- Email: [email protected]
Perceptions, obstacles, and solutions for offering Introductory Pharmacy Practice Experiences in the community hospital setting: A qualitative survey
Available online at www.sciencedirect.com
Currents in Pharmacy Teaching and Learning 6 (2014) 632–638
Research
http://www.pharmacyteaching.com
Perceptions, obstacles, and solutions for offering Introductory Pharmacy Practice Experiences in the community hospital setting: A qualitative survey Tina Harrach Denetclaw, PharmD, BCPSa,*, Elizabeth W. Young, PharmD, BCPSb, Amy M. Tiemeier, PharmD, BCPSc, James D. Scott, PharmD, FCCPd, Melody L. Hartzler, PharmD, AE-C, BCACPe a
Department of Clinical Pharmacy, School of Pharmacy, University of California—San Francisco, San Francisco, CA b Clinical Pharmacist, Thrombosis Service University of Utah Hospitals and Clinics Salt Lake City, UT c St. Louis College of Pharmacy, St. Louis, MO d Western University of Health Sciences College of Pharmacy, Pomona, CA e Cedarville University School of Pharmacy, Cedarville, OH
Abstract Objective: We sought to identify barriers and possible solutions for community hospitals providing Introductory Pharmacy Practice Experiences (IPPE). Methods: A survey was developed and made available online to a segment of members of the American College of Clinical Pharmacy. Responses were collected anonymously. Results of the survey were assessed using descriptive statistics. Results: A total of 45 individuals who self-identified as being employed in acute care hospitals or hospital systems currently hosting IPPE students responded to the survey, with 35 of these individuals completing the entire survey. Pharmacy department staff-, school-, and student-related burdens and barriers were identified, and successful approaches to providing IPPE were described. It is unknown how many members receiving the survey practice in acute care community hospital settings, so the true response rate for this survey is unknown, and the responses to this survey cannot be generalized. Conclusions: Informed planning and preceptor support for IPPE may enhance the quality of learning activities available to students and decrease the burden of providing IPPE for hospital-based preceptors. This survey provides preliminary information that may be built upon; a subsequent quantitative study is needed to glean generalizable information on this topic. r 2014 Elsevier Inc. All rights reserved.
Keywords: Experiential; Introductory pharmacy practice experiences; Pharmacy education
Introduction
* Corresponding author: Tina Harrach Denetclaw, PharmD, BCPS, Department of Clinical Pharmacy, School of Pharmacy, University of California—San Francisco, San Francisco, CA 94143-0622. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2014.05.011 1877-1297/r 2014 Elsevier Inc. All rights reserved.
As the profession of pharmacy has evolved, the framework by which we educate professional pharmacy students has changed. Our pharmacy education model in the last decade has shifted from a product focus to patient focus as schools seek to train pharmacists who are patient care providers.
T.H. Denetclaw et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 632–638
The newest Accreditation Council for Pharmacy Education (ACPE) standards require that at least 5% of the curriculum (300 hours) be devoted to Introductory Pharmacy Practice Experiences (IPPEs).1 These standards also “require active participation” by the student in direct patient care. Colleges of pharmacy agree that introducing students to the practice of pharmacy early in their professional development benefits them by reinforcing their didactic learning, enhancing professional development, and assists students in defining their career pathway.2 A well-structured IPPE that provides students with coordinated learning experiences is rewarding for both the student as well as the preceptor.3 Defining preceptor needs is crucial to the sustainability and success of an IPPE program. Surveys of preceptor needs have found that they desire training and training needs to be ongoing.4 Surveys have been helpful in identifying issues such as preceptor’s workload, time/ quality concerns, and compensation.5,6 However, little has been reported on the types of student activities performed on IPPEs or perceptions of those precepting IPPEs. While multiple programs have demonstrated successful IPPE models,2,3,7–15 concern still exists across the profession that students in IPPE experiences are not utilized to their full potential due to lack of experiences that integrate the student into the health care team with a defined active role in the care of patients.16 Internal discussion among members of the American College of Clinical Pharmacy (ACCP) Education and Training Practice Research Network (EDTR PRN) also suggested that IPPE students do not have a defined active role in the care of patients, and preceptors report a lack of time available for IPPE students, specifically in the health-system setting (unpublished data, 2011). In response to this discussion, the ACCP EDTR PRN developed a survey to identify barriers and possible solutions that colleges of pharmacy could employ to enhance the success of IPPEs in community hospital settings.
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Methods The Scholarly Activity Committee of the ACCP EDTR PRN developed a 23-item web-based survey to assess hospital-based IPPEs occurring in health-systems where ACCP members practice (Appendix B). The electronic survey tool was developed using SurveyMonkeys software. The committee created a draft survey based on their collective experiences that was piloted by 32 members of the ACCP EDTR PRN and refined for content and clarity. Survey items are included in Tables 1–3. Respondents were allowed to select all responses that applied for each survey item, and each survey item included an opportunity for additional responses from individual responders. Respondents were asked to describe which approaches their pharmacy department has found to be particularly successful in providing IPPEs. The survey also included opportunity for individual responders to identify and comment on issues not addressed in the survey items. The primary areas the survey addressed were the perceived value of training IPPE students, the perceived obstacles for training IPPE students, and the characteristics of successful IPPE training approaches. The project was deemed exempt by Institutional Review Boards (IRBs) at three of the institutions employing committee members. Investigators from other institutions where IRB approval was not sought completed training requirements and were approved as sub-investigators by one of the approving institutions. ACCP PRNs whose members may practice in a hospital setting were invited to participate in the survey. The survey was available online to 1268 non-duplicated members of the participating PRNs during April 2012. Two reminders were distributed to improve the response rate. Responses were collected anonymously. Results of the survey were assessed through descriptive statistics using Excel 2010s and SurveyMonkeys software in June 2012.
Table 1 Perceived value of working with IPPE students (n ¼ 35) Items of pharmacy department perceived value of working with IPPE students
Frequencya
Maintain positive relationships with area schools of pharmacy Develop or improve relationships with area schools of pharmacy Provide staff professionally rewarding experiences through working with students Improve recruiting potential to fill resident pharmacist positions Improve recruiting potential to fill staff pharmacist positions Help with data collection for quality assurance projects Improve recruiting potential to fill intern pharmacist positions Maintain positive relationships with faculty member(s) in area schools of pharmacy Develop or improve relationships with faculty member(s) in area schools of pharmacy Improve recruiting potential to fill clinical pharmacist positions Assistance with other projects—please specify in comments field There is no value to the pharmacy department for providing IPPE
28 19 19 11 9 9 6 5 4 4 3 3
a
Values add up to 435 as respondents could pick multiple activities.
634
T.H. Denetclaw et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 632–638
Table 2 Perceived obstacles for working with IPPE students (n ¼ 35) Items of pharmacy departments’ perceived obstacles for working with IPPE students
Frequencya
Staff perception that the students are a hindrance to getting the work done Staff perception that students demand time without offering value in return Students’ lack of basic knowledge to allow for a meaningful active experience at IPPE level Students’ limited knowledge of how to use the site’s computer software Site’s limited capacity for precepting IPPE students Staff perception that students do not take responsibility for learning during IPPE Staff disinterest in working with IPPE students Site’s limited access to computers Schools not providing guidance for IPPEs Schools not providing financial incentive to offer IPPE at site Staff perception that students are unprepared to learn during IPPE Staff perception that site is not valuable to student learning Schools not providing faculty members to precept these students Schools requiring multiple written evaluations Students answering questions for other HCP without consulting preceptor Staff perception that students ask too many questions during IPPE Schools not providing feedback about IPPEs
16 16 15 15 12 9 9 9 7 6 5 4 4 3 2 2 2
a
Values add up to 435 as respondents could pick multiple obstacles.
Results
Perceived value and obstacles
A total of 45 individuals who self-identified as being employed in acute care hospitals or hospital systems currently hosting IPPE students responded to the survey. Of these respondents, 35 completed the entire survey. Of those that completed the survey, ten were clinical coordinators, seven were pharmacists staffing specialized clinical services, five were pharmacy directors or supervisors, five were university-funded pharmacists, five were pharmacists staffing generalized clinical services, one was a pharmacist staffing centralized pharmacist services, one was an ambulatory care pharmacist, and one was a pharmacy resident. Centralized pharmacy was the most frequently reported area where IPPEs occur (33 respondents) followed by intravenous compounding room (29) and clinical services (26). Similarly, pharmacists staffing centralized pharmacies were most frequently identified as being among those individuals contributing to the majority of precepting for IPPE students (25), followed by pharmacy director or supervisor (15), pharmacist staffing clinical services (15), resident pharmacists (7), and technicians (7). Three respondents indicated that intern pharmacists or Advanced Pharmacy Practice Experience (APPE) students provide the majority of precepting of IPPE students. Shadowing pharmacists was the most frequently reported activity (42% weighted-average time spent on this activity), followed by participating in pharmacist activities (21% weighted-average time), shadowing technicians (21% weighted-average time), participating in projects (15% weighted-average time), and participating in technician activities (13% weighted-average time).
Table 1 shows the respondents’ perceived value of working with IPPE students. Maintaining or developing positive relationships with area schools of pharmacy was the most frequently cited perceived value of working with IPPE students, followed by providing staff professionally rewarding experiences through working with students. Survey items assessing the pharmacy staff perception of IPPE students showed that 37% of respondents indicated that pharmacists staffing clinical or decentralized pharmacy services found working with IPPE students professionally rewarding while 25% of respondents indicated the same for pharmacists staffing centralized pharmacy services. Approximately 25% of respondents indicated that the benefits of hosting IPPE students outweigh the burdens for clinical, decentralized, and centralized pharmacy services. Only three respondents noted there is no value to the pharmacy department for providing IPPE. Table 2 shows the respondents’ perceived obstacles for working with IPPE students. Among them, 16 respondents (45%) indicated that IPPE student activities interfere with work production and demand time without offering value in return, and 15 respondents (43%) indicated that students’ lack of basic knowledge and understanding of site computer software was an obstacle. Students asking questions, students inappropriately responding to questions, and lack of feedback from the school were the only issues noted by two respondents (6%). Additional comments from individual respondents were focused on student quality (variable), time on site (too short), and student knowledge (limited). Individual comments from
T.H. Denetclaw et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 632–638
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Table 3 Characteristics of IPPE activities cited in the survey (n ¼ 35)a,b
Values 435 as respondents could pick multiple activities. Degree of shading indicates the relative value of the activities to the pharmacy department. The darker shades in the table indicate activities that the survey suggests are considered more valuable by pharmacy departments, schools of pharmacy, and IPPE student pharmacists, and also less problematic by pharmacy departments. a
b
the respondents indicate that IPPE students do not have enough skills to be useful to the hospital, and their rotations are too short to gain useful skills. However, others commented that when IPPE students are in the department for a few weeks, they can become useful in all aspects of operations provided they receive training and are adequately supervised. Respondents expressed that since IPPE students have significantly less knowledge than APPE students, they require careful supervision and cannot provide as much assistance as an APPE student. Furthermore, comments indicate IPPE students often are scheduled during times when the department is short-staffed (holiday breaks, summer, and weekends), and thus student needs impact the staff when the staff is least able to accommodate them. Conversely, other comments indicate that precepting IPPE students can be a challenge when the census is high. Still other respondents commented that providing IPPE students space to work and time with staff is challenging, in general. Some individual comments pertained to challenges with school program logistics. Scheduling students for short blocks of time was noted to require constant and timeconsuming orienting of new students. Other respondents commented that scheduling IPPE students once per week for six weeks makes it difficult for the students to retain new information from visit to visit. Lack of standardized
evaluations between different schools presents a challenge. Several schools of pharmacy have been queried, but they have not been able to offer useful suggestions to improve the experience of hosting IPPE students. Table 3 shows the IPPE student activities noted in the survey with the response rate for activities required by schools, student activities considered problematic by the respondents’ pharmacy departments, student activities considered valuable by the respondents’ pharmacy departments, and student activities perceived to receive the most positive student feedback. The activities identified as being required by schools that were noted most frequently to be considered valuable by pharmacy departments included looking up drug information and assisting with data collection for quality assurance projects. Within the comments section for this portion of the survey, three respondents commented that IPPE students usually find everything new and interesting for the first two weeks. In addition, three respondents commented that students enjoy working with clinical pharmacists and one respondent commented that students enjoy rounding with physicians. Successful approaches Approaches cited by respondents as being successful for providing IPPE fall into the following broad categories: (1)
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encouraging active learning, (2) incorporating students into the pharmacy practice model, (3) rotating experiences throughout the hospital and pharmacy, (4) making use of all precepting resources, (5) creating innovative roles for IPPE students, (6) matching student interests with planned activities, (7) developing an IPPE student “job description,” and (8) providing support for preceptors. Further detail about activities that can be performed in each category is provided in Appendix A. Discussion The model for educating students in APPEs is well established. However, it appears IPPE students are spending a majority of their time shadowing, and they may not be utilized to their full potential, especially in hospital settings. Given that less than 10% of survey respondents reported student engagement in pharmacist duties or projects, healthsystems may be underutilizing IPPE students. Our survey indicated preceptors felt students were unprepared and lacked knowledge to effectively participate in direct patient care duties. Many open-ended responses discussed the IPPE student’s lack of training as a barrier to involving these students in patient care. Moreover, 16 respondents (46%) report staff view that IPPE students are a hindrance to their pharmacy workflow, and 16 (46%) report that preceptors view students as a burden, which provides little in return for their investment. These responses could be due to one of two factors. First, pharmacy schools may consider surveying their preceptors to determine if expectations of IPPE students’ abilities are reasonable. If expectations exceed what is appropriate given the student’s level in the curriculum, schools may want to develop informational materials (development programming, webinars, etc.) to address the disparity and identify applicable IPPE student proficiencies for preceptors. Second, addressing lack of student training and sufficient knowledge base should be an area of consideration by schools. Survey results suggest that students should receive training in sterile product preparation and hospital workflow systems prior to their rotation. Computer system training often does not occur pre-IPPE and may be challenging due to the wide variety of electronic medical record (EMR) systems across institutions. However, many health-systems are utilizing EPIC© for EMR, and facilities such as the Veterans Affairs Medical Centers have standardized software. It could be worthwhile for experiential departments to work with their local health-systems to determine how best to train students on EMR systems prior to IPPE experiences. This may allow students better hands-on experiences instead of the traditional shadowing experiences. Training students on medication dispensing systems such as Pyxis MedStationss prior to their rotations may also free up orientation time to be spent on clinical activities. If academic institutions partnering with regional health-systems can provide training, it lessens the burden on individual medical centers to provide such training
and also allows the academic institution to standardize a portion of their IPPE learning experience. Mantong et al.11 reported 76% of preceptors noted an increased staff workload during the first 20 hours of IPPEs with students. However, after the first 20 hours of the experience, when the same preceptors where surveyed, only 32% noted an increased workload and 60% indicated a decreased workload. This suggests that standardization of pre-IPPE training may decrease preceptor burden and allow IPPEs to be mutually beneficial for the health-system and the academic institution.11 Further studies are warranted to determine the effect of such training programs. Proper training prior to IPPEs may expand opportunities for IPPE students to be involved in direct patient care. In addition, the findings of Mantong et al.11 suggest that both students and preceptors may benefit from IPPE programs that involve full-time activities over a period of time, such as a mini- or full-rotation over two to four weeks, as opposed to intermittent hours over a period of many weeks. A rotation-style program may allow students to be oriented, and then move into activities that require less preceptor effort and provide more value to the department. Open-ended portions of our survey suggest that a portion of IPPE students are already engaged in the pharmacy workflow and are given basic clinical activities to participate in, such as intravenous (IV) to oral (PO) conversions, renal dosing calculations, obtaining medication histories, and collecting data for adverse drug reactions (ADRs). IPPE students also have participated in answering drug-information questions and journal club activities with APPE students. Activities such as these have been well received and are mutually beneficial for the departments and IPPE students. The American Association of Colleges of Pharmacy (AACP) and the American Society of Health-System Pharmacists (ASHP) collaborated in 2008 to determine the capacity of hospitals to partner with academia to meet experiential education requirements for pharmacy students. In the report, one action item was “colleges and schools should collaborate with hospitals and health-systems to develop curricular models for introductory experiences in hospitals and health-systems so that students progress from introductory to increasingly complex levels of pharmacy services as they advance in their doctor of pharmacy degree programs.”17 While we agree with these recommendations, we also recognize the challenge many colleges face in finding institutional IPPE sites. Geographic constraints determine the number of potential sites within an area, and given the growth in number of pharmacy schools as well as the standardization in required institutional IPPE hours (which was for many schools an increase in hours), availability of these sites for student placement can be very limited. Increasing placement can be accomplished through various models that have previously demonstrated success. One such model proven successful was Kesslar et al.’s structured longitudinal introductory medicine experience that was layered onto an established APPE. The students spent time over the course of the P1–P3 years completing a variety of activities
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ranging from medical team rounds to literature evaluation and discharge counseling. The students involved in this type of program had increased confidence in their skills verses their peers who did traditional IPPEs. Utilizing APPE students alongside IPPE students provided mentorship opportunities and proved valuable to both types of students.8 Numerous sites have developed other innovative curricular sequences and combined didactic/experiential course work programs,2,9,14 one of which has improved clinical and communication skills on APPE rotations.13 An IPPE model described by Walker et al.7 involved the development of a pilot program where IPPE students were involved in medication reconciliation including debriefing sessions with their preceptors. Their survey results indicated students have a positive attitude toward the process and recognized the importance of the pharmacist role in medication reconciliation. Mantong et al. reported that hospitals in Central and Northern California would like to utilize IPPE students for medication safety activities in the future. Activities included ADR reporting, unapproved abbreviation audits, warfarin patient education, and automated dispensing cabinet audits. The hospitals surveyed felt students needed to have competence in medication safety resources such as the Institute for Safe Medication Practices (ISMP) Confused Drug Name list, ISMP Error Prone Abbreviation List, and ASHP guidelines prior to the rotation.12 Lastly, respondents to our survey mentioned they are often overwhelmed by the numerous types of evaluations by various schools and desire evaluations to be standardized. ASHP and AACP also called for academic pharmacy and health-system pharmacy to “collaborate to ensure the availability and standardization of educational preparation for preceptors as well as standardization of processes and evaluations.”17 Another method to decrease preceptor burden in IPPEs would be for pharmacy schools within geographic proximity to work together to standardize processes and evaluations, especially when sharing IPPE and APPE sites. Additionally, a syllabus created by a college for all of their institutional IPPE sites would provide preceptors support and clear direction for structure and expectations for the IPPE experience. Study limitations Historically, ACCP members are largely composed of university faculty and clinical scientists. Among the five PRNs whose leadership agreed to distribute this survey to its members, it is unknown how many members practice in acute care community hospital settings, so the true response rate for this survey is unknown. Therefore, responses to this survey cannot be generalized, and they serve only to suggest potential avenues for improving the ability of community hospitals to provide quality IPPE. Although respondents identified central pharmacy as most frequently providing IPPE supervision, only one respondent staffs in a central pharmacy, and therefore results of this survey appear not to include perspective from a sufficient number of individuals currently most likely to be
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providing IPPE precepting. Although the majority of survey respondents (18) provide direct clinical care, and therefore responses appear to suggest obstacles and possible solutions for expanding IPPE into direct care experiences, it is unknown whether our survey responders constitute a representative sample. A clearly identified cohort of individuals directly involved in precepting IPPE must be surveyed, and with a sufficient response rate, in order to produce data that can be generalized. Thus, this survey serves to provide preliminary information that may be built upon; further studies are needed to reliably address the questions presented by this survey. Conclusion Based on responses to this survey, it appears that formal planning and preceptor support for IPPE can enhance the availability of direct patient care activities for IPPE students. Proper training pre-IPPE and enhanced collaboration between pharmacy schools and health-systems has the potential to improve introductory experiences for students with fewer burdens, and provide benefit for the healthsystem. Additionally, pharmacy schools sharing experiential sites may want to consider standardizing processes and evaluations to decrease preceptor burden. Collaborating to provide excellent preceptor development opportunities may also lead to improved relationships. Furthermore, statistically valid studies are needed to provide recommendations that can be generalized across the United States. Acknowledgments American College of Clinical Pharmacy Education and Training Practice Based Research Network.
Appendix A. Supporting Information Supplementary material cited in this article is available online at doi:10.1016/j.cptl.2014.05.011.
References 1. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree: standard no. 10. 〈https://www.acpe-accredit.org/pdf/FinalS2007Guide lines2.0.pdf〉; Accessed May 30, 2014. 2. Mackinnon G, McAllister DK, Anderson SC. Introductory practice experience: an opportunity for early professionalization. Am J Pharm Educ. 2001;65(3):247–253. 3. Sager R, Woodward C. Providing an institutional introductory pharmacy practice experience (IPPE) in a hospital setting: our first year experience. ASHP Midyear Clinical Meeting [serial online]. January 1, 2007;42 (DEC) Available from: International Pharmaceutical Abstracts, Ipswich, MA. Accessed June 29, 2014.
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4. Assemi M, Corelli RL, Ambrose PJ. Development needs of volunteer pharmacy practice preceptors. Am J Pharm Educ. 2011;75(1): Article 10. 5. Skrabal MZ, Jones RM, Nemire RE, et al. National survey of volunteer pharmacy preceptors. Am J Pharm Educ. 2008;72(5): Article 112. 6. Skrabal MZ, Jones RM, Walters RW, et al. National survey of volunteer pharmacy preceptors: effects of region, practice setting, and population density on responses. J Pharm Pract. 2010;23(3):265–272. 7. Walker PC, Kinsey KS, Kraft MD, Mason NA, Clark JS. Improving student education and patient care through an innovative introductory pharmacy practice experience. Am J Health Syst-Pharm. 2011;68(8):655–660. 8. Kessler TL, Vesta KS, Smith WJ, Dennis VC, Bird ML, Harrison DL. Students’ attitudes and perceptions of a structured longitudinal introductory pharmacy practice experience (IPPE) medicine rotation. Curr Pharm Teach Learn. 2011;3(1):2–8. 9. Crill CM, Matlock MA, Pinner NA, Self TH. Integration of first- and second-year introductory pharmacy practice experiences. Am J Pharm Educ. 2009;73(3): Article 50. 10. Williams J, Taylor R. Calabrese S. Guide to introductory pharmacy practice experience: navigating the medication-use system. ASHP Midyear Clinical Meeting [serial online]. n. d.;2009. Available from: International Pharmaceutical Abstracts, Ipswich, MA. Accessed June 29, 2014. 11. Mantong M, Carr-Lopez S, Bandy V, Fusco B, Boyce E. Impact of hospital introductory pharmacy practice experiences
12.
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on students, preceptors and sites. ASHP Midyear Clinical Meeting [serial online]. n.d.;2011:003. Available from: International Pharmaceutical Abstracts, Ipswich, MA. Accessed June 29, 2014. Mantong M, Carr-Lopez S, Black K, Ting Y. Bridging the gap preparing hospital introductory pharmacy practice experience (IPPE) students to participate in medication safety activities in healthcare systems. ASHP Midyear Clinical Meeting [serial online]. n.d.;2011:P. Available from: International Pharmaceutical Abstracts, Ipswich, MA. Accessed June 29, 2014. Mort JR, Johnson TJ, Hedge DD. Impact of an introductory pharmacy practice experience on students’ performance in an advanced practice experience. Am J Pharm Educ. 2010;74(1): Article 11. Wuller WR, Luer MS. A sequence of introductory pharmacy practice experiences to address the new standards for experiential learning. Am J Pharm Educ. 2008;72(4): Article 73. Woelfel JA, Boyce E, Patel RA. Geriatric care as an introductory pharmacy practice experience. Am J Pharm Educ. 2011;75(6): Article 115. Haase KK, Smythe MA, Orlando PL, Resman-Targoff BH, Smith LS. Ensuring quality experiential education. Pharmacotherapy. 2008;28(12):1548–1551. American Society of Health System-Pharmacists, American Association of Colleges of Pharmacy. Capacity of hospitals to partner with academia to meet experiential education requirements for pharmacy students. Am J Pharm Educ. 2008;72(5): Article 117.
Currents in Pharmacy Teaching and Learning 6 (2014) 632–638
Research
http://www.pharmacyteaching.com
Perceptions, obstacles, and solutions for offering Introductory Pharmacy Practice Experiences in the community hospital setting: A qualitative survey Tina Harrach Denetclaw, PharmD, BCPSa,*, Elizabeth W. Young, PharmD, BCPSb, Amy M. Tiemeier, PharmD, BCPSc, James D. Scott, PharmD, FCCPd, Melody L. Hartzler, PharmD, AE-C, BCACPe a
Department of Clinical Pharmacy, School of Pharmacy, University of California—San Francisco, San Francisco, CA b Clinical Pharmacist, Thrombosis Service University of Utah Hospitals and Clinics Salt Lake City, UT c St. Louis College of Pharmacy, St. Louis, MO d Western University of Health Sciences College of Pharmacy, Pomona, CA e Cedarville University School of Pharmacy, Cedarville, OH
Abstract Objective: We sought to identify barriers and possible solutions for community hospitals providing Introductory Pharmacy Practice Experiences (IPPE). Methods: A survey was developed and made available online to a segment of members of the American College of Clinical Pharmacy. Responses were collected anonymously. Results of the survey were assessed using descriptive statistics. Results: A total of 45 individuals who self-identified as being employed in acute care hospitals or hospital systems currently hosting IPPE students responded to the survey, with 35 of these individuals completing the entire survey. Pharmacy department staff-, school-, and student-related burdens and barriers were identified, and successful approaches to providing IPPE were described. It is unknown how many members receiving the survey practice in acute care community hospital settings, so the true response rate for this survey is unknown, and the responses to this survey cannot be generalized. Conclusions: Informed planning and preceptor support for IPPE may enhance the quality of learning activities available to students and decrease the burden of providing IPPE for hospital-based preceptors. This survey provides preliminary information that may be built upon; a subsequent quantitative study is needed to glean generalizable information on this topic. r 2014 Elsevier Inc. All rights reserved.
Keywords: Experiential; Introductory pharmacy practice experiences; Pharmacy education
Introduction
* Corresponding author: Tina Harrach Denetclaw, PharmD, BCPS, Department of Clinical Pharmacy, School of Pharmacy, University of California—San Francisco, San Francisco, CA 94143-0622. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2014.05.011 1877-1297/r 2014 Elsevier Inc. All rights reserved.
As the profession of pharmacy has evolved, the framework by which we educate professional pharmacy students has changed. Our pharmacy education model in the last decade has shifted from a product focus to patient focus as schools seek to train pharmacists who are patient care providers.
T.H. Denetclaw et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 632–638
The newest Accreditation Council for Pharmacy Education (ACPE) standards require that at least 5% of the curriculum (300 hours) be devoted to Introductory Pharmacy Practice Experiences (IPPEs).1 These standards also “require active participation” by the student in direct patient care. Colleges of pharmacy agree that introducing students to the practice of pharmacy early in their professional development benefits them by reinforcing their didactic learning, enhancing professional development, and assists students in defining their career pathway.2 A well-structured IPPE that provides students with coordinated learning experiences is rewarding for both the student as well as the preceptor.3 Defining preceptor needs is crucial to the sustainability and success of an IPPE program. Surveys of preceptor needs have found that they desire training and training needs to be ongoing.4 Surveys have been helpful in identifying issues such as preceptor’s workload, time/ quality concerns, and compensation.5,6 However, little has been reported on the types of student activities performed on IPPEs or perceptions of those precepting IPPEs. While multiple programs have demonstrated successful IPPE models,2,3,7–15 concern still exists across the profession that students in IPPE experiences are not utilized to their full potential due to lack of experiences that integrate the student into the health care team with a defined active role in the care of patients.16 Internal discussion among members of the American College of Clinical Pharmacy (ACCP) Education and Training Practice Research Network (EDTR PRN) also suggested that IPPE students do not have a defined active role in the care of patients, and preceptors report a lack of time available for IPPE students, specifically in the health-system setting (unpublished data, 2011). In response to this discussion, the ACCP EDTR PRN developed a survey to identify barriers and possible solutions that colleges of pharmacy could employ to enhance the success of IPPEs in community hospital settings.
633
Methods The Scholarly Activity Committee of the ACCP EDTR PRN developed a 23-item web-based survey to assess hospital-based IPPEs occurring in health-systems where ACCP members practice (Appendix B). The electronic survey tool was developed using SurveyMonkeys software. The committee created a draft survey based on their collective experiences that was piloted by 32 members of the ACCP EDTR PRN and refined for content and clarity. Survey items are included in Tables 1–3. Respondents were allowed to select all responses that applied for each survey item, and each survey item included an opportunity for additional responses from individual responders. Respondents were asked to describe which approaches their pharmacy department has found to be particularly successful in providing IPPEs. The survey also included opportunity for individual responders to identify and comment on issues not addressed in the survey items. The primary areas the survey addressed were the perceived value of training IPPE students, the perceived obstacles for training IPPE students, and the characteristics of successful IPPE training approaches. The project was deemed exempt by Institutional Review Boards (IRBs) at three of the institutions employing committee members. Investigators from other institutions where IRB approval was not sought completed training requirements and were approved as sub-investigators by one of the approving institutions. ACCP PRNs whose members may practice in a hospital setting were invited to participate in the survey. The survey was available online to 1268 non-duplicated members of the participating PRNs during April 2012. Two reminders were distributed to improve the response rate. Responses were collected anonymously. Results of the survey were assessed through descriptive statistics using Excel 2010s and SurveyMonkeys software in June 2012.
Table 1 Perceived value of working with IPPE students (n ¼ 35) Items of pharmacy department perceived value of working with IPPE students
Frequencya
Maintain positive relationships with area schools of pharmacy Develop or improve relationships with area schools of pharmacy Provide staff professionally rewarding experiences through working with students Improve recruiting potential to fill resident pharmacist positions Improve recruiting potential to fill staff pharmacist positions Help with data collection for quality assurance projects Improve recruiting potential to fill intern pharmacist positions Maintain positive relationships with faculty member(s) in area schools of pharmacy Develop or improve relationships with faculty member(s) in area schools of pharmacy Improve recruiting potential to fill clinical pharmacist positions Assistance with other projects—please specify in comments field There is no value to the pharmacy department for providing IPPE
28 19 19 11 9 9 6 5 4 4 3 3
a
Values add up to 435 as respondents could pick multiple activities.
634
T.H. Denetclaw et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 632–638
Table 2 Perceived obstacles for working with IPPE students (n ¼ 35) Items of pharmacy departments’ perceived obstacles for working with IPPE students
Frequencya
Staff perception that the students are a hindrance to getting the work done Staff perception that students demand time without offering value in return Students’ lack of basic knowledge to allow for a meaningful active experience at IPPE level Students’ limited knowledge of how to use the site’s computer software Site’s limited capacity for precepting IPPE students Staff perception that students do not take responsibility for learning during IPPE Staff disinterest in working with IPPE students Site’s limited access to computers Schools not providing guidance for IPPEs Schools not providing financial incentive to offer IPPE at site Staff perception that students are unprepared to learn during IPPE Staff perception that site is not valuable to student learning Schools not providing faculty members to precept these students Schools requiring multiple written evaluations Students answering questions for other HCP without consulting preceptor Staff perception that students ask too many questions during IPPE Schools not providing feedback about IPPEs
16 16 15 15 12 9 9 9 7 6 5 4 4 3 2 2 2
a
Values add up to 435 as respondents could pick multiple obstacles.
Results
Perceived value and obstacles
A total of 45 individuals who self-identified as being employed in acute care hospitals or hospital systems currently hosting IPPE students responded to the survey. Of these respondents, 35 completed the entire survey. Of those that completed the survey, ten were clinical coordinators, seven were pharmacists staffing specialized clinical services, five were pharmacy directors or supervisors, five were university-funded pharmacists, five were pharmacists staffing generalized clinical services, one was a pharmacist staffing centralized pharmacist services, one was an ambulatory care pharmacist, and one was a pharmacy resident. Centralized pharmacy was the most frequently reported area where IPPEs occur (33 respondents) followed by intravenous compounding room (29) and clinical services (26). Similarly, pharmacists staffing centralized pharmacies were most frequently identified as being among those individuals contributing to the majority of precepting for IPPE students (25), followed by pharmacy director or supervisor (15), pharmacist staffing clinical services (15), resident pharmacists (7), and technicians (7). Three respondents indicated that intern pharmacists or Advanced Pharmacy Practice Experience (APPE) students provide the majority of precepting of IPPE students. Shadowing pharmacists was the most frequently reported activity (42% weighted-average time spent on this activity), followed by participating in pharmacist activities (21% weighted-average time), shadowing technicians (21% weighted-average time), participating in projects (15% weighted-average time), and participating in technician activities (13% weighted-average time).
Table 1 shows the respondents’ perceived value of working with IPPE students. Maintaining or developing positive relationships with area schools of pharmacy was the most frequently cited perceived value of working with IPPE students, followed by providing staff professionally rewarding experiences through working with students. Survey items assessing the pharmacy staff perception of IPPE students showed that 37% of respondents indicated that pharmacists staffing clinical or decentralized pharmacy services found working with IPPE students professionally rewarding while 25% of respondents indicated the same for pharmacists staffing centralized pharmacy services. Approximately 25% of respondents indicated that the benefits of hosting IPPE students outweigh the burdens for clinical, decentralized, and centralized pharmacy services. Only three respondents noted there is no value to the pharmacy department for providing IPPE. Table 2 shows the respondents’ perceived obstacles for working with IPPE students. Among them, 16 respondents (45%) indicated that IPPE student activities interfere with work production and demand time without offering value in return, and 15 respondents (43%) indicated that students’ lack of basic knowledge and understanding of site computer software was an obstacle. Students asking questions, students inappropriately responding to questions, and lack of feedback from the school were the only issues noted by two respondents (6%). Additional comments from individual respondents were focused on student quality (variable), time on site (too short), and student knowledge (limited). Individual comments from
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Table 3 Characteristics of IPPE activities cited in the survey (n ¼ 35)a,b
Values 435 as respondents could pick multiple activities. Degree of shading indicates the relative value of the activities to the pharmacy department. The darker shades in the table indicate activities that the survey suggests are considered more valuable by pharmacy departments, schools of pharmacy, and IPPE student pharmacists, and also less problematic by pharmacy departments. a
b
the respondents indicate that IPPE students do not have enough skills to be useful to the hospital, and their rotations are too short to gain useful skills. However, others commented that when IPPE students are in the department for a few weeks, they can become useful in all aspects of operations provided they receive training and are adequately supervised. Respondents expressed that since IPPE students have significantly less knowledge than APPE students, they require careful supervision and cannot provide as much assistance as an APPE student. Furthermore, comments indicate IPPE students often are scheduled during times when the department is short-staffed (holiday breaks, summer, and weekends), and thus student needs impact the staff when the staff is least able to accommodate them. Conversely, other comments indicate that precepting IPPE students can be a challenge when the census is high. Still other respondents commented that providing IPPE students space to work and time with staff is challenging, in general. Some individual comments pertained to challenges with school program logistics. Scheduling students for short blocks of time was noted to require constant and timeconsuming orienting of new students. Other respondents commented that scheduling IPPE students once per week for six weeks makes it difficult for the students to retain new information from visit to visit. Lack of standardized
evaluations between different schools presents a challenge. Several schools of pharmacy have been queried, but they have not been able to offer useful suggestions to improve the experience of hosting IPPE students. Table 3 shows the IPPE student activities noted in the survey with the response rate for activities required by schools, student activities considered problematic by the respondents’ pharmacy departments, student activities considered valuable by the respondents’ pharmacy departments, and student activities perceived to receive the most positive student feedback. The activities identified as being required by schools that were noted most frequently to be considered valuable by pharmacy departments included looking up drug information and assisting with data collection for quality assurance projects. Within the comments section for this portion of the survey, three respondents commented that IPPE students usually find everything new and interesting for the first two weeks. In addition, three respondents commented that students enjoy working with clinical pharmacists and one respondent commented that students enjoy rounding with physicians. Successful approaches Approaches cited by respondents as being successful for providing IPPE fall into the following broad categories: (1)
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encouraging active learning, (2) incorporating students into the pharmacy practice model, (3) rotating experiences throughout the hospital and pharmacy, (4) making use of all precepting resources, (5) creating innovative roles for IPPE students, (6) matching student interests with planned activities, (7) developing an IPPE student “job description,” and (8) providing support for preceptors. Further detail about activities that can be performed in each category is provided in Appendix A. Discussion The model for educating students in APPEs is well established. However, it appears IPPE students are spending a majority of their time shadowing, and they may not be utilized to their full potential, especially in hospital settings. Given that less than 10% of survey respondents reported student engagement in pharmacist duties or projects, healthsystems may be underutilizing IPPE students. Our survey indicated preceptors felt students were unprepared and lacked knowledge to effectively participate in direct patient care duties. Many open-ended responses discussed the IPPE student’s lack of training as a barrier to involving these students in patient care. Moreover, 16 respondents (46%) report staff view that IPPE students are a hindrance to their pharmacy workflow, and 16 (46%) report that preceptors view students as a burden, which provides little in return for their investment. These responses could be due to one of two factors. First, pharmacy schools may consider surveying their preceptors to determine if expectations of IPPE students’ abilities are reasonable. If expectations exceed what is appropriate given the student’s level in the curriculum, schools may want to develop informational materials (development programming, webinars, etc.) to address the disparity and identify applicable IPPE student proficiencies for preceptors. Second, addressing lack of student training and sufficient knowledge base should be an area of consideration by schools. Survey results suggest that students should receive training in sterile product preparation and hospital workflow systems prior to their rotation. Computer system training often does not occur pre-IPPE and may be challenging due to the wide variety of electronic medical record (EMR) systems across institutions. However, many health-systems are utilizing EPIC© for EMR, and facilities such as the Veterans Affairs Medical Centers have standardized software. It could be worthwhile for experiential departments to work with their local health-systems to determine how best to train students on EMR systems prior to IPPE experiences. This may allow students better hands-on experiences instead of the traditional shadowing experiences. Training students on medication dispensing systems such as Pyxis MedStationss prior to their rotations may also free up orientation time to be spent on clinical activities. If academic institutions partnering with regional health-systems can provide training, it lessens the burden on individual medical centers to provide such training
and also allows the academic institution to standardize a portion of their IPPE learning experience. Mantong et al.11 reported 76% of preceptors noted an increased staff workload during the first 20 hours of IPPEs with students. However, after the first 20 hours of the experience, when the same preceptors where surveyed, only 32% noted an increased workload and 60% indicated a decreased workload. This suggests that standardization of pre-IPPE training may decrease preceptor burden and allow IPPEs to be mutually beneficial for the health-system and the academic institution.11 Further studies are warranted to determine the effect of such training programs. Proper training prior to IPPEs may expand opportunities for IPPE students to be involved in direct patient care. In addition, the findings of Mantong et al.11 suggest that both students and preceptors may benefit from IPPE programs that involve full-time activities over a period of time, such as a mini- or full-rotation over two to four weeks, as opposed to intermittent hours over a period of many weeks. A rotation-style program may allow students to be oriented, and then move into activities that require less preceptor effort and provide more value to the department. Open-ended portions of our survey suggest that a portion of IPPE students are already engaged in the pharmacy workflow and are given basic clinical activities to participate in, such as intravenous (IV) to oral (PO) conversions, renal dosing calculations, obtaining medication histories, and collecting data for adverse drug reactions (ADRs). IPPE students also have participated in answering drug-information questions and journal club activities with APPE students. Activities such as these have been well received and are mutually beneficial for the departments and IPPE students. The American Association of Colleges of Pharmacy (AACP) and the American Society of Health-System Pharmacists (ASHP) collaborated in 2008 to determine the capacity of hospitals to partner with academia to meet experiential education requirements for pharmacy students. In the report, one action item was “colleges and schools should collaborate with hospitals and health-systems to develop curricular models for introductory experiences in hospitals and health-systems so that students progress from introductory to increasingly complex levels of pharmacy services as they advance in their doctor of pharmacy degree programs.”17 While we agree with these recommendations, we also recognize the challenge many colleges face in finding institutional IPPE sites. Geographic constraints determine the number of potential sites within an area, and given the growth in number of pharmacy schools as well as the standardization in required institutional IPPE hours (which was for many schools an increase in hours), availability of these sites for student placement can be very limited. Increasing placement can be accomplished through various models that have previously demonstrated success. One such model proven successful was Kesslar et al.’s structured longitudinal introductory medicine experience that was layered onto an established APPE. The students spent time over the course of the P1–P3 years completing a variety of activities
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ranging from medical team rounds to literature evaluation and discharge counseling. The students involved in this type of program had increased confidence in their skills verses their peers who did traditional IPPEs. Utilizing APPE students alongside IPPE students provided mentorship opportunities and proved valuable to both types of students.8 Numerous sites have developed other innovative curricular sequences and combined didactic/experiential course work programs,2,9,14 one of which has improved clinical and communication skills on APPE rotations.13 An IPPE model described by Walker et al.7 involved the development of a pilot program where IPPE students were involved in medication reconciliation including debriefing sessions with their preceptors. Their survey results indicated students have a positive attitude toward the process and recognized the importance of the pharmacist role in medication reconciliation. Mantong et al. reported that hospitals in Central and Northern California would like to utilize IPPE students for medication safety activities in the future. Activities included ADR reporting, unapproved abbreviation audits, warfarin patient education, and automated dispensing cabinet audits. The hospitals surveyed felt students needed to have competence in medication safety resources such as the Institute for Safe Medication Practices (ISMP) Confused Drug Name list, ISMP Error Prone Abbreviation List, and ASHP guidelines prior to the rotation.12 Lastly, respondents to our survey mentioned they are often overwhelmed by the numerous types of evaluations by various schools and desire evaluations to be standardized. ASHP and AACP also called for academic pharmacy and health-system pharmacy to “collaborate to ensure the availability and standardization of educational preparation for preceptors as well as standardization of processes and evaluations.”17 Another method to decrease preceptor burden in IPPEs would be for pharmacy schools within geographic proximity to work together to standardize processes and evaluations, especially when sharing IPPE and APPE sites. Additionally, a syllabus created by a college for all of their institutional IPPE sites would provide preceptors support and clear direction for structure and expectations for the IPPE experience. Study limitations Historically, ACCP members are largely composed of university faculty and clinical scientists. Among the five PRNs whose leadership agreed to distribute this survey to its members, it is unknown how many members practice in acute care community hospital settings, so the true response rate for this survey is unknown. Therefore, responses to this survey cannot be generalized, and they serve only to suggest potential avenues for improving the ability of community hospitals to provide quality IPPE. Although respondents identified central pharmacy as most frequently providing IPPE supervision, only one respondent staffs in a central pharmacy, and therefore results of this survey appear not to include perspective from a sufficient number of individuals currently most likely to be
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providing IPPE precepting. Although the majority of survey respondents (18) provide direct clinical care, and therefore responses appear to suggest obstacles and possible solutions for expanding IPPE into direct care experiences, it is unknown whether our survey responders constitute a representative sample. A clearly identified cohort of individuals directly involved in precepting IPPE must be surveyed, and with a sufficient response rate, in order to produce data that can be generalized. Thus, this survey serves to provide preliminary information that may be built upon; further studies are needed to reliably address the questions presented by this survey. Conclusion Based on responses to this survey, it appears that formal planning and preceptor support for IPPE can enhance the availability of direct patient care activities for IPPE students. Proper training pre-IPPE and enhanced collaboration between pharmacy schools and health-systems has the potential to improve introductory experiences for students with fewer burdens, and provide benefit for the healthsystem. Additionally, pharmacy schools sharing experiential sites may want to consider standardizing processes and evaluations to decrease preceptor burden. Collaborating to provide excellent preceptor development opportunities may also lead to improved relationships. Furthermore, statistically valid studies are needed to provide recommendations that can be generalized across the United States. Acknowledgments American College of Clinical Pharmacy Education and Training Practice Based Research Network.
Appendix A. Supporting Information Supplementary material cited in this article is available online at doi:10.1016/j.cptl.2014.05.011.
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