Contemporary Pharmacist Education – challenges from

Assoc Prof Martin Henman

Trinity College Dublin

Health Outcomes and Social Pharmacy, Belgrade – March 2018

Contemporary Pharmacist Education –

challenges from society and practice to

academia and vice versa

Trinity College Dublin, The University of Dublin

Current issues in Education

Qualifications Framework

Quantification of learning activity

Integrated curricula*

Competency-Based curricula*

Experiential learning*

Interprofessional learning*

Enabling Research, Innovation & Entrepreneurship

Progression/Link to Professional Practice – Continuing

Professional Development

Accreditation & Continuous Quality Improvement


The challenges that Health Care poses for

pharmacists & for education & for societyComplex & interactive

Demand led

Benefits, risks & consequences

Impact on individuals, small groups & society

Changing while delivering

Diversity, vulnerability & rarity

Ever increasing demand & ever decreasing resources


Complex and interactive

Complicated – a lot to know, a lot to do, a lot to monitor

Interactive – each element interacts with others, so changing one, changes others – over time health status changes

Individual – physiology ↔ pathology ↔ pharmacology

psychology

Group – team, small business

Organisation – hospital, Health Service, National Agency


Consequences of complexity

Hard to understand, & hard to predict

Simplification of knowledge may lead to superficial view

– Scientific view vs biomedicalpsychosocial view

– Structure→ Process → Outcome

Distortion & underestimation

– Knowledge changes behaviour

Unintended and unexpected outcomes

– The least worst option

Difficult to explain

Education = Apprenticeship – observing & working for someone

& learning on the job


Learning & Working in pharmacy …separate cultures?

Academic Environment

•Tradition

•Hierarchy

•Regulation

•Divided by academic discipline

•Research-led

•High quality scientists

•Researchers

•Practitioners in waiting

Practice Environment

•Tradition

•Hierarchy

•Regulation

•Divided by profession

•Demand/Service-led

•High quality practitioners

•Manage demand

•Wish lists

4 years of University education + 1 year of practice, with 6 months

in hospital or community


Pharmacy Education & Practice –

separate worldsAll other Health Care Professions integrate in the undergraduate

course

Because separation is the enemy of learning, of high quality health

care & of quality research in health sciences

Academic Workplace Practice


Integration & ProgressionIndependent

practice in a

supervised

environment

Supervised

practice

Talking to

Patients,

Practitioners

Simulation of

practice

Observation of

practice

Novice

Proficient

Year 1 - Novice

Year 5 - Proficient


Curriculum planningReverse engineering

– What Competencies do our students

need?

– What Learning Outcomes will align

with these?

– What Assessment will provide evidence

of those Outcomes?

– What teaching methods can we use to

deliver the content & prepare students

for the assessment?FIP 2016


Competence-based education

Education

Remember

Appraise

Solve problems

Demonstrate Skill

Simulation, time-limited

Assessment

Practice

Apply

Interpret

Resolve unknowns

Judgement

Experiential, open-ended

Performance

What do you want your students to be able to do?

List the competences required.


Example: Competence - Dispensing

Domain 1

1. Obtains individual patient history

1.1 Accesses patient medication records/notes

Behavioural descriptors:

1.1.1. Effectively uses records on pharmacy

computer/patient medical notes/animal records

1.1.2. Obtains copies of records (computer/hard copy) from

other health professionals


Competence & behaviour

• Competence - the skill and

the standard of performance

attained

- Competences - skills

• Competency – behaviour by

which the competence is

achieved

- Competencies – behaviours

- May be core/generic, or

specific/technical

Irish Core Competency Framework for Pharmacy

6 Domains → 25 Competences → 177 Behaviours!


Learning & Working…different cultures?

Undergraduate Learning

Environment

Peer contact

Defined curriculum

Tutor Access

Regular Appraisal

Guided study

material

Learning

Support

Employees learning in the

workplace

Individualised

Curriculum

Limited Tutor

Support

Infrequent

Appraisal

Unable to identify

learning needs

Limited

Opportunity to

learn

Academic Competences Practice Competences

Competency Framework

Teacher- Practitioner

Adapted from G. Davies

Academic Environment

Tradition, Hierarchy, Regulation

Research-led

Practice Environment

Tradition, Hierarchy, Regulation

Demand/Service-led


Pharmacists’ roles

• Securing & providing medicines & medical devices

• Improving medicines use

• Contribute to health & wellbeing policies

Pharmacists can connect directly to patients in familiar roles

Pharmacists’ contribution to the health system can be increased by changing pharmacists’ roles and the way pharmacists work

To do this, Pharmacy education and Pharmacy Practice must change together

– And the health system itself must be changed


Medication-related Skills

Main Activities

•Counselling patients receiving prescription medicines

•Responding to requests for non-prescription medicinal products

•Responding to symptoms

Additional Relevant Knowledge & Skills

•Dispensing, Prescriptions & Medicines supply schemes

•Communications skills


Medication Related

Consultation FrameworkAbdel-Tawab R, et al, Patient Education

& Counselling 2011 Jun;83(3):451-7.

Sections of a consultation Aims of sections

(A) Introduction “To build a therapeutic relationship with the patient”

(B) Data collection &

Problem Identification

“To identify the pharmaceutical needs of the patient”

(C) Actions & Solutions “To establish an acceptable management plan with the patient”

(D) Closing “To negotiate safety netting strategies with patient”

“natural flow of a consultation”


Medication Related Consultation Framework

Abdel-Tawab R, et al, Patient Education &

Counselling 2011 Jun;83(3):451-7.


Medication Related Consultation Framework

Tool


Researching more into the Consultation

Our review suggests that sound medication therapy decisions cannot be made without

good insight and attention to Patient Lived Experience with Medicines.

Hence, actively exploring and engaging PLEM when making therapeutic decisions may help

provide individualised care. Mohammed MA, Moles RJ, Chen TF. BMJ Open 2016;6:e010035. doi: 10.1136/bmjopen-2015-010035


Experiential education

• Supervised, structured or semi-structured teaching and

learning activities that take place in a practice setting

• Part of curriculum, and so each placement is responsibility of

University

• Real-life situations and inter-personal interactions with

patients, caregivers

• And with other health professionals

• Work-based learning, Practice-based learning

Education is not an Apprenticeship – observing & working for

someone & learning on the job


Clinical settings for Experiential

Community pharmacies

Hospitals

Nursing/residential homes

Compared to University

Governed by specific rules & norms

Clinical staff – hierarchy & teams

– Setting specific

– Variable range of responsibilities

Teacher-practitioners

Preceptors & Tutors

Krk

USA

TCD


Simulation: learn skills effectively

& without risk to prepare for Experiential- Simulation is a technique, not a

technology

- Replicate elements of practice

- Fully interactive

- Recorded by observation or video

- Allows practice, learning from

mistakes

Therefore simulation is a valuable prior

requirement to Experiential learning.

At each stage of development.

Allows Peer review.

Assessment e.g. Objective Structured

Clinical Examination

Pharmacy – Trinity College Dublin Non-prescription stock shelves (right), EPOS system(centre), General sale stock shelves (left), Dispensary (rear)

Laerdal – UDLA, Santiago, Chile


P/O/C are not equivalent to Experiential

Pharmacist Practitioners lecturing in College

Useful, but it is not practice

Patients lecturing is more valuable

Observation

Visiting a pharmacy is a useful precursor but not a substitute

– aims, objectives & outcomes are required

Clinical visits

Often used to mean any relevant experience

Settings such as regulatory bodies, health service management or even some

industrial practice

Providing the scope of activities, required supporting knowledge and skills

and the need for professional judgement are clearly evident


Experiential learning

Active, focussed process in a prepared environment

Knowledge is ‘apprehended’ (captured) by student

Nor is Experiential simply about being there, or being there and

doing

Thinking & talking about experience may also lead to learning

And the experience of their peers in same/similar setting is

credible & useful

Sofia

Ljubljana


ObservationA crucial skill with people who are unwell

Observing, noting & integrating all of the sensory &

factual information during an encounter, particularly

the unusual – useful skill for clinician and scientist

Observation as a Novice & as one who is Proficient

What is going on here?

What is different about this situation?

What can I see, as opposed to, what am I supposed to

be looking for?


Learning OpportunitiesTaking a patient history – patient’s attitude to medicines

Communication skills - from basic to empathy

Drug-Related Problems – Actual vs Potential

Making decisions on balance of available information

Benefits & limitations of guidelines

Pharmacists’ roles (services)

– Leading Practitioners

Concrete situations in which the evidence base is poor, lacking or contradictory

Tirana


Professional work environmentStudents’ must present their knowledge, make

recommendations to others

They must work with less qualified but more

knowledgeable people

They must meet not only academic standards,

but also professional practice, follow workplace

procedures, co-ordinate with others, account for

their actions

Appreciation of the environment & of meeting

patients helps students learn from the

experience of others

Students bring new ideas & energy


Who can cross from one side to

the other?

Undergraduate Learning

Environment

Peer contact

Defined curriculum

Tutor Access

Regular Appraisal

Guided study

material

Learning

Support

Workplace learning

Individualised

Curriculum

Limited Tutor

Support

Infrequent

Appraisal

Unable to identify

learning needs

Limited

Opportunity to

learn

Academic Competences Practice Competences

Preceptor-Tutor

Teacher- Practitioner

Adapted from G. Davies


Preceptors – Tutors & Teacher PractitionersPersonal expertise & experience

Help to ‘define’ and map competencies

How is the role defined?

Context & significance of generic competencies

When & which specific competences are required

– Particular combination of generic & specific competences

Experiential learning - identification of and access to opportunities

Practicalities of teaching & learning of specific activities

Pragmatic assessment & evaluation

Training & support of Preceptors/Tutors is essential

Measuring

Evaluation Assessment

The process of gathering and discussing information from multiple and diverse sources in order to develop a deep understanding of what students know, understand and can do with their knowledge as a result of their educational experiences.‒Huba and Freed, 2000

The systematic process of

determining the merit, value,

and worth of someone or

something (such as a product,

program, policy, procedure, or

process).

Evaluation Glossary (n.d.) from Western Michigan

University, The Evaluation Center Web site


Aligning the processes of

education to the practice setting

Interprofessional learning

Experiential learning

Simulation

Methods of measurement

Types of Assessment

Competency framework


Preparing for Learning in PracticePractitioner

Demands of learning •Balance work & life responsibilities with learning

•Adaptable & continuous

Role of mentor • Guide & support learning• Assess

Professional & personal life experiences

• Make connections with & between experiences

• Acknowledging, accepting, revising

Purpose for learning • Competence • Capability to deal with uncertainty• Coping with acute, serious events

Permanence of learning • Self-initiated • Long-term

Adapting Knowles’ Learning Theory


Supervision & Questioning aligned

to level of student development

Supervision Level of development Questioning

S1 Coaching & directing Incompetent –

unconsciously or

consciously

What?

What – Remember

Why - Understand

S2 Supporting Consciously competent So what?

Which… - Apply

What do you think

about… - Analyse

How will this affect…

S3 Delegating Unconsciously

competent - Intuitive

Now what?

Evaluate…

Develop… - Create

Barnum, Guyer, Levy & Graham,

2009

Howell & Fleischman, 1982 Barnum, 2008; Bloom’s taxonomy


Feedback- assessed against validated criteria

Confirming/Reinforcing

– Let student know they are doing something well

– Reinforce appropriate behaviours

Corrective

– Modify or improve behaviour to more appropriate form

– Prevent students developing incorrect techniques or accepting inaccurate evaluations/statements

Guiding

– Help student by making clear, suggesting improvements, refinements

Nottingham & Henning, 2014

• Timing

• Specificity

• Content

• Form

• Privacy

Nottingham & Henning, 2014


Interprofessional Learning &

Collaborative practice • Service provision

delivered by multidisciplinary teams with emphasis on health promotion, preventative services and chronic disease management

• The multidisciplinary nature of these services will necessitate health care professionals working together in a more integrated way than ever before WHO 2010


Learning together to work together

Overcoming the problem of education in silos

Accreditation and regulatory bodies require evidence of IPL in professional courses

Developed with collaboration from across the faculty and clinical partners

Refined in response to student/facilitator feedback following workshops

Based on constructivist learning theory

..…..that is students build new knowledge based upon the learning they achieved together

Workshops designed to

facilitate skills and attributes

desirable in health

professionals


Student evaluationsProfessional identify

“Even though I thought I had a good understanding of the disciplines I learned a lot about everyone’s individual roles” Medical student

“Found the session very useful in developing MDT relationships, learning various roles and showing your area of expertise.” Physiotherapy student

Collaboration and teamwork

“It was a great learning experience. Also brought up questions for me about how to explain things that SALT (Speech and Language therapy) do. Helped me try and be concise and to summarise and be relevant with my information” SALT student

“Good insight into the role of other professionals and encourages respect and admiration of the integral and important work other professionals do” Pharmacy student

“Workshops were great and consolidated a lot of things for me. Disheartening however when some group members did not prepare or seem to interact enough” OT student


Interprofessional Learning & ReFEEHSIPL is difficult because, in most countries, the Health Professions

have not agreed what Inter-Professional Practice or

collaboration are – we just look at the clinical outcome

Each profession has not yet addressed this because within each

one the range of views is wide and some are irreconcilable

A national consensus would enable a competency framework to

be developed, but we cannot wait for this

We need to look at standardised patient scenarios in which both

teams and individuals are assessed

We need to consider how more IPL can be introduced

And how it can be delivered in the periods of Experiential

Learning


Stakeholders in Pharmacy Education

In Health Sciences, the technicalities of assuring the quality of the

education are overshadowed by one primary objective, patient safety


System

ProblemsKoehring M, 2016


Increasing complexity of Health Care

leads to ever increasing demand for

ever decreasing resourcesDemand

– Increased capability

• New knowledge

• New investigative capabilities

– Prevailing attitudes & values

• Political imperative

• Social acceptability

Resources

– More to be done

• More complicated things to be

done

– More people to do it

• More people paid less

• Higher salaries for those paid

more

• More supports & support

people


Consequences of increasing demand and

decreasing resources

Doing more with less – becoming Lean

Using resources to assess costs, benefits, to find inefficiencies

Increasing difficulty of managing

– Current expenditure & budget

– Capital/Investment resources

Alternate facts

Poor Practice


As an individual, I may not be

able to change the System but…Performance

– Do our best, in our setting

– Effective, safe & responsive to patients’ needs and wants

Continuing performance

– Address all of the essential roles that comprise the current scope of

practice of pharmacy & pharmacists

– Meet external standards

– Demonstrate both of the above for each new role/service that is

incorporated into the scope of practice

– Argue, based on the above for the resources to do more


4

4

ReFEEHS ongoing work

Momentum generated by;

– Reform of Higher Education in Serbia.

– International Bologna conferences.

– Erasmus Plus and Tempus Programmes

– Support from Public Health Institute of Serbia

– Networking of Teaching and Learning Competencies

– Postgraduate Cert/Diploma and MA in Teaching and Learning in Higher Education

Maintaining the Momentum;

Make a start with like-minded people.

Keep it simple, at first.

Academic & Pharmacy staff training is the key.

Provide support to all staff.

A team effort.


Education has an impact on Practice

and vice versa

Re-configuration of the curriculum

– Via simulation/action, reflection, patient impact, collaboration

– Nowhere has achieved perfection

Maximising learning opportunities in Practice

– Types of knowledge & settings for learning

– Learning outcomes & assessment

– Reflection & continuous improvement

Re-envisioning of pharmacy

– Academic & Practice pharmacists focussed on providing high quality care

– Meeting needs of patients

– Meeting the needs of pharmacists

Thank You

Go Raibh Maith Agaibh.Havla Vam

Documents

Contemporary Pharmacist Education – challenges from