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Currents in Pharmacy Teaching and Learning 7 (2015) 231–238

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Implementing a learner-centered introductory pharmacy practice experience model at a community hospital Shusen Sun, PharmD, BCPSa,*, Eric C. Nemec, PharmD, BCPSa, Ed Tessier, PharmD, BCPS, MPHb, Brian Joyce, PharmDb a

Department of Pharmacy Practice, College of Pharmacy, Western New England University, Springfield, MA b Department of Pharmacy Services, Baystate Franklin Medical Center, Greenfield, MA

Abstract Objectives: To implement and evaluate a learner-centered introductory pharmacy practice experience (IPPE) model for doctor of pharmacy students at a community hospital. Design: A learner-centered IPPE model was implemented to promote engagement and self-learning for IPPE students. A Core Teaching Team (CTT) was established to provide consistent training and didactic lectures to all IPPE students on selected topics at the practice site. Pharmacy instructors were trained to conduct learner-centered teaching as well as to provide effective and immediate feedback to IPPE learners upon completion of each teaching and learning. An IPPE Learning Assessment Grid (ILAG) was used to track learners’ progress and to select weekly IPPE activities and pharmacy instructors. Assessment: The outcome of the IPPE model was assessed through a survey to pharmacy instructors at the practice site and through evaluations from IPPE learners. Conclusion: A learner-centered IPPE model was associated with preceptor and learner satisfaction and facilitated pharmacy instructor teaching. r 2015 Elsevier Inc. All rights reserved.

Keywords: Pharmacy learner; Introductory pharmacy practice experience; Learner-centered; IPPE model

Introduction In 2007, the Accreditation Council for Pharmacy Education (ACPE) adopted new Accreditation Standards and Guidelines for the Professional Doctor of Pharmacy program.1 These Standards emphasize the importance of clinical experience in the education of pharmacy learners, and they established the concept of the introductory pharmacy practice experience (IPPE) as a critical element

* Corresponding author: Shusen Sun, PharmD, BCPS, Department of Pharmacy Practice, College of Pharmacy, Western New England University, 1215 Wilbraham Road, Springfield, MA 01119. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2014.11.018 1877-1297/r 2015 Elsevier Inc. All rights reserved.

of future pharmacists’ education and training. IPPE must involve actual practice experiences in both community and institutional settings and allow learners, under appropriate supervision and as permitted by practice regulations, to assume direct patient care responsibilities. IPPE should begin early in the curriculum, be interfaced with didactic course work that provides an introduction to the profession, and continue in a progressive manner leading into the advanced pharmacy practice experiences (APPEs).1 IPPE should instill the philosophy of pharmaceutical care, facilitate and enhance professionalism, increase motivation for learning in the didactic curriculum, and promote the selflearning process.2 A successful IPPE curriculum requires the pharmacy school to work closely with its experiential sites to develop

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high-quality rotations that maximize learning. Many creative and interesting experiential programs have been developed and reported in the literature over the past few years. Examples of IPPE that provided exposure to different pharmacy practice environments in order to improve a student’s knowledge and competency include geriatric care, immunization, cultural sensitivity, and improving medication adherence.3–8 Examples of IPPE that were enhanced through integration with APPE and innovative forms of delivery, such as use of online modules and high-fidelity patient simulation, have also been previously described in the literature.9–12 However, the current body of knowledge lacks descriptive studies on how best to implement a structured, learner-centered IPPE. A dedicated pharmacy staff is a critical component to implementing a successful IPPE rotation. At Baystate Franklin Medical Center (BFMC), we believe and promote that all members of the pharmacy department, including both pharmacists and technicians, serve as a pharmacy instructor to the IPPE learners. Technicians are frequently used as pharmacist extenders for daily tasks; this can be extrapolated to parts of a student pharmacist’s education.13 Many of the technician duties align with the learning objectives of IPPE rotations. These activities may include processing, dispensing, and billing of medications. Perceptions of a pharmacy learners experience with learning from technicians have been reported as positive in the literature.14 This report describes the implementation of a Core Teaching Team (CTT) and an IPPE Learning Assessment Grid (ILAG) in a required IPPE at BFMC and the learner and instructor perceptions of the experience. The IPPE rotation described in this article was structured as a once per week, semester-long experience with learners in professional years one to three. This report intends to provide a reproducible model for other preceptors and institutions that are new to precepting pharmacy learners or for existing programs wishing to improve the structure of their rotations. The specific objectives were to (1) determine whether the CTT model provided pharmacy instructors with appropriate tools to teach IPPE students as demonstrated by a pharmacy instructor survey, (2) assess feedback obtained from experiential learners toward this IPPE model, and (3) identify areas of improvement based on feedback from pharmacy instructors and experiential learners. Methods Establishment of a pharmacy Core Teaching Team and preparation of pharmacy instructors and learners The complex balance of pharmacist staffing and teaching responsibilities can result in a lack of contact time between IPPE learners and instructors. To enhance the quality of student pharmacist education, the institution established a Core Teaching Team (CTT) consisting of the pharmacy faculty appointed to the site, the designated IPPE

coordinator, and the pharmacy manager. The primary objective of the CTT was to provide learners contact time with at least one of the CTT members on any rotation day. The hospital’s IPPE coordinator served as the core of the CTT and was responsible for conducting formal written performance evaluations and communicating with the college experiential office. CTT members were responsible for the oversight of learning, addressing instructor and learner concerns, assessment of overall performance, and the discussion of daily activities. CTT members gave didactic lectures on selected topics of interest and importance to learners throughout the IPPE. Pharmacists and technicians cannot be expected to provide learners with a positive training experience if they have not been given a clear explanation of their role.15 To prepare pharmacy instructors to precept IPPE learners, a one-hour live continuing education (CE) session centered on teaching strategies was presented by members of the CTT. The CE focused on the rotation structure, the promotion of professionalism, effective feedback, and how to motivate learners. These focused areas were consistently reviewed and reinforced at monthly departmental pharmacy staff meetings.

Assessment of learning objectives through IPPE Learning Assessment Grid (ILAG) The second critical component of a successful IPPE rotation is providing learners with specific and measureable learning objectives. The CTT developed the IPPE Learning Assessment Grid (ILAG) (Table 1) to evaluate progress and to direct teaching and learning activities. The ILAG translated IPPE learning objectives provided by the College of Pharmacy into measureable action items that were easily visualized using the following code. Objectives in the grid were evaluated using the outcome parameters of “not met,” “partially met,” and “met,” which correspond to a blank box, a half-colored box, or a fully colored box. This allowed learners to visually track their progress throughout the rotation. The goal was to have each learning objective “met” by the end of the rotation. All learning objectives were evaluated each rotation day. This review guided the learner activities for the day for both the instructor(s) and the learner. It also allowed for multiple instructors to easily visualize completed objectives and facilitated week-to-week instructor assignments. The use of this assessment grid created a sense of responsibility for both the learners and the pharmacy instructor. It was also used to facilitate student self-learning and reflection on addressing course objectives at the beginning and end of each IPPE day. The main role of the CTT was to ensure that each learner progresses toward achieving the predefined learning objectives. Although each learner is assigned to a pharmacy instructor to gain knowledge of pharmacy operations, it is the responsibility of the CTT to validate that specific

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Table 1 Introductory pharmacy practice experiences (IPPE) Learning Assessment Grid (ILAG) (a five-week page 1 example) Student: John Doe □ ¼ Not Met

◢ ¼ Partial Met

■ ¼ Met

Week 1 Week 2 Week 3 Week 4 Week 5 Date: 8/30 9/6 9/13 9/20 9/27 □ ◢ ■ □ ◢ ■ □ ◢ ■ □ ◢ ■ □ ◢ ■

1. Participate in accurate prescription/medication order processing  Review and interpret prescription orders by providers for accuracy and completeness  Identify all appropriate patient information for entry into computer system  Recognize names and indications of commonly prescribed medications  Fill medication orders by selecting correct medication and dosage form  Accurately calculate doses, total quantities, and infusion rates from a medication order  Accurately fill patient cassettes and automated dispensing equipment  Select appropriate substitute generic products as applicable to an institution’s formulary  Apply appropriate state and Federal regulations in the prescription-filling process  Identify components in the preparation of total parenteral nutrition (TPN) solutions or intravenous (IV) admixtures  Identify steps in the preparation of parenteral and/or sterile products  Relay understanding of the United States Pharmacopeia (USP) 797  Identify appropriate drug information literature resources used in prescription processing Initials of evaluator: Evaluation: [ ] Self assessment by student [ ] Assessment by preceptor [ ] Preceptor:

learning goals are being achieved before the learner moves to the next assignment. In order to quantify the impact of the CTT and ILAG, a pharmacy instructor survey was developed. Both Baystate Franklin Medical Center and Western New England University Institutional Review Boards (IRB) approved this study. The study period was from January 2012 through June 2013 and included three rotations with four learners for a total of 12 learners. Survey data were analyzed, and descriptive statistics were reported using Microsoft Excel 2010s. The survey, which consisted of 19 questions (Table 2), intended to review the preceptor training, validate precepting time and activities, and measure the satisfaction with this IPPE model. The survey questions were evaluated in a straw man poll of faculty preceptors at the Western New England University College of Pharmacy to gauge for bias and clarity of the questions. Faculty provided feedback on the clarity and sources of potential bias in the questions. Subsequently, the questions were put into a paper-based survey format and piloted again with faculty to ensure reasonable flow. The survey was distributed on paper at the hospital to the pharmacy staff (N ¼ 14). The pharmacy educators were instructed to deposit the completed survey to a locked box located at the pharmacy to ensure anonymity. Learner perceptions of the IPPE model were assessed through analyzing site/rotation evaluations provided by the college. The College Office of Experiential Affairs in consultation with local preceptors developed the site/rotation evaluation questions to assess learner satisfaction with the site, the preceptors, and questions for a plus delta-type analysis for orientation and the environment (Table 3).

The site/rotation evaluations are required by the College of Pharmacy. Learners completed the evaluation at the conclusion of their IPPE rotation, after they have departed their experiential sites. These evaluations are made available to experiential sites for quality improvement purposes. Results A total of 11 pharmacy instructors completed the survey (79% response rate; Table 2). Overall, 73% indicated that the IPPE model was highly structured and the design helped students achieve the predefined learning objectives. The mean satisfaction score was 4.20 (SD ¼ 0.79) on a 5-point Likert scale (ranging from 1 ¼ “not satisfied” to 5 ¼ “very satisfied”). Overall, 82% of pharmacy instructors attended the IPPE orientation live CE (per allowance of their work schedule) conducted by the CTT and considered the CE to be very helpful in providing them with teaching strategies to precept students and maximize students’ learning (M ¼ 4.50, SD ¼ 0.55). In addition, 82% of pharmacy instructors indicated that they provided immediate feedback after observing a learners’ performance for an activity, which illustrated their use of effective teaching strategy in their weekly teaching, and 91% of pharmacy instructors agreed that learners were actively involved in their learning and that a learner-centered teaching/learning environment was cultivated for the IPPE rotation. In total, 12 pharmacy learners completed the IPPE rotation; 83% of them (n ¼ 10) completed the site evaluation form (Table 3). This evaluation form consists of both openended questions and Likert scale questions using a 5-point scale (the maximum score is 65). The mean satisfaction score

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Table 2 Introductory pharmacy practice experiences (IPPE) Pharmacy Instructor Survey 1. Did you attend the one-hour continuing education (CE) on introductory pharmacy practice experiences: Creating an optimal experience for IPPE students? (a) Yes (b) No 2. The CE was designed to provide you with teaching strategies to precept students and maximize their learning. Please rate the helpfulness of this CE presentation (rate on a scale from 1 to 5 with 5 being MOST helpful). LEAST MOST HELPFUL HELPFUL 1 2 3 4 5

3. Have you interacted with IPPE students? (a) Yes (b) No 4. How often do you work with IPPE students? (a) Whenever I’m on duty while students are here (b) Only when I am assigned 5. Which part of IPPE precepting activities have you been involved (please select all that is/are applicable)? (a) Medication order processing (b) Medication preparation and compounding (c) Medication distribution/filling functions (d) Automation (e) Drug inventory/purchase (f) Controlled substance/C-II (g) Drug information (h) Pharmacokinetics and/or drug monitoring (i) Interdisciplinary round (j) Pharmacy operation (k) Pharmacy law (l) Inter-professional and patient communication (m) Other (please specify) 6. Feedback is an essential part of the learning process for experiential students. A great opportunity to provide feedback is after observing students' performance for an activity. Did you provide immediate feedback on student’s performance for the activity? (a) Yes. Please provide comments if you will. (b) No

7. Did you ask students any questions for them to research? (a) Yes (b) No 7a. If yes, what type of questions did you ask student (please select all that is/are applicable)? (a) Medication order processing (b) Medication preparation and compounding (c) Medication distribution/filling functions (d) Automation (e) Drug inventory/purchase (f) Controlled substance (g) Drug information (h) Pharmacokinetics and/or drug monitoring (i) Interdisciplinary round (j) Pharmacy operation (k) Pharmacy law (l) Inter-professional and patient communication (m) Other (please specify)

8. Did (a) (b) (c) (d)

the student(s) follow up with your questions? Yes No Some did some did not (if you have multiple students to precept) The student was not able to get hold of me

9. Did (a) (b) (c)

you follow up with the student for the questions you asked? Yes No I got busy and lost track of the student

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Table 2 Continued

10. Please rate the degree of effort that the student made to answer your question? (rate on a scale from 1 to 5 with 5 being the BEST effort) LEAST EFFORT Student 1: Student 2: Student 3:

1 1 1

BEST EFFORT 2 3 4 5 2 3 4 5 2 3 4 5

11. Each day our goal is to provide you and student(s) with clearly well-defined learning objectives to maximize students learning. In your opinion how consistent has this been done (rate on a scale from 1 to 5 with 5 being VERY consistent)? NOT VERY CONSISTENT CONSISTENT 1 2 3 4 5

12. Do you perceive that the student takes his/her responsibilities for active learning? Student 1: (a) Yes Student 2: (a) Yes Student 3: (a) Yes

(b) No (b) No (b) No

(c) Not able to assess (c) Not able to assess (c) Not able to assess

13. Establishing the “learner-centered” teaching/learning environment can help to maximize students' motivation and learning. Do you think “learner-center” teaching/learning environment was cultivated for the IPPE rotation at the site? (a) Yes (b) No (c) Unable to comment

14. On average how many questions did student ask you per day? (a) 0 (b) 1–3 (c) 4–6 (d) 7–10 (e) More than 10 15. What type of questions did the student ask you? (a) Medication order processing (b) Medication preparation and compounding (c) Medication distribution/filling functions (d) Automation (e) Drug inventory/purchase (f) Controlled substance (g) Drug information (h) Pharmacokinetics and/or drug monitoring (i) Interdisciplinary round (j) Pharmacy operation (k) Pharmacy law (l) Inter-professional and patient communication (m) Other (please specify) 16. An introductory pharmacy practice experience is the first “testing ground” of pharmacy students' professionalism. Have you ever had to correct student's unprofessional/unethical behavior? (a) Yes. If so, please provide comments if you will. (b) No

17. Our goal is to design and deliver a highly structured IPPE to help students achieve predefined learning objectives by the College of Pharmacy. Overall is this IPPE rotation highly structured? (a) Yes (b) No (c) Unable to comment

18. Overall how satisfied are you with this IPPE teaching/learning model (rate on a scale from 1 to 5 with 5 being VERY satisfied)? NOT SATISFIED 1 2 3

VERY SATISFIED 4 5

19. Do you have suggestions to improve this IPPE teaching/learning model? We’d like to hear! Remember this will benefit future pharmacy students. Please feel free to write your comments:

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Table 3 Student introductory pharmacy practice experiences (IPPE) evaluation form Your input is valued. Please select the responses which best reflect your opinion using the 5-point scale (Questions 3, 5–9, and 11–17). Additional comments are encouraged in the spaces provided. (1) Did you contact the rotation site/preceptor prior to your arrival? (a) Yes (b) No (2) Were there other students at this site during your rotation? (a) Yes (b) No (3) Did the on-site orientation provide you with an awareness of the information and resources that you would need for the experience? Not applicable (0) Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5) (4) What else could have been provided during the orientation? (5) The site provided me with adequate safety information (bloodborne pathogens, hazard communication, evacuation, etc.) Not applicable (0) Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5) (6) The overall physical facilities of the site were clean and well maintained. Not applicable (0) Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5) (7) The overall physical facilities were adequate to fulfill my rotation objectives (work space, equipment, hand washing sinks, etc.) Not applicable (0) Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5) (8) I received adequate introductions to all key staff. Not applicable (0) Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5) (9) During this experience, ancillary pharmacy staff maintained an open environment conductive to professional practice and growth. Not applicable (0) Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5) (10) What suggestions could you offer for improvement of the environment for professional practice and growth? (11) The site provided me with the necessary tools to meet the course objectives (computer access, job-specific training, library resources, etc., as applicable). Not applicable (0) Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5) (12) The experience improved my ability to interact and work efficiently with other health care professionals. Not applicable (0) Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5) (13) The patient population at the site was sufficient for increasing my knowledge base of medications and their effects. Not applicable (0) Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5) (14) The patient population at the site was sufficient for applying medication evaluation principles and formulating treatment plan. Not applicable (0) Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5) (15) The rotation enhanced/improved my ability to counsel and educate patients. Not applicable (0) Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5) (16) Overall, I feel that this site and this rotation contributed to developing my skills in becoming a practicing pharmacist. Not applicable (0) Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5) (17) I would recommend this site to other students. Not applicable (0) Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly Agree (5)

was 60.40 (SD ¼ 5.23), range from 51 to 65. All participating learners either strongly agreed (70%) or agreed (30%) that the CTT and ILAG used during the IPPE contributed to the development of their skills related to becoming a practicing pharmacist. All participating learners also either strongly agreed (80%) or agreed (20%) that they would recommend the site to other learners. Moreover, 90% of learners indicated on the survey that the IPPE experience improved their abilities to interact and work efficiently with other health care professionals. All pharmacy instructors had some interaction with IPPE learners and were involved in various teaching activities. It is important to remember that the more time spent in the role of an educator, the more they will enhance their skills as a practitioner. These results illustrate the instructors’ engagement with the learners and were echoed by the learner evaluation results. All IPPE

learners who completed the rotation/site evaluation either strongly agreed (90%) or agreed (10%) that pharmacy staff maintained an open environment, conducive to their professional practice and growth. Discussion Consistent evaluation and timely feedback from pharmacy instructors is of utmost importance to build a strong foundation for learners. Immediate feedback upon completion of a specific task provides the most valuable and real-time learning to students.16 Effective feedback consists of providing timely comments that are specific, factual, descriptive, and clearly understood. These comments should be constructive and sensitive to the learner and should always focus on a specific behavior, not on a

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person or their intentions. Feedback not only includes constant daily assessment but also a final written summative evaluation. The formation of a CTT and the utilization of the ILAG ensure that evaluation and feedback are provided immediately by each pharmacy instructor and more formally by a CTT member at the end of each rotation day. This IPPE model promotes and cultivates a learnercentered and motivating educational environment. A motivating environment is generally one in which learners are challenged and encouraged to use originality and resourcefulness to solve problems. It is also one in which learners feel safe making mistakes. In learner-centered teaching, pharmacy instructors assume a facilitation role, and learners are engaged in a carefully structured, responsive, and guided learning environment. The learner-centered approach outlined in the ILAG shifts from the traditional knowledge transmission to an emphasis on the facilitation of active learning. Realizing that IPPE learners will have varying degrees of pharmacy experience, it is important to ask about background, interests, and previous pharmacy experience during the orientation session. The information obtained will help identify strengths or weaknesses and any areas in which learners may need extra assistance. Learners were encouraged to ask questions and research areas of interest related to IPPE learning objectives. The authors observed that simple curiosity may be the most important motivator of all for IPPE learners. By reorienting much of the focus in IPPE education from the pharmacy instructor to the learner and by fostering a greater sense of respect on the part of educators for the people they are teaching, the overall quality of the IPPE education can be enhanced. Professionalism is a continually evolving issue that must be addressed in the context of expectations and goals for pharmacy instructors and student pharmacists. The concept of learner professionalism has received increasing attention in pharmacy education in recent years.17 As practicing pharmacists have known for many years, professionalism is crucial in establishing positive relationships with patients, coworkers, and other members of the health care team. IPPE is the first “testing ground” of a pharmacy learner’s professionalism. For what may be the first time, learners are faced with patient, employer, and employee interactions while representing their profession, college or school of pharmacy, and practice setting to others.18 The implementation of the CTT ensured that IPPE provides learners with the real world of pharmacy practice through observing the work ethic and professionalism of pharmacy instructors, how they manage various situations, how they interact with other health care providers and patients, and how they follow the laws and regulations of pharmacy practice. The CTT and the pharmacy instructors serve as role models to pharmacy learners. The importance of professionalism, what constitutes professionalism, and strategies to address inappropriate behavior were presented to pharmacy instructors during staff orientation.

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The CTT orientation set clear expectations at the start of a rotation that provided the infrastructure for a successful IPPE rotation. Orientation should include an introduction to the practice site, pharmacy instructors, learner expectations, and learning objectives of the rotation presented through the ILAG. The value of a learner-centered teaching and learning environment should also be stressed. Overall, the orientation highlights what the rotation weeks will hold and allows the student to know in advance what to expect. Orientation checklist templates are available and can be adapted to a specific site to guide this process.19 Areas of improvements were identified from both the results of pharmacy instructor survey and learners evaluation. Pharmacy instructors would like to see each learner assigned a longitudinal project for every rotation block with a related presentation at the conclusion to evaluate overall learning. Learners identified that they would like to have had more opportunities to interact with patients to work on their communication skills. The goal of the article is to provide guidance for the formation of a CTT and the implementation of an ILAG to promote learning during IPPE. While this information is paramount, the supporting data do have limitations. First, the study only used the site/preceptor evaluation provided by the College of Pharmacy to evaluate learner feedback about the rotation. Certain questions such as learners’ perceptions on the professionalism of pharmacy instructors, the utility of the assessment grid, and the environment of self-learning were not evaluated. A second limitation is that only a small number of IPPE learners provided additional comments for the open-ended questions that could provide more summative feedback about their experiences. A final limitation was that learning was not formally assessed as an outcome. Conclusion This study demonstrates that a structured, learnercentered IPPE rotation, including a Core Teaching Team (CTT) and an IPPE Learner Assessment Grid (ILAG) to engage all pharmacy instructors and learners, leads to a satisfactory learning and teaching experience for both pharmacy learners and pharmacy staff. The framework of this approach is structured; however, it is adaptable to many practice settings and other schools/colleges of pharmacy. References 1. American Council of Pharmaceutical Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. 〈www.acpe-ac credit.org/pdf/FinalS2007Guidelines2.0.pdf〉; 2011 Accessed January 19, 2015. 2. Chisholm MA, DiPiro JT, Fagan SC. An innovative introductory pharmacy practice experience model. Am J Pharm Educ. 2003;67(1): Article 22.

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