (eMCQ) quiz in the LMS. The eMCQ quiz was designed to assess the student's ability to collect information from the EHR, develop a medication therapy problem list, and document a discharge medication list for the patient based on information found in the EHR, with several questions written specifically to link to a step in the PPCP. The skill of taking a medication history was added to the Professional Practice Skills Lab course in 2018, so the faculty decided to adjust the Capstone assessment to include discharge counseling instead of taking a medication history. Therefore in 2018, the pharmacy students started Part 4 of the Capstone with the eMCQ quiz before they individually conducted discharge counseling with the SP. Assessments used throughout the Capstone are outlined in Table 2. After the conclusion of the Capstone learning experiences, students completed the JeffSATIC and RR quiz. The results of the pre- and post-experience JeffSATIC (2017 offering only) and postRR quizzes were compared using paired t-tests to assess any change in attitudes towards IP collaboration or knowledge about the other professions that may have resulted from participation in the Capstone. In 2018, a five-question survey related to IP team dynamics was also completed.10 Pharmacy student SOAP notes were assessed using a rubric, with students earning one of four grades (excellent, competent, needs improvement, or not acceptable) on six components of the note (subjective, objective, assessment of medical conditions, treatment plan, structure (including spelling and unsafe abbreviations), and global assessment (including consistency, appropriate level of detail included)). In 2018 only, the rubric had a check mark (no point value) to assess if pharmacy students mentioned IP collaboration with the dental student in their note or not. The eMCQs, written by the faculty and designed to assess clinical thinking, linked to specific steps in the PPCP.11 SPs used a scoring rubric for grading the medication history interview (2017 only) and discharge counseling (2018 only). Students were also asked to provide feedback on the Capstone through open ended-questions. The JeffSATIC, pre-and post-RR quizzes, SOAP note and discharge counseling scores were summarized using means. The pre- and post-scores for JeffSATIC and RR quizzes were compared using paired t-tests. An asymptotic Wald test was used to evaluate responses to the teamwork dynamics questions, comparing the percentages of students with positive vs. negative feedback. Open-ended comments were summarized by theme. p-Values < 0.05 were considered statistically significant. All analyses were performed using SAS version 9.4 or R version 3.2.3.12,13 This study was submitted to the institutional review board (IRB) at The University of Florida who designated the study as exempt research.
Table 2 Summary of assessments used in the capstone.
Part 1. Interprofessional (IP) introductions Part 2. IP outpatient visit with standardized patient (SP) Part 4. Inpatient visit with SP Feedback
Knowledge/skill/attitude assessed
Assessment tool
Pre-experience knowledge of other profession Pre-experience attitude towards IP collaboration (2017 only) Documentation of care plan (SOAP note) Collection/assessment of information in EHR Medication history interview with SP (2017 only) Discharge counseling with SP (2018 only) Post-experience knowledge of other profession Post-experience attitude towards IP collaboration (2017 only) IP teamwork (2018 only)
Pre-RR quiz JeffSATIC SOAP note rubric eMCQ quiz Medication history interview rubric Discharge counseling rubric Post-RR quiz JeffSATIC Assessing teamwork: a reliable fivequestion survey
RR quiz = roles and responsibilities quiz; JeffSATIC = The Jefferson Scale of Attitudes Toward Interprofessional Collaboration; SOAP = subjective, objective, assessment, plan; EHR = electronic health record; eMCQ = extended multiple-choice questions. 43
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Results In 2017, 230 second year pharmacy students and 68 D4 students participated in the Capstone. In 2018, 265 second year pharmacy students and 90 D3 students participated in the Capstone. The overall mean score for the pre-JeffSATIC for dental students was 83.6% (raw mean score 117, standard deviation (SD) 12, maximum possible score 140, higher scores indicate more positive attitudes towards IP collaboration). The overall mean score for the post-JeffSATIC for dental students was 83.6% (raw mean score 117, SD 13). The overall mean score for the pre-JeffSATIC for pharmacy students was 87.9% (raw mean score 123, SD 11). The overall mean score for the post-JeffSATIC for pharmacy students was 88.6% (raw mean score 124, SD 13). For students who completed both the pre- and post-JeffSATIC (n = 68 dental, n = 226 pharmacy), there was a mean difference in score of −0.5 (95% CI −1.84, 0.84, p = 0.46) and there was no statistically significant change in attitudes towards IP collaboration observed in dental or pharmacy students. In 2017, the overall mean score for the pre-RR quiz for dental students was 82% (raw mean score 82, SD 9, maximum possible score 100). The overall mean score for the post-RR quiz for dental students was 80% (raw mean score 80, SD 7). A paired t-test was done for dental students who completed both the pre- and post-RR quizzes with a mean difference in score of 2.15 (95% CI −0.66, 4.97, p = 0.13). The overall mean score for the pre-RR quiz for pharmacy students was 65% (raw mean score 65, SD 9). The overall mean score for the post-RR quiz for pharmacy students was 64% (raw mean score 64, SD 10). For students who completed both the pre- and post-RR quizzes, there was a mean difference in score of 1.31 (95% CI −0.32, 2.95, p = 0.11). In summary, there was no statistically significant change in the knowledge about the roles and responsibilities of the other profession before and after the Capstone. In 2018, the RR quizzes were built as surveys in the LMS instead of as quizzes so scores were not available for comparison. The results of the five-question survey related to teamwork conducted after the IP portions of the Capstone in 2018 are shown in Table 3. The overall mean score for the SOAP note in 2017 was 84% (raw mean score 50.2, SD 6.5, maximum possible score 60). The overall mean score for the SOAP note in 2018 was 83% (raw mean score 49.8, SD 4.9). In 2018, only 29% (n = 77) of pharmacy student notes included information about consulting the dental student prior to developing the patient care plan. Further breakdown of the SOAP note scores is shown in Table 4. Table 5 shows the results of the eMCQs asked during Part 4 of the Capstone including to which step of the PPCP each question related. Patient case details were changed from 2017 to 2018 and not all questions were asked both years. Because of the changes to the case and the changes made in content and skills taught to students prior to the Capstone from 2017 to 2018, there were several confounding variables that prevented statistical analysis from being useful for comparing 2017 to 2018 eMCQ results. In 2017, the overall mean score for the medication history rubric was 93% (raw mean score 14.9, SD 1.2, range 10–16, maximum possible score 16). In 2018, the overall mean score for the discharge counseling rubric was 96% (raw mean score 48.2, SD 2.4, range 39–50, maximum possible score 50). Results of the feedback questions asked of both pharmacy and dental students in both years of the Capstone can be found in Table 6. Open-ended comments in both years identified a student desire for additional time to collaborate face-to-face with the IP team and fewer activities requiring electronic communication. Discussion The results from the pre- and post-Capstone JeffSATIC and RR quizzes lead us to believe that this Capstone did not have a statistically significant impact on either pharmacy or dental students' attitudes towards IP collaboration or their knowledge about the other profession. While this was disappointing, there may be several reasons for these results. The Capstone provided an opportunity for dental and pharmacy students to communicate and collaborate on a medically complex patient case. Communication and collaboration are stated outcomes of other didactic and simulation-based IP experiences.14 Students who participated in this Capstone scored comparably to other health professions students on the JeffSATIC leading us to believe the participants likely had a positive baseline attitude towards IP collaboration and this activity did not negatively affect that.11 It is likely a single opportunity to collaborate with another profession would not have a significant impact on one's attitudes towards IP collaboration.15,16 Because of this, the faculty decided not to conduct the JeffSATIC in the 2018 offering of the Capstone. Others have shown longitudinal IP experiences throughout the curriculum can help students meet Interprofessional Education Collaborative (IPEC) Competencies.17–19 The students who participated in the Capstone do participate in other IP learning experiences during their education. Therefore, future studies could include assessing the impact of the complete IP curriculum at this institution on the students' attitudes towards IP collaboration and knowledge of other professions. Pharmacy student members of the IP teams had worked together in team-based learning (TBL) courses throughout the academic year and the dental students were added for the IP parts of this Capstone. While it was not clear exactly how the addition of this new team member would impact team dynamics, the five-question survey related to teamwork showed teams worked well together (Table 3).8 Overall, the pharmacy students performed well on their SOAP note documentation. In 2018, the most common error leading to a rating of “not acceptable” on the subjective portion of the note was neglecting to mention the patient's anaphylactic allergy to penicillin in the note (Table 4). Because this patient was being prescribed an antibiotic, this omission was considered potentially harmful to the patient, resulting in a “not acceptable” rating. The patient case was designed in a way so expertise from both pharmacy and dental students was needed to develop a treatment plan. Only 29% of pharmacy students mentioned IP collaboration in their SOAP note, leading us to believe additional opportunities to document IP encounters would be beneficial. 44
45
c
b
9
6 10 17 11
Not very positive frequency (team rating < 3)
80.43
86.96 78.26 63.04 76.09
Very positive percentage (%)
< 0.001
< 0.001 < 0.001 0.038 0.0002
p-Valuec
1 = strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree. n = 46/46 teams, n = 313/355 individual students. Asymptotic Wald test was used to compare the percentages of teams with very positive vs. not very positive feedback about their team dynamics, with significance defined as p < 0.05.
37
3.2
a
40 36 29 35
3.3 3.2 3.1 3.2
This team encouraged everyone to share ideas. Leadership in this team created an environment where things could be accomplished. People in this team had the information that they need to do their jobs well. When people in this team experienced a problem, they made a serious effort to figure out what's really going on. Everyone in the team felt able to act on the team vision.
Very positive frequency (team rating ≥ 3)
Response (mean value)a,b
Question
Table 3 Results of teamwork survey conducted after interprofessional activities in the capstone in 2018.
K.J. Smith
Currents in Pharmacy Teaching and Learning 12 (2020) 41–48
Currents in Pharmacy Teaching and Learning 12 (2020) 41–48
K.J. Smith
Table 4 Results of documentation of patient care with SOAP note rubric in the capstone. Criteria
% of students receiving each rating Excellent
Subjective Objective Assessment Treatment plan Structure Global assessment
Competent
Needs improvement
Not acceptable
2017
2018
2017
2018
2017
2018
2017
2018
83 77 31 19 49 31
61 77 10 11 87 26
16 22 48 62 44 58
14 23 79 87 13 72
1 <1 20 15 6 10
10 0 11 2 0 2
0 0 1 4 <1 1
15 0 <1 0 0 0
SOAP = subjective, objective, assessment, plan. Table 5 Results of eMCQ on electronic health record (EHR) part 4 of capstone. “According to the information found in the EHR and your clinical judgement…”
…which of the following medications are on SP's home medication list? …which of the following medical conditions should appear on SP's “current problems” list? …what is SP's INR goal? …what is SP's blood pressure goal? …what is SP's A1C goal? …which of the following medications should be on SP's discharge medication list? …when should SP have a follow up appointment for INR monitoring? …when should SP have a follow up appointment for diabetes management?
Step of PPCP
Collect Assess Assess Assess Assess Plan Plan Plan
% correct 2017
2018
85 32 89 75 –a 0 –a –a
98 52 80 –a 88 92 97 99
PPCP = Pharmacists' Patient Care Process; SP = standardized patient; INR = international normalized ratio; A1C = glycosylated hemoglobin. a Question was not asked. Table 6 Dental and pharmacy student feedback on interprofessional capstone learning activities.
Rate the following activities in terms of their value to your learning: Learning about roles/responsibilities of other profession Collaborating interprofessionally to interview the standardized patient (SP) Collaborating interprofessionally to develop a care plan Prescription writing/verifying Written follow up consultation and collaboration on the SP (2018 only) To what extent do you agree or disagree with the following statements? This learning experience prepares students to collaborate with a dentist/pharmacist in future practice when a patient presents with a complex medical/dental program. This learning experience enhanced my understanding of how a patient's care can be improved when both a pharmacist and a dentist provide input into the care. The patient case allowed both the pharmacy students and dental students to contribute to developing a plan. Input from both pharmacy students and dental students was necessary in order to develop the best care plan. The care plan would not have been complete had students from only my profession contributed to development of the plan. Overall, I recommend this learning experience for other dental/pharmacy students.
2017
2018
% V/EV 89 82 88 81 – % A/SA 91
% V/EV 72 76 78 75 67 % A/SA 71
91
74
93 90 81 89
80 78 70 63
V = valuable; EV = extremely valuable; SP = standardized patient; A = agree; SA = strongly agree.
eMCQs have been shown to assess clinical reasoning which is why they were selected for assessing steps in the PPCP during the Capstone.9 Students most often struggled with steps related to the assessment step. This included questions about developing a list of health conditions for the patient. The students had previous exposure applying the PPCP to patients with all health conditions experienced by the Capstone SP. In 2017, the most often missed medical condition was seasonal allergies while in 2018, the most often missed medical condition was a history of opioid dependence. Since this patient was in the hospital for chest pain, shortness of breath, and new onset atrial fibrillation, it could be argued that a history of seasonal allergies is not clinically significant. However, a history of opioid dependence is important to note in any patient presenting with pain, so additional training may be beneficial to our students in this content area. While the assessment step is potentially the most difficult step of the PPCP, it is the most critical step, wherein the pharmacist uses a combination of drug knowledge and critical thinking to consider how current therapies are helping or failing to meet the patient's therapeutic goals. When developing a plan for SP, it was surprising that not a single student was able to compile a discharge medication list that matched what faculty had developed. After debriefing with students about the case, it 46
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K.J. Smith
seemed there was some confusion about the definition of “sliding scale insulin” and its use in the hospital setting. The Institute for Safe Medication Practices (ISMP) Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults outline the errors and poor outcomes associated with the use of sliding scale insulin as the only strategy for managing hyperglycemia in the inpatient setting.20 A safer and more appropriate term to use as an answer choice would have been “scheduled subcutaneous insulin doses that includes basal, nutritional, and correctional components”.20 Since the Comprehensive Medication Management in Primary Care Research Team released the operational definitions of each step of the PPCP, it will be easier to communicate to students what is expected in each step of the PPCP.21 With a clearer and most consistent definition of each step in the PPCP and their growing drug and disease state knowledge, students will improve their ability to demonstrate competence with each step of the PPCP. During the medication history interview and discharge counseling, students most commonly left out verification of both the patient name and date of birth, potentially leading to gathering information from or providing information to the wrong patient. These results point to patient safety as a topic which could be emphasized more often in the pharmacy curriculum. The student feedback reflected a decreased perception of the value of the Capstone activities from 2017 to 2018 (Table 6). While this result was not expected by the faculty, it did prompt additional reflection when considering future years of the activity. Different classes of students have different “personalities” and experience the same activities differently. From 2017 to 2018, the number of opportunities to collaborate interprofessionally on the SP increased from one to two, but only 67% of students rated the second collaboration activity as valuable or very valuable (Table 6). After reflecting on the specifics of the second collaboration activity, faculty decided they would need to clarify the directions and the clinical problem students were being asked to solve during this step of the Capstone. Additionally, pharmacy students were required to travel from distance campus sites to the main campus location for the IP part of the Capstone. This almost certainly affected the percentage of pharmacy students who would recommend this activity in the future as distance campus students dislike adding travel time and expense to their already busy schedule. As previously stated, the Capstone takes place at the end of the second year of the PharmD curriculum. Future studies could include assessing the impact of this Capstone on performance of the steps of the PPCP during the third year OSCE, on written clinical documentation, or on IP collaboration opportunities that occur in the third year of the curriculum. Limitations include only conducting the activity at one institution and only including two professions in the study. However, this type of activity could be conducted at institutions of various sizes with multiple health professions students if the patient case was written to require input from various members of the health care team. The Capstone activities did provide pharmacy students an opportunity to demonstrate ability to complete each step of the PPCP. Further research may include helping pharmacy and dental students develop a process for collaboration by comparing patient care processes between the two professions and adding more opportunities for these groups of students to work together to collaborate on patient care during their education. Conclusions The learning activities in Interprofessional Second Year Capstone were designed to assess the pharmacy students' ability to carry out the PPCP and to give them practice with IP collaboration. While the activities may not have had a significant impact on the students' attitudes towards IP collaboration, the Capstone did allow students the opportunity to practice each step of the PPCP. As the PPCP is integrated into pharmacy curriculum around the country, assessments such as this will be essential for determining practicereadiness and team-readiness of our graduates. Financial disclosures None. Declaration of competing interest None. Acknowledgments The author wishes to thank the pharmacy faculty who helped with case development and logistics support, Lori Dupree, Bethany Shoulders, and Lisa Vandervoort; the collaborating dental faculty, Gail Childs and Venita Sposetti; and Yan Gong and Yiqing Chen, who provided statistical support. References 1. Pharmacists’ patient care process. Joint Commission of Pharmacy Practitioners; 2014 https://jcpp.net/wp-content/uploads/2016/03/PatientCareProcess-withsupporting-organizations.pdf Published 29 May. Accessed 15 October 2019. 2. Accreditation Standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree (“standards 2016”). Accreditation Council for Pharmacy Education; 2015 https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf Published February. Accessed 15 September 2019. 3. Smith KJ. The pharmacists’ patient care process as sensemaking. Pulses; 2018 https://cptlpulses.com/2018/01/16/ppcp-sensemaking/ Published 16 January. Accessed 15 October 2019. 4. Cooley J, Lee J. Implementing the pharmacists’ patient care process at a public pharmacy school. Am J Pharm Educ. 2018;82(2) https://doi.org/10.5688/ ajpe6301.
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5. Kolar C, Hager KD, Losinski V. Beyond the pharmacists’ patient care process: cultivating patient care practitioners by uyilizing the pharmaceutical care framework. Innov Pharm. 2017;8(3) https://doi.org/10.24926/iip.v8i3.532. 6. Gonyeau MJ, DiVall M, Conley MP, Lancaster J. Integration of the Pharmacist’s Patient Care Process (PPCP) into a comprehensive disease management course series. Am J Pharm Educ. 2018;82(6) https://doi.org/10.5688/ajpe6311. 7. 2015–2019 PharmD Curriculum. University of Florida College of Pharmacy; 2019 https://curriculum.pharmacy.ufl.edu/curriculum-courses/about-the-curriculum/ 2015-2017-pharmd-curriculum/ Updated 1 September. Accessed 15 October 2019. 8. Hojat M, Ward J, Spandorfer J, Arenson C, Van Winkle LJ, Williams B. The Jefferson Scale of Attitudes Toward Interprofessional Collaboration (JeffSATIC): development and multi-institution psychometric data. J Interprof Care. 2015;29(3):238–244. 9. Vrontos EB, Kuhn CH, Brittain KL. Impact of interprofessional activities on health professions students’ knowledge of community pharmacists’ role and services. Am J Pharm Educ. 2011;75(8) https://doi.org/10.5688/ajpe758152. 10. Lurie SJ, Schultz SH, Lamanna G. Assessing teamwork: a reliable five-question survey. Fam Med. 2011;43(10):731–734. 11. Beullens J, Struyf E, Van Damme B. Do extended matching multiple-choice questions measure clinical reasoning? Med Educ. 2005;39(4):410–417. 12. SAS [computer program]. Version 9.4. Cary, NC: SAS Institute; 2014. 13. R [computer program]. Version 3.2.3. Vienna, Austria: R Foundation for Statistical Computing; 2019. 14. Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional education. Med Educ Online. 2011;16(1) https://doi.org/10.3402/meo.v16i0.6035. 15. Van Winkle LJ, Bjork BC, Chandar N, et al. Interprofessional workshop to improve mutual understanding between pharmacy and medical students. Am J Pharm Educ. 2012;76(8) https://doi.org/10.5688/ajpe768150. 16. Grice GR, McCorkle NA. Difference in student pharmacist attitudes and readiness for interprofessional learning after an activity with student nurses. J Interprofessional Educ Pract. 2016;3:29–33. 17. Woltenberg L, Taylor S. Successes, challenges, and impact of a large-cohort preclinical interprofessional curriculum: a four-year reflection. Curr Pharm Teach Learn. 2018;10(5):662–668. 18. Poling D, Kiersma M. A unique interprofessional and multi-institutional education series. J Nurs Educ. 2014;53(7):415–420. 19. Core competencies for interprofessional collaborative practice: 2016 update. Interprofessional Education Collaborative; 2016 https://nebula.wsimg.com/ 2f68a39520b03336b41038c370497473?AccessKeyId=DC06780E69ED19E2B3A5&disposition=0&alloworigin=1 Accessed 15 October 2019. 20. ISMP guidelines for optimizing safe subcutaneous insulin use in adults. Institute for Safe Medication Practices; 2018 https://www.ismp.org/sites/default/files/ attachments/2018-09/ISMP138D-Insulin%20Guideline-090718.pdf Accessed 15 October 2019. 21. The patient care process for delivering Comprehensive Medication Management (CMM): optimizing medication use in patient-centered, team-based care settings. CMM in Primary Care Research Team; 2018 http://www.accp.com/cmm_care_process Accessed 15 October 2019.
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