- Email: [email protected]
Partners in pharmacy: An intraprofessional educational event with pharmacy and pharmacy technician students
Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Experiences in Teaching and Learning
Partners in pharmacy: An intraprofessional educational event with pharmacy and pharmacy technician students Fadi Guirguisa, Robin Andradea, Connie Beckb, Debbie Ellena, Jennifer Sliveckaa, ⁎ Cynthia L. Richarda, a b
School of Pharmacy, University of Waterloo, 10 Victoria St. S, Kitchener N2G 1C5, Ontario, Canada Lambton College, 1457 London Rd., Sarnia N7S 6K4, Ontario, Canada
A R T IC LE I N F O
ABS TRA CT
Keywords: Intraprofessional OSCE Pharmacy technician
Background and purpose: Upon graduation and licensing, pharmacists work very closely with pharmacy technicians. Despite this, opportunities for learning together as students are limited. We developed and implemented a pilot intraprofessional event for pharmacy and pharmacy technician students. The purpose of this study was to evaluate the perceived value and learner confidence through analysis of participant feedback. Education activity and setting: Pharmacy students from the University of Waterloo School of Pharmacy and pharmacy technician students from Lambton College participated in an intraprofessional event that included a three-station practice objective structured clinical exam (OSCE) and a case discussion regarding a methadone dispensing error, followed by a facilitated debrief. Upon completion of the event, students were invited to complete an online feedback questionnaire. Findings: Twenty-one pharmacy students and 22 pharmacy technician students participated in the event. Twenty-one students completed the questionnaire, for a response rate of 49%. The majority of respondents agreed or strongly agreed that the event enhanced learning and confidence in working together to provide interprofessional care. Students seemed to find the OSCE to be particularly valuable. Feedback suggestions for improvement indicated a desire for more activities and time allocated to the event. Summary: We designed and implemented a pilot intraprofessional event that was well-received by pharmacy students and pharmacy technician students. This supports the development of future similar events.
Background and purpose In pharmacy practice, collaboration is fundamental for the optimization of patient care. When professionals work seamlessly in a team, patients receive improved therapy.1,2 As an example, one intervention study demonstrated that when pharmacists collaborated with physicians in prescribing, prevalence of appropriate statin therapy in patients with diabetes increased by 7%.2 Historically, emphasis has been placed on interprofessional collaboration in health care settings and its effects on patient care.3 Although interprofessional work is irrefutably beneficial, the majority of pharmacists in primary care have much more interaction with pharmacy technicians, assistants, and other pharmacists in the intraprofessional setting.
⁎
Corresponding author. E-mail address: [email protected] (C.L. Richard).
https://doi.org/10.1016/j.cptl.2019.12.010
1877-1297/ © 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Fadi Guirguis, et al., Currents in Pharmacy Teaching and Learning, https://doi.org/10.1016/j.cptl.2019.12.010
Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx
F. Guirguis, et al.
In Canada, pharmacy technicians are regulated in nine of ten provinces.4 The process of becoming a registered pharmacy technician typically involves completion of an accredited Canadian Pharmacy Technician Program (variable length, typically two years), followed by completion of national licensing exams through the Pharmacy Examining Board of Canada.5,6 The licensing exams are based on professional competencies outlined by the National Association of Pharmacy Regulatory Authorities, and includes both multiple choice questions and an objective structured performance examination (OSPE; analogous to an objective structured clinical exam (OSCE)).6,7 Scope of practice for pharmacy technicians varies by province, but completing the final checks of prescription products prior to release, transferring and receiving verbal prescriptions, obtaining the best possible medication history with assistance from the pharmacist, and instructing patients about the operation of medical devices are commonly performed tasks.8 In Ontario, Canada, registered pharmacy technicians are registered with the Ontario College of Pharmacists. The participatory roles of pharmacy technicians have become instrumental in facilitating changes in pharmacy's scope of practice.9 Technicians support medication-use processes and pharmacy operations, which allows pharmacists time to be freed for more patient-centered clinical endeavours.9 Due to their critical involvement in tasks such as dispensing, billing, staff training, medical device education, and compounding, they prove to be essential for developing a logistically and financially thriving pharmacy.9 Although research on intraprofessional education in the context of pharmacy is scarce,9 with none existing to our knowledge in the Canadian pharmacy setting, there are other professions that have demonstrated its value.10,11 A past survey analysis showed agreement among 94% of dental and dental hygiene students that intraprofessional education builds stronger oral health care teams.11 This survey was conducted based on a pilot study, which randomly paired dental and dental hygiene students for completion of an intraprofessional activity that included the cooperative review of a patient's history, periodontal diagnosis, treatment plan, and outcomes.12 The majority of participants also agreed that dental and dental hygiene students must have education opportunities in collaborative settings.11 Other health care professions such as occupational therapy have also stressed the importance of intraprofessional competencies, suggesting that occupational therapy and occupational therapy assistant programs address disparities in attitude, knowledge, and skill reflected in their curricula.13 Recommendations from dental and occupational therapy professionals can be extrapolated to suggest a need for intraprofessional education development in pharmacy. Given the complementary scopes of practice of pharmacists and pharmacy technicians, an examination of where these roles intersect can assist with identifying areas of focus for intraprofessional education. Additional areas related to teamwork such as conflict management, communication, and responsibility could also be explored so as to adequately address common scenarios in the practice setting. Collaborative pharmacy examples have been outlined in existing literature, as found in The Report of the 2013–2014 Professional Affairs Standing Committee: Advancing the Pharmacy Profession Together Through Pharmacy Technician and Pharmacy Education Partnerships.14 In this report, scenarios include pharmacy technician students delivering education to pharmacy students in forms of didactic lectures and laboratory instruction.14 One could modify the activities from this report, along with those in used in dental and occupational therapy education to develop intraprofessional events in pharmacy. As necessary as intraprofessional learning is, the strategic task of planning often comes with its own obstacles. American surveys have mentioned reasons that prohibit this collaboration including large geographical distances between pharmacy and pharmacy technician programs, lack of funding and time, scheduling difficulties and lack of participating practice sites.14 Despite these hurdles, advocates agree that the biggest barrier to developing intraprofessional education is the absence of interest.9,14 As a primary health care profession, pharmacy must first take steps in recognizing the importance of pharmacy and pharmacy technician students learning together and from each other. To this end, the University of Waterloo School of Pharmacy and the Lambton College pharmacy technician program collaborated to create a pilot intraprofessional educational event. The purpose of this study was to assess whether the event improved student confidence in collaborative practice, and whether it was perceived to provide educational value. In addition, feedback was explored regarding what aspects provided the greatest learning and what suggestions could enhance the experience. Educational activity and setting A pilot intraprofessional event entitled “Partners in Pharmacy” was held at the University of Waterloo Health Sciences campus in Kitchener, Ontario, Canada. It was two hours in duration and was composed of a practice OSCE, case discussion, and facilitated debrief. Participants included 21 (of 113) students enrolled in year four of the doctor of pharmacy (PharmD) program at the University of Waterloo School of Pharmacy and 22 (of 22) students enrolled in the second year of the pharmacy technician program at Lambton College. This represents the final year of study for each program. Participation was mandatory for pharmacy technician students, who attended the event as part of a three-day capstone experience, and optional for pharmacy students. Pharmacy students could count participation toward their passport of required interprofessional education (IPE) experiences (described previously).15 The OSCE was composed of three stations, and was completed in pairs (one student from each program), and one group of three (two pharmacy technician students and one pharmacy student) due to the slight mismatch in numbers. The first station included a standardized patient who was using a glucometer incorrectly. Pharmacy technician students provided education on proper use of the device, and pharmacy students discussed glycemic targets. In the second station, learners contacted a prescriber (simulated by a faculty member) regarding the need to change therapy based on insurance coverage for prescribed medication. For this station, the learners worked together to interpret information on coverage in the drug formulary, and then the pharmacy student used his or her clinical knowledge to suggest a therapeutic alternative to the prescriber. The third station did not include an actor; instead students checked four filled prescriptions. This task simulated a role that could be completed by either pharmacists or pharmacy technicians in Ontario, so students were not assigned to specific roles but could work together however they wished. Students had 7 min to work through each station, with 2 min between each station for movement and for reading a brief summary of the next station before 2
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beginning. The second component of this event was a case discussion surrounding a methadone dispensing error in which a patient received a dose tenfold higher than prescribed. Students were assigned to groups of five to six learners (two to three learners from each program) to address the case. Printed material included a pharmacy scenario, patient profile, and thematic questions that related to roles, responsibilities, communication, and conflict management. Answers to the three OSCE stations and key themes emerging from the case discussion were discussed during the facilitated debrief session. Upon completion of the Partners in Pharmacy event, students were asked to evaluate the event by completing an electronic questionnaire, disseminated via email using Qualtrics software. Likert-scale questions were based on the Canadian Interprofessional Health Collaborative competency framework,16 with open-ended questions designed to identify aspects of the event that were perceived to be most valuable or could be improved. Questionnaire results were presented and analyzed using descriptive statistics and summarized in aggregate. The mean and standard deviation values were calculated for Likert-scale questions using Microsoft Excel.17 Written responses to open-ended questions were categorized according to key themes that emerged. This project received clearance and approval from both the University of Waterloo and Lambton College Research Ethics Committees. Findings A total of 43 students participated in the event (21 pharmacy students, 22 pharmacy technician students), and 21 completed the questionnaire for a response rate of 49%. This included nine pharmacy students (43%), 11 pharmacy technician students (50%), and one who did not indicate the program of study. As evident in Table 1, the event was well-received with the majority (> 85%) of respondents agreeing or strongly agreeing with Table 1 Questionnaire results- 5 point Likert-scale questions. Survey item
Program
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Mean (SD)
1. After the session I am better able to recognize how others' skills and knowledge complement and overlap with my own 2. After the session I am better able to listen actively and encourage the ideas and opinions of others
PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total
0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1
0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 2 0 2 1 0 1 1 0 1 1 0 1 1 0 1 0 0 0 1 0 1 0 0 0 1 0 1 0 0 1
6 3 10 5 2 8 1 3 5 3 5 9 4 3 8 6 3 10 3 2 6 6 3 9 5 2 7 6 3 10 2 3 5 5 3 8
3 7 10 3 8 11 6 7 13 5 5 10 4 7 11 2 7 9 5 8 13 3 7 11 3 8 11 3 7 10 6 7 13 4 7 11
4.3 (0.5) 4.4 (1.2) 4.3 (0.9) 4.1 (0.9) 4.5 (1.2) 4.3 (1.1) 4.4 (0.9) 4.4 (1.2) 4.4 (1.0) 4.4 (0.7) 4.2 (1.2) 4.3 (1.0) 4.3 (0.7) 4.4 (1.2) 4.3 (1.0) 4.1 (0.6) 4.4 (1.2) 4.2 (0.9) 4.4 (0.7) 4.5 (1.2) 4.4 (1.0) 4.3 (0.5) 4.4 (1.2) 4.4 (0.9) 4.2 (0.7) 4.5 (1.2) 4.4 (1.0) 4.3 (0.5) 4.4 (1.2) 4.3 (0.9) 4.6 (0.7) 4.4 (1.2) 4.5 (1.0) 4.4 (0.5) 4.4 (1.2) 4.3 (1.0)
3. After the session I am better able to use a team approach with the patient to provide care 4. After the session I am better able to provide constructive feedback to IP team members 5. After the session I am better able to reflect on my individual performance for my improvement 6. After the session I am better able to address conflict in a respectful manner 7. Completing the OSCE simulation increased my confidence in working collaboratively 8. Completing the case discussion increased my confidence in working collaboratively 9. The debrief session after the experience was valuable
10. I feel that my skills were utilized in this experience
11. Completing the OSCE simulation in pairs enhanced my learning 12. Completing the case discussions in groups enhanced my learning
PharmD = Doctor of Pharmacy students; PharmT = Pharmacy Technician students; SD = standard deviation. Survey was completed by nine PharmD students, 11 PharmT students, and one student who did not indicate program of study and did not respond to Questions 9 and 11. 3
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F. Guirguis, et al.
Table 2 Questionnaire results – short answer questions. Question What aspect(s) of the event did you find most valuable?
My key take-away from the workshop was…
This workshop could be improved by…
When I work with the other profession in the future I will…
Theme (sample quote; number of responses) 1. OSCE (“The OSCE portion was the most valuable aspect.”; 8 responses) 2. Understanding how pharmacists & pharmacy technicians can work together, understanding scope of practice (“Collaboration and understanding how pharmacists and pharmacy technicians can complement each other's knowledge and skills.”; 3 responses) 3. Case study (“The case really showed me that regulated technicians in Ontario are vital to a pharmacy and that we should let them practice to their full scope of practice.”; 2 responses) 1. Understanding and staying within scope (“Trying to apply my knowledge of the pharmacy technician's scope of practice made me realize that I did not know how far their scope of practice could go.”; 6 responses) 2. Value of working together/teamwork (“Rely on your team”; 5 responses) 1. More time/activities, meeting more frequently (“I would have enjoyed a longer discussion of the methadone case”; 6 responses) 2. More emphasis on scope (“Having the standardized patients/HCPs ask specific questions so the techs and pharmacy students can show each other specific things we know”; 2 responses) 1. Understand roles/work within scope (“Make sure I stay within my scope of practice”; 5 responses) 2. Communicate effectively (“Make sure I listen to what they say”; 4 responses) 3. Have mutual respect/trust (“Ensure a mutual respect and trust in each other”; 3 responses)
OSCE = objective structured clinical exam; HCP = healthcare professional.
all statements in the questionnaire. Results appeared similar between both groups of learners, although the small number of participants did not permit statistical analysis. Fourteen students (33%) provided answers to open-ended questions that were included in the questionnaire. Themes emerging from the responses are summarized in Table 2. Many respondents (more than half) indicated that they found the OSCE to be the most valuable component. This reinforced the strong agreement with the Likert statement “Completing the OSCE simulation in pairs enhanced my learning”. Students also appreciated the opportunity to understand more regarding each profession's scope of practice, and indicated that a key take-away was the importance of working together. The importance of effective communication and mutual respect were identified as themes as well. Students indicated they would have liked even more opportunity to interact, such as having a longer session with more activities. Discussion In this study, we report the implementation and evaluation of a new intraprofessional learning activity between learners in the pharmacy community. There is a paucity of similar reports in the literature. This may be due to challenges that are present in organizing such events, such as scheduling, classroom space, distance between educational institutions, resources, and imbalance in student numbers between programs. We were able to overcome several of these challenges for this event. The campuses for our two institutions are a two-hour drive apart. However, students from Lambton College travel to Toronto for a capstone experience during their second year of study, and drive past Kitchener on the way. This presented a window of opportunity to organize an event when students were en route. We intentionally chose fourth-year pharmacy students to participate in the event since they did not have scheduled classes on the day that the pharmacy technician students would be passing through the region, which minimized scheduling barriers. We saw the year of study as being advantageous, because both groups of learners were in their final year, so were on similar timelines for licensure. Furthermore, since it was an optional activity for pharmacy students, we were able to limit numbers to create a one-to-one ratio among learners. This was particularly important for the OSCE, as it allowed students to complete the stations in intraprofessional pairs, and minimized the likelihood of one profession dominating the interaction. With only 43 students total participating, classroom space also became less of an issue. In terms of resources, the main cost for the event involved hiring standardized patients for the OSCE component, with a total cost of approximately $300 (CAD), or $7 per learner. Other roles were filled by faculty and staff volunteers to minimize cost. Given the importance of intraprofessional education for accreditation in the Canadian pharmacy education context, the cost was justifiable to administrators.18,19 In this pilot study, we found that the event was well-received by students in both programs. According to questionnaire results, the majority of pharmacy and pharmacy technician students appreciated the opportunity to collaborate in an intraprofessional setting. Well over 80% of all responses were either in agreement or strong agreement with the Likert scale reflection statements. This implies that after the event, students felt more confident working with the other profession and managing conflicts collaboratively. Participants also agreed that the intraprofessional experience was valuable and enhanced education. Interestingly, one pharmacy technician student strongly disagreed with all reflection statements. It is uncertain whether this was their true sentiment, or if it was in error, as it stood in contrast to the respondent's answers to open-ended questions. For example, the respondent's only suggestion for how the workshop could be improved was having “more activities”. Students particularly appreciated the OSCE component. The OSCE format was chosen because students in both programs must complete an OSCE or OSPE as part of national licensing exams upon graduation, and students often indicate they would like more practice with this type of performance-based assessment. Thus we anticipated it would be perceived as worthwhile. The case study emphasized a methadone dispensing error, but many participants from both programs were not familiar with some details of methadone dispensing. The choice of case content more familiar to both 4
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F. Guirguis, et al.
learner groups may have further enhanced the perceived value. As previously stated in the literature, principal recommendations for improvement suggest the need for more of these activities to take place in pharmacy education.9 This is consistent with our findings, where participants indicated that they would have liked more time to interact, and more activities. Given the positive response to this pilot event, we will look to offer the event again but perhaps include additional case studies and one to two more OSCE stations. Our study did have some limitations. The Partners in Pharmacy event had a small number of participants with only 21 pharmacy students and 22 pharmacy technician students. Furthermore, less than half of all participants (49%) completed the online questionnaire. This small number of participants did not allow for statistical comparisons among learner groups. Furthermore, only 21 of approximately 120 pharmacy students participated in the event (registration was limited to allow for roughly equal numbers of learners from each program), and they self-identified for participation based on interest in the event. This could have positively impacted results, as students may have held pre-existing convictions that intraprofessional collaboration is important, and their views may not be representative of the whole cohort. Summary Although the concept of intraprofessional education may be viewed as important and valuable, practical implementation is not without barriers, such as funding, time, and scheduling. We overcame these barriers and implemented a pilot intraprofessional event that was well-received by pharmacy and pharmacy technician students. This supports the development of future similar events and further research to evaluate the value of such events. Disclosures None. Declaration of competing interest None. Acknowledgements We would like to thank Sherilyn Houle, Rosemary Killeen, and Preet Sian for assisting with the event. Sherilyn Houle also provided useful feedback on this manuscript. References 1. Gobis B, Yu A, Reardon J, Nystrom M, Grindrod K, McCarthy L. Prioritizing intraprofessional collaboration for optimal patient care: a call to action. Can Pharm J (Ott). 2018;151(3):170–175. 2. Vincent R, Kim J, Ahmed T, Patel V. Pharmacist statin prescribing initiative in diabetic patients at an internal medicine resident clinic. published online J Pharm Pract. 29 January 2019. https://doi.org/10.1177/0897190018824820. 3. Gregory PA, Austin Z. Conflict in community pharmacy practice: the experience of pharmacists, technicians and assistants. Can Pharm J (Ott). 2016;150(1):32–41. 4. Frequently asked questions. National Association of Pharmacy Regulatory Authoritieshttps://napra.ca/frequently-asked-questions, Accessed date: 4 December 2019. 5. Canadian pharmacy technician programs. The Canadian Council for Accreditation of Pharmacy Programs (CCAPP) http://ccapp-accredit.ca/pharmacy-technician-programs/ , Accessed date: 4 December 2019 (Updated 2019). 6. Qualifying examination blueprint. The Pharmacy Examining Board of Canadahttps://www.pebc.ca/index.php/ci_id/3082/la_id/1.htm, Accessed date: 4 December 2019. 7. Professional competencies for Canadian pharmacy technicians at entry to practice. National Association of Pharmacy Regulatory Authoritieshttps://napra.ca/sites/default/ files/2017-08/Comp_for_Cdn_PHARMTECHS_at_EntrytoPractice_March2014_b.pdf; March 2014, Accessed date: 4 December 2019. 8. Model standards of practice for Canadian pharmacy technicians. National Association of Pharmacy Regulatory Authoritieshttps://napra.ca/sites/default/files/documents/ Model_Standards_of_Practice_for_Canadian_Pharmacy_Technicians_FINAL-June2018.pdf; November 2011, Accessed date: 4 December 2019. 9. Mospan CM, Bright DR, Eid D. Highlighting a gap in student pharmacist training: Intraprofessional education with pharmacy technicians. Curr Pharm Teach Learn. 2018;10(9):1160–1164. 10. Otsuka H, Kondo K, Ohara Y, et al. An inter- and intraprofessional education program in which dental hygiene students instruct medical and dental students. J Dent Educ. 2016;80(9):1062–1070. 11. Brame JL, Mitchell SH, Wilder RS, Sams LD. Dental and allied dental students’ attitudes towards and perceptions of intraprofessional education. J Dent Educ. 2015;79(6):616–625. 12. Jones VE, Karydis A, Hottel TL. Dental and dental hygiene intraprofessional education: a pilot program and assessment of students’ and patients’ satisfaction. J Dent Educ. 2017;81(10):1203–1212. 13. Diamant R, Pitonyak JS, Corsilles-Sy C, James AB. Examining intraprofessional competencies for occupational therapist and occupational therapy assistant collaboration. Occup Ther Health Care. 2018;32(4):325–340. 14. Mobley Smith MA, Boyle CJ, Keresztes JM, et al. Report of the 2013-2014 professional Affairs Standing Committee: advancing the pharmacy profession together through pharmacy technician and pharmacy education partnerships. Am J Pharm Educ. 2014;78(10) https://doi.org/10.5688/ajpe7810S22. 15. Nagge JJ, Lee-Poy MF, Richard CL. Evaluation of a unique interprofessional education program involving medical and pharmacy students. Am J Pharm Educ. 2017;81(10) https://doi.org/10.5688/ajpe6140. 16. A national interprofessional competency framework. Canadian Interprofessional Health Collaborativehttps://www.uthsc.edu/simulation/documents/canadian-ipcompetencies.pdf; February 2010, Accessed date: 4 December 2019. 17. Microsoft Excel (for Windows) [computer program]. Version 16.0.4266.1001. Redmond, WA: Microsoft; 2016. 18. Accreditation standards for Canadian first professional degree in pharmacy programs. The Canadian Council for Accreditation of Pharmacy Programs (CCAPP)http://ccappaccredit.ca/wp-content/uploads/2016/01/Accreditation-Standards-for-Canadian-First-Professional-Degree-in-Pharmacy-Programs.pdf; January 2018, Accessed date: 4 December 2019. 19. Accreditation standards for Canadian pharmacy technician programs. The Canadian Council for Accreditation of Pharmacy Programs (CCAPP)https://ccapp-accredit.ca/wpcontent/uploads/2018/04/April6-CCAPP-PharmTech-Standards_ENG.pdf; July 2019, Accessed date: 4 December 2019.
5
Contents lists available at ScienceDirect
Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Experiences in Teaching and Learning
Partners in pharmacy: An intraprofessional educational event with pharmacy and pharmacy technician students Fadi Guirguisa, Robin Andradea, Connie Beckb, Debbie Ellena, Jennifer Sliveckaa, ⁎ Cynthia L. Richarda, a b
School of Pharmacy, University of Waterloo, 10 Victoria St. S, Kitchener N2G 1C5, Ontario, Canada Lambton College, 1457 London Rd., Sarnia N7S 6K4, Ontario, Canada
A R T IC LE I N F O
ABS TRA CT
Keywords: Intraprofessional OSCE Pharmacy technician
Background and purpose: Upon graduation and licensing, pharmacists work very closely with pharmacy technicians. Despite this, opportunities for learning together as students are limited. We developed and implemented a pilot intraprofessional event for pharmacy and pharmacy technician students. The purpose of this study was to evaluate the perceived value and learner confidence through analysis of participant feedback. Education activity and setting: Pharmacy students from the University of Waterloo School of Pharmacy and pharmacy technician students from Lambton College participated in an intraprofessional event that included a three-station practice objective structured clinical exam (OSCE) and a case discussion regarding a methadone dispensing error, followed by a facilitated debrief. Upon completion of the event, students were invited to complete an online feedback questionnaire. Findings: Twenty-one pharmacy students and 22 pharmacy technician students participated in the event. Twenty-one students completed the questionnaire, for a response rate of 49%. The majority of respondents agreed or strongly agreed that the event enhanced learning and confidence in working together to provide interprofessional care. Students seemed to find the OSCE to be particularly valuable. Feedback suggestions for improvement indicated a desire for more activities and time allocated to the event. Summary: We designed and implemented a pilot intraprofessional event that was well-received by pharmacy students and pharmacy technician students. This supports the development of future similar events.
Background and purpose In pharmacy practice, collaboration is fundamental for the optimization of patient care. When professionals work seamlessly in a team, patients receive improved therapy.1,2 As an example, one intervention study demonstrated that when pharmacists collaborated with physicians in prescribing, prevalence of appropriate statin therapy in patients with diabetes increased by 7%.2 Historically, emphasis has been placed on interprofessional collaboration in health care settings and its effects on patient care.3 Although interprofessional work is irrefutably beneficial, the majority of pharmacists in primary care have much more interaction with pharmacy technicians, assistants, and other pharmacists in the intraprofessional setting.
⁎
Corresponding author. E-mail address: [email protected] (C.L. Richard).
https://doi.org/10.1016/j.cptl.2019.12.010
1877-1297/ © 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Fadi Guirguis, et al., Currents in Pharmacy Teaching and Learning, https://doi.org/10.1016/j.cptl.2019.12.010
Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx
F. Guirguis, et al.
In Canada, pharmacy technicians are regulated in nine of ten provinces.4 The process of becoming a registered pharmacy technician typically involves completion of an accredited Canadian Pharmacy Technician Program (variable length, typically two years), followed by completion of national licensing exams through the Pharmacy Examining Board of Canada.5,6 The licensing exams are based on professional competencies outlined by the National Association of Pharmacy Regulatory Authorities, and includes both multiple choice questions and an objective structured performance examination (OSPE; analogous to an objective structured clinical exam (OSCE)).6,7 Scope of practice for pharmacy technicians varies by province, but completing the final checks of prescription products prior to release, transferring and receiving verbal prescriptions, obtaining the best possible medication history with assistance from the pharmacist, and instructing patients about the operation of medical devices are commonly performed tasks.8 In Ontario, Canada, registered pharmacy technicians are registered with the Ontario College of Pharmacists. The participatory roles of pharmacy technicians have become instrumental in facilitating changes in pharmacy's scope of practice.9 Technicians support medication-use processes and pharmacy operations, which allows pharmacists time to be freed for more patient-centered clinical endeavours.9 Due to their critical involvement in tasks such as dispensing, billing, staff training, medical device education, and compounding, they prove to be essential for developing a logistically and financially thriving pharmacy.9 Although research on intraprofessional education in the context of pharmacy is scarce,9 with none existing to our knowledge in the Canadian pharmacy setting, there are other professions that have demonstrated its value.10,11 A past survey analysis showed agreement among 94% of dental and dental hygiene students that intraprofessional education builds stronger oral health care teams.11 This survey was conducted based on a pilot study, which randomly paired dental and dental hygiene students for completion of an intraprofessional activity that included the cooperative review of a patient's history, periodontal diagnosis, treatment plan, and outcomes.12 The majority of participants also agreed that dental and dental hygiene students must have education opportunities in collaborative settings.11 Other health care professions such as occupational therapy have also stressed the importance of intraprofessional competencies, suggesting that occupational therapy and occupational therapy assistant programs address disparities in attitude, knowledge, and skill reflected in their curricula.13 Recommendations from dental and occupational therapy professionals can be extrapolated to suggest a need for intraprofessional education development in pharmacy. Given the complementary scopes of practice of pharmacists and pharmacy technicians, an examination of where these roles intersect can assist with identifying areas of focus for intraprofessional education. Additional areas related to teamwork such as conflict management, communication, and responsibility could also be explored so as to adequately address common scenarios in the practice setting. Collaborative pharmacy examples have been outlined in existing literature, as found in The Report of the 2013–2014 Professional Affairs Standing Committee: Advancing the Pharmacy Profession Together Through Pharmacy Technician and Pharmacy Education Partnerships.14 In this report, scenarios include pharmacy technician students delivering education to pharmacy students in forms of didactic lectures and laboratory instruction.14 One could modify the activities from this report, along with those in used in dental and occupational therapy education to develop intraprofessional events in pharmacy. As necessary as intraprofessional learning is, the strategic task of planning often comes with its own obstacles. American surveys have mentioned reasons that prohibit this collaboration including large geographical distances between pharmacy and pharmacy technician programs, lack of funding and time, scheduling difficulties and lack of participating practice sites.14 Despite these hurdles, advocates agree that the biggest barrier to developing intraprofessional education is the absence of interest.9,14 As a primary health care profession, pharmacy must first take steps in recognizing the importance of pharmacy and pharmacy technician students learning together and from each other. To this end, the University of Waterloo School of Pharmacy and the Lambton College pharmacy technician program collaborated to create a pilot intraprofessional educational event. The purpose of this study was to assess whether the event improved student confidence in collaborative practice, and whether it was perceived to provide educational value. In addition, feedback was explored regarding what aspects provided the greatest learning and what suggestions could enhance the experience. Educational activity and setting A pilot intraprofessional event entitled “Partners in Pharmacy” was held at the University of Waterloo Health Sciences campus in Kitchener, Ontario, Canada. It was two hours in duration and was composed of a practice OSCE, case discussion, and facilitated debrief. Participants included 21 (of 113) students enrolled in year four of the doctor of pharmacy (PharmD) program at the University of Waterloo School of Pharmacy and 22 (of 22) students enrolled in the second year of the pharmacy technician program at Lambton College. This represents the final year of study for each program. Participation was mandatory for pharmacy technician students, who attended the event as part of a three-day capstone experience, and optional for pharmacy students. Pharmacy students could count participation toward their passport of required interprofessional education (IPE) experiences (described previously).15 The OSCE was composed of three stations, and was completed in pairs (one student from each program), and one group of three (two pharmacy technician students and one pharmacy student) due to the slight mismatch in numbers. The first station included a standardized patient who was using a glucometer incorrectly. Pharmacy technician students provided education on proper use of the device, and pharmacy students discussed glycemic targets. In the second station, learners contacted a prescriber (simulated by a faculty member) regarding the need to change therapy based on insurance coverage for prescribed medication. For this station, the learners worked together to interpret information on coverage in the drug formulary, and then the pharmacy student used his or her clinical knowledge to suggest a therapeutic alternative to the prescriber. The third station did not include an actor; instead students checked four filled prescriptions. This task simulated a role that could be completed by either pharmacists or pharmacy technicians in Ontario, so students were not assigned to specific roles but could work together however they wished. Students had 7 min to work through each station, with 2 min between each station for movement and for reading a brief summary of the next station before 2
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beginning. The second component of this event was a case discussion surrounding a methadone dispensing error in which a patient received a dose tenfold higher than prescribed. Students were assigned to groups of five to six learners (two to three learners from each program) to address the case. Printed material included a pharmacy scenario, patient profile, and thematic questions that related to roles, responsibilities, communication, and conflict management. Answers to the three OSCE stations and key themes emerging from the case discussion were discussed during the facilitated debrief session. Upon completion of the Partners in Pharmacy event, students were asked to evaluate the event by completing an electronic questionnaire, disseminated via email using Qualtrics software. Likert-scale questions were based on the Canadian Interprofessional Health Collaborative competency framework,16 with open-ended questions designed to identify aspects of the event that were perceived to be most valuable or could be improved. Questionnaire results were presented and analyzed using descriptive statistics and summarized in aggregate. The mean and standard deviation values were calculated for Likert-scale questions using Microsoft Excel.17 Written responses to open-ended questions were categorized according to key themes that emerged. This project received clearance and approval from both the University of Waterloo and Lambton College Research Ethics Committees. Findings A total of 43 students participated in the event (21 pharmacy students, 22 pharmacy technician students), and 21 completed the questionnaire for a response rate of 49%. This included nine pharmacy students (43%), 11 pharmacy technician students (50%), and one who did not indicate the program of study. As evident in Table 1, the event was well-received with the majority (> 85%) of respondents agreeing or strongly agreeing with Table 1 Questionnaire results- 5 point Likert-scale questions. Survey item
Program
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Mean (SD)
1. After the session I am better able to recognize how others' skills and knowledge complement and overlap with my own 2. After the session I am better able to listen actively and encourage the ideas and opinions of others
PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total PharmD PharmT Total
0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1 0 1 1
0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 2 0 2 1 0 1 1 0 1 1 0 1 1 0 1 0 0 0 1 0 1 0 0 0 1 0 1 0 0 1
6 3 10 5 2 8 1 3 5 3 5 9 4 3 8 6 3 10 3 2 6 6 3 9 5 2 7 6 3 10 2 3 5 5 3 8
3 7 10 3 8 11 6 7 13 5 5 10 4 7 11 2 7 9 5 8 13 3 7 11 3 8 11 3 7 10 6 7 13 4 7 11
4.3 (0.5) 4.4 (1.2) 4.3 (0.9) 4.1 (0.9) 4.5 (1.2) 4.3 (1.1) 4.4 (0.9) 4.4 (1.2) 4.4 (1.0) 4.4 (0.7) 4.2 (1.2) 4.3 (1.0) 4.3 (0.7) 4.4 (1.2) 4.3 (1.0) 4.1 (0.6) 4.4 (1.2) 4.2 (0.9) 4.4 (0.7) 4.5 (1.2) 4.4 (1.0) 4.3 (0.5) 4.4 (1.2) 4.4 (0.9) 4.2 (0.7) 4.5 (1.2) 4.4 (1.0) 4.3 (0.5) 4.4 (1.2) 4.3 (0.9) 4.6 (0.7) 4.4 (1.2) 4.5 (1.0) 4.4 (0.5) 4.4 (1.2) 4.3 (1.0)
3. After the session I am better able to use a team approach with the patient to provide care 4. After the session I am better able to provide constructive feedback to IP team members 5. After the session I am better able to reflect on my individual performance for my improvement 6. After the session I am better able to address conflict in a respectful manner 7. Completing the OSCE simulation increased my confidence in working collaboratively 8. Completing the case discussion increased my confidence in working collaboratively 9. The debrief session after the experience was valuable
10. I feel that my skills were utilized in this experience
11. Completing the OSCE simulation in pairs enhanced my learning 12. Completing the case discussions in groups enhanced my learning
PharmD = Doctor of Pharmacy students; PharmT = Pharmacy Technician students; SD = standard deviation. Survey was completed by nine PharmD students, 11 PharmT students, and one student who did not indicate program of study and did not respond to Questions 9 and 11. 3
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Table 2 Questionnaire results – short answer questions. Question What aspect(s) of the event did you find most valuable?
My key take-away from the workshop was…
This workshop could be improved by…
When I work with the other profession in the future I will…
Theme (sample quote; number of responses) 1. OSCE (“The OSCE portion was the most valuable aspect.”; 8 responses) 2. Understanding how pharmacists & pharmacy technicians can work together, understanding scope of practice (“Collaboration and understanding how pharmacists and pharmacy technicians can complement each other's knowledge and skills.”; 3 responses) 3. Case study (“The case really showed me that regulated technicians in Ontario are vital to a pharmacy and that we should let them practice to their full scope of practice.”; 2 responses) 1. Understanding and staying within scope (“Trying to apply my knowledge of the pharmacy technician's scope of practice made me realize that I did not know how far their scope of practice could go.”; 6 responses) 2. Value of working together/teamwork (“Rely on your team”; 5 responses) 1. More time/activities, meeting more frequently (“I would have enjoyed a longer discussion of the methadone case”; 6 responses) 2. More emphasis on scope (“Having the standardized patients/HCPs ask specific questions so the techs and pharmacy students can show each other specific things we know”; 2 responses) 1. Understand roles/work within scope (“Make sure I stay within my scope of practice”; 5 responses) 2. Communicate effectively (“Make sure I listen to what they say”; 4 responses) 3. Have mutual respect/trust (“Ensure a mutual respect and trust in each other”; 3 responses)
OSCE = objective structured clinical exam; HCP = healthcare professional.
all statements in the questionnaire. Results appeared similar between both groups of learners, although the small number of participants did not permit statistical analysis. Fourteen students (33%) provided answers to open-ended questions that were included in the questionnaire. Themes emerging from the responses are summarized in Table 2. Many respondents (more than half) indicated that they found the OSCE to be the most valuable component. This reinforced the strong agreement with the Likert statement “Completing the OSCE simulation in pairs enhanced my learning”. Students also appreciated the opportunity to understand more regarding each profession's scope of practice, and indicated that a key take-away was the importance of working together. The importance of effective communication and mutual respect were identified as themes as well. Students indicated they would have liked even more opportunity to interact, such as having a longer session with more activities. Discussion In this study, we report the implementation and evaluation of a new intraprofessional learning activity between learners in the pharmacy community. There is a paucity of similar reports in the literature. This may be due to challenges that are present in organizing such events, such as scheduling, classroom space, distance between educational institutions, resources, and imbalance in student numbers between programs. We were able to overcome several of these challenges for this event. The campuses for our two institutions are a two-hour drive apart. However, students from Lambton College travel to Toronto for a capstone experience during their second year of study, and drive past Kitchener on the way. This presented a window of opportunity to organize an event when students were en route. We intentionally chose fourth-year pharmacy students to participate in the event since they did not have scheduled classes on the day that the pharmacy technician students would be passing through the region, which minimized scheduling barriers. We saw the year of study as being advantageous, because both groups of learners were in their final year, so were on similar timelines for licensure. Furthermore, since it was an optional activity for pharmacy students, we were able to limit numbers to create a one-to-one ratio among learners. This was particularly important for the OSCE, as it allowed students to complete the stations in intraprofessional pairs, and minimized the likelihood of one profession dominating the interaction. With only 43 students total participating, classroom space also became less of an issue. In terms of resources, the main cost for the event involved hiring standardized patients for the OSCE component, with a total cost of approximately $300 (CAD), or $7 per learner. Other roles were filled by faculty and staff volunteers to minimize cost. Given the importance of intraprofessional education for accreditation in the Canadian pharmacy education context, the cost was justifiable to administrators.18,19 In this pilot study, we found that the event was well-received by students in both programs. According to questionnaire results, the majority of pharmacy and pharmacy technician students appreciated the opportunity to collaborate in an intraprofessional setting. Well over 80% of all responses were either in agreement or strong agreement with the Likert scale reflection statements. This implies that after the event, students felt more confident working with the other profession and managing conflicts collaboratively. Participants also agreed that the intraprofessional experience was valuable and enhanced education. Interestingly, one pharmacy technician student strongly disagreed with all reflection statements. It is uncertain whether this was their true sentiment, or if it was in error, as it stood in contrast to the respondent's answers to open-ended questions. For example, the respondent's only suggestion for how the workshop could be improved was having “more activities”. Students particularly appreciated the OSCE component. The OSCE format was chosen because students in both programs must complete an OSCE or OSPE as part of national licensing exams upon graduation, and students often indicate they would like more practice with this type of performance-based assessment. Thus we anticipated it would be perceived as worthwhile. The case study emphasized a methadone dispensing error, but many participants from both programs were not familiar with some details of methadone dispensing. The choice of case content more familiar to both 4
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learner groups may have further enhanced the perceived value. As previously stated in the literature, principal recommendations for improvement suggest the need for more of these activities to take place in pharmacy education.9 This is consistent with our findings, where participants indicated that they would have liked more time to interact, and more activities. Given the positive response to this pilot event, we will look to offer the event again but perhaps include additional case studies and one to two more OSCE stations. Our study did have some limitations. The Partners in Pharmacy event had a small number of participants with only 21 pharmacy students and 22 pharmacy technician students. Furthermore, less than half of all participants (49%) completed the online questionnaire. This small number of participants did not allow for statistical comparisons among learner groups. Furthermore, only 21 of approximately 120 pharmacy students participated in the event (registration was limited to allow for roughly equal numbers of learners from each program), and they self-identified for participation based on interest in the event. This could have positively impacted results, as students may have held pre-existing convictions that intraprofessional collaboration is important, and their views may not be representative of the whole cohort. Summary Although the concept of intraprofessional education may be viewed as important and valuable, practical implementation is not without barriers, such as funding, time, and scheduling. We overcame these barriers and implemented a pilot intraprofessional event that was well-received by pharmacy and pharmacy technician students. This supports the development of future similar events and further research to evaluate the value of such events. Disclosures None. Declaration of competing interest None. Acknowledgements We would like to thank Sherilyn Houle, Rosemary Killeen, and Preet Sian for assisting with the event. Sherilyn Houle also provided useful feedback on this manuscript. References 1. Gobis B, Yu A, Reardon J, Nystrom M, Grindrod K, McCarthy L. Prioritizing intraprofessional collaboration for optimal patient care: a call to action. Can Pharm J (Ott). 2018;151(3):170–175. 2. Vincent R, Kim J, Ahmed T, Patel V. Pharmacist statin prescribing initiative in diabetic patients at an internal medicine resident clinic. published online J Pharm Pract. 29 January 2019. https://doi.org/10.1177/0897190018824820. 3. Gregory PA, Austin Z. Conflict in community pharmacy practice: the experience of pharmacists, technicians and assistants. Can Pharm J (Ott). 2016;150(1):32–41. 4. Frequently asked questions. National Association of Pharmacy Regulatory Authoritieshttps://napra.ca/frequently-asked-questions, Accessed date: 4 December 2019. 5. Canadian pharmacy technician programs. 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