Interprofessional Education: Just Another Catch Phrase?

by Allison Butts, Pharm.D., PGY1 Pharmacy Practice Resident, The Johns Hopkins Hospital

Only nine months into my pharmacy career and I’m tested every day to effectively use my clinical knowledge, rational decision-making skills, adaptability, and confidence to deliver optimal patient care working alongside health professional colleagues.  I found the transition from student pharmacist to licensed pharmacist to be fairly smooth, which I attribute to the interprofessional education I received in pharmacy school.  If healthcare practitioners are expected to work together, communicate, and use their skills in an integrated manner, it seems clear that it is best to train students in an interprofessional environment.  In writing this essay I reflected on my educational experiences and how best to prepare students for practice in healthcare today.

In 2003, the Institute of Medicine (IOM) issued a report entitled, “Health Professions Education:  A Bridge to Quality.”  This report highlighted a number of necessary changes to professional health care education to improve the quality of care provided in the United States.  The report emphasized five core competencies that should be addressed through professional education:  patient-centered care, evidence-based practice, quality improvement, informatics, and interprofessional teams.¹   The Accreditation Council for Pharmacy Education (ACPE) addressed the 2003 IOM reports and adopted the core competencies into their 2007 Guidelines for ACPE Accreditation Standards, with a special focus on interprofessional education.²  In 2011, a joint effort between the American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association, Association of American Medical Colleges, and the Association of Schools of Public Health further refined the core competencies.³  A 2012 survey found that only 34% of the participating colleges of pharmacy provided instruction regarding interprofessional teaming.  Most of these colleges / schools of pharmacy has some interprofessional teaching in their curriculum (53%), while others offered it as topic within a course (24%) or as a standalone course (17%) format.  While only a third were actively teaching interprofessional teaming, an impressive 83% of respondents indicated a desire to include this core competency into their curriculum.⁴

Colleges of pharmacy from across the country continue to look for new ways to teach the principles of interprofessional teaming in their curriculum.  Faculty from the South Carolina College of Pharmacy, MUSC Campus, recently published data on pharmacy students’ perceptions regarding interprofessional collaboration after completing a required longitudinal clinical assessment course.  The course addressed several domains of interprofessional education in nine separate learning activities.  The activities involved students from pharmacy, physician assistant studies, medicine, and nursing.  The Interprofessional Education Perception Scale (IEPS) was used to assess the perceptions of pharmacy students prior to and at the completion of the course.  In 16 of the 18 questions surveyed, perceptions of interprofessional collaboration improved after completing the course.  The items that had the most improvement were:  “individuals in other professions respect pharmacists” and “individuals in my profession are positive about their goals and objectives.”⁵

Other published examples of interprofessional teaching models include a required introductory pharmacy practice experience (IPPE) course in which pharmacy students visit practice sites of local physicians and nurse practitioners who serve as primary preceptors, participation in a service-learning advanced pharmacy practice experience (APPE), medical missions trips, patient simulation activities, and interprofessional didactic coursework.^6-12

Looking back on my pharmacy education, I recognize how fortunate I was to have trained at an institution located within a large academic medical center, especially one in which clinical pharmacy services are full integrated in the delivery of care.  When considering my personal experiences and reconciling them with examples from the literature, there is a combination of approaches that I believe will create the optimal environment for students to learn about the principles of interprofessional teaming and become skillful team members:

• Provide interprofessional experiences early and often.  It is never too early in the curriculum to introduce students to their health care colleagues.  Students across disciplines take many of the same basic science classes early in their respective programs, so should be feasible to have students from different professional programs in the classroom together.  Activities should evolve as students move through their curricula, allowing for the development of solid relationships prior to clinical rotations.
• Engage students in the development of interprofessional initiatives.  Students themselves can be the best gauges of a program’s success.  By understanding their needs, goals, and perceptions, educators can tweak the curriculum to best prepare students for clinical practice.
• Develop unique methods of student assessment.  Students are often graded at the completion of a interprofessional patient care activity (real or simulated) based on a SOAP note or patient presentation.  Educators should also measure the success of the team by how well they utilize their colleagues.  Students should be asked what each team member contributed as well as how they utilized their teammates to accomplish their tasks.
• Provide variety.  Ideally, health care students should interact with students from several different professional programs.  There are admittedly resource limitations and logistical barriers, but colleges/schools of pharmacy should strive to work with at least two other professional degree programs.  Create a variety of learning activities and consider nontraditional experiences to achieve the competency standards. 

The concept of interprofessional education is more than a catch phrase in today’s professional education landscape.  It is a true necessity in preparing pharmacy and other health professional students to become successful practitioners.  Primary professional education organizations have formed a united voice in favor of this practice model and interprofessional training should be a priority at schools/colleges across the country.

References

1. Greiner AC, Knebel E, eds.  Institute of Medicine.  Health Professions Education:  A Bridge to Quality.  Washington, DC:  National Academies Press; 2003. Accessed 10 March 2014. 
2. Accreditation Council for Pharmacy Education.  Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree.  Guidelines Version 2.0 for Standards 2007.  Effective February 14, 2011.  Accessed 10 March 2014. 
3. Interprofessional Education Collaborative Expert Panel.  Core Competencies for Interprofessional Collaborative Practice:  Report of an Expert Panel.  Washington, DC: Interprofessional Education Collaborative; 2011.
4. Zeind CS, Blagg JD, Amato MG, and Jacobson S.  Incorporation of Institute of Medicine Competency Recommendations within Doctor of Pharmacy Curricula.  Am J Pharm Educ.  2012; 76: Article 83.
5. Shrader S, Griggs C.  Multiple Interprofessional Education Activities Delivered Longitudinally Within a Required Clinical Assessment Course.  Am J Pharm Educ.  2014; 78: Article 14.
6. Turner CJ, Altiere R, Clark L, Dwinnell B, and Barton A.  An Interprofessional Introductory Pharmacy Practice Experience Course.  Am J Pharm Educ. 2004; 68: Article 10.
7. Jones KM, Blumenthal DK, Burke JM, et al.  Interprofessional Education in Introductory Pharmacy Practice Experiences at US Colleges and Schools of Pharmacy.  Am J Pharm Educ.  2012; 76: Article 80.
8. Johnson JF.  A Diabetes Camp as the Service-Learning Capstone Experience in a Diabetes Concentration.  Am J Pharm Educ.  2007; 71: Article 119.
9. Werremeyer AB, Skoy ET.  A Medical Mission to Guatemala as an Advanced Pharmacy Practice Experience.  Am J Pharm Educ.  2012; 76:  Article 156.
10. Fernandez R, Parker D, Kalus JS, Miller D, Compton S.  Using a Human Patient Simulation Mannequin to Teach Interprofessional Team Skills to Pharmacy Students.  Am J Pharm Educ.  2007; 71: Article 51.
11. Van Winkle LJ, Cornell S, Fjortoft N, et al.  Critical Thinking and Reflection Exercises in a Biochemistry Course to Improve Prospective Health Professions Students’ Attitudes toward Physician-Pharmacist Collaboration.  Am J Pharm Educ.  2013; 77: Article 169.
12. Westberg SM, Adams J, Thiede K, Stratton TP, Bumgardner MA.  An Interprofessional Activity Using Standardized Patients.  Am J Pharm Educ.  2006; 70: Article 34.

Distance Education in Healthcare Degree Programs

by Maureen Jones, M.S., Pharm.D., PGY-1 Pharmacy Practice Resident, Carroll Hospital Center

Distance Education has been defined as “the separation of educator and learner in time and space.”¹  Among advanced healthcare degrees, nursing², dental hygienist³, public health⁴ and Doctor of Pharmacy degrees^5-6 can currently be completed through distance education programs. Many (perhaps most) traditional healthcare degree programs incorporate aspects of distance learning into their curricula as well.^7-8  But what kind of evidence do we have evaluating the quality of distance education to traditional methods?  Should we celebrate distance education as an equal (or better!) alternative to traditional methods of instruction?  Or should we reject it?  The answer: we have data (but perhaps not enough) and it’s mostly positive.

Nursing programs have by far the most data on distance education.  One systematic review on the effectiveness of tele-education in nursing and medical education found that there was no significant difference in overall knowledge gain between face-to-face instruction and videoconferencing.⁹  Another study evaluating the effect of learning environment in a graduate nursing program found that there were no significant differences in final course grades or the student’s perceived learning between online versus traditional face-to-face classes.  The authors emphasized that it was the “quality of instruction [that was] more important than the medium by which the course content was delivered.”¹⁰

There has also been research on distance learning in the dental sciences. For example, traditional classroom versus e-learning in infection control education for first year dental hygienist students showed that both methods of teaching were comparable based on knowledge assessments and a competency based exam (CBE).  The researchers concluded either method could be used depending on school preference and resources.  It is true that the traditional face-to-face group performed significantly better on a multiple choice exam (mean score=86.8 vs. 82.8 p=0.011), however the difference was not deemed to be a “practical” difference as both group’s mean scores were passing.  Regarding the CBE, there was no significant difference in the pass rate in each pathway.¹¹  Many Dental Schools offer distance education courses in their curriculum. The University of Missouri-Kansas City School of Dentistry conducted a pilot program whereby the school’s pharmacology course, which was previously taught by the University’s School of Pharmacy, was transitioned to an online course taught by dental school faculty.  The pilot study showed student grades in the online cohort were similar to grades in previous year’s.  Additionally, the dental school was able retain a highly qualified professor who would have otherwise sought employment elsewhere.⁷

Pharmacy Schools have researched distance education strategies as well.  Creighton University is the only school of pharmacy that has a distance learning pathway for some students in their entry-level Doctor of Pharmacy degree program.  Many schools now have hybrid pathways and satellite campuses. One particular school of pharmacy that has two satellite campuses evaluated student performance in a pharmacotherapeutics class taught synchronously between the campuses. Over the course of five years, there was no significant difference between the final grades of students attending each campus.¹²

While the academic aspects of online education are very positive, there are potential negatives associated with distance learning: namely students potentially feeling isolated, both from other students and professors, as well as technological frustrations.  In two separate studies, students in an online dental terminology class and students in an online Doctor of Nursing program both cited feelings of isolation and disconnectedness as drawbacks to distance learning.^13-14 However, students overwhelmingly thought the benefits of distance education (convenience, access, good school-life balance) outweighed this drawback.¹⁴ Additionally, students and faculty can feel frustrations towards the technology needed for distance learning.  These may be from slow download speeds, dropped internet connections, or the lack of information technology (IT) support from the school.¹³ Practical ways that educators can overcome these shortcomings include utilizing synchronous online chat discussions or assigning group projects to help students feel more connected, promptly answering student emails and phone calls, preparing back-up plans for activities in the event of a technological failure, and making certain there is adequate IT support available during synchronous online events.  Practical ways that students can address potential negativities include utilizing social media outside of class time to become more connected to classmates and obtaining high-quality, reliable internet service.

While some individuals may still hold certain negative perceptions about distance education, the evidence shows that well-designed instruction delivered at a distance is equally effective as traditional teaching methods in educating our future healthcare providers.

References

1. Du S, Liu Z, Liu S, Yin H, Xu G, Zhang H and Wang A Web-based distance learning for nurse education: a systematic review. Nurse Educ Perspect. 2011;32:406-10.
2. US News. The Best On-line education programs in 2014. Accessed 2/25/2014.
3. American Dental Hygienists Association. List of on-line Master’s of Dental Hygiene programs. Accessed 2/25/2014.
4. Davis MV, Sollecito WA and Williamson W. Examining the Impact of a Distance Education MPH Program: A One-Year Follow-Up Survery of Graduates. J Public Health Management Practice. 2004;10:556-563.
5. Lenz TL, Monaghan MS, Wilson AF, Tilleman JA, Jones RA and Hayes MM. Using Performance Based Assessments to Evaluate Parity Between Campus and Distance Education Pathway. Am J Pharm Educ 2006;70: Article 90.
6. The Non-Traditional Doctor of Pharmacy Pathway. The Bernard J. Dunn School of Pharmacy at Shenandoah University. Accessed 3/4/2014.
7. Gadbury-Amyot CC and Brockman WG. Transition of a Traditional Pharmacology Course for Dental Students to an Online Delivery Format: a pilot project. J of Dental Educ. 2011;75:633-45.
8. Haney M, Silvestri S, Van Dillen C, Ralls G and Papa L. A Comparison of Tele-Education Versus Conventional Lectures in Wound Care Knowledge and Skill Acquisition. J Telemed Telecare. 2012;18:79-81.
9. Chipps J, Brysiewicz P and Mars M. A Systematic Review of the Effectiveness of Videoconference-based Tele-education for Medicaland Nursing Education. Worldviews Evid. Based Nurs. 2012;9:78-87.
10. Wells M and Dellinger AB. The Effect of Type of Learning Environment on Perceived Learning Among Graduate Nursing Students. Nurs. Educ. Perspect. 2011;32:406-10.
11. Garland KV. E-learning vs. Classroom Instruction in Infection Control in a Dental Hygiene Program. J of Dent Educ. 2010;74:637-643
12. Steinburg M. and Morin AK. Academic Performance in a Pharmacotherapeutics Course Sequence Taught Synchronously on Two Campuses Using Distance Education Technology. Am J Pharm Educ. 2011;75:Article 150.
13. Grimes EB. Student Perceptions of an Online Dental Terminology Course. J of Dent Educ. 2002;66:100-107.
14. Halter MJ, Kleiner C and Hess RF. The Experience of Nursing Students in an Online Doctoral Program in Nursing: A Phenomenological Study. Int. J of Nurs Studies. 2006;43:99-105.

A Quality IPPE Institutional Experience

by Teresa Elsobky, Pharm.D., PGY2 Psychiatric Pharmacy Resident, University of Maryland School of Pharmacy

Introductory Pharmacy Practice Experiences (IPPE) are a requirement designed to be a pharmacy student’s first structured experience with direct patient care in a health care setting.¹  They provide transitional experiential activities and active learning opportunities for students to apply lessons learned in the classroom in the “real world.”² As a pharmacy student, I had to complete two IPPEs: a 40-hour IPPE community experience and an 80-hour IPPE institutional experience. My IPPE institutional rotation experience, in particular, stands out in my mind. During this rotation, I did not have a chance to participate in the medication use process in its entirety – from when a prescriber writes a medication order to when the medication is administered to the patient.  While I mastered the task of stocking a Pyxis^® machine, I did not understand why these specific medications were made available or how to prevent medication errors from occurring. During that introductory experience, I never entered a medication order into the hospital’s health information system.  It wasn’t until my advanced pharmacy practice experience (APPE) during a institutional rotation that I learned about the medication use process.

Image from: http://www.pharmacy.arizona.edu/programs/rotations

An IPPE institutional rotation can be conducted in many ways, but the goals and objectives should be clear and similar across all Doctor of Pharmacy curricula. According to the Accreditation Council for Pharmacy Education (ACPE), an IPPE rotation should “continue in a progressive manner leading to entry into the advanced pharmacy practice experiences.”3  IPPE rotations should be appropriately designed in order to prepare students for the direct patient care activities that occur during advanced rotations. In 2009, a task force of the American Association of Colleges of Pharmacy (AACP) developed a nationally defined set of IPPE competencies that these competencies should be mastered prior to APPEs.⁴ These competencies included the following broad categories: processing and documenting prescriptions/drug orders; understanding professional norms and behaving in a professional manner; understanding dosage forms/devices and how their use should be communicated to patients; and assisting patients with self care.⁴  These competencies were established to help schools and preceptors create valuable IPPE rotations with clear goals, objectives, and activities.

After looking at several different institutions’ IPPE rotation syllabi, here are some general goals and objectives that I believe should be achieved during an IPPE: participating in pharmacy operations in a role similar to the pharmacist’s,⁵ observing an interprofessional team,⁵ explaining the roles and responsibilities of every pharmacy staff member,⁶ and identifying personal learning needs by participating in a continuing professional development process.⁶

How will a pharmacy student accomplish these objectives?  What activities can the preceptor arrange to aid in the successful completion of these goals?  Preceptors can not spend every moment with their students during the rotation, but they should facilitate the necessary tasks to make it a fulfilling experience.¹ Certain activities that will help achieve the rotation goals include:⁶ being involved in the preparation and dispensing of oral, topical, and intravenous medications; observing the medication use process (understanding how orders are written and delivered to the pharmacy, shadowing a pharmacist as he/she inputs and verifies medication orders, and seeing how the patient receives the medication after the order has been processed); attending Pharmacy & Therapeutics Committee meetings; helping to maintain patients’ medication profiles; assisting the pharmacist report an Adverse Drug Reaction (ADR); formulating an alternative drug selection when a drug-drug interaction exists; communicating verbally and in writing with various healthcare disciplines and patients; formulating a timely response to drug information questions from hospital staff members; and utilizing resources (efficiently!) to look up answers to drug information questions.

Creating a quality IPPE institutional rotation is important and vital to pharmacy students’ professional growth, as this is the first structured experience with patient care.   Schools/Colleges of Pharmacy and preceptors should focus on setting realistic goals and designing fulfilling experiences during these rotations that will enable students to accomplish these goals. The recommendations set forth by the AACP Task Force for IPPE rotations should be used as a resource⁴ and every student should be expected to master these competencies before advancing to APPE rotations.

References

1. Owle C, Lawrence S. IntroductoryPharmacy Practice Experiences: What Students Should Expect [Internet]. Southern Pines (NC): Coastal Research Group; 2011 Dec 14.
2. Chisholm M, DiPiro J, Fagan S. An Innovative Introductory Pharmacy Practice Experience Model. Am J Pharm Educ. 2003; 67:171-8.
3. American Council on Pharmacy Education Standards 2007. Accessed March 9, 2014
4. Task Force on IPPE Competencies, American Association of Colleges of Pharmacy (ACCP). Report to: Board of Directors 2009 May.
5. Ackman M, Mysak T. Structuring an Early Clinical Experience for Pharmacy Students: Lessons Learned from the Hospital Perspective. Can J Hosp Pharm 2009;62:320-5.
6. Eshelman School of Pharmacy (University of North Carolina). Rotation workbook to: IPPE pharmacy students (University of North Carolina Eshelman School of Pharmacy). 2013.

Benefits of Fostering the Student-Faculty Relationship

by Jamie Amero, Pharm.D., PGY1 Pharmacy Practice Resident, The Johns Hopkins Hospital

If asked “What contributes to students’ success in college?” many would respond with answers such as hard work, motivation, or talent. All of them are important contributors, but there is another component to success that often gets overlooked. Many people do not realize a positive relationship between the student and educator can have a large impact on a student’s success.

The influence the student and teacher relationship on student success in college courses has been examined.  Researchers have found that a positive relationship between students and the teacher increases student motivation, satisfaction, confidence, and learning.^1,2 One study by Marina Micari and Pilar Pazos evaluated the impact of faculty-student relationships in an organic chemistry course using a survey tool. This study was designed to evaluate if there was a correlation between the students’ perceived relationship with the professor and their performance and confidence in the course. The results found favorable student outcomes were correlated with certain student feelings such as looking up to the professor and, in return, feeling respected by the professor.  Student success was also correlated with feeling comfortable approaching the professor. Positive relationships with the professor resulted in higher final grades and increased the students’ confidence.²  Other positive benefits include increases in student motivation to learn, influences on professional career choices, and increases in class attendance.^3-6

Thinking back on my years as a student, the educators who made the biggest difference were the ones that created meaningful relationships with me. It is often easy to get “lost in the crowd” when sitting in a lecture of over 160 students.  Those educators which took the time to get to know me were hands down my best professors. Having a relationship with the professor made it easier to ask for help when I was struggling and I was more interested in the course material. There are a variety of ways to build relationships with your students.  Here are a few suggestions:

Conduct one-on-one meetings.  Make it a requirement for students to schedule a meeting with you at least once during the first month of the course. These meetings will give you a chance to learn more about the students and get to know them. One professor met with each student individually within the first four weeks of the class and found positive results from these meetings. The professor had created a questionnaire about basic personal information for the student to fill out and bring to the meeting. About 95% of the students reported they enjoyed the meetings and felt the meetings showed the professor was interested in them as more than just a student. Students also felt it was easier to speak up during class because of the rapport built from the one-on-one meetings.¹

Know your students’ names.  It may sound obvious, but, learning someone’s name is essential to building a relationship. This small act demonstrates respect and personal investment in your students’ wellness. Dr. Mary McKinney, recommends to take roll call the first day of class, obtain a list of names from the registrar to use as a guide, try and connect the students’ names to another person you know with the same name, or frequently call your students by name.⁷

Make yourself available.  Hold office hours! Office hours are a time to make yourself available for students to come and ask questions. This helps create the image that you are available to help and take time out of your own busy schedule to give attention to students in need. The College of Liberal Arts & Sciences Teaching Academy at the University of Illinois states office hours allow educators to help students by facilitating deeper learning, coaching students early to avoid poor performance as the course progresses, and learning how to guide a student who is struggling with the materials.⁸

Incorporate personal stories into the lectures.  Adding a personal story or anecdote related to the material can help students connect with you as a person and not just as the educator. It also helps create more of a conversational feel to the delivery of lectures. Wright and colleagues conducted a study to try and distinguish what characteristics make a teaching physician a great role model and teacher. The survey results found that if a physician took the time to share information about him/herself with learners, in this case residents, then they were more likely to be classified as an “excellent” role model.³ Being viewed as a role model can help create that positive relationship between yourself and the students.³

Provide prompt and meaningful feedback.  When delivered appropriately, feedback can greatly enhance a student’s success. Make students aware of areas for improvement and provide some suggestions on what they can do to improve. Chickering and Gamson include prompt feedback as part of the “seven good principles for good practice in undergraduate education.” They believe learning can be more focused by providing feedback to help the student become more aware of their weak areas.⁹

Taking the time to build rapport and creating meaningful relationships with students can provide numerous positive results for you and the students.  It will help you be an effective educator by increasing student engagement, commitment, and participation in group discussions. It will also help you earn respect.

As an educator, it may seem as if there is no room in your schedule for relationship building. I encourage you to find the time. As a professional who recently graduated, the impact of positive relationships with (some) faculty is fresh in my mind. I contact those professors for help both in my work and personal life.  A couple of hours a week can build relationships that will have a lifelong impact for both the learners and you.

References

1. Starcher K. Intentionally building rapport with students. College Teaching. 2011;59:162.
2. Micari M, Pazo P. Connecting to the professor: impact of the student-faculty relationship in a highly challenging course. College Teaching. 2012; 60:41-47.
3. Wright et al. Attributes of excellent attending-physician role models. N Engl J Med. 1998;339:1986-1993.
4. Haidet P et al. The role of the student-teacher relationship in the formation of physicians. J Gen Intern Med. 2006; 21:S16-20.
5. Rimm-Kaufman S. Improving students' relationships with teachers to provide essential supports for learning. American Psychology Association [Internet]. Washington (DC), 2014 [cited 2014 Mar 10].
6. Fjortoft N. Students' motivations for class attendance. AJPE. 2005; 69: Article 15.
7. McKinney. What's your name again? Successful Academic News [Internet]. Chapel Hill (NC), 2005 [cited 2014 Mar 10].
8. The Liberal Arts and Sciences Teaching Academy (LASTA), University of Illinois. Making the Most of Office Hours [Internet]. Urbana (IL) [cited 2014 Mar 10].
9. Chickering A, Gamson Z. Seven principles for good practice in undergraduate education. AAHE 1997;39:252-262.