Soft Skills Are Important Too

by Chelsea McSwain, Pharm.D., PGY1 Pharmacy Practice Resident, Holy Cross Hospital

Soft skills vs. hard skills…what is the difference?  Soft skills are those personal qualities and interpersonal abilities that are needed to relate to other people and work in groups.¹ In contrast, “hard skills” are those skills that are essential to job function and can more easily be quantified.  For pharmacists hard skills include filling and checking the accuracy of prescriptions, calculating doses, and recalling information about drug therapy.  The pharmacist’s soft skills would include communicating effectively, critical thinking, problem solving, teamwork, time management, conflict management, cultural awareness, responsibility, leadership, and work ethic (to name but a few!).  These skills, although often under-appreciated, are essential to a successful career in pharmacy.  Unfortunately, these important skills are frequently overlooked and have been historically de-emphasized in pharmacy curricula.

A recent editorial by Dr. Cynthia Boyle in the American Journal of Pharmaceutical Education (AJPE) titled “Leadership is Not a Soft Skill” discusses the importance of emphasizing leadership in pharmacy education.² She argues that leadership development is a lifelong process – the time and dedication required to master self-efficacy, self-assessment, reflection, entrepreneurship, and advocacy does not happen overnight.  The importance of leadership, rooted in the social and administrative sciences, has diminished in recent years and was placed on the “back burner” relative to the other two core areas of pharmacy education – clinical and pharmaceutical sciences.  Boyle argues that there needs to be more emphasis on the affective domain as we design and develop pharmacy curricula and courses.³

The Center for the Advancement of Pharmacy Education (CAPE) released its revised educational outcomes in 2013.  The new CAPE outcomes document addresses feedback that called for the “inclusion of an affective domain that would address personal and professional skills, attitudes, and attributes required for the delivery of patient-centered care.”⁵ The educational outcomes are centered around four domains, including 1) foundational knowledge, 2) essentials for pharmacy practice and patient-centered care, 3) effective approaches to pharmacy practice and care, and 4) the ability to develop personally and professionally. The document cites self-awareness, leadership, innovation, entrepreneurship, and professionalism as key outcomes in this fourth domain.⁵ These outcomes have been included in the 2016 American Council for Pharmacy Education (ACPE) Draft Accreditation Standards, and if accepted, it will be a requirement for all pharmacy schools and pharmacy educators to ensure that graduates of Doctor of Pharmacy curricula have achieved them.⁶ At the American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting 2013, the proposed revised PGY1 Pharmacy Residency Accreditation Standards were discussed at a town hall session.  In the draft standards, a new competency domain was articulated: Professionalism, Leadership, and Practice Management.⁷ As a participant in the town meeting, I noted that many speakers advocated for increased emphasis on these competencies.  It makes sense that all three major bodies in pharmacy education have proposed changes. 

With revised standards on the horizon with a renewed emphasis on “soft skills”, educators should be aware of the impact that this may have on instructional design and curriculum development.  Boyle notes that with the addition of these new expectations, we will be exposing a “hidden curriculum” – skills for which students have not been held directly accountable will now become major components of the formal curriculum. Students will need to develop their knowledge and skill through need guided learning opportunities and teachers will need to develop learning materials.  This poses significant challenges — how does one teach soft skills like leadership, professionalism, and advocacy? Perhaps it is not the act of teaching such skills that is the challenge, but a lack of effective evaluation and assessment tools that pose a problem.  Sorenson et al. piloted an elective course at the University of Minnesota that taught leadership skills to students.⁸ They utilized an end-of-course evaluation and focus groups to evaluate instructional design and student reactions to the learning experiences.  This may be the key to “evaluating” pharmacy leadership.  While it is difficult to objectively assess another person’s leadership skills, encouraging students to self-assess and reflect on the core components of leadership may well prove to be a key element of leadership education.  

With the evolution of new standards and a focus on the affective domain, graduates will (hopefully) possess not only the knowledge and clinical skills needed to care for patients but also the soft skills to lead and advocate for change. 

References

1. Schulz B. The importance of soft skills: education beyond academic knowledge. NAWA Journal of Language and Communication 2008;146-154. 
2. Boyle CR, Robinson ET.  Leadership is Not a Soft Skill. Am J Pharm Educ. 2013;77(10):Article 209. 
3. Clark DR. Bloom’s Taxonomy of Learning Domains. Accessed February 17, 2014.
4. Bradley-Baker LR, Murphy NL. Leadership Development of Student Pharmacists. Am J Pharm Educ. 2013;77(10):Article 219
5. Medina MS, Plaza CM, Stowe CD, et al. Center for the Advancement of Pharmacy Education (CAPE) Educational Outcomes 2013. Am J Pharm Educ. 2013;77(8):Article 162. 
6. Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree [draft]. American Council for Pharmacy Education. 2016; in progress. 
7. Annotated PGY1 Pharmacy Residency Accreditation Standards Revision Drafts, For Comment and Feedback. American Society of Health System Pharmacists. Dec 2013. Accessed May 10, 2014.
8. Sorenson TD, Traynor AP, Janke KK. Instructional Design and Assessment: A Pharmacy Course on Leadership and Leading Change. Am J Pharm Educ. 2009;73(2):Article 23. 

Accreditation – Should All Pharmacy Programs Be Alike?

by Caitlin Frese, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Bayview Medical Center

The Accreditation Council for Pharmacy Education (ACPE) is the national agency responsible for accrediting professional pharmacy degree programs since 1932.¹  According to ACPE’s 2013 annual report, there were 109 fully accredited programs, 16 schools in candidate status, and 4 with pre-candidate status.²  Accreditation in healthcare is commonplace – schools/colleges, continuing education providers, and residency training programs are all accredited. Why is accreditation important?  And should all programs be the same?

Accreditation is intended to ensure that high standards are met – not only in terms of the instructional design of the learning program but also its execution. For colleges/schools that offer the Doctor of Pharmacy degree, standards relate to the curriculum, experiential education program, strategic plan, faculty qualifications, and organizational support.  Although accreditation is intended to ensure that every school/college meets and maintains high standards, there is wide variability in skills and competencies obtained by students.  For example, schools of pharmacy located on a academic health sciences campus provide the opportunity for interdisciplinary interactions earlier in their curricula.  Programs located in states with progressive pharmacy practice acts may offer students a greater breadth of practice experiences relative to other programs that are limited by legal constraints.  Differences in curricular design, assessment strategies, experiential education opportunities, and interprofessional interaction often sets one accredited school apart from another.

National pharmaceutical organizations have advocated for revisions in the ACPE accreditation standards to ensure that future graduates are ready for practice and can meet employer expectations.  At a 2012 conference, stakeholders provided recommendations including:

• Greater emphasis on developing skills for literature evaluation and data interpretation.
• Identifying and cultivating behavioral attributes needed by pharmacists in practice including interprofessional collaboration, clinical reasoning, and motivation.
• Ensuring assessment data is utilized for program improvement.
• Using standard assessment questions at the conclusion of advanced practice experiences such as “Would you hire this student?” and “Are the student’s skills at a level ready to enter practice?”³

Many of the recommendations focus on ensuring the pharmacy program adequately trains student pharmacists to enter the workforce as healthcare providers capable of providing direct-patient care.

Reviewing future employer expectations highlights gaps in the current ACPE standards.  Some expectations relate to managerial and business aspects of pharmacy (e.g. delegating tasks, measure/report performance, pharmaceutical supply chains); others place emphasis on health care delivery systems.⁴  Some employers expressed expectations that students should be competent in everyday activities such as documenting in electronic records, respecting patient confidentiality, managing drug waste, and administering common dosage forms.⁴   

After reflecting on my education and listening to the experiences of other recent graduates from different schools of pharmacy, many (but not all) of these expectations are already included in the curriculum.  However, the depth to which they are taught (if they are taught at all) varies greatly.  This likely explains the variability in competencies seen among graduating students today.

ACPE has released a draft version of the 2016 accreditation standards for comment.  These draft standards incorporate many of the recommendations from the stakeholders conference.⁵ These new standards would force schools/colleges of pharmacy to critically review their current curriculum and find opportunities for enhancement. Terminology within the proposed standards better delineates which items are necessary (i.e. “must” statements listed in the standard document) versus items recommended to enhance the quality of the program (i.e. “should” and “could” statements listed in the guidance document).⁵ Twenty-six standards are organized into three major themes: Educational Outcomes, Structure and Process to Promote Achievement of Education Outcomes, and Assessment.⁵ This change in organization of the standards document mirrors the change pharmacy. As health care delivery changes, the pharmacist’s role has shifted from the traditional dispensing/drug distribution functions to a focus on patient care functions, health outcomes, and cost-effective use of drugs.  This shift is evident within the proposed draft of Educational Outcomes as there is greater emphasis on patient care functions and practicing in interprofessional healthcare teams.⁵

One key change between the current and proposed standards is the separation of standards and guidance statements.^5,6 This separation is where pharmacy schools/colleges can customize their program and truly shine.  ACPE acknowledges that pharmacy programs differ and the guidance document is intended to elevate a program from meeting the bare minimum to producing outstanding graduates with unique skills that are highly sought by employers.

For faculty (or those seeking faculty positions), knowledge of the proposed standards and guidance documents should inform course development. The new standards allow for flexibility in terms of innovative course design and delivery methods.⁶  This could include adopting the “flipped classroom” method when redesigning a course or creating a new interdisciplinary elective.  The guidance document includes examples of co-curricular experiences that can be built into courses including student participation in activities such as Legislative Day, brown bag and medication review events, and serving as an institutional ambassador.⁶  It is unlikely that a school/college of pharmacy will be able to successfully implement and master all recommendations included in the guidance document.  Being selective about what can be optimally incorporated into the pharmacy program will maximize student learning and help set the school/college apart.

Ultimately the guidance document encourages schools to strive for excellence.  Accreditation ensures that students gain foundational knowledge and attain a reasonably similar level of competency to perform core professional functions regardless of what school/college they attend.  However, not all schools / colleges are alike.  Utilizing the guidance recommendations and capitalizing on local or state resources will help good programs become great programs.

References

1. 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, Adopted: January 23, 2011, Effective: February 14, 2011). Accessed March 14, 2014.
2. Vlasses PH, Wadelin JW, Boyer JG, et al. Annual Report of the Accreditation Council for Pharmacy Education. Am J Pharm Educ 2013; 77(4):Article 83.
3. Zellmer WA, Beardsley RS, Vlasses PH. Recommendations for the Next Generation of Accreditation Standards for Doctor of Pharmacy Education. Am J Pharm Educ 2013; 77(3):Article 45.
4. Vlasses PH, Patel N, Rouse MJ, et al. Employer Expectations of New Pharmacy Graduates: Implications for the Pharmacy Degree Accreditation Standards. Am J Pharm Educ 2013; 77(3):Article 47.
5. Accreditation Council for Pharmacy Education. Accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree (Draft Standards 2016, Released: February 3, 2014).  Accessed March 14, 2014
6. Accreditation Council for Pharmacy Education. Guidance for the accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree (Draft guidance for standards 2016, Released: February 3, 2014).  Accessed March 14, 2014.

Providing Effective Feedback

by Monique L. Mounce, Pharm.D., PGY1 Pharmacy Resident, Johns Hopkins Bayview Medical Center

One of the toughest yet crucial aspects of being an instructor is providing effective and constructive feedback.  Whether you are inside or outside the classroom teaching, you will have the responsibility of providing feedback both praise and constructive at some point in your career.   Although it may be uncomfortable for some, there are many techniques to assist you with providing verbal and written feedback to a learner.  Personally, as a Doctor of Pharmacy student and now a resident, providing written and verbal feedback to preceptors or pharmacy students has been a struggle.   Like others, I am always afraid of hurting someone’s feelings. I believe the key to effective feedback is the timing and the environment in which the feedback is delivered.

Feedback is defined as information provided by an agent (teacher, peer, parent, self, or experience) regarding aspects of one’s performance, thus it is a consequence of performance.¹ Feedback should be structured to fill the gap between what is understood and what is expected of the learner.  Structured methods for providing feedback date back to the early 1900s when behaviorism was developed.  In behaviorist terms, “positive feedback” is positive reinforcement and “negative feedback” is punishment.  Although feedback is powerful, it is not always accepted.  Feedback can be accepted, modified, or rejected by the learner thus it does not necessarily reinforce actions despite behaviorist’s initial theories on how feedback shaped behavior.  Feedback methods vary based on timing, amount, mode, audience, and its content.  Furthermore, the content varies based on focus, comparison, function, valence, clarity, specificity, and tone (Table 1).¹

Table 1 - Feedback Strategies and Content

Feedback Strategy	Aspects	Recommendations
Timing	-When -How often -Where	Provide immediate feedback for incorrect facts Reserve criticism for appropriate timing and when there is privacy Suggest a different location other than your office to make learner more comfortable.
Amount	-Number of points to make -Elaboration	Prioritize: No more than 2 “lessons” in one session The smaller and more frequent, the better
Mode	-Verbal -Written -Electronic	In-person discussions are best to allow a conversation and to ensure understanding Electronic can be interpreted differently than intended. Use this with short remarks only
Audience	-Individual -Group/Class	Focused attention is best- avoids embarrassment Share the feedback if common among learners but be careful about “picking on” one person
Feedback Content	Aspects	Recommendations
Focus	-Process used for task -Work/actions itself -Student’s self-regulation -Student personally	Most effective- focus on the process used for task completion and observed behavior Avoid personal comments because it makes learner get defensive and reject feedback
Comparison	-To standard of work (criteria-specific) -To other students (norm-specific) -To learner’s own past performance (self-specific)	Criteria-specific feedback for work itself Norm-specific feedback for student’s process or effort Self-specific feedback for illustrating growth and progress towards task
Valence	-Positive -Negative	Use positive comments that describe what actions were well done Give examples for improvement with negative comments
Specificity	-Excessive -Balanced -Vague	Be specific as possible, yet avoid nitpicking Provide specific feedback but do not complete the task for them Be direct: do not beat around the bush
Tone	-Implications -What students “hear”	Brainstorm what you will say and how you want the feedback to be received Choose words that communicate respect for the student and their work

Adapted from:   Brookhart SM. How to Give Effective Feedback to Your Students.  Alexandra, VA: Association for Supervision and Curriculum Development (ASCD); 2008.

How effective is feedback?

A comprehensive meta-analysis by Hattie in 2007 evaluated the effect of providing feedback in the classroom.²  This analysis examined factors that influence educational achievement such as schooling, homes, students, teachers, and curricula.  A subgroup analysis of studies evaluating feedback observed an average effect 50% greater than the effect than schooling itself.  Other influences on achievement in decreasing order of their magnitude of effect include direct instruction, reciprocal teaching, homework, the use of calculators, and reducing class size.  Most teachers are comfortable with providing homework and calculators, yet feedback is at least 50% more powerful at influencing the learners’ achievement.   Not all modes of providing feedback are effective.  Praise, punishment, and rewards contributed to the smallest effect on achievement.

A study evaluating survey responses of over 340 pharmacy students in the United Kingdom on their perceptions of feedback from faculty showed that 98% of students agreed that receiving feedback was an important part of their degree program and 80% of students agreed that feedback from faculty improved their performance.³  Not surprisingly, less than 33% of the students agreed that they were satisfied with the feedback they received.  Inconsistencies in providing feedback, the quantity, quality, and timing were common reasons cited by students.  Feedback given at the end of a module was viewed as the least useful.

Balance between positive and negative feedback

“Negative feedback isn’t always bad and positive feedback isn’t always good.  Too often, they say, we forget the purpose of feedback.  It’s not to make people feel better, it’s to help them do better”

- A. Tugent, New York Times

Studies have shown that learners that truly desire to improve their skills want constructive feedback and view the comments as opportunities for improvement and growth.  People learning a new task prefer positive reinforcement to boost their confidence.⁴   Yet some instructors struggle to give what some would perceive as “negative” feedback.  The term “constructive feedback” is perhaps better nomenclature.  Constructive feedback includes remarks that are productive, useful, redirecting, and motivational, not destructive.  This does not mean the learner should only receive praise.

Example of feedback techniques & Strategies ^(4-6)

One common method of providing feedback is the Feedback Sandwich.⁴  This technique provides the so-called negative feedback between two positive comments.  This strategy has received much criticism for being ineffective because many learners will only hear the praise, thus undermining the intent.  Authors of The Power of Feedback argue that focusing the feedback on the task and self-regulation are the most powerful modes of feedback, whereas feedback about the self as a person is the least effective. ²    In the One Minute Preceptor technique, the preceptor probes the learner for supporting evidence after the learner has articulated a recommendation.  The preceptor then reinforces actions done well and lastly makes recommendations for improvement.⁵   Another common way of providing feedback is the W3 in which the preceptor allows the learner to self-reflect utilizing three questions:  what worked well, what did not work well, what we can do differently next time.  There are other strategies such as 360 degrees that attempts to elicit feedback from various sources such as other learners, colleagues, as well as supervisors.

I like the W3 method but sometimes learners are their own worst critic; therefore, I like utilizing the W3 informally. I like constructive feedback from the instructor about a specific task in real time (e.g. while I’m performing the task or immediately afterward).  As a learner, the worst experience is not receiving any feedback until the end of the learning experience and realizing you weren’t meeting expectations.  It is human nature to assume if there is no feedback that everything must be fine.  At the very least, feedback sessions should be held formally at the middle and end … but informal feedback should be given as much as possible.

Effective feedback is essential for the learner’s growth and professional develop.  With practice, the instructor will develop his/her own strategy to effectively deliver motivational and useful feedback to learners of all levels.  Effective feedback is FAST:  frequent, accurate, specific, and timely.   If you are going to make a feedback sandwich, make it a “meaty” one.

References:

1. Brookhart SM. How to Give Effective Feedback to Your Students.  Alexandra, VA: Association for Supervision and Curriculum Development (ASCD); 2008. [cited March 5 20014]
2. Hattie J, Timperley H. The power of feedback.  Review of Educational Research. 2007:77-81.
3. Hall M, Hanna L, Quinn S. Pharmacy students’ views of faculty feedback on academic performance.  Am J Pharm Educ. 2012; 76: Article 5.
4. Tugend A. You’ve been doing a fantastic job. Just one thing... New York Times [online]. April 2013.
5. Hohrenwend, A.  Serving up the feedback sandwich.  Fam Pract Manag. 2002;9:43-6.
6. Furney SL, Orsini AN, Oretti KE, et. al.  Teaching the one-minute preceptor.  J Gen Inten Med. 2001;16:620-4.