- Email: [email protected]
Qualitative analysis of students' attitudes of duration of community pharmacy practice experiences
Available online at www.sciencedirect.com
Currents in Pharmacy Teaching and Learning 1 (2009) 110 –114 http://www.pharmacyteaching.com
Qualitative analysis of students’ attitudes of duration of community pharmacy practice experiences Lisa Smith, PharmD, BCPS*, Joy Greene, PharmD, Lisa Meade, PharmD, CDE, Beth Spencer, PharmD Wingate University School of Pharmacy, Wingate, NC
Abstract Objective: To gain insight into the perceived benefit of one continuous 10-week Advanced Community Pharmacy Practice Experience (ACPPE) versus two five-week ACPPEs, through qualitative focus group research. Methods: Students were randomly assigned to spend either two five-week practice experiences at different community sites or one continuous 10-week rotation (at the same site) during their fourth professional year. Afterward, three student focus groups were convened to elicit responses to four questions related to: (1) optimal duration for an ACPPE, (2) description of the community care project they delivered, (3) students’ perceived advantages or disadvantages of their sites, and (4) barriers to successfully completing a community care project. Results: Students unanimously preferred two five-week rotations. Pharmacies with supportive staff and preceptors, ample space, pharmacy residents, or MTM programs were perceived advantages. There was a variety of community care projects developed. The most frequently reported barrier to the ACPPE project involved the preceptor’s limited support of the project, unwillingness to continue the project long-term, or not communicating the purpose of the project to pharmacy staff. Other barriers included physical design of the pharmacy, both high and low prescription volume, and poor support from pharmacy management in chain pharmacies. Conclusion: Improvements to ACPPE sites, including preceptor training and elimination of barriers to the development of the ACPPE project, might change student perception and thus should be implemented before replacing two shorter experiences within the 10-week rotation. © 2009 Published by Elsevier Inc. Keywords: Advanced community pharmacy practice experience; Focus group; Assessment
Introduction Current Accreditation Council for Pharmaceutical Education (ACPE) standards and guidelines require that advanced pharmacy practice experiences (APPEs) comprise 25% of the Doctor of Pharmacy curriculum totaling at least 1440 hours or 36 weeks. Students must complete required and elective APPEs that include primary, acute, chronic,
* Corresponding author. Lisa Smith, PharmD, BCPS, Assistant Professor, Director of Advanced Pharmacy Practice, Wingate University School of Pharmacy, Campus Box 3087, 316 N. Main Street, Wingate, NC 28174. E-mail address: [email protected]. 1877-1297/09/$ – see front matter © 2009 Published by Elsevier Inc. doi:10.1016/j.cptl.2009.10.002
and preventive care among patients of all ages. In addition, they must develop pharmacist-delivered patient care competencies in a variety of settings, including the community pharmacy setting.1 Survey data from The National Association of Boards of Pharmacy (NABP) indicate that more than 60% of licensed pharmacists in the United States practice in a community pharmacy setting.2 With the implementation of pharmaceutical care, medication therapy management (MTM) programs, and pharmacist-administered immunizations, the pharmacist’s role is beginning to shift focus from dispensing medications to patient care.3 Community pharmacists will become integral to the delivery of that patient-centered care.
L. Smith et al. / Currents in Pharmacy Teaching and Learning 1 (2009) 110 –114
As a reflection of that paradigm shift, ACPE guidelines now emphasize that students should be encouraged to participate in the education of patients, and within the required APPEs, students should be encouraged to provide continuity of care. The APPE community rotation model should allow students to develop clinical skills to provide pharmaceutical care, including wellness programs and disease state management in the community setting.1 To meet these accreditation guidelines, students at our institution are required to complete nine five-week APPE rotations during the fourth professional year, including two advanced community rotations. In the latter, each student is required to complete a patient care project focused on provision of direct patient care. It entails the development of a new patient care service delivered at least one time or delivery of an existing patient care service multiple times. Theoretically, students who complete a 10-week rotation at one location should have more opportunities for patient follow-up and skill application. However, a potential shortcoming of this longer rotation model is a decrease in the variety of learning experiences compared with the possibility of a wider variety of learning experiences in multiple settings. Pharmacy student focus groups have been used in the development of community pharmacy rotations.4 The intent of the focus group questions in this study was to qualitatively analyze students’ attitudes of the optimal duration for Advanced Community Practice Experiences and identify barriers related to experiential training. Although most tools for evaluating student assessment of the didactic and experiential programs in pharmacy schools involve surveys,5– 8 qualitative studies that capture student perceptions through focus groups and surveys (for both didactic and experiential course evaluations) are a helpful evaluative tool.9 –15 One study reported that students view focus groups favorably.11 Focus groups grant participants the opportunity to discuss and comment on the research topic from personal experience.11
Methods To gain insight into the perceived benefit of one 10-week APPE community rotation versus two five-week rotations, a focus group was conducted with our program’s pharmacy students before graduation. The university’s Research Review Board reviewed and approved the research project. An informed consent was collected from all students in the fourth professional year after providing them with a description and the purpose of the study. Before the rotation process, preceptors were queried for their willingness to precept students for 10 weeks versus five weeks. All preceptors received the same preceptor training. Students were randomly assigned to fulfill their Advanced Community Pharmacy experience requirement with either two separate five-week rotations at different community pharmacies or one 10-week Advanced Community Pharmacy rotation at a single site. After standard pro-
111
tocol, students were given one week to trade rotations with other students or to select an alternate rotation with remaining availability. After this week, rotation assignments were finalized. Before fourth-year APPE deployment, the Coordinator of Advanced Community Practice Experience conducted two training sessions in the Pharmacy 770 Orientation to Clerkship course. These sessions provided helpful tips and examples of successful community projects. At the end of the P4 APPE year, students were invited by e-mail to participate in focus groups. A subsequent e-mail was sent to solicit optimal response. Three focus groups were convened. Each group contained four students, one moderator, and a professional transcriptionist to record the one-hour session. The moderators were faculty of the school of pharmacy with primary responsibilities in the experiential program, including the Director of Introductory Pharmacy Practice Experience, the Coordinator of Advanced Community Practice, and an APPE Coordinator. The study coordinator, the Director of APPE, along with the moderators, developed four primary questions for the groups. The questions asked the students’ opinions of (1) the optimal duration for an Advanced Community Pharmacy Practice Experience, (2) type of community care project developed, (3) students’ perceived advantages of their sites, and (4) barriers to completing the community care project. Before the focus group session, moderators received instructions on how not to share his/her opinion during the session. Moderators were coached to facilitate student discussion with open-ended questions such as, “That was an interesting point. Can you elaborate?” Immediately after the focus group sessions, the moderators and study coordinator debriefed on themes that emerged, including observation of nonverbal clues. Session transcripts were broken into individual responses and compiled into a database. The database was analyzed by key words, and key phrases were coded into clusters. Clusters were subsequently investigated for overarching themes.
Results In the P4 class, 47% of students completed a 10-week rotation at the same site versus 58% of students in the focus groups. The percentages of students in focus groups 1, 2, and 3 who completed a 10-week rotation at the same site were 50%, 50%, and 75%, respectively. The 12 students who participated in the focus groups were 75% female and the average cumulative grade point average (GPA) was 3.65. The entire student cohort had a cumulative GPA of 3.57 and was 58% female. Students in the focus groups represented the school’s five geographic zones, both independent and chain community pharmacies and both fiveand 10-week duration.
112
L. Smith et al. / Currents in Pharmacy Teaching and Learning 1 (2009) 110 –114
Table 1 Student community care projects
Focus group 1
Focus group 2
Focus group 3
Community care project
Newly developed (yes or no)
Length of rotation
Smoking cessation service Blood pressure clinic Influenza vaccine clinic (2 students)
Yes Yes 1 Yes 1 No Yes No No Yes No No No Yes Yes
10 weeks 5 weeks 1 10-week 1 5-week 5 weeks 10 weeks 5 weeks 5 weeks 5 weeks 10 weeks 5 weeks 5 weeks 10 weeks
Lipid monitoring service Community wellness program Lipid monitoring service Blood pressure clinic Community wellness program Osteoporosis screening Influenza vaccine clinic Hypertension clinic Sleep hygiene clinic
Focus group results indicated that participating pharmacy students unanimously preferred two five-week rotations. Respondents felt that the benefit of a longitudinal experience in one setting did not outweigh the educational benefit of the variety provided by experiences in two community pharmacies. Five of the 12 students indicated that if both the site and preceptor were of high quality, they may prefer a single 10-week rotation. Four of the 12 students did not feel that a high-quality site or preceptor affected their assessment. Of the 12 students, four expressed the belief that one 10-week site limited the variety of learning opportunities. One student felt that a 10-week rotation at one site would be preferred if there was more structure to the rotation. The remainder felt that other factors (e.g., excellent site or preceptor) would influence their preference. When asked about barriers to conducting the patient care project, the most frequently mentioned barrier involved the preceptor and included poor communication of project details to pharmacy staff, limited support of the student’s initiatives, and a diminished desire to continue the project long term. In addition, unmotivated or disorganized preceptors, as well as overzealous preceptors that request a project that could not be implemented in a five- or 10-week rotation were characterized as challenges for students. Other barriers reported included the physical design of the pharmacy, the prescription volume, lack of resources including Internet access, or underused resources. Students able to acquire adequate space to market and deliver direct patient care services reported more satisfaction with their project’s quality. Students also considered the prescription volume of the site in their assessments. They found it difficult to develop a strong patient base in low-volume pharmacies or in highvolume pharmacies where staff support was limited to dispensing prescriptions. In the chain pharmacy environment, students who reported a lack of support from corporate-
level pharmacy management considered it a barrier to the development and delivery of their project. One student completed a rotation in an independent pharmacy located in a building that also housed an Internal Medicine physician practice. The pharmacists did not engage with the patients or the physicians at the practice and were an underused resource. The student felt her patient care project would have benefited patients more if there was a formal relationship between the pharmacy and physician practice. Table 1 describes the participants’ patient care projects. When asked about the advantages of their sites, students in pharmacies with low prescription volume felt the slower pace allowed time for patient counseling. Other advantages of specific sites included preceptors who had a desire and time to spend with students, supportive staff, ample space to work, opportunity for MTM, a pharmacy resident on site, flexible scheduling, and the sense of being treated as a future colleague. All of the students who completed a rotation in an independent pharmacy felt the setting was an advantage and described less restrictive policies and ample space for developing and implementing MTM services. Those students reported that an independent pharmacy site might be more beneficial than a chain pharmacy unless the student had extensive experience in the community setting. Because there are two required APPE community rotations in the curriculum, an evaluation and grade are required at weeks five and 10. Students reported both they and the preceptors felt occasionally apprehensive completing an evaluation of the other twice during the 10-week rotation.
Discussion At the outset of this study, investigators felt that one continuous 10-week community experience would provide the greatest benefit to students. It could logically be theo-
L. Smith et al. / Currents in Pharmacy Teaching and Learning 1 (2009) 110 –114
rized that students would become more comfortable in the setting, be able to design a new project of greater scope instead of delivering an existing project, and develop longterm relationships with patients through follow-up care. Investigators thought these benefits would offset potential disadvantages of the decreased exposure of a variety of settings. The results of the focus group indicated otherwise. The number of students who developed a new patient care service was similar in both the continuous 10-week rotation and two five-week rotations at different sites (4 versus 3, respectively). The additional time spent in the continuous 10-week experience did not enhance the ability to develop a new service. In fact, in the longer experience, students reported preceptors waited several weeks to discuss the project with them. One common theme that emerged from the focus group was the belief that the preceptor was frequently a barrier to a successful patient care project. Chain pharmacy management often prevented the student from developing a new service in one store. Alhough students were not asked directly to define a high-quality rotation site or preceptor, three basic themes emerged: 1. Students frequently felt they were considered pharmacy employees functioning as technicians. 2. Despite the enthusiasm of the preceptor to serve as a mentor, he/she often had multiple responsibilities that limited the time available to the student. 3. Prescription volume, whether excessively low or high, seemed to negatively affect perceived quality of the rotation. However, when asked directly to explain the advantages of their particular site, low patient volume was consistently mentioned as a positive factor for patient counseling. Limitations of focus groups, including that used in our study, include the assumption that the focus group is a good representation of the larger population and participants who feel pressure to agree with one another and the small number of participants. In one of the focus groups 75% of students completed a 10-week rotation at the same site versus 47% of the overall P4 class. The focus group participants had a slightly higher cumulative GPA and there were a greater percentage of females than the entire class as a whole. Volunteer participation could also introduce selfselection bias. Other limitations of focus group research are recording all of the comments in the session and inadequate skill of the moderator. We sought to minimize both of these by using a professional transcriptionist and providing moderator training. Conclusion Under current conditions, three pharmacy student focus groups clearly conveyed a preference for two five-week rotations at different community pharmacy sites rather than
113
one longitudinal 10-week rotation at the same community pharmacy site. The focus group students perceived more benefit from the variety of two locations than from the continuity of one location. Improvements to community rotation sites, including preceptor training and elimination of or reduction to barriers to implementation of the community care project may mitigate this preference. Before replacing two shorter experiences with the 10-week rotation, our school would be well-served to implement changes related to the results of the focus groups and to repeat the focus group evaluation after changes are made.
Acknowledgments The authors would like to acknowledge the invaluable participation and feedback of Dr. Julie Applegate. We also would like to thank Dr. Leslie Ochs for suggestions on study design and data analysis.
References 1. Accreditation Council for Pharmacy Education. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Chicago, IL: Author; 2006. Available at: http://www.acpe-accredit.org/pdf/ ACPE_Revised_PharmD_Standards_Adopted_Jan152006.pdf. Accessed October 14, 2009. 2. National Association of Boards of Pharmacy. Written communication, November 13, 2008. 3. Lee K, Machado M, Wenzel M, et al. An advanced professional pharmacy experience in a community setting using an experiential manual. Am J Pharm Educ 2006;20:42. 4. Kassam R, Volume-Smith CI. Focus group methodology to develop a community pharmaceutical care clerkship program. Am J Pharm Educ 2003;67:1–20. 5. Holford D, Reinders TP. Development of an instrument to assess student perceptions of the quality of pharmaceutical education. Am J Pharm Educ 2001;65(Summer):125–31. 6. Hill LH, Kirkwood CK. Student and preceptor perception of performance in advanced pharmacy practice experiences. Am J Pharm Educ 2005;69:467–74. 7. Harpe SE, Phipps LB. Evaluating student perceptions of a learner-centered drug literature evaluation course. Am J Pharm Educ 2009;72:1– 6. 8. Freeman MK, Schrimsher RH, Kendrach MG. Student perceptions of online lectuers and webCT in an introductory drug information course. Am J Pharm Educ 2006;70:1–7. 9. Piper B, DeYoung M, Lamsam GD. Student perceptions of a service-learning experience. Am J Pharm Educ 2000; 64(Summer 2001):153– 65. 10. Wilson NW, Bouhuijs PAJ, Conradie HH, et al. Perceived educational value and enjoyment of a rural clinical rotation for medical students. Rural Remote Health 2008;8:999. 11. Er NL, Letassy NA. A pilot study: evaluating student experiential learning in the ambulatory care setting. Paper pre-
114
L. Smith et al. / Currents in Pharmacy Teaching and Learning 1 (2009) 110 –114
sented at the annual meeting of the American Association of Colleges of Pharmacy, Lake Buena Vista, Florida, July 14, 2007. 12. Bhavasr VM, Bird E, Anderson HM. Pharmacy student focus groups for formative evaluation of the learning environment. Am J Pharm Educ 2007;71:22. 13. Huston S, Hobson E. Using focus groups to inform pharmacy research. Res Soc Admin Pharm 2008;4:186 –205. 14. Grace P, Brazeau G, Brazeau D. Congruency of a curricular
mapping survey with student focus groups and curriculum outcomes surveys. Paper presented at the annual meeting of the American Association of Colleges of Pharmacy, San Diego, California, July 5, 2006. 15. Brazeau G, Sauberan M, Renzi SE, et al. Five-years of experience with student focus groups (SFG) as a tool for curricular assessment. Paper presented at the annual meeting of the American Association of Colleges of Pharmacy, San Diego, California, July 5, 2006.
Currents in Pharmacy Teaching and Learning 1 (2009) 110 –114 http://www.pharmacyteaching.com
Qualitative analysis of students’ attitudes of duration of community pharmacy practice experiences Lisa Smith, PharmD, BCPS*, Joy Greene, PharmD, Lisa Meade, PharmD, CDE, Beth Spencer, PharmD Wingate University School of Pharmacy, Wingate, NC
Abstract Objective: To gain insight into the perceived benefit of one continuous 10-week Advanced Community Pharmacy Practice Experience (ACPPE) versus two five-week ACPPEs, through qualitative focus group research. Methods: Students were randomly assigned to spend either two five-week practice experiences at different community sites or one continuous 10-week rotation (at the same site) during their fourth professional year. Afterward, three student focus groups were convened to elicit responses to four questions related to: (1) optimal duration for an ACPPE, (2) description of the community care project they delivered, (3) students’ perceived advantages or disadvantages of their sites, and (4) barriers to successfully completing a community care project. Results: Students unanimously preferred two five-week rotations. Pharmacies with supportive staff and preceptors, ample space, pharmacy residents, or MTM programs were perceived advantages. There was a variety of community care projects developed. The most frequently reported barrier to the ACPPE project involved the preceptor’s limited support of the project, unwillingness to continue the project long-term, or not communicating the purpose of the project to pharmacy staff. Other barriers included physical design of the pharmacy, both high and low prescription volume, and poor support from pharmacy management in chain pharmacies. Conclusion: Improvements to ACPPE sites, including preceptor training and elimination of barriers to the development of the ACPPE project, might change student perception and thus should be implemented before replacing two shorter experiences within the 10-week rotation. © 2009 Published by Elsevier Inc. Keywords: Advanced community pharmacy practice experience; Focus group; Assessment
Introduction Current Accreditation Council for Pharmaceutical Education (ACPE) standards and guidelines require that advanced pharmacy practice experiences (APPEs) comprise 25% of the Doctor of Pharmacy curriculum totaling at least 1440 hours or 36 weeks. Students must complete required and elective APPEs that include primary, acute, chronic,
* Corresponding author. Lisa Smith, PharmD, BCPS, Assistant Professor, Director of Advanced Pharmacy Practice, Wingate University School of Pharmacy, Campus Box 3087, 316 N. Main Street, Wingate, NC 28174. E-mail address: [email protected]. 1877-1297/09/$ – see front matter © 2009 Published by Elsevier Inc. doi:10.1016/j.cptl.2009.10.002
and preventive care among patients of all ages. In addition, they must develop pharmacist-delivered patient care competencies in a variety of settings, including the community pharmacy setting.1 Survey data from The National Association of Boards of Pharmacy (NABP) indicate that more than 60% of licensed pharmacists in the United States practice in a community pharmacy setting.2 With the implementation of pharmaceutical care, medication therapy management (MTM) programs, and pharmacist-administered immunizations, the pharmacist’s role is beginning to shift focus from dispensing medications to patient care.3 Community pharmacists will become integral to the delivery of that patient-centered care.
L. Smith et al. / Currents in Pharmacy Teaching and Learning 1 (2009) 110 –114
As a reflection of that paradigm shift, ACPE guidelines now emphasize that students should be encouraged to participate in the education of patients, and within the required APPEs, students should be encouraged to provide continuity of care. The APPE community rotation model should allow students to develop clinical skills to provide pharmaceutical care, including wellness programs and disease state management in the community setting.1 To meet these accreditation guidelines, students at our institution are required to complete nine five-week APPE rotations during the fourth professional year, including two advanced community rotations. In the latter, each student is required to complete a patient care project focused on provision of direct patient care. It entails the development of a new patient care service delivered at least one time or delivery of an existing patient care service multiple times. Theoretically, students who complete a 10-week rotation at one location should have more opportunities for patient follow-up and skill application. However, a potential shortcoming of this longer rotation model is a decrease in the variety of learning experiences compared with the possibility of a wider variety of learning experiences in multiple settings. Pharmacy student focus groups have been used in the development of community pharmacy rotations.4 The intent of the focus group questions in this study was to qualitatively analyze students’ attitudes of the optimal duration for Advanced Community Practice Experiences and identify barriers related to experiential training. Although most tools for evaluating student assessment of the didactic and experiential programs in pharmacy schools involve surveys,5– 8 qualitative studies that capture student perceptions through focus groups and surveys (for both didactic and experiential course evaluations) are a helpful evaluative tool.9 –15 One study reported that students view focus groups favorably.11 Focus groups grant participants the opportunity to discuss and comment on the research topic from personal experience.11
Methods To gain insight into the perceived benefit of one 10-week APPE community rotation versus two five-week rotations, a focus group was conducted with our program’s pharmacy students before graduation. The university’s Research Review Board reviewed and approved the research project. An informed consent was collected from all students in the fourth professional year after providing them with a description and the purpose of the study. Before the rotation process, preceptors were queried for their willingness to precept students for 10 weeks versus five weeks. All preceptors received the same preceptor training. Students were randomly assigned to fulfill their Advanced Community Pharmacy experience requirement with either two separate five-week rotations at different community pharmacies or one 10-week Advanced Community Pharmacy rotation at a single site. After standard pro-
111
tocol, students were given one week to trade rotations with other students or to select an alternate rotation with remaining availability. After this week, rotation assignments were finalized. Before fourth-year APPE deployment, the Coordinator of Advanced Community Practice Experience conducted two training sessions in the Pharmacy 770 Orientation to Clerkship course. These sessions provided helpful tips and examples of successful community projects. At the end of the P4 APPE year, students were invited by e-mail to participate in focus groups. A subsequent e-mail was sent to solicit optimal response. Three focus groups were convened. Each group contained four students, one moderator, and a professional transcriptionist to record the one-hour session. The moderators were faculty of the school of pharmacy with primary responsibilities in the experiential program, including the Director of Introductory Pharmacy Practice Experience, the Coordinator of Advanced Community Practice, and an APPE Coordinator. The study coordinator, the Director of APPE, along with the moderators, developed four primary questions for the groups. The questions asked the students’ opinions of (1) the optimal duration for an Advanced Community Pharmacy Practice Experience, (2) type of community care project developed, (3) students’ perceived advantages of their sites, and (4) barriers to completing the community care project. Before the focus group session, moderators received instructions on how not to share his/her opinion during the session. Moderators were coached to facilitate student discussion with open-ended questions such as, “That was an interesting point. Can you elaborate?” Immediately after the focus group sessions, the moderators and study coordinator debriefed on themes that emerged, including observation of nonverbal clues. Session transcripts were broken into individual responses and compiled into a database. The database was analyzed by key words, and key phrases were coded into clusters. Clusters were subsequently investigated for overarching themes.
Results In the P4 class, 47% of students completed a 10-week rotation at the same site versus 58% of students in the focus groups. The percentages of students in focus groups 1, 2, and 3 who completed a 10-week rotation at the same site were 50%, 50%, and 75%, respectively. The 12 students who participated in the focus groups were 75% female and the average cumulative grade point average (GPA) was 3.65. The entire student cohort had a cumulative GPA of 3.57 and was 58% female. Students in the focus groups represented the school’s five geographic zones, both independent and chain community pharmacies and both fiveand 10-week duration.
112
L. Smith et al. / Currents in Pharmacy Teaching and Learning 1 (2009) 110 –114
Table 1 Student community care projects
Focus group 1
Focus group 2
Focus group 3
Community care project
Newly developed (yes or no)
Length of rotation
Smoking cessation service Blood pressure clinic Influenza vaccine clinic (2 students)
Yes Yes 1 Yes 1 No Yes No No Yes No No No Yes Yes
10 weeks 5 weeks 1 10-week 1 5-week 5 weeks 10 weeks 5 weeks 5 weeks 5 weeks 10 weeks 5 weeks 5 weeks 10 weeks
Lipid monitoring service Community wellness program Lipid monitoring service Blood pressure clinic Community wellness program Osteoporosis screening Influenza vaccine clinic Hypertension clinic Sleep hygiene clinic
Focus group results indicated that participating pharmacy students unanimously preferred two five-week rotations. Respondents felt that the benefit of a longitudinal experience in one setting did not outweigh the educational benefit of the variety provided by experiences in two community pharmacies. Five of the 12 students indicated that if both the site and preceptor were of high quality, they may prefer a single 10-week rotation. Four of the 12 students did not feel that a high-quality site or preceptor affected their assessment. Of the 12 students, four expressed the belief that one 10-week site limited the variety of learning opportunities. One student felt that a 10-week rotation at one site would be preferred if there was more structure to the rotation. The remainder felt that other factors (e.g., excellent site or preceptor) would influence their preference. When asked about barriers to conducting the patient care project, the most frequently mentioned barrier involved the preceptor and included poor communication of project details to pharmacy staff, limited support of the student’s initiatives, and a diminished desire to continue the project long term. In addition, unmotivated or disorganized preceptors, as well as overzealous preceptors that request a project that could not be implemented in a five- or 10-week rotation were characterized as challenges for students. Other barriers reported included the physical design of the pharmacy, the prescription volume, lack of resources including Internet access, or underused resources. Students able to acquire adequate space to market and deliver direct patient care services reported more satisfaction with their project’s quality. Students also considered the prescription volume of the site in their assessments. They found it difficult to develop a strong patient base in low-volume pharmacies or in highvolume pharmacies where staff support was limited to dispensing prescriptions. In the chain pharmacy environment, students who reported a lack of support from corporate-
level pharmacy management considered it a barrier to the development and delivery of their project. One student completed a rotation in an independent pharmacy located in a building that also housed an Internal Medicine physician practice. The pharmacists did not engage with the patients or the physicians at the practice and were an underused resource. The student felt her patient care project would have benefited patients more if there was a formal relationship between the pharmacy and physician practice. Table 1 describes the participants’ patient care projects. When asked about the advantages of their sites, students in pharmacies with low prescription volume felt the slower pace allowed time for patient counseling. Other advantages of specific sites included preceptors who had a desire and time to spend with students, supportive staff, ample space to work, opportunity for MTM, a pharmacy resident on site, flexible scheduling, and the sense of being treated as a future colleague. All of the students who completed a rotation in an independent pharmacy felt the setting was an advantage and described less restrictive policies and ample space for developing and implementing MTM services. Those students reported that an independent pharmacy site might be more beneficial than a chain pharmacy unless the student had extensive experience in the community setting. Because there are two required APPE community rotations in the curriculum, an evaluation and grade are required at weeks five and 10. Students reported both they and the preceptors felt occasionally apprehensive completing an evaluation of the other twice during the 10-week rotation.
Discussion At the outset of this study, investigators felt that one continuous 10-week community experience would provide the greatest benefit to students. It could logically be theo-
L. Smith et al. / Currents in Pharmacy Teaching and Learning 1 (2009) 110 –114
rized that students would become more comfortable in the setting, be able to design a new project of greater scope instead of delivering an existing project, and develop longterm relationships with patients through follow-up care. Investigators thought these benefits would offset potential disadvantages of the decreased exposure of a variety of settings. The results of the focus group indicated otherwise. The number of students who developed a new patient care service was similar in both the continuous 10-week rotation and two five-week rotations at different sites (4 versus 3, respectively). The additional time spent in the continuous 10-week experience did not enhance the ability to develop a new service. In fact, in the longer experience, students reported preceptors waited several weeks to discuss the project with them. One common theme that emerged from the focus group was the belief that the preceptor was frequently a barrier to a successful patient care project. Chain pharmacy management often prevented the student from developing a new service in one store. Alhough students were not asked directly to define a high-quality rotation site or preceptor, three basic themes emerged: 1. Students frequently felt they were considered pharmacy employees functioning as technicians. 2. Despite the enthusiasm of the preceptor to serve as a mentor, he/she often had multiple responsibilities that limited the time available to the student. 3. Prescription volume, whether excessively low or high, seemed to negatively affect perceived quality of the rotation. However, when asked directly to explain the advantages of their particular site, low patient volume was consistently mentioned as a positive factor for patient counseling. Limitations of focus groups, including that used in our study, include the assumption that the focus group is a good representation of the larger population and participants who feel pressure to agree with one another and the small number of participants. In one of the focus groups 75% of students completed a 10-week rotation at the same site versus 47% of the overall P4 class. The focus group participants had a slightly higher cumulative GPA and there were a greater percentage of females than the entire class as a whole. Volunteer participation could also introduce selfselection bias. Other limitations of focus group research are recording all of the comments in the session and inadequate skill of the moderator. We sought to minimize both of these by using a professional transcriptionist and providing moderator training. Conclusion Under current conditions, three pharmacy student focus groups clearly conveyed a preference for two five-week rotations at different community pharmacy sites rather than
113
one longitudinal 10-week rotation at the same community pharmacy site. The focus group students perceived more benefit from the variety of two locations than from the continuity of one location. Improvements to community rotation sites, including preceptor training and elimination of or reduction to barriers to implementation of the community care project may mitigate this preference. Before replacing two shorter experiences with the 10-week rotation, our school would be well-served to implement changes related to the results of the focus groups and to repeat the focus group evaluation after changes are made.
Acknowledgments The authors would like to acknowledge the invaluable participation and feedback of Dr. Julie Applegate. We also would like to thank Dr. Leslie Ochs for suggestions on study design and data analysis.
References 1. Accreditation Council for Pharmacy Education. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Chicago, IL: Author; 2006. Available at: http://www.acpe-accredit.org/pdf/ ACPE_Revised_PharmD_Standards_Adopted_Jan152006.pdf. Accessed October 14, 2009. 2. National Association of Boards of Pharmacy. Written communication, November 13, 2008. 3. Lee K, Machado M, Wenzel M, et al. An advanced professional pharmacy experience in a community setting using an experiential manual. Am J Pharm Educ 2006;20:42. 4. Kassam R, Volume-Smith CI. Focus group methodology to develop a community pharmaceutical care clerkship program. Am J Pharm Educ 2003;67:1–20. 5. Holford D, Reinders TP. Development of an instrument to assess student perceptions of the quality of pharmaceutical education. Am J Pharm Educ 2001;65(Summer):125–31. 6. Hill LH, Kirkwood CK. Student and preceptor perception of performance in advanced pharmacy practice experiences. Am J Pharm Educ 2005;69:467–74. 7. Harpe SE, Phipps LB. Evaluating student perceptions of a learner-centered drug literature evaluation course. Am J Pharm Educ 2009;72:1– 6. 8. Freeman MK, Schrimsher RH, Kendrach MG. Student perceptions of online lectuers and webCT in an introductory drug information course. Am J Pharm Educ 2006;70:1–7. 9. Piper B, DeYoung M, Lamsam GD. Student perceptions of a service-learning experience. Am J Pharm Educ 2000; 64(Summer 2001):153– 65. 10. Wilson NW, Bouhuijs PAJ, Conradie HH, et al. Perceived educational value and enjoyment of a rural clinical rotation for medical students. Rural Remote Health 2008;8:999. 11. Er NL, Letassy NA. A pilot study: evaluating student experiential learning in the ambulatory care setting. Paper pre-
114
L. Smith et al. / Currents in Pharmacy Teaching and Learning 1 (2009) 110 –114
sented at the annual meeting of the American Association of Colleges of Pharmacy, Lake Buena Vista, Florida, July 14, 2007. 12. Bhavasr VM, Bird E, Anderson HM. Pharmacy student focus groups for formative evaluation of the learning environment. Am J Pharm Educ 2007;71:22. 13. Huston S, Hobson E. Using focus groups to inform pharmacy research. Res Soc Admin Pharm 2008;4:186 –205. 14. Grace P, Brazeau G, Brazeau D. Congruency of a curricular
mapping survey with student focus groups and curriculum outcomes surveys. Paper presented at the annual meeting of the American Association of Colleges of Pharmacy, San Diego, California, July 5, 2006. 15. Brazeau G, Sauberan M, Renzi SE, et al. Five-years of experience with student focus groups (SFG) as a tool for curricular assessment. Paper presented at the annual meeting of the American Association of Colleges of Pharmacy, San Diego, California, July 5, 2006.